Hyperthermia deaths in Finland in 1970-86

All cases in which hyperthermia had been determined as the basic cause of death during the period 1970-86 were collected from the records of the Central Statistical Office of Finland. Of the total of 230 cases, 228 were included in the present study; the two remaining victims died abroad, and no autopsy was performed in Finland. Most of the hyperthermia deaths occurred while the decedent was taking a sauna bath; most decedents were men aged 42-62 years. An increase in the total number of hyperthermia deaths, and of male victims, was noted from the beginning of the 1970s onward; the number of female victims remained at a relatively steady level throughout, with the exception of a slight rise in 1986. Acute alcohol consumption was detected in most of the victims; in some cases there was also a reference to chronic alcoholism or recent long-term heavy drinking. The findings suggest that in addition to the acute hazardous effect of ethanol on thermoregulatory mechanisms, the long-term consumption of alcohol may have promoted fatal hyperthermia in these subjects.     

Urinary catecholamines in hyperthermia-related deaths

A group of five hyperthermia-related deaths is presented in which urinary noradrenaline (NA) concentrations were elevated (172.1 +/- 119.4 ng/ml) compared with a control group of rapid violent deaths (43.7 +/- 26.1 ng/ml). Urinary adrenaline (A) concentrations were not elevated in the hyperthermia cases, nor were there any significant differences in urinary dopamine (DA) concentrations between the two groups. All except one of the hyperthermia victims were under the influence of ethanol. It is suggested that a combination of heat stress and ethanol consumption was responsible for the elevated urinary NA in the hyperthermia cases, reflecting increased sympathetic nervous system activity. A combination of high urinary NA with low A seems to be characteristic of hyperthermia fatalities, in contrast to hypothermia deaths, where both NA and A are usually elevated.     

Fatal complications of intramuscular and intra-articular injections

Four fatalities related to intramuscular and intra-articular injections are reported. In two of these cases a Staphylococcus aureus sepsis developed, as a consequence of injections into the left hip joint in one and in the lateral upper quadrant of the gluteal region in the other. The intra-articular injection of triamcinolone produced severe pain, but no marked signs of purulent arthritis were seen at autopsy, probably because of the anti-inflammatory effect of the corticosteroid. A cutaneous infection was seen in the gluteal region of the other patient, but no apparent abscess formation. In another case of intra-articular injection, purulent knee joint arthritis developed after an injection of glucosaminoglycan. The patient died of renal insufficiency, which was probably connected with the treatment of the arthritis with tobramycin and cefuroxim. The fourth case was that of a mentally ill patient who suffered sudden cardiac arrest after an intramuscular injection of chlorpromazine, but with no apparent signs of an anaphylactic reaction. It is suggested that vasodilatation and drop in blood pressure caused by the chlorpromazine could have had some effect, while cardiotoxicity of other psychotropic drugs with which he had been treated cannot be ruled out.     

Drugs and alcohol in hypothermia and hyperthermia related deaths: a retrospective study

Hypothermia and hyperthermia related cases recorded for the period 1973 to 1984 were collected from the files of the Department of Forensic Medicine, University of Oulu, and the necropsy protocols including toxicological results were analyzed. The fact that similar alcohol concentrations were found in both types of fatalities points to the poikilothermic effect of alcohol in humans, as found in animal studies. Both types of deaths seem to be associated with the alcohol elimination phase. Antidepressants and neuroleptics were most often found in the hypothermia cases, but benzodiazepines were also quite frequently present. In spite of the diminished use of barbiturates, these still appear in hypothermia fatalities. Certain other drugs that affect thermoregulation were also noted in solitary cases. Extended toxicological analysis was seldom made in the cases of hyperthermia deaths, and no firm conclusions on the poikilothermic effect of psychotropic drugs could be reached, for example. Therapeutic drug concentrations did not alone predispose the subjects to hypothermia, but appeared in connection with alcohol consumption or chronic diseases.     

