Ruptured abdominal aortic aneurysms: clinical presentation in Auckland 1993-1997.

BACKGROUND: Rupture of an abdominal aortic aneurysm (RAAA) carries a reported mortality rate in the range of 32-95%. Survival requires prompt diagnosis and surgical management. The presenting features, however, are varied, often insidious and potentially misleading with Osler noting nearly 100 years ago that a correct premortem diagnosis was achieved in only 33% of cases. The present study aims to review our present accuracy in diagnosing this condition and outline demographic and presenting features of patients with RAAA. METHODS: A review was undertaken of hospital and Coroner's files of all patients residing in the Auckland Coronial region who had RAAA between 1 January 1993 and 31 December 1997. RESULTS: Three hundred and twenty-nine cases of RAAA were identified, and they occurred most commonly in the 8th decade. The male:female ratio was 3:1 and at least 73% of patients were Caucasian. The overall mortality was 71%. Nearly half underwent surgery and the hospital averaged mortality rate was 46%. No patient survived without surgery. Classic presenting features of RAAA were absent in many cases. Abdominal pain, back pain and a palpable mass occurred in only 49%, 36% and 18% of patients, respectively. Other common presenting symptoms included vomiting, general malaise and pelvic or hip pain. Forty-three patients (16%) were initially misdiagnosed. CONCLUSIONS: Although our ability to correctly diagnose a RAAA has improved since Osler's time, the initial misdiagnosis rate of 16% leaves no room for complacency. Ruptured abdominal aortic aneurysms must be included in the differential diagnosis of any patient over the age of 55 years who presents with shock, even if the pain is non-specific or atypical.

The forensic pathology of nonagenarians and centenarians: do they die of old age? (The Auckland experience).

The aim of this study is to provide awareness of the common causes of death and their associated trends in the very aged. Forensic autopsies on patients aged >90 years were reviewed. The study lasted from January 1, 1988 to December 11, 1998 and was done in Auckland, New Zealand, the population of which is 1.3 million. Cases were divided into natural or unnatural deaths. Of the total of 319 cases, 272 (85%) deaths were natural. Of those, only 13 (5%) were "written off" as being attributed to old age or senile debility. The most common causes of death were ischemic heart disease (IHD), 74 cases (23%); bronchopneumonia, 37 cases (12%); fractures, 28 cases (9%); acute myocardial infarction, 25 cases (8%); cerebrovascular accident, 19 cases (6%); and ruptured aneurysm, 17 cases (5%); 61 (19%) deaths were multifactorial. Fractures, either as the primary cause of death or as a complicating factor, accounted for 29 cases, third only to IHD and bronchopneumonia. Forty-seven deaths (15%) were unnatural; of those, 43 were accidents, 3 were suicides, and 1 was a homicide. From these results it is clear that the very elderly succumb to disease; they do not often die of old age.

Diffusion of gamma globulin into the arterial wall identifies localized entry of lipid and cells in atherosclerosis.

BACKGROUND: The localization of atheromatous lesions in vulnerable arteries and their relatively rare occurrence in other arteries of the same subject cannot be explained by current theories of the aetiology of atherosclerosis. OBJECTIVE: To determine whether abnormal diffusion of gamma globulin into the arterial wall from the lumen will identify defects of barrier function allowing localized entry of lipid and cells in atherosclerosis. METHODS: Paraffin sections of left anterior descending coronary arteries and corresponding internal thoracic arteries from 80 human subjects aged 1-65 years were stained for gamma globulin by the immunoperoxidase technique. Duplicate sections were stained with orcein to demonstrate the elastin structure. RESULTS: The barrier function of the luminal surface of the thickened intima was associated with the presence of an elastin lamina beneath the endothelial cells. With advancing age, the coronary arteries exhibited breakdown of this barrier function in localized areas with entry into the arterial wall of gamma globulin, lipid and cells. This was rare in the internal thoracic artery. CONCLUSION: Lack of continuity or incomplete formation of this sub-endothelial lamina, which was seen particularly in the coronary artery, was associated with localized entry into the arterial wall of gamma globulin, lipid and cells from the circulating blood and with the development of atheromatous lesions.

The effect of age and duration of disease on airway structure in fatal asthma.

