The modern autopsy: what to do if infection is suspected.

Deaths due to infectious diseases are common worldwide. The autopsy, although less frequently performed than previously, is important to our understanding of disease pathogenesis. The autopsy also provides critical information regarding potential disease outbreaks. To optimize the benefits of an autopsy, the pathologist should approach the autopsy with a well-constructed differential diagnosis that provides the framework for appropriate selection of diagnostic specimens and tests. Standard microbiologic cultures, although necessary and important, are often insufficient and must be supplemented by newer molecular methodologies

Suicide Rates Among Active Duty Service Members Compared with Civilian Counterparts, 2005-2014.

The objective of this study was to compare military suicide rates with civilian suicide rates, adjusting for age and sex differences that exist between the two populations. The number of active component (AC) service members whose manner of death was certified as suicide was determined for specific age and sex groups for each year from 2005 to 2014. Indirect standardization was then used to determine the expected number of suicides for each age/sex group, based on the U.S. suicide rates for the corresponding age/sex groups obtained from the Centers for Disease Control and Prevention\u27s Web-based Injury Statistics Query and Reporting System. Although suicide rates among U.S. active duty Service Members were found to increase between 2005 and 2009, overall age- and sex-adjusted AC suicide rates were lower than or comparable to civilian rates every year of the study period. When suicide numbers were analyzed within specific age and sex categories, there was a significant association between higher suicide incidence and AC military status for 17-29-yr-old females in 2010, 2012, and 2014, and a significant association between lower suicide incidence and AC military status for 25-49 -yr-old males in some years

Needle thoracentesis decompression: observations from postmortem computed tomography and autopsy.

BACKGROUND: Needle thoracentesis decompression (NTD) is a recommended emergency treatment for tension pneumothorax. Current doctrine recognizes two suitable sites: the second intercostal space in the midclavicular line and the fourth or fifth intercostal space in the anterior axillary line. METHODS: A review was conducted of postmortem computed tomography and autopsy results in 16 cases where NTD was performed as an emergency procedure. RESULTS: In 16 cases with 23 attempted procedures, the outcome was confirmed in 17 attempts. In 7 placements, the catheter was in the pleural cavity; in 7 placements, the catheter never entered the pleural cavity; and in 3 placements, cavity penetration was verified at autopsy even though the catheter was no longer in the cavity. Success was noted in 6 of 13 anterior attempts and 4 of 4 lateral attempts, for an overall success rate of 59% (10 of 17). In the remaining 6 attempted procedures, a catheter was noted in the soft tissue on imaging; however, presence or absence of pleural cavity penetration was equivocal. All placements were attempted in the combat environment; no information is available about specifically where or by whom. CONCLUSION: NTD via a lateral approach was more successful than that via an anterior approach, although it was used in fewer cases. This supports the revision of the Tactical Combat Casualty Care Guidelines specifying the lateral approach as an alternative to an anterior approach

Placement of tibial intraosseous infusion devices.

Post-mortem preautopsy multidetector computed tomography was used to assess the placement of tibial intraosseous infusion needles in 52 cases of battlefield trauma deaths for which medical intervention included the use of the technique. In 58 (95%) of 61 needles, the tip was positioned in medullary bone. All 3 (5%) unsuccessful placements were in the left leg, and the needle was not directed perpendicular to the medial tibial cortex as recommended. Considering the nature of military trauma and the environmental conditions under which care is rendered, military medical personnel appear to be highly successful in the placement of tibial intraosseous infusion needles

Observational case series: an algorithm incorporating multidetector computed tomography in the medicolegal investigation of human remains after a natural disaster.

An algorithm incorporating multidetector computed tomography (MDCT), digital radiographs, and external examination was used to triage cases for noninvasive or complete autopsy after a natural disaster. The algorithm was applied to 27 individuals who died during or soon after the earthquake that struck the Republic of Haiti on January 12, 2010. Of the 27 cases reviewed, 7 (26%) required a complete autopsy to determine cause and manner of death. In the remaining 20 (74%), cause and manner of death were determined with a reasonable degree of medical certainty after review of circumstances, an external examination, and postmortem imaging by MDCT and digital radiography (noninvasive autopsy). MDCT was particularly useful in detecting skeletal fractures caused by blunt force injury which were not evident on digital radiographs. The algorithm incorporating postmortem MDCT can be useful in the triage of human remains for autopsy after a natural disaster

Necrotizing staphylococcal pneumonia in a neonate.

