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The sutured linear incisions are due to organ donation with retrieval of bone and soft tissues generic 600 mg sustiva with visa. Note the white dis- coloration from chemical burns at the lips purchase sustiva 600mg free shipping, mouth order 600 mg sustiva visa, tongue buy 200 mg sustiva with mastercard, and esophagus. His leg contacting the ladder completed the circuit through his heart, producing a fatal arrhythmia. The decedents fell to the ground lifeless within about 15–20 seconds after contact. These are examples of second- to third- degree postmortem burns due to being submerged in warm to hot water. Note the pictures demonstrate red discoloration with skin slippage and a sharply demar- cated border defning the submerged and unsubmerged areas. To help the viewer distinguish between these regions we placed a line adjacent to this demarcation. Individuals who drown in bathtubs have some contributing factor dictating why they could not keep their head above the water. The above demonstrates an antemortem subdural hematoma altered by extensive postmortem thermal injuries. Various poisons such as carbon uptake or use, together with decreased carbon dioxide monoxide or cyanide interfere with oxygen uptake and elimination. Airway obstruction may occur by smothering, neck Chest compression can produce asphyxia by prevent- compression, foreign body aspiration, excess secretions ing air fow into the lungs. Smothering is defned as Neck compression, as with hanging and strangu- external occlusion of the mouth and/or nose, which lation, can also produce asphyxia by obstruction of prevents air exchange. Children may aspirate foreign various neck structures, including the airway, venous bodies such as peanuts, hotdogs, popcorn, watch bat- circulation, and arterial circulation. Adults Interpretation of autopsy fndings with respect to who aspirate food are usually neurologically compro- hanging vs. Each sub- mised (Alzheimer, Parkinson, brain infections, malig- heading below will describe the presenting classic and nancies, etc. Airway obstruction due to most common features of each, and then elaborate on excess mucus or swelling, as with asthma, anaphylaxis, less common features. Also, various there is overlap between how the two present; depend- body positions may produce airway obstruction or the ing on how the act is carried out, they may appear very inability to expand one’s chest (positional asphyxia) as similar. In establishing the manner of death, one should with occupants of motor vehicles trapped afer colli- consider all aspects of the case including the past medi- sions or intoxicated people passing out and sliding into cal history (i. Autopsy fndings associated with smothering may Hanging refers to ligature compression of the neck be very subtle or nonexistent. Findings may include mitigated by the gravitational forces of the hanging abrasions around the nose and/or mouth that cannot head, causing partial or complete obstruction of the be explained by other means (e. Great force is applied to the mouth and lips, which In a typical nonjudicial suicidal hanging an indi- may cause tears to the frenulum of the lip, the mucous vidual places a ligature with a slip knot encircling the membrane that connects the inside of the lip to the cor- superior aspect of his or her neck. Smothering may occur with the use the other end of the rope to a fxed support and allows the of hands or by placing an object over a face, such as a entire or partial body weight to pull downward, occlud- pillow. In this case there should be furrow pattern that structures compressed, there may or may not be pete- matches the overlying ligature, which forms an inverted chiae present on the skin of the face, mucous mem- “V” mark or indentation, extending upward at the supe- branes, or in the eyes. With the entire body in size and strength between the perpetrator and the vic- weight pulling downward, all of the neck structures (i. Tere are typically no hemorrhages or with little ability to efectively defend with struggle. It is fractures of the neck structures or other injuries to the important that in cases of suspected smothering, experi- body indicating a struggle. Te cervical vertebrae are enced police interrogators and medical investigators per- rarely fractured in suicidal hangings. In cases where autopsy fndings are hangs for longer periods of time, the furrow indenta- very subtle, well-documented descriptions of the circum- tion becomes more prominent. A wide, sof as methane or carbon dioxide will displace oxygen ligature will leave less of a mark than a narrow, more from the air and produce asphyxia by depletion or resistant ligature. If the body is lef to hang for days, 477 478 Color Atlas of Forensic Medicine and Pathology decomposition with stretching may eventually lead to around the neck. Tese external marks can In the case of a judicial hanging, the body is dropped be somewhat variable and can range from a few to many. In situations where dominating, ofen non-premeditated, way of killing the body is adjacent to another structure, the individual somebody. Tis act takes time and comes with the risk may partially pull his or her body up and down, caus- of injury to all those involved. Te individual strangled ing varying degrees of pressure–release before loss of is usually smaller and of weaker strength. Tis will produce a similar efect to what component to the assault exists and a rape kit should is seen in strangulation. Venous are usually hemorrhages in the strap muscles of the neck, circulation requires the least amount of pressure for and there may be fractures of the laryngeal cartilages occlusion, as compared to the arterial system and the and/or hyoid bone. When venous circulation is obstructed and arte- in older victims because the cartilages are more calci- rial circulation is not, the higher pressure arterial blood fed, brittle, and less elastic. Older people may also have beats through the capillary beds, rupturing small blood osteoporosis.

