Trends and characteristics in barbiturate deaths Australia 2000-2019: a national retrospective study.

INTRODUCTION: There have been increasing reports documenting barbiturate-related deaths, despite routine prescribing for only relatively rare indications. The aims of the current study were to examine trends in barbiturate-related deaths in Australia from 2000 to 2019 and determine the case characteristics and circumstances of barbiturate-related deaths. METHODS: All barbiturate-related deaths identified in the Australian National Coronial Information System were examined. Information was collected on cause, manner, demographics, location, psychosocial factors, circumstances of deaths and toxicology. We examined these based on the age categories 18-44 years, 45-64 years and ≥65 years. RESULTS: We identified 511 cases. Mean age was 57.9 years (SD 20.2, range 18-100) and 56% were male. Intentional poisoning was the most common cause of death (87.5%) and was slightly higher in the oldest age group (92.1%) and lowest in the youngest age group (81.1%). Pentobarbitone was the most common barbiturate (75.7%) and pentobarbitone-related deaths increased from 0% in 2000 to 93.6% in 2017. There were notable differences between age categories, with the youngest age group recording more severe psychiatric histories. In contrast, the oldest age group were more likely to have severe physical health problems, such as cancer, chronic non-cancer pain, neurological conditions and significant cardiopulmonary morbidity. Euthanasia resources were commonly documented (33.9%), most frequently in the oldest age group (52.3%). CONCLUSION: Barbiturate-related deaths in Australia are increasing, particularly pentobarbitone-related deaths. Most deaths were intentional and involved adults across the lifespan. Younger people were more likely to have significant mental health problems, whilst the oldest age group were more likely to have severe physical health conditions.

Variation of the clavicle's muscle insertion footprints - a cadaveric study.

The muscle footprint anatomy of the clavicle is described in various anatomical textbooks but research on the footprint variation is rare. Our goal was to assess the variation and to create a probabilistic atlas of the muscle footprint anatomy. 14 right and left clavicles of anatomical specimens were dissected until only muscle fibers remained. 3D models with muscle footprints were made through CT scanning, laser scanning and photogrammetry. Then, for each side, the mean clavicle was calculated and non-rigidly registered to all other cadaveric bones. Muscle footprints were indicated on the mean left and right clavicle through the 1-to-1 mesh correspondence which is achieved by non-rigid registration. Lastly, 2 probabilistic atlases from the clavicle muscle footprints were generated. There was no statistical significant difference between the surface area (absolute and relative), of the originally dissected muscle footprints, of male and female, and left and right anatomical specimens. Visualization of all muscle footprints on the mean clavicle resulted in 72% (right) and 82% (left) coverage of the surface. The Muscle Insertion Footprint of each specimen covered on average 36.9% of the average right and 37.0% of the average left clavicle. The difference between surface coverage by all MIF and the mean surface coverage, shows that the MIF location varies strongly. From the probabilistic atlas we can conclude that no universal clavicle exists. Therefore, patient-specific clavicle fracture fixation plates should be considered to minimally interfere with the MIF. Therefore, patient-specific clavicle fracture fixation plates which minimally interfere with the footprints should be considered.

Towards a more circular economy for WEEE plastics - Part A: Development of innovative recycling strategies.

This two paper series describes a method to develop and evaluate innovative recycling strategies for WEEE plastics. Part A presents a SWOT analysis of a new dismantling based recycling process of plastic components and the integration in an existing post-shredder separation recycling facility. Subsequently, recycling strategies are developed and the economic potential is evaluated. Part B investigates the technical feasibility of the recycling strategies. As a case study the dismantling of LCD TV plastic back cover housings is taken. First, the advantages and disadvantages of the new process and the main external factors based on the market for recycled plastics and the waste material input are discussed on industrial level. Subsequently, five recycling strategies are developed: Strategy (1) produces recycled granulates with the dismantling process for direct re-application in electronic products, strategy (2) recycles plastics for the use as carrier materials for flame retardant masterbatches, strategy (3) blends the recycled plastic with post-shredder recyclates for material upgrading, strategy (4) recycles the plastics with the post-shredder process and strategy (5) thermally treats plastics. Finally, the economic evaluation shows that the special engineering plastics used for LCD TV back covers have very high virgin prices up to 5 € per kg. The implementation of the new process indicates a significant potential for value recovery based on plastics that would otherwise be incinerated or downcycled.

