Proximate Cause Of Death Research Articles

Continuous versus interrupted suture techniques of pancreaticojejunostomy after pancreaticoduodenectomy

BackgroundPostoperative pancreatic fistula (POPF) has traditionally been a source of significant morbidity and potential mortality after pancreaticoduodenectomy (PD). Both patient-derived and technical factors contribute to pancreatic anastomotic failure. The continuous suture duct-to-mucosa pancreaticojejunostomy (PJ) described previously is associated with a low rate of POPF. The aim of the present study was to observe whether the new technique would effectively reduce the POPF rate in comparison with conventional interrupted suture duct-to-mucosa PJ. MethodsData on 255 consecutive patients, who underwent the two methods of PJ after standard PD by one group of surgeons between 2006 and 2013, were collected retrospectively from a prospective database. The primary end point was the POPF rate. The risk factors of POPF were investigated by using univariate and multivariate analyses. ResultsA total of 120 patients received continuous suture PJ and 135 underwent interrupted suture PJ. Rate of POPF for the entire cohort was 12.5%. There were 9 fistulas (7.5%) in the continuous anastomosis group and 23 fistulas (17%) in the interrupted anastomosis group (P = 0.022). The rates of major complications (Clavien grades 3–5) were less in the continuous anastomosis group (5%) compared with the interrupted anastomosis group (13.3%) (P = 0.023). The greatest risk factor for a POPF was pancreatic duct diameter: POPF developed in only 3 patients (3.6%) with large pancreatic ducts (≥3 mm) and in 29 patients (16.9%) with small pancreatic ducts (<3 mm). There were four postoperative (in-hospital) deaths (both in the interrupted anastomosis group); two of which had POPF as the proximate cause of death, followed by bleeding and sepsis. ConclusionsThe continuous suture duct-to-mucosa PJ effectively reduces the POPF rate after PD in comparison with interrupted anastomosis. The results confirm increased POPF rates in patients with pancreatic duct diameter <3 mm compared with pancreatic duct diameter ≥3 mm.

The syndrome of excited delirium

The excited delirium syndrome (EDS) is a life-threatening condition caused by a variety of factors including drug intoxication and psychiatric illness. Fatal instances of excited delirium frequently come to the attention of the medical examiner/coroner due to the circumstances and potential causes. Excited delirium may include paranoid, aggressive, and incoherent behavior which may lead to an encounter with law enforcement. In some instances, the person may die while in the presence of law enforcement. This circumstance further broadens the potential causes of death particularly as EDS has no pathognomonic autopsy finding. Although the syndrome of excited delirium is sufficient to explain death, other intervening causes need to be considered. These include chest or neck compression during restraint, blunt trauma, and underlying natural disease. Since chest/neck compression, natural disease (e.g., atherosclerosis), blunt trauma, and excited delirium are not mutually exclusive, all may be present in one death. The forensic pathologist's role is to determine what caused and/or contributed to the death. When attempting to determine the proximate cause of death in instances with multiple potential causes, determining the mechanism of death often is useful. As not all causes of death have pathologically-demonstrable mechanisms of death, examination of the circumstances of the death often are diagnostically important. The main goal of the autopsy of deaths suspected to be due to EDS is to identify (or exclude) intervening diseases or injuries sufficient to explain the death in the context of the investigated circumstances.

YOLK EMBOLISM ASSOCIATED WITH TRAUMA IN VITELLOGENIC SEA TURTLES IN FLORIDA (USA): A REVIEW OF 11 CASES

Case information and postmortem examination findings are presented for 11 adult female sea turtles in reproductive form that died in Florida, USA. All had abundant, large vitellogenic follicles, and most were either gravid or had recently nested. Species included six loggerheads (Caretta caretta) and five green turtles (Chelonia mydas). Identified proximate causes of death included falls or entrapment by obstructions on nesting beaches, burial under collapsed dunes, and other traumatic injuries of different causes. Evidence of yolk embolization was found in 10 cases and suspected in an 11th turtle. Ten turtles also had various amounts of free intracoelomic yolk. Although the effects of yolk embolization are uncertain at this time, precedence of pathologic importance in other species suggests that embolism may complicate traumatic injuries, including seemingly minor events.

