Magnetic resonance imaging of the sternal extremity of the clavicle in forensic age estimation: towards more sound age estimates.

OBJECTIVES: The development of the sternal extremity of the clavicle was examined prospectively with magnetic resonance imaging (MRI) for forensic bone age assessment. The objectives were to examine whether these results were comparable with the literature on plain radiography and CT, to provide age prediction intervals that correctly reflect the high variability in clavicular growth among individuals and to investigate whether MRI of the clavicle can be used to differentiate between individuals younger or older than 18 years. METHODS: The clavicles of 220 volunteers (16-26 years) were examined with 3-T MRI and evaluated according to the Schmeling and Kreitner classification (Schmeling, Int J Legal Med 118:5-8, 2004; Kreitner, Eur Radiol 8:1116-1122, 1998). An additional hand/wrist radiograph was taken and evaluated according to Greulich and Pyle (1959). After a descriptive analysis, a multivariate ordinal regression model was fitted and embedded in a Bayesian framework based on Thevissen et al. (Int J Legal Med 124:35-42, 2009). RESULTS: The descriptive results were concordant with the literature, although the Kreitner classification is recommended and simultaneous evaluation of the hand is considered a basic requirement (Schmeling, Int J Legal Med 118:5-8, 2004). The 95 % credibility interval for both genders with bilateral stage IV is 20-26 years. The corresponding estimated probability of being younger than 18 years is 0.8 % in females and 0.2 % in males. CONCLUSION: MRI of the sternal extremity of the clavicle can be used to differentiate between being younger or older than 18, but a simultaneous evaluation of the hand/wrist is essential. Future evaluation of the predictive performance of the model, using comparable but larger reference samples, is necessary to validate these results.

Methadone-related fatalities: review in the Ghent district between 1978-2008.

Previous research demonstrated that Methadone Maintenance Programs (MMP) and Methadone Maintenance Treatment/Therapy (MMT) could significantly reduce the mortality risk. However, in current forensic practice, methadone ingestion can still directly or indirectly be involved in fatalities. The objectives of this study were twofold. Firstly, referring to the wide range of blood levels reported in methadone-related fatalities, we aimed to provide insight into the interpretation of a quantitative post-mortem blood concentration. Secondly, to examine and discuss possible causes, mechanisms and manners of death. During a 30-year-period, all medico-legal files at the Department of Forensic Medicine (Ghent University) were searched through, to investigate whether methadone was involved in the fatal outcome. A significant increase in the methadone-related fatalities was found since 1995, which has also been noticed in other studies. In our study (n=48), the most frequent cause of death was intoxication: only one was due to a pure methadone intoxication, whereas in all other fatal intoxications, a poly-drug intoxication was found. In this study, cardiopulmonary failure, induced by depression of the vital centres in the brainstem, was--as expected--the most important mechanism of death. When we considered the post-mortem blood levels in our study group, we observed a wide range, namely between 0.10 and 4.13 microg/ml (median: 0.54 microg/ml, mean: 0.81 microg/ml, SD: 0.14). This was in line with previous reports, although the extreme values differed. We conclude that the interpretation of post-mortem methadone blood levels is still hazardous due to e.g. difficulties to assess the individual tolerance level, the variety of surviving periods after ingestion, interfering post-mortem redistribution and the combined ingestion of methadone with other drugs. Therefore, a close collaboration between the forensic pathologist and toxicologist is recommended in order to provide a well-grounded conclusion.

[Self-medication of regular headache: a community pharmacy-based survey in Belgium]. / Automédication des céphalées fréquentes: étude dans les officines belges.

AIM: This observational community pharmacy-based study aimed to investigate headache characteristics and medication use of persons with regular headache presenting for self-medication. METHODS: Participants (n=1205) completed ii) a questionnaire to assess current headache medication and previous physician diagnosis, (ii) the ID Migraine Screener [ID-M] and (iii) the MIDAS questionnaire. RESULTS: Forty-four % of the study population (n=528) did not have a physician diagnosis of their headache, and 225 of them (225/528, 42.6%) were found to be ID-M positive. The most commonly used acute headache drugs were paracetamol (used by 62% of the study population), NSAIDs (39%) and combination analgesics (36%). Only 12% of patients physician-diagnosed with migraine used prophylactic migraine medication, and 25% used triptans. About 24% of our sample (n=292) chronically overused acute medication, which was combination analgesic overuse (n=166), simple analgesic overuse (n=130), triptan overuse (n=19), ergot overuse (n=6) and opioid overuse (n=51). Only 14.5% was ever advised to limit intake frequency of acute headache treatments. CONCLUSIONS: This study identified underdiagnosis of migraine, low use of migraine prophylaxis and triptans, and high prevalence of medication overuse among subjects seeking self-medication for regular headache. Community pharmacists have a strategic position in education and referral of these self-medicating headache patients.

