Anomalous origin of 4 coronary ostia from the right sinus of Valsalva in a patient with hypertrophic cardiomyopathy.

Anomalous origin of 4 separate coronary ostia from a single coronary sinus has rarely been reported. We report what is to our knowledge a previously undescribed variation characterized by the left anterior descending, left ramus, left circumflex, and right coronary arteries originating from separate ostia in the right sinus of Valsalva. In addition, the autopsy disclosed features of hypertrophic cardiomyopathy, rarely associated with congenital coronary anomalies.

Seatbelts contribute to location of lesion in moderate to severe closed head trauma.

The relationship between seatbelt use and injury severity, brain lesion location, and functional outcome was investigated in 163 individuals who sustained traumatic brain injuries in motor vehicle collisions. Of this group, 31 were using a seatbelt at the time of the accident and 132 were not. Restrained motor vehicle occupants were significantly more likely to sustain damage to subcortical brain structures than unrestrained occupants. Conversely, unrestrained occupants sustained a greater frequency of posterior brain lesions. In addition, demographic and behavioral variables were significantly related to increased likelihood of seatbelt use. Analyses revealed no significant differences between groups for injury severity variables and functional outcome measures. Seatbelts alter the body's response to forces applied in motor vehicle collisions, creating disparities in lesion sites between restrained and unrestrained motor vehicle occupants. The relationship between seatbelt use and injury severity and functional outcome is discussed.

Underutilization of neuropsychology in traumatic brain injury rehabilitation: is managed care to blame?

We evaluated factors determining which individuals received neuropsychological evaluations (NPEs) following traumatic brain injury (TBI). Comprehensive records from a State-wide/sponsored Head Injury Program were followed from 1985--1995 to monitor effects of managed care on provision (or absence) of formal NPEs and ultimately on rehabilitation outcome. Only 26% of 273 individuals received NPEs (within their first three years post-injury). In the years prior to and after large changes in managed care, there were no differences in the provision of formal NPEs. Discriminant analysis identified functional status at discharge from primary rehabilitation and total number of rehabilitation facilities as the two variables that most distinguished those who had received NPEs with 69% classification accuracy. Between group analyses revealed that individuals were more likely to receive NPEs if they were young, involved in liability claims, attended multiple rehabilitation facilities, or had higher functional status at discharge from primary rehabilitation, regardless of the nature or severity of their TBI. Individuals receiving formal NPEs ultimately achieved higher levels of functional independence, suggesting a potential selection bias. Individuals were no more likely to receive NPEs according to insurance status (private versus government assisted) or as a function of the decade of their injury (1980's versus 1990's). It appears that health-care reform has had no deleterious effect on neuropsychologists' ability to provide consultative services for this population, and following TBI, only a discrete sample of individuals receive and benefit from NPEs.

Schizophrenia and sudden death: a medical examiner case study.

This study reviews the causes of sudden death of 66 schizophrenic patients who presented to the Office of the Chief Medical Examiner (OCME) for the State of Maryland over a 3-year period from 1994 through 1996. We identified an increased incidence of suicide compared with the general population of OCME cases. This observation is consistent with reports by other investigators. The majority of the deaths were the result of natural diseases, mostly atherosclerotic cardiovascular disease. Accidents, suicides, and 1 homicide were also present in this group.

Perphenazine distribution in a postmortem case.

The case of a 34-year-old, mentally challenged, Caucasian female found dead in a group home is presented. Empty containers of perphenazine and valproic acid were found next to her bed. The perphenazine had been prescribed to another patient. No anatomic cause of death was determined at autopsy. Comprehensive testing of the heart blood for ethanol and drugs identified perphenazine at a concentration of 4.4 mg/L and valproic acid at a concentration of 950 mg/L. The distribution of perphenazine in other specimens was consistent with previously reported phenothiazine cases. The medical examiner ruled that the cause of death in this case was multiple drug intoxication and the manner of death was suicide.

Air bag-associated injury to a child in the front passenger seat.

We report the case of a 3.5-year-old front seat passenger who suffered significant head and neck injuries as a result of air bag deployment in a collision of <30 mph. These lesions included multiple abrasions of the lower half of the face, nose, forehead, and right ear, torn frenula, conjunctival petechiae, comminuted fractures of the left and right lateral frontal regions and right parietal bone, diastatic fracture of the coronal suture, subgaleal and subarachnoid hemorrhages, cortical contusions, subluxation of the atlantooccipital joint, and fracture of the C4 vertebral body. These lesions are consistent with trauma secondary to the deploying air bag and the head striking the interior of the car. The findings in this case further support the Centers for Disease Control and Prevention (CDC) guidelines of keeping children properly restrained, preferably in the back seat, or as far as possible from air bags.

Injury patterns in a plastic (AR-1) baton fatality.

Rubber and plastic bullets or batons have been used in countries outside the United States for several years. These devices were designed to inflict nonlethal force in riot control. The authors report a case of fatal injury sustained by an elderly woman struck in the chest by a plastic baton, including the circumstances surrounding this unusual incident, the autopsy findings and a review of the literature.

A penny (or peso) for your thoughts: an unusual intermediate target.