Towards a more circular economy for WEEE plastics - Part B: Assessment of the technical feasibility of recycling strategies.

This two paper series describes a method to develop and evaluate new recycling strategies for WEEE plastics. Part A presents a SWOT analysis that leads to five recycling strategies for the optimal integration of new dismantling based recycling processes for plastic components in an established post-shredder separation infrastructure. In this paper the technical feasibility of the strategies is demonstrated by means of LCD TV back cover housings. The component recycling is shown to produce recycled PC/ABS with phosphorous flame retardants suitable for direct re-application in electronic products. The high quality is characterized by a good mechanical and aesthetical properties as well as a recovered flammability. HIPS with brominated flame retardants was recycled to produce masterbatches. The technical feasibility of this strategy was proven by mechanical and flammability testing. However, the presence of deca-BDE requires this material to be incinerated. A combination of EU legislation research and forecasting shows that the origin of this flame retardant are TV models produced before 2008 and restricted concentrations still need to be expected for decades to come. Further, a blending strategy of HIPS/PPE is shown to improve the mechanical properties of post-shredder recycled HIPS. The evaluation of refeeding ABS/PMMA into the post-shredder recycling process of ABS indicates only partial compatibility. Further, complications due to density differences make this strategy more suitable for polymers that are already commercially recycled such as ABS and HIPS. Colour is identified as a key requirements that limits the use of WEEE plastics in high-quality products.

Inflammatory characteristics of premature coronary artery disease.

Although inflammation is a key process in atherogenesis, little is known about the inflammatory characteristics of culprit plaque in premature coronary artery disease (CAD). We investigated inflammation in coronary atheroma from subjects who died of premature CAD. From 2001-2005, we collected coronary plaque samples from consecutive cases of CAD (n=23) reported to the Department of Forensic Medicine which led to unexpected death in men aged <45 years. Coronary plaque from younger CAD decedents (<35 years, n=12) had lower levels of T cells (CD3+) (p=0.03), higher macrophage (CD 68+) (p=0.01) and T regulator cells (FOXP3+) (p=0.03) infiltration when compared to older CAD decedents (>35 years, n=11). Interestingly, there was no significant age-related difference between groups in the smooth muscle cell, apoA-I, myeloperoxidase and MMP-2 content within plaque. Hence, we demonstrate that higher expression of FOXP3 is associated with younger age at the time of fatal outcomes from CAD. These findings may have implications for plaque pathophysiology and thus warrant further investigation.

Mild neuritic changes are increased in the brains of fatally injured older motor vehicle drivers.

Given the expected increase in the older population and driving in this age group, concerns have been raised about the safety of older drivers. People over 65 years are over-represented in motor vehicle fatalities when calculated by distance driven. They are also at risk of neurodegenerative diseases, such as Alzheimer's disease, that affect cognitive function. We have examined the brains of older drivers (15M:12F) who died as a result of a motor vehicle accident (MVA) to determine the extent of Alzheimer's disease-related neurofibrillary changes (neuritic plaques and neurofibrillary tangles), Lewy body pathology and cerebrovascular disease and compared them to a control group of older licenced drivers (23M:5F) who died of other causes. The prevalence of moderate or severe neuritic plaque pathology was less than expected for the general population of this age and there was no difference between the groups. However, mild neuritic plaque pathology was increased for MVA deaths compared to controls. There was no evidence of vascular dementia or dementia with Lewy bodies. The current mandatory age-related re-licencing procedures in NSW may contribute to the low percentage of drivers with severe pathology. Further research into the role of mild pathology in cognitive impairment and older drivers is warranted.

