Genetic basis of sudden death after COVID-19 vaccination in Thailand.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 vaccination reduces morbidity and mortality associated with coronavirus disease 2019 (COVID-19); unfortunately, it is associated with serious adverse events, including sudden unexplained death (SUD). OBJECTIVE: We aimed to study the genetic basis of SUD after COVID-19 vaccination in Thailand. METHODS: From April to December 2021, cases with natural but unexplained death within 7 days of COVID-19 vaccination were enrolled for whole exome sequencing. RESULTS: Thirteen were recruited, aged between 23 and 72 years; 10 (77%) were men, 12 were Thai; and 1 was Australian. Eight (61%) died after receiving the first dose of vaccine, and 7 (54%) died after receiving ChAdOx1 nCoV-19; however, there were no significant correlations between SUD and either the number or the type of vaccine. Fever was self-reported in 3 cases. Ten (77%) and 11 (85%) died within 24 hours and 3 days of vaccination, respectively. Whole exome sequencing analysis revealed that 5 cases harbored SCN5A variants that had previously been identified in patients with Brugada syndrome, giving an SCN5A variant frequency of 38% (5 of 13). This is a significantly higher rate than that observed in Thai SUD cases occurring 8-30 days after COVID-19 vaccination during the same period (10% [1 of 10]), in a Thai SUD cohort studied before the COVID-19 pandemic (12% [3 of 25]), and in our in-house exome database (12% [386 of 3231]). CONCLUSION: These findings suggest that SCN5A variants may be associated with SUD within 7 days of COVID-19 vaccination, regardless of vaccine type, number of vaccine dose, and presence of underlying diseases or postvaccine fever.

Variation of Hair Follicle Counts among Different Scalp Areas: A Quantitative Histopathological Study.

INTRODUCTION: Scalp biopsy is a standard method for the definitive diagnosis of alopecia. The hair count parameters of each scalp area remain unclear. This study aimed to determine hair count values at different scalp locations from histopathology and to establish reference values for each part of the scalp. METHODS: We obtained biopsy specimens from the frontal, vertex, temporoparietal, and occipital areas of the scalps of normal deceased subjects. All specimens were evaluated for the number of follicular units, hair counts, hair types, and stages of the hair cycle. RESULTS: In total, 240 specimens were collected from 60 cadavers. Across all scalp sites, the temporoparietal area showed the lowest mean hair count, number of follicular units, terminal and vellus hairs, and terminal-to-vellus hair ratio. The average anagen-to-telogen hair ratio was comparable across all scalp sites. This study did not observe a significant association of hair parameters with gender differences or increasing age in all scalp areas. CONCLUSIONS: The present study revealed the diversity of the hair index among different scalp areas and suggested that normal hair count values should be separately standardized on each scalp region. Our findings may provide useful reference values for the histopathological evaluation of hair disorders in Asians.

The Causes of Death and Pathological Findings of Kratom Users: A 5-Year Retrospective Analysis.

ABSTRACT: Kratom is a psychoactive substance in Thailand. The major psychoactive chemical component of Kratom is mitragynine. This study aims to elucidate the characteristics and pathologies of autopsied cases where mitragynine was present and quantify the amounts of mitragynine. The autopsy reports in which the blood samples were positive for mitragynine were selected in Ramathibodi Hospital between January 2015 and December 2019. Data from autopsy reports comprised sex, age, circumstances of death, pathological findings, other substances, causes of death, and mitragynine concentrations. Mitragynine was quantitatively analyzed using liquid chromatography-mass spectrometry/mass spectrometry. Twenty-four cases from 2160 autopsy cases were found to be positive for mitragynine. The most commonly observed pathological findings were pulmonary edema (7 cases) and coronary atherosclerosis (6 cases). Antihistamine (8 cases), ethanol (4 cases), and amphetamine (4 cases) were commonly found. The mitragynine concentrations were 0.0035 to 3.6 mg/L (median 0.069). One interesting case involved a 43-year-old man whose pathological findings showed chronic asthma with a high concentration of mitragynine in the blood (3.6 mg/L), although no other substances were detected. In conclusion, the use of mitragynine may be a direct or indirect cause of death, whereas the lethal concentration has yet to be clearly determined.

The study of hair follicle counts from scalp histopathology in the Thai population.

