Evaluation of an Educational Scholarship Fellowship Program for Health Professions Educators.

Introduction: Historically, the requirement to produce scholarship for advancement has challenged health professions educators heavily engaged in teaching. As biomedical scientists or healthcare practitioners, few are trained in educational scholarship, and related faculty development varies in scope and quality across institutions. Currently, there is a need for faculty development and mentoring programs to support the development of these skills. Methods: The International Association of Medical Science Educators (IAMSE) established the Medical Educator Fellowship (MEF) Program to foster health professions educational scholarship. MEF addresses the following: curriculum design, teaching methods and strategies, assessment, educational scholarship, and leadership. Participants receive mentorship and faculty development, and complete an educational scholarship project. Using a logic model, we conducted a retrospective program evaluation with data from Program records, database searches, graduate surveys, and focus groups. Results: Over 14 years, MEF graduated 61 participants with diverse terminal degrees from five continents and six academic program areas. Graduate survey responses indicated enhanced post-Program skills in all focus areas, that the majority would recommend MEF to a colleague, and that mentorship, networking, and professional development were strengths. Focus group outcomes indicated professional growth, increased confidence, and increased sense of community. Conclusion: MEF addresses health professions educators' need for faculty development and mentorship in educational scholarship. Evaluation outcomes suggest that MEF effectively enhanced perceived skills across focus areas. Similar programs are essential to support faculty who dedicate significant time to teaching. Organizations like IAMSE can demonstrate the value of educational scholarship and positively impact health professions educator careers by supporting such programs.

Improving departmental psychological safety through a medical school-wide initiative.

BACKGROUND: Psychological safety is a team-based phenomenon whereby group members are empowered to ask questions, take appropriate risks, admit mistakes, propose novel ideas, and candidly voice concerns. Growing research supports the benefits of psychological safety in healthcare and education for patient safety, learning, and innovation. However, there is a paucity of research on how to create psychological safety, especially within academic medicine. To meet this need, the present study describes and evaluates a multi-year, medical school-wide psychological safety initiative. METHODS: We created, implemented, and assessed a multi-pronged psychological safety initiative including educational training sessions, departmental champions, videos, infographics, and targeted training for medical school leaders. Employees' perceptions of psychological safety at both the departmental and institutional levels were assessed annually. The impact of educational training sessions was quantified by post-session surveys. RESULTS: Deidentified employee surveys revealed a statistically significant increase in departmental psychological safety between the first and second annual surveys. Perceived psychological safety remained lower at the institution-wide level than at the departmental level. No significant differences in psychological safety were observed based on gender, position, or employment length. Post-educational training session surveys showed that the sessions significantly increased knowledge of the topic as well as motivation to create a culture of psychological safety within the medical school. CONCLUSIONS: This study establishes an evidence-based method for increasing psychological safety within medical school departments and serves as a template for other health professions schools seeking to promote psychological safety. Training leadership, faculty, and staff is an important first step towards creating a culture of psychological safety for everyone, including trainees.

Supporting Medical Student Scholarship: A Novel Case Report Elective to Teach the Writing and Publishing Process.

PROBLEM: Successful residency placement requires medical students to pursue activities beyond formal education, including showing their commitment to the specialty. Case reports are a common publication pursued by medical students, which provide trainees with opportunities to show commitment to the specialty, broaden their clinical and scholarly knowledge, improve their ability to find and interpret literature, and gain faculty mentorship. However, case reports can be intimidating to trainees with limited exposure to medical writing and publishing. The authors describe a case report elective designed specifically for medical students. APPROACH: Since 2018, Western Michigan University Homer Stryker M.D. School of Medicine has offered a week-long medical student elective designed to teach the process of writing and publishing a case report. Students wrote a first draft of a case report during the elective. Students could pursue publication, including revisions and journal submission, after the elective. An optional, anonymous survey was sent to students who participated in the elective to evaluate their experience with the elective, motivations for taking the elective, and perceived outcomes. OUTCOMES: Between 2018 and 2021, the elective was taken by 41 second-year medical students. Five scholarship outcomes of the elective were measured, including conference presentations (35, 85% of students) and publications (20, 49% of students). Students who completed the survey (n = 26) indicated the elective was very valuable with an average score of 85 ± 15.6 (range: minimally valuable [0] to extremely valuable [100]). NEXT STEPS: Next steps for this elective will be to allocate more faculty time to this curriculum promoting both education and scholarship at the institution, and to curate a list of journals to ease the publication process. Overall, student experiences with this case report elective were positive. This report aims to provide a framework for other schools to implement similar courses for their preclinical students.

