Systemic inflammatory response due to chloroform intoxication--an uncommon complication.

Well-known adverse effects of chloroform are drowsiness, nausea, and liver damage. Two cases with an uncommon complication due to chloroform intoxication are presented. In the first case, a general physician, because of nausea and dyspnea, admitted a 34-year-old woman to hospital. She developed a toxic pulmonary edema requiring mechanical ventilation for a few days, and a systemic inflammatory response syndrome (SIRS) with elevated white blood cell counts, a moderate increase of C-reactive protein, and slightly elevated procalcitonin levels. There were inflammatory altered skin areas progressing to necrosis later on. However, bacteria could be detected neither in blood culture nor in urine. Traces of chloroform were determined from a blood sample, which was taken 8 h after admission. Later, the husband confessed to the police having injected her chloroform and put a kerchief soaked with chloroform over her nose and mouth. In the second case, a 50-year-old man ingested chloroform in a suicidal attempt. He was found unconscious in his house and referred to a hospital. In the following days, he developed SIRS without growth of bacteria in multiple blood cultures. He died several days after admission due to multi-organ failure. SIRS in response to chloroform is a rare but severe complication clinically mimicking bacterial-induced sepsis. The mechanisms leading to systemic inflammation after chloroform intoxication are currently unclear. Possibly, chloroform and/or its derivates may interact with pattern recognition receptors and activate the same pro-inflammatory mediators (cytokines, interleukins, prostaglandins, leukotrienes) that cause SIRS in bacterial sepsis.

[Perioperative fatal bleeding: link between acetabular anchoring of a cementless implant]. / Perioperative tödliche Blutungskomplikation: Lagebeziehung zwischen azetabulären Verankerungen einer zementfreien Hüftpfanne und den Iliakalgefässen.

This case report concerns a 75-year-old patient who suffered haemorrhagic shock and mors in tabula during implantation of a total hip arthroplasty. The cause was established as an injury of the external iliac vein, probably as a result of the predrilling of holes for the anchoring screws and pegs. The surgical method and topographic anatomy of the operating area are presented. Such vascular injuries are a rare but life-threatening complication of this procedure; the literature quotes a frequency of about 0.3%. So far, no fulminate venous bleeding process has been reported. Complications in such operations cannot always be avoided. However, detailed knowledge of the acetabular geometry can provide more safety for the surgeon when carrying out the secondary anchoring of a press-fit implant.

Concentration dependency of the BAC/BrAC (blood alcohol concentration/breath alcohol concentration) conversion factor during the linear elimination phase.

According to the theoretical pharmacokinetical considerations put forward by Wehner et al. the BAC(ven)/BrAC conversion factor Q is not a constant value and varies depending on the pharmacokinetic phase deduced from the alcohol concentration curve. Based on these considerations we propose that Q must be inversely proportional to the BrAC during the postabsorptive linear elimination phase, expressed as the hyperbola Q=1/kappa+(CT)/BrAC. The constants kappa or 1/kappa and (CT)--where (CT) consists of different parameters which remain constant during the linear elimination phase--can be experimentally determined from the linear relationship BrAC = kappaBAC(ven)-kappa(CT). To test this hypothesis 12 human volunteers received parenteral doses of ethanol. During the elimination phase, BAC and BrAC of each volunteer were measured between 18 and 34 times in a BrAC range between 0.65 mg/l and 0.12 mg/l. The conversion factor Q was either expressed in the form of the hyperbola Q=1/kappa+(CT)/BrAC or directly calculated from the ratio BAC(ven)/BrAC and the results obtained using both methods were found to be very similar. The values of 1/kappa of the hyperbolic functions varied between 1.808 and 2.165 and those of (CT) between 0.004 and 0.127. For a BrAC of 0.25 mg/l, an average value of 2.308+/-0.080 could be calculated for the conversion factor Q(0.25). On average, the value of Q(0.40) amounted to 2.207+/-0.048 and that of Q(0.55) to 2.160+/-0.056.

Investigations on the reliability of determining an individual's age from the proximal femur.

