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Gitto L, Serinelli S, Werner FW, Ordway NR, Stoppacher R. Determination of the Force Required to Produce Stab "Wounds" in Fruit Compared With Cadaveric Chest Tissue. Am J Forensic Med Pathol 2022; 43:311-314. [PMID: 35588165 DOI: 10.1097/paf.0000000000000766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT In laymen's terms, it can be difficult to communicate how much force is needed to create a stab wound into a person's chest. Previous work has determined the force to puncture the skin, rib cartilage, or bone but without putting the results in terms that are easy to understand.The purpose of this study was to determine the force needed to puncture 3 types of fruit using 3 different types of knives, namely, a steak knife, a butcher's knife, and a lock-blade knife, to help put these previous results in perspective.There was wide variation in the force required to insert a knife into different fruits, but no force for any knife at any location for all fruits exceeded 93.1 N. Results show that force needed to penetrate the skin and allow for an 8-cm blade penetration into the chest is similar to the force required to insert a steak knife for a 6-cm distance into a cantaloupe. In addition, the force needed to penetrate the cartilage is most similar to stabbing a watermelon to 6 cm with a butcher knife. However, the forces required to penetrate the bone are greater than those required to penetrate any fruit with any type of blade.
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Affiliation(s)
| | | | - Frederick W Werner
- Orthopedic Surgery, State University of New York, Upstate Medical University, Syracuse, NY
| | - Nathaniel R Ordway
- Orthopedic Surgery, State University of New York, Upstate Medical University, Syracuse, NY
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2
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Abstract
Dyskeratosis congenita (DC) is a genetic syndrome with progressive multisystem involvement classically characterized by the clinical triad of oral leukoplakia, nail dystrophy, and reticular hyperpigmentation. Frequent complications are bone marrow failure, increased rate of malignancy, lung and liver diseases. DC results from an anomalous progressive shortening of telomeres resulting in DNA replication problems inducing replicative senescence. We report a death due to DC in a 16-year-old male with bone marrow failure and multiple organ dysfunction. At autopsy, nail dystrophy and skin hypopigmentation were observed. Gross and microscopic examinations of the internal organs showed cardiac hypertrophy, multiple lung consolidations and prominent interstitial fibrosis, liver cirrhosis, and fibrosis. Multiple foci of extramedullary hematopoiesis were identified, including on the epidural surface of the dura, that is an infrequent location, mimicking a focal area of epidural hemorrhage. Only a few autopsy studies about DC are reported in the literature. Further research should be done to understand the pathophysiology of the disease and its complications.
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Affiliation(s)
- Lorenzo Gitto
- State University of New York, Upstate Medical University, Department of Pathology, Syracuse, NY, USA
| | - Robert Stoppacher
- State University of New York, Upstate Medical University, Department of Pathology, Syracuse, NY, USA
| | - Timothy Eric Richardson
- State University of New York, Upstate Medical University, Department of Pathology, Syracuse, NY, USA
| | - Serenella Serinelli
- State University of New York, Upstate Medical University, Department of Pathology, Syracuse, NY, USA
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3
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Serinelli S, Arunkumar P, Stoppacher R, Wang D, Gitto L. Relationship between opiates and asthma in the determination of death. J Forensic Leg Med 2020; 74:102030. [PMID: 32738646 DOI: 10.1016/j.jflm.2020.102030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 06/22/2020] [Accepted: 07/16/2020] [Indexed: 11/26/2022]
Abstract
Several studies have shown an association between asthma and opiate abuse. This retrospective study aims to analyse the demographic, toxicological, and seasonal differences in asthmatic and non-asthmatic subjects who died of opiates. In addition, the relationship between toxicological levels of opiates and histologic grade of lung inflammation is examined. Deaths from 2013 to 2018 involving opiates as the primary cause of death in Cook County, Illinois (USA) were reviewed. Twenty-six cases of opiate deaths of individuals with a history of asthma and lung histology slides available were identified. In comparison, 40 cases of deaths due to opiates only were analysed. A check-list system for the evaluation of the grade of microscopic inflammation in asthma was developed. We found statistically significant differences between the asthmatics and the non-asthmatics regarding demography (age and race) and toxicology (6-MAM presence). In particular, the "opiate and asthma group" was mainly composed of African-American subjects, in contrast with the "opiate group", consisting mostly of Caucasian. The mean age was significantly higher in the "opiate and asthma group" compared with the "opiate group". A greater presence of 6-MAM was detected in the "opiate group" compared with the "opiate and asthma group". While we expected to find that low opiate levels would lead to deaths in asthmatics and, in particular, that lower opiate concentrations would cause deaths in subjects with higher grades of histologic inflammation, our study suggests that the quantity of drug and the level of inflammation are not statistically significant in the determination of death. We, therefore, recommend histologic examination of the lungs to evaluate for asthma, particularly in suspected low-level opiate-related deaths, to help further clarify any relationship between asthma and opiate use.
