Retrograde venous cerebral air embolism from disconnected central venous catheter: an experimental model

There are few reported cases of death attributed to retrograde cerebral air embolism from central venous catheter. The pathophysiological mechanism and the necessary conditions are not fully understood, also because of missing experimental data. We performed experimental simulation while working on a possible case of retrograde cerebral air embolism. A hermetic system consisting of two containers connected to each other and to an electric pump by means of rubber hoses was built. In this system, a fluid (water and blood) could continuously flow under conditions similar to those of the common jugular vein. The part of the system representing the jugular vein could be freely positioned at angles between 0 and 90°. A central venous catheter was inserted into this part. After disconnection, the behavior of the air bubbles entering the hose through the tip of the catheter was evaluated at different positions. At angles between 0 and 45°, the air bubbles followed the fluid flow. At angles >45°, the air bubbles showed the tendency to flow upstream; this phenomenon was more evident the more vertically the hose was located. We were able to demonstrate that a retrograde air embolism can be caused by a disconnected catheter and is even more likely if the neck is in a vertical position.     

Evolution of Swan-Ganz catheter-related pulmonary valve nonbacterial endocarditis

Invasive resuscitative and supportive therapy subsequent to accidental trauma, assault, or medical mishap may create lesions that forensic pathologists must interpret. Pulmonary valve nonbacterial endocarditis sometimes complicates placement of flow-directed pulmonary artery (Swan-Ganz) catheters. We examined ten cases of endocarditis from patients dying 0-10 days after removal of a Swan-Ganz catheter, and compared the natural evolution of vegetations in critically ill patients with the reported evolution of similar vegetations in experimental animals in the Freedman model. There was wide variation in macroscopic, as well as in the light- and scanning electron-microscopic, appearances in our cases and we could not establish a direct relationship between vegetation structure and time elapsed after removal of the catheter. These findings suggest that parameters related to critical illness and species account for the differences between this disease in human and animal models.     

Postmortem angiography of catheter-induced pulmonary artery perforation.

A case of pulmonary artery perforation by the placement of a balloon-tipped, flow-directed (Swan-Ganz) catheter, as demonstrated postmortem by angiography and confirmed by conventional autopsy method, is reported. Angiography is an effective adjunctive modality in the postmortem diagnosis and localization of pulmonary artery perforation. In cases of suspected catheter-induced pulmonary artery perforation and death, postmortem angiography may prove useful to the forensic pathologist.     

Importance of electromyography and the electrophysiological severity scale in forensic reports

Forensic reports on traumatic peripheral nerve injuries include dysfunction degrees of extremities, which are arranged according to the Turkish Penalty Code. The aim of this study is to discuss the role and importance of electromyography while preparing forensic reports in the cases of traumatic peripheral nerve injuries and the usefulness of scoring systems. A modified global scale, recommended by Mondelli et al., was used to assess the electrophysiological impairment of each peripheral nerve. Forensic reports of 106 patients, reported between 2002 and 2004, were evaluated. Thirty-four percent of the cases were reported as "total loss of function," 41.5% were reported as "functional disability," and there were no dysfunctions in the other cases in forensic reports that were prepared based on Council of Social Insurance Regulations of Health Processes and Guide prepared by the Council of Forensic Medicine and profession associations of forensic medicine. When we rearranged these forensic reports based on the electrophysiological severity scale (ESS), it was clearly found that all of the score 2 cases and 86.7% of the score 3 cases corresponded to "functional disability" and 91.4% of the score 4 cases correspond to "total loss of function." We found a significant correlation between the ESS and functional evaluation in peripheral nerve injury cases. Evaluation of functional disabilities in peripheral nerve injuries with the ESS represents a standardized and objective method used for forensic reports.     

