"Legal highs"-Toxicity in the clinical and medico-legal aspect as exemplified by suicide with bk-MBDB administration

The easily available "legal highs", which are products containing psychoactive substances, such as cathinones, piperazines and synthetic cannabinoids, are abused by adolescents in Poland and in the world as alternatives to classic drugs, such as amphetamines or marijuana. The majority of these potentially dangerous substances are still legal and they are associated with a risk of severe poisoning or even death, and provide new challenges in clinical and forensic toxicological practice. Investigations in the field of "designer drugs" may be well illustrated by the case of a suicide of a 21-year old male who ingested a specified dose of a preparation called "Amphi-bi-a" that contains bk-MBDB, chemically 2-methylamino-1-(3,4-methylenedioxyphenyl) butan-1-one, which belongs to the cathinone group, as a synthetic euphoric empathogen and psychoactive stimulant that is chemically similar to MDMA. It is one of more common components of "legal highs" examined in Poland and other countries. The documentation of the case includes a clinical assessment of the patient's health status performed during his almost 4-h hospitalization before death, autopsy and histological examinations supported by toxicological findings revealing bk-MBDB at extremely high concentrations (at 20mg/l in the blood and 33mg/kg in the liver); hence, this body of evidence contributes to knowledge in the field of "designer drugs". Inventions of designers of new psychoactive xenobiotics, which are much in demand, especially in view of the dynamic Internet marketing, which drums up narcobusiness, must be balanced by a national strategy developed by medical, legal and educational circles in the modern civilized world in order to prevent the spreading of the phenomenon.     

医疗事故技术鉴定专家出庭质证问题阐释

医疗事故技术鉴定专家出庭接受质证是法院审查、认定鉴定结论以及克服医疗事故技术鉴定自身中立性不足和程序不完善等问题的必然要求。鉴定专家出庭接受质证程序要体现交叉询问原则,同时,要引入专家辅助人、专家陪审员制度以构建均衡合理的质证主体结构。质证的内容应该围绕鉴定专家资格,鉴定结论的相关性、科学性、事实材料充分性、证明过程符合逻辑性等来展开。     

医疗事故技术鉴定专家出庭质证问题阐释

医疗事故技术鉴定专家出庭接受质证是法院审查、认定鉴定结论以及克服医疗事故技术鉴定自身中立性不足和程序不完善等问题的必然要求。鉴定专家出庭接受质证程序要体现交叉询问原则,同时,要引入专家辅助人、专家陪审员制度以构建均衡合理的质证主体结构。质证的内容应该围绕鉴定专家资格．鉴定结论的相关性、科学性、事实材料充分性、证明过程符合逻辑性等来展开。     

The methodological basis for the expert assessment of unfavourable outcomes of the treatment

Procedures of forensic medical examination are considered with special reference to the cases of unfavourable outcomes of the treatment and methodological basis of their expert assessment. The step-by-step analysis of the doctor's actions is proposed for their objective evaluation. The objective opinion of the expert commission should be based on the medical criteria for the doctor's actions.     

The use of alcohol and other psychoactive substances by victims of traffic accidents in Greece.

Alcohol is one of the main causes of traffic accidents worldwide. Its use decreases significantly the driving ability of an individual as well as the reflexes of a pedestrian increasing in this way the possibilities of their involvement in motor-vehicle accidents. The above possibilities are increased when a psychoactive substance has been taken in combination with alcohol due to their synergistic effect. The Laboratory of Forensic Medicine and Toxicology of the University of Athens is authorized to perform the toxicological investigation of traffic accidents that happen in the major part of Greece. The findings of the toxicological analyses that were performed in our laboratory during the years 1995 to 1997 are classified according to the alcohol concentration and the kind of psychoactive substance detected as well as to the gender and the age of the victims, drivers or pedestrians. The results of the above classification are evaluated and the conclusions regarding alcohol, drugs and traffic accidents in Greece are discussed thoroughly.     