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Affiliation(s)
- Serenella Serinelli
- Department of Pathology, State University of New York Upstate Medical University, 750 East Adams Street, Syracuse, NY, USA.
| | - Ponni Arunkumar
- Cook County Office of Medical Examiner, 2121, W Harrison Street, Chicago, IL, USA
| | - Robert Stoppacher
- Department of Pathology, State University of New York Upstate Medical University, 750 East Adams Street, Syracuse, NY, USA
| | - Dongliang Wang
- Department of Public Health and Preventive Medicine, State University of New York Upstate Medical University, 750 East Adams Street, Syracuse, NY, USA
| | - Lorenzo Gitto
- Department of Pathology, State University of New York Upstate Medical University, 750 East Adams Street, Syracuse, NY, USA
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4
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Eggleston W, Stoppacher R, Suen K, Marraffa JM, Nelson LS. Drs. Eggleston et al. Reply to Drs. Grundmann et al. Pharmacotherapy 2019; 39:1121-1122. [PMID: 31729072 DOI: 10.1002/phar.2337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- William Eggleston
- School of Pharmacy and Pharmaceutical Sciences, Binghamton University, Binghamton, New York.,Department of Emergency Medicine, SUNY Upstate Medical University, Syracuse, New York
| | - Robert Stoppacher
- Department of Pathology, SUNY Upstate Medical University, Syracuse, New York
| | - Kyle Suen
- Department of Emergency Medicine, SUNY Upstate Medical University, Syracuse, New York
| | - Jeanna M Marraffa
- Department of Emergency Medicine, Upstate New York Poison Center, SUNY Upstate Medical University, Syracuse, New York
| | - Lewis S Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
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Abstract
BACKGROUND Kratom is an herbal supplement containing alkaloids with opioid properties. This review was conducted to determine toxicities associated with kratom use in the United States in order to provide insight into its safety as a dietary supplement. METHODS We conducted a retrospective review of kratom exposures reported to the National Poison Data System to determine the toxicities associated with kratom use. We also reviewed records from a county medical examiner's office in New York State to identify kratom-associated fatalities. RESULTS A total of 2312 kratom exposures were reported, with 935 cases involving kratom as the only substance. Kratom most commonly caused agitation (18.6%), tachycardia (16.9%), drowsiness (13.6%), vomiting (11.2%), and confusion (8.1%). Serious effects of seizure (6.1%), withdrawal (6.1%), hallucinations (4.8%), respiratory depression (2.8%), coma (2.3%), and cardiac or respiratory arrest (0.6%) were also reported. Kratom was listed as a cause or contributing factor in the death of four decedents identified by the county medical examiner's office. CONCLUSIONS Kratom use is increasing and is associated with significant toxicities. Our findings suggest kratom is not reasonably expected to be safe and poses a public health threat due to its availability as an herbal supplement.
