Fatal anterior mediastinal mass in a pregnant lady

We report a fatal case of a 26-year-old nulliparous woman who presented with an anterior mediastinal mass in her late pregnancy. She had complained of a progressively increasing neck swelling and occasional dry cough in the early second trimester, which was associated with worsening dyspnoea, reduced effort tolerance and orthopnoea. Ultrasound of the neck showed an enlarged lymph node, and chest X-ray revealed mediastinal widening. At 35 weeks' gestation, the patient was referred to a tertiary centre for a computed tomography (CT) scan of the neck and thorax under elective intubation via awake fibreoptic nasal intubation as she was unable to lie flat. However, she developed sudden bradycardia, hypotension and desaturation soon after being positioned supine, which required resuscitation. She succumbed after 3 days in the intensive care unit. An autopsy revealed a large anterior mediastinal mass extending to the right supraclavicular region, displacing the heart and lungs, encircling the superior vena cava and right internal jugular vein with tumour thrombus extending into the right atrium. Histopathology examination of the mediastinal mass confirmed the diagnosis of a primary mediastinal large B-cell lymphoma. This report emphasizes the severe and fatal outcome resulting from the delay and misinterpretation of symptoms related to a mediastinal mass.

Use of thermal drone in detection and assessment of larval mass temperature in decomposed rabbit carcasses

Manual ground searches and cadaver dogs are traditional methods for locating remains, but they can be time- and resource-intensive, resulting in the decomposition of bodies and delay in victim identification. Therefore, thermal imaging has been proposed as a potentially useful tool for detecting remains based on their temperature. This study investigated the potential of a novel search technique of thermal drones to detect surface remains through the detection of maggot mass temperatures. Two trials were carried out at Selangor, Malaysia, each utilizing 12 healthy male Oryctolagus cuniculus European white rabbits and DJI Matrice 300 RTK drone China, equipped with a thermal camera; Zenmuse H20T to record the thermal imaging footage of the carcasses at various heights (15, 30, 60-100 m) for 14 days for each trial. Our results demonstrated that the larval masses and corresponding heat emissions were at their largest during the active decay stage; therefore, all the carcasses were observable in thermal images on day 5 and remained until day 7. Statistical analyses showed that (1) no statistically significant differences in thermal images between clothed and unclothed subjects (p > 0.05); (2) 15 m above ground level was proven to be the optimal height, as it showed the greatest contrast between the carcass heat signature and the background (p < 0.005). Our data suggested the potential window of detection of thermal signatures was detectable up to 7 days post-deposition. This could be an important guideline for the search and recovery teams for operational implementation in this tropical region.

The effect of post-mortem computed tomography angiography (PMCTA) on biomarkers of coronary artery disease

Coronary atherosclerosis is due to build-up of plaque within the coronary arteries. Post-mortem computed tomography (PMCT) allows non or minimally invasive visualization of abnormalities prior to an autopsy, however PMCT-angiography (PMCTA) greatly enhances relevant findings, especially in viewing the cardiovascular system which is important in the diagnosis of coronary atherosclerosis. Contrast media used in PMCTA however has been reported to cause distortion of tissue which may interfere with post-mortem investigation outcomes. A cross sectional study to investigate the effect of PMCTA on tissue biomarkers in coronary arteries was performed involving cases brought in dead to the Institute and Accident and Emergency Unit. Sixty-three autopsy cases were included in this study, whereby 18 cases underwent PMCT while 45 cases underwent PMCTA. The subjects subsequently had a conventional autopsy where coronary artery sections were collected for standard histological examination and immunohistochemistry examination for endothelial inflammatory (CD36), prothrombogenic (TPA) and plaque stability (MMP-9) markers. The subjects consisted of 55 males and 8 females with a mean age ±SD of 49 ± 18.11 years. There were no significant differences in the coronary artery endothelial expression of CD36, MMP-9 and TPA between PMCT and PMCTA subjects. PMCTA does not alter CD36, TPA and MMP-9 markers supporting the safe use of PMCTA in post-mortem examinations.

