Death from 2,4-Dinitrophenol Poisoning: An Autopsy Case / 대한법의학회지

DNP (2,4-dinitrophenol) has been commonly used as a weight loss aid; in particular, it has been used by body builders to achieve significant fat loss while maintaining muscle mass. The sale of DNP was banned due to some cases of fatal poisoning. We describe an autopsy case of a 39-year-old man who died from taking DNP to treat obesity. He was 183 cm tall and weighed 101 kg (body mass index of 31). External examination did not reveal any specific findings implicating the cause of death. Gross examination revealed that the heart weight was 450 g, and there were no significant findings in the coronary arteries and myocardium, except for a few petechiae of the epicardium. The DNP concentration in the subject’s blood was 38.28 mg/L. According to references, a DNP blood concentration of 28 mg/L or higher would result in death. Therefore, the cause of death in this autopsy case was DNP toxicity.

Surgical Results of Minimally Invasive Percutaneous Plate Fixation in the Treatment of Clavicle Shaft Fracture

PURPOSE: This study analyzed the results of the midclavicle fracture treatment using the minimally invasive percutaneous plate osteosynthesis (MIPO) technique in a retrospective manner. MATERIALS AND METHODS: Between March 2013 and March 2017, this study analyzed 40 patients who received MIPO surgery. Excluding 1 patient who underwent surgery on another body part injury, and 4 patients who were lost to follow-up over 1 year, 40 patients were analyzed for their operation time, bone union, functional American Shoulder and Elbow Surgeons score, scar lengths, pain relief (visual analogue scale), and complications. RESULTS: All patients over a 1 year of follow-up achieved bone union, and American Shoulder and Elbow Surgeons score 97.6 (94–100) on their shoulder functional scores. Their average operation time was 42.7 minutes, and the average scar length was 6.1 cm. Eighteen patients successfully received metal removal using the previous scar without additional incision. The clavicle length was similar in the normal and operated group. CONCLUSION: Despite its small sample size, clavicle fixation using the MIPO technique can be considered an effective treatment because of its limited number of complications, such as nonunion and rotational angulations.

Changes in Clinical and Legal Autopsy Rates in Korea from 2001 to 2015

Increased Ventrolateral Prefrontal Cortex Activation during Accurate Eyewitness Memory Retrieval: An Exploratory Functional Near-Infrared Spectroscopy Study / 대한법의학회지

We investigated the neural correlates of accurate eyewitness memory retrieval using functional near-infrared spectroscopy. We analyzed oxygenated hemoglobin (HbOâ‚‚) concentration in the prefrontal cortex during eyewitness memory retrieval task and examined regional HbOâ‚‚ differences between observed objects (target) and unobserved objects (lure). We found that target objects elicited increased activation in the bilateral ventrolateral prefrontal cortex, which is known for monitoring retrieval processing via bottom-up attentional processing. Our results suggest bottom-up attentional mechanisms could be different during accurate eyewitness memory retrieval. These findings indicate that investigating retrieval mechanisms using functional nearinfrared spectroscopy might be useful for establishing an accurate eyewitness recognition model.

The Assessment of Eyewitness Memory Using Electroencephalogram: Application of Machine Learning Algorithm / 대한법의학회지

This study was conducted to investigate whether memory accuracy can be assessed by analyzing electrophysiological responses (i.e., electroencephalography [EEG]) for retrieval cues related to the witnessed scene. Specifically, we examined the different patterns of EEG signals recorded during witnessed (target) and unwitnessed (lure) stimuli using event-related potential (ERP) analysis. Moreover, using multivariate pattern analysis, we also assessed how accurately single-trial EEG signals can classify target and lure stimuli. Participants watched a staged-crime video (theft crime), and the EEG signals evoked by the objects shown in the video were analyzed (n=56). Compared to the target stimulus, the lure stimulus elicited larger negative ERPs in frontal brain regions 300 to 500 milliseconds after the retrieval cue was presented. Furthermore, the EEG signals observed 450 to 500 milliseconds after the retrieval cue was presented showed the best classification performance related to eyewitness memory, with the mean classification accuracy being 56%. These results suggest that the knowledge and techniques of cognitive neuroscience can be used to estimate eyewitness memory accuracy.

