When is a peri-procedural death iatrogenic in nature?

In almost any instance of suspected iatrogenic fatality, the attending forensic pathologist faces the challenging and often daunting task in ascertaining the cause of death, determining if an iatrogenic injury had indeed occurred and if so, its contribution to the causation of death. The Forensic Medicine Division of the Health Sciences Authority in Singapore embarked on a 6 year study of such deaths to identify pertinent factors that may facilitate the assessment of iatrogenic injuries and their contribution to mortality. A total of 106 iatrogenic deaths, arising from 613 coroner’s peri-procedural autopsies conducted during the period of 2005–2010 were reviewed with particular reference to the following parameters: (1) clinico-pathological correlation; (2) the length of survival; (3) the number of interventional procedures. A comprehensive analysis of these cases indicated that they could be classified into the following 3 categories, in relation to the role of clinico-pathological correlation in the ascertainment of the causes of death: (A) advantageous but not essential; (B) essential; (C) critical. A large proportion of the cases (76.5%) were assigned categories B and C. Only the minority of cases (23.6%) were assigned category A. Also, as the number of days of survival between injury and death, and the number of interventional procedures after injury increases, the greater the need for detailed clinical documentation to ascertain the cause of death.     

When is a diagnosis of sclerosing adenosis acceptable at core biopsy?

PURPOSE: To determine concordance of imaging findings and diagnosis of sclerosing adenosis at histopathologic core biopsy and to establish the accuracy of core biopsy when cancer was coexistent. MATERIALS AND METHODS: From a database of 1,166 percutaneous biopsies in which sclerosing adenosis was reported, 88 (7.5%) lesions were identified, and imaging and histopathologic findings were reviewed for concordance. Sclerosing adenosis proved to be a minor component at core biopsy for 44 lesions, including one invasive ductal carcinoma, one ductal carcinoma in situ (DCIS), one focus of atypical ductal hyperplasia (ADH), and one atypical lobular hyperplasia. Sclerosing adenosis was a major (> or =50%) component for 44 lesions, including four malignancies, all DCIS manifested as clustered calcifications (pleomorphic [n = 2] or amorphous [n = 2]), and seven foci of ADH manifested as amorphous calcifications. In 30 patients with 33 lesions without atypia or malignancy, sclerosing adenosis was the major finding at core biopsy (21 lesions at 14-gauge core biopsy and 12 at 11-gauge vacuum-assisted biopsy); these patients formed the study population. Mammographic (33 lesions) and sonographic (18 lesions) features were recorded. Twenty-seven lesions had at least 20-month follow-up (n = 25) or excision (n = 2). RESULTS: One spiculated mass was considered discordant and was excised, showing a prospectively unrecognized radial sclerosing lesion with several 2-5-mm foci of invasive tubular and lobular carcinoma. Seventeen (53%) of 32 lesions manifested as masses; 10 (59%) were circumscribed, five (29%) were indistinctly marginated (one with punctate calcifications), and two (12%) were partially circumscribed and partially obscured (one with amorphous calcifications). Fifteen (47%) lesions manifested as clustered calcifications; nine (60%) were amorphous and indistinct, four (27%) were pleomorphic, and two (13%) were punctate. Of 27 lesions with acceptable follow-up, 26 (96%) were believed to have been accurately sampled at core biopsy. Of six radial sclerosing lesions associated with the original 88 lesions, only three (50%) were prospectively recognized. CONCLUSION: Sclerosing adenosis is an acceptable result at core biopsy of circumscribed masses and nonpalpable indistinctly marginated masses and for clustered amorphous, pleomorphic, and punctate calcifications. Recognition and reporting of coexistent radial sclerosing lesions is encouraged and may prompt excision. Malignancy can be seen with sclerosing adenosis; core biopsy was accurate in six (86%) of seven coexistent malignancies in this series.     

EIB or not EIB? That is the question

This editorial comments on the paper of Pedersen et al. focusing, in particular, on the criteria set by the IOC-MC for documenting exercise-induced asthma and exercise-induced bronchoconstriction (and therefore permitting the use of beta-2 adrenergic drugs) in athletes participating in the Beijing Olympic Games.     

When is air medical service faster than ground transportation?

The purpose of this study was to mathematically define a distance or travel-time interval in which air medical evacuation would benefit the patient more than ground transport. The authors derived mathematical formulas from known variables (ground travel, extrication and rendezvous times) and fixed averages (on-scene time, lift-off time, and speeds) and used those formulas to test actual flights for appropriateness. The formulas were: [formula: see text] where Y = ground travel time; R = rendezvous time; Z = extrication time; D = distance to scene (km); and X = air travel time. The formulas provide a guide to prospectively determine the legitimacy of air medical transport. They can also be used retrospectively as a guide for quality assurance purposes. During this study of 123 consecutive scene flights, helicopter benefitted all the entrapped patients but only one-third of non-entrapped patients. Of 44 flights from areas with known ground times, helicopter transport benefitted 14 of 16 entrapped, five of 16 non-entrapped, but only three of 17 rendezvous.     

When DNA profiling is not enough? A case of same-sex siblings identification by odontological assessment after gas explosion-related building collapse

We aimed to show the usefulness of odontological assessment in forensic investigation. Charred remains of two female siblings were found in a collapsed building after a gas explosion. Due to thermal damage of the bodies, the facial characteristics, fingerprints, height and weight could not be used to distinguish between siblings. Since the victims, 4 and 10-year-old, died simultaneously and all personal belongings were lost, DNA profiling performed with their parents only confirmed the relationship. As dental charts of siblings were not found, we could not easily discriminate which remains would be of the elder and which of the younger sister. The odontological examination enabled us to discriminate between the siblings based on differences in deciduous and permanent dentition. We conclude that although DNA profiling is becoming a standard method of personal identification in some cases it should be supported by additional methods to deliver comprehensive forensic reports.