Cannabis misinterpretation and misadventure in a coroner's court

Marijuana use and acute myocardial infarction: A systematic review of published cases in the literature

BACKGROUND AND OBJECTIVE

Marijuana use has gained popularity following legalization in the US. Marijuana can affect the heart through various mechanisms. This study aims to conduct a systematic review of published case reports of individuals with acute myocardial infarction (AMI) following marijuana use.

METHODS

We conducted a systematic review of literature, including case reports, case series, and the letter to the editor on MEDLINE. Forty-six studies were included, with a total number of 62 patients with AMI and marijuana use.

RESULTS

The mean age was 27.7 (±10.3) years with male predominance. About 3.7 g marijuana was used for an average of 9.7 years by the patients. From the cases reporting the onset of AMI symptoms, the average time was within 5 h after last marijuana use. The angiographic findings were normal in 36.8% of cases. In 42.1% of individuals, the left anterior descending coronary artery was occluded, making it the most common artery involved, followed by the right coronary artery (10.5%). Most cases were managed medically, followed by thrombectomy and stent placement, and percutaneous transluminal coronary angioplasty (PTCA). Complications included cardio-embolic stroke, and seven deaths were reported.

CONCLUSION

It is important to consider episodic marijuana use as a significant risk factor of AMI, particularly in individuals with no cardiac risk factors, as delay in management can result in fatal outcomes including increased risk of mortality.

The spectrum of expert reports on clinical biochemical toxicology and medicine from an Irish practice

The compounds which generated an expert opinion report in the area of medical toxicology in the period 1999 to 2015 are presented from the toxicological case files of a specialist in chemical pathology and general internal medicine. There were 132 different compounds from 86 cases. Alcohol was involved in 43%, drugs of abuse in 18.6%, volatile carbon compounds in 17.4%, metals in 9.3%, and carbon monoxide in 4.6%. Many compounds appeared once. The duty of the medical expert witness to provide an objective report for the court irrespective of the payer is stated. The addition of references from peer reviewed literature to substantiate the pros and cons of each case is recommended as a standard operating procedure in completing each report.

Coronary thrombosis and marijuana smoking: a case report and narrative review of the literature

We encountered evidence of myocardial infarction due to coronary thrombosis in an autopsy of an occasional marijuana smoker. These findings prompted us to perform a narrative review of the literature to determine when post-mortem toxicological tests may support a temporal relationship between marijuana smoking and cardiovascular disease. Toxicological examination showed the presence of Δ-9-tetrahydrocannabinol, its main metabolite and cannabinol in blood and urine. Quali-quantitative analysis revealed that Δ-9-tetrahydrocannabinol was taken within 2 h of the onset of cardiovascular symptoms, according to circumstantial data. Post-mortem toxicological results must take into account the degradation and post-mortem redistribution of analytes. However, for any inference about the specific cardiovascular triggering effect of Δ-9-tetrahydrocannabinol intake, we maintain that cannabinoid analysis in blood samples must be considered an essential requirement to estimate the time of last intake and avoid incomplete documentation. The literature, combined with the present case report, highlights an association between marijuana use and negative cardiovascular events, although few authors have supported their conclusions with toxicological results. Thus, additional research is needed.

Fault lines in forensic medical toxicology in Ireland exposed through replies of pathologists and coroners to anonymous questionnaires

The attitudes and experiences of pathologists and coroners to the provision of biochemical forensic toxicology in the Republic of Ireland were determined using separate questionnaires to each group anonymously. Replies were received from 36/88 (41%) of pathologists and 19/71 (27%) of coroners. 37% of coroners considered that histopathologists give an adequate opinion in forensic toxicology yet 58% of pathologists reported that they did not have adequate access to expert medical interpretative toxicological opinion. For drug-drug interactions and metabolic diseases, 69% of pathologists were unhappy with the processes and 68% of coroner replies did not know if vitreous samples were used appropriately. There is a clear requirement for retraining of coroners and for the appointment of medical toxicology expertise to improve the quality of service for coroners.

Proposing and developing a National Institute for Forensic Toxicology in Ireland - transformation through education

Toxicology for coroners is an important minority service whose quality is central to the validity and integrity of the death certification system. Multidisciplinary case conferences are routine practice in the major medical specialties. In conventional practice for the coroners’ courts, the dissecting pathologist is often relied upon to interpret toxicological data usually without specialist training. In Ireland the service is fragmented and there is at present no medically trained toxicologist directly involved in the direction or reporting of cases even where multiple drugs are found in blood at various levels and drug-drug interaction may be possible or likely. To encourage both medical professionals and political administration to confront the issues, the education literature on action research and critical incident methodology is reviewed to develop a strategy for change in this service. An example of action research being applied to medicine is used as an indicator that an action research template could be used to advocate for a new National Institute for Forensic Toxicology in Ireland. The main participant groups are identified and the development cycle outlined.