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.     

司法鉴定中303例骨龄小于“年龄”分析

目的探讨司法鉴定中骨龄小于"年龄"的现象和可能原因。方法参考中国人手腕骨发育标准CHN法附带的检验样本所提供的骨龄验证值,结合鉴定时公安机关提供的"年龄"、"户籍"等相关资料,并追踪回访部分案例,对829例使用CHN法行骨龄司法鉴定资料进行回顾性分析。结果骨龄小于"年龄"共303例,占(303/829)36.6%,在742例有"年龄"案例组中占(303/742)40.8%。如以两者差值小于0.5岁(含0.5岁)为正常范围内计则降至190例,所占比例为(190/829)22.9%和(190/742)25.6%。差值在0.5岁以内时与骨龄值相近的"年龄"可信度最高,在0.6～2.0岁时难以确定何者有误,但随差值增大"年龄"有误可能性上升。"年龄"和骨龄本身诸多不确定因素均可导致骨龄小于"年龄",并可能是多种因素共同影响的结果。结论在鉴定实践中骨龄小于"年龄"发生率不低;鉴定结论以综合评估后谨慎使用为宜。     

Wrongful death claims. Harriton v Stephens. [2002] NSWSC 461. Edwards v Blomeley. [2002] NSWSC 460. Waller v James [2002] NSWSC 462

Studdert J in all three cases went to great length to summarise the global judicial position of "wrongful life" claims. He did not, however, examine in great length how or whether "wrongful life" claims or "wrongful birth" claims are reconcilable with tort and common law principles. Although the cases identify the difficulty in assessing and quantifying damages, they do not directly address the strict legal principles which apply in the assessment of damages. The main conclusion of the three judgments was that no duty of care is owed to the plaintiff in these circumstances and, even if a duty could be established, the impossibility of quantifying damages and public policy considerations warrant the rejection of such a claim: "thus conscience does make cowards of us all." The significance of the decisions cannot be understand. The decisions deny recognition of "wrongful life" claims in circumstances where a disabled person has incurred injuries en ventre sa mere (in the mother's womb) as a result of infections contracted by a plaintiff's mother or genetic material passed on by a plaintiff's parents. Some countries have now legislated for the abolition of "wrongful life and birth" suits. In January 2002 the French legislature passed a Bill overturning the "wrongful life" decision of the Cour de Cassation in Perruche (17 November 2000). As the issue now falls for ultimate determination by the French Senate, the French pro-life movement continues to lobby for the prohibition of "wrongful birth" suits as well. Furthermore, eight States in the United States have prohibited either one or both actions and the State of Michigan prohibited both actions in 2001. It is likely that all three cases will be appealed. The appeal in Harriton will re-examine the viability of a "wrongful life" claim in Australia whereas the cases of Edwards and Waller still need to determine the "wrongful birth" claims brought by the plaintiffs' parents. It is likely that the latter two cases will not be determined until the High Court has considered the Queensland "wrongful birth" case of Melchior v Cattanach, expected to be late in 2002.     

Postmortem investigation of lamotrigine concentrations

Lamotrigine is a relatively new anticonvulsant. Therapeutic plasma concentrations generally range from 1 to 4 mg/L, although several studies have shown that good control of epilepsy has been achieved with concentrations reaching 10 mg/L generally, with little toxicity. In overdose, however, the drug has been linked to ECG changes that may suggest a possible arrythmogenic effect and hence cardiac toxicity. Lamotrigine has also been shown to cause encephalopathy and thus neurotoxicity. There is no information concerning postmortem lamotrigine concentrations and their interpretation. We describe lamotrigine concentrations in postmortem specimens including blood, liver, bile, vitreous humour, and urine from eight cases. A high performance liquid chromatography (HPLC) method is described with extraction procedures for the various tissues. Two possible groups were identified. The first being the "broader therapeutic" group with blood concentrations ranging from 0.9 to 7.2 mg/L and corresponding liver concentrations ranging from 16 to 36 mg/kg. The second being a "supratherapeutic" group with blood concentrations ranging from 20 to 39 mg/L and corresponding liver concentrations ranging from 53 to 350 mg/kg. Although none of the eight cases described were attributed to overdose by lamotrigine alone, the cause of death for one of the three cases in the "supratherapeutic" group was given as mixed drug toxicity. Cause of death for the remaining two cases in this group was reported as epilepsy. However, both these cases showed elevated concentrations of lamotrigine and both were co-medicated with valproic acid. Such co-administration has been shown in the literature to lead to elevated lamotrigine concentrations and a reduction in lamotrigine dose has been recommended. With such data, we highlight the importance of monitoring lamotrigine concentrations in cases co-medicated, particularly with valproic acid.     