Determination of cause and manner of death

Medical certificates of death and post-mortem examinations reflect the exclusive competence of medical doctors, according to Article 17 of the Medical Service Act. Although a medical certificate of death is a legal document that requires the certifier's best intellectual effort to complete, the attempts of certifiers do not seem to improve the accuracy of the content. The death certificate plays several important roles. First, it guarantees legal proof of death, which exempts individuals from various rights and duties. Second, official investigations can be performed on the basis of the death certificate to elucidate the nature of any crime that may have been committed. Third, death certificates are the backbone of national death statistics, and therefore play a role in the distribution of national resources for health policy. The determination of cause and manner of death is inherently a laborious task. The World Health Organization has suggested that the medical certificate of death should present the chain of events leading to death in a successive sequence. Medical doctors should have a precise understanding of how to assess the cause and manner of death and must use succinct, clear language to ensure the credibility of death certificates.

Retrospective Genetic Analysis of 200 Cases of Sudden Infant Death Syndrome and Its Relationship with Long QT Syndrome in Korea

BACKGROUND: There has been a campaign by the National Education on Sleeping Habits and Living Environment, to reduce the incidence of sudden infant death syndrome (SIDS). However, more than 100 infants die suddenly and unexplainably before the age of 1 year in Korea. Long QT syndrome (LQTS), an inheritable cardiac disease, has been reported to likely be associated with up to 14% of SIDS cases. However, genetic studies of the association between SIDS and LQTS have not yet been conducted in Korea. METHODS: We conducted genetic analysis using genomic DNA extracted from paraffin-embedded tissue blocks from 200 SIDS cases autopsied between 2005 and 2013. We analyzed the following genetic mutations associated with LQTS, KCNQ1, SCN5A, KCNE1, KCNE2, KCNJ2, and CAV3. RESULTS: Of the 200 SIDS cases, 58% involved male infants (116 male and 84 female infants, respectively), the mean age was 140 days (median, 107 days; range, 24–270 days), and they were all of Asian-Korean ethnicity. SIDS IA category criteria comprised 45 cases (22.5%) while the rest were SIDS IB. Fifteen infants (7.5%) had R1193Q in SCN5A, of doubtful pathogenicity, and no pathogenic LQTS variants were observed. CONCLUSION: This genetic investigation of LQTS in SIDS showed a low diagnostic yield. These findings suggest that LQTS molecular autopsy could be cautiously conducted in selected cases with family involvement to improve the available genetic counseling information. Meanwhile, a national SIDS registry should be established to document and evaluate the genetic risk of SIDS in Korea.

How Difficult Is It to Surgically Treat AO-C Type Distal Humerus Fractures for Inexperienced Orthopedic Surgeons?

PURPOSE: Twenty early surgical management cases of distal humerus type-C fractures were analyzed. MATERIALS AND METHODS: This study analyzed 20 early patients, who received surgical management of distal humerus type-C fractures, and could be followed-ups for more than one year between March of 2013 and May of 2015. The operative time, bone union time, and elbow range of motion were analyzed. The Mayo's functional score was used to evaluate their postoperative function. The primary and secondary complications of each patient immediately after each of their surgery were also reviewed. RESULTS: All patient groups achieved bone union within an average period of 16.4 weeks. Based on the Mayo functional score, 6, 10, and 4 patients scored excellent, good, and fair, respectively. The average range of motion was a flexion contracture of 14.5° with a follow-up improvement averaging 120.7°. Six patients received nine revision operations due to major and minor complications. Two patients received revision fixation from an inadequate fixating power, and another patient received an ulnar nerve transposition. Other complications included olecranon osteotomy site displacement, superficial operational site infection, and pin loosening. CONCLUSION: Distal humerus fractures of the AO-C type can cause a range of complications and has a very high rate of revision due to its difficult nature of surgical manageability. Therefore, it is imperative for a surgeon to expect various complications beforehand and a careful approach to their postoperative rehabilitation is essential.

