"Ecstasy" associated deaths: what is a fatal concentration ? Analysis of a case series.

Amphetamine derivative drugs, particularly 3,4-methylenedioxymethamphetamine (MDMA), commonly known as ecstasy, are popular recreational drugs. MDMA is associated with causing death by a number of mechanisms, including hyperpyrexia, cardiac arrhythmia water intoxication and liver failure. Seventy-seven deaths where MDMA was detected in body fluids/organs were reviewed. Of these cases 59 deaths had MDMA present in blood. In 13 cases death was attributable to the toxic effects of MDMA alone with a range of 0.478-53.9 mg/l, mean 8.43 mg/l, median 3.49 mg/l. In 22 cases death was due to polydrug use, with an MDMA range of 0.04-41.5 mg/l, mean 2.90 mg/l, median 0.76 mg/l. In 24 cases death was due to trauma with an MDMA range of 0.035-4.81 mg/l, mean 0.862 mg/l, median 0. 483 mg/l. There is considerable overlap between the concentration of MDMA seen in deaths from direct MDMA toxicity and deaths associated with trauma. These findings show, that like other stimulant drugs, no specific concentration can be used to determine death without consideration of the history and full autopsy findings.

Armanni-Ebstein lesion, ketoacidosis and starvation in a child.

The Armanni- Ebstein lesion was first reported in 1877 and has been associated with deaths due to diabetic ketoacidosis. The lesion consists of subnuclear vacuolation of the kidneys, which contain fat. We report a case of the Armanni- Ebstein lesion in a non-diabetic child with documented ketoacidosis who died of starvation.

Dilated cardiomyopathy and sudden death in a teenager with palmar-plantar keratosis (occult Carvajal syndrome).

A 16-year-old female who was diagnosed with palmar-plantar keratosis and Papillon-Lefevre syndrome in life died following a period of stress/affray. Autopsy examination revealed evidence of minor trauma and a grossly abnormal heart. The heart was sent fresh and intact to a cardiac pathologist for examination. This revealed a dilated cardiomyopathy with left ventricular fibrosis, without fatty infiltration of the right ventricle. The features were in keeping with Carvajal syndrome, a variant of Naxos disease. This rare cardiac pathology and the interaction between stress (physiological, psychological and traumatic) and natural disease are discussed. The role of prompt referral for cardiac pathology assessment and association with the genodermatoses is also considered.

Telemedicine for acute plastic surgical trauma and burns.

Visual images can enhance communication over a distance. In the UK, plastic surgery provides services over large distances by a 'hub and spoke' model. Telemedicine could help to increase the efficiency of service for plastic surgery patients. Telemedicine, along with the impending Electronic Patient Record system could combine to improve communication, patient triage, record keeping, audit and could lead to a better quality of clinical care. Another benefit could be significant cost savings. We report our experience of the introduction of telemedicine to a Regional Plastic Surgery Service. Our first study compared assessments from images and patient examinations, which gave us confidence in the use of images [Jones SM, Milroy C, Pickford MA. Telemedicine in acute plastic surgical trauma and burns. Ann R Coll Surg Engl 2004;86:239-42]. We proceeded to a 10-week evaluation of all 973 referrals to our unit. We found that the system was used for a wide variety of injuries and for 42% of the 452 patients where the system was available. Initial resistance was overcome by the ease of use of the system, with both receiving and referring clinicians reporting benefits. The third phase was a 12-week prospective cohort study of 996 patients comparing the referrals with and without the telemedicine system. The system was available for 389 patients, and used for 243 patients (63%). The groups were analysed by a chi squared test and confidence interval calculation. We demonstrated a significant difference in the initial management of patients, with 10% more being booked directly to our Day Surgery Unit. There was a decrease in number of occasions when we were unable to accept a patient due to a lack of capacity. We found no change in the patients being managed with telephone only advice. We found that telemedicine is a valuable method of providing useful preliminary information in the referral process for injured patients and often significantly modifies their treatment and/or management plan. This has implications for the use of Information Technology resources and potentially the delivery of healthcare in relation to the management of injured patients.

Telemedicine in acute plastic surgical trauma and burns.

BACKGROUND: Telemedicine is a relatively new development within the UK, but is increasingly useful in many areas of medicine including plastic surgery. Plastic surgery centres often work on a hub-and-spoke basis with many district hospitals referring to one tertiary centre. The Queen Victoria Hospital is one such centre receiving calls from more than 28 hospitals in the Southeast of England resulting in approximately 20 referrals a day. OBJECTIVE: A telemedicine system was developed to improve trauma management. This study was designed to establish whether digital images were sufficiently accurate enough to aid decision-making. A store-and-forward telemedicine system was devised and the images of 150 trauma referrals evaluated in terms of injury severity and operative priority by each member of the plastic surgical team. RESULTS: Correlation scores for assessed images were high. Accuracy of "transmitted image" in comparison to injury on examination scored > 97%. Operative priority scores tended to be higher than injury severity. CONCLUSIONS: Telemedicine is an accurate method by which to transfer information on plastic surgical trauma including burns.