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Affiliation(s)
- William Eggleston
- School of Pharmacy and Pharmaceutical Sciences, Binghamton University, Binghamton, New York.,Department of Emergency Medicine, SUNY Upstate Medical University, Syracuse, New York
| | - Robert Stoppacher
- Department of Pathology, SUNY Upstate Medical University, Syracuse, New York
| | - Kyle Suen
- Department of Emergency Medicine, SUNY Upstate Medical University, Syracuse, New York
| | - Jeanna M Marraffa
- Department of Emergency Medicine, SUNY Upstate Medical University, Syracuse, New York.,Upstate New York Poison Center, Syracuse, New York
| | - Lewis S Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
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6
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Serinelli S, Gitto L, Stoppacher R. A Case of Sudden Death Due to Persistent Severe Pulmonary Arterial Hypertension After Late Atrial Septal Defect Closure. J Forensic Sci 2019; 64:1916-1920. [PMID: 31150105 DOI: 10.1111/1556-4029.14076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/10/2019] [Accepted: 04/23/2019] [Indexed: 11/29/2022]
Abstract
Atrial septal defects (ASDs) are one of the most prevalent congenital cardiac anomalies in adults. These interatrial communications can produce changes in the right heart (remodeling and failure) and the lungs (pulmonary hypertension). Most adults with ASDs are surgically treated with excellent results. However, a small fraction of patients is at risk for postoperative complications, particularly the persistence of pulmonary hypertension. A case of a 47-year-old woman who was found unresponsive in the bathroom of her house and died despite resuscitative efforts is described. According to medical records, the woman underwent a surgical repair of an atrial septal defect at the age of 37. At the autopsy, macroscopic and microscopic signs of advanced pulmonary hypertension were detected, highlighting the importance for the forensic pathologists to recognize pulmonary hypertension as a cause of sudden death in adults with a history of late surgical closure of an atrial septal defect.
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Affiliation(s)
- Serenella Serinelli
- Department of Pathology, State University of New York, Upstate Medical University, Syracuse, NY
| | - Lorenzo Gitto
- Department of Pathology, State University of New York, Upstate Medical University, Syracuse, NY
| | - Robert Stoppacher
- Department of Pathology, State University of New York, Upstate Medical University, Syracuse, NY
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7
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Vohra V, Hodgman M, Marraffa J, Barba K, Stoppacher R. Fentanyl- and fentanyl analog-related deaths across five counties in Central New York between 2013 and 2017. Clin Toxicol (Phila) 2019; 58:112-116. [DOI: 10.1080/15563650.2019.1613548] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Varun Vohra
- Upstate NY Poison Center, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Michael Hodgman
- Upstate NY Poison Center, SUNY Upstate Medical University, Syracuse, NY, USA
- Department of Emergency Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Jeanna Marraffa
- Upstate NY Poison Center, SUNY Upstate Medical University, Syracuse, NY, USA
- Department of Emergency Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Kristie Barba
- Onondaga County Medical Examiner’s Office, Syracuse, NY, USA
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8
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Abstract
Acute pancreatitis can present as sudden, expected death and, therefore, fall under the jurisdiction of the medical examiner/coroner (ME/C). Although its etiologies are varied, alcohol abuse, trauma, and drugs are important to consider in the forensic setting. It is therefore important for the forensic pathologist to have an understanding of these and other etiologies, to have a functional knowledge of the pancreatic anatomy and physiology, and to be able to diagnose acute pancreatitis and distinguish it from postmortem artifact. This review will highlight the forensic aspects of acute pancreatitis, with particular focus on acute hemorrhagic pancreatitis. This will include an overview of the developmental anatomy and normal physiology of the pancreas, the various causes of pancreatitis that may result in deaths coming to the attention of the ME/C, the underlying pathophysiology of the disease, the postmortem diagnosis of acute pancreatitis, and ancillary studies that support the diagnosis. Acad Forensic Pathol. 2018 8(2): 239-255.
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Affiliation(s)
- Robert Stoppacher
- Robert Stoppacher MD, 100 Elizabeth Blackwell Street Syracuse NY 13210, US.
