Validity of a minimally invasive autopsy for cause of death determination in stillborn babies and neonates in Mozambique: An observational study

Over 5 million stillbirths and neonatal deaths occur annually. Limited and imprecise information on the cause of these deaths hampers progress in achieving global health targets. Complete diagnostic autopsies (CDAs)-the gold standard for cause of death determination-are difficult to perform in most high-burden settings. Therefore, validation of simpler and more feasible methods is needed. Methods and findings: In this observational study, the validity of a minimally invasive autopsy (MIA) method in determining the cause of death was assessed in 18 stillbirths and 41 neonatal deaths by comparing the results of the MIA with those of the CDA. Concordance between the categories of diseases obtained by the 2 methods was assessed by the Kappa statistic, and the sensitivity, specificity, positive, and negative predictive values of the MIA diagnoses were calculated. A cause of death was identified in 16/18 (89%) and 15/18 (83%) stillborn babies in the CDA and the MIA, respectively. Fetal growth restriction accounted for 39%, infectious diseases for 22%, intrapartum hypoxia for 17%, and intrauterine hypoxia for 11% of stillborn babies. Overall, the MIA showed in this group a substantial concordance with the CDA (Kappa = 0.78, 95% CI [0.56-0.99]). A cause of death was identified in all (100%) and 35/41 (85%) neonatal deaths in the CDA and the MIA, respectively. In this group, the majority of deaths were due to infectious diseases (66%). The overall concordance of the MIA with the CDA in neonates was moderate (Kappa = 0.40, 95% CI [0.18-0.63]). A high percentage of accuracy was observed for the MIA in all the diagnostic categories in both stillbirths and neonates (>75%). The main limitation of this study is that some degree of subjective interpretation is inherent to cause-of-death attribution in both the MIA and the CDA; this is especially so in stillbirths and in relation to fetal growth restriction. Conclusions: The MIA could be a useful tool for cause-of-death determination in stillbirths and neonatal deaths. These findings may help to accelerate progress towards meeting global health targets by obtaining more accurate information on the causes of death in these age groups, which is essential in guiding the design of new interventions and increasing the effectiveness of those already implemented.

Validity of a minimally invasive autopsy tool for cause of death determination in pediatric deaths in Mozambique: An observational study

Background: In recent decades, the world has witnessed unprecedented progress in child survival. However, our knowledge of what is killing nearly 6 million children annually in low- and middle-income countries remains poor, partly because of the inadequacy and reduced precision of the methods currently utilized in these settings to investigate causes of death (CoDs). The study objective was to validate the use of a minimally invasive autopsy (MIA) approach as an adequate and more acceptable substitute for the complete diagnostic autopsy (CDA) for pediatric CoD investigation in a poor setting. Methods and findings: In this observational study, the validity of the MIA approach in determining the CoD was assessed in 54 post-neonatal pediatric deaths (age range: ≥1 mo to 15 y) in a referral hospital of Mozambique by comparing the results of the MIA with those of the CDA. Concordance in the category of disease obtained by the two methods was evaluated by the Kappa statistic, and the sensitivity, specificity, and positive and negative predictive values of the MIA diagnoses were calculated. A CoD was identified in all cases in the CDA and in 52/54 (96%) of the cases in the MIA, with infections and malignant tumors accounting for the majority of diagnoses. The MIA categorization of disease showed a substantial concordance with the CDA categorization (Kappa = 0.70, 95% CI 0.49-0.92), and sensitivity, specificity, and overall accuracy were high. The ICD-10 diagnoses were coincident in up to 75% (36/48) of the cases. The MIA allowed the identification of the specific pathogen deemed responsible for the death in two-thirds (21/32; 66%) of all deaths of infectious origin. Discrepancies between the MIA and the CDA in individual diagnoses could be minimized with the addition of some basic clinical information such as those ascertainable through a verbal autopsy or clinical record. The main limitation of the analysis is that both the MIA and the CDA include some degree of expert subjective interpretation.

