Suicide by Bomb, with Decapitation

Suicide by explosion is rare outside of the context of terrorist activities. We present a case of a man with a history of explosives expertise who committed suicide by bomb/decapitation. The case serves to remind forensic pathologists of several important issues when presented with a case involving explosives, such as ensuring the safety of all those involved in the investigation and the importance of interagency cooperation. Potentially invaluable ancillary tests at autopsy include performing radiology, collecting trace evidence, retaining clothing, ensuring the positive identity of the decedent, and recognizing the importance of documenting injury types and patterns

Death Resulting from Pneumocephalus Complicating Endoscopic Food Bolus Retrieval in a Patient with Eosinophilic Esophagitis

Pneumocephalus is a rare complication of esophagogastroduodenoscopy (EGD), but existing literature does not discuss pneumocephalus surrounding endoscopic food bolus retrieval. We present a death involving pneumocephalus complicating endoscopic food removal from the esophagus. A 40-year-old man presented with dysphagia and suprasternal discomfort 12 hours following chicken ingestion. On flexible endoscopy, chicken was visualized in the distal esophagus. After successful retrieval, a mucosal laceration was noted where the chicken had been lodged. He was unarousable following the procedure and was emergently transported to a hospital, where computed tomography scanning showed pneumocephalus. He was later declared brain dead. The case was referred for medicolegal autopsy. The brain was examined first, revealing rare air bubbles within meningeal vessels and numerous, diffuse petechiae-like hemorrhages within the brain parenchyma. The esophageal mucosa had focal discoloration and a partial thickness laceration; microscopic examination revealed eosinophilic esophagitis. Eosinophilic esophagitis is a known risk factor for food bolus impaction and should be suspected in such patients. Pneumocephalus is a rare possible complication of EGD for food bolus retrieval. In patients unresponsive after endoscopy, radiographic detection of potential pneumocephalus should be encouraged to enable timely therapy and improved outcomes, or to supplement autopsy in the event of patient death. Forensic pathologists should understand that pneumocephalus is a potential mechanism of injury/death in patients experiencing esophageal trauma, including injury incurred during EGD

Childhood Idiopathic Pulmonary Hypertension: a Case Report

Introduction: Pulmonary arterial hypertension (PAH) is characterized as average pulmonary artery pressure of greater than 25mm Hg at rest. Childhood idiopathic pulmonary hypertensions (CIPH) is distinguishable from PAH by the absence of family history or underlying disease. Symptoms of CIPH include dyspnea, exercise limitation, and syncope. Common organ-specific changes include right ventricular hypertrophy and right ventricular strain. We present the case of a 6-year-old girl presenting with idiopathic pulmonary arterial hypertension aggravated by esophageal intubation. Methods: This case is from the files of one of the authors, a forensic pathologist. Case Report and Discussion: Diagnosed with pulmonary arterial hypertension when she was six years old, this patient had a history of syncope on exertion. She was readmitted to the hospital shortly afterward with seizures secondary to pulmonary hypertensive crisis and hypoxia. Two months later, after another seizing episode, the patient’s mother called EMS, who began chest compressions at the scene. While under EMS care, the patient was intubated and subsequently became pulseless and asystolic. She was pronounced dead in the Emergency Department. The case was then referred to the coroner. Autopsy findings include marked right ventricular dilation and hypertrophy and lung microscopic features consistent with CIPH. The endotracheal tube was found with its tip in the distal esophagus with the cuff inflated and surrounded by blanched underlying mucosa, all indicative of esophageal intubation, which was considered a contributory cause of death. The case serves as an excellent example of CIPH. In addition, the esophageal intubation allows for discussion of complications related to medical procedures

Death Related to Fistulas Involving the Gastrointestinal and Cardiovascular Systems

BACKGROUND/INTRODUCTION: Gastrointestinal tract fistulas are relatively uncommon and can be congenital or acquired. Fistulas may communicate with a variety of anatomic locations, including body cavities, the skin, and other organ systems. Acquired fistulas which communicate with the cardiovascular system are of particular concern, as they may be associated with significant morbidity and mortality. This study reports on three cases of acquired, post-surgical fistula formation involving the gastrointestinal and cardiovascular systems. CASE REPORTS: Case 1 - A 57-year-old man experienced sudden cardiac death shortly after having a permanent pacemaker placed for atrial fibrillation. Approximately two years earlier, he underwent surgical resection of his esophagus for cancer, and he had a diaphragmatic hernia repair several weeks before death. He also had hypertensive and atherosclerotic cardiovascular disease and emphysema. At autopsy, the cause of death was determined to be upper gastrointestinal tract hemorrhage due to a gastro-left atrial fistula which developed as a complication following the esophagectomy for esophageal cancer. Case 2 – A 67-year-old female with severe chronic obstructive pulmonary disease (COPD), as well as a thoracic aortic aneurysm for which she had undergone aortic reconstruction with graft placement, presented to the hospital with massive hematemesis with associated breathing difficulties. Prior to dying, an upper endoscopy revealed a probable esophageal fistula thought to be communicating with the respiratory system. At autopsy, the fistula was found to be communicating with the aorta. Case 3 – A 51-year-old woman was found unresponsive at home. All resuscitative efforts were unsuccessful. The case was referred for medicolegal autopsy. She had a past history of COPD, gastric bypass surgery, and relatively recent bacterial pericarditis, which required drainage and antibiotic therapy. Autopsy revealed the presence of a gastric fistula involving and traversing the left hemidiaphragm to involve the posterior wall of the left ventricle of the heart. Approximately 500-1000 mL of dark blood intermixed with gastrointestinal contents was present within the stomach and proximal small intestines, but no fresh-appearing hemorrhage was evident. DISCUSSION/CONCLUSION: Postoperative gastrointestinal-cardiovascular fistulas are relatively rare but can result in significant morbidity and mortality. They may develop following gastrointestinal tract or cardiovascular surgery. Clinicians are advised to be aware of these rare, but often fatal, post-operative complications