Intermediate targets becoming secondary projectiles in gunshot wounds is a well recognized phenomenon. Secondary projectiles usually possess a fraction of the kinetic energy compared to the primary projectile, leading to superficial wounds of skin and soft tissue. We describe the case of a foreign object that was propelled by the primary bullet with sufficient energy to penetrate not only skin and soft tissue, but also temporal skull and brain. The report also examines the energy requirements for an object to penetrate bone and unique radiographic findings.

Synaptic changes in the striatum of schizophrenic cases: a controlled postmortem ultrastructural study.

Although studies indicate abnormalities in the striatum of schizophrenic people, little information exists on the synaptic changes that may be present at the ultrastructural level. Autopsy specimens of striatal tissue from people with schizophrenia, normal controls, and psychiatric controls were obtained from the Maryland Brain Collection. Several abnormalities were noted in the schizophrenic group that were not present in the normal or psychiatric controls. In schizophrenic tissue, the density and/or proportion of symmetric synaptic profiles, particularly those ending on spines, were lower in the caudate vs. the putamen, implying an imbalance in inhibitory synaptic transmission between these two structures. The density of perforated synaptic profiles, cortical afferents thought to be involved in synaptic turnover and cognition, was lower in the striatum of the schizophrenic group compared to the control groups. The density of axodendritic synaptic profiles, particularly of the asymmetric type, was decreased in the caudate, but not the putamen, of a subset of schizophrenic cases that were nondyskinetic and off drugs (NDODS). The proportion of asymmetric axospinous synaptic profiles was elevated in the caudate of the NDODS cases in comparison to normal controls. The variety of synapses affected in the schizophrenic group implies the involvement of several neuronal circuits. The alterations observed in the schizophrenic striatum were usually due to changes in the caudate, but not the putamen, which argues against drug-related alterations. Since the striatum, particularly the caudate nucleus, is involved in cognition and emotion, these neuroanatomical changes could underlie, in part, aspects of schizophrenic psychopathology.

Immunocytochemical localization of tyrosine hydroxylase in the human striatum: a postmortem ultrastructural study.

An electron microscopic evaluation of tyrosine hydroxylase (TH) immunocytochemistry was used to describe the synaptic organization of dopamine innervation of the striatum in postmortem human brain tissue. TH immunoreactivity was qualitatively and quantitatively similar in the caudate and putamen. TH immunoreactivity was present mainly in unmyelinated axons and occasionally in myelinated axons. Both TH-immunoreactive (TH-i) varicosities (0.75-1.5 microm) and intervaricose segments (0.2-0.3 microm) formed synapses with spines and dendrites. Most synapses formed by TH-i profiles were symmetric axospinous (57-62%) or symmetric axodendritic (33-35%). An occasional asymmetric axodendritic or asymmetric axospinous synapse was observed. Approximately 35-50% of all symmetric axospinous and axodendritic synapses were formed by TH-i boutons. Synapses formed by TH-i profiles were short in length (0.226 microm) and had nonperforated postsynaptic densities. TH-i profiles formed synapses with both the head (40%) and the neck (60%) of spines. Typically, the TH-i bouton was apposed to both a spine and a nonlabeled terminal which formed an asymmetric synapse with that spine. Direct, nonsynaptic appositions were often seen between TH-labeled and nonlabeled boutons forming asymmetric synapses. The general pattern ofTH immunoreactivity was similar to that of other species except for the presence of TH-i myelinated axons and the observation that the majority of TH-i synapses were formed with spines rather than with dendritic shafts.

Benzodiazepine receptors in the post-mortem brain of suicide victims and schizophrenic subjects.

To examine the role of benzodiazepine (BZ) receptors in suicide and schizophrenia, we determined BZ receptors in post-mortem brain (Brodmann's area 10) obtained from suicide victims, schizophrenic patients, and control subjects using [3H]RO15-1788 as the radioligand. The maximum number of binding sites (Bmax) of BZ receptors in the cortex of suicide victims was significantly higher compared with controls, but this increase was mainly due to those suicide victims who died by violent means and whose Bmax was significantly higher than of those who died by non-violent means or control subjects. In schizophrenic patients, Bmax was not significantly different from that of control subjects. When the schizophrenic subjects were separated into two groups, those on neuroleptics and those off neuroleptics for at least 12 months, however, the mean Bmax of BZ receptors in the prefrontal cortex in post-mortem brain obtained from schizophrenic patients on neuroleptics was significantly lower than Bmax in drug-free schizophrenic patients or normal controls. There were no significant differences among groups in values of the apparent dissociation constant (KD) of [3H]RO15-1788 binding. These results suggest that BZ receptors are up-regulated in the cortex of suicide victims, specifically those who used violent means, and that neuroleptic treatment may result in decreased central BZ receptor binding in the cortex of schizophrenic patients. Thus, the method of suicide and previous exposure to neuroleptics should be considered in the interpretation of data on BZ receptors.

Synaptic organization of the human striatum: a postmortem ultrastructural study.

