Attitudes of UK pathologists and judicial officers towards medicolegal view and grant examinations: a cross-sectional mixed-methods study.

AIMS: Despite the 1988 'Dundee Initiative', which maximised the use of view and grant examinations to reduce the invasive forensic autopsy rate in Tayside, the view and grant itself remains controversial. This is the first study to measure attitudes towards view and grants, applying the Theory of Planned Behaviour to investigate what attitudes are held, the reasons behind them and their association with deciding the scope of postmortem examinations. METHODS: A mixed-methods cross-sectional study examined 62 UK pathologists, coroners and procurators fiscal using an online questionnaire. Participants were asked their demographics and attitudes towards view and grants before allocating five fictitious reportable deaths to either view and grant or invasive forensic autopsy (both in ideal and real world conditions), explaining their decisions using free-text. RESULTS: Participants held both positive and negative attitudes towards view and grants, and most were relatively strong and ambivalent. Attitudes predicted respondents' decisions to favour view and grant or invasive forensic autopsy in all ideal world scenarios, but no real world scenarios. There were significant differences in attitudes and decisions when comparing pathologists and judicial officers, and respondents working in Coroner and Fiscal systems. Thematic analysis was conducted on free-text responses. CONCLUSIONS: Discrepancies between attitudes, and ideal and real world choices suggest that what respondents wanted to do did not necessarily translate to what they would actually do in the scenarios tested. Applying concepts of attitudes, norms and perceived control can help to understand decision-making by death investigators, and why some jurisdictions favour more invasive procedures.

Better clinical and post mortem photography: A crash course in ten technical tips.

For forensic clinicians and pathologists, photography of bodily regions, injuries and skin lesions present a number of technical challenges including proper framing, avoidance of distortion, choice of background and inclusion of a properly orientated scale. Photography of internal organs at autopsy presents further difficulties with regard to correct exposure, light reflections and limited depth of field. Situations commonly arise in clinical forensic and autopsy practice which require photographic documentation but which may not warrant calling upon the clinical photographer or police Scenes of Crime Officer. This article provides a brief explanation of various technical considerations which will allow forensic practitioners and technicians to take their own high quality external and internal photographs. Technical aspects discussed include aperture, shutter speed, ISO, depth of field, camera shake, and use of flash, scales, focal planes and backgrounds. The possible pitfalls encountered in several common photographic situations are illustrated and discussed, together with suggested workarounds and camera settings. Whilst the photographic examples presented here mostly relate to autopsy practice, the general principles and technical discussion also apply to wider clinical forensic photography practice.

The role of depression in unnatural death: A case-based retrospective study.

BACKGROUND: Depression affects the life of millions around the globe and perhaps also the manner of death. This study examined the role of depression in specific causes of unnatural death and whether alcohol and substance use affect this relationship, in one locality in Scotland. METHODS: The research used a retrospective case-based study approach to analyse 168 cases, quantifying data reported in mortuary files to allow for quantitative statistical analysis of associations and differences amongst the variables. RESULTS: A diagnosis of depression was associated with a higher likelihood of unnatural death due to suicide, drugs or homicide. A diagnosis of substance abuse was associated with a diagnosis of depression and with an increased likelihood of death due to suicide or drugs. A diagnosis of alcohol abuse was associated with a reduced likelihood of a diagnosis of depression but was associated with an increased likelihood of suicide. LIMITATIONS: This study relied on a small sample from one locality in Scotland which limited the ability to generalise the results and the retrospective case-based design also limited the potential for checking data accuracy or to consider temporal relationships, which limited the ability to interpret causality. CONCLUSIONS: This study found that there was a relationship between depression and unnatural death, which was mediated by alcohol and substance use. The importance of this study lies within the recognition of these relationships which identified the complexities of these relationships but suggested that some unnatural deaths within this population could be prevented.

Portal hypertension: Imaging of portosystemic collateral pathways and associated image-guided therapy.

