[A study of post-traumatic stress reactions among war refugees based on medical records. A standard model may support the treatment]. / Journalstudie av krigsflyktingars posttraumatiska stressreaktioner. Standardmall kan ge stöd i behandlingen.

A special project designed to aid Bosnian refugees in Stockholm County was initiated and funded by the County Council in February 1994. The present study, a joint endeavour involving the Bosnian Project, the Centre for Trauma and Torture Diagnostics, and the Red Cross Centre for torture victims, was designed to fulfil the following aims: To characterise the patient population in terms of social situation, trauma history, symptoms and treatment; To review accumulated experience at the three centres; To outline and discuss the treatment; and To suggest new avenues for further research concerning refugees and trauma. To obtain comparable material for this retrospective review of case records at the three centres, a special case chart format was adopted, covering pre-war and pre-treatment information on general background, social situation, health status and medication, as well as trauma history, symptoms and treatment. Most patients reported good pre-war health, but at the time of the study exhibited manifest effects of trauma history; 95 per cent reported mental problems, and 39 per cent medical disease or physical disorders. These refugees were thus characterised by manifest post-traumatic stress symptoms and need of treatment. Despite their relatively short time in Sweden, almost all had permanent residence permits and fixed addresses. The absence of a comparable control group precluded comparison with other refugee or normal populations. The findings suggest the need of co-ordination and co-operation between the special facilities available to refugees, and of a standardised format for case records.

[Benzodiazepine findings in autopsy material. A study shows interacting factors in fatal cases]. / Bensodiazepinfynd i obduktionsmaterial. Studie påvisar samverkande faktorer vid dödsfall.

The paper consists in a report of a retrospective study (of data from 1987) on the prevalence of benzodiazepines in blood at the time of death. Of 2,007 autopsies, forensic chemical analyses were performed in 1,587 cases, in 159 of which benzodiazepines were found. Of these 159 deaths, 22 were considered to be due to natural causes, and in another 22 cases the cause of death was still unclear after examination; the remaining 115 deaths were due to accidents (N = 16), suicide (N = 60), drug addiction (N = 29) or alcoholism (N = 10). Multiple benzodiazepine intake was found in 37 cases, a subgroup including all 29 cases of death due to drug addiction. In a comparison of suicides and natural deaths, the concentrations both of flunitrazepam and nitrazepam were significantly higher among the suicides (P < 0.001 and P < 0.05, respectively). In four cases, the sole cause of death was benzodiazepine intake. It is concluded that some benzodiazepines, particularly flunitrazepam, may be more toxic than formerly supposed.

The prevalence of alcohol-related mortality in both sexes: variation between indicators, Stockholm, 1987.

OBJECTIVES: The purpose of this study was to analyze the prevalence rates of alcohol-related mortality--according to various indicators--in both sexes in Stockholm, Sweden. METHODS: A study of alcohol involvement at death was undertaken for all 668 deceased persons aged 15 through 54 years in 1987 in Stockholm. Death certificates, autopsy information, police records, and information about earlier conviction were analyzed. RESULTS: When different measures of estimation were compared, there were great differences in the prevalence rates of alcohol involvement. According to the death certificates, 9.2% of the males and 11.2% of the females had alcoholism, alcohol intoxication, pancreatitis or liver cirrhosis as underlying cause of death. When all accessible information was used, potential alcohol involvement was found in 57.5% of the male and in 32.2% of the female deaths. There was a marked association between earlier drunken driving and alcohol involvement. After reevaluation of the diagnoses with autopsy findings, the number of cases with cardiac enlargement and suspected cardiomyopathy increased from 10 to 62. CONCLUSION: The results point to the serious underdiagnosis of alcohol involvement in death certificates and the misclassification of important causes of death (i.e., liver cirrhosis and cardiac disease); they also call for increased efforts regarding prevention.

Causes of death in a cohort of 50,465 young men--validity of recorded suicide as underlying cause of death.

