Strong association between insufficient plasma exchange and fatal outcomes in Japanese patients with immune-mediated thrombotic thrombocytopenic purpura.

Plasma exchange (PEX) using fresh frozen plasma has considerably reduced the mortality rate in patients with immune-mediated thrombotic thrombocytopenic purpura (iTTP). However, some patients still do not survive even with treatment, but little information is available regarding which treatment these patients received. This study was conducted to obtain this information in 240 patients who met the current iTTP diagnostic criteria and completed at least 30 days of follow-up except for deceased cases. These patients were divided into three groups: survivors (n = 195), TTP-related deaths (n = 32), and other cause of death (n = 13). In the TTP-related death group, 26 of 32 patients experienced sudden death, mostly following radical hypotension and bradycardia. The median follow-up time after admission was 5.0 days, and the median number of PEX sessions was 2.5. Nine patients underwent autopsy and had cardiac microvascular thrombi in arterioles. Levels of lactate dehydrogenase, total bilirubin, serum creatinine, and D-dimer were significantly higher in the TTP-related death group than in the survivors group. Frequent PEX (> 20 sessions) was not associated with TTP-related death. In the acute phase of iTTP, patients with substantial organ damage caused by microthrombi have a greater mortality risk, even after just a few PEX sessions.

An autopsy case: Unusual characteristics of stab wounds inflicted by a survival knife.

A woman was stabbed 10 times and killed. The suspect confessed that he had used a thick (0.7 cm), single-edged survival knife with a serrated spine. However, the bilateral ends of the stab wounds appeared sharp. To address this discrepancy, we used pig skin to examine whether the knife could have been used to make the thin stab wounds observed. The widths of the pig skin wounds were approximately half the width of the knife and the ends of some wounds appeared sharp, particularly when the knife was held at a right angle. It was concluded that the suspect could have killed the victim using the survival knife. Similar pig skin experiments could be useful for forensic pathologists to determine whether a weapon of interest might have been used to inflict certain injuries.

Pattern recognition analysis of proton nuclear magnetic resonance spectra of postmortem cerebrospinal fluid from rats with drug-induced seizure or coma.

Cerebrospinal fluid (CSF) is routinely subjected to gross evaluation in postmortem investigations; however, its use in chemical evaluations has not been fully realized. Analysis of nuclear magnetic resonance (NMR) spectra with pattern recognition methods was applied to CSF samples. Rats were treated with pentylenetetrazol (PTZ) to induce seizure or pentobarbital (PB) to induce coma, and postmortem CSF was collected after CO2 gas euthanization. Pattern recognition analysis of the NMR data was performed on individual postmortem CSF samples. The aim of this study was to determine if pattern recognition analysis of NMR data could be used to classify the rats according to their drug treatment. The applicability of NMR data with pattern recognition analysis using postmortem CSF was also assessed. Partial Least Squares-Discriminant Analysis (PLS-DA) score plots indicated that the PTZ, PB, and NS (control) groups were clustered and clearly separated. PLS-DA correlation loading plots showed respective spectral and category variances of 41% and 42% for factor 1, and 17% and 27% for factor 2. Thus, factors 1 and 2 together described 58% (41%+17%) and 69% (42%+27%) of the variation, respectively. NMR study of postmortem CSF has the potential to be utilized as both a novel forensic neurochemistry method and in the clinical setting.

An Autopsy Case of a Pregnant Woman With Severe Placental and Fetal Damage From Domestic Violence.

We present an autopsy case of a pregnant woman who was a victim of domestic violence. The deceased showed injuries mainly to her head and abdomen. Postmortem examination revealed 1400 mL of abdominal hemorrhage, ablation of the perimetrium, placental avulsion, and intracranial hematoma. The cause of death was diagnosed as hemorrhagic shock. The uterus contained a fetus of 7 months' gestational age. Fetal autopsy revealed laceration of the lungs, laceration and avulsion of the liver, and 15 mL of hemoperitoneum. Both placental and fetal injuries suggested repeated severe attacks to the abdomen, such as those expected to result from kicking or hitting.

