Fatal poisoning in Nordic drug addicts in 2002.

The present study from 2002 includes medicolegally examined fatal poisonings among drug addicts in the five Nordic countries: Denmark, Finland, Iceland, Norway and Sweden. A common definition "drug addict" is applied by the participating countries. The number of deaths, age, sex, place of death, main intoxicant and other drugs present in the blood are recorded in order to obtain national data, as well as comparable Nordic data and data comparable to earlier studies from 1997 and 1991. The Icelandic results are commented on separately due to the low number of cases. The most fatal overdoses are seen in Norway, in both the death rate (number per 100,000 inhabitants=8.44) and in absolute number (n=232). The comparable figures for the other four countries are Denmark 5.43 (n=175), Iceland 3.6 (n=6), Finland 2.93 (n=94) and Sweden 2.56 (n=136). In earlier studies from 1991 and 1997, the highest death rate is seen in Denmark, with Norway as number two. Denmark is the only country where the death rate decreases from 1997 to 2002. A relatively large increase in deaths in the younger age groups (<30 years) is noted from 1997 to 2002, except in Denmark, where only a small increase in overdose deaths in very young people (15-19 years) is observed. Females account for 12-20% of the overdoses (three out of six deaths in Iceland). Relatively fewer deaths are recorded in the capital areas in 2002 than in 1997 and 1991, suggesting more geographically widespread drug use in the Nordic countries. Heroin/morphine is the single most frequently encountered main intoxicant, varying from 10% of the cases in Finland to 72% of the cases in Norway. Finland differs from the other countries in that a high percentage of the fatal overdoses in Finland are not caused by an illicit drug; buprenorphine overdoses are seen, and relatively few deaths resulting from heroin are seen. Methadone is the main intoxicant in 41% of the Danish overdose cases, 15% of the Norwegian cases, 4% of the Swedish cases and none of the Finnish overdose cases, an observation probably linked to different national prescription rules for methadone. The analytical screening reveals extended polydrug use. Frequently seen substances, in addition to the main intoxicant are amphetamine, tetrahydrocannabinol (THC), benzodiazepines and ethanol.

An improved procedure for the electrochemical determination of serum ionized calcium.

The "Orion model 99-20 serum calcium flow-through system" has been rendered insensitive to protein poisoning by the plascing of a dialysis membrane in front of the electrode membrane, making the addition of trypsin and triethanolamine to standards unnecessary. Flow dependency of the results obtained has been investigated.

Alcohol and drugs (medical and illicit) in fatal road accidents in a city of 300,000 inhabitants.

During a 1-year period all fatal road accidents in the police district of Aarhus, Denmark, were investigated regarding the presence of alcohol, medical drugs or narcotic substances, and the nature of the accident. Out of a total of 30 accidents 24 were investigated. Two thirds had been caused by the victim him- or herself. In one third of the accidents alcohol was present and considered an important contributory factor. Medical drugs and narcotic substances played a lesser role.

Verification testing of the bearings used in the electrohydraulic total artificial heart.

This article reports the verification testing performed on the ball bearings used in the electrohydraulic total artificial heart (EHTAH) device. The bearings were tested for 70 days under conditions intended to simulate those actually experienced by the bearings in the EHTAH device. Vibration analysis to predict the condition of the bearings, as well as diagnosis of the wear experienced by the bearings, was included in this study. Examination of the bearings using light microscopy indicated the presence of wear, and in some instances the contact surfaces had undergone temper coloring, a warning sign that hardness of the bearing may have been impaired, and that the bearing has experienced a temperature excursion. Temper coloring can be caused by too thick a coating of grease or by insufficient hydrodynamic film thickness. In this investigation, the vibration amplitudes at specific frequencies that correlated with the bearing components were monitored for change. From analysis of the vibration spectra, it was found that the change in amplitude did not predict the damage incurred by the bearings. The type of damage experienced by the bearings is difficult to predict using spectral analysis.

Development of a totally implantable artificial heart.

