Electrocardiographic changes associated with isolated right ventricular infarction.

Isolated infarction of the right ventricle is an extremely rare entity. A patient is described with diffuse interstitial lung disease who developed ST segment elevation in inferior and anterior leads on a routine electrocardiogram and at autopsy was found to have an isolated right ventricular infarct involving approximately 70% of the right ventricular circumference without involvement of the left ventricle and septum. This case illustrates that isolated right ventricular infarction in the presence of cor pulmonale and right ventricular hypertrophy can produce an injury current in the limb and precordial leads of the electrocardiogram which mimics that seen in typical transmural infarction of the left ventricle.

Incidental myocarditis with intravenous drug abuse: the pathology, immunopathology, and potential implications for human immunodeficiency virus-associated myocarditis.

Human immunodeficiency virus (HIV)-associated myocarditis is well reported. Many of these patients are also intravenous (IV) drug abusers. This study examined sudden death victims from the Office of the Chief Medical Examiner, State of Maryland, for active myocarditis. A group of HIV-negative drug abusers is compared with a group of HIV-negative victims without any known risk factors for the acquired immunodeficiency syndrome. Using modified Dallas criteria combined with an avidin-biotin-labeled immunoperoxidase procedure, the cases were classified as active, borderline, or absent myocarditis. Serologic analysis for circulating antimyocardial antibody was performed along with phenotypic analysis of the infiltrate. Of the 15 IV drug abuse cases examined, none were positive for HIV (enzyme-linked immunosorbent assay and Western blot). With IV drug abuse as the primary risk factor, five cases demonstrated active myocarditis, while five others had borderline myocarditis. Only one of 10 low-risk patients had a lymphocytic infiltrate consistent with borderline myocarditis. Drug abuse-related myocarditis was associated with cardiac pathology resulting in sudden death in only one case. Antimyocardial antibodies were positive in four of the 15 IV drug abuse cases, including patients with active, borderline, and absent myocarditis. The phenotypic expression of the lymphocytic infiltrates was similar to the findings reported for idiopathic and HIV-related myocarditis (Am J Pathol 137:1365-1371, 1990). Toxicology studies did not implicate any particular drug of abuse, but the increased frequency of myocarditis observed may reflect complications of cocaine or the combined effects of opiates and cocaine. Intravenous drug abuse is an independent risk factor for myocarditis and must be taken into consideration in studies of HIV-associated myocarditis.

A fentanyl fatality involving midazolam.

A case is presented of a 35-year-old black African male anesthesiology resident, found dead in his apartment. At the scene a syringe, butterfly intravenous line and a bottle of Versed (Midazolam) were recovered. A comprehensive screen for common drugs of abuse and therapeutic agents failed to detect any drugs in blood and urine. The blood ethanol concentration was 0.06 g/dl. A GC/MS SIM assay for midazolam was developed. A sub-therapeutic midazolam blood concentration of 7.5 ng/ml was detected and concentrations (ng/ml or ng/g) in bile, urine, and liver were 3.3, 7.5, and 96, respectively. The syringe fluid was then analyzed and found to contain only fentanyl, midazolam was absent. The blood fentanyl concentration was 4.9 ng/ml which is consistent with those reported in fentanyl fatalities. Fentanyl concentrations (ng/ml or ng/g) in bile, urine, and liver were 8.8, 5.0, and 5.9, respectively. The cause of death was ruled to be fentanyl intoxication and the manner of death undetermined.

Complication of prolonged transpyloric feeding: formation of an enterocutaneous fistula.

Enteral feeding tubes have been associated with perforations of the gastrointestinal tract, usually requiring surgical repair. A neonate with centronuclear myopathy developed an enterocutaneous fistula from the duodenum following prolonged placement of a transpyloric catheter. He did not require surgery and died later of unrelated complications.

Analysis of spleen specimens for carbon monoxide.

Crucial to the investigation of aircraft fatalities is the analysis of biological specimens for carbon monoxide (CO). In many cases, blood specimens are unavailable or unsuitable for analysis, and the testing of an alternate specimen for CO becomes necessary. Spleen specimens provide a rich source of red blood cells and hence can be a primary substitute for blood. To verify this, 40 paired blood and spleen specimens were analyzed for CO by using a gas chromatographic method. Ten specimens with a spleen CO saturation level (sat.) of less than 10% were associated with corresponding blood specimens with CO sat. less than 10%. Fifteen of the 18 spleen specimens with CO sat. greater than 29% were associated with blood specimens with greater than 48% sat. Results were inconclusive when the spleen CO sat. was between 10 and 29%. We concluded that spleen CO sat. can reflect blood CO sat. in certain situations, particularly when spleen CO sat. is high.

Effect of statins on the clinical outcomes of patients with sepsis.

