Criminal poisoning of commuters in Bangladesh: prospective and retrospective study

Travel-related poisoning is an emerging social and public health emergency in Bangladesh but its cause and significance have not been determined. To investigate this syndrome we performed a prospective clinical study and retrospective analysis of hospital records in a general medicine unit of a public tertiary care teaching hospital in Dhaka, Bangladesh, using toxicological analysis by fluorescence polarization immunoassay (FPIA) and liquid chromatography coupled to time-of-flight mass spectrometry (LC-TOF MS). The participants of the prospective study were 130 consecutive patients aged 16-80 years who were admitted with central nervous system depression (Glasgow Coma Score 3-14) after using public transportation, in the absence of other abnormalities, from January through June 2004, and a convenience sample of 15 such patients admitted during 3 days in May 2006. In 2004-2006, travel-related poisoning increased from 6.1 to 9.5% of all admissions (210-309 of 3266-3843 per year), representing 46.6-55.7% of all admitted poisoning cases. Incidents were associated with bus (76%), taxi, train, and air travel, or local markets; 98% of patients remembered buying or accepting food or drinks before losing consciousness. Direct financial damage (missing property) was diverse and frequently existential. Among 94 urine samples analyzed by FPIA, 74% tested positive for benzodiazepines. Among 15 urine samples analyzed by LC-TOF MS, lorazepam was detected in all; five also contained diazepam or metabolites; nitrazepam was present in three. FPIA results obtained for these 15 samples were below the recommended cut-off in eight (53%; lorazepam only). Our findings show that the massive medicosocial emergency of travel-related poisoning in Bangladesh is the result of drug-facilitated organized crime and that benzodiazepine drugs are used to commit these crimes, suggesting modifications to the local emergency management of the victims of this type of poisoning. They also highlight the need for more research in the neglected field of acute poisoning in Bangladesh, and for criminal investigations of the use of benzodiazepine drugs in this country.     

Mental health weapons prohibition: demographic and psychiatric factors in petitions for relief

Federal law and most states prohibit possession of firearms by individuals with a history of certain psychiatric diagnoses and/or treatment. In California, an involuntary 72-h hold can trigger a 5-year ban on firearm possession. Individuals so prohibited may petition for early termination of the ban. We report on the demographic and psychiatric characteristics of a sample of individuals petitioning for early relief in Los Angeles County, and on the results of their petitions. The majority of petitioners were Caucasian men over age 40. Sixteen percent of petitioners were employed in law enforcement or armed security, and all of their petitions were granted. Individuals for whom there was greater evidence of mental disorder were significantly less likely to petition successfully. The results are discussed in terms of the benefits of involving a forensic expert in the petition process, which is not presently required under California law.     

Coronal cleft vertebra initially suspected as an abusive fracture in an infant

A case of a four-month-old male infant is described who was found unresponsive at home and brought to the emergency room. He lived for four days. During his hospital admission he was diagnosed by radiography with a fracture of the third lumbar vertebra that was presumed abusive in nature. Autopsy examination failed to confirm a fracture. However, a defect in the development of the vertebral bodies was discovered. He was diagnosed with possible failure of the notochord to regress, a condition with no significant sequelae. The cause of death was certified as sudden infant death syndrome after full investigation, and all autopsy studies were negative.     

Death caused by myocarditis in Wayne County, Michigan: a 9-year retrospective study

This paper reviews 72 cases of death caused by myocarditis between the years 1996 and 2004, autopsied at the Office of the Wayne County Medical Examiner in Michigan. Myocarditis as a cause of sudden and unexpected death represented 1.3% of all natural deaths in Wayne County during said period. The year 1999 contained the highest number of deaths of this cause (18), where the average number of myocarditis deaths was 8 per year for this 9-year span. In this study, each case was reviewed based on information gathered from investigative, autopsy, and toxicology reports. Significantly, 58% of these cases were male, and 63.4% were African American. Myocarditis caused death in every age group between 7 months and 67 years, but adults between the ages of 19 and 67 were most significantly affected (75%). Flu and/or cold were the most common symptoms experienced in the days directly proceeding death (28%), followed by shortness of breath (17%) and sudden collapse (15%). Sixty-nine percent of these 72 cases were pronounced dead after ACLS (advanced cardiac life support) protocol by emergency medical services or hospital attendants. Cardiomegaly was observed in 24 cases of adults aged 19 or older (54%), and flabby/soft myocardial tissue was observed grossly in 16% of all 72 cases.     