The first generation of an integrated, totally implantable electrohydraulic total artificial heart was designed for long-term cardiac replacement. The system consists of an elliptical blood pump with an interatrial shunt, Medtronic-Hall 27 mm and 25 mm inflow and outflow valves, respectively, an energy converter consisting of an axial-flow, hydraulic pump driven by a brushless DC motor, and an electronics system with transcutaneous energy transmission and telemetry. Energy is supplied by internal nickel-cadmium rechargeable batteries that supply power for 20 min and external silver-zinc batteries that are designed to supply energy to run the system for 5 hr. The blood pump consists of a single layer diaphragm cast from Biolon, with joined right and left ventricles sharing a common base. The dynamic stroke volume is 84 ml, and maximum cardiac output is 9.2 L/min at a heart rate of 110 beats/min on the mock circulation. A 4.3 mm diameter interatrial shunt is used to balance the volumetrically coupled ventricles. The energy converter pumps hydraulic fluid alternately between ventricles, with controlled, active filling in one ventricle during the systolic phase of the other ventricle. Internal or external controllers adjust the heart rate and motor speed to maintain normal atrial filling pressures and full stroke. Electromagnetic induction is used to transfer energy through the skin and a bidirectional infrared data link incorporated within the transcutaneous energy transmission coils is used to transmit information. The entire system is being assembled and refined for long-term animal implant studies.

In vivo long-term evaluation of the Utah electrohydraulic total artificial heart.

An electrohydraulic total artificial heart (EHTAH) has been developed and evaluated by long-term in vivo studies. The EHTAH is composed of blood pumps with an interatrial shunt (IAS), an energy converter, and electronics. The EHTAH with external electronics was implanted in four calves weighing from 81-90 kg. Two animals died on the 1st and 5th post operative days, the third animal survived for 32 days, and the fourth for 159 days. The IAS was free of thrombus at autopsy in all animals. The longest surviving animal increased in size from a pre operative weight of 81 kg to 134 kg on day 144. Cardiac output ranged from 9.3 to 10.5 L/min, whereas right and left atrial pressures increased with the calf's growth from 4-10 to 16-20 mmHg and from 8-14 to 18-22 mmHg, respectively. The animal favorably tolerated up to 3.4 km/hr of treadmill exercise, both hemodynamically and metabolically. The elevation of atrial pressures during treadmill exercise was significantly alleviated by employing an automatic control mode. It is concluded that the device has the potential to be a totally implantable system for permanent use.

A blood pump with an interatrial shunt for use as an electrohydraulic total artificial heart.

A recently designed blood pump subsystem for the completely implantable electrohydraulic total artificial heart (EHTAH) has been developed and is under evaluation. The subsystem consists of joined left and right ventricles, atrial cuffs with an interatrial shunt (IAS), and two outflow grafts. The ventricles were developed to fit within the pericardial space based on the results of anatomic fit trials. An optimized configuration for animal use, which was adaptable for human use with minimal modification, was identified. The core dimensions of the ventricles with an energy converter are approximately 10 x 11 x 7 cm. Maximum output and stroke volume are 9.2 L/min and 81 ml, respectively. The IAS is used to balance the volumetrically coupled EHTAH, and is made by forming an orifice in the common septum of the left and right atrial cuffs. Performance and durability of the IAS were examined in animal experiments for up to 9 days. The diameter of the IAS was 3.4-5.5 mm, and the left-right atrial pressure difference ranged from 2 to 10 mmHg, with 0.57-1.48 L/min of theoretically calculated shunt flow. No evidence of thrombus formation was found in or around the IAS at autopsy. The entire EHTAH system with a new blood pump is being assembled for long-term animal studies.

Prevalence of cannabinoids in urine samples from forensic autopsies.

Urine samples from 393 forensic autopsies were tested for the presence of cannabinoids by means of the radio-immunoassay test kit from DPC, Los Angeles. Fifteen per cent were found positive, mainly men and young adults. Use of cannabis was found to be closely related to drug addiction, and thus in cannabis-positive drug addicts, non-natural manners and causes of death dominate. In non-addicts the prevalence of cannabis use was 7.5%, and in non-addicted cannabis users, manners and causes of death were not very different from those found in cannabis-negatives.

[Deaths due to poisoning in Denmark in 1983-1987]. / Forgiftningsdødsfald i Danmark 1983-1987.

Deaths due to poisoning in Denmark during the five-year period 1983-1987 are described on the basis of the information from the register of causes of deaths in the Danish Institute of Clinical Epidemiology. The average annual number of deaths due to poisoning was 935.63% of these were suicides, 21% accidents, less than 1% manslaughter and in 16% of the cases the manner of death had not been established. 68% were due to medicaments, nearly half of these unspecified, 25% were due to carbon monoxide, 5% to alcohol, and 2% to other causes. The value of this account is restricted by the fact that not all of these deaths were submitted to medico-legal investigation, and that there were technical limitations in the classification and coding of causes and manners of death. In this connection, it is emphasized that almost one third of the deaths due to poisoning were caused by an unknown medicament. Differences in manners and causes of death are noted by comparing the results of this account to the material from the institutes of forensic medicine concerning chemically investigated deaths due to poisoning. This account applies to the prophylaxis of deaths due to poisoning, with special reference to medical drugs in general, carbon monoxide, alcohol, alcohol in combination with medicaments or narcotics, and over-the-counter analgesics containing acetylsalicylic acid. It is concluded that a more carefully examined representative material is required.

