Anticipated deaths with physician care (mitori) at home in one town in Japan: A preliminary report.

Background: There are few reports on the numbers of anticipated deaths (mitori [り]) at home in Japan. Method: We used the Japanese death certificate system (shiboukohyou []) for Toyono town citizens who died between 2020 and 2022 and judged a death to constitute mitori when the certificate was not written by a doctor referred from the police. Results: Among 756 deaths, 109 (14.4%) were mitori at home. Deaths at home were 144 and mitori at home accounted for 75.7%. Conclusion: Shiboukohyou appear to provide numbers of mitori at home. Death certificate should include a space which shows mitori or not.

A study on the diagnostic support system of the repetitive brain concussion based on the reconstruction analysis of the accident.

In this paper the effectiveness of the support system which predicts the risk of the repetitive brain concussion is studied biomechanically. In the risk prediction system, the accident that caused the concussion is reconstructed by analyzing the game video via multibody dynamics and the resulting brain injury is calculated in detail by the finite element method. In order to calculate the aggravation of the brain injury by the repeated brain concussion, the following two methods are examined. In the first method, the material properties of the part of the brain damaged by the1st impact are changed in the simulation of the 2nd impact. In the second method, each brain damage caused by the repeated impacts is accumulated. The system was applied to the real-life accidents that occurred during Judo and American football games. As a result of the simulations, the aggravation of the brain damage due to repetitive concussion was determined numerically in terms of the maximum strain of the brain and the brain damage rate of the whole brain. The biomechanical process of the collision accidents and the resulting brain damage were reconstructed based on the video and the results are effective to prevent the future repeated concussion accidents. J. Med. Invest. 70 : 213-220, February, 2023.

A case of complete decapitation in suicidal hanging : the mechanism and condition of decapitation.

Complete decapitation due to suicide by hanging is rare. We report the case of a decapitated man who was found in the sea near an estuary. A polyethylene rope was tied to the handrail of the bridge across a strait near the site of the body. The rope was 12 mm in diameter and 19 m in length from the handrail. It ended with a slip knot noose, and skin and mustache-like hair fragments were attached to it. The decapitated head was not found. The deceased weighed 82 kg and was 152 cm long without the head. The autopsy revealed coarse abrasions and intramuscular hemorrhage around the severed edge. The third cervical spine was not fractured. We reviewed the literature and suggested the conditions of body weight, fall height, rope diameter, and number of rolls in cases of decapitation by hanging. We calculated the hanging decapitation index (HDI) as the fall height (m) multiplied by the body weight (kg), divided by the rope diameter (mm), divided by the number of rolls ; and discussed the differences between complete and incomplete decapitation cases. J. Med. Invest. 70 : 290-293, February, 2023.

A case of fatal multi-organ inflammation following COVID-19 vaccination.

A 14-year-old Japanese girl died unexpectedly 2 days after receiving the third dose of the BNT1262b2 mRNA COVID-19 vaccine. Autopsy findings showed congestive edema of the lungs, T-cell lymphocytic and macrophage infiltration in the lungs, pericardium, and myocardium of the left atria and left ventricle, liver, kidneys, stomach, duodenum, bladder, and diaphragm. Since there was no preceding infection, allergy, or drug toxicity exposure, the patient was diagnosed with post-vaccination pneumonia, myopericarditis, hepatitis, nephritis, gastroenteritis, cystitis, and myositis. Although neither type of inflammation is fatal by itself, arrhythmia is reported to be the most common cause of death in patients with atrial myopericarditis. In the present case, arrhythmia of atrial origin was assumed as the cause of cardiac failure and death. In sudden post-vaccination deaths, aggressive autopsy systemic search and histological examination involving extensive sectioning of the heart, including the atrium, are indispensable.

An infant autopsy case of bowel obstruction due to internal abdominal hernia.

Internal abdominal hernia, defined as protrusion of viscera through a defect of the mesentery, has been considered a rare clinical entity. Recent clinical reviews reported a wide range of onset age (from newborns to the elderly) and symptoms (from minimal abdominal symptoms to severe acute abdomen). Sudden and unexpected death due to internal abdominal hernia is rare in infants or toddlers, and only 4 autopsy cases had been reported previously. We report the case of a 3-month-old Japanese boy who unexpectedly died 4 h after first vomiting. Autopsy showed a wide bowel obstruction with necrosis through a congenital mesenteric defect. The larynx was filled with gastric content (milky white viscous muddy material). In the cross section of both lungs, the same material was found to be expressed from the bronchioles. We diagnosed the cause of death as asphyxiation by viscous milk/vomitus aspiration caused by bowel obstruction due to an internal abdominal hernia. In case of sudden and unexpected death of an infant, autopsy is crucial to determine the cause of death. During autopsy, it is helpful to determine the character and distribution of gastric and airway contents to confirm milk or vomitus aspiration.

