Frequency and extent of contraction band necrosis in orthotopically transplanted human hearts. A morphometric study

BACKGROUND

The aims of the present study are to quantify forms of myocardial and coronary changes found at postmortem and to discuss their significance in relation to causes of death and cardiac arrest in orthotopic transplanted human hearts.

METHODS

The examined material included (1) 46 orthotopic transplanted human hearts and, as "controls", hearts from (2) 25 sudden/unexpected coronary death cases, 38 patients with acquired immunodeficiency syndrome, 34 subjects with "silent" Chagas' disease who died suddenly, 27 non cardiac patients who died from intracranial hemorrhage due to a ruptured cerebral aneurysm and 45 healthy subjects dead from head trauma.

RESULTS

Contraction band necrosis was observed in 85% of transplanted hearts, 66% of AIDS cases and in 100% Chagas' disease, 89% intracranial hemorrhage, 71% sudden coronary death, and 18% normal head trauma cases. Foci of lymphocytic infiltrate were present in 89% of transplanted heart, 50% AIDS, 100% Chagas' disease, 37% intracranial hemorrage and 64% head trauma groups. An allograft coronary vasculopathy was observed in four transplanted hearts with a survival greater than 202 days. In another 12 cases, who survived more than one year, atherosclerosis was the only coronary lesion found. No relation was observed between coronary lesions of any degree of stenosis and myocardial injuries.

CONCLUSIONS

In the group studied acute rejection was the least frequent cause (2%) of graft failure at any time following transplantation and coronary vasculopathy a questionable cause of it in four cases. Rather, contraction band necrosis as an expression of catecholamine myotoxicity seemed to play a role in graft failure related to increased myocardial catecholamine sensitivity after global denervation.

The cocaine "body stuffer" syndrome: a fatal case

Body stuffer, sometimes called "mini packer", is the definition of someone who admits to or is strongly suspected of ingesting illegal drugs in order to escape detection by authorities, and not for recreational purposes or to transport the drug across borders. Cocaine is the drug most commonly involved in the body stuffer syndrome. Reported cases of body stuffer deaths are rare, however a fatality related to the ingestion of a plastic bag containing cocaine is described regarding a 17-year-old dealer. The authors describe how the cocaine body stuffer syndrome differs from the usual body packer. Histological and toxicological findings are examined and discussed for a better definition of this unique syndrome.

Markers of cardiac oxidative stress and altered morphology after intraperitoneal cocaine injection in a rat model

This study was designed to assess the parameters of myocardial oxidative stress and related cardiac morphological changes following intraperitoneal cocaine exposure in rats. The cardiac levels of reduced glutathione(GSH), oxidised glutathione(GSSG), ascorbic acid (AA), and the production of malondialdehyde (MDA) were measured, as well as the variations of activity in the enzyme systems involved in cell antioxidant defence, glutathione peroxidase (GSH-Px), glutathione reductase (GR) and superoxide dismutase (SOD). After chronic cocaine administration for 30 days GSH was significantly depleted in the heart from 30 min (P < 0.001) to 24 h (P < 0.001) after exposure, and GSSG was increased for a similar time (P < 0.05 at 30 min and P < 0.01 at 24 h). SOD increased during the first hour (P < 0.001), GR and GSH-Px both increased from 30 min to 24 h, and these increases were statistically significant (P < 0.01 and P < 0.001 at 30 min and P < 0.01 and P < 0.001 at 24 h, respectively). The AA levels increased after 1 h (P < 0.01), remaining significantly so for 24 h (P < 0.001) and MDA increased from 30 min to 24 h, all values being highly significant (P < 0.001). The body weight was significantly (P < 0.001) reduced in both cocaine groups (40 mg/kg x 30 days and 40 mg/kg x 10 days + 60 mg/kg x 20 days). The heart weight (P < 0.01) and its percentage of the body weight (P < 0.001) were significantly higher in these two groups than in the controls. Similarly, in the noradrenaline 4 mg/ kg x 30 days group, the body weight was significantly (P < 0.001) reduced and the heart weight (P < 0.01) and its percentage of body weight (P < 0.001) were significantly higher than in the controls. In comparing the cocaine and noradrenaline experiments, the frequency and extent of cardiac lesions obtained with 40 mg/kg x 10 days + 60 mg/kg x 20 days of cocaine were similar to those with 8 mg/kg of noradrenaline at 24 h. In this experimental model, cocaine administration compromised the antioxidant defence system of the heart associated with a significant increase of heart weight and the percentage of body weight.

