Forensic Science International Supplement Series

Proceedings of the 17th International Meeting on Forensic Medicine

Jože Balažic — 2009-12-01

This supplement contains a total of 30 articles presented at the 17th International Meeting on Forensic Medicine Alpe-Adria-Pannonia, in Portorož, Slovenia (May 7th–May 10th 2008). This Alpe-Adria-Pannonia 2008 meeting represents a broad outline of the problems and novelties in alcohol, drug and traffic security research including latest innovations.

Simulation of hit-and-run road accidents

A. Thierauf, S. Pollak, M. Große Perdekamp — 2009-12-01

Abstract: Criminal offences are simulated for manifold reasons and are often associated with the intentional self-infliction of injuries and unrealistic, typically dramatic descriptions of the alleged incident. In the two cases presented here, the injuries were caused accidentally and the motive of the subsequent simulation of a road accident was to divert from previous misconduct.Case 1: A 33-year-old man was taken to a hospital by his girlfriend with fractures of the pelvis, the left distal lower leg and the metatarsus. According to the friend, the man had been struck and injured by a car as a pedestrian. The driver did not stop after the accident. The physical examination revealed an extensive soft tissue lesion distal to the left inner ankle and on the back of the left foot as well as scratch-like skin lesions on the legs, but no injuries typical of the impact of a car. The external and internal findings were not consistent with the reported collision. Later, the girlfriend admitted that her statements regarding the incident were wrong. According to the police investigations, he sustained the injuries while fleeing after a burglary.Case 2: An injured 29-year-old woman was found lying on the pavement in front of her house. In the hospital, she stated that she had almost been struck by a van as a pedestrian and had fallen to the ground. She was diagnosed with an open pilon fracture of the right tibia and a fracture of the end plate of the first lumbar vertebra. In view of the findings, the forensic expert expressed doubts as to the alleged fall from a standing position. In an additional interrogation, she admitted that she had jumped from a window of her boyfriend's room on the first floor as she did not want that the fellow occupants got to know about her love affair. In order to cover up the real origin of the injuries, she invented the story of the near-accident and alleged hit-and-run offence.Conclusion: In both cases the medical findings were not in line with the findings to be expected from the described course of events. In the first case, the traffic accident was simulated to divert from an attempted burglary, in the second case the motive was to prevent the disclosure of an embarrassing love affair.

Expert examination and assessment of state under the influence of psychoactive substances

J. Balažic, B. Štefanič, E. Kralj, B. Ermenc — 2009-12-01

Abstract: An expert examination is a medical examination performed by a doctor on the order of a police officer or investigating judge. It includes a clinical examination of the subject, collection of samples for toxicological analysis, and the doctor's assessment of whether the subject is under the influence of psychoactive substances. The doctor requires expert knowledge, skill, experience and sufficient time to successfully perform the examination. Since the accurate assessment of the effects of psychoactive substances present depends on a comprehensive evaluation of toxicological test results, the calculation of results at the time of the event and the results of the medical examination, an unprofessionally performed examination can have far-reaching consequences, primarily legal in nature.

The modern trends in alcohol, drugs and driving research

Elke Raes, Kristof Pil, Alain G. Verstraete — 2009-12-01

Abstract: Research on alcohol, drugs and driving can be broadly separated into experimental and epidemiological studies. Every approach has its inherent advantages and disadvantages. Experimental studies can result in an interpretation by single cause, but can only identify potential risks, and the results can sometimes be of limited value because of the use of non-realistic doses or because of the drug use history or inter-individual differences of the volunteers. Recent studies have used higher, more realistic doses and paid more attention to the combination of alcohol and drugs and have shown that the chronic use of illicit drugs can be associated with some cognitive and/or psychomotor impairment, and can lead to a decrease in driving performance even when the subject is no longer intoxicated.Epidemiological studies include roadside surveys, studies in a subset of drivers, accident risk studies, responsibility analyses, surveys and pharmaco-epidemiological studies. Between studies, results may be incomparable due to testing different populations, different kinds of samples, etc. More large-scale roadside studies are conducted now.Advances in analytical toxicology have also contributed to a better understanding of the risks associated with driving under the influence. While older studies measured the inactive metabolite THC-COOH and did not show an increased risk in cannabis-positive drivers, more recent studies measured the active THC in blood and did show a concentration dependent increase in crash risk. The use of LC–MS/MS has allowed more broad-range screening as this technique can measure many different drugs in a small sample volume. While some older studies used saliva but had many analytical problems (including an insufficient sample volume in up to a third of the cases), newer methods of saliva sampling and analysis give better results. The use of saliva for roadside surveys allows non-invasive sampling, but the lack of correlation with the concentrations in blood makes interpretation of results difficult.The results of both epidemiological and experimental studies should be combined to obtain a good estimate of the impact of certain drugs on driving performance and accident risk. In 2006–07 a committee of international experts drafted guidelines for future research into drugs and driving. These have been taken on board by the DRUID project, a large-scale EU funded project on driving under the influence of drugs, alcohol and medicines.

