Radiography of perforating centerfire rifle wounds of the trunk.

All deaths resulting from perforating centerfire rifle wounds of the chest and abdomen, investigated by the Office of the Chief Medical Examiner for the Province of Alberta from 1988 to 1995. were reviewed retrospectively to determine whether the radiographic distribution of bullet fragments in such cases is a useful predictor of bullet trajectory. Study cases were limited to single gunshot wounds without surgical intervention or intermediate targets, and for which adequate radiography was available. Three pathologists individually viewed the radiographs on two separate occasions; wound locations were provided for the second viewing (Group 2). Differences in opinion regarding direction of fire were resolved by consensus review. A trauma radiologist independently made two sets of interpretations in the same way. Comparisons of these groups of interpretations were made with the actual bullet direction determined at autopsy. Of 21 cases included in the study, only three (14.3%) did not require consensus resolution in either group. Accuracy of pathologists' interpretation improved from 38.1% (8/21) to 76.2% (16/21) with provision of wound locations (p = 0.012). The radiologist achieved similar improvement, from 28.6% (6/21) to 47.6% (10/21). The rate of agreement between radiologist and pathologists increased from 42.9% (9/21) to 61.9% (13/21) between Groups 1 and 2. Both the pathologists and radiologist interpreted several cases the same way in both groups; of those cases interpreted differently, the second interpretation was occasionally incorrect after correct interpretation in Group 1. We conclude that bullet direction for perforating centerfire rifle wounds cannot be accurately determined from postmortem radiographs. When wound location is known, the ability to predict bullet direction improves but is still subject to error, including a lack of consistency between observers.

Dissecting aneurysm of the pulmonary trunk.

Dissecting aneurysms of the pulmonary trunk are a rare cause of sudden death. We report a case in a patient with pulmonary hypertension secondary to a patent ductus arteriosus. A brief review of the condition is also presented.

Simultaneous acute thrombosis of two major coronary arteries following intravenous cocaine use.

Myocardial infarction is now a well-recognized complication of cocaine abuse. This report describes a 38-year-old man who sustained simultaneous acute thrombosis of two major epicardial coronary arteries shortly after intravenous cocaine use. The finding of layers of mural thrombus of varying age, from acute to two to three days, in both coronary arteries represents a previously unreported finding (to our knowledge) in cocaine-associated cardiac death. Potential mechanisms for the association between cocaine use and infarction and the cardiac pathologic findings in cocaine-associated death are discussed.

Sudden death due to left coronary artery occlusion in infective endocarditis.

A 44-year-old man died suddenly, shortly after admission to the hospital with complaints of abdominal pain. Medical history was significant for chronic alcoholism and homozygous hemoglobin C disease. Autopsy revealed vegetations on the aortic valve, especially on the left coronary cusp. There was anomalous origin of the coronary arteries from the left sinus of Valsalva. The large vegetation on the left coronary cusp had extended into the left main-stem coronary artery and obstructed it. There was evidence of prior embolization to the right coronary artery with mycotic aneurysm formation and myocardial infarction. Other lesions included a cerebral artery mycotic aneurysm and metastatic abscesses within the myocardium and spleen. Although the aortic valve was free of underlying chronic pathology, the causative organism was Streptococcus viridans. This case illustrates several unusual, and, in some instances, unique findings in infective endocarditis.

Shotcup petal abrasions in close range .410-caliber shotgun injuries.

Shotcup petal abrasions centered around a shotgun wound of entrance are generally thought to occur at a range of 30 to 90 cm. A suicidal .410-caliber shotgun injury of the right eye is described in which typical petal abrasions were noted around the entrance wound. However, significant soot deposition around the wound suggested that the range of fire was less than 30 cm and perhaps closer to 15 cm. Test-firing of the weapon and ammunition used by the decedent showed some spread of the shotcup petals at a range of 7.5 cm, progressing to maximum spread at 30 to 52.5 cm. Further testing with other .410 ammunition, containing shotcups, confirmed the spread of shotcup petals at ranges less than 30 cm, irrespective of manufacturer, shotshell length, and birdshot size. When a variety of shotguns were tested, it was found that one weapon with a very short barrel and cylinder bore did not exhibit petal spread until a range of 30 cm was reached. The remaining shotguns, with longer barrels and full choke, all demonstrated definite petal spread at a range of 12.5 cm. The long, narrow configuration of .410 shotcup petals may explain their early spread and the production of petal abrasions at ranges of less than 30 cm.

Spontaneous coronary artery dissection occurs with and without periadventitial inflammation.

Dissection of a coronary artery not associated with aortic dissection or trauma is a rare condition that occurs most frequently in peripartum or postpartum women. It has been suggested that localized periadventitial inflammation, often found adjacent to these lesions, may represent a primary vasculitis which causes dissection. Two cases of spontaneous coronary artery dissection are described, together with a brief review of previously published cases. Based on this review, we conclude that periadventitial inflammation is reactive, rather than primary, in nature.

'Eve' and 'Ecstasy'. A report of five deaths associated with the use of MDEA and MDMA.

3,4-Methylenedioxymethamphetamine (MDMA, "Ecstasy"), a synthetic analogue of 3,4-methylenedioxyamphetamine, has been the center of recent debate over its potential for abuse vs its use as a psychotherapeutic agent. Following its emergency classification in Schedule 1 by the Drug Enforcement Administration in 1985, 3,4-methylenedioxyethamphetamine (MDEA, "Eve") has appeared as MDMA's legal replacement. MDMA is thought to be safe by recreational users and by psychotherapists who support its use. The details of five deaths associated with the use of MDMA and MDEA are reported. In three patients, MDMA or MDEA may have contributed to death by the induction of arrhythmias in individuals with underlying natural disease. In another patient, use of MDMA preceded an episode of bizarre and risky behavior that resulted in accidental death. In another patient, MDMA was thought to be the immediate cause of death. Death as a consequence of the use of these drugs appears to be rare, but it does occur; this outcome may be more common in individuals with underlying cardiac disease.

Disaster planning for air crashes. A retrospective analysis of Delta Airlines flight 191.

The effectiveness of previously untested disaster plans was demonstrated during the aftermath of the crash of Delta Airlines Flight 191 at D/FW International Airport on Friday, August 2, 1985. These plans, in effect for years and subjected to periodic review, were as yet untried before this first disaster at D/FW International since its opening. This paper outlines the disaster plans, the actual problems encountered, the logistics of a disaster of this kind, and insights gained from the experience.

The histogenesis of adenocarcinoma of the gallbladder.

A prospective study of 277 cholecystectomy specimens for evidence of isolated epithelial dysplasia of gallbladder mucosa is presented. In addition, 15 cases of primary adenocarcinoma of the gallbladder are retrospectively reviewed with particular reference to the presence of metaplasia and dysplasia adjacent to the infiltrating tumor, in order to establish the relationship between metaplasia, isolated epithelial dysplasia, and adenocarcinoma of the gallbladder. Only one case of isolated epithelial dysplasia was found in the 277 cholecystectomy specimens, and this arose within focal incomplete intestinal metaplasia. In the 15 cases of adenocarcinoma of the gallbladder, benign antral and/or incomplete intestinal metaplasia was found adjacent to the tumor in 11 cases. In 10 cases, dysplasia of this metaplastic epithelium was found in continuity with the tumor. The authors conclude that the most common pathway to adenocarcinoma is via dysplasia of metaplastic gallbladder epithelium.