Incidental diffuse esophageal intramural pseudodiverticulosis. A rare autopsy finding / Pseudodiverticulosis intramural difusa esofágica incidental. Un raro hallazgo de autopsia

Esophageal intramural pseudodiverticulosis (EIPD) is a rare condition of uncertain etiopathogenesis which usually presents with either intermittent or progressive dysphagia. A review of the literature revealed very few studies of its histopathology. We report the case of a 70-year-old diabetic man who died after a road traffic accident. The patient had no history of dysphagia. The entity was discovered incidentally during the medico-legal autopsy. The esophagus showed numerous dilated pseudodiverticula confined to the submucosa and lined by both stratified squamous and cuboidal epithelium. EIPD can remain stable and asymptomatic. This case demonstrates the importance of a thorough investigation during a forensic autopsy (AU)

La pseudodiverticulosis intramural esofágica (PDIE) es un raro proceso de etiopatogénesis incierta que generalmente se manifiesta con disfagia intermitente o progresiva. Una revisión de la literatura ha revelado muy pocos casos publicados mostrando el aspecto histológico de esta condición. Presentamos el caso de un varón de 70 años de edad, diabético, que falleció tras un accidente de tráfico. El paciente no tenía historia de disfagia. La entidad fue descubierta incidentalmente al practicar la autopsia médico-legal. El esófago mostraba numerosos pseudodivertículos confinados a la submucosa y tapizados por epitelio estratificado escamoso y cuboideo. La PDIE puede permanecer estable y asintomática. Este caso demuestra la importancia de una exhaustiva investigación en la autopsia forense (AU)

Autopsia judicial y autopsia clínica / Forensic autopsy and clinical autopsy

No disponible

Autopsia médico-legal en casos de supuesta mala praxis médica / Medico-legal autopsy in suspected medical malpractice

No disponible

Correlación radiológico-neuropatológica. Lesión traumática de la médula espinal / Radiological-neuropathological correlation. Traumatic injury of the spinal cord

Se presentan los hallazgos neuropatológicos de la autopsia de una mujer de 80 años de edad que, tras una caída casual en su domicilio, sufrió un síndrome de compresión medular agudo, falleciendo 9 días después del ingreso en el contexto de un cuadro respiratorio agudo. Se realizó estudio neuropatológico mediante extracción del bloque cervical, congelación y cortes sagitales seriados del bloque para evaluación de las lesiones traumáticas. El caso mostró una buena correlación con los estudios de neuroimagen efectuados. El examen macroscópico de la columna cervical constató la presencia de diversas roturas discales y del ligamento longitudinal anterior, diversos focos hemorrágicos paravertebrales, epidurales y centromedulares, y una compresión aguda del cordón medular, sugiriendo un mecanismo lesivo de aceleración anteroposterior del raquis. La remoción y el estudio del bloque cervical, en casos de sospecha de patología traumática, ofrece al patólogo las ventajas de un segundo tiempo de autopsia, la posibilidad de comparar con los diagnósticos de neuroimagen y, en última instancia, una óptima evaluación de las lesiones neuropatológicas. Implementar la correlación radiológico-patológica en el campo de la neuropatología forense puede contribuir al conocimiento epidemiológico y etiopatológico de las lesiones traumáticas del sistema nervioso central (AU)

We report the neuropathological findings in a 80-years-old woman with acute spinal cord compression after an accidental fall at home, who died of acute respiratory failure 9 days after admission. Neuropathological examination was performed by cervical bloc removal, and the examination of frozen serial sagittal sections to assess the presence of traumatic injuries. The case showed a good correlation with previous imaging studies. Gross examination of the cervical spine confirmed the presence of numerous disc lesions and anterior longitudinal ligament rupture, several paravertebral, epidural and centromedullar hemorrhagic foci, and an acute compression of the spinal cord, suggesting an anteroposterior acceleration mechanism of injury of the spine. The removal and study of the cervical block in cases of suspected traumatic pathology, offers the advantages of a second time autopsy, the opportunity to compare with the diagnostic imaging, and ultimately an optimal evaluation of histopathological changes. Implementing radiologic-pathologic correlation in the field of forensic neuropathology, could contribute to the epidemiological and etiopathologic knowledge of the central nervous system injuries (AU)

Common Postmortem Computed Tomography Findings Following Atraumatic Death: Differentiation between Normal Postmortem Changes and Pathologic Lesions

Computed tomography (CT) is widely used in postmortem investigations as an adjunct to the traditional autopsy in forensic medicine. To date, several studies have described postmortem CT findings as being caused by normal postmortem changes. However, on interpretation, postmortem CT findings that are seemingly due to normal postmortem changes initially, may not have been mere postmortem artifacts. In this pictorial essay, we describe the common postmortem CT findings in cases of atraumatic in-hospital death and describe the diagnostic pitfalls of normal postmortem changes that can mimic real pathologic lesions.