Occupational workplace and traffic fatalities in Alsace, France (2000–2005): Results of toxicological investigations

E. Szwarc, A. Tracqui, B. Ludes, A. Cantineau — 2009-12-01

Abstract: France ranks as leader country in Europe for the consumption of cannabis as well as of psychoactive medications. Whereas the relationship between psychotropics and road accidents is now well-established, few data are still available on the influence of drugs on occupational accidents. The purpose of the present study was to measure the prevalence of psychoactive drug intake (alcohol excepted) among victims of occupational fatalities (including workplace accidents+traffic accidents, i.e. on the way to and from work) occurred in the region Alsace over the period 2000–2005. Data were collected by compiling files on occupational accidents from two different public agencies (CRAM, Regional Sickness Fund Alsace-Moselle; DRTEFP, Regional Department of Work, Employment and Professional Training) together with those from the Medico-Legal Institute of Strasbourg over the period tested. Data analysis showed that 3% of the victims of workplace fatalities were under the influence of drugs (alcohol excluded) at the time of accident, as well as 5% of the victims of occupational traffic accidents. Our results also highlight a low rate of toxicological analyses, since these investigations were requested by the authorities in 41% of traffic victims and only 15% of workplace victims. In France, the relevance of psychoactive drug intake in occupational deaths is much better targeted in the case of traffic fatalities (due to the existence of specific regulations, e.g. compulsory urinalysis for drugs of abuse in drivers involved in a road accident) than in those occurred at workplace (no specific regulations).

Toxicological investigations for drugs of abuse in arrested drivers: A 2-year retrospective study (2005–2006) in Strasbourg, France

A. Tracqui, E. Szwarc, C. Jamey, B. Ludes — 2009-12-01

Abstract: Driving under the influence of drugs of abuse (DRUID) is prosecuted in France since 2001. Biological controls are performed according to a 2-step procedure: urine immunoscreening followed, in case of positivity, by a blood analysis using a separative technique coupled to mass spectrometry. This paper presents a 2-year (2005–2006) retrospective review of blood analyses performed in this framework at the Medico-Legal Institute of Strasbourg, France. Over this period 611 subjects were controlled on request of the authorities. Of this population, 532 (87.1%) were male. Mean age was 31.7±14.4 years, 57.9% of subjects were in the range 15–29 and 31.1% in the range 20–24. On the 611 drivers, 296 (48.4%) were found positive for at least 1 drug using a preliminary blood immunoassay (ELISA). Among them, 254 were positive for cannabis, 81 for opiates, 22 for cocaine and 8 for amphetamine derivatives. Psychoactive medications were additionally tested in 278 drivers, and detected in 53 (19.1%). Benzodiazepines were the most frequently identified. On the 254 subjects tested positive for cannabis by ELISA, 202 had detectable levels of THC in blood (which is mandatory for engaging prosecution against the drivers). THC concentrations were in the range 0.1–49.9ng/ml. Our results clearly illustrate the huge prominence of cannabis among substances involved in DRUID. This study also highlights some pitfalls of the DRUID repression policy currently followed by France, especially interpretation of low concentrations of drugs of abuse (in our study, 28.2% of drivers found positive for cannabis at the immunoassay screening had blood THC levels<1ng/ml): since no minimum threshold for blood concentrations has been defined in our country the fate of arrested drivers is prone to vary depending on the sensitivity of techniques employed from one laboratory to another, which might contradict the principle of equality of citizens before the law.

Suicidal yew ingestion

P. Roll, Ch. Beham-Schmid, A. Beham, M. Kollroser, B. Reichenpfader — 2009-12-01

Abstract: A 41-year-old man was found dead, lying in prone position on the ground near a parking area, where the car of the person was parked. Remarkable were the spasm-like hands of the decedent, cause of death was unknown. Primary an epileptical attack was assumed. A medicolegal autopsy was performed followed by histological and forensic toxicological analysis. Furthermore a plant anatomical investigation was applied. Autopsy revealed fragments of greenish needle-like leaves in the stomach and the intestines, but not in the colon. Plant anatomical investigation indicated the presence of yew. Histological findings were in concordance with the literature, in addition the investigation of bone marrow was performed for the first time. Forensic toxicological analysis revealed the presence of 3,5-dimethoxyphenol, the marker for intoxication with taxus baccata.This case reports the importance of medicolegal examinations in order to avoid misdiagnosis. Here the suspection of an epileptical attack as a possible cause of death was excluded by an autopsy, in addition an intoxication by yew leaves was proved.

The mystery of shrinking heads

B. Reichenpfader, W. Buzina, P. Roll — 2009-12-01

Abstract: Shrinking heads as trophies are well known all over the world. Several forms of mummified human trophy heads were produced by different tribes, in addition not true or not traditional shrunken heads were put out. A well preserved shrunken head of unknown origin was examined by our group. Besides anatomy histological and DNA analysis of the mummified material was performed. Furthermore larvae connected to the hair were examined microscopically. Histology of the skin from the neck region showed cellular structures with cytoplasm and nucleus. The larvae were identified as from Pediculus humanis capitis, the human hair lice. Finally DNA analysis of the mummified head revealed a human female STR profile.

Motorcyclists’ fatalities in multiple crashes: Who is responsible for death? (three cases)

D.R. Schillaci — 2009-12-01

Abstract: In Italy in 2007, 26% of two-wheeled motor vehicle injury/fatalities concerned motorcyclists. However, it is rare (4%) that a motorcycle (MC) crashes with two other road users and even more exceptional is a crash between a MC and three other vehicles. In general, in MC–vehicle crashes, the vehicle driver is at fault in more than 50% of the cases and the motorcyclist in 37%. The study concerns three MC lethal road accidents in which the culpability of the motorcyclist's death was questioned by the prosecutor because it was supposed that one or more vehicles ran over the motorcyclist after a fall. The crucial question in these three cases was if it was possible to assign injuries to a specific crash-aetiology and to assign/exclude the responsibility of motorcyclist's death to a defined subject (motorcyclist himself and/or car drivers) after a crash-dynamics study made by an engineer consultant or by the police authority. Case (1) A 56-year-old motorcyclist on a highway had a front–rear end collision with a car that suddenly stopped; he was therefore projected against a concrete traffic island, thrown on the soil and run over by another car. Case (2) A 29-year-old motorcyclist on the East ring road fell on the soil, perhaps by a supposed front–rear end contact with a car and was run over by two cars in rapid succession. Case (3) A 34-year-old motorcyclist on the North ring road fell suddenly on the soil for unknown reasons; during first aid, the medical team around him was run over by the ambulance which pushed after a rear-end collision with a car. A stepwise analysis of the indicated crash dynamics and an evaluation of all the injuries revealed at autopsy, the study proposed, when possible, injury aetiology for each case and the related responsibility assignments and exclusions.

