Concealment of Homicidal Asphyxial Deaths by Pyre of Fire: A Case Series

Cytomegalovirus (CMV) is a common cause of morbidity in human immunodeficiency virus (HIV) infected patients, predominantly when severe immunosuppression has occurred. Although CMV infection of the retina and gastrointestinal tract is well recognised as causing substantial morbidity, the significance of infection at other sites, in particular the lungs and adrenal glands is unclear. To assess the extent of CMV infection in postmortem examinations performed on HIV-infected patients. To estimate the degree of concordance between clinical and postmortem findings and the effect of prior diagnosis and/or treatment of CMV infection. The postmortem examination findings and clinical records of 25 consecutive HIV-infected patients who underwent a complete autopsy were examined. CMV infection was demonstrated in 19 patients (76%) at postmortem examination, with the most common sites of infection being the adrenal glands (56%) and lungs (44%). Concordance between clinical diagnosis of CMV infection and postmortem findings was low with only five of 19 patients (26%) having an antemortem diagnosis. No patient with CMV infection of the lungs or adrenal glands had a clinical diagnosis made, despite four patients having florid CMV pneumonitis at postmortem examination; in three the probable cause of death. CMV infection is a common postmortem finding in HIV-infected patients but the concordance between clinical diagnosis and autopsy findings is low. CMV appears to be a significant pathogen in HIV-related respiratory disease.

The pathology of lethal exposure to the Riot Control Agents: Towards a forensics-based methodology for determining misuse

Mortality in orthopaedic patients is not a common event. This study sets out to review the incidence and causes of mortality in orthopaedic and trauma admissions in a tertiary centre in a developing country. Medical records of patients admitted to the Orthopaedic wards of the Obafemi Awolowo University Teaching Hospital, Ile-Ife over a ten year period (January 1999-December 2008) were retrospectively reviewed. The death certificates and postmortem examination findings were used in conjunction with the medical records to arrive at the possible cause of death in the deceased patients. Frequency analysis was done using SPSS version 13. Over this period, 2418 patients were admitted for orthopaedic and trauma with 84 deaths giving an overrall crude mortality rate of 3.47% (1.27% for paediatrics and 4.39% for the adults). Fourty nine patients (58.4%) died from trauma (fracture) related diagnoses followed by tumour (21, 25%) and infection (14,16.7%). Males were more affected 73.8% and the average age at death was 45.7years. Co-morbid conditions were found in 393% of the deceased patients. Trauma related deaths were the leading cause of mortality in our ward admissions and male patients at the prime of their lives were more often involved. Accident prevention and provision of facilities for appropriate management of trauma victims will help reduce substantially these untimely deaths in our world. The high incidence of co-morbid conditions emphasizes the role of multidisciplinary care in orthopaedic and trauma patients.

Objective: Mortality in orthopaedic admissions is not a common event. This study sets out to review the incidence and causes of mortality in orthopaedic and trauma admissions in a tertiary centre in a developing country. Methods: Medical records of patients admitted to the Orthopaedic wards of the Obafemi Awolowo University Teaching Hospital, Ile-Ife over a ten year period (January 1999-December 2008) were retrospectively reviewed. The death certificates and postmortem examination findings were used in conjunction with the medical records to arrive at the possible cause of death in the deceased patients. Frequency analysis was done using SPSS version 13. Results: Over this period, 2418 patients were admitted for orthopaedic and trauma with 84 deaths giving an overrall crude mortality rate of 3.47% ( 1.27% for paediatrics and 4.39% for the adults). Fourty nine patients (58.4%) died from trauma (fracture) related diagnoses followed by tumour (21(25%) and infection (14(16.7%). Males were more affected 73.8% and the average age at death was 45.7years. Co-morbid conditions were found in 39.3% of the deceased patients. Conclusion: Trauma related deaths were the leading cause of mortality in our ward admissions and male patients at the prime of their lives were more often involved. Accident prevention and provision of facilities for appropriate management of trauma victims will help reduce substantially these untimely deaths in our world. The high incidence of comorbid conditions emphasizes the role of multidisciplinary care in orthopaedic and trauma patients.Key words: Mortality, orthopaedic and Trauma, In-patients.