Despite numerous attempts at novel intervention and tests to aid in earlier diagnosis and improved treatment, there has been an increased incidence of overall mortality related to sepsis, despite improvements in in-hospital mortality. Statins have emerged as potential immunomodulatory and antioxidant agents that might impact on sepsis outcomes. Definitive evidence to support the routine use of statins in patients with sepsis has not yet been elicited. We retrospectively analysed data from patients who presented with sepsis, severe sepsis or septic shock, stratifiying them according to statin use into two groups (statin and no statin). Sequential Organ Failure Assessment was used to evaluate severity of illness. The primary outcome was hospital mortality. Secondary outcomes included intensive care unit (ICU) mortality, hospital and ICU length of stay, and mechanical ventilation and vasopressor therapy duration. Five hundred and sixty-eight patients were included. Patients with prior statin use (statin group) were older; more obese and had higher prevalence of smoking, diabetes and ischaemic heart disease. There was no difference in Sequential Organ Failure Assessment scores and mortality did not vary between the two groups (19.6 vs. 16.9%). Furthermore, secondary outcomes including ICU mortality, hospital and ICU length of stay, mechanical ventilation and vasopressor duration did not differ Multivariate analysis revealed age and Sequential Organ Failure Assessment score were independent predictors of survival, while history of statin use was not (p = 0.403). This current retrospective study did not find any benefit of statin use on primary and secondary outcomes of the patients admitted to an academic hospital with sepsis.

Mind your manners. Part II: General results from the National Association of Medical Examiners Manner of Death Questionnaire, 1995.

More than 700 physician medical examiner/coroners (ME/Cs) were surveyed to assess differences in manner of death classifications for typical but often controversial death scenarios: 198 physicians participated by choosing the manner of death (homicide, suicide, accident, natural, undetermined) for 23 such scenarios. Sixteen questions related to death certificate training, work location, and manner of death issues were also asked. The classification of manner of death by ME/Cs was highly variable. For some challenging death scenarios, majority agreement was lacking. Agreement was > or = 80% for only 11 of the 23 scenarios and was 100% for only 1. Manner of death classification method was not influenced by forensic pathology board certification status, by whether or not the physician actually completed death certificates, or by previous threats of lawsuits over manner of death classification. However, there were some differences by state. No textbook or individual was widely recognized as authoritative on manner of death issues. Few ME/Cs had formal death certification training in medical school or residency. The data lend credence to the practice of the National Center for Health Statistics (NCHS) of classifying manner of death for statistical purposes by using coding and classification rules and selection criteria rather than solely on the basis of the classification of manner chosen by ME/Cs. The data also indicate that caution is in order when one compares manner of death statistics of one ME/C with those of another Published guidelines and more uniform training are needed so that ME/Cs may become more consistent in their manner of death classifications. Further information is presented in Part I (history of manner of death classification) and in Part III (individual death scenarios and their analysis) companion articles in this issue of the Journal.

Mind your manners. Part III: Individual scenario results and discussion of the National Association of Medical Examiners Manner of Death Questionnaire, 1995.

In 1995, a questionnaire was distributed to the > 700 physician medical examiner/coroners (ME/Cs) who are members of the National Association of Medical Examiners (NAME, St. Louis, MO, U.S.A.). The questionnaire consisted of 23 death scenarios for which individual responders were asked to assign a manner of death (homicide, suicide, accident, natural, or undetermined); 198 questionnaires were completed and analyzed. The distribution of manner of death responses was tabulated. In addition, a nosologist from the National Center for Health Statistics was provided with a cause-of-death statement based on each scenario and was asked to assign an International Classification of Diseases (ICD) code for the underlying cause of death, from which a manner of death was inferred from the ICD code's literal text description. Overall, agreement on a given manner of death in a single scenario was > 90% in only 4 of 23 scenarios and > 70% in only 12 of 23 scenarios. However, in 21 scenarios, the most common response comprised a majority. The manner of death inferred from the ICD code that was assigned by the National Center for Health Statistics (NCHS) matched the most common response of participants in 18 of the 23 scenarios. The questionnaire results show that there is substantial disagreement among experienced MEs concerning the manner of death classification that is preferred for selected types of death. Encouraging, however, is the fact that the manner of death coded for statistical purposes generally agreed with the most common classification of manner made by ME/Cs. Highlights from the discussion of each scenario that occurred during the NAME interim meeting (Nashville, Tennessee, February 1996) are also included. Other portions of the program including history of manner of death concepts and results of questions regarding responder training and characteristics are published separately in this issue of the Journal. Information derived from the questionnaire should be useful to those planning strategies to improve the consistency of manner of death classifications by ME/Cs.

Vesiculated Hairs: A Mechanism for Salt Tolerance in Atriplex halimus L.

