Haemolytic staining of the intima of the aortic root-- a useful pathological marker of freshwater drowning?

The significance of haemolytic staining of the aorta is unclear. While it has been associated with freshwater drowning, data are lacking. To study this phenomenon further a prospective study looking at the colour of the intima of the pulmonary trunk and aortic root was undertaken in 47 randomly selected coronial control cases and in 13 consecutive fresh drowning deaths. There were 16 putrefied control cases each of which showed haemolytic staining of both great vessels. Of the other 44 non-putrefied cases (31 controls, 9 saltwater drownings, and 4 freshwater drownings), only one (a freshwater drowning) showed marked staining of the aortic root with no staining of the intima of the pulmonary trunk. Conclusion: This study has demonstrated that haemolytic staining of the aorta at autopsy, in the absence of significant staining of the pulmonary trunk and putrefaction, may be a pathological feature that is supportive of freshwater drowning. It is not, however, present in all cases. Given the relatively small numbers in this study further work is required to clarify this issue.     

Svechnikov’s sign as an indicator of drowning in immersed bodies changed by decomposition: an autopsy study

Purpose

Bodies recovered from water often present as a difficult problem in forensic pathology. The aim of this study was to examine the presence and amount of free liquid in the sphenoid sinus in cases of freshwater drowning, and to compare this to the amount found in putrefied bodies recovered from freshwater, as well as in putrefied bodies found in an indoor environment.

Methods

Free liquid from the sphenoid sinuses was aspirated using a syringe and a needle, after piercing the hypophyseal fossa. Non-putrefied drowning cases were also examined for hemolytic staining of the intima of the aortic root.

Results

In 29 non-putrefied cases of freshwater drowning there was 1.36 ± 1.48 ml in the sphenoid sinuses, with 21 of them having hemolytic staining of aortic intima. In putrefied bodies recovered from freshwater (22 cases) there was 1.26 ± 1.40 ml within the sphenoid sinuses, and in putrefied bodies found in an indoor environment (52 cases), there was significantly less—0.57 ± 0.92 ml.

Conclusions

Free liquid in the sphenoid sinuses (Svechnikov’s sign) may be considered a vital reaction in drowning non-putrefied cases. Hemolytic staining of the aortic intima could be a significant sign of freshwater drowning. In putrefied bodies recovered from water, an amount of 0.55 ml of free liquid in the sphenoid sinuses may imply that the victim was alive upon their contact with the water, but the presence of free liquid in the sphenoid sinuses does not necessarily indicate that drowning had been the cause of death.     

超声、MR、CT、X线诊断主动脉夹层的比较

目的：比较超声、MR、CT及X线对主动脉夹层的诊断价值。方法：2005—01～2008—09经手术病理证实的26例主动脉夹层患者,26例均经超声、X线检查,17例经MR及CT检查,重点观察超声主动脉声像,内膜有无撕裂及撕裂部位,真假腔血流情况,主动脉瓣有无受累及瓣膜反流情况、心包积液、左室收缩功能等。结果．26例超声诊断25例,其中12例为DeB—bakeyI型,占46．2％,5例为Ⅱ型,占19．2％,9例为Ⅲ型,占34．6％,I型最常见。19例中量以上主动脉瓣反流,7例少量主动脉瓣反流,9例少一中量心包积液。16例LVEF％及LVFS％降低。17例经MR及CT检查诊断15例,26例胸片提示主动脉增宽,心影增大。结论：超声可作为诊断主动脉夹层的首选检查项目。     

Application of electrolyte analysis of pleural effusion to diagnosis of drowning

We measured concentrations of sodium (Na), chloride (Cl), calcium (Ca), and magnesium (Mg) in pleural effusion from forensic autopsy cases to examine whether they were useful for a diagnosis of drowning. We analyzed a total of 51 cases (15 seawater drowning, 10 freshwater drowning, and 26 non-drowning), and determined the following reference values. If the concentration of Na or Cl is under 65 mEq/l, a diagnosis of freshwater drowning can be made. If the concentration of Na is higher than 175 mEq/l, or that of Cl is higher than 155 mEq/l, or that of Ca is higher than 16 mg/dl, or that of Mg is higher than 15 mg/dl, a diagnosis of seawater drowning can be made. We recommend that pleural effusion from the left and the right thoracic cavities should be collected and analyzed separately because large differences may be observed between each side in the case of drowning. If one side corresponds to the reference value for seawater or freshwater drowning and the other side does not, a diagnosis of drowning can still be made according to the obtained value.     