In the context of individual identifications the reliable determination of age is important. It has been suggested that the femur is appropriate for reliably determining age and excellent results were indeed claimed but calculated errors of estimation were often missing in the studies. In order to check the reliability and validity for forensic diagnostics, two independent investigators who were not informed of the actual age of the femur specimens evaluated x-ray views of 90 femurs according to methods described in the literature. The results of the two investigators differed by maximally 5 years in 64.4% of all cases examined; the average error of estimation amounted to 10.1-17.0 years. Only one-seventh of all cases examined could be precisely grouped into the 5-year class. Deviations of more than 15 years occurred in nearly one fourth of all cases. In particular, individuals over 50 years of age were estimated as being much younger. We must therefore conclude that the method under examination is only appropriate for rough estimations of age. A more accurate estimation within a five-year interval is only rarely possible.

[Animal bites caused by a song bird?]. / Tierfrass durch einen Singvogel?

The report describes a case of post-mortem scavenging by a songbird. A married couple had opened the cage of an astrild (finch) prior to their joint death. The body of the wife showed unusual patchy epidermal lesions on parts of the body not covered by the clothing, which were obviously caused by the songbird. According to the observations made by Roll and Rous they are attributable to "pecking and pulling". The behaviour of the bird was most probably due to lack of fluid.

Rupture of an intracranial aneurysm--unusual complication of an electric shock.

Here we report about a 35-year-old electrical engineer who was found dead in his study. Postmortem examination revealed that death resulted because of subarachnoid and intraventricular hemorrhage caused by the rupture of an intracranial aneurysm. Right hand and left cheek revealed electrical marks with metallizations on skin, an electric shock was diagnosed to have preceded death. The close temporal correlation suggests that a sudden rise in blood pressure was caused by the electric current and was thus responsible for the rupture of the aneurysm.

Experiences with a compound method for estimating the time since death. I. Rectal temperature nomogram for time since death.

The temperature-based nomogram method for estimation of the time period since death was used at the scene of death as the primary method within a compound method in 72 consecutive cases. The situation and cooling conditions inspected and evaluated by the forensic pathologist at the scene are described as far as necessary to enable handling of the method. A comparison of the estimated period since death with the period determined by the police investigations demonstrates the reliability of the method. There were no contradictions in any of the 60 cases between the period of death estimated by this method and that determined by the police investigations. The criminal investigations were effectively supported in the earliest stages in 11 cases despite the fact that the period estimated was of considerable duration.

Experiences with a compound method for estimating the time since death. II. Integration of non-temperature-based methods.

The period since death was estimated at the scene in 72 consecutive cases using the temperature-based nomogram method as the primary method and supplemented by examination of criteria such as lividity, rigor mortis, mechanical and electrical excitability of skeletal muscle and chemical excitability of the iris. A case-oriented, computer-assisted selection of the non-temperature-based methods and integration of the results into a common result of the compound method was made following a special logistic. The limits of the period since death as estimated by the nomogram were improved in 49 cases by including the non-temperature-based methods and also provided results in 4 cases where the temperature method could not be used. In a further 6 cases the non-temperature-based methods confirmed the limits estimated by the temperature method but in 14 cases a useful result could not be obtained. In only one of the cases investigated was the upper limit of the period since death, as estimated by the criterion re-establishment of rigor (8 h post-mortem), in contradiction with the period determined by the police investigations (9.4 h post-mortem).

Invasion and distribution of methanol.

After the enzyme systems responsible for methanol oxidation were blocked by ethanol, five test persons were given methanol at a dose of approximately 10 mg/kg weight, once orally and once parenterally. Taking into account the endogenous blood methanol levels detectable before the administration of methanol, C0 concentrations of 11.1-15.9 mg/kg were reached. This corresponds to a distribution volume of approximately 0.77 +/- 0.07 l/kg, which is comparable to the 0.78 +/- 0.09 l/kg obtained for ethanol. After parenterally administering methanol as a bolus, the distribution half-life was on average 8 min (range: 3.8-13.8 min). After oral administration of methanol diluted in 100 ml water on an empty stomach, invasion took place with a half-life of approximately 5 min (3.8-6.9 min). In one case, however, due to vegetative disturbances the invasion half-life was 23.1 min.

Effects of prepulses and d-amphetamine on performance and event-related potential measures on an auditory discrimination task.

