Peter Lin

Delayed Homicides and the Proximate Cause

Delayed homicides result from complications of remote injuries inflicted by “the hands of another.” The investigation of delayed homicides may be a challenge due to a number of factors including: failure to report the death to the proper authorities, lack of ready and adequate documentation of the original injury and circumstances, and jurisdictional differences between the places of injury and death. The certification of these deaths also requires the demonstration of a pathophysiologic link between the remote injury and death. In sorting through these issues, it is helpful to rely upon the definition of the proximate cause of death. Over a 2-year period in New York City, there were 1211 deaths certified as homicide of which 42 were due to injuries sustained greater than 1 year before death. The survival interval ranged from 1.3 to 43.2 years. The most common immediate causes of death were: infections (22), seizures (7), and intestinal obstructions/hernias (6). Common patterns of complications included infection following a gunshot wound of the spinal cord, seizure disorder due to blunt head trauma, and intestinal obstruction/hernia due to adhesions from an abdominal stab wound. Spinal cord injuries resulted in paraplegia in 14 instances and quadriplegia in 8. The mean survival interval for paraplegics was 20.3 years and 14.8 years for quadriplegics; infections were a frequent immediate cause of death in both groups, particularly infections due to chronic bladder catheterization. The definition of proximate cause originated with civil law cases and was later applied to death certification as the proximate cause of death. The gradual extinction of the “year and a day rule” for the limitation of bringing homicide charges in delayed deaths may result in more of these deaths going to trial. Medical examiners/coroners must be able to explain the reasoning behind these death certifications and maintain consistent standards for the certification of all delayed deaths due to any injury (homicides, suicides, and accidents).

Homicides of pregnant women.

Homicidal injury is a leading cause of death among pregnant and postpartum women in the United States. We studied all homicides in which the victim was pregnant at the time of the lethal injury. Records of the New York City Office of Chief Medical Examiner were reviewed. There were 27 homicides: the age ranged from 15 to 41 years (mean 27 years). The causes of death were: 13 gunshot wounds, 7 asphyxial deaths (eg, neck compression), 5 stabs, 1 blunt, and 1 blunt/stab. The gestational age ranged from 8 weeks to 40 weeks with an average of 24.5 weeks. Two live born infants (40 and 28 weeks gestation) were delivered following gunshot wounds of the mother and infant, however, both subsequently died. The victim and suspect were known to each other in 19 homicides. Of these, 16 involved an existing or prior intimate relationship including: 2 current husbands, 1 ex-husband, 9 current boyfriends, 3 ex-boyfriends, and 1 father. The issues that arise for the forensic pathologist include proper collection of a DNA sample from the fetus, estimation of the gestational age, and certification of death.

An Association of Hippocampal Malformations and Sudden Death? We Need More Data

Two recent studies from the San Diego SUDC Research Project describe a case series of 151 children, age 1–7 years, who died suddenly and unexpectedly [1, 2]. Cases were not population based and accrued retrospectively from offices across the US and abroad, with varied and unstandardized investigations. Limitations of this retrospective study are reflected in deficiencies of available data (56 % lacked radiology, 31 % lacked microbiology, 51 % lacked vitreous electrolytes, and 97 % lacked genetic testing). In addition, neuropathology sections were incomplete: 57 % hippocampus, 50 % medulla, and 72 % cortex. Thus, most investigations were limited in scope. These children died at a mean age of 1.7 years, were predominantly male, nearly always died during sleep, and half were associated with a personal or family history of febrile seizures. Hippocampal anomalies, including a combination the authors term hippocampal maldevelopment associated with sudden death (HMASD) were found in almost half of cases with available hippocampal sections; i.e., a quarter of the overall SUDC cohort. The authors described HMASD as a frequent finding in sudden unexplained death in childhood (SUDC), but did not suggest that this represents an entity distinct from SUDC without hippocampal abnormalities. Notably, there were no differences in SUDC children with and without HMASD with respect to a wide range of clinical and circumstances of death parameters [2]. Nevertheless, the question arises whether HMASD children should be removed from the SUDC group and considered a separate cause of death.

