Fatal cerebral air embolism post esophageal endoscopy with dilatation: A case report.

This is a case of a patient who underwent an esophageal dilatation for benign esophageal strictures. As a consequence of the procedure, she developed an esophageal rupture and multiple cerebral and cerebellar air emboli resulting in infarction. The patient died after being placed on comfort care measures. The postmortem examination revealed focal breach of the esophageal mucosa but no sites of cardiac or vascular shunting that could account for the transit of air from the esophagus to the central nervous system. The phenomenon of vascular air entry as a consequence of upper gastrointestinal endoscopic intervention is an uncommon but very serious complication of balloon dilatation therapy. Instances of progression to intracranial arterial gas embolism are even less common, but are well described in a small number of case reports. We present a fatal case of central nervous system air embolism post-balloon dilatation therapy with associated antemortem imaging, autopsy, and microscopic images followed by a discussion of potential mechanisms of entry of air into the brain.

Shotgun slug wads as a marker of range of fire: A case report and novel firearm testing data.

Assessment of wound characteristics and the identification of various constituents of firearm discharge at autopsy play a key role in the determination of range of fire. In relation to wounds caused by shotguns, identification of the wad within the wound track, or of injury caused by the wad, is typically thought to suggest a fairly close range of fire. We present a case of a fatality due to a shotgun slug wound where the presence of the wad within the decedent's body was proposed by defense at criminal trial to favor accidental close range discharge during a struggle for the weapon-as opposed to the prosecution's contention of intentional firing of the weapon from a greater range and through an intermediate target. We undertook test firing of a shotgun of similar design to that which was fired during the interaction (a 12-gauge pump-action shotgun) using shotshells consistent with the slug that was recovered from the body (Winchester Super X brand), which demonstrated that the non-attached fiber wad present in this shotshell design can accompany the slug over distances of at least up to 22 feet (6.7 m) and even after transit through intermediate targets such as a vehicle headrest. These novel data provide assistance with estimation of range of fire in instances of injuries caused by shotgun slugs.

Hidden IgG4-Related Coronary Disease.

OBJECTIVES: We present a full autopsy with a focused radiology and pathologic review of the coronary arteries. We hope that the results described in this article will help create better diagnostic measures and prevent future coronary artery vasculitis misdiagnosis. METHODS: A full autopsy was performed on the body of Dr Myung Choong Yoon, with full consent from the family, within the department of pathology and laboratory medicine at Vancouver General Hospital. Tissue samples from the heart, brain, lungs, and spinal cord were submitted to specialist pathologists for histologic processing. RESULTS: Cardiac gated computed tomography coronary angiography suggested periarteritis. Coexistent calcified coronary atherosclerosis with linear calcifications was present along the luminal wall, along with coronary artery ectasia. Histologic assessment confirmed features of dense adventitial fibrosis around the coronary arteries, with an exuberant lymphoplasmacytic infiltrate and numerous plasma cells consistent with IgG4-related disease. The media of the coronary arteries was markedly attenuated or completely absent, which likely contributed to the coronary arterial ectasia noted microscopically. These findings confirmed IgG4-related coronary arteritis. CONCLUSIONS: Coronary periarteritis is an uncommon manifestation of IgG4-related disease established radiographically and later by autopsy.

Autopsy Education in Canadian Pathology Programs: A Survey of Canadian Trainees.

INTRODUCTION: This survey of Canadian pathology residents was designed to quantify the number of autopsies Canadian residents aim to complete during residency training, to better understand the perception of residents about access and quality of autopsy skills education. In addition, the interest of current pathology residents in autopsy and forensic pathology as a future career was also assessed. METHODS: A web-based survey was sent to all Canadian pathology residents. This survey consisted of 19 questions on institution, level of training, intention to complete the American Board of Pathology examination, number of autopsies completed, perception of quality/access to autopsy skills education, interest, and factors contributing to autopsy and forensic pathology. RESULTS: Eighty two (26%) of a possible 310 residents (12/47 general pathology, 70/263 anatomical pathology) across all Canadian institutions offering anatomical or general pathology programs (16/16 institutions) participated in the survey. Eighty-three percent of the respondents rated autopsy education as either very important or important. Fifty-five percent of the respondents intended to either challenge the American Board of Pathology examination or wanted the option to do so in the future, whereas only 47% of the participants agreed that all residents who wish to challenge the examination will easily be able to complete 50 autopsies during residency. Only 18% of the respondents were interested in performing autopsies as a major part of their career, and a combined 52% were only interested in performing autopsies to secure a desired position or felt that having to do autopsies would be a job deterrent. The quality of autopsy teaching received and the number of autopsies performed was identified as the most significant factors affecting interest in performing autopsies as part of a future career. A combined 68% of the respondents felt that the job market in forensic pathology in Canada was either good (better than most subspecialties) or very good (more jobs than graduating fellows). Seventy-one percent (12/17) of postgraduate year 5 respondents reported having completed 50 or more autopsies at the time of survey completion. Eleven percent of the respondents did not agree that all residents who document having completed an autopsy at their institution will have participated in all 8 essential autopsy tasks. Twenty four (29%) of the 82 respondents provided detailed narrative comments. DISCUSSION: Most Canadian pathology residents believe that autopsy education is an important component of residency training. Limited access to quality autopsy teaching seems to be an important factor in resident interest in forensic pathology as a future career, despite a perceived good job market in comparison with most other subspecialties.

