Internet-Purchased Sodium Azide Used in a Fatal Suicide Attempt: A Case Report and Review of the Literature.

There has been a significant increase in sodium azide intoxications since the 1980s. Intoxications caused by sodium azide are becoming increasingly prevalent in the Netherlands as a result of its promotion for the purpose of self-euthanasia. The mechanism of toxicity is not completely understood but is dose-dependent. The presented case describes a suicide by sodium azide of a young woman (26 years old) with a history of depression and suicide attempts. The decedent was found in the presence of prescription medicine, including temazepam, domperidone in combination with omeprazole, and the chemical preservative sodium azide. Quantitative toxicology screening of whole blood revealed the presence of 70 µg/L temazepam (toxic range > 1000 µg/L) and 28 mg/L sodium azide (fatal range: 2.6-262 mg/L). Whole blood qualitative analysis revealed the presence of temazepam, temazepam-glucuronide, olanzapine, n-desmethylolanzapine, and acetaminophen. In circles promoting sodium azide, it is recommended to use sodium azide in combination with medications targeting sodium azide's negative effects, such as analgesics, antiemetics, and anti-anxiety drugs. The medicines recovered at the body's location, as well as the results of the toxicology screens, were consistent with the recommendations of self-euthanasia using sodium azide.

Scene of death investigation in apparent suicidal deaths in Rotterdam, the Netherlands.

Guidelines from the Netherlands describe that unnatural deaths should be investigated by a forensic physician and Crime Scene Technicians, but this is not always the case. In this study, we aimed to determine what predicts the non-attendance of the Crime Scene Technicians at the scene of the death of suicides in the police region in Rotterdam, the Netherlands. Data of 315 suicides (2016-2017) that have been externally examined by forensic physicians and reports from the Crime Scene Technicians were analysed. Statistical analysis was performed to determine the factors predicting the involvement of the Crime Scene Technicians at the scene of death. The Crime Scene Technicians were not attending in 23% (n = 72) cases, and over half of these cases were not found in the registration system of the Crime Scene Technicians. About some the Crime Scene Technicians was not informed. Predictors of the non-attendance of the Crime Scene Technicians were suicide by poisoning, the individual was found by an acquaintance or family, a history of suicide attempts and examination of the deceased in the hospital. In this study, we observed that the Crime Scene Technicians were sometimes not attending the investigation of apparent suicides. More research on this topic should be done to investigate the value of the presence of the Crime Scene Technicians at the scene before concluding that non-attendance of Crime Scene Technicians on-site influences the quality of the scene of death investigation and corresponding conclusions. Since 2017, several quality improvements were made, but an (inter)national conjoint protocol for uniform and structural suicide investigation could secure the quality of the scene of death investigation of suicides and would provide information useful for evaluation.

Performance of an on-site urine multidrug test used by forensic physicians in determining the cause of death.

Forensic physicians in the region of Amsterdam routinely collect blood and urine samples during external examinations. A rapid on-site multidrug test is used to screen the urine samples for the presence of commonly used drugs classes. Urine and blood samples are sent to the laboratory for additional toxicological analysis. This study aimed to investigate how the substances found in urine using the on-site multidrug test relate to the substances identified with laboratory methods. In 2018 and 2019, 465 cases underwent an on-site multidrug test as well as toxicological laboratory analyses and were included in this study. Fifty-three percent (n = 247) of these cases included a positive on-site multidrug test for at least one substance. The level of total agreement between the on-site multidrug test performed by the forensic physician and the laboratory analyses either in urine or in blood varied per substance groups, with the best results for barbiturates, cocaine, ecstasy and methadone. In conclusion, the on-site multidrug test appeared to perform well for certain substance groups and is an economical and rapid tool. However, the results from the laboratory analyses in blood occasionally provided additional insights concerning the circumstances that could be of importance in the cause of death.

Suicide by helium inhalation in the Netherlands between 2012 and 2019.

