A Systematic Review of Single-Layer Versus Double-Layer Intestinal Anastomosis: Is One Better?

INTRODUCTION: To perform a systematic review of randomized controlled trials comparing outcomes from handsewn single-layer and double-layer intestinal anastomosis in adults. METHODS: A literature search was conducted using PubMed, SCOPUS, and Web of Science databases for studies published up to September 14, 2023 using the following keyword search query: ((one) OR (single)) AND ((two) OR (double)) AND (layer) AND ((anastomoses) OR (anastomosis)). RESULTS: In seven of the eight studies, there was no significant difference in anastomotic leakage rate. In one of the eight studies, Moeen et al., double-layer anastomosis was associated with a significantly higher anastomotic leakage rate than single-layer anastomosis (5/100 versus 15/100, P = 0.018). Time to complete single-layer anastomosis was shorter than double-layer anastomosis. CONCLUSIONS: Single-layer and double-layer intestinal anastomosis have similar rates of anastomotic leak, mortality, and hospital stay in adults, with single-layer intestinal anastomosis having the benefit of shorter time to complete.

Appendicitis in the Neutropenic Patient: A Systematic Review.

Neutropenia increases the complexity of surgical decision-making in cases of acute appendicitis. In this systematic review, we discuss medical vs surgical management and timing of appendectomy in the neutropenic adult patient. We queried databases utilizing the key words "neutropenia" and "appendicitis." The search identified 999 articles of which 481 articles were reviewed after duplicates were removed. Studies with pediatric patients, single case studies, and abdominal pain in neutropenic patients not caused by appendicitis were excluded. Seven studies remained in this review accounting for 130 patients, of which 28 were diagnosed with neutropenic appendicitis, and were included for final analysis. Four of the 7 articles were case reports, demonstrating the relative paucity of literature on this subject. Studies referred to the high risk of morbidity and mortality after surgical intervention in the neutropenic population, and attempting medical management first was common but not universal, reserving appendectomy for failure of medical management. Three studies suggested medical therapy as first-line management while 2 studies suggested surgical management and 2 studies did not distinguish a precedence. Both medical and surgical management have been successfully used in treating appendicitis in neutropenic patients. In most patients, medical management was attempted first (n = 16/28) vs immediate appendectomy (n = 7/28). Appendectomy was performed when medical management failed (n = 2/28) or after correction of neutropenia (n = 1/28). Timing or performance of appendectomy was unclear in 2 patients. With the increasing use of immunosuppressive medications, broad-spectrum antibiotics, and recent data from the CODA (Comparison of Outcomes of Antibiotic Drugs and Appendectomy) trial, medical management as a first-line treatment for most patients with neutropenia and appendicitis is warranted, and identifying a protocol for such patients would be of value.

A Survey of Fetal Deaths as Reported to a Medical Examiner's Office.

ABSTRACT: This article is a review of the fetal deaths reported to the Pima County Office of the Medical Examiner in Tucson, Arizona, from January 2000 to May 2020. The 115 cases included in this study were analyzed for the decedent's estimated gestational age, sex, maternal drug use, toxicology results, and cause of death. The male/female ratio was 0.95:1.0. The average gestational age of nonterm infants older than 20 weeks was 27.2 weeks. Nearly half of the cases had suspected or known maternal drug use. In these cases, cocaine and methamphetamine were most often detected in postmortem testing of the fetus. The most common causes of death in descending frequency were intrauterine fetal demise of unknown etiology, drugs, infection, and prematurity. Other notable causes of death included trauma and placental abruption. Congenital malformations were detected in only 3.5% of cases.

Radiodense bullet wipe around osseous entrance gunshot wounds.

"Bullet wipe" is the material deposited by a bullet on any surface with which it comes into contact after it is fired and may contain debris from the gun barrel, including particles of primer and metal fragments from previously fired bullets. X-ray analysis is a non-destructive method by which traces of metallic elements can be visually detected. The analysis of osseous defects for radiodense bullet wipe (RBW) assists in determining the presence or absence of perforating gunshot wounds, especially in fragmented, skeletonized remains. The aim of our current study was to determine the frequency of RBW around entrance firearms injuries that perforated bone. We prospectively analyzed entrance gunshot wounds for RBW over a three-year period using digital X-ray analysis (n = 59). We retrospectively reviewed the corresponding autopsy reports to determine the frequency of RBW by biologic sex, reported ancestry, age-at-death, location of wound, manner of death, range of fire, bullet caliber, and presence of bullet jacket. Data were analyzed by Fisher's exact test or Chi-square test with significance levels accepted at p < 0.05. RBW was present in 66% (n = 39) of examined cases. Decedent characteristics did not significantly alter RBW distribution, including biologic sex (p = 0.75), reported ancestry (p = 0.49), and age-at-death (p = 0.43). Additionally, the location of the osseous entrance gunshot wound, manner of death, range of fire, and cartridge caliber did not affect RBW detection. All cases involving non-jacketed rounds (n = 5) showed RBW (p = 0.30). To our knowledge, this study is the first to report the frequency of RBW detection from osseous entrance gunshot wounds.

