Pentobarbital overdose: A case of contract killing

Suicides by pentobarbital overdose have increased since about 2012, which appear to be influenced by technical information on active euthanasia that has spread over the Internet. We encountered a pentobarbital poisoning case of a patient with amyotrophic lateral sclerosis. A caregiver found the patient unconscious immediately after two visitors left the room. The patient was immediately transferred to the emergency hospital but eventually declared dead. A fatal concentration of pentobarbital was detected in peripheral blood samples collected in the emergency hospital and during autopsy (53.8 μg/mL and 29.4 μg/mL, respectively). Because the ratios of pentobarbital concentrations between the gastric contents and peripheral blood were 35 and 29 in the hospital and autopsy samples, respectively, it is likely that pentobarbital was administered via the gastrostomy tube. The patient had contacted the visitors through social media. Although the patient had requested the doctor perform active euthanasia and expressed a desire to end their life on social media, nobody had noticed the plan to commit suicide.     

Critical Appraisal of Network Meta-Analyses Evaluating the Efficacy and Safety of New Oral Anticoagulants in Atrial Fibrillation Stroke Prevention Trials

ObjectivesTo critically appraise published network meta-analyses (NMAs) evaluating the efficacy or safety of the new oral anticogulants (NOACs) dabigatran, rivaroxaban, and apixaban for the prevention of stroke in patients with nonvalvular atrial fibrillation (AF).MethodsA systematic literature review was performed to identify the relevant NMAs using MEDLINE, EMBASE, Cochrane Library, Database of Abstracts of Reviews of Effects, and Health Technology Assessment. The synthesis studies were evaluated using the “Questionnaire to assess the relevance and credibility of the NMA.”ResultsEleven NMAs evaluating NOACs among adults with nonvalvular AF were identified. Most NMAs included three large phase III randomized controlled trials, comparing NOACs to adjusted-dose warfarin (Randomized Evaluation of Long-Term Anticoagulation Therapy [RE-LY], Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation [ROCKET-AF], and Apixaban for Reduction of Stroke and Other Thromboembolic Events in Atrial Fibrillation [ARISTOTLE]). The main differences identified related to potential treatment effect modifiers regarding the mean time spent in therapeutic range (TTR) in the warfarin arm, the risk of stroke or systemic embolism across the trials (mean CHADS₂ score: C = congestive heart failure, H = hypertension, A = older than age 75 years, D = diabetes mellitus, S2 = prior stroke or history of transient ischemic attack) or primary versus secondary prevention, and type of populations used in the analysis. Kansal et al. [Kansal AR, Sharma M, Bradley-Kennedy C, et al. Dabigatran versus rivaroxaban for the prevention of stroke and systemic embolism in atrial fibrillation in Canada: comparative efficacy and cost-effectiveness. Thromb Haemost 2012;108:672–82] appropriately adjusted the ROCKET-AF TTR to match the RE-LY population on the basis of individual patient data. Meta-regressions are not expected to minimize confounding bias given limited data, whereas subgroup analyses had some impact on the point estimates for the treatment comparisons.ConclusionsResults of the synthesis studies were generally comparable and suggested that the NOACs had similar efficacy, although some differences were identified depending on the outcome. The extent to which differences in the distribution of TTR, CHADS₂ score, or primary versus secondary prevention biased the results remains unclear.     

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??Objective    To evaluate the efficacy of ropivacaine in extraction of mandibular impacted third molar. Methods    In this study 150 healthy patients who need to extract one mandibular impacted third molar were randomly divided into two groups. The experimental group was given 0.75% ropivacaine to get anesthesia??while the control group received 2% lidocaine. The time to onset and duration of action were noted. The visual analogue score??VAS??was recorded 30 min and 4 h after extraction. The rate of taking pain relieving drugs was noted. Blood pressure and pulse were monitored during the operation. Monitor the anesthetic complications and compare the anesthetic effect of the two drugs. Results               Ropivacaine had a significantly shorter onset and longer duration of oral anesthesia than lidocaine??P??0.05??. The experimental group had lower VAS 30 min and 4 h after operation??P??0.05??and fewer patients needed pain relieving drugs than the control group??P??0.05??. There was a slight decrease of the pulse in the experimental group 30 min postoperatively??P??0.05??. The pulse and blood pressure in the control group and the blood pressure in the experimental group had no obvious change. There was no complications in both groups. Conclusion    Ropivacaine may be suitable for time-consuming oral procedures because of its short onset??long duation??prolonged postoperative analgesia and minimal cardiovascular risk.