Ventricular fibrillation during football training as a consequence of kratom and caffeine use in an adolescent: case report.

Background: There is an increase in the sale of legal drugs in our country. One of these substances is kratom. Kratom (Mitragyna speciosa) is a partial agonist of the opioid kappa, mu, and delta receptors. It acts as a stimulant at low concentrations, making users feel more energetic and euphoric. It has sedative and antinociceptive effects at higher doses. Case summary: An 18-year-old man collapsed during football training and required cardiopulmonary resuscitation; the initial rhythm was ventricular fibrillation managed by defibrillation. Laboratory parameters were unremarkable. Blood samples sent for toxicological evaluation were positive for kratom and caffeine. Echocardiographic examination, coronary computed tomography angiography, and cardiac magnetic resonance imaging did not prove the cause. Genetic testing did not find a pathogenic gene variant associated with familial ventricular fibrillation, but a variant of unknown significance was found in MYOM1. Given this situation, we implanted an implantable cardioverter-defibrillator (ICD) from the secondary prevention of sudden cardiac death (SCD) according to the guidelines of the European Society of Cardiology (ESC). No recurrence of ventricular arrhythmia has been reported by ambulatory ICD memory checks on our patient. Discussion: In some country, kratom is freely available and sold as a plant, not a drug. Only incident cases of ventricular fibrillation after kratom use are described in the literature. There is insufficient scientific evidence linking kratom to ventricular fibrillation. This is an absolutely crucial case report of this type, which has not yet been published in similar circumstances in the world. Therefore, the development of ventricular fibrillation was assumed to be due to a combination of kratom, caffeine, and exercise. The safety profile and effects of kratom should be the subject of future research. We would like to stress the importance of reporting further case series for more scientific evidence and thus increasing the pressure for stricter availability and regulation of kratom in some countries, especially where it is over-the-counter.

Contribution of methamphetamine and insulin to the death of a woman suffering from type I diabetes - which played the greater role?

This report presents a fatal case of a young female Type I diabetic patient who developed convulsions and loss of consciousness after taking methamphetamine and spending some time in a dance club. During the convulsions, she was given sugar and when no response occurred, her boyfriend who was not experienced in the use of insulin administered a dose of insulin to her. The woman lost consciousness and died despite the efforts of the emergency service. A biochemical analysis revealed a high level of insulin (196.67 mU/L) and low levels of glucose (2.96 mmol/L) and C-peptide (26 pmol/L). Toxicological analysis revealed a methamphetamine concentration of 389 ng/mL and an amphetamine concentration of 19 ng/mL. The forensic perspective of the difficult determination of the contribution of each of the factors to the death, i.e., the pre-existing medical condition (Type I diabetes), the use of methamphetamine, the physical exertion at the dance club, and, finally, the non-indicated administration of insulin, is discussed. The ruling of the court is also reported.

Simulation of Orbital Fractures Using Experimental and Mathematical Approaches: A Pilot Study.

This contribution gives basic information about the mechanical behavior of the facial part of the human skull cranium, i.e., the splanchnocranium, associated with external loads and injuries caused mainly by brachial violence. The main areas suffering from such violence include the orbit, frontal, and zygomatic bones. In this paper, as a first approach, brachial violence was simulated via quasi-static compression laboratory tests, in which cadaveric skulls were subjected to a load in a testing machine, increasing till fractures occurred. The test skulls were also used for research into the dynamic behavior, in which experimental and numerical analyses were performed. A relatively high variability in forces inducing the fractures has been observed (143-1403 N). The results lay the basis for applications mainly in forensic science, surgery, and ophthalmology.

Determining the manner of death in victims in drug-induced psychosis: a case of an atypical head stab wound.

This case report presents a rare case of an atypical head stab wound suffered by a drug addict and inflicted with a screwdriver during drug-induced psychosis. It describes the diagnostic and treatment procedures in the hospital and the findings of the subsequent autopsy. It also analyzes the review of the interpretation of the CT scans made upon admission and the subsequent treatment by an independent medical review panel, which revealed signs of medical mismanagement. Therefore, it also discusses the legal consequences that the case may have involved for the attending physicians in addition to the consequences for the suspected perpetrator. The report raises many issues encountered in the case in terms of the clinical treatment and forensic determination of the manner of death in cases of injuries caused by sharp instruments and highlights the importance of comprehensive evaluation of the circumstantial evidence together with the clinical or autopsy findings, since such evidence may sometimes be overlooked in clinical practice.

