Application of Virtopsy in Forensic Pathology

Virtopsy employs computed tomography and magnetic resonance imaging,which are commonly used in clinical medicine,to determine the cause and manner of death.Virtopsy is a multidisciplinary technique that combines forensic medicine,pathology,radiology,computer graphics,biomechanics,and physics.Virtopsy is rapidly gaining importance in forensic science and has been extensively studied in several areas of forensic pathology.In this study,we reviewed domestic and international research on causes of death,traffic injuries,medical disputes,gunshot trauma,postmortem changes,and inference of time of death to discuss with colleagues the role of virtopsy in forensic pathology.

Forensic-Pathological Analysis of Blunt Cardiac Rupture Involving the Relationship between Injury and Disease: 2 Cases Report and Review of the Literature

Blunt cardiac rupture is a characteristic of high death rates and rapid death process. But sometimes it is hard to find out the cause of cardiac rupture of traumatized patients, especially when it relates the relationship between injury and disease. In the 2 cases reported herein, both of the 2 patients had pre-existent cardiac pathological changes when suffered from traumatic injury. Our aim is to evaluate autopsy findings from a medicolegal point of view, and offer our proposals on how to deal with this sort of cases.

Forensic Pathological Expertise of Medical Tangle Analysis of 139 Autopsy Cases

In this article , we report 139 autopsy cases of medical tangle , which were examined by the Department of Forensic Pathology, Faculty of Medicine, Tongji Medical University from Jan. 1972 to Dec. 1992.The emphasis is put on analyses of the status of medical tangle autopsy in forensic pathology, involved medical departments , distribution of victim's age and sex , differences between clinical diagnosis and autoptical conclusion, the composition and causes of medical tangle. The associated problems in forensic pathological autopsy are also discussed.

Improving Evidence-Based Practice in Forensic Medicine:Validation of INtegration of Forensic Epidemiology and the Rigorous EvaluatioN of Causation Elements and Principles of Evidence-Based Reporting in FORensic Medicine-Pathology version in Indonesia

Introduction: Expert opinions presented in legal proceedings should be scientifically accountable, which is known as evidence-based practice (EBP). Although forensic medical expert opinions are essential in legal proceedings, the methods used to formulate them are not always evidence based or based on standard methods. In forensic medicine, EBP has not been explicitly applied, including in Indonesia. One potential approach to formulate evidence-based expert opinions is called INtegration of Forensic Epidemiology and the Rigorous EvaluatioN of Causation Elements (INFERENCE). In addition, there is also no universal guideline for making forensic pathological reports. One prospective guideline is named the Principles of Evidence-based Reporting in FORensic Medicine-Pathology version (PERFORM-P). Methods: This article describes the validation process of INFERENCE and PERFORM-P in Indonesia. This study uses a mixed method through three interrelated phases, i.e., (1) a cross-sectional survey to determine the characteristics of Indonesian forensic doctors and their current practice, (2) the adaptation and validation process of the two tools through a review by the Indonesian College of Forensic Medicine, and (3) a one-group pre-postintervention study to assess the validity and reliability of forensic medical expert opinions formulated using Indonesian-INFERENCE (i-INFERENCE) and reported using Indonesian-PERFORM-P (i-PERFORM-P). Results and Discussion: In general, both tools received a positive reception and can potentially be used in the Indonesian setting with some additions/clarifications in the user manuals. Participants envision that both tools will be most useful in complex cases. Conclusions: By obtaining the i-INFERENCE and the i-PERFORM-P, it is hoped that Indonesian forensic medical doctors are better equipped in analyzing and reporting complex cases, and the implementation of EBP can be improved.

Correlative Analysis on the Relationship between PMI and DNA Degradation of Cell Nucleus in Human Different Tissues

Summary： To determining the postmortem interval （PMI） through quantitative analysis of the DNA degradation of cell nucleus in human brain and spleen by using image analysis technique （IAT）. The brain and spleen tissues from 32 cadavers with known PMI were collected, subjected to cell smear every 1 h within the first 5-36 h after death, stained by Feulgen-Van＇s staining, Three indices reflecting DNA in brain cells （astrocytes） and splenic lymphocytes, including integral optical density （IOD）, average optical density （AOD）, average gray （AG） were measured by employing the mage analysis instrument. The results showed that IOD and AOD declined and AG increased with the prolongation of dead time within 5 36 h. A correlation between the PMI and gray parameters （IOD,AOD and AG） was identified and the corresponding regression equation was obtained. The parameters （IOD, AOD and AG） were proved to be effective quantitative indicators for accurate estimation of PMI within 5-36 h after death.