RATIONALE: Prepulse inhibition (PPI) of the startle reflex is a measure of sensorimotor gating, that is the processing of the startle stimulus (S2) is inhibited by the interfering processing of a closely preceding prepulse (S1). It has been demonstrated that PPI is disrupted in a variety of mental disorders and that several neurotransmitter systems, including dopamine, participate in the modulation of sensorimotor gating. Previous studies have also shown that a task-relevant S1 enhances PPI in healthy subjects but not in schizophrenic patients. These findings indicate an influence of attentional processes on sensorimotor gating and an impairment of this modulation in schizophrenia. OBJECTIVE: Assuming a dopamine-mediated suppression of S1 processing as a mechanism of resource management and selective attention, which might be impaired in certain mental disorders, the present study investigated the effects of the indirect dopaminergic agonist d-amphetamine on prepulse-altered S2 discrimination and event related potentials (ERPs). METHODS: Twelve healthy volunteers were tested in a double-blind, placebo-controlled experimental design. Here, S2 is the target in a difficult Go/NoGo auditory discrimination task. RESULTS: Confirming our previous results, S2 processing is "accentuated" by a weak acoustic prepulse in healthy subjects, thus leading to a lower rate of errors of omission but also to more false alarms (i.e. a liberal response bias). This performance change correlated with a prepulse-induced increase in the amplitude of the P3 ERP towards non-targets ("prepulse-induced non-target positivity"; PINTP). In addition, the results of the present study show that under prepulse conditions amphetamine disrupts "S2 accentuation" associated with a dose-related reduction of the P2 component of the S1 response and a plasma level related reduction of PINTP. CONCLUSIONS: These data suggest an involuntary attentional shift towards S1 processing with increasing dopamine-release similar to that observed in patients with schizophrenia or OCD. It is concluded that sensory gating alters selective attention via dopaminergic modulation.

Tentative injuries to exposed skin in a homicide case.

A 28-year-old man stabbed both his wife and his 3-year-old son to death, before unsuccessfully attempting to commit suicide. The incident occurred against a background of marital conflict. The child's body exhibited six tentative wounds to the skin in the area of the heart, with no corresponding defects in the overlying clothing, a pattern normally seen only in suicide. Their presence can be explained by the fact that this can be considered an extended suicide, the father's motivation for the killing being comparable to that for true suicide. However, wounds of this nature can be produced in such cases only if the victim is severely limited in his ability to defend himself, here due to the superior physical strength of the father.

The form of the supraorbital margin as a criterion in identification of sex from the skull: investigations based on modern human skulls.

Sexual dimorphism in the shape of the supraorbital margin was reported by Broca and various subsequent authors, but no consistently applied, precise definition has been established. In this study of modern human skulls, the value of our definition of the sex-related difference in this area in the identification of sex from the skull was investigated. It was found that this feature can be assessed reliably, is strongly related to sex, and is independent of the side. The accuracy of identification of sex using this method alone was found to be about 70%.

Curvilinear increase in methanol concentration after inhibition of oxidation by ethanol: significance for the investigation of endogenous methanol concentration and formation.

Endogenous methanol production was assessed over a period of 5 h in subjects given an infusion of ethanol to inhibit methanol oxidation in the liver after a period of fasting and abstinence from alcohol. Ethanol was administered to each of five subjects at rates of 0.35 g/kg per hour and 0.70 g/kg per hour. The rise in methanol concentration was biphasic regardless of the rate of ethanol administration, with a steeper gradient in the first 10-30 min. This may be due to the existence of a deep compartment from which methanol can be displaced by ethanol. This could take the form of loose binding of methanol to the hepatic oxidation enzymes as an enzyme-substrate complex, or a shift of the oxidation-reduction equilibrium between methanol and formaldehyde. The biphasic nature of the increase, with an initial steeper rise, means that the values obtained in the first 30 min should be excluded from the calculations when the rate of endogenous methanol production is determined by linear regression analysis. Endogenous methanol concentrations to be taken into account after ethanol administration are on average 0.4-0.6 mg/kg higher than those detectable in the absence of ethanol due to the additional method displaced from the deep compartment.

The kinetics of methanol elimination in alcoholics and the influence of ethanol.