Asphyxial games in children and adolescents

Asphyxial games, as played by young adolescents, and going by various names, are not new phenomena. What seems to be different at present is an increase in lethality introduced by the increasing use of ligatures and "playing" the game alone. The authors present a properly certified but insufficiently appreciated case followed 2 years later by 2 closely spaced but unrelated deaths in young adolescent males that made known this practice in New Hampshire youth. Other cases presented to the author from other jurisdictions are reviewed in aggregate. Presented are characteristics of victims of this practice that may help distinguish these deaths from suicidal asphyxia. A relative paucity of literature regarding asphyxial games outside the realm of autoerotic asphyxia gives rise to certification difficulties given the high prevalence of youth suicide.     

Block Randomized Trials at Places: Rethinking the Limitations of Small N Experiments

Objectives

Place-based policing experiments have led to encouraging findings regarding the ability of the police to prevent crime, but sample sizes in many of the key studies in this area are small. Farrington and colleagues argue that experiments with fewer than 50 cases per group are not likely to achieve realistic pre-test balance and have excluded such studies from their influential systematic reviews of experimental research. A related criticism of such studies is that their statistical power under traditional assumptions is also likely to be low. In this paper, we show that block randomization can overcome these design limitations.

Methods

Using data from the Jersey City Drug Market Analysis Experiment (N = 28 per group) we conduct simulations on three key outcome measures. Simulations of simple randomization with 28 and 50 cases per group are compared to simulations of block randomization with 28 cases. We illustrate the statistical modeling benefits of the block randomization approach through examination of sums of squares in GLM models and by estimating minimum detectable effects in a power analysis.

Results

The block randomization simulation is found to produce many fewer significantly unbalanced samples than the naïve randomization approaches both with 28 and 50 cases per group. Block randomization also produced similar or smaller absolute mean differences across the simulations. Illustrations using sums of squares show that error variance in the block randomization model is reduced for each of the three outcomes. Power estimates are comparable or higher using block randomization with 28 cases per group as opposed to naïve randomization with 50 cases per group.

Conclusions

Block randomization provides a solution to the small N problem in place-based experiments that addresses concerns about both equivalence and statistical power. The authors also argue that a 50 case rule should not be applied to block randomized place-based trials for inclusion in key reviews.     

Interpretation of postmortem digoxin levels: evaluating a "corrective factor" for postmortem blood digoxin concentration

Interpretation of postmortem serum digoxin levels is made difficult above all by a possible prefinal or postmortem rise in digoxin concentrations in the blood. To compensate for this postmortem increase, Eriksson et al. (1984) divided the level of postmortem digoxin in femoral venous blood by a factor of 1.5; in the opinion of these authors, postmortem digoxin levels still exceeding "therapeutic levels" after division by 1.5 are an index of digoxin overdose. The diagnostic value of this "correction factor" was investigated. In 56 cases with documented digoxin medication, samples of postmortem femoral venous blood were taken and the level of digoxin determined. In none of the cases had there been a clinical diagnosis of digoxin intoxication. Fifty percent of the measured values were above "therapeutic levels" (0.7 ng/ml to 2.2 ng/ml). Following division by 1.5, 20% of the cases still showed levels exceeding 2.2 ng/ml; the highest "corrected" value was 4.44 ng/ml. Taking into account the length of time between final dosage and death, individual differences in sensitivity to digitalis glycoside, and the complexity of ante- and postmortem dispersion processes, we concluded for the cases we studied that an (undetected) digoxin overdose was not even likely in those cases whose postmortem values after division by 1.5 lie above "therapeutic levels". The "correction factor" proposed by Eriksson et al. (1984) is only of limited diagnostic value; at best the "corrected" values can give an approximate indication of the corresponding antemortem serum digoxin concentrations. In particular, "corrected" values only a little above "therapeutic levels" could not confirm suspicion of an overdose with sufficient certainty.     

Fatal cervical necrotizing fasciitis (a report of two cases of confirmed odontogenic origin and one of possible odontogenic origin).

