A tale of two cities: a review of homicide in Melbourne and Glasgow in 2005.

The Departments of Forensic Medicine and Science at the University of Glasgow and the Victorian Institute of Forensic Medicine in Melbourne are academic university-based forensic medicine units providing a medico-legal death investigation service to the Strathclyde region of Scotland and the State of Victoria, Australia, respectively. We reviewed and compared homicides in the two jurisdictions for the year 2005. Whilst gross numbers were comparable, the homicide rate per capita was significantly higher in Glasgow. Death due to stabbing comprised a greater proportion of homicides in Glasgow, reflective of a well recognised social epidemic of knife-related trauma amongst young males. Blunt force trauma was the most prevalent cause of homicidal injury in the Australian cases. The cities shared a low incidence of firearm- related homicide, reflective of strict legislative initiatives.

Immunohistochemical evidence of Clostridium sp, Staphylococcus aureus, and group A Streptococcus in severe soft tissue infections related to injection drug use.

Severe soft tissue infections are caused by either single or multiple microorganisms. We performed a retrospective immunohistochemical (IHC) study on formalin-fixed, paraffin-embedded soft tissue samples from 20 injection drug users who were part of a cluster of severe illness and death after skin and soft tissue infections in Scotland and Ireland in 2000. The IHC assays used antibodies against Clostridium sp, Staphylococcus aureus, group A streptococci, and Bacillus anthracis. Intact bacilli and granular Clostridium antigen staining in areas with necrosis, edema, and inflammation were observed in skin, fascia, or muscle samples of 12 (60%) patients. A variety of clostridia were isolated from affected soft tissues in 10 IHC-positive cases. Staphylococcus aureus antigens were observed in 3 cases including 1 where S aureus was isolated, 1 with negative cultures, and 1 where mixed cultures were obtained. Group A streptococcal antigens were observed in 1 case in which Streptococcus pyogenes and S aureus were isolated. By using IHC, we detected different bacteria in archival soft tissue samples from patients with severe skin and soft tissue infections. Immunohistochemical assays can be of great diagnostic value, particularly for bacteria such as Clostridium sp, which are difficult to isolate because of their anaerobic fastidious growth requirements.

Lethal outbreak of infection with Clostridium novyi type A and other spore-forming organisms in Scottish injecting drug users.

This report describes the investigation and management of an unprecedented outbreak of severe illness among injecting drug users (IDUs) in Scotland during April to August 2000. IDUs with severe soft tissue inflammation were prospectively sought among acute hospitals and a mortuary in Scotland. Cases were categorised as definite or probable: probable cases had severe injection site inflammation or multi-system failure; definite cases had both. Information about clinical course, mortality, post-mortem findings and laboratory data was gathered by standardised case-note review and interview. Sixty cases were identified--23 definite and 37 probable. Most had familial or social links with each other and 50 were from Glasgow. Median age was 30 years; 31 were female. The majority, especially definite cases, injected heroin/citric acid extravascularly. Of definite cases, 20 died (87% case-fatality rate; 13 after intensive care), 15 had necrotising fasciitis, 22 had injection site oedema and 13 had pleural effusion. Median white cell count was 60 x 10(9)/L. Of 37 probable cases, three died (8% case-fatality rate). Overall, the most frequently isolated pathogen was Clostridium novyi type A (13 cases: 8 in definite cases). The findings are consistent with an infection resulting from injection into soft tissue of acidified heroin contaminated with spore-forming bacteria. Toxin production led to a severe local reaction and, in many, multi-system failure.

Recent contact with health and social services by drug misusers in Glasgow who died of a fatal overdose in 1999.