活体鉴定400例放射学特点分析──兼论法医临床学与放射学的关系

为探讨法医临床学鉴定与放射学的关系，本文对４００例活体鉴定就放射学检查的有关问题进行回顾性研究。结果表明：２６６例进行了放射学检查（占６６．５％），其中Ｘ线１７６例（６６．２％），ＣＴ４３例（１６．１％），两者均有的４７例（１７．７％）。放射学检查部位中，Ｘ线以四肢为多，ＣＴ以颅脑为多。误诊率为９．０２％，放射学检查与致伤原因之间有一定关系，轻微伤中不必要的ＣＴ检查多见。并就放射学误诊的法律后果及不必要的放射学检查问题进行了讨论。本文从法医临床学的角度对放射学进行了评价，指出在活体鉴定中可以应用放射学知识协助证明损伤、推断损伤形成机制、个人识别及研究损伤时间。因此法医学鉴定人必须有放射学理论和技术方面的知识。作者还试图提出法医临床放射学。     

Two cases of death associated with the use of lithium carbonate

Two cases of death associated with the use of lithium carbonate are described. The first one concerns a 39-year-old man who was found suddenly dead on his hospital bed. Toxicologic analysis revealed "therapeutic" levels of lithium, nitrazepam, flurazepam, and phenobarbital. The second case involves a 54-year-old woman initially treated for acute cardiac failure and hypertension, who was finally recognized as a case of lithium intoxication; she died of cardiac arrest without evident cardiac lesions and without lithium ions in serum and urine. The medicolegal aspects of both cases are discussed, with reference to the problems of diagnosis, clinical and toxicological correlations, and the medical responsibility.     

日本和意大利刑事庭审中的证据调查程序评析

日本和意大利都通过立法手段将刑事诉讼的构造从传统的职权主义转向了当事人主义 ,但同时又保留了一些传统的原则和做法 ,由此在庭审的证据调查程序上形成了不同于职权主义或当事人主义的鲜明特点 ,这些特点反映了两国对“实体真实”与“正当程序”两大诉讼理念的调和。日本和意大利的改革思路以及庭审证据调查的程序设计值得我国借鉴。     

De-moralized: Glucksberg in the malaise

Ten years down the road, what is the enduring significance of the "assisted suicide" cases, Washington v. Glucksberg and Vacco v. Quill? The cases reflect an unusually earnest, but nonetheless unsuccessful, attempt by the Supreme Court to grapple with a profound moral issue. So, why was the Court unable to provide a more satisfying justification for its conclusions? This Article, written for a symposium on the tenth anniversary of Glucksberg, discusses that question. Part I examines some of the flaws in reasoning in the Glucksberg and Quill opinions and suggests that these flaws stem from the opinion writers' inability to recognize and articulate their underlying normative assumptions. More specifically, both the Justices and the lower court judges, on both sides of the issue, evidently attributed normative significance to something like a "natural course of life" (even when they denied doing so), but none were willing or able to make this attribution explicit. Part II discusses the modern separation of moral reasoning from the metaphysical or theological perspectives that might once have endowed "nature" with normative significance, and it suggests that the deficiencies in Glucksberg-Quill are evidence of how that separation renders moral reasoning problematic. The Conclusion wonders whether in this situation, a renewed emphasis on formalism or tradition might make legal reasoning less unacceptable.     

