[An Autopsy Case of Abnormal Behaviour Induced by Zolpidem].

Zolpidem is a widely used ultrashort-acting non-benzodiazepine in clinical practice; compared with benzodiazepines, it does not have side effects such as daytime hangover, rebound insomnia, and development of tolerance. We report an autopsy case of abnormal behaviour induced by zolpidem. A man in his 60's had suffered from postherpetic neuralgia about 2 months ago and had been prescribed zolpidem for insomnia. According to his family, he had no memory of his actions such as striking a wall, taking his futon outside, and eating 5 times a day after he took zolpidem. Because his postherpetic neuralgia did not improve, he was hospitalized and treated with an epidural block. During hospitalization, he took off his clothes, removed the epidural block catheter by himself, and slept on others' beds. He disappeared from the hospital one day; the next day, he was found dead in a narrow water storage tank 10 km away from the hospital. He was thought to have driven a car by himself to reach the place. Forensic autopsy revealed that the cause of death was drowning. Zolpidem and several other drugs were detected by toxicological analysis of his blood; the concentrations of these drugs were within therapeutic range. There are several reports about somnambulism induced by zolpidem such as sleepwalking, sleep driving, and eating. Considering the strange episodes following zolpidem administration, his behaviour on the day of his death was considered abnormal behaviour induced by zolpidem.

Medical neglect death due to acute lymphoblastic leukaemia: an autopsy case report.

We report the case of 2-year-old girl who died of precursor B-cell acute lymphoblastic leukaemia (ALL), the most common cancer in children. She had no remarkable medical history. She was transferred to a hospital because of respiratory distress and died 4 hours after arrival. Two weeks before death, she had a fever of 39 degrees C, which subsided after the administration of a naturopathic herbal remedy. She developed jaundice 1 week before death, and her condition worsened on the day of death. Laboratory test results on admission showed a markedly elevated white blood cell count. Accordingly, the cause of death was suspected to be acute leukaemia. Forensic autopsy revealed the cause of death to be precursor B-cell ALL. With advancements in medical technology, the 5-year survival rate of children with ALL is nearly 90%. However, in this case, the deceased's parents preferred complementary and alternative medicine (i.e., naturopathy) to evidence-based medicine and had not taken her to a hospital for a medical check-up or immunisation since she was an infant. Thus, if she had received routine medical care, she would have a more than 60% chance of being alive 5 years after diagnosis. Therefore, we conclude that the parents should be accused of medical neglect regardless of their motives.

A familial case of ABO phenotype-genotype discrepancy.

In the present study, we detected a familial case of ABO phenotype-genotype discrepancy. Although the observed phenotypes were B and O, the corresponding ABO genotypes were AB and AOG, respectively, by routine examination. Exons 6 and 7 of the ABO gene were sequenced and subsequently, the sequence of the allele responsible for ABO phenotype-genotype discrepancy was examined. Our results indicated that the Ax allele was present in 3 family members. By employing traditional serological methods, we further identified and confirmed that the allele Ax and the resulting Ax phenotype are responsible for ABO phenotype-genotype discrepancy.

Development of an artificial intelligence-based algorithm to classify images acquired with an intraoral scanner of individual molar teeth into three categories.