Gore Iliac Branch Endoprosthesis for treatment of bilateral common iliac artery aneurysms

Objective: The Gore Iliac Branch Endoprosthesis (IBE; W. L. Gore & Associates, Flagstaff, Ariz) has recently been approved by the Food and Drug Administration for treatment of common iliac artery (CIA) aneurysms. Despite early excellent results in clinical trial, none of 63 patients were treated for bilateral iliac aneurysms. The goal of this study was to examine real‐world experience using the Gore IBE for bilateral CIA aneurysms. Methods: A retrospective review of an international multicenter (16 U.S., 8 European) experience using the Gore IBE to treat bilateral CIA aneurysms was performed. Cases were limited to those occurring after Food and Drug Administration approval (February 2016) in the United States and after CE mark approval (November 2013) in Europe. Demographics of the patients, presentation, anatomic characteristics, and procedural details were captured. Results: There were 47 patients (45 men; mean age, 68 years; range, 41‐84 years) treated with bilateral Gore IBEs (27 U.S., 20 European). Six patients (12.7%) were symptomatic and 12 (25.5%) patients were treated primarily for CIA aneurysm (aorta <5.0 cm). Mean CIA diameter was 40.3 mm. Four patients had aneurysmal internal iliac arteries (IIAs). Two of these were sealed proximally at the IIA aneurysm neck and two required coil embolization of IIA branches to achieve seal in the largest first‐order branches. Technical success was achieved in 46 patients (97.9%). No type I or type III endoleaks were noted. There was no significant perioperative morbidity or mortality. IIA branch adjunctive stenting was required in four patients (one IIA distal dissection, three kinks). On follow‐up imaging available for 40 patients (85.1%; mean, 6.5 months; range, 1‐36 months), 12 type II endoleaks (30%) and no type I or type III endoleaks were detected. Two of 80 (2.5%) IIA branches imaged were occluded; one was intentionally sacrificed perioperatively. Conclusions: Preservation of bilateral IIAs in repair of bilateral CIA aneurysms can be performed safely with excellent technical success and short‐term patency rates using the Gore IBE device. Limb and branch occlusions are rare, usually are due to kinking, and can almost always be treated successfully with stenting.

Healed Fracture of Superior Horn of Thyroid Cartilage in Autoerotic Asphyxia: An Indication of Prior Activity? A Case Report Utilizing 3D Scanning and Printing of the Larynx

Evidence of prior autoerotic asphyxia is often difficult to establish due to the decedents efforts to hide the activity from others. In this case report, we suggest that a healed fracture of the thyroid cartilage is indicative of prior autoerotic asphyxia activity. The decedent was a 45-year-old man who was found unclothed on the floor of his bedroom with a belt ligature around the neck. A second rope ligature was loosely wrapped around the decedents wrists, scrotum, and penis. A definitive escape mechanism was not identified, but a nearby towel and barbell weight may have comprised a possible escape mechanism. There was no known history of depression or prior autoerotic activity. Autopsy was notable for the presence of a healed fracture of the right superior horn of the thyroid cartilage. Three-dimensional (3D) surface scanning and 3D printing was utilized to preserve the anatomical findings prior to histologic sampling. To our knowledge, this is the first reported use of 3D surface scanning and 3D printing for the purpose of documenting a forensic finding prior to alteration of the anatomical specimen for histologic sampling. Acute fractures of the superior horns of the thyroid cartilage are not infrequently seen in ligature hanging. Therefore, the presence of a healed fracture in the setting of autoerotic asphyxia likely indicates prior activity. Histologic sampling of the laryngeal cartilages to detect occult healed fractures in autoerotic asphyxia may be useful. Three-dimensional scanning and printing may alleviate concerns for specimen alteration due to histology sampling.

Technical Advances for the Clinical Genomic Evaluation of Sudden Cardiac Death: Verification of Next-Generation Sequencing Panels for Hereditary Cardiovascular Conditions Using Formalin-Fixed Paraffin-Embedded Tissues and Dried Blood Spots

Background— Postmortem genetic testing for heritable cardiovascular (CV) disorders is often lacking because ideal specimens (ie, whole blood) are not retained routinely at autopsy. Formalin-fixed paraffin-embedded tissue (FFPET) is ubiquitously collected at autopsy, but DNA quality hampers its use with traditional sequencing methods. Targeted next-generation sequencing may offer the ability to circumvent such limitations, but a method has not been previously described. The primary aim of this study was to develop and evaluate the use of FFPET for heritable CV disorders via next-generation sequencing. Methods and Results— Nineteen FFPET (heart) and blood (whole blood or dried blood spot) specimens underwent targeted next-generation sequencing using a custom panel of 101 CV-associated genes. Nucleic acid yield and quality metrics were evaluated in relation to FFPET specimen age (6 months to 15 years; n=14) and specimen type (FFPET versus whole blood and dried blood spot; n=12). Four FFPET cases with a clinical phenotype of heritable CV disorder were analyzed. Accuracy and precision were 100% concordant between all sample types, with read depths >100× for most regions tested. Lower read depth, as low as 40×, was occasionally observed with FFPET and dried blood spot. High-quality DNA was obtained from FFPET samples as old as 15 years. Genomic analysis of FFPET from the 4 phenotype-positive/genotype unknown cases all revealed putative disease-causing variants. Conclusions— Similar performance characteristics were observed for next-generation sequencing of FFPET, whole blood, and dried blood spot in the evaluation of inherited CV disorders. Although blood is preferable for genetic analyses, this study offers an alternative when only FFPET is available.

