Recurrent congestive heart failure in a child due to probable myocarditis.

Recurrent congestive heart failure (CHF) attributable to myocarditis is a seldom-discussed entity in the scientific literature. This report describes the case of an 8-year-old girl who had three clinically identical episodes of CHF, beginning at the age of 5 years, with each episode preceded by a viral prodrome. The clinical features and the echocardiography and electrocardiogram findings were most supportive of myocarditis. Symptoms and investigations completely normalized between episodes. The third episode, associated with influenza A (strain H1N1) infection, led to cardiac arrest and death on day 2 after admission. Autopsy showed mild cardiomegaly with microscopic foci of myocardial fibrosis and extensive contraction band necrosis. This report is the first to describe recurrent CHF due to probable myocarditis in a pediatric patient.

Increased incidence of CPR-related rib fractures in infants--is it related to changes in CPR technique?

OBJECTIVE: A recent increase in the number of infants presenting at autopsy with rib fractures associated with cardio-pulmonary resuscitation (CPR) precipitated a study to determine whether such a phenomenon was related to recent revision of paediatric resuscitation guidelines. METHODS: We conducted a review of autopsy reports from 1997 to 2008 on 571 infants who had CPR performed prior to death. RESULTS: Analysis of the study population revealed CPR-related rib fractures in 19 infants (3.3%), 14 of whom died in the 2006-2008 period. The difference in annual frequency of CPR-related fractures between the periods before and after revision of paediatric CPR guidelines was statistically highly significant. CONCLUSIONS: The findings indicate that CPR-associated rib fractures have become more frequent in infants since changes in CPR techniques were introduced in 2005. This has important implications for both clinicians and pathologists in their assessment of rib fractures in this patient population.

Unexpected death related to restraint for excited delirium: a retrospective study of deaths in police custody and in the community.

BACKGROUND: Some people in states of excited delirium die while in police custody. Emerging evidence suggests that physical restraint in certain positions may contribute to such deaths. In this study the authors determined the frequency of physical restraint among people in a state of excited delirium who died unexpectedly. METHODS: The authors reviewed the records of 21 cases of unexpected death in people with excited delirium, which were investigated by the Office of the Chief Coroner for Ontario between 1988 and 1995. Eyewitness testimony, findings during postmortem examinations, clinical history, toxicological data and other official documents describing the events surrounding the deaths were analyzed. Specific reference was made to documented eyewitness testimony of restraint method, body position and use of capsicum oleoresin (pepper) spray. Because cocaine was detected in the blood of some of these people during the postmortem examination, the role of cocaine in excited delirium was examined by comparing the cocaine levels in these cases with levels in 2 control groups: 19 people who died from acute cocaine intoxication and 21 people who had used cocaine shortly before they died but who had died from other causes. RESULTS: In all 21 cases of unexpected death associated with excited delirium, the deaths were associated with restraint (for violent agitation and hyperactivity), with the person either in a prone position (18 people [86%]) or subjected to pressure on the neck (3 [14%]). All of those who died had suddenly lapsed into tranquillity shortly after being restrained. The excited delirium was caused by a psychiatric disorder in 12 people (57%) and by cocaine-induced psychosis in 8 (38%). Eighteen people (86%) were in police custody when they died. Four (19%) had been sprayed with capsicum oleoresin, and heart disease was found in another 4 at autopsy. The blood level of cocaine in those whose excited delirium was cocaine induced was similar to levels found in recreational cocaine users and lower than levels found in people who died from cocaine intoxication. INTERPRETATION: Restraint may contribute to the death of people in states of excited delirium, and further studies to test this hypothesis are recommended. Meanwhile, law enforcement authorities and others should bear in mind the potential for the unexpected death of people in states of excited delirium who are restrained in the prone position or with a neck hold.

The diagnostic value of the diatom test for drowning, I. Utility: a retrospective analysis of 771 cases of drowning in Ontario, Canada.