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The results and sample sizes were as follows: n ¼ 31; s2 ¼ 35; 000 1 1 n ¼ 41; s2 ¼ 20; 000 2 2 Construct the 95 percent confidence interval for the ratio of the two population variances cheap 600 mg sustiva overnight delivery. Glucose responses to oral glucose were recorded for 11 patients with Huntington’s disease (group 1) and 13 control subjects (group 2) discount sustiva 600 mg overnight delivery. Statistical analysis of the results yielded the following sample variances: s2 ¼ 105; s2 ¼ 148 sustiva 600mg otc. Construct the 95 percent confidence interval for the ratio of the two 1 2 population variances sustiva 600 mg overnight delivery. Measurements of gastric secretion of hydrochloric acid (milliequivalents per hour) in 16 normal subjects and 10 subjects with duodenal ulcer yielded the following results: Normal subjects: 6. The concepts and methods involved in the construction of confidence intervals are illustrated for the following parameters: means, the difference between two means, proportions, the difference between two proportions, variances, and the ratio of two variances. In addition, we learned in this chapter how to determine the sample size needed to estimate a population mean and a population proportion at specified levels of precision. We learned, also, in this chapter that interval estimates of population parameters are more desirable than point estimates because statements of confidence can be attached to interval estimates. Define the following: (a) Reliability coefficient (b) Confidence coefficient (c) Precision (d) Standard error (e) Estimator (f) Margin of error 6. What are the assumptions underlying the use of the t distribution in estimating a single population mean? What are the assumptions underlying the use of the t distribution in estimating the difference between two population means? Arterial blood gas analyses performed on a sample of 15 physically active adult males yielded the following resting PaO2 values: 75; 80; 80; 74; 84; 78; 89; 72; 83; 76; 75; 87; 78; 79; 88 Compute the 95 percent confidence interval for the mean of the population. Of 70 manufacturing plants of a certain type visited, 21 received a “poor” rating with respect to absence of safety hazards. Construct a 95 percent confidence interval for the population proportion deserving a “poor” rating. How large a sample would be required to estimate the population proportion to within. In a dental survey conducted by a county dental health team, 500 adults were asked to give the reason for their last visit to a dentist. Of the 220 who had less than a high-school education, 44 said they went for preventative reasons. Of the remaining 280, who had a high-school education or better, 150 stated that they went for preventative reasons. Construct a 95 percent confidence interval for the difference between the two population proportions. A breast cancer research team collected the following data on tumor size: Type of Tumor n x s A 21 3. A certain drug was found to be effective in the treatment of pulmonary disease in 180 of 200 cases treated. Seventy patients with stasis ulcers of the leg were randomly divided into two equal groups. At the end of the experiment, treatment effectiveness was measured in terms of reduction in leg volume as determined by water displacement. The means and standard deviations for the two groups were as follows: Group (Treatment) x s A cc B 125 cc 30 Construct a 95 percent confidence interval for the difference in population means. What is the average serum bilirubin level of patients admitted to a hospital for treatment of hepatitis? A sample of 10 patients yielded the following results: 20:5; 14:8; 21:3; 12:7; 15:2; 26:6; 23:4; 22:9; 15:7; 19:2 Construct a 95 percent confidence interval for the population mean. Determinations of saliva pH levels were made in two independent random samples of seventh-grade schoolchildren. Sample A children were caries-free while sample B children had a high incidence of caries. An independent random