Integrating DSM-IV Factors to Predict Violence in High-Risk Psychiatric Patients

Abstract:  This study incorporated Axis-II and Axis-IV factors in DSM-IV to test the relationship between predicted risk for violence assessed in the psychiatric emergency room and actual violence during hospitalization. Psychiatric nurses lack an objective instrument to use during the acute psychiatric assessment. The retrospective study comprised consecutive psychiatric admissions ( n  = 161) in one tertiary veterans' hospital. Statistical testing for the predictive power of risk factors, relationships between variables, and violent events included nonparametric tests, factor analysis, and logistic regression. Of the 32 patients who committed violence during hospitalization, 12 had committed violence in the psychiatric emergency room. Statistical significance was shown for violent incidents and dementia, court-ordered admission, mood disorder, and for three or more risk factors. The 13-item Risk of Violence Assessment (ROVA) scale suggests validity and sensitivity for rating DSM-IV factors and psychosocial stressors to predict risk for violence during hospitalization. Replication studies are recommended to strengthen validity of the ROVA scale.     

Pseudo-subarachnoid hemorrhage of the head diagnosed by computerized axial tomography: a postmortem study of ten medical examiner cases

In this report, we describe ten cases of pseudo-subarachnoid hemorrhage on computer axial tomography (CT) scan of the head. A pseudo-subarachnoid hemorrhage is a false positive finding by CT of the head in which the scan is interpreted as being positive for a subarachnoid hemorrhage not substantiated by subsequent neuropathologic findings. This study is a retrospective review of postmortem cases brought into the Office of the Chief Medical Examiner for the State of Maryland over a three-year period (from 1997 to 2000). We compared the clinician's impression of the CT scan with the postmortem neuropathology. The clinical diagnosis of subarachnoid hemorrhage was based on misinterpretation of non-contrast CT scans of the head. In six of the ten cases, the reading was performed by a radiologist and in four cases by nonradiologist physicians (emergency room physician, neurologist, or neurosurgeon). All the patients survived between a few hours to a few days after being admitted to the hospital. For most of the cases (80%), the neuropathology showed hypoxic/ischemic encephalopathy. The most common cause of death (four out of ten cases) was narcotic intoxication. This report is submitted so that clinicians and pathologist become more familiar with this entity.     

Accidental fire deaths. The 5-year Metropolitan Dade Country experience from 1979 until 1983

Accidental fire deaths that occurred in Metropolitan Dade County, encompassing Miami, Fla., USA, during the years from 1979 until 1983 were studied. A total of 108 cases were collected, representing 6.1% of the nontraffic-related accidents during this 5-year period, and analyzed as to the age, race, sex, cause of death of the victim along with the blood alcohol content at autopsy, toxicologic analysis, location of the fire, and how the fire started. Essentially, the victims ages cluster in the 0-5 years and does 70 years, although other age groups are evenly distributed. A white male population predominates. The cause of death is listed as either smoke inhalation or thermal injury. Most toxicologic analyses were not performed due to the high rate of fire rescue intervention and at least emergency room hospitalization prior to death. Carboxyhemoglobin levels, when analyzed, ranged from less than 20% to over 80%. In a smaller group of cases, cyanide was analyzed for and was found negative (or none detected) in the majority of the cases. More fires occurred in residences and started due to cigarette smoking or electric malfunction.     