INTRODUCTION: In 2012 and 2013 a movie and a book about a 'dignified end of life' were published in the Netherlands. These items described suicide using an 'exit bag' to establish asphyxiation using helium (the helium method). 'Right-to-die-organisations' inform the elderly about this method. The purpose of this study is to investigate whether the use of suicidal asphyxiation by means of the helium method substituted other, related, methods following its publication in the Netherlands. MATERIAL AND METHODS: We analysed suicides in the Netherlands over the period from 1 July 2012 to 30 June 2019. We compared the number of deaths caused by the helium method with other, related, cases. Secondly, we related these deaths to the total number of inhabitants and suicides recorded by Statistics Netherlands. RESULTS: The study showed a stable trend in the use of the helium method in the period 2012-2019 and this was the same for the other, related methods. Individuals using the helium method were significantly younger than those using other, related, methods. At the scene of death, information about suicide and suicide notes were found more often at 'helium method' cases than with the 'other, related, methods' cases. Family was significantly more often present during a helium method suicide than during suicide by other, related, methods. DISCUSSION: The number of suicides by the helium method and other, related, cases is stable in the Netherlands over the past years. Therefore, we conclude that there is no substitution effect within this category of suicides. Whilst 'right-to-die-organisations' strive to inform the old and sick of the helium method, it is noteworthy that the individuals using the helium method are significantly younger than the individuals who choose other, related, methods.

Undiscovered solitary deaths in the four largest cities in the Netherlands.

BACKGROUND: Research has shown a higher prevalence of individuals lying dead unnoticed in their homes (domestic-setting corpses) in Amsterdam, compared to adjacent less urbanized cities and villages. OBJECTIVE: To determine if there is a difference in incidence of domestic-setting corpses in the four major cities in the Netherlands and identifying demographic patterns accounting for possible differences. METHODS: Data of domestic-setting corpses with a post mortem interval of at least 14 days were extracted from forensic registrations of the four largest cities in the Netherlands. These data were analysed using Poisson-regression and compared to numbers of Statistics Netherlands to calculate the incidence rate of domestic-setting corpses. Only single households were included. RESULTS: The incidence of DSC14 is not significantly different between Amsterdam, The Hague and Rotterdam. The incidence rate of DSC in these cities is almost twice as high compared to Utrecht (corrected for age and sex 1,9; 95% CI:1,1-3,0). CONCLUSION: The incidence rate of DSC14 is comparable in the three largest cities of the Netherlands, and significantly higher compared to the smallest of the four (Utrecht). Possibly the lower number in Utrecht is related to less loneliness, a higher social participation and a difference in architecture.

[Forensic implications of humane self-chosen death in the Netherlands]. / Zelfgekozen levenseinde: een forensisch dilemma.

Euthanasia is legal in the Netherlands. Nevertheless, some individuals decide to plan their self-chosen death without the help of a physician. 'Right-to-die' organisations provide advice about humane deaths, which include voluntary refusal of food and fluids, the helium method and use of a lethal overdose of medication. It is known that suicides are sometimes influenced by the media and internet. Since 2013, 'right-to-die' organisations have informed individuals about the use of a deadly barbiturate overdose and the helium method. A rise in suicides resulting from these methods has subsequently been observed in the Netherlands. Suicides are recorded as deaths resulting from unnatural causes and are therefore investigated by a forensic physician, forensic investigator and tactical investigator. Investigation should determine the cause of death and rule out a staged crime, 'criminal' assisted suicide or an accident.

The rise of suicides using a deadly dose of barbiturates in Amsterdam and Rotterdam, the Netherlands, between 2006 and 2017.