The Mahaweli wildlife region is mostly in the dry zone of the country with 1993.44km2 of protected areas. There are about 500-800 elephants habitats in thisregion. The Human Elephant Conflict (HEe) in this region intensified in the lastfew years, due to the civil war and Accelerated Mahaweli development scheme.This study is explored the (1) The DS divisional-wise distribution pattern ofhuman and elephant mortalities, (2) The causes of elephant mortalities and (3)How the HEC affect on the rate of elephant extinction. The data for the study isbased on cases reported to the Department of Wildlife Conservation between1990-2000 and descriptive post mortem finding of most recent 25 elephantmortalities. The possible causes of deaths, ages, breeding efficiency andphysiological status were evaluated during post mortems using various indicators.Between 1990-1999, 316 elephant mortalities and between 1992-1999, 105human mortalities have been recorded. The sex ratio of elephants that died were3.18 male: 1 female. The post mortems findings revealed the causes of death as12% natural, 64% gun shot injuries, 8% electrocution, 8% railway accidents and8% drowned in canals. Among those that were shot, 69% were injured byautomatic guns, 25% by shotguns and 6% by trap guns. The 72% males that died,68% were good sound breeding bulls, between 15-35 years of age. Many scientists have attributed the HEC to the associate with rainfall andcultivation pattern. Today the lands are cultivated year round and the HEC isspread throughout the year. The present rate of elephant mortality, sex imbalanceand weakening of the gene pool due to the death of breedings bulls, all contributeto the extinction of this flagship species.

Background: CT is a well-known tool to assess several conditions in living patients. The post-mortem CT (PMCT) has been introduced to determine the cause of death in dead subjects. CT is also the imaging modality of choice for the analysis of autopsy findings including fracture, hematoma, gas collection and gross tumor injury. The rate of standard autopsy is continuing to decline and there are several reasons for refusing autopsy. Objective: The current research endeavor is investigate the usefulness of computed tomography (CT) in cases refusing autopsy. Materials and Methods: In this study, the PMCT were evaluated in 150 subjects in different contexts of death. The causes of death were classified into four categories which include a definite cause of death, a possible cause of death, a minor pathological finding and no fatal findings. For the definite cause of death and the possible cause of death, the specific lesions are described in detail. Results: The definite cause of death was detected in 48 (32%) of the subjects. The possible cause of death was detected in 18 (12%) of the subjects. The remaining 84 subjects were classified into minor pathological findings and no fatal findings in 46 (30.7%) and 38 (25.3%) of the patients, respectively. The fatal lesions of PMCT were found in 93 lesions(48 subjects) that were demonstrated by anatomical locations into the traumatic bone, intracranial, spine, thoracic, heart leak and abdominal lesions. We found definite causes of death in 6 subjects, which had no history of trauma and malignancy and were mentioned about a cardiopulmonary failure as a cause of death at first. Conclusion: The PMCT is a useful tool for identifying the cause of death in many cases that have limitations for conventional autopsy. The morphological change such as intracranial hemorrhage is easily diagnosed with PMCT. The PMCT appears to be an alternative tool to assess the cause of death in any reason of objections.

Antenatal death is the cessation of fetal heart contractions during pregnancy for more than 22 weeks prior to the onset of labor. Objective: to evaluate the capabilities of the method of ultrasound in antenatal fetal death. Tasks of ultrasound in the presence of a dead fetus: a statement of his death; determining the position, presentation, size, estimated fetal weight and gestational age; detection of congenital malformations (CM) and possible causes of death; clarification of the statute of limitations of death. We have analyzed 126 standard ultrasound protocols of pregnant women with antenatal fetal death. Ascertaining the cessation of heart contractions and determining the location of the fetus present no difficulties for the ultrasound doctor. The assessment of the conformity of the size of the fetus to the gestational period during antenatal death is better determined by measuring the diaphysis of the long bones. Head sizes are used only when it is possible to clearly assess the typical structures of a biparietal slice. The determination of the estimated mass of the fetus is difficult due to autolytic changes and, usually, lack of water. The diagnosis of CM, first established after ascertaining antenatal fetal death, should cause the doctor to doubt that it is in front of us — a developmental defect, as a possible cause of intrauterine death or post-mortem changes that depend on previous intravital changes, cause and duration of death. The article describes the dynamics of the appearance of post-mortem changes. Conclusions: with antenatal fetal death, it is impractical to determine the expected mass of the fetus, it is preferable to estimate the period of probable cessation of development from the measurement of long tubular bones; during an ultrasound of the deceased fetus, it is often impossible to reliably determine the presence/absence of CM and the exact time of death; change in the amount of amniotic fluid is not a reliable diagnostic criterion for the duration of death.