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9
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Rao A, Ramani N, Stoppacher R, Coyle T. Complete response to temozolomide in chronic lymphocytic leukemia. Clin Case Rep 2017; 5:1130-1131. [PMID: 28680610 PMCID: PMC5494405 DOI: 10.1002/ccr3.978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 01/05/2017] [Accepted: 03/03/2017] [Indexed: 12/31/2022] Open
Abstract
We report a case of incidentally diagnosed chronic lymphocytic leukemia (CLL) in a patient with glioblastoma, which responded completely following standard treatment of the glioblastoma with temozolomide and cranial irradiation. The patient remained without an evidence of CLL until his death from recurrent glioblastoma. Further study of temozolomide for the treatment of CLL is indicated.
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Affiliation(s)
- Archana Rao
- Hematology Oncology Associates of CNY 5008 Brittonfield Parkway East Syracuse 13057 New York
| | - Nisha Ramani
- Department of Pathology SUNY Upstate Medical University 750 East Adams street Syracuse 13210 New York
| | - Robert Stoppacher
- Department of Pathology SUNY Upstate Medical University 750 East Adams street Syracuse 13210 New York
| | - Thomas Coyle
- Department of Benign Hematology TriHealth Cancer Institute 10506 Montgomery Rd Cincinnati 45242 Ohio
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10
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Caza TN, Mercedes A, Stoppacher R, Catanese CA. A Complex Case of Loeys-Dietz Syndrome: A Case Report and Review of the Literature. Acad Forensic Pathol 2016; 6:731-738. [PMID: 31239945 DOI: 10.23907/2016.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 10/15/2016] [Accepted: 11/18/2016] [Indexed: 11/12/2022]
Abstract
Loeys-Dietz syndrome is a rare autosomal dominant connective tissue disorder with a genetic predisposition to aneurysm formation and congenital cardiofacial defects through genetic mutation affecting the transforming growth factor-beta (TGFβ) signaling pathway. We present a case of a 6-year-old female patient with Loeys-Dietz syndrome who developed an annular aortic valve abscess and ascending aortic dissection due to Staphylococcus aureus endocarditis. Within this case, multiple complications from Loeys-Dietz syndrome were identified, including prosthetic valve infection, aneurysm formation and dissection, septic embolism, and aspiration pneumonia. The clinical presentation, pathologic findings, and pathophysiology will be discussed.
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Affiliation(s)
- Tiffany N Caza
- State University of New York Upstate Medical University - Pathology
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11
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Labay LM, Caruso JL, Gilson TP, Phipps RJ, Knight LD, Lemos NP, McIntyre IM, Stoppacher R, Tormos LM, Wiens AL, Williams E, Logan BK. Synthetic cannabinoid drug use as a cause or contributory cause of death. Forensic Sci Int 2016; 260:31-39. [PMID: 26795398 DOI: 10.1016/j.forsciint.2015.12.046] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 12/17/2015] [Accepted: 12/29/2015] [Indexed: 11/18/2022]
Abstract
Adverse effects associated with synthetic cannabinoid use include agitation, psychosis, seizures and cardiovascular effects, all which may result in a lethal outcome. We report the collection of data from 25 medical examiner and coroner cases where the presence of synthetic cannabinoids was analytically determined. Participating offices provided case history, investigative and relevant autopsy findings and toxicology results along with the cause and manner of death determination. This information, with the agency and cause and manner of death determinations blinded, was sent to participants. Participants offered their opinions regarding the likely contribution of the toxicology findings to cause and manner of death. The results show that some deaths are being attributed to synthetic cannabinoids, with the highest risk areas being behavioral toxicity resulting in excited delirium, trauma or accidents and as contributing factors in subjects with pre-existing cardiopulmonary disease. While insufficient information exists to correlate blood synthetic cannabinoid concentrations to effect, in the absence of other reasonable causes, the drugs should be considered as a cause or contributory cause of death based on history and circumstances with supporting toxicological data.