Magnetic resonance imaging of the medial extremity of the clavicle in forensic bone age determination: a new four-minute approach.

OBJECTIVES: The use of 3T magnetic resonance imaging (MRI) of the clavicle in forensic bone age determination was prospectively examined and compared with plain radiography. METHODS: Four MRI sequences and three radiographs of 121 healthy subjects between 11 and 30 were studied by two observers. RESULTS: The number of images assessable for bone age determination was lower for plain radiography (PA: 68.7%; oblique: 97.5%) compared with MRI (VIBE: 99.0%). Concerning the subjective level of difficulty to assess bone age, the observers found it easier to assess bone age on MRI than on radiography. The developmental stages of the clavicle, as used on plain radiography, were transferable to MRI. Especially the VIBE gradient echo sequence provided an excellent depiction of the growth cartilage and ossification centre with a slice thickness of 0.9 mm and only a 4-min acquisition time. When the developmental stages were assigned, less variability between the observers was seen on MRI, compared with plain radiography. CONCLUSION: We conclude that 3T MRI provides high resolution, cross-sectional images of the maturation of the clavicle without ionising radiation in a very short time, allowing more accurate determination of bone age than plain radiography.

Study of the relationship between lipid binding properties of cyclodextrins and their effect on the integrity of liposomes.

It is well known that cyclodextrins are able to extract lipids constituting membranes, increasing their fluidity and permeability. This behaviour towards biological membranes is directly linked to the toxicological effects of methylated cyclodextrins. However, confusion is currently made in the literature between the different methylated cyclodextrin derivatives. Moreover, a new methylated cyclodextrin derivative recently occurred in the market, the Crysmeb. We wanted to compare and understand the effect of the most currently used cyclodextrins on a model membrane. We studied the influence of natural cyclodextrins (betaCD and gammaCD), methylated derivatives (2,6-dimethyl-betaCD (Dimeb), 2,3,6-trimethyl-betaCD (Trimeb) and randomly methylated-betaCD (Rameb), as well as the new derivative Crysmeb), hydroxypropylated derivatives (HPbetaCD of different substitution degrees and HPgammaCD) and the sulfobutylated derivative (SBEbetaCD) on the release of a fluorescent marker encapsulated in the inner cavity of liposomes. It was shown that the observed effect on calcein release can be directly related to the affinity of cyclodextrins for both lipid components of liposomes, cholesterol and phosphatidylcholine. From this relationship, we were able to determine, for each cyclodextrin, a theoretical concentration giving rise to 50% or 100% calcein release. This theoretical concentration was confirmed experimentally. We have also showed that cyclodextrins which provoke calcein release also induce large structure modifications of liposomes.

Occurrence of polychlorinated biphenyls and polybrominated diphenyl ethers in belgian human adipose tissue samples.

Levels of polychlorinated biphenyls (PCBs) and polybrominated diphenyl ethers (PBDEs) were measured in 53 human adipose tissue samples. The samples consisted of adipose tissue from 31 men and 22 women having a mean age of 53 years. No information about diet or occupational exposure was collected. Cleanup was performed using a glass column containing acidified silica, deactivated alumina, and anhydrous sodium sulphate. Subsequently, samples were analyzed by high-resolution gas chromatography/tandem mass spectrometry. PBDE concentrations (sum of BDEs 28, 47, 99, 100, 154, 153, and 183) ranged between 1.23 and 57.2 ng g(-1) lipid weight and were comparable with levels in samples from other European countries. The sum of seven International Council for the Exploration of the Sea (ICES) indicator PCB congeners (PCBs 28, 52, 101, 118, 138, 153, and 180) ranged from 126 to 2090 ng g(-1) lipid weight. No age dependency was found for PBDEs (Pearson correlation -0.023, p = 0.873), whereas PCBs showed higher correlation coefficients with age (Pearson correlation 0.613, p < 0.0005). There was no relationship between PBDE and PCB levels (Pearson correlation -0.010, p = 0.943).