Chlamydia trachomatis Alters Mitochondrial Protein Composition and Secretes Effector Proteins That Target Mitochondria.

Mitochondria are critical cellular organelles that perform a wide variety of functions, including energy production and immune regulation. To perform these functions, mitochondria contain approximately 1,500 proteins, the majority of which are encoded in the nuclear genome, translated in the cytoplasm, and translocated to the mitochondria using distinct mitochondrial targeting sequences (MTS). Bacterial proteins can also contain MTS and localize to the mitochondria. For the obligate intracellular human pathogen Chlamydia trachomatis, interaction with various host cell organelles promotes intracellular replication. However, the extent and mechanisms through which Chlamydia cells interact directly with mitochondria remain unclear. We investigated the presence of MTS in the C. trachomatis genome and discovered 30 genes encoding proteins with around 70% or greater probability of mitochondrial localization. Five are translocated to the mitochondria upon ectopic expression in HeLa cells. Mass spectrometry of isolated mitochondria from infected cells revealed that two of these proteins localize to the mitochondria during infection. Comparison of mitochondria from infected and uninfected cells suggests that chlamydial infection affects the mitochondrial protein composition. Around 125 host proteins were significantly decreased or absent in mitochondria from infected cells. Among these were proapoptotic factors and those related to mitochondrial fission/fusion dynamics. Conversely, 82 host proteins were increased in or specific to mitochondria of infected cells, many of which act as antiapoptotic factors and upregulators of cellular metabolism. These data support the notion that C. trachomatis specifically targets host mitochondria to manipulate cell fate decisions and metabolic function to support pathogen survival and replication. IMPORTANCE Obligate intracellular bacteria have evolved multiple means to promote their intracellular survival and replication within the otherwise harsh environment of the eukaryotic cell. Nutrient acquisition and avoidance of cellular defense mechanisms are critical to an intracellular lifestyle. Mitochondria are critical organelles that produce energy in the form of ATP and regulate programmed cell death responses to invasive pathogenic microbes. Cell death prior to completion of replication would be detrimental to the pathogen. C. trachomatis produces at least two and possibly more proteins that target the mitochondria. Collectively, C. trachomatis infection modulates the mitochondrial protein composition, favoring a profile suggestive of downregulation of apoptosis.

A novel presentation of childhood systemic lupus erythematosus in a 6-year-old child.

Childhood systemic lupus erythematosus (cSLE) is an autoimmune disorder, characterized by the formation of autoantibodies, that most often presents in children around the age of 12. Antiphospholipid antibody syndrome (APS) is a condition in which antiphospholipid antibodies produced by the patient cause the formation of thromboses. While reports estimate that 30%-40% of cSLE patients have antiphospholipid antibodies, only 4% develop symptomatic APS, with venous thromboses being more common than arterial. Overall, thrombosis has an incidence of about 0.1/10,000 in the pediatric population and usually only occurs in the setting of underlying disease or in relation to medical procedures. Here, we report a case of a 6-year-old female who presented with abdominal pain, arthralgia, fever, and right popliteal artery thrombus. Further testing revealed an abundance of autoantibodies including antinuclear, lupus anticoagulant, and anticardiolipin which resulted in a diagnosis of cSLE with associated APS. This presentation is novel due to both the young age of the patient at disease onset and the presence of concurrent cSLE and APS at initial diagnosis. Childhood systemic lupus erythematosus can be difficult for providers to recognize as it can present with varied nonspecific symptoms but being aware of the potential for onset in children significantly younger than the average will allow for early detection and potentially better outcomes.

