Methadone-related death in detention.

Oral methadone may be prescribed to detainees with the aim of minimising the risk of fatal opioid poisoning on release. To study the circumstances under which methadone-related deaths can occur in detention, we audited reports of 17 [14 male, 3 female; median (range) age 34 (22-52) years] such deaths, July 2010-December 2011. The median (range) methadone dose was 40 (10-110) mg/d (N = 16). The median (range) post-mortem blood methadone concentration was 0.42 (0.16-1.40) mg/L. Those who died within 7 days of the commencement of methadone treatment were significantly younger (Mann-Whitney U 102.5, p < 0.05), were prescribed a significantly lower dose (U = 80.0, p < 0.05) and had significantly lower blood methadone concentrations at death (U = 106.5, p < 0.02) than in those given methadone long-term. In 8 reports the prisoner had been recorded as either 'sleepy' (N = 7), or 'unwell' in the hours before death. In 13 deaths, the prisoner was either found dead first thing in the morning, or in one instance could not be roused ('snoring heavily'). Pneumonia, tracheobronchitis, end-stage cirrhosis, and ischaemic heart disease/coronary artery atherosclerosis were cited as associated factors in four patients, all of whom were on long term stable methadone treatment. Attention to warning signs of likely methadone toxicity (daytime or excessive drowsiness, snoring, nausea/vomiting) and associated risk factors (use of drugs such as benzodiazepines and gabapentinoids, the presence of respiratory infection, liver or renal disease) could help minimise the risk of unexpected death in patients given methadone.

Sudden death in elderly women with Fabry's disease.

We report two cases of elderly women who died unexpectedly. In both cases, light- and electron-microscopical examination proved a diagnosis of Fabry's disease. The major pathological changes were myocardial mottling, foamy vacuolation of myocytes and glomerular endothelial cells, and characteristic lamellar inclusions. Neither woman had either a personal or family history of Fabry's disease. Fabry's disease presenting as sudden death is very rare. We present the findings in two cases together with a review of literature particularly relevant to the cardiovascular system.

Accidental self-strangulation in a young child--a case report and review.

The accidental self-strangulation of a child of 3 years is described. This is an unusual occurrence and has, in this case, resulted from a particular group of circumstances. The features of the case are presented and asphyxial deaths in young children are reviewed. The dangers of loose wires, cords or other potential ligatures in or adjacent to sleeping or play areas is emphasized. That a relatively small amount of force is required to asphyxiate a child appears to be confirmed by this case.

Mechanism of sudden death associated with volatile substance abuse.

1. Sudden death is a recognized hazard of volatile substance abuse and may occur during exposure or in the subsequent hours. Intoxication may also lead to indirect deaths due to trauma. 2. Specific post-mortem features have not as yet been identified either macroscopically or microscopically in VSA-related deaths. Toxicological examination for volatile substances of all unnatural teenage deaths is strongly recommended. 3. Four mechanisms for acute, direct VSA-related deaths are discussed, viz anoxia, vagal inhibition, respiratory depression and cardiac arrhythmia. Of these, cardiac arrhythmia due to 'sensitization' of the heart to adrenaline is probably the most common and is well documented in experimental conditions. 4. Deaths from cardiac arrhythmia during or soon after VSA are unpredictable, unpreventable and resuscitation is rarely successful. Previous uneventful sessions of abuse provide no protection from this mode of death.

The incidence and significance of vaginal metaplasia of the bladder trigone in adult women.

One hundred and six bladders were removed at autopsy from adult women dying of diseases unrelated to the urinary tract. A fixative solution had been introduced into the bladder as soon as possible after death. The naked-eye appearances were recorded before and after application of Lugol's iodine solution and the trigones then submitted to histological examination. Vaginal metaplasia of the trigone was present in the majority (72%) of bladders, a similar incidence being found in both pre-menopausal and post-menopausal age groups. Histological evidence of chronic inflammation was found significantly more frequently in bladders showing vaginal metaplasia and it is suggested that vaginal metaplasia is not a consequence of chronic inflammation but that its surface characteristics may predispose to chronic infection. Its purported hormonal aetiology does not explain all observed features. Prominent venous channels within the tunica propria around the urethral orifice were a constant feature in all bladders studied. Two of the 76 bladders showing vaginal metaplasia also displayed atypical hyperplasia of this squamous epithelium, a previously unrecorded observation. The possible implications of such atypical hyperplasia are briefly discussed.