Time dependence of elimination of different PEth homologues in alcoholics in comparison with social drinkers.

BACKGROUND: Phosphatidylethanol (PEth) is a direct marker of alcohol consumption, which has been known for almost 30 years. Each PEth molecule carries 2 fatty acids, which differ in chain length and degree of unsaturation. It is formed by means of phospholipase D in the presence of ethanol. Usually, this marker was used by quantification of the PEth homologue 16:0/18:1. The intention of this work was to get more information about the distribution and the quantity of the different PEth homologues. METHODS: Blood samples from 12 alcohol-dependent subjects were collected and analyzed during withdrawal therapy. For comparison, blood from 78 healthy social drinkers was also analyzed. PEth analysis was performed as follows: after liquid-liquid extraction, the homologues were separated on a Luna Phenyl Hexyl column, injected to an HPLC system (1100 system; Agilent) and identified by ESI-MS/MS (QTrap 2000; AB Sciex) using multiple reaction monitoring. RESULTS: PEth 16:0/18:1 is the major homologue comparing the area ratios of PEth homologues in blood samples from alcoholics. Additional prevalent homologues were PEth 16:0/18:2, 18:0/18:2, and 18:0/18:1. The homologues occurring in blood samples from alcoholics as well as from social drinkers were mostly the same, but differences among their distribution pattern were observed. CONCLUSIONS: In addition to the approach to quantitate the PEth homologue 16:0/18:1, this is a new and alternative proceeding for the differentiation between alcoholics and social drinkers using this alcohol consumption marker.

Suicidal ligature strangulation using gymnastics bands.

Suicidal ligature strangulation is a rare event. The most important issue to solve in the investigation is whether it is a case of homicide or suicide. The characteristics of suicidal ligature strangulation are summarized by Koops and Brinkmann with the emphasis on the nature of the ligature instrument(s). In this article, we present two cases of self-strangulation with an almost identical modus operandi using gymnastics bands. The autopsy findings and the nature of the ligature in these cases are depicted and in good accordance with the described typical observations in suicidal cases. The importance of a broad medico-legal investigation is demonstrated.

Muzzle-loading weapons discharging spherical lead bullets: two case studies and experimental simulation using a skin-soap composite model.

In current forensic practice, fatal injuries from black powder guns are rare events. In contact and close-range shots, the intensity of GSR deposition (soot, powder particles) is much greater than that in shots with smokeless powder ammunition. The same applies to any burning effects from the combustion gases. Besides, a wad of felt interposed between the propellant and the lead bullet may enter the wound channel. Apart from these findings seen in close-range shots, another characteristic feature results from the mostly spherical shape of the missiles causing maximum tissue damage at the entrance site. Two fatal injuries inflicted with muzzle-loading weapons are reported. In the first case, suicide was committed with a cal. 11.6 mm miniature cannon by firing a contact shot to the back of the neck. In test shots using black powder (1 and 2 g) as propellant, the mean bullet velocity measured 1 m away from the weapon was 87.11 and 146.85 m/s, respectively, corresponding to a kinetic energy of 32.49 and 92.95 J, respectively. Contact test shots to composite models consisting of ballistic soap covered by pig skin at the entrance site were evaluated by CT and revealed cone-like cavitations along the bullet path as known from spherical missiles and penetration depths up to 25 cm. The second case presented deals with a homicidal close-range shot discharged from a muzzle-loading percussion pistol cal. .44. The skin around the entrance site (root of the nose) was densely covered with blackish soot and powder particles, whereas the eyebrows and eyelashes showed singeing of the hairs. The flattened bullet and the wad had got stuck under the scalp of the occipital region. In both cases, there was a disproportionally large zone of tissue destruction in the initial parts of the wound tracks.

The varying size of exit wounds from center-fire rifles as a consequence of the temporary cavity.

