The Dangerous Pattern of Concurrent Use of Alcohol and Cocaine Among Drunk-Drivers of Northeast Italy

Aim

To estimate the prevalence of drug and polydrug use among drunk-drivers during the driving license regranting program, in order to assess the inclusion of toxicological tests on hair and urine samples in the systematic methodology in this category of subjects.

Short summary

A total of 2160 drunk-drivers were tested for alcohol and drugs during driving license regranting. Thirty-one subjects showed alcohol use, 212 illicit drug use and, among these, 131 were polydrug users. Nineteen different patterns of drug and polydrug use were found. Cocaine was detected in 165 subjects.

Methods

The study was performed on 2160 drunk-drivers examined at Legal Medicine and Toxicology Unit of the University of Padova, in a 3-year-period (2014-2017). The positivity for one or more illicit drugs in hair or urine samples was confirmed by LC/MS and GC/MS methods. Chi-square test, Fischer's exact test and Cochran-Armitage Trend test were used to study the correlation between general characteristics of the examined sample and the presence of drug/polydrug use.

Results

Thirty-one subjects showed alcohol use, 212 illicit drug use and, among these, 131 were polydrug users. Nineteen different patterns of drug and polydrug use were found. Cocaine was detected in 165 subjects in whom 122 showed a concurrent use of alcohol and cocaine, identified through the detection of cocaethylene in hair samples. No significant association and/or trends between drug/polydrug use and the general characteristics of the sample were detected.

Conclusions

The results show that drug and polydrug use among drunk-drivers should be subjected to toxicological as well as alcohological monitoring, especially in the regranting procedure. The implementation of this procedure could improve the knowledge of dimensions of the issue, providing a powerful means for the reduction of phenomenon of driving under the influence of alcohol and drugs.

Driving under the influence of drugs: Prevalence in road traffic accidents in Italy and considerations on per se limits legislation

OBJECTIVE

The objective of this study was to present the prevalence and concentrations of drugs in blood samples of drivers involved in road traffic accidents (RTAs) and to discuss the effects of adopting different concentration cutoff values proposed or applied in other European countries on the number of driving under the influence of drugs (DUID) offenses.

METHODS

Blood samples from drivers involved in RTAs in Padova province from 2014 to 2017 were analyzed for the presence of alcohol and drugs. The prevalence of positive subjects was reported for each substance adopting the limits of quantification (LOQs) of our laboratory and the concentration cutoff values proposed and/or used in other European countries. The reduction of cases of driving under the influence of illicit drugs in applying different cutoffs was calculated.

RESULTS

Four thousand four hundred forty-three blood samples were analyzed: 23.7% were positive for alcohol and 19.9% for psychoactive drugs, with prevalences of polydrug and alcohol-drug abuse of 4.5 and 6%, respectively. The most frequently detected drugs were cannabinoids (9.7%) and cocaine (7.2%), followed by benzodiazepines (4.1%), opiates (1.9%), and other opioids (1.7%). Barbiturates, amphetamines, and ketamine were identified in a much smaller number of cases. The overall decrease in DUID cases when adopting different cutoffs with respect to cases above the LOQs was between 8 and 84%. The adoption of high LOQs such as those used in the European Union's research project on Driving Under the Influence of Drugs, Alcohol and Medicines (DRUID) decreases the hypothetical number of DUID offenses by a quarter, and per se limits proposed as broadly equivalent to a blood alcohol concentration (BAC) between 0.2 and 0.8 g/L dramatically reduce the cases of DUID (cocaine -81%, cannabis -79%, opioids -97%, opiates -96%, and amphetamines -77%); no ketamine-positive samples were above the cutoff.

CONCLUSIONS

The implementation of high analytical limits or per se limits based on impairing concentrations in the Italian legislation could result in the prosecution of a much lower number of drugged drivers involved in RTAs, with a decrease from 25% to more than 80% depending on the limits.

Relationship between anatomical sites and severity of the lesions and use of alcohol and psychotropic substances in traumatized drivers admitted to the Emergency Department of Padua, Italy

INTRODUCTION

Driving under the influence of alcohol and/or psychoactive substances increases the risk of road accidents, but it is controversial whether this affects site and severity of injuries.

MATERIAL AND METHODS

We search for alcohol, cannabinoids, cocaine, benzodiazepines, opioids, methadone, amphetamines and barbiturates in biological fluids of 1764 traumatized drivers admitted to the Emergency Department (ED) of Padua between 2010 and 2014.