Murder-suicide by carbon dioxide (CO2) poisoning: a family case from Berlin, Germany

This report demonstrates how carbon dioxide (CO(2)) may be a potent weapon in murder-suicide, where the death scene offers virtually no clues as to the lethal modality and the autopsy findings are nonspecific. Four bodies were discovered in an apartment in midsummer 2012 in Berlin, Germany. The bodies were those of a father (a 69-year-old business consultant), his wife (aged 26-years), and two sons (aged 3 and 6 years, respectively). The police found the wife and two sons lying in their beds and the husband in a supine position on the floor with a plastic bag over his head tied loosely around his neck with a rope. A 500 g single-use CO(2) cylinder was standing on the floor. The container was almost empty and according to the label had been sold as a CO(2)-fertilizer for aquarium plants. Two synthetic inhalation face masks and tubing were also found, which tested positive for the DNA of all four deceased family members. It is hypothesized that the husband placed an inhalation mask over the mouths and noses of his wife and children while they were sleeping. Inhalation of pure CO(2) ensured their rapid unconsciousness due to hypercapnia and severe anoxia. The rapid increase in CO(2) concentration would render a victim helpless, with no time to wake and defend themselves, or others. The proximate cause of death in all cases was attributed to CO(2) intoxication, based on the scene findings, the reconstructed sequence of events, the autopsy, and results of toxicological studies.

Survival and causes of mortality in a northern population of western gray squirrels

We studied survival of radio-marked western gray squirrels (Sciurus griseus) and quantified causes of mortality including incidence and severity of notoedric mange in south-central Washington, 1998–2005. We used known-fate models in Program MARK to explore alternative hypotheses on factors related to survival and correlation analysis to investigate parameters that might be related to incidence of mange. The best-supported models indicated that survival varied by year and by sex and that survival of males was lower during the breeding season compared to the non-breeding season. We found little support for differences in survival between juvenile (5–12 months old) and adult squirrels, or for winter severity or size of the acorn crop as significant influences on survival. We determined the likely proximate cause of death for 81 animals; 63% were killed by predators and 37% succumbed to disease, with most disease deaths attributed to mange. Mange was documented in the population during all years and occurred more frequently in animals captured in spring than in animals captured in fall. Counter to our predictions, occurrence of mange was not correlated with 2 measures of winter severity but was strongly correlated with mildness of the preceding winter (number of days with mean air temperature ≥0° C). Sequential use of nests by individual squirrels during mild winters with temperatures conducive to survival of ephemeral, free-living mites may partially explain the periodic epizootics of notoedric mange in this western gray squirrel population. Continued deterioration of squirrel habitat through fragmentation will place additional stressors on the population and may compound the effects of mange on this threatened species. © 2013 The Wildlife Society.

