Citations

The National Association of Medical Examiners convened a panel to create a position paper for recommendations for the investigation of infant deaths due to inflicted head trauma. The correct certification of both the cause and manner of death is dependent upon an evaluation of all available data including information derived from the investigation, scene, postmortem examination, and ancillary studies. This paper provides recommendations for the forensic pathologist on what constitutes the dataset to be produced during the postmortem examination of infants who have died of, or have apparently died of, inflicted head trauma. Specifically, this paper describes 1) procedures, 2) ancillary laboratory tests, and 3) forms of documentation that are important in the investigation of these deaths. The evaluation and documentation of such infant deaths involves the production of a detail oriented and thoroughly documented examination that is independently reviewable to support the multitude of inquiries that may follow from the public and the criminal justice system.

Intraoperative Transesophageal Echocardiography (TEE) during orthotopic liver transplant (OLT) is used to gather real-time information on cardiovascular function and intravascular volume status. We report a case where nonstandard TEE views were used to inspect the hepatic vasculature after allograft implantation. A 29-year-old male with secondary biliary cirrhosis with a MELD score of 20 underwent OLT using a liver from a 21-year-old brain-dead donor. Postreperfusion TEE, using the modified hepatic vein views, confirmed the presence of an inferior vena cava (IVC) suprahepatic anastomotic stenosis and hepatic vein and IVC thrombus resulting in hepatic venous outflow obstruction, allograft congestion, and hemodynamic instability. These nonstandard TEE images established the extent of suprahepatic caval outflow obstruction, in which intraoperative ultrasound was unable to definitively demonstrate. This guided real-time surgical decision-making in the postimplantation phase of the operation—ultimately leading to hepatic vein and IVC thrombectomy and revision of suprahepatic caval anastomosis.

AbstractIntroductionPatients undergoing unilateral adrenalectomy for primary aldosteronism (PA) may have a solitary adenoma, unilateral hyperplasia, or multiple adenomas on final pathology. This study investigated whether the underlying pathological diagnosis was associated with differences in clinical presentation and postoperative outcomes.MethodsA retrospective cohort study of patients undergoing unilateral adrenalectomy for PA from 2004 to 2015 at our institution was performed. Baseline clinical and laboratory parameters, as well as postoperative biochemical and hypertension cure rates, were compared across the three aforementioned pathological groups.ResultsOf 206 patients who met criteria for inclusion, 152 (73.8%) had a single adenoma, 33 (16%) had unilateral hyperplasia, and 21 (10.2%) had multiple unilateral adenomas. Patients with unilateral hyperplasia were more likely to be male (81.2% vs 57.9%, P = .03), undergo left‐sided adrenalectomy (78.8% vs 47.4%, P < .01), and had a lower median adrenal venous sampling lateralization index (9.8 vs 19.8, P = .04) compared to those with solitary, but not multiple unilateral adenomas. No differences were seen in age, duration of hypertension, preoperative plasma aldosterone levels, plasma renin activities, 24‐h urinary aldosterone excretion, serum potassium concentrations, and the number of preoperative antihypertensive medications across all three pathological groups. All patients achieved biochemical cure following adrenalectomy, and no significant differences in the rates of hypertension cure or improvement were observed in comparisons across pathological subtype.ConclusionsClinical presentation and postoperative outcomes are similar regardless of underlying pathology in patients with PA. Because one in four patients may harbor unilateral hyperplasia or multiple adenomas, total unilateral adrenalectomy should be performed as the operation of choice over adrenal‐sparing approaches.