RESULTS

We note correlation between alcohol and benzodiazepines and admission in ICU and between all the intoxications and the reserved prognosis. The sites of injuries were: head (37.13%), maxillofacial (8.33%), spinal column (44.67%), thoracic (15.31%), abdominal (5%), pelvic (2.55%) and limb traumas (23.58%). We observed a correlation between head trauma (p < 0.0001), maxillofacial trauma (p = 0.0418), thoracic trauma (p = 0.0215), pelvic trauma (p = 0.0008), spinal column trauma (p < 0.0001) and the totality of the intoxication and an association between benzodiazepines and thoracic and pelvic trauma.

CONCLUSIONS

Alcohol and benzodiazepines intoxication increases the risk of reserved prognosis and admission in ICU; benzodiazepines intoxication correlates with thoracic and pelvic trauma.

The Rise of New Alcoholic Games Among Adolescents and the Consequences in the Emergency Department: Observational Retrospective Study

BACKGROUND

The links between the internet and teenager behavior are difficult situations to control and may lead to the development of new and excessive methods of drinking alcohol during alcoholic games. Findings indicate that reported cases are very useful sources for better understanding of alcoholic games, yielding successful measures promoting health among adolescents. Admittance of adolescents to hospital emergency departments (EDs) after consumption of excessive amounts of alcohol has become the norm in developed countries. The harmful effects of acute alcohol abuse are reported in this paper.

OBJECTIVE

The aim of this work was to investigate the close connections between new drinking behaviors among adolescents and study the increase in new alcoholic games, together with the challenges that cause acute alcohol intoxication, the influence of the internet and social networks, and their consequences for public health services.

METHODS

Data came from prehospital and intrahospital admissions attributable to alcohol consumption. From 2013 to 2015, 3742 patients were admitted to EDs due to acute alcohol intoxication: 830 of them were aged 15 to 30 years, and 225 were adolescents and young adults between 15 and 20 years who had been playing alcoholic games. Retrospectively, diagnostic data associated with extrahospital anamneses were selected by one of the hospital management information systems, Qlik. As a result of our previous experience, questionnaires and face-to-face interviews were performed at a later stage, when a clinical audit for intoxicated adolescent patients was described, with the overall goal of establishing a potential methodological workflow and adding important information to research carried out so far.

RESULTS

Between 2013 and 2015, 830 young patients aged 15 to 30 years were admitted to EDs for acute alcohol intoxication. About 20% (166/830) of the sample confirmed that they had drunk more than 5 alcoholic units within 2 hours twice during the past 30 days as a result of binge drinking. Referring to new alcoholic games, 41% of the sample stated that they knew what neknomination is and also that at least one of their friends had accepted this challenge, describing symptoms such as vomiting, headache, altered behavior, increased talkativeness, and sociability. The median value of the weighted average cost of the diagnosis-related group relating to interventions provided by hospitals was the same for both genders, €46,091 (US $56,497; minimum €17,349 and maximum €46,091).

CONCLUSIONS

Drinking games encourage young people to consume large quantities of alcohol within a short period of time putting them at risk of alcohol poisoning, which can potentially lead to accidental injuries, unsafe sex, suicide, sexual assault, and traffic accidents. The spread of these games through the internet and social networks is becoming a serious health problem facing physicians and medical professionals every day, especially in the ED; for this reason, it is necessary to be aware of the risks represented by such behaviors in order to recognize and identify preliminary symptoms and develop useful prevention programs. The strategic role of emergency services is to monitor and define the problem right from the start in order to control the epidemic, support planning, coordinate the delivery of assistance in the emergency phase, and provide medical education. Hospital-based interdisciplinary health care researchers collected specific data on hazardous drinking practices linked to evaluation of increased alcohol-related consequences and cases admitted to the ED.

A Social Media-Based Acute Alcohol Consumption Behavior (NekNomination): Case Series in Italian Emergency Departments

Background

NekNomination, also known as NekNominate, Neck and Nominate, or Neck Nomination, is a social network–based drinking game which is thought to have originated in Australia and spread all over the world between 2013 and 2014. Individuals record videos of themselves while rapidly drinking excessive quantities of alcoholic drinks (necking) and then nominate friends to outdo them within 24 hours; the videos are then posted on social media such as Facebook or YouTube. The consequences of this drinking game have been very dangerous; at least 5 people under age 30 years have died after drinking deadly cocktails, and many others have suffered from alcohol intoxication.

Objective

The goal of the research is to evaluate data about clinically important acute alcohol intoxication among teenagers and young adults and inform and educate the general public, especially parents, teachers, and health workers, about the spreading craze of dangerous Internet-related behavior among today’s teenagers and young people up to the age of 23 years.