The utility and validity of the diatom test for drowning was studied using a retrospective analysis of 771 cases of drowning mostly from Ontario, Canada, over the period 1977 to 1993. In this article (part one), the utility of the test was assessed using an analysis of test outcomes. In the companion article (part two), the validity of the test was assessed by analyzing the relationship between test outcome and characteristics of diatoms in the bone marrow and samples of putative drowning medium. In the present study, freshwater drownings accounted for 738 of the cases and 33 cases were drownings in bathtubs, pools, or toilets. Diatoms were recovered from the femoral bone marrow of 205 cases (28%) of freshwater drowning and four cases (12%) of domestic water drowning. There was a monthly variation in the frequency of positive test outcomes that could not be explained by seasonal differences in the total number of drownings. However, the monthly variation was strongly correlated with the periodic cycle of diatom blooms that occurs in freshwater. Positive diatom tests were characterized by a limited number of distinctive diatom species per case, and a restricted quantity and size range of diatom frustules. These results indicate that the diatom test for drowning will identify approximately one in three victims of freshwater drowning and may be useful in the assessment of deaths occurring in bathtubs. The correlation of the outcome of the diatom test for drowning with diatom blooms provides further evidence for the reliability of the test.

Sudden unexplained death in Asian immigrants: recognition of a syndrome in metropolitan Toronto.

OBJECTIVE: To determine the number of Southeast Asians in Ontario who died of the sudden unexplained death syndrome in Asian immigrants. DESIGN: Retrospective review. SETTING: Ontario. CASES: All deaths reported to the Office of the Chief Coroner for Ontario from 1992 to 1995. OUTCOME MEASURES: Age, residence and country of origin of people who died of sudden unexplained death syndrome in Asian immigrants, as defined by standard criteria, autopsy findings and social history of cases. RESULTS: Eight cases of sudden unexplained death in Asian immigrants were reported during the study period. All involved men, and the mean age at death was 34 (standard error of the mean 7) years (range 23 to 44 years). All of the people were residents of metropolitan Toronto. Four were from Vietnam, three from China and one from the Philippines. Seven people lived with family members; the eighth was unemployed and lived alone. Death occurred during sleep or in the waking hours of the morning in six cases; in two of these cases the person's spouse was awakened by loud, laboured breathing. Two men experienced chest pain, and one of them also had sudden-onset dyspnea. There was no prodromal illness in any case. The only consistent autopsy finding was acute nonspecific pulmonary edema and congestion. Analysis of heart weights failed to reveal signs of significant cardiomegaly. CONCLUSION: Men from Southeast Asia aged 20 to 45 years are at risk of sudden unexplained death, which usually occurs during sleep. No specific factors have been found that could be used to identify people at risk.

Fracture of the hyoid bone in strangulation: comparison of fractured and unfractured hyoids from victims of strangulation.

The hyoid is the U-shaped bone of the neck that is fractured in one-third of all homicides by strangulation. On this basis, postmortem detection of hyoid fracture is relevant to the diagnosis of strangulation. However, since many cases lack a hyoid fracture, the absence of this finding does not exclude strangulation as a cause of death. The reasons why some hyoids fracture and others do not may relate to the nature and magnitude of force applied to the neck, age of the victim, nature of the instrument (ligature or hands) used to strangle, and intrinsic anatomic features of the hyoid bone. We compared the case profiles and xeroradiographic appearance of the hyoids of 20 victims of homicidal strangulation with and without hyoid fracture (n = 10, each). The fractured hyoids occurred in older victims of strangulation (39 +/- 14 years) when compared to the victims with unfractured hyoids (30 +/- 10 years). The age-dependency of hyoid fracture correlated with the degree of ossification or fusion of the hyoid synchondroses. The hyoid was fused in older victims of strangulation (41 +/- 12 years) whereas the unfused hyoids were found in the younger victims (28 +/- 10 years). In addition, the hyoid bone was ossified or fused in 70% of all fractured hyoids, but, only 30% of the unfractured hyoids were fused. The shape of the hyoid bone was also found to differentiate fractured and unfractured hyoids. Fractured hyoids were longer in the anterior-posterior plane and were more steeply sloping when compared with unfractured hyoids. These data indicate that hyoids of strangulation victims, with and without fracture, are distinguished by various indices of shape and rigidity. On this basis, it may be possible to explain why some victims of strangulation do not have fractured hyoid bones.