Ovarian Neoplasm: Delivering Suspicion of Cancer in the Emergency Department.

Cancer is not infrequently detected in the Emergency Department (ED) and is sometimes even an incidental finding on imaging. Since the ED is designed to identify and treat acutely ill patients, the time providers can spend with patients and the depth of investigation into patient conditions is limited. However, Emergency Medicine physicians must ensure the appropriate follow-up for patients with presumptive diagnosis of cancer to ensure timely confirmatory testing, prompt treatment, and accurate prognosis. A 26-year-old woman presented to the ED for evaluation of abdominal pain and urinary complaints and was ultimately found to have a 36cm ovarian mass that was suspicious for neoplasm. The mass caused obstruction of urinary outflow leading the patient to develop a urinary tract infection. Emergency Medicine physicians are faced with the challenge of having limited time and short-lived doctor-patient relationships. In cases of suspicious findings, balancing the urgency of follow-up without causing undue harm from heightened anxiety for patients is essential. It is important to discuss findings that may be concerning for cancer with both clear verbal and written communication. Employ strategies such as direct communication with primary care physicians and outpatient specialists via phone consultation and electronic medical record messaging, as well as providing clear discharge instructions in-person and in-writing to the patient including whom to call and the time frame for follow-up.

Factors impacting the rapid transition of anatomy curricula to an online environment in response to Covid-19.

Due to the Covid-19 pandemic, many academic institutions had to rapidly transition education to a remote online environment. While a hurdle for most educators, this transition posed an even greater challenge for anatomy educators, many of whom were forced to depart from the traditional cadaver-based laboratory to a virtual format. Recent publications have discussed the rapid transition to online formats necessitated by Covid-19 and the accompanying difficulties, but none have identified specific factors that influenced the difficulty of this transition. Anatomy educators were surveyed to examine how this transition was accomplished and perceived. Of the 165 educators who responded, the majority utilized cadaver-based laboratory instruction. Educators felt that transitioning the laboratory portion of their courses was significantly more difficult and required more time than converting lecture materials. Factors that impacted the difficulty of the transition included a number of pedagogical aspects of the pre-Covid-19 curricula, including the delivery format of prior content, availability of pre-existing electronic materials, and the laboratory technique previously used. Additionally, the length of time an educator had been teaching prior to Covid-19 impacted their perception of difficulty, with newer and more senior educators finding this much more challenging than mid-tenure educators. Ease of transition may be related to previous exposure to curricular reform, experience with multiple anatomy pedagogies, and educator adaptability. While not surprising that converting a cadaver-based laboratory to an online format was challenging, knowledge of the alignment of this difficulty with prior educator pedagogy can help guide future innovations to anatomy education.

Incidental finding of renal cell carcinoma in an asymptomatic patient on low-dose computed tomography screening for lung cancer.

INTRODUCTION In 2013, the United States Preventive Services Task Force recommended annual low-dose computed tomography (CT) screening for lung cancer in high-risk adults with a significant smoking history. These screenings result in large numbers of incidental findings, and although most of these do not warrant further investigation, there have been reported cases of incidental findings identified on CT screening that led to successful treatment of a previously undiagnosed comorbidity. CASE HISTORY Here, we report a case of papillary renal cell carcinoma that was detected incidentally on low-dose CT in an asymptomatic individual, a rare diagnosis considering that renal neoplasms account for <1% of incidental findings on these screenings. CONCLUSION This case highlights the value of investigating these incidental findings, with the goal of detecting underlying disease in some cases before it would have presented symptomatically.

Evaluation of Basic Life Support First Responder Naloxone Administration Protocol Adherence.

