A case of fatal overdose involving both hydromorphone and kratom

Kratom is a plant originating in Southeast Asia that has been used for its dose-dependent stimulant and opioid effects. The main active compound in kratom is mitragynine, an alkaloid with affinity for the mu-opioid receptor. Toxicity and fatalities related to kratom use have increased substantially in recent years. In this case report, we describe a 44-year-old man who was found deceased in bed. The only significant finding at autopsy was abdominal distension with >4 L of ascites. Toxicology testing was performed on femoral blood which showed 79 ng/mL of hydromorphone, 560 ng/mL of mitragynine, and 240 ng/mL of olanzapine. In addition, creatinine and urea in vitreous humor were significantly elevated, consistent with renal impairment. Death was attributed to hydromorphone toxicity with mitragynine being a contributing factor.     

Phenibut screening and quantification with liquid chromatography–tandem mass spectrometry and its application to driving cases

An analytical strategy for identification by an LC–MS/MS multitarget screening method and a suitable LC–MS/MS based quantification were developed for the psychotropic drug phenibut. The samples analyzed were collected during traffic control and were associated with driving under the influence of drugs. A positive sample for phenibut was identified in a single case of driving under the influence. The quantification revealed a drug concentration of 1.9 μg/mL. An interaction with blood alcohol (BAC = 0.10%) was discussed as the explanation of the way of driving and deficit manifestations observed (swaying, nystagmus, quivering of the eyelid, and reddened eyes). According to the available information, the quantified phenibut concentration could be explained by an intake of four tablets (self-reported) during the day containing 250 mg of the drug. Chromatography was performed with a Luna 5 μm C18 (2) 100 A, 150 mm × 2 mm analytical column, and a buffer system consisted of 10 mM ammonium acetate and 0.1% acetic acid (v/v) included in mobile phases marked as A (H₂O/methanol = 95/5, v/v) and B (H₂O/methanol = 3/97, v/v). An effective limit of detection (LOD = 0.002 μg/mL) could be achieved for the multitarget screening method. The quantification of phenibut was performed on a second LC–MS/MS system with LOD/LOQ values of 0.22/0.40 μg/mL. Since phenibut quantification data are rare, the presented information can be used with caution for evaluation of positive cases in the future.     

Fat embolism syndrome associated with atraumatic compartment syndrome of the bilateral upper extremities: An unreported etiology

Fat embolism syndrome (FES) is a potentially life-threatening condition that develops when fat embolism leads to clinical symptoms and multisystem dysfunction. The classic triad of respiratory distress, neurologic symptoms, and petechial rash are non-specific, and the lack of specific laboratory tests makes the diagnosis of FES difficult. Although FES is most common after long bone fractures, multiple conditions some of which are atraumatic have been associated with the development of FES. We report a case of FES that occurred in the setting of a non-traumatic compartment syndrome of the upper extremities. The pathologic and clinical findings, pathophysiology, diagnostic challenges, and pathologic methods to properly diagnose FES are discussed with a review of the relevant literature. This case highlights the importance of the autopsy in making a diagnosis of FES in cases where death could otherwise be incorrectly attributed to multi-organ system failure, shock, or sepsis.     

Military Structure,Civil Disobedience,and Military Violence

In this article, I argue that factors inherent to the structure of a military organization and their relationship with the political leadership play a role in the organization's tendency to perpetrate violence against civilians during civil disobedience campaigns. To examine this hypothesis, I conducted a three-phased statistical analysis on a database containing 97 campaigns that took place between 1972 and 2012. In the first phase, I examined the relationship between military centric factors and violent crackdowns. In the second phase, I examined the relationship between military centric factors and mass killing. In the third stage, I examined the relationship between two specific types of discrimination in the military and mass killing. I found strong evidence supporting the hypothesis mentioned above. High-risk militaries that served a militarized regime, contained loosely regulated or indoctrinated paramilitaries, and discriminated against the protesting group, were much more likely to perpetrate violence against civilians during civil disobedience campaigns than low-risk militaries. The conclusions of this study suggest that further examination of the military's role in perpetrating violence against civilians during protests and conflict may provide some novel findings.     

Clinical applications of hair testing for drugs of abuse--the Canadian experience

During the last 2 decades there has been a substantial increase in illicit drug consumption in North America. It has been repeatedly shown that the personal history of drug use is far from being accurate. Fearing legal consequences and embarrassment of admitted illicit substance use, most users tend to deny or, to under-report illicit drug consumption. These facts have stressed an urgent need for a biological marker which does not lose its sensitivity within a few days after the end of exposure and which may yield a cumulative reflection of long term exposure to illicit drugs. Hair analysis has emerged as such a marker. A variety of illicit and medicinal compounds have been shown to be incorporated into hair including trace metals, barbiturates, amphetamines, opiates, phencyclidine, cocaine, nicotine and cannabis. Hair analysis for drugs of abuse provides long-term information on an individual's drug use; its window of detection is limited only by the length of the hair and typically, ranges from a week to several months. After establishing and validating several hair tests during the last decade, we have analyzed over 1000 hair samples for different drugs of abuse. We used RIA for screening and GC-MS for confirmation of positive results. The aim of this report is to illustrate the diagnostic usefulness of hair testing in different age groups (newborns, children, adults) and circumstances: (criminal cases, athletes, child custody cases, etc.).     

Holding assets in Israel

This article concerns the use of US asset protection trustsby non-US settlers. After considering the basics of US assetprotection trusts, it examines key issues including fraudulenttransfers, revocability, powers of appointment and the income,gift and estate tax consequences for non-US settlers beforefinally turning its attention to the issues of jurisdictionand the recognition and enforcement of foreign judgments.     

The Politics of Electoral Reform Abolition: The Informed Process of Israel's Return to Its Previous Electoral System

This article examines the process that led to the repeal of Israeli electoral reform (1992–2001) and compares it with that of reform adoption (1987–92). The most significant difference between the two processes is in the kinds of information that were available in them. In the politics of reform adoption, information was susceptible to manipulation and its supply was a crucial part of the struggle itself. In the politics of reform abolition, the real consequences of reform were constantly unfolding. This substantial difference resulted in other differences – not in type but in extent. First, while both were ongoing processes in which coalitions of supporters and opponents had to be built and then rebuilt several times, the cohesion of the camps throughout the struggle for reform abolition was higher than in the struggle for reform adoption. Second, while office-seeking successfully served as a basis for understanding the behavior of most parliamentary actors, the actual perceptions of its exact contextual meaning was dependent upon different available information. The two processes also had two common characteristics: power was diffused in both arenas of the politics of reform and in both instances the selection of the right timing proved to be necessary for successfully promoting the initiatives against veto players who were interested in preserving the status quo.