Methods

Patients aged 15 to 23 years with acute alcohol intoxication who came to the emergency department (ED) of 2 major hospitals in Italy from January 1, 2011, to June 30, 2014, were included in this study. Data were retrieved from prehospital and intrahospital medical records and included personal information, methods of intoxication, triage color code, date and time of access to the ED, any relevant signs and symptoms, blood alcohol concentration, and diagnosis at discharge.

Results

A total of 450 young patients (male 277/450, 61.5%, female 173/450, 38.5%; age 15 to 16 years 15/450, 3.3%, age 17 to 18 years 184/450, 40.9%, age 19 to 23 years 251/450, 55.8%) were recruited. The causes of intoxication were happy hour, binge drinking, NekNominate, eyeballing, other alcoholic games, or a mix of them. Happy hour was found to be more common among the older patients, whereas NekNominate accounted for almost half of the youngest group of hospitalizations. Eyeballing occurred in 1.6% (7/450) of cases; binge drinking and other alcoholic games caused 23.3% (105/450) and 23.8% (107/450) of hospitalizations, respectively. On admission, 44.2% (199/450) of patients were assigned a red or yellow color code requiring immediate medical attention; about 14% of them required additional medical assistance (after being in the ED) or hospitalization, some in semi-intensive care units.

Conclusions

Our study shows that the increased numbers of hospitalizations due to alcohol intoxication in the adolescent age group, as a consequence of NekNominate or other drinking games, is alarming and represents a serious public health issue. The potential markers of improper use of social networks must be clearly identified, including categories at risk of alcohol abuse, in order to develop intervention and prevention strategies in terms of education and awareness, which may help in averting potentially fatal episodes.

Pedestrian Inattention Blindness While Playing Pokémon Go as an Emerging Health-Risk Behavior: A Case Report

BACKGROUND

Cases of trauma resulting from the use of mobile phones while driving motor vehicles have become quite common in recent years. Road injuries incurred by people playing video games on mobile phones (or other media devices) while walking have also become a cause for concern. Pokémon Go has been the world's most popular game since it was launched in July 2016, with more than 15 million players trying to catch all Pokémon available in the game; however, the case detailed here is the first reported accident in the medical literature caused by a pedestrian distracted by the game while crossing a street.

OBJECTIVE

We aim to provide additional information on the innovative nature of distractions that generate risks in road-users, and to explore the underreporting of pedestrian-motor vehicle collisions due to mobile device usage.

METHODS

We included in this case report a 25-year-old male who suddenly crossed a road while playing Pokémon Go and was hit by a van, reporting several injuries and being assisted by the Emergency Medical Service of our hospital (Padova, Italy). The patient's history, the circumstances in which the collision happened, imaging data, and clinical course information were recorded per our hospital's privacy policy.

RESULTS

The patient hit by the van was playing Pokémon Go on his mobile phone while crossing a street, despite red traffic lights, which he did not notice due to of the distraction induced by the game.

CONCLUSIONS

Mobile videogames that imply movement (ie, walking, running, cycling) to play are an effective way to improve physical activity practice, especially in adolescents and young adults. Nevertheless, cases like the one presented here point out that these games could pose a significant risk to users who play while walking, cycling, or driving in unsafe areas such as city streets, because players become distracted and may ignore surrounding hazards. Comprehensive, multilevel interventions are needed to reduce accidents caused by distraction, and to stress findings on the positive and negative effects of video games, which are becoming a source of public health concern. Health care providers should be aware of their chief role in these possible prevention strategies, based on their direct interactions with road incident victims.

Planking or the "Lying-Down Game:" Two Case Reports

Background

The monitoring and management of risks regarding children and young people admitted to the emergency department as a result of dangerous behaviors distributed via the Internet should be based on clinical reasoning and knowledge about these social media–related phenomena. Here we examine 2 cases of teenagers who reported severe injuries while performing the “planking” craze, a challenge that consists in lying face-down stiffly like a board on any kind of surface.

Objective

Our objective is to examine and describe the Internet craze called planking, also known as the “lying-down game,“ through 2 case reports from our experience, enriching this study with information gained through discussions with secondary school teenagers.

Methods

Details of the 2 case reports were taken from electronic medical records giving information on care support processes, care management, and the costs of traumatic episodes. Demographic data, hemoglobin and serum lactate values, and Injury Severity Scores were evaluated. The study took place in secondary schools of our city from 2013 to 2014 during medical education courses, with the aim of analyzing the influence of social media on teenagers' activities and behaviors.

Results

Both patients suffered multiple trauma injuries and needed high-level health assistance. The first patient underwent a splenectomy and the second one a nephrectomy; both of them required a long hospital stay (14 and 20 days, respectively), and the costs for their management have been estimated at US $27,000 and US $37,000, respectively. Their decision to perform the planking in dangerous locations was due to their ambition to gain peers' acclaim through shared videos and pictures.