Extreme obesity and associated cardiovascular disease verified at autopsy: time trends over 3 decades

Extreme obesity is a strong predictor of premature death, but the prevalence of cardiovascular disease in morbidly obese populations is largely unknown. The aim of the present study was to find out whether there has been an increase in extreme obesity with body mass index 40.0 kg/m(2) or greater in medicolegal autopsy material in a known geographical area in Finland during a period of 3 decades and to examine the prevalence and time trends of associated cardiovascular disease in this obesity category. Autopsy reports of 235 cases examined in 1975 to 2006 were analyzed. The number of extremely obese individuals increased from 0.6% of the yearly amount of autopsies in the 1970s and 1980s to 2.8% and 2.5% in 2005 and 2006, respectively. The most frequent cause of death was cardiomyopathy or cardiomegaly (28.9%), followed by coronary heart disease (24.3%). Either coronary arteries were lesion-free, or only fatty streaks had been observed in 46.8% of the women and in 43.1% of the men. No significant changes in the average body mass index or severity of coronary atherosclerosis were observed. Younger individuals younger than 40 years began to appear more often after 1995. An increased trend of extreme obesity in a region where autopsy frequency is high may refer to a general increase of this obesity category. A large number of extremely obese people are resistant to coronary atherosclerosis, but cardiac hypertrophy may be accompanied by several mechanisms leading to sudden death even among the youngest extremely obese individuals.     

Increased adrenaline to noradrenaline ratio is a superior indicator of antemortem hypothermia compared with separate catecholamine concentrations

The significance of urinary catecholamines and small gastric mucosal bleedings, Wischnewsky's spots, in postmortem diagnosis of hypothermia deaths was evaluated. Autopsy cases (n=358) were divided into hypothermia, suspected hypothermia, and control groups. The catecholamine levels did not correlate with the length of the postmortem period. The adrenaline to noradrenaline ratio was most effective in detecting hypothermia (68.9% sensitivity, 78.1% specificity). The median adrenaline concentrations were significantly higher in hypothermia than in control groups. The control group containing mostly sudden cardiac deaths with no cold exposure had a noradrenaline level comparable to the hypothermia groups. The sensitivity and specificity of determining Wischnewsky's spots in hypothermia deaths were 63.9% and 88.3%, respectively. The adrenaline to noradrenaline ratio is more suitable in proving antemortem cold stress than either of these independently, and its diagnostic value is comparable to that of Wischnewsky's spots.     

Chlorpromazine-induced alterations in hypothalamic amine metabolism and stress responses in severe cold

To investigate the effects on the central nervous system of severe cold stress with and without chlorpromazine, guinea pigs were treated with chlorpromazine or 0.9% NaCl and exposed to -20 degrees C or +23 degrees C for 1 h. Hypothalamic noradrenaline (NA), dopamine (DA), 5-hydroxy-tryptamine (5-HT), 3-methoxy-4-hydroxyphenyl ethylene glycol (MHPG), homovanillinic acid (HVA) and 5-hydroxy-indoleacetic acid (5-HIAA) were determined by high-performance liquid chromatography. Serum, urinary and vitreous fluid catecholamines, muscle and liver glycogen, and blood glucose were also measured. Chlorpromazine caused distinct hypothermia at -20 degrees C and slight hypothermia at +23 degrees C. The rise in hypothalamic MHPG, 5-HIAA and MHPG/NA and in 5-HIAA/5-HT ratios in the cold indicate increased noradrenergic and serotonergic activity. The latter was inhibited by chlorpromazine and a drug-induced inhibition of noradrenergic neurons could not be ruled out. Chlorpromazine increased the turnover of DA at room temperature and the same tendency was seen in the cold. The hypothermic animals had low serum catecholamines, indicating diminished sympathetic activity. The chlorpromazine-treated cold-exposed animals did not react to the environmental stress by sympathetic activation, as urinary NA and adrenaline were not elevated, but DA was excreted by all the drug-treated animals. Vitreous fluid NA and DA were elevated as an indicator of cold stress, and no drug effect was seen in this fluid.