Asfixia por un pólipo fibrovascular gigante de la hipofaringe / Asphyxiation due to a giant fibrovascular polyp of the hypopharynx

La asfixia mecánica debida a factores intrínsecos tales como los tumores de la hipofaringe es poco frecuente. Presentamos un caso de muerte súbita en un varón de mediana edad que se atragantó mientras comía. La autopsia médico-legal reveló la presencia de un pólipo fibrovascular gigante (PFV) en la glotis que no estaba diagnosticado. El tallo del tumor se originaba a partir de la mucosa hipofaringea. La muerte fue considerada natural. El PFV es una masa tumoral muy rara que puede alcanzar un gran tamaño, y potencialmente bloquear la entrada laríngea. Hasta donde llega nuestro conocimiento, solo han sido publicados 13 casos de asfixia debida a aspiración de un PFV (AU)

Mechanical asphyxia due to intrinsic factors such as tumors of the hypopharynx is an uncommon situation. Here, we report a case of sudden death in a middle-aged man who began to choke while eating. The medico-legal autopsy revealed an undiagnosed giant pedunculated fibrovascular polyp (FVP) impacted in the glottis. The stalk of the tumor originated from hypopharynx mucosa. The cause of death was ruled natural. FVP is a very rare benign tumor-like condition that can reach a large size and potentially block the laryngeal inlet. To our knowledge, only 13 cases of asphyxia due to aspiration of a FVP have been reported (AU)

Autopsia cardiaca en patología forense / Cardiac autopsy in forensic pathologhy

El estudio del corazón es esencial en la investigación de un gran número de autopsias judiciales, especialmente en los casos de muerte súbita cardiaca. Un estudio óptimo requiere un examen macroscópico y microscópico protocolizado. El objetivo de este artículo es presentar unos conceptos básicos sobre el procedimiento de estudio del corazón, con el fin que los médicos forenses estén familiarizados con el mismo(AU)

The study of the heart is essential in the investigation of a large number of forensic autopsies, especially in cases of sudden cardiac death. An optimal study requires a protocolized macroscopic and microscopic examination. The aim of this article is to present some basic concepts about the procedure for examining the heart, thus ensuring the forensic physicians are familiar with it(AU)

Leiomiosarcoma de la vena cava inferior. Presentación de un caso y revisión del cuadro clinicopatológico / Leiomyosarcoma of the inferior vena cava. A case report and review of the clinical and pathological features

Se presenta el caso de un hombre de 63 años de edad con leiomiosarcoma de la vena cava inferior que falleció por síndrome de vena cava inferior secundario al tumor. Se realizó el estudio de autopsia donde se demuestra el sitio primario de la neoplasia, así como reacciones de inmunohistoquímica para confirmar su estirpe histológica. Se hace una revisión de la literatura, ilustrando las características morfológicas, y se discuten los diagnósticos diferenciales(AU)

We present a case of leiomyosarcoma of the inferior vena cava in a 63 year old man who subsequently died due to vena cava syndrome secondary to the tumour. Autopsy revealed the primary neoplasm, and immunohistochemistry confirmed the histological diagnosis. Morphology and differential diagnosis are discussed together with a review of the literature(AU)

Adaptación y Validación de la Semi-Structured Interview for Psychological Autopsy (SSIPA) en Español / Adaptation and Validation of the Semi- Structured Interview for Psychological Autopsy (SSIPA) in Spanish