To study the question whether and how the size and position of the temporary cavity influence the morphology and especially the size of a bullet exit wound, test shots were fired to composite models consisting of gelatine and pig soft tissue covered with skin (at the exit site). The dimensions of the composite model were determined such that the exit planes were located either at the level of the narrow channel or within the temporary cavity or behind it. The chronological sequence of wound formation and its relation to the current position of the bullet were documented by means of a high-speed camera. Test shots were fired from a distance of 10 m using 5.56 × 45 mm cartridges with full metal-jacketed pointed bullets (v 0 ∼ 912 m/s, E 0 ∼ 1,663 J). The study proved that the extension and position of the temporary wound cavity was decisive for the size of the exit wound: An exit plane within the cavity resulted in particularly large skin lesions, whereas the wound diameters were much smaller if the exit plane was located in front or behind the cavity. The exit hole reaches its maximum size only after the bullet has left the target synchronous to the staggered expansion of the temporary cavity.

A case of a distinct difference between the measured blood ethanol concentration and the concentration estimated by Widmark's equation.

In the last century, several mathematical models have been developed to calculate blood ethanol concentrations (BAC) from the amount of ingested ethanol and vice versa. The most common one in the field of forensic sciences is Widmark's equation. A drinking experiment with 10 voluntary test persons was performed with a target BAC of 1.2 g/kg estimated using Widmark's equation as well as Watson's factor. The ethanol concentrations in the blood were measured using headspace gas chromatography/flame ionization and additionally with an alcohol dehydrogenase (ADH)-based method. In a healthy 75-year-old man a distinct discrepancy between the intended and the determined blood ethanol concentration was observed. A blood ethanol concentration of 1.83 g/kg was measured and the man showed signs of intoxication. A possible explanation for the discrepancy is a reduction of the total body water content in older people. The incident showed that caution is advised when using the different mathematical models in aged people. When estimating ethanol concentrations, caution is recommended with calculated results due to potential discrepancies between mathematical models and biological systems.

[Postmortem detection of accidental methadone intoxication in a 10-year-old girl]. / Postmortale Aufdeckung einer akzidentellen Methadon-Intoxikation bei einem 10-jährigen Mädchen.

Intoxications in children still account for a large part of the cases reported to poison control centres. Among drug intoxications, substitution drugs have gained in importance lately. Careless storage of take-home medications puts children living in the same household at risk. The authors report on a fatal case of a 10-year-old girl who died from intoxication with methadone belonging to a carer. The accidental intoxication had not been diagnosed at the hospital where the girl was treated for suspected meningitis. The question of medical malpractice is discussed.

Formation of phosphatidylethanol and its subsequent elimination during an extensive drinking experiment over 5 days.

BACKGROUND: For almost 30 years, phosphatidylethanol (PEth) has been known as a direct marker of alcohol consumption. This marker stands for consumption in high amounts and for a longer time period, but it has been also detected after 1 high single intake of ethanol (EtOH). The aim of this study was to obtain further information about the formation and elimination of PEth 16:0/18:1 by simulating extensive drinking. METHODS: After 3 weeks of alcohol abstinence, 11 test persons drank an amount of EtOH leading to an estimated blood ethanol concentration of 1 g/kg on each of 5 successive days. After the drinking episode, they stayed abstinent for 16 days with regular blood sampling. PEth 16:0/18:1 analysis was performed using liquid chromatography-tandem mass spectrometry (high-performance liquid chromatography 1100 system and QTrap 2000 triple quadrupole linear ion trap mass spectrometer. Values of blood alcohol were obtained using a standardized method with headspace gas chromatography flame ionization detector. RESULTS: Maximum measured concentrations of EtOH were 0.99 to 1.83 g/kg (mean 1.32 g/kg). These values were reached 1 to 3 hours after the start of drinking (mean 1.9 hours). For comparison, 10 of 11 volunteers had detectable PEth 16:0/18:1 values 1 hour after the start of drinking, ranging from 45 to 138 ng/ml PEth 16:0/18:1. Over the following days, concentrations of PEth 16:0/18:1 increased continuously and reached the maximum concentrations of 74 to 237 ng/ml between days 3 and 6. CONCLUSIONS: This drinking experiment led to measurable PEth concentrations. However, PEth 16:0/18:1 concentrations stayed rather low compared with those of alcohol abusers from previous studies.

Two-gun suicide by simultaneous shots to the head: interdisciplinary reconstruction on the basis of scene investigation, autopsy findings, GSR analysis and examination of firearms, bullets and cartridge cases.