Exercise training with a heart device: a hemodynamic, metabolic, and hormonal study

PURPOSE: The mechanisms of the training-induced improvements in left ventricular assist (LVAD) patients are unknown. METHODS: We measured the hemodynamic, gas exchange, and metabolic and hormonal effects of 6-wk exercise training in a cardiogenic shock patient who was assisted by an LVAD. RESULTS: After training, the peak power and VO2 increased by 166% and 56%, respectively (80 W and 16.1 mL x min(-1) x kg(-1)), whereas the ventilatory drive decreased. Although the LVAD output increased little with exercise, the systemic cardiac output rose (adequately for the VO2) from 5.91 and 4.90 L x min(-1) at rest to 9.75 and 9.47 L x min(-1) at peak work rate, before and after training, respectively. Thus, the left ventricle ejected again through the aortic valve. Unloading and/or retraining resulted in a left ventricular filling pressure decrease. Although the right ventricular ejection fraction increased with exercise, it decreased again at the maximal load after training. For a given work rate the arterial lactate, the norepinephrine (NE) and epinephrine (E) concentrations fell after training, but the enhanced maximal work rate elicited higher NE and E concentrations (4396 and 1848 pg x mL(-1), respectively). The lack of right ventricular unloading might have kept the atrial natriuretic peptide higher after training, but the blood cyclic GMP and endothelin were lower after training. CONCLUSION: In an LVAD patient, retraining returns the exercise capacity to the class III level by peripheral and left ventricular hemodynamic improvements, but the safety of maximal exercise remains to be proven in terms of right ventricular function and orthosympathetic drive.     

Effects of different sodium concentrations in replacement fluids during prolonged exercise in women

OBJECTIVE: To investigate the effect of different sodium concentrations in replacement fluids on haematological variables and endurance performance during prolonged exercise. METHODS: Thirteen female endurance athletes completed three four hour runs on a 400 m track. Environmental conditions differed between the three trials: 5.3 degrees C and snow (trial 1), 19.0 degrees C and sunny weather (trial 2), 13.9 degrees C and precipitation (trial 3). They consumed 1 litre of fluid an hour during the trials with randomised intake of fluids: one trial (H) with high sodium concentration (680 mg/l), one trial (L) with low sodium concentration (410 mg/l), and one trial with only water (W). Before and after the trials, subjects were weighed and blood samples were taken for analysis of [Na(+)](plasma), packed cell volume, and mean corpuscular volume. RESULTS: The mean (SD) decrease in [Na(+)](plasma) over the whole trial was significantly (p<0.001) less in trial H (2.5 (2.5) mmol/l) than in trial W (6.2 (2.1) mmol/l). Mild hyponatraemia ([Na(+)](plasma) = 130-135 mmol/l) was observed in only six women (46%) in trial H compared with nine (69%) in trial L, and 12 (92%) in trial W. Two subjects (17%) in trial W developed severe hyponatraemia ([Na(+)](plasma)<130 mmol/l). No significant differences were found in performance or haematological variables with the three different fluids. There was no significant correlation between[Na(+)](plasma) after the run and performance. There was a significant correlation between changes in [Na(+)](plasma) and changes in body weight. CONCLUSIONS: Exercise induced hyponatraemia in women is likely to develop from fluid overload during prolonged exercise. This can be minimised by the use of replacement fluids of high sodium concentration. Sodium replacement of at least 680 mg/h is recommended for women in a state of fluid overload during endurance exercise of four hours. However, higher [Na(+)](plasma) after the run and smaller decreases in [Na(+)](plasma) during the trials were no indication of better performance over four hours.     