The Death Rattle and the Old Man's Friend

To the Editor: Sir William Osler first referred to pneumonia as “the old man's friend”—identifying it as a common cause of relatively peaceful death in the late 1800s.1 Pneumonia remains among the most common primary or proximate causes of death in 2012.2 Most pneumonias share the common feature of defeating the normally robust mechanical, cellular, and immune mechanisms to prevent infection of the lower respiratory tract. Denudation of the trachea or bronchi due to viral (e.g., influenza) infections or toxic inhalants (e.g., smoking-related injury) predisposes to bacterial superinfection and subsequent pneumonia.3 Dysphagia is also a well-studied risk for aspiration of upper aerodigestive secretions causing pneumonia,3 but little has been written about another antecedent, encountered by clinicians regularly and recognized since the time of Laennac. This is upper airway incompetence marked by the sound of air gurgling through secretions above the glottis, heard with or without the stethoscope, when individuals speak or breathe—gargouillement.4 Laennac may also have been first to connote gurgling breath sounds with death—“the death rattle.”5 There is no published research that ties the “death rattle” or gargouillement to pneumonia, even though early clinicians acknowledged this association.4, 5 One study demonstrated gurgling in 20 individuals admitted during a 5-month period to a 24-bed hospital ward; 11 developed pneumonia, and the odds of pneumonia in gurglers were 130 times those of nongurglers.6 The epidemiology of inappropriate pooling of supraglottic secretions and gurgling, rates of subglottic aspiration in such individuals, and subsequent rates of pneumonia of those who aspirate are all unknown. There are some data that describe the relationship between advancing age and disease and aspiration. For example, of 127 home-based elderly adults (mean age 84), 44% had “laryngeal penetrations” seen on nasopharyngeal endoscopy. Medications (neuroleptics), stroke, and other neurological disorders were risks, and odds of aspiration were 12 times as great in those with abnormal water swallowing tests.7 In another study, subglottic aspiration was noted in 62% of hospitalized elderly adults and 6% of ambulatory normal elderly adults. Pooled secretions in the larynx were associated with aspiration, but age was not.8 “Wet phonation” is highly associated with subglottic penetration of secretions,9 and another study showed that “none of the patients coughed or cleared their throats after penetrating/aspirating.”10 Risk factors for pathological pooling of secretions and gurgling include neurological disorders,7 dementia,6 acute nonneurological illness in elderly adults,6, 10 and sedating medications.6 There are no data to support that risk of gurgling increases with age, except insofar as diseases and medications that predispose to gurgling accumulate with age. There is abundant evidence that antipsychotics increase the risk of pneumonia, presumably by causing occult micro-aspiration.7 There is a subset of such individuals with extreme medication-induced blunting of upper respiratory reflexes unto gurgling.6 If it is accepted that gurgling breath sounds promote pneumonia and that pneumonia is a common cause of death in elderly adults, a number of research questions arise that may be of interest to those—geriatricians, internists, intensivists, palliative care clinicians—who provide care at the end of life. What are the epidemiology, risks, and reversible causes of gurgling? For reversible causes, what are countermeasures (e.g., levels of care and monitoring, medications, positions, frequent oropharyngeal suctioning) that can be taken to mitigate risk until gurgling is corrected by treating underlying causes? For irreversible causes of gurgling, is pneumonia inevitable? If so, is there any long-term benefit to treating the pneumonia with antibiotics or endotracheal intubation if it will only recur, or do such treatments simply prolong dying—inevitably of pneumonia or its complications? All who gurgle are not certain to develop pneumonia and die.6 Gargouillement may be a rattle, but not necessarily a death rattle. Perhaps a more-accurate description in 2013 is that gurgling is a “risk-of-death rattle,” and greater understanding of gurgling sounds may permit clinicians to more-deliberately identify and treat reversible causes. To the extent that gurgling may signal extreme risk,6 this clinical sign, easily recognized by simple physical examination, might also be a useful additional trigger for rapid response, assessment, and treatment for as-yet-to-be-determined reversible causes or to allow those whose gurgling portends recurrent pneumonia to die peacefully—as Osler described—without multiple endotracheal intubations and trials of death-prolonging critical care. Conflict of Interest: Dr. Manthous has no financial conflicts of interest relevant to this manuscript. Author Contributions: Dr. Manthous is responsible for the entire content of this paper. Sponsor's Role: None.

Pediatric Starvation by Neglect

Starvation due to neglect is a form of fatal child abuse. Although a thorough autopsy examination for organic causes of malnutrition is warranted, the detection or exclusion of such a disease is not determinative for the manner of death. When neglect results in these deaths, it is irrelevant for the manner determination whether the malnutrition is caused by untreated disease or by inadequate feeding. The physical appearance of the child should be documented photographically at autopsy. Autopsy measurements, vitreous analysis, radiology, scene and medical history investigations, and histologic examinations are important components of the death investigation. Secondary infections are common immediate causes of death with malnutrition, however, they should not be listed as the underlying cause of death. The proximate cause of death is malnutrition/starvation. If neglect is involved with the malnutrition, these deaths are appropriately certified as homicides.

Fatal drowning as a result of an airplane crash—Case report

An ULM (Ultra Light Motorized) plane Aeroprakt 22-L with two men on board dived unexpectedly into the Dworackie lake near the town of Olecko in Warmia and Mazury district, Northeastern Poland. The pilot and the passenger had multiorgan blunt injuries, including subdural and subarachnoid hemorrhage, fractured ribs, fractured thigh (in one of the deceased) and pulmonary contusions as a result of the impact with the lake. The multiorgan injuries and unconsciousness resulting from head trauma prevented the casualties from saving themselves. The underlying cause of the death was the crash into the lake, however drowning was assessed as the proximate cause of death. The accident was analyzed together with an account prepared by State Commission on Aircraft Accident Investigation and with the Human Factor Analysis and Classification System – HFACS (the standardized method of analysis of flight accidents, the tool originally developed and tested within the U.S. military).

