Biomedical subjects
Publications and source records attributed to J M Richmond.
A worker died after a witnessed fall from an 8-foot ladder. Autopsy revealed an unexpected penetrating wound to the hard palate. This report details the importance of the forensic autopsy in reevaluating the scene.
OBJECTIVE: The objective of this postmortem study was to use high-detail skeletal surveys, specimen radiography, and histopathologic analysis to determine the number, distribution, and age of inflicted skeletal injuries in infants studied at the University of Massachusetts Medical Center from 1984 to 1994. MATERIALS AND METHODS: Thirty-one infants (average age, 3 months) who died with inflicted skeletal injuries were studied with high-detail skeletal surveys and specimen radiography and histopathologic analysis. The distribution and number of fractures was determined for each technique, and dating was performed on the basis of radiologic and histologic criteria. The skull fractures noted in 13 cases were excluded from the numerical analysis. RESULTS: The radiologic-histopathologic correlation revealed 165 fractures involving the ribs in 84 (51%), long bones in 72 (44%), bones of the hands and feet in 6 (4%), clavicles in 2 (1%), and spine in 1 (< 1%). Of the 72 long bone fractures, the metaphyses were involved in 64 (89%, or 39% of the total), and the shaft was involved in 8 (11%, or 5% of the total). One hundred sixteen fractures were healing, 36 were acute, and 13 were of indeterminate age. In all but two infants, at least one healing fracture was present. Of fractures diagnosed histopathologically, specimen radiography increased the yield of fractures noted on skeletal survey from 58% to 92%. CONCLUSION: Most infants who die with inflicted injury have fractures at multiple sites. Metaphyseal and rib fractures are much more common than long bone shaft injuries, the opposite of the pattern found in older children. Because most abused infants who die have evidence of healing fractures at the time of autopsy, aggressive radiologic efforts to identify these injuries in living as well as in decreased infants appear justified.
Fractures of the posterior ribs are well-recognized sequelae of infant abuse. Previous reports have indicated a predilection for fracture near the costotransverse process. This study expands the spectrum to include fractures involving the rib head. The radiologic and histologic features are described, and the mechanism of injury of this lesion is examined. In situ and specimen radiography, followed by histopathologic examination, was performed in 78 ribs removed from seven abused infants who died with posterior rib fractures. Computed tomography of the intact posterior thorax was performed in two of these infants. Fifty posterior rib fractures were identified; 29 involved the rib head. Frontal radiography was insensitive in identifying these fractures, clearly revealing injury only when periosteal reaction was present (four of 29 cases). Axial specimen radiography delineated the fractures in all cases. In the two infants studied, CT depicted five of 19 fractures visible only with axial specimen radiography. The morphologic features of these fractures further support the concept that most fractures in abused infants occur by means of indirect forces and are consistent with anteroposterior manual thoracic compression during assaults.
The present study was carried out to determine if healing metaphyseal injury in abused infants is accompanied by an increase in the thickness of the growth-plate zone of hypertrophic cartilage and if a radiolucent extension from the growth plate into the metaphysis correlates with this histologic indicator of healing fracture. The radiologic studies of 13 infants who died with evidence of inflicted injury were reviewed. Thirteen distal metaphyseal fractures were identified. Histologically, nine of these fractures were noted to be healing and four showed no evidence of healing. The nine healing injuries were accompanied by statistically significant thickening of the zone of hypertrophic cartilage. Seven of these demonstrated localized areas of hypertrophic cartilage extension; in six of these, corresponding radiolucent extensions of the growth plate into the metaphysis were seen. The extensions tended to be single and focal with minimal osseous injury and broad and multiple with extensive injury. No similar extension was visible in the four acute injuries. Because metaphyseal injuries are notoriously difficult to date, the presence of a reliable radiologic indicator of healing metaphyseal fracture can be important in the evaluation of infant abuse. Because the radiologic findings reflect the histologic alterations, extension of the growth-plate cartilage into the metaphysis may have implications for estimating fracture age.
67Ga scintigraphy was performed in 44 patients with various biopsy proven forms of renal disease and in a further 64 patients, some with clinically diagnosed renal disease and some with non-renal disorders. Renal uptake of gallium at 48 hours was graded by two blinded observers and by tissue ratios determined by computer. All 11 patients with biopsy proven acute drug-induced interstitial nephritis demonstrated intense, diffuse, bilateral renal 67Ga uptake, a phenomenon observed in only five of the other 30 patients with biopsy proven renal disease and in four of the 64 patients with clinical diagnoses only. No patient with acute tubular necrosis demonstrated significant renal gallium uptake. It is suggested that 67Ga scintigraphy is an excellent screening test for the presence of acute interstitial nephritis and helps to identify which patients with unexplained acute renal failure require renal biopsy.