BACKGROUND: Forensic dentistry identifies deceased individuals by comparing postmortem dental charts, oral-cavity pictures and dental X-ray images with antemortem records. However, conventional forensic dentistry methods are time-consuming and thus unable to rapidly identify large numbers of victims following a large-scale disaster. OBJECTIVE: Our goal is to automate the dental filing process by using intraoral scanner images. In this study, we generated and evaluated an artificial intelligence-based algorithm that classified images of individual molar teeth into three categories: (1) full metallic crown (FMC); (2) partial metallic restoration (In); or (3) sound tooth, carious tooth or non-metallic restoration (CNMR). METHODS: A pre-trained model was created using oral-cavity pictures from patients. Then, the algorithm was generated through transfer learning and training with images acquired from cadavers by intraoral scanning. Cross-validation was performed to reduce bias. The ability of the model to classify molar teeth into the three categories (FMC, In or CNMR) was evaluated using four criteria: precision, recall, F-measure and overall accuracy. RESULTS: The average value (variance) was 0.952 (0.000140) for recall, 0.957 (0.0000614) for precision, 0.952 (0.000145) for F-measure, and 0.952 (0.000142) for overall accuracy when the algorithm was used to classify images of molar teeth acquired from cadavers by intraoral scanning. CONCLUSION: We have created an artificial intelligence-based algorithm that analyzes images acquired with an intraoral scanner and classifies molar teeth into one of three types (FMC, In or CNMR) based on the presence/absence of metallic restorations. Furthermore, the accuracy of the algorithm reached about 95%. This algorithm was constructed as a first step toward the development of an automated system that generates dental charts from images acquired by an intraoral scanner. The availability of such a system would greatly increase the efficiency of personal identification in the event of a major disaster.

An autopsy case of misdiagnosis based on postmortem computed tomography findings.

A middle-aged man was found lying beside his bicycle on an early winter morning. The cause of death was diagnosed by clinicians as traumatic intracerebral hemorrhage and cerebral contusion with frontal bone fracture based on the findings of Computed Tomography (CT) of the head. However, forensic autopsy revealed that there were no evidences of intracerebral hemorrhage and left frontal bone fracture but the defect of golf ball size on the frontal lobe which was considered to be a complication from the old cerebral contusion and old bone fracture. The bleeding and pooling blood from subarachnoid hemorrhage (SAH) to the frontal lobe defect had the appearance of an intracerebral hemorrhage. Disruption of left renal artery was found and the cause of death was diagnosed as massive hemorrhage due to this rupture. Although postmortem CT is a useful tool for obtaining information on the body prior to conducting an autopsy, it should be used with extreme caution.

Examination of the usefulness of next-generation sequencing in mixed DNA samples.

The identification of individuals from mixed DNA samples is an important application of DNA typing. Although the discriminatory power of DNA profiling has improved dramatically, a limiting factor is that individuals cannot be identified via short tandem repeat (STR) analysis. We used next-generation sequencing (NGS) to examine the mixed DNA samples. Our results showed that STR nucleotide sequences and single nucleotide polymorphisms (SNPs) analysis via NGS may enable the identification of each distinct subject from a DNA mixture containing DNA of the victim and suspect.

Gene expression profiling of functional murine embryonic stem cell-derived cardiomyocytes and comparison with adult heart: profiling of murine ESC-derived cardiomyocytes.

Although embryonic stem cell (ESC)-derived cardiomyocytes may be a powerful tool in drug discovery, their potential has not yet been fully explored. Nor has a detailed comparison with adult heart tissue been performed. We have developed a method for efficient production of cardiomyocyte-rich embryoid bodies (EBs) from murine ESCs. Analysis of global gene expression profiles showed that EBs on day 7 and/or 21 of differentiation (d7CMs and d21CMs, respectively) were similar to adult heart tissue for genes categorized as regulators of muscle contraction or voltage-gated ion channel activity, although d21CMs were more mature than d7CMs for contractile components related to morphological structures. Calcium and sodium channel blockers altered Ca2+ transients, and isoproterenol, a beta-adrenergic compound, increased the rate of beating in d7CMs and d21CMs. Our gene analytic system therefore enabled us to identify genes that are expressed in the physiological pathways associated with ion channels and structural components in d7CMs and d21CMs. We conclude that EBs might be of use for the basic screening of drugs that might affect contractile function through ion channels.

False negative result for amphetamines on the Triage Drug of Abuse panel? The cause of the unusual phenomenon with experimental analyses.

