脑钠尿肽的表达调控机制及其法医学应用

脑钠尿肽是主要由心肌细胞分泌的钠尿肽类激素,通常在心肌细胞受到牵拉时产生,具有利钠、利尿、舒张血管、调节血压等功能。临床上BNP是反映心功能的重要指标之一,近年的研究表明,BNP在法医学中对心源性猝死的诊断也具有十分重要的价值。本文综述了BNP的分子结构、表达调控及法医学应用的进展。     

178例心源性猝死法医组织病理学诊断分析

目的探讨心源性猝死(SCD)的病理特点与鉴别要点。方法对四川华西法医学鉴定中心2000—2005年尸检出的178例SCD死亡案例进行回顾性分析,主要对其病因、年龄、诱因及病理改变进行分析。结果本组资料显示冠心病、心传导系统病变、心肌炎、心肌病等在SCD中占有较大比例。冠心病猝死是中老年人SCD的最主要原因,青壮年人SCD的病因以非冠心病为主。如传导系统病变、心肌炎、心肌病。在儿童的SCD中先天性心脏病、传导系统病变及心肌炎占主导地位。结论不同的病因,其病理特点不同,其病理变化是法医学鉴定的主要依据。     

Use of Cardiac Injury Markers in the Postmortem Diagnosis of Sudden Cardiac Death

In the daily practice of forensic pathology, sudden cardiac death (SCD) is a diagnostic challenge. Our aim was to determine the usefulness of blood biomarkers [creatine kinase CK‐MB, myoglobin, troponins I and T (cTn‐I and T), and lactate dehydrogenase] measured by immunoassay technique, in the postmortem diagnosis of SCD. Two groups were compared, 20 corpses with SCD and 8 controls. Statistical significance was determined by variance analysis procedures, with a post hoc Tukey multiple range test for comparison of means (p < 0.05). SCD cases showed significantly higher levels (p < 0.05) of cTn‐T and cTn‐I compared to the control group. Although only cases within the first 8 h of postmortem interval were included, and the control group consisted mainly of violent death cases, our results suggest that blood troponin levels may be useful to support a diagnosis of SCD.     

过敏性和冠心病猝死者心肌组织中肥大细胞类胰蛋白酶、脑利钠肽的表达

目的探讨肥大细胞类胰蛋白酶、脑利钠肽(brain natriuretic peptide,BNP)在过敏性猝死和冠心病猝死鉴别诊断中的意义。方法选取山西医科大学法医病理学教研室2010—2015年尸检案例心肌标本共30例,分为颅脑损伤致死组、过敏性猝死组、冠心病猝死组,每组各10例。采用免疫荧光染色和Western印迹法分析各组心肌组织肥大细胞类胰蛋白酶和BNP的表达。结果过敏性猝死组、冠心病猝死组心肌组织内肥大细胞类胰蛋白酶免疫荧光染色均出现阳性染色;三组间两两比较,表达差异均具有统计学意义(P0.05)。冠心病猝死组心肌组织内BNP的表达量高于过敏性猝死组、颅脑损伤致死组(P0.05),过敏性猝死组与颅脑损伤致死组之间差异无统计学意义(P0.05)。结论联合检测心肌组织内肥大细胞类胰蛋白酶、BNP有望为过敏性猝死和冠心病猝死的法医学鉴别诊断提供帮助。     

生物化学指标检测在心源性猝死法医鉴定中的应用

早期缺血性心肌病变引起的心源性猝死（sudden cardiac death,SCD）由于发病突然,常缺乏典型的形态学改变和临床表现,易被怀疑为刑事案件,查明其死亡原因对法医学实践有指导作用。本文对国内外有关无机离子、肌酸激酶、肌钙蛋白、心房利钠尿肽、脑利钠尿肽等生物化学指标检测在诊断SCD方面的研究进展加以综述,以期为SCD的法医学诊断提供参考。     

