Evolution of Swan-Ganz catheter-related pulmonary valve nonbacterial endocarditis.

Invasive resuscitative and supportive therapy subsequent to accidental trauma, assault, or medical mishap may create lesions that forensic pathologists must interpret. Pulmonary valve nonbacterial endocarditis sometimes complicates placement of flow-directed pulmonary artery (Swan-Ganz) catheters. We examined ten cases of endocarditis from patients dying 0-10 days after removal of a Swan-Ganz catheter, and compared the natural evolution of vegetations in critically ill patients with the reported evolution of similar vegetations in experimental animals in the Freedman model. There was wide variation in macroscopic, as well as in the light- and scanning electron-microscopic, appearances in our cases and we could not establish a direct relationship between vegetation structure and time elapsed after removal of the catheter. These findings suggest that parameters related to critical illness and species account for the differences between this disease in human and animal models.

Deaths from trauma in Auckland: a one year study.

We report a one year prospective study of all deaths from trauma in the Auckland region. Data was collected on the circumstances of death from coroner's, police and hospital records. All cases had autopsies and the injuries were scored using the abbreviated injury scale (AIS) system. The group of 236 had a median age of 27 years and 73% were under the age of 45. Seventy-two percent were male. Blunt trauma, predominantly the result of road crashes, accounted for 89% of the fatalities. Most deaths occurred at the site of injury and only 37% survived to reach hospital. Cases were audited if death occurred without a critical or unsurvivable injury. Thirteen cases were considered to be potentially salvageable if medical treatment had been optimal. The implications for the organisation of prehospital and inhospital trauma care are discussed.

Contraction-band necrosis: patterns of distribution in the myocardium and their diagnostic usefulness in sudden cardiac death.

Experimentally-produced acute regional myocardial infarcts of 2 or more hours duration show a characteristic pattern of myocardial cell alteration known as "contraction-band necrosis". To investigate the potential usefulness of this feature in assessing the myocardial status in sudden cardiac death, detailed histological examinations of the coronary arteries and midventricular myocardium were carried out on hearts from 70 unselected cases of sudden cardiac death. Contraction-band necrosis was frequently encountered and occurred in 3 main patterns which could be correlated with the coronary artery pathology and the case history: a regional distribution consistent with early subendocardial or transmural infarction, not yet characterized by coagulative necrosis, associated in most cases with a recent thrombotic event in the relevant supply artery (27.1%); adjacent to pre-existing infarction (recent or healed) or to subendocardial fibrosis resulting from severe coronary artery disease, consistent with recent extension of ischemic injury (18.6%); a global, full-transmural distribution, consistent with reperfusion injury from delayed resuscitation in the absence of significant coronary artery pathology (8.6%). Thus, examination of the myocardium for a specific pattern of contraction-band necrosis may frequently facilitate the definitive diagnosis of sudden cardiac death.

Childhood pedestrian deaths: experience of the Auckland coronial area 1977-1983.

The Auckland coronial district experience of 65 childhood pedestrian deaths over a seven year period is presented. The behaviour of this group of pedestrians is reviewed and a major factor was the unpredictable behaviour of children. Suggestions as to prevention are made.

Fatal postpartum coronary artery dissection. A light- and electron-microscope study.

A case report of fatal spontaneous dissection of the distal left circumflex coronary artery in a 37-year-old postpartum female is presented. Samples of arterial wall from this patient and from six other postpartum females who died of unrelated causes were examined by light (LM), scanning electron (SEM), and transmission electron (TEM) microscopy. Morphological changes to explain the recognized predisposition of this cohort to coronary artery dissection were sought. The origin of the dissection was demonstrated by serial LM sections to be in midmedia with no intimal extension. The predominant plane of dissection was the junction of media and adventitia. Sarcolemmal blebbing and accumulation of amorphous intercellular material were demonstrated at the dissection site by SEM but were not seen elsewhere in the affected heart or in any of the six control hearts. These changes could not be distinguished by TEM from prolonged ischemic injury. There was no accumulation of eosinophilic leukocytes in the vessel wall or adventitia, and adventitial mast cells were not consistently more frequent than in the controls. No increase of stainable intramural mucopolysaccharides was seen in the fatal case. The results indicated no generalized arterial change in postpartum coronary arteries to account for the increased frequency of dissection. A focal degenerative process remains the most likely possibility.

Idiopathic giant cell myocarditis: case report.

Idiopathic giant cell myocarditis has not been previously reported from Australasia; a typical case is presented, and the clinical and pathological findings discussed. Possible aetiologies are discussed in the light of positive serology to coxsackie B viruses.

Fatal injuries to bicycle riders in Auckland.

Twenty bicycle riders were fatally injured in Auckland between 1974 and 1984. Eighteen were male and nine aged under 15 years. The age distribution of fatalities corresponds closely to the known age distribution of the cycling population. Few differences in pattern of injury were demonstrable between younger (under 15 years) and older riders. Sixteen died of fatal injury to multiple organ systems. Fourteen had fatal injury to brain, including four with no other significant organ injury. Fatal cardiopulmonary trauma was seen in seven riders and fatal abdominal trauma in seven. Cervical and high thoracic fracture dislocation with cord injury were seen in seven riders. Compared to the population base, incidence of fatalities is low, and no recent significant increase is detected.

