Rapid Deaths Research Articles

The Microbiological Characteristics of Acinetobacter Baumannii Associated With Early Mortality in Patients With Bloodstream Infection.

Despite rapid deaths resulting from Acinetobacter baumannii bacteremia, the clinical impact of the microbiological characteristics of A baumannii strains on early mortality (EM) is unclear. We aimed to identify the microbiological characteristics of A baumannii strains associated with EM. Clinical information and isolates from patients with A baumannii bacteremia from January 2015 to December 2021 were collected. EM was defined as death within 3 days of the initial positive blood culture, whereas late mortality meant death within 5-30 days. The microbiological characteristics of A baumannii were analyzed using multilocus sequence typing, polymerase chain reactions, and a Galleria mellonella in vivo infection model. Among 130 patients, 69 (53.1%) died within 30 days and EM occurred in 38 (55.1% of 30-day deaths). Sequence type 191 (ST191) strain was more prevalent in patients with EM than in 30-day survivors (31.6% vs 6.6%). Regarding virulence genes, bfmS was more frequent (92.1% vs 47.5%), whereas bauA was less frequent (13.2% vs 52.5%) in patients with EM than in 30-day survivors. Higher clinical severity, pneumonia, and ST191 infection were identified as independent risk factors for EM. In the G mellonella infection model, ST191, bfmS+, and bauA- isolates showed higher virulence than non-ST191, bfmS-, and bauA+ isolates, respectively. ST191 and bfmS were more frequently found in the EM group. ST191 infection was also an independent risk factor for EM and highly virulent in the in vivo model. Tailored infection control measures based on these characteristics are necessary for A baumannii bacteremia management.

Variations in Management and Clinical Outcomes for Children With Diabetic Ketoacidosis in an Academic Pediatric Versus Community Emergency Department Setting.

Our objectives were to characterize variations from standardized, evidence-based guidelines in the management of pediatric patients with diabetic ketoacidosis (DKA) based on initial presentation to a tertiary pediatric emergency department (PED) versus a community emergency department (OSH) and compare clinical outcomes. We conducted a retrospective study on children 18 years and younger with DKA who presented to an OSH or PED over a 3-year period. Treatments monitored for variation included intravenous fluid management, insulin delivery, and sodium bicarbonate administrations. Clinical outcomes included time to anion gap correction and on insulin infusion, hypokalemia, hypoglycemia, rapid serum glucose decline, cerebral edema, mechanical ventilation, mortality, and time from initial presentation to hospital discharge. Children with DKA who presented to an OSH (n = 250) were more acidotic (pH 7.11 vs. 7.13, P = 0.001) and had larger anion gaps (28.8 vs. 25.5, P < 0.001) compared with children presenting to the PED (n = 237). The OSH patients were more likely to receive larger fluid boluses (>20 cc/kg or >1000 ml, 43% vs. 4%, P < 0.001), sodium bicarbonate (5% vs. 0%, P < 0.001), and intravenous bolus insulin (28% vs. 0%, P < 0.001). The OSH group were less likely to be started on maintenance intravenous fluids (70% vs. 99%, P < 0.001) or receive potassium in maintenance intravenous fluids (14% vs. 42%, P < 0.001). The OSH group had longer anion gap correction times (754 vs. 541 mins, P < 0.001), insulin infusion times (1018 vs. 854 min, P = 0.003), and times to hospital discharge (3358 vs. 3045 mins, P < 0.001). Incidence of hypokalemia, hypoglycemia, rapid glucose decline, cerebral edema, and deaths were similar between the 2 groups. Our study demonstrated significant variations in the initial management of pediatric DKA patients by OSH facilities that deviated from an evidence-based treatment pathway utilized by a PED. Statewide quality improvement initiatives could help improve the overall clinical care provided to pediatric DKA patients.