Aggressive basal cell carcinoma in young patients: fact or fiction?

It has been suggested that basal cell carcinomas (BCC) arising in younger patients may be of a more aggressive phenotype than those that present in the older population. The purpose of this study was to investigate this hypothesis by comparing the histological types of BCC in a large cohort of young and old patients.A total of 271 histological specimens and clinical records were evaluated. A consecutive series of 120 patients under 50 years old were compared with a consecutive series of 151 patients over 50 years of age. Tumours were classified according to the accepted definition of aggressive (morphoeic, infiltrative and micronodular) and less aggressive (nodular and superficial) histological growth patterns. Aggressive growth types were found in 35% of patients over 50 and 33% of patients under 50. There was a higher rate of incomplete excision in younger patients but this did not reach significance (16% compared to 9%, P = 0.1). This study found that BCC arising in young patients are not histologically different to those found in the older population. Clinically observed aggressive behaviour of BCC in young patients may result from inadequate surgical excision due to cosmesis and diagnostic doubt.

Deaths associated with MBDB misuse.

The use of phenethylamines in the dance scene is now well established. Apart from amphetamine, the commonest phenethylamine encountered in clinical and forensic settings is 3,4-methylenedioxymethamphetamine (MDMA) commonly known as ecstasy. Other phenethylamines, which have similar effects are encountered, such as 3,4-methylenedioxyethylamphetamine (MDEA) and their use has resulted in death. We report two deaths associated with another less commonly encountered member of the group, N-methyl-1-(3,4-methylenedioxyphenyl)-2-butanamine (MBDB), also known as Methyl-J and Eden.

Methadone deaths: a toxicological analysis.

AIMS: To perform a toxicological analysis of deaths involving methadone and to determine the fatal concentration of methadone in such deaths. METHODS: Deaths in which methadone was mentioned in the cause of death were identified. Deaths were divided into those associated with methadone only and deaths in which the cause of death was a combination of methadone and other drugs. Toxicological findings in these deaths were analysed and compared with previously published data. RESULTS: One hundred and eleven cases were analysed. In 55 cases, methadone poisoning was given as the sole cause of death. Fifty victims were adults, age range 17-51 years (median, 23), with five victims under 14 years of age. The mean methadone concentration in the adult deaths was 584 micrograms/litre (median, 435; range, 84-2700). In 56 cases, age range 15-49 years, (median, 28), death was ascribed to a combination of methadone and other drugs. The mean methadone concentration in these deaths was 576 micrograms/litre (median, 294; range, 49-2440). In 26 cases, multiple site sampling was performed. This revealed that there could be a 100% discrepancy between methadone concentrations, and other drugs, in samples collected in different sites in the same body. CONCLUSIONS: There is an overlap between quoted therapeutic methadone concentrations and methadone concentrations seen in fatalities. However, those dying from methadone poisoning might not be the same as those in a methadone programme. A degree of caution must be exercised in determining a fatal concentration because of the phenomenon of postmortem redistribution. Pathologists and toxicologists need to examine all the available postmortem findings in identifying the cause of death.

Munchausen syndrome by proxy and intra-alveolar haemosiderin.

Munchausen syndrome by proxy is characterised by the invention of a false history and/or the deliberate inducement of a factitious illness by parents in their child. First reported as a disorder of mothers, this syndrome is now recognised to have male perpetrators. One of the most common characteristic presentations is with the child allegedly suffering repeated apnoeic attacks. These are in fact deliberately induced episodes of upper airway obstruction. The children of these parents are at great risk of serious harm or death if not recognised. The identification of smothering at autopsy is fraught with difficulty and the presence of intra-alveolar haemosiderin has been claimed to be a marker of previous smothering. A case of Munchausen syndrome by proxy is presented where there were deliberate acts of repeated partial smothering and where the finding of intra-alveolar haemosiderin at autopsy provided additional supportive evidence of smothering.

Reporting basal cell carcinoma: a survey of the attitudes of histopathologists.

AIMS: To investigate the histopathological reporting of basal cell carcinoma. METHODS: Methods of classification and attitudes to excision margins were ascertained from histopathologists in 130 centres; 82 replies were obtained (63% response rate). RESULTS: 24% of those replying did not use any classification system for basal cell carcinoma. The remainder (76%) used a wide variety of different classification systems. A small number (9%) of those questioned felt reporting on completeness of excision was not important. The majority of histopathologists considered the excision margin was worth reporting but there were differences in methods of processing and reporting biopsies. CONCLUSIONS: There is considerable variation in histopathological reporting of basal cell carcinoma. There is a need for uniformity of histopathological reporting to allow both improved management decisions and comparative audit of this extremely common skin cancer.

Impact of phenotype on treatment and prognosis of laryngeal malignancies.