Portal hypertension is a common clinical syndrome, defined by a pathologic increase in the portal venous pressure. Increased resistance to portal blood flow, the primary factor in the pathophysiology of portal hypertension, is in part due to morphological changes occurring in chronic liver diseases. This results in rerouting of blood flow away from the liver through collateral pathways to low-pressure systemic veins. Through a variety of computed tomographic, sonographic, magnetic resonance imaging and angiographic examples, this article discusses the appearances and prevalence of both common and less common portosystemic collateral channels in the thorax and abdomen. A brief overview of established interventional radiologic techniques for treatment of portal hypertension will also be provided. Awareness of the various imaging manifestations of portal hypertension can be helpful for assessing overall prognosis and planning proper management.

Intra-individual and inter-individual variation in breath alcohol pharmacokinetics: Variation over three visits.

Eleven male and 7 female student subjects underwent serial Breath Alcohol Concentration (BrAC) measurements after being given alcohol as 13% white wine (5.7 ml/kg for males and 4.7 ml/kg for females) in a fasting state on three separate occasions. BrAC versus time curves were constructed for each subject and the values of peak BrAC (Cmax), theoretical BrAC extrapolated at zero time (Co), time taken to reach peak (Tmax) and rate of elimination (ß) from breath were recorded directly from the curves. Average Intra-individual variation for each individual between the 3 visits (for males and females, respectively) was 5.6% and 8% for Co, 12% and 13% for Cmax, 42% and 37% for Tmax and 11% and 13% for ß. Inter-individual variation (for males and females) was 7.5% and 13% for Co, 16% and 15% for Cmax, 43% and 46% for Tmax and 21% and 15% for ß. Average elimination rates in males (5.3 µg/100 ml breath/h, range 4-7.7) and females (5.6 µg/100 ml breath/h, range 4-7) were not significantly different. Widmark factors calculated by various established mathematical methods were 0.71-0.81 in males and 0.59-0.68 in females, higher than the originally quoted mean experimental levels.

Intraprostatic hematoma with active bleeding post-prostate biopsy.

To the best of our knowledge, we report the first known case of a large intraprostatic hematoma with active bleeding following transrectal ultrasound-guided prostate biopsy.

Intra-individual and inter-individual variation in breath alcohol pharmacokinetics: the effect of short-term variation.

Ten male and 8 female students underwent serial breath alcohol concentration (BrAC) measurements on a CAMIC Datamaster on two consecutive occasions, early evening and again the following morning. Subjects were fasted for 6 h before receiving alcohol as white wine (12.5% by volume) at doses of 38-45 g for males and 26-37 g for females, consumed over 10 min. Specific individual doses were calculated individually from height and weight (according to the Forrest Method) to give target C0 breath alcohol concentrations of 35 µg/100 ml breath in males and 31 µg/100 ml breath in females. BrAC versus time curves were constructed for each subject and the values of peak BrAC (Cmax), BrAC extrapolated at zero time (C0), time taken to reach peak (Tmax) and rate of elimination (ß) were recorded directly from the curves. Values of C0 taken from the BrAC-time curves varied widely, from 21 to 47 µg/100 ml on visit 1 and from 22 to 45 µg/100 ml on visit 2. Widmark Factors calculated from these C0 values averaged 0.74 (range, 0.59-1.06) in males and 0.73 (range, 0.58-1.05) in females. Elimination rate was higher in the morning than evening in both males (7.4 versus 5.7 µg/100 ml/h) and females (6.9 versus 5.8 µg/100 ml/h). Elimination rates in males and females were not significantly different. Total body water, measured by electronic scales, averaged 58.7% (range, 56.6-63%) in males and 48.3% (range, 40.9-57.6%) in females. Widmark Factors calculated by various established mathematical methods were 0.73-0.77 in males and 0.61-0.64 in females.

The evolution of a purpose designed hybrid trauma operating room from the trauma service perspective: the RAPTOR (Resuscitation with Angiography Percutaneous Treatments and Operative Resuscitations).