High-resolution 3D-MRI of postmortem brain specimens fixed by formalin and gadoteridol.

PURPOSE: The purpose of this investigation was to compare magnetization-prepared rapid gradient echo (MP-RAGE) images with T1-weighted images (T1WI) and T2-weighted images (T1W2) of postmortem brain tissue fixed by admixtures of formalin and gadoteridol. We additionally sought to explore the feasibility of using fixed brain magnetic resonance imaging (MRIs) in forensic practices. METHODS: Specimens included in the study were eight whole brains that had been removed during forensic autopsy. Brain specimens were randomly divided into three groups and MRIs were performed either (A) the day of autopsy (n=2) on unfixed tissue, (B) after immersion fixation in 20% formalin (n=3), or (C) after immersion fixation in 20% formalin mixed with 4 mL/L ProHance® (gadoteridol) (n=3). T1WI, T2WI, and MP-RAGE images of all group samples were acquired with a 3T clinical MR scanner. Gray and white matter contrasts of the cortex and basal nucleus in every fixation group and image sequence were then visually compared. RESULTS: Gray/white matter contrasts of the cortex were good in all images obtained by MP-RAGE, and T1WIs of specimens fixed by formalin and gadoteridol-mixed formalin. Additionally, gray/white matter contrast in the basal nucleus was sufficient in the MP-RAGE sequence of specimens fixed by gadoteridol-mixed formalin. CONCLUSIONS: MRI of brains immersion-fixed in formalin and gadolinium could serve as a promising tool for neuropathological assessment in forensic practices.

An unusual case of suicide by handcrafted shotgun and slug.

Injuries by handcrafted firearms are uncommon, and those by handcrafted shotguns are very rare. We present an unusual case of suicide using a handcrafted shotgun and slug. A 73-year-old male, who was a glass-grinding artisan, was found dead at a workshop on the premises of his residence. Autopsy showed a contact shotgun wound to the forehead, which perforated the cranium and caused extensive damage to the brain. The handcrafted shotgun was found in the proximity of the body. The shotgun consisted of metal pipes fixed to the vise and did not take the form of a conventional gun. The recovered slug was also found to be manufactured manually. It appeared that the handcrafted shotgun was only intended for committing suicide using his ballistics knowledge, skills, and resources.

An autopsy case of otogenic intracranial abscess and meningitis with Bezold's abscess: evaluation of inflammatory bone destruction by postmortem cone-beam CT.

The deceased was an unidentified young male found unconscious on a walkway. On autopsy, outer and inner fistulae of the left temporal bone, subcutaneous abscess in the left side of the neck and head, and an intracranial abscess were noted. A portion of the left temporal bone was removed and scanned by cone-beam computed tomography (CT) (normally used for dentistry applications) to evaluate the lesion. The cone-beam CT image revealed roughening of the bone wall and hypolucency of the mastoid air cells, consistent with an inflammatory bone lesion. According to autopsy and imaging findings, the cause of death was diagnosed as intracranial abscess with Bezold's abscess secondary to left mastoiditis as a complication of otitis media. Although determining the histopathology of bone specimens is time-consuming and costly work, we believe that use of cone-beam CT for hard tissue specimens can be useful in forensic practice.

A case of lethal soft tissue injuries due to assault.

A 42-year-old male had been assaulted by his family over the two previous days and went into a deep coma. When the emergency technician arrived, the patient was in a state of cardiopulmonary arrest. On arrival, his electrocardiogram showed asystole. His body showed swelling with subcutaneous hemorrhage, suggesting multiple contusional wounds. Serum biochemistry evaluation revealed blood urea nitrogen of 80 mg/dL, creatinine of 5.99 mg/dL, creatine phosphokinase of 10,094 IU/L, and potassium of 11.0 mEq/L. Advanced cardiopulmonary resuscitation failed to obtain a return of spontaneous circulation. Laboratory findings revealed rhabdomyolysis, renal failure, and hyperkalemia. Autopsy did not indicate the direct cause of death to be traumatic organ injuries. Because trauma was not the direct reason of death, we speculated that the patient died of hyperkalemia induced by multiple contusional soft tissue injuries, following rhabdomyolysis, hemolysis, and acute renal failure. The physician should maintain a high index of suspicion for hyperkalemia induced by rhabdomyolysis and acute renal failure, especially in patients presenting with symptoms of multiple soft tissue injuries with massive subcutaneous hemorrhaging.

