[Fat embolism in forensic pathology].
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Embolism, Fat↗
Biomedical subjects
Slobodan Savić
Publications and source records attributed to Slobodan Savić.
[Sudden cardiac death caused by complicated atherosclerosis of the anterior intraventricular branch of the left coronary artery with a myocardial muscle bridge].
When coronary artery, which is located subepicardially, submerges into myocardium and then, after a short intramural course, again appears subepicardially, it is called embedded coronary, while a part of myocardium above--a myocardial bridge. Muscular bridges are usually small and have no clinical significance. In the proximal part of coronary artery, preceding a myocardial bridge, there occurs a disturbance of blood course and myocardial perfusion, turbulence, collecting of lipids and mucopolysaccharides, lesion of elastica, which all leads to atheromatous lesions of intima of the arterial proximal part and to the resultant complications of atheroma. Degenerative changes of myocardium and its blood vessels, and in connection with it myocardial vulnerability, could be a consequence of this congenital arterial variation. We report a case of a 40-year-old male, without medical data about previous diseases, who died suddenly and unexpectedly in his apartment. The autopsy and microscopical examination revealed an acute ischemic lesion, myocardial bridge in the middle part of the left coronary artery descending branch and the complicated atherosclerotic plaque proximally of this bridge.
Adult↗
[Factors which could affect the severity of post-traumatic pulmonary fat embolism--a prospective histological study].
INTRODUCTION: Each fracture of long or pelvic bones as well as large contusions of subcutaneous fat tissue cause releasing of fat globules that rapidly penetrate into circulation through the ruptured veins of the injured tissue, and reach the lung circulation [1,2]. During the first phase, fat emboli block the functional lung circulation by their mechanical effect in capillaries producing so called isolated post-traumatic lung fat embolism [3]. The surface layer of a fat embolus, which is practically in liquid state, behaves as a membrane of very high density, i.e., as it is under high pressure which obstruct the blood stream [4] that is finally stopped at the level of lung blood vessels with diameter of approximately 20 mu [5]. This pathophysiological mechanism produces cor pulmonale acutum, with poor pathological findings [8]. Nowadays, the post-mortem diagnosis of lung fat embolism is based on microscopical examination of tissue specimens, usually prepared with special histological staining (Sudan III) [9]. The grading of fat embolism according to Sevitt's criteria is generally accepted [10]. Taking of slices from apicoventral areas of the lungs has been recommended [11]. With longer outliving period, the total number of fat emboli in the lung circulation gradually decreases, due to their disintegration and resorption. It has been stated that fat globules completely disappear about 4-6 weeks after injury, and that they should not be searched for microscopically in this post-traumatic phase [11]. OBJECTIVES: The aim of our work was to determine whether the age of injured, their gender, total severity of trauma, outliving period, and hypovolemic shock that develops after injuring, may induce development of more severe forms of post-traumatic lung fat embolism. MATERIAL AND METHODS: A prospective histological study was performed on the autopsy material of the Institute of Forensic Medicine in Belgrade. The analyzed sample consisted of individuals with injuries that might be a source of fat emboli (fractures of long bones, large contusions of subcutaneous fat tissue). The lung slices were systematically taken and stained with special fat staining (Sudan III). In each particular case, the grade of lung fat embolism was counted on the basis of microscopical appearance, according to Sevitt's criteria. The total severity of trauma was estimated by calculation of the Injury Severity Score (ISS) [13, 14]. In no cases from the analyzed sample, the fat embolism was mentioned as either singular or plural cause of death. The obtained results were analyzed by means of appropriates statistical methods (ANOVA, LSD-test, chi 2 test. Man-Whitney test, Fischer's test of correct probability). RESULTS AND DISCUSSION: The analyzed sample included 58 fatally injured individuals, 39 males and 19 females. The average age was 54.10 years (SD = 16.56), the average value of ISS was 34.69 (SD = 5.88), and the average outliving period was 3.74 days (SD = 5.88). However, all these data look differently when the analyzed sample has been stratified and analyzed according to the estimated grade of lung fat embolism. It was not showed that severity of lung fat embolism depends on sex of the injured (chi 2 = 0.842; p > 0.05). The groups with the slightest and the most severe grade of lung fat embolism are statistically significantly different in relation to age of individuals (ANOVA, p = 0.017). By means of LSD test, it has been showed that the group with the most severe grade of lung fat embolism (grade III) is statistically significantly different comparing to other two groups (with grade I and II) in relation to the age of injured (the values are p = 0.16 and p = 0.19 respectively, and the both groups are less than p = 0.05). In the group with the most severe grade of lung fat embolism, the older individuals are statistically significantly represented comparing to other two groups. CONCLUSION: The analysis of our sample showed that the most severe grade of post-traumatic lung fat embolism (microscopical grade III according to Sevitt's criteria) was determined in older individuals, more severely injured, and with shorter outliving period. The severity of fat embolism depends neither on sex of the injured, nor on development of post-traumatic hypovolemic shock. The obtained results related to the influence of hypovolemic shock on severity of fat embolism should be accepted with a caution. Namely, sometimes there is an intention to simplify a procedure of creating of autopsy conclusion about the cause of death, so that loss of blood is not mentioned at all, in spite of fact that it could have been a concurrent cause of death, while in other cases exsanguination is designated as a sole cause of death, forgetting the possibility that fat embolism could have really been the immediate cause of death.
Adult↗
[An accident after an accident--an unusual death in a hospitalized patient].
The authors present a case of accidental fatal laryngopharyngeal obstruction with bolus of food, in hospital, in a patient who has been treated for twenty days because of injuries sustained in a traffic accident. The injuries were multiple fractures and brain contusions that were not clinically diagnosed, while their symptomatology (somnolence) was attributed to morbous lesions--multifocal brain infarction. Mechanical asphyxiation and death occurred when the patient was fed in hospital by his brother. Unofficially we got an information that whole event was very dramatical, and that medical staff tried to attempt resuscitative measures, but without any written note about that in medical documentation. The terminal phase of his chronic desompensated cardiomyopathia was clinically announced as a cause of death. For forensic pathologists it was relatively easy task to prove mechanical asphyxiation due to laringopharyngeal blockage as a real cause of death on medicolegal autopsy.
Accidents, Traffic↗
[Munchausen syndrome by proxy].
This review deals with bibliography on Munchausen syndrome by proxy (MSbP). The name of this disorder was introduced by English psychiatrist Roy Meadow who pointed to diagnostic difficulties as well as to serious medical and legal connotations of MSbP. MSbP was classified in DSM-IV among criteria sets provided for further study as "factitious disorder by proxy", while in ICD-10, though not explicitly cited, MSbP might be classified as "factitious disorders" F68.1. MSbP is a special form of abuse where the perpetrator induces somatic or mental symptoms of illness in the victim under his/her care and then persistently presents the victims for medical examinations and care. The victim is usually a preschool child and the perpetrator is the child's mother. Motivation for such pathological behavior of perpetrator is considered to be unconscious need to assume sick role by proxy while external incentives such as economic gain are absent. Conceptualization of MSbP development is still in the domain of psychodynamic speculation, its course is chronic and the prognosis is poor considering lack of consistent, efficient and specific treatment. The authors also present the case report of thirty-three year-old mother who had been abusing her nine year-old son both emotionally and physically over the last several years forcing him to, together with her, report to the police, medical and educational institutions that he had been the victim of rape, poisoning and beating by various individuals, especially teaching and medical staff. Mother manifested psychosis and her child presented with impaired cognitive development, emotional problems and conduct disorder.
Adult↗