Trends in MDMA-related mortality across four countries

AIMS

To determine trends in 3,4 methylenedioxymethamphetamine (MDMA)-related death rates across Australia, Finland, Portugal and Turkey and to analyse the toxicology and causes of death across countries.

DESIGN

Analysis of MDMA-related deaths extracted from a national coronial database in Australia (2001-19) and national forensic toxicology databases in Finland (2001-17), Portugal (2008-19) and Turkey (2007-17). Presentation of MDMA use and seizure data (market indicators).

SETTING

Australia, Finland, Portugal and Turkey.

CASES

All deaths in which MDMA was considered by the forensic pathologist to be contributory to death.

MEASUREMENTS

Information collected on cause and circumstances of death, demographics and toxicology.

FINDINGS

A total of 1400 MDMA-related deaths were identified in Turkey, 507 in Australia, 100 in Finland and 45 in Portugal. The median age ranged from 24 to 27.5 years, and males represented between 81 and 94% of the deaths across countries. Standardized mortality rates significantly increased across all four countries from 2011 to 2017 during a period of increased purity and availability of MDMA. The underlying cause of death was predominantly due to drug toxicity in Australia (n = 309, 61%), Finland (n = 70, 70%) and Turkey (n = 840, 60%) and other causes in Portugal (n = 25, 56%). Minorities of all deaths across the countries were due to MDMA toxicity alone (13-25%). These deaths had a significantly higher blood MDMA concentration than multiple drug toxicity deaths in Australia, Finland and Turkey. Drugs other than MDMA commonly detected were stimulants (including cocaine, amphetamine and methamphetamine) (Australia 52% and Finland 61%) and alcohol (Australia 46% and Portugal 49%). In addition to MDMA toxicity, benzodiazepines (81%) and opioids (64%) were commonly identified in these deaths in Finland. In comparison, synthetic cannabinoids (15%) and cannabis (33%) were present in a minority of deaths in Turkey.

CONCLUSIONS

Deaths related to 3,4 methylenedioxymethamphetamine (MDMA) increased in Australia, Finland, Portugal and Turkey between 2011 and 2017. Findings show MDMA toxicity alone can be fatal, but multiple drug toxicity remains more prevalent.

Effect of clival bone growth on the localization of the abducens nerve at the petroclival region: a postmortem anatomical study

PURPOSE

To investigate the effect of the clival bone pattern on the abducens nerve (AN) localization in the petroclival region between the Pediatric and Adult Groups.

METHODS

This study used 12 pediatric and 17 adult heads obtained from the autopsy. The length and width of the clivus and the length of the petrosphenoidal ligaments (PSLs) were measured. The ratio of the length and width of the clivus was accepted as the clival index (CI). The localization of the AN at the petroclival region below the PSL, classified as lateral and medial, were recorded.

RESULTS

The average length of the clivus was 26.92 ± 2.88 mm in the Pediatric Group, and 40.66 ± 4.17 mm in the Adult Group (p < 0.001). The average width of the clivus was 22.35 ± 2.88 mm in the Pediatric Group, and 29.96 ± 3.86 mm in the Adult Group (p < 0.001). The average value of the CI was 1.20 in the Pediatric Group and 1.36 in the Adult Group (p = 0.003). The length of the PSL was 7.0 ± 1.47 mm in the Pediatric Group and 11.05 ± 2.95 mm in the Adult Group (p < 0.001). The nerve was located below the medial side of the PSL in the Pediatric Group and below the lateral side in the Adult Group (p = 0.002).

CONCLUSIONS

The petrous apex localization of the AN in adults compared with pediatric subjects could be related to the increased growth in the length of the clivus than its width.

