Fatality involving complications of bupivacaine toxicity and hypersensitivity reaction

This case represents unusual findings of elevated bupivacaine and tryptase concentrations following local anesthetic, bupivacaine, administered as a scalene nerve block for elective rotator cuff repair surgery. Following bupivacaine injection, the patient exhibited almost immediate seizure activity, bradycardia, and cardiac arrest. Resuscitative efforts including cardiopulmonary bypass restored a cardiac rhythm. However, the clinical medical status of the patient progressively declined and he died 7 h following administration of the local anesthetic. Autopsy revealed several abnormalities of the heart including cardiomegaly, myocardial bridging, and lipomatous hypertrophy of the intraatrial septum, which may have contributed to bradycardia and arrhythmia. Postmortem toxicology results revealed elevated bupivacaine and tryptase concentrations. Elevated postmortem bupivacaine concentrations 7 h following administration and abrupt onset of seizures indicate unintentional intravascular injection instead of nerve and tissue infiltration. An elevated postmortem tryptase concentration points to the possibility of a hypersensitivity reaction to bupivacaine.     

Suicide by asphyxiation due to helium inhalation

Suicide by asphyxiation using helium is the most widely-promoted method of "self-deliverance" by right-to-die advocates. However, little is known about persons committing such suicides or the circumstances and manner in which they are completed. Prior reports of suicides by asphyxiation involving helium were reviewed and deaths determined by the North Carolina Office of the Chief Medical Examiner to be helium-associated asphyxial suicides occurring between January 1, 2000 and December 31, 2008 were included in a new case series examined in this article. The 10 asphyxial suicides involving helium identified in North Carolina tended to occur almost exclusively in non-Hispanic, white men who were relatively young (M age = 41.1 T 11.6). In 6 of 10 cases, decedents suffered from significant psychiatric dysfunction; in 3 of these 6 cases, psychiatric disorders were present comorbidly with substance abuse. In none of these cases were decedents suffering from terminal illness. Most persons committing suicide with helium were free of terminal illness but suffered from psychiatric and/or substance use disorders.     

Cost Effectiveness and Target Group Influence in Norwegian Climate Policy

Cost effectiveness is a key principle of climate policies in industrialised countries, yet there are significant political barriers against its implementation. The Norwegian case demonstrates that differences in the climate policy instruments targeting different sectors cannot be explained by the sectors' relative significance in the national economy. Whereas the economically insignificant energy‐intensive industries (EIIs) successfully resisted mandatory greenhouse gas (GHG) regulations until 2008, the offshore petroleum industry (the most important sector for Norway's gross domestic product) has paid NOK 300 per tonne of CO₂ since 1991. What explains why some sectors successfully resist GHG regulations while others do not? This analysis indicates that a key determinant is interdependence between target groups and decision makers in winning coalitions. EIIs were capable of issuing relevant and credible threats to shut down and relocate if costly GHG policies were imposed. In contrast, decision makers did not perceive as credible the offshore petroleum industry's claim that a CO₂ tax would undermine its competitiveness. Moreover, when target groups can issue effective threats, private information becomes more relevant and reinforces decision makers' dependence on target group cooperation.     

Advising Ministers – The Special Problem of Defence

Successive Australian Defence Ministers have been frustrated and occasionally embarrassed by the quality of advice and information provided to them by the Defence organisation. Decades of reviews and reorganisations have failed to find solutions to the special difficulties that Defence faces in providing accurate, timely information and advice to ministers across the broad spectrum of their responsibilities. This article argues that there are multiple explanations for the concerns that are frequently expressed about its policy advisory capacity – most of which are inherent to Defence organisations around the world. While the Defence culture of secrecy is partly responsible, other factors such as the scale of Defence's operations, the multiple cultures that exist within it (military, civilian, and intelligence) that make coherence harder than in more homogenous departments, the long‐time horizons of defence planning as well as the high costs of procurement, must also be considered. The erosion of trust between the organisation and minister has been exacerbated by the intense scrutiny of the media that overburdens ministers and adds another layer of complexity to their role. As history shows, there are push and pull factors that continue to embroil ministers in the minutiae of defence difficulties, while the complexity and scale of operations will undoubtedly continue to impact on the timeliness of advice.     

