Noncompaction in mitochondrial myopathy: visible on microscopy but absent on macroscopic inspection.

OBJECTIVES: Disappearance of left ventricular hypertrabeculation (LVHT) over time has been occasionally recognized, but absence on echocardiography and autopsy and presence on histological examination after autopsy has not been reported. METHODS: Routine investigations such as chocardiography, cardiac MRI and coronary angiography were applied. Autopsy studies included macroscopic inspection and dissection but also histological work-up. RESULTS: In a 64-year-old male, LVHT was diagnosed at age 51 years during diagnostic work-up for hypertrophic cardiomyopathy. He had a history of mitochondrial myopathy which was diagnosed long before the cardiac problem became evident. Thickening of the left ventricular myocardium increased over years, resulting also in thickening of the trabeculations and the disappearance of the intertrabecular recesses. This is why LVHT was no longer visible on echocardiography shortly before death at age 64 years. The autopsy revealed that macroscopically no LVHT was visible but upon histological work-up the preformed recesses were still visible but had become unfolded. CONCLUSIONS: This case shows that LVHT may disappear due to thickening of the trabeculations but may remain visible on postmortem histological examination in patients with hypertrophic cardiomyopathy from a mitochondrial myopathy.

Experimental sharp force injuries to ribs: Multimodal morphological and geometric morphometric analyses using micro-CT, macro photography and SEM.

Tool marks on bones induced by knife blades can be analysed morphometrically in order to enable an allocation of the suspected "inflicting weapon" to the particular morphology of the bone lesions. Until now, geometric morphometrics has not been used to analyse the morphology of knife lesions on fleshed bones in detail. By using twelve experimental knives and a drop weight tower, stab/cut injuries were inflicted on untreated pig ribs. The morphology of the experimentally produced lesions was subsequently recorded with three imaging techniques (µCT, macro photography and SEM) and analysed with different morphometric software (Amira, tps and Morpheus). Based on the measured distances between the walls of the kerf marks, which corresponded to the thickness of the blade, one could conclude to the respective blade thickness with a deviation of max. ±0.35mm and match the injuries to the knives. With subsequent reanalysis after maceration, an average shrinkage factor up to 8.6% was observed. Among the three imaging techniques used in this study, µCT was the most accurate and efficient technique, particularly because it represented the only non-destructive modality to document injuries without maceration, even though µCT is more expensive and time-consuming as well as less accessible than a macro SLR-camera or a SEM. For optimal characterizations of the blades' and kerfs' shapes the software tps proofed to be the best choice. Accordingly, geometric morphometrics could serve as a tool in forensic investigations concerning kerf marks.

Feasibility and efficacy of a new non-invasive surface cooling device in post-resuscitation intensive care medicine.

AIM OF THE STUDY: There is sufficient evidence that therapeutic hypothermia after non-traumatic cardiac arrest improves neurological outcome and reduces mortality. Many different invasive and non-invasive cooling devices are currently available. Our purpose was to show the efficacy, safety and feasibility using a non-invasive cooling device to control patient temperature within a range of 33-37 degrees C. MATERIALS AND METHODS: A convenience sample of patients who have been resuscitated successfully from cardiac arrest and were intended for mild hypothermia therapy according to the guidelines and inclusion criteria were studied in a prospective observational case series at an emergency department of a tertiary care university hospital. The Medivance Arctic Sun System provides a new, non-invasive approach to reach a target temperature of 33 degrees C quickly, to maintain the target temperature for 24h, and then to actively re-warm at 0.4 degrees C/h to normothermia. Cooling was applied using the Arctic Sun in 27 patients. Data are presented as median and the interquartile range (25, 75%). RESULTS: Median age was 58 (49.5, 70) years. Time from cooling start to target temperature was 137 (96, 168)min, cooling rate was 1.2 degrees C/h (0.8, 1.5), stability of target temperature during hypothermia maintenance phase was satisfactory at 33.0 degrees C (32.9, 33.1), and duration of re-warming was 428 (394, 452)min. CONCLUSION: Using the Arctic Sun System in post-resuscitation care medicine for cooling cardiac arrest survivors is feasible and has proven to be highly effective in lowering patients' temperature rapidly without inducing skin irritations.

