Retropharyngeal Hematoma Secondary to Cervical Spine Surgery: Report of One Fatal Case

A 53‐year‐old woman suffering from radicular pain due to cervical herniation underwent a spinal surgery consisting of anterior cervical discectomy and fusion with an implantable titanium cage. Five hours after the procedure, the patient developed cervical swelling and dyspnea. An emergency surgery permitted evacuation of a deep cervical hematoma and intubation of the patient, who died some minutes later. The family of the deceased lodged a complaint with the public prosecutor because of unclear circumstances of death. After analysis of the medical records by two forensic pathologists, a medicolegal autopsy was ordered. Massive retropharyngeal and mediastinal hematomas were diagnosed. Pathological study confirmed acute cervical hemorrhage, but failed to detect the source of bleeding. The forensic pathologists concluded that death was due to mechanical asphyxia secondary to pharyngeal compression by the cervical hematoma. To the best of our knowledge, death secondary to retropharyngeal hematoma in this neurosurgical context is rarely encountered.     

A case of fatal overdose involving both hydromorphone and kratom

Kratom is a plant originating in Southeast Asia that has been used for its dose-dependent stimulant and opioid effects. The main active compound in kratom is mitragynine, an alkaloid with affinity for the mu-opioid receptor. Toxicity and fatalities related to kratom use have increased substantially in recent years. In this case report, we describe a 44-year-old man who was found deceased in bed. The only significant finding at autopsy was abdominal distension with >4 L of ascites. Toxicology testing was performed on femoral blood which showed 79 ng/mL of hydromorphone, 560 ng/mL of mitragynine, and 240 ng/mL of olanzapine. In addition, creatinine and urea in vitreous humor were significantly elevated, consistent with renal impairment. Death was attributed to hydromorphone toxicity with mitragynine being a contributing factor.     

Phenibut screening and quantification with liquid chromatography–tandem mass spectrometry and its application to driving cases

An analytical strategy for identification by an LC–MS/MS multitarget screening method and a suitable LC–MS/MS based quantification were developed for the psychotropic drug phenibut. The samples analyzed were collected during traffic control and were associated with driving under the influence of drugs. A positive sample for phenibut was identified in a single case of driving under the influence. The quantification revealed a drug concentration of 1.9 μg/mL. An interaction with blood alcohol (BAC = 0.10%) was discussed as the explanation of the way of driving and deficit manifestations observed (swaying, nystagmus, quivering of the eyelid, and reddened eyes). According to the available information, the quantified phenibut concentration could be explained by an intake of four tablets (self-reported) during the day containing 250 mg of the drug. Chromatography was performed with a Luna 5 μm C18 (2) 100 A, 150 mm × 2 mm analytical column, and a buffer system consisted of 10 mM ammonium acetate and 0.1% acetic acid (v/v) included in mobile phases marked as A (H₂O/methanol = 95/5, v/v) and B (H₂O/methanol = 3/97, v/v). An effective limit of detection (LOD = 0.002 μg/mL) could be achieved for the multitarget screening method. The quantification of phenibut was performed on a second LC–MS/MS system with LOD/LOQ values of 0.22/0.40 μg/mL. Since phenibut quantification data are rare, the presented information can be used with caution for evaluation of positive cases in the future.     

Fat embolism syndrome associated with atraumatic compartment syndrome of the bilateral upper extremities: An unreported etiology

Fat embolism syndrome (FES) is a potentially life-threatening condition that develops when fat embolism leads to clinical symptoms and multisystem dysfunction. The classic triad of respiratory distress, neurologic symptoms, and petechial rash are non-specific, and the lack of specific laboratory tests makes the diagnosis of FES difficult. Although FES is most common after long bone fractures, multiple conditions some of which are atraumatic have been associated with the development of FES. We report a case of FES that occurred in the setting of a non-traumatic compartment syndrome of the upper extremities. The pathologic and clinical findings, pathophysiology, diagnostic challenges, and pathologic methods to properly diagnose FES are discussed with a review of the relevant literature. This case highlights the importance of the autopsy in making a diagnosis of FES in cases where death could otherwise be incorrectly attributed to multi-organ system failure, shock, or sepsis.     

ALTERNATIVE ARRANGEMENTS FOR COST EFFECTIVE POLLUTION ABATEMENT: THE NEED FOR IMPLEMENTATION ANALYSIS

After examining policies and proposals designed to achieve cost-effective pollution abatement, the authors argue that design of economically elegant solutions to pollution control problems needs implementation analysis if the policies are to be successfully carried out. They review some institutional obstacles to implementation and conclude that these impediments should not prevent adoption.     

Swiss taxation of trusts currently and in the future

At the International Trust & Tax Planning Summit Conference,held from 30 October to 1 November 2006 in Coral Gables, Florida,Frédéric Vuilleumier considered the Swiss taxregime in a paper entitled ‘Inbound Guide: What ShouldYou Do When Assumptions Change?’ In this article, theSwiss direct tax system was discussed and the distinction madebetween federal and cantonal taxation, tax residence in Switzerlandand the question of jurisdiction under Swiss private internationallaw and the application of Swiss civil law where Swiss courtshave jurisdiction and the applicable law in matrimonial matters.The article is part of that paper and concentrates on the taxtreatment of trusts in Switzerland, the current position andthe impact of the draft circular to accommodate the then expectedaccession of Switzerland to the Hague Convention.     

Quantitative Differentiation of Bloodstain Patterns Resulting from Gunshot and Blunt Force Impacts

Bloodstain pattern analysis (BPA) provides significant evidentiary value in crime scene interpretation and reconstruction. In this work, we develop a quantitative methodology using digital image analysis techniques to differentiate impact bloodstain patterns. The bloodstain patterns were digitally imaged and analyzed using image analysis algorithms. Our analysis of 72 unique bloodstain patterns, comprising more than 490,000 individual droplet stains, indicates that the mean drop size in a gunshot spatter pattern is at most 30% smaller than the mean drop stain size in blunt instrument patterns. In contrast, we demonstrate that the spatial distribution of the droplet stains—their density as a function of position in the pattern—significantly differs between gunshot and blunt instrument patterns, with densities as much as 400% larger for gunshot impacts. Thus, quantitative metrics involving the spatial distribution of droplet stains within a bloodstain pattern can be useful for objective differentiation between blunt instrument and gunshot bloodstain patterns.     

Suicide by self-removal of a pacemaker

A 70-year-old man extracted his own pacemaker and subclavian port used for delivery of chemotherapy, both implanted 2 weeks earlier. The patient died of septicemia within 6 days. This fatal outcome illustrates the risks of complications associated with severe psychiatric disorders after implantation of prosthetic devices.