Penile Microdissection: A Live Donor Feasibility Study in Feminizing Gender-Affirming Surgery.

Femininizing gender affirmation surgery includes the creation of external female genitalia such as a new clitoris, labia, and vagina with removal of the glans and urethral remnants and full corpora cavernosa. We evaluated the possibility of using preserved cavernosal bodies with glans and urethral remnants for potential live-donor penile transplantation. Between March 2021 and February 2023, penile microvascular dissection followed by gender-affirming vaginoplasty was performed in 41 patients aged 18 to 57 years (mean 30.5 years). The mean follow-up was 15 months (ranging from 6 to 26 months). The removed penile entities were properly measured. The corpora cavernosa were completely preserved in all cases; the length of remaining anterior urethra ranged from 12.70 cm to 16.40 cm, while the mean glans remnant volume was 85.37% of the total volume. All patients reported satisfactory results after gender-affirming vaginoplasty. Microvascular penile dissection in gender-affirming vaginoplasty is simple and safe, suggesting a good possibility of using the full corpora cavernosa, glans, and anterior urethra remnants for live-donor penile transplantation.

The United States Department of Energy and National Institutes of Health Collaboration: Medical Care Advances via Discovery in Physical Sciences.

Over several months, representatives from the U.S. Department of Energy (DOE) Office of Science and National Institutes of Health (NIH) had a number of meetings that lead to the conclusion that innovations in the Nation's health care could be realized by more directed interactions between NIH and DOE. It became clear that the expertise amassed and instrumentation advances developed at the DOE physical science laboratories to enable cutting-edge research in particle physics could also feed innovation in medical healthcare. To meet their scientific mission, the DOE laboratories created advances in such technologies as particle beam generation, radioisotope production, high-energy particle detection and imaging, superconducting particle accelerators, superconducting magnets, cryogenics, high-speed electronics, artificial intelligence, and big data. To move forward, NIH and DOE initiated the process of convening a joint workshop which occurred on July 12th and 13th, 2021. This Special Report presents a summary of the findings of the collaborative workshop and introduces the goals of the next one.

Proper death certification in the time of the COVID-19 pandemic: Forensic perspective.

It is well known that the quality of death certificates determines the accuracy of public health mortality data. In the light of a pandemic, forensic pathologists must understand the true definition of a COVID-19 death and the requirements for filling out the death certificate, as these are critical for maintaining accurate and trustworthy mortality data. To determine the scope and evolution of the COVID-19 epidemic, accurate death certification is critical. We believe that COVID-19 should be enlisted under part II or section "note" (if it exists in DC form in a particular country) of the DC in all suicide instances and putrefied bodies with positive autopsy swabs for SARS-CoV-2. In addition to our suggestions for the completion of the DC in some COVID-19 instances, we feel that forensic pathologists should follow the WHO criteria for proper DC completion in COVID-19 cases. Better physician education at this stage of the pandemic would increase adherence to existing (WHO and CDC) standards. As a result, forensic pathologists with competence in death certification could help by teaching treating physicians in this area.

Early detection of cerebrovascular pathology and protective antiviral immunity by MRI.

Central nervous system (CNS) infections are a major cause of human morbidity and mortality worldwide. Even patients that survive, CNS infections can have lasting neurological dysfunction resulting from immune and pathogen induced pathology. Developing approaches to noninvasively track pathology and immunity in the infected CNS is crucial for patient management and development of new therapeutics. Here, we develop novel MRI-based approaches to monitor virus-specific CD8+ T cells and their relationship to cerebrovascular pathology in the living brain. We studied a relevant murine model in which a neurotropic virus (vesicular stomatitis virus) was introduced intranasally and then entered the brain via olfactory sensory neurons - a route exploited by many pathogens in humans. Using T2*-weighted high-resolution MRI, we identified small cerebral microbleeds as an early form of pathology associated with viral entry into the brain. Mechanistically, these microbleeds occurred in the absence of peripheral immune cells and were associated with infection of vascular endothelial cells. We monitored the adaptive response to this infection by developing methods to iron label and track individual virus specific CD8+ T cells by MRI. Transferred antiviral T cells were detected in the brain within a day of infection and were able to reduce cerebral microbleeds. These data demonstrate the utility of MRI in detecting the earliest pathological events in the virally infected CNS as well as the therapeutic potential of antiviral T cells in mitigating this pathology.