Conclusions

Reporting and understanding these cases may potentially help prevent future events occurring in similar circumstances: the scientific community cannot leave this problem unaddressed. There is also a role of education resources for health care professionals; for this, we must identify and follow up strange or misleading information found on websites. A key element of this research study was to report physicians’ misperceptions concerning planking and, with these cases used for teaching purposes, improve knowledge of the clinical and forensic aspects of this emerging problem.

Fatal asthma; is it still an epidemic?

BACKGROUND

Asthma mortality has declined since the 1980s. Nevertheless the World Health Organization (WHO) identified asthma as responsible for 225.000 deaths worldwide in 2005, and 430.000 fatal cases are expected by 2030. Some unexpected and concentrated fatal asthma events all occurred between 2013 and 2015 in Veneto, a North Eastern region of Italy, which prompted a more in-depth investigation of characteristics and risk factors.

METHODS

A web search including key words related to fatal asthma in Italy between 2013 and 2015 has been performed. Concerning the cases that occurred in Veneto, subjects' clinical records have been evaluated and details about concomitant weather conditions, pollutants and pollen count have been collected.

RESULTS

Twenty-three cases of asthma deaths were found in Italy; 16 of them (69%) occurred in the Veneto Region. A prevalence of male and young age was observed. Most of patients were atopic, died in the night-time hours and during the weekends. The possible risk factors identified were the sensitization to alternaria, previous near fatal asthma attacks and the incorrect treatment of the disease. Weather condition did not appear to be related to the fatal exacerbations, whereas among the pollutants only ozone was detected over the accepted limits. Smoking habits, possible drug abuse and concomitant complementary therapies might be regarded as further risk factors.

DISCUSSION

Although not free from potential biases, our web search and further investigations highlight an increasing asthma mortality trend, similarly to what other observatories report. The analysis of available clinical data suggests that the lack of treatment more than a severe asthma phenotype characterizes the fatal events.

CONCLUSIONS

Asthma mortality still represents a critical issue in the management of the disease, particularly in youngsters. Once more the inadequate treatment and the lack of adherence seem to be not only related to the uncontrolled asthma but also to asthma mortality.

Misinterpretation of Anogenital Findings and Misdiagnosis of Child Sexual Abuse: The Role of the Forensic Pathologist

BACKGROUND

The interpretation of anogenital postmortem findings is an issue of main concern, because the nature and appearance of anogenital tissues during the postmortem interval is not widely known by health providers.

CASE

An 8-year-old girl died in the hospital 48 hours after hospitalization. On the basis of the atypical anogenital findings, the health care professionals notified the fact to the Public Prosecutor as an alleged child abuse. The forensic pathologist ruled out this possibility, interpreting the anal findings due to physiological postmortem anal alterations and to the insertion of suppositories before death.

SUMMARY AND CONCLUSION

Forensic pathological analysis should be included in routine postmortem evaluation in the case of suspected child sexual abuse, because normal postmortem findings could be misinterpreted by physicians, whose sole experience is on the basis of antemortem scenarios.

Underlying substance abuse problems in drunk drivers

OBJECTIVES

The aim of this study was to investigate polydrug use in drunk drivers.

METHODS

The experimental study was conducted on 2,072 drunk drivers undergoing a driving license reissue protocol at the Department of Legal Medicine of Padova University Hospital in the period between January 2011 and December 2012. The study protocol involved anamnesis, clinical examination, toxicological history, and toxicological analyses on multiple biological samples.

RESULTS

One thousand eight hundred seventy-seven subjects (90.6%) were assessed as fit to drive, and 195 (9.5%) were declared unfit. Among those unfit, 32 subjects (1.6%) were declared unfit due to recent use of an illicit drug (time span < 6 months), 23 (1.1%) spontaneously interrupted the protocol before its end, and 140 (6.8%) completed the assessment. Ineligibility to drive after completeness of the protocol was established in 1.2% of cases for alcohol disorders and in 5.7% of cases for illicit drug abuse; only one subject was included in both subgroups. Cocaine was the most widely used substance, followed by cannabis, opiates, and psychotropic pharmaceutical drugs.

CONCLUSIONS

The application of the protocol presented in this study allowed the identification of underlying polydrug use in drunk drivers. The study led to the identification of 6.8% unfit subjects on the basis of alcohol disorders and/or drug abuse, compared to 1.2% of identifiable unfitness if the protocol were limited to the mere assessment of alcohol consumption. The frequent association of alcohol and cocaine is different from other patterns of use in North Europe countries.