Traumatic injury is the leading cause of potentially preventable lost years of life in the Western world and exsanguination is the most potentially preventable cause of post-traumatic death. With mature trauma systems and experienced trauma centres, extra-abdominal sites, such as the pelvis, constitute the most frequent anatomic site of exsanguination. Haemorrhage control for such bleeding often requires surgical adjuncts most notably interventional radiology (IR). With the usual paradigm of surgery conducted within an operating room and IR procedures within distant angiography suites, responsible clinicians are faced with making difficult decisions regarding where to transport the most physiologically unstable patients for haemorrhage control. If such a critical patient is transported to the wrong suite, they may die unnecessarily despite having potentially salvageable injuries. Thus, it seems only logical that the resuscitative operating room of the future would have IR capabilities making it the obvious geographic destination for critically unstable patients, especially those who are exsanguinating. Our trauma programme recently had the opportunity to conceive, design, build, and operationalise a purpose-designed hybrid trauma operating room, designated as the resuscitation with angiographic percutaneous techniques and operative resuscitation (RAPTOR) suite, which we believe to be the first such resource designed primarily to serve the exsanguinating trauma patient. The project was initiated after consultations between the trauma programme and private philanthropists regarding the greatest potential impacts on regional trauma care. The initial capital construction costs were thus privately generated but coincided with a new hospital wing construction allowing the RAPTOR to be purpose-designed for the exsanguinating patient. Many trauma programmes around the world are now starting to navigate the complex process of building new facilities, or else retrofitting existing ones, to address the need for single-site flexible haemorrhage control. This manuscript therefore describes the many considerations in the design and refinement of the physical build, equipment selection, human factors evaluation of new combined treatment paradigms, and the final introduction of a RAPTOR protocol in order that others may learn from our initial efforts.

Cyclophosphamide creates a receptive microenvironment for prostate cancer skeletal metastasis.

A number of cancers predominantly metastasize to bone, due to its complex microenvironment and multiple types of constitutive cells. Prostate cancer especially has been shown to localize preferentially to bones with higher marrow cellularity. Using an experimental prostate cancer metastasis model, we investigated the effects of cyclophosphamide, a bone marrow-suppressive chemotherapeutic drug, on the development and growth of metastatic tumors in bone. Priming the murine host with cyclophosphamide before intracardiac tumor cell inoculation was found to significantly promote tumor localization and subsequent growth in bone. Shortly after cyclophosphamide treatment, there was an abrupt expansion of myeloid lineage cells in the bone marrow and the peripheral blood, associated with increases in cytokines with myelogenic potential such as C-C chemokine ligand (CCL)2, interleukin (IL)-6, and VEGF-A. More importantly, neutralizing host-derived murine CCL2, but not IL-6, in the premetastatic murine host significantly reduced the prometastatic effects of cyclophosphamide. Together, our findings suggest that bone marrow perturbation by cytotoxic chemotherapy can contribute to bone metastasis via a transient increase in bone marrow myeloid cells and myelogenic cytokines. These changes can be reversed by inhibition of CCL2.

Intra-individual and inter-individual variation in breath alcohol pharmacokinetics: The effect of food on absorption.

Eight male and 8 female subjects underwent serial breath alcohol concentration (BrAC) measurements in the fasting state, following a snack of crisps and following a light meal. BrAC versus time curves were constructed for each subject and the values of peak BrAC (C(max)), theoretical (extrapolated) BrAC at zero time (C(0)), time taken to reach peak (T(max)) and rate of elimination (ß) were recorded directly from the curves. In all subjects values of C(0) extrapolated from the post-meal BrAC-time curves were significantly lower than in the fasting and snack fed states. Since Widmark factor (W.F.) is inversely proportional to C(0), values of WF calculated from extrapolated C(0) after a meal were spuriously high. WF obtained from the fasting BrAC-time curves were usually only slightly higher than those calculated by the Forrest mathematical method. C(max) was highest in fasting subjects (mean 30.5, range 22.5-42µg/100ml) and lowest after a meal (mean 21.4, range 13.5-32µg/100ml). T(max) was shortest after a meal and also remarkably consistent (mean 22, range 17-50min). 'Overshoot' was seen in most fasting subjects within about 40min of consuming alcohol. Elimination of alcohol from breath was slightly lower after a meal (mean 5.4, range 3.9-8.5µg/100ml/h) than after either fasting (mean 6, range 4.7-7.3µg/100ml/h) or a snack (mean 6, range 4.4-8.8µg/100ml/h). The availability of alcohol for absorption (as a percentage of the predicted value) was almost complete after fasting or a snack but after a meal was reduced to only 66% in females and 71% in males. The practical significance of this much reduced peak BrAC after food occurs in relation to forward or back calculations and cases involving post-accident drinking ("the hip flask" defence) as ingestion of a meal before or with alcohol is a common social situation which may complicate BAC estimation in some medico-legal cases.