Automated method for the determination of a new matrix metalloproteinase inhibitor in ovine plasma and serum by coupling of restricted access material for on-line sample clean-up to liquid chromatography.

A fully automated liquid chromatographic method was developed for the determination of Ro 28-2653, a new synthetic inhibitor of matrix metalloproteinases (MMPs), in ovine serum and plasma. The method was based on the coupling of a pre-column packed with restricted access material, namely LiChrospher RP-8 ADS (alkyl diol silica), for sample clean-up to an analytical column containing octyl silica stationary phase. One hundred microl of biological sample, to which 2-propanol was automatically added, were injected onto the ADS pre-column, which was then washed with a washing liquid consisting of a mixture of 25 mM phosphate buffer (pH 7.0) and acetonitrile (90:10; v/v) for 10 min. By rotation of the switching valve, the analyte was then eluted in the back-flush mode with the LC mobile phase composed of a mixture of acetonitrile and 25 mM phosphate buffer (pH 7.0) (57:43; v/v). The UV detection was performed at 395 nm. The main parameters likely to influence the sample preparation technique were investigated. The method was then validated over a concentration range from 17.5 to 1950 ng/ml, the first concentration level corresponding to the lower limit of quantitation. At this concentration level, the mean bias and the R.S.D. value for intermediate precision were -2.4% and 4.2%, respectively.

Monitoring of polychlorinated biphenyls in Belgian human adipose tissue samples.

Polychlorinated biphenyls (PCBs) were monitored in Belgian human adipose tissue samples from deceased individuals (n=100). Their mean age was 52, ranging from 2 to 91 years. There were 57 men and 43 women. Other known variables were date of autopsy and place of residence. No information about diet or occupation was available. The seven marker congeners PCB 28, 52, 101, 118, 138, 153 and 180 were analysed in the samples with a GC-MS/MS method validated according to Commission Decision 2002/657/EC. Extracted fat was cleaned-up over a glass column filled with n-hexane, acid silica, deactivated alumina and anhydrous sodium sulfate. The whole procedure was subjected to a rigorous quality control programme with retention times, ion chromatograms and intensity ratios of the monitored product ions as identification criteria. The total PCB concentration ranged between 10 and 1640 ng g-1 fat, with a mean value of 658 ng g-1 fat. In the age groups of 0-9 (n=1), 10-19 (n=4), 20-29 (n=11), 30-39 (n=13), 40-49 (n=15), 50-59 (n=14), 60-69 (n=14), 70-79 (n=20), 80-89 (n=6) and 90-99 (n=2), the mean total PCB concentrations were 10, 134, 253, 445, 557, 687, 807, 962, 959, and 1191 ng g-1 fat, respectively. So, there was an increase of PCB body burden with age. For the male subjects (n=57; mean age of 53) the mean total PCB concentration was 633 ng g-1 fat. For the female subjects (n=43; mean age of 52) it was 690 ng g-1 fat. There was no significant sex-related difference in the concentrations of marker PCBs.

Fatality due to combined use of the designer drugs MDMA and PMA: a distribution study.

We present a fatal case involving the combined ingestion of amphetamine, 3,4-methylenedioxymethylamphetamine, 3,4-methylenedioxyamphetamine, and paramethoxyamphetamine. Various postmortem specimens (e.g., several blood samples, urine, and tissue samples) were analyzed to study the distribution of the compounds and their metabolites in the human body. Quantitation took place using liquid chromatography-sonic spray ionization-mass spectrometry after pretreatment with a liquid-liquid extraction. The medico-legal findings were compatible with a disseminated intravascular coagulation induced by hyperthermia caused by the simultaneous intake of the amphetamine analogues.

Analysis of flecainide and two metabolites in biological specimens by HPLC: application to a fatal intoxication.

