Mass poisoning with NPS: 2C-E and Bromo-DragonFly.

BACKGROUND: Reports of intoxications with new psychoactive substances (NPS) mostly involve young people, as they are the main consumers of these types of drugs. This report centers on a case that was unusual due to it being a mass-poisoning event involving middle-aged individuals who had consumed a combination of the two different new psychoactive drugs 2,5-dimethoxy-4-ethylphenethylamine (2C-E) and 1-(8-bromofuro[2,3-f][1]benzofuran-4-yl)-2-propanamine (Bromo-DragonFly, BDF). CASE HISTORY: The mass poisoning of 29 individuals (24-56 years old) resulted in their admission to six different hospitals with severe symptoms of intoxication. All symptoms manifested after consumption of an unknown drug formulation around lunchtime during an esoteric weekend seminar. INVESTIGATION: Urine (n = 11) and blood samples (n = 29), collected from the 29 individuals for police investigation, were analyzed with immunochemical techniques, GC/MS and LC-MS/MS. 2C-E was confirmed in seven urine samples, but not in blood. BDF was confirmed in all urine samples, and in 17 blood samples. The blood samples exhibited BDF concentrations between ca. 0.6 and ca. 2.0 µg/L, while urine concentrations of BDF ranged from ca. 1.6 to 35 µg/L. The concentration of 2C-E in urine was found to be between ca. 1.5 and 183 µg/L. All patients made a complete recovery, although some had required mechanical ventilation. CONCLUSION: The investigation and the presentation of this case illustrates not only mass intoxication with 2C-E and BDF, with corresponding blood and urine concentrations, but also the necessity of collecting urine samples in cases where NPS-consumption is suspected, in order to improve the chances of analytical detection.

Correction to: Mass poisoning with NPS: 2C-E and Bromo-DragonFly.

The original version of this article contains an error. The Author S. Lehmann incorrectly listed as S. Lehman. The correct spelling is presented above. The original article has been corrected.

Critical appraisals and cultural acceptance of the dead donor rule: A revisit of the contemporary transplantation era

Transplantation remains one of the most rapidly expanding surgical specialties. Harvesting organs plays a crucial step in this highly complex surgical and communication process, and the moment at which vital organs can be donated depends on the declaration of end-of-life. This declaration must be performed by medical practitioners on the basis of clear standardized criteria of death confirmation, within competent local and regional jurisdictions, and with the use of confirmatory tests as indicated to ascertain the irreversibility of end-of-life. The current medically and legally accepted definition of death in most societies challenges the traditional and societal understandings of the process of end-of-life. Significant criticisms and cultural oppositions to transplantation still exist, and there is an ongoing debate about the role and the status of transplantation as surgical and medical sciences continue to evolve. By discussing the social acceptance and common understanding of end-of-life determination, we aim to highlight the current knowledge on transplant ethics with respect to the balance between the need to protect the potential organ donor and the need to donate organs at their utmost viability. No report has been done on social acceptance of transplantation in Rwanda or other Low- and Middle-Income countries (LMIC); though, as emphasis on organ transplantation evolves, we also aim to highlight the need for clear directions towards new transplantation regulations. Technical and non-technical critical arguments and moral acceptance are juxtaposed with the elucidated ethical and deontological principles to support the contemporary concept of the dead donor rule

Forensic Anthropological Examination and DNA Analysis in the Identification of Human Remains in Rwanda

The identification of human remains plays a big role in solving legal and social challenges. To date; significant strides have been made to help positively identify human body remains following both natural and man-made disasters as well as reported cases of missing individuals. Thorough anthropological examination and DNA analysis of the remains can be used to conclusively link the profiles of the remains to persons if a potential living match is available even after a long period of time. We present cases of excavated human remains and samples from Rwanda that were part of both legal and social disputes. Following anthropological examination and DNA analysis; the disputes were conclusively settled. This case report also highlights the possibilities as well as challenges of identifying victim remains of larger calamities such as the 1994 Genocide perpetrated against the Tutsis in Rwanda in which an estimated one million Tutsis lost their lives

The Singh Index does not correlate with bone mineral density (BMD) measured with dual energy X-ray absorptiometry (DXA) or peripheral quantitative computed tomography (pQCT).

