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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.

Accidental death from postural or positional asphyxia can occur when an individual’s body compromises their respiration. The diagnosis of positional asphyxia is usually based on circumstantial evidence supported by the absence of other significant underlying causes of death. A female in her twenties was found dead in the so-called bridge position on a chair with wheels. Her jacket had rolled under one of the chair’s wheels. She was 159 cm in height and weighed 28.8 kg. Her body mass index was 11.4 (she was severely emaciated), and her muscles, including the rectus abdominis muscle, were thin. Her head, face, and neck were markedly congested. Her lungs, especially the upper lobes, were also congested. A small quantity of left cardiac blood was detected, which was slightly coagulated. The right cardiac blood was liquid (21 ml), and the right ventricle was slightly enlarged. It was suggested that the circulation from the lungs to the heart had been restricted. Toxicological tests detected psychoactive agents in the deceased’s blood and urine. The concentration of one of them, tofisopam, was slightly higher than normal. It was suggested that the effects of tofisopam and the deceased’s poor physical condition had impaired her motility, trapping her in an abnormal body position, ‘the reverse jack-knife position’. Therefore, her manner of death was considered to be accidental positional asphyxia. We should be aware that chairs with wheels can occasionally cause such accidents.

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.

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.

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.

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. Language: en

We report two cases of monostotic Paget's disease which were effectively treated with bisphosphonate. Case 1 was a 60-year-old female. Medical examination revealed high alkaline phosphatase (ALP) levels making her visit our clinic. Hematological examination showed high levels of ALP isozyme 3 and bone metabolism markers, and bone scintigraphy demonstrated strong accumulation of 99mTc on the skull. With the diagnosis of monostotic Paget's disease of the skull, treatment with bisphosphonate (etidronate) was started. The response to etidronate was good and after 12 weeks of treatment, the ALP levels decreased to about 26% of the levels before treatment, without the appearance of any symptoms or lesion development. One year and three months later, ALP increased again, and etidronate administration was resumed. However, four years after the diagnosis of the disease, etidronate became ineffective and oral administration of alendronate, a stronger bisphosphonate, was started at 5 mg/day. The patient responded favorably to the bisphosphonate and is still under observation. Case 2 was a 71-year-old female. High ALP levels were found during the follow-up of type 2 diabetes, and the case was diagnosed as monostotic Paget's disease of the pelvis based on bone metabolism markers and bone scintigraphy. Etidronate treatment at 200 mg/day resulted in the improvement of bone metabolism markers and bone scintigraphy findings. When she died of colon cancer twelve months later, with no marked progress of the Paget's disease of bone observed clinically.

Lectins are proteins which specifically bind (or crosslink) carbohydrates. Recently, importance of glycosylation has been emphasized in pathogenesis of diseases. Lectin-positive spherical deposits (SPD), 3-10 micron in diameter, have been detected in the molecular layer of dentate gyrus of hippocampus in schizophrenia, dementia, Down's syndrome, and aged individuals. In schizophrenia, SPD was observed without exception, regardless of having history of pharmacotherapy. By using multi-labeling histochemical methods, single strand DNA was co-localized in hippocampal SPD of schizophrenia with lectin, including GSI-B4 for galactose, and UEA-I for fucose, suggesting that SPD formation in schizophrenia is related to apoptotic process. The molecular basis of SPD formation should further be investigated in brains with neuropsychiatric illnesses.