Unusual suicidal penetrating heart injury by captive-bolt gunshot.

We present a case of a 56-year-old man who committed suicide using a captive-bolt gun, pressed against the left side of his chest. As the victim worked as a butcher, slaughtering livestock, he owned a captive-bolt gun. Just before committing suicide, he received a disturbing phone call from a person to whom he owed money. The autopsy revealed a 12-mm wound in the left pectoral region with two symmetrical, oval soot deposits. The wound extended through the fifth left rib, the pericardium, and the inferior portion of the anterior wall of the left ventricle. There was a partial-thickness tear in the left aspect of the interventricular septum with associated contusion. About 300 ml of the blood was found within the pericardial sack and about 1200 ml in the left pleural cavity. Atypical location (left chest vs. head), absence of previous suicide attempts and suicide note, and the apparent immediate provoking event suggest abrupt rather than premeditated suicide.

Ectopic right thoracic kidney associated with Bochdalek hernia as the cause of diagnostic confusion.

A 61-year-old man who was a psychiatric patient and an alcoholic was admitted to hospital after a fall in his bathroom. He showed signs of hemorrhagic shock, and CT scans showed the presence of the right kidney and part of the right retroperitoneum in the right hemithorax, surrounded by liquid. Surgery showed that the right hemidiaphragm was intact and that no intraabdominal viscera prolapsed into thoracic cavity. The bleeding in the right retroperitoneum was evacuated. The surgical report also stated that "the right kidney and ureter were explored and no injuries or active bleeding were found". The patient died the third day after admission. Autopsy revealed a livid swelling covered with parietal pleura in the right half of the thoracic cavity, behind the costophrenic sinus, about 20 × 15x12 cm in size, filled with about 1500 ml of blood, with ectopic right kidney in the right half of the thorax, slightly rotated posteriorly and downwards. The kidney was smaller (80 g in weight), compared to the normally positioned enlarged left kidney (300 g). The right hemidiaphragm was also intact with small Bochdalek's foramen behind the posterior edge, with communication between the right retropleural and retroperitoneal spaces, through which intact elongated right renal artery (15 cm), vein (14 cm) and ureter were passing. The cause of death was hemorrhagic shock due to retroperitoneal bleeding, with coagulation disorder as possible contributing factor. Intrathoracic kidneys may pose many diagnostic and management dilemmas for clinicians and pathologists. Association between a Bochdalek hernia and an intrathoracic renal ectopia is very rare and may be confusing for doctors in different clinical situations.

Case Report: Post-mortem Histopathological and Molecular Analyses of the Very First Documented COVID-19-Related Death in Europe.

In Europe, the first case of coronavirus disease (COVID-19) and the first COVID-19-related death were reported in France on January 24th and February 15th, 2020, respectively. Officially, the first case of COVID-19 infection in the Republic of Serbia was registered on March 6th. Herein, we presented the first case of retrospective detection of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in the post-mortem-obtained vitreous humor (VH), which took place on February 5th, 2020. This is the first death in Europe proven to be caused by COVID-19 by means of post-mortem histopathological and molecular analyses. Based on this finding, it appears that SARS-CoV-2 has been spreading faster and started spreading much earlier than it had been considered and that COVID-19 was probably the cause of the much-reported pneumonia of unknown origin in January and February 2020.

Death due to consumption of ibogaine: case report.

Ibogaine is a psychotropic indole alkaloid extracted from the roots of the Tabernanthe iboga shrub from the Apocynaceae family. Depending on the taken dose, it can lead to stimulant effects, euphoria, visual and auditory hallucinations, along with auditory, olfactory, and gustatory synesthesia. In addition to its historical usage in spiritual rituals of African tribes, these days iboga extract presents a prohibited, alternative drug widely used as a part of addiction treatment. Ibogaine used in opioid withdrawal is associated with serious side effects and sudden deaths. Besides its main use as an anti-addiction medication in alternative medicine, in moderate doses (from 100mg to 1g) ibogaine most commonly causes a "trance-like state".In this paper, we report the case of a heroin addict who died suddenly 5-12 hours after oral ingestion of powder labeled Tabernanthe iboga which had been bought online and used in the process of detoxification during an addiction treatment. The man was found dead in a rented apartment, where he was undergoing the addiction treatment.External examination revealed no lesions other than nonspecific injuries on the legs. The autopsy showed congestion of internal organs and pulmonary edema. Histopathological analysis of the heart showed neither macroscopic nor microscopic abnormalities. The concentration of ibogaine was 3.26mg/L. Moreover, systematic toxicological analyses of biological samples showed the presence of morphine and codeine. These data suggest that death, which occurred unnaturally after initiation of the "treatment", was probably the result of the cardiovascular effects caused by the ibogaine powder.The presented case highlights the worldwide problem of various products being widely available over the internet and the danger associated with consumption thereof.