INTRODUCTION: The three 'advised' suicide methods are helium asphyxiation, voluntarily stop eating and drinking and the use of a deadly dose of medication such as barbiturates. The aim of this study was to analyse the number of suicides resulting from barbiturate overdose and examine the influence of publications and internet on this suicide method in the two larger cities of the Netherlands. METHODS: Data of suicides by medication and drugs overdose were extracted from the electronic registration systems of the forensic physicians of the district of Amsterdam and Rotterdam over the period 1 January 2006-31 December 2017. We analysed whether or not the number of suicides using barbiturate overdose has significantly risen since 2013. This was the year 'right-to-die-organisations' informed individuals about this method and a book was published describing this as a humane death. In addition, a regression analysis was used to examine which factors predict a suicide resulting from barbiturate overdose. RESULTS: A total of 553 overdose suicides were identified and 91 suicides resulting from barbiturate overdose were included for further evaluation. During 2013-2017 there were significantly (p < 0.00) more suicides resulting from barbiturate overdose compared to 2007-2012. Individuals using barbiturate overdose to die by suicide were significantly (p < 0.00) older than those using other medication and drugs (65 years compared to 55 years respectively). 48% of these cases were male. In barbiturate suicides, information sources (books or information on the internet, p < 0.01) and the presence of family during suicide (p < 0.00) occurred significantly more often than in suicides resulting from other medication and/or drugs overdose. The odds for barbiturate suicides were 4.8 higher (CI 2.6-9.2) after 2013 compared to before 2013 after correction for age, sex, city and postmortem toxicology results. DISCUSSION: Our data showed a rise in suicides resulting from barbiturate overdose whereas the total number of inhabitants and suicides resulting from medication overdose has remained more or less constant. Easy access of information or medication through the internet and 'right-to-die-organisations' may have directly impacted the rise in suicides resulting from an overdose of barbiturates. To our knowledge this is the first study analysing the rise of barbiturate suicides and the influence of media in published literature.

The use of cardiac troponin T (cTnT) in the postmortem diagnosis of acute myocardial infarction and sudden cardiac death: A systematic review.

Being sudden cardiac death (SCD) and acute myocardial infarction (AMI) frequent occurrences in forensic medicine, extensive research has been published about the use of cardiac troponin T (cTnT) as a potential specific postmortem biochemical marker. However, cTnT has produced uncertain results, leading to the lack of a standardized application in routine postmortem examinations. The present systematic review focuses on the determination of whether cTnT may be considered as a suitable marker for the postmortem diagnosis of AMI and SCD, analysing the literature according to the following criteria: only human experiments, published from 1st January 2001 to 12th April 2018, available in English, on the following databases: (1). Medline/PubMed/MeSH search words: (("heart"[MeSH Terms] OR "cardiac"[All Fields]) AND ("troponin"[MeSH Terms] OR "troponins"[All Fields]) AND forensic[All Fields] AND "postmortem"[All Fields]); (2). Embase, Lilacs and Cochrane Library. 16 full-text articles were included. cTnT has been demonstrated to be elevated in a variety of pathological conditions, not strictly related to cardiac causes, but rather to the severity and extent of myocardial damage from various causes. cTnT levels have been consistently found higher in pericardial fluid than in the peripheral blood. Reviewed studies showed that the most suitable biological sample for cTnT evaluation seems to be pericardial fluid, since it may be less affected by haemolysis of blood. cTnT seems to be quite stable up to a PMI (postmortem interval) smaller than 48h; after this time, a mild time-dependent increase has been demonstrated. CPR seems to have no influence on cTnT values. The postmortem cut-offs differ from clinical ones, and at present no consensus has been reached concerning the postmortem ranges. Further research needs to be carried out in order to establish a common accepted cut-off value for forensic use.

Eight years of psychiatric examination of detainees by forensic physicians in the Netherlands.