Introducción: Objetivo. El objetivo de este trabajo es adaptar y validar en español la Semi-structured Interview for Psychological Autopsy (SSIPA) (Entrevista Semi-Estructurada para Autopsia Psicológica). Métodos. El instrumento está constituido por 69 ítems divididos en 4 módulos: precipitantes y estresores, motivación, letalidad e intencionalidad. Se realizó traducción y retrotraducción del instrumento original, y discusión del cuestionario resultante por un grupo de expertos. El instrumento adaptado se ha empleado para entrevistar a los familiares que voluntariamente aceptaron participar de 26 personas fallecidas presumiblemente por suicidio en la provincia de Ourense. Las entrevistas fueron grabadas digitalmente y después valoradas por medio de un formulario de toma de decisiones de forma ciega por el entrevistador y por dos evaluadores independientes. Resultados. El grado de concordancia entre evaluadores se midió por medio del estadístico kappa. La participación en el trabajo (27,6%) ha sido similar a la obtenida en Brasil (20%) en el estudio original. Los valores de kappa obtenidos son estadísticamente significativos. Se considera el grado de correlación como bueno (k> 0,60) o muy bueno (k> 0,80) en 15 pasos incluyendo 3 de los 4 pasos finales de cada módulo y el resultado final de la autopsia; moderado (k> 0,40) en 8 pasos, de los que 3 se localizan en el módulo de motivación y débil (k> 0,20) en tan sólo 2 pasos. Conclusión. La versión española de la SSIPA es un instrumento fiable para la realización de autopsia psicológica. La baja concordancia en dos de los pasos del algoritmo de toma de decisiones puede deberse a falta de precisión del cuestionario y debe mejorarse (AU)

Introduction: objectives. The aim of this work was to adapt and validate into Spanish the Semi-Structured Interview for Psychological Autopsy (SSIPA). Method. The SSIPA consists of 69 items distributed into four modules: precipitants and/or stressors, motivation, lethality, and intentionality. The original instrument was translated from Portuguese into Spanish and back translated by bilinguals persons. The resulting questionnaire was compared with the original and discussed by an expert panel. The adapted instrument was then applied to the relatives of 26 presumed suicide cases in Ourense (Spain) who voluntarily accepted to participate. Interviews were digitally recorded and evaluated using a decision-making algorithm by the interviewer and two independent judges blind to the results of the others. Results. Interrater agreement was measured using Kappa statistics. Participation in the study (27.6%) was similar to that obtained in the original study in Brazil>(20%). The Kappa values obtained were statistically significant. Correlation index was considered good (k>0.60) or very good (k> 0.80) in 15 steps including 3 out of 4 final steps of each module and the final result of the autopsy; moderate (k> 0.40) in 8 steps, 3 of them located in the motivation’s module; and weak (k> 0.20) just in 2 steps.Conclusions. The Spanish version of the SSIPA is are liable instrument for psychological autopsy studies. Low correlation in two of the algorithm steps for decision making may be due to the lack of accuracy of the questionnaire and should be improved (AU)

Ainda o valor da autópsia no ensino da medicina / Although the value of autopsy in medical education

Conforme relatei no meu artigo anterior ?O problema da autópsia no ensino médico? [Diagnóstico e Tratamento. 2009;14(4):162], quando fui titular de Anatomia Patológica da Escola Paulista de Medicina (1970-1986), eu obrigava grupos de alunos a executar a autópsia comigo ou um assistente. O necroscopista, tal como o cirurgião, deve ser auxiliado por um médico ou estudante e não pelo servente, a não ser que tenha sido adestrado para o mister. Esclareça-se que a quase totalidade dos atuais patologistas e legistas no Brasil transferem a abertura do cadáver e a extração das vísceras ao servente, limitando-se apenas ao exame dos órgãos.

O problema da autópsia no ensino médico / The problem of autopsy in medical education

Compreendo perfeitamente que professores absorvidos pela carga administrativa ou interessados mais em pesquisas experimentais do que clínicas, nem sempre dispõem de tempo para essa tarefa que leva pelo menos duas horas.A meu ver, a solução estaria em designar um substituto para pessoalmente intervir no cadáver, devendo ser auxiliado pelos alunos e não pelo servente, como é a regra no Brasil.Esse aprendizado técnico torna-se imperioso quando um médico não patologista do meio rural é solicitado pelo delegado ou juiz para elucidar casos de morte violenta.E se o médico for curioso, ele não hesitará em abrir o cadáver para saber a causa mortis do seu doente.

