Brita Teige

Fatal poisoning in drug addicts in the Nordic countries in 2007

The frequency of medico-legally examined fatal poisonings in 2007 among drug addicts was investigated in five Nordic countries; Denmark, Finland, Iceland, Norway, and Sweden. The number of deaths, age, sex, place of death, main intoxicant, and other drugs present in blood samples were recorded to obtain national and comparable Nordic data, as well as data to compare with earlier studies in 2002, 1997, and 1991. Norway had the highest incidence of drug addict deaths by poisoning followed by Denmark, with 8.24 and 6.92 per 100,000 inhabitants, respectively. The death rates in Finland (4.02), Iceland (4.56), and Sweden (3.53) were about half that of Norway and Denmark. Compared with earlier studies, the death rates were unchanged in Denmark and Norway, but increased in Finland, Iceland, and Sweden. In all countries, fewer deaths (29-35%) were recorded in the capital area compared with earlier studies. Females accounted for 11-19% of the fatal poisonings. Iceland deviates with a more equal distribution between men and women (40%). Deaths from methadone overdoses increased in all Nordic countries, and methadone was the main intoxicant in Denmark in 2007, accounting for 51% of the poisonings. In Norway and Sweden, heroin/morphine was still the main intoxicant with a frequency of 68% and 48%, respectively. In Iceland, 3 deaths each were due to heroin/morphine and methadone, respectively. Finland differs from other Nordic countries in having a high number of poisonings caused by buprenorphine and very few caused by heroin/morphine. The total number of buprenorphine deaths in Finland doubled from 16 in 2002 to 32 in 2007, where it constituted 25% of deaths. The general toxicological screening program showed widespread multi-drug use in all countries. The median number of drugs per case varied from 3 to 5. The most frequently detected substances were heroin/morphine, methadone, buprenorphine, tramadol, amphetamine, cocaine, tetrahydrocannabinol, benzodiazepines and ethanol.

Fatal poisonings in Oslo: a one-year observational study

BackgroundAcute poisonings are common and are treated at different levels of the health care system. Since most fatal poisonings occur outside hospital, these must be included when studying characteristics of such deaths. The pattern of toxic agents differs between fatal and non-fatal poisonings. By including all poisoning episodes, cause-fatality rates can be calculated.MethodsFatal and non-fatal acute poisonings in subjects aged ≥16 years in Oslo (428 198 inhabitants) were included consecutively in an observational multi-centre study including the ambulance services, the Oslo Emergency Ward (outpatient clinic), and hospitals, as well as medico-legal autopsies from 1st April 2003 to 31st March 2004. Characteristics of fatal poisonings were examined, and a comparison of toxic agents was made between fatal and non-fatal acute poisoning.ResultsIn Oslo, during the one-year period studied, 103 subjects aged ≥16 years died of acute poisoning. The annual mortality rate was 24 per 100 000. The male-female ratio was 2:1, and the mean age was 44 years (range 19-86 years). In 92 cases (89%), death occurred outside hospital. The main toxic agents were opiates or opioids (65% of cases), followed by ethanol (9%), tricyclic anti-depressants (TCAs) (4%), benzodiazepines (4%), and zopiclone (4%). Seventy-one (69%) were evaluated as accidental deaths and 32 (31%) as suicides. In 70% of all cases, and in 34% of suicides, the deceased was classified as drug or alcohol dependent. When compared with the 2981 non-fatal acute poisonings registered during the study period, the case fatality rate was 3% (95% C.I., 0.03-0.04). Methanol, TCAs, and antihistamines had the highest case fatality rates; 33% (95% C.I., 0.008-0.91), 14% (95% C.I., 0.04-0.33), and 10% (95% C.I., 0.02-0.27), respectively.ConclusionsThree per cent of all acute poisonings were fatal, and nine out of ten deaths by acute poisonings occurred outside hospital. Two-thirds were evaluated as accidental deaths. Although case fatality rates were highest for methanol, TCAs, and antihistamines, most deaths were caused by opiates or opioids.

Drug-related deaths during the 1980s. A comparative study of drug addict deaths examined at the institutes of forensic medicine in Aarhus, Denmark and Oslo, Norway