The Association of Inflammatory Cytokines in the Pulmonary Pathophysiology of Respiratory Failure in Critically Ill Patients With Coronavirus Disease 2019.

OBJECTIVES: The majority of coronavirus disease 2019 mortality and morbidity is attributable to respiratory failure from severe acute respiratory syndrome coronavirus 2 infection. The pathogenesis underpinning coronavirus disease 2019-induced respiratory failure may be attributable to a dysregulated host immune response. Our objective was to investigate the pathophysiological relationship between proinflammatory cytokines and respiratory failure in severe coronavirus disease 2019. DESIGN: Multicenter prospective observational study. SETTING: ICU. PATIENTS: Critically ill patients with coronavirus disease 2019 and noncoronavirus disease 2019 critically ill patients with respiratory failure (ICU control group). INTERVENTIONS: Daily measurement of serum inflammatory cytokines. MEASUREMENTS AND MAIN RESULTS: Demographics, comorbidities, clinical, physiologic, and laboratory data were collected daily. Daily serum samples were drawn for measurements of interleukin-1ß, interleukin-6, interleukin-10, and tumor necrosis factor-α. Pulmonary outcomes were the ratio of Pao2/Fio2 and static lung compliance. Twenty-six patients with coronavirus disease 2019 and 22 ICU controls were enrolled. Of the patients with coronavirus disease 2019, 58% developed acute respiratory distress syndrome, 62% required mechanical ventilation, 12% underwent extracorporeal membrane oxygenation, and 23% died. A negative correlation between interleukin-6 and Pao2/Fio2 (rho, -0.531; p = 0.0052) and static lung compliance (rho, -0.579; p = 0.033) was found selectively in the coronavirus disease 2019 group. Diagnosis of acute respiratory distress syndrome was associated with significantly elevated serum interleukin-6 and interleukin-1ß on the day of diagnosis. CONCLUSIONS: The inverse relationship between serum interleukin-6 and Pao2/Fio2 and static lung compliance is specific to severe acute respiratory syndrome coronavirus 2 infection in critically ill patients with respiratory failure. Similar observations were not found with interleukin-ß or tumor necrosis factor-α.

Deaths Associated With Community Donation Bins: A Ten-Year Retrospective Review Describing Five Cases in British Columbia and Ontario.

INTRODUCTION: Community donation bins have become more common in the urban setting over the past several years. Many nonprofit organizations use these sturdy metal enclosures for unobserved collection of various donated items such as clothing, books, and household items. Although the donated items are often of low individual value, donation bins may become a target of individuals in low socioeconomic situations seeking desired items for personal use or resale, or for personal shelter within the bin. METHODS: To identify donation bin-associated deaths, we reviewed cases taken under the jurisdiction of the coroner for investigation in the provinces of British Columbia and Ontario, Canada, over the years 2009 to 2019. RESULTS: We present the circumstances and postmortem findings of five deaths that occurred in British Columbia and Ontario (Canada) between 2009 and 2019, wherein the decedents were each believed to have been reaching into donation bins and became caught within the door mechanism and died as a consequence of compression asphyxia involving the chest and/or neck. DISCUSSION: Donation bins have the potential for harm when individuals attempt to access the bin contents through the entry portal. We advocate for greater attention and changes in the placement location and/or design of these potentially dangerous devices.

Non-Traumatic Acute Subdural Hemorrhage Due To Cranial Venous Hypertension.

Acute subdural hemorrhage is typically associated with a history of head trauma, and as such it is a finding with significant potential medicolegal consequences. In this article, 37 adult and post-infantile pediatric sudden death autopsy cases with small volume ("thin film" or "smear") acute subdural hemorrhage are presented-in which there is either no further evidence of head trauma or only features of minor head injury. The possible underlying pathophysiological mechanisms are explored, and it is concluded that a common thread in many of these cases is likely to have been cranial venous hypertension at around the time of death. These findings may have implications in instances where small volume subdural hemorrhage is identified in the absence of other evidence of significant head injury.