Review of patterns in homicides by sharp force: one institution's experience.

This paper presents a retrospective review of patterns found in cases of homicides by sharp force over a 13-year period at the Department of Forensic Pathology of the Ostrava University Hospital, Czech Republic. The review summarizes all frequently discussed aspects of such cases including the number and localization of injuries, the presence of defensive wounds, the type of the offending weapon, the cause of death, the place of death, victims' and perpetrators' profiles, their relationship, or toxicological findings. Furthermore, special attention was paid to the evaluation of any accompanying blunt force trauma that may be indicative of an escalation of the assault. The set of data was statistically analyzed. Even though most of the results of this review are consistent with available published studies, noteworthy differences have emerged in some aspects such as the sex and age of the victims, the relationship between the number of injuries suffered and the victims' sex, or the severity of alcohol intoxication in victims.

Tension pneumopericardium in a polytrauma patient.

INTRODUCTION: Tension pneumopericardium is a life-threatening condition, manifesting most commonly as hemodynamic instability caused by cardiac tamponade. Reduced cardiac output and blood pressure can lead to difficulties in the detection of arterial bleeding from associated injuries while the increased venous pressure can increase the rate of bleeding. CASE REPORT: This is the case of a patient after a car accident, with bilateral serial fractures, bilateral pulmonary contusion, bilateral pneumothorax, emphysema of the neck and chest, pneumomediastinum and pneumopericardium, and other injuries. During treatment, the patient developed a gradually progressing hemodynamic instability, resulting in pulseless electrical activity. Further progression of the case is detailed in the paper. CONCLUSIONS: Tension pneumopericardium is a rare complication of a high-energy blunt thoracic trauma that manifests through hemodynamic instability. Its treatment requires early diagnosis and immediate decompression of the pericardial cavity, which should, where possible, be performed even before putting the patient on mechanical ventilation as ventilation bears a high risk of worsening the pneumopericardium due to the increased air pressure in the lungs. During diagnosis and treatment of associated injuries, we must bear in mind that the hemodynamic changes caused by pneumopericardium can mask typical signs of such injuries.

Indeterminacy of the Diagnosis of Sudden Infant Death Syndrome Leading to Problems with the Validity of Data.

The validity of infant mortality data is essential in assessing health care quality and in the setting of preventive measures. This study explores different diagnostic procedures used to determine the cause of death across forensic settings and thus the issue of the reduced validity of data. All records from three forensic medical departments that conducted autopsies on children aged 12 months or younger (n = 204) who died during the years 2007-2016 in Moravia were included. Differences in diagnostic procedures were found to be statistically significant. Each department works with a different set of risk factors and places different emphasis on different types of examination. The most significant differences could be observed in sudden infant death syndrome and suffocation diagnosis frequency. The validity of statistical data on the causes of infant mortality is thus significantly reduced. Therefore, the possibilities of public health and social policy interventions toward preventing sudden and unexpected infant death are extraordinarily complicated by this lack of data validity.

Toluene abuse as a contributing factor in a case of fatal autoerotic asphyxia.

Autoerotic asphyxia is a form of deviant sexual behavior that seeks sexual gratification by means of manipulation with one's own body resulting in asphyxia, and may sometimes turn out to be fatal. Autoerotic fatalities involving autoerotic asphyxia are divided into two groups: "typical" autoerotic fatalities involve mechanical compression of the neck, chest or abdomen, whereas "atypical" autoeroticism involves sexual self-stimulation by other means. Cases where asphyxiophilic behavior is accompanied by volatile substance abuse are reported to be rather rare, but may involve a high risk of fatal results. This paper presents a case of accidental "atypical" autoeroticism involving victim's abuse of toluene, which, combined with asphyxiophilic airway occlusion, led to death. For the sake of comprehensiveness, both a verbal description and a schematic representation of the major metabolic pathways of acute and chronic abuse metabolic markers is provided.

Role of orthoptics and scoring system for orbital floor blowout fracture: surgical or conservative treatment.

