Shedding light on the hidden methamphetamine abuse: a nation-wide 7-year post-mortem study in Taiwan.

BACKGROUND: The number of methamphetamine-related deaths has been increasing in recent decades. However, current data primarily rely on a few large-scale national surveys, highlighting the need for diverse data sources. Post-mortem studies offer advantages that compensate for the limitations of cohort studies. In this study, we aimed to (1) examine mortality rates and years of potential life lost, (2) compare proportionate mortality with previous cohort studies, and (3) quantitatively investigate causes of death as potential risk factors associated with each manner of death. METHODS: We analyzed 740 cases from 2013 to 2019 in Taiwan. RESULTS: The mean age of cases was 38.4 years, with a notable loss of 30s years of potential life, and 79.6% were male. The crude mortality rate was 0.45 per 100,000 person-years. The proportionate mortality indicated that autopsy dataset, compared to cohort studies, provided more accurate estimations for accidental deaths, equivalent suicides, underestimated natural deaths, and overestimated homicides. Accidental deaths were evident in 67% of cases with 80% attributed to drug intoxication. Multiple substances were detected in 61% of cases, with psychiatric medications detected in 43% of cases. Higher methamphetamine concentrations and a greater proportion of multiple substances and benzodiazepines were detected in suicidal deaths. Among accidental deaths, traffic accidents (7.9%) were the second most common cause, particularly motorcycle riders. CONCLUSIONS: Using autopsy dataset as a secondary source, we identified that over half of the cases involved accidental drug intoxication. The significant proportion of cases involving multiple substances, psychiatric medications, and drug-impaired driving raises concerning.

"Breaking heart" due to hydrofluoric acid burns in a case of homicide.

Homicide attacks in which hydrofluoric acid (HF) is used are very rare, and few studies have reported the pathological changes. Hypocalcemia is thought to be the cause of sudden death from HF; nevertheless, after neutralization of the blood concentration of calcium ions, HF-induced arrhythmia may still occur, suggesting that in addition to hypocalcemia, direct toxic effects of HF may play a pivotal role in myocardial damage. Here, we report a homicidal forensic autopsy case with pathological changes of the myocardium due to HF burns. Von Kossa staining and immunohistochemical staining were also performed. The cause of death was given as HF toxicity with direct toxic effects on myocardial damage as ischemic injury may occur prior to ventricular fibrillation in the present case. The present case shows that myocardial damage should be given more attention in the clinical treatment and forensic autopsy of HF burns.

Decreased Expression of Plakophilin-2 and αT-Catenin in Arrhythmogenic Right Ventricular Cardiomyopathy: Potential Markers for Diagnosis.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a hereditary disease of the heart muscle. Clinical challenges remain, however, in identifying patients with ARVC in the early or concealed stages with subtle clinical manifestations. Therefore, we wanted to identify potential targets by immunohistochemical (IHC) analysis in comparison with controls. Pathogenic mutations were identified in 11 of 37 autopsied patients with ARVC. As observed from IHC analysis of the RV, expression of αT-catenin and plakophilin-2 is significantly decreased in autopsied patients with ARVC as compared to controls, and the decreased expression is consistent in patients with and without pathogenic mutations. Furthermore, ARVC specimens demonstrated a reduced localization of αT-catenin, desmocollin-2, desmoglein-2, desmoplakin, and plakophilin-2 on intercalated discs. These findings have been validated by comparing RV specimens obtained via endomyocardial biopsy between patients with ARVC and those without. The pathogenic mutation was present in 3 of 5 clinical patients with ARVC. In HL-1 myocytes, siRNA was used to knockdown CTNNA3, and western blotting analysis demonstrated that the decline in αT-catenin expression was accompanied by a significant decline in the expression of plakophilin-2. The aforementioned effect was directed towards protein degradation rather than mRNA stability. Plakophilin-2 expression decreases concurrently with the decline in CTNNA3 expression. Therefore, the expression of αT-catenin and plakophilin-2 could be potential surrogates for the diagnosis of ARVC.

Tuberculosis Surveillance in Taiwan Forensic Autopsy Cases: A Retrospective Analysis of 71 Cases From 2012 to 2017.

Tuberculosis (TB) is one of the most important public health issues worldwide, and global efforts have altered the TB epidemic. This study analyzed 71 cases of TB at autopsy notified via Taiwan Medical Examiner Surveillance for Lethal Infectious Disease (Taiwan Med-X) between 2012 and 2017 and applied immunohistochemistry to formalin-fixed lung tissue. Tuberculosis was present in 0.57% (71/12,369) forensic autopsy cases in the institute. Among the study cases, 30 (42.3%) cases were newly diagnosed with TB at autopsy, whereas 41 (57.7%) cases were notified before death and have still seen the TB pathological changes. Regarding the death investigation, cause of death was TB accounted for 46.5%, and non-TB, 53.5% (including trauma, 26.8%; other diseases, 19.7%; drowning, 4.2%; and drug abuse, 2.8%, respectively). Compared with the staining signal, immunohistochemistry has better sensitivity than acid-fast staining. This study provides a reassessment of the reference value to estimate the burden of disease caused by TB and emphasizes the importance of biosafety in an autopsy room.