Environmental Deaths in Southern Arizona.

INTRODUCTION: The Pima County Office of the Medical Examiner (PCOME) maintains medicolegal jurisdiction over Southern Arizona, which includes the Sonoran Desert and the Arizona/Mexico border. Given the unique climate and biodiversity of the Sonoran Desert coupled with the Mexican border, environmental-related deaths are represented in proportions different from other jurisdictions in the United States. METHODS: A retrospective study of deaths falling into one of five categories (hyperthermia, hypothermia, undetermined with skeletal and/or mummified modifiers, venom-related, and lightning) certified by the PCOME between January 1, 2010 and December 1, 2017 was conducted by searching the PCOME electronic database. RESULTS AND DISCUSSION: Of the 16 649 cases certified by the office during that time, 639 were categorized into one of the above five categories. Hyperthermia cases were the most common, followed by undetermined, hypothermia, venom-related, and lightning. A unique population of individuals referred to as undocumented border crossers (UBCs) is discussed and accounted for 470 of the 639 deaths.

Parachute Deaths in Southern Arizona.

INTRODUCTION: Parachuting is said to be a relatively safe activity. We sought to undertake a study to assess parachute-related deaths in our jurisdiction. METHODS: A retrospective study of parachute-related deaths in Southern Arizona was conducted by searching the Pima County Office of the Medical Examiner database between 2001 and 2016. This search revealed 24 deaths. RESULTS: The decedents ranged from 19 to 61 years of age, with a median age of 36 years. Twenty-two of the decedents were male. The racial breakdown was 22 white, one Asian, and one not recorded. The manner of death in all cases was classified as an accident. All deaths were due to multiple blunt force injuries and only one case was found to have no injuries to the head or neck. The most common circumstances were failure of chute deployment (seven), mid-air collisions (three), and becoming entangled with other parachutists (three). Six deaths occurred during military training. Four of the nonmilitary decedents were described as "experienced" parachutists and one case involved a tandem jump team with a survivor. Natural disease was found in four cases with three having moderate coronary artery atherosclerosis. Toxicology was performed in 21 of the deaths with three positive for cannabinoids, one positive for 7-aminoclonazepam, and one positive for 3, 4-methylenedioxymethamphetamine (MDMA). DISCUSSION: Parachuting is a relatively safe activity, with very few deaths. Investigation of these deaths should include a complete autopsy with toxicology as well as a thorough scene investigation and evaluation of the jumper's equipment.

Association of Antemortem Central Nervous System Symptoms and Location of Aortic Dissections; A Retrospective Study from 2001-2014.

Aortic dissections (AD) are a frequent cause of sudden death and are typically associated with chest, back, and/or abdominal pain. Several cases of AD with neurologic presenting symptoms, such as paresthesia, headache, and seizures were noted at the Pima County Office of the Medical Examiner (PCOME) in Tucson, Arizona. Our aim was to compare the location of AD with central nervous system (CNS) versus classic symptoms. Retrospective data were collected from the archives at the PCOME from 2001-2014. There were 61 natural death cases involving the aorta with known antemortem symptoms; 43 cases of AD with classic (non-CNS) symptoms and 18 cases with CNS symptoms. The cases were classified based on Debakey and Stanford classification systems. Patients with CNS symptoms had a greater proportion of Debakey type II dissections (44%) than without CNS symptoms (16%). This association was statistically significant (p = 0.0337, chi-square test). Seventeen percent of cases with CNS symptoms had AD involving the carotid arteries, and involvement of the carotid arteries was significantly associated with CNS symptoms (p = 0.0227, Fisher's exact test). There were a higher percentage of females with CNS symptoms (44%), than without CNS symptoms (23%). Our findings suggest a need for a higher index of suspicion and further investigation of cases with neurologic symptoms, focusing particularly on the aortic arch and its branches.

Case reports of synthetic cannabinoid XLR-11 associated fatalities.

Synthetic cannabinoids have been available in herbal incense and potpourri products over the Internet and in smoke shops for the last several years. We report the deaths of two individuals that were associated with XLR-11. Specimens were extracted via a liquid-liquid extraction at basic pH into hexane:ethyl acetate and analyzed by liquid chromatography tandem mass spectrometry. For these two case reports, we describe the instrumental analysis and extraction methods for XLR-11, toxicological results for postmortem blood specimens, relevant case information and autopsy findings. We also briefly review any previously published peer-reviewed reports in which XLR-11 was analytically confirmed and determined to be an intoxicating agent.

Pediatric fatalities associated with over the counter (nonprescription) cough and cold medications.