Improving the Effectiveness of the International Law of Human Trafficking: A Vision for the Future of the US Trafficking in Persons Reports

In 2000, the United States Congress passed the Victims of Trafficking and Violence Protection Act requiring its State Department to issue annual Trafficking in Persons Reports (TIP Reports) describing “the nature and extent of severe forms of trafficking in persons” and assessing governmental efforts across the world to combat such trafficking against criteria established by US law. This article examines the opportunities and risks presented by the TIP Reports, tracing their evolution over the past decade and considering their impact on the behavior of states. In looking to the future, the article focuses on how this influential unilateral compliance mechanism could improve its legitimacy, respond to negative impacts, and better contribute to the international legal regime around trafficking.     

Depressive symptoms among working women in rural North Carolina: a comparison of women in poultry processing and other low-wage jobs

We report on the prevalence of self-reported depressive symptoms and associated factors among women employed in a poultry processing plant and a community comparison group of other employed women in northeastern North Carolina in the southern United States. The rural area is poor and sparsely populated with an African American majority. The largest employer of women in the area is a poultry processing plant. The goals of the analyses were 1) to evaluate whether women employed in poultry processing had a higher prevalence of depressive symptoms than other working women from the same geographic area, and 2) to evaluate factors which might be associated with depression among all of these working women, including specific characteristics of their work environment. Recruitment of participants (n=590) and data collection were by community-based staff who were also African American women. Depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (CES-D). Work organization factors were measured with the Job Content Questionnaire (JCQ). Log-binomial regression was used to calculate crude and adjusted prevalence ratios. The prevalence of depressive symptoms, based on a CES-D measure of sixteen or more, was 47.8% among the poultry workers and 19.7% among the other working women (prevalence ratio=2.3). After adjusting for socioeconomic variables, health-related quality of life and coping style, the prevalence of depressive symptoms remained 80% higher among the poultry workers. The prevalence of symptoms was also higher among those who perceived low social support at work, hazardous work conditions, job insecurity, and high levels of isometric load. These factors were all more common among the women employed in the poultry plant. The concentration of this low-wage industry in economically depressed rural areas illuminates how class exploitation and racial discrimination may influence disparities in health among working women.     

Partial Agonist Therapy in Schizophrenia: Relevance to Diminished Criminal Responsibility

Abstract: Pathological gambling (PG), classified in the DSM‐IV among impulse control disorders, is defined as inappropriate, persistent gaming for money with serious personal, family, and social consequences. Offenses are frequently committed to obtain money for gambling. Pathological gambling, a planned and structured behavioral disorder, has often been described as a complication of dopamine agonist treatment in patients with Parkinson’s disease. It has never been described in patients with schizophrenia receiving dopamine agonists. We present two patients with schizophrenia, previously treated with antipsychotic drugs without any suggestion of PG, who a short time after starting aripiprazole, a dopamine partial agonist, developed PG and criminal behavior, which totally resolved when aripiprazole was discontinued. Based on recent advances in research on PG and adverse drug reactions to dopamine agonists in Parkinson’s disease, we postulate a link between aripiprazole and PG in both our patients with schizophrenia and raise the question of criminal responsibility.     

Suicide by skull stab wounds: a case of drug-induced psychosis

Suicide by stabbing to the head and/or driving sharp objects into the skull is of extreme rarity. This article reports the case of a 27-year-old man, who committed suicide by multiple knife stabs and cuts to the head, the torso, one shoulder and the forearms. Autopsy showed a perforating wound of the skull and the 10-cm long broken blade of the knife being still embedded in the right temporal lobe of the brain. The deceased had no history of psychiatric illness but was currently treated by mefloquine, a quinine derivative associated with a high rate of psychiatric adverse effects. Toxicological examination confirmed a recent intake of mefloquine together with chloroquine, another antimalarial drug. To our knowledge, this is the first report of a completed suicide with very strong evidence of mefloquine implication. Discussion focuses upon mefloquine-induced psychiatric disorders and highlights the importance of performing toxicological investigations in cases of unusual suicides.