Serum lipoprotein (a) concentrations in a population of 819 non-insulin-dependent diabetic patients.

Variations in serum Lp(a) concentrations were studied in a large population of non-insulin-dependent diabetic (NIDDM) patients in relation to long-term complications. Lp(a) concentrations were measured by immunonephelometry in 819 NIDDM subjects and compared with those of 128 controls. Correlations were investigated relative to plasma lipid and glycaemic parameters, body mass index (BMI) and macro- and microvascular complications. Mean absolute and relative variations of Lp(a) concentrations were studied in a subgroup of 245 patients over a one-year period. No significant differences were found between Lp(a) concentrations in NIDDM and control subjects. No relationship was evidenced with macrovascular and microvascular complications or glycaemic control. Mean relative Lp(a) variations were correlated with BMI and absolute and relative variations in triglyceridaemia. These results confirm the absence of any alterations of Lp(a) concentrations in a large cohort of NIDDM patients, either with or without micro- and macrovascular complications, but suggest a particular modulatory role for BMI and serum triglyceride variations.

Determinants of echocardiographically measured left ventricular mass in diabetic patients with or without silent myocardial ischaemia.

Left ventricular hypertrophy (LVH) is a recognized independent risk factor for cardiovascular morbidity and mortality. The purpose of this study was to assess the determinants of left ventricular mass index (LVMI), according to the presence or absence of silent myocardial ischaemia (SMI), in diabetic patients with at least two additional risk factors but with no known coronary artery disease. Eighty diabetic patients (14 Type 1 and 66 Type 2) were studied, and LVMI was measured echocardiographically. Three non-invasive tests (the ECG stress test, thallium-201 myocardial scintigraphy with intravenous dipyridamole infusion, and ambulatory 48-h ECG monitoring) were performed on all patients. Forty-five percent of patients had LVH (LVMI > or = 110 g/m2 in men and > or = 106 g/m2 in women). Twenty-six patients (37%) had SMI assessed on at least one of the non-invasive tests, 7 of whom had significant coronary stenoses on angiography. LVMI was significantly higher in patients with coronary stenoses on angiography than in those with SMI but without coronary stenoses or in those without SMI (p < 0.05), and was correlated with systolic blood pressure. In patients free of SMI, LVMI correlated with creatininemia. In patients with SMI and normal coronary arteries on angiography, LVMI correlated with the waist/hip girth ratio, the log urinary albumin excretion rate and the red blood cell filtration index (a rigidity index). This study suggests that LVH is very frequent in diabetic patients and that the main factor contributing to the increase of LVMI differs according to the presence or absence of SMI and coronary stenoses: volume load in patients free of SMI, microcirculatory disorders in those with SMI but with normal coronary arteries, and blood pressure in those with coronary stenoses.

Silent myocardial ischaemia and left ventricle hypertrophy in diabetic patients.

The purpose of this study was to evaluate the ability of three noninvasive techniques to detect silent myocardial ischaemia and analyse the factors associated with this condition, particularly left ventricular hypertrophy, in diabetic patients. An ECG stress test, a thallium-201 myocardial scintigraphy with dipyridamole intravenous infusion, ambulatory 48 h ECG monitoring and an echocardiographic study were performed in 92 diabetic patients without cardiac symptoms but with > or = 2 additional cardiovascular risk factors. At least one of these tests was positive in 28 patients (30.4%), suggesting silent myocardial ischaemia. Twenty-four of these patients had a coronary angiography which showed significant coronary stenosis in only 9 cases. An accurate echocardiographic tracing was obtained in 79 patients, particularly in 7 of the 9 with coronary stenosis. Left ventricular hypertrophy was detected in 34 patients, 6 of whom had coronary stenosis. In patients with left ventricular hypertrophy, the positive predictive values of myocardial scintigraphy and the ECG stress test were respectively 50% and 100%, as compared to only 33% and 11% in those without hypertrophy. In summary, coronary stenoses were found in < 10% of asymptomatic diabetic patients with > or = 2 cardiovascular risk factors, but more frequently in individuals with left ventricular hypertrophy. Thus, silent myocardial ischaemia should be searched for first in diabetic patients with hypertrophy, for which the stress test was the most accurate detection method in this study.