Objectives Literature suggests an inconsistent, but largely inverse, association between asthma and risk of glioma, which is primarily due to methodological inconsistency in sampling frame and ascertainment of asthma. The objective of the study was to clarify the association between asthma and risk of glioma by minimising methodological biases (eg, recall and detection bias). Design A population-based case–control study. Setting General population in Olmsted County, Minnesota, USA. Participants All eligible biopsy-proven incident glioma cases (1995–2014) and two sets of controls among residents matched to age and sex (first set: community controls without glioma; second set: MRI-negative controls from the same community). Methods The predetermined asthma criteria via medical record review were applied to ascertain asthma status of cases and controls. History of asthma prior to index date was compared between glioma cases and their matched controls using conditional logistic regression models. Propensity score for asthma status was adjusted for multivariate analysis. Results We enrolled 135 glioma cases (median age at index date: 53 years) and 270 controls. Of the cases, 21 had a history of asthma (16%), compared with 36 of MRI controls (27%) (OR (95% CI) 0.48 (0.26 to 0.91), p=0.03). With MRI controls, an inverse association between asthma and risk of glioma persisted after adjusting for the propensity score for asthma status, but did not reach statistical significance probably due to the lack of statistical power (OR (95% CI) 0.48 (0.21 to 1.09); p=0.08). Based on comparison of characteristics of controls and cases, community controls seem to be more susceptible to a detection bias. Conclusions While differential detection might account for the association between asthma and risk of glioma, asthma may potentially pose a protective effect on risk of glioma. Our study results need to be replicated by a larger study.

AbstractObjectiveThis study assesses the attitudes and preferences of Chinese clinicians toward their involvement in shared decision making (SDM).MethodsFrom May 2014 to May 2015, 200 Chinese clinicians from two hospitals were enrolled to complete a survey on their attitude towards SDM. We conducted the survey via face‐to‐face interviews before and after an educational intervention on SDM among young Chinese clinicians. The clinicians were asked to give the extent of agreement to SDM. They also gave the extent of difficulty in using decision aids (DAs) during the SDM process. The variation in the range of responses to each question before and after the SDM intervention was recorded. The frequency of changed responses was analyzed by using JMP 6.0 software. Data were statistically analyzed using Chi‐square and Mann–Whitney U tests, as appropriate to the data type. Multiple logistic regressions were used to test for those factors significantly and independently associated with preference for an approach for each scenario.ResultsOf the 200 young Chinese clinicians sampled, 59.0% indicated a preference for SDM and a desire to participate in SDM before receiving education or seeing the DA, and this number increased to 69.0% after seeing the DA with the sample video of the SDM process on Statin Choice. However, 28.5% of the respondents still reported that, in their current practice, they make clinical decisions on behalf of their patients. The clinicians who denied a desire to use the DA stated that the main barriers to implement SDM or DA use in China are lack of time and knowledge of SDM.ConclusionsMost young Chinese clinicians want to participate in SDM. However, they state the main barriers to perform SDM are lack of experience and time. The educational intervention about SDM that exposes clinicians to DAs was found to increase their receptivity.

Abstract An estimated 14.1 million patients survive sepsis each year. Many survivors experience poor long-term outcomes, including new or worsened neuropsychological impairment; physical disability; and vulnerability to further health deterioration, including recurrent infection, cardiovascular events, and acute renal failure. However, clinical trials and guidelines have focused on shorter-term survival, so there are few data on promoting longer-term recovery. To address this unmet need, the International Sepsis Forum convened a colloquium in February 2018 titled “Understanding and Enhancing Sepsis Survivorship.” The goals were to identify gaps and limitations of current research and shorter- and longer-term priorities for understanding and enhancing sepsis survivorship. Twenty-six experts from eight countries participated. The top short-term priorities identified by nominal group technique culminating in formal voting were to better leverage existing databases for research, develop and disseminate educational resources on postsepsis morbidity, and partner with sepsis survivors to define and achieve research priorities. The top longer-term priorities were to study mechanisms of long-term morbidity through large cohort studies with deep phenotyping, build a harmonized global sepsis registry to facilitate enrollment in cohorts and trials, and complete detailed longitudinal follow-up to characterize the diversity of recovery experiences. This perspective reviews colloquium discussions, the identified priorities, and current initiatives to address them.