Suicidal asphyxiation with helium: report of three cases.

Helium is an inert gas that among other things is used medically to alleviate the symptoms of airway obstruction, as part of a diving mix in deep-sea diving or as balloon gas. In recent years the so-called right-to-die literature has suggested suffocation with inhaled helium as an effective and peaceful means of self-deliverance for terminally ill patients. Helium displaces oxygen and carbon dioxide and can thus lead to asphyxia. We report three cases of suicidal asphyxiation with helium gas that were examined at the Department of Forensic Medicine Vienna within three months in 2006. In all three cases, autopsy was unrewarding from the point of view of gross pathology. Special autopsy techniques and devices are required for collection of the gas from the lungs. Gas-chromatography is used to examine the gas for helium; however, this requires replacement of the carrier gas, which is itself usually helium. The fact that three people in Vienna committed suicide using this method within a short period of time, together with the abundance of detailed how-to literature on the Internet, suggests a possible future increase in the number of deaths associated with the inhalation of inert gases, particularly helium. Because of the diagnostic obstacles involved, it is necessary to rely on good death-scene investigation for situational evidence when the body is discovered.

Evaluation of a novel tagging and tissue preservation system for potential use in forensic sample collection.

The authors describe a new, easy-to-use barcode-based tissue collection, preservation and body tracking system, which might prove instrumental in the containment of mass fatalities such as aircraft accidents, war related accidents, environmental disasters (e.g. earthquakes, hurricanes, and floods) terrorist bombings or mass murders.

Effect of temperature on development of the forensically important holarctic blow fly Protophormia terraenovae (Robineau-Desvoidy) (Diptera: Calliphoridae).

Immature development times of the blow fly Protophormia terraenovae (Robineau-Desvoidy, 1830) were studied in the laboratory at five different constant temperatures (15, 20, 25, 30, 35 degrees C). The minimal duration of development from oviposition to adult emergence was inversely related to temperature, ranging from 9.19+/-0.3 days at 35 degrees C to 37.78+/-2.96 days at 15 degrees C. From linear regression of development rates at the five studied constant temperature regimes, it followed that the minimum development threshold (t(L)) for total immature development is 8.95 degrees C ( approximately 9 degrees C) and the overall thermal constant (K) for P. terraenovae is 240.2+/-9.3 day-degrees (DD) above the threshold. Linear regression of developmental rates from oviposition to pupariation resulted in a minimum development threshold of 9.8 degrees C. However, it is possible that developmental time from oviposition to adult eclosion might be different in various regions of the world, and that the thermal constant of a holarctic species like P. terraenovae is not same everywhere. Additionally, as the present paper shows, studies characterizing variation in these parameters between geographically distinct populations of the same species would be of great value for future forensic entomological casework.

Effect of temperature on development of Liopygia (= Sarcophaga) argyrostoma (Robineau-Desvoidy) (Diptera: Sarcophagidae) and its forensic implications.

The temperature-dependent development of the forensically important flesh fly Liopygia (Thomsonea) argyrostoma (Robineau-Desvoidy) (=Sarcophaga argyrostoma) was studied at six constant temperature regimes in the laboratory. Total developmental time of L. argyrostoma from larviposition to adult emergence was 54.9+/-1.45, 31.3+/-1.1, 22.2+/-0.67, 16.3+/-0.54, and 14.9+/-0.4 days (+/-S.D.) when reared at 15, 20, 25, 30, and 35 degrees C, respectively. At 8 degrees C, larval development was not completed. From linear regression of development rates of five of the six studied constant temperature regimes, it was determined that the minimum development threshold (tL) for total immature development is 7.4 degrees C, and the overall thermal constant (K) for L. argyrostoma is 396.4+/-19.18 (mean +/- S.D.) day-degrees (DD) above the threshold.

Pathomorphologic findings in left ventricular hypertrabeculation/noncompaction of adults in relation to neuromuscular disorders.