Evaluation of fatal diving accidents in Turkey

In any kind of diving there is a risk of accidents, as the move from the topside environment to underwater can affect a diver’s physiological and psychological condition. It is important to investigate dive accidents to clarify the causative factors and determine preventive measures. In this study, autopsy files of fatal dive accident cases were reviewed to evaluate demographic data, type of diving, purpose of dive, seasonal distribution, autopsy findings, and causes of death. We reviewed 56 fatal dive accident files from autopsy units in cities where dive activities are concentrated and from the archive of the Turkish Underwater Federation. Four cases were excluded from the study since we were unable to obtain autopsy reports. Of 52 cases there were 20 scuba divers, two surface-supplied divers and 30 breath-hold divers. The majority of cases involved males (94%). The average age of 50 cases was 38.6; age estimation for two cases could not be determined due to advanced putrefaction. Of these fatal dive accidents 75% took place over a period of six months between May and October. Drowning was recorded as the primary cause of death in these cases. X-ray imaging was used in four (8%) cases. A special autopsy technique was used for nine (17%) cases, to detect possible pulmonary barotrauma and arterial gas embolism. The forensic specialist who is planning to conduct the autopsy for a dive fatality should have knowledge and experience about dive physics and physiology as well as physiopathology of dysbaric injuries.

Coincidence of Nicolau Syndrome and Rhabdomyolysis: Report of a Forensic Autopsy Case and Review of the Literature

Nicolau syndrome (NS) is a dermatological adverse reaction of intramuscular injections and is caused by several mechanisms. The etiopathogenesis remains unclear, and several hypotheses have suggested a vascular origin. Rhabdomyolysis (RM) is the destruction of striated muscle, with the subsequent release of muscle cell contents into circulation. NS and RM diagnoses may overlap. Herein, we present the autopsy findings of a 40-year-old female with NS complicated with RM. On clinical follow-up, creatine kinase (CK) was 7146 IU/L, and urea and creatinine levels were elevated on the third day after intramuscular diclofenac injection. Possible ischemic process triggered the RM and subsequent acute renal failure. The opportunity for an early diagnosis was missed because the patient delayed seeking medical aid. The prognosis worsened, and the patient died due to secondary sepsis. Early diagnosis of NS before the occurrence of complications is the most important issue in patient education and can be life-saving.

Spinal nerve root compositions of musculocutaneous nerve: an anatomical study

AIM

This study was aimed to investigate the variations in the spinal nerve root compositions of musculocutaneous nerve and to confirm which spinal nerve root is the main ingredient in participating amount.

MATERIAL AND METHODS

A total of 20 fresh cadavers were dissected. Brachial plexus and its branches were extracted. Musculocutaneous nerve stump was traced back to the roots to identify its fascicular origin. The number of fascicles originating from a particular nerve root and their axial location with in the nerve were noted.

RESULTS

The most frequent type of spinal nerve compositions of musculocutaneous nerve was C5, C6, and C7 with incidence of 60%. Musculocutaneous nerve had bundles from C5 root in all specimens, 90% of the specimens had contribution from C6 and only 70% of them had bundles from C7 root. There were a total of 46 (37.7%) bundles in C5 fascicles, 48 (39.3%) bundles in C6 fascicles, and 28 (22.9%) bundles in C7 fascicles.

CONCLUSIONS

In electrophysiological studies it should be remembered that C7 or C6 lesions may not impair musculocutaneous nerve functions. The success of musculocutaneous nerve neurotization may be improved if care is taken to ensure whether or not C7 root is contributing to the musculocutaneous nerve.

Microsurgical anatomy of the cisternal anterior choroidal artery with special emphasis on the preoptic and postoptic subdivisions

Object

The object of this study was to delineate the microsurgical anatomy of the cisternal segment of the anterior choroidal artery (AChA). The authors also propose a new classification of this segment on the basis of its complicated course within the carotid and crural cisterns in relation to important neurovascular structures, and the site of origin, course, and areas of supply of perforating arteries.

Methods

Thirty cadaveric cerebral hemispheres injected with colored latex were dissected under surgical magnification to view the cisternal segment of the AChA and its perforators. Fiber dissections using the Klingler technique were performed in two additional latex injected hemispheres to follow the penetration points, courses, and terminal areas of supply of perforating branches that arise from the cisternal segment of the AChA.