We hypothesized that if airway remodeling is related to duration of asthma, that when matched for severity, the airways of older adults should show greater alterations than the airways of younger adults. Using standard morphometric techniques, we compared airways with basement membrane perimeters (Pbm) between 2 and 10 mm from young individuals who died of asthma (n = 14, range 17-23 yr), and older individuals with fatal asthma (n = 13, range 40-49 yr). Comparisons were also made with normal airways from age-matched adults. Wall area was increased in old individuals with fatal asthma compared with young individuals with fatal asthma, primarily due to greater adventitial area, whereas wall area in young individuals with fatal asthma was not different from control subjects. Within muscle bundles the connective tissue matrix was increased around individual cells in individuals with asthma, unrelated to age. After adjustment for this change, smooth muscle area in both asthma groups was still greater than in age-matched control subjects, in old individuals with fatal asthma 4-fold greater (p = 0.04), and in young individuals with fatal asthma 2-fold greater (p = 0.03). Airway narrowing was increased in old versus young individuals with fatal asthma, with both groups more narrowed than control subjects. Intralumenal obstruction and subepithelial collagen in the two asthma groups were significantly greater than in control subjects, but there was no age effect. These data provide support for the hypothesis that there is an increase in airway wall area, including smooth muscle, and airway narrowing with increasing duration of severe asthma or with older age. The observation that total wall thickness was not greater in young individuals with young fatal asthma than in control subjects suggests that factors other than airway wall geometry contribute to the pathogenesis of fatal attacks in this age group.

Phaeochromocytomas discovered during coronial autopsies in Sydney, Melbourne and Auckland.

BACKGROUND: The diagnosis of phaeochromocytoma can be difficult and previous autopsy studies have found that many of these tumours are not recognised during life. AIM: To determine the incidence of phaeochromocytoma during coronial autopsies and the characteristics of the individuals concerned. METHOD: Review of coronial autopsy records from Auckland (1981-97), Melbourne (1991-97) and Sydney (1991-97). RESULTS: Twenty-two patients were found giving an incidence of 0.05% (one tumour per 2031 autopsies) with similar figures in each centre. Thirteen of the patients were men, 12 were overweight (body mass index >25 kg/m2) and three of the seven Auckland patients were Maori. Fourteen of the tumours were left-sided, one was extra-adrenal and none had metastasised. The one patient with bilateral tumours had multiple endocrine neoplasia syndrome type 2 (MEN-2) which had not been recognised during life. The heart weight was increased in 95% of the patients. The tumour may have contributed to the patient's death in up to 50% of the cases, although the true significance of these lesions as a cause of death remains unclear. Three patients died soon after general anaesthetics had been given for unrelated reasons. CONCLUSIONS: Even though phaeochromocytomas are uncommon, we fail to diagnose a significant number of these tumours during life. Methods are needed to increase the detection of phaeochromocytoma and to distinguish functional and non-functional tumours.

Suicide in Auckland 1989 to 1997.

AIM: The aim of this study was to describe the population of people who had committed suicide in Auckland in the nine years, 1989 to 1997. METHODS: We extracted data from the police records to the coroner and the autopsy reports on people who had killed themselves in the Auckland coronial region. RESULTS: Suicide is common and disproportionately affects young men, the unemployed and sickness beneficiaries. Few people who kill themselves appear to be in contact with the mental health services. CONCLUSIONS: For effective prevention, up to date local information on suicide and deliberate self-harm is needed.

Meningococcal disease and meningitis: a review of deaths proceeding to coroner directed autopsy in Auckland.

AIMS: To assist the early diagnosis of meningitis, by finding trends and patient profiles, where delay or other factors may have lead to a fatal outcome. METHODS: All deaths from meningitis and meningococcal disease, confirmed at autopsy were reviewed. The study involved the Auckland area, in the period January 1988 November 1997. RESULTS: Cases were divided into those caused by N meningitidis and other meningitides. Death due to N meningitidis is often within 12-24 hours of the first symptomatology. Symptoms are often vague and may be indistinguishable from any other infection, often leading to fatal patient or doctor delay. A diagnosis of meningococcal disease cannot be excluded on: no rash (44%), no "meningitis" symptoms as sepsis without meningitis occurs (44%), age (50% were over 15 years old) or the presence of other abnormalities, eg bronchopneumonia or hydrocephalus. Non-N meningitidis menigitis is a disease of the very young or old, its time course is also swift with 30% suffering similar vague symptoms for less than 24 hours before death. CONCLUSIONS: For both categories, treat immediately and treat on suspicion, otherwise conformation of the diagnosis might be postmortem.

Death due to unrecognised myocardial infarction causing left ventricular rupture: can we improve the diagnostic rate?