The role of turmeric and black pepper oil nanoemulsion in attenuating cytokine storm triggered by duck hepatitis A virus type I (DHAV-I)-induced infection in ducklings

The cytokine storm induced by duck hepatitis A virus type 1 (DHAV-1) infection significantly contributes to severe, rapid deaths and economic losses in the duck industry in Egypt. This study aimed to investigate the potential inhibitory effect of a nanoemulsion containing turmeric and black pepper oil on the immune response and pathogenesis of DHAV-1 in ducklings. A total of 105 ducklings from nonvaccinated breeders were divided into 5 experimental groups, each comprising 21 birds. The negative control group (G1) remained noninfected with DHAV-1 and nontreated with nanoemulsion, while the positive control group (G2) was infected with DHAV-1 but not treated with nanoemulsion. The other 2 groups (G3, the supplemented group which was noninfected with DHAV-1), and group 4 (the prophylactic group G4) which was infected with DHAV-1, both received nanoemulsion throughout the experiment. Group 5 (G5, the therapeutic group), on the other hand, which was infected with DHAV-1 received nanoemulsion only from the onset of clinical signs. At 5 days old, the ducklings in the positive control (G2), the prophylactic (G4), and the therapeutic group (G5) were infected with DHAV-1. All the ducklings in the infected groups exhibited depression, anorexia, and opisthotonos, and their livers displayed various degrees of ecchymotic hemorrhage, liver enlargement, and microscopic pathological lesions. Notably, the positive control group (G2) experienced the most severe and pronounced effects compared to the other infected groups treated with the nanoemulsion. Meanwhile, the viral RNA loads were lower in the liver tissues of the infected ducklings treated with the nanoemulsion (G4, and G5) compared to the positive control group G2. Additionally, the nanoemulsion effectively modulated proinflammatory cytokine expression, antioxidant enzymes, liver enzymes, and lipid profile of treated ducklings. In conclusion, the turmeric and black pepper oil nanoemulsion has the potential to be a therapeutic agent for regulating and modulating the immune response, decreasing DHAV-1-induced cytokine storms, and minimizing mortality and economic losses in the duck business. More research is needed to understand how turmeric and black pepper oil nanoemulsion alleviates DHVA-1-induced cytokine storms and lowers duckling mortality.

Effectiveness of Pacemaker Care Protocol on Knowledge and Skill Regarding Care of Client Undergoing Pacemaker Implantation Among Nurses

Non Communicable Diseases (NCDs) also known as chronic diseases, which includes cardiovascular diseases (like heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructed pulmonary disease and asthma) and diabetes. NCDs result in rapid deaths as seen in certain diseases like autoimmune diseases, heart diseases, stroke, cancers, diabetes, chronic kidney disease, osteoporosis, Alzheimer's disease, cataracts, and others. Cardiovascular diseases are one of the major incidence of non-communicable diseases and leading causes of deaths in India. The heart is endowed with a specialized system for generating rhythmic electrical impulses and for conducting these impulses rapidly throughout the heart to cause contraction of the heart muscle. When this system functions normally, the atria contract about one-sixth of a second ahead of the ventricles. This orderly electrical activity must precede contraction to provide adequate cardiac output for perfusion of all body organs and tissues. Aim and objective: To assess the effectiveness of pacemaker care protocol on knowledge and skill regarding care of client undergoing pacemaker implantation among nurses at selected hospital. Methodology: A quasi-experimental non equivalent control group design was chosen to conduct the study among 60 Nurses, who were selected using purposive sampling technique. Immediately after pretest assessment, intervention was given in experimental group and hospital routine was carried out in control group. After seven days post test was collected in both the groups. The comparison of post test level of knowledge between experimental and control group revealed that t of 12.002, was statistically significant at p&lt;0.001level.The comparison of the post test level of skill, revealed t value of 9.577, which was highly statistically significant at p&lt; 0.001level.