Evaluación de la calidad de los diagnósticos premortem de causas de muerte en las autopsias del Hospital Clínico Universitario de Valencia (1985-1992) / A comparative study of the pre- and post-mortem diagnoses of the cause of death in the University Hospital of Valencia between 1985 and 1992

Se estudiaron 998 autopsias realizadas en el Servicio deAnatomía Patológica del Hospital Clínico Universitario deValencia entre 1985 y 1992, introducidas y procesadas en elSistema Automatizado de Registro y Control de AnatomíaPatológica (SARCAP) en el Hospital «Hermanos Ameijeiras» de La Habana, Cuba. Los principales resultados fueron:predominio del sexo masculino y las edades avanzadas; lasprincipales causas básicas de muerte fueron los tumoresmalignos, la ateromatosis coronaria, la cirrosis hepática y elSIDA, y las principales causas directas de muerte fueron labronconeumonía, la extensión del cáncer y el tromboembolismopulmonar. Hubo 10,6% de discrepancias diagnósticaspremortem y postmortem en la Causa Básica de Muerte(CBM) y 30,7% en la Causa Directa de Muerte (CDM). Sedestaca la importancia del estudio multicausal de la muertey la utilidad del SARCAP para la creación de una base dedatos de todas autopsias realizadas en el Hospital Universitariode Valencia y que forme parte de una base de datos detodas las autopsias Iberoamericana(AU)

998 necropsies carried out in the Department of Pathologyof the University Hospital of Valencia between 1985and 1992 were evaluated and the data obtained was analyzedby the Pathology Registry and Automated ControlSystem (PRACS) at the «Hermanos Ameijeiras» Hospital inLa Habana (Cuba). The results showed a predominance ofelderly males and that the principal, basic causes of death(BCD) were malignant tumours, coronary atheromatosis,hepatic cirrhosis and AIDS. The major direct causes ofdeath (DCD) were broncopneumonia, tumour progressionand thromboembolism in the lung. A 10.6% discrepancywas found between the pre- and post-mortem results ofBCD and a 30.7% discrepancy in the results of DCD. It wasconcluded that a multicausal study of death is important andthat the PRACS is a useful tool for creating a common databaseof all the necropsies performed in the University Hospitalof Valencia within an Iberoamerican network(AU)

Avaliação da resistência de larvas de Contracaecum sp. (nematoda: anisakidae) à ação da citronela, Cymbopogon sp., in natura, administrada como tratamento da anisakiose em coelhos infectados experimentalmente / Evaluation of the resistence of the Contracaecum sp. larvae, (nematoda: anisakidae), to the action of the citronella, Cymbopogon sp., in natura, administered as treatment of anisakiosis in experimentally infected rabbits

A avaliação da ação larvicida da citronela, Cymbopogon sp., in natura foi feita através da administração da planta ad libitum a coelhos, Oryctolagus cuniculi, experimentalmente infectados com larvas de Contracaecum sp. Com intervalos regulares de 24 horas após o início da administração da planta, foram realizadas eutanásias e necropsias dos animais infectados, analisando-se a eficácia através de parâmetros como número e viabilidade de larvas recuperadas. A citronela in natura apresentou baixa ação larvicida sobre Contracaecum sp Federal

The evaluation of the larvicide action of the citronella, Cymbopogon sp., in natura was done through the feeding of the citronella grass ad libitum to rabbits, Oryctolagus cuniculi, experimentally infected by Contracaecum sp. larvae. By regular intervals of 24 hours after the beginning of the experiment, the infected animals went submitted to eutanasy and necropsy exams to analyse the action of the plant, using parameters as the number and viability of the recovered larvae. The citronella in natura produced low larvicide action over Contracaecum sp. experimentally.

Pterobothrium crassicolle (Eucestoda: Trypanorhyncha) em corvinas, Micropogonias furnieri, comercializadas no município de Niterói, Rio de Janeiro, Brasil / Pterobothrium crassicolle (Eucestoda: Trypanorhyncha) in croacker, Micropogonias furnieri, purchased at Niterói municipality, Rio de Janeiro, Brazil

Micropogonias furnieri (Desmarest, 1823) é uma das espécies de peixes mais consumidas pela população do estado do Rio de Janeiro. Entre os meses de maio e setembro de 2006, 30 espécimes deste pescado foram obtidos do mercado de São Pedro no município de Niterói, estado do Rio de Janeiro. Eles foram necropsiados e analisados para presença de cestóides Trypanorhyncha. Um total de oito espécimes apresentou no mesentério plerocercos de Pterobothrium crassicolle, com prevalência de 26,7%, intensidade média de infecção de 2,25, variando de uma a três larvas por peixe e a abundância média de 0,6. Os resultados obtidos no presente trabalho são analisados e comparados com os registros anteriores estudados sobre esta espécie de peixe no Brasil.