On-site drug screening devices are widely used today for their simple test procedures and instantaneous results. Among other devices, a Triage Drug of Abuse panel is considered to be highly reliable for its high specificity and sensitivity of abused drugs. Although it is known that a false positive amphetamine (AMP) result may be obtained from the urine samples containing putrefactive amines or ephedrine-related compounds, no clinical false negative methamphetamine results have been reported to date. However, a false negative Triage result was obtained from the urine of a fatal methamphetamine poisoning victim taking Vegetamine tablets. Further experimental analyses revealed that the cross-reactivity of methamphetamine and chlorpromazine metabolites, including nor-2-chlorpromazine sulfoxide, was the cause for a false negative Triage reaction for AMP. Forensic scientists and clinicians must be aware of the limitations of on-site drug testing devices and the need for the confirmatory laboratory tests for the precise identification and quantification of drugs in suspicious intoxication cases, as also recommended by the manufacturers.

Predictive equation for post-mortem interval using spectrophotometric values of post-mortem lividity: A pilot study.

The colour of post-mortem lividity and control skin of 86 cadavers was measured spectrophotometrically to obtain L* (value), a* (chroma) and b* (hue) values. In addition, left heart blood (n = 58), right heart blood (n = 57) and blood from the femoral vein (n = 21) were measured. Using these data, we analysed the relationship between post-mortem lividity, control skin and blood colours. L* of post-mortem lividity (L*p) and control skin (L*c) were strongly correlated ( r = 0.64). a* and b* of post-mortem lividity (a*p and b*p) significantly increased with an increasing post-mortem interval (PMI) but r2 values were low (0.11 and 0.070, respectively). Predictive equations for post-mortem lividity colour (L*p, a*p and b*p) were developed using control skin colour (L*c, a*c and b*c) and autopsy findings for the first time. The predictive equation for L*p explained almost 65% of the observed L*p. We created predictive equations for PMI with and without blood colour values, and the most accurate equation, which did not use blood colour values, made it possible to estimate PMI within ± 10.29 h. Further study of these equations will help us to understand the factors that affect post-mortem lividity colour and increase the accuracy of equations for predicting post-mortem lividity colour and PMI.

Predictive equation to estimate post-mortem interval using spectrophotometric blood-colour values.

Forensic pathologists use post-mortem phenomena to estimate the post-mortem interval (PMI). We have reported on the usefulness of post-mortem lividity spectrophotometric values to estimate PMIs. Here, we focused on blood colour, looking for associations between blood colour, age and PMI. We generated predictive equations for blood-colour values and the PMI. We included data from a total of 129 cadavers (84 males and 45 females). We measured the colour of 124 left ventricular blood ( L*l, a*l, b*l), 123 right ventricular blood ( L*r, a*r, b*r) and 57 femoral blood ( L*f, a*f, b*f) samples. We found no significant associations between blood colour and age or between blood colour and the PMI, but the values of a*l, b*l, a*r and b*r were significantly increased with increased age, and those of L*f, a*f and b*f were significantly decreased with increased PMI. We created equations to estimate blood colour. The equations for femoral blood colour had higher adjusted R2 values and lower root mean square error values than those for left and right ventricular blood colours. We generated equations to estimate PMIs using blood-colour values and autopsy findings. Our estimated PMIs up to 67 hours had accuracies within 8.84 hours, without measuring post-mortem lividity colour or considering the age of the deceased. This is the first study to estimate PMIs based on blood-colour spectrophotometric values.

The derivation of predictive equations to speculate the post-mortem interval using cases with over 20-mL pleural effusion: A preliminary study.

Often, pleural effusion is noted at autopsy when the cause of death is drowning or diseases such as heart, renal and liver failure. Several studies have established a correlation between the concentrations of electrolytes in pleural effusion and the post-mortem interval (PMI) or those concentrations and drowning site. The present study aims to investigate the relationship between the amount of pleural effusion, concentrations of electrolytes and total protein in pleural effusion, by integrated interpretation using various factors such as the deceased's gender, age, cause of death, drowning site, PMI and body temperature. We included 40 cadavers (26 male, 14 female) with >20-mL pleural effusion, which were categorised into four groups as follows: freshwater drowning; brackish water drowning; seawater drowning (drowning group); and not drowning. An equation derived to assess the lung weight revealed that the drowning site affected the lung weight. An equation for the amount of pleural effusion in the drowning group for the first time revealed that the amount of pleural effusion was directly proportional to the PMI. Using an equation to assess the PMI, we could estimate the PMI within 13.0-13.2 h in cases with >20-mL pleural effusion. Despite a small number of cases in the present study, we attained exciting results from the integrated statistical analysis.