Increased Ventrolateral Prefrontal Cortex Activation during Accurate Eyewitness Memory Retrieval: An Exploratory Functional Near-Infrared Spectroscopy Study / 대한법의학회지

We investigated the neural correlates of accurate eyewitness memory retrieval using functional near-infrared spectroscopy. We analyzed oxygenated hemoglobin (HbO₂) concentration in the prefrontal cortex during eyewitness memory retrieval task and examined regional HbO₂ differences between observed objects (target) and unobserved objects (lure). We found that target objects elicited increased activation in the bilateral ventrolateral prefrontal cortex, which is known for monitoring retrieval processing via bottom-up attentional processing. Our results suggest bottom-up attentional mechanisms could be different during accurate eyewitness memory retrieval. These findings indicate that investigating retrieval mechanisms using functional nearinfrared spectroscopy might be useful for establishing an accurate eyewitness recognition model.

The Assessment of Eyewitness Memory Using Electroencephalogram: Application of Machine Learning Algorithm / 대한법의학회지

This study was conducted to investigate whether memory accuracy can be assessed by analyzing electrophysiological responses (i.e., electroencephalography [EEG]) for retrieval cues related to the witnessed scene. Specifically, we examined the different patterns of EEG signals recorded during witnessed (target) and unwitnessed (lure) stimuli using event-related potential (ERP) analysis. Moreover, using multivariate pattern analysis, we also assessed how accurately single-trial EEG signals can classify target and lure stimuli. Participants watched a staged-crime video (theft crime), and the EEG signals evoked by the objects shown in the video were analyzed (n=56). Compared to the target stimulus, the lure stimulus elicited larger negative ERPs in frontal brain regions 300 to 500 milliseconds after the retrieval cue was presented. Furthermore, the EEG signals observed 450 to 500 milliseconds after the retrieval cue was presented showed the best classification performance related to eyewitness memory, with the mean classification accuracy being 56%. These results suggest that the knowledge and techniques of cognitive neuroscience can be used to estimate eyewitness memory accuracy.

Determination of cause and manner of death

Medical certificates of death and post-mortem examinations reflect the exclusive competence of medical doctors, according to Article 17 of the Medical Service Act. Although a medical certificate of death is a legal document that requires the certifier's best intellectual effort to complete, the attempts of certifiers do not seem to improve the accuracy of the content. The death certificate plays several important roles. First, it guarantees legal proof of death, which exempts individuals from various rights and duties. Second, official investigations can be performed on the basis of the death certificate to elucidate the nature of any crime that may have been committed. Third, death certificates are the backbone of national death statistics, and therefore play a role in the distribution of national resources for health policy. The determination of cause and manner of death is inherently a laborious task. The World Health Organization has suggested that the medical certificate of death should present the chain of events leading to death in a successive sequence. Medical doctors should have a precise understanding of how to assess the cause and manner of death and must use succinct, clear language to ensure the credibility of death certificates.

Bath-related Deaths in Korea between 2008–2015

BACKGROUND: The diagnostic criteria for bathtub drownings are not standardized, and the risk factors associated with bath-related deaths are unclear. METHODS: We analyzed a Korean nationwide database of bath-related deaths that occurred between January 2008 and December 2015. Eighty-four cases were enrolled after reviewing 31,123 autopsy records. RESULTS: The subjects' ages ranged from 18 to 91 years, with a mean age ± standard deviation of 61.3 ± 16.0 years. Bath-related deaths in the winter were approximately 4.6-fold greater than those in the summer. Of the 84 subjects, the primary cause of death in 57 (67.9%) was drowning in the bath; 24 (28.6%) drowned of other causes such as natural diseases, and 3 (3.6%) died of acute alcohol intoxication. We analyzed water-inhalation signs to establish criteria for bathtub drowning diagnosis. There were significantly higher incidences of hyperinflated lungs, water in the sphenoid sinus and stomach/duodenal contents, and Paltauf's spots (subpleural hemorrhage) in bathtub-drowned subjects compared to non-drowned individuals (P < 0.01). Multiple signs of water inhalation were significantly associated with bathtub drowning (P < 0.01). The two leading contributory causes of bath-related death were cardiovascular diseases and alcohol intoxication (binge drinking before bathing). CONCLUSION: The diagnosis of bath-related deaths could present considerable medico-legal problems; therefore, a comprehensive autopsy with a thorough scene investigation can clarify the cause of death in these situations. Preventive strategies for reducing such deaths should target alcohol drinking before bathing and long soaking times in bathtubs, especially among elderly individuals with preexisting cardiovascular diseases.

