Postmortem measurements of thyroid hormones in blood and vitreous humor combined with histology.

The aim of this study was to investigate whether clinical reference premortem values can be used to assess postmortem concentrations of thyroxine, triiodothyronine, and thyroid stimulating hormone (TSH), to compare the postmortem concentrations in blood and vitreous humor, and to study the possibility of diagnosing hyperthyroidism by comparing thyroid histologic appearance and postmortem hormone values. Biochemical analyses of free thyroxine (FT4), free triiodothyronine (FT3), and TSH in femoral blood and vitreous humor were made in 38 cases. In 40 cases, the hormones and thyroid histologic appearance were studied; 22 had no significant pathologic changes, and 18 showed focal hyperplasia of the follicular epithelium. A positive correlation was seen between the femoral blood and vitreous humor concentrations of FT4 (R = 0.66) but not between the corresponding concentrations of FT3 and TSH. A positive correlation was also seen between FT3 and FT4 in femoral blood (R = 0.74). In cases with normal thyroid histologic appearance, 58% were found to have FT4 values >24 pmol/L (clinical reference interval 9-24 pmol/L), mean value 27.5 +/- 9.4 pmol/L), which did not differ from the FT4 values in the cases with hyperplasia, 31.6 +/- 15 pmol/L. Only 5% of the T3 measurements in the group with normal histologic appearance were >9 pmol/L (clinical reference interval 3-9 pmol/L). The mean value of FT3 in cases with normal histologic appearance was 3.4 +/- 1.3 pmol/L, and in the group with hyperplasia 8.6 +/- 6.1 pmol/L. The difference was statistically significant P < .005). It is concluded that postmortem values of FT3 and FT4 in femoral blood are fairly comparable to premortem clinical reference values, but the upper normal limit, especially for T4, has to be adjusted upward. Analysis of vitreous humor cannot be used post mortem to assess thyroid function. Histologically, hyperplastic changes correlate well with elevated FT3 in femoral blood.

Preventability of vehicle-related fatalities.

Several different methods have been used to evaluate the survivability of traffic injuries. Previously published methods were reviewed to develop a specific method for vehicle-related fatalities. All fatally injured victims (n = 474) of vehicle-related crashes in the four northern-most counties of Sweden during a 5-year period were studied. Almost half (48%) of the victims had non-survivable injuries. The remaining cases were classified into different injury groups according to the Injury Severity Score (ISS) including 56 (12%) with an ISS < 25, 150 (32%) with ISS 25-49 and 42 (9%) with ISS 50-74. The median distance from the scene to the nearest hospital was 49 km. In the cases with ISS < 50 the medical care was further analyzed. In close to half of these cases, the victim did not receive optimal care in time with transportation time being of major importance. The absence of first aid was judged to have contributed to the death in 4% of the cases.

[Inadequate management of unnatural deaths]. / Bristfällig handläggning av onaturliga dödsfall.

A death certificate was issued without a medicolegal autopsy in one third of all Swedish cases of unnatural death during 1991 through 1996. Out of 415 unnatural deaths in the northern part of Sweden, not subjected to a medicolegal autopsy but analyzed in this study, only 14% were reported to police authorities. Elderly, women and patients dying after a longer period of hospital care were more often not reported to the police. It is recommended that forensic pathologists be consulted in order to achieve better management of unnatural deaths.

Pedestrian fatalities and alcohol.

Since the share of alcohol-positive victims has been reported not to show the same reduction in pedestrian fatalities as in other 'road users', this study analysed pedestrian fatalities with special emphasis on the presence of alcohol. Autopsied pedestrian fatalities (286 victims) in northern Sweden from 1977 to 1995 were investigated, using autopsy and police reports. Blood alcohol was detected in 19% of the fatalities, with a median concentration of 1.6 g/l. The proportion of test-positive victims did not change significantly during the period of study. Males more often tested positive for alcohol than females (24 vs. 11%). Further, the test-positive victims had a lower mean age (49 vs. 59 years) and the proportion of test-positive victims was higher during weekends and nights. Pedestrian fatalities testing positive for alcohol differ from those testing negative in several respects. The public should be enlightened of the fact that drinking is a risk not only among users of motor vehicles, but also among pedestrians. Separation of pedestrians from motor vehicles by, e.g. fences, is of greatest importance.

Work-place homicide by bow and arrow.

