Fatal outcome of poisoning with the benzodiazepines flunitrazepam and diazepam

On a wintry day a 29-year-old woman was found dead beside her car showing head injuries and signs of hypothermia. Several empty packets of sedative and hypnotic drugs were lying inside the car. Toxicological analysis revealed the presence of flunitrazepam (heart blood of the left and right chamber 0.033 mg/L each), norflunitrazepam (left heart blood 0.029 mg/L, right heart blood 0.027 mg/L), 7-amino-flunitrazepam (left heart blood 0.090 mg/L, right heart blood 0.104 mg/L), diazepam (left heart blood 0.395 mg/L, right heart blood 0.386 mg/L), nordazepam (left heart blood 0.112 mg/L, right heart blood 0.115 mg/L) and temazepam (left heart blood 0.034 mg/L, right heart blood 0.033 mg/L). Neither alcohol nor other drugs were found. It was concluded that benzodiazepine intake led to a disturbance of consciousness. Whether the woman died in this situation due to the icy temperature as a result of hypothermia or whether she died or would have died solely due to benzodiazepine overdosage could not be clarified.     

Autonomy, guardianship and mental disorder: one problem, two solutions

The law in England and Wales governing both the provision of medical care in the case of adults with incapacity and the provision of care and treatment for mental disorder presents serious problems for the principle of patient autonomy. The adult with incapacity has no competence either to consent to or refuse medical treatment but the law provides no statutory structure for substitute decision making on that adult's behalf. On the other hand the law does allow a person with mental disorder to be treated for that disorder despite his or her competent refusal. The nature of these inconsistencies is considered and the implications which flow from the singling out of mental disorder are examined with reference to experience in two Australian jurisdictions. The current proposals for reform of the Mental Health Act are then considered in the light of the conclusions drawn.     

Analysis of ionic ratios in myocardial tissue and their relation to cardiac damage

The authors evaluated the usefulness of the postmortem biochemical analysis of ionic ratios in different parts of the heart and their relation to cardiac damage caused by chest trauma, as observed by anatomopathologic study. Fifty-nine 59 cases were studied, selected from routine necropsies, and samples were taken from different sites of cardiac tissue. The cause of death was trauma in 40 cases and nontraumatic causes in 19 cases. The object of this study was to analyze the levels of Na+, K+, Ca+2, Mg+2, and Zn+2 in different zones of the heart, and the relationship between intracellular and extracellular ion ratios and the different causes of death and any anatomopathologic alterations observed. The biochemical tests revealed a possible relation between the ionic values and cause of death. Alterations in cell membrane permeability and corresponding modification of the ionic ratios were produced earlier than histologic alterations, which need longer to establish themselves whether or not they follow a traumatic process.     

Recovery of a mummified pregnant woman from a 55-gallon drum more than 30 years after her death

The body of a 28-year-old near-term pregnant woman was found in a 55-gallon steel drum in a crawl space under a house more than 30 years after her disappearance and death. At autopsy the body was remarkably well preserved and mummified, as was that of a male fetus. The decedent had 10 scalp lacerations and multiple comminuted depressed skull fractures and had died as a result of blunt force head trauma.     

Accidental drowning due to tropane alkaloid abuse

The cause of drowning deaths in good swimmers may be difficult to solve. After homicide, suicide and other kinds of immersion deaths have been ruled out, not only alcohol and narcotics, but also other psychotropic substances such as thornapple and angel's trumpet should be taken into consideration--at least in adolescents and young adults. The article reports on an accidental death by drowning under the influence of tropane alkaloids after consumption of a decoction of the flowers of angel's trumpet.     

A fatal case of cocaine poisoning in a body packer

A 27-year-old man was carrying in his digestive tract 99 packages each containing about 10 g of a 86% cocaine powder. The courier died by acute cocaine intoxication due to inflation and rupture of four packages during a flight from Bogotá to Rome. At the autopsy, the external examination was unremarkable. The internal examination showed edema and generalized congestion of the organs. Toxicological analyses were performed by gas chromatography-mass spectrometry after solid phase extraction using Bond Elut Certify columns and derivatization with BSTFA/TMCS. High levels of cocaine and benzoylecgonine were found in blood (4.0 microg/mL and 17.0 microg/mL), urine (152.0 microg/mL and 512.0 microg/mL), bile (99.8 microg/mL and 54.0 microg/mL), vitreous humor (7.1 microg/mL and 5.8 microg/mL), brain (7.5 microg/mL and 3.5 microg/mL), and hair (55.5 ng/mg and 27.7 ng/mg). The presence of the cocaine and its metabolite in the hair suggested that the man was a cocaine user.     

A kinetic model describing the pharmacokinetics of ethyl glucuronide in humans

The glucuronide conjugation is a minor pathway of ethanol metabolism. The determination of ethyl glucuronide (EG) in serum and urine has gained importance in forensic and other legal decisions. To prospectively calculate the serum concentration of this non-oxidative ethanol metabolite, the computer program developed includes a parameter fitting routine. Multiple ethanol doses can be handled.The mathematical modeling was based on the following assumptions and simplifications, respectively. A single enzyme system is responsible for ethanol conjugation at one distinct site; the distribution of EG into the systemic circulation is delayed; the elimination of EG follows first-order kinetics.The concentration of EG was calculated using three kinetic parameters: a rate constant for the first-order formation of EG from serum ethanol, a transfer constant for an obstructed transfer of EG from the formation site (FS) into the central compartment (CC) and an exponential elimination constant.The program was applied to the data collected from 21 drinking experiments. The fitting algorithm optimized the three kinetic parameters, until the sum of concentration error squares of the data points was minimized. The means+/-standard deviation of the rate constant for the first-order formation of EG from serum ethanol was 0.0011+/-0.0006 h(-1), the transfer constant for an obstructed transfer of EG from the FS into the CC was 0.43+/-0.1996 h(-1) and the exponential elimination constant was 3.0+/-1.45 h(-1).Using the range of these parameters, it is now possible to calculate minimum and maximum serum concentrations of EG based on ethanol doses and drinking times. The comparison of calculated and measured concentrations can prove the plausibility of an alleged ethanol consumption. This can be crucial when the serum ethanol concentration (SEC) itself is not meaningful.