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Objectives: Gas is a common finding in cervical intervertebral separation. However, intervertebral gas is also found in many decedents without intervertebral separation. Here, we quantified intervertebral gas and examined its value in the diagnosis of cervical intervertebral separation., Methods: We retrospectively reviewed data from 1118 decedents who underwent post-mortem computed tomography (CT) and autopsy from May 2011 to July 2016 and selected those with cervical intervertebral gas with or without intervertebral separation. These data comprised 56 cervical intervertebral spaces with gas [intervertebral separation in 19 (33.9%)] in 43 subjects [intervertebral separation in 17 (39.5%)]. We categorised the decedents according to gas volume, position, and shape and determined the significance of the differences between the decedents with and without separation., Results: The gas volume did not differ significantly between decedents with and without separation (p = 0.063). However, there were significant differences in the gas position between decedents with and without separation. In the sagittal plane: gas was seen in the "centred" position in the ventral-to-dorsal direction in more decedents without separation than in those with separation (p = 0.018). Gas was seen in the ventral-to-dorsal positions in more decedents with separation than in those without separation (p = 0.049). In the cranio-caudal direction, gas in the upper position was more common in decedents with separation than in those without separation in the sagittal plane (p = 0.03). In the coronal plane: gas was seen in the upper position more frequently in decedents with separation in the cranio-caudal direction than in those without separation (p = 0.001). A significant difference in gas shape was observed only in the coronal plane (p = 0.024); irregular gas was associated with decedents without separation., Conclusion: Gas in the ventral-to-dorsal and upper positions in the sagittal plane and in the upper position in the coronal plane was rather indicative of cervical intervertebral separation. An irregular gas shape in the coronal plane was indicative of degenerative changes., Competing Interests: Conflict of interest The authors declare no conflicts of interest associated with this manuscript., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Excessive intake of caffeine, otherwise known to be a safe and mild central nervous system stimulant, causes nausea, vomiting, convulsions, tachycardia, and eventually fatal arrhythmias and death. Caffeine intoxication, a global problem, has been increasing in Japan since 2013. Thus, there is a need for rapid and accurate diagnosis of caffeine poisoning in forensic and clinical toxicology investigations. Herein, we demonstrate rapid and accurate caffeine quantitation by liquid chromatography tandem mass spectrometry using the standard addition method in a fatal case. Biological samples were diluted 500-100,000-fold and subjected to a simple pretreatment (adding caffeine standard and internal standard and passing through a lipid removal cartridge). The multiple reaction monitoring transitions were 195 → 138 for quantitation, 195 → 110 for the qualifier ion, and 204 → 144 for the internal standard (caffeine-d9). The standard plots were linear over 0-900 ng/mL (r 2  = 0.9994-0.9999) for biological samples, and the reproducibility (%RSD) of the method was 1.53-6.97% (intraday) and 1.59-10.4% (interday). Fatal levels of caffeine (332 μg/mL) and toxic to fatal levels of olanzapine (625 ng/mL), along with other pharmaceuticals were detected in the external iliac venous blood. The cause of death was determined to be multi-drug poisoning, predominantly caused by caffeine. Our method is useful for not only forensic cases but also the rapid diagnosis of caffeine overdose in emergency clinical settings., (Copyright © 2020 Elsevier Inc. All rights reserved.)

A 4-year-old girl who had been treated for asthma since the age of 2 years had a severe coughing fit and died suddenly. The patient had a history of occasional severe coughing fits, and these fits had been worsening in severity during the week before her death. Prior to death, she was taken to a clinician, and thymic hypertrophy was suspected based on chest X-ray findings. The clinician recommended that she visit a general hospital at a later date; however, she died that night. Postmortem radiology and autopsy revealed a large mass in the anterior mediastinum compressing the heart and airway, and no other findings attributable to sudden death were observed. Therefore, we concluded that the patient's death was attributable to acute respiratory and cardiac circulatory failure secondary to the pressure induced by the mass. Microscopically, the mass showed a cavernous structure composed of cystically dilated, thin-walled large vessels filled with blood. The final diagnosis was a cavernous hemangioma. Hemangiomas are the most common benign vascular anomalies seen in young children; however, mediastinal hemangiomas are rare and can cause life-threatening complications because of their size and location. Therefore, forensic pathologists should include hemangioma as a differential diagnosis in children with anterior mediastinal masses., (Copyright © 2017 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