Arrow wounds represent an unusual class of wounds rarely seen by most forensic pathologists. In this paper we present a case of homicide by bow and arrow and the characteristics of such injuries. The essential characteristics of the lesions obtained from conically-tapered field points and from hunting broadhead tips are described and discussed in relation to injuries caused by firearm bullets. In the present case, three arrows struck the victim, and the order in which the injuries were sustained are analyzed. We also discuss the possibilities of localizing the shooter relative to the victim by analysis of the trajectories.

Vehicle-related fatalities among Swedish conscripts.

All traffic fatalities among conscripts in Sweden from 1979 through 1988 (N = 106) were studied. More than half (58%) of the victims were on leave, nearly one-third (30%) were traveling to or from the regiment, and 13 (12%) were on duty. Forty-one percent of the drivers on leave who were involved in crashes were inebriated; the mean blood alcohol concentration was 1.6 g/kg. Fifty-two percent of the conscripts on leave were injured in single-vehicle crashes. Fatalities occurring during travel to or from the regiment most often occurred in crashes with another vehicle (69%), and all the drivers were sober. At least one of the fatally injured drivers on duty was inebriated, and in another two crashes, safety belts were not used although this was compulsory for both passengers and drivers. We conclude that collective travel could reduce the danger in traveling to and from the regiment. In addition, identifying alcohol abusers and preventing them from driving is of prime importance. Increased use of safety belts and installation of airbags should also be beneficial as well.

Role of disease in initiating the crashes of fatally injured drivers.

All autopsied car drivers (n = 480) aged > or = 18 years, who were fatally injured and died within 3 days of the crash in northern Sweden over a 13-year period were studied. A grading system was developed to assess the probability of contribution of intrinsic medical factors to the crash. This system takes into account both the risk of sudden incapacitation (inability to cope), based on intrinsic medical factors revealed in the medical history and at autopsy, and extrinsic non-medical contributing factors. Almost one quarter of the drivers were found to have intrinsic medical factors. Intrinsic medical factors were more common in males than in females. Drivers with intrinsic medical factors were often at fault and usually crossed over to the wrong side of the road and crashed into an oncoming vehicle or roadside object. In 6% of the drivers, intrinsic medical factors were probably the underlying cause of the crash; in 1.3% the probability was strong. In the > or = 60-year-old group, intrinsic medical factors were the underlying cause of the crash in 19% of the cases; the probability was strong in 4%.

Carbon monoxide suicide from car exhausts.

STUDY OBJECTIVE: the aim of the study was to analyse the victims and circumstances in carbon monoxide suicides from car exhausts in order to find strategies for mitigation of the suicide risk. DESIGN: necropsy, police and hospital records were scrutinized for 194 victims who committed suicide by carbon monoxide poisoning from car exhausts during a four-year period in Sweden. SETTING AND PARTICIPANTS: the State Institutes of Forensic Medicine in Umeå and Stockholm. RESULTS: a higher incidence (24.2/million population) was seen in the rural region than in the urban region (14.9). Males dominated (88%), most of them middle aged. Most victims committed suicide in a car outdoors. A vacuum cleaner tube connected to the compartment was most commonly used. Severe disease, mostly psychiatric, was seen in 61% of the victims. Drugs were detected in 8% of the victims under psychiatric treatment. In 37%, earlier suicide behaviour was documented. Suicide notes were found in 40%. Blood alcohol was detected in 51% of the victims and other drugs in 7%. CONCLUSIONS: environmental changes may reduce the number of carbon monoxide suicide from car exhausts, e.g. introduction of a law requiring catalyst exhaust, of automatic idling stop, and of exhaust pipes incompatible with vacuum cleaner tubes. The importance of accurate treatment of psychiatric patients is stressed.

Role of alcohol in traffic crashes involving women: passenger car fatalities in northern Sweden.

OBJECTIVE: Since increased alcohol consumption and increased driving among women may lead to a growing mortality due to drunken driving among women, the study analyzed gender differences among traffic fatalities. METHOD: Traffic fatalities (597 victims, 159 women) in northern Sweden were investigated, using autopsy and police reports, for a 10-year period, 1980-1989. RESULTS: The incidence of inebriated female driver fatalities was 0.51 per 100 million km (men, 0.66). Eighty-six percent of the female inebriated drivers (98% of men) and 68% of female sober drivers (78% of men) initiated the crash. Blood alcohol was detected in 10% of the women (men, 32%) with a mean blood alcohol concentration of 1.1 g/kg (men, 1.9 g/kg). Of the women, 13% had liver steatosis (men, 28%). The proportion of victims with liver steatosis increased with increasing blood alcohol concentration. Only one case of liver cirrhosis was found (a man). The majority of the inebriated victims were killed from May through October (women, 73%; men, 76%), and from Fridays through Sundays (women, 87%; men, 70%). Only 27% of the inebriated women crashed between 9 PM and 6 AM, compared to 62% of the men. The body location of fatal trauma was similar in men and women and was not influenced by alcohol. CONCLUSIONS: Female traffic fatalities differ from those of men in several respects. No evidence was found for an increase in the number of women in alcohol-related traffic fatalities in Sweden over the 10-year period studied. Drunken driving and alcohol abuse in traffic is still mainly a male problem.