An overview of the impact of the phenotype on treatment and prognosis of different laryngeal malignancies is presented.

Air weapon fatalities.

AIMS: To describe characteristics of a series of people accidentally and deliberately killed by air powered weapons. METHODS: Five cases of fatal airgun injury were identified by forensic pathologists and histopathologists. The circumstances surrounding the case, radiological examination, and pathological findings are described. The weapon characteristics are also reported. RESULTS: Three of the victims were adult men, one was a 16 year old boy, and one an eight year old child. Four of the airguns were .22 air rifles, the other a .177 air rifle. Two committed suicide, one person shooting himself in the head, the other in the chest. In both cases the guns were fired at contact range. Three of the cases were classified as accidents: in two the pellet penetrated into the head and in one the chest. CONCLUSIONS: One person each year dies from an air powered weapon injury in the United Kingdom. In addition there is considerable morbidity from airgun injuries. Fatalities and injuries are most commonly accidents, but deliberately inflicted injuries occur. Airguns are dangerous weapons when inappropriately handled and should not be considered as toys. Children should not play with airguns unsupervised.

Definitive repair of anovaginal fistula in Crohn's disease.

Anovaginal fistula may be a very distressing complication of Crohn's disease. We review the definitive repair of such fistulas in ten patients. The objectives were to cure the fistula, maintain continence and avoid proctectomy. The fistula was low trans-sphincteric in five patients, high trans-sphincteric in three and suprasphincteric in two. Loop ileostomies were formed in nine patients. Overall, after 14 repair procedures 8/10 fistulas are healed. Seven remain healed at a mean of 38 months (range 10-66 months) after ileostomy closure (six) or repair without ileostomy (one). All of the patients are continent. Definitive repair is effective and worthwhile in selected patients with Crohn's anovaginal fistula.

A review of neuroendocrine neoplasms of the larynx: update on diagnosis and treatment.

Neuroendocrine neoplasms of the larynx have been divided into those of epithelial or neural origin. The latter consist of paragangliomas while the epithelial origin group can be divided into the typical and atypical carcinoids and small cell neuroendocrine carcinomata, the latter consisting of the oat cell type, the intermediate cell type and the combined cell type. There are now over 500 cases of neuroendocrine neoplasms of the larynx in the literature. The diagnosis is primarily based on light microscopy, and, in some instances, it may be supported by special histochemical studies. It should be confirmed by immunocytochemical and/or ultrastructural investigation. The different biological behaviour of neuroendocrine neoplasms of the larynx makes a specific diagnosis of paramount importance, since treatment depends on diagnostic accuracy. Typical carcinoid is an extremely rare lesion. It is treated preferably by conservative surgery; elective neck dissection is not necessary because of the lack of lymph node metastases at diagnosis. Chemotherapy and/or radiotherapy have not been effective in the limited number of patients treated thus far. Prognosis is excellent with cure following surgery. Atypical carcinoid is the most frequent non-squamous carcinoma of the larynx. The mainstay of treatment is surgery. Elective neck dissection should be performed because of the high likelihood of cervical lymph node metastases. Primary radiation therapy with adjuvant chemotherapy is not indicated. The survival rate is 48 per cent at five years and 30 per cent at 10 years. Although the larynx is one of its most common extrapulmonary sites, small cell neuroendocrine carcinoma is still a rare tumour. Surgical results for this tumour have been disappointing and is reserved for cases of local relapse with no evidence of metastasis. Chemotherapy and radiotherapy currently appear to offer the least disabling and most effective forms of therapy. The two- and five-year survival rates are 16 per cent and five per cent, respectively. Paraneoplastic syndromes have occasionally been reported in association with carcinoid tumours (typical and atypical) and small cell neuroendocrine carcinoma. There have been also rare reports of an elevated neuropeptide serum level. Paraganglioma is the only laryngeal neuroendocrine neoplasm with a female preponderance (3:1). Confusion with atypical carcinoid has led to incorrect diagnosis and inappropriate classification schemes, erroneously suggesting that laryngeal paraganglioma has the potential for aggressive behaviour. Conservative surgery represents the treatment of choice; elective neck dissection is not necessary, and the prognosis is excellent.

Homicide followed by suicide: remorse or revenge?

Homicide is followed by the suicide of the assailant in around 4% of homicide-suicide episodes in England and Wales. The assailant is invariably a man who most commonly kills his spouse and/or children. Shooting is the most common method of suicide and homicide in these cases. It has been asserted that the low rate of homicide and relatively high rate of suicide in killers is a result of English killers internalizing their culture's abhorrence of killing. However, examination of homicide-suicide episodes indicate that in most episodes the decision to commit suicide has been taken before the decision to kill and that only a minority of suicides in assailants are out of remorse. Homicide followed by suicide is a distinct category of homicide which has features that differ from other forms of killing. These episodes are complex and do not reflect simple remorse following the killing. Homicide-suicide episodes in England are similar to those in countries with higher homicide rates.