Sudden death resulting from lesions of the cardiac conduction system

Sudden unexpected deaths in young persons with noncontributory histories, autopsy results, and drug screen results are a common problem in forensic pathology. As part of the evaluation of such cases, the cardiac conduction system (CCS) should be studied. To determine the type and incidence of lethal CCS lesions, the authors reviewed their files of sudden unexpected cardiac deaths with particular attention to cases with causes of death in the conduction system. Cases of sudden cardiac death in patients aged < or=40 years during a 10-year period (Michigan) and a 4 year-period (Spain) were selected from the files. From this group, cases were identified in which the cause of death was a lethal change in the CCS. The portions of the heart containing the CCS were excised, and at least one hematoxylin and eosin slide and at least one trichrome or elastic trichrome slide per block were studied. In the two centers, 381 cases of sudden cardiac death were identified. The most common causes of sudden cardiac death were arteriosclerotic narrowing of the coronary arteries, cardiomyopathy, and myocarditis. In 82 cases, there was no identifiable cause of death even after complete gross and microscopic autopsy was performed, a medical history was obtained, and a drug screen was performed. In 11 cases, the CCS contained lesions that were considered lethal: narrowing of the atrioventricular node artery by fibromuscular hyperplasia (7 cases) and atrioventricular node tumors (4 cases). The 11 cases accounted for 2.9% of the 381 cases of sudden cardiac death and 11.8% of the indeterminable cases. It was concluded that examination of the CCS in deaths in which the gross and microscopic autopsy, history, and drug screen fail to provide a cause of death can yield a cause of death in a significant percentage of cases. If heart block was not documented during life and no explanatory lesions were found during routine cardiac examination, examination of the CCS can yield valuable information.     

Death resulting from ruptured cerebral artery aneurysm: 219 cases

To characterize the demographics of ruptured cerebral artery aneurysm as a cause of death and to examine the effect of improved diagnostic and therapeutic techniques on the incidence of sudden death associated with the condition, the authors reviewed 219 autopsies performed at the Dallas County Medical Examiner's Office between 1977 and 1997 in which the cause of death was ruptured cerebral artery aneurysm. Ruptured cerebral artery aneurysms accounted for 1.5% of 15,033 natural deaths and 0.4% of all deaths (45,492) followed by autopsy during this period. The majority (56%) of cases occurred in females, with Caucasian females composing the largest group (38%). Seventy-seven percent of cases occurred in individuals between the ages of 31 and 70 years, with the highest concentration in the 41- to 50-year decade (29%). The most common location for ruptured aneurysms was the middle cerebral artery distribution (39%). Multiple aneurysms occurred in 22 (9.1%) cases. Other factors, such as medical history, coexisting disease, symptoms, activity at onset of symptoms, survival time, and toxicology results are also presented. Compared with literature reports before 1980, when ruptured cerebral artery aneurysms were reported as the cause of death in approximately 4% to 5% of sudden natural deaths, the results of this study suggest that despite improved diagnostic and therapeutic techniques during the past two decades, morbidity and mortality from ruptured aneurysms remain a significant health problem.     

Deaths associated with liposuction: case reports and review of the literature

Tumescent liposuction is a common cosmetic procedure that is performed as an outpatient service in physician's offices and is largely believed to be safe. The protuberant areas of the body containing the undesirable fat deposits are injected with normal saline containing lidocaine and epinephrine for pain control and hemostasis, and the waterlogged cells are suctioned out via cannula through a small incision. We recently encountered three cases in which deaths were attributed to this procedure. Two showed fat embolization in the lung and one died from fluid overload. The osmium tetroxide post-fixed lung sections showed fat emboli in the interstitial capillaries and arterioles. We reviewed the recent literature and found that pulmonary thromboemboli, fat embolization, fluid overload, and lidocaine and epinephrine intoxication are found at autopsy in many cases. Forensic pathologists responsible for determining the cause and manner of death should become familiar with the postmortem findings and risks of liposuction therapy and communicate them to their clinical colleagues and communities.     

Systems Ideologies and Street-Level Bureaucrats: Policy Change and Perceptions of Quality in a Behavioral Health Care System

This article examines the stability of street-level bureaucrats' negative perceptions regarding a newly implemented managed care system on quality of care and service delivery in a publicly funded behavioral health care system. Overall findings indicate that the generally negative perception of managed care did not differ between staff in the two programs, indicating a weak effect on attitudes of frontline workers. More proximal variables to the caregiver, such as service type and job title, show more influence on attitudes. The conclusion discusses the implications of these findings for practicing administrators and academic researchers.     

Coming to Terms with Intramural Differences Over Policy Frameworks: How Policy Researchers Accommodate Rival Claims Among their Peers

Although we readily scrutinize conflicts among political stakeholders, similar attention is seldom paid to how we deal with contestable understandings within our own field of inquiry. Debates over competing scholarly perspectives and contested models are rarely subject to any systematic postmortem or attempts to account for differential survival. Given the indeterminacy of many of our conceptual schemes, empirical data seldom carry the day to a resolution all can accept. Accordingly, there are eventually many different versions of any given dispute, each offering a different path to resolution or equanimity. Disputants retire and conflicts fade, providing a demographic resolution of sorts, but not a scientific or a conceptual one. The work presented here claims that there is much to be gained from systematic scrutiny of our conceptual disputes, especially as a means to access the different perspectives we assume to handle them. We argue that there is an internal logic to the different perspectives on any given dispute. It is not the dispute per se that draws our interest; but rather, how any given dispute generates multiple interpretations and reconstructed versions. We propose and illustrate an approach to analyzing disputes that makes their internal logic more transparent and attends to the pathways that emerge for resolution. We will find, in the process, that there are some reliable routes to conciliation and some fault lines that remain unstable.     

Searching for Symptoms of Political Shirking: Congressional Foreign Travel

Despite the hypothesized propensity for shirking to marklegislative institutions, the evidence is rather equivocal;moreover, most of the research has focused exclusively onlegislator voting, thereby constraining whatevergeneralizations might emerge. The purpose of this paper is tocontribute to the debate over the question of politicalshirking by extending the range of phenomena examined toinclude congressional foreign travel. Our analysis providesevidence that opportunism is a problem in Congress. We findthat last-period problems have arisen in the area of foreigntravel, and that increased scrutiny to the problem on the partof Congress only shifted consumption patterns, i.e.,legislators began taking foreign junkets near, but not at theend of, their legislative careers. Not all foreign travelshould be construed as worthless junketing since there isstrong evidence that some foreign travel is related tomembers' responsibilities on congressional committees.     

Presidential Party,Incumbency, and the Effects of Economic Fluctuations on House Elections, 1916–1996

There is little professional consensusregarding the effect of economic conditionson House Elections. We argue that recentwork still uses the paradigm of Party toorganize their data and tests. Given thatrecent developments in the theory ofcongress emphasize the paradigm ofIncumbency, we investigate the empiricalrelevance of that competing paradigm. Weshow that (1) Incumbency matters in a purePresidential Party Model of HouseElections, (2) Presidential Party mattersin a pure Incumbency Model, (3) Once bothParty and Incumbency are accounted for,economic conditions exert a highlysignificant and temporally stable influenceon House elections, (4) Return Rates aremore affected by economic fluctuations thanare Vote Shares, and (5) Not allPresidential Party incumbents face the samedegree of electoral accountability foreconomic fluctuations.