Toxicology Reports Research Articles

Opioid-Related Deaths in Eastern Ontario from 2011 to 2016.

There has been a growing opioid crisis in the United States and Canada. The aim of this study was to analyze trends in opioid-related deaths from the Eastern Ontario Regional Forensic Pathology Unit so that prevention strategies for these deaths can be developed. The analyses included examining the opioids involved and demographic characteristics of the individuals in these deaths so that possible risk factors for opioid-related deaths could be identified. A retrospective cross-sectional analysis of the full autopsy and toxicology data between 2011 and 2016 was conducted. Trends regarding the opioids involved in the death, all opioids reported in the toxicology reports and certain nonopioid drugs reported in the toxicology reports were examined. The distribution of opioid-related death by age-group and manner of death was also conducted. Two hundred seventy-four opioid-related deaths met the inclusion criteria and were examined. The majority of individuals overdosing were male. The most frequent age range for opioid-related deaths was 45 to 54 years with increasing deaths among individuals aged 55 years and older over the period studied. Fentanyl was responsible for most deaths overall when single or multiple opioids were involved. However, hydromorphone involvement was the only opioid to have a statistically significant increase over the time period. Analysis of nonopioid-related drugs revealed extensive use of antidepressants, benzodiazepines, and their metabolites. Accident was the most common manner of death throughout all age groups except for those aged 65 years or older, where suicide was most common.

Fatal overdoses involving carfentanil: A case series

Carfentanil, an ultrapotent analog of fentanyl, has invaded the street drug market, unbeknownst to many heroin users. About 10,000 times more potent than morphine, it was initially suspected that 20 μg of the substance was lethal. In this case series, we present 17 confirmed carfentanil overdoses in Michigan, with a primary focus on the concentration levels. Through a retrospective review, each public death reported in Oakland County, Michigan, with a subsequent toxicology report was investigated for suspected carfentanil use. To characterize each fatality, the autopsy results were collected, including the postmortem findings at scene and the decedent's medical and social history. Carfentanil levels were measured through liquid chromatography and tandem mass spectrometry (LC-MS-MS) by National Medical Services (NMS) Laboratories. Our case series found postmortem carfentanil concentrations as low as 10 ng/mL, with a mean concentration of 0.387 ng/mL. Ultimately, there are implications on law enforcement, first responders, and health care providers when dealing with this emerging illicit substance, and there is an alarmingly high mortality rate associated with the abuse of carfentanil.

Sudden Death in a Patient with Undiagnosed Diabetes, Acute Pancreatitis and Acute Adrenalitis

It has been well documented that acute pancreatitis and diabetic ketoacidosis (DKA) co-occur, and both of them present either as a cause or result of the other [1] [2]. Recently, hypertriglyceridemia has been reported to co-occur as well [3] [4]; the involvement of acute adrenalitis in the setting of acute pancreatitis and DKA has not been reported. We report a case of sudden death due to diabetic ketoacidosis, acute pancreatitis and acute adrenalitis in a 37-year-old female. She was found unresponsive and breathless in bed by her mother at their residence. At the time of the autopsy, both lungs were expanded and sigmoid diverticulosis was discovered on gross examination. Histology of the pancreas and the adrenal glands revealed acute inflammation despite appearing normal upon gross examination. The postmortem toxicology report showed high levels of acetone (12 mg/dL) in the postmortem blood and extremely high levels of glucose (>500 mg/dL) in the postmortem vitreous fluid. This is the first reported case of fatal diabetic ketoacidosis co-occurring with acute pancreatitis and acute adrenalitis.

Before the crash: A systematic analysis of police narratives to determine the prevalence of pre-crash factors in fatality road transport crashes

Objectives: The objectives of this study were to identify the prevalence of pre-crash factors that were present in fatal road transport crashes for the deceased and counterpart road user.Methods: The study is a retrospective population-based case series study of transport-related deaths reported to coroners in Australia from 2013 to 2016. Data was extracted from the National Coronial Information System.Results: In total, 6,137 fatality crashes occurred during the study period. Police reports were available for 5,523 crashes (89.9%). The most frequently reported pre-crash factors reported behaviour specifically drivers (e.g., driving without a license or while license was disqualified). Presence of intoxicating substances were also reported in the deceased and counterparts. Analyses of toxicology reports are continuing to determine if rates are comparable to level of use in community.Conclusions: Coronial report provide detailed information that may be pertinent to understanding and potentially preventing crashes. Also emerging from the data is the extent of pre-crash factors that relate to illegal or deviant behavior and whether these are contextual or contributory factors.

