MA 01605. Address reprint requests to P. K. Kleinman. 2p , t of Anatomy, lk'iiversity of Massachusetts Medical Center, Worcester, MA 01605. Depending upon the size of the injury, the degree of involvement of the periphery of the bone, and the radiographic projection, a bucket-bundle lesion, corner fracture, or metaphyseal lucency will result In some cases, the radiographs may be normal even though there is significant histologic alteration. Although cartilaginous injuries may play a role in infant abuse, none of the specimens examined in this study evidenced injury through the germinal layers of cartilage.On the basis of the findings described here, it is recoinmended that postmortem analysis of all radiographically suspicious metaphyses be carried out in cases of suspected infant hOmiCide. If there are other clinical or pathologic indications to support abuse, a strong argument can be made for removal of radiologically normal but high-risk metaphyses.Instituting these procedures will require closer cooperation between the radiologist and the medical examiner, but the potential to Caffey, "After the application of injuring force to the bone, it is transmitted to these terminal levels of tightest attachment;where the injuring force is sufficiently strong, bits of cartilage and bone are torn off and displayed in a variety of patterns" [2]. Caffey also asserted that when a "small chunk" of bone is pulled from the margin of the metaphysis, it projects as a discrete metaphyseal fragment. This pattern is frequently

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We conclude that VEGF CSF concentrations are significantly higher in infants who die of SIDS. We postulate that hypoxia is a frequent event that precedes the sudden and unexpected death of these infants.

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SUMMARYIn order to better understand the problem of prehospital sudden cardiac death (SCD) two groups of individuals were studied. One group was monitored by rescue squads during attempted rescue. These subjects were defibrillated from prehospital ventricular fibrillation (VF) and hospitalized if they survived or autopsied if they could not be resuscitated. The second group were SCDs which were witnessed and described by observers. Detailed past histories of both groups were collected, and either clinical or autopsy diagnoses were obtained.On the day of death or VF, one quarter reported new symptoms (primarily chest pain and dyspnea) preceding collapse by more than 30 minutes, one quarter reported symptoms lasting from 1 to 30 minutes, and one half collapsed instantaneously or within 1 minute of acute symptoms. A history of old myocardial infarction (MI) was present in 41% and of angina pectoris in 54%, and 27% reported new or changing symptoms within four weeks.In defibrillated survivors, "'would-be SCDs,-electrocardiographic (ECG) changes of acute myocardial infarction (AMI) or ischemia were nearly three times more frequent than changes detected histologically in SCDs, and in the former involved predominantly the anterior wall in contrast to the inferior wall in most autopsied deaths. This disparity implicates acute myocardial lesions, particularly of the anterior wall, in the majority of SCDs.Acute coronary lesions were found in 58% of SCDs autopsied. Most of these were ruptured plaquealthough almost one fifth of all autopsied SCDs had thromboses without intimal rupture. Severe chronic multivessel stenosis was present in most subjects, although 15% had only disease of a single vessel and in these, the left anterior descending (LAD) or left main coronary artery were involved in three quarters.The SCD population may be subgrouped into those with recent MI, those with only myocardial ischemia, and those with no detectable myocardial change. When rescuers were able to monitor prehospital SCDs, VF was found in the majority; however, 28% did have other terminal rhythms.