Drunk drivers—Chances for and difficulties in giving medico-legal opinions on drivers’ alcohol intoxication levels, on the basis of the material analyzed in the Forensic Medicine Department, Medical University of Silesia, Katowice in the years 2003–2007

K. Rygol, M. Chowaniec, Cz. Chowaniec, K. Droździok, A. Nowak — 2009-12-01

Abstract: The authors have conducted a statistical analysis of 340 court files investigated in the Forensic Medicine Department Medical University of Silesia, Katowice in the years 2003–2007 with regard to chances for as well as difficulties in giving medico-legal opinions on drivers’ alcohol intoxication levels, which would be valid for court purposes.

The toxicological challenges in the European research project DRUID

Kristof Pil, Elke Raes, Alain G. Verstraete — 2009-12-01

Abstract: Within the epidemiological studies of the integrated European research project DRUID (Driving Under the Influence of Drugs, alcohol and medicines), 13 laboratories from across Europe will analyse whole blood, oral fluid (OF) or urine from the general driving population and injured drivers. To ensure the comparability of toxicological results from the different studies, the collection of samples, analytical methods, target analytes and analytical cut-offs have been standardized for all laboratories involved.Target analytes were selected based on suspected impairing effects and prevalence. Twenty-three drugs are included in the ‘core list’ for which analysis is mandatory: ethanol, amphetamine, MDMA, MDA, MDEA, methamphetamine, cocaine, benzoylecgonine, THC, THC-COOH, 6-acetylmorphine, diazepam, flunitrazepam, alprazolam, clonazepam, oxazepam, nordiazepam, zolpidem, zopiclone, lorazepam, morphine, codeine and methadone. Additionally, 28 other drugs will be analysed in 1–12 countries.All whole blood samples are collected in glass Vacutainer-type tubes containing sodium fluoride and potassium oxalate. Based on a comparative study of 10 collection devices, it was decided to collect oral fluid using the Statsure™ device. Since only a small sample volume is available (5–10mL blood and 1mL oral fluid), all laboratories have to develop methods for simultaneous detection of the target analytes. All laboratories agreed to use either LC–MS–MS or GC–MS in SIM-mode. Proficiency testing for both blood and oral fluid are organized.Analytical cut-offs were established for the core list based on those used in ROSITA-2, SAMHSA cut-off values for oral fluid and recommendations from an expert meeting in Talloires.Because of practical and legal considerations, different sample types are used: whole blood, serum/plasma and oral fluid. Literature on correlation between analyte concentrations in these body fluids is limited, which makes several comparisons of study results difficult: (1) comparison of epidemiological (blood, oral fluid and urine) and experimental studies (serum and plasma) performed in DRUID and (2) comparisons within the epidemiological studies themselves (most countries: oral fluid in road-side survey, blood in hospital studies).A combination of literature findings, new findings from DRUID and semi-quantitative results will likely have to be used to solve these problems.

Influence of alcohol intoxication of pedestrians on injuries in fatal road accidents

T. Prijon, B. Ermenc — 2009-12-01

Abstract: Pedestrians belong to the group of road users with the highest mortality rate. The frequency of road accidents involving pedestrians is 2% but pedestrians represent as many as 13% of all road accident deaths. Because of the mechanism and dynamics of injury and the effects of alcohol on physical and mental performance, pedestrians under the influence of alcohol are classed among the road users most at risk.Our retrospective study included 125 pedestrian fatalities treated at the Institute of Forensic Medicine, Faculty of Medicine, University of Ljubljana between 1999 and 2006. We classified the victims into two groups by blood alcohol level Group I (alcohol positive) and Group II (alcohol negative), defined differences in gender, age, incidence of injuries and established causes of death and period of survival following the road accident. In Group I (n=53) 96% were male and 4% female; the average age was 45.6 years. In Group II (n=72) 40% were male and 60% female; the average age was 63.1 years. The percentage of injuries to individual parts of the body was higher in Group I than among the deceased pedestrians in Group II. The most common cause of death in both groups was craniocerebral trauma. Death occurred in the first 6h following the accident in 92% of cases in Group I and in 69% of cases in Group II.Alcohol-positive pedestrians are predominantly younger men, who have a higher level of risk of a road accident, greater incidence of injuries and a shorter period of survival following a road accident.

Interpretation of blood alcohol concentration in maritime accidents—A case report

2009-12-01

Abstract: The human element is increasingly acknowledged as an important factor contributing to accidents at sea. Alcohol and drug abuse is becoming an increasing problem among seafarers in the last few years. Recently we registered a few similar maritime accidents on the Adriatic coast. During the analysis of these incidents, it became apparent that the consumption of alcohol on duty was the main cause of the ship being stranded. We report a maritime accident recently happened in port of Rijeka, where the merchant ship stranded on the main breakwater. During the investigation, forensic alcohol analysis established that master's consumption of alcohol on duty was the main cause of the incident. The BAC–UAC relation we found was not physiologically possible, so further diagnostic workup demonstrated that urine was diluted. Various issues are being discussed, such as urine dilution, retrograde calculation, elimination rate, two subsequent blood samples, drinking after the accident, as well as prevention measures. Our observations indicate a need for stricter and more precise legislation as well as more frequent police control that will hopefully result in prevention of serious maritime accidents caused by alcohol consumption. In our opinion, better understanding of the above mentioned apparent problems in navigation rules and maritime law regulations can prevent similar accidents from happening in the future. Accidents like the one described cause double damage for society: due to acute health problems of the crew and navigation safety, as well as due to the long-term harmful consequences such as suspension of career on ship board and early retirement of employees.