BACKGROUND: The horizontal section of a scalp specimen offers an advantage over a vertical section by providing quantitative information. The reference data for hair counts in Asians, including Thais, are inconclusive. We aimed to determine the normal values of hair counts in scalp biopsy specimens in the Thai population. METHODS: A 4-mm punch biopsy was performed at the occipital area of the scalp from subjects presenting with clinically normal hair and scalp appearance. All specimens were horizontally sectioned and observed to assess the number of follicular units and hair follicles, type of hairs, and phase of the hair cycle. The results were further compared between sexes and with the pre-existing data from previous studies. RESULTS: Ninety specimens were collected from 90 subjects. The average number of total hairs, terminal hairs, vellus hairs, and follicular units per 4-mm punch scalp skin were 20.5 ± 5.2, 18.2 ± 4.1, 2 (range 0-7), and 9.1 ± 1.6, respectively. The mean ratio of terminal to vellus hair was 8.9:1 and of anagen to telogen hair was 91.9:7.9. There were no gender differences in any of the parameters and no correlations with changing age. Compared to other Asian populations, Thais and Taiwanese showed intermediate values between Iranians and Koreans; when compared to other ethnic groups, hair density in Asians showed lower than Caucasians and Hispanics but was comparable to Africans. CONCLUSION: This study established reference values of scalp horizontal sections in the Thai population; this will be helpful for clinicians and researchers to evaluate hair disorders.

Corrugated Sheet of Unsintered Hydroxyapatite Poly-L-Lactide for Sternal Fixation: A Preclinical Study.

PURPOSE: To stabilize the sternum after median sternotomy, unsintered hydroxyapatite poly-L-lactide (u-HA/PLLA) sternal pins are frequently used in Japan. However, sternal pins are ineffective in the fragile bone marrow. Thus, a corrugated sheet made of u-HA/PLLA was developed as a new sternal fixation device. METHODS: To examine the effects of the device, we measured the shear force using a sternal model and cadaver. The shear force of the corrugated sheet, sternal pin, and simple wire was compared. The device size was determined after reviewing the sternal computed tomography (CT) of 128 patients. RESULTS: The shear force of the model with the corrugated sheet (286 [256-295] N) was higher than that with sternal pins (135 [134-139] N, p = 0.03) and simple wire (94 [90-104] N, p = 0.03) at 2-mm displacement. In the cadaver test, the shear force of the sternal halves with the device was about two times higher than that without the device. Retrospective CT showed that 18-mm wide device applies to 99% male and 87% female patients at the fourth intercostal level. CONCLUSION: The corrugated sheet might provide a stronger fixation effect in the fragile bone marrow. The device width was modified to 18 mm to be applicable for most Japanese patients.

Entrance and exit wounds of high velocity bullet: An autopsy analysis in the event of dispersing the mass rally in Bangkok Thailand, May 2010.

Fatal mass casualties by high velocity bullets (HVBs) are rare events in peaceful countries. This study presents 27 forensic autopsy cases with 32 shots fired by 5.56×45mm. HVB (M-16 rifle bullets) during the dispersing the mass rally in Bangkok Thailand, May 2010. It was found that twenty-three (71.88%) typical entrance HVB wounds had round sizes less than the bullet diameters. Most entrance wounds had microtears but no collar abrasion since a HVB has a small streamlined spitzer tip and full metal jacket. For exit wounds, there were various sizes and shapes depending on which section of wound ballistics presented when the bullet exited the body. If a bullet exited in the section of temporally cavity formation, there would be a large size exit wound in accordance with the degree of bullet yaw. This is different from civilian bullets whereby the shape looks like a cylindrical round nose and at low velocity that causes entrance wounds with a similar size to the bullet diameter and is usually round or oval shape with collar abrasion. The temporary cavity is not as large as in a HVB so exit wounds are not quite as large and present a ragged border compared to a HVB. We also reported 9 out of 32 shots (28.13%) of atypical entrance wounds that had various characteristics depending on site of injury and destabilization of bullets. These findings may be helpful to forensic pathologists and to give physicians, who need to diagnose HVB wounds, more confidence.

The use of pilocarpine eye drops for estimating the time since death.

OBJECTIVE: The objective of this study was to estimate the time since death using pilocarpine eye drops. METHODS: In this study, 100 postmortem cases with known time of death were included. In each case, the left pupil was measured in millimeter units using a vernier caliper, and pilocarpine eye drops were applied. The pupil was measured again 10 min later, and statistical analysis was used to analyze the correlation between the time since death and the change in the pupil. RESULTS: The longest duration since death that the pupils showed reaction to pilocarpine was 15 h. The correlation between the change in the pupil and the postmortem interval was found (Spearman's rho, r = -0.304, p = 0.002), and the change in the pupil may be used to predict the postmortem interval by the following regression equation: postmortem interval (PMI) = 8.310-3.702 (Diff) ± 0.735 (PMI was postmortem interval in hours and Diff was the difference in the size of the pupil after administering pilocarpine in millimeter units). CONCLUSION: The present study showed that pilocarpine eye drops can be used to estimate the time since death.

Committed suicide: forensic autopsy analysis at Ramathibodi Hospital during year 2001-2010.

BACKGROUND: Suicide is one of the most important causes of death in the world. To study the behaviors and risk factors may be helpful to prevent suicide. OBJECTIVE: To retrospectively study the factors that affected suicide in forensic postmortem cases at Ramathibodi Hospital, Bangkok, Thailand between 2001 and 2010. MATERIAL AND METHOD: Two hundred ninety suicidal cases from 7,102 forensic postmortem autopsies in Ramathibodi Hospital between 2001 and 2010 were descriptively retrospective studied. Study topics included sex, age, nationality, year, methods of suicide, and HIV. RESULTS: The suicide-rate in the present study varied between 2.53% and 6.91% (average 4.08%) of the forensic autopsy cases. The peak was found in 2003. Males had higher suicide rate than females [ratio of M:F of 4.3:1 (235 males and 55 females)]. The age varied from seven years to 91 years. Although the average age of suicide was 37.38 years, the peak was found in the young adult (age group of 21 to 30 years). Male, younger age, and foreigner were related to suicide with statistical significance. Hanging was the most frequent method of suicide followed by fall from height (62.1% and 17.2% respectively) and by firearm (in male) and toxic substance ingestion (in females). Of all the suicide, 5.1% were HIV seropositive, which is slightly more than non-HIV cases (4.0%) but this was not statistically significant. CONCLUSION: The suicidal cases among unusual death were related to varieties of factors. Male, younger age, and foreigner were significant related to suicide. Hanging and falling from height were the most frequent method of suicide.

Comparison between prostate specific antigen and acid phosphatase for detection of semen in vaginal swabs from raped women.

OBJECTIVE: To compare the effectiveness of the prostate specific antigen (PSA) test and the acid phosphatase (AP) test for semen detection in human vaginal samples. MATERIAL AND METHOD: The source materials were vaginal swabs that were tested at Ramathibodi Hospital between 2008 and 2010 from 2450 cases of raped women. Each swab was tested for semen by three methods: sperm detection by light microscopy, the AP enzymatic reaction, and the presence of PSA by using an immuno-chromatographic rapid kit test. The efficiencies of the AP and PSA tests were compared using the light microscopy result for the presence of sperm as the gold standard. RESULT: The specificities of the AP, the PSA and the combined AP-PSA tests were 96.4%, 92.3% and 91.9%, respectively, and the sensitivities were 65.5%, 80.4% and 84.5%, respectively. The receiver operating characteristic (ROC) area of the AP, PSA and combined AP-PSA tests were 0.8091, 0.8639 and 0.8823, respectively. The ROC area of the PSA test was significantly greater than that of the AP test (p < 0.0001), and the ROC area of the combined AP-PSA test was significantly greater than both the tests individually (p < 0.0001). DISCUSSION: Based on the ROC area, the PSA test was better than the AP test for semen detection in the vaginal swabs, and the combined results (AP + PSA) were better than the individual tests. The specificity of the AP test was higher than the PSA test in this study because a positive detection was made within only 15 s. While the PSA test was more convenient as it was available in a rapid test kit format, our recommendation is PSA detection should be done together with AP test and spermatozoa examination to identify evidence of rape. CONCLUSION: Using these three tests together (AP, PSA, and spermatozoa detection) was recommended as a forensic tool for investigations of vaginal swabs of the rape victims.

Pathology of HIV seropositive: forensic autopsy study in a tertiary care hospital, Bangkok, Thailand.

OBJECTIVE: To retrospectively study the pathology of HIV seropositive in forensic autopsies. MATERIAL AND METHOD: Three hundred thirty five HIV seropositive cases, selected from 7,387 forensic postmortem inquests by law, were studied in Ramathibodi hospital between 2000 and 2010. The study topics were sex, age, cause of death, manner of death, and pathological features. Autopsies were done in 67 cases. The pathological features were classified into five groups, (a) HIV disease with infectious and parasitic diseases, (b) HIV disease with malignant neoplasms, (c) HIV disease with other specified diseases, (d) HIV disease with other conditions, and (e) HIV disease with unspecified pathology. RESULTS: The average prevalence of HIV seropositive cases was 4.5%. The peak was 10.0% in 2001 and gradually decreased until 1.8% in 2010. The ratio of male:female was 4:1. The most manner of death was natural death (83.6%). In unnatural death cases, the most frequently method was suicide by hanging. The prevalence of HIV group (a) to group (e) were 56.7%, 6.0%, 3.0%, 17.9%, and 16.4%, respectively. Pulmonary tuberculosis is the most common found in group (a) with frequency of 28.4%. Kaposi's sarcoma of skin, coronary atherosclerosis, and fatty change of liver were frequently observed in HIV group (b) to group (d), respectively. The pathology showed multiple pathological features in each group, i.e., group (a) pulmonary tuberculosis, pneumonia, disseminated fungal infection, brain abscess, and meningitis, group (b) Kaposi's sarcoma of skin and acute lymphoblastic leukemia, group (c) coronary atherosclerosis, chronic pyelonephritis, gastritis, and cirrhosis of the liver, and group (d) cardiomegaly, fatty change of liver; pulmonary edema, and splenomegaly. CONCLUSION: HIV disease causes pathology of various organs. The severities vary from severe to asymptomatic disease. Five pathological patterns of HIV were established in this study that showed interesting topics, i.e., pulmonary tuberculosis was the most frequent and occurred (28.4%) in HIV disease with infectious and parasitic diseases while Kaposi's sarcoma of skin frequently occurred in HIV disease with malignant neoplasms. The decreasing rate of HIV transmitted infection in forensic postmortem may reflect the success of using antiretroviral drug treatment in the National AIDS program during the ten-year period of this study

HELLP syndrome in pregnancy as a cause of sudden unexpected death and spontaneous hepatic rupture: A medico-legal autopsy case report.

This is the first reported medico-legal autopsy case in Thailand. It is a case of a 26-year-old Thai female with primigravida and 34 weeks gestational age that had sudden unexpected death. The laboratory investigations before death revealed evidence of hemolysis, which is decreased hematocrit, elevated lactate dehydrogenase (865 U/L), and low platelet count (8.7 x 10(9) cells/L). These findings were compatible with HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelets) syndrome. The autopsy findings showed two ruptures of the right lobe of the liver hepatic subcapsular hematoma, rupture of Glisson's capsule, and massive hemoperitoneum with abruptio placentae. Histological features of liver and kidneys revealed specific characteristics that can assist the forensic pathologist to diagnose HELLP syndrome when laboratory examinations are not available.

Application of the multiple drugs immunoassay test for rapid detection of drug abuse in postmortem urine.

OBJECTIVE: The ADVANCED QUALITY One Step Multi-Drug Screen test is a new urine on-site immunoassay test that is designed to detect multiple drugs of abuse in one time (barbiturates, benzodiazepines, cocaine, methylenedioxymethamphetamine (MDMA), methamphetamine, and opiates group). Thus, the present research was done to evaluate the diagnostic performance of this test. MATERIAL AND METHOD: Urine samples obtained from corpses subjected to medicolegal autopsy at the forensic unit in Ramathibodi Hospital between October 2007 and March 2009 were used for the present study. The diagnostic performance of this immunoassay test was determined by using the results of the rapid emergency drug identification high sensitivity (REMEDi HS) system as the gold standard. RESULTS: Two hundred forty six urine samples were used in the present study. The sensitivity with their 95% confidence interval of cocaine, opiates, methamphetamine, and benzodiazepines assay was 100% (100-100%) each. The specificity with their 95% confidence interval of these was 100% (100-100%), 98% (96.75-99.94%), 95% (91.70-97.38%), and 93% (89.89-96.24%), respectively. The MDMA and barbiturates were not evaluated because there was no true positive result. CONCLUSION: The ADVANCED QUALITY One Step Multi-Drug Screen test is reliable for drugs of abuse screening in postmortem urine.

A carbon dioxide fatality from dry ice.

This report documents a rare case of carbon dioxide intoxication in a young healthy male. The deceased hid in a small plastic container, size 1.5 x 1 x 1 m, and within 5 min he was located suffering convulsions and was reported as dead within minutes. Scene investigation revealed dry ice in the container. Autopsy findings were unremarkable. The probable cause of the convulsions was carbon dioxide intoxication due to both the dry ice sublimation and the small confined space in which he was hiding. This report emphasizes the significance of scene investigation in establishing the cause of the death.

An autopsy case report of suicide by multiple self-cutting and self-stabbing over the chest and neck.

A 27-year-old male with a clinical history of acquired immunodeficiency syndrome committed suicide by cutting and stabbing himself in his bedroom. During the scene investigation, the knife was recovered below his body and the room was not ransacked The external examination revealed one deep incised wound with one superficial incised wound over the anterior aspect of the neck, three horizontal stab wounds with five superficial small incised wounds over the chest and two superficial incised wounds over the ventral aspect of the left wrist. They showed multiple hesitation wounds. Subsequent autopsy showed a cut wound of the thyroid cartilage penetrating trachea and a penetrating wound of the left lower lung with 500 ml fresh blood hemothorax. All findings lead to suspicion of suicide by multiple sharp forces.