Biomedical subjects
Publications and source records attributed to J A Perper.
The mechanisms thought to be responsible for cocaine-associated gastrointestinal injury are presented. In addition, the literature available concerning the enteric consequences of cocaine use is reviewed.
The mechanisms evaluated in animals as being responsible for cocaine associated hepatotoxicity are presented. The importance of the P-450 enzyme system in cocaine associated hepatotoxicity is emphasized. Moreover, the putative critical role of free radicals in such injury is discussed. Finally, the growing literature on clinical cases of cocaine hepatotoxicity is reviewed.
Cardiovascular complications are among the most common and dangerous complications of cocaine abuse, ranging from episodic arrhythmias to myocardial infarction, strokes, cardiomyopathy, and sudden death. The central nervous system-mediated action of cocaine triggers an increase in circulating catecholamines, resulting in arterial vasoconstriction, increase in myocardial oxygen demand, myocardial ischemia, tachycardia, and other arrhythmias. The peripheral cardiovascular action of cocaine involves the inhibition of reuptake of catecholamines at adrenergic nerve terminals, with local release of epinephrine, direct stimulation and vasospasm of the coronary arteries, coronary intimal hyperplasia, inhibition of baroreceptors, interference with the electrical conduction through the myocardium, and direct myocardial toxicity. The cardiovascular complications of cocaine include cardiac dysrhythmias and hypertension, acute myocardial infarction, myocarditis, infectious endocarditis, ventricular dysfunction, dilated cardiomyopathy, hypotensive shock, and cerebral strokes. Cocaine-related vascular changes in the pregnant woman and fetus have been related to an increased incidence of abortion, abruptio placentae, and congenital anomalies of the fetus.
Upper respiratory and pulmonary complications of cocaine addiction have been increasingly reported in recent years, with most of the patients being intravenous addicts, users of freebase, or smokers of "crack." The toxicity of cocaine is complex and is exerted via multiple central and peripheral pathways. Recurrent snorting of cocaine may result in ischemia, necrosis, and infections of the nasal mucosa, sinuses, and adjacent structures. Pulmonary complications of cocaine toxicity include pulmonary edema, pulmonary hemorrhages, pulmonary barotrauma, foreign body granulomas, cocaine related pulmonary infection, obliterative bronchiolitis, asthma, and persistent gas-exchange abnormalities. Respiratory manifestations are nonspecific and include shortness of breath, cough, wheezing, hemoptysis, and chest pains. Severe respiratory difficulties have been reported in neonates of abusing mothers. In the absence of a cocaine-abuse history, it may be difficult to recognize the etiological role of cocaine, especially in the absence of needle tracks pointing to previous intravenous drug abuse and/or negative toxicology.
A rapid method of identification by using computerized videotape erasure of mutilating injuries is presented. The identification of a human head, which was mutilated and severed in two major fragments, illustrates the application of the method. Following the reconstruction and suturing of the head fragments, the face was videotaped and the mutilating injuries were electronically erased. The televised broadcasting, in color, of the reconstructed face, free of injuries, elicited prompt visual identification by relatives of the deceased within < 1 h.
A case of sudden death associated with fatty liver and encephalopathy is described in a 4-year old white boy with medium-chain acyl-coenzyme A dehydrogenase (MCAD) deficiency. The death was caused by hypoglycemia triggered by fasting and vomiting associated with a minor viral infection. The differential diagnosis of the hepatoencephalopathy is discussed in relation to other conditions, especially Reye's syndrome. The forensic pathologist should be familiar with MCAD and other deficiencies of beta-oxidation of fatty acids as a cause of sudden unexpected death in children in order to advise parents in genetic counseling to prevent disability or death of other affected, but still asymptomatic siblings.
OBJECTIVE: The presence of guns in the home, the type of gun, and the method of storage were all hypothesized to be associated with risk for adolescent suicide. DESIGN: Case-control study. SUBJECTS: The case group consisted of 47 adolescent suicide victims. The two psychiatric inpatient control groups were 47 suicide attempters and 47 never-suicidal psychiatric controls, frequency-matched to the suicide victims on age, gender, and county of origin. SETTING: The cases were a consecutive community sample, whereas the inpatients were drawn from a university psychiatric hospital. MAIN OUTCOME MEASURE: Odds of the presence of guns in the home of suicide victims (cases) relative to controls. RESULTS: Guns were twice as likely to be found in the homes of suicide victims as in the homes of attempters (adjusted odds ratio, 2.1; 95% confidence interval, 1.2 to 3.7) or psychiatric controls (adjusted odds ratio, 2.2; 95% confidence interval, 1.4 to 3.5). Handguns were not associated with suicide to any statistically significantly greater extent than long guns. There was no difference in the methods of storage of firearms among the three groups, so that even guns stored locked, or separate from ammunition, were associated with suicide by firearms. CONCLUSIONS: The availability of guns in the home, independent of firearms type or method of storage, appears to increase the risk for suicide among adolescents. Physicians should make a clear and firm recommendation that firearms be removed from the homes of adolescents judged to be at suicidal risk.
