Assessment of a Sudden Death Case due to Coronary Artery Disease Based on the PMCT and Forensic Autopsy

It is never an easy thing to diagnose heart vascular disease only depending on the unenhanced postmortem computed tomography(PMCT).This article reported a case of sudden natural death after the complaint of anterior chest pain in which coronary artery calcification(CAC) was clearly displayed using PMCT scan.The entire coronary artery system was almost reconstructed via multiplanar reformation(MPR) and volume-rendering reconstruction(VR),and the total calcium score of the coronary arteries was obtained with CaScoring automatic analysis software.The results showed that CAC was conspicuous;the total calcium score was 640.3,considerably higher than 400.The pulmonary ground-glass opacity(GGO) and small amount of fluid both in the subglottic trachea and main bronchi were also found.The imaging results confirmed those of autopsy.In addition,the results concluded that PMCT might serve as an invaluable adjunct to the classic autopsy procedure.

Sudden Death due to Brainstem Leukemic Hemorrhage： A Case Report

Introduction Leukem ia is a hem atologic neoplasm characterized by potential infectious and hem orrhagic com plications In adult patients with acute leukem ia,in fection is the most com m on com plication.Imtrcra nial hem orrhage (ICH) is the second most common com plication.H ow ever,ICH has been identified as the m ajor cause of m orbidity and m ortaliity in pa tients with leukem ia[1-6].A num ber of case ceports ascribed the death of leukem ic patients due to hem orrhge of the supratentorial and infratentorial brain,basal ganglia,and cerebellum [2,7-9].However,few cases have reported on brainstem hem orrhage.The current case report involved a young wom an who died of brainstem hem orrhage due to acute leukem ia,discussing the pathophysiologic m echanism underly ing ICH.Futhherm ore,the risk factors were specified,w ith a provision of suggestions to forensic pathologists in handling deaths associated w ith ICH,especially sudden unexpected deaths.

Sudden Death due to Diffuse Alveolar Hemorrhage Induced by Pul- monary Renal Syndrome： Two Case Reports

Patients developing hemoptysis or pulmonary infiltrates together with glomerulonephritis, particu- larly the rapidly progressive cases, are considered to be pulmonary renal syndrome （PRS）. The occur- rence of PRS, an etiologically rare heterogeneous group of diseases, constitutes a medical emergency associated with a high risk of fatal outcome.

不稳定冠状动脉粥样斑块病理特征及分类

冠状动脉粥样硬化性心脏病猝死的法医学重要诊断指标如急性或慢性心肌缺血改变,有时由于死亡过程短暂、组织缺少反应时间,使得缺血部位定位困难,部分案件中死者首次发病即猝死,导致法医难以准确作出诊断。然而临床医学对于冠状动脉不稳定斑块的研究揭示了其病变引发的冠状动脉痉挛、血栓形成在冠心病猝死过程中所起的关键作用。本文主要归纳整理了基于临床医学研究的不稳定冠状动脉粥样斑块的病理特征,包括斑块破裂、斑块侵蚀和钙化结节,以及导致斑块不稳定的影响因素,并简述粥样斑块研究进展与研究技术方法,以期通过诊断冠状动脉粥样斑块的不同病理状态,完善冠心病猝死死亡机制研究,提高冠心病猝死法医学诊断的准确性。

超极化激活环核苷酸门控通道4和钙依赖性蛋白激酶Ⅱ在心源性猝死患者窦房结中的表达情况及其法医学意义

目的探讨心源性猝死(SCD)患者窦房结组织超极化激活环核苷酸门控通道4(HCN4)和钙依赖性蛋白激酶Ⅱ(CaMKⅡ)蛋白表达情况及其法医学意义。方法收集2018年1月至2022年12月川北医学院司法鉴定中心尸检心脏标本200份,其中SCD100份(SCD组),非SCD100份(非SCD组)。两组均进行常规苏木精-伊红(HE)染色,采用免疫组织化学方法检测两组标本窦房结组织中HCN4和CAMKⅡ蛋白表达,图像处理软件计算目的蛋白的AOD值。结果SCD以成年男性为主且在死因中以冠心病占比最多。SCD组中HCN4的AOD值低于非SCD组,CAMKⅡ的AOD值高于非SCD组,差异有统计学意义(P<0.05)。结论窦房结中HCN4、CaMKⅡ异常表达可能是心源性猝死的机制,HCN4、CaMKⅡ有望成为心源性猝死的分子标记。