Clothing damage analysis and the phenomenon of the false sexual assault.

This paper describes three recent false sexual assaults examined at the Victoria Forensic Science Centre laboratory where clothing damage analysis assisted in the resolution of the case. Suspected false reports of sexual assaults are often sensitive cases with little other forensic evidence. Any evidential value that can be obtained is thus valuable in order to minimize any ordeal to the complainant and any suspect and to conserve valuable resources. The findings illustrate the application of clothing damage analysis in a cross section of confirmed false sexual assault reports and the fact that the forensic examiner should be aware of the potential evidential value of this kind of analysis. Furthermore, the corroboration of a victim's scenario when the investigator has doubts may be no less valuable as it may minimize the adversarial ordeal that is often faced by a rape victim.

Comparing the alleged weapon with damage to clothing--the value of multiple layers and fabrics.

The examination of damage to multiple layers of clothing of an attempted murder victim is described. The large number of cuts to the garments, the multiple layers and the varying types of fabric composing these garments gave valuable information as to the possible implement causing the damage. The results also show that some types of material may better reflect the geometry of the suspect weapon than others.

Hair and fiber transfer in an abduction case--evidence from different levels of trace evidence transfer.

Levels of trace evidence transfer were examined in a casework context. A girl was allegedly abducted in a car and rape attempted by the accused, who denied any contact with the victim. Clothing worn by the victim and the accused, and the covers from the front seats of the car, were analyzed for trace evidence. Three types of corresponding fibers and four possible pathways of transfer were identified. Synthetic fibers similar to those composing the car seat covers were located on the victim's clothing, consistent with direct transfer. Secondary transfer was indicated by dyed brown human head-type hairs (possibly originating from the accused's wife) located on the seat covers and on the victim's clothing. Secondary and possibly tertiary transfer was indicated by pink synthetic material and associated fibers (possibly originating from the victim's mother) located on the victim's clothing, a car seat cover and the accused's clothing. Light microscopy, comparison microscopy, and cross-sectioning techniques were used. The multiple fiber matches and the differing pathways and levels of transfer increased the strength of the association between the accused and the victim. After the fiber evidence was led at the trial, the accused pleaded guilty, thereby affirming the value of secondary transfer evidence.

Arrow damage to textiles--analysis of clothing and bedding in two cases of crossbow deaths.

Two cases of crossbow deaths involving analysis of damage to clothing and bedding are described. The distinctive characteristics of the damage examined in these cases indicate that there is merit in examining damage to clothing as well as wounds to the body in crossbow injuries. Clothing damage analysis may be especially useful if the body is badly decomposed or never recovered. Furthermore, damage to textiles may reflect a clearer geometry of the weapon than that of the associated wounding.

Testing conflicting scenarios--a role for simulation experiments in damage analysis of clothing.

Damage to clothing is commonly encountered in serious crimes of violence such as homicide and rape. Examination of damage to clothing and other textiles may provide valuable information as to the possible implement that caused the damage and the manner in which it was caused. Damage analysis may corroborate or refute a particular crime scenario. This report describes two recent cases examined at the Victoria Forensic Science Centre laboratory where opposing views as to the origin of the damage to the clothing of the victim were proposed. The results confirm the value of simulation experiments mimicking each case scenario. They also demonstrate that it may not be possible to unequivocally choose between opposing scenarios because of limitations inherent in damage analysis.

[Spontaneous pneumopericardium. Review of the literature apropos of 2 cases in the young adult]. / Les pneumopéricardes spontanés--revue de la littérature. A propos de deux observations chez l'adulte jeune.