Fatal parvovirus B19 infections: a report of two autopsy cases.

Parvovirus B19 (PVB19) commonly infects children and is usually asymptomatic. Lethal outcomes of PVB19 infection are unusual; nevertheless, the two cases reported here are rare examples of PVB19-induced hemophagocytic syndrome and myocarditis in infants and children. The two cases show the indisputable usefulness of immunohistochemistry and in situ hybridization in the detection of PVB19. In the death investigations, histopathological examinations provided stronger evidence than did serology or molecular biology. The cases also highlight the importance of forensic autopsy in vaccine-related death. As vaccine-related deaths are what people fear and may cause declines in vaccination rates, it is important to clarify deaths temporally or causally associated with vaccine administration.

Rhabdomyolysis observed at forensic autopsy: a series of 52 cases.

Rhabdomyolysis is characterized by skeletal muscle injury resulting in the release of intracellular proteins (such as myoglobin) and electrolytes into the blood circulation, which cause acute kidney injury, myoglobinuria and electrolyte imbalances. Clinical diagnosis of rhabdomyolysis is made on the basis of biochemical analysis; however, for forensic autopsies, biochemical data are often not available, and it is necessary to diagnose rhabdomyolysis via histopathological examinations. This study analyzed 52 cases with rhabdomyolysis and applied myoglobin immunohistochemistry to kidney, urine and blood samples. We found that blunt force injuries were the most common cause of rhabdomyolysis across all age groups, and drugs were the second most common cause. The drugs included ketamines, amphetamines, synthetic cathinones, entheogens, benzodiazepines, opioid analgesics, and anesthesia. Less than 60% of our cases had biochemical data, including myoglobin (92.5~416,978 ng/mL), creatine kinase (220~774,015 U/L), potassium (1.6~10.3 meq/L), calcium (2.7~29.2 mg/dL), and phosphorus (2.6~14.2 mg/dL). In the kidney tissue sections, we found that 95% of the rhabdomyolysis cases were positive for myoglobin immunohistochemistry and that 96% were associated with acute tubular necrosis. Our findings describe the features of fatal rhabdomyolysis in a large series and suggest that myoglobin immunohistochemistry can be used in post-mortem blood and urine cell blocks to detect myoglobin.

Adult femicide victims in forensic autopsy in Taiwan: A 10-year retrospective study.

BACKGROUND: Violence against women and adult femicides are critical medico-legal issues worldwide. Intimate partner violence is one of the leading contributory risk factors. This study aimed to describe the characteristics of femicides in Taiwan. METHODS: A retrospective analysis of forensic autopsy records of adult femicide victims in Taiwan during a 10-year period was carried out. The age, victim-offender relationship, injury patterns and causes of death were analyzed. RESULTS: Among the 220 adult femicide victims recruited, 114 were killed by intimate partners and 106 were killed by non-intimate partner offenders. The average age of victims killed by intimate partners (40.0 y/o) were younger than those killed by non-intimate partner perpetrators (48.6 y/o). The most common site of injuries in the intimate partner group and the non-intimate partner group was the neck and the upper limbs, respectively. The rates of bruise and intracranial injury of non-intimate partner group were significantly higher than that of the intimate partner group. The most common causes of death in both groups were strangulation and sharp force injury. The heart injury was significantly more frequent in victims offended by intimate partners than by other assailants. CONCLUSIONS: The characteristics of adult femicides, and the patterns of injury in victims killed by intimate partners and non-intimate partner offenders were different. This data is helpful for corpus inspection in forensic casework and for strategic planning of femicides prevention.

Child homicide victims in forensic autopsy in Taiwan: A 10-year retrospective study.

BACKGROUND: Child homicides are critical medico-legal issues worldwide. Data on the characteristics of these cases in Asia are limited. This study aimed to describe the characteristics of child homicides in Taiwan. METHODS: A retrospective analysis of forensic autopsy records of child homicide victims (aged 0-17 years) in Taiwan, during a 10-year period between 2001 and 2010, was carried out. The age, sex, relationship with the perpetrator(s), injury patterns of the victims, and causes of death were analyzed. RESULTS: In all, 193 child homicide autopsies were identified. There were 38 (19.7%), 82 (42.5%), 25 (13.0%), and 48 (24.9%) homicide victims aged under 1, 1-5, 6-12, and 13-17 years, respectively. One-hundred boys (mean age: 8.4±7.0) and 93 girls (mean age: 3.7±4.3) were included. A female predominance was noted among the victims aged 0-5. Blunt force (53.4%) was the most frequent method of injury, followed by suffocation/strangulation (20.2%) and sharp force (13.0%). Bruise (64.8%) and brain injury (45.1%) were the most common types of injuries. The cranium (62.2%) and face (60.6%) were the most frequently injured body regions. The distribution of fatal injuries varied among victims in different age groups. Neurogenic shock, asphyxia, and hemorrhagic shocks were most common in victims aged 0-5, 6-12, and 13-17, respectively. The most frequent causes of death included blunt force head injury (40.4%), suffocation/strangulation (20.2%), and sharp force lung trauma (7.3%). The type of offenders, injury methods, types of injuries, distribution of injuries, mechanism of death, and causes of death were significantly different among victims of different age groups. Eighteen (9.33%) victims displayed no external evidence of trauma. CONCLUSIONS: The patterns of injuries, mechanism of death, and causes of death were different among victims of different age groups. A female predominance was noted among the victims aged 0-5. Complete forensic autopsy is necessary to identify child homicide. This report will help forensic examiners and forensic pathologists recognize the signs of child homicide and serve as a working basis for these professionals.