Alcohol drinking, mean corpuscular volume of erythrocytes, and alcohol metabolic genotypes in drunk drivers

Regular and irregular abuse of alcohol are global health priorities associated with diseases at multiple sites, including cancer. Mechanisms of diseases induced by alcohol are closely related to its metabolism. Among conventional markers of alcohol abuse, the mean corpuscular volume (MCV) of erythrocytes is prognostic of alcohol-related cancer and its predictivity increases when combined with functional polymorphisms of alcohol dehydrogenase (ADH1B [rs1229984] and ADH1C [rs698]) and the mitochondrial aldehyde dehydrogenase (ALDH2 [rs671]). Whether these genetic variants can influence abuse in alcohol drinking and MCV has never been examined in drunk-driving traffic offenders. We examined 149 drunk drivers, diagnosed as alcohol abusers according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition Text Revision (DSM-IV-TR) and enrolled in a probation program, and 257 social drinkers (controls), all Caucasian males. Alcohol intake was assessed according to self-reported drink-units/d and MCV unadjusted and adjusted for age, smoking, and body mass index. Multivariable models were used to compute MCV adjusted means. Genotype analyses were performed by PCR on DNA from blood. The adjusted MCV mean was higher in drunk-driving abusers than in controls (92 vs. 91fL; P<.0001) and increased with the number of drink-units/d in both abusers and controls (P-trend=.0316 and .0089) already at intermediate quantities (0-1 vs. 2-4 drink-units/d: P=.054 and .024). Carriers of the common ADH1B*1/*1 (rs1229984) genotype were more likely to be drunk-driving abusers (P=.008), reported higher drink-units/d (P=.0126), and had larger MCV (P=.035). The rs698 ADH1C and rs671 ALDH2 polymorphisms were not associated with MCV. ADH1B*1/*1 polymorphism is significantly associated with being a drunk-driving abuser, higher alcohol drinking, and MCV enlargement. This suggests that drunk drivers with augmented MCV modulated by the alcohol metabolic ADH1B*1/*1 genotype may be at higher risk of driving incapability and of alcohol-related cancer.

Iatrogenic perforation of a pulmonary angiomatoid lesion: histopathological study and review of the literature

Percutaneous tube thoracostomy (PTT) remains the most widely performed procedure to manage blunt or penetrating chest traumas. This life-saving manoeuvre can be frequently associated with complications. We present the case of a 76-year-old man, admitted to a peripheral hospital after a car accident and treated by PTT, who died shortly after the withdrawal of the chest tube. At autopsy, the victim was found to be affected by an extensive haemothorax resulting from the perforation of a subpleural angiomatoid lesion. The histopathological characteristics and the pathogenesis of the iatrogenic injury involving the vascular abnormality, along with its causal role in determining the fatal haemothorax, are critically discussed under both clinical and forensic points of view.

Shortened telomeres in individuals with abuse in alcohol consumption

Alcohol abuse leads to earlier onset of aging-related diseases, including cancer at multiple sites. Shorter telomere length (TL) in peripheral blood leucocytes (PBLs), a marker of biological aging, has been associated with alcohol-related cancer risks. Whether alcohol abusers exhibit accelerated biological aging, as reflected in PBL-TL, has never been examined. To investigated the effect of alcohol abuse on PBL-TL and its interaction with alcohol metabolic genotypes, we examined 200 drunk-driving traffic offenders diagnosed as alcohol abusers as per the Diagnostic and Statistical Manual of Mental Disorders [DSM-IV-TR] and enrolled in a probation program, and 257 social drinkers (controls). We assessed alcohol intake using self-reported drink-units/day and conventional alcohol abuse biomarkers (serum γ-glutamyltrasferase [GGT] and mean corpuscular volume of erythrocytes [MCV]). We used multivariable models to compute TL geometric means (GM) adjusted for age, smoking, BMI, diet, job at elevated risk of accident, genotoxic exposures. TL was nearly halved in alcohol abusers compared with controls (GMs 0.42 vs. 0.87 relative T/S ratio; p<0.0001) and decreased in relation with increasing drink-units/day (p-trend=0.003). Individuals drinking >4 drink-units/day had substantially shorter TL than those drinking ≤4 drink-units/day (GMs 0.48 vs. 0.61 T/S, p=0.002). Carriers of the common ADH1B*1/*1 (rs1229984) genotype were more likely to be abusers (p=0.008), reported higher drink-units/day (p=0.0003), and exhibited shorter TL (p<0.0001). The rs698 ADH1C and rs671 ALDH2 polymorphisms were not associated with TL. The decrease in PBL-TL modulated by the alcohol metabolic genotype ADH1B*1/*1 may represent a novel mechanism potentially related to alcohol carcinogenesis in alcohol abusers.