The Singh Index (SI), a classification system by which the severity of osteoporosis is assessed based on plain radiographs, is a renowned, simple and inexpensive form of evaluating osteoporosis. The aim of this study was to evaluate the correlation between the SI and bone mineral density (BMD) as measured by dual energy X-ray absorptiometry (DXA) and peripheral quantitative computed tomography (pQCT). The SI was evaluated in 128 cadaveric femora (64 patients, mean age 66.7 years, range 24-89 years) by three independent observers, all blinded to plain radiographs. BMD was also analysed by means of DXA and pQCT in the cadaveric femora. The mean interrater correlation was found to be 0.629. The correlation of the mean BMD measured by DXA (DXA-BMD) and SI was found to be poor, with r = 0.49. The corresponding sensitivity of 45.2 % and specificity of 92.3 % were even poor. The BMD measured by pQCT (pQCT-BMD) also revealed a poor correlation with SI, such that r = 0.337 and r = 0.428 for the trochanteric and neck regions, respectively. Due to the poor correlation of the SI with BMD and the poorer interrater correlation, the SI should be rejected as a tool for evaluating osteoporosis. The SI was found to be too imprecise and is therefore unsuitable for diagnosing osteoporosis and osteopenia.

[ENT emergency treatment and alcohol related head and neck injuries]. / HNO-Notfallversorgung mit besonderem Blick auf die Gruppe alkoholisierter Patienten.

The spectrum of ENT-diseases can differ widely among emergency departments (ED) of different geographic regions. Especially in terms of head and neck trauma a higher number of injuries can be expected in large cities due to alcohol related violence.The ED of a large hospital situated in the center of Hamburg Germany was analysed for ENT-emergency treatments in 2011 retrospectively. Beside usual patient statistics, the study focused on alcohol related injuries with an ENT-surgeon involved. All data were compared to reports by other EDs in Germany and alcohol related costs were approximated for initiation of prevention programs in the future.2 339 ENT-patients were admitted to the ED. 19% of all patients used an ambulance whereas 80% reached the ED by private transportation. The majority of patients were between 21 and 30 years of age. For 143 of all trauma cases alcohol involvement was documented. Subanalysis revealed male dominance and a high use of ambulance transportation.The high number of traumata differs considerably from other ENT studies. One reason is the hospital's close proximity to all time party districts like "Reeperbahn" and the "Port of Hamburg". In those areas high amounts of alcohol ingestion takes place leading to more injuries at the head- and neck region. Theoretically financial resources would be plenty after the initiation of those programs as the severe costs for alcohol related medical treatment would decline.

Post-mortem tissue donation at the Institute of Legal Medicine in Hamburg: talking to the next of kin guidelines and first experiences.

While building up a tissue donation program at the Institute of Legal Medicine in Hamburg we had to organize the contact to the deceased's close relatives and to develop guidelines for an appropriate approach. Loosing a family member may cause intense psychological reactions as an Acute Stress Disorder (ICD-10F43.0). An "Informed Consent", according to the German Tissue Law, requires a good emotional contact, enough time and a detailed discussion on donation between the tissue coordinator and the contacted next of kin. A reliable decision for tissue donation can activate the coping strategies of the deceased s family.

Quantitative analysis of victim demographics and injury characteristics at a metropolitan Medico-Legal Center.

For the timeframe of February 1st, 2003 until December 31st, 2005, all forensic medical experts at the Medico-Legal Center of the Institute of Legal Medicine in Hamburg, Germany, completed a standardized questionnaire for every consenting surviving violence victim (n=2733) age 14 and older. Central to the quantitative analysis of the data collected was the extraction of specific injury characteristics from the sample population. A correlation was demonstrated between injury typologies and four possible perpetrator-victim constellations, each of which was subcategorized into sexual and non-sexual assaults.

Natural and traumatic sports-related fatalities: a 10-year retrospective study.