Pneumopericardium is defined as the presence of air in the pericardial cavity. It is a rare condition in adults, usually due to trauma; it is commoner in the more exposed neonate and usually iatrogenic. The clinical presentation of chest pain and shortness of breath is associated with the pathognomonic auscultatory sign described by Bricheteau: a water-mill bruit. The diagnosis is confirmed by chest X-ray which shows the air-gap sign surrounding the cardiac silhouette. The principal differential diagnosis is a pneumomediastinum. The prognosis of pneumopericardium depends on the cause and complications of which tamponade and infection are the most serious and potentially life-threatening. The treatment of pneumopericardium is bed rest and surveillance when uncomplicated: evacuation of the air becomes necessary when complications set in.

[Acute dysfunction of mitral bioprosthesis: Doppler expression of a musical holosystolic murmur. Apropos of 2 cases]. / Dysfonctionnement aigu de bioprothèse mitrale: traduction doppler d'un souffle musical holosystolique. A propos de 2 observations.

Two women who had been fitted with a porcine mitral valve seven years previously suddenly developed acute dysfunction of the bioprosthesis with regurgitation. In both patients physical examination revealed an intense, vibrating, musical holosystolic murmur sounding like a "goose cry" and located at the apex. Pulsed doppler showed major, jet-like, central orothetic mitral regurgitation. A harmonic graph was recorded when the doppler window was positioned upstream of the porcine valve leaflets. The finding of such a doppler signal in this clinical context suggests tearing or perforation of one cuspid and rules out the possibility of bioprosthesis degeneration.

[Postoperative hemopericardium compressing the left atrium. Apropos of a case]. / Hémopéricarde postopératoire comprimant l'oreillete gauche. A propos d'un cas.

We report a case of tamponade due to an effusion of blood which had occurred two weeks after an aorto-coronary bypass and was unusually located behind the left atrium. The effusion, with severe clinical symptoms, was diagnosed by echocardiography and computerized tomography of the chest. These examinations provided an accurate anatomical diagnosis on which the approach route of the emergency operation was based.

Forensic hair morphology comparison--a dying art or junk science?

There has been debate in both the judicial and forensic fields concerning the admissibility and reliability of the so-called forensic comparison sciences such as handwriting, tool mark analyses, and hair analysis. In particular, there has been increasing controversy over the use and interpretation of hair comparison evidence and it has been held partly responsible for miscarriages of justice. There has also been a perceived devaluation of the worth of microscopic human hair analysis particularly since the advent of DNA profiling. This article will attempt to initiate discussion on the past, current and future role of forensic human hair analysis and comparison.

[Floating thrombus of the right atrium in acute pulmonary embolism. Clinical, echocardiographic aspects and therapeutic sequelae]. / Thrombus flottant de l'oreillette droite dans l'embolie pulmonaire aiguë. Aspects cliniques, échocardiographiques et incidences thérapeutiques.

The performance of a systematic sonocardiography in all our patients hospitalized since January 1985 for pulmonary embolism, has enabled to discover five cases of floating thrombus of the right atrium. Three patients presented an abnormal auscultation, with one of them presenting a tricuspid wedge syndrome. On the sonogram, the aspect of the thrombus, "coil or ball-shaped", floating in the atrial cavity, sometimes prolapsed through the tricuspid valve, associated with the signs of a pulmonary heart, enables to rule out other right intraatrial masses. Pulmonary angiography seems contra-indicated because of the risk of embolus of this thrombus, the migration of which may be fatal. Embolectomy, under extra-corporeal circulation (heart-lung pump) with examination of the right cavities appears to be the treatment of choice.

[Postoperative hemopericardium compressing the left atrium. Apropos of 8 cases]. / Hémopéricardes post-opératoires comprimant l'oreillette gauche. A propos de huit cas.