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Affiliation(s)
- Laura M Labay
- NMS Labs, 3701 Welsh Rd, Willow Grove, PA, United States.
| | - James L Caruso
- City and County of Denver, 660 Bannock Street, Denver, CO, United States
| | - Thomas P Gilson
- Cuyahoga County Regional Forensic Science Laboratory, 11001 Cedar Avenue, Cleveland, OH, United States
| | - Rebecca Jufer Phipps
- Office of the Chief Medical Examiner, 900W. Baltimore Street, Baltimore, MD, United States
| | - Laura D Knight
- SUNY Upstate Medical University, Syracuse, NY, United States
| | - Nikolas P Lemos
- Department of Laboratory Medicine, School of Medicine, University of California, San Francisco, United States
| | - Iain M McIntyre
- San Diego County Medical Examiner's Department, San Diego, CA, United States
| | - Robert Stoppacher
- Onondaga County Medical Examiner's Office, 100 Elizabeth Blackwell Street, Syracuse, NY, United States
| | - Lee Marie Tormos
- Medical University of South Carolina, 181 Ashley Avenue MSC 908, Charleston, SC, United States
| | - Andrea L Wiens
- Oklahoma Office of the Chief Medical Examiner, 1115 West 17th Street, Tulsa, OK, United States
| | - Erica Williams
- Coroner's Offices, Chester and Montgomery Counties, PA, United States
| | - Barry K Logan
- NMS Labs, 3701 Welsh Rd, Willow Grove, PA, United States
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12
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Abstract
Duloxetine is a second-generation selective serotonin and norepinephrine reuptake inhibitor used primarily for the treatment of depression. Relatively few fatalities have been reported in association with its use. Similarly, there are no known reports that provide a comprehensive analysis of blood, fluid and tissue samples in an overdose setting. Herein we present a fatal case of duloxetine toxicity with both the highest reported post-mortem blood concentration and a comprehensive toxicological analysis of duloxetine in femoral blood, vitreous humor, liver tissue, urine and gastric contents. In doing so, we hope to provide data that can assist both toxicologists and forensic pathologists with assessing duloxetine toxicity in the future.
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Affiliation(s)
- Kelly Ann Scanlon
- Medical Examiner's Office, Onondaga County Health Department, Syracuse, NY, USA
| | - Robert Stoppacher
- Medical Examiner's Office, Onondaga County Health Department, Syracuse, NY, USA
| | | | - Samantha J Starkey
- Medical Examiner's Office, Onondaga County Health Department, Syracuse, NY, USA
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13
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Abstract
The death of a person who is incarcerated often raises public concern, family inquiries, and media attention, and such deaths require special handling. The careful investigation of deaths of individuals held in the custody of the corrections system is necessary not only to discover any evidence of abuse, but moreover to ensure that the custodians are cleared of any false allegations of mistreatment. The same logic applies to use-of-force cases resulting in inmate injury but not fatality, in which inmate and correctional officers’ accounts of the events may be incongruous. The forensic pathologist is indispensible in both situations. The purpose of this article is to consider all aspects of the inmate's uniquely vulnerable situation relevant to the forensic pathologist, to review the various types of disease, injury and death occurring in the incarcerated and their relative prevalence, to present a 4.5-year retrospective review of inmate death investigations, and to describe best practices to be utilized in the medicolegal investigation of deaths of incarcerated individuals.