First observation of Afromorgus chinensis (boheman, 1858) (Coleoptera: Trogidae) on a rabbit (Oryctolagus cuniculus L., 1758) carcass and its implications in forensic entomology

Beetles (Coleoptera) are known to constitute forensic evidence in medico-legal investigations as their presence can be used to date human remains in almost all decomposition stages. Many forensic studies focus on the successional colonization pattern of flies (Diptera); however, beetles have not so far been studied extensively for this aspect. A beetle of the genus Afromorgus Scholtz, 1986, A. chinensis (Boheman, 1858) (Scarabaeoidea: Trogidae), was found beneath a late decaying rabbit carcass at Paya Indah Wetland, Dengkil, Malaysia, for the first time. Both genus and species are already known to occur in Malaysia from literature.

Use of Post-Mortem Computed Tomography During the COVID-19 Pandemic: The Malaysian Experience

Background

COVID-19 was declared a pandemic by the World Health Organization (WHO). COVID-19 is highly contagious, making it a threat to healthcare workers, including those working in mortuaries. Therefore, it is important to determine if the cause of death (COD) could be identified using limited autopsy, diagnostic tests and post-mortem imaging modalities instead of full autopsy. This study aims to examine the effectiveness of post-mortem imaging, specifically post-mortem computed tomography (PMCT) at determining the COD during a pandemic.

Methods

This cross-sectional study included 172 subjects with suspected or unknown COVID-19 status brought in dead to the institute's mortuary during the pandemic in Malaysia. PMCT images reported by forensic radiologists and their agreement with conventional autopsy findings by forensic pathologists regarding COD were analysed to look at the effectiveness of PMCT in determining COD during a pandemic.

Results

Analysis showed that 78.7% (133) of cases reported by forensic radiologists concurred with the COD certified by forensic pathologists. Of these cases, 85 (63.9%) had undergone only external examination and real-time reverse transcriptase polymerase chain reaction (rRT-PCR) COVID-19 testing, meaning that imaging was the sole method used to determine the COD besides history from available medical records and the investigating police officer.

Conclusion

PMCT can be used as a complement to medicolegal autopsies in pandemic contexts, as it provides significant information on the possible COD without jeopardising the safety of mortuary health care workers.

Distribution of frontal sinus pattern amongst Malaysian population: a skull radiograph study

Frontal sinus has unique anatomical features that are distinct to every population. However, the distribution of frontal sinus patterns has yet to be explored in the Malaysian population. This study aimed to describe the distribution of frontal sinus patterns among adult Malaysians. 409 adult Malaysian posteroanterior skull radiographs, consisting of 200 males and 209 females of Malay, Chinese, and Indian races aged between 20–69 years old, were included in the study. The frontal sinus patterns were classified according to total and percentage of presence or absence of frontal sinus, symmetry or asymmetrical (right or left dominant), unilateral absence (right or left), bilateral absence, and lobulation. The findings showed that bilateral presence of frontal sinus is common, in 95.4% of individuals and bilateral absence was noted in 2.7% individuals. Unilateral absence was found in 2.0% of individuals. Asymmetrical frontal sinus was observed in 54.5% of population meanwhile 40.8% showed symmetrical frontal sinus. The majority of individuals, regardless of sex, race, and age, possessed 1 to 3 lobes on both sides of the frontal sinus. The findings suggest that the frontal sinus is highly asymmetric, and the absence of the frontal sinus is rare. This morphological variation provides an insight into the landmarking placement for measurement during forensic application and assists neurosurgeons in surgical procedure to avoid breaching of the frontal sinus.

Stature estimation of Malaysians using post-mortem computed tomography images of the spine

Background

Stature estimation is important in medical investigations to identify victims and is most accurate using anatomical methods utilizing the entire skeleton. However, in cases of mass fatalities, it has been calculated using regression analysis formulas of different body parts. Radiology especially post-mortem computed tomography (PMCT) is increasingly being used in victim identification as it is non- invasive and allows for multi planar reconstruction.

Methods

This study aims to generate stature estimation formulae using regression analysis of the vertebral column incorporating population that form the Malaysian ancestry i.e. Malay, Chinese and Indian using PMCT. This was a retrospective study involving 115 subjects who had a PMCT. Subjects consisted of Malaysian males and females (92 males and 23 females) aged 18–70 years. Cervical length (CL), thoracic length (TL), lumbar length and the whole spine length (WSL) incorporating cervical, thoracic and lumbar length were compared against cadaveric length.

Results

Whole spine length had the highest correlation coefficient of 0.570 and showed highest correlation with cadaveric length among female subjects compared to males. Whole spine length amongst the Malay was the highest followed by the Chinese and Indian ethnic groups (r = 0.671, 0.629, 0.402).

