Giant primary angiosarcoma of an adolescent girl's breast diagnosed postmortem: a case report.

BACKGROUND: Angiosarcoma is an endothelial malignant tumor; angiosarcoma located in the breast is extremely rare, less than 0.01%. We report a case of a giant angiosarcoma diagnosed postmortem in a 16-year-old girl in a resource-constrained country. CASE PRESENTATION: A 16-year-old black African girl was admitted for altered consciousness and a left breast tumor. She was admitted in a state of apparent death. Her death was confirmed on clinical examination. A postmortem biopsy of the mammary tumor showed standard histology of a proliferation of fusiform or rounded tumor cells in places, which were not very cohesive with marked anisokaryosis and numerous foci of tumor necrosis. Immunohistochemistry showed a positivity of CD31 and factor VIII markers with a proliferation index (Ki-67) estimated at 30%. CONCLUSION: Primary angiosarcoma of the breast is exceptional in adolescents and has a poor prognosis, especially in countries with limited resources.

Subcutaneous Granulomatous Inflammation due to Basidiobolomycosis: Case Reports of 3 Patients in Buruli Ulcer Endemic Areas in Benin.

BACKGROUND: Basidiobolomycosis is a rare subcutaneous mycosis, which can be mistaken for several other diseases, such as soft tissue tumors, lymphoma, or Buruli ulcer in the preulcerative stage. Microbiological confirmation by PCR for Basidiobolus ranarum and culture yield the most specific diagnosis, yet they are not widely available in endemic areas and with varying sensitivity. A combination of histopathological findings, namely, granulomatous inflammation with giant cells, septate hyphal fragments, and the Splendore-Hoeppli phenomenon, can confirm basidiobolomycosis in patients presenting with painless, hard induration of soft tissue. CASE PRESENTATIONS: We report on three patients misdiagnosed as suffering from Buruli ulcer, who did not respond to Buruli treatment. Histopathological review of the tissue sections from these patients suggests basidiobolomycosis. All patients had been lost to follow-up, and none received antifungal therapy. On visiting the patients at their homes, two were reported to have died of unknown causes. The third patient was found alive and well and had experienced local spontaneous healing. CONCLUSION: Basidiobolomycosis is a rare subcutaneous fungal disease mimicking preulcerative Buruli ulcer. We stress the importance of the early recognition by clinicians and pathologists of this treatable disease, so patients can timely receive antifungal therapy.

Diagnostic Accuracy of Clinical and Microbiological Signs in Patients With Skin Lesions Resembling Buruli Ulcer in an Endemic Region.

Background: The diagnosis of the neglected tropical skin and soft tissue disease Buruli ulcer (BU) is made on clinical and epidemiological grounds, after which treatment with BU-specific antibiotics is initiated empirically. Given the current decline in BU incidence, clinical expertise in the recognition of BU is likely to wane and laboratory confirmation of BU becomes increasingly important. We therefore aimed to determine the diagnostic accuracy of clinical signs and microbiological tests in patients presenting with lesions clinically compatible with BU. Methods: A total of 227 consecutive patients were recruited in southern Benin and evaluated by clinical diagnosis, direct smear examination (DSE), polymerase chain reaction (PCR), culture, and histopathology. In the absence of a gold standard, the final diagnosis in each patient was made using an expert panel approach. We estimated the accuracy of each test in comparison to the final diagnosis and evaluated the performance of 3 diagnostic algorithms. Results: Among the 205 patients with complete data, the attending clinicians recognized BU with a sensitivity of 92% (95% confidence interval [CI], 85%-96%), which was higher than the sensitivity of any of the laboratory tests. However, 14% (95% CI, 7%-24%) of patients not suspected to have BU at diagnosis were classified as BU by the expert panel. The specificities of all diagnostics were high (≥91%). All diagnostic algorithms had similar performances. Conclusions: A broader clinical suspicion should be recommended to reduce missed BU diagnoses. Taking into consideration diagnostic accuracy, time to results, cost-effectiveness, and clinical generalizability, a stepwise diagnostic approach reserving PCR to DSE-negative patients performed best.

Smartphone-based Music Listening to Reduce Pain and Anxiety Before Coronarography: A Focus on Sex Differences.