Human papillomavirus and Epstein Barr virus in prostate cancer: Koilocytes indicate potential oncogenic influences of human papillomavirus in prostate cancer.

INTRODUCTION: The purpose of this study is to determine if high risk human papillomaviruses (HPV) and Epstein Barr virus (EBV) are both present in the same prostate cancer specimens. METHODS: We used a range of analytical techniques including in situ polymerase chain reaction (IS-PCR) and standard liquid PCR followed by sequencing of the product to seek to identify HPV and EBV in normal, benign, and malignant prostate tissues. RESULTS: Both HPV type 18 and EBV gene sequences were identified in a high and approximately equal proportion of normal, benign, and prostate cancer specimens. These sequences were located in the nuclei of prostate epithelial cells. HPV associated koilocytes were identified in 24% of prostate cancer specimens. CONCLUSIONS: The presence of both HPV and EBV gene sequences in most of the same normal, benign, and malignant prostate specimens is particularly noteworthy because of recent experimental evidence demonstrating that EBV and HPV can collaborate to increase proliferation of cultured cervical cells. Because the presence of EBV and HPV in normal, benign, and malignant prostate tissues appears to be ubiquitous, it is possible that they are harmless. On the other hand HPV type 18 in particular, has high oncogenic potential and may be associated with some prostate cancers. The identification of HPV associated koilocytes in prostate cancer specimens is an indication of HPV infection and potential oncogenic influences of human papillomavirus in prostate cancer.

Myocardial pathology in pulmonary thromboembolism.

OBJECTIVE: To assess the nature of necroinflammatory changes identified in postmortem histological sections of the right ventricular myocardium in cases of fatal pulmonary thromboembolism (PTE). DESIGN/SETTING: A retrospective study examining coronial autopsy cases (n = 28, age 58 ± 21 years, 9 men/19 women) of PTE in which isolated right ventricular myocardial pathology was encountered. Detailed immunohistological analysis was undertaken on sections of myocardium, and comparison was made to age- and sex-matched controls (n=28, age 57 ± 21 years, 9 men/19 women) without significant cardiorespiratory disease. RESULTS: The PTE was considered extensive in 86% of cases, and histological features of organisation were observed in 68%. PTE cases had similar body mass indices to controls (32 ± 2 kg/m(2) vs 28 ± 2 kg/m(2), p = 0.13) but greater heart weights (414 ± 17 g vs 358 ± 18 g, p = 0.02) and, where documented, thicker right ventricular walls (4.8 ± 0.3 mm (n = 18) vs 3.4 ± 0.2 mm (n = 15), p = 0.0008). The inflammatory infiltrate in PTE cases comprised predominantly macrophages and T cells, though neutrophilic inflammation was a frequent accompaniment. Myocyte necrosis was identified in association with the inflammatory foci in 64%. There was a 6.6-fold greater amount of diffuse macrophage recruitment within the right ventricle in cases of PTE compared to controls (p<0.0001), and there was a 6.1-fold increase in right ventricular fibrosis (p = 0.01). Right ventricular fatty replacement was similar between the two groups (p = 0.46). CONCLUSIONS: We conclude that PTE may result in right ventricular myocardial inflammation and necrosis, distinct from that seen in typical myocardial infarction due to atherosclerotic coronary artery disease, or myocarditis. This observation may be explained, in part, by local stretch and strain of the right ventricle due to increased afterload, possibly compounded by diminished diastolic blood flow to the right ventricular myocardium and the effects of global myocardial hypoxia.

High prevalence of prostatic neoplasia in Australian men.

AIMS: The purpose of this study was to document the extremely high level of prostatic neoplasia among Australian men. METHODS: The study was based on histological assessment of prostate tissue sampled from an unselected series of 133 cadavers referred for coronial autopsy at the Department of Forensic Medicine, Sydney South West Area Health Service, New South Wales. RESULTS: Evidence of neoplastic growth was identified in prostate tissue sampled from 30% of the 70 men aged 50 years and over, with invasive carcinoma present in 25.7% of subjects, and suspected prostatic intraepithelial neoplasia (PIN) in a further 4.3% of subjects. These findings were in marked contrast to the 63 subjects under 50 years of age. In this age group one subject had invasive prostate carcinoma, and one other had suspected PIN. CONCLUSIONS: The prevalence of invasive prostate carcinoma is extraordinarily high in this sample of Australian men. Among those subjects who were 50 years of age or over, more than one in four had apparently undiagnosed invasive cancer of the prostate gland.