AIM: To explore the recent contact with health and social services by drug misusers who died of a fatal overdose and identify opportunities for preventive intervention. DESIGN: Retrospective case analysis. SUBJECTS: Eighty-seven residents of the Greater Glasgow area who died of a drug misuse-related overdose in 1999. METHODS: Analysis of matched data from several sources: Strathclyde Police; University of Glasgow Department of Forensic Medicine and Science; the Scottish Prison Service; general practitioners' medical notes, including records of accident and emergency attendances and psychiatric assessments; and five specialist agencies for drug misusers or the homeless. FINDINGS: Most of those who died of an overdose were males, long-standing heroin injectors and resident in a deprived area. Heroin caused most deaths, either alone or with other drugs. Twenty-three per cent died within 2 weeks of release from prison. For the 77 whose medical records were available, 90% had seen their general practitioner (32% in the month before death), 48% had attended accident and emergency services and 22% had received a psychiatric assessment in the year before death. Over 40% of the 87 used a drug agency in the year before death and 20% had used more than one agency. CONCLUSIONS: Previous suicidal ideation, attempted suicide and depression were common among those who died of an overdose, as was recent release from prison. Almost all had been in contact with and several were receiving specific treatment from health or specialist addiction services in their last weeks or months. The findings highlight both the numerous opportunities for intervention and the challenge of using them to prevent death.

The role of methadone in drug-related deaths in the west of Scotland.

AIMS: To determine the incidence of methadone as either the principal cause of death or as a contributing factor in drug related deaths in the Strathclyde Police region of Scotland and to assess the impact of supervised consumption of methadone on the number of deaths that occurred within each health board area within this region. DESIGN: Retrospective analysis of records held within the Department of Forensic Medicine and Science based at the University of Glasgow over the 11-year period 1991-2001. SETTING: The Strathclyde Police region of Scotland (population approximately 2.25 million). FINDINGS: In 1991, there was one death recorded which was attributable to methadone. Following the introduction of the methadone maintenance programme (MMP) in Glasgow during 1994, there was a 100% increase in these deaths compared to the previous year, a trend which continued over the subsequent 2 years. Following a confidential enquiry into these deaths and a greater compliance from pharmacies supervising methadone consumption, deaths involving methadone had decreased by 48% in 1997. This was particularly evident in the Greater Glasgow Health Board Area, where methadone prescribing has continued to rise annually. However, some difficulties still exist. Multiple take home doses are sometimes prescribed when a pharmacy is closed, which may lead to inadvertent overdose or facilitate diversion of legitimate supplies. In addition, continued use of heroin was found in approximately one-fifth of MMP patients, suggesting possible underdosing. CONCLUSIONS: A growing prevalence of heroin misuse has resulted in an increase in the number of individuals entering the MMP. Despite a continuing increase in the amount of methadone prescribed, methadone deaths in Strathclyde have decreased since 1996 due possibly to changes in both prescribing and clinical care. With efficient management to establish that the patient is complying with the guidelines of the programme and has stopped heroin misuse, methadone can be a safe drug for substitution therapy.

Unsuspected meningoencephalitis in a case of assault by blunt force trauma.

Reported is a case of an assault causing extensive blunt force injuries in which the clinical, radiologic, and postmortem findings were all consistent with death resulting from brain damage arising from the assault. The assailant was charged with murder. Subsequent full neuropathologic (including histologic) examination revealed the unsuspected finding of a widespread meningoencephalitis but no evidence of significant traumatic brain damage. The contributions of the infective process and of the trauma to death were felt to be unclear and a guilty plea to attempted murder was accepted. This case highlights the importance of a full neuropathologic examination, including histology, in cases of trauma to the head, even when the cause of death may initially appear obvious.

Death by obstruction: sudden death resulting from impromptu ingestion of drugs.

Over an 18-month period, the department of Forensic Medicine and Science at the University of Glasgow investigated four rather unusual drug-related deaths. In all cases, death was due to the obstruction of the airway by a foreign body after an attempt to evade arrest. In all cases, the obstruction was drug packages of various shapes and sizes. Results of toxicology revealed levels of drugs that may have had a significant respiratory effect on the deceased in three of the cases. Rupturing of the packages and hence leakage of drugs being conducive to death was obvious in only one case.