【摘要】 目的 分析心脏瓣膜置换术后死亡案例的法医病理学特点，探讨有关瓣膜置换术后死亡案例的法医病理学鉴定思路及原则。 方法 从手术方式、术前心脏状况及术中所见、法医病理检验所见、死亡时间、死亡原因等方面，对2008年1月-2010年2月4例心脏瓣膜置换术后死亡案例进行综合研究分析。 结果 4例均患有风湿性心脏病，且术前心功能较差；3例二尖瓣瓣膜置换术，3例主动脉瓣瓣膜置换术，2例三尖瓣成形术；二尖瓣瓣膜置换术1例平行房间沟的左房纵行切口，1例右心房-房间隔切口，1例右心房-房间隔-左房联合切口；主动脉瓣瓣膜置换术均行升主动脉根部斜形切口或S状切口；死亡时间为1例术中，1例术后30 min，1例术后2 d，1例术后8 d；死亡原因为1例心肌炎，1例传导系统出血，2例失血性休克；1例术前有潜在感染灶。 结论 对有关心脏瓣膜置换术后死亡案例的法医病理学鉴定时，应在了解患者瓣膜置换术前心脏情况以及手术方式、手术路径和缝合方法的基础上，结合法医病理组织学检查进行综合分析。【Abstract】 Objective To analyze the forensic pathological characteristics of those who died after cardiac valve replacement and explore the mentality and principle of documentary evidence of medicolegal expertise. Methods Four death cases after cardiac valve replacement between January 2008 and February 2010 were comprehensively analyzed from various aspects of surgery style, preoperational heart condition, peri-operational observations, results of forensic pathological tests, time of death, and causes of death. Results All cases were rheumatic heart disease and the preoperational heart function was poor. Of the four cases, three had mitral valve replacement (MVR), three had aortic valve replacement (AVR) and two had tricuspid valvuloplasty. Of the three MVR cases, cutting on the left atrium paralleling the interatrial groove was performed in one case, cutting through right atrium and interauricular septum was performed in one case, and cutting left atrium and right atrium through interauricular septum was performed in another case. For all the three AVR cases, cutting on the root of aorta with the shape of diagonal or ’S’ was carried out. One patient died during operation, one died thirty minutes after operation, one died two days after operation and one died eight days after operation. Among them, one died of myocarditis, one died of hemorrhage in the conducting system and two died of hemorrhagic shock. Besides, one patient had potential bacterial infection before surgery. Conclusion For patients who died after cardiac valve replacement, we should acquaintance ourselves with the preoperational heart condition, surgery style, surgical approach and the methods of stitch to make a comprehensive analysis with forensic pathology examination.
ObjectiveTo investigate the expression of caspase-3 and Toll-like receptor 4 (TLR4) in the incised rat skin healing process and its relationship with the wound time and to provide an experimental evidence for the prediction of injury time. MethodsAfter the rat incised wound model was established, hematoxylin-eosin dyeing technology and immunohistochemical staining technique were used to observe the expression of caspase-3 and TLR4. Then Image Pro Plus Image analysis software and SPSS statistical analysis software were used to deal with the experimental results. ResultsCaspase-3- and TLR4-positive cells were detected in epidermis, hair follicle and sebaceous gland cells in the control skin. The expression of caspase-3 and TLR4 of the ante mortem groups were significantly different compared with the control group except the 0 h group (P<0.05). Caspase-3- and TLR4-positive cells were detected in neutrophils around the hair follicle half an hour later. Caspase-3- and TLR4-positive cell rate increased with the infiltration of inflammatory cells. Caspase-3- and TLR4-positive cell rate reached the maximum on the 3 rd day, and then it began to decrease, and they were mainly expressed in fibroblasts and mononuclear macrophages. Caspase-3- and TLR4-positive cells were mainly expressed in fibroblasts on the 10th day. There was no significant differences between the postmortem injury groups and the normal control groups (P>0.05). ConclusionCaspase-3- and TLR4-positive cell rate is time dependent and stable in 25℃ temperature environment which makes it possible to determine the time of injury.