SummaryCases of fatal poisoning among drug addicts examined at the institutes of forensic medicine in Aarhus, Denmark (n = 238) and Oslo, Norway (n = 263) are compared and discussed on the basis of the availability of illicit and medical drugs during the 1980s. The annual number of deaths among drug addicts in age groups over 30 years increased, but there was no increase in the number of deaths among younger drug addicts in either country. More than 80% of the drug addicts in both samples were men. Heroin-/morphine-related deaths comprised three-quarters of the Norwegian material compared with one-third of the Danish material. The registered medical drugs propoxyphene, methadone and ketobemidone accounted for half of the Danish cases but only a small number of the Norwegian cases. Amphetamine caused few deaths in either country. Alcohol and benzodiazepines were present in more than one-third of the cases in both countries, indicating frequent use of these substances.ZusammenfassungTödliche Vergiftungen Drogenabhängiger, untersucht in den Instituten für Forensische Medizin in Aarhus, Dänemark (n = 238) und Oslo, Norwegen (n = 263) werden verglichen und vor dem Hintergrund der Verfügbarkeit illegaler Drogen und mißbräuchlich verwendeter Arzneistoffe während der 80er Jahre diskutiert. Die jährliche Zahl von Todesfällen unter jungen Drogenabhängigen in den Altersklassen über 30 Jahren nahm zu, aber es gab in keinem der beiden Länder eine Zunahme der Zahl der Todesfälle unter jungen Drogenabhängigen. Mehr als 80% der Drogenabhängigen in beiden Kollektiven waren Männer. Heroin- und morphinbezogene Todesfälle machen Dreiviertel des norwegischen Materials aus, verglichen mit einem Drittel des dänischen Materials. Die dort rezeptpflichtigen Medikamente Dextropropoxyphen, Methadon und Ketobemidon standen für die Hälfte der dänischen Fälle, aber nur für eine kleine Zahl der norwegischen Fälle. Amphetamin verursachte wenige Todesfälle in jedem der beiden Länder. Alkohol und Benzodiazepine waren in mehr als einem Drittel der Fälle in beiden Ländern vorhanden. Dies weist auf einen häufigen Gebrauch dieser Substanzen hin.

Subtyping of haptoglobin — Presentation of a new method

SummaryA method is described for large scale routine phenotyping of haptoglobin (Hp) which allows complete subtyping without prior purification of the Hp molecule. The procedure includes polyacrylamide gel isoelectric focusing of reduced, neuraminidase treated serum or plasma samples, and nitrocellulose blots developed with the immunoperoxidase technique. Different variables including sample treatment, electrofocusing, blotting procedures, and immunoperoxidase visualization are discussed.Characteristic α-chain patterns allow identification of the common allotypes 2FS, 2SS, 2FF, IS, IF, and Johnson. Isoelectric variations in the β-chain may also be recognized. For comparison, two-dimensional Hp-patterns are presented. The results from concurrent typing of 600 samples by ordinary starch gel electrophoresis and by the described isofocusing technique, are evaluated.

A one-year observational study of all hospitalized and fatal acute poisonings in Oslo: Epidemiology, intention and follow-up

BackgroundUp to date information on poisoning trends is important. This study reports the epidemiology of all hospitalized acute poisonings in Oslo, including mortality, follow-up referrals, and whether the introduction of over-the-counter sales of paracetamol outside pharmacies had an impact on the frequency of poisonings.MethodsAll acute poisonings of adults (≥16 years) treated at the five hospitals in Oslo from April 2008 to April 2009 were included consecutively in an observational cross-sectional multicentre study. A standardized form was completed by the treating physician, which covered the study aims. All deaths by poisoning in and outside hospitals were registered at the Institute of Forensic Medicine.ResultsThere were 1065 hospital admissions of 912 individuals; 460 (50%) were male, and the median age was 36 years. The annual incidence was 2.0 per 1000. The most frequent toxic agents were ethanol (18%), benzodiazepines (15%), paracetamol (11%), and opioids (11%). Physicians classified 46% as possible or definite suicide attempts, 37% as accidental overdoses with substances of abuse (AOSA), and 16% as other accidents. Twenty-four per cent were discharged without any follow-up and the no follow-up odds were highest for AOSA. There were 117 deaths (eight in hospital), of which 75% were males, and the median age was 41 years. Thus, the annual mortality rate was 25 per 100 000 and the in-hospital mortality was 0.8%. Opioids were the most frequent cause of death.ConclusionsThe incidence of hospitalized acute poisonings in Oslo was similar to that in 2003 and there was an equal sex distribution. Compared with a study performed in Oslo in 2003, there has been an increase in poisonings with a suicidal intention. The in-hospital mortality was low and nine out of ten deaths occurred outside hospitals. Opioids were the leading cause of death, so preventive measures should be encouraged among substance abusers. The number of poisonings caused by paracetamol remained unchanged after the introduction of over-the-counter sales outside pharmacies and there were no deaths, so over-the-counter sales may be considered safe.

Carboxyhemoglobin concentrations in fire victims and in cases of fatal carbon monoxide poisoning.

