Relationships between the deinstitutionalization of healthcare for patients with mental disorder, substance abuse, and isolated death

Isolated death (ID) (i.e., dying alone without anyone noticing for several days) has been suggested to be related to social isolation, mental disorder, and alcohol and/or drug abuse. A major transfer of patients with a mental disorder and/or alcohol and/or drug abuse from institutionalized care to treatment as outpatients has been enacted in Sweden during the past decade. On the basis of the assumption that such deinstitutionalization is likely to result in increased social isolation, our working hypothesis was that the incidence of ID among patients belonging to these categories has increased in Sweden. The present study involved all deaths subjected to a medicolegal examination in Stockholm County (with a population of approximately 1.9 million people) during the period 1992-2000. The pattern of ID (defined as cases involving a postmortem delay between death and discovery of at least 1 week), as well as the incidence of fatalities subjected to medicolegal examination with a record of mental disorder and/or alcohol and/or drug abuse was evaluated. Throughout this period, the proportion of the deceased with a record of a mental disorder was high among all the cases examined and higher still among the cases of ID, especially among those younger than 65 years of age. There was a rather limited increase in the incidence of ID and a much more pronounced increase in the number of former psychiatric patients whose deaths were subjected to medicolegal examination, but did not satisfy the criteria for ID. A record of alcohol and/or drug abuse was more common than a diagnosis of mental disorder among both the males and females who died at an age of less than 65, with a clear difference between the cases of ID and non-ID in the case of men. There was no significant increase in incidence over the course of this study. Thus, this study reveals a slight increase in the number of IDs and a more pronounced increase in the number of medicolegal examination of non-IDs of individuals with a record of a mental disorder.     

Spontaneous rupture of the urinary bladder

The report presents the case of a 33-year-old man under the primary assumption of homicide in which the court-ordered autopsy revealed death as a result of bleeding due to a spontaneous rupture of the urinary bladder. The article gives a short summary of the pathomorphological findings and their respective causes, for example the typical location of the rupture at the posterior wall and roof of the bladder and the common concomitant drunkenness. Furthermore, obligatory forensic investigations--beside the autopsy--are mentioned and discussed.     

Medicolegal aspects of witnessed suicide due to gunshot to the head. II. Legal medicine aspects and examination of the firing hand

The second part of the paper on suicides by gunshots to the head in the presence of witnesses focuses on relevant morphological autopsy findings such as entrance site, signs of close range or contact shots, bullet path etc. and also discusses selected aspects of ascertaining gunshot residues. For the identification of the shooter an integral medicolegal assessment of all the facts including the investigation results and the autopsy findings is essential. However, the morphological findings alone do not allow safe diagnosis, as for example in a homicide the temporal region, which was affected in all our cases, may have been deliberately chosen by the perpetrator as a localization typical of suicide. Thus methods to ascertain gunshot residues on the firing hand (by means of adhesive films and the polyvinyl-alcohol collection method--PVAL) are of great practical importance. In seven cases adhesive films and/or the polyvinyl-alcohol collection method were used. In one case the gunshot residues (GSR) were analysed by means of tape lifts and subsequent scanning electron microscopy (SEM). It was found that especially the combined application of topographical (adhesive tape/PVAL) and cumulative (SEM) methods allowed for the doubtless identification of the shooter, thus usually confirming the suicide. By the example of one case it is demonstrated that without the immediate collection of evidence at the scene objective reconstruction of the event becomes impossible. On the basis of the reported cases recommendations are finally given for a differentiated approach in the medicolegal evaluation of alleged witnessed suicide by gunshot (to the head).     

Y-STR polymorphism in Central Anatolian Region of Turkey

Eight Y-chromosome specific STR (Y-STR) loci including DYS19, DYS388, DYS389I, DYS389II, DYS390, DYS391, DYS392 and DYS393 were investigated in a group of males from Central Anatolian Region of Turkey. Healthy 59 males living in this region for at least three generations were included in the study. PCR analysis was carried out with Y-STR specific primers on genomic DNA obtained from peripheral blood samples and size determination of PCR products was performed by silver staining following 6% polyacrylamide gel electrophoresis (PAGE). DYS388 was found to be the locus with lowest diversity (D) whereas DYS389II was the locus with highest diversity. The current study presented a framework of variation for the eight Y-STR loci in Central Anatolian population.     

The time-dependent expression of fibronectin,MRP8, MRP14 and defensin in surgically treated human skin wounds

Fibronectin, MRP8, MRP14 and defensin were detected immunohistochemically in 46 surgically treated, fresh (hours old) human wounds and in wounds of 13 individuals who died immediately from fatal trauma (airplane crashes or train rollovers). In immediate fatal trauma, it was not possible to detect fibronectin outside of bleeding areas nor could inflammatory cells be visualized in the interstitium using MRP8, MRP14, or defensin antibodies. Fibronectin staining could be regularly demonstrated in wounds at least 20 min-old. Granulocytic infiltrates limited to the perivasal space could be detected 20-30 min after infliction of the wound expressing MRP8, MRP14 and defensin. It was also possible to detect fibronectin networks and MRP8-, MRP14-, and defensin-positive granulocytes and macrophages in particular wounds up to 30 days-old. No differences between the expression of MRP8 and MRP14 could be demonstrated in the wounds, the majority of which were only several hours old. As wound age increased, the number of defensin-positive granulocytes detected decreased. The immunohistochemical detection of fibronectin is a useful way to demonstrate vitality in fresh wounds, beginning about 20-30 min post-trauma. However, detection of MRP8, MRP14 and defensin provides no advantage over the routine histological detection of granulocytes and macrophages in wounds under 1-2 days old.     

