A survey of solitary deaths in Japan for shortening postmortem interval until discover.

Recently in advanced nations, the number of solitary households is increasing. Data from Japanese population survey in 2010 showed that the percent of solitary households was 32.4% and that was the largest category of household types. The Japanese government regards solitary death as important problem, but a useful survey on solitary death has not been performed. We have focused on the postmortem interval until discovery of the death as a measure of solitary deaths. We conducted a survey of 582 forensic autopsy cases in the Osaka medical examiner's office over three years, from April in 2010 till March in 2012. We excluded suicide cases. We collected data on the, gender, age, postmortem interval (PMI) until discovery, family structure, situation of discovery of the body, cause of death, and the time interval from the last hospital visit. Here, we found that people who had high risk of solitary death ranged in, age from 60 to 69 which is the age of retirement for many people. In order to prevent solitary death, we suggest that people who live alone should take better care of themselves and participate in a community setting after their retirement. We can show that the recent efforts of the Japanese government for reducing solitary death had been working well. The government care givers take care of the person living alone almost like their own family. We also suggest that the people who unfortunately do not have any home care should subscribe to a newspaper for shortening the PMI.

Discovery of Liopiophila varipes and Protopiophila contecta (Diptera: Piophilidae) from human cadavers.

Here, we present two cases in which larvae of the family Piophilidae were detected in human cadavers. Both cases were found in Tochigi Prefecture, which is located in the middle of Honshu Island, Japan. Case 1: A corpse was found hanging in the sun lounge of a house. Dipteran larvae were collected from inside the spinal canal, despite no visible breach on the skin. The adults derived from these larvae were identified as Piophila casei (Linnaeus, 1758) and Liopiophila varipes (Meigen, 1830). Case 2: Skeletal human remains were found in a mountainous forest. Dipteran larvae were detected in the bone marrow cavity of a tibial section during autopsy. One adult fly derived from the larvae was identified as Protopiophila contecta (Walker, 1860). This is the first report of the identification of L. varipes and P. contecta in human cadavers.

Changes in blood viscosity by heparin and argatroban.

Anticoagulants are effective for preventing both venous and arterial thrombosis. Although antithrombotic agents have been reported to reduce thrombin formation, to our knowledge, the relation between blood viscosity (BV) and antithrombotic agents has not been examined. We examined the effects on whole BV of various dosages of the antithrombotic agents-heparin sodium and argatroban. Thirty microliters of either drug was added to 3-ml samples of blood obtained from healthy male volunteers. Whole BV was then immediately examined with an oscillation-type viscometer. When either agent was added, BV decreased and coagulation time increased dose dependently. BV was 4.5+/-0.3 mPa.s in untreated blood but decreased in a dose-dependent manner to a minimum of 2.5+/-0.3 mPa.s with heparin sodium and decreased dose dependently in a sigmoid manner with argatroban. Because thrombin generation is inhibited in all antithrombotic therapies, this inhibition might be reflected by changes in BV. Our results suggest that BV in accordance with blood coagulability are indexes of thrombotic tendency and that decreasing BV prevents life-threatening thromboembolic conditions.

[An autopsy case of accidental hanging during home care].

A 73-year-old man who had suffered from old myocardial and cerebral infarction for 4 years had been secured in wheelchair due to left hemiplegia and aphasia and also been received a home care of his wife. One day, his wife tied a cloth belt around his head and secured it to the wheelchair to prevent the flexion of his neck. One hour later, he was found dead by his wife. He also had slipped down in his wheelchair. The autopsy performed 24 hours after death revealed a ligature marks on the front of the neck. Petechial hemorrhages, visceral congestion and fluid blood, compatible with asphyxial death, were also found. Although severe cerebral cortical atrophy, old myocardial infarction, moderate to severe atherosclerosis and decubitus of the back were also found, they were not considered primary cause of death. No other anatomical or toxicological cause of death was present. Therefore, we concluded that the man died of accidental hanging. Recently, the home care of aged or handicapped patient is a social problem in Japan due to the increase in the number of elderly people. The death was caused by the inappropriate restraints used by his wife. This case suggests the importance of proper advice to non-professional caretakers from care professionals.

Incomplete decapitation of a motorcyclist from hyperextension by inertia: a case report.

This is a rare case involving a motorcyclist. A 57 year old motorcycle rider wearing a full face type helmet, suffered incomplete decapitation. The autopsy findings revealed a wide lacerated wound accompanied by extension marks in the front neck, atlanto-occipital dislocation and complete transection of the brainstem. According to the police traffic report, the man's head was stationary at the moment of impact and the remainder of the body continued in a backward motion. We concluded that the inertia of the torso caused hyperextension of the neck and subsequent incomplete decapitation.

An autopsy case of sudden death in a patient with idiopathic scoliosis.

A 38-year-old woman with idiopathic scoliosis (right convex thoracic scoliosis, 78 degrees; left convex lumbar curvature, 75 degrees) died suddenly. Forensic autopsy and histopathologic examination revealed chronic congestive oedema, numerous cavities and atrophic changes of heart. These changes, including both respiratory changes and biventricular failure caused by hypoplastic cardiac changes, were due to a deformed thoracic cage. This case illustrates that not only abnormalities of respiratory function and cor pulmonare, but also hypoplastic cardiac changes, may cause sudden death in a patient with untreated scoliosis.

