Evan W. Matshes

Diverticular disease of the vermiform appendix: a diagnostic clue to underlying appendiceal neoplasm

Acquired diverticula of the vermiform appendix are rare and arise as a result of different pathogenetic mechanisms. One of the etiologies includes proximally located, often unsuspected small neoplasms. Although the association of appendiceal diverticulosis and neoplasia is known, it remains underemphasized in the teaching and practice of surgical pathology. To investigate the frequency of appendiceal neoplasms with acquired diverticulosis, we conducted a retrospective analysis of all appendectomy specimens received in our institution for a 55-month period (January 2002-July 2006). A total of 1361 appendectomy specimens were identified. Diverticulosis was diagnosed in 23 (1.7%) of all cases. Eleven (48%) appendectomy specimens with diverticulosis also harbored an appendiceal neoplasm. The association of appendiceal neoplasms with diverticulosis was statistically significant (P < .0001, 2-sided Fisher exact test). Neoplastic processes included 5 well-differentiated neuroendocrine tumors (carcinoids), 3 mucinous adenomas, 1 tubular adenoma, and 2 adenocarcinomas. In one case, routine representative sections sampled only a small focus of carcinoma, which originally went undiagnosed. We stress the need for meticulous gross assessment with histologic examination of the entire appendectomy specimen in cases of appendiceal diverticulosis. Thorough examination is required to rule out an underlying neoplasm as a cause of diverticulosis. As acquired diverticula represent a rare finding, examination of the entire appendix in this setting does not create a significant impact on the workload within the pathologic laboratory.

Do Resuscitation-Related Injuries Kill Infants and Children?

Occasionally, individuals accused of inflicting fatal injuries on infants and young children will claim some variant of the “CPR defense,” that is, they attribute the cause of injuries found at autopsy to their “untrained” resuscitative efforts. A 10-year (1994–2003) historical fixed cohort study of all pediatric forensic autopsies at the Miami-Dade County Medical Examiner Department was undertaken. To be eligible for inclusion in the study, children had to have died of atraumatic causes, with or without resuscitative efforts (Natraumatic = 546). Of these, 382 had a history of cardiopulmonary resuscitation (CPR; average age of 4.17 years); 248 had CPR provided by trained individuals only; 133 had CPR provided by both trained and untrained individuals; 1 had CPR provided by untrained individuals only. There was no overlap between these 3 distinct groups. Twenty-two findings potentially attributable to CPR were identified in 19:15 cases of orofacial injuries compatible with attempted endotracheal intubation; 4 cases with focal pulmonary parenchymal hemorrhage; 1 case with prominent anterior mediastinal emphysema; and 2 cases with anterior chest abrasions. There were no significant hollow or solid thoracoabdominal organ injuries. There were no rib fractures. The estimated relative risk of injury subsequent to resuscitation was not statistically different between the subset of decedents whose resuscitative attempts were made by trained individuals only, and the subset who received CPR from both trained and untrained individuals. In the single case of CPR application by an untrained individual only, no injuries resulted. The remaining 164 children dying from nontraumatic causes and who did not undergo resuscitative efforts served as a control group; no injuries were identified. This study indicates that in the pediatric population, injuries secondary to resuscitative efforts are infrequent or rare, pathophysiologically inconsequential, and predominantly orofacial in location. In our population, CPR did not result in any rib fractures or significant visceral injuries. Participation of nonmedical or untrained individuals in resuscitation did not increase the likelihood of injury.