Conclusion

Our study concluded that the use of WSL from PMCT images can be used for body height estimation amongst Malaysians. This study has also successfully generated population-specific database for Malaysian experts to perform stature estimation using measurements of the vertebral column.

Applications of drone in disaster management: A scoping review

The use of drones has rapidly evolved over the past decade involving a variety of fields ranging from agriculture, commercial and becoming increasingly used in disaster management or humanitarian aid. Unfortunately, the evidence of its use in mass disasters is still unclear and scarce. This article aims to evaluate the current drone feasibility projects and to discuss a number of challenges related to the deployment of drones in mass disasters in the hopes of empowering and inspiring possible future work. This research follows Arksey and O'Malley framework and updated by Joanna Briggs Institute Framework for Scoping Reviews methodology to summarise the results of 52 research papers over the past ten years, from 2009 to 2020, outlining the research trend of drone application in disaster. A literature search was performed in Medline, CINAHL, Scopus, individual journals, grey literature and google search with assessment based on their content and significance. Potential application of drones in disaster are broad. Based on articles identified, drone application in disasters are classified into four categories; (1) mapping or disaster management which has shown the highest contribution, (2) search and rescue, (3) transportation and (4) training. Although there is a significant increase in the number of publications on use of drone in disaster within the last five years, there is however limited discussion to address post-disaster healthcare situation especially with regards to disaster victim identification. It is evident that drone applications need to be further explored; to focus more on drone assistance to humans especially in victim identification. It is envisaged that with sufficient development, the application of drones appears to be promising and will improve their effectiveness especially in disaster management.

Isolated hyoid bone fracture in a child due to a fall

Hyoid bone fractures due to blunt trauma are rare accounting for only 0.002% of all head and neck fractures with most documented fractures being due to strangulation, hanging, motorcycle helmet straps, sports injuries and rarely as a complication of intubation. However, they are even rarer in the paediatric age group. We present a hyoid bone fracture in a two-year-old child as a result of a fall down three steps. Hyoid bone fractures though generally heal well with conservative treatment must be diagnosed early to avoid air way obstruction leading to morbidity and mortality.

Correlation and assessment of coronary artery luminal stenosis: Post-mortem computed tomography angiogram versus histopathology

BACKGROUND

Post-mortem Computed Tomography (PMCT) allows non-invasive or minimally invasive detection of findings that may or may not be visible during conventional autopsy, however, it does not allow the investigator to draw any conclusions regarding patency of the vessel's lumen. To address this deficiency, Post-mortem Computed Tomography Angiography (PMCTA) utilizing different contrast media and techniques have been introduced with various studies looking at the correlation between PMCTA, autopsy (gross) findings and coronary artery histology in diagnosing coronary artery disease.

OBJECTIVES

The aim of this study is to investigate the sensitivity and specificity of PMCTA in diagnosing coronary artery stenosis using water-based contrast media introduced though the vessels of the neck, compared to the gold standard of diagnosis i.e. gross and histological evaluation of the coronary artery.

METHOD

This was a cross sectional study of 158 arterial sections involving 37 subjects recruited from the National Institute of Forensic Medicine (IPFN), Hospital Kuala Lumpur (HKL). An unenhanced PMCT was performed followed by PMCTA using water-based contrast media introduced though the vessels of the neck. Coronary artery stenosis was determined using multiplanar reconstructionD while the degree of stenosis was determined by calculating the percentage of luminal diameter divided by the diameter of the vessel internal elastic.

RESULTS

The analysis of PMCTA and histopathology examinations revealed a sensitivity of 61.5%, specificity of 91.7%; positive predictive value (PPV) of 40.0% and negative predictive value (NPV) of 96.4%.

CONCLUSION

PMCTA utilizing water-based contrast introduced though the vessels of the neck yielded similar results as other methods and techniques of PMCTA. We would therefore conclude that PMCTA utilizing this technique could be used to assess the degree of calcification and the presence of significant stenosis.

Postmortem CT scan in intoxication cases: A necessity or just an indulgence

Introduction:

The aim of this study is to correlate urinary bladder distension and pulmonary edema on postmortem computed tomography (CT) scans with toxicology results in postmortem cases.