The goal of this study was to characterize the synaptic organization of the normal human adult striatum for comparison with other species and with the diseased human striatum. Samples of striatal tissue from the Maryland Brain Collection obtained at autopsy with postmortem intervals of less than 4 hours were prepared for electron microscopic analysis according to standard techniques. The caudate nucleus and the putamen were similar in terms of the proportions of synaptic subtypes, the lengths of synaptic subtypes, and the area of most types of axon terminals. The proportions of major striatal synaptic subdivisions, such as axospinous synapses (83.5%) and asymmetric synapses (77.5%), were similar to that of the monkey (82% and 77%, respectively) but slightly lower than found in the rat (90% and 89%, respectively). Interestingly, the proportion of synapses with perforated postsynaptic densities (23%), a type of synapse thought to represent synaptic plasticity, was much higher in humans than in rats (5-8%). The lengths of asymmetric synapses (0.697 micron) were significantly longer than that of symmetric synapses (0.423 microns), a relationship found in other mammals. Also, the areas of terminals forming asymmetric synapses (0.707 micron2) were larger than those forming symmetric synapses (0.401 micron2), also consistent with data from other species. The length of axospinous synapses (0.656 micron) and the area of the terminals forming them (0.611 micron2) were not significantly different from the length of axodendritic synapses (0.523 micron) or the area of terminals forming them (0.602 micron2). This study is the first quantitative study on synaptic organization in human postmortem striatum. The results indicate that the synaptic organization of the human striatum is similar, but not identical, to that of other mammalian species.

Reduced striatal spine size in schizophrenia: a postmortem ultrastructural study.

Numerous studies using in vivo imaging or light microscopic analysis of autopsy specimens have found abnormalities in the striatum of schizophrenics. Striatal tissue from the Maryland Brain Collection with short postmortem intervals was used in the present study. Electron micrographs of striatal neuropil were digitized to determine the area of dendritic spines. Spines were similar in size in both the caudate and the putamen in normal individuals. The spines in tissue from schizophrenics were also similar in size between these two regions. However, striatal spines in schizophrenics were approximately 30% smaller than in controls (p < 0.05). Since the majority of synapses in the striatum are formed with spines, this change in the schizophrenic brain may represent aberrant synaptic conductance and/or efficacy.

ProsthesisWare: concepts and caveats for microcomputer-based aids to everyday living.

Two main approaches have been taken in using the microcomputer as an aid to the elderly for everyday living. The first strategy is often termed cognitive rehabilitation and uses the computer as a tutor for the training or retraining of such general cognitive skills as memory or attention. The strength of this strategy is that it is inexpensive and deliverable; its weakness is that it is ineffective for many people because it requires plasticity and the ability to generalize to real-life situations. The second strategy, termed ProsthesisWare, uses the computer as a prosthetic or augmentative device for any deficiencies in cognitive or motor abilities. The strength of the ProsthesisWare approach is that it can be effective in providing compensation and in maintaining the independent home environment that most people desire; its weakness is that it requires acceptance, maintenance, and idiosyncratic customization. As an illustration of the ProsthesisWare program. SpeechWare is presented. This software serves as a prosthetic aid for those who, as a result of stroke, amyotrophic lateral sclerosis, or other neurological impairment, have lost the ability to communicate and who may also have severe motor impairments. SpeechWare also includes telephone, distance electronic, and written communication functions as well as basic control of household appliances and environment.

When in vitro fertilization fails: a prospective view.

New reproductive technologies such as in vitro fertilization (IVF) offer much hope to infertile couples, yet the odds for success are not high. In this study we examine the experiences of a cohort of women undergoing IVF or a related technology at three points in time: before technological intervention, approximately one month after the first failed cycle, and six months later. We consider the women's expectations and experiences and discuss implications of the findings for social work practice.

Flecainide intoxication.

A fatal case attributed to flecainide intoxication is presented. Quantitation was by capillary gas chromatography with nitrogen-phosphorus detection. The flecainide concentration in the blood was 13 mg/L as compared to a therapeutic range in serum of 0.2-1.0 mg/L. Flecainide concentrations in other specimens were as follows: bile, 160 mg/L; urine, 54 mg/L; vitreous humor, 7.4 mg/L; liver, 180 mg/kg; kidney, 74 mg/kg; and stomach contents, 120 mg.

Decreased phosphorylation of synaptic glycoproteins following hippocampal kindling.

Rats with chronic electrode implants to region CA3 of the hippocampus were rapidly kindled by stimulation with a 10 s, 10 Hz train of biphasic square waves presented every 5 min, until generalized seizures developed (60-70 stimulations). The hippocampi were isolated from the brains of control animals (implanted but not stimulated), and experimental animals which had developed generalized seizures. Synaptic membranes (SM) were prepared. SM were incubated with [gamma-32P]ATP and the incorporation of 32P into proteins and glycoproteins isolated by affinity chromatography on concanavalin-A-agarose was investigated. There was no difference in the phosphorylation pattern of total SM proteins between groups. In contrast, the phosphorylation of a glycoprotein with an apparent molecular weight of 180,000 was decreased 20-40% in kindled animals. This result was replicated in three independent experiments. The results suggest that the phosphorylation of glycoprotein 180 may be related to neuroplastic events.