Ethyl glucuronide concentrations in two successive urinary voids from drinking drivers: relationship to creatinine content and blood and urine ethanol concentrations

The concentrations of alcohol in blood (BAC) and two successive urine voids (UAC) from 100 drunk drivers were compared with the concentration of ethyl glucuronide (EtG), a minor metabolite of ethanol in urine, and the urinary creatinine content as an indicator of dilution. The subjects consisted of 87 men with mean age 42.2+/-14.2 years (+/-standard deviation, S.D.) and 13 women with mean age 42.5+/-14.4 years. Ethanol was measured in blood and urine by headspace gas chromatography (GC) and EtG was determined in urine by liquid chromatography-mass spectrometry (LC-MS). The mean UAC was 2.53+/-1.15g/l for first void compared with 2.35+/-1.17g/l for second void, decreasing by 0.18+/-0.24g/l on average (P<0.001 in paired t-test). The ratios of UAC/BAC were 1.35+/-0.25 for first void and 1.20+/-0.16 for second void and the difference of 0.15+/-0.27 was statistically significant (P<0.001). The UAC/BAC ratio was not correlated with creatinine content of the urine specimens, whereas the concentration of urinary EtG was positively correlated with creatinine (r=0.64 for first void and r=0.62 for second void). The UAC was not correlated with urinary EtG directly (r=-0.03 for first void and r=0.08 for second void) but after adjusting for the relative dilution of the specimens (EtG/creatinine ratio) statistically significant positive correlations were obtained (r=0.58 for first void and r=0.57 for second void). The dilution of the urine, as reflected in creatinine content, is important to consider when EtG measurements are interpreted. The excretion of EtG in urine, like glucuronide conjugates of other drugs, is influenced by diuresis. EtG represents a sensitive and specific marker of acute alcohol ingestion with applications in clinical and forensic medicine.     

Serum cannabinoid levels 24 to 48 hours after cannabis smoking

Low concentrations of THC and 11-hydroxy-THC in serum samples are often claimed not to result from recent cannabis use. Prediction of time of exposure is difficult, especially if distinctive features of drug use could not be observed. Therefore, the aim of the study was to investigate the presence of THC and 11-hydroxy-THC in serum samples as well as to obtain preliminary data on the analyte profile for a time window of 24-48 hours after discontinuation of cannabis smoking. Serum samples from heavy (n = 12, > 1 joint/day), moderate (n = 11, < or = 1 joint/day) and light (n = 6, < 1 joint/week) smokers of cannabis were analyzed for THC, 11-hydroxy-THC and free THC-COOH by GC/MS as well as for glucuronidated THC-COOH by LC/MS-MS. The blood samples were collected 24-48 hours after abstaining from cannabis use. Additionally, 8 specimens were obtained from persons after discontinuation of the drug for more than 48 hours. During collection of the blood samples, distinctive effects due to drug use could not be observed. For heavy users of cannabis, THC was detectable in 8 samples, and in 5 cases both biologically active compounds, THC and 11-hydroxy-THC, were present (1.3-6.4 ng THC/mL serum, 0.5-2.4 ng 11-hydroxy-THC/mL serum). Among moderate users, in 1 sample 1.8 ng THC/mL serum and 1.3 ng 11-hydroxy-THC/mL serum were determined, and another sample was tested positive with low concentrations close to the limit of detection. In serum samples of light users both analytes could not be detected, indicating that in those persons a positive finding of THC and 11-hydroxy-THC may rather result from recent consumption than from cannabis use 1 or 2 days prior to blood sampling. The concentrations of THC-COOH and its glucuronide covered a wide range in all groups of cannabis users. However, there was a trend to higher concentrations in heavy users compared to moderate users, and the mean concentration was smaller in light smokers than in moderate smokers. Overall, the findings indicated that data from pharmacokinetic studies should be supplemented by data obtained from "real-life" samples.     

Fatalities after injuries by wild animals

The article summarises three fatalities after attacks by wild animals. The first case describes a 90-year-old woman who died as a result of pneumonia after a bear fell on her and caused multiple chest fractures. The second case deals with a 76-year-old woman who was hit in the middle face by the hoof of a camel and, thereafter, died of myocardial infarction. The third case describes a 27-year-old biologist who died from severe blunt trauma after an attack of a wild living elephant. The article gives a summary of typical injury patterns of selected wild animals and outlines potential reasons of death as a result of the injuries.     

Rare pattern of injuries after being run over by a railroad train

The article reports on findings after a suicide committed by being run over by the driving unit of an ICE train in a railway station. After recovering the body a fresh abrasion was found on the right upper abdomen with a minor laceration. Some hours later a circular abrasion mark and zones of contusion were discernible on the trunk. Whereas the integument was largely intact, the spine was severed and inner organs of the trunk were ruptured.     

Virtopsy-postmortem multislice computed tomography (MSCT) and magnetic resonance imaging (MRI) in a fatal scuba diving incident

The body of a 44-year-old scuba diver was examined using postmortem multislice computed tomography (MSCT) and magnetic resonance imaging (MRI), and findings were verified by subsequent autopsy. The goal was to find out whether the important pathomorphological findings for the reconstruction of events and the identification of cause and manner of death could be identified using modem digital cross-sectioning techniques. The findings of a massive vital decompression with pulmonary barotrauma and lethal gas embolism were identified in the radiological images. MSCT and MRI were superior to autopsy in the demonstration of the extent and distribution of gas accumulation in intraparenchymal blood vessels of internal organs as well as in areas of the body inaccessible by standard autopsy.