Heroin-Related Fatalities in Jeddah, Saudi Arabia, between 2008 and 2018

To date, epidemiological studies have not evaluated heroin-related deaths in the Middle East and North African regions, especially Saudi Arabia. All heroin-related postmortem cases reported at the Jeddah Poison Control Center (JPCC) over a 10-year period (21 January 2008 to 31 July 2018) were reviewed. In addition, liquid chromatography electrospray ionization tandem mass spectrometry (LC/ESI-MS/MS) was utilized to determine the 6-monoacetylmorphine (6-MAM), 6-acetylcodeine (6-AC), morphine (MOR), and codeine contents in unhydrolyzed postmortem specimens. Ninety-seven heroin-related deaths were assessed in this study, and they represented 2% of the total postmortem cases at the JPCC (median age, 38; 98% male). In the blood, urine, vitreous humor, and bile samples, the median morphine concentrations were 280 ng/mL, 1400 ng/mL, 90 ng/mL, and 2200 ng/mL, respectively; 6-MAM was detected in 60%, 100%, 99%, and 59% of the samples, respectively; and 6-AC was detected in 24%, 68%, 50%, and 30% of the samples, respectively. The highest number of deaths (33% of total cases) was observed in the 21-30 age group. In addition, 61% of cases were classified as "rapid deaths," while 24% were classified as "delayed deaths." The majority (76%) of deaths were accidental; 7% were from suicide; 5% were from homicide; and 11% were undetermined. This is the first epidemiological study to investigate heroin-related fatalities in Saudi Arabia and the Middle East and North African region. The rate of heroin-related deaths in Jeddah remained stable but increased slightly at the end of the study period. Most patients were heroin-dependent abusers and from the middle-aged group. The availability of urine, vitreous humor, and bile specimens provided valuable information regarding the opioids that were administered and the survival time following heroin injection.

Confirmation Using Triple Quadrupole and High-Resolution Mass Spectrometry of a Fatal Canine Neurotoxicosis following Exposure to Anatoxins at an Inland Reservoir.

Cyanobacterial blooms are often associated with the presence of harmful natural compounds which can cause adverse health effects in both humans and animals. One family of these compounds, known as anatoxins, have been linked to the rapid deaths of cattle and dogs through neurotoxicological action. Here, we report the findings resulting from the death of a dog at a freshwater reservoir in SW England. Poisoning was rapid following exposure to material at the side of the lake. Clinical signs included neurological distress, diaphragmatic paralysis and asphyxia prior to death after 45 min of exposure. Analysis by HILIC-MS/MS of urine and stomach content samples from the dog revealed the detection of anatoxin-a and dihydroanatoxin-a in both samples with higher concentrations of the latter quantified in both matrices. Detection and quantitative accuracy was further confirmed with use of accurate mass LC-HRMS. Additional anatoxin analogues were also detected by LC-HRMS, including 4-keto anatoxin-a, 4-keto-homo anatoxin-a, expoxy anatoxin-a and epoxy homo anatoxin-a. The conclusion of neurotoxicosis was confirmed with the use of two independent analytical methods showing positive detection and significantly high quantified concentrations of these neurotoxins in clinical samples. Together with the clinical signs observed, we have confirmed that anatoxins were responsible for the rapid death of the dog in this case.

Pyroptosis activation by photodynamic-boosted nanocatalytic medicine favors malignancy recession

Although pyroptosis as a newly-emerging but burgeoning programmed cell death fashion has been extensively accepted to outperform apoptosis in inducing rapid and complete cell deaths, potentiating immunity and mitigating resistance, its contribution is low. Therefore, the demand to elevate pyroptosis level is highly desirable and highlighted. Herein, a RGD-modified and pyroptosis-engineered theranostic agent (PETA) consisting of Fe3O4-embedded magnetic mesoporous silica nanoparticles (MMSN) vehicles and chlorin e6 (Ce6) photosensitizers (i.e., MMSN-cRGD@Ce6) is established to heighten ROS level for inducing pyroptosis by Ce6-mediated photodynamic process. Inspiringly, Fe3O4-mediated nanocatalytic medicine contributes to O2 release and hypoxia mitigation, which liberates hypoxia-induced resistances to ROS production and further favors ROS production. Consequently, ROS-activated pyroptosis is accessible to circumvent the hypoxia-induced resistance to ROS-activated apoptosis especially when uniting with cRGD-enhanced active targeting, which significantly represses malignant breast cancer in vitro and in vivo. The design principles of targeted PETAs can serve as a general method to develop new pyroptosis-highlighted theranostic agents, and coincidently indicate that pyroptosis contribution should be surveyed to veritably and comprehensively reflect death pathway when investigating ROS-based anti-tumor pathways.