Is the role of forensic medicine in the covid-19 pandemic underestimated?

We believe that forensic medicine should play a significant role in the COVID-19 pandemic. Forensic pathologists should ask and answer various questions through autopsy cases during the COVID-19 period, thus providing a significant contribution to science. Some of the potential roles of forensic medicine in this issue include: determining the exact cause of death among the deceased who were SARS-CoV-2 positive, contribution to the accuracy of mortality statistics, understanding pathological mechanisms of COVID-19, tracking the presence of the virus over time, survival of the virus after death as well as dealing with medicolegal issues. A detailed multidisciplinary analysis of autopsy samples would undoubtedly help understand this new illness and its clinical management. Therefore, autopsies during the COVID-19 pandemic should not be an exception, but certainly a rule.

Safe Composite Calf Augmentation: A Staged Procedure.

BACKGROUND: Calf augmentation can be achieved by fat grafting, calf implants, or a combination of both methods (composite augmentation). For safety reasons, it is important to be aware of important calf anatomic features, specific physiologic considerations, and some health conditions that can hinder the outcome of these procedures. OBJECTIVES: The aim of this study was to present our experience with performing composite calf augmentation, and to describe indications, surgical techniques and safety issues. METHODS: We retrospectively analyzed 63 patients who had undergone composite calf augmentation for cosmetic and reconstructive surgery in our practice. We reviewed group demographics, complications, and results, and identified all the pitfalls encountered in our cases. Additionally, dissection of the calf regions in fresh cadavers was performed to obtain more accurate anatomy. We also measured intracompartmental pressures before and after calf augmentation with implants in 6 cases to determine pressure changes. RESULTS: All cases received subfascial implant insertion and fat grafting as a delayed procedure. If there is a need for multiple implants, we recommend a staged procedure. Our study showed high muscle sensitivity to pressure increase after augmentation. Hence, from the standpoint of safety, we advocate subcutaneous fat grafting only. No patients developed compartment syndrome. CONCLUSIONS: Composite calf augmentation surgery is safe and easy to reproduce, with a short recovery period and a low complication rate when done as a staged procedure and respecting specific anatomic and physiologic calf features.

The significance of post-mortem vitreous calcium concentration in forensic practice.

Calcium, as one of the main extracellular ions, maintains a key role in numerous biologic functions. For forensic purposes, it was analyzed mostly for estimation of postmortem interval (PMI). We have designed our experiment with the concept that the repetitive withdrawal of vitreous humor (VH) might clarify the postmortem metabolism of calcium in greater detail to estimate the PMI. Accordingly, 248 samples of VH from 31 autopsy cases were evaluated over three years; samples (0,1 mL of VH) were taken and analyzed at equal time intervals after death-every three hours until 24 h after death. Each sample was centrifuged and analyzed using the ARCHITECT C SYSTEM 8000. Moreover, functional relationship between PMI and calcium concentration was established: PMI (hours) = [Ca2+] × 13.696-7.843. Although the concentration of calcium in VH in the analyzed group increases with time, the coefficient of variation for the regression (CVreg = 46.8%) indicates that this correlation is not so strong, meaning that the level of predictiveness of calcium for estimation of time since death is poor when is not used in combination with other relevant substances.

Two cases of firearm-related murder-suicide: Forensic implications of the ability to act.

One of the most important tasks in forensic medicine is differentiating between a homicide and a suicide, especially in cases where more than one self-inflicted gunshot wound is present. The significance is even greater when the victim's ability to act after the first gunshot is questionable. In these cases, the only way to determine the sequence of the shots is to consider the severity of the injuries and their disabling effect. Therefore, the importance of previously mentioned facts is even greater, not only in everyday forensic practice but also in court. The questions dealing with the crime scene and interpretation of the wounds' trajectories are of the utmost importance.

