Concentrations of opiates and psychotropic agents in polydrug overdoses: a surprising correlation between morphine and antidepressants

The relationship between postmortem concentrations of morphine and co-detected psychoactive drugs in fatal overdoses is examined. Morphine and other drugs were detected in 161 medicolegal autopsy cases. Subsets of these morphine-positive cases based on drug class were established, including opioids, antidepressants, ethanol, benzodiazepines, and "other." Each subset was split into high or low concentration groups based on median drug concentrations. Morphine concentrations of the [high] and [low] groups were compared, with no significant difference in morphine concentration identified in the opioid, ethanol, or benzodiazepine subsets. The "other" drug class was too heterogeneous for statistical assessment. Morphine concentrations did show a significant direct relationship (p = 0.01) with antidepressants, namely increased concentrations of antidepressant drugs are associated with an increased concentration of morphine. This trend probably remains even after excluding cocaine-positive cases. The unsuspected finding that postmortem concentrations of antidepressants positively correlate with morphine levels may be important in the treatment of depression in drug addicts.

Fatalities associated with fentanyl and co-administered cocaine or opiates

Fatalities associated with fentanyl hydrochloride are increasingly seen in Massachusetts. Between September 2005 and November 2006, 5009 medicolegal investigations associated 107 deaths with licit or illicit fentanyl use, along with a co-detection of an opiate/opioid or cocaine/benzoylecognine, or both. Deaths associated with illicit fentanyl use occur in younger people (39.4 vs. 61.5 years) with higher fentanyl (17.1 ng/mL vs. 4.4 ng/mL) and lower morphine (76.9 ng/mL vs. 284.2 ng/mL) postmortem blood concentrations, and more frequent cocaine co-intoxication (65% vs. 3%), than deaths associated with illicit fentanyl use. A wide range of postmortem blood concentrations of fentanyl was detected (trace-280 ng/mL), with a minimum concentration of 7 ng/mL of fentanyl strongly associated with illicit use of fentanyl in poly-drug cases. The most commonly detected opiates/opioids in illicit fentanyl users were: morphine (29%), oxycodone (14.5%), and methadone (14.5%). Ethanol, cannabinoids, diazepam, citalopram, and diphenhydramine were each detected in greater than 10% of the licit fentanyl cases. Most fentanyl abusers died at their own home and their deaths were most often classified as accidental. Mapping of primary residences of decedents revealed conspicuous clustering of the illicit fentanyl use cases, as opposed to the random pattern in licit use cases. Fentanyl misuse is a public health problem in Massachusetts.

EMR for Barrett's esophagus-related superficial neoplasms offers better diagnostic reproducibility than mucosal biopsy

BACKGROUND

EMR of Barrett's esophagus (BE)-related superficial neoplasms represents an efficacious staging modality. It also allows for better pathologic grading compared with mucosal biopsy specimens. However, the interobserver variation in the interpretation of EMR specimens has not been tested.

OBJECTIVE

To evaluate consistency in the diagnosis of BE-related neoplasia on EMR specimens.

DESIGN

Nine pathologists reviewed 25 esophageal EMR specimens and corresponding biopsy specimens independently. Each pathologist classified the cases as either non-neoplastic BE, low-grade dysplasia, high-grade dysplasia, intramucosal adenocarcinoma, or invasive adenocarcinoma. Interobserver concordance for both specimens from EMRs and biopsies was measured by intraclass correlation and Kendall's coefficient of concordance. The proportion of agreement was also calculated for each specimen and compared for EMR and biopsy by using the Wilcoxon signed rank test.

SETTING

Teaching hospitals.

PATIENTS

Twenty-five patients who underwent EMR for BE-related neoplasia.

RESULTS

The intraclass correlation and the Kendall's coefficient for the 25 biopsy specimens was 0.938 (95% CI 0.880-0.965) and 0.677, respectively; for the 25 EMRs, these were significantly improved, at 0.977 (95% CI 0.957-0.987) and 0.831, respectively. In addition, the proportion of agreement for EMR specimens was significantly better compared with biopsy specimens (P = .015).

CONCLUSIONS

Interobserver agreement of BE-related neoplasia on EMR specimens is significantly higher compared with biopsy specimens. The results may relate to the larger tissue sampling compared with biopsy specimens and the ability to evaluate mucosal landmarks, such as double muscularis mucosae. Thus, we suggest that EMRs, in addition to being a staging and therapeutic procedure, improve diagnostic consistency.