精神障碍者不明原因猝死现状及鉴识进展

精神障碍者猝死风险较普通人群显著增加,同时这类死亡常受精神药物、外伤等多重复杂因素干扰,死亡原因分析极具挑战性。精神障碍者不明原因猝死由于缺乏科学的死因解释及死后精准鉴识策略,一直是司法鉴定的研究难点。近年来,随着解剖学、毒理学和遗传学等方面的研究深入,国内外已对精神障碍者不明原因猝死有了更深的认识。基于国内外相关文献,从解剖学、毒理学和遗传学等角度介绍精神障碍者不明原因猝死的研究现状与猝死机制,并凝练相关鉴识进展,以期提高对相关案件的法医学认识,供法医学鉴定参考。

一起云南不明原因猝死案件中4种野生菌的细胞毒性

目的探究一起云南不明原因猝死(Yunnan sudden unexplained death,YNSUD)案件中涉及的4种野生菌的细胞毒性,为YNSUD的防治提供实验依据。方法采集事件发生家庭食用过的4种野生菌,通过专家辨认和基因测序鉴定种属。运用超声波萃取法提取4种野生菌的生品浸膏干预HEK293细胞,然后用细胞计数试剂盒-8(Cell Counting Kit-8,CCK-8)筛选出有明显细胞毒性的野生菌。将筛选出的野生菌再分别制成生品、熬煮和熬煮后酶解3种浸膏,所得3种浸膏以不同浓度干预HEK293细胞,用CCK-8与乳酸脱氢酶(lactate dehydrogenase,LDH)检测法联合检测细胞毒性,并用倒置相差显微镜观察细胞形态。结果4种野生菌分别为粉黄黄肉牛肝菌(Butyriboletus roseoflavus)、美味牛肝菌(Boletus edulis)、变绿红菇(Rus⁃sula virescens)和隐花青鹅膏(Amanita manginiana)。仅在隐花青鹅膏中发现细胞毒性,其生品浸膏在质量浓度为0.1 mg/mL时显示出细胞毒性,熬煮浸膏和熬煮后酶解浸膏分别在质量浓度为0.4 mg/mL和0.7 mg/mL时有明显细胞毒性。除数量明显减少外,隐花青鹅膏提取物干预后的HEK293细胞还表现出突触增多及折光性差等改变。结论该起YNSUD案件涉及的野生菌中,隐花青鹅膏的提取物具有明显细胞毒性,通过熬煮和酶解两种工艺可以降低其部分毒性,但不能完全灭毒,食用该菌具有一定的安全隐患,隐花青鹅膏可能是导致该起YNSUD案件的原因之一。

心源性猝死医疗纠纷鉴定78例分析

目的探讨心源性猝死(sudden cardiac death,SCD)引起的医疗纠纷的特点、原因和鉴定路径。方法对78例SCD的鉴定案例进行回顾性分析。结果SCD患者男性明显多于女性;多发年龄段为40~59岁;急性冠脉综合征37例,主动脉夹层24例,心肌炎10例,心脏传导系统疾病1例,瓣膜病2例,先天性心脏病2例,其他2例;医疗过错主要责任科室:心血管内科48例,急诊科15例,普外科7例,骨科3例,呼吸科3例,内分泌科2例。上述医疗纠纷案例,6例诊疗不存在过错,15例诊疗虽有过错,但与患者死亡无因果关系,32例诊疗过错与患者死亡的因果关系为轻微,18例的因果关系为次要,仅有3例因果关系为主要,完全因果关系的为0。结论SCD医疗纠纷的发生受到医患多方因素影响,鉴定过程中应综合考虑疾病的高风险性、诊疗过错程度以及患方的依从性。其中,SCD起病急、病情变化极快,临床表现不典型,抢救成功率低等特点是导致医疗过错与患者死亡之间原因力大小比例普遍较低的主要原因。