Autopsy case of right ventricular rhabdomyoma in tuberous sclerosis complex.

Tuberous sclerosis complex (TSC) is a genetic multisystem disorder characterized by widespread hamartomas in several organs, including the brain, heart, skin, eyes, kidney, lung, and liver. Rhabdomyoma is the most common cardiac tumor diagnosed in fetuses, neonates and infants, and is closely linked to TSC. Here we describe an autopsy case of right ventricular rhabdomyoma in TSC. The deceased was a 3-month-old male infant, and TSC with a cardiac tumor had been diagnosed before his death. Since the cardiac tumor had not been physically blocking the blood flow, he had not undergone surgical intervention. At autopsy, the patient's height was 62 cm and his body weight was 6 kg. The heart weighed 37.3 g and the right ventricle was filled with the tumor. The tumor measured 2.1 cm × 1.6 cm, being a fusion of multiple tumors with several attachment sites to the myocardium. Histologically, the tumor was diagnosed as a rhabdomyoma, and was positive for mammalian target of rapamycin (mTOR). The brain weighed 795.0 g, without hydrocephalus. The cut surface of the brain revealed multiple cortical tubers and subependymal nodules. Through screening for the TSC1 (hamartin) and TSC2 (tuberin) genes, a nonsense mutation, c.1108C>T:p.Gln370∗, was detected in the TSC2 gene. Immediate cause of death was determined to be ventricular obstruction by a cardiac rhabdomyoma with insidious growth. This case highlights the need for forensic pathologists to perform a complete autopsy to determine the cause of sudden death with cardiac tumor, including genetic examination.

Sudden cardiac death during first-time jogging.

With increased interest in fitness and health care, jogging has become more popular as an exercise to promote health. However, sudden cardiac death during sports or exercise has also been reported. Some apparently healthy elderly individuals take up sports for both recreation and health improvement based only on completion of a questionnaire, without undergoing medical evaluation. We report the case of a 66-year-old Japanese man who suddenly died of acute ischemic heart disease during first-time jogging. He collapsed an hour after starting. A trainer promptly started cardiopulmonary resuscitation. An automated external defibrillator (AED) was applied, and defibrillation was attempted once by bystanders. However, he remained in cardiopulmonary arrest until he reached the emergency department, where he was pronounced dead. The autopsy found concentric hypertrophy of the left ventricular wall without fibrosis or degeneration, atherosclerotic changes in the coronary arteries, and severe lung congestion. We diagnosed death from acute myocardial ischemia. We suspect that many healthy elderly individuals have provoked a heart attack by prematurely attempting moderate or vigorous exercise, as in this case. The elderly require comprehensive medical assessment before exercise can be started. Moreover, this case shows that an AED is not always helpful. J. Med. Invest. 64: 184-186, February, 2017.

Postmortem Diagnosis of Anorexia Nervosa: An Endocrinological and Immunohistochemical Approach.

A female in her 30s was found dead after a fire. She was severely emaciated and had been diagnosed with anorexia nervosa (AN) about 5 years ago, but had not been treated recently. Therefore, we investigated not only her cause of death but also her condition of AN. Some of her organs weighed less than normal although no clear lesions were observed. In the pituitary gland, the number of follicle-stimulating hormone-immunopositive cells was markedly decreased although a normal number of thyroid-stimulating hormone-positive cells were detected. A histological examination of the ovary suggested that she had been suffering from amenorrhea. The thyroid gland was atrophic, and marked variations in follicle size were observed. Because we could not obtain enough volume of her blood for endocrinological examinations, we tried to investigate her endocrinological condition by immunohistochemistry. Immunohistochemical staining detected decreased triiodothyronine immunoreactivity and normal thyroxine immunoreactivity. The adrenal glands were also atrophic. Based on these findings, it was considered that she had been suffering from AN at the time of her death. The autopsy and other findings revealed that she had died of burning with carbon monoxide intoxication. J. Med. Invest. 63: 305-309, August, 2016.