Background: Histopathological examination in autopsies following cardiac arrest provides important guide into the underlying causes of sudden cardiac death. Common findings include coronary artery atherosclerosis, myocardial infarction, fibrosis, and myocarditis. These changes identify structural or pathological abnormalities missed clinically. Autopsy-based histology is essential for accurate diagnosis, in unexplained deaths, and supports preventive methods and better understanding of cardiovascular pathology. This systematic review aimed to evaluate the predictors of survival following OHCA and to summarize autopsy and postmortem findings where the cause of death was unknown. Methods: A literature search was conducted in PubMed, PubMed Central, Scopus, and Google Scholar to find eligible studies published between 2010 and 2024. Studies were included if they focused on predictors of survival in adult OHCA cases or provided autopsy findings in unexplained deaths. Data were extracted regarding study design, population characteristics, survival rates, predictors, and outcomes. Results: sixteen studies were included. Histopathological findings from included studies indicate coronary atherosclerosis, myocardial infarction, and structural heart changes as an important cause of sudden cardiac death, show autopsy’s role in identifying cardiac pathology and guide prevention strategies. Predictors of survival included initial shockable rhythm, witnessed arrest, early defibrillation, bystander CPR, and rapid EMS response. Early coronary angiography and targeted temperature management correlated with better outcomes. Autopsy findings in unexplained deaths revealed cardiac causes. Molecular autopsy was needed to identify inherited arrhythmia syndromes in structurally normal hearts. Conclusion: Survival after OHCA is influenced by early intervention and clinical factors. Autopsy, when combined with genetic testing, is essential to diagnose unexplained sudden deaths and guide family risk assessment.

The key role of examining the placenta in establishing a probable cause for stillbirth

Background: Medicolegal autopsy is a vital component of forensic practice, undertaken to investigate sudden, suspicious, or unnatural deaths. Accurate determination of the cause and manner of death is essential for the administration of justice, reliable mortality statistics, and public health planning. Objective: To analyze medicolegal autopsy cases to determine the pattern of deaths and to assess the role of medicolegal autopsy in establishing the cause and manner of death. Methods: A cross-sectional descriptive study was conducted in the Department of Forensic Medicine, International Medical College, Gushulia, Sataish, Tongi, Gazipur, from June 2023 to July 2024. A total of 382 medicolegal autopsy cases were included. Data were collected from police inquest reports, postmortem examination findings, and ancillary investigation reports using a structured data collection form. Results: Males constituted 68.6% of cases, with a male-to-female ratio of approximately 2.2:1. The highest number of cases occurred in the 21–30 years age group (26.2%), followed by the 31–40 years group (22.0%). Suicidal deaths were the most common manner of death (44.0%), followed by accidental (32.5%), homicidal (14.1%), and natural deaths (9.4%). Asphyxia, mainly due to hanging, was the leading cause of death (30.4%), followed by poisoning (25.7%) and road traffic accidents (22.0%). Conclusion: Unnatural deaths, particularly suicide, constituted the majority of medicolegal autopsy cases, predominantly affecting young and middle-aged adults. Medicolegal autopsy plays an indispensable role in accurately determining the cause and manner of death and remains essential for justice delivery and effective public health interventions.

Bangladesh is densely populated country where male and female ratio is closer to each other. This descriptive study investigates the gender disparity of postmortem examination findings among 7 districts in the Rajshahi division of Bangladesh. Postmortem (PM) examination stations were located in Rajshahi, Rangpur, Bogra and Dinajpur Medical Colleges & Pabna, Natore and Chapai Nawabganj Sadar Hospitals. The findings of the autopsy reports (Total 3164) over the two years (2004 & 2005) were collected retrospectively from the register book of the authority. In this study we wanted to find out gender disparity - if exists in PM examination findings and, to what extent. Manually verified data were analyzed employing SPSS/WIN V-11.5. An obvious gender disparity existed in overall occurrence of unnatural deaths, male predominate female victims (M: F ratio = 1.51:1). A significant association existed in death circumstances & gender (p<0.0001); male (634) outnumbered female (250) in homicidal deaths, in suicidal deaths female (612) outnumbered male (364) and in accidental deaths male (583) outnumbered female (135). This classical gender difference in death circumstances remains similar to our national context. Findings of this study revealed an obvious gender difference in the overall numbers of cadaveric PM examination. Males were more victimized than females in majority of medico-legal aspects analyzed, except in suicidal cases.DOI: http://dx.doi.org/10.3329/fmcj.v7i1.10293Faridpur Med. Coll. J. 2012;7(1): 23-25