Results

The cisternal segment of the AChA was divided into pre- and postoptic parts that meet at the artery's genu, the most medial extension point of the cisternal segment where the artery makes an abrupt turn after passing under the optic tract. The preoptic part of the AChA extended from its origin at the inferomedial side of the internal carotid artery to the artery's genu, which is commonly located just inferomedial to the initial part of the optic tract. The postoptic part coursed within the crural cistern and extended from the genu to the inferior choroidal point. The genu of the AChA was 8 mm medial to the artery's origin and was located medial to the optic tract in 13% of the hemispheres. The postoptic part was longer than the preoptic part in all hemispheres and had more perforating arteries supplying critical deep structures (preoptic 3.4 per hemisphere vs postoptic 4.6 per hemisphere), and these results were statistically significant (p = 0.01). At the preoptic part, perforating arteries arose from the superolateral portion of the artery and coursed laterally; at the postoptic part, perforators arose from the inferomedial portion of the artery and coursed medially. Perforating arteries from both segments passed most commonly to the optic tract, followed by the anterior segment and apex of uncus in the preoptic part and the cerebral peduncle in the postoptic part.

Conclusions

Both parts of the cisternal segment of the AChA come into surgical view during surgeries for different pathologies in and around the perimesencephalic cisterns. However, attending to the artery's genu and defining pre- and postoptic parts during surgery may help the surgeon locate the origin and eventual course of these perforators, and even estimate the terminal areas of supply of most of the perforating arteries. The proposed classification system can prove helpful in planning any operative procedure along the crural cistern and may reduce the probability of inadvertent injury to perforating branches of the cisternal segment.

Microsurgical anatomy of membranous layers of the pituitary gland and the expression of extracellular matrix collagenous proteins

BACKGROUND

There are several reports about the microanatomical and histological features of sellar and parasellar membranous structures and clinical studies about MMP proteinase as a predictive factor. However, studies on collagen contents of sellar and parasellar membranous structures are limited. We demonstrated the membranous structures surrounding the pituitary gland and defined extracellular matrix (ECM) collagenous proteins, collagen I-IV expression patterns of sellar and parasellar connective tissues.

METHODS

The study was carried out on ten fresh postmortem human bodies at the Forensic Medicine Institution. Cavernous sinuses were resected with sellar structures and were stored at -80°C liquid nitrogen tanks. Medial wall of the cavernous sinus, pituitary capsule and pituitary tissue samples were obtained for RT-PCR. Opposite side specimens were used for histological and immune staining studies. Collagens I-IV were studied by immunohistochemical and reverse transcription polymerase chain reaction (RT-PCR) methods.

FINDINGS

The pituitary capsule and medial wall were identified as two different structures. The fibrous membrane, as the third membrane, was identified as staying whole in eight of ten specimens. Increased type IV collagen was determined in the pituitary gland, medial wall and pituitary capsule, respectively, in both RT-PCR and immunhistochemical studies. Immunhistochemical studies revealed that collagen I was strongly expressed in both the medial wall and pituitary gland.

CONCLUSION

Increased type IV collagen was detected especially in pituitary tissue, the medial wall and the pituitary capsule by immune staining and RT-PCR. Type IV collagen was considered to be an important factor in the progression of adenoma and invasion.

Microsurgical and endoscopic anatomy of Liliequist's membrane and the prepontine membranes: cadaveric study and clinical implications

BACKGROUND

Liliequist's membrane is mostly described as having a diencephalic leaf, mesencephalic leaf, and diencephalic-mesencephalic leaves in the literature. Also different descriptions of the prepontine membranes were reported. In this study, we visualized the regular structural forms of membranes without disturbing any attachments and defined infrachiasmatic and prepontine safety zones. We discussed the clinical significance of these structures.

MATERIALS AND METHODS

The study was carried out on 24 adult human cadavers at the Morgue Specialization Department of the Forensic Medicine Institution following the initial autopsy examination. Liliequist's membrane and the prepontine membranes were explored after retraction of the frontal lobes. Dissections were performed under the operative microscope. A 0- and 30-degree, 2.7-mm angled rigid endoscope (Aesculap, Tuttlingen, Germany) was advanced through the prepontine cistern from the natural holes of membranes, or small holes were opened without damaging the surrounding structures.