Electrolyte analysis of pleural effusion as an indicator of drowning in seawater and freshwater

It is important for forensic pathologists to determine the diagnosis of drowning as well as the site of drowning. In a previous study, we propose that analysis of electrolytes in pleural effusion from rats may be useful for determining whether drowning has occurred in seawater or freshwater. To test this proposal, we measured the concentration of sodium, potassium and chloride ions and total protein in pleural effusion from 40 autopsy cases: 24 involving seawater drowning, 9 freshwater drowning and 7 no drowning. The concentrations of sodium and chloride ions in pleural effusion showed a significant difference between seawater drowning and freshwater drowning. The concentration of potassium ions and total protein showed no difference between each group, although they increased in proportion to the postmortem interval in cases of both seawater and freshwater drowning. These results are almost same as our previous study and, thus, the quantitative analysis of electrolytes in pleural effusion may be useful for determining whether drowning has occurred in seawater or freshwater.     

Sodium addition to nonionic contrast media. Effects on cardiac monophasic action potentials and hemodynamics in a dog model

In order to study the electrophysiologic and hemodynamic effects of sodium addition to low-osmolality contrast media during coronary arteriography, eight dogs with surgically opened thoraces were studied. Epicardial monophasic action potentials (MAP) were recorded from the contrast perfused area, using suction electrodes. Six milliliters of iohexol, iohexol with addition of 20 to 80 mmol/L Na+ and ioxaglate, were selectively administered into the left coronary artery. Only minor hemodynamic alterations occurred with the iohexol solutions, whereas ioxaglate decreased left ventricular (LV) inotropy and pressures initially. Iohexol and iohexol containing less than 40 mmol/L Na+ did not change MAP duration significantly. The addition of 80 mmol/L Na+ to iohexol lengthened MAP duration at 25%, 50%, and 90% repolarization by 14 +/- 2, 18 +/- 3, and 18 +/- 5 mseconds, respectively. Ioxaglate lengthened MAP duration by 14 +/- 3, 17 +/- 3, and 26 +/- 8 mseconds, respectively. Thus, during coronary arteriography in dogs, iohexol with sodium added, like ioxaglate, induced regional electrophysiologic changes in the contrast-perfused area of the myocardium, while sodium-free iohexol did not.     

Simultaneous measurement of blood and myocardial velocity in the rat heart by phase contrast MRI using sparse q-space sampling

PURPOSE: To measure cardiac blood flow patterns and ventricular wall velocities through the cardiac cycle in anesthetized Wistar Kyoto (WKY) rats. MATERIALS AND METHODS: A gradient-echo cine pulse sequence incorporating pulsed field gradients (PFGs) provided phase contrast (PC) motion encoding. We achieved a range of velocity sensitivity that was sufficient to measure simultaneously the large flow velocities within the cardiac chambers and aortic outflow tract (up to 70 cm s(-1) during systole), and the comparatively small velocities of the cardiac wall (0-3 cm s(-1)). A scheme of sparsely sampling q-space combined with a probability-based method of velocity calculation permitted such measurements along three orthogonal axes, and yielded velocity vector maps in all four chambers of the heart and the aorta, in both longitudinal and transverse sections, for up to 12 time-points in the cardiac cycle. RESULTS: Left ventricular systole was associated with a symmetrical laminar flow pattern along the cardiac axis, with no appearance of turbulence. In contrast, blood showed a swirling motion within the right ventricle (RV) in the region of the pulmonary outflow tract. During left ventricular diastole a plume of blood entered the left ventricle (LV) from the left atrium. The ventricular flow patterns could also be correlated with measurements of left ventricular wall motion. The greatest velocities of the ventricular walls occurred in the transverse cardiac plane and were maximal during diastolic refilling. The cardiac wall motion in the longitudinal axis demonstrated a caudal-apical movement that may also contribute to diastolic refilling. CONCLUSION: The successful measurements of blood and myocardial velocity during normal myocardial function may be extended to quantify pathological cardiac changes in animal models of human cardiac disease.     