OBJECTIVE: To identify the most common causes of death during sports activity in the population of Hamburg, Germany, and to identify which groups of sportspeople are particularly in danger of dying during sports and in which types of sport most fatalities occur. DESIGN AND SETTING: We performed a 10-year autopsy-based retrospective study of all 48,335 fatalities in Hamburg and the surrounding areas that were subjected to police investigations between 1997 and 2006 and screened for sports-related deaths. The main outcome measure was cause of death depending on form of sport, age and risk factors. RESULTS: Most of the fatalities were male. In natural deaths, cardiac causes were the most frequent causes found, with running and football being the most frequent forms of sport in which death had occurred. In some of the cases, sports medical examinations had been performed before death, certifying eligibility for the respective activity. Traumatic deaths were found in all age groups, with younger age groups more likely to have traumatic than natural deaths, and as expected, occurred more commonly in "risky" outdoor activities. CONCLUSIONS: Although exercise can have beneficial effects on health, fatalities related to sports activity occur. Cardiac disease is the main cause of sudden death from natural causes. In patients with pre-existing coronary heart disease, left ventricular hypertrophy constitutes a risk factor for exercise-related sudden death. Traumatic deaths often happen on holiday outside the person's country of dwelling, and are most commonly attributable to drowning and blunt trauma. Preparticipation medical screening cannot always prevent fatal incidents during sports activity. Postmortem macroscopic and histological examination can clarify the cause of death and legal issues.

An approach to the evaluation of fatal hypothermia.

The diagnosis of death caused by hypothermia can often only be made by exclusion. In this article, we discuss the significance of rectal temperature determination at the death scene for establishing the diagnosis of fatal hypothermia. Six cases of fatal hypothermia subjected to medico-legal autopsy at the Institute of Legal Medicine, Hamburg, Germany, were reviewed. Findings at external examination, autopsy findings with special regard to characteristics hypothermia-related changes, histological findings, and toxicology results were analyzed. In all cases investigated, a discrepancy between a low rectal temperature and other parameters for estimation of the time since death such as still displaceable postmortem lividity and electrical excitability of skeletal muscles was present, leading to the prompt suspicion of fatal hypothermia at the medico-legal death scene investigation. An early death scene investigation by a forensic specialist is of striking importance for establishing the correct diagnosis, because this discrepancy can only be observed in the early postmortem interval.

High-grade decubitus ulcers in the elderly : A Postmortem Case-Control Study of Risk Factors.

Some elderly persons develop high-grade decubitus ulcers, whereas others with comparable risk factors do not. In Germany, forensic pathologists are increasingly confronted by situations that necessitate an expert opinion on whether prevention of decubitus ulcers has been neglected in cases of suspected malpractice. This investigation was carried out in an attempt to identify risk factors for decubitus ulcers. We performed a postmortem case-control study in elderly persons who developed high-grade decubitus ulcers from 6 months to 14 days before death. Deceased with decubitus ulcers graded 3 or higher and controls at comparable risk were examined before cremation. After written informed consent had been obtained from the nearest living relatives, all available nursing and medical records of the deceased were thoroughly evaluated. Decubitus ulcer cases and controls were matched according to age, gender, immobility, and cachexia. One-hundred cases of decubitus ulcers with 71 grade 3 decubitus ulcers and 29 grade 4 decubitus ulcers were compared with 100 controls with 27 decubitus ulcers graded 2 or lower and the maximal risk as assessed by the Norton scale. The mean age was 86 years, 80% were females, 86% were bedridden, and cachexia was found in 66%. The individuals with decubitus ulcers were more often severely disabled, had more immobility of joints, and were more often under treatment with antidepressive and/or sedative drugs (e.g., opioid analgesies, neurolepties, benzodiazepines). Patients' impaired ability or unwillingness to comply or cooperate with preventive and therapeutic measures was more often recorded in cases of decubitus than in the control group. There was no evidence that supplementary nutrition or use of preventive pressure relief and protective devices differed between the decubitus cases and the controls.

First inventory of resorption lacunae on rods and plates of trabecular bone as observed by scanning electron microscopy.

In the present study a novel systematic distribution scheme of resorption lacunae (RL) was applied using scanning electron microscopy. RL, classified as either reticulate patch resorption lacunae (RPR) or as longitudinally extended resorption lacunae (LER) [11, were analyzed and quantified according to their localizations on rods (middle, nodes or both) and plates (central or peripheral) in standardized segments from the femoral head of 24 Caucasian subjects without bone disease. Age and gender variations were explored. No clear gender-related distribution pattern could be detected on plates. On rods of males, however, the distribution of RL tended to be higher at the nodes, but seemed to be more prevalent in the middle or extended from the middle to the nodes of rods in females. Certain other non-conclusive tendencies in relation to age, gender, type of RL and localization were observed.

Use of PCR-RFLP for differentiation of calliphorid larvae (Diptera, Calliphoridae) on human corpses.