Novel image-guided management of a uterine arteriovenous malformation.

The investigators present a novel image-guided embolization, not previously described, of a uterine arteriovenous malformation (AVM) resistant to endovascular management. The uterus was exposed surgically, and Histoacryl (Braun, Fulda, Germany) was injected directly into the nidus using ultrasound guidance and fluoroscopy. The patient had a successful full-term pregnancy after this procedure. This technique may be a useful alternative management strategy in patients with uterine AVM who fail traditional endovascular embolization and who still desire fertility.

Identification of a mechanical rheostat in the hydrophobic core of protein L.

The ability of proteins and their complexes to withstand or respond to mechanical stimuli is vital for cells to maintain their structural organisation, to relay external signals and to facilitate unfolding and remodelling. Force spectroscopy using the atomic force microscope allows the behaviour of single protein molecules under an applied extension to be investigated and their mechanical strength to be quantified. protein L, a simple model protein, displays moderate mechanical strength and is thought to unfold by the shearing of two mechanical sub-domains. Here, we investigate the importance of side-chain packing for the mechanical strength of protein L by measuring the mechanical strength of a series of protein L variants containing single conservative hydrophobic volume deletion mutants. Of the five thermodynamically destabilized variants characterised, only one residue (I60 V) close to the interface between two mechanical sub-domains was found to differ in mechanical properties to wild type (Delta F(I60 V-WT)=-36 pN at 447 nm s(-1), Delta x(uI60V-WT)=0.2 nm). Phi-value analysis of the unfolding data revealed a highly native transition state. To test whether the number of hydrophobic contacts across the mechanical interface does affect the mechanical strength of protein L, we measured the mechanical properties of two further variants. protein L L10F, which increases core packing but does not enhance interfacial contacts, increased mechanical strength by 13+/-11 pN at 447 nm s(-1). By contrast, protein L I60F, which increases both core and cross-interface contacts, increased mechanical strength by 72+/-13 pN at 447 nm s(-1). These data suggest a method by which nature can evolve a varied mechanical response from a limited number of topologies and demonstrate a generic but facile method by which the mechanical strength of proteins can be rationally modified.

Population-based review of the outcomes following hepatic resection in a Canadian health region.

BACKGROUND: Higher hospital and surgeon volumes have been associated with improved outcomes following hepatic resection; however, there appear to be additional factors that also play a role. The objective of our study was to examine the outcomes following hepatic resection over the past 13 years in a large urban Canadian health region. METHODS: We used administrative procedure codes to identify all patients from 1991/92 to 2003/04 who underwent a hepatic resection in the Calgary health region, which has a referral base of about 1.5 million people. The primary outcome was operative mortality, defined as death before discharge. RESULTS: There were 424 hepatic resections performed in the stated time period. Annual volume was stable until 2000, when it increased substantially. This corresponded to the formation of a multidisciplinary group that provided care to these patients. There were 25 deaths over the study period for a mean mortality of 5.9%. The mean length of stay in hospital was 14.6 (median 10) days. Over time, however, mortality steadily decreased. This corresponded to a concomitant increase in the volume of hepatic resections performed. CONCLUSION: Over the past 13 years, the number of hepatic resections performed has increased; there has been a corresponding improvement in mortality rates. The improved rates are likely the result of multiple factors.