Suicidal shots fired simultaneously to the head from two handguns are rare. The authors report about a recent case in which a Smith & Wesson cal. 9 mm pistol and a Smith & Wesson cal. .357 Magnum revolver were used. Sitting on a sofa, a 33-year-old man (member of a shooting club) fired two simultaneous shots to the head; the pistol held in the left hand was discharged into the left temple, and the revolver held in the right hand was fired into the mouth. Both weapons remained in the respective hands. An upside-down muzzle imprint in the left temporal region and recoil injuries of a mandibular incisor, and the lower lip indicated that both the pistol and the revolver had been held in an inverted manner at the time of discharge. Blood stains (backspatter) and gunshot residues were present on both firing hands, whereas forward spatter originating from the exit wounds was deposited on the wall behind the suicide's head.

GSR deposition along the bullet path in contact shots to composite models.

In contact shots, all the materials emerging from the muzzle (combustion gases, soot, powder grains, and metals from the primer) will be driven into the depth of the entrance wound and the following sections of the bullet track. The so-called "pocket" ("powder cavity") under the skin containing soot and gunpowder particles is regarded as a significant indicator of a contact entrance wound since one would expect that the quantity of GSR deposited along the bullet's path rapidly declines towards the exit hole. Nevertheless, experience has shown that soot, powder particles, and carboxyhemoglobin may be found not only in the initial part of the wound channel, but also far away from the entrance and even at the exit. In order to investigate the propagation of GSRs under standardized conditions, contact test shots were fired against composite models of pig skin and 25-cm-long gelatin blocks using 9-mm Luger pistol cartridges with two different primers (Sinoxid® and Sintox®). Subsequently, 1-cm-thick layers of the gelatin blocks were examined as to their primer element contents (lead, barium, and antimony as discharge residues of Sinoxid® as well as zinc and titanium from Sintox®) by means of X-ray fluorescence spectroscopy. As expected, the highest element concentrations were found in the initial parts of the bullet tracks, but also the distal sections contained detectable amounts of the respective primer elements. The same was true for amorphous soot and unburned/partly burned powder particles, which could be demonstrated even at the exit site. With the help of a high-speed motion camera it was shown that for a short time the temporary cavitation extends from the entrance to the exit thus facilitating the unlimited spread of discharge residues along the whole bullet path.

LC-MS/MS analysis of phosphatidylethanol in dried blood spots versus conventional blood specimens.

Phosphatidylethanol (PEth), which is formed extrahepatically by the action of phospholipase D on phosphatidylcholine in the presence of ethanol, has been suggested as a promising marker of alcohol misuse. Analysis of dried blood spots (DBS) is particularly advantageous for the determination of delicate analytes such as PEth. Therefore, measurement of PEth species (18:1/18:1, 16:0/18:1) in DBS versus whole blood was performed to ascertain whether respective results are directly comparable. Samples were obtained from subjects (n = 40) undergoing alcohol detoxification treatment. Analysis involved liquid-liquid extraction from both, DBS and whole blood (100 µL, respectively), with phosphatidylpropanol as the internal standard. Extracts were subjected to LC gradient separation using multiple reaction monitoring of deprotonated molecules. Results from measurements of corresponding DBS and whole blood specimens were compared by estimating the respective mean values and by a Bland and Altman analysis. Concentrations of PEth 18:1/18:1 ranged from 46.1 to 3,360 ng/mL in whole blood (mean, 461.7 ng/mL) and from 35.8 to 3,360 ng/mL in DBS (mean, 457.6 ng/mL); for PEth 16:0/18:1, concentrations were from 900 to 213,000 ng/mL (mean, 23,375 ng/mL) and 922-213,000 ng/mL (mean, 23,470 ng/mL) in blood and DBS, respectively. Estimated mean differences were -4.3 ng/mL for PEth 18:1/18:1 and 95.8 ng/mL for PEth 16:0/18:1. The Bland-Altman plot of both PEth species showed that the variation around the mean difference was similar all through the range of measured values and that all differences except one were within the limits of agreement. It could be shown that the determination of PEth species in DBS is as reliable as in whole blood samples. This assay may facilitate monitoring of alcohol misuse.

[Differential diagnostics of stomach contents showing blue discoloration]. / Zur Differentialdiagnose des blau Verfärbten Mageninhalts.