Background • Music Care is a smartphone-based application providing a musical intervention for the management of pain and anxiety in a clinical setting. Coronarography is a medical procedure frequently associated with examination anxiety. Objectives • The study intended to perform an initial evaluation of the application for use with patients undergoing a coronarography. Design • The research team performed an uncontrolled, observational study. Setting • The study took place at Nouméa General Hospital in Nouméa, New Caledonia, France. Participants • Participants were 35 patients, 17 women and 18 men, who were undergoing a coronarography between November 2010 and April 2011 at the Nouméa General Hospital. Intervention • Participants listened to a standardized musical sequence of adjustable length by choosing a preferred style of music (eg, classic rock or folk music) from a variety of choices that the research team had chosen to include in the application. Outcome Measures • Before and after listening to the music, all participants were asked to rate their anxiety and pain on an 11-item, visual analogue scale and to complete a questionnaire on their satisfaction with use of the application. Results • The paired sample t test revealed a significant reduction in participants' anxiety (t33 = 4.12, P < .0001) after they had listened to the music. No significant reduction in self-reported pain occurred; however, only a few participants reported pain associated with the procedure. No significant sex differences existed. Women and men both showed reduced anxiety after listening to music as well as reported a high level of satisfaction in using the Music Care application. Conclusions • The smartphone-based Music Care application is an easy-to-use tool to reduce anxiety in patients undergoing coronarography. Future large-scale, controlled trials are necessary to compare its effectiveness with other interventions. Both women and men can benefit from the use of the application.

[Broncho-pulmonary aspiration of brain and cartilage tissue in a context of gasping]. / Inhalation broncho-pulmonaire de matières cérébrales et cartilagineuses au cours d'une respiration agonique.

Evidence of post-mortem breath movements are rarely reported. We present two cases of broncho-pulmonary aspiration of brain and cartilage tissue following two fatal suicidal gunshots to the head. We also discuss the physiopathological implications for the agony.

The heart of Blessed Anne-Madeleine Remuzat: a biomedical approach of "miraculous" heart conservation.

We present here the results of our inter-disciplinary examination of the mummified heart of Blessed Anne-Madeleine Remuzat (1696-1730). This organ has been examined in the context of a canonization process. This analysis is related to important aspects of the early history of anatomy in Europe, that of "Holy autopsies", and to the relationship between anatomical investigations, Catholic theology, and religious/medical customs. According to anatomical, genetic, toxicological, and palynological analyses, it has been shown that this organ has not been naturally ("miraculously") conserved but embalmed using myrtle, honey, and lime. Moreover, a right ventricle dilatation has been diagnosed, that may represent a post-tuberculosis condition and may have played a role in the cause of death of this religious figure.

Maori heads (mokomokai): the usefulness of a complete forensic analysis procedure.

Based on an analysis of 19 mummified Maori heads (mokomokai) referred to our forensic laboratory for anthropological analysis prior to their official repatriation from France to New Zealand, and data from the anthropological and medical literature, we propose a complete forensic procedure for the analysis of such pieces. A list of 12 original morphological criteria was developed. Items included the sex, age at death, destruction of the skull base, the presence of argil deposits in the inner part of the skull, nostrils closed with exogenous material, sewing of eyelids and lips, pierced earlobes, ante-mortem and/or post-mortem tattoos, the presence of vegetal fibers within nasal cavities, and other pathological or anthropological anomalies. These criteria were tested for all 19 mokomokai repatriated to New Zealand by the French authorities. Further complementary analyses were limited to fiberscopic examination of the intracranial cavities because of the taboo on any sampling requested by the Maori authorities. In the context of global repatriation of human artifacts to native communities, this type of anthropological expertise is increasingly frequently requested of forensic anthropologists and other practitioners. We discuss the reasons for and against repatriating non-authentic artifacts to such communities and the role played by forensic anthropologists during the authentication process.

An incomplete fatal trepanation diagnosed on cremation remains (Rome, Italy, 2nd c. AD).

BACKGROUND: An original case of incomplete (and reasonably fatal) human trepanation is described in this short paper. The diagnosis was made on the cremated remains of a young adult individual who died in Rome, Italy during the 2nd century AD. CLINICAL PRESENTATION: The trepanation was incomplete, as death occurred quickly due to vascular lesions, according to the anatomic analysis of the bone piece. Comparable trepanation from Roman times are described and related to this case. CONCLUSION: Even if archaeological, this case highlights the possibility of such a diagnosis on post-fire fragmented bones. Very suggestive lesions of section are of great interest for the history of such a practice during classical Antiquity. Lastly, from a medical and forensic point of view, such a diagnosis may be of interest during any identification process and research for a cause of death during anthropological analyses.

Death, cadavers and post-mortem biomedical research: a point of view from a Christian community.

Facing modern developments of medicine and biomedical researches, religious communities are a strong source of ethics principles and orientations. Human dignity does not disappear after life, in a context of biomedical research on cadavers. Moral, political, social and scientific aspects of research on human cadavers (mainly autopsies) have been widely discussed in biomedical publications, whereas the religious ones (which could be predominant for some) have rarely been analyzed and presented. This article will present the results of a survey carried out a French Benedictine Abbey (relative to death, cadaver's status and biomedical research) and subsequent Christian background according to canonic texts and practical cases from anthropological, historical, archeological and biomedical origin.

Is suicide risk correlated to thyroid weight?