The Effect of Second Toe Valgus on Correction Loss of Hallux Valgus Angle in Surgical Treatment / 대한족부족관절학회지

PURPOSE: The purpose of this study is to determine the correlation between the correction loss of hallux valgus angle and the severity of valgus angle of the second toe. MATERIALS AND METHODS: We selected 312 cases from 268 surgical patients with hallux valgus deformity receiving distal chevron osteotomy. For a radiological evaluation, we analyzed the changes in the hallux valgus angles, first to second intermetatarsal angles, and valgus angle of the second toe post index operations. All patients were women; the mean age was 46 years. The mean follow-up period was 17 months. RESULTS: The mean hallux valgus angle was 33.6° preoperatively (range, 25.7°~44.8°), 13.1° (range, 8.4°~16.4°) after 4 weeks of postoperative period, and 17.1° (range, 9.4°~28.5°) at their final follow-up. The mean valgus angle of the second toe was 8.4° preoperatively (range, 2.0°~25.8°) and 8.3° (range, 1.7°~24.9°) at the final follow-up. Preoperatively, there was a positive correlation between the valgus angle of the second toe and hallux valgus angle (r=0.747, p=0.001). The correction loss of hallux valgus angle had a significant correlation with the severity of valgus angle of the second toe (r=0.802, p=0.001). CONCLUSION: The existence of the second toe valgus deformity may present itself as a cause of correction loss of hallux valgus angle. The preoperative measurement of the second toe valgus angle may be a good predictor of correction loss; therefore, thorough preoperative warning on the possibility of correction loss should be conducted to maximize patient satisfaction after the procedure.

A Comparison between Minimally Invasive Percutaneous Plate Osteosynthesis and Plate Fixation in the Treatment of Clavicle Midshaft Fracture / 대한정형외과학회잡지

PURPOSE: To retrospectively compare minimally invasive percutaneous plate osteosynthesis (MIPPO) with open plate fixation for the treatment of clavicle midshaft fracture. MATERIALS AND METHODS: Between November 2011 to May 2014, 40 cases that were followed for more than 1 year–among all cases of MIPPO and open plate fixation–were analyzed. The study population was divided into two groups: group A included 20 cases of MIPPO and group B included 20 open plate fixation cases. The comparative analysis between the two groups was based on the operative time, bone union, functional evaluation (American Shoulder and Elbow Society score), incision length, pain relief (visual analogue scale, VAS), and complication. RESULTS: The bone union was successful for all the cases, and the functional evaluation scores of the shoulder joint were satisfactory for both groups (p>0.05). The operative time was 47.5 minutes and 58.7 minutes for group A and B, respectively (p<0.05). The incision length for group A was 6.2 cm and that for group B was 10.7 cm with statistical significance (p<0.05). Pain relief (VAS) after surgery for group A showed a quick recuperation in the early stages. For complications, there were 2 cases of dysesthesia and 1 case of malunion due to metal fixation failure in group A. There were 6 cases of dysesthesia and 2 cases of cosmetic problem due to hypertrophic scar in group B. CONCLUSION: Surgical results of clavicle shaft fracture were satisfactory for both groups, but group A had advantages of shorter operative time, minimal incision length, and better pain relief in the early stages compared with group B. However, we need further evaluations with long-term follow-up results and complications, such as malunion and exposure on radiation.

Mid-Term Results of Oxford Medial Unicompartmental Knee Arthroplasty in Young Asian Patients Less than 60 Years of Age: A Minimum 5-Year Follow-up

PURPOSE: The purpose of this study was to evaluate the efficacy of unicompartmental knee arthroplasty (UKA) in young active Asian patients by analyzing clinical outcomes, complications and survival rates. MATERIALS AND METHODS: Eighty-two knees were evaluated with a minimum follow-up of 5 years after Oxford phase 3 UKA in patients less than 60 years of age at the time of surgery. Their mean age was 54.7 years (range, 44 to 59 years). The mean follow-up period was 8.9 years (range, 5.3 to 12 years). Kaplan–Meier survivorship analysis was used to estimate implant survival. RESULTS: Including 3 bearing dislocations, 1 medial tibial collapse and 1 lateral osteoarthritis, the total complication rate was 6.1% (5/82). Of the 3 cases of bearing dislocation, 2 cases were resolved by replacing with a thicker bearing and 1 case was converted to total knee arthroplasty (TKA) due to repeated dislocation. The two knees with a medial tibial collapse and a lateral osteoarthritis were converted to TKA. The 10-year cumulative survival rate using Kaplan-Meier survival method was 94.7% (95% confidence interval: 88.7%–100%). CONCLUSIONS: Oxford medial UKA was reliable and effective in young active Asian patients providing good clinical results and survival rate in the mid-term follow-up.

