Food embolus.

A 74 year old man with chronic dysphagia acutely developed nausea, vomiting and fever, followed by abrupt, fatal brainstem stroke. Autopsy revealed an esophagoatrial fistula with multiple food emboli to visceral and cerebral arteries. Review of previous cases indicates that new onset atrial fibrillation or pericardial effusion in patients with chronic esophageal symptoms may herald fistula formation. Early recognition of such fistulas may provide an opportunity to intervene before catastrophic embolization or gastrointestinal hemorrhaging occurs.

Cockroach: the omnivorous scavenger. Potential misinterpretation of postmortem injuries.

Interpretation of postmortem injuries, including their differentiation from those produced antemortem, may be difficult even for experienced forensic pathologists. A variety of animals or insects residing in the death environment may alter the appearance of the deceased. Dictyoptera blattaria (the cockroach) is common in the residential setting. Three cases of sudden and unexpected infant death are presented in which postmortem injuries inflicted by cockroaches initially raised concern of nonaccidental injury. The true nature of the lesions was not recognized by the people at the death scene and, in one case, observation of neck injuries raised suspicion of possible strangulation. In another, the lesions were thought to be burns of different ages. Cockroaches are omnivorous scavengers that devour keratin. They will bite human flesh in both the living and dead with resultant injury. Recognition of cockroach bites will help in the evaluation of injuries discovered during child death investigations.

A national survey of autopsy cost and workload.

We mailed survey questionnaires to a random sample of medicolegal offices throughout the USA. The survey asked how many forensic pathologists were used, their American Board of Pathology forensic examination (Board) status, how many autopsies they performed, and, if payment were fee-for-service, what fees were paid for medicolegal autopsies. Response rate was 61%, with 188 offices returning questionnaires. The average fee, was $518 with a standard error of $27. The number of fee-for-service autopsies was split evenly between Board qualified and Board ineligible pathologists, accounting for about one-third of medicolegal autopsies nationwide. Although smaller offices used more pathologists ineligible for forensic Boards, they paid a premium for such qualification. Larger offices used more forensic Board qualified pathologists, but paid them less than those ineligible to take the examination! Overall there was no significant premium paid for Board qualification. The average fee paid is far less than the published estimates of the cost of an autopsy. The low fees paid may reflect: (1) the value of the teaching experience supplied to medical students and/or residents; (2) pathologists performing medico-legal examinations as community service; and (3) the lower marginal cost of additional autopsies.

Feasibility, accuracy, and incremental value of intraoperative three-dimensional transesophageal echocardiography in valve surgery.

In this prospective trial, intraoperative 2-dimensional (2-D) and 3-dimensional (3-D) transesophageal echocardiography (TEE) examinations were performed on 60 consecutive patients undergoing cardiac valve surgery. Both 2-D (including color flow and Doppler data) and 3-D images were reviewed by blinded observers, and major valvular morphologic findings recorded. In vivo morphologic findings were noted by the surgeon and all explanted valves underwent detailed pathologic examination. To test reproducibility, 6 patients also underwent 3-D TEE 1 day before surgery. A total of 132 of 145 attempted acquisitions (91%) were completed with a mean acquisition time of 2.8 +/- 0.2 minutes. Acquisition time was significantly shorter in patients with regular rhythms. Reconstructions were completed in 121 of 132 scans (92%) and there was at least 1 good reconstruction in 56 of 60 patients (93%). Mean reconstruction time was 8.6 +/- 0.7 minutes. Mean effective 3-D time, which was the time taken to complete an acquisition and a clinically interpretable reconstruction, was 12.2 +/- 0.8 minutes. Intraoperative 3-D echocardiography was clinically feasible in 52 patients (87%). Three-D echocardiography detected most of the major valvular morphologic abnormalities, particularly leaflet perforations, fenestrations, and masses, confirmed on pathologic examination. Three-D echocardiography predicted all salient pathologic findings in 47 patients (84%) with good quality images. In addition, in 15 patients (25%), 3-D echocardiography provided new additional information not provided by 2-D echocardiography, and in 1 case, 3-D echocardiographic findings resulted in a surgeon's decision to perform valve repair rather than replacement. In several instances, 3-D echocardiography provided complementary morphologic information that explained the mechanism of abnormalities seen on 2-D and color flow imaging. In the reproducibility subset, preoperative and intraoperative 3-D imaging detected a similar number of findings when compared with pathology. Thus, in routine clinical intraoperative settings, 3-dimensional TEE is feasible, accurately predicts valve morphology, and provides additional and complementary valvular morphologic information compared with conventional 2-D TEE, and is probably reproducible.

Gender identification of human hair using fluorescence in situ hybridization.

Identification of the gender of hair represents relevant medicolegal evidence in criminal cases. The efficacy of Fluorescence In Situ Hybridization (FISH) using chromosome X and Y centromeric probes was tested to determine its ability to identify correctly the gender of hair. In this preliminary study, FISH correctly identified the gender of cells from hair as old as 26 days. The technique is accurate, rapid, sensitive, easily performed, and readily available. As a forensic laboratory technique, FISH shows great promise.