AIM: To assess the role of orthoptics in referring patients with orbital floor blowout fracture (OFBF) for conservative or surgical treatment and based on the results, to propose a scoring system for such decision making. METHODS: A retrospective analysis of 69 patients with OFBF was performed (35 treated conservatively, 34 surgically). The role of orthoptics in referring to surgery or conservative treatment was retrospectively evaluated, the factors with the highest significance for decision making were identified, and a scoring system proposed using Logistic regression. RESULTS: According to defined criteria, the treatment was unsuccessful in 2 (6%) surgically treated and only in one (3%) conservatively treated patient. The proposed scoring system includes the defect size and several values resulting from the orthoptic examination, the elevation of the eyebulb measured on Lancaster screen being the most significant. CONCLUSION: The study demonstrates the benefits of orthoptic examination when making decisions on conservative or surgical treatment and for diagnosing ocular motility disorder (with or without binocular diplopia) in OFBF patients. The proposed scoring system could, following verification in a prospective study, become a valuable adjunctive tool.

Detecting Binocular Diplopia in Orbital Floor Blowout Fractures: Superiority of the Orthoptic Approach.

Background and Objectives: In patients with orbital floor blowout fracture (OFBF), accurate diagnosis of ocular motility disorder is important for decisions about conservative or surgical therapy. However, the accuracy of the traditional test for detecting binocular diplopia/ocular motility disorder using a moving pencil or finger (hereinafter, "finger test") has been generally accepted as correct and has not been subject to scrutiny so far. Hence, its accuracy relative to full orthoptic examination is unknown. Materials and Methods: In this paper, the results of the "finger test" were compared with those derived from a complex examination by orthoptic tests (considered "true" value in patients with OFBF). Results: "Finger test" detected ocular motility disorder in 23% of patients while the full orthoptic examination proved much more efficient, detecting ocular motility disorder in 65% of patients. Lancaster screen test and test with color filters were the most important tests in the battery of the orthoptic tests, capable of identifying 97.7% and 95.3% of patients with ocular motility disorder, respectively. Still, none of the tests were able to correctly detect all patients with ocular motility disorder in itself. Conclusions: As the presence of ocular motility disorder/binocular diplopia is an important indication criterion for the surgical solution of the orbital floor blowout fracture, we conclude that a complex orthoptic evaluation should be always performed in these patients.

Identification of the phase composition of solid microparticles in the nasal mucosa of patients with chronic hypertrophic rhinitis using Raman microspectroscopy.

Solid particles, predominantly in micron and submicron sizes, have repeatedly been observed as a threat to a human health unique compared to the other textures of the same materials. In this work, the hypothesis the solid metal-based particles play a role in the pathogenesis of chronic hypertrophic rhinitis was investigated in patients who had not responded positively to medication. In the group of 40 randomly selected patients indicated for surgical mucotomy, the presence of solid micro- and submicron particles present in their nasal mucosa was assessed. For comparison, a set of 13 reference samples from patients without diagnosed chronic hypertrophic rhinitis was evaluated. The analysis was performed using Raman microspectroscopy. The advantage of this method is the direct identification of compounds. The main detected compounds in the mucosa samples of patients with chronic hypertrophic rhinitis were TiO2, carbon-based compounds, CaCO3, Ca(Fe, Mg, Mn)(CO3)2 MgCO3, Fe2O3, BaSO4, FeCO3 and compounds of Al and Si, all of which may pose a health risk to a living organism. In the reference samples, only TiO2 and amorphous carbon were found. In the control group mucosa, a significantly lower presence of most of the assessed compounds was found despite the longer time they had to accumulate them due to their higher mean age. Identification and characterisation of such chemicals compounds in a living organism could contribute to the overall picture of the health of the individual and lead to a better understanding of the possible causes not only in the chronic hypertrophic rhinitis, but also in other mucosal and idiopathic diseases.

A rare suicide case involving fatal bleeding from varicose veins.