The legal basis for ethical withholding and withdrawing of life-sustaining medical treatment in children

Withholding and withdrawing life-sustaining medical treatment are common in paediatric practice, especially in intensive care units. However, not all clinicians apparently adhere to principles in ethical guidelines or to the principles which are to be found in judgments from common law cases arising when doctors and parents dispute treatment. This article examines selected ethical guidelines and compares them to judgments in leading cases. The rationale to forgo treatment is usually the child's "best interests" in both clinical practice guidelines and legal cases but in the former "best interests" may remain ill defined. Although "best interests" must essentially pertain to the individual child, the interests of others are not irrelevant. In legal cases "best interests" of the child are defined in terms such as "burden versus benefit", "futility", "indignity", "intolerability", "prolonging death rather than saving life" and "quality of life". These or like terms should form the basis of ethical decisions in discussions with parents when contemplating withholding or withdrawing life-sustaining treatment.     

Fatty degeneration in renal tubule epithelium in accidental hypothermia victims

The diagnosis "death due to hypothermia" is mainly based on circumstances and gross autopsy findings like frost erythema and gastric erosions. Up to now, there are no reliable histologic criteria available to confirm the diagnosis "death due to hypothermia." However, fatty changes of organs have been reported already in the literature as a histological finding contributing to the diagnosis "death due to hypothermia." To evaluate these reports, cases with well-documented hypothermia (study-group; n=83), cases with other causes of death (control-group; n=25) and additionally also seven cases with a past medical history of diabetes mellitus were investigated. Renal tissue autopsy samples were taken from both the left and the right kidney and investigated for signs of fatty degeneration within the renal tubule epithelium. The results were compared with regard to macroscopic signs of hypothermia (Wischnewski-ulcers, erythema), as reported in the autopsy protocols. The results lead to the conclusion, that fatty degeneration is a very reliable histologic diagnostic criterium in cases of hypothermia, comparable to the significance of Wischnewski-ulcers.     

Digital dental radiographic identification in the pediatric, mixed and permanent dentitions.

The purpose of this paper is to investigate the utility of digital dental radiographic superimposition in the various stages of development of the human dentition. Digital, computer assisted dental identification is a means of identification which allows the spatial relationships of the root and support structures of the teeth to be compared one to the other. The technique has not been tested in patients with developing dentitions. Dental radiographs from patients in the pediatric, mixed and permanent dentition stages of development, simulating "antemortem" and "postmortem" radiographs, were digitized using a flat field radiograph scanner. Anatomic features were used as points of comparison utilizing image editing software whereby anatomic sections were digitally cut from the antemortem image and compared to the same anatomic locations on the postmortem image to assess for points of concordance. The technique was applied to 25 cases within the primary dentition, 25 cases within the mixed dentition and 25 cases within the permanent dentition. Results showed that this was a viable technique within both the pediatric and permanent dentition although it was of little value within the mixed dentition.     

Nonhuman remains and relics encountered by the medical examiner: Fulton County, Georgia, 2003-2004

BACKGROUND: Medical examiner and coroner offices occasionally respond to "death scenes" which, after investigation, are found to involve nonhuman remains or other relics not requiring further investigation or certification of death. This report describes such cases encountered by the Fulton County medical examiner during 2003 and 2004. METHODS: The electronic database used by the office contains check boxes to indicate whether a reported case involved nonhuman remains or other relics, in which case the name of the "deceased" is listed as "nonhuman remains" by selecting those words from a pull-down menu. Subject cases were identified during the 2-year period by searching the database for any case in which one of the boxes was checked or in which the name of the deceased was listed as nonhuman. RESULTS: Four thousand five hundred fifty-four deaths were investigated during the 2-year period, and 23 cases (0.5%) involved nonhuman remains or relics. Thus, the observed rate was about 5 cases per 1000 death investigations. Nineteen cases involved nonhuman bones. One case involved 2 human fetuses that had been teaching specimens. The other 3 cases involved a nonhuman fetus, a large decomposing dog that had been wrapped and dumped in residential area, and a sheep heart found in a bag which was a medical teaching specimen. CONCLUSIONS: Nonhuman remains and other relics are uncommonly seen in death investigation work and usually involve nonhuman bones, although a small variety of other atypical cases present themselves occasionally. Knowledge of these types of encounters is helpful so that the "unexpected" may become more "expected" and office policy and procedures tailored accordingly to facilitate case management.     