Postmortem coronary subtraction angiography.

Thorough examination of the coronary arteries is essential when performing medicolegal autopsies. In some cases, evaluation is optimized by using postmortem angiography before dissection. Unfortunately, most techniques are far too time-consuming to be readily employed by forensic pathologists. We describe a simple technique of "subtraction angiography" that provides valuable information in a timely manner in cases that can benefit from postmortem angiographic analyses. We find the technique particularly helpful in cases that have had invasive coronary artery procedures contemporaneous with death.

Gender identification of dried human bloodstains using fluorescence in situ hybridization.

Identification of the gender of an individual(s) from whom a bloodstain is derived represents important evidence in medicolegal cases. The efficacy of fluorescence in situ hybridization (FISH) using chromosome X and Y centromeric probes was tested to determine its ability to identify correctly the gender of extracted dried bloodstains. In this preliminary study, FISH correctly identified the gender of 2-week-old dried bloodstains in prepared mixtures of male-to-female blood as low as 1%. The technique is accurate, rapid, sensitive, easily performed and readily available. This application of FISH as a forensic laboratory technique holds great promise.

Oleoresin capsicum (pepper) spray and "in-custody deaths".

Increasing use of oleoresin capsicum (OC) spray devices (i.e., pepper spray, pepper mace, OC, capsaicin) by law enforcement agencies as a means of sublethal force to control suspects has brought into question whether exposure to this noxious irritant (capsaicin) can cause or contribute to unexpected in-custody deaths. Capsaicin stimulates nociceptors in exposed mucous membranes to produce intense pain, particularly involving the conjunctiva, and generates systemic physiologic and behavioral responses consonant with such extreme discomfort. We describe two cases of in-custody death, both associated temporally with the use of pepper spray, to illustrate salient investigative considerations. As with any other in-custody death, a thorough autopsy and toxicologic analysis, coupled with evaluation of the premortem chain of events, postexposure symptomatology, and the extent of natural disease processes, will help to reveal the role of oleoresin capsicum spray as unrelated, contributory, or causative.

The use of next-of-kin in assessing handedness.

The present study administered a 15-item handedness questionnaire to 129 college students and their next-of-kin. This questionnaire was similar to the Edinburgh Handedness Inventory, except that a 7-point scale was used instead of a 2-choice scale. Test-retest reliability was evaluated with a second administration of the handedness questionnaire to each subject. Analysis showed a high test-retest reliability for all items and a high correlation between subjects and next-of-kin responding for most items. However, some items on the Edinburgh Handedness Inventory showed much higher correlations than others when comparing subject and next-of-kin responding. The contribution of these data is that subjects' handedness can be accurately estimated from next-of-kin responses if a subset of these questionnaire items are used.

Identification of male epithelial cells in routine postcoital cervicovaginal smears using fluorescence in situ hybridization. Application in sexual assault and molestation.

In a prospective blinded controlled study, the efficacy of fluorescence in situ hybridization (FISH) to detect non-sperm male cells verifying sexual contact was examined. Cervicovaginal smears (CVS) from 40 women with reported post-coital intervals were examined for sperm by cytology and for sperm and non-sperm male cells by FISH using X and Y chromosome specific DNA probes. Fluorescence in situ hybridization identified sperm and/or non-sperm male cells in all specimens from women with positive coital histories, including when the partner had a vasectomy. Male cells were also detectable by FISH in CVS up to 3 weeks after coitus. In comparison, cytology identified sperm in 41% of the positive coital history cases, and none beyond 2 weeks. Fluorescence in situ hybridization is highly sensitive and specific in detecting male cells, and can be performed rapidly on routine CVS. Application of this technique can provide new and additional evidence of sexual contact when current tests are inconclusive.

Sudden death in epilepsy due to an isolated subependymal giant cell astrocytoma of the septum pellucidum.

We report a case of sudden unexpected death in an individual with epilepsy. Autopsy revealed a subependymal giant cell astrocytoma of the septum pellucidum, but there were no other lesions of tuberous sclerosis. We discuss sudden death in epilepsy, deaths related to primary brain tumors, the pathology of subependymal giant cell astrocytoma, and whether or not such a tumor can exist outside the setting of tuberous sclerosis. We also discuss the implications such findings may have on surviving family members, as well as the important role of the forensic pathologist in such cases.

Medical examiner/death investigator training requirements in state medical examiner systems.