A 42-year-old man evidently had died from an intoxication. On the basis of the findings at scene it was primarily assumed that the man had ingested a larger quantity of an ethylene glycol-containing antifreeze for suicidal purposes. The man was said to have had an alcohol problem and did not only consume drinking alcohol, but also other alcoholic liquids. At autopsy, a bluish liquid with an aromatic smell was found in the oesophagus and stomach. However, toxicological analyses did not furnish evidence of ethylene glycol--as expected--but a potentially fatal concentration of ethanol (blood alcohol concentration 4.01 per mille). The blue colour (patent blue C.I.42051) came from a liquid used in the wind-screen washer system in winter, which now contains ethanol (denatured with 2-butanone) instead of ethylene glycol. The results of the toxicological findings including the analysis of congener alcohols and the differential diagnostics of blue-coloured stomach contents are discussed.

Secondary skull fractures in head wounds inflicted by captive bolt guns: autopsy findings and experimental simulation.

Apart from one article published by Rabl and Sigrist in 1992 (Rechtsmedizin 2:156-158), there are no further reports on secondary skull fractures in shots from captive bolt guns. Up to now, the pertinent literature places particular emphasis on the absence of indirect lesions away from the impact point, when dealing with the wounding capacity of slaughterer's guns. The recent observation of two suicidal head injuries accompanied by skull fractures far away from the bolt's path gave occasion to experimental studies using simulants (glycerin soap, balls from gelatin) and skull­brain models. As far as ballistic soap was concerned, the dimensions of the bolt's channel were assessed by multi-slice computed tomography before cutting the blocks open. The test shots to gelatin balls and to skull-brain models were documented by means of a high-speed motion camera. As expected, the typical temporary cavity effect of bullets fired from conventional guns could not be observed when captive bolt stunners were discharged. Nevertheless, the visualized transfer of kinetic energy justifies the assumption that the secondary fractures seen in thin parts of the skull were caused by a hydraulic burst effect.

Pulmonary arteriovenous malformation causing sudden death due to spontaneous hemothorax.

A sudden death due to hemothorax caused by spontaneous rupture of a congenital pulmonary arteriovenous malformation (AVM) is reported. A 44-year-old woman died unexpectedly with chest pain and dyspnea. The post-mortem examination revealed a massive right-sided hemothorax arising from a subpleural AVM of the upper lobe. There were multiple telangiectases in the tongue and the tonsils, as typically associated with Osler-Weber-Rendu disease (hereditary hemorrhagic telangiectasia, HHT). The post-mortem molecular genetic analysis proved the presence of a disease-causing mutation in the endoglin gene constituting a predisposition for pulmonary AVMs. According to the literature, almost half of the AVMs in the lung are seen in HHT patients. Based on the presented case and the relevant literature, the article addresses the forensic aspects of fatal hemothorax and the importance of detecting the source of bleeding.

Medicolegal evaluation of suicidal deaths exemplified by the situation in Germany.

Suicide is a significant form of unnatural death and must be differentiated as such from other violent manners of death (homicide, accident), but also from unexpected deaths due to natural causes. The distinction is made on the basis of a careful collection and correct interpretation of post-mortem forensic findings on the one hand, the general background of the case and the criminal investigation at the scene on the other. For competent assessment by the post-mortem medical examiner and/or forensic pathologist, a thorough knowledge of the numerous methods of committing suicide and their pathomorphological correlates is indispensable. This not only includes the constellation of findings and injury patterns typical of suicide, but also unusual manifestations. Highly conspicuous are complex suicides, in which several methods are applied simultaneously, or one after the other, as well as joint suicides and homicide-suicides involving several persons. Certain settings also deserve special attention. Moreover, simulated or dissimulated suicide is a possibility that must always be borne in mind in forensic practice.

A survey of warning colours of pesticides.

Pesticides are used to protect plants all over the world. Their increasing specificity has been due to utilization of differences in biochemical processes, and has been accompanied by lower human toxicity. Nevertheless cases of poisoning are still observed. While certain toxic substances are provided with characteristic dyes or pigments to facilitate easy identification, no overview of pesticide colors exists. The lack of available product information prompted us to explore the colors and dyes of pesticides registered in Germany, most of which are commercially available worldwide. A compilation of the colors and odors of 207 pesticide products is presented. While some of the substances can be identified by their physical characteristics, in other cases, the range of possibilities can be narrowed by their nature and color.

