Diagnostic accuracy of extended biopsies for the staging of microfocal prostate cancers in autopsy specimen.

Clinically insignificant prostate cancers may be predicted when biopsies show a microfocal cancer (MiFC). However, at least one-third of MiFC are underestimated by biopsies. The aim of this study was to evaluate the staging accuracy of different biopsy regimen showing a MiFC. We performed 18 biopsy cores on 164 autopsy prostates. Six cores were taken from the mid-peripheral zone (MPZ), 6 from the lateral PZ (LPZ) and 6 from the central zone (CZ). We tested seven different biopsy regimens by distinguishing the MPZ, LPZ or CZ biopsies either separately or associated with each other. Of the cancers detected by biopsies, we selected those showing a MiFC and compared our findings with whole mount analysis. The positive predictive value of a MiFC referred to how often, when needle biopsies showed a MiFC, there was a clinically insignificant cancer on whole mount prostate analysis. We found that the positive predictive value of a MiFC on 6 or 12 biopsy cores was similar irrespective of biopsy location (P approximately 1). On MPZ, MPZ plus LPZ and all 18 biopsies, it was 40, 70 and 87%, respectively (P<0.1). Tumor volume of cancers showing a MiFC on MPZ biopsies was significantly higher than those showing a MiFC on MPZ plus LPZ, or all 18 biopsies (P<0.05). These results show that performing additional cores in case of MiFC on sextant biopsies may help differentiating significant from insignificant cancers.

Autoerotic asphyxiation in a female.

Autoerotic asphyxiation is an unusual but increasingly more frequently occurring phenomenon, with >1000 fatalities in the United States per year. Understanding of this manner of death is likewise increasing, as noted by the growing number of cases reported in the literature. However, this form of accidental death is much less frequently seen in females (male:female ratio >50:1), and there is correspondingly less literature on female victims of autoerotic asphyxiation. The authors present the case of a 31-year-old woman who died of an autoerotic ligature strangulation and review the current literature on the subject. The forensic examiner must be able to discern this syndrome from similar forms of accidental and suicidal death, and from homicidal hanging/strangulation.

Airway obstruction by a ball.

A toddler died as the result of choking on a toy ball that occluded his upper airway. The size of this toy was within the federal safety standards for use by children under the age of three years. Though it has been recognized since 1987 that the minimum safe diameter set by the Federal Hazardous Substances Act may be too small, no change has been made to the regulation (1). In 1995 a comprehensive review of asphyxia related to the size of the foreign object found 4.44 cm diameter and 7.62 cm length a more comprehensive standard (1). Currently federal warning labels are required on some items that contain balls smaller than 4.44 cm to prevent use by children less than three years of age (2). The small parts fixture test in use by the federal government is available as a safety tool for parents to use at home. Unfortunately the "safe" diameter of 3.17 cm is too small to provide assurance that a toy is not a choking hazard.

Open air carbon monoxide poisoning.

An unusual manner of carbon monoxide poisoning claimed the lives of two adults in two separate incidents. In the first case, a young man was four wheeling in a swampy area when his jeep became stuck in the mud as he continued to floor the accelerator. Carbon monoxide fumes entered the vehicle through the rusted floorboards, killing the driver. In the second case, two teens were skinny dipping behind a motor boat when they became affected by the boat exhaust. One of the youths was overcome and submerged into the lake. Both incidents were initially attributed to incorrect causes--a car accident and a drowning--because of the false notion that carbon monoxide is not a hazard in a ventilated area. The carboxyhemoglobin levels in these victims were 78 and 62% respectively. It was only through laboratory testing that carbon monoxide poisoning was identified as the cause of their demise. Physicians as well as the public need to be aware of the potential for this life threatening hazard to occur so that there can be proper emergency treatment and the prevention of fatalities.

Alkylamine antihistamine toxicity and review of Pediatric Toxicology Registry of the National Association of Medical Examiners. Report 4: Alkylamines.