Methanol concentrations were studied during the end phase of ethanol elimination and for about five hours afterwards in 12 alcoholics admitted with alcohol intoxication for acute care. The rate of ethanol elimination (beta 60) ranged from 0.114 g/kg/h to 0.270 g/kg/h (mean 0.178 +/- 0.045 g/kg/h). The methanol concentration was found to remain almost steady as long as ethanol levels were relatively high, and changed only to an extent that could be explained by the combined opposing influences of methanol excretion and endogenous synthesis. There was no significant relationship between the rate of ethanol elimination and the methanol level. The methanol concentration began to decrease when the ethanol concentration had fallen to under 0.2 g/kg. When the ethanol concentration had fallen to base levels, methanol was eliminated at a rate characterized by an elimination constant (kel) of 0.212-0.481 h-1, and a half life of 1.44-3.27 h. There was a positive correlation between the rate of ethanol elimination and the rate of methanol elimination (r = 0.642; p < 0.05).

Methanol elimination in non-alcoholics: inter- and intraindividual variation.

Five male subjects aged between 25 and 40 years were given methanol at a dose of 10 mg/kg, once orally and once intravenously, while the enzyme systems responsible for methanol oxidation were blocked by ethanol. The study assessed the duration of inhibition of methanol oxidation in relation to the blood ethanol concentration, and the elimination of methanol not influenced by ethanol. Methanol elimination was found to begin at a blood ethanol concentration of 0.04-0.13 g/kg. Elimination constants of 0.406-0.267 h-1 with corresponding half-lives of 1.71-2.60 h were established for methanol not influenced by ethanol. When data from a previous study using an identical protocol for parenteral administration were included, making the total number of subjects nine, the mean elimination constant was found to be 0.298 +/- 0.470 h-1 and the mean half-life 2.37 +/- 0.357 h, distribution being normal. No evidence of any differences in methanol elimination kinetics between alcoholics and non-alcoholics or of a significant influence of the route of administration was found. The extent of intraindividual variation in methanol elimination as indicated by the difference in each subject between the values established, expressed as a percentage of the corresponding mean values, was found to be 3-25%, which is comparable to the magnitude of intraindividual variation in the rate of ethanol elimination.

Endogenous methanol: variability in concentration and rate of production. Evidence of a deep compartment?

The endogenous methanol concentration was determined in 72 men aged between 18 and 35 years in the morning after a 12-h period of fasting and abstinence from alcohol. The distribution curve was found to be skewed to the right, the concentrations ranging from '0' (below the detection threshold) to 3.4 mg/kg. The median was 0.1 mg/kg and the mean 0.35 mg/kg. Significant differences were found between three groups defined according to the duration of prior abstinence from alcohol (8 h, 30 h, and 5 days). The highest values were seen after the shortest period of abstinence and the lowest values after the longest period of abstinence. The course followed by the methanol concentration in the presence of blocking of methanol oxidation by orally or parenterally administered ethanol was observed over at least 10 h on two separate occasions in a further 8 subjects aged between 24 and 35 years. At blood ethanol concentrations of more than 0.20 g/kg, the rate of production of methanol, calculated by regression, ranged from 0.09-0.37 mg/kg/h (r = 0.970-0.554, S(y.x) = 0.227-0.565 mg/kg). The rise in methanol concentration at the start of ethanol administration was significantly more rapid than the subsequent rise. It is hypothesised that there may be a so-called deep compartment for methanol that would explain the dependence of the endogenous methanol level on the duration of the preceding period of abstinence from ethanol, and the occurrence of an initial phase of faster rise in methanol concentration associated with the administration of ethanol.

[Traffic accidents in alcoholic intoxication]. / Verkehrsunfälle unter Alkoholeinfluss.

A study of group comprising all road accidents caused by drivers of private cars who were under the influence of alcohol (BAC > = 0.3 g/kg; X = 1.56 +/- 0.62 g/kg) that occurred in a defined area over the span of one calendar year (n = 625) was compared with a randomly selected control group of 718 road accidents in which the drivers had not been under the influence of alcohol. The drivers in the study group were marginally younger than the ones in the control group. However, there was no evidence of an alcohol related increase in the risk of an accident associated with younger age. The sex ratio in the study group corresponded to that, generally found amongst people driving under the influence of alcohol. In the study group there was no evidence of a restricted manner and extent of car use, based on the distances between the sites of the accidents and the offenders' homes. However, the proportion of accidents occurring out of towns was greater in the study group. Alcohol associated accidents occurred more frequently in the evenings and at night, which reflects habitual drinking patterns. Therefore these accidents occurred mainly in darkness and twilight. Surprisingly, unfavorable weather conditions such as rain or ice did not lead to an increase in accidents due to alcohol. In fact, in the study group, proportionally fewer accidents occurred on icy roads. Both injury to persons and damage to property were more severe in the study group. While no relationship between accident severity and blood alcohol concentration could be proven within the study group, the risk of death or severe injury was 3 to 4 times greater in this group than in the control group.