Shaken Infants Die of Neck Trauma, Not of Brain Trauma

Objective review of the vital statistics of sudden unexplained infant death indicates a failure of what was, initially, a public health success. Early categorization of sudden unexplained infant deaths as SIDS was a tremendously productive stimulus for wide-ranging, high profile research. It provided a very important proverbial flag around which to rally. Over time, however, many death investigators recognized the major shortcomings of the use of SIDS: 1) its inconsistent use among forensic pathologists wreaks havoc with vital statistics and 2) it masks the fundamental truth for any consumer of death certificate information (in-

What is a Complete Autopsy

Postmortem examinations have taken place over the past several thousand years. Despite this, the definition of a “complete” autopsy remains nebulus and the subject of controversy. Although ‘minimal autopsy practice standards’ have been published by professional bodies globally, recognition of, and adherence to those standards remains sporadic. An underlying refutation that ‘autopsies can never be complete’ – the reductio ad absurdum fallacy – has influenced many forensic pathologists’ opinions about autopsy. More pragmatic pathologists attempt to balance the financial and workload burdens of autopsies with the principles of adequacy and accuracy. Some medical examiners cite “statutory duty” as the force guiding the nature and completeness of their work, and as such, external examinations, partial autopsies and other limited variants are substituted for complete autopsies. Although it is impossible to perform every conceivable test in any one autopsy, an evidence-based approach guided by three forensic autopsy goals – statutory duty, the creation of a minimal dataset for societal and governmental inquiry, and maintenance of practitioner competency – ensure the completeness of any one postmortem examination.

Sudden Unexpected Death Due to a Brainstem Glioma in an Adult

Sudden death due to undiagnosed central nervous system tumors is an uncommon, but well-described occurrence. Most of the tumors in these circumstances are supratentorial and occur in a wide spectrum of ages. Brainstem tumors are more rare and occur predominantly in the pediatric and adolescent populations. We present the case of a 48-year-old man who died suddenly and unexpectedly of a brainstem glioma. This case is unusual because of his age and the paucity of antecedent symptoms.

Homicide by Unspecified Means

The fundamental function of all North American systems of death investigation is to determine cause and manner of death. Modern teaching emphasizes the need to consider all investigative aspects including careful evaluation of the scene and circumstances, history, physical examination of the body, and ancillary laboratory studies, prior to death certification. This integrative approach to forensic pathology differs from an autopsy-focused practice whose function is to produce “anatomic” cause of death statements.Some individuals die under suspicious circumstances and, despite thorough autopsy, have no anatomic cause of death. In Miami-Dade County, when the preponderance of evidence and investigative data suggest homicide despite the absence of an identifiable cause of death, “homicide by unspecified means” has been used as a summative cause of death statement. The records of the Miami-Dade County Medical Examiner Department were searched for this diagnosis, identifying 18 such cases between 1990 and 2004. The characteristics of these cases are discussed. Guidelines for the use of this diagnostic label are provided.

Routine Metabolic Testing is Not Warranted in Unexpected Infant Death Investigations

Inborn errors of metabolism (IEM) only rarely cause sudden unexpected infant death. Yet, postmortem metabolic screening is often ordered reflexively during infant death investigations, even in the absence of historical, clinical or autopsy findings suggestive of IEM. This retrospective descriptive study examines the impact of metabolic screening of infants who die suddenly in a medical examiners jurisdiction. The study population included 135 cases, one of which was certified as death due to IEM with historical and pathologic findings suggestive of IEM and an abnormal postmortem screening study, one which was certified as death due to IEM with historical and pathologic findings suggestive of IEM and a negative postmortem screening study, and one which was certified as undetermined with pathologic features of IEM and a negative postmortem screening study, but also with features suggestive of accidental asphyxia. Nine cases had abnormal postmortem screens that were deemed to represent false positives. During the entire nine-year study of these 135 cases, the utilization of screening tests in cases without historical or autopsy features of IEM did not detect any unsuspected cases. IEM may rarely cause unexpected infant death, and it can be suggested by historical and autopsy findings. Thus, within the appropriate investigative and autopsy context, judicious use of metabolic screening tests is warranted. Caution is advised when interpreting negative screening studies with suggestive historical and/or autopsy findings as the success of testing decreases with increasing postmortem interval.