Antihistamines are popular nonprescription medications for the treatment of allergy and cold symptoms. Accidental exposures to these preparations are common with > 14,000 occurring annually in children under the age of 6 years (1). Despite this, there is limited information about toxic and lethal concentrations of these drugs in children. We present a case of a pediatric fatality due to a common brompheniramine and phenylpropanolamine preparation and review available Pediatric Toxicology Registry data on alkylamine antihistamines. The data collected by the Pediatric Toxicology Registry on the drug phenylpropanolamine has been previously reported (2). A review of the Registry data suggests that postmortem blood brompheniramine concentrations of 0.4 mg/L and greater in children is indicative of brompheniramine poisoning. However, pheniramine was also present in the blood in the same case and may have caused an additive effect. The data are insufficient to establish the threshold of fatal blood pheniramine concentration in children. Data for chlorpheniramine are lacking.

Fatal injuries in a minor traffic collision.

An elderly woman was the driver and sole occupant of a midsize car involved in a minor collision with a standard sized automobile. She was restrained with a lap and shoulder belt and the air bag was deployed. Yet she suffered fatal chest injuries. No injuries were sustained by the unrestrained driver and passenger of the larger vehicle. Despite maximum restraint in a fully functioning new model car, even a minor collision can be fatal.

Accidental toddler drowning in 5-gallon buckets.

We have identified a previously unrecognized source of accidental drowning in infants and toddlers: 5-gal (19-L) industrial buckets. Twelve cases of drownings in these large-capacity buckets constituted 24% of all infant and toddler (age less than 3 years) drownings investigated by the Cook County (Illinois) Medical Examiner's Office from January 1985 to June 1989. The buckets, all with 5-gal and 18-kg capacity, are constructed of heavy, rigid plastic and are intended for industrial use. Home use, typically as mop buckets, was associated with the toddlers' death. The large size and heavy construction of these buckets as well as the toddlers' cephalad center of gravity and undeveloped coordination prohibit the toddlers from extricating themselves after peering into and falling inside the buckets. Parents and public health officials should be advised that domestic use of these containers poses a serious threat to the safety of curious toddlers. Adults should never leave toddlers unattended around even small amounts of water.

Successfully treated Hodgkin's disease followed by mycosis fungoides: case report and review of the literature.

We report the case of a 30-year-old man who had Hodgkin's disease of the nodular sclerosing type and subsequently developed mycosis fungoides. The Hodgkin's disease was treated with radiation therapy and chemotherapy, and the patient was in complete remission. Seven years later mycosis fungoides occurred and rapidly became progressive. Autopsy revealed that the mycosis fungoides involved multiple organs without any evidence of Hodgkin's disease. The possible significance of the association of these two diseases is presented.

In utero cerebral hemorrhage in alloimmune thrombocytopenia.

Central nervous system hemorrhage is a well-recognized complication of neonatal alloimmune thrombocytopenia attributed to perinatal trauma from passage through the birth canal. That central nervous system (CNS) hemorrhage can occur in utero is not as well recognized, and congenital CNS lesions have only circumstantially been linked to thrombocytopenia. We report two cases of intrauterine CNS hemorrhage shown to have occurred prenatally, resulting in porencephaly. The second case is unique in that the necropsy finding of a porencephalic cyst arising from an old hemorrhagic site pathologically confirms that the etiology of congenital CNS lesions in alloimmune thrombocytopenia is due to hemorrhage. This second case received close prenatal monitoring and yet died as a result of hemorrhage that was not detected until emergency operative delivery. A review of the literature revealed 10 cases, including two other pairs of siblings, who had CNS damage attributable to intrauterine hemorrhage. These findings indicate that congenital CNS lesions in alloimmune thrombocytopenia are due to intrauterine hemorrhage that careful obstetric and prenatal care may not identify or prevent. This fact should be included when genetic counseling is offered to alloimmunized mothers.