Methods and Results:

The study population was the postmortem cases of Asian population ranging from 16 to 75 years old in which blood and/or urine samples sent for alcohol and/or drug of abuse (DoA) analysis in year 2016 at our centre. Out of 434 cases, 54 from each group of positive and negative alcohol and/or DoA. Postmortem findings of lungs and postmortem CT scan urinary bladder volume (UBV) were recorded. Statistical significant correlation was obtained between urinary bladder distension on postmortem CT scan and cases with positive alcohol detection. However, the sensitivity was relatively low at 51.7%, whereas the specificity was 75% at the cut-off point. Low sensitivity and specificity at around 52.7% were obtained for pulmonary edema related to alcohol/DoA. This showed that UBV alone or pulmonary edema alone was not really a good indicator for alcohol or DoA intoxication. However, combination of both indicators provided higher sensitivity (73.3%) although specificity was lowered to 53.8%.

Conclusion:

The findings of postmortem CT scan bladder distension and pulmonary edema could possibly identify intoxication cases but not conclusive.

Idiopathic Thyroid Abscess - A Rare Occurrence

Thyroid abscesses are rare as the gland has a rich blood supply, well-developed capsule and is high in iodine. However, clinicians must be aware of this fact and make an early diagnosis as it can lead to serious morbidity if left untreated. Infection may involve one or both lobes of the thyroid gland, although the left lobe is more often affected and is successfully treated with surgery and antibiotics. This case study involves a 22-year-old woman with a history of painful swelling over the neck accompanied by low-grade fever without any underlying cause. Both the ultrasound and computed tomography revealed a heterogeneous mass within the left lobe of the thyroid gland. Fine needle aspiration revealed an abscess collection and culture Staphylococcus aureus had grown. She was successfully treated with intravenous and oral amoxicillin clavulanate and no surgical treatment was carried out. In conclusion, thyroid abscesses are rare as the gland is resistant to infection and must be differentiated from an infected branchial cleft cyst or sinus, infected thyroid tumour or lymphadenitis in the region of the thyroid in order to avoid serious morbidity if left untreated.

Manifestation of Coronary Atherosclerosis in Klang Valley, Malaysia: An Autopsy Study

Aims: The present study aimed to determine the epidemiological aspects of medico-legal autopsies and manifestation of coronary atherosclerosis.

Methods: This was a cross sectional study involving 222 cases recruited from National Institute of Forensic Medicine (NIFM) Hospital Kuala Lumpur (HKL) and Department of Forensic Medicine Hospital Sungai Buloh (HSgB) for a period of 15 months, from December 2012 to April 2014. Sociodemographic and autopsy findings, including the cause and manner of death were documented.

Results: Male and female subjects aged 18–70 years were recruited. Males contributed to 86% of the total subjects and comprised 61% of young adults. Road traffic accidents were the primary cause of death, contributing almost 50% of the subjects. One third of the cases comprised of death due to natural causes, wherein almost 75% of the subjects within this category succumbed to sudden cardiac death. Coronary artery disease (CAD) contributed to 60% of the sudden cardiac death (SCD). Single and double-vessel diseases were the most common pattern of atherosclerosis. In almost 80% of CAD cases, atherosclerosis affected the left anterior descending artery (LAD).

Conclusion: Cardiovascular diseases were the most significant natural cause of sudden death with a staggering figure of 75%. CAD was the single most commonly encountered pathology within the SCD. Most cases presented with single and double-vessel diseases, observed in all subjects, as well as the young adult population.

Progressive gas formation in a deceased person during mortuary storage demonstrated on computed tomography

We report the case of an 82-year-old woman with a past history of diabetes mellitus who died following blunt head injury sustained in a fall resulting in an acute subdural hematoma. Serial postmortem CT scans of the chest and abdomen performed over a 3-day period demonstrated progressive intra-hepatic and intra-cardiac gas formation whilst the deceased was stored in a standard mortuary refrigerator at a nominated temperature of 4 degrees C. Measured mortuary refrigerator temperatures over a 7 day period showed statistically significant day to day variability in temperatures above 4 degrees C as well as variations in temperature depending on location within the refrigerator space. In the absence of other known factors associated with such gas formation, putrefaction seems the likely cause despite a lack of obvious external features. This phenomenon must therefore be taken into account when interpreting the presence of visceral gas on postmortem CT and relating such gas to the cause of death.