成人心脏性猝死的心脏大体病理学测量数据报告

目的分析不同原因心脏性猝死(sudden cardiac death,SCD)的大体病理学数据,为不明原因的猝死鉴定提供证据支持。方法收集南京医科大学司法鉴定所2010—2020年行法医病理鉴定的167例成人SCD案件,汇总SCD案例的大体病理学检验数据,统计分析不同死因的特征。结果男、女性SCD案例比例3.4∶1。冠状动脉粥样硬化性心脏病是引起SCD的首要原因,主要分布于40岁以上的人群。心肌炎导致的猝死主要分布于年轻群体,平均死亡年龄为(34.00±9.55)岁。分析不同原因SCD的心脏病理学参数差异发现,主动脉瘤或动脉夹层猝死者的主动脉瓣瓣环周径多呈明显扩张(P<0.05)。男性主动脉瘤或动脉夹层和合并死因组的心脏质量增大,合并死因组的肺动脉瓣和三尖瓣瓣环均扩张(P<0.05)。结论不同原因SCD存在多个大体病理学测量指标差异,在心脏性猝死的原因推断中具有参考价值。

尸体靶向心脏冠状动脉造影在诊断冠心病猝死中的应用

目的 应用靶向心脏冠状动脉死后计算机体层成像血管造影(postmortem computed tomography angiography,PMCTA)方法 对冠状动脉狭窄进行诊断,探索其对冠心病猝死的诊断价值。方法 选用鉴定实践中的6例死亡案例,用5F猪尾型导管经股动脉入路高压注射对比剂碘海醇,获取冠状动脉影像学数据并处理分析,将冠状动脉靶向显影及冠状动脉钙化积分与常规尸体解剖、组织病理学检验结果 进行比较。结果 尸体解剖和组织病理学检验存在冠状动脉狭窄的病例在靶向心脏冠状动脉造影中均得到相似的结果 ,诊断吻合率达83.3%。靶向心脏冠状动脉造影方法 可以有效显示心脏冠状动脉病变,冠状动脉钙化积分与常规尸体解剖、组织病理学检验结果 具有一致性。结论 靶向心脏冠状动脉造影技术在冠心病猝死案件中可以作为常规尸体检验的有效辅助手段。

婴儿猝死综合征与婴儿感染性猝死共同相关基因的筛选及其调控网络的生物信息学分析

目的应用生物信息学方法筛选出经尸体检验确诊的婴儿猝死综合征(sudden infant death syndrome,SIDS)和婴儿感染性猝死(infectious sudden death in infancy,ISDI)死者脑、心脏和肝组织中共有的差异表达mRNA,探讨SIDS与ISDI的共有分子标记和发生机制。方法下载GSE70422、GSE136992数据集,用R软件limma包筛选SIDS和ISDI死者不同组织样本中差异表达的mRNA,进行重叠分析,并用R软件clusterProfiler包进行基因本体论(gene ontology,GO)和京都基因和基因组数据库(Kyoto Encyclopedia of Genes and Genomes,KEGG)富集分析,使用STRING数据库构建蛋白质-蛋白质相互作用(protein-protein interaction,PPI)网络,基于cytoHubba插件筛选hub基因。结果与数据集中的对照组相比,SIDS和ISDI死者组织样本中有19个显著的共同差异基因,其中心脏组织中16个、肝组织中3个,心脏组织星形肌动蛋白1(astrotactin 1,ASTN1)基因表达差异最显著。PPI网络确定了Ras同源基因家族成员A(ras homolog family member A,RHOA)、整合素亚单位α1(integrin subunit alpha 1,ITGA1)和H2B簇状组蛋白5(H2B clustered histone 5,H2BC5)是hub基因。GO和KEGG分析结果表明,共同差异基因富集在肌动蛋白细胞骨架的调节、黏着斑及对霉酚酸的反应等分子通路中。结论ASTN1、RHOA和ITGA1可能参与SIDS与ISDI的发生发展。共同差异基因富集在免疫与炎症反应相关通路中,说明SIDS与ISDI在免疫与炎症反应方面可能存在共同的分子调控机制。这些发现有望为SIDS与ISDI的分子解剖和法医学鉴定提供新的生物标记。