BACKGROUND: Aim of this study was to assess pathomorphologic findings (PATHO) in patients with echocardiographically (ECHO) diagnosed left ventricular hypertrabeculation/noncompaction. METHODS: ECHO-criteria for LVHT were: >3 trabeculations, moving synchronously with the compacted myocardium, and forming the noncompacted part of a two-layered myocardium. At autopsy, the hearts were investigated according to the pathologists' preferences. RESULTS: Twelve patients (2 females, age 27-81 years) were included. Seven suffered from neuromuscular disorders, 5 patients were not investigated neurologically. The specimens were acquired after explantation during heart transplantation (n=1), death due to heart failure (n=6), sudden death (n=2), pneumonia (n=2) and stroke (n=1). Eight hearts were investigated without fixation and 4 after formaldehyde fixation. The hearts were opened along the long-axis, in 3 hearts additional short-axis cuts were carried out. At PATHO the trabecular meshwork was better visible in the formaldehyde-fixed hearts than in the fresh hearts. Differentiation from papillary muscles was easier on the long-axis cuts, whereas the two-layered structure was better visible on short-axis cuts. The trabecular pattern was similar in patients with neuromuscular disorders and those who did not undergo neurologic investigation. Subendocardial fibrosis was found in each case. Due to the complex three-dimensional geometry, it was impossible to count the number of trabeculations. CONCLUSION: Formaldehyde-fixation should be performed when comparing ECHO with PATHO findings in LVHT. Long-axis as well as short-axis cuts should be carried out in order to assess the course of trabeculations and the extent of the two-layered structure. Subendocardial fibrosis in LVHT deserves further research.

Acute type A aortic dissection and pregnancy: a population-based study.

OBJECTIVE: Pregnancy has been reported to be an independent risk factor for 50% of acute aortic dissections recorded in women younger than 45 years of age. The present epidemiologic study aimed to identify whether this putative association of pregnancy and acute type A dissection could be an artifact of selective reporting. METHODS: This population-based study was conducted in the City of Vienna, Austria, Europe, in an average female population of 34,1381 women in the age range of 15-45 years who were followed up between 1994 and 2004 (total of 3755.195 person-years of observation). During this study, the incidence, management, and outcome of acute type A dissection were determined. RESULTS: Fifteen patients (mean age: 38.8 years, SD: 4.8) with acute aortic dissection were identified, and an overall incidence of 0.4 case per 100000 person-years was estimated. The prehospital mortality rate was recorded to be 53%. Six patients, including two women in late pregnancy (incidence: 0.05 cases per 100000 person-years), were treated successfully by surgical repair during deep hypothermic circulatory arrest (in-hospital mortality rate: 6.6%). Pregnancy and aortic dissection were identified as events that were not related (RR: 3.27; 95% confidence interval (CI): 0.82-12.95; P=0.14). Observation during long-term follow-up was uneventful. CONCLUSIONS: Acute aortic dissection represents a rare pathology in women younger than 45 years of age; however, it is associated with a high rate of sudden death. Pregnancy may not be a risk factor for this life-threatening vascular emergency. Immediate referral to surgery, even during pregnancy, will result in a prognosis of favorable outcome.

Comparison of surface cooling and invasive cooling for rapid induction of mild therapeutic hypothermia in pigs--effectiveness of two different devices.

AIM OF THE STUDY: The effectiveness and safety of non-invasive surface cooling was compared to invasive endovascular cooling in an animal model. METHODS: Eight healthy pigs (29-38 kg) were cooled twice, starting in the first 4 pigs with unique surface cooling pads followed by endovascular cooling. In the second 4 pigs the order was reversed. The goal was to quickly lower pulmonary artery temperature from 38 to 33°C. A paired t-test was used to compare cooling rates (°C/h, mean±standard deviation) between both cooling techniques. RESULTS: Mean non-invasive surface cooling rate (11.9±3.8°C/h) significantly exceeded mean invasive cooling rate (3.9±0.7°C/h; p<0.001). The mean difference in cooling rates was 8.0±3.6°C/h. No surface cooling related adverse skin reactions were observed. CONCLUSIONS: Surface cooling is a simple method for achieving fast cooling rates. In our animal model, non-invasive cooling was three times faster than rapid endovascular cooling without overshoot.