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Affiliation(s)
- Laura D. Knight
- Deputy Chief Medical Examiner at the Onondaga County Medical Examiner's Office in the Wallie Howard Jr. Center for Forensic Sciences, Pathology at State University of New York Upstate Medical University, and a Part-time Instructor in the Forensic and National Securities Sciences Institute at Syracuse University, Syracuse, NY
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14
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Hookano R, Knight LD, Brunelli RA, Stoppacher R. Applications of Social Network Media in Medicolegal Death Investigation. J Forensic Sci 2013; 58:1628-32. [DOI: 10.1111/1556-4029.12173] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Revised: 07/12/2012] [Accepted: 08/05/2012] [Indexed: 10/26/2022]
Affiliation(s)
- Ryan Hookano
- Forensic and National Security Sciences Institute; Center for Science and Technology; Syracuse University; Syracuse NY 13244
| | - Laura D. Knight
- Forensic and National Security Sciences Institute; Center for Science and Technology; Syracuse University; Syracuse NY 13244
- Onondaga County Medical Examiner's Office; Center for Forensic Sciences; 100 Elizabeth Blackwell Street Syracuse NY 13210
- Department of Pathology; State University of New York Upstate Medical University; 750 East Adams Street Syracuse NY 13210
| | - Ronald A. Brunelli
- Onondaga County Medical Examiner's Office; Center for Forensic Sciences; 100 Elizabeth Blackwell Street Syracuse NY 13210
| | - Robert Stoppacher
- Onondaga County Medical Examiner's Office; Center for Forensic Sciences; 100 Elizabeth Blackwell Street Syracuse NY 13210
- Department of Pathology; State University of New York Upstate Medical University; 750 East Adams Street Syracuse NY 13210
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15
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Abstract
Synthetic cannabinoids are chemical compounds that act on the cannabinoid receptors to produce psychoactive effects. Originally created to better understand the cannabinoid receptors, these drugs are readily accessible over the internet or in “head shops” and are sold as herbal incense under various names such as K2, Spice, K9, or Legal Phunk. While neurologic and cardiac toxicity from the use of these compounds has been described, and deaths of individuals that have used synthetic cannabinoids have been publicized in the media, no fatalities directly related to synthetic cannabinoid toxicity have been reported in the scientific literature. This report describes a fatality directly related to the toxic effects of synthetic cannabinoid use. It will also review the development of synthetic cannabinoids, current literature with respect to their toxicity, and the regulatory issues surrounding these substances.
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Affiliation(s)
- Robert Stoppacher
- Chief Medical Examiner in Onondaga County New York, SUNY Upstate Medical University, and Forensic and National Security Sciences Institute at Syracuse University
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16
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Holland MG, Schwope DM, Stoppacher R, Gillen SB, Huestis MA. Postmortem redistribution of Δ9-tetrahydrocannabinol (THC), 11-hydroxy-THC (11-OH-THC), and 11-nor-9-carboxy-THC (THCCOOH). Forensic Sci Int 2011; 212:247-51. [PMID: 21764230 DOI: 10.1016/j.forsciint.2011.06.028] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2011] [Revised: 06/20/2011] [Accepted: 06/26/2011] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Postmortem redistribution (PMR), a well-described phenomenon in forensic toxicology for certain drugs, can result in increased central blood concentrations relative to peripheral blood concentrations. Δ(9)-tetrahydrocannabinol (THC), the primary psychoactive component in cannabis or marijuana, is the illicit substance most commonly implicated in driving under the influence of drugs (DUID) cases and fatally-injured drivers. No investigation of PMR of THC in human blood has been reported to date. METHODS Matched heart and iliac postmortem blood specimens were collected from 19 medical examiner cases (16 Males, 3 Females) with positive cannabinoid urine immunoassay screens. THC, its equipotent metabolite 11-hydroxy-THC (11-OH-THC) and non-psychoactive metabolite 11-nor-9-carboxy-THC (THCCOOH) were quantified by two-dimensional gas chromatography-mass spectrometry with cryofocusing, with 0.5 ng/mL limits of quantification (LOQ) for all analytes. RESULTS 10 cases had quantifiable THC and 11-OH-THC; THCCOOH was present in all 19. Median (range) heart:iliac blood ratios were 1.5 for THC (range: 0.3-3.1); 1.6 for 11-OH-THC (range: 0.3-2.7); and 1.8 for THCCOOH (range: 0.5-3.0). DISCUSSION Cannabinoids, in general, exhibited a mean and median central:peripheral (C:P) concentration ratio of less than 2 following death. A trend was observed for greater PMR with increasing postmortem interval between death and sampling. To our knowledge, these are the first data on THC PMR in humans, providing important scientific data to aid in the interpretation of postmortem cannabinoid concentrations in medico-legal investigations.
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Affiliation(s)
- Michael G Holland
- Department of Emergency Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, United States.