Rheologic changes in venous blood during prolonged sitting.

We examined blood rheologic changes, mainly blood viscosity, during long-term quiet sitting. Samples of blood were obtained from the arm and foot veins of the healthy adult male volunteers before and after 2 h of quiet sitting. Blood viscosity, was immediately determined with an oscillation viscometer, and blood count and blood chemistry were analyzed. We found that the viscosity in blood from a foot vein but not from an arm vein increased significantly after 2 h of sitting. Our results show that 2 h of quiet sitting can increase thrombotic tendency locally in the leg but not systemically and suggests the importance of measuring focal venous blood viscosity.

A case of strangulation by a vehicle seat belt.

A healthy 23-year-old man wearing a three-point seat belt suffered from a roll-over traffic accident. When the man was found, the fastened seat belt had loosened and the diagonal belt was tightened against the neck. Autopsy findings revealed ligature marks on the surface of the neck, hemorrhages in the muscles of the neck, petechial hemorrhages in palpebral conjunctivae and viscera, dark red liquid blood in the heart cavities and visceral congestion. We concluded that the man died of strangulation by the seat belt. In this case, the loose belt allowed the body to move and subsequently the diagonal belt applied external pressure to the neck while the car was rolling over. Although there have been several reports of neck injuries due to diagonal belts, this is the first report of strangulation by a properly used three-point belt in a roll-over vehicle accident.

Injury severity in motor vehicle occupants.

We performed a retrospective analysis of injury severity and the effect of seat belt use with findings from forensic autopsies of 50 persons who had died in motor vehicle accidents. From autopsy findings and accident reports, the abbreviated injury scale (AIS) and the injury severity score (ISS) were calculated and analyzed epidemiologically. Among unrestrained occupants, drivers usually sustained more severe chest and abdominal injuries. Furthermore, three-point seat belts significantly decreased the severity of drivers' chest and abdominal injuries. Our results may be useful for forensic pathologists and clinicians and for mechanical engineers who investigate new safety devices for vehicle occupants.

Retrospective analysis of the forensic autopsy cases of psychiatric patients.

This paper describes a retrospective analysis dealing with the sudden natural or unnatural death of psychiatric patients using actual autopsy findings, clinical information and demographic status. More than 70% of the 141 patients had schizophrenia, mood disorders or substance-related disorders. Accidental deaths were the most common (34.8%) and followed by natural deaths (28.4%), suicide (22.7%) and homicide (9.2%). Nearly half of mentally retarded patients died natural deaths, whereas two-thirds of patients with substance-related disorders died accidental deaths and about one-third of patients with schizophrenia and mood disorders committed suicide. Furthermore, patients with substance-related disorders were significantly more likely to live alone than were patients with schizophrenia or mood disorders. Twenty-five cases died in hospitals or other healthcare facilities; it is noteworthy that in the 12 patients who died natural deaths the reported symptoms had been less severe than might be expected and correct clinical diagnosis was not made before death. The present findings should be useful for both forensic pathologists and clinical psychologists.

Injuries of motorcyclists and bicyclists examined at autopsy.

Few studies of autopsy findings of persons dying of head and neck injuries in cyclists have been published. We performed a retrospective analysis of injury severity and the relation between head and neck injuries and helmet use. Seventy-six bicyclists and motorcyclists were collected from among the forensic autopsy at the Jikei University School of Medicine. From autopsy findings and accident reports, the abbreviated injury scale (AIS) and the injury severity score (ISS) were calculated and analyzed epidemiologically. As a result, helmet use significantly decreased the severity of head and neck injuries but had no effect on overall injury severity or the severity of injuries to other body regions. Furthermore, helmets had little effect on injuries remote from the point of impact, injuries resulting from angular acceleration, or injuries at the junction of the head and neck. These findings may be useful for both forensic pathologists and clinicians evaluating injuries in bicyclists and motorcyclists.

Estimation of normal heart weight in Japanese subjects: development of a simplified normal heart weight scale.

To estimate cardiac workload from total heart weight (HW) in persons who have died suddenly, standards of normal HW must be established. We present standards of normal HW for Japanese subjects and propose a simplified scale for calculating normal HW from body height (BH) and body weight (BW). A total of 830 persons (506 male and 324 female) who had died suddenly of unnatural causes were selected for analysis from among persons examined at forensic autopsy at the Jikei University School of Medicine. The HW, BH and BW of each subject were measured. Body surface area (BSA) in square meters was calculated from BH in centimeters and BW in kilograms with Takahira's equation. We found allometric relations between HW and BSA represented by these equations: HW=BSA(1.441) x 168.200 for males and HW=BSA(1.367) x 161.970 for females. For practical use, we developed a simplified scale with which normal HW can be easily and quickly calculated from BH and BW. Our simple technique can be used to estimate normal HW in routine autopsy practice.