The concentration of salts in the vesiculated hairs of Atriplex halimus L. was measured and was remarkably higher than that of the leaf sap and xylem exudate. In spite of their unusually high salt content, these hairs when immersed seemed unable to absorb water, in apparent contradiction to the previously held hypothesis that vesiculated hairs make it possible for such plants to absorb water from the atmosphere. Although growing the plants under saline conditions increased the salt content of the hairs from 2.3 m Na+K to 11.6 m, salt content of the expressed leaf sap from young leaves did not change significantly. This observation indicates that in A. halimus the vesiculated hairs play a significant role in removing salt from the remainder of the leaf and preventing the accumulation of toxic salts in the parenchyma and vascular tissues. Thus, a nearly constant salt content is maintained in leaf cells other than the hairs.

Somatic embryogenesis and plant regeneration in cotton (Gossypium hirsutum L.).

Tissue culture methods for improvement of cotton has lagged seriously compared to other major crops. A method for regeneration of cotton which includes a morphogenetically competent cell suspension was needed to facilitate selection of stress-resistant variants and gene manipulation. Preliminary screening of eight strains of Gossypium hirsutum L. for embryogenic potential resulted in the production of somatic embryos in all strains. Coker 312 was selected for use in the development of a model regeneration system for G. hirsutum. Calli were initiated from hypocotyl tissues of 3-day-old-seedlings. Globular embryos were present after six weeks in culture. Calli were subcultured to liquid suspension in growth regulator-free medium. After three to four weeks, suspensions were sieved to collect globular and heart stage embryos. Collected embryos developed further when plated onto semi-solid medium. To induce germination and plantlet growth, mature embryos were placed on sterile vermiculite saturated with medium. Upon development of roots and two true leaves, plantlets were potted in peat and sand, and hardened. Mature plants and progeny have been obtained with this procedure. A high percentage of infertile plants was observed among the regenerants.

Sports-related and non-sports-related sudden cardiac death in young adults.

Sports-related sudden cardiac deaths were compared with non-sports-related sudden cardiac death in individuals (14 to 40 years old) who were autopsied from 1981 to 1988 at the Maryland Medical Examiner's Office. Thirty-four of 690 total cases of sudden cardiac death were sports-related, which represents 5% of sudden cardiac death in this age group. Causes of death were severe atherosclerosis (nine), hypertrophic cardiomyopathy with asymmetry (eight), coronary artery anomalies (four), idiopathic concentric left ventricular hypertrophy (three), myocarditis (two), arrhythmogenic right ventricle (one), Kawasaki disease (one), and unknown (six); two of the cases with unknown causes had tunnel arteries. Exercise-related deaths were more likely due to hypertrophic cardiomyopathy (p = 0.0007) compared with 102 age-, sex-, and race-matched controls in the non-exercise group; there was no difference in the incidence of severe atherosclerosis (p = 0.4). The mean age of individuals with hypertrophic cardiomyopathy with asymmetry was less than that of those with severe atherosclerosis (24 vs 32 years, p = 0.03). Thus exercise precipitates sudden cardiac death in younger individuals with hypertrophic cardiomyopathy.

Right ventricular dysplasia associated with sudden death in young adults.

The frequency of right ventricular dysplasia (RVD) in an autopsy series of young persons with sudden cardiac death in the United States has not been previously reported. We reviewed the autopsies from cases of sudden cardiac deaths in young adults in the state of Maryland and noted three cases of RVD among 547 cardiac deaths (0.55%). These three cases of RVD in young adults and three additional cases from our file are presented. Their ages ranged from 19 to 28 yr, and there were five males and one female. Five deaths occurred during strenuous exercise while the sixth was unwitnessed. Three of these cases had a documented history of arrhythmias and 1 had palpitations. In each case, autopsy revealed right ventricular dilatation with partial absence of the myocardium and extensive fatty infiltrates with and without fibrosis. In four cases, collections of chronic lymphocytic infiltrates were seen, of which two had associated myocyte necrosis. In one patient, the disease was familial, while in the remaining five it was sporadic, suggesting a nongenetic cause.

T4+ (helper phenotype) chronic lymphocytic leukemia: case report with liver failure and literature review.

T-cell lymphomas and leukemias are a heterogeneous group of neoplasms found in each anatomic compartment of the T system (marrow, thymus, and various peripheral tissues) and that have varying phenotypic expressions. Histopathologic features of the thymic and peripheral T neoplasms do not fit into a clearly defined pattern, and clinical expressions of T neoplasms are likewise variable. This report describes a 60-year-old man with "chronic" lymphocytic leukemia of T4+ (helper) phenotype. Rapid deterioration in liver function, presumably due to tumor infiltration, was unexpected and has not previously been reported. The unusual clinical and pathologic features are reviewed in the context of T-cell neoplasms, particularly T4+ processes.