Helmut Haibach

Homicide by insulin administration

This report describes a case of homicide by insulin administration and a study of the effects of storage conditions on insulin in serum. The study revealed insulin to be remarkably stable at refrigerator temperatures. Therefore, for forensic science purposes, insulin immunoassay data are interpretable even when serum is not stored by the standard laboratory method of freezing.

Evidence of impaired myocardial perfusion and abnormal left ventricular function during exercise in patients with isolated systolic narrowing of the left anterior descending coronary artery

Seven men ranging in age from 35 to 63 years with a chest pain syndrome and cineangiographically documented systolic narrowing of the left anterior descending coronary artery underwent thallium-201 myocardial scintigraphy and gated cardiac blood pool imaging. Grade II (50 to 75 percent) systolic coronary arterial constriction was present in three patients and grade III constriction (greater than 75 percent) in four. Three of the four patients with grade III constriction had an exercise-induced perfusion abnormality in the thallium-201 scintigram and impaired left ventricular ejection fraction response during exercise. (In two patients the left ventricular ejection fraction did not change and in one patient it decreased.) Each of the three patients with grade II constriction had normal thallium-201 perfusion and a normal increase in ejection fraction during exercise. These data provide evidence of abnormal myocardial perfusion and impaired left ventricular function during exercise in patients with high grade systolic coronary arterial narrowing.

Cold pressor thallium-201 myocardial scintigraphy in the diagnosis of coronary artery disease

Thallium-201 myocardial scintigraphy was performed during cold pressor stimulation in 36 patients aged 36 to 69 years. Thirty-one patients had coronary artery disease and 5 patients did not, as confirmed by coronary cineangiography. Thallium-201 (1.5 to 2 mCi) was injected at 30 seconds of the cold pressor stimulation. The product of systolic pressure X heart rate increased from a baseline of 77.4 +/- 16 (standard deviation [SD]) to 103.6 +/- 17 at 30 seconds of the cold pressor test (p less than 0.0005). Transient perfusion deficits developed in 24 of 31 patients with coronary artery disease (sensitivity 77%), and all 5 patients without coronary artery disease had normal scintigrams. The sensitivity in detecting coronary artery disease was 40% in patients with 1 vessel disease, 91% in patients with 2 vessel disease, and 100% in patients with 3 vessel disease. Exercise electrocardiograms (available in 29 of 36 patients) were positive for ischemia in 18 of 24 patients with coronary artery disease and in 1 of 5 patients without coronary artery disease (sensitivity 75% and specificity less than 80%). Exercise thallium-201 scintigrams, obtained in 16 patients, were positive in 11 patients with coronary artery disease and positive cold pressor thallium-201 scintigrams. Five patients without coronary artery disease and with normal cold pressor thallium-201 scintigrams had normal exercise thallium-201 scintigrams. Coronary cineangiography performed during cold pressor stimulation in 6 patients who had positive cold pressor and exercise thallium-201 scintigrams did not show coronary spasm. Our data indicate that cold pressor thallium-201 scintigraphy offers promise as a noninvasive test in the diagnosis of coronary artery disease and may be used in patients in whom exercise testing is not feasible.

Serum creatine kinase in marathon runners.

Serum creatine phosphokinase (CK) and CK-MB activity were determined in 21 trained runners participating in a marathon race (42.2 km). Enzyme activities immediately after the race increased two to three times compared with activities before the race. The greatest increases were found in the slowest runners, suggesting greater skeletal muscular trauma in the least trained or fit. As these are likely to include the older athletes who are also more likely to suffer acute myocardial injury during strenuous exercise, our findings assume special import in the interpretation of increased CK and CK-MB serum activities of older athletes.

Ciliated Adenocarcinoma of the Endometrium

Abstract. Two cases of ciliated endometrial adenocarcino‐ma which came to attention in less than one year are described. This entity deserves emphasis, as its ciliation may distract from its histological malignant features. Association of cilia with atypical nuclear features in the same cell is the diagnostic characteristic which distinguishes it from non‐ciliated adenocarcinoma overrunning non‐malignant ciliated endometrium. The ultrastructural detail of the cilia of malignant cells does not differ from that of non‐malignant endometrial glandular epithelium. Our cases raise the question of a possible association of estrogenic effect with ciliated endometrial adenocarcinoma.

Central Pontine Myelinolysis: A Complication of Hyponatremia or of Therapeutic Intervention?

We report four cases of central pontine myelinolysis (CPM) that illustrate important features of the disorder. The condition is described mainly in the neurological literature and, to our knowledge, is not discussed in the forensic science journals. This disorder must be recognized and understood by the forensic science expert who addresses issues of liability. In cases of multiple motor deficits and death with a history of hyponatremia, CPM must be included in the differential diagnosis. Careful examination of the pons and adjoining structures must be performed. Myelin stains are advisable. The association of CPM with major illnesses, hyponatremia and the correction of hyponatremia by intravenous saline infusions is discussed.

Left ventricular function in patients with mitral valve prolapse. A radionuclide evaluation.

Thirty patients with cineangiographically confirmed mitral valve prolapse (MVP) were studied by radionuclide angiography at rest and during exercise. Twelve patients had isolated MVP and 18 patients had associated coronary artery disease. All patients had normal resting left ventricular ejection fraction and wall motion. Of 18 patients with MVP and coronary artery disease, the left ventricular ejection fraction remained unchanged during exercise in 15 patients, decreased in two patients, and increased in one patient. Of 12 patients with MVP without associated coronary artery disease, ejection fraction increased during exercise in 6 patients, remained unchanged in 4 patients, and decreased in 2 patients. We conclude that an abnormal left ventricular function response during exercise does not always indicate the presence of coronary artery disease and may occur in patients with isolated MVP. Furthermore, the left ventricular dysfunction of patients with isolated MVP may be obvious only during exercise.

Systemic Mastocytosis Associated With Membranous Nephropathy and Peripheral Neuropathy

A report of the occurrence of membranous nephropathy and peripheral neuropathy in a patient with systemic mastocytosis is presented. Previous reviews of patients with systemic mastocytosis have not noted this association. During cyclical therapy with prednisone and chlorambucil in this case, nephrotic-range proteinuria remitted. Peripheral neuropathy resolved 10 months after discontinuation of therapy. Pathophysiological mechanisms resulting in this clinical presentation may be immunologically mediated.

Rat bladder irrigation with PVP-I2.

Despite technical advances, Foley catheter associated urinary tract infections continue to be the leading cause of nosocomial infections. PVP-I2 has been shown to be nonirritating to abraded tissue and we have shown that dilute solutions are bactericidal for organisms causing Foley catheter associated urinary tract infections. The purpose of this study was to ascertain the toxicity of PVP-I2 on the catheterized rat bladder and to measure the systemic absorption of I2. Bladder catheters were surgically placed into each of 3 groups of rats: group 1, catheters only; group 2, irrigation with PBS q.8h; and group 3, irrigation with a 1:3 dilution of a 10 per cent PVP-1 per cent I2 solution q-8h. One-half of each group was sacrificed at 1 and 2 weeks respectively. Photographs of mounted bladders and histologic sections were then graded by 3 independent observers. Blood for protein bound iodine (PBI), T3 and T4 levels was obtained before the study and at sacrifice. No difference in ulcerations, erythema or inflammation was noted. PBI was higher in group 3 rats at conclusion than group 1 and 2 (6.88 mg./dl. versus 3.42 mg./dl.) (p less than 0.05). There was no difference in T3 or T4 levels. In this study, PVP-I2 was no more toxic to the bladder than catheterization alone or irrigation with PBS.