Current status and prospects for developing chemical-toxicological (forensic chemical) studies in the Russian Federation

The authors discuss modern state and prospects of planning and carrying out research in forensic (toxicological) chemistry within the framework of practical forensic medical expert evaluation, state of forensic medical expert evaluation of alcohol and narcotic intoxication, and other pressing problems of forensic medical expert practice.     

Suicidal gunshot to the head while driving a car

A severe traffic accident occurred on the German autobahn. According to eye witnesses, the car had changed from the left to the right lane at 160 km/h before crashing into a thicket at full speed. In the car, a sports pistol was found in the footwell of the driver's side. The emergency doctor who performed the external examination of the victim's body found a gunshot wound in the region of the driver's right lower jaw. As the prosecutor released the body without further examination, the family of the suicide asked for an autopsy, which demonstrated a lethal suicidal gunshot to the head; toxicological tests proved a previous consumption of cocaine.     

医疗损害鉴定主体改革刍议

医疗损害鉴定主体,包括鉴定机构及鉴定人,是医疗损害鉴定制度改革的起点。医疗事故鉴定模式中的专家组并不是鉴定主体,但其合议制的实质对鉴定结论的科学性具有重要作用,应予保留。应改革鉴定结论形成机制,允许出具多样化的鉴定结论。医疗损害鉴定制度的改革应采取司法行政部门主管、司法鉴定机构组织鉴定工作、医学会推荐鉴定人的模式。由于医学的专业性极强,鉴定人应当来自于现任专职医务人员。在保证鉴定人中立性、公正性的同时,要重视保证医务人员参与鉴定工作的积极性。     

Death by smothering following forced quetiapine administration in an infant

We present a case of smothering of a 2-year-old male infant by his schizophrenic mother who was having a psychotic episode. In addition to the initial autopsy findings of conjunctival petechial hemorrhages, facial linear abrasions and bruises, and mucosal abrasions and bruises, expert odontologic examination revealed indentations of the cusps of central incisors and molars, providing additional evidence of smothering. The postmortem and toxicological examination revealed features of forced quetiapine administration. The case presented is the first case of forced administration of quetiapine described. Our case also highlights the value of expert forensic odontological examination.     

关于我国医疗过失与因果关系之鉴定和认定的思考

我国法律在医疗过失和因果关系的认定问题上,应坚持医疗＂专家＂判断和＂同行＂鉴定,旨力于构建平衡患者利益和医方利益的规则,区分医疗专家意见和法官法律判断,区分违反通常诊疗义务的医疗侵权和违反告知义务的医疗侵权,区分＂合理医生＂标准、＂医疗水平＂标准和＂医疗常规＂标准。     

医疗损害鉴定主体改革刍议

医疗损害鉴定主体,包括鉴定机构及鉴定人,是医疗损害鉴定制度改革的起点。医疗事故鉴定模式中的专家组并不是鉴定主体．但其合议制的实质对鉴定结论的科学性具有重要作用,应予保留。应改革鉴定结论形成机制,允许出具多样化的鉴定结论。医疗损害鉴定制度的改革应采取司法行政部门主管、司法鉴定机构组织鉴定工作、医学会推荐鉴定人的模式。由于医学的专业性极强,鉴定人应当来自于现任专职医务人员。在保证鉴定人中立性、公正性的同时,要重视保证医务人员参与鉴定工作的积极性。     

Thermometry of cadavers

The purpose of this study was to analyze the norm-setting documents on the order of thermometry, regulating the steps of physician during examination at the site where the cadaver was found and of medical expert during expert evaluations and to disclose the relationship between the depth to which the thermometer is inserted during measurements of rectal temperature and thermometry value. The following conclusions are made: 1) even at the same time of death, the data of rectal thermometry are in direct proportion to the depth to which the thermometer is inserted into the rectum; 2) some assumptions in the norm-setting documents regulating the order of cadaver thermometry are to be revised; and 3) thermometers and method of thermometry performed by medical specialists at the site of accident and by experts at thanatological departments of Bureaus of Forensic Medical Expert Evaluations are to be standardized.     