论绑架案件侦查与人权保障

当前,刑事案件侦查中是否尊重人权成为社会关注的热点问题,绑架案件侦查中涉及到多方人员基本人权保障问题,引人注目,尤其公开绑架人质案件的接连发生,使人们对绑架案件的人权问题极为关注。人权观念在绑架案件侦查中的确立与发展包括三方面内容:一是“人质安全第一”观念的提出和实践;二是从一元安全观到多元安全平衡价值观的思辩;三是可持续性侦查策略与措施的凸现。     

Spleen and portal lymphnode pathology in fatal drug addiction

Spleen and portal lymphnode sections from 86 drug addicts submitted for medico-legal autopsy at the Institute of Forensic Medicine in Copenhagen in the year 1979 were studied together with tissue sections from 24 "normal" persons. In 70% of the drug addicts the spleen weight was more than 200 g, and in 71% portal lymphnode hyperplasia was found. Birefringent foreign material was found in spleen tissue of drug addicts in 72% and in portal lymphnode tissue in 44%. Signs of antigen stimulation in both spleen and portal lymphnode tissue evaluated by the number of germinal centre and plasma cells were found in more than 80% of the drug addicts compared with about 20% of the "normal" persons. The results were related to anamnestic information of duration of drug abuse, to the spleen weight, to the occurrence of birefringent material and to the liver changes. Examination of lysozyme and immunoglobulin containing cells using the indirect preoxidase technique was performed in a total of 72 cases of spleen tissue, 59 cases of portal lymphnode tissue from drug addicts, 24 cases of spleen tissue and 18 of portal lymphnode tissue from "normal" persons. Lysozyme, IgM and IgG containing cells were found significantly more often among drug addicts than "normal" persons. The results indicate that the splenomegalia and the portal lymphnode hyperplasia often found in drug addicts are caused by continuous antigen stimulation due to repeated injections of various antigens.     

Differentiation of drug and non-drug Cannabis using a single nucleotide polymorphism (SNP) assay

Cannabis sativa is both an illegal drug and a legitimate crop. The differentiation of illegal drug Cannabis from non-drug forms of Cannabis is relevant in the context of the growth of fibre and seed oil varieties of Cannabis for commercial purposes. This differentiation is currently determined based on the levels of tetrahydrocannabinol (THC) in adult plants. DNA based methods have the potential to assay Cannabis material unsuitable for analysis using conventional means including seeds, pollen and severely degraded material. The purpose of this research was to develop a single nucleotide polymorphism (SNP) assay for the differentiation of "drug" and "non-drug"Cannabis plants. An assay was developed based on four polymorphisms within a 399 bp fragment of the tetrahydrocannabinolic acid (THCA) synthase gene, utilising the snapshot multiplex kit. This SNP assay was tested on 94 Cannabis plants, which included 10 blind samples, and was able to differentiate between "drug" and "non-drug"Cannabis in all cases, while also differentiating between Cannabis and other species. Non-drug plants were found to be homozygous at the four sites assayed while drug Cannabis plants were either homozygous or heterozygous.     

Criminal professional body packers and harmless "swallowers"

Body packing practices used by professional drug smugglers are sometimes imitated. However, both groups can develop the same clinical symptoms induced by body packing. The paper describes four cases of criminal professional body packers and two cases of "swallowers" not regarded as criminals who required medical treatment. The authors discuss the necessity of an abdominal X-ray and show how the increasingly professional methods used by body packers make a reliable diagnosis more difficult.     

Application of forensic toxicology to the problem of domestic violence.

