Case report: radiation-induced lumbosacral plexopathy - a very late complication of radiotherapy for cervical cancer.

BACKGROUND: Lumbosacral plexopathy caused by radiotherapy is a rare but severe consequence of cancer treatment. This condition often leads to varying degrees of sensory and motor impairment. Neurological complications, which are typically permanent, manifest a long period after irradiation. CASE PRESENTATION: We describe a case of progressive lower extremity weakness and sensory impairment in a woman who had been effectively treated with radiotherapy for cervical cancer with development 36 years after irradiation. The electrophysiological assessment revealed a subacute bilateral axonal lesion of the lumbosacral plexus. None of the clinical manifestations, serology, cerebrospinal fluid or imaging data discovered an explanation other than radiation-induced lumbosacral plexopathy (RILP). CONCLUSIONS: This case demonstrates that RILP may emerge more than 30 years after the radiotherapy.

Deadly injuries through recoilless anti-tank weapons while military shooting practice-two case studies from Germany and Switzerland.

In this casuistry, two accidents from Germany and Switzerland are presented that happened during the shot of recoilless anti-tank weapons. In both cases, the injuries led to the death of two soldiers: A 22-year-old soldier in Germany was struck by the counter mass of a so-called Davis gun which had been fired by a comrade during a firing exercise; he died from his severe injuries, especially in the abdominal part of the body. As a peculiarity of the wound morphology, it was found to be a thick-layered, metallic, gray material in the wound cavity, which corresponded to the material of the counter mass that was ejected opposite to the shooting direction. The other case took place in Switzerland, where a 24-year-old soldier was seriously injured during an exercise with portable anti-tank rockets. At the time the shot was fired, he stood behind the launcher and was hit by the propulsion jet of the rocket motor. He died as well from his severe injuries, which were located at the chest done by the gas jet and by the very high pressure. In both cases, two different causes of death were present: massive blunt violence in the first case versus a jet of hot gases of very high speed and temperature in the second case.

Synergistic Effects of Forensic Medicine and Traumatology: Comparison of Clinical Diagnosis Autopsy Findings in Trauma-Related Deaths.

BACKGROUND: Trauma is the third leading cause of death worldwide after cardiovascular and oncologic diseases. Predominant causes of trauma-related death (TD) are severe traumatic brain injury (sTBI), hemorrhagic shock, and multiple organ failure. An analysis of TD is required in order to review the quality of trauma care and grasp how well the entire trauma network functions, especially for the most severely injured patients. Furthermore, autopsies not only reveal hidden injuries, but also verify clinical assumed causes of death. MATERIAL: During the study period of 3 years, a total of 517 trauma patients were admitted to our supraregional University Centre of Orthopaedics and Traumatology in Dresden. 13.7% (71/517) of the patients died after trauma, and in 25 cases (35.2%), a forensic autopsy was instructed by the federal prosecutor. The medical records, death certificates, and autopsy reports were retrospectively evaluated and the clinical findings matched to autopsy results. RESULTS: The observed mortality rates (13.7%) were 4.2% less than expected by the calculated RISC II probability of survival (mortality rate of 17.9%). The most frequent trauma victims were due to falls >3 m (n = 29), followed by traffic accidents (n = 28). The median ISS was 34, IQR 25, and the median New ISS (NISS) was 50, IQR 32. Locations of death were in emergency department (23.9%), ICU (73.2%), OR and ward (1.4%, respectively). Clinicians classified 47.9% of deaths due to sTBI (n = 34), followed by 9.9% thoracic trauma and multiple organ failure (n = 7), 8.4% multiple trauma (n = 6), and 2.8% hypoxia and exsanguination (n = 2). In 18.3%, cases were unspecific or other causes of death recorded on the death certificates. Evident differences with evident clinical consequences were ascertained in 4% (n = 1) and marginal clinical consequences in 24% (6/25). In 16% (4/25), marginal differences with minor forensic consequences were revealed. CONCLUSIONS: Even in a supraregional trauma center, specialized in multiple trauma management (4.2% survival benefit), room for improvement exists in more than a quarter of all casualties. This underlines the need for higher autopsy rates to uncover missed injuries and to understand the pathomechanism in each trauma fatality. This would also help to uncover potential insufficiencies in clinical routines with regard to diagnostics. The interdisciplinary cooperation of trauma surgeons and forensic pathologists can increase the quality of trauma patient care.