Background: The impact of maturation on lower extremity strength and function after anterior cruciate ligament reconstruction (ACLR) may help guide future studies of age-specific rehabilitation. Hypothesis Pediatric ACLR patients would demonstrate higher thigh strength symmetry and knee-related function at return to sport (RTS) compared with adolescent and young adult participants who underwent traditional ACLR. Study Design: Prospective cohort study. Level of Evidence: Level 2. Methods: A total of 144 young athletes at the time of RTS clearance post-ACLR were classified into 3 maturational groups (pediatric, n = 16 with physeal-sparing ACLR [mean age = 12.3 years; range = 9.2-14.6 years]; adolescent, n = 113 [mean age = 16.5 years; range = 14.1-19.8 years]; young adult, n = 15 [mean age = 22.0 years; range = 20.5-24.9 years]). Quadriceps and hamstring strength were measured using an electromechanical dynamometer. Knee-related function was measured using the International Knee Documentation Committee (IKDC) subjective form and single-leg hop tests. The Limb symmetry Index (LSI) was used in calculations for hop and strength tests. Group differences were compared with Kruskal-Wallis tests and Mann-Whitney U post hoc tests. Proportions of participants meeting literature-recommended RTS criterion cutoffs were compared among the groups using chi-square tests. Results: The pediatric group demonstrated higher quadriceps LSI ( P = 0.01), IKDC scores ( P < 0.01), single-hop LSI ( P < 0.01), and crossover-hop LSI ( P = 0.02) compared with the young adult group. In addition, the pediatric group demonstrated higher IKDC scores ( P < 0.01) and single-hop LSI ( P = 0.02) compared with the adolescent group. The adolescent group demonstrated higher IKDC scores ( P < 0.01), single-hop LSI ( P = 0.02), and crossover-hop LSI ( P = 0.03) compared with the young adult group. The proportions of participants meeting all RTS criterion cutoffs were highest in the pediatric group and lowest in the young adult group ( P = 0.03). Conclusion: Young athletes at RTS clearance after pediatric ACLR demonstrated higher quadriceps strength symmetry and knee-related function than adolescents and young adults after traditional ACLR. Clinical Relevance: These findings demonstrate the need for further study regarding the impact of these group differences on longitudinal outcomes after ACLR, including successful RTS and risk of second ACL injury.

Abstract Recent thymic emigrants that fail postpositive selection maturation are targeted by complement proteins. T cells likely acquire complement resistance during maturation in the thymus, a complement-privileged organ. To test this, thymocytes and fresh serum were separately obtained and incubated together in vitro to assess complement deposition. Complement binding decreased with development and maturation. Complement binding decreased from the double-positive thymocyte to the single-positive stage, and within single-positive thymocytes, complement binding gradually decreased with increasing intrathymic maturation. Binding of the central complement protein C3 to wild-type immature thymocytes required the lectin but not the classical pathway. Specifically, MBL2 but not MBL1 was required, demonstrating a unique function for MBL2. Previous studies demonstrated that the loss of NKAP, a transcriptional regulator of T cell maturation, caused peripheral T cell lymphopenia and enhanced complement susceptibility. To determine whether complement causes NKAP-deficient T cell disappearance, both the lectin and classical pathways were genetically ablated. This blocked C3 deposition on NKAP-deficient T cells but failed to restore normal cellularity, indicating that complement contributes to clearance but is not the primary cause of peripheral T cell lymphopenia. Rather, the accumulation of lipid peroxides in NKAP-deficient T cells was observed. Lipid peroxidation is a salient feature of ferroptosis, an iron-dependent nonapoptotic cell death. Thus, wild-type thymocytes naturally acquire the ability to protect themselves from complement targeting by MBL2 with maturation. However, NKAP-deficient immature peripheral T cells remain scarce in complement-deficient mice likely due to ferroptosis.