Haematic silicon in drowning

The aim of this paper was to evaluate silicon (Si) concentration in human whole ventricular blood as a further potential chemical marker in the diagnosis of drowning. We employed an acidic digestion for the extraction of soluble Si, and an alkaline digestion for the determination of total Si, including particulate matter, both arising from drowning medium. 29 suspected drowning situations, 24 in fresh water (Fw) and 5 in seawater (Sw), were examined. The difference in Si concentration between the left and right ventricular blood (Si Δ_L–R) was measured and alkaline Si Δ_L–R seems, indeed, a potentially significant complementary tool in the diagnosis of Fw drowning, because insoluble silicon fraction does not undergo hemo-dilution or hemo-concentration, and the Δ_L–R is not affected by exogenous factors. In spite of the limited number of cases investigated, a good correlation was observed between the analytical results and the macro-microscopic autoptic findings.     

Hemodynamic effects of high versus low-osmolar contrast media for ventriculography in severe aortic stenosis

The hemodynamic effects of high-(diatrizoate meglumine/sodium) and low-(iopamidol) osmolar constrast administration for left ventriculography were compared in 15 patients with severe aortic valve stenosis. Patients were similar with respect to aortic valve gradient, aortic valve area, age, body surface area, and baseline hemodynamics as well as associated coronary disease and valvular insufficiency. Administration of diatrizoate meglumine/sodium was associated, with a 22% increase in heart rate, and marked (27%) decrease in left ventricular systolic pressure, with a small (15%) increase in left ventricular end diastolic pressure. In contrast, administration of larger volumes of iopamidol was associated with only a slight (9%) increase in heart rate, a small (6%) decrease in left ventricular systolic pressure, and a smaller (6%) increase in left ventricular end diastolic pressure. In patients with severe aortic valve stenosis iopamidol may offer a safer hemodynamic profile than diatrizoate meglumine/sodium.     

Comparison of cine MR imaging with Doppler echocardiography for the evaluation of aortic regurgitation

Regurgitant blood flow is associated with localized signal loss of the blood pool within the recipient chamber on cine MR images, which may be useful for assessing regurgitant valvular disease. To evaluate the potential of this technique for determining the severity of aortic regurgitation, multilevel cine MR imaging was performed in 10 normal volunteers and in 25 patients with aortic regurgitation documented and graded for severity by Doppler echocardiography. Cine MR images were analyzed to obtain cardiac chamber volumes and to measure the extent of the signal loss associated with regurgitation. All regurgitant lesions were visualized on cine MR images as areas of diastolic signal loss extending from the aortic valve into the left ventricle. The extent of signal loss and the regurgitant volume determined from analysis of MR images correlated with the echocardiographic severity of the lesion. The total area of diastolic left ventricular signal loss was 0 cm2 in 10 normal volunteers, 24 +/- 13 (+/- SD) cm2 in eight patients with mild aortic regurgitation, 49 +/- 11 cm2 in nine patients with moderate aortic regurgitation, and 62 +/- 20 cm2 in eight patients with severe aortic regurgitation (p less than .05 for moderate and severe vs mild). Left ventricular volumes calculated from MR images correlated well with echocardiographic volumes (r = .92, SEE = 30 ml, p less than .0001). Regurgitant fraction calculated from analysis of cine MR images was 4 +/- 7% in normal volunteers and 31 +/- 8% in mild, 45 +/- 11% in moderate, and 56 +/- 9% in severe aortic regurgitation (p less than .05 for moderate and severe vs mild and normal). Thus, cine MR imaging can provide useful qualitative and quantitative data regarding cardiac dimensions and regurgitant valvular flow in patients with aortic regurgitation.     

Possible postmortem serum markers for differentiation between fresh-, saltwater drowning and acute cardiac death: a preliminary investigation

The aim of the present study was to investigate the differences in postmortem blood biochemistry between fresh-, saltwater drowning and acute myocardial infarction/ischemia (AMI) (n=11, n=15 and n=23, respectively; postmortem interval <48 h). Left and right cardiac blood samples were examined for the serum markers: sodium (Na), chloride (Cl), magnesium (Mg), blood urea nitrogen (BUN), creatinine (Cr), pulmonary surfactant-associated protein A (SP-A) and cardiac troponin T (cTn-T). The most efficient markers were the left-right cardiac BUN ratio for determination of drowning (hemodilution) and the left heart blood Mg level for differentiation between fresh- and saltwater aspiration. A characteristic feature of saltwater drowning was a low left-right BUN ratio and a marked elevation in the serum Cl, Mg and Ca levels of the left heart blood. Serum cTn-T level was usually low in drownings, showing a difference from most cases of AMI. Freshwater drowning showed a significant elevation of serum SP-A, although there was considerable overlapping with saltwater drowning and AMI. These findings suggested the usefulness of serum markers in the investigation of death from drownings.     