In determining the time of death in infants based on rectal temperature, the same methods used in adults are generally used. However, whether the methods for adults are suitable for infants is unclear. In this study, we examined the following 3 methods in 20 infant death cases: computer simulation of rectal temperature based on the infinite cylinder model (Ohno's method), computer-based double exponential approximation based on Marshall and Hoare's double exponential model with Henssge's parameter determination (Henssge's method), and computer-based collinear approximation based on extrapolation of the rectal temperature curve (collinear approximation). The interval between the last time the infant was seen alive and the time that he/she was found dead was defined as the death time interval and compared with the estimated time of death. In Ohno's method, 7 cases were within the death time interval, and the average deviation in the other 12 cases was approximately 80 min. The results of both Henssge's method and collinear approximation were apparently inferior to the results of Ohno's method. The corrective factor was set within the range of 0.7-1.3 in Henssge's method, and a modified program was newly developed to make it possible to change the corrective factors. Modification A, in which the upper limit of the corrective factor range was set as the maximum value in each body weight, produced the best results: 8 cases were within the death time interval, and the average deviation in the other 12 cases was approximately 80min. There was a possibility that the influence of thermal isolation on the actual infants was stronger than that previously shown by Henssge. We conclude that Ohno's method and Modification A are useful for death time estimation in infants. However, it is important to accept the estimated time of death with certain latitude considering other circumstances., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

A man in his 40s was found unconscious on a sofa in a communal residence for people with various disabilities. He appeared to have drunk 800 ml of undiluted citric acid from a commercial plastic bottle. The instructions on the label of the beverage specified that the beverage be diluted 20- to 30-fold before consumption. The patient was admitted to an emergency hospital with severe metabolic acidosis (pH, 6.70; HCO3(-), 3.6 mEq/L) and a low ionized calcium level (0.73 mmol/L). Although ionized calcium and catecholamines were continuously administered intravenously to correct the acidosis, the state of acidemia and low blood pressure did not improve, and he died 20 h later. Citric acid concentrations in the patient's serum drawn shortly after treatment in the hospital and from the heart at autopsy were 80.6 mg/ml and 39.8 mg/dl, respectively (normal range: 1.3-2.6 mg/dl). Autopsy revealed black discoloration of the mucosal surface of the esophagus. Microscopically, degenerated epithelium and neutrophilic infiltration in the muscle layer were observed. In daily life, drinking a large amount of concentrated citric acid beverage is rare as a cause of lethal poisoning. However, persons with mental disorders such as dementia may mistakenly drink detergent or concentrated fluids, as in our case. Family members or facility staff in the home or nursing facility must bear in mind that they should not leave such bottles in places where they are easily accessible to mentally handicapped persons., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Infant cases frequently show a diffuse increase in the concentration of lung fields on post-mortem computed tomography (PMCT). However, the lungs often show simply atelectasis at autopsy in the absence of any other abnormal changes. Thus, we retrospectively reviewed the PMCT findings of lungs following sudden infant death and correlated them with the autopsy results., Materials and Methods: We retrospectively reviewed infant cases (0 year) who had undergone PMCT and a forensic autopsy at our institution between May 2009 and June 2013. Lung opacities were classified according to their type; consolidation, ground-glass opacity and mixed, as well as distribution; bilateral diffuse and areas of sparing. Statistical analysis was performed to assess the relationships among lung opacities, causes of death and resuscitation attempt., Results: Thirty infant cases were selected, which included 22 sudden and unexplained deaths and 8 other causes of death. Resuscitation was attempted in 22 of 30 cases. Bilateral diffuse opacities were observed in 21 of the 30 cases. Of the 21 cases, 18 were sudden and unexplained deaths. Areas of sparing were observed in 4 sudden and unexplained deaths and 5 other causes of death. Distribution of opacities was not significantly associated with causes of death or resuscitation attempt. The 21 cases with bilateral diffuse opacities included 6 consolidations (4 sudden and unexplained deaths, 2 other causes of death), 4 ground-glass opacities (3 sudden and unexplained deaths and 1 other) and 11 mixed (11 sudden and unexplained deaths). Types of opacities were not significantly associated with causes of death or resuscitation attempt., Conclusion: Atelectasis is very common in sudden and unexplained death of infants. Bilateral diffuse mixed opacity was observed only in sudden and unexplained deaths. Bilateral diffuse pure consolidation or ground-glass opacity was also observed in other causes of death., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