[Changes in the spectrum of alcohol-induced traffic accidents in relation to blood alcohol level]. / Veränderungen des Spektrums alkoholbedingter Verkehrsunfälle in Abhängigkeit zur Höhe der BAK.

A retrospective study was undertaken to determine whether the degree of alcohol intoxication has an effect on the driving performance with regards to both the quantity and quality. A total of 625 accidents caused by drivers who were under the influence of alcohol were reviewed. They were divided into three groups according to the blood alcohol concentration (BAC):0.30 - 1.09 g/kg, 1.10 - 1.99 g/kg and > 2.00 g/kg. In order to exclude the influence of factors unrelated to alcohol, the groups were matched for age, sex, location of accident and the light and road conditions. This resulted in a total of 85 accidents in each group. The accidents were classified with reference to the "Register of causes of accidents" used in road accident statistics. The three groups differed significantly in their causes of accidents (p < 0.025), although those due to speeding dominated in each group. In the group with low BAC, the next most common accidents were the ones caused by failure to give way. In the group with medium BAC, rear-end collisions and accidents occurring during low speed manoeuvres were the second most common. In the group with highest BAC, the next most common causes of accidents were the leaving of the correct traffic lane unassociated with speeding.

[Study on the significance of mercury accumulation in the brain from dental amalgam fillings through direct mouth-nose-brain transport]. / Untersuchung zur Bedeutung einer cerebralen Quecksilberbelastung aus Amalgamfüllungen durch direkten Mund- und Nase- Hirn-Transport.

The transport of mercury (Hg) from the oro-nasal to the cranial cavity via a direct route was investigated. In 55 deceased persons, Hg concentrations were measured in the olfactory bulb and the trigeminal ganglion, and the number of dental amalgam fillings was assessed. For the purpose of comparison, Hg concentrations were also determined in the occipital lobe cortex, the pituitary gland and the kidney cortex. Quantitative Hg analysis was performed by cold vapor atomic absorption spectroscopy after acid digestion using high pressure microwave treatment. In the olfactory bulb (geom. mean 17.4 micrograms/kg w. w.), the Hg concentration was significantly higher than in the occipital lobe cortex (geom. mean 9.2 micrograms/kg w. w.) (p < 0.0001). No significant difference was found between the Hg concentration in the trigeminal ganglion (geom. mean 12 micrograms/kg w. w.) and the occipital lobe cortex (alpha = 0.005; p = 0.0342). Regression analysis did not reveal a statistically significant correlation between the number of dental amalgam fillings and the Hg content in the olfactory bulb and the trigeminal ganglion, respectively (alpha = 0.01). Therefore, these results do not support the hypothesis of a significant flow o Hg from dental amalgam fillings to the cranial cavity by a direct oro-nasal route. In contrast, a statistically significant correlation exists between the number of dental amalgam fillings and the Hg concentration in the kidney cortex (r2 = 0.317; p < 0.0001), and, to a lesser extent, the Hg concentration in the occipital lobe cortex (r2 = 0.17; p = 0.0016). The highest Hg concentrations (geom. mean 93.1 micrograms/kg w. w.) were detected in the kidney cortex, followed by the pituitary gland (geom. mean 30.0 micrograms/kg w. w.). In this study, Hg concentration in the pituitary gland did not correlate with the number of dental amalgam fillings.

Spleen findings in drowning.

A retrospective study of spleen findings in 42 victims of drowning and a comparison group of 42 cases of asphyxiation due to other causes (hanging, ligature strangulation and manual strangulation), that were matched for sex, age, body weight and build, was performed. Significantly smaller spleen weights (P < 0.05), spleen weight:body weight ratios (P < 0.01) and spleen weight:liver weight ratios (P < 0.01) were found in the victims of drowning. The difference in weight was approximately 18%. A significant negative correlation between spleen weight and blood alcohol concentration was found in the study group (r = -0.44; P < 0.01), but not in the control group. The possibility that the findings are due to a stress reaction caused by hypoxia in the presence of cooling and an influence of alcohol on reflex mechanisms is discussed.