Mohammed Madadin

A community-based model of rapid autopsy in end-stage cancer patients

To the Editor: Systematic genomic studies, including the Cancer Genome Atlas (TCGA)1 and the International Cancer Genome Consortium (ICGC)2, have provided an unprecedented catalog of driver mutations in human cancer. However, these studies use mainly primary, pre-treatment tumor material obtained at surgery with curative intent. There is an urgent need to identify and characterize resistance mechanisms to understand how cancers can evade even the best medical efforts and kill patients; therefore, access to end-stage disease is important. Solid cancers show considerable spatial3, temporal4,5 and genomic heterogeneity at diagnosis. Selective pressure and mutagenic impact of treatment6 drives intra-patient evolution of cancer cell populations4,7. Understanding acquired resistance requires access to paired preand post-treatment samples4,7; however, curative surgery is typically confined to patients with locoregional disease, and opportunities for tumor sampling in advanced disseminated disease are limited. Here, we describe Cancer Tissue Collection After Death (CASCADE), an autopsy program that overcomes logistical challenges to enable collection of samples at end stage for research in melanoma and breast, ovarian and prostate cancers. For the CASCADE study, we aimed to recruit cancer patients close to the end of life, including those outside the minority of patients who die in hospitals. To preserve tissue integrity, autopsies must commence within a few hours of death, requiring access to around-the-clock services. Intervention in the emotionally charged end-of-life environment must be managed in an ethical manner and to a high standard. Finally, we aimed for the study to be highly cost-effective. We believe our approach to meeting these challenges is applicable to researchers in other large urban centers. Here we summarize the main steps in CASCADE’s operating protocol and our experiences from the initial 3 years and 30 autopsies performed (Fig. 1). Information about institutional review board approvals (including a detailed patient informationand-consent form), the autopsy procedure and certain laboratory processes is given in Supplementary Methods and Supplementary Figure 1. Recruitment of participants was led by the clinicians. Such discussions require careful consideration, in timing and in language, and were initiated only if there was a perception that tissue donation would be acceptable to the patients and their families. Factors suggesting acceptability include the emotional stability of the participant and family members and their clarity about and acceptance of the terminal nature of the disease. On occasion, participants prompted discussion by asking about organ or body donation. Consent discussions typically involved oncologists and/or palliative care physicians employed at recruiting hospitals who had established a care relationship with the participant and their family during the patient’s cancer journey. Frequently, the study was introduced at one meeting and discussed over several subsequent clinic visits, allowing patients and their families time to consider participation. We view the involvement of family members in the consent process as essential to support the participant and facilitate decisionmaking. Involvement of family members also ensures that they are fully aware of the autopsy process and helps to clarify funeral arrangements for the study team. After obtaining consent, study investigators collated clinical information, including that related to past and current treatment and diagnostic procedures such as imaging, on an ongoing basis. Between September 2012 and August 2015, 40 patients were approached, and 37 (92.5%) expressed interest in participating. Of those 32 patients (80%) consented; the other 5 had rapid clinical deterioration precluding

Endosulfan poisoning: An overview

Endosulfan, an organochlorine (OC) insecticide, is a widely used agricultural pesticide, despite its life threatening toxic effects. In this review, the pharmacokinetics of endosulfan, mechanism of endosulfan toxicity, clinical presentations and management, histopathological findings, and toxicological analysis are described, in addition to its environmental toxicity. The toxic effects of endosulfan can affect many organs and systems presenting in a wide array of signs and symptoms. Although termed a restricted OC-classed pesticide, it continues to be used, especially in the developing world, owing to its beneficial effects on agriculture. Several cases of endosulfan poisoning have been reported from different regions of the world. Whether accidental or intentional, endosulfan ingestion proves to be fatal unless immediate, aggressive treatment is initiated. Management is mainly supportive as no antidote exists for endosulfan poisoning as yet. The use of endosulfan needs to be strictly regulated and eventually banned worldwide altogether to lower the current morbidity and mortality resulting from this pesticide. Additionally, monitoring biological samples, using non-invasive techniques such as breast milk sampling, can provide an effective method of observing the elimination of this environmentally persistent organic pollutant from the general population.

