Possible Fatal Acetaminophen Intoxication with Atypical Clinical Presentation

Acetaminophen or paracetamol, a commonly used over‐the‐counter analgesic, is known to elicit severe adverse reactions when taken in overdose, chronically at therapeutic dosage or, sporadically, following single assumptions of a therapeutic dose. Damage patterns including liver damage and, rarely, acute tubular necrosis or a fixed drug exanthema. We present a case of fatal acetaminophen toxicity with postmortem blood concentration 78 μg/mL and unusual clinical features, including a visually striking and massive epidermolysis and rhabdomyolysis, disseminated intravascular coagulation and myocardial ischemia. This case is compared with the most similar previous reports in terms of organ damage, clinical presentation, and cause of death. We conclude that a number of severe patterns of adverse effects to acetaminophen are emerging that were previously greatly underestimated, thus questioning the adequacy of the clinical spectrum traditionally associated with acetaminophen intoxication and leading to the need to review this spectrum and the associated diagnostic criteria.     

Management Discretion and Political Interference in Municipal Enterprises. Evidence from Italian Utilities

The attention of scholars and policy-makers is shifting from full privatisation to alternative measures as a means to improve the efficiency of public services. This article focuses on three restructuring measures adopted by local governments: partial privatisation (without transfer of control rights), inter-municipal joint ventures, and the presence of outside directors on the Board. Divergent hypotheses on these measures have emerged from two economic theories, namely public choice and the agency perspective. An empirical analysis investigates the effects of restructuring processes on a sample of Italian municipal utilities. Partial privatisation has been shown to play a significant and positive role, while Board independence from management has a less significant influence. Multi-government utilities have been found to suffer from severe coordination costs, which are not outweighed by scale benefits. Our findings reveal that management discretion is a significant source of inefficiency in municipal enterprises.     

Free Trade: A Paradox for Democracy

Free trade and global markets are issues that have dominated for some time the political and economic agendas of both industrialized and newly developing nations. While greater prosperity for all peoples is most frequently cited as the main gain, free trade is also considered a promoter of democracy, an argument deployed in bringing China into the World Trade Organization. World peace has also been cited as one of the fruits of closer economic integration, as parochial walls between peoples are undermined, interdependence grows and is made more transparent, and mutual prosperity assured. We contest the faith upon which these assumptions rely. We argue that the theory and practice of neo-liberal free trade and neo-revisionist democracy implicate the modern democratic nation state in paradoxes that it is ill-equipped to negotiate. To exit these paradoxes, or at least to mollify the rancor they can produce, both the ideas of free trade and of democracy need to become more robust.     

Free Speech,Political Equality,and Campaign Finance Reform: A Paradox for Democracy?

Liberty to speak free of government interference and political equality are both essential to democracy. Yet political equality requires governmental regulation of resources needed for political speech. Analysis of Supreme Court cases, supplemented by considerations from democratic theory, suggest that this apparent paradox is better understood as a tension within the idea of free speech itself: between liberty to speak and the need for government to oversee fair distribution of resources necessary for politically effective speech. Although it is a tension worth negotiating with care, democracy simply requires fairness in distribution of politically relevant resources. The Supreme Court has erred in not reading the Constitution as mandating political equality as a fundamental right, and also in not incorporating real political equality as a compelling state interest. Therefore, the public should seek a 28th Amendment that would mandate political equality regardless of economic circumstance as a fundamental right, and inscribe into the document, for the first time, the word “democracy.”     

Subarachnoid hemorrhage during sexual activity after sildenafil intake: an accidental association?

We report and describe an autopsy case of a man dead for rupture of cerebral artery aneurysm with subsequent subarachnoid hemorrhage after sexual intercourse. Toxicologic analysis demonstrated that he had consumed sildenafil (Viagra). Although subarachnoid hemorrhage has been reported to be associated with sexual intercourse, it is not among the known adverse effects of sildenafil. However, sildenafil has been found to interact with vascular physiology via multiple mechanisms and in most of the vascular districts of the human body. This case provides an example of a very rare association between this drug and a fatal pathologic event and deserves to be added to the existing clinical knowledge about sildenafil and the pathophysiology of the events involved. This knowledge may be helpful in orienting further investigation into the mechanisms of action of sildenafil and their clinical implications.     

An Exceptional Case of Acute Respiratory Failure Caused by Intra‐Thoracic Gastric Perforation Secondary to Overeating

An 18‐year‐old female patient arrived at the emergency department complaining of abdominal pain and fullness after a heavy meal. Physical examination revealed she was filthy and cover in feces, and she experienced severe abdominal distension. She died in ED and a diagnostic autopsy examination was requested. At external examination, the pathologist observed a significant dilation of the anal sphincter and suspected sexual assault, thus alerting the Judicial Authority who assigned the case to our department for a forensic autopsy. During the autopsy, we observed anal orifice expansion without signs of violence; food was found in the pleural cavity. The stomach was hyper‐distended and perforated at three different points as well as the diaphragm. The patient was suffering from anorexia nervosa with episodes of overeating followed by manual voiding of her feces from the anal cavity (thus explaining the anal dilatation). The forensic pathologists closed the case as an accidental death.