Accidental drownings in Auckland children.

We consider the circumstances surrounding 60 consecutive cases of accidental drowning of children in the Auckland coronial district. More deaths occurred around the home than anywhere else. Forty-one of the fatalities occurred around the home with only two being over the age of six years. The unfenced or inadequately fenced domestic swimming pool was the most common hazard. The household bath and partly filled buckets represent further although less frequent dangers. The study reaffirms the need for legislation making the fencing of domestic swimming pools mandatory. Elsewhere, young children playing in or near water need constant supervision. More victims received either no resuscitation or inadequate resuscitation until an ambulance crew arrived at the home. This further emphasises the value of a sound knowledge of cardiopulmonary resuscitation techniques in the general population.

Complete heart block and bowel infarction secondary to rheumatoid disease.

A case of complete heart block secondary to rheumatoid involvement of the conduction system is presented. The same patient died after infarction of the colon as a consequence of arterial spasm superimposed upon pre-existing rheumatoid changes in the mesenteric arteries. The coexistence of rheumatoid involvement of the heart and of the bowel vasculature has not previously been reported.

Deaths from electricity.

This paper reviews the circumstances of 95 fatalities from electrical injuries. Eighty-nine were accidental, four were suicides and two occurred during autoerotic electrical stimulation. Forty-nine of the accidental fatalities occurred at work, Twenty-eight in the home and twelve in the course of outside recreational activities. In many accidents the circumstances were distressingly similar and included: (1) Contact with overhead distribution lines by a length of conductor such as a yacht mast or crane. (2) Faulty wiring or electrical repairs performed by unqualified people. (3) Badly deteriorated cords, plugs and occasionally appliances. (4) Failure to use isolating transformers when indicated. Deaths involving children are a particular cause of concern. Nine fatalites involved children under the age of five years who contacted inadequately protected wires.

Deaths from drowning.

During an eight year period in the Auckland coronial district, 225 persons over the age of fifteen years died from drowning and were subject to autopsy. Of these, 129 males and 21 females drowned because of accidents whilst 31 males and 29 females committed suicide by drowning. There was one homicide and in 14 cases it was unclear as to whether drowning was accidental or suicidal. At least half of the accidents showed analytical evidence of having consumed alcohol and in 37% of these the blood alcohol level was over 100 mg per 100 ml of blood. The activities in which the accidentally drowned were engaged at the time of their deaths are documented and the role of intercurrent illnesses in some drownings illustrated.

Deaths from drugs and poisons.

In the eight years from 1975 to 1982, 11 262 ***coronial**autopsies were performed in the School of Medicine, Auckland. Three hundred and ninety-four of the deaths were due to the action of a drug or poison. In this paper we examine the motives and circumstances, age and sex distribution, drugs used and other aspects of these 394 deaths.

Lupus nephritis: clinicopathological correlations.

We have reviewed our experience of lupus nephropathy in Auckland over a 15 year period during which time 70 biopsies were obtained from 56 patients with systemic lupus erythematosus. Based on appearances by light microscopy, the biopsies were categorised as mesangial, focal, diffuse or membranous lupus nephritis. Immunofluorescence, where performed, was positive in all instances, including those biopsies showing only mesangial disease by light microscopy. By electronmicroscopy, biopsies with mesangial disease by light microscopy usually had deposits confined to the mesangium, while more severe forms of disease usually had deposits present both around the loops and in the mesangium. Clinical renal abnormalities were uncommon in the mesangial group, usual in the focal group and ubiquitous in the diffuse group. Notably, four of the 18 patients who had no clinical renal or urinary abnormalities, had focal or diffuse disease, indicating a small but definite risk of missing significant renal disease if a biopsy is not performed.

Conduction tissue changes associated with enlarged membranous septum--a cause of sudden death?

We have studied four hearts in which enlargement of the ventricular membranous septum was associated with histological abnormalities of the atrioventricular conduction tissues. Two of the cases showed unusually formed penetrating and non-branching main atrioventricular bundles. These two cases plus one other also showed right-sided penetrating and main atrioventricular bundles. In addition these three cases all showed extensive fibre loss affecting the origin of the left bundle, which in one heart was further accompanied by fibre loss in the main bundle. The conduction tissue damage in the fourth case, though more extensive, was not as clearly related to the enlarged membranous septum since the heart in this case was also enlarged and dilated (congestive cardiomyopathy). Our findings, while obviously not conclusive, suggest that conduction changes in the presence of an enlarged membranous septum could be added to the list of causes of sudden cardiac death. They certainly indicate that when an enlarged membranous septum is found in cases of sudden death, histological study of the conduction system is desirable.

Glomerulonephritis associated with an infected ventriculo-atrial shunt.

We present the case of a seven year old girl with a ventriculo-arterial shunt who developed haematuria and the nephrotic syndrome. Renal biopsy showed a diffuse proliferative glomerulonephritis of mesangiocapillary type. Cultures of blood, cerebrospinal fluid and later, the removed shunt, grew Staphylococcus epidermidis. Her renal function subsequently improved following antibiotic therapy and revision of the shunt.