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- Dental abscess and “unexpected death”...Publication . Costa, Margarida; Henriques de Gouveia, Rosa; Simoes Da Silva, Beatriz; Monsanto, Paula Venâncio; Cordeiro, Cristina; Corte Real, F.Even though we are living in an era of major technical-scientific advances and effective antimicrobial and antiviral therapy,dental infections are still the most important predisposing factors for head and neck infections. Odontogenic infections can cause severe complications, e.g. compromised airways, tissue necrosis, deep neck infections, mediastinitis, endocarditis and sepsis. These severe odontogenic infections can be potentially life-threatening. Usually odontogenic infections respond well to a combination of surgical treatment (incision, rainage) and antibiotic therapy. However, especially when the medico-surgical therapy is installed late, cases may evolve unfavourably and be fatal. The authors report a case of a 30-year-old man who was observed on three consecutive occasions by the General Practitioner in a District Hospital, for a decayed tooth with abscess and was, then, referred to a Central Hospital. There, he was examined for the fourth time, this one by a Stomatologist at the Emergency Department, where he died. The post mortem examination revealed bacterial (Gram +) acute neutrophilic (purulent) infection of soft tissues of the mandibular region and neck with para-tracheal extension, as well as thrombosis ofthe left jugular vein. Circumstantial clinical information, post mortem findings, pathophysiology (including complications andprogression of the disease to death) are discussed, highlighting the relevance of accurate and timely diagnosis and treatmentto avoid malpractice and mortality.
- Suicide by self-administration of pethidine, propofol and anxiolytics : a case reportPublication . Proença, Paula; Castanheira, Alice; Castanheira, Fernando; Monteiro, Carla; Simoes Da Silva, Beatriz; Franco, João Miguel; Corte Real, FranciscoBackground and aim: Recreational use of anesthetic and sedative agents in health care practitioners is becoming an increasing problem due to its easy availability and, therefore, they become vulnerable to misusing or abusing of these drugs. The authors present a fatal case involving a a 50-year-old man, nurse, found dead in a hospital room, in supine position, with intravenous access devices in the forearm that were attached to two packages of saline solutions. Some empty packages were close to the victim. A white viscous fluid found at the death scene was send to analysis. The expert's investigation at the scene indicated possible propofol poisoning. Methods: The blood samples were initially subjected to a qualitative analysis. A systematic toxicological drug screening was carried out in blood with a combination of enzyme immunoassays (ELISA) and liquid chromatography-tandem mass spectrometry (LC-MS/MS) analysis. Femoral blood alcohol concentration was measured by gas chromatography with headspace (GC/FID) technique. Due to suspected propofol intoxication, a specific analytical methodology was developed in order to detect and quantify this substance in the postmortem samples. Chromatographic analysis of propofol was preceded by protein precipitation of 0.1 mL of blood samples with acetonitrile. Chromatographic separation was achieved with a reversed-phase column, using a gradient elution of 2 mM aqueous ammonium formate (0.1% formic acid), and 2mM ammonium fluoride in methanol, at a flow rate of 0.4 mL/min, with a run time of 10 minutes. Results and discussion: Toxicological results revealed the presence of the anesthetic (propofol) in femoral blood (33.5 mg/L) and heart blood (113.3 mg/L), and also in the white viscous fluid found at the death scene. The remaining laboratory analyses revealed the presence of nordiazepam, temazepam and metoclopramide in therapeutic concentrations, but toxic blood concentrations of midazolam (1473 μg/L), diazepam (5182 μg/L) and pethidine (8622 μg/L). The blood alcohol analysis result was positive (0.18 g/L) as well as positive for opiates (morfine < 25 μg/L). Pesticides were not present in the analysed samples. Conclusion: The development of the method for confirmation and quantification of the anesthetic propofol was crucial given the suspicion of poisoning by this substance. However, laboratory analysis has also revealed the simultaneous presence of an opioid analgesic agent (pethidine) and anxiolytics in high blood concentrations. These findings have allowed to identify a case where several drugs were abused and whose synergy of effects and intoxication, that were not considered at first, were lately found to have contributed to the medico-legal etiology of suicide.