Gunshot Suicide: Cherry-Red Discoloration of the Temporal Muscle Beneath the Exit Wound.

The article describes a case of gunshot suicide to the head in a 51-year-old man. The entrance wound was located in the left temple and exit wound in the right temple. The entrance wound had the characteristics of a hard-contact gunshot wound. The most interesting finding in this case was cherry-red discoloration of the right temporal muscle surrounding the exit wound. This finding could make the determination of the entrance versus exit gunshot wound challenging, especially if the wounds are of atypical appearance. In addition, the finding described in the presented case could be the proof that carbon monoxide may follow the missile through the body and may be prominent in the soft tissue at the exit.

Circumferential suicidal cutting of the lower legs.

A 69-year-old woman committed suicide by cutting her lower legs with a safety razor blade. Autopsy revealed horizontal incised wounds around the circumference of the lower legs, 24 cm above the heels, cutting superficial veins on both sides, the underlying lower legs muscles, and extending into both lower leg bones with associated hematoma formation. Also, there were a large number of superficial tentative or "hesitation" cuts ranging from 3 to 6 cm over the lower legs. Death was attributed to hemorrhagic shock following injuries to blood vessels of the lower legs.

Aesthetic Improvement of Undeveloped Calves After Treatment of Congenital Clubfoot Deformity.

BACKGROUND: Even when clubfoot deformity is treated in a timely manner, the consequences observed in adulthood include hypoplasia of the calf muscles, gait impairment, decreases in foot size, and it can also affect the tibial length. These consequences may have negative impacts on the patient's subjective appraisal of long-term outcomes, and can influence the patient's self-esteem in both male and female patients. OBJECTIVES: We present our experience in the treatment of undeveloped calves after surgical treatment of congenital clubfoot. METHODS: In total, 72 patients underwent corrective surgery in order to improve undeveloped calves resulting from a congenital clubfoot deformity. We used calf silicone implants in combination with fat grafting in multistaged procedures, in order to decrease complication rates and improve aesthetic outcome. RESULTS: Amongst our patients there were 54 (75%) females and 18 (25%) males. All of the patients, except one, had unilateral calf hypoplasia. The procedures were divided into several groups: (1) medial calf augmentation with silicone implants; (2) medial calf augmentation with silicone implants and fat grafting; and (3) medial and lateral calf augmentation with silicone implants and fat grafting. We had one case of a hyperpigmented scar and one case of partial scar dehiscence. There were no cases of compartment syndrome. The average follow-up period was 9.8 months. CONCLUSIONS: Calf enhancement surgery in patients with congenital clubfoot deformity is very gratifying. When combining calf implants with fat grafting in multistaged procedures, we can achieve excellent results with low complication rates.

Transcranial manganese delivery for neuronal tract tracing using MEMRI.

There has been a growing interest in the use of manganese-enhanced MRI (MEMRI) for neuronal tract tracing in mammals, especially in rodents. For this MEMRI application, manganese solutions are usually directly injected into specific brain regions. Recently it was reported that manganese ions can diffuse through intact rat skull. Here the local manganese concentrations in the brain tissue after transcranial manganese application were quantified and the effectiveness of tracing from the area under the skull where delivery occurred was determined. It was established that transcranially applied manganese yields brain tissue enhancement dependent on the location of application on the skull and that manganese that enters the brain transcranially can trace to deeper brain areas.

Safety and Efficacy of Subfascial Calf Augmentation.

