Caffeine fatalities--four case reports

Four cases of fatal intoxications with caffeine are described. Caffeine is widely available in beverages and in different OTC-products, in many of them in combinations with other drugs like ephedrine. Caffeine is not as harmless as one might believe. An overdose of caffeine alone, intentional or not, might be deadly. It seems to be warranted to include caffeine in the drug-screening of forensic autopsy cases. It is not motivated from a medical point of view to sell pure caffeine over the counter.     

Fatal poisoning in drug addicts in the Nordic countries.

The study includes medicolegally examined fatal poisonings among drug addicts in 1997 in the five Nordic countries: Denmark, Finland, Iceland, Norway and Sweden, and the results are compared to a similar investigation from 1991. A common definition of "drug addict" was applied by the participating countries.The highest death rate by poisoning in drug addicts was observed in Denmark, where it was 6.54 per 10(5)inhabitants, followed by Norway with 6.35, Sweden with 2.21, Finland with 1.63 and Iceland with 1.20 per 10(5)inhabitants. All countries showed a higher death rate in 1997 than in 1991. For all countries the distribution of deaths according to geographical regions showed a decreasing number of drug deaths in the metropolitan area and an increasing number in other cities. Heroin/morphine dominated as the cause of death and was responsible for about 90% of the cases in Norway. In Sweden and Denmark, however, heroin/morphine caused only about 70% of the fatal poisonings. About 30% of the fatal poisonings in Denmark and Sweden were caused by other group I drugs, in Denmark mainly methadone and in Sweden mainly propoxyphene. Apart from two cases in Sweden methadone deaths were not seen in the other Nordic countries. In Finland heroin/morphine deaths have increased from about 10% in 1991 to about 40% in 1997. Forty-four percent of the fatal poisonings in Finland were caused by other group I drugs, mainly codeine and propoxyphene. The two fatal poisonings in Iceland were caused by carbon monoxide. Only few deaths in this investigation were caused by amphetamine and cocaine. A widespread use of alcohol, cannabis and benzodiazepines, especially diazepam, was seen in all the countries.     

Citizenship identity among Norwegian Sami in core Sami areas

This analysis of citizenship identity among Sami living in core Sami areas in Norway clearly shows that the Sami population feel more closely connected to their local communities than is the case for non-Sami living in the same areas and for the Norwegian populace as a whole. Some significant differences also emerge as regards citizenship identity between Sami who have chosen to be registered in the Sami electoral roster and those who are not registered – in terms of identification with different identity groups, affiliation with different territorially defined areas and the intensity of their Sami identity. However, none of our findings suggest that the total Norwegian citizenry is an unimportant identity group for the Sami population, or that the Sami do not feel affiliated with Norway as a whole. The fact that the perceived content of Norwegian-ness does not seem to include elements that are incompatible with the perceived content of Sami-ness also indicates that it may not be particularly difficult for individuals to combine Sami and Norwegian identity.     

Performance Management and Public Sector Reform: The Norwegian Hospital Reform

This article addresses the development of new performance management systems related to public sector reforms. One such system is Management by Objectives and Results (MBOR), based on an official OECD model. Such a system tries to establish unambiguous goals, objectivity, and incentive elements into often traditionally trust-based systems embedded in a complex political-administrative context. To analyze such performance management systems and how they work in practice, we focus on a recent reform of the hospital structure in Norway. Using a broad institutional perspective, we argue that the MBOR-system in Norway is a mixed and complex system encompassing different kinds of logic. These include instrumental elements from the new performance management systems combined with ad hoc preventive efforts by the political leadership, the influence of cultural constraints, elements of rather inappropriate self-interested action, and pressure from the environment. The study reveals that the hospital reform in Norway in practice can be seen as an integrated model, combining informal trust-based approaches and formal performance management measures. It also shows that negative side effects and dysfunctions might occur.     

Multiculturalism,memory, and ritualization: Ukrainian nationalist monuments in Edmonton,Alberta

Canadians of Ukrainian descent constitute a significant part of the population of the Albertan capital. Among other things, their presence is felt in the public space as Ukrainian monuments constitute a part of the landscape. The article studies three key monuments, physical manifestations of the ideology of local Ukrainian nationalist elites in Edmonton: a 1973 monument to nationalist leader Roman Shukhevych, a 1976 memorial constructed by the Ukrainian Waffen-SS in Edmonton, and a 1983 memorial to the 1932–1933 famine in the Ukrainian SSR. Representing a narrative of suffering, resistance, and redemption, all three monuments were organized by the same activists and are representative for the selective memory of an “ethnic” elite, which presents nationalist ideology as authentic Ukrainian cultural heritage. The narrative is based partly upon an uncritical cult of totalitarian, anti-Semitic, and terroristic political figures, whose war crimes, ethnic cleansing, and collaboration with Nazi Germany the nationalists deny and obfuscate. The article argues that government support and direct public funding has strengthened the radicals within the community and helped promulgate their mythology. In the case of the Ukrainian Canadian political elite, official multiculturalism underwrites a narrative at odds with the liberal democratic values it was intended to promote. The failure to deconstruct the “ethnic” building blocks of Canadian multiculturalism and the willingness to accept at face value the primordial claims and nationalist myths of “ethnic” groups has given Canadian multiculturalism the character of multi-nationalism.     