We report a case of a seventy-year-old woman with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and adrenal insufficiency induced by Rathke's cleft cyst. She experienced nausea, vomiting, diarrhea, and headache and disturbance of consciousness induced by hyponatremia at a serum sodium level of 100 mEq/l. In spite of severe hyponatremia, urinary sodium excretion was not suppressed and serum osmolality (270 mOsm/kg) was lower than urine osmolality (304 mOsm/kg), and arginine vasopressin (AVP) remained within normal range. SIADH was diagnosed because she was free from other diseases known to cause hyponatremia such as dehydration, cardiac dysfunction, liver dysfunction, renal dysfunction, hypothyroidism, and adrenal insufficiency. Cranial computed tomographic (CT) scan and cranial magnetic resonance (MR) imaging showed a cystic lesion of approximately 2 cm in diameter in the pituitary gland. These images suggested that the cystic lesion was a Rathke's cleft cyst, which was the cause of SIADH. Water restriction therapy normalized her serum sodium concentration and improved her symptoms. After one year, she suffered from general fatigue, appetite loss, fever, and body weight loss (5 kg/2 months). She had neither hypotension nor hypoglycemia, but her serum sodium level was low and serum cortisol, ACTH, and urine free cortisol were very low. Therefore, secondary adrenal insufficiency was suspected and diagnosed by stimulation tests. After start of hydrocortisone replacement therapy (10 mg/day), her symptoms disappeared. In conclusion, Rathke's cleft cyst should be kept in mind as a potential cause in a patient with SIADH, hypopituitarism, and/or adrenal insufficiency.

Suicide notes (SN) are potentially valuable sources of information about the psychological states of the suicidal person. It was hypothesized that there was a significant relation between suicide rate and note-leaving rate and that the incidence of note-leaving was increased during prolonged economic recession. During 21 years (1981-2001) in Kobe, of a total of 18 558 violent deaths, 5161 were due to suicide (27.8%), with 3417 male cases (66.2%) and 1754 female cases (33.8%). For each year the annual suicide rates and note-leaving rates were calculated, and this represents the percentage of committed suicides in which SN were left, among all suicide victims. In spite of the prolonged economic slump, the note-leaving rate remained almost constant (23.4-36.2%). Pearson's correlation coefficient showed no significant correlation between suicide rate and note-leaving rates (r = 0.27, P = 0.23). The finding that the incidence of note-leaving remains constant despite increasing suicide rates may suggest that the reasons for suicide do not affect note-leaving. There are cross-cultural, ethnic, and racial variations in suicidal behaviors. Although this finding may be specific in Japan, further studies of SN are needed to help clarify the suicidal states of mind.

We studied an influence of genetic polymorphisms in the cytochrome P-450IIE1 (CYP2E1) gene on ethanol elimination rate in alcoholic patients and healthy subjects. The CYP2E1 genotype was determined by polymerase chain reaction-restriction fragment length polymorphism method for 124 alcoholics and 54 healthy subjects. There was no significant difference in the gene frequency of CYP2E1 between alcoholics and healthy control subjects. Blood ethanol concentrations in the 65 alcoholics on admission ranged from 0.32 to 4.22 mg/ml. In the patients with the c1/c2 genotype, the elimination rate was significantly correlated with blood ethanol concentration. In each of the three genotypes of CYP2E1, the patients were divided into three groups based on ethanol concentrations. The average of the ethanol elimination rate in the patients with c1/c2 having blood ethanol levels of ≥2.5 mg/ml was significantly higher than the rates in the two other groups of c1/c2. When blood ethanol levels were ≥2.5 mg/ml, the elimination rate in the patients with c1/c2 was significantly higher than that in those with c1/c1. Regardless of the CYP2E1 genotype, the elimination rate in the alcoholics was higher than that in the control subjects when blood ethanol levels were

A serotonergic dysfunction in the brain has been reported to be involved in suicidal behavior independently of the presence of a specific psychiatric disorder. Serotonin 1A (5-HT1A) receptors are known to be located on serotonergic nerve terminals and to be involved in the presynaptic regulation of serotonin release. Genetic factors partly explain the risks for suicide, and a suicide completion group is thought to be more uniform than a suicide attempt group. To explore the hypothesis that the 5-HT1A receptor-induced serotonergic dysfunction is implicated genetically in suicide, we focused on the structural polymorphisms, Pro16Leu and Gly272Asp, of the 5-HT1A receptor gene, and examined the association between suicide victims who completed suicide and these two polymorphisms. In both polymorphisms, we found no significant difference in genotype distribution or allele frequencies between suicide victims and controls. These findings suggest that neither of these two polymorphisms is associated with suicide victims and it is unlikely that the 5-HT1A receptor gene is implicated in the susceptibility to suicide. © 2002 Wiley-Liss, Inc.

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.