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。     

IMA和H-FABP在心源性猝死法医学诊断中的应用

急性心肌缺血的发生是心源性猝死的最常见原因,而如何认定早期急性心肌缺血是法医学研究的热点,同时也是临床预防心肌梗死发生的重要环节。本文通过对缺血修饰白蛋白(ischemia modified albumin,IMA)和心型脂肪酸结合蛋白(heart-type fatty acid binding protein,H-FABP)的结构、功能、临床应用价值及法医学中的应用前景进行综述,旨在分析二者是否可作为早期心肌缺血的生化检测指标用于心源性猝死的诊断,并为今后选择心源性猝死的科研方向提供借鉴。     

Measurement of Postmortem Pupil Size: A New Method with Excellent Reliability and Its Application to Pupil Changes in the Early Postmortem Period

Measurement of postmortem pupil width is a potential component of death time estimation. However, no standardized measurement method has been described. We analyzed a total of 71 digital images for pupil–iris ratio using the software ImageJ. Images were analyzed three times by four different examiners. In addition, serial images from 10 cases were taken between 2 and 50 h postmortem to detect spontaneous pupil changes. Intra‐ and inter‐rater reliability of the method was excellent (ICC > 0.95). The method is observer independent and yields consistent results, and images can be digitally stored and re‐evaluated. The method seems highly eligible for forensic and scientific purposes. While statistical analysis of spontaneous pupil changes revealed a significant polynomial of quartic degree for postmortem time (p = 0.001), an obvious pattern was not detected. These results do not indicate suitability of spontaneous pupil changes for forensic death time estimation, as formerly suggested.     

Sudden Death from Cardiopulmonary Arrest on Arrival of a Patient with Pulmonary Tuberculosis: A Case Diagnosed by Postmortem CT and Autopsy

Sudden death due to massive hemoptysis during management of tuberculosis occurs in a considerable number of patients. However, when massive airway hemorrhage occurs in a patient in whom tuberculosis has not been confirmed and a blood is not apparent externally on the face/body, it is difficult to immediately identify the cause of death as airway obstruction by tuberculous bleeding in the airway. We encountered an 83‐year‐old Japanese woman with her medical history included treatment of tuberculosis in her 20s who was in cardiopulmonary arrest on arrival (CPAOA), and the cause of sudden death could not initially be identified. Postmortem CT (PMCT) and autopsy revealed that the cause of sudden death was airway obstruction/asphyxia by tuberculous massive airway hemorrhage. Identification of the cause of death facilitated a subsequent active contact investigation and led to prevention of secondary tuberculosis infection.     

Sudden Cardiac Deaths in Adults with Congenital Heart Disease with Structural Abnormalities: A Retrospective Review of Cases in the Cook County Medical Examiner's Office

Sudden cardiac death is a significant cause of mortality in adults with congenital heart disease (CHD). The Cook County Medical Examiner's Office database was queried for cases of CHD as a cause of death in the period between July 2008 and April 2019. Twenty-two cases were identified, including 11 decedents with simple defects and 10 decedents with complex defects. All of the subjects were in apparent good health at the time of death. In the absence of other obvious causes of death, simple defects were considered cases of sudden cardiac death. Significant cardiac morphological changes were common in complex defects. While 16 cases had known, diagnosed/treated CHD, 5 cases had no diagnosis prior to autopsy. In these cases, the ability to recognize CHD (sometimes subtle) helped in determining the causes of death. Therefore, forensic pathologists must be able to properly recognize various forms of CHD and request consultations, when needed.     

Temperature‐Dependent Postmortem Changes in Human Cardiac Troponin‐T (cTnT): An Approach in Estimation of Time Since Death

Estimation of time of death is an indispensible requirement of every medico‐legal autopsy, but unfortunately, there is not a single method by which it could be determined accurately. This study focused on the temperature‐dependent postmortem degradation of cardiac troponin‐T and its association with postmortem interval (PMI) in human. The analysis involved extraction of the protein, separation by denaturing gel electrophoresis (SDS‐PAGE), and visualization by Western blot using cTnT‐specific monoclonal antibodies. The area of the bands within a lane was quantified by scanning and digitizing the image using Gel Doc (Universal Hood). The results indicate a characteristic banding pattern among human cadavers (n = 6) and a pseudo‐linear relationship between percentage of cTnT degradation and the log of the time since death (r > 0.95), which can be used to estimate the postmortem interval. The data presented demonstrate that this technique can provide an extended time range during which PMI can be more accurately estimated.