Three cases of cervical necrotizing fasciitis (CNF), two of confirmed odontogenic origin and one of probable odontogenic origin, were observed from 1993-1999. This is in addition to three cases previously reported by this office. A rare sequelae of dental infection, CNF can be a severe, rapidly progressing infection of the cervical tissues having a mortality rate of up to 50%. "Hospital gangrene" was first described during the Civil War. It was later to be described as necrotizing fasciitis and later yet was designated as a separate clinicopathological diagnosis.     

Changing trends in the diagnosis of sudden infant death

A study of 114 consecutive cases of unexpected infant death that occurred in South Australia over a 5-year period from January 1994 to December 1998 was undertaken. There were 45 deaths attributed to sudden infant death syndrome (SIDS), 19 to natural causes, 21 to accidents. and 5 to homicides; 24 cases were listed as "undetermined." Although there has been a genuine and continued decline in SIDS numbers in this population, there has also been an increase in the diagnosis of cases of accidental asphyxia due to unsafe sleeping environments and of cases in which the family background and autopsy findings suggested more complex mechanisms. The change in diagnostic profile has followed the introduction of more rigorous clinical history review, death scene examination, and autopsy testing. Thus, although diagnostic outcomes have altered in this population, it is more likely the result of more careful interpretation of the extensive investigations that are now undertaken rather than arbitrary reclassification.     

Revisiting the legal standards that govern requests to sterilize profoundly incompetent children: in light of the "Ashley Treatment," is a new standard appropriate?

This Note discusses the recent controversy surrounding a six-year-old girl named Ashley, whose parents chose to purposefully stunt her growth and remove her reproductive organs for nonmedical reasons. A federal investigation determined that Ashley's rights had been violated because doctors performed the procedure, now referred to as the "Ashley Treatment," without first obtaining a court order. However, the investigation did not make any conclusions regarding whether the "Ashley Treatment" could present a legally permissible treatment option in the future. After discussing the constitutional rights that the "Ashley Treatment" implicates and the current legal standards in place, this Note examines how courts have applied these legal standards to cases involving extreme requests. Drawing upon legal commentators, this Note concludes that a court could approve a request for the "Ashley Treatment" in appropriate and limited cases where the parents have presented clear and convincing evidence before a court that the benefits that the "Ashley Treatment" would provide to the child and her family outweigh the risks associated with the procedure. This Note argues that those benefits may include extrinsic considerations, but courts should remain cautious when considering such evidence and be sure that the evidence as a whole supports their conclusions.     

Metastatic cancer of the urinary bladder: can it be a nonnatural death?

Deaths from metastatic carcinoma are almost exclusively viewed as wholly natural deaths. However, if it can be shown that a cancer has arisen as a result of a prior traumatic injury and the body's healing response to the injury, or treatment thereof, then in select cases, the manner of death shall reflect that of the precipitating injury. This case report is that of a woman who was rendered quadriplegic from spinal cord injury sustained in a motor vehicle crash when she was 22 years old. She died at the age of 49 years from widely metastatic squamous cell carcinoma of the urinary bladder. Her bladder cancer most likely arose from decades-long chronic irritation of the bladder epithelium by physical contact with an indwelling Foley catheter and urinary infections. Over the years, the chronic bladder irritation likely precipitated metaplastic, dysplastic, and finally neoplastic changes of the bladder epithelium, providing a link between her spinal cord injury, the indwelling Foley catheter, and her bladder cancer, engendering an accidental manner of death. The manner of death reflected the circumstances of her injury that predisposed her to the cancer that eventually caused her death.     