Identification of transcriptional regulatory elements for Ntng1 and Ntng2 genes in mice.

BACKGROUND: Higher brain function is supported by the precise temporal and spatial regulation of thousands of genes. The mechanisms that underlie transcriptional regulation in the brain, however, remain unclear. The Ntng1 and Ntng2 genes, encoding axonal membrane adhesion proteins netrin-G1 and netrin-G2, respectively, are paralogs that have evolved in vertebrates and are expressed in distinct neuronal subsets in a complementary manner. The characteristic expression patterns of these genes provide a part of the foundation of the cortical layer structure in mammals. RESULTS: We used gene-targeting techniques, bacterial artificial chromosome (BAC)-aided transgenesis techniques, and in vivo enhancer assays to examine transcriptional mechanisms in vivo to gain insight into how the characteristic expression patterns of these genes are acquired. Analysis of the gene expression patterns in the presence or absence of netrin-G1 and netrin-G2 functional proteins allowed us to exclude the possibility that a feedback or feedforward mechanism mediates their characteristic expression patterns. Findings from the BAC deletion series revealed that widely distributed combinations of cis-regulatory elements determine the differential gene expression patterns of these genes and that major cis-regulatory elements are located in the 85-45 kb upstream region of Ntng2 and in the 75-60 kb upstream region and intronic region of Ntng1. In vivo enhancer assays using 2-kb evolutionarily conserved regions detected enhancer activity in the distal upstream regions of both genes. CONCLUSIONS: The complementary expression patterns of Ntng1 and Ntng2 are determined by transcriptional cis-regulatory elements widely scattered in these loci. The cis-regulatory elements characterized in this study will facilitate the development of novel genetic tools for functionally dissecting neural circuits to better understand vertebrate brain function.

Immunohistochemical investigation of the coma blister and its pathogenesis.

The erythematous patches and vesicles that are observed in coma patients, usually from an overdose of medication, are known as coma blisters. However, it is unknown whether the degenerated sweat gland is a necrosis or apoptosis. We immunohistochemically examined such skin lesions to investigate the characteristics and pathogenesis of the coma blister. Skin lesions were obtained from a forensic autopsy case, a woman in her thirties, of caffeine intoxication. Those lesions were observed in the left femoral, the lower left thigh, and the right knee. Histologically, the skin lesions showed that the keratinocytes had necrosed and the epidermis was thin in some areas. Eccrine sweat gland degeneration was observed. Obvious inflammatory cell infiltrations were not detected. Immunohistochemically, we stained each skin lesion against CD3, CD8, CD45RO, cytokeratin, 70 kD heat shock protein, ubiquitin, 150 kD oxygen regulated protein, and caspase-cleaved keratin 18 neo-epitope M30. They were also stained with an in situ apoptosis detection kit. Degenerated sweat glands featured CD45RO and M30 immunoreactivity. Immunohistochemical staining for CD45RO, CK-L, and M30 might be useful to observe sweat gland degeneration in the coma blister. Therefore, the apoptosis might be related to coma blisters and sweat gland degenerations.

Fatal child abuse in Japan: does a trend exist toward tougher sentencing?

BACKGROUND: It has been pointed out in Japan that criminal punishment in domestic homicide cases, especially in fatal child abuse cases, tends to be more lenient than in public homicide cases that occur outside the home. In recent news accounts of fatal child abuse cases, however, the media has reported that court-imposed sentences have tended to be stricter every year. METHODS: Using the online databases of three major Japanese newspapers, we collected articles about fatal child abuse cases that had been published from January 2008 to December 2009. We analyzed these articles to determine, whether a tendency towards tougher penalties, as was put forward by the media, actually exists at present time in the criminal system in Japan. RESULTS: We found 24 cases, out of which 20 involved only one offender and 4 involved two offenders. These 28 offenders comprised nine biological fathers, 11 biological mothers, and eight other male relatives of the child victims. We found that the sentences handed down by the court clearly tended to be more lenient for female offenders. A new system of criminal jurisprudence, the so-called saiban-in system wherein citizens serve as "lay judges" in criminal trials involving serious crimes, was implemented in Japan at the start of 2009. Each, district court has gradually adopted this new system after a preparation period of approximately five years starting in 2004. CONCLUSIONS: Many figures in the Japanese media predicted that the gap between social expectations and court sentences for sanction against domestic homicide cases would be filled with the present transitional period of the Japanese criminal system. However, the present study found no significant difference in the laws regarding sentencing in fatal child abuse cases before and after the preparation period of the saiban-in system.