SARS Cov2 in Children

It is a general viral disease, which means that it can be transmitted from animal to human and vice versa, and this indicates that it is a virus that transcends different races and types of living organisms. The disease is characterized by wide and different clinical symptoms from one patient to another, their severity and types depend on the type of organ or tissue that the virus infects and the physiological condition, age and immune status of the patient. At the end of a year 2019, the Coronavirus infection spread very quickly in the suburbs of Wuhan chine’s city and infected large numbers of city dwellers, it was characterized by symptoms that differ from person to person in severity, nature and duration, which led to death in many cases of severe infection. The rapid spread of the virus surprised researchers, doctors, the health community, and citizens in Wuhan and China in general Which provoked and instilled the spirit of challenge among scientists, researchers and those interested in health care in China to search and investigate the cause of all these infection and the rapid spread and deaths that occurred so quickly, finally that their investigation ended with the diagnosis of Corona virus (SARS cov2) as the cause of this pandemic that began in the Chinese city of Wuhan.

Genetic variants associated with inherited cardiovascular disorders among 13,131 asymptomatic older adults of European descent

Genetic testing is used to optimise the management of inherited cardiovascular disorders that can cause sudden cardiac death. Yet more genotype–phenotype correlation studies from populations not ascertained on clinical symptoms or family history of disease are required to improve understanding of gene penetrance. We performed targeted sequencing of 25 genes used routinely in clinical genetic testing for inherited cardiovascular disorders in a population of 13,131 asymptomatic older individuals (mean age 75 years) enrolled in the ASPREE trial. Participants had no prior history of cardiovascular disease events, dementia or physical disability at enrolment. Variants were classified following ACMG/AMP standards. Sudden and rapid cardiac deaths were clinically adjudicated as ASPREE trial endpoints, and assessed during mean 4.7 years of follow-up. In total, 119 participants had pathogenic/deleterious variants in one of the 25 genes analysed (carrier rate of 1 in 110 or 0.9%). Participants carried variants associated with hypertrophic cardiomyopathy (N = 24), dilated cardiomyopathy (N = 29), arrhythmogenic right-ventricular cardiomyopathy (N = 22), catecholaminergic polymorphic ventricular tachycardia (N = 4), aortopathies (N = 1), and long-QT syndrome (N = 39). Among 119 carriers, two died from presumed sudden/rapid cardiac deaths during follow-up (1.7%); both with pathogenic variants in long-QT syndrome genes (KCNQ1, SCN5A). Among non-carriers, the rate of sudden/rapid cardiac deaths was significantly lower (0.08%, 11/12936, p < 0.001). Variants associated with inherited cardiovascular disorders are found in asymptomatic individuals aged 70 years and older without a history of cardiovascular disease.

Novel patterns of progression upon immunotherapy in other thoracic malignancies and uncommon populations

In the immunotherapy era, considering the prolonged survival benefit and responses observed with immunecheckpoint inhibitors (ICI) in many cancer types, the identification of patients with rapid progression (PD) and deaths upon ICI has found some skepticism and resistance among the scientific community. Nevertheless, an acceleration of tumour during ICI, defined as hyperprogressive disease (HPD), has been recognized across different cancer types and evidence regarding rapid PDs and deaths are emerging in patients with malignant pleural mesothelioma (MPM), small cell lung cancer (SCLC) and thymic malignancies and in uncommon non-small cell lung cancer (NSCLC) populations. Of note, PD and early deaths (ED) rates upon single agent ICI were up to 60% and 30% in MPM and 70% and 38% in SCLC patients, respectively. Similarly, rapid PDs and deaths were observed in clinical trials and retrospective studies including patients with poor performance status (PS), HIV infection and rare NSCLC histologies. Atypical patterns of response, such as pseudoprogression (PsPD) may also occur in other thoracic malignancies (MPM) and in some uncommon populations (i.e., HIV patients), however probably at lower rate compared to HPD. The characterizations of HPD and PsPD mechanisms and the identification of common definition criteria are the next future challenges in this area of cancer research.

High-Grade Pleomorphic Sarcoma of the Left Atrium after Incomplete Resection and Adjuvant Chemotherapy

Introduction Primary cardiac tumors are extremely rare, found in only 0.02% of all autopsies. These tumors are malignant in only 25% of the cases, 75% of which are sarcomas, frequently affecting young people with no risk factors.² The median overall survival is less than 1 year,³ ranging from 9 to 16 months,, with rapid proliferation and deaths caused by arrhythmias, thrombosis, pulmonary embolism, and, most importantly, heart failure. Due to its rarity, reports in the literature about the best treatment [...]