Heart evaluation by cine CT: use of two new oblique views

Two new oblique views on cine computed tomography for examination of the left ventricle of the heart are described. A short-axis view sections the left ventricle transversely, demonstrating all the ventricular walls; a long-axis view sections the left ventricle longitudinally, demonstrating the mitral valve, proximal aortic root, aortic outflow tract, and ventricular apex. These views are produced by a combination of table slew and patient positioning. Reproducible short-axis views were obtained in 16 healthy volunteers and 11 patients. Long-axis views were obtained in 11 patients. Patient studies in the long-and short-axis views were compared with results from angiocardiography, with nearly identical findings.     

Pulmonary immunohistochemistry and serum levels of a surfactant-associated protein A in fatal drowning

To evaluate the immunohistochemical distribution and serum levels of a pulmonary surfactant-associated protein A (SP-A) in fatal drowning with regard to the pulmonary alveolar injury, 53 autopsy cases were investigated. SP-A was membranously or linearly demonstrated in varying intensities on the intra-alveolar interior surface and on the interface of the intra-alveolar effusion. A high score of intra-alveolar aggregates of SP-A was significantly more frequently observed in freshwater than saltwater drowning. The left/right ratios of cardiac blood SP-A level were significantly high both in fresh- and saltwater drowning, showing no relationship to aggregated SP-A scores. Immunohistochemical score and serum level of SP-A were independent of the lung weight or pleural effusion. These observations suggest a partial difference of pulmonary pathophysiology depending on the immersion medium in fatal drowning.     

Evaluation of left ventricular enlargement in isolated aortic insufficiency. Importance of the total cardiac volume calculated on the standard chest film

A radiographic and hemodynamic investigation has been performed in 53 patients with pure isolated aortic regurgitation, in order to evaluate the most reliable method to detect left ventricular enlargement in this condition. Twelve plain chest film measurements have been compared to the end diastolic volume of the left ventricle calculated by left ventricular angiography. The most sensitive detector of left ventricular enlargement was the plain film total heart volume ( r = 0.754); the cardiothoracic ratio, the cardiac perimeter and the frontal area were less sensitive measurements, but still statistically significant (p less than 0.001). The results of our investigation support the conclusion that plain film total heart volume is the most reliable single measurement for evaluating the left ventricular enlargement in patients with isolated pure aortic incompetence.     

Electrolyte analysis in pleural effusion as an indicator of the drowning medium

In medico-legal autopsies for drowned bodies, the location of drowning needs to be determined. To investigate the usefulness of electrolyte analysis in pleural effusion as an indicator of the location where the deceased has drowned, we determined the concentrations of electrolytes in the pleural effusion of rats drowned in four kinds of water. The concentrations of sodium and chloride ions in the pleural effusion of rats that drowned in seawater were significantly greater than those of rats that drowned in freshwater at both 1 day and 3 days after drowning. The concentration of potassium ions in pleural effusion 1 day after drowning showed no difference between each group, although it then increased from 1 to 3 days after seawater drowning, whereas it decreased from 1 to 3 days after freshwater drowning. The concentration of total protein in pleural effusion increased from 1 to 3 days after drowning, however, there was no significant difference in the concentration of total protein in pleural effusion between each group at either 1 day or 3 days after drowning. These results suggest that analysis of electrolytes in pleural effusion may be useful for determining whether drowning has occurred in seawater or in freshwater.     