【背景及び目的】院外心肺停止（Cardiopulmonary arrest以下CPA）症例は臨床経過が不明な場合が多く，たとえ目撃があっても不十分な病歴しか得られない。蘇生行為中の限られた検査所見により臨床的死因推定が行われているのが現状であり，死因不明症例が数多く存在する。当院の位置する神戸市は監察医制度の対象地域であり，CPA症例の解剖実施率は高い。臨床的死因推定と監察医の解剖所見の相違は散見され，救急医が行う死因推定の妥当性は明らかでない。今回我々は自験例から，臨床的死因推定と死因不明症例の検証を行った。【対象と方法】2010年4月から2011年3月までの12か月間を対象期間とし，同期間に当院へ搬送された連続223症例のCPAについて臨床的死因推定と兵庫県監察医務室での解剖所見を後方視的に比較検討した。【結果】223症例中151症例が監察医務室で検案され，うち100症例で行政解剖が行われた。解剖が実施された100症例中，臨床的に死因が推定できなかったものは36％，心原性が20％であった。この臨床的死因推定不能症例の解剖結果では，43％が心原性疾患と最多であり，外因性25％，大動脈疾患11％，消化器疾患7％，呼吸器疾患4％，肺塞栓症3％，脳血管障害2％，不明1％，その他4％であった。臨床的死因推定と解剖所見との不一致例は17％存在した。【考察】臨床的死因推定がなされた場合の解剖所見との一致率は83％であり，その妥当性は高かった。死因が臨床的に推定できない場合の解剖結果は非心原性が57％を占め，臨床経過が似る大動脈解離や肺塞栓の割合も少なくない。臨床的死因不明症例においては解剖を実施せずに正確な死因特定を行うことは困難である。【結語】臨床的死因推定の妥当性は高いが，臨床的死因不明症例では解剖によるさらなる死因究明が望ましい。 Background: The clinical history of a patient with cardiopulmonary arrest (CPA) who is transported to the emergency department is commonly unknown. Even if a witness is present, the patient’s available clinical history is usually limited. Clinicians presume the cause of death from results of limited tests performed during active resuscitation, which leaves many causes undetermined. Kobe city has a medical examiation system in which, autopsies are performed at a high rate. However, because of many differences between clinical and autopsy diagnoses, the validity of clinical diagnosis is currently unclear. In this study, we evaluated the clinical diagnosis of CPA against autopsy findings and investigated cases of unknown cause of death. Patients and Method: We reviewed the records of patients with CPA who were transported to our hospital between April 2010 and March 2011 and compared the differences between clinical and autopsy diagnoses in the Medical Examiner’s Office of Hyogo Prefecture. Results: Over the study period, 151 subjects underwent postmortem examination or autopsy; of them, postmortem examination alone was performed in 51, while postmortem examination plus autopsy was performed in 100. A total of 36% of the autopsy cases had an unknown cause of death. Causes of death confirmed by autopsy included cardiogenic disease in 43%, exogenous factors in 25%, aortic disease in 11%, digestive disorder in 7%, respiratory disease in 4%, pulmonary embolism in 3%, cerebrovascular disease in 2%, unknown in 1%, and other in 4%. Of those subjects with a clinical diagnosis, 17% had a different autopsy diagnosis. Discussion: The rate of agreement between clinical diagnosis and autopsy diagnosis was 83%, which demonstrates that clinical diagnoses are generally reliable. Moreover, considering the possibility of preceding endogenous disease in drowning or asphyxiation cases, led to even greater accuracy. When the clinical diagnosis was unknown, non–cardiac CPA was diagnosed at a rate of 57%. Because aortic dissection and pulmonary embolism are commonly clinically similar to cardiogenic CPA, it is difficult to identify an individual’s cause of death without an autopsy. Conclusion: Findings in this study show that clinical diagnosis has high validity. If an individual’s clinical diagnosis is unknown, an autopsy is recommended. 