Assessment of knowledge about, attitudes toward, and awareness of a forensic medicine course among medical students at the University of Dammam

AIM This study assesses the knowledge about, awareness of, and attitudes toward forensic medicine and the forensic medicine undergraduate course among medical students at the University of Dammam in Dammam, Saudi Arabia. METHOD We conducted a cross-sectional study of 143 fourth-year students. We used a structured, self-administered questionnaire containing 10 items relating to forensic medicine to assess the knowledge about, awareness of, and attitudes toward forensic medicine and the forensic medicine undergraduate course. RESULTS The results showed inadequate knowledge about, poor attitudes toward, and limited awareness of the importance of the forensic medicine course among medical students. Media had an effect on the students as they are a major source of forensic science information among medical students. CONCLUSION The forensic medicine undergraduate course is important for medical students. We recommended that it be taught at the undergraduate level because it is the only academic source for forensic medicine that physicians may encounter in their careers. Teaching how to conduct an autopsy is important and has a positive role in medical education, and the forensic medicine curriculum must include instruction on autopsies, both from theoretical and practical perspectives. Medical institutes must take responsibility to increase awareness about the effect of media on medical education.

Evaluation of the mastoid triangle for determining sexual dimorphism: A Saudi population based study

Demographic assessment of skeletal remains in forensic investigations includes identification of sex. The present study aimed to develop population-specific, sex-discriminating anthropometric standards for the mastoid triangle of a documented Saudi population using computed tomographic (CT) images of the lateral aspect of the skull. The present study was performed on 206 CT images of a documented Saudi population of known sex and age. The clinical CT images of subjects visiting the Department of Radiology, Dammam Medical Complex, Dammam, Saudi Arabia (KSA) were evaluated to know the validity of the metric assessment of the mastoid triangle for identification of sex in a Saudi population. The distance between asterion to porion (AP), asterion to mastoidale (AM), porion to mastoidale (PM) were measured and the area of the mastoid triangle (AMT) was calculated using these measurements. Discriminant function procedure was used to analyze the data for sexual dimorphism. In conclusion, the results of the present study indicate that all the 3 sides of the mastoid triangle and AMT were sexually dimorphic in the sampled Saudi population with PM being the best individual parameter in discriminating sex with an accuracy of 69.4%. Whereas, all the parameters combined showed the highest accuracy (71.4%).

Child homicide in Cairo from 2006 to 2010: Characteristics and trends

BACKGROUND Crimes towards children have drawn public attention over the decades. Several studies have been conducted to determine the risk factors of victimizing children. Conducting studies of this crime in Cairo, the capital city of Egypt, would help in understanding the motives behind it in such a densely populated area. RESEARCH DESIGN AND METHODOLOGY A review of death charts was conducted in Zeinhom morgue in the years of 2006-2010 to study the trends and characteristics of child homicide in Cairo. The cut-off for a child age was at 18 years. Data related to the victim and offender was collected. RESULTS Child homicides represented 7.97% of total child deaths in the studied period. Most of them (25%) fall in the age group of 1-6 years. Females were the majority in the age group of 12-18 years (89%). The offender was the father in 28% of cases and the cause of death was mainly trauma to the head (42%). CONCLUSION Further studies should be conducted to discern the risk factors of this crime in Cairo with special considerations to the motives behind murdering females in teen ages.

Morphometric evaluation of the foramen magnum for sex determination: A study from Saudi Arabia

The present study provides a database of various morphometric dimensions of the foramen magnum region in the Saudi population. The objective of this study was to evaluate various measurements of the foramen magnum region for sex determination in the Saudi population by using computed tomography (CT) images. The various radiological measurements of the foramen magnum region were measured in a total of 200 adult subjects of Saudi origin including 100 males and 100 females. Sexual dimorphism was observed in five parameters related to the foramen magnum, namely length of the right occipital condyle (LROC), length of the left occipital condyle (LLOC), width of the foramen magnum (WFM), area of the foramen magnum (AFM) and length of the foramen magnum (LFM). The accuracy to discriminate sex ranged from 65.5% to 62.5% when LROC, LLOC, WFM, AFM, and LFM were considered as individual parameters. When multiple parameters were combined to discriminate sex, the highest accuracy of 71% was achieved.