The Significance of a Knee Injury in the Investigation of an Unsuspected Motor Vehicle-Pedestrian Collision.

Characteristic injury patterns have been described in pedestrians struck by motor vehicles. The common injury pattern seen in upright pedestrians consists of a triad of head, pelvis, and lower extremity trauma. There are several factors such as vehicular type, design, mass and speed, and impact surfaces that influence the type and distribution of these injuries. We report a case that illustrates the importance of examination of the knee at autopsy when the typical lower extremity diaphyseal fractures that are usually seen in a motor vehicle-pedestrian collision are absent.

miR-142-3p Expression Is Predictive for Severe Traumatic Brain Injury (TBI) in Trauma Patients.

BACKGROUND: Predictive biomarkers in biofluids are the most commonly used diagnostic method, but established markers in trauma diagnostics lack accuracy. This study investigates promising microRNAs (miRNA) released from affected tissue after severe trauma that have predictive values for the effects of the injury. METHODS: A retrospective analysis of prospectively collected data and blood samples of n = 33 trauma patients (ISS ≥ 16) is provided. Levels of miR-9-5p, -124-3p, -142-3p, -219a-5p, -338-3p and -423-3p in severely injured patients (PT) without traumatic brain injury (TBI) or with severe TBI (PT + TBI) and patients with isolated TBI (isTBI) were measured within 6 h after trauma. RESULTS: The highest miR-423-3p expression was detected in patients with severe isTBI, followed by patients with PT + TBI, and lowest levels were found in PT patients without TBI (2-∆∆Ct, p = 0.009). A positive correlation between miR-423-3p level and increasing AIShead (p = 0.001) and risk of mortality (RISC II, p = 0.062) in trauma patients (n = 33) was found. ROC analysis of miR-423-3p levels revealed them as statistically significant to predict the severity of brain injury in trauma patients (p = 0.006). miR-124-3p was only found in patients with severe TBI, miR-338-3p was shown in all trauma groups. miR-9-5p, miR-142-3p and miR-219a-5p could not be detected in any of the four groups. CONCLUSION: miR-423-3p expression is significantly elevated after isolated traumatic brain injury and predictable for severe TBI in the first hours after trauma. miR-423-3p could represent a promising new biomarker to identify severe isolated TBI.

Polytrauma from a North American Black Bear Attack.

Bear attacks, although rare, can inflict life-threatening injuries. We present the case of a 50-y-old woman from rural Pennsylvania who was attacked by a North American black bear, Ursus americanus. She sustained multiple complex injuries including near-complete scalp avulsion, bilateral ear avulsions, and fractures of the face, ribs, and pelvis. These injuries are similar to those sustained in other bear maulings reported in the literature and required both acute intervention and a multidisciplinary approach to recovery.

Fatal gyroplane crash.

Gyroplanes are mainly used for sports aviation. Experience is required when flying these special aircraft because in 40% of gyroplane crashes, the passengers do not survive. Herein, a fatal gyroplane crash of a tandem-seat gyroplane with two occupants is reported. The occupants, both 49-year-old males, fell from a height of approximately 20 m to 30 m. In both cases, the cause of death was polytrauma with typical findings of deceleration trauma. The pilot, who probably lost his helmet in the crash, had a ring fracture at the base of his skull. As there is not much literature on autopsy findings in the case of light aircraft crashes, these autopsy findings are presented and discussed.

King Richard III revisited.