Dopamine neurons in the ventral tegmental area: an autopsy case of disorganized type of schizophrenia.

The mesolimbic dopamine (DA) system has been associated with the pathogenesis of schizophrenia. Here, we examined DA-containing neuronal structures of the ventral tegmental area (VTA) of an autopsy case of disorganized type of schizophrenia (75-year-old female), using tyrosine hydroxylase (TH) immunohistochemistry. A free floating method using 50-µm cryostat sections and three-dimensional imaging analyzer AxioVision were applied to observe the wide range structures of TH-immunoreactive (-ir) neurons. TH-ir neuronal cell bodies in the VTA of the present case had irregular shape and various size, and TH-ir neuronal processes had irregular thickness and straightened shape or curved shape having many corners, when compared to a control autopsy case with no detectable neurological and psychiatric diseases (64-year-old male). The mechanisms underlying the morphological characteristics of DA neurons of the brains with schizophrenia should be elucidated epigenetically as well as genetically.

Are lectin positive spherical deposits detected in the molecular layer of the hippocampal formation related with neuronal apoptosis?

Previously, multi-lectin positive spherical shaped deposits were detected in the hippocampal formation of degenerative demented and schizophrenic brains and reported they possessed some possibility as a predominant tool of postmortem diagnosis, more detected in schizophrenia cases than age-matched control cases. Multi-fluorescent immunohistochemical and lectin histochemical method and immuno electron microscope method were performed on 51 forensic autopsied brains containing 16 cases of schizophrenia. In multi-fluorescent staining, partial disrupted nucleus with decreased staining properties by mean of SYBR green were detected, and lectin and single strand DNA were co-stained in the portion of partial disrupted nucleus. In immuno electron microscope method, lectin positive structures were also detected in the portion of partial disrupted nucleus. These neurons were suspected in the process of apoptosis by their distinguishable features. Some experimental studies were reported that a kind of therapeutic products of major tranquillizers induced neuron apoptosis in dentate gyrus. As the lectin positive spherical shaped deposits were detected in not only 5 schizophrenia cases without drug treatment but also in 11 schizophrenia cases with drug treatment in this study, they might be detected as the intrinsic pathological change of schizophrenia. The lectin positive spherical shaped deposits detected in the hippocampal formation were suspected as the histopathological marker of the postmortem diagnosis for schizophrenia. Further examination for specifying group of neurons detected them in and initiated apoptosis are necessitated.

Aromatic L-amino acid decarboxylase-immunoreactive structures in human midbrain, pons, and medulla.

The objective of the present study was to determine with precision the localization of neurons and fibers immunoreactive (ir) for aromatic L-amino acid decarboxylase (AADC), the second-step enzyme responsible for conversion of L-dihydroxyphenylalanine (L-DOPA) to dopamine (DA) and 5-hydroxytryptophan (5-HTP) to serotonin (5-hydroxytryptamine: 5-HT) in the midbrain, pons, and medulla oblongata of the adult human brain. Intense AADC immunoreactivity was observed in a large number of presumptive 5-HT neuronal cell bodies distributed in all of the raphe nuclei, as well as in regions outside the raphe nuclei such as the ventral portions of the pons and medulla. Moderate to strong immunoreaction was observable in presumptive DA cells in the mesencephalic reticular formation, substantia nigra, and ventral tegmental area of Tsai, as well as in presumptive noradrenergic (NA) cells, which were aggregated in the locus coeruleus and dispersed in the subcoeruleus nuclei. In the medulla oblongata, immunoreaction of moderate intensity was distributed in the mid and ventrolateral portions of the intermediate reticular nucleus, which constitutes the oblique plate of A1/C1 presumptive adrenergic and/or NA neurons. The dorsal vagal AADC-ir neurons were fewer in number and stained more weakly than cells immunoreactive for tyrosine hydroxylase (TH). AADC immunoreactivity was not identified in an aggregate of TH-ir neurons lying in the gelatinous subnucleus of the solitary nucleus, a restricted region just rostroventral to the area postrema. Nonaminergic AADC-positive neurons (D neurons), which are abundant in the rat and cat midbrain, pons, and medulla, were hardly detectable in homologous regions in the human brain, although they were clearly distinguishable in the forebrain.

Influence on the suicide rate two years after a devastating disaster: a report from the 1995 Great Hanshin-Awaji Earthquake.