STUDY OBJECTIVE: The use of nonprescription cough and cold medicines is widespread, but their use has been sporadically associated with severe toxicity and death. We evaluate the role of these medications in pediatric fatalities and identified factors that contributed to the death. METHODS: Fatalities that involved a child younger than 12 years and mentioned a cough and cold ingredient were obtained from 5 sources. An independent panel of 8 experts (pediatrics, pediatric critical care, pediatric toxicology, clinical toxicology, forensic toxicology, forensic pathology) used explicit definitions to assess the causal relationship between medication ingestion and death. Contributing factors were identified. RESULTS: Of 189 cases included, 118 were judged possibly, likely, or definitely related to a cough and cold ingredient. Of these 118 cases, 103 involved a nonprescription drug, whereas 15 cases involved a prescription medication alone. Of 103 cases associated with nonprescription drugs, the evidence indicated that 88 involved an overdosage. A dosage could not be assessed in the remaining 15 cases. Several contributing factors were identified: age younger than 2 years, use of the medication for sedation, use in a daycare setting, use of 2 medicines with the same ingredient, failure to use a measuring device, product misidentification, and use of a nonprescription product intended for adult use. All cases that occurred in a daycare setting involved a child younger than 2 years. CONCLUSION: In our sample, pediatric fatalities caused by nonprescription cough and cold medications were uncommon, involved overdose, and primarily affected children younger than 2 years. The intent of caregivers appears to be therapeutic to relieve symptoms in some cases and nontherapeutic to induce sedation or to facilitate child maltreatment in other cases.

A new type of shotgun ammunition produces unique wound characteristics.

The Tucson Police Department, Tucson, AZ, has begun using the Polyshok Impact Reactive Projectile (IRP), a new type of shotgun ammunition that includes a lead bead core that travels within single, plastic-encased projectile. On impact, the core is released to distribute over a small area, thereby disintegrating on impact to reduce the likelihood of exit or collateral damage on missed shots. After a brief review of shotgun slug ballistics and wound characteristics and a discussion of the mechanism of the Polyshok IRP, we report the first death in the United States from this ammunition. Findings included a single entrance wound with plastic ammunition components and small lead particles recovered from the body, the combination of which normally would suggest a close-range shooting with birdshot. However, the characteristics of this ammunition create different patterns than are found with slugs or shot, so that a medical examiner unfamiliar with the Polyshok IRP could draw inaccurate conclusions about ammunition and range of fire. Because the single projectile fired from this ammunition is composed of both plastic and lead, plastic components are likely to be found within the wound at any range of fire, unlike traditional shot or slug ammunition. Also, the small size of lead particles found spread through the wound cavity would ordinarily suggest a small-size shot, whereas the external appearance of the wound (a single entrance with no dispersion of shot) and the pattern of tissue destruction are more consistent with the patterns of injury associated with shotgun slugs.

Detection of medical examiner cases from review of cremation requests.

Title 9, Chapter 19, Article 3 of the Arizona Administrative Code requires all bodies that are to be cremated must have the death certificate reviewed by a county medical examiner. In Tucson, AZ, and surrounding Pima County, all cremation requests are submitted to the Forensic Science Center, where the death certificates are reviewed by one of 5 board-certified forensic pathologists. In 2002, there were 5557 cremation requests, and in 2003 there were 5662 cremation requests. Of these requests, 670 (12.1%) and 447 (7.9%) death certificates were flagged for further investigation in 2002 and 2003, respectively. Eventually, 47 cases (0.8% of total, 7.0% of flagged cases) were accepted as medical examiner cases in 2002, and 43 cases (0.8% of total, 9.6% of flagged cases) were accepted as medical examiner cases in 2003. In 2002, the majority of cases were handled as a records review; however, 4 cases were brought in for autopsy and 1 was certified after an external examination only. In 2003, all cases were certified via a records review. The manner of death in all but 3 of these deaths was certified as accident, with complications of remote trauma being the most common proximate cause of death. The 3 most common injuries were complications of fractured pelvis or femur (15 in 2002, 22 in 2003), head injury due to fall (18 in 2002, 8 in 2003), and complications of remote motor vehicle accident (3 in 2002, 6 in 2003). The other 3 deaths included 2 homicides, 1 in each year, and 1 suicide in 2003.

Fatal intravenous fentanyl abuse: four cases involving extraction of fentanyl from transdermal patches.

The transdermal fentanyl system delivers a specific dose at a constant rate. Even after the prescribed application time has elapsed, enough fentanyl remains within a patch to provide a potentially lethal dose. Death due to the intravenous injection of fentanyl extracted from transdermal patches has not been previously reported. We present 4 cases in which the source of fentanyl was transdermal patches and was injected. In all of these cases, the victim was a white male who died at home. Case 1 was a 35-year-old with no known history of drug use, who was found by his wife on the floor of his workshop. Police recovered a fentanyl patch, needle, and syringe at the scene. Case 2 was a 38-year-old with a known history of drug use whose family claimed that he was in a treatment program that used fentanyl patches for unknown reasons. His brother found him dead in bed, and law enforcement officers found a hypodermic needle beside the body; a ligature around his left hand, and apparent needle marks between his first and second digits were also noted. Case 3 was a 42-year-old with a recent attempted suicide via overdose who was found dead at his home. An empty box of fentanyl patches, Valium, Ritalin, and 2 syringes were found at the scene. Case 4 was a 39-year-old found by his mother, who admitted to removing a needle with attached syringe from the decedent's arm. Medications at the scene included hydrocodone, alprazolam, zolpidem, and fentanyl patches. All reported deaths were attributed to fentanyl intoxication, with blood concentrations ranging from 5 to 27 microg/L.