The PMMA epidemic in Norway: comparison of fatal and non-fatal intoxications

During a 6 month period (July 2010-January 2011) we observed 12 fatal intoxications and 22 non-fatal cases related to the drug paramethoxymethamphetamine (PMMA) in Norway (4.8 mill inhabitants). This toxic designer drug, also known as "Death", is occasionally found in street drugs offered as "ecstasy" or "amphetamine". The present study aimed to evaluate the cause of death, and to compare the PMMA blood concentrations in fatal and non-fatal cases. Methods for identification and quantification of PMMA are presented. The median age of fatalities was 30 years (range 15-50) with 67% males; in non-fatal cases 27 years (20-47) with 86% males. In the 12 fatalities, the median PMMA blood concentration was 1.92 mg/L (range 0.17-3.30), which is in the reported lethal range of 0.6-3.1 mg/L in peripheral blood and 1.2-15.8 mg/L in heart blood. In the 22 non-fatal cases, the median PMMA concentration was 0.07 mg/L (range 0.01-0.65). Poly-drug use was frequent both in fatal and non-fatal cases. The PMA concentrations ranging from 0.00 to 0.26 mg/L in both groups likely represented a PMMA metabolite. Three fatalities were attributed to PMMA only, six to PMMA and other psychostimulant drugs, and three to PMMA and CNS depressant drugs, with median PMMA concentrations of 3.05 mg/L (range 1.58-3.30), 2.56 (1.52-3.23) and 0.52 mg/L (0.17-1.24), respectively. Eight victims were found dead, while death was witnessed in four cases, with symptoms of acute respiratory distress, hyperthermia, cardiac arrest, convulsions, sudden collapse and/or multiple organ failure. In summary, all fatalities attributed to PMMA had high PMMA blood concentrations compared to non-fatal cases. Our sample size was too small to evaluate a possible impact of poly-drug use. A public warning is warranted against use and overdose with illegal "ecstasy" or "speed" drugs.     

Patterns of prior offending by child abductors: A comparison of fatal and non-fatal outcomes

Our study examines the prior offending of 750 individuals who are known to be responsible for the abduction of a child under the age of 18 years. The first group comprised of 311 offenders (42%) who had abducted a child that was later located alive (found alive, referred to as FA). The second group was comprised of 439 offenders (58%) who had abducted a child that was either found murdered or was still missing and presumed dead (found murdered, referred to as FM). While males perpetrated the majority of the abductions, women perpetrated 31 (10%) of the offenses in the FA group and 10 (2%) of the offenses in the FM group. The average number of prior offenses as reflected in the NCIC criminal history of each offender was seven with these occurring over an average of 12 years. Seventy-five percent of the offenders had prior arrests for an assortment of different crimes while 25% had no known criminal history, a finding that was consistent across both the FA and FM groups. Of those with a criminal history, 41% had been arrested for assault, 40% for larceny, 35% for burglary/breaking and entering, 33% for forcible sex offenses, 25% for drug/narcotic offenses, 21% for weapons law violations, 17% for motor vehicle thefts, 15% for robbery, and 14% for kidnapping. Our findings are congruent with the theme of criminal diversity among child abductors and argue against the specificity in offending that is often assumed with this type of sexual offender. This information is relevant to our understanding of the progression in criminal offending that is manifested by offenders who abduct children and will hopefully be used by law enforcement in helping to direct and focus their investigations.     

Fatal versus non-fatal heroin "overdose": blood morphine concentrations with fatal outcome in comparison to those of intoxicated drivers

The study was performed to distinguish fatal from non-fatal blood concentrations of morphine. For this purpose, blood levels of free morphine and total morphine (free morphine plus morphine conjugates) in 207 cases of heroin-related deaths were compared to those in 27 drivers surviving opiate intoxication. The majority of both survivors and non-survivors were found to show a concomitant use of depressants including alcohol or stimulants. Blood morphine levels in both groups varied widely, with a large area of overlap between survivors (free morphine: 0-128 ng/ml, total morphine: 10-2,110 ng/ml) and non-survivors (free morphine: 0-2,800 ng/ml, total morphine: 33-5,000 ng/ml). Five (18.5%) survivors and 87 (42.0%) non-survivors exhibit intoxication only by morphine. In these cases, too, both groups overlapped (survivors-free morphine: 28-93 ng/ml, total morphine: 230-1,451 ng/ml; non-survivors-free morphine: 0-2,800 ng/ml, total morphine: 119-4,660 ng/ml). Although the blood levels of free or total morphine do not allow a reliable prediction of survival versus non-survival, the ratio of free/total morphine may be a criterion to distinguish lethal versus survived intoxication. The mean of the ratio of free to total morphine for all lethal cases (N=207) was 0.293, for those that survived (N=27) 0.135, in cases of intoxication only by morphine 0.250 (N=87) and 0.080 (N=5), respectively. Applying a cut-off of 0.12 for free/total morphine and performing ROC analyses, fatal outcome can be predicted in 80% of the cases correctly, whereas 16% of the survivors were classified as dead. Nevertheless, in this study, all cases with a blood concentration of 200 ng/ml and more of free morphine displayed a fatal outcome.     