The role of the forensic toxicologist in helping to determine causes of death or in aiding in the resolution of "driving under the influence" or similar cases is well known and clearly understood. Less clearly defined is the position of the forensic toxicologist vis-à-vis other socially significant problems. However, as the 21st century approaches, it is worth considering how forensic toxicology can help in unraveling some of these problems. The problem of violence between intimates--that is, domestic violence--is a social problem in which it has been long felt that alcohol has played a part. Until now, though, no carefully controlled toxicological studies have been conducted to substantiate this or to determine whether other drug use is associated with domestic violence. At the San Francisco Medical Examiner's Office, toxicological data from both the victim and the suspect in 20 cases of domestic violence that ended in homicide have been gathered. It was found that alcohol or other drugs or a combination of these factors was invariably present in the suspect, the victim, or both. The implications of these results and how they can be used to develop a toxicological strategy to help reduce the most serious consequences of domestic violence are presented.     

试论指导性案例的“指导性”

指导性意味着权威性和一般性;指导性案例目前在我国其实是一种非正式意义上的法律渊源,作为一种法律渊源它既具有形式合法性,也具有实质合法性。作为非正式的法律渊源,它具有辅助性,即效力上的说服性和参考性、功能上的从属性、效力位阶上的次级性和产生方法的有限性。为了保证指导性案例的指导性,需要从内容与形式两个方面来确定选择指导性案例,注重判决中所确立的法律观点或对有关问题的法律解决方案以及对该观点或该方案的法律论证;应当采用"一元、二级、多层次"的案例制作、确定与选择体制,编辑出版新型的具有统一性、普遍性、系统性和便利性的指导性案例汇编;应当鼓励、引导对指导性案例的规范性使用。     

A cross-cultural review of sudden mass assault by a single individual in the oriental and occidental cultures

A nonrandom sample of North American cases of sudden mass assault by a single individual (SMASI, n = 30) is compared with a nonrandom sample of Laotian amok cases (n = 18) and other amok studies. Perpetrators in both studies show evidence of social isolation, loss, depression, anger, pathological narcissism, and paranoia, often to a psychotic degree. The term "innovative perpetrator" is reintroduced and expanded upon. Similarities among samples far outweigh differences, leading the authors to conclude that SMASI and its appearance in different cultures is not a culture-bound syndrome.     

Subvalvular aortic stenosis as a cause of sudden death: two case reports

Sudden death is defined as a death that occurs suddenly, develops during an unpredictable course, and is due to natural or unnatural causes. Although there is no universally standardized definition on how "sudden" a sudden death is, WHO defines sudden death as a death that occurs within 24 hours after the onset of symptoms. The aim of this study is to present 2 rarely reported autopsy cases and to emphasize the importance of systemic autopsy at sudden death. On macroscopic examination, crescent-shaped, thick, fibrous membranes, located 5 mm and 3 mm away from the aortic valves, were detected. Fibrous membranes extended from the ventricular septum to the left ventricular outflow tract, thus apparently narrowing this region. Left ventricular wall and septum were slightly thickened, and there were scattered grayish-white areas of a small diameter. These became more intense in the septum and myocardium of the left ventricle on the anterior plane of the myocardial sections. In both cases, the aortic valves of were thickened and also markedly narrowed on one of them. In this case, the fibrous membrane adhered to the aortic valve and extended to the anterior leaflet of the mitral valve at one side. Both aortic valves comprised 3 leaflets. Other valves and coronary arteries showed no macroscopic pathologic findings. Microscopic examination of both cases demonstrated that the fibrous membrane comprising abundant collagen fibers was situated on the ventricular septum. Hypertrophy, moderate to severe interstitial fibrosis, and focal areas of scarring were observed in the specimens taken from the septal and ventricular myocardium. No abnormality was found on the conduction system examinations. Toxicologic analysis results in blood were negative. Based on the findings, membranous-type (discrete type) subvalvular aortic stenosis, diagnosed during the autopsy, was considered as the cause of sudden death in both cases.