Seasonal variation in the frequency of sudden cardiac death and ventricular tachyarrhythmia in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy: the effect of meteorological factors.

BACKGROUND: Sudden cardiac death (SCD) is the most catastrophic presentation in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C). OBJECTIVES: To investigate the seasonal variations in the frequency of SCD and ventricular tachyarrhythmia in patients with AVRD/C and to elucidate the meteorological factors that trigger these events. METHODS: From 1998 to 2012, we enrolled 88 consecutive patients with ARVD/C from Taipei City. The cohort included 20 living patients who received implantable cardioverter-defibrillator (ICD) and 68 autopsied patients with SCD from the Taiwan National Forensic Institute registry. The baseline clinical characteristics, seasonal distribution, and associated meteorological factors were explored to predict the occurrences of events, which include appropriate ICD interventions and SCD. RESULTS: There were 106 events, including 38 (35.8%, 1.9 episodes per patient) appropriate ICD interventions in living patients with ARVD/C and 68 (64.2%) SCD events. The seasonal peak occurred predominantly in summer (P < .05) in both groups. For meteorological factors, the onset of event was associated with higher average daily temperature and longer sunshine duration. The variation in humidity within 3 days of events was significantly increased. After multivariate logistic regression analysis, higher average daily temperature and larger variation in humidity were associated with increase in events (odds ratio 1.23, 95% confidence interval 1.16-1.31, P < .001, and odds ratio 1.19, 95% confidence interval 1.15-1.23, P < .001, respectively). CONCLUSIONS: There was seasonal variation with a summer peak in the occurrence of ventricular arrhythmias and SCD in patients with ARVD/C. Meteorological factors including higher temperature and larger variation in humidity within 3 days of events were independently associated with the development of events.

Liquid chromatography-tandem mass spectrometry determination of the toxicity and identification of fish species in a suspected tetrodotoxin fish poisoning.

Suspected tetrodotoxin (TTX) poisoning was associated with eating unknown fish in April 2009 in Taiwan. After ingestion of the fish, symptoms of the victim included perioral paresthesia, nausea, vomiting, ataxia, weakness of all limbs, respiration failure, and death within several hours. The toxicity in the remaining fish was determined, with the mice exhibiting symptoms of neurotoxin poisoning. The implicated fish and deceased victim tissues were analyzed for TTX by liquid chromatography-tandem mass spectrometry. The urine, bile, cerebrospinal fluid (spinal cord), pleural effusion, and pericardial effusion of the victim contained TTX. In addition, the partial cytochrome b gene of the implicated fish was determined by PCR. The DNA sequence in the partial 465-bp cytochrome b gene identified the implicated fish as Chelonodon patoca (puffer fish). These results indicate that people should avoid eating unknown fish species from fish markets where harvested fish may include toxic species.

A method for studying knife tool marks on bone.

The characteristics of knife tool marks retained on hard tissues can be used to outline the shape and angle of a knife. The purpose of this study was to describe such marks on bone tissues that had been chopped with knives. A chopping stage with a gravity accelerator and a fixed bone platform was designed to reconstruct the chopping action. A digital microscope was also used to measure the knife angle (θ) and retained V-shape tool mark angle (ψ) in a pig skull. The κ value (elasticity coefficient; θ/ψ) was derived and recorded after the knife angle (θ) and the accompanied velocity were compared with the proportional impulsive force of the knife and ψ on the bone. The constant impulsive force revealed a correlation between the V-shape tool mark angle (ψ) and the elasticity coefficient (κ). These results describe the tool marks--crucial in the medicolegal investigation--of a knife on hard tissues.

The strategies to DVI challenges in Typhoon Morakot.

Small village populations in which there is a high amount of kinship can cause complications in cases of disaster victim identification. This problem was highlighted by the loss of life after Typhoon Morakot struck Taiwan where over 500 people from small isolated communities lost their lives. Most of the victims were buried by landslides in the remote mountainous areas of southern Taiwan. Only 146 pieces of human remains were recovered after searching for 4 months. Most of the human remains were received for examination as severely damaged fragments prevented possible identification by morphological features. DNA testing using the traditional duo parent/child or sibling screening by STR data opens the possibility of including not only the actual victim but also false positives. Variable likelihood ratios were obtained when comparing DNA types from human remains to those from potential relatives; however, with the DNA typing of numerous members of the same living family, multiple matches to potential families were avoided. Of the 146 samples obtained and collapsed to 130 victims, they were linked to 124 individuals resulting in their identification when compared to a pool of 588 potential relatives. Six of the human remains could not be linked to any living relative and remain unknown.