Efficacy of metformin on postprandial plasma triglyceride concentration by administration timing in patients with type 2 diabetes mellitus: A randomized cross-over pilot study.

AIMS/INTRODUCTION: Preprandial metformin administration significantly reduces postprandial plasma triglyceride levels in animal studies by reducing intestinal absorption through delayed gastric emptying. However, this effect has not been shown in a clinical study. Therefore, we planned to investigate the efficacy of preprandial metformin administration on postprandial hypertriglyceridemia and the related gastrointestinal effects in patients with type 2 diabetes mellitus. MATERIALS AND METHODS: A total of 11 patients taking single-dose metformin at 500-1,000 mg, with non-fasting plasma triglyceride levels of 150-1,000 mg/dL, were recruited at a single university hospital. The difference between preprandial and postprandial metformin administration on postprandial hypertriglyceridemia was examined by a meal test. The gastrointestinal effects of metformin, including stomach heaviness, heartburn and satiety, were also assessed using a visual analog scale. RESULTS: The mean bodyweight of patients was 80.6 kg (body mass index 27.9 kg/m2 ), and the mean non-fasting plasma triglyceride level was 275.9 ± 57.0 mg/dL. The area under the curve of triglyceride during the meal test was significantly lower in the preprandial protocol than in the postprandial protocol (P < 0.05). Compared with postprandial administration, preprandial administration of metformin increased satiety (P = 0.036) without stomach heaviness or heartburn. CONCLUSIONS: Preprandial metformin administration significantly reduced plasma triglyceride level during meal testing without marked exacerbation of gastrointestinal adverse effects. The present results suggest that a simple change in the timing of metformin administration represents a novel approach for enhancing triglyceride-lowering strategies in patients with type 2 diabetes mellitus and postprandial hypertriglyceridemia.

Experimental studies on identification of the driver based on STR analysis.

Identification of the driver based on STR analysis at a crime scene or following a traffic accident would be of enormous assistance in criminal investigation. We performed STR analysis on samples obtained from parts of a car; the steering wheel, the gear lever, the handbrake lever, the indicator lever and the door handle, with a view to obtaining DNA profiles of the owner and any another person who had driven the car just before sampling. As a result, it was found that a cotton swab is suitable for sample collection and that STR analysis of samples from a car, especially from the entire steering wheel, makes it possible to identify of the driver. We conclude that this method is very useful for crime scene investigation, even when the person who had touched the parts of a car had driven only briefly with bare hands.

[An unusual case of fatal airbag injury].

We report an unusual case of fatal airbag injury. A woman in her forties was driving a light car when it was involved in an accident. When the car was found, the left front wheel had dropped into the gutter, the front bumper was dented and the airbag had deployed. Forensic autopsy revealed that the right subclavian artery and the left vertebral artery were ruptured and 1,570 ml and 360 ml of blood with clots were observed in the left and the right thoracic cavity, respectively. It was considered that the unusual collision produced by deployment of the airbag had caused these ruptures and massive hemorrhaging. Although an airbag is an effective tool for ensuring the safety of a driver and the passengers, it may injure and occasionally kill the occupants if they do not remain in the appropriate and restrained seating position.

Decreased intestinal CYP3A and P-glycoprotein activities in rats with adjuvant arthritis.