Porto,C.J.S., São Clemente, S.C., Freitas, M.Q., São Clemente R.R.B., Knoff. M. and Matos, E. [Pterobothrium crassicolle (Eucestoda: Trypanorhyncha) in croacker, Micropogonias furnieri, purchased at Niterói municipality, Rio de Janeiro, Brazil.] Micropogonias furnieri (Desmarest, 1823) is one of the species of fish most consumed by the population of the State of Rio de Janeiro. Between May and September 2006, 30 specimens of this fish were obtained from the market of San Pedro in Niterói municipality, State of Rio de Janeiro. They were necropsied and examined for the presence of cestodes Trypanorhyncha. A total of eight specimens showed the mesentery with plerocerci of Pterobothrium crassicolle, with a prevalence of 26.7%, mean intensity of infection of 2.25, ranging from one to three larvae per fish and mean abundance of 0.6. The results obtained in this study are analyzed and compared with previous records on the studied fish species in Brazil.

Hipertensão arterial pulmonar idiopática manifestada durante a gestação: correlação anátomo-clínica com necropsia. Relato de caso / Idiopathic pulmonary arterial hypertension manifested during pregnancy: anatomical-clinical correlation with necropsy. Case report

JUSTIFICATIVA E OBJETIVOS: A hipertensão arterial pulmonar idiopática (HAPI) é uma entidade rara, com prevalência estimada em 1-2 casos por milhão de pessoas. Sua relação com a gestação é relatada na literatura com freqüência de 4,5% em pacientes com HAPI. O objetivo deste estudo foi demonstrar um caso de HAPI relacionado com a gravidez, de evolução prolongada, a discordância entre o grau de lesão das artérias de pequeno calibre na anatomia patológica e a medida da pressão da artéria pulmonar no ecocardiograma. RELATO DO CASO: Paciente com 33 anos, branca, em sua segunda gestação, iniciou com quadro de dispnéia e edema nos membros inferiores, intensificados ao final do segundo trimestre, sendo realizada cesariana eletiva. Manteve os sintomas por dois meses. Referiu também dor precordial no hipocôndrio direito em sua segunda internação. Ao exame físico, observou-se estase jugular e hepatomegalia dolorosa, à ausculta cardíaca observou-se ritmo de galope protodiastólico, hiperfonese de segunda bulha em focos da base e sopro holossistólico em foco tricúspide. A investigação complementar confirmou a origem idiopática da doença. O óbito ocorreu por choque cardiogênico. CONCLUSÕES: A observação clínica indicou o diagnóstico de HAPI, afastando outras causas de hipertensão pulmonar. À necropsia, o diagnóstico pôde ser reforçado e foram afastadas outras causas específicas de hipertensão pulmonar na gestação. Apesar de não ter sido realizado estudo hemodinâmico, a pressão média da artéria pulmonar estimada pelo exame ultra-sonográfico foi discordante com a magnitude das lesões nas artérias de pequeno calibre detectadas no exame histopatológico. A HAPI durante a gestação possui elevada mortalidade e trata-se de uma doença ainda sem cura e com muitos aspectos fisiopatológicos a serem esclarecidos. As medidas de maior impacto continuam sendo a prevenção na gestação; e, se esta ocorrer, recomenda-se a sua interrupção precoce.(AU)