院外心肺停止（Cardiopulmonary arrest以下CPA）症例は基礎疾患や臨床経過が不明な場合が多く，たとえ目撃があるCPA症例であっても不十分な病歴しか得られない。不十分な病歴や蘇生行為中の限られた身体所見・検査所見により臨床的死因推定が行われているのが現状であり，臨床的に死因が推定困難な症例も多く存在する。 神戸市は総人口が約150万人の都市であり，その大部分が監察医制度の対象地域となっている。年間死亡数は約1万4千人であり，そのうち救急搬送されるCPA患者は約900～1,000人／年である。2010年の兵庫県監察医務室による検案数は1,685件であり，解剖数は1,130件であった 1。 当院は神戸市の中核病院として年間約250人のCPA症例を受け入れている。我々は当院に搬送され監察医制度により検案・行政解剖が行われた症例について監察医と救急医による合同カンファレンスを定期的に開催し，臨床所見と解剖所見のすり合わせを行ってきた。実際には臨床的に心原性と判断した症例が脳神経疾患や感染症であったなど，臨床的な死因推定と解剖所見の相違点が散見される。 一方，院外CPA症例の記録集約としてウツタイン様式 2が世界的にも使用されている。ウツタイン様式では死因は心原性と非心原性に大別され，原因不明の場合は除外診断として心原性に分類することになる。しかし，除外診断によって心原性に分類することへの妥当性は不明である。 本研究の目的は，原因不明のCPA患者の多くを解剖している当院の症例を用い，臨床的死因不明患者の死因究明と臨床的死因推定の妥当性を検討することである。 2010年4月から2011年3月の12か月間に当院へ搬送されたCPA患者連続223症例を対象とし，カルテレビューにより臨床的死因推定と解剖所見を比較検討した。 死因分類については，心原性疾患・脳血管障害・消化器疾患・呼吸器疾患・大動脈疾患・肺塞栓症・外因性・その他・不明に分類すると定義した。臨床的死因推定は，診療した救急医により病歴・蘇生中の検査（血液検査：血算・一般生化学 トロポニンT 胸部レントゲン 超音波検査）により総合的に判断されたものであり，死亡時画像診断Autopsy imaging（以下Ai）は原則として実施していない。 臨床的に死因が推定されるが特定には至っていない症例，もしくは臨床的に死因が不明な症例は監察医制度にのっとり監察医により検案が行われた。当院かかりつけ患者であり既知の疾患による死亡と判断した症例，もしくはかかりつけ医と連絡がとれて既知の疾患による死亡と判断できる症例，明らかに死因が特定できる症例は死亡診断書を作成している。 期間内対象患者223症例の内訳は，男性134例（平均年齢65.6〈2～96〉歳），女性89例（平均年齢69.0〈0～99〉歳）であった。223症例中，監察医制度にのっとり検案・解剖された症例は151症例（検案のみ51症例・解剖あり100症例：解剖実施率66％）であった（Fig. 1）。 Description of databases. Cases framed by a bold line represent the number of data in this study. CPA; cardiopulmonary arrest. 解剖が実施されず検案のみとなるのは，縊頸・多発外傷など明らかな外因死の症例，家族の同意が得られない症例などである。解剖未実施の症例は，監察医務室にて病歴・検査所見などの臨床情報や検案所見に基づいて死体検案書が作成された。検案のみの51症例中，明らかな外因死は28症例（55％），死体検案書に家族の不承諾が解剖未実施の理由と明記されているものが12症例（24％），明らかな外因死でないが解剖未実施理由の明記がないものが11症例（21％）であった。 検案のみの51症例の臨床的死因推定の結果内訳は，外因性31症例（61％），消化器疾患3症例（6％），大動脈疾患2症例（4％），心原性疾患2症例（4％），呼吸器疾患1症例（2％），その他1症例（2％），不明11症例（21％）。検案結果は外因性30症例（59％），心原性疾患8症例（17％），消化器疾患4症例（8％），大動脈疾患1症例（2％），その他2症例（4％），不詳5症例（10％）であった。 解剖が実施された100症例の臨床的死因推定は，不明が36症例（36％）と最多であり，外因性25症例（25％），心原性疾患20症例（20％），消化器疾患7症例（7％），大動脈疾患5症例（5％），脳血管障害2症例（2％），呼吸器疾患2症例（2％），肺塞栓症1症例（1％），その他2症例（2％）であった（Table 1）。 一方，実際の解剖所見では43症例（43％）が心原性疾患と最多であり，外因性が25症例（25％），大動脈疾患11症例（11％），消化器疾患7症例（7％），呼吸器疾患4症例（4％），肺塞栓症3症例（3％），脳血管障害2症例（2％），不明1症例（1％），その他4症例（4％）であった（Table 1）。 臨床的死因が推定できなかった36症例での解剖結果の内訳は，心原性疾患16症例（44％），大動脈疾患5症例（14％），外因性3症例（8％），呼吸器疾患2症例（5.5％），脳血管障害2症例（5.5％），消化器疾患2症例（5.5％），肺塞栓症2症例（5.5％），不明1症例（3％），その他3症例（8％）であった（Table 2）。 非心原性疾患か心原性疾患について，臨床的死因推定と解剖所見の不一致症例は11症例（17％）であった。 