Sudden death due to thrombotic thrombocytopenic purpura

This case studies the clinical, laboratory, and pathologic findings observed in thrombotic thrombocytopenic purpura (TTP). Although TTP is a well-recognized syndrome, it is frequently undetected antemortem and represents a rare cause of sudden death. We recently were involved in a case of TTP in which an 18-year-old woman with no previous history died suddenly. The case was referred to our office for consultation because of a recent history of methamphetamine abuse. We report herewith our approach to the diagnostic workup of TTP and review relevant literature.     

Virtopsy,a new imaging horizon in forensic pathology: virtual autopsy by postmortem multislice computed tomography (MSCT) and magnetic resonance imaging (MRI)--a feasibility study

Using postmortem multislice computed tomography (MSCT) and magnetic resonance imaging (MRI), 40 forensic cases were examined and findings were verified by subsequent autopsy. Results were classified as follows: (I) cause of death, (II) relevant traumatological and pathological findings, (III) vital reactions, (IV) reconstruction of injuries, (V) visualization. In these 40 forensic cases, 47 partly combined causes of death were diagnosed at autopsy, 26 (55%) causes of death were found independently using only radiological image data. Radiology was superior to autopsy in revealing certain cases of cranial, skeletal, or tissue trauma. Some forensic vital reactions were diagnosed equally well or better using MSCT/MRI. Radiological imaging techniques are particularly beneficial for reconstruction and visualization of forensic cases, including the opportunity to use the data for expert witness reports, teaching, quality control, and telemedical consultation. These preliminary results, based on the concept of "virtopsy," are promising enough to introduce and evaluate these radiological techniques in forensic medicine.     

Barriers to Seeking Police Help for Intimate Partner Violence

Intimate partner violence is underreported to police. A study was conducted utilizing focus group methodology to identify women's perceptions of the barriers to seeking police help for intimate partner violence (IPV). Facilitators used a structured format with open-ended questions for five focus group sessions that were recorded and subsequently analyzed using Ethnograph software. Participants were 41 women identified from social service agencies in an urban setting serving IPV women with diverse ethnic and cultural backgrounds. Participants identified many barriers for victims, which fell within the following three themes: (1) Predisposing characteristics — situational and personal factors; (2) fears and negative experiences with police response; and (3) fears of possible repercussions. Participants also described positive experiences with police and generated a wish list for improving police response to IPV. Policies and actions that can be taken by police and social service agencies to address the barriers IPV victims face in seeking police help are discussed.     

A soft-tissue calcification: differential diagnosis and pathogenesis

An autopsy of a 72-year-old white male revealed a 30.5 x 5.1 cm vertically aligned heterotopic ossification just deep to a 30.5 cm midline abdominal scar. The ossified mass was determined to be a heterotopic ossification or myostitis ossificans (MO) traumatica resulting from an abdominal surgical incision during life. While, MO traumatica is relatively common accounting for roughly 60-75% of patients with soft-tissue ossification, heterotopic ossification of abdominal incisions are relatively rare and thus infrequently reported. This article details the manifestation of this relatively large heterotopic bone and provides a comprehensive review of the literature and pathogenesis of this unusual ossification. A review of the English literature from 1920 to the present produced only a handful of articles for a total of 185 reported cases. All had bone formed within vertical incisions, usually within 1 year of surgery, and 89% were males. Knowledge of this phenomenon and the variable size at presentation is useful to both the autopsy pathologist and the anthropologist in generating a diagnosis for abnormal calcifications.     

Children’s Susceptibility to Misidentifying a Familiar Bystander From a Lineup: When Younger is Better

Children from 5 to 12 years of age (N=779) were shown a videotape where a preschool teacher has money stolen from her wallet. Children were shown a lineup, and for children in the bystander condition, the lineup contained a familiar bystander without the thief. Children in the control condition viewed the same lineup but they had not seen the bystander in the videotape. Among the 11–12-year olds, participants in the bystander condition were significantly more likely than control participants to misidentify the familiar bystander. This effect was not found in children from 5 to 10 years of age. When children in the control condition were shown a lineup that contained the thief without the bystander, the 11–12-year olds were significantly more likely than the younger children to correctly identify the thief. These findings demonstrate that age can both increase and decrease the accuracy of children’s lineup identification accuracy depending on the task at hand and the content of a lineup.     