Tobacco and Substance Use among Psychiatric Inpatients in a Community Hospital: Cessation Counseling, Correlates, and Patterns of Use.

Background Epidemiological and experimental models have been applied to describe the disproportionately high prevalence of tobacco use in patients with mental illness. This observed association has become a dire public health concern. The main objective of the present study was to examine the provision of tobacco treatment strategies in a community teaching hospital serving a predominantly underserved African American population. Methods The study was designed as a retrospective review of eight hundred and thirty patients admitted to the inpatient psychiatric units. Results 52.2% of the entire cohort described themselves as current smokers. Gender, primary psychiatric diagnosis, and urine toxicology showed significant differences in the tobacco smoking and nontobacco smoking groups (P<0.05). Almost all current tobacco smokers (91.9%) had tobacco cessation counseling during the course of their hospitalization, but only 64% were offered treatments for tobacco dependence. More than half (57.9%) of the 680 participants who had urine toxicology reports were positive for any illicit substance with cannabis and cocaine being the most frequently used (32.4% and 23.2%). Direct logistic regression revealed gender, psychiatric diagnosis, and substance use as the only significant predictors of tobacco smoking among our cohort (P= 0.021, 0.001, and 0.001, respectively). Conclusions Tobacco screening, cessation counseling, and treatment continue to be a challenge in community psychiatric hospitals and need increased focus in the comprehensive management of patients with psychiatric disorders. The strong association between tobacco smoking and other substance use lends itself to the hypothesis that tobacco smoking debut prevention may be an effective public health strategy for addressing illicit drug use.

Spicing it up - synthetic cannabinoid receptor agonists and psychosis - a systematic review

Synthetic cannabinoid receptor agonists (SCRAs) are suggested to have increased potential to induce psychosis compared to natural cannabis (NC). In this review we synthesise current knowledge about the association of SCRA use with psychotic symptoms. Following a literature search we identified 2 toxicology reports, 4 case-control studies, 3 cross-sectional studies and 15 case reports. In each of the case reports, we identified the presence or absence of symptoms based on the items of the Postitive and Negative Syndrome Scele (PANSS). The toxicology reports highlighted the main presenting features as being toxic psychosis and delirium (40%), agitation (10%) and hallucinations (4–7%). The median age was 25 years, and around 80% cases were male. Cross-sectional studies reported that SCRA use was present in approximately 10–13% patients presenting to acute psychiatric services, and was often the cause of their presentation, and that psychotic symptoms were present in 15% patients attending emergency departments following SCRA use. Case-control studies reported that SCRA use was significantly associated with psychotic symptoms and that SCRA users had higher levels of positive psychotic symptoms than NC users. The case reports supported the association of SCRA use with a wide range of positive and negative psychotic symptoms as well as with self-harm, agitation and aggressive behaviour. SCRA use is relatively prevalent in patients with psychosis and may lead to psychotic symptoms in individuals with no past psychiatric history. Further work is required to understand the long term risks of SCRA use and optimal management strategies.

Abstract 335: Distinguishing Cardiac From Non-Cardiac Causes of Sudden Death: The Value of Novel Factors to Identify Risk of SCD