An unusual case of an exertional heatstroke in a healthy 25-year-old man is presented. Initially, the patient was deeply comatose and developed severe rhabdomyolysis and massive hepatic necrosis. Subsequently, he received a liver transplant with remarkable improvement in his mental status, although the rhabdomyolysis continued. The patient died 41 days after the transplant due to a complicating infection. Providing that infections can be effectively controlled, liver transplants might be a promising therapeutic alternative for the few patients who survive the initial neurological consequences of this unusual event.
A case of rhabdomyolysis induced by exertional heat stroke in a police officer recruit is reported. Technetium-99m methylene diphosphonate scintigraphy demonstrated marked uptake of the injured skeletal muscle. This bone-scanning agent provided an excellent means of localizing and evaluating the muscle injury of rhabdomyolysis. Nuclear medicine physicians should be aware of the special conditions and causes in which bone scan may demonstrate striking findings.
Impotence, infertility and feminization have been frequently reported among male cirrhotic patients. Previous studies have suggested that liver disease was the basis of these effects. Recent clinical and laboratory experimental studies have suggested that alcohol consumption may have a direct effect on both testosterone metabolism and spermatogenesis. The effect may be mediated through the central nervous system or directly on the testes. The present study compared the pathology in the liver and testes and the estimated alcohol consumption among men who had died suddenly from a variety of causes. Of 137 men studied, 20(14%) had moderate to severe decrease in spermatogenesis. Only 9 of 19 with decreased spermatogenesis also had severe or very severe fatty infiltration of the liver. However, 17 of 19 were classified as heavy alcohol drinkers and 14 were estimated to consume at least 417 gm of alcohol per week. Finally, the alcohol history was reviewed in relation to liver and testicular pathology. Only a weak association between the liver and testes pathology was noted.
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Extensive demographic data concerning homicide victims and perpetrators in Allegheny County, 1966-1974, were obtained retrospectively from the records of the County Coroner's Office and Police Department. Analysis revealed that the demographic characteristics describing perpetrators and victims were essentially identical. Rates of homicide peaked in the young adult years of life. The race ratio (B/W) among victims was 18.7 for males and 6.7 for females, while sex ratio (M/F) was 5.4 for blacks and 1.9 for whites. An inverse relationship between the rate of homicide and socioeconomic status was present among both black and white races. The majority of victims were killed by a spouse, relative, or friend (66%), usually in familiar locations, i.e., residence or place of work (60%), and usually during an alteration (68%). Shooting was the method used to perpetrate 61% of the killings, most of which were by means of a handgun. An increasing trend of homicide was noted, particularly for the type perpetrated by shooting.
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A study of the relationship between carbon monoxide exposure and heart attacks was conducted in Baltimore. There was no evidence of clustering of either myocardial infarction or sudden ASHD on a specific day, nor was there correlation between the number of cases per day and ambient CO levels. Postmortem HbCO levels were slightly higher in ASHD sudden deaths than in sudden deaths due to other causes. Any differences were probably primarily due to cigarette smoking. Cigarette smokers who died suddenly due to ASHD had substantially higher postmortem HbCO levels than nonsmokers. Practically all of the elevated HbCO levels could be related to cigarette smoking or specific environmental exposure. There were no differences between HbCO levels in ASHD sudden death patients and in living controls. There was also no relationship between cardiac pathologic findings and postmortem HbCO levels among patients dying suddenly of ASH.
Thirty-seven cases of unexpected, unexplained death in epileptic patients were recorded by the Allegheny County Coroner's Office during the years 1969 through 1973. In no case was there anatomic or chemical evidence at autopsy sufficient to explain death. All patients had a duration of epilepsy greater than a year. All but two had less than one seizure per month. Blood levels of anticonvulsants at autopsy revealed only three patients with therapeutic levels of the drugs. Almost 50 percent of the cases studied had no demonstrable anticonvulsant. It is suggested that inadequate levels of anticonvulsant drugs are a significant factor associated with unexpected, unexplained death in epileptic patients.
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The authors graphically studied the topographic pattern and severity of coronary arteriosclerosis in arteriosclerotic heart disease (ASHD) sudden deaths using an improved technique involving in toto removal and decalcification of the main coronary tree. The study involved 171 cases of ASHD sudden death and 154 deaths from other causes. White males were the most severely affected group. The majority of the ASHD deaths had three or four major coronary vessels showing greater than 75% luminal stenosis; single-artery disease was a rare occurence. The intra- and interarterial pattern of coronary stenosis was equally severe and diffuse, with the exception of the arteries to SA and AV nodes. No small intramyocardial blood vessel disease was evident. Severe chronic coronary stenosis was associated with a high incidence of old myocardial infarction. The anatomical and pathological pattern of coronary stenosis in ASHD deaths appears to have ominous therapeutic implications.