Immunohistochemical quantification of pulmonary mast-cells and post-mortem blood dosages of tryptase and eosinophil cationic protein in 48 heroin-related deaths

Recent studies suggest that many fatal heroin overdoses are caused by anaphylactoid reaction. In the present study we measured tryptase and eosinophil cationic protein in post-mortem blood of 48 deaths after heroin injection. We also investigated the presence and pulmonary distribution of mast-cells using specific immunohistochemical antibody for tryptase and morphometric evaluation in those cases of heroin-related deaths. The data were compared with 44 subjects who died following head trauma and to 32 cases of fatal anaphylactic shock. In the heroin-related death cases, the measurements of serum tryptase levels and eosinophil cationic protein dosages resulted in particularly elevated concentrations compared with the trauma cases. Nevertheless, the data that our study supplies by immunohistochemical techniques indicate that when mast-cells count in the lung was determined, no definite pattern was obtained between fatal heroin overdose cases and the control groups. Furthermore, the wide range of morphine concentrations found in post-mortem blood samples suggest that the term 'overdose' is relative and does not sufficiently characterize death associated with heroin addiction. Our study confirms that elevated concentrations of serum tryptase are associated with many heroin-related deaths. At this moment to attribute the cause of these deaths to 'heroin overdose' ignores the likely causal contribution of other possible systemic reactions to the mechanism of death.

The Jehovah's Witnesses' refusal for blood transfusions: the jurisprudence and the medico-legal debate in Italy

The Jehovah's Witnesses (JWs) patient's refusal of a lifesaving transfusion creates a conflict for the physician. In Italy, we are met with a great disparity of behaviour among physicians; the JW's eventual refusal for transfusional therapy often necessitates the physician's recourse to the court. Jurisprudence has thus arrived at an analysis of the juridical value of so-called advance directives. The analysis demonstrates a noteworthy argumentative coherence and reflects a specific doctrinaire development in transfusional therapy. In fact, in Italy most of medicolegal doctrine recognizes, in the JW's blood refusal, the physician's limited position whereby, it seems, he or she must submit legally to an expressed therapeutical dissent even when the patient is in a condition of incompetence and is no longer capable of expressing his or her refusal, or else must risk an indiscriminate violation of the patient's right to religious freedom and choice. According to the Constitutional Chart, the physician's duty to respect the JW's refusal of blood transfusions is absolute in order to avoid any treatment that is in conflict with the religious faith that each patient is free to profess.

Myocardial findings in fatal carbon monoxide poisoning: a human and experimental morphometric study

The aim of this study was to define the status of the myocardium in selected human cases of acute, fatal carbon monoxide intoxication and the myocardial changes in rats exposed to carbon monoxide in relation to the type of cardiac arrest and the effects of reoxygenation following pre-fatal CO intoxication. The human study consisted of 26 cases (17 accidental and 9 suicide) of acute, fatal CO intoxication, without evidence of obstructive coronary atherosclerosis or history of ischemic heart disease which were compared with 45 cases of fatal head trauma in subjects who died instantaneously (26 cases) or within 1-12 h (19 cases). Inhalation of a lethal dose of CO in rats was compared with sub-lethal doses plus reoxygenation with and without pre-treatment by a betablocker. In all human and experimental histological sections, changes were normalised per mm2 area. In the human cases the myocardium did not show any ischemic types of changes or other lesions. Only in "three accidental" cases a few, small foci of coagulative myocytolysis were detected. In the case of spontaneous death in 31 rats following CO intoxication, no pathological myocardial changes were seen. Of the 15 "reoxygenated" rats, 2 of the 7 spontaneous deaths presented coagulative myocytolysis with 15 +/- 6 foci and 381 +/- 255 necrotic myocells. All the eight rats sacrificed at 3 h had coagulative myocytolysis with 5 +/- 4 foci and 60 +/- 47 myocells. Of the 24 reoxygenated rats pre-treated with a betablocker, 5 died spontaneously after a short survival and 2 of these showed 11 +/- 9 foci and 21 +/- 20 myocells. The 19 rats sacrificed after 3 h all presented coagulative myocytolysis with figures of 75 +/- 43 and 356 +/- 301 with 0.5 mg/kg of propranolol hydrochloride and 55 +/- 45 and 253 +/- 216 with 2 mg/kg, respectively.

Anabolic steroid abuse and cardiac sudden death: a pathologic study

CONTEXT

Androgenic anabolic steroids (AAS) used for improving physical performance have been considered responsible for acute myocardial infarction and sudden cardiac death.

OBJECTIVE

To establish the relationship between AAS and cardiac death.

DESIGN

Case report.

PATIENTS

Two young, healthy, male bodybuilders using AAS.

MAIN OUTCOME MEASURES

Pathologic cardiac findings associated with AAS ingestion.

RESULTS

The autopsy revealed normal coronary arteries. In one case, we documented a typical infarct with a histologic age of 2 weeks. A segmentation of myocardial cells at the intercalated disc level was observed in the noninfarcted region. This segmentation was the only anomaly detected in the second case. No other pathologic findings in the heart or other organs were found. Urine in both subjects contained the metabolites of nortestosterone and stanozolol.