Introduction: Identifying those at risk for Sudden Cardiac Death (SCD) is imperative to prevent future events. There may be risk factors (RFs), triggers or warning symptoms preceding the SCD that could help identify those at greatest risk. Methods: This retrospective study included out-of-hospital cardiac arrests (OHCAs) of “no obvious cause” in the Greater Toronto Area, ages 2-45 from 2009-2012. Expert reviewers systematically adjudicated EMS, coroner, autopsy, toxicology and police reports to classify the etiology of arrest as SCD or SD due to non-cardiac etiologies (non-cardiac SDs). We compared past medical history, triggers and symptoms in the adjudicated SCD and non-cardiac SD groups and assessed their potential associations with SCD. Results: 872 OHCAs were classified as SCDs (488; 56%) or non-cardiac SDs (384; 44%). The SCDs were mostly CAD (203; 41.6%), structural (155; 31.8%), congenital (8; 1.6%) and primary arrhythmic (76; 15.6%). The non-cardiac SDs were due to acute infection (67; 17.4%), metabolic (75, 19.5%), epilepsy (69, 18.0%), vascular (106; 27.6%) and respiratory (35, 9.1%). Cardiac RFs and exercise as a trigger were observed significantly more in SCDs vs. non-cardiac SDs (Table 1). Symptoms ≤24 hours prior were similar between groups except for chest pain and diaphoresis. After adjusting for patient and resuscitation variables, factors associated with increased risk of SCD were: increasing age (OR 1.03; 95%CI 1.01-1.05), male sex (OR 1.90; 95%CI 1.30-2.70), HTN (OR 1.80; 95%CI 1.11-3.10), smoking (1.60; 95%CI 1.02-2.60), public location (OR 2.10; 95%CI 1.13-3.80), exercise (OR 3.0 95%CI 1.56-5.59) and chest pain ≤24 hours prior (OR 2.90 95%CI 1.30-6.42). Conclusion: Many young SCDs have previously diagnosed cardiac RFs and acute symptoms suggestive of ischemia prior to their event. These findings highlight the potential value of better public awareness in the younger age group for signs and symptoms of ischemia and potential risk for SCD.

THE SUPERINFECTION THAT’S A REAL HEADACHE

SESSION TITLE: Critical Care 1 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Legionnaires’ disease serves as one of the most ubiquitous causes of community-acquired pneumonia. We are reporting a rare case of influenza with a superinfection of Legionnaires disease presenting with altered mental status due to severe hyponatremia. CASE PRESENTATION: A 60-year-old woman with no significant medical history was brought to the ER by her sister after she was found on the ground. According to her sister, the patient had a right facial droop with dried blood in her nares and sub-conjunctival hemorrhage as well as an “unusual posturing” of her hands and feet. Prior to the event, she had been complaining of nausea and vomiting for the past two days for which she had been taking Alka-Seltzer and herbal teas. On physical examination, she remained unconscious with bilateral conjunctival swelling and injection but no nuchal rigidity or apparent head injury. Temperature was 99.7 F with heart rate of 70 bpm, blood pressure was elevated to 221/105 mmHg. She was intubated with subsequent improvement in BP. The initial laboratory results revealed hyponatremia with sodium of 109 mEq/L and elevated creatinine kinase level of 11108. Urine toxicology report was negative. CT imaging of head demonstrated cerebral edema with loss of the gray and white matter significant for global ischemia. After admission to the ICU for management of hyponatremia and cerebral edema, she was found to be influenza and legionella positive. She completed a course of Tamiflu and Levaquin and sodium was slowly corrected to 134mEq/L. She was extubated on hospital day 3, by day 6 she had complete restoration of mental status and strength and was discharged home. DISCUSSION: While the most common superinfections with influenza are S. pneumoniae, H. influenzae, and S. aureus, Legionella has been associated with influenza virus (1). There exists no particular set of clinical features that should raise suspicion for the disease as the presentations may differ. Legionella etiology of community acquired pneumonia serves as a strong predictor for low sodium level, independent of disease severity (2). Although previous studies suggested antidiuretic hormone-independent mechanisms such as direct renal effects of cytokines and toxins as the culprit, the mechanism still remains unknown. (3). However, since hyponatremia can cause a number of serious complications, such as coma and death, there still needs to be a careful management of those patients presenting as symptomatic hyponatremia. When dealt with the right management with correction of sodium level and appropriate antibiotics in a timely manner, one may expect a dramatic improvement in patients’ physical and mental status. CONCLUSIONS: Even though the extent of hyponatremia in patients with Legionella pneumonia may not correlate with the severity of the disease, hyponatremia in itself can lead to dangerous outcomes and suspicion for legionella infection should be high. Reference #1: Morris DE, Cleary DW, Clarke SC. Secondary Bacterial Infections Associated with Influenza Pandemics. Frontiers in Microbiology. 2017;8:1041. https://doi.org/10.3389/fmicb.2017.01041. Reference #2: Yu, Victor L. Legionnaires' Disease: Importance of High Index of Suspicion in Patients in the ICU with Community-Acquired Pneumonia. CHEST. 2014;145:2. DOI: https://doi.org/10.1378/chest.13-2170 Reference #3: Schuetz P, Haubitz S, Christ-Crain M, Albrich WC, Zimmerli W, Mueller B. Hyponatremia and anti-diuretic hormone in Legionnaires’ disease. BMC Infectious Diseases. 2013;13:585. https://doi.org/10.1186/1471-2334-13-585. DISCLOSURES: No relevant relationships by Erica Altschul, source=Web Response No relevant relationships by Cyra-Yoonsun Kang, source=Web Response