Therapeutic misadventure. An 11-year study from a metropolitan coroner's office

"Therapeutic misadventure" and its alternative forms is a controversial, though necessary, manner of ruling deaths that result from unexpected complications of medical procedures. Such cases must be brought to the attention of the medical-legal office so that they are thoroughly investigated and documented, and so that appropriate and consistent rulings are made. While it is not generally agreed that a ruling of therapeutic misadventure implies medical negligence, a number of such cases do become the bases for litigation. During an 11-year period in a metropolitan coroner's office that examines about 2,000 cases yearly, 44 cases were ruled therapeutic misadventure, an incidence of 0.46%. A recent increase in such cases is probably the result of improved case finding and investigation. The largest category was that of surgical complications, followed, in order, by complications of anesthesia and of therapeutic and diagnostic procedures, and by drug reaction. No case occurred in ambulatory surgery. There apparently has been a low incidence of attendant lawsuits. The study of cases of therapeutic misadventure is potentially of great value in identifying outcomes and trends, and for the prevention of such cases in the future.     

“公司人格否认”辨

通常所谓公司人格否认,不仅称谓上辞不达意,且在逻辑上含混了公司人格与股东有限责任两个概念。对其予以解构、整合：划分为公司人格否认、公司人格“个案”否认和股东有限责任的个案否认三个层次,将其归属于相应的法律范畴,分别设定条款并安置于恰当位置,从而既使概念清晰准确,又可节约制度移植和立法成本,而且利于贯彻执行。     

Fatal pyomyositis: a report of 8 autopsy cases

Pyomyositis is an acute bacterial infection manifesting as pyemic abscess formation in the skeletal muscles. We examined 8 autopsy cases (seven males, one female; age range 21-75 years) of fatal nontropical pyomyositis to better describe individual case characteristics and pathologic features of this rare disease. The pathogen most frequently involved was Staphylococcus aureus. In most cases, there were several abscesses and multiple sites involved. The trunk, shoulder girdle, and thigh muscles were most frequently affected and involvement of multiple sites was a common finding. In 6 cases, a recent trauma had occurred to the anatomic location where the pyemic abscesses were found. Three deceased were known as intravenous drug abusers. Except for the presence of pyomyositis, liver diseases such as cirrhosis in 3 cases, and a fatty liver in 2 cases were the most frequent autopsy findings. Death was due to sepsis in all cases. Because pyomyositis may develop in association with intravenous catheterization in the clinical setting, the question whether pyomyositis was caused by an infected or improperly placed indwelling intravenous catheter may be of forensic importance in the light of alleged medical malpractice. According to our observations, severe underlying illnesses seem not always necessary for fatal outcome of pyomyositis. Because a detailed dissection of superficial as well as deep skeletal muscles during autopsy is a prerequisite for the diagnosis, the disease may be overlooked when this essential step is not performed.     

Regulation Crisis: Evaluating the Potential Legitimizing Effects of "Corporate Manslaughter" Cases

This article identifies a new direction for discussion of the proposed "corporate manslaughter" offense. Considering work-related fatality cases with reference to the concept of legitimacy allows us to obtain a fuller understanding of their importance and the potential benefits associated with reform of the law. Work-related fatality cases have inherent power as "signal offenses." A failure to resolve these cases in a manner that satisfies the interests of the "publics" that the Health and Safety Executive (HSE) faces, may lead to a crisis of legitimacy for the agency. Reforming the law so as to facilitate such a response may offer important legitimatory benefits to regulators.     

Conceiling the cadaver in masonry and cement

Encasing with concrete and/or bricks are relatively rare forms of hiding or disposing of a body; criminologically, cases of this kind are often treated as "matters involving a missing person" at first. The article describes the circumstances and findings of 2 cases in which bodies were encased with concrete. Under the aspects of reconstruction it is of importance that bodies may be preserved quite well in concrete, which allows not only identification of the victim but also determination of the cause of death even after a prolonged post-mortem interval, the more so as occasionally tools used for committing the offense are also encased together with the body.     

