Early and late meningeal reaction to trauma after long-term brain death.

We examined histologically the meninges adherent to traumatic lesions of a patient with brain death sustained for 101 days and observed both early and late reactions of wound healing at the same site of the dura mater. Some parts of the dura mater were thick and histological examinations revealed formation of new vessels and fibrosis with strong positive reaction for iron and fat staining. We also observed fresh haemorrhage and some cell infiltration in the dura and fresh haemorrhage in a small piece of necrotic brain tissue adhered to the dura mater, while other areas of the brain tissue were completely necrotic, enabling the sites of head injury to be localised. These observations suggested that the blood flow in the dura mater fluctuates due to a change of microenvironment, which probably causes repeated secondary petechial haemorrhages in the dura and its adherent necrotic brain tissue, even 101 days after brain death.     

Right ventricular damage due to pulmonary embolism: examination of the number of infiltrating macrophages

To investigate the pathological changes in the heart induced by pulmonary embolism, 20 autopsy cases of pulmonary embolism and 10 control cases of acute death from traumatic injury were examined. Adding to the routine hematoxylin-eosin (HE) staining, immunostaining with CD68 pan-macrophage marker was performed on the specimens obtained from both right and left ventricular walls. The number of macrophages was counted semi-quantitatively in 100 random high-power fields (HPF). Although typical pathological findings of myocardial infarction was not observed in any of the cases, 16 of the 20 pulmonary embolism cases showed an increase in the number of macrophages, mainly in the right ventricular wall. Four cases showed massive macrophage infiltration in the entire right ventricular wall. It is speculated that ischemia due to pulmonary embolism may be connected to its pathogenesis.     

Screening of milk aspiration in 105 infant death cases by immunostaining with anti-human alpha-lactalbumin antibody.

To determine the frequency and degree of milk aspiration in infant death cases, immunohistochemical examinations were performed on lung sections from 41 sudden death cases and 64 in-hospital death cases using anti-human alpha-lactalbumin antibody. Milk aspiration to some degree was detected in more than half of the sudden death cases and in about one-third of the in-hospital death cases. A semi-quantitative examination of the amount of aspirated milk was subsequently performed in the positive cases. The amount of aspirated milk in the sudden death cases was significantly higher than that in the in-hospital death cases. The frequency distribution of the amount of aspirated milk was similar in shape in both groups. In most cases, a very small amount of aspirated milk was detected. The aspirated milk was assumed to be a result of occasional gastroesophageal reflux or cardiopulmonary resuscitation. However, in five cases, much larger amounts of aspirated milk were found. In these cases, milk aspiration may have been an important part of the cause of death. We concluded that slight milk aspiration is not rare in infant death cases, and that in a few cases, the aspiration is lethal. An immunohistochemical screening test is available to perform a postmortem diagnosis in these cases.     

Historicizing the power of civil society: a perspective from decentralization in Indonesia

The devolution of power to subnational governments and the involvement of civil society in policy decisions and implementation are the twin pillars of neoliberal governance reforms in post-authoritarian Indonesia. Yet, for the poor, these reforms have failed to bring about downward accountability and popular participation. Based on a political ethnography in the Priangan highlands of West Java, this article explores how a civil society approach to decentralization has compromised local democracy. Drawing on state–society relations, state formation, and institutional choice literatures, and focusing on power relations, social structures, and historical experiences in Indonesia, the article illustrates the complicity of civil society in the failure of decentralization to benefit the poor.     

Fatal paradoxical air embolism diagnosed by postmortem imaging and autopsy

The recognition and visualization of an arterial gas embolism are difficult. We report a case of sudden death caused by paradoxical air embolism of coronary and cerebral arteries, diagnosed by the pre autopsy computed tomography (CT) scanning. A 54-year-old woman suddenly died after the self-removal of the jugular vein catheter. Postmortem imaging examination using CT scanning showed multiple gas embolisms in the cerebral arteries, pulmonary artery, right atrium and ventricle, left ventricle, aorta, and coronary arteries. These findings suggested that the occurrence of acute ischemia of the brain and heart caused by massive air inflow to the artery. Conventional autopsy revealed a patent foramen ovale of the heart. These results indicated that the patient died of paradoxical air embolization of the coronary and cerebral arteries through a patent foramen ovale because of right-to-left shunting. The use of postmortem imaging as an aid for conventional autopsy has proved to be of advantage in the case of gas embolism.     

Diagnostic value of the placenta in medico-legal practice

In three suspected cases of infanticide, histological examinations of the placentas were effective in clarifying the circumstances. We have estimated the 5th month of pregnancy from pieces of the placenta in one case and diagnosed the causes of perinatal abnormalities in two cases, those being acute chorioamnionitis and possible premature separation of normally implanted placenta.     

A case of strangulation with postmortem amputation of the penis

A case of homicide with postmortem amputation of the penis was described. The penis found later in a home freezer in the apartment of the culprit showed "zigsaw" fit to the victim. In order to substantiate the morphological findings, phenotypes of three isozymes, phosphoglucomutase1 (PGM1), phosphogluconate dehydrogenase (PGD), and esterase D (EsD) together with ABO blood type were determined in the skin of the penis amputated. All of the four genetic markers determined with the penis were the same as those determined with heart blood of the victim.     

Postmortem molecular screening for mutations in ryanodine receptor type 1 (RYR1) gene in psychiatric patients suspected of having died of neuroleptic malignant syndrome

Postmortem diagnosis of neuroleptic malignant syndrome (NMS) is difficult to perform, because the clinical symptoms just before death are not usually available. Malignant hyperthermia (MH) is a catastrophic, life-threatening hypermetabolic syndrome triggered by certain anesthetics. Ryanodine receptor type 1 (RYR1) gene mutations are known to be involved in susceptibility to MH. Similarities in clinical features, such as elevated body temperature, between NMS and MH have led to the suggestion that NMS is a neurogenic form of MH. In this study, we analyzed possible mutations of the RYR1 gene in 11 psychiatric patients suspected at autopsy to have died of NMS. All cases were suspected of having elevated body temperature at death, and their causes of death could not be determined by autopsy examinations. Two mutations (R4645Q and A612T) in the RYR1 gene were identified. The R4645Q mutation has previously been reported in MH patients, but five heterozygous mutations were also found in 400 Japanese control alleles. The other mutation was novel, and was not found in the same control alleles. The results of this study provide the first successful identification of RYR1 mutations in psychiatric patients suspected at autopsy of having died of NMS. However, the association between RYR1 gene mutations and cause of death in psychiatric patients suspected of dying of NMS remains unclear.