AIM: To investigate the clinical presentations of ruptured myocardial infarction, where the initial diagnosis of myocardial infarction was missed, to enhance the diagnostic rate of primary care physicians. METHODS: We studied 67 cases of myocardial infarction, terminating with left ventricular rupture, between January 1988 and December 1996. The study was restricted to sudden death where, at coroner-directed autopsy, a ruptured myocardial infarction was determined as the cause of death. It was also restricted to patients who consulted a doctor within the two weeks prior to death. The report made to the coroner by attending police and the autopsy report was studied, and the requisite data were abstracted. RESULTS: Half of our study group did not present with chest pain. Of the atypical presentations: 15/67 cases (22%) were from referred pain (neck, arm, abdomen or back), 12/ 67 patients presented with "flu-like illness" (18%), 4/67 cases had respiratory presentations (cough or shortness of breath) (6%) and 2/67 falls (3%). Of those with chest pain, 16/34 (47%) were diagnosed or referred and 2/15 infarcts with atypical or referred pain were diagnosed. None of those presenting with "flu like illness" or respiratory symptoms was diagnosed or referred. CONCLUSION: Fifty per cent of our patients had "silent" myocardial infarcts. A large proportion of this group complained of a flu-like illness, which is currently not considered a presentation of this disease. Patients at higher risk of a myocardial infarct, should be treated with a high index of suspicion when unwell, especially when complaining of a flu-like illness. Pathologically, posterior and lateral infarcts accounted for over half the cases.

Complications of epilepsy and a ruptured pyonephrosis: radiology to the rescue in the Brooks murder case.

A woman and her lover were accused of murdering the woman's husband. Five weeks after fracture/dislocations of both shoulders and a central fracture/dislocation of the right hip were diagnosed the woman's husband died of septicaemia consequent on a ruptured infected hydronephrosis. The shoulder and hip injuries and the ruptured hydronephrosis were attributed to a beating with a blunt instrument. A review of the medical records of the deceased, particularly his radiological examinations, led the authors to conclude that his joint injuries and ruptured kidney were not due to the alleged assault. The joint injuries were the consequence of epileptic seizures and the ruptured kidney was also due to natural causes. These medical opinions provided evidence that led to acquittal of the accused.

Primary plexogenic pulmonary hypertension shows imperfect formation of the internal elastic lamina of the pulmonary arteries.

Lung tissue from subjects dying from primary plexogenic pulmonary hypertension (PPH) has shown defects of elastin formation of the lung arteries. Lung vessels from 5 cases of PPH were compared with those of 9 age-matched normal subjects, and 24 individuals having secondary pulmonary hypertension (2 degrees PH). PPH cases and those with 2 degrees PH due to congenital heart disease with left-to-right shunts (2 degrees PH, LRS), showed active proliferation of medial smooth muscle cells (SMC) through defects of the internal elastic lamina (IEL) into the arterial lumen to form typical plexiform lesions. Larger arteries showed accelerated intimal thickening similar to normal aging. Plexiform lesions were not seen in normal subjects or in those developing high pulmonary pressures later in life. The observations showed that the development of discontinuities of the IEL of the pulmonary arteries and intimal thickening is accelerated in normal subjects by high pulmonary artery pressure, especially when this is established at a very young age. They suggest that such discontinuities occur in PPH due to inherent abnormality of the elastin of the arterial walls, with advanced early proliferation of medial SMC and obstruction of the pulmonary arterial circulation.

Cave vulgantem morbum--tuberculosis.

This study investigates the circumstances surrounding all cases of tuberculosis found at autopsy in Auckland during the period 1975-1992. Cases were placed in one of six categories according to the medical history and autopsy findings. Of the 34 cases in the study 22 were clinically undiagnosed prior to autopsy. Of these, six exhibited respiratory symptoms that should have led to a diagnosis and three reported unexplained chronic symptoms such as weight loss for which tuberculosis should at least have been considered. Only 10 cases were correctly diagnosed before death. The autopsy plays an important role in finding undiagnosed cases of tuberculosis, as patient contacts may then be followed up. The vital role of post-mortem examination in medical audit and public health is, once again, demonstrated.

Homicide offenders in Auckland, New Zealand.

In the 14-year period from 1976 to 1989, 183 homicide offenders have been recorded in Auckland, New Zealand. Data accessed from police files show that Maori and Polynesians made up the majority of the offenders. Almost all offenders were male, and the largest proportion was between 20 and 24 years of age. Racial differences were noted in the methods used to commit the homicide, in the offender-victim relationship, and in whether the offender acted alone. The majority of offenders were not convicted of murder, but were convicted on lesser charges.

Child passenger fatalities and restraint use in Auckland.

