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.     

An Unusual Case of Multiple‐Gunshot Suicide of an Alcohol‐Intoxicated Cancer Sufferer with Prolonged Physical Activity

Multishot firearm suicides are relatively rare and suggest the possibility of homicide. Physical activity following gunshots to the head, the neck, and the thorax does occur, and immediate incapacitation does not occur in every fatal gunshot wound that penetrates the head or perforates the heart. Cancer patients appear to be at increased suicide risk, but alcohol intoxication is less common in such cases. We present—to the best of our knowledge for the first time—a case of a 54‐year old, male, liver cancer sufferer, who under the influence of alcohol, discharged his revolver three times, suffered, among other wounds, a heart‐perforating wound, and died after c. 1.5 h, being able to talk until just before he died. Our case underlines the importance of keeping an open critical mind when dealing with multiple‐gunshot fatalities, especially when posttraumatic physical activity might be crucial in differentiating homicide from suicide.     

Alcohol intoxicated eyewitnesses' memory of intimate partner violence

Alcohol affects memory in many, and mostly negative, ways. This is a problem in legal contexts as many witnesses are alcohol intoxicated when taking part of the critical event. However, research is sparse regarding how, and under what circumstances, the reports of alcohol intoxicated witnesses differ from those of sober witnesses. This study investigated whether alcohol intoxicated and sober eyewitnesses differ regarding completeness, accuracy, and type of information reported, as well as whether gender influenced these variables. Eighty-seven healthy men (n = 44) and women (n = 43) received either an alcoholic beverage (0.7 g/kg) or a control (juice) in a laboratory setting before viewing a film picturing intimate partner violence. Ten minutes after viewing the film, they were interviewed. Reports by alcohol intoxicated women were less complete, but as accurate, as sober women's. In contrast, intoxicated and sober men did not differ regarding completeness or accuracy. Furthermore, compared with sober women, intoxicated women reported fewer actions but no difference was found between the groups regarding reported objects. At this moderate dose, alcohol affected women's reports more than men's, which may be because alcohol affects attention and memory consolidation more clearly at a lower dose for women than for men.     

A Framework for Immigration

Abstract

This paper presents a framework for immigration, regardless of country of origin or of destination. It identifies factors that precipitate emigration and those that affect immigration, providing a background for understanding the immigration experience.     

Exogenous Lipoid Pneumonia as a Contributory Factor in a Drug‐related Death

Postmortem investigation often reveals various conditions, which may or may not have played a part in the death of the individual. The case of a 32‐year‐old woman is reported, with a long history of drug addiction. She was found dead in her bed. The autopsy revealed diffuse pulmonary edema with congestion of the lungs, brain, liver, and spleen. Microscopic examination of the lungs showed multiple intra‐alveolar and interstitial foamy macrophages and extracellular fat droplets surrounded by polynuclear giant cells. Death was attributed to acute polydrug intoxication. As microscopic examination had revealed severe pulmonary lesions, lipoid pneumonia was considered as a contributing factor to death. Lipoid pneumonia is an uncommon entity with the characteristic radiograph features and histologic findings of alveoli filled with vacuolated, lipid‐laden histiocytes. It can be either exogenous or endogenous in cause, based on the source of the lipid. Exogenous lipoid pneumonia usually results from aspiration or inhalation of fat‐like material, such as mineral oil or petroleum‐based lubricants and decongestants, resulting in pulmonary inflammatory reactions.     

英美法系醉态辩护述评

英美醉态辩护分为自愿醉态与非自愿醉态。自愿醉态通常只对特定意图的犯罪进行辩护,非自愿醉态则没有这种限制。我国对醉态下犯罪的刑事责任的认识还很肤浅,英美法系的醉态辩护值得我们借鉴。     

Ethical analysis of a curious event of a forensic case becoming an involuntarily hospitalized psychiatric patient

It is not uncommon in forensic psychiatry that the duty to care for the patient conflicts with the responsibility to the court, or the duty to protect the public from harm from the potentially dangerous patient-offender. This paper exemplifies the scenario of what happens when the line between forensic and clinical psychiatry is crossed and whether crossing that boundary can be justified. Ethical discussion also embodies and clarifies the issues of unjustified violation of the patients’ autonomy and an undue infringement on their right to liberty on the arbitrary basis of existing or perceived mental illness. The paper provides an in-depth analysis of the issues of physicians’ conflicting duties, vulnerability of patient-offenders, and their human rights in the light of court orders and involuntary hospitalizations.