OBJECTIVES: Opioid overdoses have become a significant problem across the United States resulting in respiratory depression and risk of death. Basic Life Support (BLS) first responders have had the option to treat respiratory depression using a bag-valve-mask device, however naloxone, an opioid antagonist, has been shown to quickly restore normal respiration. Since the introduction of naloxone and recent mandates across many states for BLS personnel to carry and administer naloxone, investigation into the adherence of naloxone use standing protocols is warranted. METHODS: This preliminary study examined 100 initial cases of BLS first responder administration of naloxone for appropriate indications and protocol adherence. RESULTS: This study found that n=22/100 naloxone administrations were inappropriate, often given to patients who were not suffering from respiratory depression (n=11/22). Positive pressure ventilation (PPV) was not administered prior to naloxone in n=56/100 cases, of which n=42/100 had an inadequate respiratory effort documented. For patients with a known history of substance use disorder, there was a significant increase in administration of naloxone prior to PPV (60%; n=33/55) compared to patients without a known history (30%; n=9/30). CONCLUSION: Overall these preliminary data suggest that during BLS naloxone administration, the majority of cases did not follow at least one component of the standard protocol for patients with respiratory depression. This study suggests that further education and more research are needed to better understand the decision-making processes of prehospital providers to ensure adherence to standard protocols.

Squamous Cell Carcinoma of the Neck: An Unlikely Stroke Mimic.

BACKGROUND: Stroke mimics are noncerebrovascular conditions that present with classical stroke symptoms. They account for up to 30% of stroke presentations in the emergency department (ED). Emergency physicians are faced with a diagnostic dilemma-rapid treatment of stroke, a leading cause or mortality and morbidity in the United States, or ruling out the ever-growing list of conditions that mimic strokes. CASE REPORT: An 87-year-old man with a 60-year smoking history, chronic obstructive pulmonary disease, and extensive cardiovascular disease history presented to the ED with a chief symptom of new onset right-arm weakness. Computed tomography (CT) excluded hemorrhage and lesions, and additional CT angiography imaging revealed a large mass compressing the right subclavian artery. Given the initial workup, mass effect on the right brachial plexus better explained the patient's symptoms. Two weeks later, a CT scan of the chest, abdomen, and pelvis revealed masses on the pubic ramus, iliac bone, and several vertebral bodies. Biopsy of the rib mass revealed squamous cell carcinoma. The patient was diagnosed with bone metastasis of unknown origin and started on radiation therapy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Even in fast-paced settings, clinicians must maintain a high level of suspicion for stroke mimics. This case illustrates the vital importance of neuroimaging in the diagnosis of stroke mimics and discusses clinical characteristics and patient risk factors that increase the likelihood of a stroke mimic diagnosis, serving as a tool for physicians facing this diagnostic dilemma.

Charcoal-based dentifrices and powders: analyses of product labels, Instagram engagement, and altmetrics.

This study identified charcoal-based dentifrices and abrasive powders sold in Brazil and analyzed their label information. The products were searched in four online shopping platforms. The same products were searched on Instagram and their engagement metrics were investigated. Furthermore, a literature review of international publications assessing charcoal dentifrices and powders was conducted, and altmetrics were collected (Altmetric and PlumX). Thirty-six products were found with prices between $0.4-22 USD. Most frequent words in product description were sodium, stain, whitening, oil, xylitol, and coconut. Only 3 products contained fluoride. Bactericidal, antiviral, antifungal, and anti-inflammatory activities were indicated, in addition to non-scientific claims such as calming teeth or increasing oral immunity. In total, 72% of products had Instagram profiles, which generally showed low engagement rates (81%) and medium audience quality scores (65%). Twenty-two articles were found in the literature, from which 21 were in vitro studies. The single clinical study was sponsored by a charcoal product and had no control group. In total, 23% of studies showed positive results and 55% reported negative results for the charcoal products, which included no whitening ability, increased roughness, surface alterations, and lower demineralization prevention ability. Altmetric scores for the included articles varied from 0 to 55, with 40.9% of studies mentioned online. In conclusion, charcoal-based products are using marketing strategies on Instagram but their current engagement with the public is not high. Consumers are being exposed to charcoal products whose potential risks to health are still unknown.