BACKGROUND: Calf augmentation surgery is one of the least popular procedures among plastic surgeons; in contrast, it is by far one of the most gratifying procedures among patients. In this article, the authors present a retrospective analysis of a surgeon's extensive experience with calf implants. METHODS: The authors retrospectively analyzed 134 patients having calf augmentation for cosmetic and reconstructive surgery in their practice from 2003 to 2015. All patients were divided into two groups: primary cases and patients who had previously been operated on and who were referred to our service as patients who had complications after calf augmentation surgery. The subfascial approach was the preferred approach by authors for all primary cases. The authors analyzed indications, complication rates, results, and pitfalls. Secondary cases were further divided into three groups according to the origin of the problem and some possible solutions. RESULTS: Subfascial calf augmentation surgery is safe and easy to reproduce, with a short recovery period and a low complication rate (<1 percent). To achieve the best aesthetic results, surgeons should choose appropriate implants for each case. In secondary cases, fat grafting is a powerful tool and can be used alone or in combination with calf implants. CONCLUSIONS: There are several groups of patients seeking calf augmentation surgery (e.g., bodybuilders, women, those with reconstructive problems). Therefore, treatment should be planned individually. The development of a new implant is necessary and should be based on detailed anatomical findings and in accordance with surgical techniques. The process is intriguing and rewarding. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Anatomical aspects of the gastrocnemius muscles: A study in 47 fresh cadavers.

BACKGROUND: This study offers objective dimensions of the gastrocnemius muscle and analyzes correlations between dimensional variables, with a view to providing guidance on the proportions of a healthy gastrocnemius muscle for both genders. METHODS: This anatomical study was conducted at the Institute of Forensic Medicine Faculty of Medicine University of Belgrade, Serbia, from May until November 2014. We included 47 fresh cadavers (up to 12-h postmortem interval) both male and female. The inclusion criteria were absence of any trauma or degenerative findings in lower limbs, normally weighed, and age between 18 and 60 years. The exclusion criteria were significant difference in dimensions between legs and overweighed cadavers. RESULTS: After statistical analysis of gathered data, we were able to define the exact shape and average measures of the medial and lateral head of gastrocnemius muscle in male and female. Factors affecting muscle dimensions are also defined in this study. CONCLUSION: The method of dissection that we applied could be recommended for exploration of different anatomical structures of calf region. The reported dimensions and correlations are useful guide in planning cosmetic and reconstructive procedures with high accuracy.

Injury Severity Score based estimation of height of fall in bus rolling down the cliff.

A case of bus rollover into the canyon, 40 m down the road, with 47 occupants out of which 18 were fatally injured, was used to compute the Injury Severity Score (ISS) for each passengers as well as the equivalent free fall for this particular accident, to be compared to the height of fall as estimated by the Lau's model based on ISS, resulting the conclusion whether Lau's model and the computation of ISS can be considered reliable to estimate the height of fall in any other case. Dealing with this, we would be also able to assess a protective potential of the bus on occupants while it falls from the height. By using classic energy-related mechanical formulas the presented rollover down the cliff has been transferred into a corresponding free fall from the height (10 m). ISS for each passenger has been used to establish height bands of the corresponding free fall. The analysis of the presented case showed that only 30% of bus passengers sustained injuries similar to the injuries expected in the fall from height in the range of 10-20 m. The chances to be non-severely injured as a consequence of the fall in a bus is 43%, but still remains a very high chance (27%) to sustain injures more severe than expected for the equivalent free fall from height out of a vehicle. Moreover, eight passengers sustained pulmonary detraction which is characteristic of the fall above 40 m. The conclusion is that this mathematical computing for transferring one way of motion into another one may be useful for any other event similar to the fall from height and further usage of Lau's modules. Also, estimated severity of the injuries expressed through ISS can be merely an approximating indicator of the height of the fall of the bus, so ISS is not able to estimate the exact height. Finally, in majority of cases the protective potential of the bus may preserve from severe body damage, but the mortality rate still stands on a very high level.

Analysis of Closed Soft Tissue Subcutaneous Injuries-"Impact Décollement" in Fatal Free Falls From Height-Forensic Aspect.

The aim of this study was to assess the frequency of "décollement," traumatic lesions of subcutaneous soft tissue, among victims fatally injured because of falls from different heights. Three hundred seventy-five cases of fatalities due to injuries acquired when falling from various heights onto a solid, flat surface, in which the complete forensic autopsy was performed, were analyzed. Décollement was noted in 125 (33%) of the cases. Comparative analysis of groups with and without décollement and observed factors has shown that the height of fall and the manner of death have statistically significant influence on décollement appearance. With regard to suicidal, accidental, or undefined origin of death décollement is statistically more common in accidental deaths. Décollement provides important clues for forensic reconstruction and could be a significant indicator of the body's position at primary impact and the height from which the victim has either jumped or fallen.