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17
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Mukhopadhyay S, Philip AT, Stoppacher R. Pathologic findings in novel influenza A (H1N1) virus ("Swine Flu") infection: contrasting clinical manifestations and lung pathology in two fatal cases. Am J Clin Pathol 2010; 133:380-7. [PMID: 20154276 PMCID: PMC7109771 DOI: 10.1309/ajcpxy17sulqkswk] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Although novel influenza A (H1N1) virus infection has assumed pandemic proportions, there are few reports of the pathologic findings. Herein we describe the pathologic findings of novel influenza A (H1N1) infection based on findings in 2 autopsy cases. The first patient, a 36-year-old man, had flu-like symptoms; oseltamivir (Tamiflu) therapy was started 8 days after onset of symptoms, and he died on day 15 of his illness. At autopsy, the main finding was diffuse alveolar damage with extensive fresh intra-alveolar hemorrhage. The second patient, a 46-year-old woman with alcoholism, was found unresponsive in a basement and brought to the hospital intoxicated and confused. Her condition deteriorated rapidly, and she died 4 days after admission. The main autopsy finding was acute bronchopneumonia with gram-positive cocci, intermixed with diffuse alveolar damage. The pathologic findings in these contrasting cases of novel influenza A (H1N1) infection are similar to those previously described for seasonal influenza. The main pathologic abnormality in fatal cases is diffuse alveolar damage, but it may be overshadowed by an acute bacterial bronchopneumonia.
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18
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Stoppacher R, Teggatz JR, Jentzen JM. Esophageal and pharyngeal injuries associated with the use of the esophageal-tracheal Combitube. J Forensic Sci 2004; 49:586-91. [PMID: 15171180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
The Combitube is a ventilatory device consisting of a twin lumen tube with proximal and distal inflatable cuffs. The major benefit of the Combitube is that its design and function allow for ventilation through non-laryngoscope-assisted insertion into either the trachea, or esophagus. As with any invasive procedure, intubation using the Combitube carries certain risks and potential complications. The majority of complications are relatively minor; however, a rare and serious complication reported primarily in the anesthesiology literature is laceration of the esophagus. This reportedly rare injury is increasingly seen by medical examiners/coroners in the forensic setting. This paper presents a series of three cases of esophageal laceration and a single case of perforation of the hypopharynx associated with the use of the Combitube, while also exploring potential mechanisms of injury. In addition, this work demonstrates the vital role the medical examiner/coroner plays in identifying existing or potential problems with current or emerging medical devices.
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Stoppacher R, Adams SP. Malaria deaths in the United States: case report and review of deaths, 1979-1998. J Forensic Sci 2003; 48:404-8. [PMID: 12665001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Malaria is the world's most important parasitic disease, accounting for an estimated 300 to 500 million new cases and between 1.5 and 2.7 deaths annually. The majority of these deaths occur in sub-Saharan Africa where malaria is endemic and are the result of infection with Plasmodium falciparum. The number of deaths in the United States due to malaria is comparably much lower and involves so-called "imported" cases in which U.S. travelers acquire the infection upon travel to endemic areas and subsequently return to the United States or in which infected foreign citizens travel to the United States. There were a total of 118 deaths due to malaria in the United States between 1979 and 1998 with an average of 5.9 deaths per year. Specific epidemiological data provided by the CDC regarding the 40 deaths that occurred between 1992 and 1998 yielded the following results. Deaths occurred in patients ranging from 9 months to 89 years of age (median, 53 years). Thirty-eight (95%) of these were due to P. falciparum and two (5%) due to P. vivax. Anti-malarial chemoprophylaxis was taken in 40% of cases, not taken in 45% of cases, and unknown in 15% of cases. Twenty-four (60%) of the cases involved U.S. travelers to endemic areas, of whom 59% traveled to Africa, 25% to South America, 8% to India, 4% to Haiti, and 4% to unspecified areas. The remaining cases included eleven foreign travelers to the U.S. (27.5%), three induced cases (7.5%), and two undetermined cases (5%). Thirty-nine (98%) of the cases were diagnosed antemortem and only one case was known to have come to the attention of the medical examiner/coroner. An illustrative case report demonstrates many of the features associated with fatal malaria infections in the United States. The case involves a U.S. student who was studying in Africa and who, by report, had not taken antimalarial chemoprophylaxis. Despite seeking medical attention, the patient was not diagnosed with P. falciparum infection and cerebral malaria until the time of medico-legal autopsy, where the classic gross and microscopic features of cerebral malaria were identified. This case represents one of the few cases of P. falciparum infection in the United States not diagnosed antemortem. Given the worldwide prevalence of the disease, increasing international travel, and rapidly developing drug resistance, malaria will continue to be an important disease and should be considered in cases of sudden, unexplained deaths. By reviewing the major epidemiological features of malaria-related deaths in the United States and by presenting the major gross and microscopic features of cerebral malaria, an attempt is made at raising the awareness of the forensic community to the potential of malaria-related deaths.