Charcoal-based dentifrices and powders: analyses of product labels, Instagram engagement, and altmetrics

Abstract This study identified charcoal-based dentifrices and abrasive powders sold in Brazil and analyzed their label information. The products were searched in four online shopping platforms. The same products were searched on Instagram and their engagement metrics were investigated. Furthermore, a literature review of international publications assessing charcoal dentifrices and powders was conducted, and altmetrics were collected (Altmetric and PlumX). Thirty-six products were found with prices between $0.4-22 USD. Most frequent words in product description were sodium, stain, whitening, oil, xylitol, and coconut. Only 3 products contained fluoride. Bactericidal, antiviral, antifungal, and anti-inflammatory activities were indicated, in addition to non-scientific claims such as calming teeth or increasing oral immunity. In total, 72% of products had Instagram profiles, which generally showed low engagement rates (81%) and medium audience quality scores (65%). Twenty-two articles were found in the literature, from which 21 were in vitro studies. The single clinical study was sponsored by a charcoal product and had no control group. In total, 23% of studies showed positive results and 55% reported negative results for the charcoal products, which included no whitening ability, increased roughness, surface alterations, and lower demineralization prevention ability. Altmetric scores for the included articles varied from 0 to 55, with 40.9% of studies mentioned online. In conclusion, charcoal-based products are using marketing strategies on Instagram but their current engagement with the public is not high. Consumers are being exposed to charcoal products whose potential risks to health are still unknown.

Resumo Este estudo identificou dentifrícios e pós abrasivos de carvão vendidos no Brasil e analisou suas informações de rótulo. Os produtos foram pesquisados em quatro plataformas de compras online. Os mesmos produtos foram pesquisados no Instagram e métricas de engajamento dos perfis foram investigadas. Além disso, foi realizada uma revisão da literatura buscando publicações internacionais que avaliaram dentifrícios e pós de carvão; dados de altmetria foram coletados (Altmetric e PlumX). Foram encontrados 36 produtos com preços entre US$ 0,4-22. As palavras mais frequentes na descrição dos produtos foram sódio, mancha, clareamento, óleo, xilitol e coco. Apenas 3 produtos continham flúor. Foram indicadas atividades bactericidas, antivirais, antifúngicas e anti-inflamatórias, além de alegações não-científicas como acalmar dentes ou aumentar a imunidade oral. No total, 72% dos produtos tinham perfis no Instagram, que geralmente apresentavam baixas taxas de engajamento (81%) e média qualidade de audiência (65%). Vinte e dois artigos foram encontrados na literatura, dos quais 21 foram estudos in vitro. O único estudo clínico foi patrocinado por um produto de carvão e não tinha grupo controle. No total, 23% dos estudos apresentaram resultados positivos e 55% relataram resultados negativos para os produtos de carvão, que incluíram incapacidade de clareamento, aumento da rugosidade, alterações superficiais e menor capacidade de prevenção da desmineralização do esmalte. A altmetria dos artigos incluídos variou de 0 a 55, com 40,9% dos estudos sendo mencionados online. Em conclusão, os produtos à base de carvão estão usando estratégias de marketing no Instagram, mas seu engajamento atual com o público não é alto. Consumidores estão sendo expostos a produtos de carvão cujos potenciais riscos à saúde ainda são desconhecidos

Fighting diagnostic confirmation bias: Cystic fibrosis, allergic bronchopulmonary aspergillus, or both?

As diagnostic algorithms for cystic fibrosis (CF) continue to evolve, education of general practitioners is essential to prevent delayed diagnosis of CF and allow prompt referral to CF centers. For patients suffering from allergic bronchopulmonary aspergillosis (ABPA), CF should be at the top of the differential diagnosis.