This case report deals with a sharp force suicide case, which may challenge the experience of many forensic pathologists as well as the studies published to date. An overview of the published cases shows that sharp force suicides account only for 1.6%-3% of all suicides and the self-inflicted injuries are usually localized on the body parts easily accessible with one's hand including the neck, thorax, or upper extremities, as well as in locations of major vascular bundles or vital organs. Reported, however, is a case in which the victim relied on the knowledge of her medical condition and used a kitchen knife to incise her varicose veins, which resulted in fatal bleeding. The case is rare on a number of grounds: incision of varicose veins is rarely the method of choice in suicide cases, injuries of peripheral veins are rarely fatal, and so are injuries of isolated veins where no damage to arteries is suffered.

Various fatal complications of urolithiasis.

This article describes two cases of fatal complications of urolithiasis. The first case discusses the development of fatal urosepsis in a patient with a known mental health issue. The patient had self-introduced a thermometer into her bladder, which led to stone formation around the thermometer and consequently to fatal urosepsis. The second case deals with a motor vehicle accident in which a passenger with pre-existing hydronephrosis suffered a kidney injury leading to fatal bleeding into the surrounding adipose tissue. To provide a wider context, the paper also discusses the fatal complications and origin of urolithiasis.

Traumatic dislocation of the eye into the maxillary sinus: Case report and literature review.

Traumatic dislocation of the eye is usually encountered in high-energy injuries. These include traffic accidents, accidents at work, sporting accidents, falling from a height, impact of the hooves or horns of animals, gunshot injuries, and physical assault. Such incidents are accompanied by facial soft tissue damage and injuries to the facial skeleton, especially the orbit, and can be associated with varying degrees of dislocation of the eye. We describe a rare case of non-fatal traumatic eye dislocation into the maxillary sinus, coupled with an orbital fracture resulting from a physical assault on a 63-year-old woman. The cause of death was asphyxiation due to manual strangulation and mechanical asphyxia. Even though dislocations of the eye are relatively rare, forensic pathologists should be aware of such injuries to correct assessment of injury mechanism. The available literature regarding eye dislocation is summarized, and the forensic issues applicable to the assessment of such cases are reviewed.

Fatal intoxication by intravenous injection of castor bean (Ricinus communis L.) extract-a case study.

A case report of a 25-year-old man who committed suicide by intravenous injection himself of an aqueous home-made castor bean extract is presented. The patient was hospitalized and treated symptomatically and was released at its own request fourth day after intoxication. The next day, the patient's condition deteriorated, and he died 6 days after intoxication even though he was given medical care. Case history, autopsy, and toxicological investigation of ante- and post-mortem collected materials are described. Blood and urine collected from the patient ante-mortem and other several biological materials (namely blood from the upper and lower limb, blood from the right and left ventricle, pericardial fluid, vitreous humour, liver, kidney, and spleen) were collected post-mortem during autopsy. Liquid-liquid extraction procedure followed by high-performance liquid chromatography tandem mass spectrometry analysis for identification and determination of ricinine as a biomarker of ricin/castor seed intoxication was developed and validated. The method was applied on analysis of collected ante- and post-mortem biological materials. The post-mortem contents of ricinine in organs (namely the liver, kidney, and spleen) are firstly reported. The obtained results indicated approximately uniform distribution of ricinine (concentration level about 1 ng mL-1) in the body after death. In addition, the GC-MS method was also applied for the analysis of extract of castor seed and the patient's urine, to demonstrate alternative possibility for identification of ricinine for clinical and forensic purposes.

Giant cell aortitis.

Inflammatory aortic diseases are broadly classified into three categories according to the degree of inflammation: atherosclerosis, atherosclerosis with excessive inflammation, and aortitis/periaortitis. This paper presents a case of a 39-year old man with aneurysmal dilatation of thoracic aorta and aortic valve insufficiency. The aortic wall showed thickening and wrinkled "tree bark" appearance as well as apparent scarring of the intima. Histological examination revealed intimal hyperplasia, a granulomatous/giant cell pattern in the inner tunica media, a few epithelioid macrophages, abundant chronic lymphoplasmacytic and histiocytic inflammation and discrete fibrinoid necrosis. The histological findings were indicative of Horton's disease, but no typical clinical features were present. The case illustrates the difficulties involved in diagnosing inflammatory aortic diseases where it may be challenging to arrive at a specific diagnosis despite the knowledge of medical history, and available macroscopic and histological findings.