RESULTS

The basal arachnoid membrane (BAM) continued as Liliequist's membrane (LM) without any distinct separation in all specimens. The LM coursed over the posterior clinoids and split into two leaves as the diencephalic leaf (DL) and mesencephalic leaf (ML) in 18 specimens; the medial pontomesencephalic membrane (MPMM) coursed anterolaterally as a continuation of the ML and attached to the medial surfaces of the fifth and sixth nerves, joining with the lateral pontomesencephalic membrane (LPMM), which was also a posterolateral continuation of the ML in all specimens. The medial pontomedullar membrane (MPMdM) and lateral pontomedullar membrane (LPMdM) were observed in 21 specimens. The MPMdM membrane was a continuation of the MPMM, and the LPMdM was a continuation of the LPMM in all 21 specimens.

CONCLUSION

We observed that the LM is a borderless continuation of the BAM. The MPMM and LPMM split from the ML without any interruptions. The MPMdM and LPMdM were a single membrane continuing from the MPMM and LPMM. We determined infrachiasmatic and prepontine areas that can be important for inferior surgical approaches.

Review of complications due to foramen ovale puncture

We aim to evaluate the mechanisms responsible for complications during trigeminal rhizotomy via foramen ovale puncture. Ten dry skulls and 10 skull-base specimens were investigated in the present study. In cadaveric skull-base specimens, the anatomical relationships between the foramen ovale, mandibular nerve and Gasserian ganglion and the surrounding neurovascular structures were investigated intradurally. The distance between the foramen ovale and Gasserian ganglion was measured as 6 mm. The abducent nerve, adjacent to the anterior tail of the petrolingual ligament, was observed passing along the lateral wall of the cavernous sinus. Advancement of the catheter more than 10 mm from the foramen ovale is likely to damage the internal carotid artery and the abducent nerve at the medial side of the petrolingual ligament. Thermocoagulation of the lateral wall of the cavernous sinus may damage the cranial nerves by heat, giving rise to pareses.

A quick-solidifying, coloured silicone mixture for injecting into brains for autopsy: technical report

The injection of cadaver brains is invaluable for anatomic study, but cadavers that have been properly handled are not easy to obtain. A large number of cadavers pass through forensic departments around the world, and these cadavers could provide hundreds of research specimens, though they remain in the forensic unit for only a short time. The injection of a silicone mixture that quickly solidifies during autopsy would provide greater numbers of fresh specimens for study. The authors describe a technique for injecting a self-curing silicone mixture that can be used on autopsy specimens in a forensic unit. This technique does not interfere with routine autopsy findings. We describe the preparation of the mixture and autopsy specimens, the injection process, and the method for removing injected brains from cadavers. The solidifying process took a 1-h duration in this injection method and was in accord with autopsy procedure. The arterial bed was satisfactorily filled, and even small perforating branches and pial anastomoses were well demonstrated. Injecting autopsy specimens with the quick-solidifying silicone mixture allows anatomical studies of specimens even from cadavers admitted to forensic departments for only a short time. This method can provide neurosurgery laboratories with sufficient numbers of specimens appropriate for various studies.

The incidence of the foramen thyroideum in Turkish population

This study was undertaken to investigate the incidence and characteristics of the foramen thyroideum (FT) in Turkish population. A total of 50 cadaver specimens were dissected which were a randomly selected sample of population from the criminal laboratory of the Republic of Turkey's Ministry of Justice (Istanbul). Larynges were dissected with a surgical SMZ 10 Nikon stereomicroscope. Six of the 50 specimens dissected had distinctly identifiable foramina with neurovascular component. One specimen had bilateral foramina, five specimens had unilateral foramina, and two had it in the left side, three in the right. One specimen had a double foramen in the left side. All of them were male and contained neurovascular components. Our data showed 12% incidence of FT in Turkish population.