Epidemiology of Fatal Road Traffic Accidents: A Six Year Retrospective Study in the Medico legal Centre of a Tertiary Care Health Set Up in Western Maharashtra

Road Traffic Accident (RTA) is a public health concern globally. Rapid urbanisation and increase in thenumber of motor vehicles, lack of discipline and violation of traffic regulations has led to a rapid rise inthe deaths in vulnerable road users. A retrospective study was undertaken in the autopsy centre of a tertiarycare hospital to observe the pattern and trends of deaths between 2013-2018 due to RTAs. Out of 248 RTAcases analysed in this study, 75.4% were male and 24.6% were female. The most vulnerable age group was21-40 years in both two-wheeler and four-wheeler accidents while in pedestrians it was 41-50 years. Highrate of accidents was seen during summer in afternoon in cases of pedestrians as well as motor vehicleoccupants and in the evening after 6 PM in two-wheeler motorcyclists. Observation of the pattern of headinjuries showed fracture of the skull was a common occurrence in two and four-wheeler accidents whereasa greater number of pedestrians reported no skull fracture. Non helmet users suffered higher mortality in theage group of 21-30 years. Subdural haemorrhage caused maximum deaths in two-wheeler motorcyclists andpedestrians while sub arachnoid haemorrhage was seen in four-wheeler accidents. Our study agreed with theWHO report of 2018 and various other studies from India and abroad. Increased number of fatalities wasfound to occur at a particular time of the day with seasonal preference. Two-wheeler motorcyclists withouta helmet suffered maximum deaths. Real time analysis of data in various parts of the country would help inensuring safe road user practices.

How deadly sarcophagid fly larvae are for anurans? New interactions and review to Neotropical region.

Myiasis is defined as the infestation of living or necrotic tissues of vertebrates by dipteran larvae. In amphibians, it can be caused by fly larvae belonging to families Calliphoridae, Chloropidae, Muscidae, and Sarcophagidae. In this study, we report new records and infestation intensity of myiasis in anurans from two localities of the Atlantic Forest in southern Brazil, and also present a list with myiasis caused by flesh fly Sarcophagidae species in anurans of the Neotropical region. For this, we surveyed anuran communities during two breeding seasons, examined for myiasis signs, and when positive collected the specimens. We found infested individuals of 13 anurans of seven species. Different Sarcophagidae larva morphotypes were collected, and two of them emerged as adult flies of Lepidodexia (Notochaeta) fumipennis and Peckia (Sarcodexia) lambens, which were both found in the tree frog Bokermannohyla circumdata. We compiled 21 cases of myiasis in anurans in the Neotropical region from the literature reviewed. This data indicated that hosts of different lineages and modes of life can be affected and that death is often fast. The diversity of myiasis-causing flies in anurans in nature is probably a lot greater than expected, especially if we consider that the encounters are occasional, but at relatively high intensities, can cause rapid deaths.

The Effects of Ketogenic Diet Treatment in Kcna1-Null Mouse, a Model of Sudden Unexpected Death in Epilepsy.

Sudden unexpected death in epilepsy (SUDEP) is a leading cause of abrupt death in patient with epilepsy. It represents 5–30% of all rapid deaths in individuals with epilepsy. Ketogenic diet (KD) has been used in clinic for treatment of epilepsy for many decades. However, the cellular and molecular mechanisms underlying the SUDEP and the relationship between KD and SUDEP remain uncertain. Kcna1-null (Kcna1−/−) mouse, an animal model of SUDEP, is frequently used to study mechanisms underlying SUDEP. The current mini-review focus on risk factors for SUDEP and their relationship with KD treatment in Kcna1−/− mice. Emerging data suggest that factors including seizure frequency, longevity, rest, age, and gender both in Kcna1−/− mice and KD treated Kcna1−/−mice are involved in SUDEP. This provides valuable prediction for clinical application of KD for treatment of SUDEP.

Can measurements of heroin metabolites in post-mortem matrices other than peripheral blood indicate if death was rapid or delayed?