The location of hyoid fractures in strangulation revealed by xeroradiography.

The location of 19 fractures of 15 hyoid bones was studied from 13 cases of manual strangulation and two cases of hanging. The precise location of the fractures were determined by xeroradiography of isolated hyoid bones. To classify the location of the fractures, the greater cornu was divided into anterior, middle, and posterior thirds and the frequency of fracture occurrence in these locations was determined. In addition, the angle of curvature of the greater cornu was determined at the fracture site to ascertain if specific points along the greater cornu were more susceptible to fracture. Fractures were found with equal frequency in the posterior and middle thirds of the hyoid greater cornu (9/19, 47% for both posterior and middle) but were rare in the anterior portion (1/19, 5%). However, all fractures occurred between 30 degrees and 60 degrees of curvature of the hyoid and most fractures (approximately 60%) were found at approximately 50 degrees. These results indicate that fractures of the hyoid occur at vulnerable angles of curvature of the hyoid bone which, due to anatomic variation in hyoid shape, do not necessarily occur at specific segments of the hyoid bone. On this basis, although the presence of the hyoid fracture in strangulation is determined by the rigidity of the bone, the specific location is determined by the shape of the greater cornu.

Interpretation of postmortem vaginal acid phosphatase determinations.

Identification of evidence indicative of sexual assault, including elevated levels of acid phosphatase (AP) in the vagina, is an important part of the investigation of female homicidal deaths. In this study, vaginal AP levels in 43 female homicide victims, determined using sodium thymolphthalein as the substrate, were retrospectively correlated with semiquantitative assessment of spermatozoa in vaginal smears. The results were then compared with those from a prospectively studied age-matched group of controls. AP determinations ranged from 0 to 6,000 units (U)/L in the homicide group and from 1 to 726 U/L in the control group. In both groups, the majority of the AP values (homicide, 65%; and controls 85%) were < 100 U/L. Spermatozoa were identified on vaginal smears from 30% of the homicide victims and 17% of the controls. The spermatozoa-positive cases had AP levels that ranged from 2 to 6,000 U/L. In both groups, an AP value of > or = 400 U/L was always associated with the presence of spermatozoa on the vaginal smear. Intermediate AP values (100-399 U/L) were associated with the presence of spermatozoa in 60% of the control group and 22% of the homicide group; 18% of the homicide group and 3% of the control group were positive for spermatozoa despite AP values of < 100 U/L. In the absence of spermatozoa on a vaginal smear, an AP value of > 400 U/L strongly suggests the presence of semen that is either oligo- or aspermic. A low or intermediate AP determination, however, does not exclude the presence of semen and hence a careful search for spermatozoa on the vaginal smear is indicated, regardless of the AP value obtained.

Histoacryl glue in microvascular surgery.

The use of Histoacryl glue in the performance of microvascular anastomosis was examined in a rat model. An improvement in efficiency as noted by the decreased ischemic time and diminished bleeding with clamp removal was noted. Histological examination of the anastomosis at one and three weeks revealed a mild foreign body type inflammatory response to glue and suture material with no media necrosis and only minimal fibrointimal proliferation.

Prenatal sonographic diagnosis of hepatic hemangioendothelioma with secondary nonimmune hydrops fetalis.

A case of fetal hepatic hemangioendothelioma with secondary nonimmune hydrops fetalis is presented. The prenatal diagnosis, made at 27 weeks' gestation by real-time ultrasonography and pulsed Doppler ultrasound, was confirmed by angiography and pulsed Doppler ultrasound, was confirmed by angiography and autopsy after the infant was born 2 weeks later. To the best of our knowledge, this is the first report of prenatal diagnosis of such an entity.