Identification using DNA from skin contact: case reports.

The DNA content of different types of forensic materials can vary substantially. "Trace DNA" is the minute quantity of DNA transferred through skin contact. Here, we report three cases of identification of trace DNA using conventional short tandem repeat (STR) or mitochondrial DNA (mtDNA). DNA was successfully obtained from fabrics by swabbing or by direct extraction and subjected to STR genotyping or mtDNA typing. In two cases, there was no amplification of PCR products containing the STR loci. This indicates that the areas chosen for DNA extraction contained trace DNA and DNA from more than one source. Therefore, it is important for forensic investigators performing DNA typing to know where an item has been frequently touched by victims and/or offenders as this will influence the choice of sites on the item to be used for DNA extraction.

Application of SNPs in forensic casework: identification of pathological and autoptical specimens due to sample mix-up.

The analysis of single nucleotide polymorphisms (SNPs) together with conventional short tandem repeat (STR) and mitochondrial DNA (mtDNA) typing provide a forensic genetic approach for the identification of pathological and autoptical specimens in cases where the average length of DNA fragments is shorter than 150 bp in highly degraded samples. We applied a forensic genetic approach to digesta accidentally left after a training autopsy. PCR products were not amplified from samples containing the STR loci or common sequences used for mtDNA typing. The application of SNPs and deletion polymorphisms provides an alternative approach for DNA typing analysis.

Real-time PCR method for identification of Asian populations in forensic casework.

The priorities for mass disaster victim identification are rapid investigation turn-around time and low cost. We describe a DNA typing procedure to selectively identify members of Asian populations by a real-time PCR method using polymorphisms of the alpha2 chain of the type I collagen gene (COL1A2) and mitochondrial DNA (mtDNA). Among the 50 members of the Asian population included in the present study, 37 harbored a deleted allele in intron 33 of COL1A2 (26822-26823del) or the 10400C>T substitution mutation in mtDNA to give a probability of 0.740 for these SNPs in the Asian population.

Gas dispersal potential of bedding as a cause for sudden infant death.

We assessed the gas dispersal potential of bedding articles used by 14 infants diagnosed with sudden unexpected infant death at autopsy. Of these cases, eight exhibited FiCO(2) values greater than 10% within 2.5 min, six of which were found prone and two supine. The results demonstrated that these eight beddings had a high rebreathing potential if they covered the babies' faces. We did not, however, take into account in our model the large tissue stores of CO(2). As some bicarbonate pools will delay or suppress the increase of FiCO(2), the time-FiCO(2) graphs of this study are not true for living infants. This model, however, demonstrated the potential gas dispersal ability of bedding. The higher the FiCO(2) values, the more dangerous the situation for rebreathing infants. In addition, FiO(2) in the potential space around the model's face can be estimated mathematically using FiCO(2) values. The FiO(2) graph pattern for each bedding item corresponded roughly to the inverse of the FiCO(2) time course. The FiO(2) of the above eight cases decreased by 8.5% within 2.5 min. Recent studies using living infants placed prone to sleep reported that some babies exhibited larger decreases in FiO(2) than increases observed in FiCO(2). While the decrease of FiO(2) in our model is still theoretical, CO(2) accumulation and O(2) deprivation are closely related. If a striking O(2) deficiency occurs in a short period, babies can lose consciousness before an arousal response is evoked and all infants could be influenced by the poor gas dispersal of bedding; the main cause of sudden death in infancy would thus be asphyxia. When the bedding is soft, the potential for trapping CO(2) seems to be high; however, it is impossible to assess it by appearance alone. We sought to provide some objective indices for the assessment of respiratory compromise in relation to bedding using our model. When a baby is found unresponsive with his/her face covered with poor gas dispersal bedding, we should consider the possibility of asphyxia.