The in vitro production of interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha) by monocytes was examined in patients with insulin-dependent diabetes mellitus (IDDM), in those with noninsulin-dependent diabetes mellitus (NIDDM), and in healthy volunteers. The production of IL-1 and IL-6 by monocytes was significantly lower in IDDM patients than in NIDDM patients and normal subjects whereas the TNF-alpha production by monocytes did not differ between IDDM patients and normal subjects. On the other hand, the TNF-alpha production was significantly higher in NIDDM patients than in IDDM patients and normal subjects. There was a significant correlation between IL-1 and IL-6 concentrations in culture supernatants of monocytes for IDDM patients but not for NIDDM patients and normal subjects. Neither glucose nor insulin showed any stimulatory effect on in vitro production of these monokines. In the serial observation lasting 3-18 months, the monocyte production of IL-1 was found to be consistently reduced in IDDM patients unrelated to the control state of diabetes, suggesting that the reduction of the IL-1 and IL-6 production by monocytes in IDDM patients may be intrinsically affected by immunological defects.

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.

Studies on autopsy brains of mental illnesses are essential for psychiatric research. Brain materials from forensic autopsy cases have been valuable research resource. We introduced some characteristic neuronal structures of schizophrenic post-mortem brains and normal controls detected using both forensic and pathological autopsy cases and immunohistochemical method. Dopamine-related neuronal structures in schizophrenic cases were investigated by using immunohistochemistry for tyrosine hydroxylase (TH), aromatic l-amino acid decarboxylase (AADC) and phenylethanolamine- N -methyltransferase (PNMT). At the level of the striatum, the number of AADC-positive, but TH-negative neurons (d-neurons) reduced in schizophrenics compared with controls. In the brainstem structures, we described some morphological findings characteristic to catecholaminergic neurons of the ventral tegmental area of schizophrenic cases and reduction of the number of medullary catecholaminergic neurons. These results might be in accordance with recent reports describing neural stem cell dysfunction in schizophrenic brains. The authors also introduced the first systematic psychiatric brain bank in Japan, the Fukushima Psychiatric Brain Bank, constructed in 1997, and mentioned the necessity for arrangement of brain bank systems to further promote the psychiatric brain research.

Background The antiproteinuric effect of the angiotensin II receptor-antagonist losartan has been observed in patients with type 2 diabetes mellitus (T2DM). Proteinuria is considered to be a predictor of the progression of kidney disease. Objective The aims of the present study were to compare and examine the ability of losartan and amlodipine to ameliorate albuminuria in hypertensive Japanese patients (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg) with T2DM and whether the change in albuminuria was associated with a change in glomerular filtration rate (GFR). Methods This prospective, open-label, randomized, comparative study was conducted over 3 months at the Kinki University School of Medicine, Osaka-Sayama, Japan. Hypertensive patients with T2DM were enrolled and randomly assigned to 1 of 2 study groups receiving either losartan (25–100 mg/d) or the calcium channel-blocker amlodipine (2.5–5 mg/d). Urinary albumin excretion (UAE), creatinine clearance, and GFR were recorded at study initiation (baseline) and study end (month 3). The GFR was measured from the fractional renal accumulation of 99m Tc-diethylenetriaminepentaacetic acid. Adverse events (AEs) were monitored by a clinical research nurse during the examination. Results Fifty patients were asked to enroll and 38 returned the informed written consent. Thirty-five Japanese patients were included in the final study analysis. Seventeen patients were assigned to the losartan group (male sex, 10 [58.8%]; mean [SD] age, 58.1 [8.2] years) and 18 were assigned to the amlodipine group (male sex, 10 [55.6%]; mean [SD] age, 57.4 [8.9] years); no significant between-group difference in demographics was observed. A significant decrease from baseline to month 3 of mean (SD) UAE was observed in the losartan group (352.5 [556.6] mg/d vs 275.7 [466.1] mg/d; P = 0.048). No significant difference in mean (SD) UAE was observed in the amlodipine group for the same time period (298.2 [416.6] mg/d vs 322.7 [415.4] mg/d). There was a statistically significant difference found in the mean (SD) percent change of UAE from baseline to month 3 in the losartan group compared with the amlodipine group (−23.52 [28.42] vs +27.90 [63.51]; P = 0.004). Neither group was associated with a significant change in GFR during the course of the study. No patient discontinued the study due to AEs that were considered, by the investigator, to be possibly or probably associated with study treatment. Conclusions Treatment with losartan, but not amlodipine, was associated with a reduction in albuminuria in these hypertensive Japanese patients with T2DM within a period as short as 3 months. Neither drug was associated with a significant change in GFR. Therefore, the reduction of UAE was independent of a change in the GFR.