Spatial Concentration of Opioid Overdose Deaths in Indianapolis: An Application of the Law of Crime Concentration at Place to a Public Health Epidemic

The law of crime concentration at place has become a criminological axiom and the foundation for one of the strongest evidence-based policing strategies to date. Using longitudinal data from three sources, emergency medical service calls, death toxicology reports from the Marion County (Indiana) Coroner’s Office, and police crime data, we provide four unique contributions to this literature. First, this study provides the first spatial concentration estimation of opioid-related deaths. Second, our findings support the spatial concentration of opioid deaths and the feasibility of this approach for public health incidents often outside the purview of traditional policing. Third, we find that opioid overdose death hot spots spatially overlap with areas of concentrated violence. Finally, we apply a recent method, corrected Gini coefficient, to best specify low- N incident concentrations and propose a novel method for improving upon a shortcoming of this approach. Implications for research and interventions are discussed.

Poussée tensionnelle et toxidrome anticholinergique secondaire à une consommation accidentelle de datura stramonium chez l’enfant, à propos de 2 cas

ObjectiveTo identify a hypertensive clinical form of atropine or anticholinergic toxidrome secondary to accidental consumption of Datura seeds. Patients and methodsWe report two cases of Datura intoxication in two children who presented marked anticholinergic syndrome whose diagnosis was made by the anamnesis and the clinic. ResultPatient 1: A 5-year-old boy, returns home agitated with balance disorders. He was admitted to pediatric resuscitation unit. His Glasgow score was 11/15. The child made inconsistent remarks. The neurological examination revealed mydriasis. Hemodynamically, the blood pressure was 145/91mmHg, the heart rate was 145 bpm. The rest of the examination noted a temperature of 37.5°, a bladder globe. Standard biological tests were normal. ECG found sinus tachycardia. Urine analysis revealed a positive alkaloid reaction with the presence of atropine. The evolution was favorable after 48hours. Patient 2: 45-month-old boy admitted to a state of severe agitation of toxic origin. The clinical examination showed a central and peripheral anticholinergic symptomatology with severe hallucinations, severe hypertension, and a heart rate at 190 bpm. The rest of the examination found erythema in the thorax and upper limbs, bilateral mydriasis. The toxicological report confirmed the presence of alkaloids. The evolution was favorable. ConclusionHypertension crisis and other anticholinergic clinical signs of Datura stramonium intoxication achieve favorable outcomes in children.

Substance-exposed newborn infants and public health law: Differences in addressing the legal mandate to report