SummaryThe study comprises an eleven-year autopsy material of 141 cases from the Institute of Forensic Medicine, Oslo.The fatal level of carboxyhemoglobin concentration is calculate from cases of pure carbon monoxide poisoming. Carboxyhemoglobin concentrations below this level are found in approximately thirty percent of the fire victims. Alcohol intoxication, present in many fire victims, is not related to low corboxyhemoglobin concentrations.ZusammenfassungUntersucht wurden 141 Fälle während einer 11-jährigen Zeitspanne am Instit. f. gerichtl. Med., Oslo. Die tödliche CO-Hb Konzentration wurde von Fällen seiner CO-Vergiftung abgeleitet. CO-Hb Konzentrationen unter diesem Wert wurden in ungefähr 30 % von Brandleichen gefunden. Alkoholisierung scheint keinen Einfluß auf die niedrigere CO-Hb Konzentration zu haben.

Haptoglobin subtypes in Norway and a review of HP subtypes in various populations

Isofocusing and immunoblotting of reduced serum samples identify the common haptoglobin alpha-chain variants 1S, 1F, 2FS, 2SS, 2FF, 3, as well as several rare alpha- and beta-chain variants. The gene frequencies found in 6,668 unrelated persons involved in Norwegian paternity cases were: HP*1S: 0.22, HP*1F: 0.16, HP*2FS: 0.58, HP*2SS: 0.04, HP*2FF: 0.004, HP*3: 0.0004, other HP* alpha variants: 0.0004, HP* beta variants: 0.0008. The corresponding gene frequencies in 153 unrelated Norwegian Saamis (Lapps) were: HP*1S: 0.19, HP*1F: 0.07, HP*2FS: 0.70, HP*2SS: 0.04. Norwegians and Norwegian Saamis differed both in phenotype and allele distribution. An earlier Norwegian population study has shown a lower HP*1 frequency in the north than in the south. This regional difference in haptoglobin gene distribution was reflected in the present material as a lower 1F frequency, indicating a Saamish influence in northern Norway. Furthermore, the relatively low 2FF frequency in the north coincides with the lack of observed 2FF genes in the Saamish population. Non-Scandinavians involved in Norwegian paternity cases did not differ from the rest of the material. A review of published haptoglobin gene frequencies shows the 1F frequency to be a good indicator of ethnic origin, and that 2FF and 2SS frequency determinations may also be valuable in genetic population studies.

Determination of glucose in human vitreous humor. Various analytical methods give different results.

SummaryIn twenty cases, human vitreous humor glucose concentrations were measured with five different methods in common use. Striking differences in glucose values were obtained by the various analytical procedures. The reasons for these discrepancies remain obscure. Before interpretation of a given vitreous value, therefore, the analytical method employed must be known.ZusammenfassungIn Glaskörper-Flüssigkeit wurde die Glucose-Konzentration mit fünf verschiedenen Methoden, die im allgemeinen Gebrauch sind, in zwanzig Fällen bestimmt. Es wurden hierbei erhebliche Differenzen in den Glucose-Werten mit den verschiedenen Analysenmethoden erhalten, wobei die Ursachen für die Diskrepanzen unklar sind. Bei der Beurteilung von Glucose Konzentrationen im Glaskörper muß daher die angewandte Bestimmungsmethode berücksichtigt werden.

Fatal combined intoxication with new antidepressants. Human cases and an experimental study of postmortem moclobemide redistribution

Three cases are presented in which death was caused by suicidal intoxication with moclobemide in combination with a selective serotonin reuptake inhibitor. Both antidepressant drug types are considered to be relatively safe with regard to lethal overdose. However, the combination may cause the serotonin syndrome, a condition with a high mortality rate. In one of the cases, there was clinical information consistent with the serotonin syndrome, in the two other cases, there was no information of the clinical course. Postmortem redistribution of the selective monoamine oxidase inhibitor moclobemide was investigated in a rat model. Postmortem concentrations in blood from the vena cava and the heart were found to be in good accordance with antemortem concentrations. Postmortem concentrations in vitreous humour and various tissues were also measured. The apparent volume of distribution was calculated to be 0.95 +/- 0.10 l/kg, which is in the same range as that reported in man.

A comparison of drug-related deaths in Oslo, Norway and Aarhus, Denmark

Abstract A comparative survey was carried out of cases of acute fatal poisoning examined at the Institutes of Forensic Medicine in Oslo, Norway and in Aarhus, Denmark from 1981 to 1985. In both populations, two-thirds of the deaths were caused by drugs, and ethanol was detected in approximately half of these cases. Antidepressive and neuroleptic drugs predominated in the cases from Oslo, while poisoning with dextropropoxyphene was the most common cause of death in the cases from Aarhus. Barbiturates overdose was seen more frequently in cases investigated in Aarhus than in Oslo, but in both countries intoxication with these drugs declined during the period surveyed. The number of cases in which the deceased had been a drug addict was similar in the two countries. The cause of death among Norwegian addicts was mainly heroin/morphine, while most of the Danish drug addicts died from an overdose of a legally approved drug.