Medical driver selection and alcohol

M. Bilban — 2009-12-01

Abstract: Due to the rapid development of motorisation in the past few decades, the epidemic of traffic injuries has become a serious problem. Numerous studies indicate that the human factor, often in connection with alcohol consumption, plays a major role in traffic accidents. Studies also show that people addicted to alcohol often drive under the influence and are not deterred by the possibility of punishment, e.g. a revocation of their driving licence.Our study examined people who caused traffic accidents under the influence of alcohol in Slovenia, the consequences of their actions, police and judicial measures and medical selection.In the last decade, the share of people causing traffic accidents under the influence of alcohol in Slovenia has been on the rise. Higher blood alcohol levels are found in people causing fatal traffic accidents, most of them are cyclists, pedestrians and tractor drivers, aged between 25 and 34; the accidents are most common on village roads, on weekends. The discrepancy between numbers of intoxicated drivers with suspended driving licences (approximately 8500/year) and between numbers of successfully terminated judicial procedures is particularly worrisome. When these drivers get their licences back, the medical selection process is inadequate.Our results emphasise the problem of medical selection for reinstatement of penalized drivers. The inadequate approach currently in force allows too many dangerous drivers, most still addicted to alcohol, to return to traffic without medical selection. The only solution to this problem is an immediate change in legislation that would require rigorous medical selection for all reinstatements of drivers who drove under the influence of alcohol. This would decrease the numbers of intoxicated drivers in traffic and at least partly decrease the numbers of alcohol addicts in society.

Cardiac death 25 years after successful treatment for Hodgkin's disease—Case report

J. Balažic, S. Frković-Grazio, B. Jereb — 2009-12-01

Abstract: In the following case, the authors are discussing a connection between treating Hodgkin's disease in childhood and later sudden cardiac death of the patient at the age of 37. Examined expert literature describes injuries of the myocardium because of therapeutic irradiation in the childhood.

Post-mortem blood alcohol concentration of the traffic accident victims and changes in DUI legislation in Slovenia 1980–2006

E. Kralj, T. Pezdir, J. Balažic — 2009-12-01

Abstract: This study aims to contribute to the analysis of the impact of alcohol consumption on road traffic safety in Slovenia and to evaluate the effectiveness of the changes in road traffic safety legislation concerning this issue within the period 1980–2006. For this purpose we have performed a retrospective analysis of 1913 autopsy reports on traffic casualties, with an emphasis on their blood alcohol concentration (BAC), mode of participation in traffic (drivers, pedestrians, etc.) and the impact of legislation changes. In addition, we have analysed the relations between BAC, the time and day of death and the gender of victims. Changes in the legislation were made in 1981, 1985, 1988, 1989, 1990, 1998 and 2005, yet only those made in 1981, 1990 and 1998 resulted in the increase of the actual fines. Within the observed period there was a substantial reduction in the average BAC in almost all of the categories of traffic participants (pedestrians: from 1.20 to 0.73; passengers: from 1.08 to 0.56; cyclists: from 1.11 to 0.56; motorcyclists: from 0.68 to 0.33) except in the category of drivers (negligible reduction from 0.81 to 0.76). Insufficient improvement in the latter category is extremely important, because many sober vulnerable traffic participants become victims of drunk drivers. Further concern arises from the finding that heavily drinking drivers are not responsive to penalty increases. We came to the conclusion that, in addition to raising fines and expanding penalty points, the introduction and effective enforcement of complex legislative measures together with wide community action are necessary to resolve DUI problems in Slovenia.

Maternal mortality in Slovenia: Case report and the method of identifying pregnancy-associated deaths

E. Kralj, B. Mihevc-Ponikvar, T. Premru-Sršen, J. Balažic — 2009-12-01

Abstract: We report on the case of fatal intracerebral haemorrhage that followed the development of severe preeclampsia/eclampsia with haemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome in a 22-year-old primipara. Peculiarities of the reported case are abrupt onset of preeclampsia/eclampsia during the delivery, fulminant course of the disease, minimal changes in kidneys and signs of pre-existing accelerated arteriosclerosis. Since very few forensic pathologists have sufficient experience with such cases and the differential diagnosis may be difficult, we consider it necessary that in all maternal deaths the post-mortem examination is performed by a team of two forensic pathologists and the case further analysed in collaboration with expert obstetrician.Maternal deaths are rare in developed countries but extremely important, because they represent the “tip of the iceberg” of severe maternal and neonatal morbidity and because they reflect accessibility and quality of prenatal and obstetric care as well as the health status of reproductive-aged women. Unfortunately, they are often misclassified in death certificates which may lead to insufficient engagement in solving underlying problems. In Slovenia, the method of active search for pregnancy-associated deaths is used in order to enable accurate monitoring of maternal mortality and minimise underreporting. The method is based on the manual revision of death certificates and the computer-based linkage of Mortality Database with birth register and foetal deaths register and has proved to be highly efficient.