BACKGROUND: Forensic physicians are responsible for first-line medical care of detainees (individuals held in custody) in the police station. The Dutch police law contains a 'duty of care', which gives the police responsibility for the apparent mentally ill and/or confused people they encounter during their work. The police can ask a forensic physician to do a primary psychiatric assessment of any apparent mentally ill detainee. The forensic physician determines if the apparent mentally ill behavior of the detainee is due to a somatic illness, or has a psychiatric cause for which the detainee needs admission to a psychiatric hospital. The forensic physician consults the second-line Public Mental Health Care (PMHC). OBJECTIVE: This study aims to give an overview of the outcomes of psychiatric assessments of apparent mentally ill detainees in police stations. These assessments were done by forensic physicians over a period of eight years (2005-2013). A distinction is made between mental disorders, social problems, and alcohol/drugs abuse. METHODS: All psychiatric assessments were registered in a medical database. When a secondary public mental health care assessment was performed, the conclusions and/or written feedback were received and included in the medical database. This information was used for this retrospective observational study. RESULTS: Of all the apparent mentally ill individuals brought by the police into the police station, the forensic physician sent home or referred 51.8% to their own respective caretakers or the individuals were voluntarily admitted to addiction care or other care facilities. When the forensic physician referred a detainee to PMHC, a compulsory admission to a psychiatric hospital was indicated by PMHC in 62.8% of the cases. Ultimately, of the total apparent mentally ill individuals brought in by the police 30.0% was admitted to a psychiatric hospital. DISCUSSION: Many apparent mentally ill individuals brought to the police station are sent home by the forensic physician. Before the psychiatric assessment, medical causes of psychiatric illnesses, for example excited delirium syndrome and hypoglycemia, drug use (GHB, cocaine, heroin), and cerebral pathology are excluded. The police perform as one of the channels through which the mentally ill get entrance to mental health care. Our data show no changes in the number of psychiatric assessments during 2005-2013.

Suicide by asphyxiation with or without helium inhalation in the region of Amsterdam (2005-2014).

INTRODUCTION: Annually about 28% of the 5800 death of unnatural cause in the Netherlands are a result of suicide. In 2012 and 2013 a movie and a book were published about a "dignified end of life" which also described the suicide using the exit bag to establish asphyxia using helium. The purpose of this study is to investigate if the suicide methods changed since the publicity in 2013 about suicidal asphyxiation by using helium gas. This study especially focuses on suicide using the 'exit bag' with or without helium gas. MATERIAL AND METHODS: In the period 2005 to 2014 all suicides in the region of Amsterdam-Amstelland and Zaanstreek-Waterland were analyzed and from these suicides cases using the exit bag were selected. RESULTS: The study shows a rising trend with the use of the helium (P > 0.01) and a decreasing trend for suicide by asphyxia using an exit bag (P < 0.05). The data does not show a sudden difference, but there seems to be a gradually change. DISCUSSION: The number of suicides using the helium method is rising in Amsterdam-Amstelland and Zaanstreek-Waterland, while suicides by asphyxiation without helium are decreasing. The specific publicity of books about suicides using helium may have influenced this transition.

Effect of short-term NSAID use on echocardiographic parameters in elderly people: a population-based cohort study.

BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAIDs) are associated with an increased risk of heart failure. NSAIDs inhibit the synthesis of renal prostaglandin, which results in a higher total blood volume, cardiac output and preload. The association between recent start of NSAIDs in elderly people and echocardiographic parameters was investigated. METHODS: In the Rotterdam Study, a population-based cohort study, the effect of NSAIDs on left ventricular end-systolic dimension, left ventricular end-diastolic dimension, fractional shortening and left ventricular systolic function was studied in all participants for whom an echocardiogram was available (n=5307). NSAID use was categorised as current NSAID use on the date of echocardiography, past use and never used before echocardiography during the study period. Current use was divided into short-term NSAID use (≤ 14 days) and long-term NSAID use (> 14 days). Associations between drug exposure and echocardiographic measurements were assessed using linear and logistic regression analyses. RESULTS: Current NSAID use for < 14 days was associated with a significantly higher left ventricular end-systolic dimension (+1.74 mm, 95% CI 0.20 to 3.28), left ventricular end-diastolic dimension (+3.69 mm, 95% CI 1.08 to 6.31) and significantly lower fractional shortening (-6.03%, 95% CI -9.81% to -2.26%) compared with non-users. Current NSAID use for > 14 days was associated with a higher left end-diastolic dimension (+1.96 mm, 95% CI 0.82 to 3.11) but there was no change in the other echocardiographic parameters. CONCLUSION: This study is the first to investigate the association between NSAIDs and echocardiographic parameters and suggests that there is a transient effect of short-term use of NSAIDs on the left ventricular dimension and function of the heart.