Rope trauma, sedation, disentanglement, and monitoring‐tag associated lesions in a terminally entangled North Atlantic right whale (Eubalaena glacialis)

AbstractA chronically entangled North Atlantic right whale, with consequent emaciation was sedated, disentangled to the extent possible, administered antibiotics, and satellite tag tracked for six subsequent days. It was found dead 11 d after the tag ceased transmission. Chronic constrictive deep rope lacerations and emaciation were found to be the proximate cause of death, which may have ultimately involved shark predation. A broadhead cutter and a spring‐loaded knife used for disentanglement were found to induce moderate wounds to the skin and blubber. The telemetry tag, with two barbed shafts partially penetrating the blubber was shed, leaving barbs embedded with localized histological reaction. One of four darts administered shed the barrel, but the needle was found postmortem in the whale with an 80º bend at the blubber‐muscle interface. This bend occurred due to epaxial muscle movement relative to the overlying blubber, with resultant necrosis and cavitation of underlying muscle. This suggests that rigid, implanted devices that span the cetacean blubber muscle interface, where the muscle moves relative to the blubber, could have secondary health impacts. Thus we encourage efforts to develop new tag telemetry systems that do not penetrate the subdermal sheath, but still remain attached for many months.

Necropsy as a means to gain additional information about causes of dairy cow deaths

High mortality among dairy cows constitutes a problem both financially and in relation to animal welfare. Knowledge about causes of death is a fundamental step toward reducing cow mortality. Several studies have evaluated causes of dairy cow deaths. However, the vast majority of studies describing causes of death are based on questionnaires with farmers or veterinarians. It is uncertain to what degree such information is sufficient and reflects the true cause of death or euthanasia. In this study, proximate causes of death were evaluated based on a thorough necropsy of a random sample of 79 Danish dairy cows at an incineration plant. The necropsy was combined with information about the farmer’s perception regarding the cause of death and information about disease treatments from the Danish Cattle Database. Pneumonia and locomotor disorders were found to be the most predominant proximate causes of death. Often the death occurred after a prolonged period during which the cow suffered several different disorders, even though this was often not noticed by the farmer. Causes of death stated by the farmers agreed with the necropsy results in 50 to 64% of cases. Information about disease treatments from the Danish Cattle Database agreed with the necropsy results in 34 to 39% of cases. All 3 sources of information about cause of death agreed in only 1 out of 4 cases, and even when the farmer and the disease recordings did agree with the necropsy results, the latter often gave additional information about the cause of death. In many situations, therefore, a necropsy may be a valuable tool when trying to control excessive cow mortality in a herd.

Impact of anti-HLA antibodies on allogeneic hematopoietic stem cell transplantation outcomes after reduced-intensity conditioning regimens

Anti-human leukocyte antigen (HLA) antibodies are associated with several complications in solid organ transplantations, but their impact after allogeneic hematopoietic stem cell transplantation (allo-HSCT) is not yet well defined. To evaluate the relevance of anti-HLA antibodies, we have retrospectively analyzed 107 peripheral blood allo-HSCTs after reduced-intensity conditioning regimen between 2005 and 2010. Acute myeloid leukemia and multiple myeloma were the most frequent malignancies in the cohort. The detection of anti-HLA antibodies was systematically performed in all patients before transplantation. Anti-HLA antibodies were present in 24 patients (22%). There was no significant impact of anti-HLA antibodies on engraftment, incidence of relapse, and incidence of acute graft-vs-host disease. The presence of anti-HLA antibodies was associated with significantly worse overall survival (p = 0.006) and event-free survival (p = 0.024) after stratification on sex. The 3-year probability of overall survival was 34% without anti-HLA antibodies and 16% in their presence. Patients with anti-HLA antibodies had a higher transplant-related mortality associated with life-threatening vascular complications. Our study supports that anti-HLA antibodies should be tested and considered as an important impacting factor for transplantation outcomes after reduced-intensity conditioning allo-HSCT. We recommend its consideration before allo-HSCT in the donor-recipient selection parameters.

Genetic Sequence Data Identifies the Cercaria of Drepanocephalus spathans (Digenea: Echinostomatidae), A Parasite of the Double-Crested Cormorant (Phalacrocorax auritus), with Notes on its Pathology in Juvenile Channel Catfish (Ictalurus punctatus)