Safety restraint injuries in fatal motor vehicle collisions.

The presence of an apparent seat belt mark (SBM) on a car crash occupant is often used as evidence for use of a seat belt at the time of the crash and, conversely, the lack of a SBM is used as an indication that no seat belt was used. This study examined whether there are clear indications of seat belt use to be found at autopsy and evaluated the sensitivity and specificity of apparent SBM and whether the use of a seat belt and seating location affects the type and severity of injuries sustained. Information on the type of injuries sustained and seatbelt use was retrieved from autopsy reports and police reports, respectively, for cases of fatal motor vehicle collisions occurring in Sydney, Australia over a 5-year period. In this study, a SBM was only found on restrained occupants. The proportion of restrained occupants with evidence of a SBM was 36% (sensitivity), whilst unrestrained occupants showed no evidence of a SBM (100% specificity). A SBM was also found to reliably reflect the seating position of the occupant. We conclude that restrained occupants can be expected to show evidence of the seat belt in just over one third of cases and that the absence of a SBM is not necessarily an indication that no seat belt was used. Spurious SBM is very unlikely to be present if the occupant was unrestrained.

Increased neurofibrillary tangles in the brains of older pedestrians killed in traffic accidents.

BACKGROUND/AIMS: Older people are over-represented in pedestrian fatalities, and it has been suggested that the presence of cognitive impairment or dementia in these individuals may contribute to their accidents. Using neuropathological methods, we aimed to compare the prevalence of dementia pathology in fatally injured older pedestrians with similarly aged ambulatory subjects who died from other causes. METHODS: The brains of 52 pedestrians (65-93 years) and 52 controls (65-92 years) were assessed for neurofibrillary tangles (NFT), neuritic plaques, Lewy bodies and vascular lesions using established neuropathological criteria. RESULTS: The examination for Alzheimer's disease (AD) pathology showed that 43% of the pedestrians had NFT scores of III-VI using Braak and Braak staging, compared with 23% of the controls (p < 0.05, Fisher's exact test), indicating incipient, possible or probable AD. There were no differences in the prevalence of pathology for vascular dementia or dementia with Lewy bodies. CONCLUSION: These results suggest that cognitive decline associated with AD, even in the earliest stages of the disease, may be a factor in fatal traffic accidents for older pedestrians. Special measures for pedestrian safety are necessary in areas with high densities of older citizens and especially for those diagnosed as having a mild cognitive impairment or AD.

Extent and distribution of vascular brain injury in pediatric road fatalities.

This study used a multidisciplinary approach to examine the brains of pediatric road trauma fatalities in the Sydney area over a 3-year period. The brains of 32 children (0-16 years) were examined: 20 pedestrians, nine passengers, and three cyclists. The extent and distribution of brain injury was assessed, peak linear head acceleration determined, and the severity of brain damage was compared to that previously reported for adults using the same scoring method. Skull fractures (20/32) and subarachnoid haemorrhage (22/32) were the commonest head injuries. In general, the neuropathology was similar to that seen in adults, with a high percentage of damage in the corpus callosum and gliding contusions within the subcortical white matter. Intracerebral hemorrhage was relatively rare. For frontal and occipital head impacts, the corpus callosum was the most injured part of the brain, followed by the deep central structures and the temporal lobes, whereas for lateral impacts, the injuries were more evenly distributed. Comparison of the current data for children with the vascular injury sector scores reported for adults suggests that the brains of children are more severely damaged for the same peak linear head acceleration.

Pre-existing pulmonary thromboembolic disease in passengers with the "economy class syndrome".