The Statistical Analysis on the Postmortem Inspection Cases of National Forensic Service Seoul Institute in 2016 / 대한법의학회지

From January 1, 2016 to December 31, 2016, a total of 1147 postmortem inspection cases in Area 8, Seoul Metropolitan Police Agency (Gangseo, Yangcheon, and Guro police stations) were statistically analyzed. Autopsies were performed in 205 cases (17.9%), and the autopsy rates were 17.6% (75/426 cases) in the Gangseo police station, 9.5% (34/357 cases) in the Yangcheon police station, and 24.3% (82/337 cases) in the Guro police station. For 288 cases with an unknown cause of death, the autopsy rates were 70.0% (60/87 cases) in the Gangseo police station, 28.6% (26/91 cases) in the Yangcheon police station, and 63.1% (65/103 cases) in the Guro police station. For 65 cases due to fall from height, the autopsy rate was 7.7% (n=5). Of the 187 cases due to hanging, 155 cases were classified as suicide at the scene with a 4.5% (n=7) autopsy rate and 32 cases were classified as an undetermined manner of death at the scene with a 15.6% (n=5) autopsy rate. The distribution of the “manner of death” was natural death, 45% (n=516); unnatural death, 29.9% (n=343); and other and undetermined, 25.1% (n=288). Proportions of dispatch times were 50.9% (584 cases) during work hours (09:00–18:00), 13.8% (n=158) during evening hours (18:00–21:00), 13.4% (n=154) at night (21:00–00:00), 11% (n=126) at dawn (00:00–06:00), and 10.9% (n=125) during morning hours (06:00–09:00). The male-to-female ratio was 1.86:1 (746:401). These statistics are valuable for the evaluation of postmortem inspections by experts.

The Statistical Analysis on the Postmortem Inspection Cases of National Forensic Service Seoul Institute in 2015 / 대한법의학회지

Since March 1, 2015, the National Forensic Service Seoul Institute has commenced postmortem inspections at the death scene in agreement with the Korean National Police Agency. Included regions were mainly Seoul Metropolitan Police Agency Wide Area 8 (Gangseo, Yangcheon, Guro police stations), and several other areas. In total, 837 postmortem inspection cases from March 1 to December 31, 2015, were analyzed statistically. Of these, 168 were autopsy cases, and the rates were 20% (67 cases) in Gangseo Police, 14.5% (30 cases) in Yangcheon Police, and 22% (57 cases) in Guro Police stations. For 269 cases of “unknown cause of death”, the autopsy rates were 44% in Gangseo Police, 36% in Yangcheon Police, and 47% in Guro Police stations. For 82 cases of fall from height, autopsy rates were 17% (n=14). Of the 133 cases of hanging, 121 cases were classified as suicide at the scene with a 2.5% (n=3) autopsy rate. Twelve cases were classified as an undetermined manner of death at the scene with a 33% (n=4) autopsy rate. The distribution of the “manner of death” was natural death for 29% (n=250), unnatural death for 38% (n=318), and other and undetermined manner of death for 32% (n=269) of cases. Proportions of dispatch times were 49.2% (412 cases) during work hours (09:00-18:00), 15.7% (n=131) during evening hours (18:00-21:00), 13% (n=110) at night (21:00-24:00), 10% (n=88) at dawn (24:00-06:00), and 11% (n=96) during morning hours (06:00-09:00). The male to female sex ratio was 1.96:1 (556:281). These statistics are valuable for evaluation of postmortem inspections by experts.