No laughing matter : presence, consumption trends, drug awareness, and perceptions of "hippy crack" (nitrous oxide) among young adults in England

In clinical settings, nitrous oxide gas is a safe anesthetic used during childbirth, in dentistry, and to relieve anxiety in emergencies. Colloquially known as “hippy crack”’ or “laughing gas,” it is increasingly taken recreationally for its euphoric and relaxing effects and hallucinogenic properties. Using a self-reported survey, we gathered quantitative and qualitative information on users and non-users of hippy crack among a young population regarding: consumption patterns, knowledge, risk awareness and intentions toward future abuse. Quantitative responses from a total of 140 participants were analyzed for frequencies and relationships, whereas qualitative data were evaluated via identifying the reoccurring themes. Overall, 77.1% (n = 108) had heard of hippy crack and 27.9% (n = 39) admitted to past-year use. Prior users mostly indicated intended future use, had an average low number of past-year uses but some with > 20 occasions, had a varied number of inhalations per occasion (often 1–10) with an effect lasting up to 5 min, and a majority preferred social rather than lone use. For non-users, 79.2% said they would take hippy crack with the vast majority (94%) preferring a social setting. The results show a concerning gap between available evidence and awareness of side effects. Despite serious reported side effects, including psychosis and myeloneuropathy—especially on the young developing brain—only a minority (29.3%) was aware of any side effects. In contrast, in a hypothetical scenario depicting a first social encounter with hippy crack, the qualitative responses were in contrast to qualitative outcomes revealing that participants would try (n = 30)/not try (n = 25) it, would feel under pressure to try it (n = 6) with only 11 opting to exit the situation. In summary, this first report of trends and perceptions of the use of hippy crack among young adults in the England highlights a lack of concern with side effects, coupled to a willingness to partake. Because typical users are young with risks to the still developing brain, education about the nitrous oxide abuse is warranted to prevent impaired brain development. Further studies to investigate the possible effects of nitrous oxide on the developing brain in young adults would advance meaningful prevention

Biologically inspired simulation of livor mortis

We present a biologically motivated livor mortis simulation that is capable of modelling the colouration changes in skin caused by blood pooling after death. Our approach consists of a simulation of post mortem blood dynamics and a layered skin shader that is controlled by the haemoglobin and oxygen levels in blood. The object is represented by a layered data structure made of a triangle mesh for the skin and a tetrahedral mesh on which the blood dynamics are simulated. This allows us to simulate the skin discolouration caused by livor mortis, including early patchy appearance, fixation of hypostasis and pressure induced blanching. We demonstrate our approach on two different models and scenarios and compare the results to real world livor mortis photographic examples

Impact of USMLE examinations and pass/fail Level 1/Step 1 on osteopathic medical students’ 2024 residency match cycle

The United States Medical Licensing Examination (USMLE) and Comprehensive Osteopathic Medical Licensing Exam (COMLEX) are a series of board exams required for medical licensing in the United States for Doctors of Medicine (MD) and Doctors of Osteopathic Medicine (DO) students, respectively. Historically, DO students have faced a unique disadvantage compared to their MD counterparts in that specific residency programs require DOs to provide USMLE board examination scores in addition to COMLEX board examination scores. The 2022 National Resident matching Program (NRMP) Program Director (PD) Survey showed that PDs had a higher value in USMLE scores for DOs compared to COMLEX: 9% of program directors do not put weight in USMLE Step 1 and 11% for USMLE Step 2, while that number increases significantly in contrast for COMLEX Level 1 and Level 2 (16% and 18% respectively). However, there have been significant changes in the medical board examination landscape in the past few years. In 2022, the USMLE Step 1 and the COMLEX Level 1 exams transitioned from a three-digit scoring format to Pass/Fail scoring. This Pass/Fail scoring transition was significant in the medical examination landscape and will first fully impact the graduating classes of 2024. To gain insight into the effects of these changes on the class of 2024 and future classes, the study surveyed all DO students graduating from a United States osteopathic medical school in 2024 shortly after Match Day 2024. This study seeks to provide insights into the perceived advantages, disadvantages, and pressures of taking the USMLE board exams within the DO student community. The study will help to understand outcomes related to The Match as it relates to both USMLE performance as well as understanding how the decision for Step 1 and Level 1 board examinations moving to Pass/Fail scoring instead of numerical scoring has impacted medical student preparation for Step 2/Level 2. Additionally, these data will help to determine the implications of these changes on the student’s residency application, interview, and match processes. Through these characterizations, the study will help future DOs in navigating the new reality of Pass/Fail medical licensure examinations