Sudden cardiac death in the young: A consensus statement on recommended practices for cardiac examination by pathologists from the Society for Cardiovascular Pathology

Sudden cardiac death is, by definition, an unexpected, untimely death caused by a cardiac condition in a person with known or unknown heart disease. This major international public health problem accounts for approximately 15-20% of all deaths. Typically more common in older adults with acquired heart disease, SCD also can occur in the young where the cause is more likely to be a genetically transmitted process. As these inherited disease processes can affect multiple family members, it is critical that these deaths are appropriately and thoroughly investigated. Across the United States, SCD cases in those less than 40 years of age will often fall under medical examiner/coroner jurisdiction resulting in scene investigation, review of available medical records and a complete autopsy including toxicological and histological studies. To date, there have not been consistent or uniform guidelines for cardiac examination in these cases. In addition, many medical examiner/coroner offices are understaffed and/or underfunded, both of which may hamper specialized examinations or studies (e.g., molecular testing). Use of such guidelines by pathologists in cases of SCD in decedents aged 1-39 years of age could result in life-saving medical intervention for other family members. These recommendations also may provide support for underfunded offices to argue for the significance of this specialized testing. As cardiac examinations in the setting of SCD in the young fall under ME/C jurisdiction, this consensus paper has been developed with members of the Society of Cardiovascular Pathology working with cardiovascular pathology-trained, practicing forensic pathologists.

Cardiopulmonary Resuscitation Induced Posterior Rib Fractures in Nontraumatic Pediatric Deaths

ABSTRACT

Posterior rib fractures are considered suspicious for nonaccidental injury when observed in infants without significant trauma history or underlying bone disease. The biomechanical mechanism postulated for causing posterior rib fractures is anterior/posterior compression of the chest with posterior levering of the rib head over the transverse process of the vertebra creating a focal area of stress. The recommended "2-thumb" cardiopulmonary resuscitation method involves the administrator placing both thumbs on the sternum of the patient, encircling the chest with the hands, and placing the finger tips lateral to the spine. From this position, the administrator compresses the chest in an anterior/posterior direction by pressing on the sternum. Theoretically, the 2-thumb method should focus all force on the sternum while the back is supported by the fingers limiting posterior levering of the ribs and reducing the risk of posterior rib fractures. However, posterior rib fractures have been found during the autopsy of infants who received 2-thumb cardiopulmonary resuscitation, had no traumatic history, had a nontraumatic cause of death, and had no indication of underlying bone disease. This case study series presents the demographics, birth histories, circumstances surrounding death, and autopsy findings of four such medical examiner cases.

Cocaine-associated fetal death in utero

Cocaine and its principle metabolite benzoylecgonine were quantitated in blood and liver in six cocaine-related deaths within the Hennepin County Medical Examiner's jurisdiction. Postmortem blood cocaine and benzoylecgonine concentrations ranged from 0 to 5.6 mg/L and 0.6 to 18.7 mg/L respectively. Postmortem liver concentrations ranged from 0 to 5.0 mg/kg and 0.4 to 24.1 mg/kg, respectively. All cases had benzoylecgonine concentrations greater than cocaine concentrations. Most alarming were the findings regarding the cocaine and benzoylecgonine concentrations in the case of a dead pregnant woman. The amniotic fluid cocaine and benzoylecgonine concentrations of 3.3 mg/L and 1.6 mg/L displayed at parent drug to metabolite ratio greater than 1.0 compared to the blood (0.30) and liver (0.21) ratios. This was likely indicative of very recent exposure.

Improved prediction of thyroid lobar mass from parameters obtained by routine thyroid scintigraphy

Estimation of thyroid mass both from parameters derived from thyroid scintigraphy and clinical palpation for purposes of therapeutic dosimetry has not been tested for accuracy. To more precisely determine thyroid mass 90 thyroid lobes from 45 autopsies without history of thyroid disease were studied. Specimens were dissected free of nonthyroidal tissue and assessed for volume, maximum depth (D), width (W), length (L) and mass (M). Using a linear regression model and applying known lobar depth, the most accurate formula to predict true lobar mass (in grams) was 4.9D + 0.07L2W-2.3 (in cms). Length and width would be obtainable in vivo from routine scintigraphic measurements (in cm) and depth would be most accurately determined by ultrasound. For most clinical circumstances where lobar depth is unknown we found the best formula for mass (g) to be 0.1L2W (in cm).

The old-age heart: aging changes of the normal elderly heart and cardiovascular disease in 12 necropsy patients aged 90 to 101 years

In this article, morphologic changes affecting the myocardium, chambers, valves, epicardial coronary arteries, and aorta in the elderly but otherwise normal heart are discussed and are compared with and differentiated from morphologic changes causing clinical cardiac dysfunction, death, or both.

Evaluation of operatively excised cardiac valves: etiologic determination of valvular heart disease

Morphologic evaluation of operatively excised native cardiac valves can lead to an etiologic diagnosis in most instances using a simple 10-step approach. With few exceptions, histologic evaluation of excised cardiac valves provides little additional information beyond this proposed morphologic assessment.