Post-mortem CT evaluation of atlanto-occipital dissociation

Atlanto-occipital dissociation injury is an important injury in forensic pathology practice. Radiological diagnosis of atlanto-occipital dissociation clinically is assessed by direct measurement of occipito-vertebral skeletal relationships. Different measurements may be used to diagnose atlanto-occipital dissociation, including the basion-dens interval (BDI) and basion-axial interval (BAI). It is not known whether the normal ante-mortem measurements of BDI and BAI described in the literature are applicable to post-mortem CT images of the occipito-cervical junction (OCJ) or whether these measurements could be affected by early post-mortem changes. This study aims to compare post-mortem BDI and BAI measurements with ante-mortem values. Post-mortem CT scans of the cervical spines of 100 deceased adults were reviewed, and the BDI and BAI were measured. Different parameters were recorded in each case. The results from this study suggest that there are no effects of post-mortem changes on the measurement of BAI as relied upon clinically. There appear to be some effects of fully established rigor mortis on BDI measurement, shortening it. This may have consequences for the post mortem diagnosis of atlanto-occipital dissociation.

Gastrointestinal causes of sudden unexpected death: A review

Gastrointestinal conditions are a less common cause of sudden unexpected death when compared to other conditions such as cardiovascular conditions, but they are equally important. Various congenital and acquired gastrointestinal conditions that have resulted in sudden unexpected death are discussed. The possible lethal mechanisms behind each condition, along with any associated risk factors or secondary diseases, have been described. Through this article, we aim to highlight the need for physicians to prevent death in such conditions by ensuring that subclinical cases are diagnosed correctly before it is too late and by providing timely and efficacious treatment to the patient concerned. In addition, this review would certainly benefit the forensic pathologist while dealing with cases of sudden unexpected death due to gastrointestinal causes. This article is a review of the major gastrointestinal causes of sudden unexpected death. In addition, related fatal cases encountered occasionally in forensic autopsy practice are also included. There are several unusual and rare causes of life-threatening gastrointestinal bleeding that may lead to sudden unexpected death to cover all the entities in detail. Nevertheless, this article is a general guide to the topic of gastrointestinal causes of sudden unexpected death.

Breaking your heart—A review on CPR-related injuries

&NA; Cardiopulmonary resuscitation (CPR) has been shown to increase survival after cardiac arrest, but is associated with the risk of acquired injuries to the patient. While traumatic chest wall injuries are most common, other injuries include upper airway, pulmonary and intra‐abdominal injuries. This review discusses the risk factors and prevalence of CPR‐related injuries. Highlights:CPR, although lifesaving, may be associated with significant injuries.CPR is associated with a wide range of injuries, from the head and neck down to the abdomen and pelvis.Appropriate technique and position of chest compression may help prevent some CPR‐related injuries.CPR‐related injuries should be considered in all patients who do not improve despite correction of the cause of arrest

The attitude of people with an Arabic Islamic cultural background toward medico-legal autopsy

Medico-legal (forensic) autopsy is an important element in the investigative process of any suspicious death. People’s reactions toward a forensic autopsy vary among cultural and religious beliefs. This research has studied the reaction of the general public in Saudi Arabia (Arabic and Islamic cultural backgrounds) toward this procedure with the aim of exploring the cultural and religious influence on their attitude. An online survey of the awareness and attitude toward the forensic autopsy was distributed to Saudi people across different ages and educational levels. A total of 1866 persons responded to the questionnaire with the majority falling between the ages of 21 and 40 years. The majority of the participants (66%) thought that legal investigations without a forensic autopsy are not enough to determine the cause of death. Twenty-one percent were not comfortable, for religious reasons, with the performance of an autopsy and 72% thought that an autopsy should be done only after the consent was attained from the deceased’s relatives. Understanding the worries of people toward this procedure highlights the importance of awareness programmes with the goal of correcting misconceptions and relieving worries. Awareness campaigns through media could be a good source of relaying correct information regarding this topic.