Ichthyotherapy as alternative treatment for patients with psoriasis: a pilot study.

Ichthyotherapy (therapy with the so-called 'Doctorfish of Kangal', Garra rufa) has been shown to be effective in patients with psoriasis in the Kangal hot springs in Turkey. This study evaluates the efficacy and safety of ichthyotherapy in combination with short-term ultraviolet A sunbed radiation in the treatment of psoriasis under controlled conditions. We retrospectively analyzed 67 patients diagnosed with psoriasis who underwent 3 weeks of ichthyotherapy at an outpatient treatment facility in Lower Austria between 2002 and 2004. Main outcome measures are as follows: overall relative reduction in Psoriasis Area Severity Index (PASI) score; proportion of patients with an improvement in their PASI score of >/=75% (PASI-75) and >/=50% (PASI-50); patient-reported outcomes assessed with a custom questionnaire; and patient follow-up with a questionnaire sent out in March 2005. Safety was evaluated by reviewing adverse events and vital signs. Overall there was a 71.7% reduction in PASI score compared to baseline (P < 0.0001). Of the 67 patients studied, 31 (46.3%) achieved PASI-75 and 61 patients (91%) achieved at least PASI-50. Patients reported substantial satisfaction with the treatment. The reported mean remission period was 8.58 months [95% confidence interval (CI) 6.05-11.11]. A total of 87.5% of patients reported a more favorable outcome with ichthyotherapy, when asked to compare ichthyotherapy to other previously tried therapies. Sixty-five percent stated that after the relapse their symptoms were less severe than before treatment. There were no significant adverse events. The benefit demonstrated in this study along with the favorable safety profile suggests that ichthyotherapy could provide a viable treatment option for patients with psoriasis.

[Wound healing by steril fly larvas: basic mechanical, biochemical and microbiological principles]. / Wundheilung durch sterile Fliegenlarven: mechanische, biochemische und mikrobiologische Grundlagen.

Recently an old treatment for refractory wounds, the so-called "Maggot-Therapy", once again received attention in medical literature. It seems, that the biggest obstacle for a broad clinical use of fly larvae of the species Lucilia sericata in wound treatment is the lack of knowledge about the biology of these animals and the underlying mechanisms with respect to wound therapy. In this review, the known and possible mechanisms of action of Maggot-Therapy are presented and opportunities for further research are discussed.

The blowfly Chrysomya albiceps (Wiedemann) (Diptera: Calliphoridae) as a new forensic indicator in Central Europe.

During the summer months of the year 2001, six forensic cases (one is reported in the present paper), a pig carrion study in the city of Vienna (latitude 48 degrees 12'N, longitude 16 degrees 22'E) and several liver-baited traps north of Vienna, yielded large numbers of maggots of the blowfly Chrysomya albiceps (Wiedemann) (Diptera: Calliphoridae). Apart from some records from France, reports of C. albiceps from the palearctic region north of the Alps (i.e. north of a latitude of 48 degrees N) have been scarce. Our findings provided an opportunity to derive developmental schedules for C. albiceps at five different constant temperatures (15, 20, 25, 30, 35 degrees C). The minimal duration of development from oviposition to adult was inversely related to temperature, ranging from 8.3 +/- 0.5 days at 35 degrees C to 19.2 +/- 0.92 days at 20 degrees C. Although eggs hatched after 1.9 +/- 0.16 days at 15 degrees C, larvae did not complete development and frequently died during the first instar stage. We also found a high mortality rate (up to 99%) of native L. sericata larvae caused by predation of C. albiceps larvae under laboratory conditions, indicating a high susceptibility of L. sericata to attack by C. albiceps. Apart from this, the current and possible future distribution of C. albicepsin Europe is discussed. The northward expansion of its range beyond southern Europe obviously decreases the value of C. albiceps in estimating the site of death, in that it is no longer exclusive to southern European regions. Moreover, the aggressive feeding behaviour of second and third instar larve of C. albiceps could reset the post-mortem insect clock by clearing a corpse of all earlier arrivers.