臨床的死因推定が非心原性疾患であった44症例のうち解剖所見で心原性疾患であったのは9症例（20％）あり，内訳は脳血管障害2症例（症例1～2），感染症2症例（症例3～4），消化器疾患（症例5～6），外因性（症例7～9）であった（Table 3）。 症例1では鼾をかいて入眠している状態からCPAに至っているため，症例2では歩行中の突然死であったがトロポニンTが陰性であったため，脳血管障害が疑われた。症例3では発見時に34度の低体温とレントゲンにて肺炎像を認めたため，症例4ではCPAに至る前に悪寒を訴えておりレントゲンにて肺炎像を認めたため，感染症が疑われた。症例5ではCPA直前に黒色水様便を認めていたため，症例6では下腹部痛を訴えてからCPAに至っておりレントゲンにて腸管拡張を認めたため，消化器疾患が疑われた。症例7～9では，いずれも浴槽内で顔が水面に浸かった状態で発見されたCPAであり，蘇生行為中の胸部レントゲン所見・エコー所見からは死因を示唆する所見は認めなかったため溺水・窒息と判断された。 臨床的死因推定が心原性疾患であった20症例のうち解剖所見で非心原性疾患であったのは10％（2症例）であり，内訳は大動脈疾患と消化器疾患がそれぞれ1症例であった（Table 1）。 症例10では車内にてCPAの状態で発見され，PEA時の心電図モニター波形でST上昇を認めるがFAST陰性とレントゲンでの縦隔拡大を認めないことから心原性が疑われたが大動脈解離であった。症例11では，蘇生中のレントゲンにて肺水腫を認めたことから心原性が疑われたが，肝硬変が死因であった。 監察医制度がある地域は東京23区内・横浜市・名古屋市・大阪市・神戸市の5都市のみであり，それ以外の地域での院外CPA症例に対する承諾解剖実施率は多くの地域で1％以下 3である。ほとんどの場合は臨床的要因から死因推定しているのが現状だが，この推定の妥当性は不明である。解剖が行われた院外CPA症例での臨床所見と解剖所見の相違についての報告は散見され，山下ら 4は解剖結果により58症例中25例（43％）で新たな所見が得られたと報告している。また，石田ら 5は解剖が行われた院外CPA症例で，20症例中7症例（45％）において解剖結果で直接死因が判明したと報告している。滝ら 6は解剖が行われた院外CPA症例において，24症例中17症例（71％）で死因が明確になった，もしくは訂正されたと報告した。しかしこれらの報告 4, 5, 6での解剖実施率は13％～20％程度と多くの院外CPA症例が存在するなかで解剖が実施された少数であり，解剖が実施された背景など選択バイアスが存在し全体を反映しているとはいえない。 本研究の意義は監察医制度による高い解剖実施率（66％）にある。さらに，確定診断に至る決定的な証拠がないかぎり，臨床的な死因推定が行われている症例も監察医制度にて検案・行政解剖が実施されることである。 その結果，決定的な確定診断に至る証拠がない院外CPA症例は全て検案・行政解剖が実施されており，一般的な院外CPA症例の実態を反映していると考えられる。 本研究での臨床的死因推定ができた64症例での解剖所見との一致率は，心原性か非心原性かで判断した場合は83％（診断一致症例：53症例/臨床的死因推定可能症例：64症例）であり比較的高かった。臨床的には非心原性を疑ったが解剖所見では心原性と判断した症例は9％存在するが，その3分の１は入浴中の溺水や窒息症例であった。臨床的に外因死が疑われる状況であっても，内因性疾患が先行した可能性は考慮すべきである。臨床的には心原性が疑われたが解剖所見では非心原性と判断された症例は2％のみであった。以上のことから，死因推定可能であった場合の臨床的死因推定の妥当性は比較的高く，入浴中の溺水や窒息症例において先行する内因性疾患に留意することで，さらなる精度の向上が期待できる。 ウツタイン様式では臨床的死因不明患者は除外診断として心原性に分類されるが，本研究結果では臨床的死因不明患者のうち非心原性が56％であった。特に，心原性と同様に病歴では急性発症や突然死となりうる大動脈疾患や肺塞栓症が多いことは注目に値する。中尾ら 7の報告でも，監察医制度で解剖が実施されたうち10％が大動脈疾患・2％が肺塞栓であったことからも，これらの疾患は一定の頻度で存在していると推察される。ウツタイン様式に従い除外診断で心原性疾患とすると，心原性疾患20％に不明症例36％が追加されるため，結果的に56％が心原性疾患に分類される。しかし，解剖結果では臨床的死因不明の56％（非心原性疾患20症例/臨床的死因不明36症例）が非心原性疾患であり，解剖結果全体では心原性疾患が43％となるためウツタイン様式での統計結果と大きな差を認めた。ウツタイン様式による心原性分類の23％が実際には非心原性であったことは死因統計としても無視できない数字である。このことからも臨床的に死因推定困難な場合は積極的に解剖を行うことが必要であろう。 本研究の限界として非解剖症例の存在による最終確定診断の妥当性の問題と，Aiを実施した場合の臨床診断率の向上が考慮されていない点が挙げられる。 解剖実施率は66％であったが，解剖実施されなかった理由は家族の同意が得られないほかは，多発外傷や縊頸など明らかな外因死が大多数を占めていた。このため非解剖症例で，臨床的にも死因が不明な患者は22％と少ない。検案のみの症例の検案結果は臨床情報に大きく影響され，診断根拠が臨床情報であることが大多数である。そのため，解剖を行って診断を得た場合には臨床診断との不一致を認めた可能性がある。しかし，非解剖症例での内因性症例の割合は38％と少なく，解剖が実施されたとしても本研究の結果への影響は少ないと考える。 また，当院ではAiは原則として実施しておらずこれを行った場合の影響は不明である。CTを用いたAiによって診断が可能な割合は3割にとどまるといわれており，特に大動脈解離や肺塞栓といった血管病変では単純CTでは評価困難である 8。造影剤を注入後に胸骨圧迫を行い造影CTを撮影することで血管病変を指摘する試みがなされているが，現時点では発展途上の技術である 8。 今後，Aiの普及・発展により臨床的死因推定の精度がより改善し，解剖を行わなくとも確定診断に至る症例も増加すると期待できるが，Aiと解剖の適応は今後の課題である。 臨床的死因推定が不明の場合は非心原性も多いため解剖を積極的に考慮すべきである。臨床的に死因推定された場合は精度も高く信頼にたりうる。 本論文の要旨は第16回日本臨床救急医学会総会（2012年6月熊本）にて発表した。 なお本論文における利益相反はない。