Fortification of human milk: evaluation of a novel fortification scheme and of a new fortifier.

Human milk fed to very-low-birth-weight infants must be fortified with protein, minerals, and vitamins. We tested a new fortification regimen in which the amount of fortifier was adjusted on the basis of frequent determinations of serum urea nitrogen (SUN). A newly formulated fortifier based on bovine milk proteins was employed either in the new fashion (regimen ADJ) or in the conventional fixed proportion (regimen FIX). Using the fixed proportion, the study also compared the new fortifier with a fortifier based on human milk protein (regimen HMP). Twelve infants were studied with each of the three regimens; nearly all completed 3 weeks of study. Protein intake was generally higher in ADJ than FIX; the difference was significant (p < 0.01) during week 2. Weight gain was somewhat (but not significantly) greater in regimen ADJ (32.3 g/d or 18.8 g/kg/d) than in regimen FIX (30.0 g/d or 18.3 g/kg/d). SUN was higher in ADJ than in FIX, and several other serum chemical values (calcium, phosphorus, potassium) tended to be higher, probably reflecting higher intakes of these nutrients with ADJ than with FIX. Plasma concentrations of several amino acids were higher in ADJ than FIX, but none, including threonine, were outside the physiological range. In comparing regimen FIX to regimen HMP, infants on FIX received similar intakes of protein and showed slightly but not significantly more rapid weight gain. Concentrations of SUN were lower with FIX, but other serum chemical values, including amino acids, were generally similar to HMP. We conclude that use of the new adjustable fortification regimen is feasible and safe and that it should be studied further. It produced the expected increases in nutrient intakes and growth. The new bovine milk-based fortifier appears to be equivalent to the human milk-based fortifier.

Would a helmet law for snowmobile riders reduce head injuries?

Swedish authorities have discussed making the use of helmets for snowmobile riders compulsory. To evaluate the possible injury-reducing potential of such a law, 245 non-fatally injured riders and 104 fatalities were analyzed. Non-minor (AIS > 1) head injuries were far less common than in motorcycling, and many fast driving young snowmobile riders seem to use helmets regardless of a law. The persons with head injuries who had not used helmets, or whose helmet use was unknown, had violated other laws, most often the Traffic Temperance Law, or the law forbidding driving on public roads. A helmet law for snowmobile riders will probably not increase the helmet use in this group and consequently have a negligible injury-reducing effect. Helmets are, however, strongly recommended, especially for riders who favour fast driving.

National suicide prevention programme and railway suicide.

Suicidal behaviour is a public health problem closely related to other problems such as mental illness, abuse, violence and accidents. This approach is illustrated by the prevention of railway suicides. A theoretical framework is sketched, which allows for the use of principles from injury prevention in the prevention of suicide. ICD-9 encoded death certificates from 1974, 1980, 1986 and 1987 which concerned suicides and undetermined deaths on roads and railways were analysed (N = 294). Additional data were collected from autopsy, police and hospital protocols and from interviews with engine-drivers. Railroad victims dominated the sample (78% of cases). The mean age was 42 yr. Alcohol was detected in 27% of cases, drugs in 36% and severe illness (mostly psychiatric) in 57%. The relationship between types of collision and nature of injury is discussed. Environmental changes, such as changing the locomotive front design, are suggested as strategies for reducing accidents and suicides on railways.

Pedal cycling fatalities in northern Sweden.