BackgroundIn heroin-related deaths, it is often of interest to determine the approximate time span between intake of heroin and death, and to decide whether heroin or other opioids have been administered. In some autopsy cases, peripheral blood cannot be sampled due to decomposition, injuries or burns. The aim of the present study was to investigate whether measurements of heroin metabolites in matrices other than peripheral blood can be used to differentiate between rapid and delayed heroin deaths, and if morphine/codeine ratios measured in other matrices can separate heroin from codeine intakes. MethodsIn this study, we included 51 forensic autopsy cases where morphine was detected in peripheral blood. Samples were collected from peripheral and cardiac blood, pericardial fluid, psoas and lateral vastus muscles, vitreous humor and urine. The opioid analysis included 6-acetylmorphine (6-AM), morphine, morphine-3-glucuronide (M3G), morphine-6-glucuronide (M6G) and codeine. Urine was only used for qualitative detection of 6-AM. 45 heroin-intake cases were divided into rapid deaths (n=24), based on the detection of 6-AM in blood, or delayed deaths (n=21), where 6-AM was detected in at least one other matrix but not in blood. An additional 6 cases were classified as codeine-intake cases, based on a morphine/codeine ratio below unity (<1) in peripheral blood, without detecting 6-AM in any matrix. ResultsThe median morphine concentrations were significantly higher in the rapid compared with the delayed heroin deaths in all matrices (p=0.004 for vitreous humor and p<0.001 for the other matrices). In the rapid heroin deaths, the M3G/morphine concentration ratios were significantly lower than in the delayed deaths both in peripheral and cardiac blood (p<0.001), as well as in pericardial fluid (p<0.001) and vitreous humor (p=0.006), but not in muscle. The morphine/codeine ratios measured in cardiac blood, pericardial fluid and the two muscle samples resembled the ratios in peripheral blood, although codeine was less often detected in other matrices than peripheral blood. ConclusionsMeasurements of heroin-metabolites in cardiac blood, pericardial fluid and vitreous humor provide information comparable to that of peripheral blood regarding rapid and delayed heroin deaths, e.g. M3G/morphine ratios <2 indicate a rapid death while ratios >3 indicate a delayed death. However, considerable overlap in results from rapid and delayed deaths was observed, and measurements in muscle appeared less useful. Furthermore, matrices other than peripheral blood can be used to investigate morphine/codeine ratios, but vitreous humor seems less suited.

The Shock of Strep: Rapid Deaths Due to Group a Streptococcus.

Streptococcus pyogenes, also known as group A beta-hemolytic strep, is a Gram positive coccus responsible for several million infections every year. The types of infections vary widely from pharyngitis to myositis, but all can advance to severe life threatening invasive disease. Of those infected, approximately 1100 to 1600 people die each year due to invasive disease. Why certain individuals contract severe infections is not known, but many strains of Streptococcus pyogenes are known to produce toxins and superantigens. Invasive Streptococcus pyogenes infections have been shown to cause significant morbidity and rapid mortality. In many cases, patients expire before full antemortem testing can be performed, causing physicians and families to look to forensic pathologists for answers. Understanding the pathogenesis of invasive group A strep infections, relevant gross and microscopic findings, and proper culturing techniques is critical for forensic pathologists to diagnosis this condition and assist in the education and protection of the communities they serve.

Emergence of Klebsiella pneumoniae subspecies pneumoniae as a cause of septicaemia in pigs in England.

Between 2011 and 2014 outbreaks of septicaemia due to Klebsiella pneumoniae subspecies pneumoniae (Kpp) were diagnosed on thirteen English pig farms. The most consistent features were rapid deaths of pigs from ten-days-old to weaning, seasonal occurrence (May to September), affected farms being outdoor breeding herds and the location of all but one of the outbreaks in the East Anglia region in Eastern England. Molecular characterisation of the outbreak Kpp isolates showed that by multilocus sequencing all were sequence type 25 (ST25) of K2 capsular type with a combination of a 4.3kb plasmid (pKPMC25), three phage sequences and the rmpA virulence gene. No archived Kpp isolates of porcine origin pre-dating 2011 were identified as ST25. In 2013 there was the first detection of an outbreak Kpp isolate showing antimicrobial resistance to six antibiotics. Human infection with Kpp ST25 has not been reported in the UK.

Long-Acting β2-Agonists in Asthma: Enantioselective Safety Studies are Needed.