Sudden cardiac death caused by myocarditis in persons aged 1-49 years:a nationwide study of 14 294 deaths in Denmark

Myocarditis is associated with an increased risk of sudden cardiac death (SCD) in the young.However,Information on nationwide burden of SCD caused by myocarditis (SCD-myocarditis) is sparse.For this study all deaths among persons in Denmark aged 1-35years in 2000-2009 and 36-49years in 2007-2009 (27.1 million person-years) were induded.Autopsy reports,death certificates,discharge summaries,and nationwide registries were used to identify all cases of SCD-myocarditis.In the 10-year study period,there were 14294 deaths,of which we identified 1 363 (10%) SCD.Among autopsied SCD (n=753,55%),cause of death was myocarditis in 42 (6%) cases corresponding to an SCD-myocarditis incidence of 0.16 (95%CI: 0.11-0.21) per 100000 person-years.Males had significantly higher incidence rates of SCD-myocarditis compared to females with an incidence rate ratio of 2.2 (95%CI:1.1-4.1).Myocarditis was not registered as cause of death In any of the non-autopsied SCD (n=610,45%).In conclusion,after nationwide unselected Inclusion of 14294 deaths,we found that 6% of all autopsied SCD was caused by myocarditis.No cases of SCD-myocarditis were reported in the non-autopsied SCD,which could reflect underdiagnosing of myocarditis in non-autopsied SCD.Furthermore,our data suggest a female protection towards SCDmyocarditis.

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.

Sudden Death in Goldenhar Syndrome

Goldenhar syndrome(GS)is a rare congenital disorder that is characterized by incomplete development of the ear,eye,nose,soft palate,lip,and jaw.It is also called oculo-auriculo-vertebral syndrome of Goldenhar,the name describes the common structural problems seen with the eyes,ears,and vertebrae.The outlook for children with GS varies but is generally very positive.Most children can expect to live a healthy life once treatments have been administered.However,certain congenital heart defects seen in this syndrome such as ventricular septal defect(VSD),persistence of arterial conduct,tetralogy of Fallot,and big vessel transposition can lead to sudden death during childhood.These defects are usually diagnosed during intrauterine life by means of fetal echography,leading to termination of such pregnancy or necessary corrective measures after the birth of such child.If such a child dies,it will be certified by the treating pediatrician.Thus,an autopsy pathologist rarely comes across such deaths.One such case of a 45-day-old female infant suffering from craniofacial deformity who became breathless,cyanotic,and died on the way to the hospital is being discussed here.The right ventricle showed double outlets,arising from it were the pulmonary artery and aorta.A small subaortic VSD was seen.Generalized hypoplasia of all internal viscera on the right side was observed.

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.

Myocarditis–A silent killer in athletes:Comparative analysis on the evidence before and after COVID-19 pandemic

Myocarditis is a rare cardiomyocyte inflammatory process,typically caused by viruses,with potentially devastating cardiac sequalae in both competitive athletes and in the general population.Investigation into myocarditis prevalence in the Coronavirus disease 2019(COVID-19)era suggests that infection with Severe acute respiratory syndrome coronavirus(SARS-CoV-2)is an independent risk factor for myocarditis,which is confirmed mainly through cardiovascular magnetic resonance imaging.Recent studies indicated that athletes have a decreased risk of myocarditis after recent COVID-19 infection compared to the general population.However,given the unique nature of competitive athletics with their frequent participation in high-intensity exercise,athletes possess distinct factors of susceptibility for the development of myocarditis and its subsequent severe cardiac complications(e.g.,sudden cardiac death,fulminant heart failure,etc.).Under this context,this review focuses on comparing myocarditis in athletes versus non-athletes,owing special attention to the distinct clinical presentations and outcomes of myocarditis caused by different viral pathogens such as cytomegalovirus,Epstein-Barr virus,human herpesvirus-6,human immunodeficiency virus,and Parvovirus B19,both before and after the COVID-19 pandemic,as compared with SARS-CoV-2.By illustrating distinct clinical presentations and outcomes of myocarditis in athletes versus non-athletes,we also highlight the critical importance of early detection,vigilant monitoring,and effective management of viral and non-viral myocarditis in athletes and the necessity for further optimization of the return-to-play guidelines for athletes in the COVID-19 era,in order to minimize the risks for the rare but devastating cardiac fatality.