The reliability of immunoassay for determining the presence of opiates in the forensic setting

Urine immunoassays are commonly used as a rapid screen for drugs of abuse in emergency room, hospital, clinic, and forensic settings. The authors were concerned whether or not a negative screen of the urine for opiates was of significance and indicative that analysis of blood for opiates was not necessary. Specifically, we wished to determine whether a negative test for opiates by immunoassay absolutely rules out an acute overdose, and if not, what percentage of cases with negative results have opiates in the blood. A retrospective analysis was performed using the toxicology results for cases ruled an acute narcotic overdose at the Bexar County Medical Examiner's Office between 1998 and 2003. One hundred eighty-three cases met the criteria for the study. A false-negative rate of approximately 15% was found using an immunoassay as compared with blood analysis for narcotics. The authors feel that while this rate may be acceptable in a clinical setting, it is unacceptable in a forensic setting.     

创新信访制度的理性构想

伴随着信访量的居高不下,信访制度的改革与创新越来越受到关注。对此,本课题组在充分调研、深入剖析的基础上,提出创新信访制度的理性构想：通过建立党政、人大和司法信访制度三位一体的格局,建构民众利益表达机制,实现民众与政府之间的信息沟通,解决政府与民众的矛盾纠纷;通过健全和完善信访工作长效机制,进一步拓宽信访工作渠道,实现信访工作的快捷与有效;强化县级组织在解决信访问题方面的作用,将信访矛盾稳定在当地,化解在基层;实行信访干部定期轮岗制度,建设高素质的信访干部队伍。     

Sudden death caused by embolization of trophoblast from hydatidiform mole

A 16-year-old pregnant female presented to a hospital emergency room with vaginal bleeding and uterine cramping. She underwent a hysterotomy and curettage and, during the procedure, her pulse dropped from 130 to 30 beats/minute, her pO2 fell to 10 mm of mercury, and she could not be resuscitated. At autopsy, she was found to have massive pulmonary embolization of syncytiotrophoblast from a hydatidiform mole of the uterus. This is the sixth reported case of trophoblastic embolization from a hydatidiform mole ending in death. This fatal termination may occur after a period of respiratory symptoms and may occur regardless of the mode of treatment.     

The designer drug situation in Ibiza

A total of 137 urine samples and 46 serum samples, corresponding to 154 self-confessed designer drugs consumers in Ibiza island, were analyzed for the presence of designer drugs: amphetamine and amphetamine derivatives (methamphetamine, methylenedioxymethamphetamine (MDMA), methylenedioxyethylamphetamine (MDEA), methylenedioxyamphetamine (MDA), p-methoxymethylamphetamine (PMMA), p-methoxyamphetamine (PMA), etc.), ketamine and gamma-hydroxybutyric acid. Among this population, coming both from the forensic clinic and from the emergency room of a hospital, a total of 99 cases were found positive for some designer drug. This study shows the prevalence of methylenedioxymethamphetamine (MDMA) among designer drug users, sole or in association with other drugs. Also, the mixture of MDMA with other designer drugs, ethanol and/or cocaine is shown to be more likely to produce toxic symptoms requiring clinical attendance in a hospital emergency room. These findings along with the consumption history, the concentrations of drugs and metabolites in urine and serum and the toxicological significance for the interpretation of some MDMA metabolites such as 4-hydroxy-3-methoxymethamphetamine (HMMA) are discussed in this study.     

Protection orders protect against assault and injury: a longitudinal study of police-involved women victims of intimate partner violence

The objective of this study was to measure the efficacy of protection orders (POs) in reducing assault and injury-related outcomes using a matched comparison group and tracking outcomes over time. This study was a retrospective review of police, emergency department, family court, and prosecutor administrative records for a cohort of police-involved female IPV victims; all events over a 4-year study period were abstracted. Victims who obtained POs were compared with a propensity-score-based match group without POs over three time periods: Before, During, and After the issuance of a PO. Having a PO in place was associated with significantly more calls to police for nonassaultive incidents and more police charging requests that were of multiple-count and felony-level. Comparing outcomes, PO victims had police incident rates that were more than double the matched group prior to the PO but dropped to the level of the matched group during and after the order. ED visits dropped over time for both groups. This study confirmed the protective effect of POs, which are associated with reduced police incidents and emergency department visits both during and after the order and reduced police incidents compared with a matched comparison group.     