sample of 16 patients with the same complaint received drug B. The number of hours of sleep experienced during the second night after treatment began were as follows: A: 3. For the 52 women who received oral misoprostol, the mean time in minutes to active labor was 358 minutes with a standard deviation of 308 minutes. For the 53 women taking oxytocin, the mean time was 483 minutes with a standard deviation of 144 minutes. Construct a 99 percent confidence interval for the difference in mean time to active labor for these two different medications. Over a 2-year period, 34 European women with previous gestational diabetes were retrospectively recruited from West London antenatal databases for a study conducted by Kousta et al. Women older than 65 years of age who were long-term residents were invited to participate if they had no diagnosis of terminal cancer or metastatic disease. Construct a 95 percent confidence interval for the percent of women with vitamin D deficiency in the population presumed to be represented by this sample. In a study of the role of dietary fats in the etiology of ischemic heart disease the subjects were 60 males between 40 and 60 years of age who had recently had a myocardial infarction and 50 apparently healthy males from the same age group and social class. The data on this variable were as follows: Subjects with Myocardial Infarction Subject L. What do these data suggest about the levels of linoleic acid in the two sampled populations? The purpose of a study by Tahmassebi and Curzon (A-33) was to compare the mean salivary flow rate among subjects with cerebral palsy and among subjects in a control group. The following table gives the mean flow rate in ml/minute as well as the standard error. Curzon, “The Cause of Drooling in Children with Cerebral Palsy—Hypersalivation or Swallowing Defect?

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For apical fixation generic 200mg sustiva with amex, the surgeon palpates the location of interest then identifies the sacrospinous ligament at least 2 cm medial to the ischial spine purchase 200 mg sustiva with amex. The mesh arms are slowly and individually adjusted to a loose tension generic 200 mg sustiva fast delivery, and then the mesh is sutured flat sustiva 600mg fast delivery. Cystoscopy with visualization of ureteral flow is performed to ensure integrity of the bladder and ureters. Retropubic surgeries such as the Burch colposuspension are discussed in Chapter __. The preparation for vaginal paravaginal repair begins as for an anterior colporrhaphy. Marking sutures are placed on the anterior vaginal wall on each side of the urethrovesical junction, identified by the location of the Foley balloon after gentle traction is placed on the catheter (Figure 82. In patients who have had a hysterectomy, marking sutures are also placed at the vaginal apex. If a culdeplasty or apical suspension procedure is being performed, the stitches are placed but not tied until completion of the paravaginal repair and closure of the anterior vaginal wall. As for anterior colporrhaphy, vaginal flaps are developed by incising the vagina in the midline and dissecting the vaginal muscularis laterally. The dissection is performed bilaterally until a space is developed between the vaginal wall and retropubic space. Blunt dissection using the surgeon’s index finger is used to extend the space anteriorly along the ischiopubic rami, medially to the pubic symphysis, and laterally toward the ischial spine. If the defect is present and dissection is occurring in the appropriate plane, one should easily enter the retropubic space, visualizing retropubic, and paravaginal adipose tissue. After dissection is complete, midline plication of the bladder adventitia can be performed, either at this point or after placement and tying of the paravaginal sutures (Figure 82. Retraction of the bladder and urethra medially is best accomplished with the Breisky–Navratil retractor, and posterior retraction could be provided with a lighted right-angle retractor. If the white line