[Validity of postmortem alcohol determination]. / Validiteten af postmortel alkoholbestemmelse.

The aim of this study was to establish the confidence interval for the determination of alcohol in post-mortem material. The calculations in the study concern cases in which two blood samples had been taken from a dead body with the purpose of determining alcohol content of the blood. The confidence interval (calculated as twice the standard deviation) was found to be 0.50 per thousand. The study confirms the previously established slight decrease in the concentration of alcohol in the blood during the first hours after death. No post-mortem alcohol production was found to have taken place during the first 24 hours (approx.) if the body had been kept at a low temperature. It is concluded that a confidence interval of 0.50 per thousand should be applied in the evaluation of post-mortem alcohol determination. In cases of visible putrefaction of a corpse an individual assessment must be made.

[Methanol poisoning in alcohol abusers]. / Traespritforgiftning hos alkoholmisbrugere.

Methanol (wood alcohol) is sold in Denmark only to factories and laboratories with a certified knowledge of the substance or to individuals holding a special licence. Methanol is nowadays used as a solvent or for syntheses only. During a six-year period three cases of methanol poisoning were found in a selected forensic material. A screening for alcohols is routinely performed in connection with all medicolegal autopsies when the presence of alcohols cannot be ruled out in advance. All three cases concerned men accustomed to a substantial intake of alcohol. Two of the cases were accidental deaths due to methanol poisoning. The third case was suicide committed by the ingestion of a herbicide containing methanol. Methanol poisonings are rare, but do still occur. It is, therefore, important for physicians to be aware of the symptoms and know the treatment.

[Measurement of alcohol in saliva with a test strip]. / Måling af alkohol i spyt med teststrimmel.

As the concentration of alcohol in saliva follows the concentration of alcohol in the blood meticulously, a test strip to measure alcohol in saliva would provide an easy and rapid method of semiquantitative estimation of the blood alcohol concentration. The authors have submitted Alco-Screen test strips to trial by comparing five different batches by measurement on aqueous solutions of alcohol, saliva to which alcohol had been added and also in practice. The batch variations were very great and the results obtained on aqueous solutions and saliva with added alcohol were too high whereas the results in practical use were, in general, too low. In addition, it was found that the colour of the reagent field was difficult to compare with the reference fields. Instructions for use were incomplete and easily misunderstood.

[Salicylic acid poisoning]. / Salicylsyreforgiftninger.

The study analyses the role of salicylic acid (SA) in fatal intoxications with special reference to potentially avoidable, accidental poisonings. The study indicates a relation between SA intoxication and the presence of an infection of the respiratory tract. All deaths in Denmark in the period 1980 through 1989 registered as caused by SA were analysed as were all deaths submitted to forensic toxicological examination in a defined region of Denmark in the years 1985 through 1989. During the decade 1980 through 1989 the number of fatal intoxications due to SA increased from approx. five per year to approx. 23 per year. During the same period the sales of SA decreased. Many deaths in the material were registered as accidental, and an increasing frequency of accidental deaths was seen with a lower social level. Frequently, an infection of the respiratory tract was either indicated in a hospital case record or a police report, or found at autopsy.

[Alcohol, drugs and narcotics in suicides in the Aarhus police district]. / Alkohol, medicin og narkotika ved suicidier i Aarhus Politikreds.

For a period of one year all suicides in Aarhus police district were investigated with a view to identifying the presence of alcohol or drugs in the body of the deceased. Fifty-one suicides occurred, 46 of which were examined. One third of the suicides were due to poisoning and one fourth to hanging. Alcohol was detected in 20% and drugs or narcotics were found in approximately 60%. The most frequent findings were benzodiazepines, analgetics, antidepressants and carbon monoxide. Approximately 40% of the deceased had received psychiatric treatment.

[Treatment of acute chloroquine poisoning]. / Behandling af akut klorokinforgiftning.