Sudden infant death from dilated cardiomyopathy with endocardial fibroelastosis.

A four-month-old female with no previous medical history suddenly collapsed and failed to recover despite 2h of resuscitation. An autopsy showed marked cardiomegaly (88g) with prominent dilatation of the left ventricle and a whitish opacity on the endocardial surface. The ductus arteriosus was patent, but both orifices were severely stenosed. Microscopically, the endocardium showed pronounced thickening with laminar deposition of elastic and collagen fibers. Additionally, there was a mixture of myocardial fibers with a marked "wavy" appearance and a scattering of mild interstitial lymphocytic infiltration. We believe that endocardial thickening in this infant met the diagnostic criteria for endocardial fibroelastosis (EFE). Although it is controversial whether primary EFE is a distinct pathologic entity or an epiphenomenon, we speculated that "dilated cardiomyopathy with EFE" had caused the decedent's death based on the appearance of the myocardial fibers.

Adult autopsy case with marked myositis ossificans: association with repetitive physical assault and battery.

A man in his thirties was found dead in his room. The autopsy findings were as follows: multiple bruises and subdermal edema, small sized stab wounds, a number of skin scars, new and old rib fractures, mild liver contusion, and marked myositis ossificans traumatica (MOT) at both thighs. In particular, the MOT was closely associated with repetitive physical assault and battery. The deceased did not have any lethal injuries of internal organs or great vessels, and the cause of death was diagnosed as traumatic hypovolemic shock. The deceased seemed to have accepted as fate his "specific situation" in which he would be subjected to continued physical violence from his cohabiter, a woman in her thirties.

Sudden collapse after minor head injury in an elderly man; association with cardiocerebral decompensation and fat embolism syndrome.

An 86-year-old man suffering from right hemiparesis and dementia fell from a stretcher and sustained laceration and bruising to his right eyebrow. He was brought to an emergency room, and his wounds were treated. Shortly after discharge, his respiratory and mental status dramatically declined. Despite supportive care, he died about three hours after re-admission. Autopsy revealed a minor laceration to the eyebrow with minor intracranial injuries, mild cardiomegaly (370 g) with right atrial dilatation, pericardial effusion (170 ml) and marked pulmonary edema. Microscopically, fatty droplets were observed in the lung capillaries, the glomeruli and the intracerebral vessels. Although the extent of the original injuries seemed insufficient to cause systemic fat embolism syndrome (FES), the patient's decreased cardiac reserves and stress associated with this event likely contributed to his death consistent with the physiochemical model of FES pathogenesis.

Brain death with calcium oxalate deposition in the kidney: clue to the diagnosis of ethylene glycol poisoning.

A young man presented to the emergency department with mental status changes, severe metabolic acidosis, and oliguria. Acute ethylene glycol intoxication was diagnosed. The patient suffered clinical brain death three days after admission despite intensive care and continuous hemodiafiltration. The patient died one month after admission. Autopsy revealed acute tubular necrosis of the kidneys with significant calcium oxalate depositions. The brain was markedly softening and with chronic meningoencephalitis and dural sinus thrombosis. We considered that the amount and the persistence of the calcium oxalate deposition in the kidney may afford a best clue to the postmortem diagnosis of ethylene glycol poisoning even in the chronic stage.

Two small linear marks on a mandible: collaborative networking between forensic experts.

A human male mandible was found under the eaves of a house. There were no associated items that allowed for personal identification. An anthropologist, who voluntarily joined our forensics team to give an expert opinion, found two small linear marks of 0.6 cm on the surface of the right condylar process. He thought these marks had been produced by a sharp object, and at the very least were not the result of bite marks by rodents or other animals. At first, the police did not appreciate the significance of the marks. One month later, however, other remains with similar marks were found near the scene, strongly suggesting that the case was a mutilation murder with a sharp weapon. After a vigorous search, the police obtained information that a young man in his twenties had gone missing in the area one year previously. After checking up on his relationships, a suspect was identified and arrested. The suspect subsequently confessed and was convicted as guilty of the crime. There are only a few forensic anthropologists in Japan. Consequently, almost all cases requiring bone examination have been handled by forensic pathologists, but it is hard for forensic pathologists to cover all fields comprehensively. The present case might have been solved without help from the anthropologist. However, we believe that forensic pathologists, especially less experienced ones, should seek advice from an expert in the field of forensic anthropology in order to carry a multidisciplinary forensic investigation. Given the current situation in, it is difficult in many institutes of forensics to obtain direct help from forensic anthropologists. The authors believe that collaborative networking via the Internet between forensic experts in each field cannot only obtain further information on complicated cases, but would also be helpful in training young forensic pathologists.