is detached from the pelvic sidewall or clinically not felt to be durable, then the attachment should be to the fascia overlying the obturator internus muscle. The placement of subsequent sutures is aided by placing tension on the first suture. A series of three to six stitches are placed and held, working anteriorly along the white line from the ischial spine to the level of the urethrovesical junction (Figure 82. Starting with the most anterior stitch, the surgeon picks up the edge of the periurethral tissue (vaginal muscularis or pubocervical fascia) at the level of the urethrovesical junction and then tissue from the undersurface of the vaginal flap at the previously marked sites. Subsequent stitches move posteriorly until the last stitch closest to the ischial spine is attached to the vagina nearest the apex, again using the previously placed marking sutures for guidance. Stitches in the vaginal wall must be placed carefully to allow adequate tissue for subsequent midline vaginal closure. After all the stitches are placed on one side, the same procedure is carried out on the other side. The stitches are then tied in order from the urethra to the apex, alternating from one side to the other. The vaginal flaps are trimmed and closed with a running subcuticular or interlocking delayed absorbable suture. Cystoscopy Cystoscopy with visualization of ureteral flow is usually performed after cystocele repair, especially if slings or apical suspension procedures are also being performed. The purpose is to ensure that no sutures or mesh have been placed in the bladder and to verify patency of both ureters. Intraoperative release of the offending sutures almost always releases the obstruction without further sequelae. Few studies have addressed the long-term success of surgical treatments for anterior vaginal prolapse. While the majority of studies evaluating anterior vaginal prolapse repairs are uncontrolled series, an increasing number of randomized surgical trials have been done in recent years. Success rates vary considerably depending upon the outcome measure used to define success. Historically, most studies evaluating the treatment of pelvic organ prolapse have focused exclusively on anatomic success without considering other important areas such as symptoms, vaginal compliance, quality of life, or socioeconomic outcomes. For an individual patient, the most important outcome of a surgical procedure is the relief of her symptoms and improvement in her quality of life, yet until recently these areas have largely been ignored. Reported success rates for native-tissue anterior colporrhaphy range from 37% to 100% with most cohorts reporting success rates greater than 80%. Standard anterior colporrhaphy resulted in 30% of patients with an optimal or satisfactory anatomic result; anterior colporrhaphy with polyglactin 910 mesh overlay had 42% optimal or satisfactory result and ultralateral plication under tension a 46% optimal or satisfactory result. No difference was seen in anatomic or functional outcomes and most patients reported satisfaction with their symptom improvement. The low success rates found in the trial are used as evidence that anterior colporrhaphy should be augmented by either synthetic mesh or another approach used (e. Long-term results of anterior colporrhaphy are largely unknown, although Gotthart et al. No randomized trials have been performed evaluating the efficacy of paravaginal defect repair for the treatment of anterior vaginal prolapse. Single-center uncontrolled case series suggest good anatomic results for both open retropubic (success rate 75%–97%) and vaginal (success rate 67%–100%) approaches [33,34]. However, the vaginal approach appears to be associated with high risk of hemorrhage, with one series reporting a 21% blood transfusion rate [33]. Few data are available on the efficacy or safety of the laparoscopic or robotic paravaginal defect repair. Two studies evaluated the use of absorbable polyglactin 910 mesh to augment anterior colporrhaphy and reported mixed results.