The forensic pathological analysis of sport-related sudden cardiac death in Southern China

Studies regarding sport-related sudden cardiac death(SCD)mainly focus on competitive ath-letes;similar data are rare in the general population,especially in China.We conducted a retrospective study(from September 1998 to August 2013)to investigate the aetiological distribution and epidemiological features of sport-related SCD in Southern China.Selections of cases are based on details,and two subgroups were established:one was the sport-related SCD group,and the other was the disease-free accident victims group which was matched with the sport-related SCD group in gender,age and year of death.Among the 3770 sudden-death cases,1656 cases were SCD cases.A total of 65 cases(57 males)out of 1656 SCD cases were sport-related.The age range of the 65 sport-related SCD cases was from 12 to 68 years old with a mean(35.92±14.23)years old.Only two of these cases were competitive athletes.The most common circumstances of the 65 sport-related SCD cases were heavy physical labour(46.15%)and running(30.77%).The three leading forensic diag-noses were the coronary atherosclerotic disease(CAD,28 cases),cardiomyopathy(CM,14 cases)and sudden unexplained death(7 cases).CM was the most common forensic diagno-sis in those?35 years old,while CAD was the most common one in those>35 years old.Left anterior descending in which atherosclerotic plaques was most commonly found was the principal artery branch associated with sport-related SCD.There was a statistically signifi-cant difference in the weight of hearts between the 65 sport-related SCD cases and 65 dis-eases-free accidental cases.This study highlights the need to attract public attention to sport-related SCD and to issue a prevention strategy to the public,and to make the SCD-related genetic sequencing a routine tool in both forensic pathological examination and clinic screening.

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.

急性心功能障碍大鼠心肌中BNP的表达

目的研究大鼠急性心功能障碍时心肌组织中脑钠肽(brain natriuretic peptide,BNP)的表达变化,探讨BNP在急性心功能障碍的法医学诊断中的应用价值。方法建立大鼠急性心功能障碍模型,运用免疫组织化学、Western印迹法、实时RT-PCR等技术检测心功能障碍过程中心肌组织BNP蛋白和BNP mRNA的表达变化。结果随心功能障碍持续时间增加,免疫阳性着色不断增强。1～2h主要表现为弱阳性,4～6h心肌细胞主要表现为阳性,10～12h大鼠心肌细胞表现为强阳性。Western印迹法和实时RT-PCR结果均显示,随心功能障碍持续时间增加,BNP明显升高,而且心功能障碍1h即能观察到BNP mRNA显著升高。结论检测心肌组织中BNP蛋白及BNP mRNA的表达能为法医病理学工作者客观评价心功能状态提供一种新的途径。

CAR在病毒性心肌炎和扩张型心肌病心肌中的表达

目的探讨病毒性心肌炎(viral myocarditis,VMC)和扩张型心肌病(dilated cardiomyopathy,DCM)的发病机制及相互关系,从而提高心源性猝死法医学鉴定的可靠性和准确性。方法对VMC组22例、DCM组20例和对照组16例的心肌组织中柯萨奇-腺病毒受体(coxsackie-adenovirus receptor,CAR)的表达进行改良的免疫组织化学研究。结果 VMC组和DCM组心肌组织细胞膜呈现深棕黄色阳性颗粒,有较高水平的CAR表达,与对照组比较,差异有统计学意义(P<0.05),对照组染色阴性。结论 VMC和DCM组心肌中CAR的高表达,提示VMC和DCM的发病机制可能与病毒感染有关,病毒感染并破坏心肌细胞导致心肌细胞坏死,心功能受损,使VMC进展为DCM。