Forensic examination of skeletal remains exhumed in 2012 from the site of the former Church of the Greyfriars in Leicester, United Kingdom, revealed a gracile adult male of around 30 to 34 years of age with 11 perimortem injuries. These were consistent with descriptions of injuries sustained by King Richard III, the last Plantagenet King of England, at the Battle of Bosworth Field in 1485. Combining these features with DNA analyses proved that the remains were those of Richard. The finding of a severe thoracic scoliosis with a raised right shoulder confirmed that the king did have a" hunchback" which was not a later invention of Tudor and subsequent chroniclers. This investigation provides an excellent demonstration of how contemporary forensic techniques can answer historical questions. The remains of the last Plantagenet king have been identified, his vertebral disease confirmed, and the nature of his last moments verified.

Death scene investigation and autopsy proceedings in identifying the victims of the terror attack on the Breitscheidplatz in Berlin 19th December 2016.

We describe and discuss the forensic mission after the terrorist attack on the Breitscheidplatz in Berlin on 19th December 2016, focusing on co-operation with police authorities, and the injury patterns of the deceased. Even after massive blunt trauma, severe injury patterns are often unrecognizable by visual inspection of the body ("Casper's sign"), which could instill false security among rescuers or, as happened on the Breitscheidplatz, may lead to distress or even trauma in rescue personnel when obviously primarily uninjured patients die suddenly.

Fatal mauling by tigers.

Lethal injuries due to large animal attack are uncommon in routine forensic practice in Europe. Specifically, few incidents are reported concerning tiger/lion attacks that usually involve captive circus or zoo animals. We present the case of a 61-year old animal tamer who was mauled to death by four tigers while he was training them for a circus performance. Careful investigation of the circumstances surrounding the fatality revealed that the tamer had most likely been struck with a tiger paw and then mauled by additional tigers resulting in serious and fatal injuries. Although a full medico-legal autopsy was not authorized, total body CT scan coupled with post-mortem external examination allowed a reconstruction of events.

Geriatric Polytrauma-Cardiovascular and Immunologic Response in a Murine Two-Hit Model of Trauma.

BACKGROUND: The aims of the present study were to establish a clinically relevant two-hit model with trauma/hemorrhage followed by sepsis in older mice and investigate age-dependent cardiovascular and immunologic specificities under these conditions. MATERIALS AND METHODS: In aged mice (12, 18, and 24 mo old), a femur fracture followed by hemorrhage was induced. After resuscitation, animals were monitored for 72 h before sepsis was induced. Vital signs were monitored during shock. Systemic interleukin (IL)-6 levels were measured daily. Expression of sarcoplasmic or endoplasmic reticulum calcium ATPase (SERCA) and IL-6 receptor were analyzed in heart, lung, and liver tissues. RESULTS: After induction of shock, mean arterial pressure decreased significantly in all groups (12 mo, P < 0.001; 18 mo, P < 0.001; 24 mo, P = 0.013). Compared with younger animals, 24-mo old mice were not able to adequately compensate for hypovolemia by an increase of heart rate (P = 0.711). Expression of SERCA2 (P = 0.002) and IL-6 receptor on myocytes (P = 0.037), lung (P = 0.005), and liver (P = 0.009) tissues were also lowest in this group. Systemic IL-6 values showed the most distinct posttraumatic response in 24-mo-old mice (P = 0.016). Survival rate decreased significantly with increased age (P = 0.005). CONCLUSIONS: The increased mortality rate in older animals was associated with a limited compensatory physiological response and a more distinct immunologic reaction after trauma and sepsis. A decreased SERCA2 expression and missing feedback loops due to a reduced density of organ bound immune receptors might represent possible explanations for the observed age-dependent differences.

A case of suicide by double gunshot wounds to the head: the ability to act after the first shot.