Utilitarian Aspects of Postmortem Computed Tomography

Computed tomography has been used in clinical medicine for decades, but only recently introduced into the forensic pathology setting. The reasons for the slow adoption of this technology into the autopsy suite are various, including concerns about funding, infrastructural maintenance, training, competency, and scope of utilization. Practical experience in a busy statewide medical examiner department confirmed the utility of this technology as a part of daily practice. The impact of postmortem computed tomography (PMCT) on casework can be stratified into three broad groups: where PMCT 1) supplants invasive autopsy, 2) supplements invasive autopsy, or 3) has limited or no potential for impact on practice. A detailed understanding of the practical uses of this science is important for the practicing forensic pathologist so as to guide decisions about the ways in which PMCT can be implemented within their own institutions and utilized on a daily basis. Dramatic changes in personal and institutional practice trends can be observed once forensic pathologists are comfortable with the evaluation, documentation, and interpretation of PMCT data. Examples of potential paradigm shifts include the performance of only external examination and PMCT instead of invasive autopsy in many cases of motor vehicle fatalities, suicide with violence, and broad categories of death due to natural disease. Over time, the authors believe that the PMCT will become one of the fundamental tools in the forensic pathologists toolkit.

An Evaluation of the Utility of Postmortem Computed Tomography in the Diagnosis of Lethal Coronary Artery Atherosclerosis and Hypertensive Heart Disease

Autopsy is regarded as the gold standard for evaluation of human remains in the forensic pathology setting. Amongst the most common causes of death in any medical examiner jurisdiction are atherosclerotic cardiovascular disease and/or hypertensive cardiovascular disease. Practical experience shows that noncontrast “screening” postmortem computed tomography (PMCT) does not accurately document or diagnose lethal coronary artery atherosclerosis, nor does it allow for the diagnosis of hypertensive cardiovascular disease. One hundred adult forensic autopsies were selected from an 18-month period for this blinded, retrospective case-controlled study. The cases were composed of two age- and sex-matched groups by cause of death: 1) those due to hypertensive and atherosclerotic cardiovascular disease and 2) those due to other causes. Two forensic pathologists, blinded to the cause of death, reviewed pre-autopsy PMCT scans of the chest and recorded the presence or absence of clinically significant coronary artery stenosis, myocardial pathology (including left ventricular hypertrophy and myocardial infarction), cardiomegaly, and coronary artery calcium deposition. The same set of data was obtained from the corresponding autopsy reports. Results of the PMCT interpretations were compared with the results obtained from autopsy. Assessment of PMCT scans resulted in missing all 56 cases with severe coronary artery atherosclerosis, 50 cases with myocardial pathology, and 44 cases with cardiomegaly. Although PMCT did prove sensitive and superior for the detection of coronary artery calcification, this finding is clinically insignificant and of limited to no value to the vast majority of cases.

Infant Heart Dissection in a Forensic Context: Babies are Not Just Small Adults

Medical examiners who investigate infant deaths are required to consider a large number of natural and non-natural causes due to the broad differential diagnosis of unexpected infant death. Among the myriad of causes are those related to disorders in structure and function of the cardiovascular system. Adult hearts are routinely and efficiently evaluated by medical examiners because of the large anatomic structures and limited spectrum of commonly encountered diseases. Infant deaths are comparatively rare. Although infant hearts may be evaluated with similar efficiency, the pathologist must first have a detailed knowledge of developmental cardiovascular anatomy and of the subtleties of a broad spectrum of infantile cardiovascular pathology. Furthermore, the pathologist must be aware of additional details to be observed and documented in infant cardiac studies, and of the dissection techniques that facilitate acquisition of that data. Rote dissection of an infant heart as if it were an adult heart may lead to overlooked malformations and diseases that may have been the underlying cause of death. This brief review paper covers the fundamentals of pediatric cardiovascular anatomy and dissection techniques as they apply to the practice of pediatric forensic pathology.