Long-acting β2-agonists (LABAs) such as formoterol and salmeterol are used for prolonged bronchodilatation in asthma, usually in combination with inhaled corticosteroids (ICSs). Unexplained paradoxical asthma exacerbations and deaths have been associated with LABAs, particularly when used without ICS. LABAs clearly demonstrate effective bronchodilatation and steroid-sparing activity, but long-term treatment can lead to tolerance of their bronchodilator effects. There are also concerns with regard to the effects of LABAs on bronchial hyperresponsiveness (BHR), where long-term use is associated with increased BHR and loss of bronchoprotection. A complicating factor is that formoterol and salmeterol are both chiral compounds, usually administered as 50:50 racemic (rac-) mixtures of two enantiomers. The chiral nature of these compounds has been largely forgotten in the debate regarding LABA safety and effects on BHR, particularly that (S)-enantiomers of β2-agonists may be deleterious to asthma control. LABAs display enantioselective pharmacokinetics and pharmacodynamics. Biological plausibility of the deleterious effects of β2-agonists (S)-enantiomers is provided by in vitro and in vivo studies from the short-acting β2-agonist (SABA) salbutamol. Supportive clinical findings include the fact that patients in emergency departments who demonstrate a blunted response to salbutamol are more likely to benefit from (R)-salbutamol than rac-salbutamol, and resistance to salbutamol appears to be a contributory mechanism in rapid asthma deaths. More effort should therefore be applied to investigating potential enantiospecific effects of LABAs on safety, specifically bronchoprotection. Safety studies directly assessing the effects of LABA (S)-enantiomers on BHR are long overdue.

Medico-legal implications of illegal commercial toxic detergent “Prinso”: an autopsy study

Introduction Time to time there are unusual commercial products appear in the market and they become epidemics of suicide. “Prinso/Pus kudu” is an illegal commercial detergent. This washing powder is marketed as two sachets; 12.5g of oxalic acid and 1.2g of potassium permanganate. During past two years, there was an epidemic of suicide deaths due to ingestion of “Prinso” in Sabaragamuwa province, Sri Lanka. Material and Methods A descriptive cross-sectional study was conducted on all deaths reported for autopsy following self-ingestion of “Prinso” to Ratnapura Provincial General Hospital from January 2015 to December 2016. Autopsy findings were collected using a data collection form. Results There were 16 deaths. Ages ranged from 19 to 68 years. Most were young adults. Different brands of “Prinso” were used and relatives identified them as “Pus Kudu”. It is tasteless and odourless. When 2 or 3 packs are taken, most (n=11) died within 24 hours. According to autopsy, there were macroscopic and microscopic evidence of acute renal failure in five cases. Histopathology showed purple-brown stain in renal tubular cells in all cases. Conclusions It was concluded that due to attractive colour, mild corrosiveness and absence of taste or odour, “Prinso” is an ideal agent to commit suicide by ingestion. Adult males are more vulnerable and when more than one pack is ingested, death was almost certain and rapid. Rapid deaths could have been due to the direct or indirect effects of oxalic acid. Late deaths could have been due to acute renal failure by calcium oxalate. Since JMO comes to know the morbidity and mortality of such toxic products early, he/she should initiate safety measurements to prevent public harm.

Role of Survival Time and Injury Severity in Fatal Pulmonary Fat Embolism.

Pulmonary fat embolism (PFE) is frequent in blunt trauma and may occasionally lead to death. A correlation between fracture grade and severity and PFE grade has been described before, but no correlation between PFE and survival time, fat crushing extent, fat crush grade, or number of body regions with fractures could be noted in this small study. To further examine this, we decided to examine the aforementioned points in a far larger study group.Autopsy protocols of 188 nonresuscitated fatalities with blunt trauma and without right heart injury, which underwent whole body dissection, were retrospectively reviewed concerning the presence and the severity of PFE, injuries, survival time, age, sex, and the body mass index.The fracture grade, the fracture severity, and the number of the fractured regions correlated very well with the grade of PFE, but the crushed regions, crush grade, and crush severity did not. We observed a time correlation between survival time and PFE only in the sense that very rapid deaths were often PFE negative. High-grade PFE was observed most often in patients having died less than 6 hours after the incident, and PFE grades of 2 or more were occasionally noted even after 48 hours.