Progress in monitoring alcohol consumption and alcohol abuse by phosphatidylethanol.

For early diagnosis and therapy of alcohol-related disorders, alcohol biomarkers are highly valuable. Concerning specificity, indirect markers can be influenced by nonethanol-related factors, whereas direct markers are only formed after ethanol consumption. Sensitivity of the direct markers depends on cut-offs of analytical methods, material for analysis and plays an important role for their utilization in different fields of application. Until recently, the biomarker phosphatidylethanol has been used to differentiate between social drinking and alcohol abuse. After method optimization, the detection limit could be lowered and phosphatidylethanol became sensitive enough to even detect the consumption of low amounts of alcohol. This perspective gives a summary of most common alcohol biomarkers and summarizes new developments for monitoring alcohol consumption habits.

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.

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.

[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.

Suicide by carbon dioxide.

Suicides by self-poisoning are common in all parts of the world. Among these intoxications, gases are rarely used, especially carbon dioxide (CO2). Very few cases of self-inflicted and deliberate carbon dioxide poisonings have been reported. This paper presents two uncommon suicides by carbon dioxide intoxication. In one case, a 53-year-old man tightly sealed a small bathroom and locked himself in it likely with dry ice. Warning notices were tagged to the door. In another case, a 48-year-old man working in a restaurant committed suicide by closing himself in a walk-in refrigerator and opening the stored carbon dioxide containers intended for the beverage dispensing equipment. The limited possibilities of proving lethal CO2 intoxications post-mortem necessitate a close cooperation of the involved parties during investigation. Only the synopsis of all findings permits a sound assessment regarding the manner and cause of death.

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.

Ethanol concentration in breastmilk after the consumption of non-alcoholic beer.

BACKGROUND: During lactation, the consumption of ethanol is discussed controversially. After women drink alcoholic beverages, ethanol can be found in breastmilk with a time lag. To abstain from ethanol, but not from the taste of alcoholic beverages, in particular, non-alcoholic beer has become popular in recent years. According to regulations in the United States and most European countries, these "alcohol-free" beverages may still contain ethanol up to 1.2% by volume. To determine how much of this ethanol may reach the breastfed child, a drinking experiment with non-alcoholic beer was performed. SUBJECTS AND METHODS: Fifteen healthy breastfeeding women participated in the study. After at least 5 days of abstinence from ethanol and the donation of a void breastmilk sample, they were asked to drink 1.5 L of non-alcoholic beer within 1 hour. Breastmilk samples were collected using electronic breast pumps immediately after the end of drinking as well as 1 and 3 hours later. The milk was analyzed for ethanol by headspace-gas chromatography-flame ionization detection using a fully validated method. RESULTS: In two women, trace amounts of ethanol (up to 0.0021 g/L) were found in the samples gained immediately after the drinking period. In the other samples ethanol could not be detected (limit of detection=0.0006 g/L). CONCLUSIONS: The mother's consumption of non-alcoholic beer is likely innocuous for the breastfed infant.

Primarily unrecognized thoracoabdominal impalement in a motorcyclist.

In traffic accidents, fatal impalements are mostly seen in vehicle occupants injured by penetrating blunt-tipped objects such as fence posts or iron bars. Compared with this group of road users, the medical literature lacks reports on impaled motorcyclists. The article presents a case which deserves attention in several respects: 1. Both the impaling object and the victim were moving at the moment of penetration. 2. The lethal impalement trauma remained unrecognized until autopsy, particularly since the causative object did not get stuck in the wound track. 3. Two different body parts (head and trunk) were consecutively affected analogous to re-entry wounds in gunshots and stabs. 4. Due to the tubular shape and the sharp-edged end of the penetrating instrument (stanchion of a broken front-wheel's fork), clothing and soft tissues were punched out along the wound channel and partly remained lodged in the tube's cavity.

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.

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.

Modification of hematoma findings in the breast region.