Cardiomyopathy in a patient with limb-girdle muscular dystrophy type 2D: Pathomorphological aspects

2009-12-01

Abstract: Sarcoglycanopathies are a group of autosomal recessive limb-girdle muscular dystrophies caused by mutations in the genes encoding for α-, β-, γ- and δ-sarcoglycan, which are expressed in skeletal and cardiac muscle. Cardiomyopathy has rarely been reported in patients with mutations in the α-sarcoglycan gene and descriptions of heart pathology are lacking. To our knowledge, this is the first report on characteristic pathomorphological changes in cardiac muscle detected at autopsy in a patient with a proven mutation (nucleotide substitution 229C>T (R77C) in exon 3) in the α-sarcoglycan gene. The patient had the phenotype of Duchenne-like muscular dystrophy. Due to severe weakness of the respiratory muscles, permanent nocturnal mechanical ventilation via a tracheostomy had been necessary since the age of 24 years. The patient also suffered from mild pulmonary and systemic hypertension. At the age of 36, he lost consciousness and was brought to the emergency room in asystolia and unsuccessfully reanimated for half an hour. Gross heart examination disclosed scattered unsharply demarcated grey and yellow areas, characteristically localised in the outer (subepicardial) part of the lateral and posterior left ventricular wall, while the interventricular septum was spared. Similar changes were present in the apical region of the posterior right ventricular wall. Histopathological changes in focal subepicardial myocardial lesions in the free left ventricular wall consisted of myocardial degeneration in the absence of inflammatory infiltrates, fibrosis and fatty replacement of the myocardium, strikingly similar to changes in skeletal muscle. Since autopsy did not reveal any significant coronary stenosis or valvular pathology, both chronic myocardial ischemia and valvular disease could be excluded as causes of the above-described changes, which were ascribed to α-sarcoglycanopathy. Mild myocardial hypertrophy could be attributed to pulmonary and systemic hypertension. The progression of cardiomyopathy in α-sarcoglycanopathy was considered slow, since it had not reached the stage of dilated cardiomyopathy at the time of death. Focal subepicardial myocardial lesions, most pronounced in the posterobasal segment of the left ventricle, were characteristic of cardiomyopathy in α-sarcoglycanopathy. Since focal lesions may spread further, thorough cardiac monitoring is recommended in patients with α-sarcoglycanopathy.

Low blood alcohol levels. Experimental study on attention and body sway control functions

2009-12-01

Abstract: Objective: Attempting to prevent alcohol-related road accidents requires sensitive, reliable and easy-to-use methods and instruments for ascertaining drivers’ state of intoxication. This paper examines the scientific validity of a method for assessing psychomotor performance combining measurement of neurosensory functions with the effect of low blood alcohol levels: body sway control and attention functions.Methods: A double-blind, placebo-controlled study, with cross-over and random distribution on the effects of low blood alcohol levels. Psychomotor performance and body sway control were studied in 16 healthy volunteers after they had drunk a small dose of ethyl alcohol (0.5g/kg) or placebo. Neurosensory and psychomotor functions were assessed by a Divided Attention Test (DAT), composed of the association between one test exploring short-term memory (Memory Test) and one exploring attention (Response Competition Test). Alterations in body sway were recorded by stabilometry. Tests were administered at 30, 60, 120 and 180min after intake of alcohol. After a wash-out period of at least one week, subjects repeated the test after taking a second dose of alcohol or placebo. Blood alcohol concentrations were monitored by analysis of concentrations in expired air.Results: A BAC under 50mg/dL did not reveal statistically significant impaired memory capacities or motor coordination. Instead, statistically significant oscillations of body sway were measured (p-values=0.0001), especially when stabilometry was associated with deviant stimuli like those of the DAT (p-values=0.0001).Conclusions: This study showed: (1) impaired performance, at the limits of statistical significance, on a complex psychometric test like the DAT; (2) some cognitive, attentive and visual perceptive functions are not compromised or at least not in a statistically significant manner; (3) a considerable alteration in the capacity for control of body sway after intake of alcohol becomes further and massively impaired when deviant stimuli are given; (4) this impairment appeared early and was more marked 1 and 2h after intake of alcohol.

From chronic rhinitis to death: Fatal outcome of nasal polyposis treatment

D. Mayer, A. Lukic, V. Petrovecki, M. Bakovic, D. Strinovic, J. Skavic — 2009-12-01

Abstract: Introduction: Nasal polyposis (NP) is considered to be the state of chronic inflammation of nasal mucosa and sinuses presenting with various nasal symptomatology. In most cases, it is treated conservatively. Recently, functional endoscopic sinus surgery (FESS) was developed as the valuable and advantageous surgical procedure to treat NP. Despite the inherited risks of this procedure, its complication rate is considered to be acceptable compared to potential benefits for the patient.Case: Fifty-five-year-old man was admitted to the hospital for surgical removal of the nasal polypus. After the usual pre-surgery procedures, the patient underwent FESS. Under general anesthesia, left sphenoid sinus was opened and cleaned from the imflammatory discharge, polypus was excised, and following the trepanation the left maxillary sinus was left to drain out. Polypus and pieces of sinonasal mucosa were sent to pathohistological analysis, which yielded in diagnosis of inverted sinonasal papilloma.The early postoperative recovery was regular, but 2h upon the surgery, the patient started to lose consciousness gradually falling into the state of coma. CT scan and angiography of the head revealed pneumocranium, defect of the left ethmoidal sinus, hematoma in the left frontal cerebral lobe, as well as the hemorrhage in all four cerebral ventricles. A series of neurosurgical procedures followed in the next 8 days. Despite the attempts to resolve above complications, the patient remained comatous and died 16 days after the polypectomy.Autopsy revealed the extensive oval-shaped defect on the skull base in the left posterior part of cribrous plate of the left ethmoid bone. The brain appeared swollen and heavily congested, showing the zone of subarachnoidal hemorrhage in basal face of left frontal lobe. Frontal serial sections revealed large intracerebral haematoma in basal periventricular structures of left frontal lobe extending to the whole ventricular system. Apart from the above, most prominent finding was bilateral bronchopneumonia. The cause of death was attributed to bronchopneumonia following the brain trauma, manner of death ruled as violent.Conclusion: Although majority of the patients suffering from chronic rhinosinusitis or NP recover well after the endoscopic surgery, the possibility of undesirable outcome must not be ignored. This case calls for assessment of potential medical liability caused by malpractice. Having in mind rather high prevalence of chronic rhinosinusitis and NP, legal aspects of postoperative death should be carefully analyzed.