We studied the functional effects of intraperitoneal sepsis on systemic hemodynamics in general, and on renal function in particular, in sheep in whom bacterial peritonitis was induced by cecal perforation. In the first group of seven sheep (group 1) fluid was administered throughout the period of sepsis to maintain pulmonary capillary wedge pressure as close to presepsis values as possible. These sheep exhibited hemodynamic changes known to be associated with sepsis in man: increased cardiac output and decreased systemic vascular resistance. In a second group of seven sheep (group 2) fluid intake was restricted; compared with group 1, these sheep demonstrated a smaller increase in cardiac output that did not persist and that was associated with an increase in the systemic vascular resistance during the septic period. Plasma renin levels increased fivefold in group 2 but were unchanged in group 1. Serial renal biopsies during the septic period revealed that all sheep had evidence of tubular cell damage on electron microscopy: cell swelling, loss of the microvillous brush border, and cell necrosis. Both groups of sheep also demonstrated marked tubular proteinuria similar to that found in humans with generalized sepsis. Despite this, sheep in group 1 exhibited no functional renal changes: creatinine clearance levels rose slightly from control values, urine concentrating ability was unimpaired, and fractional excretion of sodium increased appropriately in response to a sodium load. In contrast, group 2 sheep exhibited a fall in creatinine clearance levels but fractional sodium excretion did not fall as would have been expected were renal function entirely normal. The results suggest that generalized "hyperdynamic" sepsis induces tubular cell damage and tubular proteinuria by an unknown mechanism. However, this does not necessarily produce renal impairment since the glomerular filtration rate does not fall unless volume contraction is also allowed to occur.
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Atypical gunshot wounds of entrance occur when bullets deviate from their stable nose-on trajectory before entering the body. When this occurs, the resulting wound may have an atypical D-shaped appearance. Ray-like abrasions or bruises may radiate from the corners of the wound. Unstable nonaxial flight may be caused by intermediate targets, ricochets , inappropriate weapon/ ammunition combinations, poor weapon construction, or use of misaligned silencers . If a bullet is deformed before entrance the configuration of the resulting wound may be bizarre, and the wound configuration may closely resemble the configuration of the striking bullet. Nine cases are presented showing the effects of various intermediate targets. A number of methods for the investigation of atypical wounds are discussed.
Urine protein excretion patterns have been studied in 42 patients with sepsis and compared with that in 21 healthy controls. Patients with sepsis were shown to have highly significant increases in fractional clearances for beta 2-microglobulin, albumin, amylase and immunoglobulin G as compared with the controls. Analysis of the pattern of protein excretion demonstrates that the proteinuria is of the tubular rather than the glomerular type. There was no evidence that administration of aminoglycoside antibiotics contributed to the production of tubular proteinuria, and in particular these drugs did not appear to affect the excretion of beta 2-microglobulin.
As part of a study of "Adaptation to home dialysis" we have examined psychological, physiological, and social factors influencing the success of 136 patients on home hemodialysis, followed for greater than 18 months. The study has demonstrated specific physical, psychological, and stress factors associated with increased probability of failure on home hemodialysis. In those under 45 years of age, the profile of failure is of higher diastolic blood pressure in training, more frequent episodes of congestive heart failure, higher levels of stress associated with varying health and loss of sleep and greater anxiety and depression. In the older age group failure was associated with higher levels of depression and self depreciation, and higher levels of stress associated with fear of death, pain during dialysis and blood clotting. On the other hand, higher denial levels were positively correlated with success. There were no significant differences between profiles of those patients who succeeded and those who died. Although analysis is based on a retrospective study, the time sequence between data collection and end points suggests that patient profiling can be used in a predictive manner. The study emphasizes the importance of psychological and social factor analysis in the overall management of the patient with renal failure.
Renal involvement in sarcoidosis has recently been emphasized with increasing reports of associated glomerulonephritis. We report in detail a further case of mesangiocapillary glomerulonephritis in association with sarcoidosis. In addition, a review of 75 cases of sarcoidosis at Royal Melbourne Hospital over a 10-year period revealed one case of membranous glomerulonephritis and one case of granulomatous interstitial nephritis. Seven patients in the series had nephrocalcinosis, and eight further patients had abnormalities of urinary sediment of clinical symptoms of renal involvement. These findings suggest that, though renal failure is rare, renal involvement in sarcoidosis is more frequent than has previously been reported.
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Hereditary nephritis is a well recognized disease, but its clinical manifestations and patterns of inheritance are variable. We report a family with hereditary renal disease in which the morphological lesion is interstitial nephritis and the pattern of inheritance autosomal dominant. In contrast with previous reports, microscopic/macroscopic hematuria was not a consistent marker for renal involvement. The family also demonstrates the inheritance of rheumatoid arthritis in an autosomal dominant pattern, not temporally related to the interstitial renal disease.
This report describes a family with the rare combination of tophaceous gout and renal failure. We emphasise that asymptomatic hyperuricemia may be associated with significant renal disease and suggest that in addition to tubular atrophy and interstitial fibrosis, both obstructive glomerular and tubular lesions and also vascular lesions are important in the pathogenesis of urate nephropathy. We recommend that potentially affected family members should be actively sought and treated at an early age in the hope of preventing the development of renal failure.
Renal failure in patients with systemic sclerosis is usually considered irreversible. Presented are two cases of patients with scleroderma and deterioration in renal function, one of whom has responded to therapy which included immunosuppressive agents, plasma exchange, and control of blood pressure.
This report discusses the treatment and recovery of a 29-year-old woman with thrombotic thrombocytopaenic purpura complicated by servere renal failure. The case is reported because of the rarity of recovery from anuric renal failure in this disease and the probable contribution of plasma exchange to this recovery.
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