Psychic trauma as cause of death

AIM

of study Psychic trauma is described as the action of 'an emotionally overwhelming factor' capable of causing neurovegetative alterations leading to transitory or persisting bodily changes. The medico-legal concept of psychic trauma and its definition as a cause in penal cases is debated. The authors present three cases of death after psychic trauma, and discuss the definition of cause within the penal ambit of identified 'emotionally overwhelming factors'.

MATERIALS AND METHODS

The methodological approach to ascertainment and criterion-based assessment in each case involved the following phases: (1) examination of circumstantial evidence, clinical records and documentation; (2) autopsy; (3) ascertainment of cause of death; and (4) ascertainment of psychic trauma, and its coexisting relationship with the cause of death.

RESULTS

The results and assessment of each of the three cases are discussed from the viewpoint of the causal connotation of psychic trauma. In the cases presented, psychic trauma caused death, as deduced from assessment of the type of externally caused emotional insult, the subjects' personal characteristics and the circumstances of the event causing death.

CONCLUSIONS

In cases of death due to psychic trauma, careful methodological ascertainment is essential, with the double aim of defining 'emotionally overwhelming factors' as a significant cause of death from the penal point of view, and of identifying the responsibility of third parties involved in the death event and associated dynamics of homicide.

Death after liposuction: case report and review of the literature

We report the case of a 41-year-old woman who died after surgical intervention for liposuction. The case was studied by a methodological approach including examination of clinical records and documentation, analysis of anatomo-histopathological findings and evaluation of physicians' behaviour. Autopsy excluded the lethal complications most frequently associated with liposuction (pulmonary embolism, sepsis, necrotizing fasciitis, perforation of abdominal organs) and identified the cause of death as 'massive necrosis of brain-stem and cerebellum, due to spontaneous thrombosis of the basilar and cerebellar district'. Analysis of the physicians' behaviour, together with a review of the literature, excluded medical errors or malpractice. The Court of Law ruled the death as a fatal unforeseeable complication of the operation. The medico-legal interest of the case lies in the singular anatomo-pathological cause of death, discussed in relation to the hypothesis of professional responsibility after surgical intervention for liposuction.

Abstract LB-397: Shortened telomeres in subjects with heavy alcohol consumption

Background: Telomere shortening in peripheral blood lymphocytes, a marker of chromosome instability, has been associated with cancer risk. Heavy alcohol consumption has been linked with oxidative stress and inflammation, two mechanisms that accelerate telomere shortening, as well as with the risk of cancer at multiple sites. Whether alcohol drinking determines telomere shortening has never been evaluated.

Objectives: To investigate the effect of alcohol drinking, as well as of single nucleotide polymorphisms in genes involved in alcohol metabolism, on telomere length.

Methods: We measured relative telomere length by multiplex real-time PCR in peripheral blood lymphocyte DNA from 59 alcohol abusers and 197 controls with variable alcohol use. All subjects were non-smoking Caucasian males living in Northeastern Italy. Abusers were identified through an alcohol abuse/dependence evaluation based on a CAGE-AUDIT questionnaire. Current drinking was higher in abusers (0.04-10 drinks/day; 13 subjects [22%] consuming 4 or more drinks/day) than in controls (0-5.4 drinks/day; 7 subjects [4%] consuming 4 or more drinks/day) [p&lt;0.0001]. Eleven (20%) abusers and 15 (8%) controls had serum -glutamyltrasferase (GGT) and/or erythrocyte mean corpuscular volume (MCV), taken as conventional biomarkers of alcohol abuse, above the clinical reference values [p=0.014].

Results: Mean lymphocyte telomere length was 0.41 (0.21-0.68) in abusers and 0.79 (0.30-4.56) in controls [p&lt;0.0001]. In the entire study population, simple linear regression analysis showed that lymphocyte telomere length was inversely associated with the number of drinks (p=0.018) and MCV (p=0.004). The proportion of subjects with MCV and/or GGT above the clinical reference values was associated with telomere shortening only among abusers (p=0.024). Carriers of the common variant homozygous genotype (rs1229984) in the alcohol dehydrogenase ADH1B metabolic gene were more likely to be abusers (p=0.008), had a higher number of drinks (p=0.0003), and showed shorter lymphocyte telomere length (p=0.026). The rs698 ADHlC and rs671 aldehyde dehydrogenase ALDH2 polymorphisms were not associated with lymphocyte telomere length. Linear multiple regression analysis on the entire study population showed that both the number of drinks (p=0.004) and ADH1B genotype (p=0.01) were independently associated with lymphocyte telomere length.

