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.     

Public security in private hands: the case of Guatemala’s Carlos Vielman

The following case study concerns the period in which Carlos Vielman, a well-heeled Guatemalan businessman from a prominent family, became the interior minister of the Óscar Berger administration. While minister, Vielman oversaw the creation of several special units that “acted as an organized crime group,” according to Guatemalan and international investigators. He, along with several of his police deputies were eventually charged for murder. He was later exonerated by a court in Spain, while others were prosecuted. This case study delves into that period, exploring how Vielman’s ministry represented an extension of the Guatemalan elite’s approach towards security and the government writ large to thwart rivals, regardless of the violent and criminal consequences.     

The Political Economy of Improving Health Care for the Poor in Rural Africa: Institutional Solutions to the Principal–Agent Problem

Both governments and private for-profit markets have been disappointing in meeting the needs of the African poor for health care. NGO services provide a much more attractive alternative for this clientele, despite the fees they charge. They do so because they represent an institutional solution to the ‘imperfect information’ problem in health care. Through simulations based on data from Cameroon, we demonstrate that if fee-charging NGOs replace the highly subsidised but poorly managed facilities operated by African governments the poor would be better off. Those NGOs that are decentralised in their financial and personnel management are most effective. The politics of making the recommended changes are assessed.     

British corporatism

Politics in Industrial Society. By Keith Middlemas. London: Andre Deutsch, 1979. Pp.512. £14.95 (case). £5.95 (paper).

The Politics of the Corporate Economy. By Trevor Smith. Oxford: Martin Robertson, 1979. £17.50.

Governing Under Pressure: The Policy Process in a Post‐Parliamentary Democracy. By J.J. Richardson and Grant Jordan. Oxford: Martin Robertson, 1979. £16.50 (case). £5.90 (paper).