Identification and analyses of female civilian victims of the 1991 war in Croatia from the Glina and Petrinja areas

M. Slaus, D. Strinovic, V. Petrovecki, D. Mayer, V. Vyroubal, Z. Bedic — 2009-12-01

Abstract: Introduction: The process of recovering and identifying human remains from individual and mass graves has proven to be the most effective method of resolving the fate of missing individuals in the former Yugoslavia. These efforts have two primary objectives: medicolegal—to identify the cause of death, and humanitarian—to bring closure to living family members, thus supporting the human rights of both the living and the deceased. From 1996 to the present, the remains of 388 individuals killed during the 1991 War in Croatia were recovered from the Glina and Petrinja areas (Sisačko–Moslovačka County). The purpose of this paper is to report on the demographic and taphonomic characteristics of the recovered remains, and identify factors responsible for the discrepancy in the identification ratios.Methods: To identify factors potentially responsible for the noted discrepancy, data were collected on the taphonomic characteristics of the recovered remains, the types of burials, as well as the factors responsible for positive identification. These factors included: forensic DNA testing, dental criteria, special signs (healed fractures, etc.), clothing and personal artifacts.Results: The age distributions between males and females in the sample are significantly different. The mean age-at-death for males is 51.6 years, for females 67.0 years. In both sexes the majority of identifications (62.9% in females and 45.9% in males) were established through a combination of biological and non-biological features. In terms of the types of graves from which the bodies were recovered, positive identification in both sexes was lowest in mass graves (61.2% for males, and 84.2% for females). Females from mass graves were, however, better preserved than males—36.6% of males recovered from mass graves were completely skeletonized, while the same was true for only 19.3% of females (χ2=7.06, P<0.029). Completely skeletonized remains were identified in only 65.1% of cases, while partially skeletonized and saponified bodies were identified in 80.1% of cases.Conclusion: Since positive identification in both sexes is strongly correlated with preservation of the bodies, the reason why female identification frequencies in the Glina and Petrinja regions are higher than male frequencies lies in the fact that females recovered from mass graves were better preserved than males recovered from mass graves. Identification of the factors responsible for this is a challenge that needs to be resolved in future studies.

Diagnostic value of post-mortem examination of the cardiac conduction system

G. Haring, E. Kralj, J. Balažic, B. Ermenc — 2009-12-01

Abstract: Introduction (Aim): Sudden unexplained death (SUD) is a common problem in forensic pathology. In many of these cases, the autopsy findings, toxicological examinations and patient history are inconclusive. Many studies suggest that in such cases, the cardiac conduction system (CCS) should be histologically examined. We decided to determine the diagnostic value of histological examination of the CCS.Methods: We reviewed autopsy files from the period 2005–2007 and selected those cases in which the CCS had been sampled. These were divided into two groups, the first comprising cases with an obvious cardiac pathology (e.g. severe coronary disease, myocardial infarction, significant myocardial hypertrophy/dilatation, valvular disease, etc.) and the second comprising cases without obvious cardiac pathology (i.e. fatal injuries, intoxications and deaths unexplainable by routine procedures). The CCS was sampled according to a detailed protocol and examined under a light microscope. On the basis of the findings of histological examination of CCS, we formed subgroups of the aforementioned main groups.Results: We analyzed 118 cases, of which 83 were males and 35 females. In 57% of cases, autopsy revealed gross pathological abnormalities of the heart. In 10 (15%) of them, examination of the CCS showed significant pathological changes (narrowing of the nodal artery and its branches, moderate to severe interstitial fibrosis, calcifications in the central fibrous body impinging upon CCS). In some, especially those with no acute findings, CCS disease can be considered to have been the cause of fatal arrhythmias. In 43% of cases, autopsy revealed no gross abnormalities of the heart, while histological examination of the CCS disclosed significant pathological changes in 4 (8%). Among them, CCS disease was regarded as the cause of death in one case and as a possible cause in another case.Conclusion: As with other similar studies, our study showed that examination of the CCS can provide valuable information on the cause of death. We therefore consider that examination of the CCS should be performed in all SUD cases, especially those in which the cause of death cannot be established by routine procedures. Although we had only 1 confirmed cause of death linked to CCS disease and one possible, we had 14 cases with significant pathological CCS changes. This leads us to the conclusion that post-mortem examination of the CCS is of diagnostic value.