Hospitalized neonates are commonly colonized soon after birth with Staphylococcus aureus. The majority of neonates do not develop infectious sequelae; however, premature neonates appear to be more susceptible to serious infections, such as pneumonia. We report a case of an extremely low birth weight infant who developed necrotizing pneumonia due to methicillin-resistant Staphylococcal aureus (MRSA). The MRSA isolate from this neonate is identical to the strains that have been causing primarily community-associated skin and soft tissue infections. The severe course of this patient may be attributed to the presence of the Panton-Valentine leukocidin gene, a well-known virulence factor leading to soft tissue and pulmonary infections

Prominent Injury Types in Vehicle Underbody Blast.

BACKGROUND: To fully understand the injury mechanisms during an underbody blast (UBB) event with military vehicles and develop new testing standards specific to military vehicles, one must understand the injuries sustained by the occupants. METHODS: Injury data from Service Members (SM) involved in UBB theater events that occurred from 2010 to 2014 were analyzed. Analysis included the investigation of prominent skeletal and visceral torso injuries. Results were categorized by killed-in-action (n = 132 SM) and wounded-in-action (n = 1,887 SM). RESULTS: Over 90% (553/606 SM) of casualties in UBB events with Abbreviated Injury Scale (AIS) 2+ injury sustained at least one skeletal fracture, when excluding concussion. The most frequent skeletal injuries from UBB were foot fractures (13% of injuries) for wounded-in-action and tibia/fibula fractures (10% of injuries) for killed-in-action. Only 1% (11/1037 SM) of all casualties with AIS 2+ injuries had visceral torso injuries without also sustaining skeletal fractures. In these few casualties, the coded injuries were likely due to trauma from a loading path other than direct UBB loading. CONCLUSION: Skeletal fractures are the most frequent AIS 2+ injury resulting from UBB events. Visceral torso injuries are infrequent in individuals that survive and they generally occur in conjunction with skeletal injuries

Feedback to the field: an assessment of sternal intraosseous (IO) infusion.

Intraosseous vascular infusion (IO) is a recognized alternative to peripheral intravenous infusion when access is inadequate. The sternum and proximal tibia are the preferred sites. A review of 98 cases at autopsy revealed successful sternal IO placement in 78 cases (80%). Assuming a worst case scenario for placement (pin mark and no tip in bone [17 cases] and tip present and not in the sternum [3 cases]), attempts were unsuccessful in 20 cases (20%). We draw no specific conclusions regarding sternal IO use, but hope that personnel placing these devices and those providing medical training can use the information

Computed Tomographic Findings in Unsuspected Aortic Dissection and Adult Polycystic Kidney Disease.

The coexistence of adult polycystic kidney disease and aortic dissection should be recognized by forensic pathologists and radiologists. Two cases with postmortem computed tomography prior to autopsy illustrate the appearance of polycystic kidneys and the hemorrhage patterns that provide clues to the presence and approximate location of the aortic dissections. Optimal imaging technique is discussed

Beyond the Forensic Pathology Investigation: Improving Warfighter Survivability.

The Armed Forces Medical Examiner System (AFMES) conducts forensic pathology investigations in accordance with Title 10 U.S. Code 1471. Since 2004, the AFMES has incorporated advanced radiologic imaging, such as computed tomography, into its protocol. This incorporation has led to increased fidelity in depicting injuries, efficient localization of foreign bodies, and the ability to accurately document medical therapy - all of which enhance the forensic pathology investigation. As with most jurisdictions, information contained in the forensic pathology investigation is disseminated to family members and criminal investigating authorities. In addition, AFMES also disseminates information regarding the location of resuscitative devices to casualty care providers and trainers, collaborates with trauma physicians and medical providers in regards to evaluating injuries and treatment for the assessment of potential improvements in medical care and survivability, and provides information and subject matter expertise to investigative boards and other organizations that reconstruct fatal events. The overarching goal of these additional collaborations is to enhance the understanding of the nature of traumatic injuries, improve casualty care, and ultimately decrease morbidity while improving survivability