The epidemiology of fatal burn injuries

The paper retrospectively reviews 80 burn fatalities from accidents or attempted suicides with patients admitted to the LAC-USC Medical Center from 1983 to 1987 to determine demographic factors, etiology of the burn injury, and existence of predisposing risk factors. The average age of fatal burn victims was 44 years; 74% were males, 39% were Caucasian, 35% were black, 21% were Hispanic, and 5% were of Asian descent. Blacks and Caucasians were overrepresented and Hispanics underrepresented in relation to all autopsy cases. Major etiologic factors included suicide, falling asleep while smoking, accidents while working with volatile solvents, housefires, scalds, cooking accidents, and accidents involving motor vehicles. Gasoline was the commonest solvent involved with burn fatalities. Significant risk factors for burn fatality were substance abuse (25% of cases) and impaired mental function (19% of cases).     

Peculiar approaches to the estimation of the severity of harm to health in children with non-fatal injuries

The medico-legal estimation of non-fatal injuries in the children and adolescents is presented. The data obtained have been used to develop and substantiate the algorithm of forensic medical expertise of such injuries. Scientifically sound criteria have been proposed to be used for the purpose of expert estimation of the severity of harm to health associated with non-fatal injuries taking into consideration their clinical manifestations. The procedures of forensic medical expertise for the estimation of the harm to health have been analysed with special reference to non-fatal injuries in children and adolescents. Main attention was given to the accompanying strategic, organizational, and methodological errors. The approaches to their prevention and correction are described.     

Analysis of fatal injuries to motorcyclists by helmet type

To clarify the characteristics of injuries of motorcyclists dying in accidents in relation to helmet type, we retrospectively analyzed forensic autopsies of 36 helmeted motorcycle riders. The presence of major injuries and injury severity were evaluated with the injury severity score and the 1990 revision of the Abbreviated Injury Scale. Persons with open-face helmets (19 cases) were significantly more likely to have sustained severe head and neck injuries, especially brain contusions, than were persons with full-face helmets (17 cases). Furthermore, major injuries of the chest or abdomen, rib fractures, lung injuries, and liver injuries were each present in more than one quarter of all cases (26.3% to 70.6%), but their prevalences did not differ significantly between riders with different types of helmet. Because many types of head and neck injuries cannot be prevented and fatal chest and abdominal injuries occur despite the use of full-face helmets, more effective helmets and devices for protecting the chest and abdomen are needed to decrease deaths from motorcycle accidents.     

A fatal poisoning with LSD

Radioimmunoassay, high-performance liquid chromatography and capillary gas chromatography-mass spectrometry were used to detect and measure LSD in the first reported case of fatal poisoning by LSD. The levels found in ante-mortem serum and plasma and in post-mortem blood, liver blood and stomach contents are given.     

Influence of alcohol intoxication of pedestrians on injuries in fatal road accidents

Pedestrians belong to the group of road users with the highest mortality rate. The frequency of road accidents involving pedestrians is 2% but pedestrians represent as many as 13% of all road accident deaths. Because of the mechanism and dynamics of injury and the effects of alcohol on physical and mental performance, pedestrians under the influence of alcohol are classed among the road users most at risk.Our retrospective study included 125 pedestrian fatalities treated at the Institute of Forensic Medicine, Faculty of Medicine, University of Ljubljana between 1999 and 2006. We classified the victims into two groups by blood alcohol level Group I (alcohol positive) and Group II (alcohol negative), defined differences in gender, age, incidence of injuries and established causes of death and period of survival following the road accident. In Group I (n = 53) 96% were male and 4% female; the average age was 45.6 years. In Group II (n = 72) 40% were male and 60% female; the average age was 63.1 years. The percentage of injuries to individual parts of the body was higher in Group I than among the deceased pedestrians in Group II. The most common cause of death in both groups was craniocerebral trauma. Death occurred in the first 6 h following the accident in 92% of cases in Group I and in 69% of cases in Group II.Alcohol-positive pedestrians are predominantly younger men, who have a higher level of risk of a road accident, greater incidence of injuries and a shorter period of survival following a road accident.     