Structural changes of smooth muscle in congenital ureteropelvic junction obstruction

BACKGROUND/PURPOSE

Ureteropelvic junction (UPJ) obstruction is the most common cause of congenital hydronephrosis. Previous studies have reported that the excess amount of collagen restricting mobility and resiliency of the UPJ is the result of an impaired collagen production by anomalous smooth muscle cells (SMCs). Our purpose was to evaluate the role of SMC differentiation in the pathogenesis of UPJ obstruction.

METHODS

Surgical specimens of UPJ from 21 patients (8 girls/13 boys) who were subjected to dismembered pyeloplasty were examined immunohistochemically using monoclonal antibodies against smooth muscle (SM) myosin heavy chain isoforms including SM1, SM2, and SMemb. The age ranged from 1 month to 13 years. Ureteropelvic walls taken from 14 forensic autopsy cases, with no urological abnormalities, served as age-matched control group.

RESULTS

The immunohistochemical expression of SM1 and SM2 in UPJ obstruction was significantly increased when compared with controls (P < .05). In contrast, there was no statistical difference of expression of SMemb.

CONCLUSION

Our findings supported the hypothesis that the primary anomaly in UPJ obstruction may be attributed to a malfunction of SMCs in the ureter.

The mechanism of injury of the abducens nerve in severe head trauma: a postmortem study

The aim of this study is to investigate the mechanism of injury of abducens nerve at petroclival region in severe head trauma. Twenty specimens provided from 10 autopsied cases due to severe head trauma were investigated macroscopically and histopathogically. The slices of the abducens nerve taken consecutively along its course at petroclival region were stained with Hematoxylline-Eosin and evaluated under light microscope. In addition, coexisting cervical injuries in these cases were assessed macroscopically. Edema and perineural hemorrhagia of abducens nerve were identified in all cases. Nerve injury was found more exaggerated at the sites of dural entry point and petrous apex than any other parts of the abducens nerve. Furthermore, microscopically, also remarkable perineural hemorrhage of the abducens nerve was observed at the site of its anastomoses with the sympathetic plexus on the lateral wall of the internal carotid artery (ICA). Abducens nerve is injured at the sites of dural entry point, petrous apex and lateral wall of the ICA, directly proportional with the severity of the trauma. This finding is also significant in verification of the severe head trauma.

Duplication of the abducens nerve at the petroclival region: an anatomic study

OBJECTIVE

During its course between the brainstem and the lateral rectus muscle, the abducens nerve usually travels forward as a single trunk, but it is not uncommon for the nerve to split into two branches. The objective of this study was to establish the incidence and the clinical importance of the duplication of the nerve.

METHODS

The study was performed on 100 sides of 50 autopsy materials. In 10 of 11 cases of duplicated abducens nerve, colored latex was injected into the common carotid arteries and the internal jugular veins. The remaining case was used for histological examination.

RESULTS

Four of 50 cases had duplicated abducens nerve bilaterally. In seven cases, the duplicated abducens nerve was unilateral. In 9 of these 15 specimens, the abducens nerve emerged from the brainstem as a single trunk, entered the subarachnoid space, split into two branches, merged again in the cavernous sinus, and innervated the lateral rectus muscle as a single trunk. In six specimens, conversely, the abducens nerve exited the pontomedullary sulcus as two separate radices but joined in the cavernous sinus to innervate the lateral rectus muscle. In 13 specimens, both branches of the nerve passed beneath the petrosphenoidal ligament. In two specimens, one of the branches passed under the ligament and the other passed over it. In one of these last two specimens, one branch passed over the petrosphenoidal ligament and the other through a bony canal formed by the petrous apex and the superolateral border of the clivus. In all of the specimens, both branches were wrapped by two layers: an inner layer made up of the arachnoid membrane and an outer layer composed of the dura during its course between their dural openings and the lateral wall of the cavernous segment of the internal carotid artery. This finding was also confirmed by histological examination in one specimen.

CONCLUSION

Double abducens nerve is not a rare variation. Keeping such variations in mind could spare us from injuring the VIth cranial nerve during cranial base operations and transvenous endovascular interventions.