Prenatal exposure to illicit substances is a finding that typically requires reporting to a child protective services agency. We examine whether there is differential reporting to two public agencies, and whether it varies by race/ethnicity and region. We also study predictors of indicating a maltreatment report as credible. Data on positive neonatal toxicology reports were obtained from the Illinois Department of Public Health (IDPH) and the Illinois Department of Children and Family Services (DCFS). Variation in reporting rates by race/ethnicity and region were compared with Pearson chi-square analysis. Multivariate logistic regression examined factors related to the likelihood of DCFS indicating a report as credible for maltreatment. IDPH recorded 1838 reports of substance-exposed newborn infants while DCFS only recorded 459 reports. There was a greater percentage of whites than blacks reported to DCFS as compared to those reported to IDPH (p < 0.001). There was a greater percentage of whites than blacks found to be indicated by DCFS as compared to those reported to IDPH (p < 0.001). Infants reported in rural areas were indicated less often (OR:0.34, 95% CI:0.17–0.67, p = 0.002) than those from urban areas. In conclusion, there was variation in reporting patterns between the two agencies. To optimize health outcomes for substance-exposed newborn infants (SEIs), the law should be clarified to provide clear standards for reporting and managing SEIs. Clinicians should ensure they are acting within the confines of existing law, and should engage in an interprofessional process with a broad array of stakeholders to develop statewide drug testing and reporting protocols.

Suicide deaths by intentional self-poisoning in people with cardiovascular disease.

We aimed to characterize self-poisoning deaths in people with cardiovascular disease (CVD) and compare to other suicide decedent groups. Suicide deaths by self-poisoning in people with CVD (n = 151) were compared to suicide deaths by other methods in people with CVD (n = 260) and suicide deaths by self-poisoning in people without CVD (n = 509). Sub-analysis of the CVD self-poisoning group compared people with depression and without depression. Toxicology reports were compared between intentional self-poisoning groups. A higher proportion of suicide deaths were due to self-poisoning in the CVD group compared to the non-CVD group. People with CVD were less likely to have any identified stressor (excluding medical stressor) prior to dying from self-poisoning compared to those without CVD. Female sex, past suicide attempts, living circumstances, and comorbid substance abuse were each significantly associated with self-poisoning as the method of suicide in people with CVD. Opioid, any antidepressants, benzodiazepines, and tricyclic antidepressants (TCAs) were commonly identified as lethal in people with CVD. Compared to people in the CVD self-poisoning without depression group, people in the CVD self-poisoning with depression group were more likely to have lethal levels of TCAs. Our findings characterize suicide deaths in people with CVD, and identified notable differences based on method of death and presence of depression.

Older women who died by suicide: suicide means, sociodemographic and psychiatric risk factors, and other precipitating circumstances.

Data are from the 2005 to 2015 US National Violent Death Reporting System (N = 12,401 female decedents aged 50 years and over). We used three logistic regression models, with overdose versus firearms, overdose versus hanging/suffocation, and overdose versus "other" means as the dependent variables, to examine associations between suicide means and sociodemographic and risk/precipitating factors. χ2 tests were used to examine positive toxicology of prescription and illicit drugs by suicide means. Compared to firearm users, overdose users were younger and had higher odds of having had previous suicide attempts/intent disclosures, mental disorders (e.g. depression/dysthymia: AOR = 1.18, 95% CI = 1.05-1.34), and substance abuse other than alcohol, but lower odds of having had relationship problems and any crisis. Compared to hanging/suffocation, overdose declined (AOR = 0.95, 95% CI = 0.93-0.97) during the study period and was less prevalent among Hispanic and Asian women and those with job/finance/housing problems. Toxicology reports showed that 47%, 43%, and 45% of overdose users were antidepressant, opiate, and benzodiazepine positive, respectively. Firearm users had the lowest rates of positive toxicology results for these drugs. Suicide prevention should include limiting access to large quantities of prescription medications and firearms for those at risk of suicide. More effective mental health/substance abuse treatment and chronic illness management support are also needed.

Nutritional analysis of Spirulina dietary supplements: Optimization procedure of ultrasound-assisted digestion for multielemental determination

Arthrospira platensis and Arthrospira maxima are a type of blue-green microalga used as a dietary supplement (Spirulina). A low time-consuming ultrasound-assisted digestion (UAD) of Spirulina supplements for multielemental determination by microwave induced plasma atomic emission spectrometry (MPAES) was performed. Several parameters such as acid concentration (AC), thermostated water bath (TWB), digestion time (DT) and UAD – probe or bath – affecting the digestion process were evaluated through a full factorial design. Under the optimal conditions −100 °C for TWB, 5% for AC and 10 min for DT- and selecting the bath as the proper UAD system, the concentrations of 15 analytes (Al, Ba, Ca, Cd, Cr, Cu, Fe, K, Mg, Mn, Na, Ni, P, V, Zn) were reported. The values are in accordance with the recommendation established by Food and Drug Administration (FDA) excepting for Cd. The knowledge of Spirulina multielemental composition contributes to an outstanding nutritional and toxicological report for human health.