Chapter 2: The Legal Position and Organizational Forms of Forensic Psychiatric Expert Examination

The practical task of forensic psychiatry, which is one of the subdivisions of psychiatry, is to give an expert evaluation, on assignment from investigatory agencies and courts, and to devise and recommend measures for the prevention of socially dangerous acts by the mentally ill. Forensic psychiatric expert examination, like forensic medical, criminal, or any other type of expert examination, aids agencies of justice in establishing the facts in a case. Forensic psychiatric expert examination is called upon to assist the investigator and the court in determining whether an individual is a criminal or a legally irresponsible, mentally ill person; whether a person sentenced to a prison term should, because of mental illness, be released before his time is served; whether the investigator and the court may pursue the interrogation of a witness or victim with mental disorders, and whether the testimony of such persons may be used as court evidence. Such an expert examination is necessary in a civil suit in deciding the question of an individual's competence.     

Drug Recognition Evaluation and Chemical Confirmation of a 25C‐NBOMe‐Impaired Driver

This case report details an individual arrested for drug‐impaired driving after leaving the scene of multiple motor vehicle collisions and evading police. The driver was examined by a drug recognition expert and failed the drug recognition evaluation. The driver admitted to using cocaine, marijuana, an antidepressant medication and “N‐bomb,” a novel psychoactive substance that possesses hallucinogenic properties. Toxicological analyses at the Centre of Forensic Sciences’ Toronto laboratory revealed only the substance 2‐[4‐chloro‐2,5‐dimethoxyphenyl]‐N‐[(2‐methoxyphenyl)methyl]ethanamine (25C‐NBOMe) in the accused's urine. This is the first report in which 25C‐NBOMe was identified through DRE and toxicological analyses in a drug‐impaired driver.     

Swollen Lips After a Night of Partying—An Allergic Reaction to Ecstasy?

Ecstasy (MDMA) is a mood‐lifting drug with numerous somatic side effects, for example, dehydration or continuous chewing and biting. We describe the case of a young woman who underwent a forensic medical examination for suspected sexual assault. She claimed to have suffered from a memory lapse, and she had a painful swelling of her lips with a plaque‐like coating on her lips and buccal mucosa. The attending physician suspected that these findings might have been caused by strong sucking pressure on her lips within the context of a sexual assault. A toxicological examination of a blood specimen verified that she had been under the influence of an extremely high dose of ecstasy (1.456 mg/L MDMA and 0.0213 mg/L MDA). Pursuant to the forensic medical assessment, the described findings on her lips, and buccal mucosa were interpreted as an allergic and mechanical reaction (through continuous chewing and biting) to ecstasy.     

Defining the limits: the clash between a doctor’s duty to preserve life and enforcement of a patient’s religious belief

This article examines the question whether, under Nigerian law, a doctor has a duty to save the life of a patient whose refusal of medical treatment will inevitably lead to death. An affirmative answer is suggested after an examination of relevant Nigerian laws on the subject matter. Mindful of developments in this area of law in some other jurisdictions, this article concludes that there is scope for the amendment of relevant Nigerian laws to institutionalise a patient’s unqualified prerogative to give informed consent. It however cautions that, in the light of complex social challenges, Nigeria does not appear ready for such a change.     

Reporting a sudden death due to accidental gasoline inhalation

The investigation of uncertain fatalities requires accurate determination of the cause of death, with assessment of all factors that may have contributed to it. Gasoline is a complex and highly variable mixture of aliphatic and aromatic hydrocarbons that can lead to cardiac arrhythmias due to sensitization of the myocardium to catecholamines or acts as a simple asphyxiant if the vapors displace sufficient oxygen from the breathing atmosphere. This work describes a sudden occupational fatality involving gasoline. The importance of this petroleum distillate detection and its quantitative toxicological significance is discussed using a validated analytical method. A 51 year-old Caucasian healthy man without significant medical history was supervising the repairs of the telephone lines in a manhole near to a gas station. He died suddenly after inhaling gasoline vapors from an accidental leak. Extensive blistering and peeling of skin were observed on the skin of the face, neck, anterior chest, upper and lower extremities, and back. The internal examination showed a strong odor of gasoline, specially detected in the respiratory tract. The toxicological screening and quantitation of gasoline was performed by means of gas chromatography with flame ionization detector and confirmation was performed using gas chromatography-mass spectrometry. Disposition of gasoline in different tissues was as follows: heart blood, 35.7 mg/L; urine, not detected; vitreous humor, 1.9 mg/L; liver, 194.7 mg/kg; lung, 147.6 mg/kg; and gastric content, 116,6 mg/L (2.7 mg total). Based upon the toxicological data along with the autopsy findings, the cause of death was determined to be gasoline poisoning and the manner of death was accidental. We would like to alert on the importance of testing for gasoline, and in general for volatile hydrocarbons, in work-related sudden deaths involving inhalation of hydrocarbon vapors and/or exhaust fumes.     