Some researchers have emphasized that, from the perspective of suicide prevention, research into the methods of suicide seemed to be particularly promising, as it has been shown repeatedly that restricting access to the prevailing method of suicide in a country will decrease suicide rates and that the lethality of the method used significantly correlated with the degree of intention to die. In this study, we examined changes in choice of method and the lethality score between the last attempted suicide (LAS) and completed suicide (CS) in 416 victims (male: 197, female: 219) to point out the tendency on their choice of method in LAS and CS. There was a significant difference in choice of suicide method between LAS and CS, and injury to themselves (33.7%) was the most common method of LAS, while hanging (37.5%) was the most common method of CS. The mean lethality score of CS method was significantly higher than that of LAS method in both sex groups, suggesting that at least one of the causes that drives suicide attempters to commit suicide finally may be the difference in the lethalities of LAS and CS. At the time of CS, suicidal victims tend to choose the same method as that of LAS again. These findings suggest that although suicide attempters tend to choose the same method, they will use a more lethal method if they change the suicide method. Interestingly, moreover, there was no sex difference in the percentage of the mean lethality score at CS.

Serotonergic systems have been reported to mediate the control of aggression and/or impulsivity in humans and to be involved in suicidal behavior. Neurochemical studies showing serotonergic dysfunction in suicide appear to support the functional alteration of serotonergic systems due to gene polymorphisms. Knock-out mice of the 5HT1B receptor gene have been reported to result in increased aggression. We hypothesized that the 5HT1B receptor-mediated serotonergic dysfunction was implicated in suicide through disinhibition of aggression and/or impulsivity. To explore this hypothesis, we examined the association between suicide victims who completed suicide and the 5HT1B receptor gene G861C polymorphism. No significant differences in genotype distribution and allele frequencies were found between suicide victims and controls. Though there is the possibility of failing to detect small effects, these results show no evidence of an association between the 5HT1B receptor gene G861C polymorphism and suicide victims in a Japanese population and indicate that it is unlikely that the 5HT1B receptor is implicated in the susceptibility to suicide.

Summary 1. In order to study the prevalence of insulin resistance syndrome (syndrome X) in Japanese subjects, inhabitants aged above 40 years living in Osaka-Sayama city from September 1992 through December 1993 were investigated. The population-based study was performed on 2498 subjects (661 males and 1837 females) constituting 10.9% of the total population aged above 40 years. 2. The prevalence of glucose intolerance was 8.7% (n= 218) in 2498 subjects. The prevalence of hypertension was 36.9% (n= 923) and that of hypertriglyceridaemia was 19.0% (n= 475). The prevalence of syndrome X as characterized by an association of glucose intolerance, hypertension and hypertriglyceridaemia was 1.6% (n= 39) in all subjects examined and 17.4% in subjects showing glucose intolerance. 3. Fasting serum insulin levels were significantly higher in patients with syndrome X than in normal subjects. Furthermore, the levels were significantly correlated with blood levels of frucutosamine, fasting glucose and triglyceride, and with body mass index as well. 4. In conclusion, insulin resistance syndrome (syndrome X) is also found among the larger Japanese population, and fasting serum insulin levels can be a useful marker of this metabolic disorder.

In the attempts of the editorial staff to improve the readability of these two abstracts, we apparently lost the essence of what the authors intended. Therefore, these two abstracts are printed here in their original form and should replace those that appeared in the abstracts supplement of Volume 12, Number 3 for the 10th World Congress on Emergency and Disaster Medicine. We apologize for any inconvenience associated with the edited versions.