Changes in ATP Levels in Rabbit Blood and Its Application for Estimation of the Postmortem Interval

Summary： Relationship between ATP changes of rabbit blood and postmortem interval （PMI） was studied. Twenty-four healthy rabbits were sacrificed and randomly divided into 3 groups with 8 rab- bits of each group. The bodies of three groups were placed in calorstat at temperature of 15℃, 25℃ and 35℃, respectively. The blood from the right ventricle was sampled through indwelling needle each 4 h until 72 h after death. ATP levels in the blood samples were measured by using ATP fluo- rescence rapid detection technique at different PMIs. Blood ATP levels slightly increased in the early stage after death and then constantly declined at all temperatures （15℃, 25℃, and 35℃）. Cubic polynomial regression equations with log[ATP] as dependent variable （y） and PMI as independent variable （x） at different temperatures and the optimal time period were established as followed： Under 15℃ and during 16-64 h after death, y=-3.027×10^-5x^3＋0.003x^2-0.096x-10.625 （Ra^2=0.992, P〈0.001）; under 25℃ and during 8-56 h after death, y=-2.921×10^-5x^3＋0.002x^2- 0.059x-11.186 （Ra^2=0.989, P〈0.001）; under 35℃ and during 4-36 h after death, y=-9.769×10^-5x^3＋ 0.005x^2 -0.117x-11.166 （Ra^2=0.991, P〈0.001）. The changes in ATP levels in blood collected from right ven- tricle of rabbit cadavers showed relatively stable and regular degradation within 72 h after death at different temperatures.

Determination of the Early Time of Death by Computerized Image Analysis of DNA Degradation: Which Is the Best Quantitative Indicator of DNA Degradation?

This study evaluated the correlation between DNA degradation of the splenic lymphocytes and the early time of death, examined the early time of death by computerized image analysis technique （CIAT） and identified the best parameter that quantitatively reflects the DNA degradation. The spleen tissues from 34 SD rats were collected, subjected to cell smearing every 2 h within the first 36 h after death, stained by Feulgen-Van＇s staining, three indices reflecting DNA content in splenic lymphocytes, including integral optical density （IOD）, average optical density （AOD）, average gray scale （AG） were measured by the image analysis. Our results showed that IOD and AOD decreased and AG increased over time within the first 36 h. A stepwise linear regression analysis showed that only AG was fitted. A correlation between the postmortem interval （PMI） and AG was identified and the corresponding regression equation was obtained. Our study suggests that CIAT is a useful and promising tool for the estimation of early PMI with good objectivity and reproducibility, and AG is a more effective and better quantitative indicator for the estimation of PMI within the first 36 h after death in rats.

Analysis of Thorax Injuries in 112 Death Cases Caused by Traffic Accidents

Objective: To explore the characteristics and mechanisms of serious injuries of chest caused by road traffic accidents. Methods: Totally 112 autopsy cases with chest injuries in the urban of Jingzhou road traffic accidents were collected. Systematic review and analysis of the general information, postmortem examinations and assessments of chest injury had carried out from Feb. 2016 to Mar. 2018. Results: Average age of the victims was 52.2 years and the ratio of male to female deaths was 2.39:1. The proportion of motor-cyclists and pedestrians increased significantly. The overwhelming majority of accident vehicles were motorcycles and bicycles. Fractures of ribs and pulmonary contusion were the most common injuries. Craniocerebral and abdominal injuries were the most common associated injuries. Conclusion: Fractures of ribs and pulmonary contusion were the most common features of fatal road traffic injuries, often associated with vitreoretinal damage and serious multiple damages. These features reflect the characteristics of great violence in traffic accidents, which provides the evidence of identification of violent injuries.