An unidentified xiphidio-type cercaria, previously thought inconsequential to catfish health, was found to be released from marsh rams-horn snails (Planorbella trivolvis) inhabiting ponds on a commercial catfish operation in the Mississippi Delta. A preliminary challenge of cohabiting channel catfish ( Ictalurus punctatus ) with snails actively shedding the unidentified cercariae resulted in death of some fish. A second cohabitation trial yielded similar results, as did a third challenge of 250 cercariae/fish. Histopathology revealed developing metacercariae concentrated in the cranial region, especially within the branchial chamber, with several metacercariae at the base of the branchial arches within, or adjacent to, blood vessels, possibly the proximate cause of death. Genetic sequence analysis of the 18S small subunit ribosomal DNA (ssDNA), 28S large subunit rDNA (lsDNA), and cytochrome oxidase (Cox1) genes all matched the cercariae to Drepanocephalus spathans (Digenea: Echinostomatidae), a parasite of the double-crested cormorant (Phalacrocorax auritus), a piscivorous bird endemic on most catfish farms. This is the first commentary regarding pathology of D. spathans in juvenile channel catfish as well as the first report of the marsh rams-horn snail as an intermediate host in the D. spathans life cycle. The data presented here suggest this parasite could have limiting effects on catfish production, further supporting the need for adequate snail control programs to reduce trematode prevalence on commercial catfish operations.

Ethical Challenges With Deactivation of Durable Mechanical Circulatory Support at the End of Life

Left ventricular assist devices (LVADs) and total artificial hearts (TAHs) are surgically implanted as permanent treatment of unrecoverable heart failure. Both LVADs and TAHs are durable mechanical circulatory support (MCS) devices that can prolong patient survival but also alter end-of-life trajectory. The permissibility of discontinuing assisted circulation is controversial because device deactivation is a life-ending intervention. Durable MCS is intended to successfully replace native physiological functions in heart disease. We posit that the presence of new lethal pathophysiology (ie, a self-perpetuating cascade of abnormal physiological processes causing death) is a central element in evaluating the permissibility of deactivating an LVAD or a TAH. Consensual discontinuation of durable MCS is equivalent with allowing natural death when there is an onset of new lethal pathophysiology that is unrelated to the physiological functions replaced by an LVAD or a TAH. Examples of such lethal conditions include irreversible coma, circulatory shock, overwhelming infections, multiple organ failure, refractory hypoxia, or catastrophic device failure. In all other situations, deactivating the LVAD/TAH is itself the lethal pathophysiology and the proximate cause of death. We postulate that the onset of new lethal pathophysiology is the determinant factor in judging the permissibility of the life-ending discontinuation of a durable MCS.

Synergistic Roles for G-protein γ3 and γ7 Subtypes in Seizure Susceptibility as Revealed in Double Knock-out Mice

The functions of different G-protein αβγ subunit combinations are traditionally ascribed to their various α components. However, the discovery of similarly diverse γ subtypes raises the possibility that they may also contribute to specificity. To test this possibility, we used a gene targeting approach to determine whether the closely related γ(3) and γ(7) subunits can perform functionally interchangeable roles in mice. In contrast to single knock-out mice that show normal survival, Gng3(-/-)Gng7(-/-) double knock-out mice display a progressive seizure disorder that dramatically reduces their median life span to only 75 days. Biochemical analyses reveal that the severe phenotype is not due to redundant roles for the two γ subunits in the same signaling pathway but rather is attributed to their unique actions in different signaling pathways. The results suggest that the γ(3) subunit is a component of a G(i/o) protein that is required for γ-aminobutyric acid, type B, receptor-regulated neuronal excitability, whereas the γ(7) subunit is a component of a G(olf) protein that is responsible for A(2A) adenosine or D(1) dopamine receptor-induced neuro-protective response. The development of this mouse model offers a novel experimental framework for exploring how signaling pathways integrate to produce normal brain function and how their combined dysfunction leads to spontaneous seizures and premature death. The results underscore the critical role of the γ subunit in this process.

The Utility of Routine Brain Histology in Forensic Cases

The medicolegal autopsy is part of a death investigation that determines the cause and manner of death and the extent of the testing performed is variable and is directed by the specifics of a particular case. Published studies disagree on the value of routine examination of microscopic sections of internal organs in forensic cases and no studies have specifically reviewed the utility of routine neuropathology microscopic sections. We reviewed the Miami-Dade County Medical Examiner Department and Mayo Clinic computer databases to determine whether routine brain histology is of value in medicolegal autopsies and the impact on the cause and manner of death. Consecutive cases from each institution were analyzed to determine whether the microscopic neuropathological findings revealed a previously unrecognized disease, changed the cause or manner of death, or significantly impacted the death investigation. In the cases in which the immediate cause of death was attributable to central nervous system (CNS) pathology, the cause of death was readily apparent from the gross brain examination. If CNS pathology was the proximate cause of death, contributed significantly to the death, or was a significant part of the death investigation, full appreciation of the neuropathology required microscopic examination and often additional special/immunostains. We conclude that microscopic brain examination is needed in selected medicolegal autopsies to exclude and/or diagnose underlying disease processes, particularly if the gross examination doesn't reveal an obvious explanation of the CNS pathology or the clinical history suggests underlying neuropathology.