n‐Ethyl Pentylone‐Related Deaths in Alabama

n‐Ethyl pentylone (NEP) is a chemical substance derived from cathinone. Synthetic cathinones are an evolving group of drugs with stimulating, mind‐altering effects sometimes referred to as novel or new psychoactive substances (NPS). There is scarce information in the medical literature regarding forensic cases in which NEP is detected in toxicological testing. We present four fatalities involving NEP from Alabama in 2017. Deaths were attributed to NEP toxicity in two cases (peripheral blood concentrations of 0.121 and 0.953 mg/L) and injuries caused by gunshot wounds in two cases (peripheral blood concentrations of 0.045 and 0.031 mg/L). One case involving NEP described an individual who exhibited classic CNS‐stimulant induced erratic behavior before being found dead. These cases enhance the forensic literature regarding specific NPS like NEP and provide contextual reference for professionals considering the significance of NEP in toxicological interpretation.     

Basic approaches to medical,forensic, and biomechanical studies in expert evaluation of a car injury

Modern approaches to forensic medical expert evaluation of car injuries are discussed. Many problems remain unsolved after examination of injuries in victims inside the car, which negatively tells on the versions suggested during criminal investigation of car accidents. The experts often neglect the most sensitive methods for evaluation of these injuries and many fundamental approaches to the problem: differential diagnosis of primary and secondary injuries; basic medical and biomechanical methods and studies of the clues; fundamentals of total systems evaluation of the results of forensic medical expert evaluation.     

Reasons, circumstances and results of repeat forensic medicine autopsy

There are only scant literature data on reasons and circumstances of medico-legal second autopsies. The present study includes 12 second autopsies from the period 1992-1997; the first post-mortem examination took place either in the home country (institutes of pathology) or abroad. 7 of the 12 cases of death investigated happened in Germany (exclusively in hospitals) and 5 of them abroad (Netherlands, Romania, Portugal, Libya). Repeat autopsies were ordered by criminal courts (n = 9), private persons (n = 2) and social insurances (n = 1). The main indication was possible medical malpractice (n = 6); acts of violence (n = 3), insurance questions (n = 2) and accidents (n = 1) followed. The time lapse between death and second autopsy was 2-35 days. It was striking, that German institutes of pathology had partially performed autopsies despite the certification of a non-natural death. Clinical autopsies were stopped twice, when evidence of a possible non-natural death occurred. It could be fundamentally stated, that first autopsies in German institutes of pathology had been carefully performed and sufficiently documented. In these cases the second autopsy presented no or only little additional information, as far as the broader taking of (toxicological) samples is not considered. The final medico-legal expertise was then mainly based on the findings of the clinical first autopsy. However, the concurrence of the forensic expert (instead of the clinical pathologist) is undoubtedly essential for the evaluation of these issues involving frequently questions of malpractice. By contrast, the quality of postmortems performed abroad varies widely. 4 of the 5 first autopsies done abroad were regarded as completely or partly insufficient with superficial or almost absent preparation of organs or contradictions in the medical reports, respectively. A repeat autopsy is absolutely necessary in such cases. On the whole, the initial question could be answered in all second autopsies at least in part. This emphasizes the high value of second autopsies and expertises, especially in non-natural cases of death (10 of 12 deaths were finally judged as non-natural).