Role of Neuropeptide Y and Peroxisome Proliferator-activated Receptor γ Coactivator-1α in Stress Cardiomyopathy

Death following situations of intense emotional stress has been linked to the cardiac pathology described as stress cardiomyopathy, whose pathomechanism is still not clear. In this study, we sought to determine, via an animal model, whether the transcriptional coactivator peroxisome proliferator-activated receptor γ coactivator-1alpha (PGC-1α) and the amino peptide neuropeptide Y (NPY) play a role in the pathogenesis of this cardiac entity. Male Sprague-Dawley rats in the experimental group were subjected to immobilization in a plexy glass box for 1 h, which was followed by low voltage elec-tric foot shock for about 1h at 10s intervals in a cage fitted with metallic rods. After 25 days the rats were sacrificed and sections of their hearts were processed. Hematoxylin-eosin staining of cardiac tissues revealed the characteristic cardiac lesions of stress cardiomyopathy such as contraction band necrosis, inflammatory cell infiltration and fibrosis. The semi-quantitative RT-PCR analysis for PGC-1α mRNA expression showed significant overexpression of PGC1-α in the stress-subjected rats (P<0.05). Fluorescence immunohistochemistry revealed a higher production of NPY in the stress-subjected rats as compared to the control rats (P=0.0027). Thus, we are led to conclude that following periods of intense stress, an increased expression of PGC1-α in the heart and an overflow of NPY may lead to stress car-diomyopathy and even death in susceptible victims. Moreover, these markers can be used to identify stress cardiomyopathy as the cause of sudden death in specific cases.

Application and Prospect of Postmortem Imaging Technology in Forensic Cardiac Pathology:A Systemic Review

Postmortem imaging(PMI)technology known as virtual autopsy or virtopsy is regarded as a useful method of noninvasive or minimally invasive autopsy in forensic practice.Postmortem computed tomography is applicable to traumatic investigation,acute hemorrhage,pulmonary parenchyma disease,calcification(calculus,atherosclerosis),and gas accumulation.Postmortem magnetic resonance(PMMR)has been proven to have advantages in soft tissue identification.Cardiac death is one of the keys and difficult points in forensic practice.With the introduction and development of PMCT angiography and PMMR,it was proved to be a very promising tool in the investigation of cardiac death,including vascular cavities and ischemic myocardium.This article reviewed the applications of the latest PMI and its related technologies in forensic cardiac pathology,including advantages,limitations,and development prospects.

Death from Fat Embolism after Lipectomy in a Patient with Madelung’s Disease

A 56-year-old man with a long history of alcoholism and a palpable raised mass about 23 cm×12 cm in size on his neck was diagnosed with Madelung’s disease(MD);the patient also had hyperuricemia.On day 1,he underwent neck lipoma tissue resection and suddenly had dyspnea 9 h after the operation,which was followed by cardiac arrest.After heart rate resuscitation,he developed a heartbeat,but he remained in a coma and died 9 days after the operation.No obvious pathological tracheal compression from a hematoma was observed while evaluating the patient’s neck on autopsy.On microscopy,the patient had an extensive pulmonary fat embolism,partial alveolar septal rupture and hemorrhage,and fat particles,and there was extensive infiltration of macrophages,which had phagocytosed fat particles,in the alveolar cavity.There was also evidence of pulmonary infection and hypoxic-ischemic encephalopathy.The cause of death was postoperative pulmonary fat embolism resulting in pneumonia and central nervous system injury.This is the first report of a patient with MD who died of a fatal pulmonary fat embolism after neck lipoma tissue resection.Medicolegal experts and clinicians should pay sufficient attention to this case.

Research progress in the estimation of the postmortem interval by Chinese forensic scholars

The determination of time since death or the postmortem interval(PMI)is one of the most important and frequently asked questions in forensic medicine.Medicolegal scholars and forensic pathologists around the world have studied the estimation of PMI extensively in the past,and many novel methods and advanced technologies have now been applied in the field.For several centuries,Chinese forensic examiners have also worked on the estimation of the PMI,and there are a large number of excellent studies published in Chinese rather than in English,and these are not easily accessible or known internationally.Therefore we have conducted a review of relevant studies published by Chinese forensic scholars in the last few decades.The scope of this review is to provide a concise summary of the current progress in the estimation of PMI by Chinese forensic researchers using molecular biology,spectroscopic technology,entomological methods,energy changes,thanatochemistry and other methods.