Tractor driving and alcohol—A highly hazardous combination

J.L. Gassend, M. Bakovic, D. Mayer, D. Strinovic, J. Skavic, V. Petrovecki — 2009-12-01

Abstract: Introduction: Approximately half of all injury-related fatalities in the agricultural industry are associated with farm tractors. Skill-based psychomotor tasks, such as driving and operating such machines, are easily impaired as a consequence of the use of alcohol. We have analyzed characteristics of fatal traffic accidents involving tractors in Zagreb County, with special accent to prevalence of alcohol use among drivers.Subjects and methods: The material comprised all fatal accidents involving tractor drivers in Zagreb County between the years 2001 and 2005 where a medicolegal autopsy had been performed and samples taken for subsequent forensic toxicological analysis. The total of 47 cases were included. Data were collected on characteristics of the fatally injured as well as on circumstances and dynamics of the accident itself. The results are presented with absolute and relative frequencies.Results: Ninety-one percent (43 out of 47 cases) of fatally injured were males. No person was under the age of 18, 70% were between 18 and 65 years of age and 30% were above 65 years of age. Blood alcohol reading was negative in only 13 out of 47 analyzed cases (28%). Six cases (13%) had blood alcohol concentration (BAC) below 0.50mg/mL, further 6 between 0.50 and 1.49mg/mL, 16 (34%) between 1.50 and 2.49mg/mL and the remaining six had BAC between 2.50 and 3.49mg/mL. Median BAC among 34 fatalities with positive blood alcohol level was 1.80mg/mL, while the highest concentration observed was 3.49mg/mL. Multiple injuries were the most common cause of death (43%) followed by crush asphyxia (26%). Most of the victims (81%) died at the scene of the accident and all of them died within the first 24h. In the majority of accidents (79%), the tractor operator was a victim of the vehicle rollover.Conclusion: High percentage of farm tractor users driving under influence and high median BAC indicates that legislation alone is not sufficient in preventing accidents. Further effort should be directed toward education aimed to increase awareness of the obvious risk that alcohol use represents to driving and workplace safety. Taking into account that the overwhelming majority of fatalities occurred from rollovers, strong encouragement should be given to implementation of rollover protecting structure (ROPS) devices in order to prevent such type of fatalities.

Psychoactive drugs in the road traffic in the legal and consultative aspects—Experience gained by the Forensic Medicine Department, Silesian University of Medicine, Katowice

2009-12-01

Abstract: Introduction: In the years 1997–2007 in the Forensic Medicine Department, Silesian University of Medicine, Katowice a total of 785 blood samples collected from drivers being the perpetrators of road accidents was tested for the presence of psychoactive drugs.Methods: The studies took advantage of FPIA (Abbott), ELISA (Neogen), LC–MS and GC FID.Results: 21% of tested samples were positive. In the blood of the driver cannabinoids, amphetamine and its derivatives were most frequently found. Moreover, individual opium alkaloids, their combinations with barbiturates, benzodiazepines or amphetamine, benzodiazepine derivatives (isolated cases), drugs of benzodiazepine group in combination with barbiturates, tramadol or tricyclic anti-depressants (isolated cases), carbamazepine, phenotiazine, cocaine, dibenzepine, benzene, toluene and acetone were determined.Conclusion: The obtained results showed cannabinoids and amphetamine derivatives to be the most frequent whereas opium alkaloids, barbiturates and benzodiazepines rather rare psychoactive drugs found in the tested blood samples of the drivers involved in the road accidents. The authors suggest screening psychoactive drugs not only in drivers involved in road accidents but also those put through the routine road check procedures. While giving opinions on the influence of the above mentioned drugs on the psychophysical efficiency of road traffic users, drugs and compounds which are not subject to legal control but have an effect on the human psychomotor efficiency and thus, enhance the risk of the road accident should be also taken into account.

Assessment of the cause and mode of death of victims of a mass industrial accident in the Halemba coal mine

M. Kobek, Z. Jankowski, Cz. Chowaniec, Ch. Jabłoński, Z. Gąszczyk-Ożarowski — 2009-12-01

Abstract: On 21 November 2006 in the Halemba coal mine, Ruda Śląska, a mass industrial accident occurred. The underground catastrophe was probably due to combustion of methane followed by explosion of pulverised coal and resulted in death of twenty-three miners. The occurrence has been acknowledged to be one of the most serious accidents in Polish mining industry. Post-mortem examinations of the deceased were carried out in Department of Forensic Medicine, Medical University of Silesia, and in some cases additional dissecting techniques were employed. Photographs were taken as well as numerous specimens for various laboratory tests were collected. Toxicological analyses of blood samples revealed high levels of carboxyhaemoglobin saturation in seventeen cases, and detected presence of methane in the lungs of seven individuals, whereas microscopic specimens mainly showed lesions characteristic of putrefaction. The post-mortem procedures eventually allowed to establish the cause of death of all victims. The authors attempt to determine a range of requisite medico-legal proceedings and examinations that should be carried out in case of a mass industrial accident, and emphasise the need for development of appropriate guidelines.

A rare case of lethal methadone intoxication of a 3-week-old infant

2009-12-01

Abstract: The authors describe a rare case of lethal methadone intoxication of a 3-week-old infant. Born of a drug-addicted mother who was undergoing methadone substitution therapy, the newborn presented withdrawal symptoms and was immediately admitted to a paediatric ward where it was treated for 3 weeks, without administration of methadone. The infant died during bottle feeding within 24h following discharge home.A post-mortem examination was performed as well as histopathological, toxicological and genetic tests were carried out in order to establish the cause and mode of death.The autopsy revealed obstruction of the lower air passages by stomach contents along with classical features of asphyxia. Toxicological tests revealed high concentrations of methadone and its metabolite in blood and urine as well as presence of methadone in stomach contents, and the DNA polymorphism analysis of the (sex-specific) amelogenin locus gave a negative result.On the basis of the results of the post-mortem examination, the laboratory tests and the police investigation, it was concluded that the drug was ingested with the bottle milk, and the possibility of administration of methadone at the hospital or its ingestion with the breast milk was precluded. Though both the cause and mode of death were established, the public prosecutor discontinued proceedings in the case due to inability to find the perpetrator.