AIMS: The relationship between suicide and disaster is an important problem but it's not clear. We conducted this study to determine whether a natural disaster affects suicide rates. METHODS: We collected data on suicides during the 84 months before and the 60 months after the earthquake and compared the suicide rate in Kobe to that in Japan as a whole. We also examined what groups were significantly affected. RESULTS: Compared with Japan as a whole, the suicide rates in Kobe significantly decreased in the 2 years after the earthquake. CONCLUSIONS: An influence on suicide rate after the disaster clearly appeared in middle-aged men.

An autopsy case of severe pleuritis induced by misinsertion of a nasogastric nourishment tube: diagnostic significance of multinucleated giant cells.

An 87-year-old female who had been hospitalized due to pneumonia was administered nourishment through a nasogastric tube. She collapsed as a result of dyspnea after the insertion of a new tube and administration of nourishment. Chest X-rays revealed that the tube was inserted into the left pleural cavity passing the trachea and left bronchi and that the nourishment pooled. In spite of immediate treatment including removal of the tube and insertion of a drain, she died 12 days later. Autopsy findings: Both the left pulmonary and parietal pleurae were thickened and covered with a dirty gray-yellowish moss-like paste. The left lower lobe was softened, and this region was suspected as the ruptured site of the pleura. Histological findings: A part of the thick pleura with inflammatory cells, including multinucleated giant cells, was positive-stained for anti alpha-lactalbumin antibody immunohistochemically. These giant cells are often observed in granulomatous inflammation against a foreign material. It was considered that those in the pleura had been induced by the nourishment, and that those in the pulmonary parenchyma had been affected by the insertion of the tube. The multinucleated giant cells clarified the cause of fatal pleuritis and pneumonia and the misinsertion of the tube.

Immunohistochemical studies on early stage of hepatic damage induced by subacute inhalation of toluene vapor in rats.

Toluene is one of the most widely used organic solvents and is commonly recognized as a noxious substance inducing chronically toxic damage to neural, hepatic and renal functions in the workers engaged in printing and painting. Although hepatic cells are generally considered to be vulnerable and susceptible to various organic solvents, particularly chloroform and other halogenated hydrocarbons, the hepatotoxic effects of aromatic hydrocarbons including toluene have not yet been sufficiently characterized. In particular, it still seems unclear whether toluene itself can directly act on hepatic cells, inducing toxic damage to their metabolism and function. To assess the toxic effect of toluene inhalation on rat liver, immunohistochemical analyses of the histological markers for hepatic damage were carried out in animals exposed subacutely to toluene vapor. The immunoreactivities of heat shock proteins (HSP-70 and HSP-90) and cytochrome P4502E1 (CYP2E1) in the liver were analyzed to assess the hepatotoxic damage induced by toluene inhalation, and the expression of these histological markers was shown to be substantially enhanced by the subacute exposure to toluene vapor. Toluene inhalation was furthermore shown to enhance the immunoreactivities of alpha-smooth muscle actin (alpha-SMA), collagen, glucocorticoid receptors (GR) and leptin receptors (Ob-R) in the liver. Additional studies using human hepatoma HepG2 cells showed that toluene can directly induce toxic damage to cells. These findings suggest that toluene inhalation may primarily induce hepatic damage, which may be secondarily exacerbated by the activation of systemic processes possibly connected with glucocorticoids and leptin.

The sentence and Kyukei in Japanese criminal procedure, especially in domestic homicide cases.

Kyukei is the prosecutor's suggestion of punishment for the accused in the closing argument in the Japanese criminal court. It is rumored that the court sentence is foreseeable in 8 out of 10 of Kyukei. In this study, the ratio of the average sentence against the Kyukei for Oyako-shinju cases was confirmed to be 0.85 for male offenders and 0.71 for female offenders. Although there is a somewhat lenient tendency observed for female offenders, the ratio may almost be found around 0.8. To make a comparative study, we referred to the Kyukei and sentences of out-of-home murder cases and fatal child abuse cases. In the murder case, the ratio of the average sentence against the Kyukei is 0.83, whereas in the child abuse case it is 0.73. What is called the "myth of 8 out of 10" is more applicable for the male offenders who commit the majority of crimes, than for the females. Most of the crimes committed by women are domestic in nature. Indeed, because most women's domestic cases are due to husbands who are absent, behave violently, or are irresponsible, their circumstances of committing the crimes may be taken into account by the judge.