Acute chloroquine poisoning is life threatening with risk of death from apnoea and cardiac arrhythmia within a few hours of ingestion. Mechanical ventilation, infusion of pressor agents and large doses of diazepam seem to provide effective treatment. This treatment was introduced by Riou et alii (N Engl J Med 1988; 318; 1-6), and we used it successfully in a case of severe chloroquine poisoning. Intensive treatment was given during the first two days of intoxication, when the whole blood chloroquine phosphate concentration was high (more than 10 mumol/kg), corresponding to absorption from the gut and distribution to the organs. Hereafter the whole blood chloroquine phosphate concentration decreased increasingly slowly, probably due to equilibrium with tissue stores.

[Deaths among drug addicts in Denmark. A forensic medical study of deaths among drug addicts during the period 1991-1992 related to the period 1984-1985]. / Narkomandødsfald i Danmark. En retsmedicinsk undersøgelse af narkomandødsfald 1991-1992 relateret til 1984-1985.

This study includes all deaths among drug addicts in the years 1991 (n = 219) and 1992 (n = 214) investigated at the three institutes of forensic medicine in Denmark. The results are compared with deaths among drug addicts in 1984-1985. The number of deaths among drug addicts increased by approximately 50% in 1991-1992 compared with 1984-1985. The increase was most significant among drug addicts over 35 years of age. The cause of death was intoxication in three-quarters of the cases in 1991-1992. In half of these cases heroin/morphine had caused death, while intoxications caused by methadone accounted for approximately 30% of the cases. In the metropolitan area the frequency of methadone intoxications increased significantly compared with 1984-1985, whereas the number of heroin/morphine intoxications did not change. Outside the metropolitan area, however, a significant increase in heroin/morphine intoxications was noticed. In all parts of the country the number of propoxyphene intoxications decreased to a few annual cases. The most commonly used drugs of abuse were heroin/morphine, diazepam and methadone, often in combination with alcohol.

[Fatal intoxications among drug addicts in Denmark in 1997]. / Forgiftningsdødsfald blandt narkomaner i Danmark i 1997.

INTRODUCTION: The purpose of this study was to investigate fatal poisonings among drug addicts in 1997 and to compare the results to similar investigations from 1985 and 1991. MATERIAL AND METHODS: All fatal intoxications among drug addicts in Denmark in 1997, investigated at the three Institutes of Forensic Medicine in Denmark. RESULTS: The number of fatal intoxications increased by 32% from 1991 to 1997, mainly outside the metropolitan area, The average age increased from 32 to 36 years. The proportion of heroin/morphine intoxications increased from 57% to 71%. The most commonly used drugs were as in 1991 heroin/morphine, diazepam and methadone. The frequency of cocaine increased from one positive case in 1991 to 14% positive cases in 1997. DISCUSSION: This study showed an increasing number of fatal intoxications and changes in drug abuse pattern and place of death since 1991.

Fatal poisoning in drug addicts in the Nordic countries in 2007.

The frequency of medico-legally examined fatal poisonings in 2007 among drug addicts was investigated in five Nordic countries; Denmark, Finland, Iceland, Norway, and Sweden. The number of deaths, age, sex, place of death, main intoxicant, and other drugs present in blood samples were recorded to obtain national and comparable Nordic data, as well as data to compare with earlier studies in 2002, 1997, and 1991. Norway had the highest incidence of drug addict deaths by poisoning followed by Denmark, with 8.24 and 6.92 per 100,000 inhabitants, respectively. The death rates in Finland (4.02), Iceland (4.56), and Sweden (3.53) were about half that of Norway and Denmark. Compared with earlier studies, the death rates were unchanged in Denmark and Norway, but increased in Finland, Iceland, and Sweden. In all countries, fewer deaths (29-35%) were recorded in the capital area compared with earlier studies. Females accounted for 11-19% of the fatal poisonings. Iceland deviates with a more equal distribution between men and women (40%). Deaths from methadone overdoses increased in all Nordic countries, and methadone was the main intoxicant in Denmark in 2007, accounting for 51% of the poisonings. In Norway and Sweden, heroin/morphine was still the main intoxicant with a frequency of 68% and 48%, respectively. In Iceland, 3 deaths each were due to heroin/morphine and methadone, respectively. Finland differs from other Nordic countries in having a high number of poisonings caused by buprenorphine and very few caused by heroin/morphine. The total number of buprenorphine deaths in Finland doubled from 16 in 2002 to 32 in 2007, where it constituted 25% of deaths. The general toxicological screening program showed widespread multi-drug use in all countries. The median number of drugs per case varied from 3 to 5. The most frequently detected substances were heroin/morphine, methadone, buprenorphine, tramadol, amphetamine, cocaine, tetrahydrocannabinol, benzodiazepines and ethanol.