We studied causes of death in a cohort of all young males (n = 50,465) conscripted for military service in 1969-70. Six hundred eighty three deaths occurred in the cohort during the follow-up through 1983. Injury-related deaths accounted for 75% of all deaths. Of these, 38% were definite suicides, 10% undetermined suicides and 30% motor vehicle accidents. The validity of officially recorded causes of death was studied by scrutinizing all death certificates (n = 683) and forensic reports, including police reports, toxicological and histological data, from a sample (n = 322) of deaths with unclear circumstances. Of 161 officially recorded suicides (E950-959), only one case was reevaluated into poisoning, "undetermined" (E980). Of 47 cases officially recorded "undetermined" (E980-989), 9 were reevaluated into definite suicide (E950-959) although we believe that this is still an underestimation of "true" suicide cases. An alcohol concentration of more than 0.1 g% was found in 45% of all violent deaths (E800-999), 34% of all suicides and 60% of all "undetermined" deaths. We conclude that the causes of death in most cases of injury related death in young age are recorded with high accuracy. Reevaluation of recorded deaths from "undetermined" causes revealed a number of definite suicides, although the "true" number of suicides is difficult to assess even after close scrutiny of the information available.

Poisoning with sodium hypochlorite solution. Report of a fatal case, supplemented with an experimental and clinico-epidemiological study.

A case of fatal poisoning in a 1-year-old girl after ingestion of a household cleanser containing 4.5% sodium hypochlorite (Klorin) in an alkaline solution (pH 12.0) is reported. The forensic medical and toxicological investigations were supplemented by animal studies. These studies indicate that 5, 10, and 15 ml of Klorin/kg body wt given to rats is highly toxic, and that local tissue damage and secondary systemic involvement develops with a severity corresponding to the amount administered. The rats, all of which died, showed various degrees of degeneration and necrosis of the esophagoventricular mucosus membranes, changes analogous to those found at the autopsy of the child. A follow-up investigation of similar cases reported to the Swedish Poison Information Centre, during a limited time, was made to complete the picture.

Biochemical and morphological markers in the post mortem diagnosis of ischemic heart distress.

The purpose of the present study was to analyze the effectiveness of different biochemical markers used clinically or proposed for the post mortem diagnosis of myocardial infarction in medico-legal practice. We analyzed seven biochemical parameters (CK, CK-MB, LDH, myoglobin, myosin, cathepsin D and total proteins) in pericardial fluid, vitreous humor and femoral vein serum from 34 cadavers. The results were compared with data from macro- and microscopic studies. Our results suggest that biochemical markers are applicable in cases in which the lack of morphological data makes diagnosis uncertain, and are helpful in ruling out myocardial infarction. The sample material of choice for biochemical tests is the pericardial fluid, and the most informative markers are myoglobin, myosin, CK-MB and cathepsin D.

Mortality among criminals with suspected mental disturbance.

Mortality rates and cause of death are reported from a long-term follow-up study of 620 Swedish criminals who were subjects of a forensic psychiatric examination in 1965-1968. The results show that there is an increased mortality rate in criminals mainly due to violent deaths (suicides, accidents) and diseases related to alcohol abuse. The increased mortality was found in all age groups throughout the follow-up period of 13-16 years. The total mortality was 17%. An analysis of different mortality risk factors showed that drug abuse, type of crime (violent crimes or property crimes) and criminal recidivism did not further increase the mortality risk. There were relatively few deaths due to overdose of drugs. Alcohol abuse increased the mortality rate significantly.

Validation of diagnoses on death certificates for male alcoholics in Stockholm.

The mortality and the causes of death have been studied in a cohort consisting of 1548 male alcoholics in Stockholm. During the period 1969-1981 there were 542 cases of death in this population. The mortality rates were triple those for males in Stockholm generally. Using the official causes of death there was a highly significant excess mortality in the following diagnostic groups: Cancer in the upper digestive region, primary hepatic cancer, cirrhosis in the liver, pancreatitis, pneumonia, alcoholism and alcoholic poisoning, suicides and other causes of violent death as well as ischemic heart disease. The underlying and contributing causes of death on the death certificates were reclassified according to ICD-rules using clinical records and autopsy protocols. It was found that the underlying cause of death was incorrect in 21.8% of the cases. Important information was withheld in further 19.8%. After validation there was no longer any excess mortality in ischemic heart disease. The number of alcohol-related diagnoses, i.e. alcoholic cardiomyopathy, cirrhosis and fatty liver with alcoholism and alcoholic intoxication, was much greater. It is concluded that there is a underreporting of alcohol-related diseases and injuries which has a great influence on the reliability of death statistics.

Cause of death in persons aged between 15 and 50 years in the community of Stockholm. A forensic-pathologic and statistical study.