Fatal Disseminated Cryptococcus as the Initial Presentation of HIV Infection in the Era of Highly Active Antiretroviral Therapy

Abstract:  Despite the availability of highly active antiretroviral treatment, many HIV-positive patients still present for the first time with a low CD4 count or an acquired immune deficiency syndrome (AIDS) defining illness. This may be due to patients' refusal to be tested for HIV, delay in seeking medical treatment, or the misdiagnosis of an AIDS-associated condition. We present a 39-year-old African American male with undiagnosed HIV, who died shortly after arrival to the emergency room. An autopsy was performed at the Dallas County Medical Examiners' Office, and the cause of death was determined to be disseminated cryptococcosis. Further investigation at autopsy revealed HIV 1/2 antibody positivity and HIV western blot positivity. This case demonstrates the importance of considering complications of HIV as a cause of death, even when the patient has no prior history.     

The designer drug situation in Ibiza

A total of 137 urine samples and 46 serum samples, corresponding to 154 self-confessed designer drugs consumers in Ibiza island, were analyzed for the presence of designer drugs: amphetamine and amphetamine derivatives (methamphetamine, methylenedioxymethamphetamine (MDMA), methylenedioxyethylamphetamine (MDEA), methylenedioxyamphetamine (MDA), p-methoxymethylamphetamine (PMMA), p-methoxyamphetamine (PMA), etc.), ketamine and γ-hydroxybutyric acid. Among this population, coming both from the forensic clinic and from the emergency room of a hospital, a total of 99 cases were found positive for some designer drug. This study shows the prevalence of methylenedioxymethamphetamine (MDMA) among designer drug users, sole or in association with other drugs. Also, the mixture of MDMA with other designer drugs, ethanol and/or cocaine is shown to be more likely to produce toxic symptoms requiring clinical attendance in a hospital emergency room. These findings along with the consumption history, the concentrations of drugs and metabolites in urine and serum and the toxicological significance for the interpretation of some MDMA metabolites such as 4-hydroxy-3-methoxymethamphetamine (HMMA) are discussed in this study.     

Detection of medical examiner cases from review of cremation requests

Title 9, Chapter 19, Article 3 of the Arizona Administrative Code requires all bodies that are to be cremated must have the death certificate reviewed by a county medical examiner. In Tucson, AZ, and surrounding Pima County, all cremation requests are submitted to the Forensic Science Center, where the death certificates are reviewed by one of 5 board-certified forensic pathologists. In 2002, there were 5557 cremation requests, and in 2003 there were 5662 cremation requests. Of these requests, 670 (12.1%) and 447 (7.9%) death certificates were flagged for further investigation in 2002 and 2003, respectively. Eventually, 47 cases (0.8% of total, 7.0% of flagged cases) were accepted as medical examiner cases in 2002, and 43 cases (0.8% of total, 9.6% of flagged cases) were accepted as medical examiner cases in 2003. In 2002, the majority of cases were handled as a records review; however, 4 cases were brought in for autopsy and 1 was certified after an external examination only. In 2003, all cases were certified via a records review. The manner of death in all but 3 of these deaths was certified as accident, with complications of remote trauma being the most common proximate cause of death. The 3 most common injuries were complications of fractured pelvis or femur (15 in 2002, 22 in 2003), head injury due to fall (18 in 2002, 8 in 2003), and complications of remote motor vehicle accident (3 in 2002, 6 in 2003). The other 3 deaths included 2 homicides, 1 in each year, and 1 suicide in 2003.     

The many faces of access: reasons for medically nonurgent emergency department visits

Investigating why people use the hospital emergency department (ED) for visits considered medically nonurgent can enhance our understanding of people's expectations of health care services, of their conceptions of prudent lay judgment, and of difficulties in negotiating the logistics of primary care services. This study identified reasons for such ED use from users' perspectives in both pediatric and adult visits. Respondents were asked to explain what brought them to the ED and to define an emergency. The study was conducted in two northeastern U.S. hospital EDs. The analysis drew on a convenience sample of 408 (331 pediatric, 77 adult users) face-to-face interviews that employed both open- and closed-ended questions. Findings indicate most patients had medical insurance and a regular place of care and most arrived by car or taxi. Twelve main themes emerged under three main categories: conceptions of needs, appropriateness, and preference for the ED. The findings indicate that various reasons for ED use may be construed as access issues. These include beliefs regarding limited availability of after-hour consultation services and of timely appointments at one's primary care site. Drawing on the findings, a typology that distinguishes between groups of users according to their preference for the ED, a level of congruence between their own reason and their definition of an emergency was developed. The typology suggests that people's concerns that influence their decision to come to the ED cannot be solved simply by expanding primary care services or by educational interventions. Its application yields recommendations for services and interventions.     