A single gunshot (or multiple) does (do) not necessarily lead to immediate loss of consciousness or rapid neurological deficits, so the victim may be able to repeatedly pull the trigger before achieving the lethal effect. Despite multiple gunshot wounds can lead to the suspicious participation of other person to the death of the victim, in the medico-legal literature suicides with multiple gunshot wounds are reported, demonstrating the ability of the victim to act after two or more gunshots. In this case, a 47-years-old man was found dead in a pool of blood in the kitchen of his house. According to findings and analysis, the victim modified a single-shot, pneumatic toy gun branded "Condor" Cal. 7 mm (a gun that is made mainly with "ZAMAK" zinc-based alloy, designed to shoot one soft-polymer bullet at a time, with an initial kinetic energy lower than 1 Joule) into an improvised firearm weapon. With this gun, the victim achieved shooting of two bullets into his head, both entering from the right temporal region of his head, with one stopped in the left occipital lobe and the other one in the left temporal lobe. His death was caused by cranium-meningo-encephalic gunshot wounds. The conditions supporting the hypothesis that the victim was able to fire two shots to his head before the onset of incapacitation (the type of bullets used, the location of injuries and their consequences) and the characteristics that typically allow to distinguish the manner of death (suicide vs homicide) were evaluated. Based on all the collected elements, it was possible to confirm that suicide was the manner of death. This case underlines the importance of evaluating all available elements (post-mortem imaging, autopsy and toxicological findings, ballistics and neuropathological evaluations) to distinguish suicide from homicide and to prevent incorrect conclusions.

An unusual case of pulmonary fat embolism following blunt trauma.

Fat embolism is markedly underdiagnosed, even though it is a well-known phenomenon following fractures of the long bones, injury to subcutaneous fat tissue, rupture of a fatty liver, surgical operations on fatty tissues, septicemia, burns and barotrauma. Forensic pathologists tend to "simplify" autopsy report conclusion in cases with multiple injuries where fat embolism and exsanguination could be considered to be the concomitant causes of death. Herein we present a case of 24-year-old male who was beaten with a metal rod by several persons. On admission to hospital his vital signs and laboratory findings indicated hemorrhagic shock with gradual respiratory failure; he died 17 h after injury. On internal autopsy examination the subcutaneous tissue of the limbs and back was severely bruised, corresponding to about 35% of the body surface area. He had fractures of several small bones. Injuries of the internal organs were absent, there was no free blood in the body cavities, and all other autopsy findings were unremarkable but suggestive of a significant blood loss. Microscopic examination showed a massive pulmonary fat embolism (grade III according to Sevitt), without systemic fat embolism. The cause of death was attributed to pulmonary fat embolism combined with severe blood loss, following extensive and severe bruising of the subcutaneous tissues and bone fractures.

An Autopsy Case of Injuries Caused by Automobile Dragging for a Distance of 3.4 km Without Thoracoabdominal Organ Injuries.

Dragging injuries caused by automobiles involved in an accident are occasionally reported; however, those without injury to the thoracoabdominal organs are rare. We present an autopsy case of a man in his 20s found dead on the road after being dragged by a passenger automobile for a distance of 3.4 km. The accident caused fatal dragging injuries but no thoracoabdominal injuries. The victim appeared to be drunk and was lying on the road in front of the parked automobile. Dragging injuries are a unique type of traffic accident that sometimes result from limited and poor visibility due to darkness, rain, or fog. In particular, lying on the road in a drunken state is a specific risk factor for dragging injuries. The dragging distance, road-surface properties, strength of pressure applied by the underbody of the automobile, and the victim's posture are considered to affect the distribution and degree of dragging injuries. Based on autopsy findings and eyewitness testimonies, we discuss the injury mechanism and attempt to reconstruct the accident.

Autopsy Features of Fatal Donkey Attack.