All deaths occurring in the age group 15-50 years in the community of Stockholm during the period November 1st 1979 to April 30th 1980 have been investigated. There were 272 deaths in total (males 176, females 96). The estimated annual death rate was in total 185/100,000 inhabitants (males 238, females 132). The autopsy rate was 82%. The deaths were divided in five main groups: 32 persons (12%) died from cardiovascular diseases, 60 persons (22%) from other natural diseases, 65 persons (25%) from conditions causally associated with exogenous influence (border line cases) such as abuse of alcohol, medicinal drugs and narcotics at sublethal concentrations. Violent deaths amounted to 108 cases (40%) and finally in 7 cases (3%) no plausible cause of death was proven. In 51 cases (19%) the underlying cause of death was attributed solely to chronic abuse of alcohol. Anamnestic information about abuse was available in 42% of all deaths. Deaths due to arteriosclerotic heart disease comprised a small group and were rare under the age of 45; about half of those were considered sudden and unexpected. The estimated annual rates of deaths due to coronary heart disease were 16.2/100,000 inhabitants for males and 1.4 for females. Difficulties were experienced in defining and delimiting the group of border line deaths due to exogenous influences.

Monooxygenase activities of human liver, lung, and kidney microsomes - a study of 42 post mortem cases.

The cytochrome P-450-dependent monooxygenase system was examined in microsomal fractions prepared from 42 post mortem human livers and 9 lungs and kidneys. Electron microscopy studies indicated that the human liver samples were relatively free of mitochondrial and plasma membrane contamination, but samples of kidney and lung were less pure. The microsomal fractions from all organs were judged to be relatively free of haemoglobin and methaemoglobin. The specific enzyme activities for several drug substrates for the monooxygenase, NADPH-cytochrome c reductase activity and the content of the microsomal cytochromes were measured. The values of the biochemical parameters studied were found to be quite variable and the values for the human liver were appreciably lower than those obtained with liver microsomes from laboratory rodents. The enzyme activities of the human kidney and lung microsomal fractions were 1-10% of those seen for human liver samples, except for NADPH-cytochrome c(P-450) reductase activity. In order to evaluate any post mortem changes in human liver, correlations between drug metabolism activities and either cytochrome P-450 or NADPH-cytochrome c (P-450) reductase content were examined. Strong correlations (r greater than 0.91) were seen only between aminopyrine or ethylmorphine demethylase activity and cytochrome P-450 content in samples obtained within 4 hours of death. Longer post mortem times gave poorer correlation between activity and cytochrome content. These studies document several conditions required in order to obtain human microsomal fractions representative of the activities in fresh, viable tissue.

Isolated viable rat cardiac myocytes as a tool for evaluating histochemical methods for diagnosis of myocardial ischemia. I. Mitochondria-bound oxidoreductases--a preliminary report.

A pilot study has been performed to evaluate the usefulness of isolated viable rat cardiac myocytes in the evaluation of histochemical oxidoreductase methods for estimating cellular anoxic damage. Data are presented in support of the use of succinate dehydrogenase and beta-hydroxybutyrate dehydrogenase for evaluating different degrees of cellular damage. It appears that upon anoxia biochemical signs of membrane leakage do occur earlier than positive histochemical reactions. However, trypan blue staining occurs at a later time point. Probably the histochemical reaction-rates are limited by the penetration of both the substrate and the electron acceptor, in this case nitro blue tetrazolium, into the cells and the mitochondria.

Oxidative biotransformation of benzo(a)pyrene by human lung microsomal fractions prepared from surgical specimens.

1. Microsomal fractions were prepared from 15--50 g specimens of human lung tissue (mostly alveolar) obtained at surgical resections of 13 middle-aged male patients suffering from different pulmonary tumours. Marker enzyme assays indicated that the frations contained about 25% of the endoplasmic reticulum of the homogenate and about 10% of its mitochondrial membranes. 2. The content of cytochrome b5 corresponded to that of rodent lung microsomes, whereas the apparent content of cytochrom P-450 was much lower. 3. The extent of benzo(a)pyrene metabolism varied 13-fold between individuals in the group and was not detectable in about 40% of the cases. 4. The dihydrodiols as % of total metabolites formed was higher than in laboratory animals, the 7,8-dihydrodiol in most cases amounting to more than 40% of total dihydrodiols. 5. The apparent rate of hydroxylation was stimulated by 1 mM 2-diethylaminothyl 2,2-diphenylvalerate and by 1 mM 1,2-oxy-3,3,3-trichloropropane, but inhibited moderately by 0.1 mM metyrapone and extensively by 0.05 mM 7,8-benzoflavone. 6. Ethoxyresorufin deethylation qualitatively paralleled benzo(a)pyrene hydroxylation among individuals.