AIMS: To determine the proportion of children killed as passengers in car crashes who were unrestrained and to estimate the reduction in mortality that might result from increasing child restraint utilisation. METHODS: All children killed as passengers in car crashes, over the period 1980-90, were identified from the Auckland coroners records. Data were recorded on sex, age, use and type of restraint, position within the motor vehicle, pattern of injuries and place of death. RESULTS: There were 49 children (25 male, 24 female) killed as passengers in car crashes over the study period (2.14/100,000/year). The median age was eight years (range 0-14 years). Of the 38 children for whom restraint use could be determined, 31 (81.6%) were unrestrained and seven (18.4%) were restrained. None of the children aged 0-2 years were restrained. Thirty-five children (71.4%) died at the scene of the crash, three (6.2%) died during transport to hospital, and 11 (22.4%) died in hospital. CONCLUSIONS: Based on overseas reports of the efficacy of child restraints, close to half (49%) of all child passenger deaths in Auckland could have been prevented with appropriate child restraint use.

Death certification in Auckland.

AIMS: to investigate the reasons behind general practitioner referral of cases of natural death to the coroner, and also the understanding of general practitioners of the relevant legislation. METHODS: as cases of natural death were referred to the coroner over a seven month period, the deceased's general practitioner was contacted by telephone and questioned regarding his/her knowledge of the death and willingness to sign a cause of death certificate. Based upon this interview, cases were divided according to whether their general practitioner could have signed the death certificate or not. RESULTS: there were 314 cases where there was a contactable general practitioner. In 257 instances, the general practitioner would not have signed the death certificate: 183 found the death unexpected, and 74 had not seen the patient recently enough. In 57 instances the general practitioner would have signed the death certificate, but did not because: 23 were unaware of the death, 13 could not be contacted, 14 did sign a death certificate but this was rejected by the medical referee, and seven would have signed but did not for miscellaneous reasons. CONCLUSION: a disturbing finding was the general lack of understanding of certification legislation in particular the concept that the patient must have been seen in their last illness to be able to sign the death certificate. When signing death certificates, doctors should be thinking in terms of last illness rather than a vague period of time between two weeks and three months.

Antral vascular ectasia: the watermelon stomach.

Antral vascular ectasia (watermelon stomach) is an uncommon localised vascular abnormality which may cause occult gastrointestinal blood loss and iron deficiency anaemia. The endoscopic appearances are characteristic with well demarcated, often raised or nodular bright red streaks radiating from the pylorus back along the antrum. Endoscopic biopsies can be taken without risk of haemorrhage and may help distinguish this condition from gastritis. The aetiology remains obscure, but there is an association with achlorhydria, hypergastrinaemia, and cirrhosis of the liver. Four patients are described; two had antrectomy with long term control of their anaemia, and two were treated conservatively. The lesion may be diagnosed more frequently with more widespread recognition of the condition.

Does advancing age modify the presentation of disease?

A group of patients who had died of either cardiac tamponade due to ruptured myocardial infarct, perforated peptic ulcer, or diverticulitis with perforation were studied to determine the effect that age has on the presentation of these three potentially fatal diseases. With advanced age, a decrease in the number of patients who had symptoms typical for the disease that was ultimately the cause of death was found. We also noted a number of patients who did not experience any symptoms, and some patients who experienced symptoms that were not typical of their disease. In many instances, the disparity between disease severity and symptoms had resulted in the disease not being diagnosed either because the patient did not seek medical advice or because the doctor was unable to make the appropriate diagnosis from the patient's symptoms.

Homicides in Auckland, New Zealand. A 14-year study.

In the 14-year period from 1976 to 1989, there have been 174 homicide victims in the Auckland colonial area. Data accessed from autopsy and police reports show that victims of marital conflict, family dispute, and arguments developing between nonmarried couples made up the largest proportion of homicide cases. Stabbing and assault with a blunt weapon were the most common causes of death. The data also show that homicide is relatively uncommon in Auckland in comparison with other cities of similar size.

Self inflicted deaths in Auckland: a study of 1057 cases.

In the eleven year period from 1 January 1976 to 31 December 1986, 1057 people took their own lives in the Auckland colonial area. These cases were analysed with respect to age, sex and mode of death. The totals have increased from 68 (1976) to 116 (1986). There were 723 males and 334 females. The total number of males has increased from 41 (1976) to 80 (1986) and the females from 27 (1976) to 36 (1986). This shows that over the period studied there was a significant difference between male and female suicide rates and a greater increase in male rate compared with female rate. The largest number of deaths for both males and females occurred in the 20-29 years age group. Drugs and poisons were the most common method used followed by hanging and the inhalation of carbon monoxide from car exhausts.