BACKGROUND: Pulmonary emboli, which have occurred in association with air travel, in the past have been thought to have arisen from deep venous thromboses (DVT) which formed during the flight. HYPOTHESIS: This study was performed to test the idea that not all pulmonary emboli which occur following air travel are the result of inflight DVT formation. METHODS: Fourteen cases of fatal "economy class syndrome" were examined histologically to determine the age of the fatal thromboemboli. RESULTS: In 5 of the cases, evidence of pre-existing pulmonary thromboembolic disease was present and in 4 of these cases the fatal thromboemboli observed in the lung tissue pre-dated the flight. Fresh perimortem thrombus without evidence of organization or hemosiderin deposition was observed in 9 cases. CONCLUSIONS: The commonly held pathological mechanism that the conditions of the flight lead to DVT formation and subsequent pulmonary embolism are not applicable in all cases of "economy class syndrome" and thus other pathophysiological mechanisms must be entertained.

Aortic dissection after ingestion of "ecstasy" (MDMA).

The authors report a case of aortic dissection and cardiac tamponade in a 29-year-old man after ingestion of ecstasy (methylenedioxymethamphetamine, MDMA) at a "rave" party. There was no history of hypertension, myxoid heart disease, or other risk factors for aortic dissection in the deceased, although a minor degree of cystic medial necrosis was noted on histologic examination of the aorta. Autopsy toxicology revealed low residual levels of MDMA in the blood about 48 hours after ingestion of the drug. This case report describes a probable association between MDMA ingestion and aortic dissection in a previously well young adult. The likely mechanisms are discussed, and the difficulties in diagnosing this complication are highlighted.

Fatal head injury in children: a new approach to scoring axonal and vascular damage.

As part of a multidisciplinary study of brain damage in children fatally injured in motor vehicle accidents, a simple method to quantify and visualise the distribution and extent of injury has been developed. Vascular and axonal injury were assessed using coronal brain sections stained for haematoxylin and eosin, or reacted immunohistochemically for beta-amyloid precursor protein. Subsequent analysis was carried out using NIH Image software, and the resulting information is displayed in schematic diagrams. These summary diagrams simply and clearly show the distribution of injury in both the coronal and horizontal planes. This technique offers an advantage over previous scoring methods in that it provides both a quantitative and a visual summary of the distribution and extent of brain injury. This information can then be used to compare the injury distribution and severity with estimated impact points and acceleration data.

Blunt traumatic rupture of the thoracic aorta: an epidemiological perspective.

A study was conducted from 1 July 1991 to 30 June 1994 to determine the incidence of blunt traumatic rupture of the thoracic aorta (RTA) in a defined area of inner-metropolitan Sydney. The study group consisted of 30 subjects with RTA following falls, rail or road accidents, who were taken by ambulance to the regional trauma centre or directly to forensic pathology. The incidence of RTA in the resident population of 330,000 was in the range 20-30/10(6)/year. There was one survivor in the series, with 24 scene deaths and five deaths en route to hospital. Road accidents were responsible for 57% of incidents. RTA was found in 36% of the fatalities that occurred as a result of car and motorbike accidents. This was 5 times more common than that observed in pedestrian deaths (P < 0.005). Twenty-seven subjects (90%) had at least one co-existent critical or lethal injury. Outcome may be improved by increasing awareness of the high prevalence of RTA in shocked car- and motor-bike-accident victims and stressing the importance of rapid transport of such cases to an appropriate hospital.

A population-based study of outcome after injury to car occupants and to pedestrians.