A few days after her admittance to a hospital for a suicide attempt with benzodiazepines, a 15-year-old girl was found dead in bed. At autopsy, no specific anatomo-pathologic cause of death was identified. Systematic toxicological analysis (HPLC-DAD, GC-NPD, and GC-MS) of postmortem blood and urine revealed the presence of high concentrations of flecainide and its two major metabolites. Flecainide is a class IC anti-arrhythmic drug causing a decreased intracardiac conduction velocity in all parts of the heart. To identify and quantitate flecainide together with its metabolites in blood, urine, and other toxicologically relevant matrices, a new method was developed using high-performance liquid chromatography with diode-array detection. All compounds were separated on a Hypersil BDS phenyl column using water, methanol, and 1.5M ammonium acetate in a gradient system. Chromatographic analysis was preceded by an optimized solid-phase extraction procedure on RP-C18 extraction columns. The flecainide concentrations in blood and urine were 18.73 and 28.3 mg/L, respectively, and the metabolites were detected only in urine at the following concentrations: 9.4 mg/L for meta-O-dealkylated flecainide and 8.59 mg/L for meta-O-dealkylated flecainide lactam. Based on these results, it was concluded that the suicide was consistent with an overdose of this anti-arrhythmic drug.

An unusual case of homicide by use of repeated administration of organophosphate insecticides.

We present an unusual murder case by use of repeated administration of organophosphate insecticides. A 49-year-old woman suffering from mental retardation, epileptic fits and acromegaly was poisoned by her husband. At first, her death was considered as a 'sudden and unexpected' natural death. Abdominal abscesses of pancreatic origin found at autopsy were compatible with repeated administration of pesticides with anticholinergic action. In her medical history at least one episode consistent with an organophosphate intoxication was retrieved. Thorough inquiry revealed that the victim had ingested phosphamidon and/or omethoate orally. Organophosphate intoxication should be considered when unexplained neurological symptoms are associated with pancreatic disturbances.

One fatal and seven non-fatal cases of 4-methylthioamphetamine (4-MTA) intoxication: clinico-pathological findings.

We present a case history involving one fatal and seven survived cases of intoxication with 4-methylthioamphetamine (4-MTA), also called para-methylthioamphetamine (p-MTA) or methylthioamphetamine (MTA), a relatively new amphetamine analogue. Two of the seven survivors required a 24-h-period of observation in hospital. This report proves once again that the new amphetamine designer drugs are not without danger, as is thought by many young people. In addition, individually different subjective reactions are described. Finally, the medico-legal implications of new, as yet unregistered drugs are discussed.

An unusual case of suicide by means of a pneumatic hammer.

We describe an extraordinary case of a 49-year-old man who committed suicide by using a pneumatic hammer. As an industrial accident was initially assumed, difficulties in determining the manner of death are discussed. In addition, the ability to perform activity and evidence of a protracted agony in a situation of extensive cerebral destruction are considered. To our knowledge, no such case of suicide has ever been reported.

Fatal 4-MTA intoxication: development of a liquid chromatographic-tandem mass spectrometric assay for multiple matrices.

The case history and toxicological findings of an overdose fatality involving 4-methylthioamphetamine (4-MTA) and 3,4-methylenedioxymethamphetamine (MDMA) are reported along with a description of the analytical method. Detection and quantitation of 4-MTA and MDMA were performed by liquid chromatography-tandem mass spectrometry using phentermine as internal standard. Application of this technique to a variety of matrices allowed an insight in the distribution of 4-MTA. Several blood samples including femoral vein blood (5.23 mg/L), urine (95.5 mg/L), vitreous humor (1.31 mg/L), bile (36.4 mg/L), and numerous tissue samples such as liver (30.8 mg/kg), spleen (4.10 mg/kg), and frontal lobe (31.7 mg/kg) were assayed. These values indicated that 4-MTA could be identified as the cause of this fatality, whereas the concentrations of MDMA, also described, are less important because the concentrations found are lower. This case reports, for the first time, an extensive toxicological analysis of 4-MTA, by which the data presented may shed some light on the distribution of 4-MTA.

Medico-legal implications of hidden thyroid dysfunction: a study of two cases.

In this paper we present two cases in which thyroid disorders were unexpectedly brought to view. The question we ponder is whether hidden thyroid dysfunction may be important in the cause, mechanism and manner of death, or just an incidental discovery during the post-mortem examination. A short literature review has been conducted in order to evaluate previously reported cases of thyroid pathology and sudden death. The significance of post-mortem evaluation of thyroid hormones (T3 and T4) will be considered briefly.

Quantitative determination of paraquat in a fatal intoxication by HPLC-DAD following chemical reduction with sodium borohydride.