Subcutaneous bruises caused by blunt injury are common findings in medicolegal case work. If the hematoma involves the anterior thoracic wall, bruises are mostly absent in the region of the nipples and the surrounding areola. A similar phenomenon has already been described for hypostatic skin hemorrhages. A possible explanation for both phenomena is the special tissue texture in the nipple-areola complex. Based on four cases from the forensic autopsy material and two cases from clinical forensic examinations, the macromorphological findings and the histological correlates are presented.

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.

Suicide by multiple blunt head traumatisation using a stone.

Apart from collisions with road or rail vehicles and falls from height, self inflicted blunt force is a rare suicide method and mainly seen in psychiatric patients. The paper presents a rare case of suicide by active blunt force. A 68-year-old man committed suicide by repeatedly hitting his head with a stone. He sustained a craniocerebral trauma and finally died from hypothermia due to the low outdoor temperature. According to the relatives, the man was not diagnosed with a mental disorder or suicidal tendencies. Uncommon manners of self-harm are challenging for those involved in the investigation, and a differentiation between suicide, accident and homicide can only be made in synopsis of all findings.

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.

Intracranial impalement with entrance site in the mandibular region: postmortem elucidation of an accidental fall on a wooden plant stick.

A 78-year-old woman with a history of transient ischemic attacks was found in the doorway of her house in a somnolent and unresponsive condition. In the right mandibular region, a small skin wound was localized, which was surgically treated. Six days after admission to the hospital, an exploratory craniotomy was performed because of abnormal CT findings. Apart from tissue lesions and hemorrhages a small bone fragment was detected in the right cerebral cortex, which was removed. After 11 days in hospital, the patient died from failure of central regulatory functions. At the forensic autopsy, a 15 cm long wound track running upward from the skin wound in the right mandibular region through the bony skull base to the right parietal lobe of the brain was noted. Apparently, the surgically removed bone fragment had been displaced from the right middle cranial fossa. The site of the incident in the deceased's house was inspected again and a bamboo pole used to stabilize a potted plant standing on the floor was found and sent to the trace evidence laboratory. Analysis showed blood and tissue deposits from the victim. On the basis of all the findings and the circumstances of the case, a fatal impalement injury caused by an accidental fall could be assumed.

Ethyl sulphate and ethyl glucuronide in vitreous humor as postmortem evidence marker for ethanol consumption prior to death.

To clarify the circumstances of death, the degree of inebriation is of importance in many cases, but for several reasons the determination of the ethanol concentration in post-mortem samples can be challenging and the synopsis of ethanol and the direct consumption markers ethyl glucuronide (EtG) and ethyl sulphate (EtS) has proved to be useful. The use of a rather stable matrix like vitreous humor offers further advantages. The aim of this study was to determine the concentrations of ethanol and the biomarkers in the robust matrix of vitreous humor and to compare them with the respective levels in peripheral venous blood and urine. Samples of urine, blood from the femoral vein and vitreous humor were taken from 26 deceased with suspected ethanol consumption prior to death and analyzed for ethanol, EtS and EtG. In the urine samples creatinine was also determined. The personal data, the circumstances of death, the post-mortem interval and the information about ethanol consumption prior to death were recorded. EtG and EtS analysis in urine was performed by LC-ESI-MS/MS, creatinine concentration was determined using the Jaffé reaction and ethanol was detected by HS-GC-FID and by an ADH-based method. In general, the highest concentrations of the analytes were found in urine and showed statistical significance. The mean concentrations of EtG were 62.8mg/L (EtG100 206.5mg/L) in urine, 4.3mg/L in blood and 2.1mg/L in vitreous humor. EtS was found in the following mean concentrations: 54.6mg/L in urine (EtS100 123.1mg/L), 1.8mg/L in blood and 0.9mg/L in vitreous humor. Ethanol was detected in more vitreous humor samples (mean concentration 2.0g/kg) than in blood and urine (mean concentration 1.6g/kg and 2.1g/kg respectively). There was no correlation between the ethanol and the marker concentrations and no statistical conclusions could be drawn between the markers and matrices.

[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.

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.

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.