Adjuvant-induced arthritis (AA) rats have been used as an animal model for rheumatoid arthritis. Several studies have shown that the pharmacokinetics of a number of drugs are altered in AA rats. We investigated the effects of AA on the barrier functions of the intestine using a rat model. Intestinal CYP3A activities (midazolam 1'-hydroxylation and 7-benzyloxy-4-(trifluoromethyl)-coumarin 7-hydroxylation) in AA rats were significantly decreased compared with those in normal rats, with marked decrease observed in the upper segment of intestine. Intestinal P-glycoprotein (P-gp) activity at upper segment was also significantly decreased in AA rats to 60% of that in normal rats, and the other segments (middle and lower) of intestine also exhibited tendencies toward decrease in P-gp activity. This decrease was supported by the finding that levels of mdr1a mRNA and P-gp protein were decreased in AA rats. No significant differences were observed in intestinal paracellular and transcellular permeability between AA and normal rats. These results suggest that intestinal CYP3A and P-gp activities are decreased in AA rats, and that the pharmacokinetics and bioavailabilities of drugs whose membrane permeation is limited by intestinal CYP3A and/or P-gp may be altered in rheumatic diseases.

Simultaneous determination of 13 amphetamine related drugs in human whole blood using an enhanced polymer column and gas chromatography-mass spectrometry.

Metamphetamine (MA) is one of the most frequently encountered abused drugs in Japan and the Triage immunoassay kit is often used to screen for this drug. However, immunoassay screening also gives positive results with other structurally related compounds, such as 3,4-methylenedioxymethamphetamine (MDMA), 3,4-methylenedioxyamphetamine (MDA), p-methoxyamphetamine (PMA), an ephedrine metabolite and beta-phenethylamine (PEA). Therefore, it is important to develop a simple and reliable method which can determine these drugs simultaneously. This paper describes a simple method for simultaneous identification and quantification of 13 amphetamine related drugs in human whole blood. The method consists of a solid phase extraction using a new polar-enhanced Focus column followed by acetylation and gas chromatography-mass spectrometry in the scan mode. Tetradeuterated MA and trideuterated methylephedrine (ME) were used as internal standards. As the Focus column required only simple extraction steps and provided a clean extract, identification of each drug was feasible even at low concentrations. The calibration curves were linear over the concentration range from 50 to 5000 ng/ml for all drugs with correlation coefficients that exceeded 0.99. The lower limits of detection of the drugs were 5-50 ng/ml. The absolute recoveries for the drugs were 65-95% and 64-89% at concentrations of 100 and 1000 ng/ml, respectively. Accuracy and precision data were satisfactory when using 2 internal standards. The applicability of the assay was proven by the analysis of blood samples in forensic cases. This method should be most useful for confirmation of positive immunoassay results for amphetamines and related drugs.

A fatal case of amoxapine poisoning under the influence of chronic use of psychotropic drugs.

A 43-year-old woman was found dead in a car in the supine position. She had been suffering from depression for 2 years and hesitation wounds on the left forearm and wrist were observed. On microscopic examination, pulmonary congestion and edema were observed with heart failure cells in many alveoli, thereby suggesting not only acute but also chronic heart failure. Drug screening in the blood by gas chromatography-mass spectrometry (GC-MS) revealed the presence of amoxapine and levomepromazine, and their concentrations in tissues were determined by GC-MS with three-step solvent extraction followed by acetylation. The concentration of amoxapine in the blood and liver was 0.86-1.77 and 18.76microg/ml, respectively; the levels were much higher than the therapeutic level but did not reach the lethal level. The concentrations of levomepromazine in tissues were within the therapeutic level. Based on the pathological and toxicological findings, the cause of death was determined to be amoxapine poisoning on the basis of chronic heart failure due to the chronic use of psychotropic drugs.

Analysis of postmortem changes in internal organs and gases using computed tomography data.