I argue that in order to promote ethical decision-making we must establish clear rules and guidelines for psychiatric practice, separate conflicting roles, and provide sufficient training of health-care professionals regarding topics of human rights and legislation governing clinical and forensic psychiatric practice. Empowering patients and enhancing their rights to autonomy and liberty can also be potent tools of promotion and protection of their human rights and prevention of ethical breaches in practice.     

An unusual case of accidental poisoning: fatal methadone inhalation

In this report, the authors present a case of unusual, accidental methadone intoxication in a 40-year-old man, who had inhaled methadone powder. The drug dealer was a pharmacy technician; methadone had been stolen from a pharmacy and sold as cocaine. After having inhaled methadone powder, he suffered cardiopulmonary arrest. He was admitted to hospital where he died after 24 h of intensive care. The autopsy revealed congestion of internal organs and cerebral and pulmonary edema. Microscopically, the heart showed no changes. The toxicological analyses performed on blood and urine taken at the hospital revealed methadone, cannabinoids, and ethanol. The blood methadone concentration was 290 μg/L. The urine methadone concentration was 160 μg/L. Midazolam and lidocaine, which were administered to the patient at the hospital, were also detected in the blood. The cause of death was determined to be methadone intoxication. The literature has been reviewed and discussed. To date, and to our knowledge, only very few cases of accidental death resulting from methadone inhalation have been described up to the case presented herein.     

Methyl alcohol poisoning in Trabzon (Turkey)

The aim of this retrospective study was to examine methyl alcohol intoxications in Trabzon (Turkey) and to determine any relations between the laboratory results and histopathologic changes. A total of 4492 forensic autopsies were performed from 1998 to 2008. Thirteen of the cases (0.3%) were because of methanol poisoning, and all were men. Their ages ranged from 25 to 62 years. The blood methanol concentrations ranged widely, from 15 to 482 mg/dL. In six cases, poisoning was because of consumption of the alcoholic beverage "Raki," while in five cases, poisoning was because of the ingestion of cologne. The products consumed were unknown in the other two cases because of insufficient history and data records. Mortality because of methanol poisoning may be prevented/decreased with the implementation of some precautions, such as public education regarding the harms of methyl alcohol, routine monitoring of the vendors that sell alcoholic beverages and cologne, and appropriate legal retribution for the illegal production of methanol.     

Basal renal tubular epithelial cell vacuolization and alcoholic ketoacidosis

Subnuclear renal tubular epithelial cell vacuolization is a marker for diabetic ketoacidosis. Whether it is because of hyperglycemia or of ketoacidosis is unclear. To examine the effect of ketoacidosis on renal cells in isolation, five cases of lethal alcoholic ketoacidosis without hyperglycemia were examined (vitreous humor β-hydroxybutyrate: 6.42-8.75 mM, mean 7.66 mM; and glucose: 0.1-4.2 mM, mean 1.46 mM). Microscopic examination of the kidneys revealed basal vacuoles in three cases (60%). Seven control cases with acute alcohol toxicity without ketoacidosis (blood alcohol: 0.18-0.43%, mean 0.31%; and β-hydroxybutyrate: 0.12-0.42 mM, mean 0.21 mM) did not have these changes. In this study, basal epithelial vacuolization was found only in cases with significant ketoacidosis. Although the numbers are small, the finding of basal renal tubular epithelial vacuolization in normoglycemic cases with elevated β-hydroxybutyrate levels provide further evidence that disordered lipid metabolism may be involved in the pathogenesis of this phenomenon.