Rare case of osteomyelitis caused by Gardnerella vaginalis and Streptococcus parasanguinis in a postmenopausal woman.

Vertebral osteomyelitis is an infection of the vertebrae that can lead to spinal degeneration, most commonly caused by Staphylococcus aureus Here, we report an unusual case of pyogenic osteomyelitis caused by Gardnerella vaginalis and Streptococcus parasanguinis in a 61-year-old postmenopausal woman. The patient presented with a 2-week history of worsening lower back pain and fever and a recent episode of cystitis following re-engagement of sexual activity. Imaging revealed a deterioration of vertebrae discs and spinal canal stenosis at the L3-L4 levels with a formation of abscess in the right psoas muscle. Needle aspiration of the abscess identified G. vaginalis and S. parasanguinis and the patient was successfully treated with a 6-week course of ceftriaxone and metronidazole. This case describes an unusual coinfection of two pathogens that normally reside in the urogenital tract and oral cavity, respectively, and highlights the risk posed when these organisms breach the body's normal barriers.

A Focal Pontine Infarct Presenting as Unilateral Facial Nerve Paralysis.

Brainstem infarction typically presents with vague symptoms, including headache, nausea, vomiting, and vertigo. Rarely do patients present with complete unilateral facial paralysis, mimicking Bell's palsy. Here we report the case of a 40-year-old woman who presented to the emergency department with intractable nausea, vomiting, and vertigo upon waking along with left-sided upper and lower extremity numbness and right-sided facial paralysis. Her atypical presentation of unilateral facial nerve paralysis in the context of nausea, vomiting, and vertigo prompted neurological studies, which were significant for a small punctate infarct in the pons involving the right facial colliculus. ​History, physical examination, and clinical suspicion are important to prevent anchoring bias. Physicians rely on history and physical examination to help distinguish true Bell's palsy from other causes of facial nerve paralysis. Stroke and other clinically emergent etiologies should be considered high on the differential diagnosis when patients have neurological signs and symptoms in addition to facial nerve palsy.

Varicella Zoster Virus Meningoencephalitis With an Atypical Presentation of Chest Pain, Impaired Memory, and Seizure.

BACKGROUND: Neurologic complications of varicella zoster virus (VZV) reactivation can be associated with considerable mortality and morbidity. Aseptic meningitis associated with VZV infection is rare, occurring in 0.5% of immunocompetent individuals. One third of VZV-related neurologic disease occurs without the classic herpes zoster exanthema, making early recognition more difficult. CASE REPORT: A 60-year-old man presented to the emergency department with chest pain and impaired memory that he attributed to a transient ischemic attack as suggested by an urgent care facility 1 day earlier. He suffered a seizure while in the emergency department and was admitted to the intensive care unit. A computed tomography scan of his head and a magnetic resonance imaging scan were both negative for acute findings. An abnormal electroencephalogram consistent with an encephalopathy together with his new-onset seizure triggered a lumbar puncture that was positive for VZV. He was placed on acyclovir and was discharged from the hospital 5 days after admission. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The typical presentation of a VZV central nervous system infection occurs with a sudden onset of fever, headache, nuchal rigidity, and focal neurologic signs. Our patient's recent impaired memory and subsequent seizure were likely manifestations of the developing VZV meningoencephalitis, while his chest pain may have correlated with subsequent development of a vesicular rash. Seizures are encountered in 11% of patients with VZV central nervous system infection, and VZV has recently been associated with cerebral vasculopathy. Awareness of alternative presentations for herpes zoster and meningitis is important in cases without classic symptoms to enable diagnosis and prevent delays in treatment.

Guided Growth with Hemiplateau Elevation as an Alternative to Epiphysiodesis for Treatment of a Young Patient with Advanced Infantile Blount Disease: A Case Report.