Postmortem computed tomography (PMCT) is a useful method to identify various causes of death and measure the volume of internal organs and gases. The purpose of this study was to investigate postmortem changes as measured by PMCT, and the relationship between the volume of organs and gases and postmortem interval (PMI). Forty-six cadavers (22 men, 24 women) were examined by CT before autopsy. The volumes of the lungs, intrahepatic gas, and intrarectal gas were measured by CT using a workstation. A stepwise regression analysis was used to establish a predictive equation to ascertain the measured volume using factors including sex, age, height, body mass index (BMI), body surface area (BSA), and PMI. For estimation of PMI, stepwise regression analysis was used. In the equations for each measured volume, height, diaphragmatic height, and BSA were adopted for the left lung; height and diaphragmatic height were adopted for the right lung; PMI was adopted for intrahepatic gas; and sex and PMI were adopted for intrarectal gas. In the PMI equations, left lung volume, intrahepatic gas, and intrarectal gas were adopted together with sex, weight, and BMI. Values of intrahepatic gas decreased with postmortem changes, while intrarectal gas increased. This may be useful in investigation of postmortem changes. It will be necessary to include other parts of the intestine and to analyze volume changes in gases from these parts after death.

Relationship between limited joint mobility of the hand and diabetic foot risk in patients with type 2 diabetes.

BACKGROUND: Foot ulceration is a serious problem for patients with type 2 diabetes (T2D), and the early detection of risks for this condition is important to prevent complications. The present cross-sectional study in T2D patients determined the relationship between limited joint mobility (LJM) of the hand and diabetic foot risk classified using the criteria of the International Working Group on the Diabetic Foot (IWGDF). METHODS: Relationships between LJM of the hand and foot risk according to IWGDF category, HbA1c, age, body mass index, blood pressure, estimated glomerular filtration (eGFR), and diabetic complications (including diabetic peripheral neuropathy [DPN] and peripheral arterial disease [PAD]) were evaluated in 528 consecutive T2D patients. Poor glycemic control was defined as HbA1c ≥ 7%. RESULTS: Patients with LJM of the hand were older and had a longer duration of diabetes, a higher prevalence of diabetic complications, including DPN and PAD, and a higher IWDGF category (all P < 0.001). Multivariate logistic regression analysis revealed that the foot risk assessed with IWDGF category was correlated with age (odds ratio [OR] 1.04; 95% confidence interval [CI] 1.01-1.06; P = 0.001), poor glycemic control (OR 1.66; 95% CI 1.00-2.77; P = 0.04), eGFR (OR 0.98; 95% CI 0.97-0.99; P = 0.02), and the presence of LJM of the hand (OR 3.86; 95% CI 2.21-6.86; P < 0.001). CONCLUSIONS: The results demonstrate a correlation between LJM of the hand and foot risk. Diagnosis of diabetic hand is simple and non-invasive, and is thus a useful method for assessing the risk of diabetic foot in T2D patients.

Vulnerability of experimentally induced fatty liver to heat stress in rats.

BACKGROUND: The aim of this study was to confirm the vulnerability of fatty liver to heat stress using fatty liver rats from the viewpoint of the induction of apoptosis. METHODS: We exposed rats with and without a fatty liver to heat stress and then looked for apoptotic cells within the liver tissue using two apoptosis detection kits. We also determined the mRNA expression of heat shock protein (HSP) 70, caspase-3, bcl-2, and bax using a quantitative reverse transcription-polymerase chain reaction method. RESULTS: Following heat stress, apoptosis was strongly visible in the fatty liver comparing with that noted in the normal liver. The expression of HSP70 was increased following heat stress in both livers, but the volume of its expression was significantly less in the fatty liver than in the normal liver. The ratio of bcl-2/bax expression tended to increase in the normal liver but decrease in the fatty liver following heat stress. Caspase-3 demonstrated no significant change following heat stress in both livers. CONCLUSIONS: The detection of apoptosis, together with changes in the mRNA expression of HSP70 and the expression ratio bcl-2/bax mRNA may indicate vulnerability of a fatty liver to heat stress and may support the hypothesis that morphologic change is induced in a fatty liver by exposure to heat stress. These results suggest that fatty liver may be more vulnerable to heat stress than normal liver.