Drug deposition in adipose tissue and skin: evidence for an alternative source of positive sweat patch tests.

In a series of licit and illicit drug-related deaths, qualitative and quantitative analyses on extracts of adipose tissue and skin were performed by GC/MS. In all cases, the adipose tissue was found to contain drugs at concentrations lower than, approximately equal to, or even greater than the concentrations of the same analytes found in the blood, which may reflect a consequence of long-term chronic exposure, or acute intoxication, or some combination of both. Approximately one cubic inch of skin with adipose tissue was removed from the mid to lower abdominal region adjacent to the midline incision during autopsy. The drugs were recovered from the specimens following incubation and alkaline, acidic, and alkaline chloroform back extraction of one to three grams of tissue. Deuterated analogs of the analytes were added to the matrix at the beginning of the incubation period. Cocaine and free morphine (from heroin) were readily identified in several cases. The presence of these illicit drugs in adipose tissue raises significant forensic questions, especially the use of 'sweat patches' to monitor recent cocaine or heroin use in chronic drug users.

Cocaine-associated agitated delirium and the neuroleptic malignant syndrome.

The incidence of this previously rare disorder, cocaine-associated agitated delirium, appears to have increased drastically within the last 18 months. The underlying neurochemical abnormalities have recently been characterized, but most clinicians have had little experience with management of agitated delirium. The basic clinical and pathological features of this disorder are reviewed, and common pitfalls in diagnosis and management that frequently lead to needless but very expensive litigation are discussed.

Surgical delays and outcomes in patients treated with pneumatic antishock garments: a population-based study.

Until mid-1991, our emergency medical services (EMS) system required the routine application of pneumatic antishock garments (PASGs) in all trauma cases, and inflation of the garment if the patient was hypotensive (systolic blood pressure < 90 mm Hg). The findings in 398 trauma patients who underwent emergency surgery when PASG was still being routinely applied were compared with the findings in 590 trauma patients who underwent emergency surgery after routine PASG application had been discontinued. Since the discontinuation of routine PASG application, scene time intervals for "intermediate" blunt and penetrating trauma activations have not changed, but scene times for "full-activation" blunt trauma have actually increased (6.4 minutes with PASG and 9.5 minutes without PASG, P = .0004). Transport times were found to be a function of the type of trauma; patients with penetrating injuries were transported more rapidly (P < .0001) than patients with blunt trauma, even after controlling for injury severity and point of origin. Total time elapsed from EMS activation to the start of surgery for "full" activations, both blunt and penetrating, was unchanged (52.8 minutes with PASG and 53.8 minutes without PASG for penetrating trauma, 117.9 minutes with PASG and 105.1 minutes without PASG for blunt trauma). Times for "intermediate" activations did not change significantly. Length of intensive care unit (ICU) stay did not change. Within the subgroup of patients with femoral but not pelvic fractures, time spent at the scene of injury was shorter for patients treated with PASG than for those treated without (9.5 minutes v 14.5 minutes, P = .0066). Predicted and actual mortality rates were unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

The influence of gender and use of barium enema on morbidity in acute appendicitis.

The records of 166 patients with appendicitis were analyzed by sex for time from presentation in the emergency department to surgery. Additionally, the effects of barium enema examinations on these times were noted. Our findings indicate that there was no significant delay in surgery based on gender (P = .42). However, those patients who had barium enema as part of their workup had significantly longer delays from presentation to surgery (P = .00005). These results support the notion that the most appropriate treatment for acute appendicitis is early diagnosis, a short preoperative resuscitation, and early surgical intervention. Barium enema is indicated only when the diagnosis is highly suspect and only if it can be carried out in a timely manner.

Cyclosporine induced myocardial fibrosis: a unique controlled case report.

Many patients treated with cyclosporine in the Stanford Heart Transplant Program have exhibited perimyocytic fibrosis in the donor heart, seen on endomyocardial biopsy specimen. Although restrictive hemodynamic effects have not been observed up to three years after transplantation, there is a possibility that such changes could become a problem. With the increasing use of cyclosporine in non-cardiac organ transplantation, it is of interest to examine the effect of this drug upon the non transplanted heart. This was possible in a man who underwent a heterotopic heart transplantation 3 1/2 years ago, and who has been followed with serial endomyocardial biopsies from both hearts. Although there were no episodes of rejection the donor heart developed significant perimyocytic fibrosis which was not seen in the native heart. This study suggests that cyclosporine induced fibrosis only occurs in the transplanted heart.

Infantile polyneuropathy with defective myelination: an autopsy study.

A case is reported of a boy who developed a severe polyneuropathy in early infancy and died of respiratory failure at the age of 18 months. Autopsy revealed almost total lack of myelin sheaths in the cranial, spinal and peripheral nerves. The defect involved the entire peripheral nervous system and was confined to it, central myelination being normal. It is suggested that this case is another example of the condition described by Lyon (1969) and by Kennedy et al. (1971) in which pathological observations were confined to biopsy material. In spite of some similarities between these cases and those of hypertrophic neuropathy reported by Déjerine and Sottas in 1893, they seem to form a distinct sub-group, possibly even a separate entity: infantile polyneuropathy with defective myelination.