COMMENT

A myocardial infarct without vascular lesions is rare. To our knowledge, its association with AAS use, bodybuilding, or both lacks any evidence of a cause-effect relationship. The histologic findings in our 2 cases and in the few others reported in medical literature are nonspecific and do not prove the cardiac toxicity of AAS. A better understanding of AAS action on the neurogenic control of the cardiac function in relation to regional myocardial contraction and vascular regulation is required.

Adam (MDMA) and Eve (MDEA) misuse: an immunohistochemical study on three fatal cases

Three fatal cases of MDMA/MDEA misuse have been examined. These referred to white males between 19 and 20 years of age, in which post-mortem toxicology showed the presence of MDMA (in one case), MDEA (in one case) and both (in one case). The clinical data were analysed and the histopathological findings were studied following immunohistochemical investigations. A complete immunohistochemical study has made it possible to demonstrate rhabdomyolysis and myoglobinuria with alterations of the organs typical of a DIC. Clinical, histopathological and toxicological data suggest that severe or fatal complications following ecstasy ingestion could be related to idiosyncratic response.

Fatal anaphylactic shock during a fluorescein angiography

The Authors describe an extremely rare fatal case (sixth case in the literature) of anaphylactic shock following a fluorescein angiography. This is the first report in which the diagnosis of anaphylactic reaction to the dye was made through laboratory analyses. The diagnosis of fatal shock due to sodium fluorescein was made based on clinical, laboratory and immunohistochemical data. Mast-cell tryptase was dosed in serum and a pulmonary immunohistochemical evaluation was performed. Tryptase, a neutral protease of human mast-cells is a potentially important indicator of mast-cell involvement in anaphylactic events.

The diagnosis of amniotic fluid embolism: an immunohistochemical study for the quantification of pulmonary mast cell tryptase

Recent clinical articles have suggested that amniotic fluid embolism (AFE) may be the result of anaphylactic reactions to fetal antigens and that the major part of this clinical syndrome is the result of mast cell degranulation and of the release of histamine, tryptase and other mediators. Tryptase, a neutral protease, is known to be the dominant protein component of the secretory granules of T and TC mast cells. In this paper we have examined the presence and the pulmonary distribution of mast cell tryptase utilizing specific immunohistochemical studies and morphometric evaluation in six cases of fatal amniotic fluid embolism compared to six subjects who died following anaphylactic shock and two control groups (five and six cases respectively) of traumatic death. The results demonstrate a numerical increase of pulmonary mast cells in the subjects who died of AFE (average cell number 54.095) with values corresponding to those encountered in cases of death due to anaphylactic shock (average cell number 51.378) compared with that of the traumatic control groups (average cell number 24.477 and 9.995 respectively). These results can shed light on additional criteria for the diagnosis of amniotic fluid embolism.

No-fault compensation for transfusion-associated hepatitis B virus, hepatitis C virus, and HIV infection: Italian law and the Tuscan experience

BACKGROUND

On February 25, 1992, in Italy, a law (Number 210; referred to as 210/1992) was promulgated providing economic indemnity for persons infected with hepatitis B virus, hepatitis C virus, and HIV via transfusion or the administration of hemoderivatives.

STUDY DESIGN AND METHODS

The requests for compensation presented in the central Italian region of Tuscany from the time of the law's promulgation through December 31, 1996, were analyzed. These requests are surveyed by medical commissions in the regional military hospitals, which must compile a report of the completed assessments, formulate a decision concerning verified illnesses, and express an opinion on the existence of a relationship of causality between the damaging event and the impairment or death of the subjects.

RESULTS

Out of 428 requests for indemnity, 372 have been granted and 56 denied. Posttransfusion infections (286 cases) were clearly more prevalent than those due to hemoderivatives (141 cases). Cases of hepatitis, particularly type C, constitute the great majority of the infections for which indemnity was sought, while cases of HIV infection are scarce and in sharp decrease in the data from 1995 and 1996.

CONCLUSIONS

Italian Law 210/1992 has been recognized as providing a benefit to persons infected medically, but its efficiency is greatly obstructed by a lack of documentation regarding transfusions performed in the past.

The new Italian code of medical ethics

In June 1995, the Italian code of medical ethics was revised in order that its principles should reflect the ever-changing relationship between the medical profession and society and between physicians and patients. The updated code is also a response to new ethical problems created by scientific progress; the discussion of such problems often shows up a need for better understanding on the part of the medical profession itself. Medical deontology is defined as the discipline for the study of norms of conduct for the health care professions, including moral and legal norms as well as those pertaining more strictly to professional performance. The aim of deontology is therefore, the in-depth investigation and revision of the code of medical ethics. It is in the light of this conceptual definition that one should interpret a review of the different codes which have attempted, throughout the various periods of Italy's recent history, to adapt ethical norms to particular social and health care climates.