High thyroglobulin (Tg) concentrations in fatal traumatic brain injuries

It is well known that under physiological conditions, the Tg molecule is the substrate for the hormones triiodothyronine and thyroxine. Its function outside the thyroid gland is unknown. Under certain pathologic conditions, an increase in Tg concentrations in the blood can occur, a phenomenon that is used in the clinical diagnosis of certain thyroid disorders. However, fatal traumatic brain injuries (TBI) can also produce a raised Tg concentration in blood. In such cases, mean (n=151) Tg concentrations of 405.8+/-353.3 ng/mL have been observed, with the values in 57% of these cases exceeding 200 ng/mL. Since it was possible to rule out specifically any thyroid disorders in these cases, the raised values may be explained by the effect of TSH in the spectrum of the "hypothalamic-pituitary-thyroid axis." This assumption has been substantiated by immunohistochemical tests for TSH and Tg. Compared with the controls (sudden unnatural deaths: Tg 23.3+/-27.6 ng/mL), the raised Tg values in the TBI cases were usually accompanied by a reduction in the intensity of immunohistochemical reactions relating to TSH and Tg. The hypophysis showed evidence of significant damage with morphologic changes such as edema, hemorrhages, and focal necrosis in association with reduced TSH levels.     

Position paper on fatal abusive head injuries in infants and young children

This article represents the work of the National Association of Medical Examiners Ad Hoc Committee on shaken baby syndrome. Abusive head injuries include injuries caused by shaking as well as impact to the head, either by directly striking the head or by causing the head to strike another object or surface. Because of anatomic and developmental differences in the brain and skull of the young child, the mechanisms and types of injuries that affect the head differ from those that affect the older child or adult. The mechanism of injury produced by inflicted head injuries in these children is most often rotational movement of the brain within the cranial cavity. Rotational movement of the brain damages the nervous system by creating shearing forces, which cause diffuse axonal injury with disruption of axons and tearing of bridging veins, which causes subdural and subarachnoid hemorrhages, and is very commonly associated with retinal schisis and hemorrhages. Recognition of this mechanism of injury may be helpful in severe acute rotational brain injuries because it facilitates understanding of such clinical features as the decrease in the level of consciousness and respiratory distress seen in these injured children. The pathologic findings of subdural hemorrhage, subarachnoid hemorrhage, and retinal hemorrhages are offered as "markers" to assist in the recognition of the presence of shearing brain injury in young children.     

A fatal methamphetamine poisoning associated with hyperpyrexia

After self-administration of 0.05g of methamphetamine hydrochloride intravenously on three occasions at intervals of 3h, a 25-year-old female methamphetamine abuser ingested approximately 1.5 g of methamphetamine hydrochloride, and was found dead 3–4 h later. Complete rigor mortis was observed 1–2 h after death and the rectal temperature was 38.4°C 3–4 h after death.Distribution of methamphetamine and amphetamine in the body was analyzed by chemical ionization mass fragmentography. Amphetamine/methamphetamine concentrations (μ mol/100 g) were $\text{0.26}\text{28.8}$ in blood, $\text{0.64}\text{68.2}$ in brain, $\text{0.96}\text{117.1}$ in liver, $\text{0.53}\text{50.6}$ in kidney, and $\text{1.49}\text{1045}$ in stomach contents. Total amount of methamphetamine hydrochloride in stomach contents was 11.6mg.Amphetamine in tissues was a metabolite of methamphetamine, and amphetamine in stomach contents resulted from excretion into saliva and gastric mucous excretion. With rectal temperature at death estimated at more than 41°C, it would seem that hyperpyrexia played an important role in causing death from methamphetamine poisoning.     

A fatal case of poisoning with cantharidin.

A case of fatal poisoning due to voluntary ingestion of cantharides powder for aphrodisiac purposes is reported. Clinical history, autopsy and analytical findings are described. Blood and urine samples collected during the 30 h of survival, as well as the cantharides product, were analyzed by gas chromatography-mass spectrometry. On the basis of the percentage of the active principle measured in the powder, an ingested dose of 26-45 mg of cantharidin could be estimated.     