Fatal cerebral injury from blows to the site of a nonadherent bone fragment from a previous craniotomy.

A young man with a prior left temporal craniotomy was brought to the emergency room after being beaten, including a blunt trauma to the head. After receiving a cranial X-ray, the patient was discharged home. He was found in a deep coma eight hours later. Autopsy revealed an approximately 4 x 5 cm bone fragment fixed to the left temporal bone, except at the inferior margin, where it had no osseous connection. There were a 44 g subdural hematoma in the left frontotemporal region, small hematomata within the left temporal lobe, and bilateral subarachnoid hemorrhage. Microscopically, we detected ruptured choroid plexus at the surface of the left temporal lobe. We speculated that the combination of the unfixed bone fragment and hyperplastic choroid plexus after craniotomy increased the decedent's vulnerability to external trauma at that site.

The relationship between bedding and face-down death in infancy: mathematical analysis of a respiratory simulation system using an infant mannequin to assess gas diffusibility in bedding.

Rebreathing is a model for the relationship between a prone sleeping position and sudden infant death syndrome. This study used a mechanical simulation model to establish the relationship between types of bedding and rebreathing potential for an infant placed prone (face down) at different postnatal ages. The infant mannequin was connected to a respirator set to deliver physiologically appropriate combinations of tidal volume (V(T)) and respiratory rates (RR) across a range of postnatal ages (0-18 months). Before measurements were made, CO(2) flow was regulated to 5+/-0.1% of end-tidal PCO(2) (EtCO(2)). After the model was placed in a prone position, any increase in the fractional concentration of inspired CO(2) (FiCO(2)) was measured. FiCO(2) increased immediately and rapidly, and reached a maximum value within a few minutes. The maximum FiCO(2) ranged from under 2% to over 10%, depending on the bedding. FiCO(2) was also affected by V(T) and RR. This model is not applicable to actual infants because of the large tissue stores of CO(2) in infants; however, it is useful for evaluation of gas diffusibility of bedding and will simplify the investigation of sleeping environments when a baby is found dead with its face covered by soft bedding. In general, the higher the FiCO(2), the greater the rebreathing potential. Theoretically, considering the paucity of body stores of O(2), changes in FiO(2) would be affected not by changes in FiCO(2), but by CO(2) production and gas movement around the infant's face. The rapid decrease of FiO(2) is approximated at the inverse of the FiCO(2) timecourse, suggesting the significance of not only CO(2) accumulation but also O(2) deprivation in the potential space around the baby's face.

Effects of rounding errors on postmortem temperature measurements caused by thermometer resolution.

Beginning 7 h after death, a datalogger was used to measure the temperature in the external auditory canal of an adult male body placed in a refrigerated room. The sequence of measured values approximated a single exponential function with a correlation coefficient of 0.998475. This suggests that the starting time of body cooling in the refrigerated room under constant temperature can be calculated with less error using any two data points recorded by the datalogger. However, the results of such calculations varied widely and longer postmortem intervals demonstrated greater calculation errors. Periodic errors also appeared. Mathematical simulations showed that this variation was caused by rounding errors, which represent the difference between the thermometer readings and the true temperature. The resolution of the thermometer was 0.1 degrees C, a normal specification; however, even this led to noticeable rounding errors. Therefore, significant errors may influence postmortem interval estimations using other body temperatures. When body temperatures are used to determine the time of death, a method that minimizes rounding errors should be considered.