A middle-aged female patient with a depressive disorder presented to a mental hospital because of a 2-month worsening history of headache, dizziness, and nausea. The next morning, she was observed to be sleeping, but was then found dead 1h later. Postmortem computed tomography and autopsy revealed a large cyst in the right cerebellar hemisphere, hydrocephalus, and transforaminal herniation. Careful observation revealed an approximately 0.4cm×0.8cm slightly grayish discoloration in the cyst wall that was diagnosed as hemangioblastoma based on its histological features. Finally, we concluded that the cause of death in this case was attributable to the brain stem compression, which was caused by obstructive hydrocephalus secondary to the cystic hemangioblastoma in the cerebellum. The symptoms for 2 months before her death had most likely resulted from increased intracranial pressure. Hemangioblastomas usually appear as nodules in the wall of the cyst, but the tumor in our case looked like just a slightly grayish discoloration. Therefore, cystic lesions in the CNS need to be carefully examined., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

A 40-year-old man was scheduled for video assisted thoracoscopic surgery due to pneumothorax. He had been diagnosed with inclusion body myositis and received nocturnal non-invasive positive pressure ventilation. Anesthesia was induced with propofol, remifentanil, and rocuronium, and maintained with propofol, remifentanil and fentanyl. The dosage of rocuronium was 10 mg. Although we administered neostigmine at the end of the operation and TOF ratio was over 90%, he was transported to the ICU with tracheal intubation because of poor spontaneous respiration. On POD 1, the tracheal tube was extubated and NPPV was administered again. Minitrach was inserted on POD 2, and he left the ICU on POD 4. Generally, in patients with myopathy the dose of muscle relaxant should be decreased in proportion to their muscle atrophy. Rocuronium 10 mg was administered in this case and we thought it could be antagonized by neostigmine, but extubation on the day of operation was impossible. We think this is not because of the residual effect of muscle relaxant, but because of decreases in pulmonary function. In this case, we expected long-term mechanical ventilation might be necessary, but he showed a good postoperative course owing to minimally invasive surgery, NPPV, and suctioning of sputum via Minitrach.

A 3-year-old girl with no particular medical history complained of a stomachache and died on the way to the hospital. The autopsy revealed marked right ventricular hypertrophy and dilation with no other cardiac abnormalities. Microscopically, the pulmonary small arteries showed marked medial hypertrophy and varying degrees of intimal and adventitial thickening. We supposed that the cause of death was attributable to pulmonary arterial hypertension (PAH). PAH is a rare disease that can cause sudden, unexpected death at any age. Forensic pathologists should consider PAH in the differential diagnosis of sudden death., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

An elderly person died of uncontrolled bradycardia in a hospital. The doctor had prescribed 1.35 mg of bisoprolol fumarate orally, but a nurse mistakenly gave the patient 10 mg of the drug 9 hours prior to her death. Bisoprolol was detected in her blood by liquid chromatography-mass spectrometry at a concentration of 176 ng/mL. Even if the patient had chronic heart failure, this concentration is double the expected value. This patient was found to have a mutation within cytochrome P2D6, with thymidine substituted for cytosine at position 100 and cytosine for guanine at position 4180, causing proline to serine and threonine to serine amino acid substitutions. This mutation in the intermediate metabolizer allele reportedly reduces enzyme activity by half. However, in addition to the type of cytochrome P450 allelic variant, the amount of enzyme product influences metabolism of this drug. In this case, the high blood concentration of bisoprolol was only partly attributable to an error in prescription; its concentration was inexplicably high., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)