Drowning—post-mortem imaging findings by computed tomography

The aim of this study was to identify the classic autopsy signs of drowning in post-mortem multislice computed tomography (MSCT). Therefore, the post-mortem pre-autopsy MSCT- findings of ten drowning cases were correlated with autopsy and statistically compared with the post-mortem MSCT of 20 non-drowning cases. Fluid in the airways was present in all drowning cases. Central aspiration in either the trachea or the main bronchi was usually observed. Consecutive bronchospasm caused emphysema aquosum. Sixty percent of drowning cases showed a mosaic pattern of the lung parenchyma due to regions of hypo- and hyperperfused lung areas of aspiration. The resorption of fresh water in the lung resulted in hypodensity of the blood representing haemodilution and possible heart failure. Swallowed water distended the stomach and duodenum; and inflow of water filled the paranasal sinuses (100%). All the typical findings of drowning, except Paltau’s spots, were detected using post-mortem MSCT, and a good correlation of MSCT and autopsy was found. The advantage of MSCT was the direct detection of bronchospasm, haemodilution and water in the paranasal sinus, which is rather complicated or impossible at the classical autopsy.     

Electrolyte analysis of pleural effusion for discrimination between seawater and freshwater drowning in decomposed bodies

ObjectiveThe diagnosis of drowning is an important issue in forensic investigations. Moreover, discriminating between seawater and freshwater drowning is crucial to identify where the drowning occurred. The present study aimed to investigate electrolyte concentrations in pleural fluid in decomposed bodies in late postmortem intervals and derive cut-off values for the diagnosis of seawater and freshwater drowning.Study designData were collected from 44 seawater drowning cases, 60 freshwater drowning cases, and 30 non-drowning cases with pleural effusion which served as controls. The levels of sodium ion (Na⁺), potassium ion (K⁺), and chloride ion (Cl⁻) of pleural fluid were measured, and two indices were calculated: summation of Na⁺ and K⁺ levels (SUM _Na + K), and summation of Na⁺, K⁺, and Cl⁻ levels (SUM _{Na + K + Cl}). The means of the three ion concentrations and two indices significantly differed between the three groups (p < 0.0001).ResultsThe receiver operating characteristic analysis revealed that the sensitivity and specificity were both 1.000 for SUM _{Na + K + Cl} of 288.3 mEq/L between the seawater and control groups. The Na⁺ value of 109.0 mEq/L also had a high sensitivity of 0.977 and a specificity of 0.933 in the seawater and control groups. The sensitivity and specificity were 0.967 and 1.000, respectively, for SUM _Na + K of 123.2 mEq/L between the freshwater and control groups.ConclusionThe electrolyte concentrations in pleural effusion may be useful for the diagnosis of drowning in decomposed bodies with a longer postmortem interval.     

Nutritional considerations in triathlon

Triathlon combines three disciplines (swimming, cycling and running) and competitions last between 1 hour 50 minutes (Olympic distance) and 14 hours (Ironman distance). Independent of the distance, dehydration and carbohydrate (CHO) depletion are the most likely causes of fatigue in triathlon, whereas gastrointestinal (GI) problems, hyperthermia and hyponatraemia are potentially health threatening, especially in longer events. Although glycogen supercompensation may be beneficial for triathlon performance (even Olympic distance), this does not necessarily have to be achieved by the traditional supercompensation protocol. More recently, studies have revealed ways to increase muscle glycogen concentrations to very high levels with minimal modifications in diet and training.During competition, cycling provides the best opportunity to ingest fluids. The optimum CHO concentration seems to be in the range of 5-8% and triathletes should aim to achieve a CHO intake of 60-70 g/hour. Triathletes should attempt to limit body mass losses to 1% of body mass. In all cases, a drink should contain sodium (30-50 mmol/L) for optimal absorption and prevention of hyponatraemia.Post-exercise rehydration is best achieved by consuming beverages that have a high sodium content (>60 mmol/L) in a volume equivalent to 150% of body mass loss. GI problems occur frequently, especially in long-distance triathlon. Problems seem related to the intake of highly concentrated carbohydrate solutions, or hyperosmotic drinks, and the intake of fibre, fat and protein. Endotoxaemia has been suggested as an explanation for some of the GI problems, but this has not been confirmed by recent research. Although mild endotoxaemia may occur after an Ironman-distance triathlon, this does not seem to be related to the incidence of GI problems. Hyponatraemia has occasionally been reported, especially among slow competitors in triathlons and probably arises due to loss of sodium in sweat coupled with very high intakes (8-10 L) of water or other low-sodium drinks.