Patrick E. Lantz

Oleoresin Capsicum (pepper) Spray and “in-custody Deaths”

Increasing use of oleoresin capsicum (OC) spray devices (i.e., pepper spray, pepper mace, OC, capsaicin) by law enforcement agencies as a means of sublethal force to control suspects has brought into question whether exposure to this noxious irritant (capsaicin) can cause or contribute to unexpected in-custody deaths. Capsaicin stimulates nociceptors in exposed mucous membranes to produce intense pain, particularly involving the conjunctiva, and generates systemic physiologic and behavioral responses consonant with such extreme discomfort. We describe two cases of in-custody death, both associated temporally with the use of pepper spray, to illustrate salient investigative considerations. As with any other in-custody death, a thorough autopsy and toxicologic analysis, coupled with evaluation of the premortem chain of events, postexposure symptomatology, and the extent of natural disease processes, will help to reveal the role of oleoresin capsicum spray as unrelated, contributory, or causative.

Fatal Carbon Dioxide Embolism Complicating Attempted Laparoscopic Cholecystectomy—Case Report and Literature Review

Laparoscopic cholecystectomy has become the surgical procedure of choice for individuals with symptomatic gallbladder disease. The procedure has gained popularity among surgeons and patients because of inconspicuous abdominal incisions/scars, less postoperative pain, shorter hospitalization, and reduced medical costs. Bile duct, vascular, and gastrointestinal iatrogenic injuries are major complications. We describe the case of a 50-year-old woman who died of CO2 embolism during elective laparoscopic cholecystectomy for symptomatic cholelithiasis. With the patient under general anesthesia, a 1.5 cm incision was made just below the umbilicus, and a pneumoperitoneum was created by CO2 insufflation with a pneumoperitoneum (modified Veress) needle. Immediately, she experienced a cardiopulmonary arrest and could not be resuscitated. At autopsy, air bubbles were admixed with blood in the epicardial veins and leptomeningeal blood vessels. A triangular 0.1 cm perforation in the left common iliac vein had been created by the pneumoperitoneum needle. A pneumoperitoneum is required for laparoscopy and CO2 is the most commonly used gas. Carbon dioxide is highly soluble in blood and fairly innocuous to the peritoneum. Small amounts absorbed into the circulation cause slight increases in arterial and alveolar CO2 and in central venous pressure. When CO2 enters the venous circulation through iatrogenically opened vascular channels, catastrophic and potentially fatal hemodynamic and respiratory compromise may result.

Feasibility, Accuracy, and Incremental Value of Intraoperative Three-Dimensional Transesophageal Echocardiography in Valve Surgery

In this prospective trial, intraoperative 2-dimensional (2-D) and 3-dimensional (3-D) transesophageal echocardiography (TEE) examinations were performed on 60 consecutive patients undergoing cardiac valve surgery. Both 2-D (including color flow and Doppler data) and 3-D images were reviewed by blinded observers, and major valvular morphologic findings recorded. In vivo morphologic findings were noted by the surgeon and all explanted valves underwent detailed pathologic examination. To test reproducibility, 6 patients also underwent 3-D TEE 1 day before surgery. A total of 132 of 145 attempted acquisitions (91%) were completed with a mean acquisition time of 2.8 +/- 0.2 minutes. Acquisition time was significantly shorter in patients with regular rhythms. Reconstructions were completed in 121 of 132 scans (92%) and there was at least 1 good reconstruction in 56 of 60 patients (93%). Mean reconstruction time was 8.6 +/- 0.7 minutes. Mean effective 3-D time, which was the time taken to complete an acquisition and a clinically interpretable reconstruction, was 12.2 +/- 0.8 minutes. Intraoperative 3-D echocardiography was clinically feasible in 52 patients (87%). Three-D echocardiography detected most of the major valvular morphologic abnormalities, particularly leaflet perforations, fenestrations, and masses, confirmed on pathologic examination. Three-D echocardiography predicted all salient pathologic findings in 47 patients (84%) with good quality images. In addition, in 15 patients (25%), 3-D echocardiography provided new additional information not provided by 2-D echocardiography, and in 1 case, 3-D echocardiographic findings resulted in a surgeons decision to perform valve repair rather than replacement. In several instances, 3-D echocardiography provided complementary morphologic information that explained the mechanism of abnormalities seen on 2-D and color flow imaging. In the reproducibility subset, preoperative and intraoperative 3-D imaging detected a similar number of findings when compared with pathology. Thus, in routine clinical intraoperative settings, 3-dimensional TEE is feasible, accurately predicts valve morphology, and provides additional and complementary valvular morphologic information compared with conventional 2-D TEE, and is probably reproducible.

Novel FOXF1 Mutations in Sporadic and Familial Cases of Alveolar Capillary Dysplasia with Misaligned Pulmonary Veins Imply a Role for its DNA Binding Domain

Alveolar capillary dysplasia with misalignment of pulmonary veins (ACD/MPV) is a rare and lethal developmental disorder of the lung defined by a constellation of characteristic histopathological features. Nonpulmonary anomalies involving organs of gastrointestinal, cardiovascular, and genitourinary systems have been identified in approximately 80% of patients with ACD/MPV. We have collected DNA and pathological samples from more than 90 infants with ACD/MPV and their family members. Since the publication of our initial report of four point mutations and 10 deletions, we have identified an additional 38 novel nonsynonymous mutations of FOXF1 (nine nonsense, seven frameshift, one inframe deletion, 20 missense, and one no stop). This report represents an up to date list of all known FOXF1 mutations to the best of our knowledge. Majority of the cases are sporadic. We report four familial cases of which three show maternal inheritance, consistent with paternal imprinting of the gene. Twenty five mutations (60%) are located within the putative DNA‐binding domain, indicating its plausible role in FOXF1 function. Five mutations map to the second exon. We identified two additional genic and eight genomic deletions upstream to FOXF1. These results corroborate and extend our previous observations and further establish involvement of FOXF1 in ACD/MPV and lung organogenesis.