OBJECTIVE: The literature indicates that trauma center pedestrian mortality rates approximate twice that of injured car occupants. This study was performed to test the hypothesis that outcomes will be similar given similar degrees of injury severity if analyzed from an epidemiologic perspective. Differences are expected in the cause and place of death because of different injury profiles. DESIGN: Prospective population-based study. METHODS: The study group consisted of all adult car occupants and pedestrians sustaining major injury -- Injury Severity Score (ISS) of >15 -- in a defined area of central Sydney from mid-1991 to mid-1994. MAIN RESULTS: The study included 65 car occupants (median ISS,32) and 101 pedestrians (median ISS,34). Major abdominal injury (p = 0.003) and thoracic aortic disruption (p = 0.06) were more common in car occupants, but major injury to the brains (p = 0.004), lower extremity long bone fractures (p = 0.0005), and thoracolumbar fractures (p = 0.01) occurred more frequently in pedestrians. The overall car occupant mortality was 38% compared with 46% in the pedestrians (p = 0.37). Seventy-two percent of car occupant fatalities occurred in the field, most commonly from ruptured thoracic aorta, whereas 63% of pedestrian deaths occurred in hospital (p = 0.005), most commonly from head injury. CONCLUSION: These findings have important implications for prehospital care. A policy of "scoop and run" is advocated for injured car occupants in shock because of the high frequency of aortic and abdominal injuries. Advanced life support measures are appropriate at the scene to stabilize the airway and to protect the entire spine in pedestrians with multiple injuries because of the high frequency of brain and vertebral trauma.

Clinico-pathological study of cytomegalovirus (CMV) in AIDS autopsies: under-recognition of CMV pneumonitis and CMV adrenalitis.

BACKGROUND: Cytomegalovirus (CMV) is a common cause of morbidity in human immunodeficiency virus (HIV) infected patients, predominantly when severe immunosuppression has occurred. Although CMV infection of the retina and gastrointestinal tract is well recognised as causing substantial morbidity, the significance of infection at other sites, in particular the lungs and adrenal glands is unclear. AIMS: To assess the extent of CMV infection in postmortem examinations performed on HIV-infected patients. To estimate the degree of concordance between clinical and postmortem findings and the effect of prior diagnosis and/or treatment of CMV infection. METHODS: The postmortem examination findings and clinical records of 25 consecutive HIV-infected patients who underwent a complete autopsy were examined. RESULTS: CMV infection was demonstrated in 19 patients (76%) at postmortem examination, with the most common sites of infection being the adrenal glands (56%) and lungs (44%). Concordance between clinical diagnosis of CMV infection and postmortem findings was low with only five of 19 patients (26%) having an antemortem diagnosis. No patient with CMV infection of the lungs or adrenal glands had a clinical diagnosis made, despite four patients having florid CMV pneumonitis at postmortem examination; in three the probable cause of death. CONCLUSION: CMV infection is a common postmortem finding in HIV-infected patients but the concordance between clinical diagnosis and autopsy findings is low. CMV appears to be a significant pathogen in HIV-related respiratory disease.

Sudden death as a result of heart disease in morbid obesity.

Patients with morbid obesity have high rates of sudden, unexpected cardiac death. The mechanism of death in these patients is uncertain. Twenty-eight patients with morbid obesity (22 sudden cardiac deaths, 6 unnatural deaths) were compared to 11 age-matched nonobese patients with traumatic deaths. Heart weight, left ventricular cavity diameter, left and right ventricular wall thickness, ventricular septal thickness, epicardial fat thickness, and extent of coronary artery atherosclerosis were determined; myocyte size, nuclear size, and degree of interstitial fibrosis were calculated morphometrically. Mean heart weights in the patients with morbid obesity were increased but remained constant as a percentage of body weight. Of the gross parameters, only heart weight and left ventricular cavity size were independent predictors of obesity. Of microscopic parameters, only nuclear area was an independent predictor of obesity. Of 22 patients with morbid obesity, dilated cardiomyopathy was the most frequent cause of sudden cardiac death in (10 patients), followed by severe coronary atherosclerosis (6), concentric left ventricular hypertrophy without left ventricular dilatation (4), pulmonary embolism (1), and hypoplastic coronary arteries (1). The cardiomyopathy of morbid obesity is characterized by cardiomegaly, left ventricular dilatation, and myocyte hypertrophy in the absence of interstitial fibrosis. It is the most common cause of sudden cardiac death in these patients.