A fatality due to a massive ingestion of paraquat is presented. Screening by enzyme-multiplied immunoassay of postmortem blood and urine disclosed the presence of tricyclic antidepressants (in urine only), benzodiazepines, cotinine, and caffeine. Further analysis of blood, urine, and stomach contents with thin-layer chromatography, high-performance liquid chromatography (HPLC), and gas chromatography confirmed the results found in the preliminary routine screening. It also revealed the presence of paraquat in blood, urine, and stomach contents, of diethyl parathion in urine and stomach contents, and of mevinphos in blood and stomach contents. Quantitation of paraquat was performed using HPLC with diode-array detection. Sample preparation involved a protein-precipitation step using trichloroacetic acid (necessary only for blood and tissue homogenate), followed by a chemical reduction with sodium borohydride of the fully ionized paraquat to a diene, which is amenable to solvent extraction. Quantitative results were obtained for all postmortem matrices available: blood, 5.05 mg/L; urine, 6.00 mg/l; stomach contents, 17.2 g/L; liver, 4.86 mg/kg; and kidney, 80.6 mg/kg. The paraquat distribution in this case is compared with analytical findings reported in the literature. As would be expected, concentrations found in fatal paraquat intoxications display large differences. The data presented illustrate the outspoken lethal nature of the herbicide paraquat and the ongoing appearance of this compound in deadly accidental and suicidal poisonings.

Is vitreous humour useful for the interpretation of 3,4-methylenedioxymethamphetamine (MDMA) blood levels? Experimental approach with rabbits.

As drug instability and redistribution are factors known to affect the interpretation of post-mortem blood levels, we questioned whether post-mortem vitreous humour concentrations could be useful as predictors for the MDMA load at the time of death. In a first series of in vivo experiments using rabbits, 3,4-methylenedioxymethamphetamine (MDMA) concentrations in plasma, blood and vitreous humour were studied as a function of time after intravenous (i.v.) administration of MDMA. Equilibration between the vascular compartment and vitreous humour was attained about 1 h after i.v. MDMA administration. In a second series of experiments, the post-mortem stability of MDMA in vitreous humour in relation to ambient temperature was investigated. Post-mortem MDMA concentrations in vitreous humour were closer to the ante-mortem blood levels when compared to cardiac blood samples. These preliminary investigations in the rabbit model indicate that measurements of vitreous humour concentrations could also be of interest for predicting the blood concentration at the time of death in humans.

Endocardial fibroelastosis as a cause of sudden unexpected death.

We present a case of primary endocardial fibroelastosis (EFE) which had been diagnosed in a 16-year-old girl who died suddenly and unexpectedly. This exceptional cause of death in adolescence led to a short literature review comparing our findings with previous medicolegal reports.

Effects of the antiestrogens tamoxifen, toremifene, and ICI 182,780 on endometrial cancer growth.

BACKGROUND: Tamoxifen has been shown to promote the growth of human endometrial tumors implanted in athymic mice, and it has been associated with a twofold to threefold increase in endometrial cancer. Toremifene, a chlorinated derivative of tamoxifen, and ICI 182,780, a pure antiestrogen, are two new antiestrogens being developed for the treatment of breast cancer. The effects of these drugs on endometrial cancer are currently unknown. Our objective was to evaluate the effects of toremifene and ICI 182,780 on the growth of human endometrial cancer in athymic mice. METHODS: Athymic, ovariectomized mice were implanted with human endometrial tumors and treated with estrogen, tamoxifen, or the new antiestrogens. RESULTS: The effects of tamoxifen and toremifene on the growth of either tamoxifen-stimulated or tamoxifen-naive endometrial tumors in athymic mice were not substantially different. ICI 182,780 inhibited the growth of tamoxifen-stimulated endometrial cancer, in both the presence and the absence of estrogen. CONCLUSIONS: Toremifene and tamoxifen produce identical effects in our endometrial cancer models. Therefore, it is possible that toremifene, like tamoxifen, may be associated with an increased incidence of endometrial cancer. In contrast, ICI 182,780 inhibited tamoxifen-stimulated endometrial cancer, both in the presence and in the absence of estrogen, suggesting that this drug may be safe with regard to the endometrium, even if it is used following tamoxifen, and that it may not result in an increased incidence of endometrial cancer. Indeed, it is even possible that ICI 182,780 may prove useful as an adjuvant agent in early stage endometrial cancer.