The Shadows of the Law: Contemporary Approaches to Regulation and the Problem of Regulatory Conflict

Regulatory analyses often assume that compliance is desirable, with literature focusing on strategies to encourage "excellence" in adherence to regulatory goals. Yet, it is not unusual for disparate regulatory goals to exist that are based on competing values of what constitutes the "good society." It is this conflict that forms the substance of this paper. In cases of competing regulatory goals, techniques that encourage exemplary compliance in one area can create incentives to breach regulatory provisions of a competing regime. In such cases, generic regulatory techniques are unable to provide a useful means for resolving regulatory conflict but do allow a political delegation of conflict resolution to the "scientific" strategies of the regulator. In turn, the regulator places responsibility on companies for resolving competing regulatory demands. Successive delegation leads to juridification as well as regulators vying to retain primacy for their regime. This problem is examined through analysis of responsibilities for subcontractor safety under Australian health and safety law and sections of the Australian Trade Practices Act 1974 aimed at protecting competition.     

Unusual characteristic patterns of postmortem injuries

Animal scavenging is one of the most significant causes of postmortem injuries. A large variety of scavenging animals have been reported on in previous papers. Although postmortem injuries attributable to birds are well known in the case of "aerial burial," the custom in Tibet, few cases of bird scavenging have been reported. In the two cases discussed herein, postmortem injuries were attributed to crows. Both cases, shared characteristic patterns of postmortem injuries, and in both cases death was attributed to fire. Although massive tissue loss by the crow scavenging made it difficult to determine the cause of the death and rendered personal identification difficult, 1 mL of blood drawn from the intracranial cavity and DNA analysis enabled this information to be determined, albeit with some difficulty.     

A statistical analysis of successional patterns in carrion-arthropod assemblages: implications for forensic entomology and determination of the postmortem interval.

A set of statistical protocols is proposed for analyzing carrion-arthropod succession in forensic entomology investigations. A total of 23 carrion-arthropod data sets from temperate, tropical, desert, and coastal environments were assembled in a standard format and analyzed using randomization tests and methods derived from quantitative community ecology. The data were analyzed in three ways. First, patterns of arthropod visitation on nonhuman carcasses were analyzed in each of the 23 cases. Analysis revealed two groups of taxa: those that persist on the carcass over a single time interval (= nonreoccurring taxa, 80% of the taxa) and those that appear, leave, and reappear over time on the carcass (= reoccurring taxa, 20%). Reoccurring taxa, which can confound estimation of the postmortem interval (PMI), were found in 6 classes, 12 orders, and 29 taxonomic families of arthropods, including some forensically important taxa (for example, calliphorids, sarcophagids, histerids). The recognition that reoccurring taxa exist and that they are found in forensically important groups is an early step toward factoring in their potential importance in future entomological investigations. Second, temporal changes in the taxonomic composition of the carrion-arthropod community were studied by quantifying the degree of taxonomic similarity between pairwise combinations of time-specific samples of the succession. In 13 of the 18 illustrated cases, the midsuccessional samples, owing to their higher species richness, were taxonomically more similar to all other pairwise samples, on the average, than early and late successional samples which were poorer in species. Variability in taxonomic composition is the norm for most periods of the succession; however, in 17 of the 23 cases, some successional periods (particularly endpoint samples) revealed no changes in arthropod species composition (= matching sample-pairs). When applied to medicolegal cases, it is suggested that data sets with large fractions of matching sample-pairs should produce wider-ranging PMI estimates, on the average, than data sets with smaller fractions of matching sample-pairs. Third, Monte Carlo simulation was applied to each of the 23 assemblages to test specific hypotheses about community-wide patterns of arthropod visitation times on nonhuman carcasses. Simulation results revealed that arthropod residence times in the majority of cases (13 or 56%) followed a "clumped" succession model, whereas, the remaining 10 cases (44%) showed a more "uniform" spacing pattern of residence times on carcasses. Comparison of species accumulation curves for observed and simulated data further revealed that among the 13 "clumped" cases, most (9 or 69%) followed a "clumped, early" model (rather than "clumped, midterm" or "clumped, late" models).(ABSTRACT TRUNCATED AT 400 WORDS)