A Study of Core Humanistic Competency for Developing Humanism Education for Medical Students

The authors conducted a survey on essential humanistic competency that medical students should have, and on teaching methods that will effectively develop such attributes. The participants consisted of 154 medical school professors, 589 medical students at Seoul National University College of Medicine, 228 parents, and 161 medical school and university hospital staff. They answered nine questions that the authors created. According to the results, all groups chose "morality and a sense of ethics," a "sense of accountability," "communication skills," and "empathic ability" were selected as essential qualities. According to the evaluation on the extent to which students possess each quality, participants believed students had a high "sense of accountability" and "morality," whereas they thought students had low "empathic ability," "communicate," or "collaborate with others". In terms of effective teaching methods, all sub-groups preferred extracurricular activities including small group activities, debates, and volunteer services. With regard to the speculated effect of humanism education and the awareness of the need for colleges to offer it, all sub-groups had a positive response. However the professors and students expressed a relatively passive stance on introducing humanism education as a credited course. Most participants responded that they preferred a grading method based on their rate of participation, not a relative evaluation. In order to reap more comprehensive and lasting effects of humanism education courses in medical school, it is necessary to conduct faculty training, and continuously strive to develop new teaching methods.

The Predictive Ratios of Intoxicated Deaths by Police's Death Scene Investigation and Doctor's Death Certificates in South Korea / 대한법의학회지

Forensic autopsies were performed on 1,821 cases in 2014 and 2,024 cases in 2015 at the National Forensic Service Seoul Institute. Based on the autopsy reports, 103 cases (5.7%) in 2014 and 130 cases (6.4%) in 2015 were selected as unnatural deaths caused by fatal intoxication. The cases were divided into five groups. The first group had ethanol intoxication, the second had drug intoxication, the third had agrochemical intoxication, the fourth had cyanide intoxication, and the fifth had miscellaneous intoxications. Of the 233 cases, 202 had death certificates. Of these 202 cases, 169 (83.7%) had an undetermined manner of death (MOD); 17 (8.4%) had an unnatrual MOD and intoxication was the cause of death (COD); nine (4.5%) had an unnatural MOD, but the COD was not intoxication; seven (3.5%) had a natural MOD and disease as a COD. The predictive ratios of intoxication as a COD were compared with the death certificates and the police death scene investigation results. The death certificates and the police investigation results showed predictive ratios of 8.4% and 55.2%, respectively, for intoxication as a COD. The discrepance in these predictive ratios and relatively low predictive ratio of police investigation results mean that intoxicated deaths have been underevaluated; thus, some homicides or intentional deaths were probably missed under South Korea's death investigation system. Doctors who specialize in forensic medicine need to supervise the entire postmortem examination process and emergency blood toxicological analysis should be performed in South Korea.

Ossification of the Medial Clavicular Epiphysis on Chest Radiographs: Utility and Diagnostic Accuracy in Identifying Korean Adolescents and Young Adults under the Age of Majority

The aim of our study was to evaluate the utility and diagnostic accuracy of the ossification grade of medial clavicular epiphysis on chest radiographs for identifying Korean adolescents and young adults under the age of majority. Overall, 1,151 patients (age, 16-30) without any systemic disease and who underwent chest radiography were included for ossification grading. Two radiologists independently classified the ossification of the medial clavicular epiphysis from chest radiographs into five grades. The age distribution and inter-observer agreement on the ossification grade were assessed. The diagnostic accuracy of the averaged ossification grades for determining whether the patient is under the age of majority was analyzed by using receiver operating characteristic (ROC) curves. Two separate inexperienced radiologists assessed the ossification grade in a subgroup of the patients after reviewing the detailed descriptions and image atlases developed for ossification grading. The median value of the ossification grades increased with increasing age (from 16 to 30 years), and the trend was best fitted by a quadratic function (R-square, 0.978). The inter-observer agreements on the ossification grade were 0.420 (right) and 0.404 (left). The area under the ROC curve (AUC) was 0.922 (95% CI, 0.902-0.942). The averaged ossification scores of 2.62 and 4.37 provided 95% specificity for a person < 19 years of age and a person ≥ 19 years of age, respectively. A preliminary assessment by inexperienced radiologists resulted in an AUC of 0.860 (95% CI, 0.740-0.981). The age of majority in Korean adolescents and young adults can be estimated using chest radiographs.