Severe pulmonic valve regurgitation due to histoplasma endocarditis

Summary A 67-year-old man with myelodysplastic syndrome, disseminated histoplasmosis, and mitral valve replacement presented with dyspnea and peripheral edema. Transthoracic echocardiography demonstrated abnormal pulmonic valve with possible vegetation. Color flow imaging showed laminar flow from main pulmonary artery into right ventricular outflow tract (RVOT) in diastole. The continuous wave Doppler signal showed dense diastolic envelope with steep deceleration slope. These findings were consistent with severe pulmonic valve regurgitation, possibly due to endocarditis. Transesophageal echocardiography demonstrated an echodense mass attached to the pulmonic valve. The mitral valve bioprosthesis appeared intact. Bacterial and fungal blood cultures were negative; however, serum histoplasma antigen was positive. At surgery, the valve appeared destroyed by vegetations. Gomori methenamine silver-stains showed invasive fungal hyphae and yeast consistent with a dimorphic fungus. Valve cultures grew one colony of filamentous fungus. Itraconazole was continued based on expert infectious diseases diagnosis. After surgery, dyspnea and ankle edema resolved. To the best of our knowledge, histoplasma endocarditis of pulmonic valve has not been previously reported. Isolated pulmonic valve endocarditis is rare, accounting for about 2% of infectious endocarditis (IE) cases. Fungi account for about 3% of cases of native valve endocarditis. Characterization of pulmonary valve requires thorough interrogation with 2D and Doppler echocardiography techniques. Parasternal RVOT view allowed visualization of the pulmonary valve and assessment of regurgitation severity. As an anterior structure, it may be difficult to image with transesophageal echocardiography. Mid-esophageal right ventricular inflow–outflow view clearly showed the pulmonary valve and vegetation. Learning points Identification and characterization of pulmonary valve abnormalities require thorough interrogation with 2D and Doppler echocardiography techniques. Isolated pulmonary valve IE is rare and requires high index of suspicion. Histoplasma capsulatum IE is rare and requires high index of suspicion.

Open staged repair of splenic and extensive superior mesenteric artery aneurysms

A 31-year-old man with a history of multiple strokes of unknown etiology presented with multiple asymptomatic visceral artery aneurysms including a 3.3-cm bilobed splenic artery aneurysm and a 3.1-cm fusiform superior mesenteric artery aneurysm. He had no family history of aneurysms, and there was no evidence of collagen disease. He underwent open splenic artery aneurysm resection without splenectomy and had an uneventful recovery. Seven months later, he had open repair of his 14.6-cm-long fusiform superior mesenteric artery aneurysm with a 15-cm-long collagen-coated polyester interposition graft with multiple visceral branch reimplantations into the graft. The postoperative course was uneventful, and computed tomography confirmed patent graft and side branches. Two years later, the patient remained free of abdominal symptoms, although he suffered another episode of a mild stroke.

The characteristics of all-terrain vehicle (ATV)-related deaths: A forensic autopsy data-based study

Using forensic autopsy-based data from a regional medical examiner office in the midwestern U.S. with a mixed small urban-rural population, we describe the characteristics of all-terrain vehicle (ATV)-related deaths occurring between 2000 and 2018. During this period, there were 25 ATV-related deaths. There was a strong male predominance with 22 male and 3 female decedents. The average age at death was 35xa0years, with a range from 10 to 82xa0years, and a bimodal age distribution with one peak at 10–19xa0years old, and a second peak at 60–69xa0years old. The most common cause of death was blunt trauma (nxa0=u200922), with the remainder being torso compression (nxa0=u20091), drowning (nu2009=u20091) and hypothermia (nu2009=u20091). Of the 22 blunt trauma deaths, 15 were due to head trauma. The most common mechanism of accident was roll-over (nxa0=u200911), followed by striking a stationary object (nxa0=u20096). Of the stationary objects struck, the most common was cable wire fencing accounting for 3 of the 6. A survival period following discovery of the body was present in 11 of the 25 deaths. Postmortem toxicology was positive for ethanol in 7 deaths and tramadol in 1 death.

Plexogenic pulmonary hypertension associated with POEMS syndrome

Pulmonary hypertension is one of the well-known clinical manifestations of polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome, occurring in approximately 25–30% of the affected individuals. However, the histopathologic spectrum of pulmonary hypertension associated with POEMS syndrome has not been fully documented in the literature. Herein, we report an autopsy case of POEMS syndrome in a patient whose lung tissues showed histopathology indistinguishable from that of idiopathic pulmonary arterial hypertension with abundant plexiform lesions in the small pulmonary arteries.