Sports-related sudden cardiac death due to myocardial diseases on a population from 1-35 years: a multicentre forensic study in Spain

This is a multicentre forensic study that identifies all sports-related sudden deaths (SRSDs) in young people,due to myocardial diseases (MDs) that occurred in a large area of Spain.The aim of the study is to assess the epidemiology,causes of death,and sport activities associated with these fatalities.This is a retrospective study based on forensic autopsies performed in the provinces of Biscay,Seville,Valencia and in the jurisdiction covered by the National Institute of Toxicology and Forensic Sciences in Madrid (Spain).The retrospective study encompasses from 2010 to 2017.All sudden cardiac deaths (SCDs) in persons 1-35years old were selected.The total number of SCDs were divided into death occurred during exercise (SRSD) and death during rest,sleep or normal activities (non-SRSD).Each of these two groups was subdivided according to the cause of death into MD (primary cardiomyopathies and myocarditis) and non-MD.Clinic-pathological,toxicological and genetic characteristics of SRSD due to MD were analysed.Over the 8-year study period,we identified 645 cases of SCD in the young: 75 SRSD (11.6%) and 570 non-SRSD (88.4%).MD was diagnosed in 33 (44.0%) of the SRSD and in 112 (19.6%) of the non-SRSD cases.All cases of SRSD due to MD were males (mean age (24.0±7.6) years) practicing recreational sports (85%).SRSDs were more frequent in arrhythmogenic cardiomyopathy (ACM) (37%) and hypertrophic cardiomyopathy (HCM) (24%),followed by myocarditis (15%) and idiopathic left ventricular hypertrophy (ILVH) (9%).Only in five cases of SRSD the MD responsible of death (HCM) had been diagnosed in life.Cardiovascular symptoms related to the disease were present in other seven patients (six of them with ACM).Postmortem genetic studies were performed in 15/28 (54%) primary cardiomyopathies with positive results in 12 (80%) cases.The most frequent sports disciplines were football (49%) followed by gymnastics (15%) and running (12%).In Spain,SRSD in young people due to MDs occurs in males who perform a recreational activity.Compared with control group we observed a strong association between MDs and exertion.One in three SRSDs are due to cardiomyopathy,especially ACM,which reinforces the need for preparticipation screening to detect these pathologies in recreational sport athletes.Further studies are warranted to understand the causes and circumstances of sudden death to facilitate the development of preventive strategies.

Research advances in forensic diatom testing

In forensic practice,it is difficult to determine whether a dead body in the water resulted from drowning or from disposal after death.Diatom testing is currently an important supporting technique for the determination of death by drowning and of drowning sites,even though it is a time-consuming and laborious task.This article reviews the development of diatom testing over the decades and discusses a new method for the potential application of deep learning in diatom testing.

Pathology of atherosclerotic coronary artery disease in the young Indian population

Atherosclerotic coronary artery disease (CAD) is of great concern in young adults because of its potential to cause great incapacitation.This arena of cardiology has gained importance in South Asian countries,particularly India due to increased prevalence that is related to traditional risk factors,altered life styles and inherent risk factors.In this study,we sought to evaluate,at autopsy,the pathology of atherosclerotic CAD in young patients with ischemic heart disease (IHD).A 10-year retrospective autopsy-based study was carried out in a large tertiary-care centre and patients aged ≤45 years with IHD were selected.Out of 545 autopsied cases of IHD,95 patients (17.4%) were young.Among these 95 patients,84 (88.4%) had IHD related to atherosclerotic CAD;the youngest patient was 18years old.Predictably there was sole involvement of left anterior descending artery and the presence of fibrous plaques.Irrespective of the plaque morphology,the commonest complication was thrombosis produced by plaque erosion seen in 36.9% of patients.Acute coronary insufficiency was noted in 52 patients (61.9%),while healed infarctions were surprisingly noted in 28 patients (33.3%).Screening for IHD in the young population may help to improve prognosis by detecting subclinical disease,although more studies are necessary to establish reference limits for this young population.Additional research must also focus on treatment concerns that are specific to young patients.