Fatal exsanguination from hemodialysis vascular access sites

Exsanguination from hemodialysis vascular sites may cause a rapid death. Due to extensive blood loss at the scene, investigators may initially suspect a homicide or suicide. We reviewed 100 deaths due to hemorrhage from hemodialysis shunt sites. The majority (81%) of these hemorrhages occurred at home and 44% subsequently died at home. Recognition of this medical complication at the scene is important to prevent the dispatch of the crime scene or homicide unit. In these instances, the common causes of kidney failure included hypertensive cardiovascular disease and diabetes mellitus. The manners of death were certified as therapeutic complication (93%), accident (5%), and suicide (2%). These fatal shunt hemorrhages are rapid and large due to their superficial subcutaneous locations and elevated shunt pressures from the arterial-venous anastamosis. The cause of death statement must include the proximate cause of death, which is usually the disease that resulted in kidney failure, if it is known.

Fin-de-siècle Vienna and the Challenge of Family Biography

Fin-de-siècle Vienna and the Challenge of Family Biography Paul Reitter (bio) I In 1851, a middle-aged German wool trader named Hermann Christian Wittgenstein entered into a partnership of sorts with his Austrian in-laws, who also dealt in raw materials, only on a greater scale. Hermann moved to Austria, where he began giving, in today’s parlance, extreme makeovers to estates local aristocrats had neglected, with the understanding that his in-laws would help him sell the wool, coal, wood, and corn the estates produced. The arrangement worked brilliantly. Frugal and hard driving—and eager to use industrial methods in a country that had been slow to industrialize—Hermann transformed poorly tended lands into robust enterprises. Meanwhile, his in-laws not only did their part, but they thought, as well, to direct the money that came streaming in toward lucrative holdings in Viennese property. Within a few years, Hermann was able to install himself, his wife, and several of their eleven children in a palace outside Vienna. They soon left it, despite Hermann’s parsimony, for an even grander residence, a castle in which one of Empress Maria-Theresa’s prime ministers had lived. Never mind that Hermann leased the place: he had built a House of Wittgenstein. It would be hard to think of a family more deserving of a group biography. After all, Hermann Christian was far outpaced by the son from whom he expected the least—namely, Karl, who failed out of high school and ran away to America as a teenager. Not long after his return, Karl, the third of Hermann Christian’s sons, followed his father in marrying well; then, thanks to good instincts, an appetite for risk, booming [End Page 665] markets, and probably some manipulation of them, he made a fortune in the steel and banking businesses. It was a fortune of Carnegie-like dimensions that dwarfed most others in his country. After retiring at fifty-one, Karl spent the majority of his remaining days in his marble palais, which spanned more than fifty yards along Vienna’s Alleegasse. When he took his last breath, in 1913, he may have been the richest man in Austria. Imperious and hot-tempered, Karl wasn’t known for behaving gently, and neither did he die that way. He suffered much the same fate as Freud: they were both prolific cigar smokers whose health was ravaged by cancer of the jaw, though in Karl’s case the proximate cause of death was an operation that was likely to have lethal effects. That he chose to spend the evening before the surgery making music with his wife, Leopoldine, would have surprised no one. For to say that Karl and Leopoldine were deeply devoted to the arts would be as much an understatement as calling them very rich. As worshippers of culture, they were zealots. Karl’s house was so full of Kunst that he began referring to his eldest daughter (Hermine), who never married and became a kind of secretary to him, as his “art director.” The house also had seven pianos, as well as one of the world’s greatest collections of musical manuscripts. Schoenberg and Mahler were regular guests. Brahms was a family friend. Then, of course, there are the dramas and soaring accomplishments of the next generation. Three of Karl and Leopoldine’s five sons committed suicide. Precocious in music and possibly autistic, Hans, the eldest, vanished during a trip to America in 1903, and is thought to have drowned himself, though where exactly this happened remains unclear. Rudi, who was gay, poisoned himself in a Berlin bar a year later, perhaps because he believed his sexual orientation was about to be made public. Like quite a few Austrian officers, Kurt shot himself during the final days of World War One. At the time, Paul was busy resurrecting his career as a concert pianist—this despite the fact that he had lost his right arm on the Eastern Front. His younger brother Ludwig had already written his epochal Tractatus, which would appear in the early interwar period. But even as Ludwig was winning new and, as it would turn out, enduring...