Using medical examiner case narratives to improve opioid overdose surveillance

BackgroundCurrent opioid overdose mortality surveillance methods do not capture the complexity of the overdose epidemic. Most rely on death certificates, which may underestimate both opioid analgesic and heroin deaths. Categorizing deaths using other characteristics from the death record including route of drug administration may provide useful information to design and evaluate overdose prevention interventions. MethodsWe reviewed California Electronic Death Reporting System records and San Francisco Office of the Chief Medical Examiner (OCME) toxicology reports and investigative case narratives for all unintentional opioid overdose deaths in San Francisco County from 2006 to 2012. We chose this time period because it encompassed a period of evolution in local opioid use patterns and expansion of overdose prevention efforts. We created a classification system for heroin-related and injection-related opioid overdose deaths and compared demographic, death scene, and toxicology characteristics among these groups. ResultsWe identified 816 unintentional opioid overdose deaths. One hundred fifty-two (19%) were standard heroin deaths, as designated by the OCME or by the presence of 6–monoacetylmorphine. An “expanded” classification for heroin deaths incorporating information from toxicology reports and case narratives added 20 additional heroin deaths (13% increase), accounting for 21% of all opioid deaths. Two hundred five deaths (25%) were injection-related, 60% of which were attributed to heroin. A combined classification of expanded heroin and injection-related deaths accounted for 31% of opioid overdose deaths during this period. ConclusionsUsing additional sources of information to classify opioid overdose cases resulted in a modest increase in the count of heroin overdose deaths but identified a substantial number of non-heroin injection-related opioid analgesic deaths. Including the route of administration in the characterization of opioid overdose deaths can identify meaningful subgroups of opioid users to enhance surveillance efforts and inform targeted public health programming including overdose prevention programs.

Patients with chronic pain on opioid therapy taking dronabinol: Incidence of false negatives using radioimmunoassay

Serum blood toxicology screens are believed to be important to monitor compliance and to identify levels of illicit substances in patients taking opioids for their chronic pain. In this study, the authors examine the incidence of tetrahydrocannabinol (THC) in consecutive blood samples of patients given dronabinol. We assessed the incidence of THC in 27 patients who participated in a single-dose, double-blind crossover trial of dronabinol (Marinol capsules), a synthetic Delta9-THC, as part of a larger study, to determine the reliability of the toxicology screening. Subjects were randomly administered 10 mg or 20 mg of dronabinol or placebo over the course of three 8-hour visits for a combined 228 serum blood samples. Levels of THC were quantified using radioimmunoassay. The majority of the samples (57.4 percent) showed presence of study drug as expected. However, 43 samples (42.6 percent) showed no detectable evidence of THC 4 and 8 hours after administration of dronabinol. Five subjects showed lower serum levels on the higher dose (20 mg) than on the lower dose (10 mg) after 4 hours, and two subjects showed lower levels with the higher dose after 8 hours. One subject had no detectable THC on any dose of dronabinol. These toxicology reports point to higher than anticipatedfalse-negative results with radioimmunoassay blood serum screening. Results could be explained by the lower sensitivity of this screening technique and also in how oral cannabinoids are metabolized. Further investigations are needed on the accuracy of the detection of THC among patients known to have used dronabinol.