Blowfly larvae found on human corpses are important for the estimation of the postmortem interval (PMI) and other questions of forensic relevance. Some of these species are difficult to differentiate morphologically, therefore a molecular method was elaborated for species identification. Specific fragments of the COI and COII region of the mitochondrial DNA (mtDNA) were amplified followed by digestion with different restriction enzymes. Using a 1.3 kb fragment, identification of Lucilia sericata, Calliphora vicina and Calliphora vomitoria was possible by digestion with only one restriction enzyme using either DraI or HinfI. Furthermore, we sequenced 349 bp (a part of the COI and COII regions) from the same three species and found 34 nucleotide distinctions between C. vicina and L. sericata, 30 between C. vomitoria and L. sericata and 15 between the two Calliphora species. These results aid in quick identification of species used for estimation of PMI.

Aggregation of postmortem platelets after stimulation with collagen and arachidonic acid.

The response to activation by collagen and arachidonic acid of platelets obtained at various intervals within the first 10 hours postmortem (hpm) was measured using a platelet aggregometer. Compared with platelets harvested from living donors, the power to aggregate remained largely intact for platelets harvested within the first 2 hpm, but dropped dramatically between 4 and 8 hpm, and was lost completely by 10 hpm. In the light of the in vivo interactions known to take place between platelets and factors of the plasma coagulation cascade, these results suggest that generalized intravascular blood coagulation ceases to take place within the first 10 hpm. After 10 hpm, fibrin can still be precipitated, but the thrombin concentration necessary for this to occur no longer leads to platelet activation.

HIV and suicide in Hamburg.

Established data relating to HIV infection, AIDS, drug user related deaths and suicides were evaluated at the Institute of Forensic Medicine in Hamburg in order to gain an insight into suicide and HIV. There was no evidence of an increased suicide ratio among HIV infected drug users. The drug aid system appears to be relatively well organized. In this group the risk of death is not dependent on HIV infection status or concomitant disease, but on overdosing. The need for detailed studies is obvious. There was no obvious increase in the suicide ratio among all HIV infected persons and AIDS cases. From the point of view of forensic medicine the number of completed suicides with HIV present was low (3 cases per year reported from the central morgue). The work of the support system in Hamburg seems to be successful, but there may be a relevant number of undetected cases. Up to now the data available about individual cases are inconclusive. An interdisciplinary European effort may be helpful in order to elucidate the problem from the point of view of different support and registration system for people with HIV infection.

Siderophages in the lung of drug addicts.

According to literature, siderophages are a characteristic histological finding in the lung of deceased drug addicts (IVDA). It was the aim of our study to evaluate their pathognomonic significance. The lungs of 591 drug deaths in Hamburg were examined histologically for siderophages in two series, with different 'Berlinerblau' (Prussian blue) staining methods. The first series (investigation period 1980-1990) showed iron-containing macrophages in 36 of 420 drug deaths (8.6%) compared with a control-group (healthy young persons dying from unnatural causes of death) in which only one was positive (2%). In a second series, using a more sensitive staining method, 80 of 171 drug deaths (47%) in the year 1991 showed siderophages, whilst in a control-group, 17 of 35 cases (49%) were positive. According to our findings the pathognomonic value of siderophages in the lung of IVDA is doubtful. There is a need for further histochemical and ultrastructural investigations concerning the morphology and etiology of pulmonary macrophages in IVDA.

Death by railway accident: incidence of traumatic asphyxia.

Eleven people were killed in a railway accident. Four of them died of severe blunt injury, three of moderate injuries combined with traumatic asphyxia and suffocation. Four of the victims were only slightly injured but showed distinct signs of traumatic asphyxia. An extensive pulmonary microembolism syndrome consisting of bone-marrow and fat embolism was found in these cases. Comparing the morphologic findings after suffocation by thoracic compression and traumatic asphyxia the authors attribute independent pathophysiologic significance to traumatic asphyxia. The importance of autopsies and histologic examinations in railway accidents is emphasized.

Assessment of the effects of cinglulate gyrus lesions by neuropsychological techniques.

Nineteen psychiatric patients undergoing bilateral cryogenic cingulate cortex lesions were extensively evaluated pre- and postoperatively with objective measures of intelligence, higher cortical functions, memory, and emotional status. Following surgery the patients as a group revealed no significant deterioration of functions; rather, they demonstrated improvement that could be interpreted as the result of decline in anxiety. Investigations of individual revealed that the overall test performance was improved in 13 and substantially unchanged in three, whereas three demonstrated some decline in performance. These results were discussed in terms of the characteristics of the changes across the various tests.