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It should be considered as the last step in situations where conversion seems inevitable sustiva 200mg on-line. The combined use of the irrigation and suction device and the fnger is particularly use- ful to break the loculations and aspirate the pus cheap sustiva 600 mg without a prescription. The greater hazard of laparoscopic appendectomy is the possibility of residual intraabdominal infection leading to pelvis abscess 600mg sustiva fast delivery. The problem is that some of the infected irrigation fuid is left behind in the pelvis discount sustiva 200 mg free shipping, further contributing to the risk of pelvic abscess. The patient is placed in Trendelenberg position and the surgeon who was looking to the right side now looks at the pelvis (Fig. Using both trocars, the sigmoid colon is retracted with the left hand, thus exposing the cul de sac (Fig. This maneuver will dramatically reduce the risk of intra abdominal abscess especially in the pelvis. The supra-hepatic area is also checked for the presence of purulent fuid that needs to be suctioned. The monitor is moved to the feet, where the surgeon then looks 128 Chapter 7  Appendectomy Fig. The entire appendix is exteriorized and ligated out- side the abdomen before the cecum is pushed back inside the abdomen (Fig. For this reason, maneuvers should be minimized while pulling the appendix out of the incision. Ann Surg 248(5):800–806 Fujita T (2009) Is laparoscopic appendectomy associated with better outcomes? Ann Surg 249(5):867 Fujita T, Yanaga K (2007) Appendectomy: negative appendectomy no longer ignored. Ann Surg 219(6):725–728 Gotz F, Pier A, Bacher C (1990) Modifed laparoscopic appendicectomy in surgery. Am J Surg 180:456–459 Katkhouda N, Mavor E, Campos G, Mason R, Waldrep D (1999) Finger assisted laparos- copy (fngeroscopy) for treatment of complicated appendicitis. Br J Surg 81(1):133–135 Lukish J, Powell D, Morrow S, Cruess D, Guzzetta P (2007) Laparoscopic appendectomy in children: use of the endoloop vs the endostapler. Consensus Development Conferences on laparoscopic cholecystectomy, appendec- tomy, and hernia repair. Surg Laparosc Endosc 6(3):205–209 Sleem R, Fisher S, Gestring M, Cheng J, Sangosanya A, Stassen N, Bankey P (2009) Perforated appendicitis: is early laparoscopic appendectomy appropriate? Br J Surg 83(9):1169–1170 Towfgh S, Formosa C, Katkhouda N, Kelso R, Sohn H, Berne T (2008) Obesity should not infuence management of appendicitis. Surg Endosc 22:2601–2605 Towfgh S, Chen F, Mason R, Katkhouda N, Chan L, Berne T (2006) Laparoscopic appen- dectomy signifcantly reduces length of stay for perforated appendicitis. Surg Endosc 20:495–499 Wagner M, Aronsky D, Tschudi J, Metzger A, Klaiber C (1996) Laparoscopic stapler appen- dectomy. Am J Surg 196(2):218–222 Zaninotto G, Rossi M, Anselmino M et al (1995) Laparoscopic versus conventional sur- gery for suspected appendicitis in women. Surg Endosc 9(3):337–340 Colorectal Procedures 8 Principles of Triangulation of ports and the creation of appropriate working space by tilting the Laparoscopic table and using gravity for organ retraction are concepts now familiar to the reader. Colectomies These principles govern the techniques of laparoscopic colorectal procedures. The surgeon uses both hands with the camera positioned between them, always posi- tioned on the opposite side of the lesion. For both left and right colectomies, the frst assis- tant stands facing the surgeon. The assistant is therefore watching the monitors in mirror fashion, and all his or her maneuvers are slowed down. It is neces- sary to use the traction countertraction concept, whereby the surgeon pulls on one side and the assistant asserts gentle traction on the opposite side to put the tissue under tension. The patient is placed in the supine position in such a way that the team can move around Right the patient with ease. The surgeon stands on the patient’s left, watching the monitor on Hemicolectomy the other side (Fig. The operation can be performed in two fashions: medial to lateral or lateral to medial. In the medial to lateral technique, the peritoneal adhesions of the colon to the abdominal wall are used as counter-traction while dissecting and dividing the ileocolic vessels. The patient is placed in Trendelenberg and right side up to remove the small bowel from pelvis and right lower quadrant. First, the terminal ileum is grasped with the left hand and pulled towards the anterior abdominal wall placing tension on the ileo- colic vessels. For this, the patient is put in the Trendelenburg, right side up position, putting the cecum under tension and facilitating the dissection. Once again, this puts the appropriate tension on the hepatic fexure to assist the dissection. The mesocolon should now be clearly identifable, and if the patient is not too obese, it is possible to perform intra-abdominal division of the vessels with vascular staplers. Otherwise, if mobilization of the colon is suffcient, it is possible to deliver the whole right colon and the terminal ileum through a right upper quadrant muscle splitting incision, followed by an anasto- mosis outside the abdomen.

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