Lethal donkey attacks have very rarely been described. The case of a 65-year-old man who was found deceased on a country road with 2 domestic donkeys nearby is, therefore, reported. Examination of the body revealed contusions and lacerations of the face and scalp, a comminuted fracture of the left maxilla, comminuted fracturing of the right radius and ulna and of the left anterior superior iliac spine, a flail chest, and pulmonary contusions. In addition, there were bite marks on the left thigh, right buttock, right axilla/upper arm, and left cheek which corresponded to the dental arcades of the donkeys. Death had resulted from blunt chest trauma due to an attack by 1 or 2 donkeys. Deaths and serious injuries are much more commonly caused by horses; however, this case shows that even domesticated donkeys may also rarely be capable of inflicting significant trauma and so should be approached with circumspection.

Unusual accidental decapitation in a road traffic incident.

Decapitation is an occurrence only rarely encountered in forensic medical practice. This fatality is generally most often described in pedestrians who have been run over by trains accidently or in cases of suicide, or alternatively in occupants of cars involved in high speed vehicle collisions. We report, for the first time, a case of a complete decapitation of a pedestrian as a consequence of a traffic accident. Due to a thorough medico-legal investigation of the body and the involved vehicle, we were able to reconstruct the unique dynamics of the accident and the mechanism of injury.

Double suicidal gunshot wounds to the heart.

A case of double gunshot wounds to the heart is reported, where police investigations determined the manner of death to be suicide. In addition, the autopsy findings supported this conclusion. The localization, appearance, and mutual relations of the inflicted wounds, as well as the direction of the bullet trajectories, helped to determine the most probable sequence of events. The victim had been able to act after the first shot and inflict the second shot as the conduction system of the heart was at least partially preserved. Even when the circumstances indicate the most probable manner of death, multiple gunshot wounds represent a challenge for forensic pathologists; a victim's ability to act after the first shot must be determined with respect to the degree of initial incapacitation.

Internal patterned injuries in trauma.

Patterned bruising of the internal organs is unusual. In these cases a cutaneous pattern of bruising is not observed but the underlying tissue may show unusual injuries that may even be recognizable as a tramline pattern. We report the suicide of a 23-year-old man by jumping off a bridge. At autopsy, an unusual finding was "tramline" bruising of the right liver lobe. The "blunt objects" that inflicted the bruising were determined to be the right ribs which were pushed against the liver capsule as a consequence of the extensive thoracic and vertebral trauma after a fall from a height with intermediate impact.

Multidrug-Resistant Pathogens in Hospitalized Syrian Children.

Since 2013, wounded and ill children from Syria have received treatment in Israel. Screening cultures indicated that multidrug-resistant (MDR) pathogens colonized 89 (83%) of 107 children. For 58% of MDR infections, the pathogen was similar to that identified during screening. MDR screening of these children is valuable for purposes of isolation and treatment.

Polytrauma-induced hepatic stress response and the development of liver insulin resistance.

Insulin resistance and metabolic dysfunction are common following injury. Polytrauma is defined as combined injuries to more than one body part or organ system, and is common in modern warfare, as well as automobile and industrial accidents. Polytrauma can include any combination of burn injury, fracture, hemorrhage, trauma to the extremities, and blunt or penetrating trauma. Multiple minor injuries are often more deleterious than a more severe single injury. To investigate the mechanisms of development of insulin resistance following injury, we have developed a rat model of polytrauma which combined soft tissue trauma with burn injury and penetrating gastrointestinal (GI) trauma. Male Sprague-Dawley rats were subjected to a laparotomy plus either a 15-18% total body surface area scald burn or a single puncture of the cecum (CLP) with a G30 needle, or the combination of both burn and CLP injuries (polytrauma). We examined the effects of polytrauma which increased markers of hepatic endoplasmic reticulum (ER) stress, and increased hepatic Trib3 mRNA levels coincident with reduced insulin-inducible insulin signaling. Phosphorylation/activation of the insulin receptor (IR) and AKT were decreased at 24, but not 6h following polytrauma. These results demonstrate a complex, time-dependent development of hepatic ER-stress and a diminished response to insulin, which were among the pathological sequelae following polytrauma.