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Affiliation(s)
- Robert Stoppacher
- Milwaukee County Medical Examiner's Office, Milwaukee, WI 53233, USA
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Karpman E, Zvara P, Stoppacher R, Jackson TL, Plante MK. Pheochromocytoma of the urinary bladder: update on new diagnostic modalities plus case report. Ann Urol (Paris) 2000; 34:13-9. [PMID: 10763419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Extra-adrenal pheochromocytoma (PCC) is a rare entity. Its occurrence in the urinary bladder has only been reported less than 200 times. Here we present two case reports of a bladder PCC with an update on the diagnostic techniques, treatment modalities and follow-up of patients with this disease.
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Affiliation(s)
- E Karpman
- Division of Urology, University of Vermont, College of Medicine, Burlington 05401, USA
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Abstract
OBJECTIVES Despite extensive research involving numerous treatments for benign prostatic hyperplasia (BPH), the ideal modality has yet to be discovered. This study evaluated chemoablation of the prostate using transurethral intraprostatic absolute ethanol injection (AEI) in an in vivo canine model. METHODS Eight mongrel dogs, 7 to 10 years old, underwent transurethral intraprostatic AEI with various ethanol volumes (10 to 26 mL/animal, mean 19.9). Injection was performed using a 20-gauge, passive deflection, hollow-core needle, introduced cystoscopically by way of a perineal urethrotomy. Oral antibiotics were administered perioperatively. Blood alcohol levels were determined. The canines were kept alive for 1 hour (n = 1), 7 days (n = 2), and 21 days (n = 5) after the treatment. The dogs were observed twice daily for a minimum of 30 minutes to determine continence. At least one spontaneous voiding was recorded at each observation. Before the dogs were sacrificed, the prostate and surrounding tissues were harvested, with gross and microscopic examination performed by a single pathologist. RESULTS Seven and 21 days after AEI, the prostates demonstrated necrosis and cavity formation. Deep injection resulted in cavity formation in a subcapsular location. Superficial injection resulted in cavity formation that was confluent with the urethra and resulted in a widened urethral lumen. No complications directly related to AEI were seen, and systemic absorption of ethanol was minimal. CONCLUSIONS AEI can effectively ablate prostatic tissue in canines with minimal systemic absorption. No disruption of the prostatic capsule or injury to the bladder urothelium and urethral sphincter was identified. Human studies of intraprostatic AEI for BPH adenomatous tissue chemoablation are ongoing at our institution.
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Affiliation(s)
- P Zvara
- Department of Surgery, University of Vermont College of Medicine, Burlington, USA
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Abstract
This case report describes an isolated plantar lateral dislocation of the medial cuneiform. We were able to find only one other similar case reported in the literature. That case had a delayed diagnosis of 5 months and with an associated an avulsion fracture of the second metatarsal base. Dines et al. reported an isolated dorsomedial dislocation at the medial cuneonavicular joint. An irreducible dorsomedial dislocation with the anterior tibialis tendon being trapped between the medial cuneiform and the navicular has been reported. A distal and lateral dislocation of the medial cuneiform was reported in association with displacement of the second to fourth metatarsal and medial fractures of the navicular and cuneiform. The current report differs from previous cases. There was not an associated fracture; the direction of the dislocation was unique and could be reduced closed.
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Affiliation(s)
- B P Levine
- University of Vermont, College of Medicine, Department of Orthopaedics and Rehabilitation, Burlington 05405-0084, USA
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