Conclusions: Alcohol abusers had severely shortened telomeres compared to non-abusers. The decrease in telomere length was related with alcohol drinking and ADH1B genotype in both abusers and non-abusers. Future studies are warranted to determine the role of telomere shortening in alcohol carcinogenicity.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr LB-397.

Early myocardial dysfunction after chronic use of anabolic androgenic steroids: combined pulsed-wave tissue Doppler imaging and ultrasonic integrated backscatter cyclic variations analysis

BACKGROUND

The chronic consumption of androgenic anabolic steroids (AAS) has shown to cause subclinical impairment of myocardial function. Pulsed-wave Doppler tissue imaging (PWDTI) detects early regional alterations of ventricular function, whereas integrated backscatter cyclic variations (IBScv) are tightly related to the contractile efficiency of the left ventricular wall. The aim of this study was to identify the effects of chronic AAS misuse on myocardial function using both PWDTI and IBScv.

METHODS

Twenty-eight male bodybuilders (11 AAS users, 17 AAS nonusers) and 20 healthy sedentary subjects (controls), matched according to age, were studied. To assess left ventricular function, each subject underwent standard Doppler echocardiography, PWDTI, and IBScv analyses.

RESULTS

Left ventricular mass was significantly higher in AAS users than in AAS nonusers and controls. Global systolic function (assessed by determining the ejection fraction) was similar in all subjects, but isovolumetric relaxation time was significantly higher in AAS users than in controls. On PWDTI analysis, AAS users showed regional systolic and diastolic dysfunction (evaluated by measuring s', e', and a') not detectable in the other two groups. IBScv identified regional systolic impairment only in AAS users at the level of the left ventricular inferior wall.

CONCLUSIONS

The present study confirms that in AAS users, PWDTI and IBScv are effective and reliable noninvasive diagnostic tools for detecting early abnormalities of the systolic and diastolic longitudinal myocardial function, probably related to an increase in myocardial collagen content, interpretable as a repair process against the direct cellular injury produced by AAS.

Chronic hydrocephalus and alcohol abuse in a young male suicide

The paper describes a case of suicide in a young man affected by compensated chronic hydrocephalus who was subject to alcohol abuse. The case was studied by means of a complex set of analyses, including circumstantial and clinical data, anatomohistopathological findings, and chemicotoxicologic tests. What clearly emerges in the case is the importance of a continuing neuropsychological follow-up in patients with shunted hydrocephalus. The forensic interest in the case is due to the peculiar autopsy findings discussed in relation to the possible causes of sudden death in subjects with hydrocephalus.

Selective stroke of the solitary tract nuclei in two cases of central sleep apnoea

Central sleep apnoea (CSA) is a breathing disorder characterized by repetitive central apnoeas with hypoxia interrupted by hyperventilation phases. In the literature, there are reports of CSA caused by brainstem infarcts. We report two patients (38 and 53 years old) with longstanding history of central sleep apnoea who died during sleep. In both cases the autopsy revealed acute bilateral hypoxic lesions at the level of the solitary tract nuclei. In one case, symmetrical selective neuronal necrosis was found in the dorsal part of the solitary tract nuclei. A chronic obstructive vasculopathy was also found, with thickening and fibrosis of the smallest vessels of the medullary tegmentum. In the other case, bilateral infarctions were found with the base at the ependymal lining of the 4th ventricle floor and the apex towards the solitary tract. An acute intramural hemorrhagic lesion in the premedullary segment of the left vertebral artery was also found. Episodes of hypoxemic hypoxia during sleep may worsen the effects of focal oligohemic hypoxia in the medullary tegmentum. Selective stroke of the solitary tract nuclei may be the acute fatal lesion in patients with both central sleep apnoea and lesions of the vertebro-basilar system. To the best of our knowledge, this is the first neuropathologic report of acute medullary ischemic-hypoxic lesions which may not be considered the cause of the CSA because of their recent onset. Our findings suggest that CSA, besides being caused by ischemic events at the level of the medulla, may also contribute to pathogenesis of strokes, through hypoxia or hemodynamic oscillations.

[Profiles of medical malpractice in the prophylaxis of pulmonary thromboembolism]

Deaths caused by pulmonary thromboembolism (PTE) are often of forensic interest, due to the frequent preexistence of a traumatic event the suddeness of death, and possible professional responsibility. Early diagnosis of vein thromboembolism is often difficult. Fatal PTE usually presents itself on an unexpected and large scale, chronologically occurring shortly before death and thus irreconcilable with any consequent efficacious therapy. Pharmacological prophylaxis, aiming at reducing the state of blood hypercoagulability, is the elective therapeutic strategy for vein thromboembolism. These are the premises for this work which, after a brief pharmacological and clinical description of heparin prophylaxis and a review of data emerging from a sample of 24 deaths due to PTE, makes some considerations regarding professional responsibility.