Investigating the causes of death for wind turbine-associated bat fatalities

Wind turbine-associated bat mortality is occurring at unanticipated rates, yet our understanding of the causes of these fatalities is limited. The prominent proximate causes of bat deaths at wind turbines are direct collision (i.e., blunt-force trauma) and barotrauma. The objectives of this study were to use veterinary diagnostic procedures to determine the lesions associated with bats killed by wind turbines and investigate relationships between patterns of injuries and proximate causes of death. A majority of the bats (74%; 29 of 39) examined by radiology had bone fractures; most of these fractures were in the wings and none was in the hind limbs. Visual inspection resulted in 33% fewer detected bone fractures when compared with radiology results. Bats dropped from a turbine nacelle (91.44 m) to determine extent and type(s) of bone fracture did not show signs of significant bone damage. Approximately one-half (52%; 12 of 23) of bats whose ears were examined had mild to severe hemorrhaging in the middle or inner ears (or both). None of the bats found during this study had any pre-existing disease. It is difficult to attribute individual fatalities exclusively to either direct collision or barotrauma. Gross necropsy, histopathology, and radiology complement each others' deficiencies and together give the best insight into cause of death. Delayed lethal effects after nonlethal contact with wind turbines are poorly understood and difficult to quantify by mortality searches alone but can result in underestimating bat mortality caused by wind energy facilities.

Brain injuries and neurological system failure are the most common proximate causes of death in children admitted to a pediatric intensive care unit.

Mortality rates from critical illness in children have declined over the past several decades, now averaging between 2% and 5% in most pediatric intensive care units. Although these rates, and mortality rates from specific disorders, are widely understood, the impact of acute neurologic injuries in such children who die and the role of these injuries in the cause of death are not well understood. We hypothesized that neurologic injuries are an important cause of death in children. Retrospective review. Pediatric intensive care unit at Children's Hospital of Pittsburgh, an academic tertiary care center. Seventy-eight children who died within the pediatric intensive care unit from April 2006 to February 2008. None. Data regarding admission diagnosis, presence of chronic illness, diagnosis of brain injury, and cause of death were collected. Mortality was attributed to brain injury in 65.4% (51 of 78) of deaths. Ninety-six percent (28 of 29) of previously healthy children died with brain injuries compared with 46.9% (23 of 49) of chronically ill children (p < .05). The diagnosed brain injury was the proximate cause of death in 89.3% of previously healthy children and 91.3% with chronic illnesses. Pediatric intensive care unit and hospital length of stay was longer in those with chronic illnesses (38.8 ± 7.0 days vs. 8.9 ± 3.7 days and 49.2 ± 8.3 days vs. 9.0 ± 3.8 days, p < .05 and p < .001, respectively). Brain injury was exceedingly common in children who died in our pediatric intensive care unit and was the proximate cause of death in a large majority of cases. Neuroprotective measures for a wide variety of admission diagnoses and initiatives directed to prevention or treatment of brain injury are likely to attain further improvements in mortality in previously healthy children in the modern pediatric intensive care unit.

Homicide by Asthma

Asthma may be the cause of death in some homicides. Bronchial asthma is a common disease, and the National Institutes of Health have estimated that 10.5% (30.2 million) of the United States population have been diagnosed with asthma. Acute exacerbations of bronchial asthma may be rapidly fatal, and medical examiner/coroner offices commonly encounter such deaths. Though asthma is a natural disease, acute exacerbations may be triggered by outside stressors, including harmful or criminal activities such as assaults. In these instances, the manner of death is appropriately certified as homicide. We describe three homicides in which asthma was deemed to be the proximate cause of death. In each of these fatalities, the decedent was subjected to physical and/or emotional stress of a harmful or criminal nature that resulted in an acute exacerbation of asthma that resulted in their death. Medical examiners/coroners must consider the decedent's history of disease; the circumstances surrounding the death; and the autopsy, histologic, and toxicologic findings in order to properly certify the cause and manner of death. A fatality with a natural proximate cause of death still may be certified as a homicide.