In this study, we aimed to compare prenatal ultrasound (USG) and postmortem examination findings of central nervous system (CNS) abnormalities in fetuses following termination of pregnancy (TOP). A total of 190 fetuses with USG-confirmed fetal CNS abnormalities of terminated pregnancies between January 2001 and January 2017 were retrospectively analyzed and USG and postmortem examination findings were compared. The most frequent CNS abnormalities were acrania/anencephaly (n=45, 24%), spina bifida (n=43, 23%), and ventriculomegaly (n=35, 18%). In 144 of the 190 (76%) cases, there was total agreement between USG and postmortem examination diagnosis. Postmortem examination provided minor findings which did not change the major clinical diagnosis in two (1%) cases with spina bifida and ventriculomegaly. In six (3%) cases, the diagnosis changed after postmortem examination. In 25 of the 190 (13%) cases with multiple abnormalities as evidenced by USG, CNS abnormality was unable to be confirmed at postmortem examination. Our study results show an overall high agreement (76%) between USG and postmortem examination findings for CNS malformations. Due to autolysis and fluid structure, USG-confirmed CNS diagnosis cannot be always confirmed by postmortem examination. This potential discrepancy should be explained to patients before considering TOP. Postmortem examination is the gold standard to confirm prenatal diagnosis.

The stillbirth rate in the United States is higher than that of other developed countries. Since 2003, the rate has stagnated at 6.2 stillbirths per 1000 births. There is a lack of information on causes of stillbirth. Strategies to reduce the stillbirth rate will require systematic investigation into the cause of death. The stillbirth rate among non-Hispanic black women is 2.3-fold higher than that of non-Hispanic white women. This racial disparity is largely unexplained. This multicenter population-based case-control study determined the causes of death among stillbirths and stratified the causes according to race/ethnicity. All stillbirths that occurred at 20 weeks or later between 2006 and 2008 were examined in data from 59 tertiary care and community hospitals that had access to at least 90% of the stillbirth and live birth deliveries in 5 catchment areas defined by state and county boundaries. Data on deliveries resulting from termination of a live fetus were excluded. Several outcome measures were evaluated to systematically assign causes of death. Standardized perinatal postmortem examination and placental pathology evaluation were performed at delivery. Other outcome measures included medical history, karyotype, and other laboratory tests. Of the 663 women with stillbirth enrolled, 500 (75.4%) allowed a complete postmortem examination of their 512 stillborn neonates. Among the stillbirths, a probable cause of death was found for 312 cases (60.9%; 95% confidence interval [CI], 56.5%–65.2%) and possible or probable cause for 390 (76.2%; 95% CI, 72.2%–79.8%). The most common causes of death were the following: obstetric complications (29.3%; 95% CI, 25.4%–33.5%), placental abnormalities (23.6%; 95% CI, 20.1%–27.6%), fetal genetic/structural abnormalities (13.7%; 95% CI, 10.9%–17.0%), infection (12.9%; 95% CI, 10.2%–16.2%), umbilical cord abnormalities (10.4%; 95% CI, 7.9%–13.4%), hypertensive disorders (9.2%; 95% CI, 6.9%–12.1%), and other maternal medical complications (7.8%; 95% CI, 5.7%–10.6%). Compared with non-Hispanic white women and all Hispanics, non-Hispanic black women had a higher proportion of stillbirths associated with obstetric complications (43.5% vs. 23.7%; difference: 19.8%; 95% CI, 9.7%–29.9%; P < 0.001) and infections (25.2% vs. 7.8%; difference: 17.4%; 95% CI, 9.0%–25.8%; P < 0.001). Intrapartum and early in gestation stillbirths were more common among non-Hispanic black women. The most likely sources contributing to identifying a probable or possible cause of death were placental histology (52.3%; 95% CI, 47.9%–56.7%), perinatal postmortem examination (31.4%; 95% CI, 27.5%–35.7%), and karyotype (9%; 95% CI, 6.3%–12.5%). These findings show that a systematic and thorough evaluation of a population-based cohort led to a probable or possible cause of death for the majority of cases of stillbirth. Causes were differentially distributed by race/ethnicity.