Fatal and severe codeine intoxication in 3-year-old twins--interpretation of drug and metabolite concentrations.

This work presents two cases of codeine intoxication in 3-year-old monozygotic twin brothers while treated with a codeine slow-release formulation. One child had to be admitted to the hospital, whereas the other one died at home after aspiration of gastric content. The concentrations of codeine and major metabolites including morphine and corresponding glucuronide conjugates were measured by liquid chromatography-tandem mass spectrometry in serum, urine, cerebrospinal fluid, and brain tissue, respectively. A genetic polymorphism study was carried out in order to determine the ability of the children to metabolize codeine by O-demethylation. A pharmacokinetic calculation was also performed to estimate the administered dose of codeine in question. High concentrations of all substances were found in samples of both children. The pharmacokinetic estimate suggests an overdose of codeine, and the possible reasons for the high opiate concentrations are discussed. Furthermore, the postmortem distribution--during and after resuscitation--might play a major role in the interpretation of postmortem concentration levels.

[Suicide by self-immolation]. / Zur Kasuistik der Selbstverbrennung.

In the Western world, self-incineration is a rare event compared with the Asian countries. The circumstances of death are often unusual, and differentiation from homicide is sometimes possible only after evaluating all the investigation results and findings. In many cases of self-cremation, a fire accelerant is used. In our study material at least 30% of the body surface were burned. Unaffected skin was predominantly found on the back of the body. The cases presented by us are inhomogenous as to the motive and differ from those reported in the literature with regard to gender distribution, scene, motivational situation and psychological constitution.

[Suicide with acetylsalicylic acid]. / Suizid durch Salicylat-Intoxikation.

The authors report on a suicide of a 41-year-old man with acetylsalicylic acid. According to his own statement the man had taken about 200 tablets of Aspirin (65 g acetylsalicylic acid) and initially showed no symptoms of intoxication. 4-5 hours after ingestion he vomited twice, but clear intoxication symptoms like convulsions and cardiac arrhythmia occurred not earlier than 11 hours after ingestion. Resuscitation by the emergency physician was not successful. The chemical-toxicological analysis (HPLC-DAD) of blood samples taken in the hospital approximately 12 h after ingestion showed salicylate in concentrations of 475 mg/L to 557 mg/L. The post-mortem concentrations of salicylate were within the lethal-toxic range, i.e. 762 mg/L in heart blood and 215 mg/L in femoral blood. All tested organs contained equally lethal salicylate levels (e.g. 503 mg/L in the liver and 251 mg/L in the brain).

Confirmatory analysis of ethylglucuronide in urine by liquid-chromatography/electrospray ionization/tandem mass spectrometry according to forensic guidelines.

beta-D-ethylglucuronide (EtG) is a stable Phase II metabolite of ethanol which can be detected in urine samples several days after elimination of ethanol. It is a useful diagnostic parameter for monitoring abstinence of alcoholics in alcohol withdrawal treatment. For this purpose, determination in urine is mainly performed by LC-MS, LC-MS/MS, or by GC-MS. For the mass spectrometric identification and detection of controlled substances in more sensitive fields such as forensic toxicology, workplace drug testing, doping analysis, and veterinary organic residue control, official guidelines have been released requiring a chromatographic separation and a minimum of two mass spectrometric transitions of the analyte. However, for detection of EtG none of the published LC-MS/MS methods could fulfill the minimum requirements of any of these guidelines. Therefore, an existing LC-MS/MS method has been modified by monitoring further MS/MS transitions instead of only one (deprotonated molecule [M - H](-)/product ions: m/z 75, 85, 113, and 159 optional) with the aim of withstanding administrative or court scrutiny in forensic or workplace drug testing cases. Full method validation has been performed in accordance to guidelines of the German Society of Toxicology and Forensic Chemistry (GTFCh) and requirements of ISO 17025. One application field in the United States is a workplace monitoring program to detect surreptitious alcohol use among recovering health professionals, who by contract had agreed on total abstinence after drug and alcohol withdrawal therapy.