BACKGROUND AND OBJECTIVES: Idiopathic pulmonary arterial hypertension (IPAH) is a rare entity, with prevalence estimated in 1-2 cases/1.000.000. Its relationship with pregnancy, in the literature, is reported a 4.5% rate of patients with IPAH. The objective of this study was to demonstrate a case of IPAH related to pregnancy with extended evolution and the discord between the injury degree of the small bore arteries in the pathological anatomy and the measure of pulmonary artery pressure in echocardiography. CASE REPORT: Patient, 33 years-old, white, in her second pregnancy, initiated with symptoms of dyspnea and peripheral edema, intensified in the end of the second trimester, been realized cesarean section. She kept the symptoms for two months and related precordial and right hypochondriac pain in her second hospitalization. On physical examination, there were elevated jugular venous pressure and painful enlarged liver. On auscultation, there were gallop rhythm, prominent aortic and pulmonary second heart sounds and tricuspid pansystolic murmur. The complementary investigation confirmed the idiopathic origin of the disease. The death occurred due cardiogenic shock. CONCLUSION: The clinical observation indicates the diagnosis of IPAH, excluding other causes of pulmonary hypertension. In the necropsy, the diagnosis could have been confirmed and other specific causes of pulmonary hypertension in pregnancy could have been excluded. Although right heart catheterization haven’t been realized, the pulmonary artery pressure determined by echocardiography is discordant of the magnitude of the injuries in the small bore arteries detected in the microscopic examination. IPAH during pregnancy has great mortality and is an illness still without cure and with many physiopathological aspects to be revealed. The pregnancy prevention is recommended, if the pregnancy occurs, precocious interruption of the same one must be realized.(AU)

Infarto cerebral hemorrágico por embolización de un trombo mural cardíaco / Hemorrhagic cerebral infarction due to embolization of a mural thrombus within the right ventricle

Las enfermedades cerebrovasculares son consecuenciade una alteración en la circulación cerebral. Suforma más distintiva de presentación es el ictus, entendidocomo un déficit neurológico focal de instauraciónbrusca y evolución rápida.Un infarto cerebral de origen oclusivo puede debersebien a una trombosis in situ o bien a una embolia procedentede un foco distante. En las embolias cerebrales lacausa principal son los trombos murales cardiacos y elárea encefálica afectada con mayor frecuencia es el territorioirrigado por la arteria cerebral media.Presentamos el caso de una mujer de 81 años, conantecedentes de Hepatitis C, cardiopatía hipertensiva yfibrilación auricular crónica, que sufrió una fractura decadera consecutiva a una caída accidental. Durante elingreso hospitalario comenzó un cuadro de deterioroneurológico progresivo que no llegó a ser filiado, falleciendo9 días después. En la autopsia médico-forense seencontró un infarto cerebral hemorrágico en el territoriode la arteria cerebral media izquierda. Dado que las arteriasdel Polígono de Willis eran permeables y ante la presenciade trombos vitales adheridos a la pared del ventrículoderecho, se estimó como causa más probable delaccidente vasculocerebral la embolización de uno dedichos trombos

Cerebrovascular diseases are due to a disturbance incerebral blood flow. The most frequent way ofpresentation is stroke, defined as a sudden and focalneurological impairment with rapid evolution.Cerebral infarction of occlusive origin can besecondary to in situ thrombosis or to embolism from adistal focus. Mural thrombi are the main cause of brainembolism and the middle cerebral artery territory is themost likely affected brain area.We report the case of an 81 year-old woman, withantecedents of Hepatitis C, hypertensive cardiopathy andchronic atrial fibrillation, who suffered a hip fracture due toan accidental fall. A progressive neurological impairment ofunknown aetiology appeared during her hospitalization,and she died 9 days after her admission. Forensic autopsyfound a hemorrhagic cerebral infarction in the territory ofthe left middle cerebral artery. As the arteries of thepolygon of Willis were patent and there were vital thrombiadhered to the free wall of the right ventricle,thromboembolism was considered the most probablecause of the cerebrovascular event

Aspectos médico-legales de la asistencia en emergencias en caso de intoxicación / No disponible

España se sitúa a la cabeza de los países europeos en consumo de sustancias tóxicas, incrementándose las asistencias relacionadas con las intoxicaciones. Los aspectos médico-legales de la asistencia en urgencias-emergencias son un tema relevante en la actualidad debido a sus importantes implicaciones jurídicas y por ello nos proponemos realizar una revisión de los aspectos médico-legales más destacados que pueden encontrarse en la actuación diaria de los médicos y demás profesionales en el área de las urgencias-emergencias desde un enfoque teórico-práctico, tanto en el sujeto vivo como en el cadáver (AU)

Spain is situated at the top on European Countries in drugs abuse, consequently the care of poisoned patients is an increasingly frequent phenomenon. The medical-legal aspects of this emergency services care are very important today, due to their legal consequences. This paper reviews the most remarkable medical-legal aspects that can be found in medical doctors day by day work in the sphere of the emergency services. Providing a theoretical-practical point of view, in living patients as well as in those who die (AU)