According to the classification system used, 15-60% of stillbirths remain unexplained, despite undergoing recommended autopsy examination, with variable attribution of fetal growth restriction (FGR) as a cause of death. Distinguishing small-for-gestational age (SGA) from pathological FGR is a challenge at postmortem examination. This study uses data from a large, well-characterized series of intrauterine death autopsies to investigate the effects of secondary changes such as fetal maceration, intrauterine retention and postmortem interval on body weight. Autopsy findings from intrauterine death investigations (2005-2013 inclusive, from Great Ormond Street Hospital and St George's Hospital, London) were collated into a research database. Growth charts published by the World Health Organization were used to determine normal expected weight centiles for fetuses born ≥ 24 weeks' gestation, and the effects of intrauterine retention (maceration) and postmortem interval were calculated. There were 1064 intrauterine deaths, including 533 stillbirths ≥ 24 weeks' gestation with a recorded birth weight. Of these, 192 (36%) had an unadjusted birth weight below the 10th centile and were defined as SGA. The majority (86%) of stillborn SGA fetuses demonstrated some degree of maceration, indicating a significant period of intrauterine retention after death. A significantly greater proportion of macerated fetuses were present in the SGA population compared with the non-SGA population (P = 0.01). There was a significant relationship between increasing intrauterine retention interval and both more severe maceration and reduction in birth weight (P < 0.0001 for both), with an average artifactual reduction in birth weight of around -0.8 SD of expected weight. There was an average 12% reduction in fetal weight between delivery and autopsy and, as postmortem interval increased, fetal weight loss increased (P = 0.0001). Based on birth weight alone, 36% of stillbirths are classified as SGA. However, fetuses lose weight in utero with increasing intrauterine retention and continue to lose weight between delivery and autopsy, resulting in erroneous overestimation of FGR. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.