Postmortem Urine Immunoassay Showing False-Positive Phencyclidine Reactivity in a Case of Fatal Tramadol Overdose

This is a report of postmortem false-positive reactivity using an enzyme-multiplied urine phencyclidine (PCP) immunoassay (EMIT II+) due to a single-agent fatal tramadol overdose. An autopsy of a 42-year-old male who died alone at home revealed no identifiable lethal anatomic abnormalities, thus leading to toxicologic analysis. Femoral blood was obtained for drug testing by high-performance liquid chromatography (HPLC) and showed a tramadol level of 14.0 mg/L, 2 orders of magnitude greater than the therapeutic range (0.1 to 0.3 mg/L). Urine was also obtained and EMIT II+ immunoassay revealed positivity for PCP at 88 mAU/min. However, confirmatory testing by HPLC failed to identify PCP in either the urine or serum. To verify the suspicion that this was a false-positive PCP result, stock solutions of tramadol and its major metabolite (O-desmethyltramadol) at concentrations of 100 mg/L in 10% methanol/H2O were compared with a blank solution (10% methanol/H2O) for EMIT II+ PCP reactivity and demonstrated reactivities of 44 mAU/min and 27 mAU/min, respectively. While these individual results were below the cutoff reactivity for a positive EMIT II+ PCP result (ca. 85 mAU/min), they were much more reactive than the blank calibrator (set at 0 mAU/min). Therefore, we conclude that the immunoreactivity of tramadol and its metabolites in aggregate is responsible for the PCP immunoassay interference and false-positive result.

Resident physician opinions on autopsy importance and procurement

The national decline in hospital autopsy cases negatively impacts physician education and medical quality control to an unknown degree. The current non-medicolegal autopsy rate is less than 5% of hospital deaths. This study compares internal medicine and pathology resident physician perceptions of the autopsy, including the importance, procurement, technique, and the pathologist-internist interaction. An 84-item survey based on autopsy literature was designed, piloted, and distributed to 214 residents at a single 800+ bed tertiary care academic teaching hospital (Massachusetts General Hospital, Boston) to accomplish this goal. Completed surveys were obtained from 72% of medicine (n = 118) and 84% of pathology (n = 42) residents. Residents strongly agree on the importance of autopsies for education, answering clinical questions, public health, and research. Autopsy rates are deemed inadequate. Internists are comfortable requesting autopsies, but report insufficient guidance and difficulty with answering technical questions. Although not requested on all hospital deaths, internists are more likely to initiate an autopsy request than a decedent's family, and worry significantly less about institutional costs and malpractice litigation than pathologists believe. Internists expressed interest in having an instructional brochure to give families, observing an autopsy, and having increased communication and support with autopsies from pathology residents. The main reasons why autopsy consent is not requested (it is unpleasant, cause of death is known, family is upset or seems unwilling) and why families refuse (patient has suffered enough, body may be handled disrespectfully, religious/moral objections, lack information) were similar for both resident groups. Despite their decline, autopsies still remain important to medicine as indicated by internal medicine and pathology residents at a large academic center. Improving autopsy education, enhancing availability of resources, and strengthening the pathologist-internist collaboration may serve to heighten awareness and ultimately procurement.

Endoscopic mucosal resection: an improved diagnostic procedure for early gastroesophageal epithelial neoplasms

Endoscopic mucosal resection (EMR), which is advocated for the treatment of early (superficial) gastroesophageal neoplasms, has also been alluded to represent a superior diagnostic and staging modality. We compared the diagnostic concordance of preceding biopsies with EMR specimens in 31 gastric and 10 esophageal EMRs consisting of 6 low-grade and 12 high-grade dysplasias, 21 intramucosal adenocarcinomas, and 2 submucosal invasive adenocarcinomas. Discrepancies were considered as either major or minor if the histologic grades differed by 2 or more, or by only 1, respectively. Discrepant and concordant cases were compared with regard to the size of lesion (maximum dimension and surface area), number of biopsy fragments, and extent of biopsy sampling (ratio between lesion size and number of biopsy fragments). These same variables were used to evaluate the differences seen between gastric and esophageal cases. Of the 41 cases, 16 (39%) had discrepant diagnoses, including 14 gastric and 2 esophageal neoplasms. A major discrepancy was seen in 2% of the cases (n = 1, gastric) and a minor discrepancy, in 15 cases. All but 2 of the discrepant cases were found to have a higher grade on EMR. The average number of biopsy fragments was 4.4 in both concordant and discrepant groups. The maximal dimension, surface area, and biopsy sampling ratios of the lesion were significantly greater in the discrepant cases than in the concordant cases. The esophageal cases trended toward having smaller size and a significantly extensive biopsy sampling. We conclude that EMR is superior to biopsy for diagnosing superficial gastroesophageal tumors. Discrepancies between the specimens occur in larger lesions (>10 mm) with less extensive biopsy sampling. EMR can substantially modify the diagnostic grade of a lesion and therefore facilitate optimal therapeutic decisions by avoiding undertreatment and overtreatment based on inaccurate grading and staging.

Aluminum welding fume-induced pneumoconiosis

Chronic exposure to high concentrations of fumes during aluminum arc welding causes a severe pneumoconiosis characterized by diffuse pulmonary accumulation of aluminum metal and a corresponding reduction in lung function. Aluminum fume-induced pneumoconiosis is a rarely reported entity, of which the true incidence is unknown. We report the clinical, radiographic, microscopic, and microanalytic results of 2 coworkers, employed by the same aluminum shipbuilding facility, who died of complications from this disease. Scanning electron microscopy and energy dispersive x-ray analysis of the exogenous particle content in the lung tissue of these cases revealed the highest concentrations of aluminum particles (average of 9.26 billion aluminum particles per cm(3) of lung tissue) among the 812 similar analyses in our pneumoconiosis database. One patient had an original clinical diagnosis of sarcoidosis but no evidence of granulomatous inflammation.

Comparison of effects of ATP-MgCl2 and adenosine-MgCl2 on renal function following ischemia

ATP-MgCl2 X administration had been shown to accelerate the recovery of renal function following warm ischemia. However, since the major breakdown product of ATP is adenosine, the relative contribution of ATP vs. adenosine in improving renal function following ischemia remains to be determined. To study this, kidneys were subjected to 45 min of normothermic ischemia and then perfused at 100 mmHg with oxygenated Krebs-HCO3 buffer containing albumin, [3H]inulin, substrates, and either 0.3 mM ATP-MgCl2 or adenosine-MgCl2 for 110 min. Perfusate and timed urine samples were collected and analyzed for radioactivity and [Na+]. The functional parameters indicated that although adenosine-MgCl2 treatment provided a transient improvement, it failed to provide a sustained improvement in renal function or attain control values compared with ATP-MgCl2 treatment. Thus, the salutary effects of ATP-MgCl2 following warm ischemia in the kidney are not mediated by adenosine.

Effects of ATP-MgCl2 and adenosine-MgCl2 administration on intracellular ATP levels in the kidney

The effects of exogenous administration of 1 mM [8-14C]ATP-MgCl2 and adenosine-MgCl2 on intracellular accumulation of adenine nucleotides were examined in isolated, perfused rat kidneys. The kidneys were made filtering or non-filtering by increasing the colloid oncotic pressure of the perfusate solution in order to assess the relative contributions of the glomerular and peritubular routes in the uptake of the nucleotides. The results indicate that: although labeled ATP is undetectable in the perfusate after 20 min, there is a significant accumulation of labeled ATP in the tissue and although labeled adenosine-MgCl2 administration also leads to labeled intracellular ATP, the total intracellular ATP is much less than with ATP-MgCl2 administration.

Reoxygenation injury in isolated hepatocytes: effect of extracellular ATP on cation homeostasis

The aims of this study were to determine 1) the effects of anoxia and reoxygenation on electrolytes and ATP content of isolated hepatocytes and 2) whether exogenous ATP-MgCl2 has any beneficial effects on the cellular alterations that are produced during the reoxygenation period. After 90 min anoxia, intracellular Na and inorganic phosphate (Pi) increased, K and ATP decreased, whereas Ca and Mg did not change. After 60 min of reoxygenation, intracellular Mg and Na levels decreased, Ca increased, and Pi levels returned to normal, but ATP levels remained low. These results suggest that the plasma membrane is relatively impermeable to divalent ions such as Ca2+, Mg2+, and HPO2-4 during anoxia but becomes permeable to them after reoxygenation. When anoxic cells were treated with ATP-MgCl2 during reoxygenation, intracellular ATP and Mg levels increased, but accumulation of Ca and Pi was also observed. Thus enhancement of Mg transport and specific stimulation of Ca-Pi sequestration occurs with ATP-MgCl2 treatment. Na and K levels exhibited biphasic reciprocal dose-response changes to ATP-MgCl2 treatment; i.e., 0.1 mM ATP-MgCl2 (low-dose) treatment increased K and decreased Na, whereas 1 mM ATP-MgCl2 (high-dose) treatment decreased K and increased Na. These results indicate that although addition of a single high-dose ATP-MgCl2 was deleterious over a period of 60 min, low-dose ATP-MgCl2 accelerates the recovery of postanoxic cellular electrolyte homeostasis.

The retrognathic mandible--surgical correction

The preceding case reports demonstrate the excellent results available to the patient with a retrognathic mandible. Etiology, adverse effects, and the modalities used in evaluation of the underdeveloped mandible have been discussed. The age at which surgical intervention is undertaken needs additional input by clinicians. Several surgical procedures have been and are employed to advance the mandible. The C osteotomy is recommended since the final result has been excellent and consistent. The surgeon has constant surgical control and vision. The advanced portion of the mandible can be firmly held by intraosseous wires. There is minimak disturbance of muscle position and the inferior alveolar nerve. We have not encountered unusual loss of blood, immediate postoperative problems with the airway, infection, or unfavorable relapse. A postoperative regimen that has been found rewarding is discussed. We have come to the conclusion that most patients can tolerate lengthy surgical procedures with few adverse side effects. Our colleagues in anesthesia and nursing provide superb operative and postoperative care. When the preoperative work-up indicates that more than one procedure is indicated, we recommend that the total surgical treatment plan be carried through at one operation, although occasionally this approach may be contraindicated. We should strive for perfection and can fall short of this goal when a patient will not return for additional surgical procedures which could have been accomplished during the first operation. Although good results have been experienced with both the C osteotomy and the sagittal split osteotomy, we believe that the C osteotomy is a superior procedure. However, this does not imply that the sagittal split osteotomy should not be a part of the armamentarium of the oral surgeon. In conclusion, the C osteotomy, the sagittal split osteotomy, genioplasty, and additional procedures--such as a mandibular alveolar osteotomy to intrude supraerupted teeth--when indicated, can provide very favorable results in cases of retrognathia or micrognathia of the mandible.