Differential diagnosis of traumatic skull findings in infants: residues after vacuum extraction

If autopsy findings in an infant show traumatic changes on the skullcap, these are not always the result of a postnatal trauma due to child abuse, a fall or another accidental event. With regard to differential diagnosis a birth trauma should also be kept in mind, so that the history of the delivery is important. The spectrum of possible residues after vacuum extraction (circular fracture and/or elevation of the outer table of skull bones, subperiostal and intraossal haematoma, extradural and subdural haemorrhage) is demonstrated by means of three examples from the forensic autopsy material.     

Alprazolam-related deaths in Palm Beach County

Alprazolam is a commonly prescribed benzodiazepine. The abuse of benzodiazepines is most frequently seen in conjunction with the abuse of other drugs. Only rare fatalities have been attributed to alprazolam alone. We undertook a retrospective review of cases investigated by the Palm Beach County Medical Examiner's Office in which postmortem toxicologic studies indicated the presence of alprazolam, to further study the pattern of alprazolam abuse. Our review consisted of 178 cases, including 87 in which death was attributed to combined drug toxicity, 2 to alprazolam toxicity alone, 44 to trauma, 12 to natural causes, and 33 to another drug or drugs. Cocaine and methadone were the most common cointoxicants in the cases of combined drug toxicity, while heroin was less frequently detected. There was considerable overlap in the postmortem blood alprazolam concentrations among the groups. The overlapping ranges of concentrations of alprazolam detected indicate that it may be difficult to define a lethal alprazolam range, and that it may not be possible to determine the actual role of alprazolam as a causal factor in cases of combined drug toxicity. This study confirms that alprazolam alone is rarely a cause of death, and that alprazolam abuse usually occurs within a polydrug use pattern. The high incidence of cocaine as a cointoxicant has not been previously reported.     

Cor triatriatum sinistrum: a rare congenital cardiac anomaly presenting in an adult with chronic atrial fibrillation

Cor triatriatum is a rare congenital cardiac anomaly in which the left atrium is divided into proximal (dorsal or upper) and distal (ventral or lower) chambers by a fibromuscular septum. The upper chamber receives the pulmonary veins and the lower chamber contains the atrial appendage and the mitral valve. The 2 chambers communicate through a defect in the membrane. Cor triatriatum is often associated with other congenital cardiac anomalies. Most frequently, the upper chamber communicates with the right atrium through a patent foramen ovale or atrial septal defect, and the clinical symptoms simulate anomalous pulmonary venous return. Less commonly, the foramen ovale communicates with the distal chamber and the clinical features mimic mitral stenosis. When cor triatriatum is the only abnormality, the clinical findings are also similar to mitral stenosis with development of pulmonary hypertension and subsequent right ventricular hypertrophy and atrial enlargement. The diagnosis is usually made in infancy or childhood, and the lack of treatment results in death in 75% of patients.We report the case of a woman who presented much later in life. The patient was a 57-year-old female with a clinical history of chronic atrial fibrillation who presented to the emergency department because of a "funny sensation" in her chest, though she denied chest pain, nausea, vomiting, or diaphoresis. EKG revealed atrial fibrillation with a rapid ventricular response and a tachycardic rate of 157. She had a therapeutic level of digoxin, and cardiac enzymes were normal. The patient was admitted and placed on Cardizem drip. Serial EKGs remained normal and heart rate control was achieved. On hospital day 2, the patient became dyspneic and cyanotic. She went into cardiac arrest and died.Autopsy revealed cardiomegaly (610 g) with 4-chamber dilatation. A septum divided the left atrium into 2 chambers. The defect in the dividing membrane measured 1 cm in diameter. No other congenital defects were noted. The large size of the defect in the membrane likely accounted for the late onset of symptoms that allowed this patient to survive into adulthood without previous diagnosis or surgical intervention (which is usually required in childhood).     

An analysis of strategies used to disseminate the PLATO system

Two aspects of efforts to disseminate an innovative computer-assisted instructional system called PLATO between 1972 and 1976 are addressed. The first pertains to the dissemination problems encountered and resolved by the system developers. The second covers dissemination modus operandi chosen by the developers to bring PLATO to the attention of large numbers of people. An ex post facto analysis of data obtained suggested PLATO developers made dissemination decisions that reflected viable dissemination theory and practice of the time, committed substantial resources to the dissemination process, and selected what appeared to be a cost-effective marketing strategy. Perhaps the most important consequence of these actions is that PLATO flourished throughout the 1970s and continues to flourish.