The aim of the study was to elucidate the crash and injury mechanisms in bicycle fatalities in the northern half of Sweden. All available autopsy protocols, hospital records and police reports were scrutinized. In 11 years, 146 bicyclists were fatally injured. The majority of the victims were males (66%) and the median age was 60 years. Most of the crashes (81%) occurred from May through October, during weekdays (84%), and during daylight (86%). Almost all victims (88%) died in a motor vehicle collision, in 21% with a truck. None was wearing a helmet. Poor hearing and cerebral arterosclerosis were probable risk factors among the elderly. Of the victims tested, 10% were under the influence of alcohol, half of whom were involved in single-bicycle crashes. In an additional five cases, the motor vehicle driver was impaired by alcohol. All injuries were due to blunt trauma and 69% of the victims died from head injuries. In 91% of all cases, there was an Abbreviated Injury Scale (AIS) score of the head region of > or = 3. The results indicate that separation of bicyclists from motor vehicle traffic by separate cycling tracks and protection of the head by a helmet would be beneficial.

Single-vehicle crashes and alcohol: a retrospective study of passenger car fatalities in northern Sweden.

This retrospective study of fatal passenger car crash victims in northern Sweden compares 396 multiple-vehicle (MV) and 201 single-vehicle (SV) fatalities from 1980 through 1989. Compared to MV fatalities, SV victims were more frequently males, were younger, were more often inebriated, had higher blood alcohol concentrations, had a higher frequency of fatty liver, and were less often restrained. The SV fatalities occurred most often from May through October, from Fridays through Sundays, and from 9 p.m. to 6 a.m. The road surface was usually dry, especially for drunken SV drivers. The SV drivers also more often lacked a valid driver's license. The study confirms that alcohol is one of the most important factors associated with traffic fatalities, particularly in SV crashes. More than half (56%) of the SV victims were inebriated by alcohol (MV, 11%), had a mean blood alcohol concentration of 1.9 g/l (MV, 1.6 g/l), and one-third had a fatty liver (MV, 20%). We also found a relation between fatty liver and increased blood alcohol concentrations, suggesting that studies regarding the role of alcohol in traffic fatalities should also include an evaluation of liver morphology.

Elderly in the traffic environment: analysis of fatal crashes in northern Sweden.

Fatal crashes of the elderly (> or = 60 years; N = 379) in northern Sweden in the traffic environment, between 1977 and 1986, were investigated using autopsy and police reports. Males had double the death rate of females. The car occupants made up the largest category (43%) followed by pedestrians, pedalcyclists, and two-wheel-motorvehicle (TWMV) riders, but the risk of fatal injury per unit distance travelled was highest for pedestrians and pedalcyclists. Most car occupants were killed in vehicle-vehicle crashes, mostly in the daylight and at intersections or straight roads. Ice and/or snow (31%) was the major precrash factor. In two-thirds of single car crashes, roadside hazards such as trees were involved. Most elderly fatally injured car drivers were responsible for the crash, and they were commonly involved in collisions with oncoming vehicles. Only 4% of the fatally injured car drivers were driving under the influence of alcohol. Head injuries appeared to be more common in side impact than in frontal impacts. Serious chest injuries were more common than head injuries in car crashes. One-quarter of the pedestrians were injured at pedestrian crossings and about half during darkness. One in six pedestrians were under the influence of alcohol. All pedalcyclists were injured in collisions with motor vehicles and most were injured at intersections. Pedestrians, pedalcyclists, and TWMV riders had more serious head injuries than chest injuries.

[When is Scandinavia getting specialized trauma care? Report from a leading trauma center in the USA]. / När får Norden specialiserad traumavård? Rapport från ett ladande traumacentrum i USA.

The specialized care provided at the trauma centre in Baltimore, Maryland, in the USA is described. By means of a sophisticated communications system, prehospital and hospital care are coordinated with a view to providing optimal care to people with various types of injuries. It is suggested how the American experience might be applied to conditions in the Nordic countries in order to improve the quality of trauma care.

Head and face injuries in bicyclists--with special reference to possible effects of helmet use.

Fatal and nonfatal head and face injuries to unhelmeted bicyclists were analyzed to assess the injury-reducing potential of bicycle helmet use. Of the fatally injured, 64% (median age, 55 years) had fatal head and face injuries compared with 38% (median age, 18 years) with head and face injuries in the nonfatal injury group. The fatally injured often had multiple impact points, mostly to the occipital and temporal regions. Brain contusions, most often to the frontal and temporal lobes, were the most common cause of fatal injury, followed by subdural hematomas. In the nonfatal injury group abrasions/lacerations were most common type of injury, followed by cerebral concussions/contusions and superficial contusions. If all types of injuries to bicyclists are taken into account a helmet might have had an injury-reducing effect in two of every five fatal cases and in one of every five nonfatal cases. To increase the helmet use among bicyclists, a law, as in Australia, would be an excellent instrument.