Diagnostics of fatal hydrogen sulfide poisonings.

INTRODUCTION: Cases of fatal hydrogen sulfide poisonings are rarely presented in forensic medicine practice. They mostly occur in occupational settings and occasionally are mass. Due to occupational poisonings caused by gases, hydrogen sulfide is ranked second regarding frequency-dependent incidence. Hydrogen sulfide at high concentrations is undetectable to human senses resulting in increased risk of fatal poisoning. Such poisonings represent a particular group with respect to their objectification by toxicological analysis. AIM: The aim of this paper is to demonstrate possibilities of laboratory diagnostics of fatal hydrogen sulfide poisonings. PATIENTS AND METHODS: The paper provides a retrospective overview of 15 cases of fatal hydrogen sulfide poisonings which occurred in the history of the Institute of Forensic Medicine of the School of Medicine, Comenius University in Bratislava. All cases were completely analysed by morphological and toxicological methods. The samples of blood and pulmonary tissue were examined in the toxicological analysis. The method of analysis of alveolar air was developed by Bauer. An experiment for detection of post-mortem production of hydrogen sulfide in the body was performed. RESULTS: Morphological findings in all autopsied and analysed cases were similar and nonspecific for poisoning diagnosis. A significant change in possibilities of toxicological analysis occurred in 1968. Since then a direct identification of toxic gas through the analysis of alveolar air has been possible. CONCLUSION: Taking into consideration summarization and comparison of the analysis results of the cases from archive materials of the authors, it is possible to claim that at the workplace in Bratislava a unique objective method of proving this gaseous poison in biological material used so far has been developed. Some negative or unconvincing results of toxicological analysis again refer to pitfalls of diagnostics of hydrogen sulfide poisonings, which must be complex and based upon an efficient collaboration particularly between a medical examiner and toxicologist-analyst together with other bodies complementing the required spectrum of investigated circumstances and clinical data.

Fatal methadone intoxication in a 11-month-old male infant.

INTRODUCTION: The number of fatal methadone intoxications in adults has been increasing in parallel with the use of methadone for opiate substitution therapy. Methadone intoxication in children occurs rarely. Its diagnostic possibilities on the basis of clinical findings are often limited. The aim of this paper is to demonstrate a case of an 11-month-old male infant, who unexpectedly died without a previous disease history. METHODS: The complex morphological analysis of the case was performed by routine methods. Toxicological analysis was aimed at detection of the presence of ethanol, psychoactive and other forensically relevant substances in available biological materials. RESULTS: Morphological findings were non-specific. Toxicological analysis of biological materials failed to reveal the presence of ethanol in body fluids. In analysed materials the presence of methadone was found at the following concentrations: in blood serum 1.3 microg/mL (calculated to 0.7 microg/mL in whole blood), in the liver 5.0 microg/g, in the kidney 2.6 microg/g and in urine 3.2 microg/mL. CONCLUSIONS: The cause of death in an 11-month-old male infant who had been referred to the autopsy with a diagnosis of sudden infant death syndrome was established as fatal methadone intoxication. With respect to determined results of toxicological analysis apart from setting the diagnosis of intoxication it is not possible to comment on the question concerning repeated administration of methadone. A high likelihood of administrating methadone to the infant by another person exists. Neither mother nor her partner who was not the infant's father is registered in the Centre for Treatment of Drug Dependencies and thus the origin and source of the methadone still remains unknown.

Collaboration between medical examiner and toxicologist-analyst.