Suicide by jumping from high-rise hotels. Fulton County, Georgia, 1967-1986

During a 20-year period from 1967 through 1986, 19 suicidal jumps from high-rise hotels (HRHs) accounted for 24% of all fatal jumping episodes and 1% of all suicides in Fulton County, Georgia, U.S.A. The rate of suicidal jumps from HRHs did not increase during the study period. The number of fatal jumps per hotel-year correlated with the height of the interior hotel atrium. The mean age for all victims was 34 years, and 63% of victims were white males. The majority of victims were local residents who were alone when they jumped and were not registered hotel guests. Registered guests tended to jump from the floor on which their room was located whereas nonregistered individuals tended to jump from the upper-most floors in the hotel. Of 19 HRH jumps, 13 occurred from the inside. Suicide notes were found in 37% of cases. HRH jumps were least common between 6 p.m. and midnight, all decedents were dressed in street clothing, only one was heard to have screamed, and all but one were dead on the scene. Alcohol and drug involvement was minimal. We hope that this information will be useful to those who investigate such deaths and to those who study the behavioral manifestations of suicide.     

Use of force by female police officers

Do female police officers use force at the same rate as male police officers? This research examined the use of force by officers in a large, suburban police department during a seven-year period (1993-1999). Use of force reports completed by departmental policy for each use-of-force incident (n = 1,863) and data on arrests (n = 31,778) were examined. A rate of force, defined as the number of use-of-force incidents per one hundred arrests, was computed for male and female officers for each type of force used. A suspect-injury rate, defined as the number of suspects injured per one hundred arrests, also was computed.Force was used in only a small percentage (5.9 percent) of the arrests made. Injury to the suspect (not including the effects of OC spray) occurred in an even smaller percentage (1.6 percent) of arrests, and injury to the suspect resulting in treatment at a hospital (generally, emergency room treatment) occurred in a still smaller percentage (0.7 percent) of arrests.No statistically significant difference between female and male officers was found in the overall rate of force or in the rate of unarmed physical force. Female officers had a lower rate of weapon use when all types of weapons were considered together (p. < 0.05), but not when the different types of weapons were considered individually. Female officers also had a lower rate of any suspect injury (p. < 0.05), but there was no statistically significant difference in the rate of suspect injury resulting in treatment at a hospital. The differences found, even when statistically significant, were small in absolute terms.     

Predictors of length of stay in forensic psychiatry: The influence of perceived risk of violence

This study describes the prevalence of adverse events and length of stay in forensic psychiatric patients with and without a restriction order. Detailed clinical and administrative information from medical records and written court decisions was gathered retrospectively from admission until discharge for a Swedish population-based, consecutive cohort of forensic psychiatric patients (n = 125). The median length of stay for the whole cohort was 951 days, but patients with a restriction order stayed in hospital almost five times as long as patients without. Restriction orders were related to convictions for violent crime, but not for any other differences in demographic or clinical variables. The majority of the patients (60%) were involved in adverse events (violence, threats, substance abuse, or absconding) at some time during their treatment. Patients with restriction orders were overrepresented in violent and threat events. Previous contact with child and adolescence psychiatric services, current violent index crime, psychotic disorders, a history of substance, and absconding during treatment predicted longer length of stay. Being a parent, high current Global Assessment of Functioning scores, and mood disorders were all significantly related to earlier discharge. In a stepwise Cox regression analysis current violent index crime and absconding remained risk factors for a longer hospital stay, while a diagnosis of mood disorder was significantly related to a shorter length of stay.