Interpretation of Fatal, Multiple, and Exiting Gunshot Wounds by Trauma Specialists

Firearm-related injuries are a leading cause of morbidity and mortality in the United States. Trauma care centers and trauma specialists (emergency medicine, trauma surgery, and neurosurgery) provide emergency care for those injured and mortally wounded from firearms. Consequently, trauma specialists may be asked to address forensic questions regarding gunshot wounds. Many firearm-related injuries are nonfatal and ultimately, fatal gunshot wounds can suffer from surgical alteration or, if the time interval between injury and death is prolonged, considerable healing of entrance and exit wounds may occur. Thus, accurate initial evaluation of firearm-related injuries is essential. We reviewed all firearm-related fatalities at our institution over the last five and a half years. Our objective was to determine how accurately trauma specialists can differentiate entrance and exit wounds in fatal perforating (exiting) gunshot wounds and determine the number of penetrating or perforating projectiles in fatal multiple gunshot wounds. A total of 271 fatal gunshot wound deaths were reviewed. Of these, we excluded all fatal penetrating (nonexiting) single gunshot wounds and fatalities not evaluated by trauma specialists. Postmortem findings were compared with the medical records from those individuals seen in the emergency department and/or admitted to North Carolina Baptist Hospital (Level I trauma center). Forty six cases with fatal multiple or exiting gunshot wounds were identified. Twenty four (52.2%) were misinterpreted by trauma specialists. Errors included inaccurate determination of the total number of multiple penetrating and/or perforating gunshot wounds and erroneous identification of entrance and exit wounds. Of the exiting, single gunshot wounds 37% were misclassified and 73.6% of multiple gunshot wounds were interpreted incorrectly.(ABSTRACT TRUNCATED AT 250 WORDS)

Identification of Sperm and Non-Sperm Male Cells in Cervicovaginal Smears Using Fluorescence In Situ Hybridization: Applications in Alleged Sexual Assault Cases

The identification of spermatozoa or constituents of seminal fluid is critical in the evaluation of alleged sexual assault victims. However, failure to identify sperm and/or elevated levels of acid phosphatase can occur for a variety of reasons. Molecular techniques, such as molecular cytogenetic analysis offers new approaches to improve on the identification of male cells in alleged sexual assault cases. Fluorescence in situ hybridization (FISH) with a Y chromosome specific DNA probe was applied to archival cervicovaginal smears from 41 alleged sexual assault cases to identify Y-bearing (male) cells. FISH identified Y-bearing sperm and non-sperm cells in 78% of the cases previously confirmed to have sperm. FISH also identified Y-bearing non-sperm male cells in 39% of the cases in which cytology did not detect spermatozoa; in one of these instances, it also detected sperm. Cervicovaginal acid phosphatase levels, determined at the time of the cervicovaginal smears, were also compared with the presence or absence of Y-positive cells. Application of this technique can detect non-spermatozoic male cells in routine cervicovaginal smears of sexual assault victims.

Sudden death in epilepsy due to an isolated subependymal giant cell astrocytoma of the septum pellucidum

We report a case of sudden unexpected death in an individual with epilepsy. Autopsy revealed a subependymal giant cell astrocytoma of the septum pellucidum, but there were no other lesions of tuberous sclerosis. We discuss sudden death in epilepsy, deaths related to primary brain tumors, the pathology of subependymal giant cell astrocytoma, and whether or not such a tumor can exist outside the setting of tuberous sclerosis. We also discuss the implications such findings may have on surviving family members, as well as the important role of the forensic pathologist in such cases.

The human cornea has a high incidence of acquired chromosome abnormalities

Abstract Structurally and functionally, the human cornea is a highly specialized tissue. The corneal stromal collagen matrix is uniquely transparent and yet maintains a mechanically tough and chemically impermeable barrier between the eye and environment. We report for the first time that stromal keratocytes of the human cornea show cytogenetic abnormalities with a frequency that is unprecedented among normal tissues. The abnormalities are acquired, clonal and nonclonal, primarily aneuploid in nature, and present in normal as well as diseased corneas.

Post-mortem analysis for two prevalent β-oxidation mutations in sudden infant death

Background: Fatty acid oxidation disorders may cause sudden and unexpected infant death and are associated with the histological hallmark of hepatic steatosis. The goal of the present study was to assess the value of post‐mortem molecular analysis for medium‐chain acyl‐coenzyme A dehydrogenase (MCAD) and mitochondrial trifunctional protein (MTP) defects in unexplained sudden infant death (SID) associated with fatty infiltration of the liver. MCAD catalyzes the first step of medium‐chain fatty acid oxidation while MTP catalyzes the last three steps of long‐chain fatty acid oxidation.

Postmortem monocular indirect ophthalmoscopy

Postmortem monocular indirect ophthalmoscopy permits examination of the posterior fundus and peripheral retina even if there is less than perfect anterior segment media such as postmortem corneal clouding. Light directed through the decedents pupil from a bright focal light source illuminates the fundus and reflected light from the retina is then projected out of the eye. An aspheric condensing lens positioned in front of the eye focuses the retinal image at the focal plane of the lens. The real inverted, laterally reversed image comprises a wide field of view permitting evaluation of the decedents fundus for retinal hemorrhages and other lesions.