Expected and actual fentanyl exposure among persons seeking opioid withdrawal management

ObjectiveFentanyl-contaminated opioid supplies have led to rising overdose fatalities in recent years. We compared beliefs, behaviors, and risk perceptions related to fentanyl with actual toxicology reports among people who used opioids. MethodParticipants (n=231) were patients undergoing short-term inpatient opioid withdrawal management in Fall River, Massachusetts. We compared persons testing positive and negative for fentanyl on urine toxicological testing at program entry. ResultsNearly all (95.7%) participants believed that fentanyl increases risk for overdose/death, and 86.6% of participants tested positive for fentanyl. Positive fentanyl toxicology test results were associated with lower educational attainment, history of injection drug use, and self-reported lifetime use of fentanyl. Of those reporting they had never been exposed to fentanyl (intentionally or unintentionally) (n=33), two-thirds tested positive for fentanyl; among those believing their tests would be negative (n=49), 71.4% tested positive for fentanyl. Heroin use was associated with fentanyl exposure; persons who reported past month heroin use (n=213) were more likely to test positive for fentanyl (91.1%) than persons using non-heroin opioids (n=18; 33.3%). ConclusionsNearly nine in ten participants tested positive for fentanyl, including participants who anticipated their tests would be negative. Leveraging toxicology results in opioid withdrawal settings may be helpful in educating patients about fentanyl exposure and risks.

An analysis of international traveller deaths at the Cliffs of Moher in Ireland, 1993-2017.

Traumatic deaths, and more particularly suicides, during international travel receive a disproportionately low level of attention in the travel medicine literature. We describe the demographic profile of international travellers whose death occurred at the Cliffs of Moher along the Atlantic seaboard in Ireland. Coroners' files for the 25 years between 1993 and 2017 were interrogated. All cases of death on or at the cliffs were examined, and demographic data were extracted, including date of death, gender, age, nationality, whether the victims were alone at the cliffs prior to their death, whether the fall was witnessed, prevailing weather conditions, post-mortem examinations, toxicology reports and inquest verdicts. Overall, 66 deaths occurred on or at the base of the Cliffs of Moher during the period 1993 through August 2017. In total, 18 (27.3%) of the victims were international visitors to Ireland, including 11 males (61.1%). The mean age of travellers (n = 17) was 34.2 years. Victims were nationals of 12 different countries, with 13 being European nationals. Most deaths occurred in summer (n = 7) or spring (n = 6), with eight deaths (44%) reported at weekends. In total, 15 victims (83.3%) had walked along the cliff path alone. A jump or fall from the cliffs was witnessed in only two cases (11.1%). Post-mortem examinations revealed multiple traumatic injuries consistent with a fall from a height. Four cases had evidence of alcohol intoxication. Suicide or open verdicts were returned in 50% (n = 9) of the cases. Travelling alone to the site, purchasing one-way tickets, or depositing belongings on the clifftop support the possibility of suicidal intent, while being intoxicated could be a co-factor in suicidal jumps or support the possibility of an accidental fall. This knowledge could help to identify travellers at the greatest risk of death at cliffs.

Clarification and lessons learned for reporting studies with hydrates. Citation: Roberts et al., 2016. Toxicology Reports 3: 531-538.

Clarification and lessons learned for reporting studies with hydrates. Citation: Roberts et al., 2016. Toxicology Reports 3: 531-538.

Alcohol use by suicide victims in the city of Sao Paulo, Brazil, 2011–2015

Excessive alcohol consumption is a serious public health issue, because drunkenness affects critical judgment and self-control which could trigger violent and self-harm behavior, with thus a potential association between alcohol consumption and suicide deaths. The objective of the present study was to assess the association between alcohol consumption and suicide deaths in the city of Sao Paulo, Brazil, from 2011 to 2015, and its relationship with socio-demographic characteristics of the victims and the circumstances of the suicide. A cross-sectional retrospective study was conducted by collection of data from 1,700 suicide victims subjected to examination of blood alcohol concentration (BAC) from toxicology reports from the Institute of Legal Medicine of the State of Sao Paulo, Brazil. Alcohol was detected in blood samples of 30.2% of the victims and mean BAC levels were 1.73 ± 0.08 g/L. The mean age of the victims was 39.90 ± 0.75 years. The majority of the victims were male (74.6%) and the prevalence of positive BAC was higher amongst men (34.7%) than women (17.1%), p<0.05. The majority of the victims were white skinned (64.7%), but there was a higher proportion of victims with positive BAC among mulatto and black individuals, p<0.05. Hanging was the most prevalent suicide method in the sample (48.7%) and amongst men (55.4%), but amongst women it was jumping from a height (35%), p < 0.05.