Sudden cardiac death and valvular pathology

Sudden death due to valvular heart disease is reported to range from 1% to 5% in native valves and around 0.2%-0.9%/year in prosthesis.The nature of the diseases is varied,from heritable,congenital to acquired.It may affect both genders in multiple age groups.The authors show and comment examples of the major nosologic aetiologies underlying unexpected exitus letalis of valvular nature.

Death due to fracture of thin calvarial hones after a fall： A forensic approach

A 45-year-old male was autopsied. He had fallen backwards from a two-stairs height to the ground and passed away. A skull fracture was detected in the left occipital area, extending up to the left side of the skul! base. The patient＇s death occurred due to the very low thickness of the calvarial bones, which led to the aforementioned fracture, and in turn resulted in subarachnoid hemorrhage and death. The cortical thickness was measured and compared with average values at standardized points. Uniform bone thinning was confirmed rather than localized. Calvarial thinning may result from various conditions. In the present case study, however, the exact mechanism which led to the low thickness of the calvarial bones of the patient is undetermined. Death due to the susceptible structure and fracture of calvarial bones has rarely been reported throughout relevant literature.

The histopathological spectrum of myocardial inflammation in relation to circumstance of death:a retrospective cohort study in clinical and forensic autopsies

Interpreting a myocardial inflammation as causal,contributory or as of no significance at all in the cause of death can be challenging,especially in cases where other pathologic and/or medico-legal findings are also present.To further evaluate the significance of myocardial inflammation as a cause of death we performed a retrospective cohort study of forensic and clinical autopsy cases.We revised the spectrum of histological inflammatory parameters in the myocardium of 79 adult autopsy cases and related these to the reported cause of death.Myocardial slides were reviewed for the distribution and intensity of inflammatory cell infiltrations,the predominant inflammatory cell type,and the presence of inflammation-associated myocyte injury,fibrosis,edema and hemorrhage.Next,the cases were divided over three groups,based on the reported cause of death.Group 1(n=27)consisted of all individuals with an obvious unnatural cause of death.Group 2(n=29)included all individuals in which myocarditis was interpreted to be one out of more possible causes of death.Group 3(n=23)consisted of all individuals in which myocarditis was reported to be the only significant finding at autopsy,and no other cause of death was found.Systematic application of our histological parameters showed that only a diffuse increase of inflammatory cells could discriminate between an incidental presence of inflammation(Group 1)or a potentially significant one(Groups 2 and 3).No other histological parameter showed significant differences between the groups.Our results suggest that generally used histological parameters are often insufficient to differentiate an incidental myocarditis from a(potentially)significant one.

Forensic appraisal of death due to acute alcohol poisoning:three case reports and a literature review

Death due to acute alcohol poisoning lacks specific anatomical characteristics,compared with other deaths due to drug poisoning.We report three forensic cases of death from acute alcohol poisoning due to inhibition of the respiratory centre and eventual asphyxia.Blood alcohol concentrations in the three fatalities were 5.28,3.33 and 3.78mg/mL,respec-tively.Lethal doses and blood alcohol concentrations showed differences between individu-als.Detailed auxiliary tests besides autopsy were undertaken.These cases show that forensic scientists should exclude other causes of death,combine the autopsy with auxiliary tests,and then make an appraisal.

Exosome Biomarkers in Cardiovascular Diseases and their Prospective Forensic Application in the Identification of Sudden Cardiac Death

Sudden cardiac death(SCD)is a common cause of death due to the high prevalence and mortality of cardiovascular disease(CVD).Currently,the forensic identification of SCD relies on traditional histomorphological examination,lacking stable biomarkers with high specificity and sensitivity.Previous studies have shown that exosomes(Exos)are ideal vectors and the application of Exos provides novel insight as the diagnostic biomarkers and treatment of CVD,and is hot research filed in biomedicine.This review briefly describes the biology of Exos,including the biogenesis of Exos and the mechanisms of action.The research progresses on Exos multi‑omics,i.e.,genomics,proteomics and metabolomics,and their roles in the diagnosis of different types of CVD,especially coronary heart disease and cardiomyopathy,are summarized.In addition,the current difficulties of applications of Exos in forensic identification of SCD and the prospective forensic applications in the future are highlighted.The aim of this review is to summarize the current advances of Exos in CVD in a disease‑oriented manner,and to provide a reference for future forensic pathological identification of SCD,as well as the early diagnosis of SCD in clinic.