The authors report 8 cases of hemopericardium compressing the left atrium occurring at varying intervals after cardiac surgery. This is an unusual anatomical and classically rare site of pericardial effusion. This type of tamponnade has special clinical features, leading to a picture of subacute left ventricular failure, by interference with filling and typical echocardiographic appearances, with special features in two-dimensional mode and, in TM mode, an abnormal anterior movement of the posterior wall of the left atrium, which is studied. CT scan of the thorax, when performed, confirms this highly specific topographic situation. This type of effusion must be managed surgically as quickly as possible, with an anterior approach, either by left thoracotomy or by midline sternotomy.

[Massive pulmonary embolism disclosing thrombocytopenia induced by low molecular weight heparin. Therapeutic success of prostacyclin]. / Embolie pulmonaire massive révélant une thrombopénie induite par héparine de bas poids moléculaire. Succès thérapeutique d'une prostacycline.

The authors report a case of massive pulmonary embolism revealing thrombocytopenia induced by a low molecular weight heparin (LMWH) initially proposed for the treatment of superficial phlebitis. The diagnosis was confirmed by in vitro aggregation tests and a fall in the platelet count when the LMWH was reintroduced. The outcome was clinically, angiographically and hematologically satisfactory in response to in situ treatment with prostaglandin, subsequently replaced by Vitamin K antagonists.

[Spontaneous idiopathic pneumopericardium in young patients. Review of the literature. Apropos of a new case]. / Le pneumopéricarde spontané idiopathique du sujet jeune. Revue de la littérature. A propos d'une nouvelle observation.

Spontaneous idiopathic pneumopericardium (SIPP) in young subjects is a rare disorder since, apart from the case described here, only 28 cases have been reported in the literature. It occurs mainly in young adults. The physiopathology of the disorder involves alveolar rupture, as described by Macklin. The symptoms of SIPP are dominated by chest pain, which usually develops suddenly and is combined with dyspnea. Clinical examination is not very helpful, cardiac auscultation detects either pericardial rubbing or a more suggestive metallic sound. Recovery usually occurs without treatment, but there is a risk of long-term recurrence. An unusual complication to be feared is aerial tamponade, which may be life-threatening and calls for emergency draining. The treatment of SIPP involves strict bed-rest, symptomatic treatment of the pain and clinical monitoring.

[Comparative study of cibenzoline and flecainide administered via an intravenous route in reducing auricular arrhythmia]. / Etude comparative de la cibenzoline et du flécaïnide par voie intraveineuse dans la réduction des troubles du rythme auriculaire.

The efficacy of intravenous flecainide and cibenzoline acetate in the reduction of atrial rhythm disorders was compared in two groups of 30 patients. These arrhythmias are divided in 31 atrial fibrillation, 11 tachy-systoles, 18 atrial flutters. Parenteral administration of the anti-arrhythmic drug over a 24 hour-period is preceded by a bolus injection of 1.5 mg/kg of flecainide acetate for group I, and a bolus of 1 mg/kg of cibenzoline for group II. The overall efficacy of the two molecules is comparable (53%) as well as the reduction of the atrial fibrillations (65% vs 57%). Flecainide acetate seems more effective in treating effectively atrial tachycardias (66.6% vs 40%), and cibenzoline is more effective in the treatment of atrial flutters (54% vs 14%). The functional, electrical and haemodynamic tolerance has always been good in both group, except in 2 patients, because of the indirect pro-arrhythmic effect of cibenzoline. We are concluding that the efficacy of both molecules is satisfactory and we advocate their use, as first intention, in recent and idiopathic atrial fibrillation; it seems that cibenzoline is more effective on ischemic cardiopathies and flecainide acetate is more effective on valvular cardiopathies. Nevertheless, the possible indirect pro-arrhythmic effect, sometimes poorly tolerated in the first minutes following administration of the bolus, only on organized atrial rhythm disorder, leads us to advocate the prescription of these two drugs when attempts of transesophageal or endocardiac atrial stimulation have failed.

[Ultrasonic diagnosis of biventricular thrombus during the acute phase of myocardial infarction]. / Diagnostic échographique d'un thrombus biventriculaire au stade aigu d'un infarctus du myocarde.

The occurrence of a left ventricular thrombus is a classic complication of acute myocardial infarction. On the contrary, this is much less frequent in the right ventricle. The authors report the case of a patient presenting a biventricular thrombus resulting as a complication of an anterior myocardial infarction, diagnosed by bidimensional ultrasonography. The course is characterized by the occurrence of a cerebral vascular accident. The sonogram following this neurological accident shows that the left ventricular thrombus has disappeared, confirming its migration. On the contrary, the right ventricular thrombus regressed under appropriate heparin treatment, without any embolic complication.

[Diagnostic, prognostic and therapeutic value of Doppler echocardiography in pulmonary embolism. Apropos of 41 cases]. / Intérêt diagnostique, pronostique et thérapeutique de l'échocardiographie Doppler dans l'embolie pulmonaire. A propos de 41 cas.

In 41 patients with acute or recent pulmonary embolus (PE), a prospective study was conducted with cardiac Doppler sonography (CDS). The test is performed first in all patients, then immediately following a treatment fibrinolytics in 10 of them. The PE is confirmed by pulmonary angiography in 39 patients and embolectomy for the 2 patients who presented a mobile thrombus in the right atrium. A tricuspid insufficiency (TI) is almost always recorded by continuous Doppler: the systolic pulmonary artery pressure (sPAP) is calculated from the maximum velocity of the regurgitating tricuspid flow, using Bernouilli's equation. The correlation between Doppler sPAP and sPAP obtained by catheterization is: r = 0.95 (n = 34; p less than 0.001). A severe pulmonary hypertension, corresponding to a TI exceeding 3.5 m/s is related to a pulmonary migration occurring on a pathological heart. There is a satisfactory relationship between the elevation of the Doppler sPAP and the degree of pulmonary obstruction in the "Pe on healthy heart" population: r = 0.6 (n = 29; p less than 0.001). The dilated right ventricle observed on the sonogram (RV) is proportional to the severity of the angiographic image: correlation between the RV/LV ratio and the percentage of vascular obstruction is r = 0.73 (n = 27; p less than 0.001). The drop in the sPAP and the regression of the symptoms of pulmonary heart noted on CDS after fibrinolysis, correspond to a significant improvement of the pulmonary perfusion. The CDS seems to be absolutely necessary in PE because of the major and reliable informations it provides.

[Lipoprotein (a) and diabetes: relationship based on 224 cases]. / Lipoprotéine (a) et diabète: relations à propos de 224 observations.

Recent studies have suggested that Lp(a) is implicated in the high incidence of coronary heart disease in diabetic subjects, but data are still controversial. We therefore studied the distribution of plasma Lp(a), assayed by radial immunodiffusion, in a group of 224 diabetics and compared them to 92 non diabetic controls. Besides plasma Lp(a), TG and glucose were evaluated in 16 insulin-requiring diabetic patients before and after 10 days of normoglycaemia. The distribution of plasma Lp(a), as usually skewed to the left, was not different either between diabetic subjects and controls or between Type 1 and Type 2 diabetic subjects. No significant correlation was observed between Lp(a) and glycaemic control expressed by HbA1c. The sequence of normoglycaemia did not affect plasma Lp(a), no significant correlation between the variations of glycaemia and Lp(a) levels and the variations of triglyceridaemia and Lp(a) levels were found. Thus our group of diabetic subjects has a similar distribution of Lp(a) to controls. Lp(a) concentrations do not seem to be affected by chronic hyperglycaemia or rapid normalisation of glycaemic levels. However there is a strong need of standardization of Lp(a) assay before any definitive conclusion. As we have so far no efficient treatment for lowering Lp(a) in daily clinical practice, the energetic care of other associated vascular risk factors is needed.