Sudden death of a patient with Crohn's disease.

We describe a case of sudden death caused by a rare complication of Crohn's disease. A 29-year-old man with Crohn's disease who had not taken medications regularly complained of nausea, vomiting, and abdominal pain for 2 days, and then died suddenly. Autopsy revealed protruding intestinal loops filled with gas, internal fistulas between fused loops of the terminal ileum, and complete obstruction of the fistulous tract. The histologic findings of transmural inflammation consisting of lymphocytic infiltration, accumulation of partially hyalinized collagen, and fibrosis in the skip areas from the ileum to the cecum were compatible with Crohn's disease. Furthermore, marked emaciation, atrophic change of the heart muscle, and diffuse fatty change of the liver were found. Although the patient died of obstructive ileus caused by a stricture produced by progression of Crohn's disease, he was severely affected by malnutrition which may have been fatal. This case not only illustrates that Crohn's disease can cause obstructive ileus and sudden death, but also makes the forensic pathologist realize the importance of suspecting the presence of an active inflammatory bowel disease in a patient with internal fistulas or malnutrition.

A case of fatal benzalkonium chloride poisoning.

Five elderly persons with senile dementia accidentally ingested Hoesmin, a 10% aqueous solution of benzalkonium chloride (BAC). The condition of one patient, an 84-year-old woman whose lips and oral cavity became erythematous, gradually deteriorated. Although gastric lavage was performed, the patient died 3 h after ingestion of Hoesmin. Autopsy revealed corrosive changes of the mucosal surfaces of the tongue, pharynx, larynx, esophagus and stomach which may have come in contact with BAC. In addition, BAC was detected in the serum. We conclude that the patient died of BAC poisoning. Fatal BAC poisoning is rare and autopsy findings in only a few cases of BAC poisoning have been reported. Our findings emphasize the risk of oral ingestion of BAC.

Autopsy case of duodenal obstruction from impacted mushroom.

We report an autopsy case of duodenal bulb obstruction caused by a shiitake mushroom. A 74-year-old woman with depression was admitted to the hospital after suffering nausea and abdominal fullness for 3 days. Because the physical findings and laboratory data on admission revealed marked dehydration, lactated Ringer's solution was administered. Twelve hours later, the patient suddenly died. Autopsy showed an enlarged stomach filled with 850 ml of partially digested food. In the anal side of the pylorus, a 9-cm-diameter shiitake mushroom had become impacted, causing complete obstruction. We conclude that the patient suffered from duodenal bulb obstruction caused by the impacted mushroom and subsequently died of ileus. This case illustrates a rare cause of duodenal obstruction and emphasizes that ingested food can cause obstructive ileus and death.

[Hemorrhagic shock death caused by not so severe injury during the medication of anticoagulants].

A 73-year-old man receiving anticoagulants (warfarin potassium) orally with a history of prosthetic heart valve replacement was struck by a truck. When admitting to the hospital, he complained of lumbago with laboratory findings of anemia and prolongation of prothrombin times. Twenty-two hours after the accident, he died suddenly in the hospital and forensic autopsy was performed 9 hours after his death. Autopsy findings revealed marked subcutaneous and intramuscular hematoma in the lumbar and gluteal region and anemic change of viscera. Furthermore, 854 ng/ml of warfarin which was well accordance with the therapeutic levels was detected in the serum obtained from cadaver by using gas chromatography-mass spectrometry. Therefore, we concluded that the man had died of hemorrhagic shock caused by the force acting to the lumbar region accompanied by the influence of anticoagulant action of warfarin. To our knowledge, this is the first report to detect the warfarin from cadaver's serum. In dealing with the unnatural death of the patient receiving the anticoagulants, it is valuable to survey the medications and detect the presence of anticoagulants in cadaver.

[An autopsy case of sudden death caused by untreated sepsis after complete remission of acute promyelocytic leukemia].

The patient was 63 year-old man. He had been diagnosed as acute promyelocytic leukemia (APL) and treated until 4 month before his death with complete remission. The patient suddenly died 9 days after he complained of occipital headache. Autopsy and histopathologic findings were as follows: the left pleura was thick and calcificated with abscess, compatible with the findings of old tuberculosis complicated with bacterial infection. Furthermore, polynuclear leukocytes and gram-positive micro-organisms were accumulated in the lungs, and pyogenic meningitis, pyonephritis, splenitis were also found. Bacteologically, Streptococcus pneumoniae was detected from cadaver's blood and cerebrospinal fluid. Therefore, we concluded that the patient was died of septic shock caused by systemic infection of Streptococcus pneumoniae. The mortality of septic shock is high and in some patients, causative organisms may not be isolated. In the present case, although the original inflammation was left pleuritis due to Streptococcus pneumoniae, correct clinical diagnosis was not made before death as the patient had lacked any complaints except for occipital headache. This case revealed that the cause of sudden death was sepsis induced by Streptococcus pneumoniae instead of a relapse of APL. This case also illustrated the importance of reviewing the previous history of a patient and doing postmortem bacteologic examination in a case of suspected sepsis.