331例交通事故致行人死亡四肢损伤特征的法医学分析

目的分析城市道路交通事故致死行人四肢损伤的特征。方法收集本区2016年至2018年交通事故行人死亡资料,对四肢损伤情况进行统计学分析。结果 331例城市道路交通事故致行人死亡案例中,死者以男性居多;机动车(不包含摩托车)、摩托车所致行人体表损伤以擦挫伤(包括擦伤、擦挫伤)为主,电动车所致体表损伤以皮下出血(挫伤)为主,占体表损伤71.8%(P <0.05);机动车骨折率最高(35.5%,P <0.05),电动车骨折率极低(3.7%,P <0.05),四肢多发骨折好发于机动车,四肢骨折好发于左侧。结论通过对行人四肢损伤特征的分析,在一定程度上为无目击者或肇事逃逸交通事故处理提供一定帮助。     

Comparison of injuries sustained by drivers and pillion passengers in fatal head-on motorcycle collision accidents

This study aimed to compare injuries sustained by motorcycle drivers with those sustained by pillion passengers in fatal head-on motorcycle collision accidents. We examined 84 cases of fatal head-on motorcycle collision accidents, causing 79 deaths of drivers and 19 deaths of pillion passengers, using medical and medico-legal examination records. The distribution of superficial injuries, characteristic injuries, injury severity as well as fatal causes was evaluated and compared using χ(2) tests. The results revealed a significant difference in the distribution of superficial injuries between drivers and passengers. The proportions of injuries in the hand and perineum regions were significantly higher in drivers than passengers. Some characteristic superficial injuries on the palms, chest, abdomen as well as the perineum areas were observed in drivers, while none of these characteristic injuries were observed in pillion passengers. Drivers were found to have suffered more severe chest and abdomen injuries than passengers. In addition, there was a higher incidence of fatalities involving run-over injuries for drivers compared with pillion passengers. The proportion of fatal injuries related to tumbling was higher for passengers than for drivers. Overall, our results revealed a difference in injury severity, superficial injury distribution and characteristic injuries between drivers and passengers. Few characteristic injuries were found in pillion passengers. These findings could help to guide medico-legal examinations, particularly in identifying drivers among victims involved in traffic accidents.     

A non-fatal case of intoxication with foxglove, documented by means of liquid chromatography-electrospray-mass spectrometry

The non-fatal self-poisoning of a 36-year-old female patient, who ingested a concoction of foxglove (Digitalis Purpurea), is presented. On the admission, initial symptoms were nausea and vomiting, abdominal pain, and cardiovascular shock with sinus bradycardia. Blood and urine were assayed for 17 cardiotonic hetorosides, using a highly specific LC-MS procedure. Serum and urine specimens were collected over five days and analyzed by liquid chromatography-electrospray-mass spectrometry (LC-ES-MS). This accurate procedure allowed the determination of the digitalis glycosides and their metabolites in serum and urine. The serum concentrations of digitalis glycosides were maximum on the first day (gitoxin 13.1 ng/mL, digitoxin 112.6 ng/mL, digitoxigenin 3.3 ng/mL, and digitoxigenin mono-digitoxoside 8.9 ng/mL) and decreased over five days. We observed a peak gitaloxin level (112.6 ng/mL) on the fifth day only. After administration of atropine as well as dimeticone, alginic acid, and metoclopramide, health status improved. The peak urine concentrations were reached at hour 30 and were respectively 91.3 and 69.9 ng/mL for gitaloxin and digitoxin, while those of digitoxigenin, digitoxigenin mono-digoxoside and gitoxin were lower (respectively 0.7, 1, and 5.6 ng/mL). The patient was discharged on the fifth day when there were no residual symptoms.     

Unusual suicides of young women with tentative cuts and fatal neck injuries by chain saw and circular saw

Suicides with chain saws and circular saws are extreme exceptions, in particular with regard to females and concerning the neck region. We report two of such rare cases involving young women. A 30-year-old female with a known schizoaffective psychosis killed herself with an electric chain saw. The autopsy revealed a deep saw cut of the neck and shoulder with partial transection of the cervical spine. Several tentative saw cuts were present on the right lower jaw. A 29-year-old woman suffering from depression committed suicide by use of a circular saw. She inflicted herself fatal neck injuries with at least three separate cutting procedures. Our cases were characterized by the following features: female sex, young adulthood, no occupational experience with saws, psychiatric disorders, absence of alcohol or drugs, use of an aggressive method of suicide, focus of saw injuries on the right side of the neck, detection of tentative saw cuts or several trials, identical causes of death (exsanguination and blood aspiration).     

子宫内翻致死1例法医学鉴定分析

子宫内翻在妇产科临床中极为少见.因子宫内翻致死者罕见.笔者在实际工作中遇见一例,现报告如下: