"Spontaneous" coronary artery dissection. The challenge of detection, the enigma of cause

Sudden death secondary to acute dissection of a coronary artery is a rare, but increasingly recognized, cause of sudden, unexpected death in apparently healthy persons. It has been reported more frequently in women and has been associated with sudden death during the puerperium. It has also been reported that these involved coronary vessels contain increased numbers of eosinophils and often show areas of cystic medial necrosis. In this article, we report a case of sudden death in a 47-year-old white woman due to dissection of the distal segment of her left anterior descending coronary artery. There was marked involvement of the coronary arterial walls with cystic degeneration of the media with accumulation of glycosaminoglycans as demonstrated by Alcian blue staining. There was no eosinophilic infiltrate within the arterial walls. This case is unusual in that this woman's mother and brother both have had aneurysms, which stresses the importance of not only searching carefully for these lesions, but also of obtaining family history in such cases.     

Computer-aided headspace gas chromatography applied to blood-alcohol analysis: importance of online process control

This paper describes the analysis of ethanol in blood specimens from suspect drunk drivers and the associated quality assurance procedures currently used in Sweden for legal purposes. Aliquots of whole blood from two separate Vacutainer tubes are diluted with 1-propanol as internal standard before analysis by headspace gas chromatography (HS-GC) with three different stationary phases: Carbopak B, Carbopak C, and 15% Carbowax 20 M. The actual HS-GC analysis, the integration of chromatographic peaks, the collection and processing of results, as well as the quality control tests involve the use of computer-aided techniques. The standard deviation of analysis(y) increased with concentration of ethanol in the blood specimen(x), and above 0.50 mg/g the regression equation was y = 0.0033 + 0.0153x. The prosecution blood-alcohol concentration (BAC) is the mean of three separate determinations made by different laboratory technicians working independently with different sets of equipment. A deduction is made from the mean analytical result to compensate for random and systematic errors inherent in the method. At BACs of 0.5 and 1.5 mg/g, which are the statutory limits in Sweden, the allowances currently made are 0.06 and 0.09 mg/g, respectively. Accordingly, the reduced prosecution BAC is less than the actual BAC with a statistical confidence of 99.9%.     

Evaluation of breath alcohol instruments II. In vivo experiments with Alcolmeter Pocket Model

The precision and accuracy of an Alcolmeter Pocket Model breath alcohol instrument have been investigated in experiments with human subjects under controlled conditions. The instrument response was zero in all tests with breath samples from alcohol-free subjects. The standard deviations of ethanol determinations in breath were ±0.0722 mg/ml during ethanol absorption and ±0.0416 mg/ml during ethanol elimination. The standard deviation during the elimination phase increased with ethanol concentration in the sample, being ±0.0416 mg/ml on average at a mean concentration of 0.420 mg/ml, corresponding to a coefficient of variation of 9.9%.The blood alcohol estimates using the Alcolmeter were somewhat too high during active absorption of ethanol, and too low during elimination, when a constant blood-breath alcohol ratio of 2100:1 was used to calibrate the instrument. During the elimination phase of ethanol kinetics and at a mean blood alcohol concentration of 0.50 mg/ml, the mean Alcolmeter result was 0.456 ± 0.169 mg/ml with 95% confidence, i.e. varying between 0.287 and 0.625 mg/ml 95 times out of 100 tests at this critical blood alcohol level.     

Urban Academic Medical Centers

Eli Ginzberg, ed., Urban Medical Centers: Balancing Academic and Patient Care Functions: Cornell University Medical College Tenth Conference on Health Policy (Boulder: Westview Press, 1996): 105 pp., ISBN 0-8133-2883-7 (cloth), $58.50. To order call 800-242-7737.     

Standard setting with incomplete enforcement revisited

Many regulatory agencies enforcing quality standards across diverse populations of firms lack sufficient resources to promote full compliance. Based on a model with lump-sum noncompliance penalties, W. Kip Viscusi and Richard J. Zeckhauser have advocated that, in most circumstances, an agency with insufficient enforcement resources should choose a less stringent standard than it would choose if it could induce full compliance. I show that the recommendation for regulatory restraint depends upon the shape of the penalty function. A review of inspection and penalty policies suggests that U.S. administrative law encompasses a diversity of variable expected penalty policies. The inspection and penalty policies employed in recent environmental statutes suggest, however, that agencies should compensate for insufficient resources by increasing the stringency of standards.     

Rents from in-kind subsidy: “Charity” in the public sector

Public choice analysis usually focuses attention on the behaviour of self-interested individuals but this paper considers rent seeking when some taxpayers are motivated by altruism. Redistribution policies initiated by self-interested rent seekers require taxpayer approval. Even if taxpayers are fully informed, their resistance to inefficient schemes is reduced when public sector schemes are the only means available to pursue altruistic goals. Altruism serves to broaden the scope within which rent seekers may operate. A discussion of international “tied” aid illustrates the impact which rent seeking can exert on public sector “charity.”