Estimating the degree of ethanol intoxication from analysis of cerebro-cranial hematomas

M. Chowaniec, Cz. Chowaniec, A. Nowak, J. Nowicka, K. Droździok — 2009-12-01

Abstract: 314 cases of combined cerebro-cranial trauma and posttraumatic intracranial hematomas were identified of which ethanol was detected in 114 hematomas. The other investigative group was 103 hospitalized patients who had hematomas evacuated during neurosurgical procedures. In 62 of these cases ethanol was detected. Blood and urine samples were also collected and the alcohol concentration was determined in all specimens by GC and ADH. The ethanol elimination rate for autopsy and operative intracranial hematomas was approximately 0.07–0.08‰/h(±0.034‰/h). The elimination rate of ethanol from blood (β60) was about two or three times greater as that from hematomas. Because of the different water content of intracranial hematomas from blood, it was necessary to adjust the ethanol concentration for water content. On the basis of the corrected ethanol concentrations and the elimination rates for both tissues it was possible to estimate the ethanol concentration at the time of injury. Intracranial hematomas are tissues of possible value in the determination of alcohol intoxication especially in alcoholism. Ethanol can be found in hematomas even after 72h from head injury.

An attempt to objectify the condition of cervical spine distortion injury in traffic accident victims for court purposes

C.Z. Chowaniec, A. Nowak, M. Chowaniec, K. Rygol, M. Kobek — 2009-12-01

Abstract: Introduction: According to morphological criteria, cervical spine injuries include, among others, contusion, distortion, luxation and fracture. Distortion of the intervertebral articulations occurs when the force of movement exceeds the physiological range, and the articular/joint capsule, cartilage and ligaments are damaged. While within the articulation a haematoma is formed, which produces clinical manifestations such as localised idiopathic pain, tenderness to palpation and analgesic limitation on both the passive and active joint mobility (i.e., a syndrome of subjective painfulness), as reported by the patient, the diagnostic imaging techniques (i.e., regular radiograph pictures) typically applied in such cases do not show any post-traumatic changes. Distortion of the cervical spine, resulting in a post-traumatic feeling of pain, usually occurs indirectly as a result of transmission of the force of injury onto the spine, as in the case of a traffic accident. Frequently, in cases of abuse, arriving at a hasty clinical diagnosis of post-traumatic cervical spine distortion apparently presents a serious problem in giving medical opinions for court purposes; thus encouraging the authors to attempt objectifying the condition of cervical spine distortion.Methods: In a retrospective investigation, the authors analysed the medical opinions given by the Department of Forensic Medicine, Medical University of Silesia, for court purposes.Results: Among nearly 5500 opinions in the past 5-year period, we analysed 167 cases related to cervical spine injury.Conclusions: An attempt is made to either substantiate or negate the clinical diagnosis issued for court purposes by assessing the following: the findings of the physical examination of the person involved, the condition of the person involved in the accident from the period prior to accident (radiograph findings confirming the level of the already existing degenerative changes; age and sex of the person involved; positive or negative history of injuries sustained prior to accident), the course of treatment after the accident (character of symptoms reported and their evolution with time; co-existence of other bodily injuries; outpatient treatment instituted, including the application of Schantze collar, rehabilitation) and also the circumstances in which the accident occurred.

Genetic identification of the mummified fetus

K. Droździok, J. Kabiesz, A. Nowak, M. Chowaniec, K. Rygol — 2009-12-01

Abstract: During executing some activities by the police, a mummified human fetus was accidentally revealed on a scrap of paper. It came from pregnancy considerably not carried to term, lasting about 2.5 lunar months. Medical examination did not give evidence of mechanical manipulation such as abortion or disintegration. The aim of the study was the genetic identification of the mummified fetus and an answer to the question if an indicated supposed mother was the mother of the fetus. In the study a relevant factor was maternity confirmation by means of statistic calculations.

The Upper Silesia (Poland) population and forensic usefulness of 11 autosomal STR loci

K. Droździok, J. Kabiesz, A. Nowak, Cz. Chowaniec, J. Kulikowska — 2009-12-01

Abstract: Allele frequencies, forensic parameters for the 11 STR loci in GenePrint STR Systems—Silver Stain Detection (Promega): CSF1PO, TPOX, TH01, D16S539, D7S820, D13S317, F13A01, FESFPS, VWA, F13B, LPL were determined in a sample of 529–1436 unrelated, dead and alive adults from the Upper Silesia region (Poland). Furthermore, gender identification was carried out. The values of heterozygosity (Ht), polymorphic information content (PIC), power of discrimination (PD), matching probability (PM), mean exclusion chance (MEC) and mean exclusion probability (MEP) were calculated using Dudek's computer programme (FatRec, High Technical School of Częstochowa, Poland). A possible divergence from HWE was determined by χ2 and exact tests using Miller's computer programme (TFPGA, Northern Arizona University, Flagstaff, USA). Comparison of allele frequencies between the Upper Silesia population and other Polish populations was performed with Carmody's test.

The Upper Silesia (Poland) population and forensic usefulness of 15 autosomal STR loci

K. Droździok, J. Kabiesz, A. Nowak, Cz. Chowaniec, J. Nowicka — 2009-12-01

Abstract: Allele frequencies, forensic parameters for the 15 STR loci in the AmpFlSTR® Identifiler Kit (Applied Biosystems), D8S1179, D21S11, D7S820, CSF1PO, D3S1358, TH01, D13S317, D16S539, D19S433, VWA, TPOX, D18S51, D5S818 and FGA were determined in a sample of 150 unrelated dead and alive adults from the Upper Silesia region (Poland). The values of heterozygosity (Ht), polymorphic information content (PIC), power of discrimination (PD), matching probability (PM), mean exclusion chance (MEC) and mean exclusion probability (MEP) were calculated. Possible divergence from HWE was determined. Comparison of allele frequencies for examined STR loci between the Upper Silesia population and other Polish populations was carried out.