Disturbances in some endocrine hormones have been implicated in the pathophysiology of depression and psychosis. We consider here further the hypothesis that there may be a correlation between suicide risk and the weight of the thyroid gland. The thyroid weight and other relevant information (sex, BMI) were collected retrospectively from 576 autopsies including 299 cases of completed suicide, analyzed in the west area of Paris between 1994 and 2010. Multiple regression model, adjusted on sex and BMI, confirmed that only for subjects more than 60 years of age, deceased by suicide, had a significant decrease in their weight of thyroid compared to those who deceased for another cause (decrease of around 3g, p=0.03, for age class 60 and over). Our hypothesis is that there could exist an anatomical correlate (thyroid weight) among people who have committed suicide, especially old individuals. Various hypotheses regarding the hypothalamus-pituitary-thyroid axis dysfunction and the physiopathology of major depression are proposed and discussed. Further studies will be necessary in order to confirm that such a tendency exists on other populations.

Diagnosis of aortic dextroposition on human skeletal remains.

The fine macroscopic observation of a young adult female skeleton recovered from a Roman graveyard in Romania revealed distinctive flattening of the vertebra related to a right-sided aorta. Associated bone anomalies may be related to a Kartagener syndrome. This case highlights the fact that visceral anomalies may be diagnosed even on skeletal remains. Such lesions could be useful for osteo-archaeologists, of course, but also for forensic anthropologist investigators dealing with skeletonized remains (for example during the identification process of a dead body, through comparison with known medical data for missing people). More, hypotheses about cause and/or manner of death may be given, and a possibility of genetic confirmation exists.

Histopathological changes and clinical responses of Buruli ulcer plaque lesions during chemotherapy: a role for surgical removal of necrotic tissue?

BACKGROUND: Buruli ulcer (BU) caused by Mycobacterium ulcerans is a necrotizing skin disease usually starting with a subcutaneous nodule or plaque, which may ulcerate and progress, if untreated, over months and years. During the currently recommended antibiotic treatment with rifampicin/streptomycin plaque lesions tend to ulcerate, often associated with retarded wound healing and prolonged hospital stays. METHODOLOGY/PRINCIPAL FINDINGS: Included in this study were twelve laboratory reconfirmed, HIV negative BU patients presenting with plaque lesions at the CDTUB in Allada, Benin. Punch biopsies for histopathological and immunohistochemical analysis were taken before start of treatment and after four to five weeks of treatment. Where excision or wound debridement was clinically indicated, the removed tissue was also analyzed. Based on clinical judgment, nine of the twelve patients enrolled in this study received limited surgical excision seven to 39 days after completion of chemotherapy, followed by skin grafting. Lesions of three patients healed without further intervention. Before treatment, plaque lesions were characterized by a destroyed subcutis with extensive necrosis without major signs of infiltration. After completion of antibiotic treatment partial infiltration of the affected tissue was observed, but large necrotic areas remained unchanged. CONCLUSION/SIGNIFICANCE: Our histopathological analyses show that ulceration of plaque lesions during antibiotic treatment do not represent a failure to respond to antimycobacterial treatment. Based on our results we suggest formal testing in a controlled clinical trial setting whether limited surgical excision of necrotic tissue favours wound healing and can reduce the duration of hospital stays.

Recent advances in diffusion MRI modeling: Angular and radial reconstruction.

Recent advances in diffusion magnetic resonance image (dMRI) modeling have led to the development of several state of the art methods for reconstructing the diffusion signal. These methods allow for distinct features to be computed, which in turn reflect properties of fibrous tissue in the brain and in other organs. A practical consideration is that to choose among these approaches requires very specialized knowledge. In order to bridge the gap between theory and practice in dMRI reconstruction and analysis we present a detailed review of the dMRI modeling literature. We place an emphasis on the mathematical and algorithmic underpinnings of the subject, categorizing existing methods according to how they treat the angular and radial sampling of the diffusion signal. We describe the features that can be computed with each method and discuss its advantages and limitations. We also provide a detailed bibliography to guide the reader.

Severe multifocal form of buruli ulcer after streptomycin and rifampin treatment: comments on possible dissemination mechanisms.

Buruli ulcer (BU), a disease caused by Mycobacterium ulcerans, leads to the destruction of skin and sometimes bone. Here, we report a case of severe multifocal BU with osteomyelitis in a 6-year-old human immunodeficiency virus (HIV)-negative boy. Such disseminated forms are poorly documented and generally occur in patients with HIV co-infection. The advent of antibiotic treatment with streptomycin (S) and rifampin (R) raised hope that these multifocal BU cases could be reduced. The present case raises two relevant points about multifocal BU: the mechanism of dissemination that leads to the development of multiple foci and the difficulties of treatment of multifocal forms of BU. Biochemical (hypoproteinemia), hematological (anemia), clinical (traditional treatment), and genetic factors are discussed as possible risk factors for dissemination.