Negative effects of the increasing number of toxic substances in the external environment affecting the human organism are highly reflected in everyday forensic practice. In parallel with new circumstances also the methods enabling identification of heterogeneous substances have been developing. Demonstrating evidence is more challenging and sophisticated particularly in cases with proving several xenobiotics including metabolites and their possible interaction. Poison intoxications of unknown origin can represent a diagnostic problem. Consequently close collaboration between involved forensic professionals i.e. medical examiner and forensic toxicologist-analyst is inevitable. The data provided by police investigators are significant as well--investigated circumstances, testimonies and in case of hospitalization detailed data from clinicians. In everyday forensic practice the shortage of medical examiners specialised in toxicology and knowledgeable toxicologists-analysts has been increasingly experienced. The urgent requirement for more specialists arises more frequently not only in suspected fatal poisonings but also in assessing of analysis results particularly in cases of persons directly involved in road traffic accidents, work-related injuries, etc. The number of cases requiring detecting psychoactive substances is also increasing. On the other hand recent experience demands expanding the spectrum and increasing the number of indications of toxicological analyses from medical examiners involved in performing autopsies. At present the Slovak forensic workplaces are in the process of being equipped with instrumentation designed for expanding the spectrum of toxicological analyses and improving their quality. There hence emerges a need for developing the contemporary concept of Slovak forensic toxicology with respect to both organizational and methodological aspects focused on better interaction of activities carried out by medical examiners and toxicologist-analysts. The essential part of developing the coordination of both expert groups is also postgraduate education with an emphasis on improving mutual recognition principles of their work.

Dietary guidelines in the Czech Republic. II.: Nutritional profiles of food groups.

Modern dietary guidelines set in terms of food groups are easy to use and understand for target populations, but rather complicated from the point of view of quantification, i.e. the correctly set number of recommended servings in different population groups according to age, sex, physical activity and physiological status on the basis of required intake of energy and individual nutrients. It is the use of abstract comprehensive food groups that makes it impossible to use a simple database of food tables based on the content of nutrients in individual foods, rather than their groups. Using groups requires that their nutritional profiles be established, i.e. that an average content of nutrients and energy for individual groups be calculated. To calculate nutritional profiles for Czech dietary guidelines, the authors used three different methods: (1) Simple profiles, with all commodities with significant representation in the Czech food basket represented in equal amounts. (2) Profiles based on typical servings, with the same commodities as in (1) but in characteristic intake quantities (typical servings). (3) Food basket-based profiles with commodities constituting the Czech food basket in quantities identical for that basket. The results showed significant differences in profiles calculated by different methods. Calculated nutrient intakes were particularly influenced by the size of typical servings and it is therefore essential that a realistic size of servings be used in calculations. The consistent use of recommended food items throughout all food groups and subgroups is very important. The number of servings of foods from the five food groups is not enough if a suitable food item is not chosen within individual groups. On the basis of their findings, the authors fully recommend the use of nutritional profiles based on typical servings that give a realistic idea of the probable energy and nutrient content in the recommended daily intake. In view of regional cultural differences, national nutritional profiles play a vital importance. Population studies investigating the size of the typical servings and the most frequently occurring commodities in the food basket should be made every three years. Nutritional profiles designed in this way constitute an important starting point for setting national dietary guidelines, their implementation and revisions.

Dietary guidelines in the Czech Republic. I.: Theoretical background and development.

Setting dietary guidelines for the healthy population of the Czech Republic has respected the methodical steps suggested by authors as follows: consideration of dietary guidelines was preceded by the consensus on general goals and methods, e.g. health and well-being promotion at the population level. The guidelines cover a total diet, not only a part of it and have to be realistic, with respect to actual frequency of food in majority of population. The second step was the declaration of nutritional goals with respect to achieving the RDI. The third step was dividing the food into defined food groups according to the following criteria: the food contained in one food group had the same/similar nutritional characteristics with regard to achieving the adequate of decreased intake. Within the groups several sub-groups were set, associating foods with another specific nutrient content. The fourth step was the setting the serving sizes as an equivalent for each food group. These equivalents must reflect typical average consumed amount of food and always within the group the content of the main nutrient has to be same/similar. The fifth step was setting nutritional profile of each group and/or sub-group. This profile represented the content of energy, proteins, lipids, carbohydrates, vitamins and minerals. The sixth step was deciding the daily number of servings of each food group, which must allow the flexibility as much as possible--authors recommend the interval solution. The seventh step was decision about the form (textual and graphic), which presents the guidelines. The decision was preceded by the study focused on accepting suggested possibilities. The last, eighth step was working out the strategy of implementation in practise, which means the summarizing organizational, administrative and political arrangements with the aim to be positively accepted by the population who identify itself with the principles of the dietary guidelines. In the formulation of dietary guidelines in the Czech Republic, the authors accepted methods described above and each of the eight steps was supported by adequately focused population study.