Comprehensive and properly performed investigation of suspicious, unusual, unnatural, and various natural deaths is necessary to maintain the health, safety, and well-being of society as a whole. Adequate investigation requires the combined efforts and cooperation of law-enforcement and other public-service agencies, medical professionals, and those within the forensic community. As such, the "death investigator" plays a crucial role in the investigation process. These front-line investigators, whether they be coroners, medical examiners, physicians, other medical professionals, or lay-people, are required to make important decisions which have far-reaching consequences on how death investigation cases proceed. Death investigation practices vary greatly among medico-legal jurisdictions. A recent publication has categorized state death investigation systems by type of system. In an attempt to better delineate death investigation practices with specific regard to investigators' training and continuing education requirements, we surveyed the 20 systems categorized as state medical examiner systems and the five states with combined state medical examiner and county coroner/medical examiner systems. We present our findings and make recommendations which address the attributes and deficiencies of current death investigation practices.

An unusual case of maternal-fetal death due to vaginal insufflation of cocaine.

Air embolism secondary to vaginal insufflation has been documented as a cause of death in pregnant women. Under pressure, the air enters the uterus, causing air emboli within the uterine venous drainage and subsequently the systemic circulation. Death is usually sudden as the air obstructs the normal flow of circulation. Acute cocaine toxicity is also a well-known cause of sudden death. Cocaine use is prevalent in our society, even among pregnant women. We report the sudden death of a 31-year-old gravid female and 39-week gestational age male fetus. The cause of death was air embolism secondary to oral-vaginal insufflation of cocaine smoke.

Identification of sperm and non-sperm male cells in cervicovaginal smears using fluorescence in situ hybridization: applications in alleged sexual assault cases.

The identification of spermatozoa or constituents of seminal fluid is critical in the evaluation of alleged sexual assault victims. However, failure to identify sperm and/or elevated levels of acid phosphatase can occur for a variety of reasons. Molecular techniques, such as molecular cytogenetic analysis offers new approaches to improve on the identification of male cells in alleged sexual assault cases. Fluorescence in situ hybridization (FISH) with a Y chromosome specific DNA probe was applied to archival cervicovaginal smears from 41 alleged sexual assault cases to identify Y-bearing (male) cells. FISH identified Y-bearing sperm and non-sperm cells in 78% of the cases previously confirmed to have sperm. FISH also identified Y-bearing non-sperm male cells in 39% of the cases in which cytology did not detect spermatozoa; in one of these instances, it also detected sperm. Cervicovaginal acid phosphatase levels, determined at the time of the cervicovaginal smears, were also compared with the presence or absence of Y-positive cells. Application of this technique can detect non-spermatozoic male cells in routine cervicovaginal smears of sexual assault victims.

Fatal carbon dioxide embolism complicating attempted laparoscopic cholecystectomy--case report and literature review.

Laparoscopic cholecystectomy has become the surgical procedure of choice for individuals with symptomatic gallbladder disease. The procedure has gained popularity among surgeons and patients because of inconspicuous abdominal incisions/scars, less postoperative pain, shorter hospitalization, and reduced medical costs. Bile duct, vascular, and gastrointestinal iatrogenic injuries are major complications. We describe the case of a 50-year-old woman who died of CO2 embolism during elective laparoscopic cholecystectomy for symptomatic cholelithiasis. With the patient under general anesthesia, a 1.5 cm incision was made just below the umbilicus, and a pneumoperitoneum was created by CO2 insufflation with a pneumoperitoneum (modified Veress) needle. Immediately, she experienced a cardiopulmonary arrest and could not be resuscitated. At autopsy, air bubbles were admixed with blood in the epicardial veins and leptomeningeal blood vessels. A triangular 0.1 cm perforation in the left common iliac vein had been created by the pneumoperitoneum needle. A pneumoperitoneum is required for laparoscopy and CO2 is the most commonly used gas. Carbon dioxide is highly soluble in blood and fairly innocuous to the peritoneum. Small amounts absorbed into the circulation cause slight increases in arterial and alveolar CO2 and in central venous pressure. When CO2 enters the venous circulation through iatrogenically opened vascular channels, catastrophic and potentially fatal hemodynamic and respiratory compromise may result.

Terminal ballistics of the 9mm with Action Safety bullet or Blitz-Action-Trauma (BAT) ammunition.

Specialty ammunition creating atypical gunshot wounds of entrance can create confusion and may be misinterpreted by pathologists unfamiliar with the terminal ballistics of these projectiles. The previously unreported wound ballistics caused by the 9mm with Action Safety bullet described in a homicide highlights the atypical entrance wound(s) and wounding capacity of this novel ammunition. Manufactured by Geco division of Dynamit Nobel, the bullet consists of a nonjacketed solid copper alloy bullet body without a conventional lead core. The large deformation well and part of the smaller central channel is filled with a hard plastic core and post that creates a round nose bullet. The internal ballistics and unique design allow the plastic nose cap and post to separate from the copper alloy base while still in the barrel. The radiolucent nose cap leaves the bullet's path but can still penetrate tissue giving the appearance of a separate but smaller entrance wound. The sharp leading edge of the deformation well and relative high velocity of the bullet body creates a punched out entrance wound with minimal marginal abrasion. When the plastic nose cap or fragments of the plastic post impact the subject, test firings may allow an inference to the muzzle-target distance even in the absence of soot deposition or stippling.