Monolateral hypoplasia of the motor vagal nuclei in a case of sudden infant death syndrome

During the development of motor vagal nuclei (MVN), the neuroblasts of the myeloencephalic basal plate migrate in the dorsolateral direction to form the dorsal motor vagal nucleus (DMVN) and ventrolaterally to form the ventral motor vagal nucleus (VMVN). Those neuroblasts that remain close to the median sulcus will form the hypoglossal nucleus. In support of the congenital origin of the alteration of the MVN in sudden infant death syndrome (SIDS), we report the case of an 8-month-old female child who was found dead in her cot. The neuropathological assessment revealed that the medullary triangle of the 4th ventricle floor was asymmetric, owing to the presence of three prominences to the left side of the median sulcus. The medial prominence corresponded to the hypoglossal nucleus, which showed a marked increase in the number of large neurons; the intermediate prominence corresponded to the DMVN whose large neurons were reduced and were recognizable mainly at the level of the medial fringe; the lateral prominence corresponded to the solitary nucleus. The left solitary tract showed a reduction of the transverse diameter. Also, the left VMVN showed marked reduction in the number of neurons. Inflammatory and astrocytic reactions were absent. We suggest that in SIDS cases the hypocellularity of the MVN and the increased number of neurons of the hypoglossal nucleus are intimately related, indicating a congenital alteration due to incomplete migration of the vagal neuroblasts with abnormality of the autonomic cardio-respiratory control.

[Medico-legal features of early discharge in acute myocardial infarction and chest pain]

The authors' aim is to outline some of the main medico-legal problems in cardiology, especially those regarding the premature hospital discharge of patients with undefined chest pain and/or with acute myocardial infarction. After a brief overview on the etiology and clinical definition of chest pain and myocardial infarction, premature hospital discharge is defined and the incidental medico-legal risks that physicians operating in such situations are exposed to are pointed out. Next, the profiles regarding both the positive and negative views of professional medical responsibility are described. In the negative frame, the authors outline the most frequent civil and penal aspects of the unpremeditated responsibility. Then the physician's error, in both qualitative (generic or specific guilt) and quantitative (degree) terms, is considered; particularly, negligence, imprudence and inexperience, as qualitatively accepted meanings of generic guilt, are dealt with by adopting illustrative cases settled in the light of the right legal interpretation. The phases of the diagnostic or prognostic error are evaluated, and clinical protocols, as a reference parameter for the identification of error, are considered. Lastly, the problem of causality, essential condition for the judgment about the professional responsibility, and the problem of the patient's consent, including an evaluation of the legal capability or incapability about the declaration of consent, are examined closely.

[Alcohol, drugs, pharmacologic agents, and street safety]

Deaths due to road accidents during weekends have become a worrying phenomenon in Italy. With the aim of highlighting the role of psychotropic substances (alcohol, drugs of abuse) in causing road accidents, a survey based on clinical and chemico-toxicological analyses has been carried out on car drivers in the Veneto region during night weekends since 1994. Rapid clinical screening was carried out on 7952 drivers. 1399 of these, suspected to be under the influence of psychotropic substances, were subjected to complete clinical and toxicological ascertainment involving the following procedures: a) anamnesis, aiming at evidence of possible current or past use of psychotropic substances; b) objective clinical examination, aiming at finding evidence of recent (signs of acute or chronic intoxication) or past use (signs of withdrawal or associated organic pathologies) of psychotropic substances; c) double sampling of blood and urine and chemico-toxicological analysis using immunochemical, GC-HS and GC/MS-SIM techniques. As well as many data of social and behavioural interest, processing of results demonstrated that: a) 56.7% of the drivers examined had consumed alcoholic beverages; b) 30.4% had BACs higher than the threshold permitted in Italy (80 mg/100 ml); c) 15.7% of drivers were found to be under the influence of drugs of abuse or psychoactive drugs; d) the most frequently found substances were (in order): cannabinoids, stimulants (cocaine, amphetamines), opiates.

Fatality due to fentanyl-cocaine intoxication resulting in a fall

This is the first report of fatal intoxication by fentanyl and cocaine outside the USA. The case involved a fall caused by toxic psychosis. The circumstantial, clinical, anatomical, histopathological and toxicological frame-work is interpreted.