Physical Restraint and Near Death of a Psychiatric Patient

Physical restraint is used as a last resort emergency measure to calm and safeguard agitated and/or aggressive psychiatric patients. This can sometimes cause injuries, and rare fatalities have occurred. One mechanism of injury and death while in physical restraint is that of severe asphyxiation. We present the case of a hospitalized man in his mid‐30s, suffering from schizophrenia. The patient was obese. He became aggressive and had to be manually restrained with a “takedown.” After having been put in the prone position on the floor with a significant weight load on his body, he lost respiration and consciousness. Subsequently, he was given CPR. He regained consciousness and respiration, while the cyanosis receded in 1–2 min. Psychiatrists and pathologists should be aware that physically restraining a patient in the prone position with a significant weight load on the torso can, in rare cases, lead to asphyxiation.     

Attitudes among stakeholders towards compulsory mental health care in Norway

Objectives

The Norwegian Mental Health Care Act allows use of coercion under certain conditions. Even though the current practice has been criticized, little empirical data exist about the attitudes towards compulsory mental health care.

Method

This study used Q-methodology to identify prototypical attitudes and to test possible differences of attitudes between groups of stakeholders towards the use of coercion in mental health care. Sixty-two respondents who represented six groups with different roles in mental health care participated: former patients, relatives of psychiatric patients, members of supervisory commissions, psychiatrists, other physicians, and lawyers.The participants were asked to assess the degree to which they agreed on 30 statements concerning use of coercion for the mentally ill.

Results

Three factors that in a meaningful way express different attitudes towards the question were found. The most widely shared attitude stated that a trusting relationship between patient and therapist is more important than the right to have an attorney. This attitude gives partial support to the present Mental Health Care Act. However, the second most common attitude argues that involuntary hospitalization, if necessary, should be decided in a court and not by the hospital doctor.

Conclusions

Differences in attitude could partly be explained by the respondents' role in mental health care. Both psychiatrists and “somatic” physicians expressed more agreement with the present legislation than the other stakeholders. The findings may have implications for the legal protection of mental health care patients.     

Concentrations of zolpidem and zopiclone in venous blood samples from impaired drivers compared with femoral blood from forensic autopsies

The concentrations of zolpidem and zopiclone were determined in peripheral blood samples in two forensic materials collected over a 10-year period (2001-2010). The z-hypnotics were determined in venous blood from living subjects (impaired drivers) and in femoral blood from deceased persons (forensic autopsies), with the latter classified as intoxication or other causes of death. The z-hypnotics were determined in blood by capillary column gas chromatography (GC) with a nitrogen-phosphorous (N-P) detector after solvent extraction with n-butyl acetate. The analytical limit of quantitation (LOQ) was 0.02mg/L for zopiclone and 0.05mg/L for zolpidem and these have remained unchanged throughout the study. When death was attributed to drug intoxication (N=918), the median concentration of zopiclone in blood was 0.20mg/L compared with 0.06mg/L for other causes of death (N=1215) and 0.07mg/L in traffic offenders (N=691) (p<0.001). Likewise, a higher median concentration (0.30mg/L) was found in intoxication deaths involving zolpidem (N=357) compared with 0.13mg/L for other causes of death (N=397) or 0.19mg/L in impaired drivers (N=837) (p<0.001). Median concentration in blood of both z-hypnotics were appreciably higher in intoxication deaths when no other substances were identified; 0 70mg/L (N=12) for zopiclone and 1.35mg/L (N=12) for zolpidem. The median concentrations of z-hypnotics in blood decreased as the number of co-ingested substances increased for intoxication deaths but not other causes of death. The most prevalent co-ingested substances were ethanol in autopsy cases and diazepam in the motorists. This large compilation of forensic cases should prove useful when toxicologists are required to interpret concentrations of z-hypnotics in blood samples in relation to cause of death.     

A new system for computer aided dental identification in mass disasters

In recent years, several computer programs for dental identification in mass disasters have been developed. Unfortunately, it may be difficult to get access to such programs. The Norwegian police presently utilizes a text retrieval program, NOVA¹STATUS, for detection work. This program is based on the British STATUS ONE program, and it enables the user to find from a large pool of postmortem dental registration one or several sets containing specific information about one tooth or several teeth. The complete relevant set(s) can be displayed for visual examination and comparison. A coding system for dental information has been developed as well as a system for interrogating the computer. This system and its efficiency have been tested on a simulated small scale disaster where various well-known difficulties in dental identification were included.