CASE: Infantile Blount disease results from deceleration of growth by the proximal posteromedial tibial physis causing tibia vara. In advanced disease stages, surgical treatment is indicated. Owing to the young age and advanced Langenskiöld stage in this patient, a novel technique was performed combining lateral proximal physeal tethering with medial hemiplateau elevation osteotomy to correct the articular surface and unload the medial proximal tibial physis. CONCLUSION: Together, these procedures allow for correction of alignment while preserving growth potential. This technique was successful in correcting tibia vara due to infantile Blount disease while allowing continued growth in a 5-year-old patient.

Differentiating Pseudohyperkalemia From True Hyperkalemia in a Patient With Chronic Lymphocytic Leukemia and Diverticulitis.

Acute changes in electrolyte levels can result in severe physiologic complications. Rapid treatment of abnormally elevated potassium levels is essential due to the increased risk of potentially fatal cardiac arrhythmias. However, there are a number of circumstances that can lead to falsely elevated serum potassium levels, including fist clenching during phlebotomy and hemolysis of hematocytes during laboratory processing. Here we present a case of an elderly woman with chronic lymphocytic leukemia who presented with lower left quadrant pain and hematochezia. Laboratory tests revealed an elevated serum potassium level (7.5 mmol/L) on initial testing, in the absence of hyperkalemia symptoms, EKG changes, and hemolysis of the blood specimen. Abdominal CT revealed inflammatory changes consistent with diverticulitis. She was treated with intravenous calcium, insulin, glucose, and bicarbonate for her hyperkalemia and admitted for treatment for diverticulitis. A subsequent serum potassium level (3.9 mmol/L) and discussion with the hospitalist suggested a diagnosis of leukolysis-induced pseudohyperkalemia, and further treatment of hyperkalemia was halted. This case serves to remind current and future physicians about the importance of maintaining clinical suspicion and clarifying unexpected laboratory readings when the clinical picture and results do not completely align.

A Case of Crossbow Homicide With Review of Crossbow Injuries and Manner of Death Considerations.

Crossbow fatalities are a rare occurrence, but crossbow use is on the rise. The manner of death in crossbow fatalities is overwhelmingly opined accident or suicide, not homicide. Despite their increasing use and reports of at least 14 crossbow-related homicides in the media for the last 5 years, crossbow homicides are rarely reported in the medical literature; only 10 articles that discussed 20 crossbow homicides were identified in the PubMed database. Here, we describe a case of a 20-year-old man who was found dead in his driveway after being shot in the abdomen with a crossbow by another person. The crossbow bolt had a mechanical 2-blade broadhead that transected the descending aorta and lodged in his vertebra. When completing a medicolegal death investigation and postmortem examination on suspected crossbow-related deaths, knowledge of crossbow components, its utility as a weapon, wound patterns, and how it can cause death are important. This case serves to build on the limited medical literature of crossbow homicides, educate forensic pathologists about the features of crossbow deaths, and highlight manner of death considerations.

Spontaneous iliac vein rupture in the setting of a long dwelling intravenous vena cava filter.

Venous thromboembolism impacts as many as 600,000 individuals each year in the United States, leading to significant morbidity and mortality. While typically treated with anticoagulants, retrievable inferior vena cava (IVC) filters may also be used for acute prevention of pulmonary embolism. The FDA recommends removing IVC filters within 29-54 days because long dwelling filters are associated with serious complications from the filter itself, such as perforation of adjacent structures and filter fracture. We report an unusual case in which a patient had an inferior venous cava filter in place for two years before experiencing spontaneous rupture of the left iliac vein. There was no evidence of filter migration or inferior venous cava perforation. Spontaneous iliac vein ruptures are rare, with fewer than 50 reported cases, and are not typically seen with a long-dwelling IVC. This case describes a unique complication of retrievable filters and highlights the importance of retrieving filters as soon as the acute danger of pulmonary embolism has resolved.