Christine Bartsch

Lethal Carbon Monoxide Poisoning in Wood Pellet Storerooms—Two Cases and a Review of the Literature

The installation of wood pellet heating as a cost-effective and climatically neutral source of energy for private households has increased steadily in recent years. We report two deaths that occurred within the space of about a year in wood pellet storerooms of private households in German-speaking countries and were investigated by forensic medical teams. This is the first report of fatalities in this special context as is shown in the literature review. Both victims died of carbon monoxide (CO) poisoning; one of the victims was a woman who was 4 months pregnant. Measurements at the scene detected life-threatening CO concentrations (7500 ppm, >500 ppm), which were not significantly reduced after ventilation of the storerooms as required by regulations. We carried out a series of experiments in order to confirm CO production by wood pellets. Thirty kilograms of freshly produced pellets from two different manufacturers were stored for 16 days in airtight containers at 26°C with different relative humidities. CO concentrations between 3100 and 4700 ppm were measured in all containers. There were no notable differences between the wood pellet products or storage at different humidities. Emission of CO from wood pellets has already been described, but fatal accidents have previously been reported only in association with pellet transport on cargo ships or storage in silos. It is therefore a new finding that fatal accidents may also occur in the wood pellet storerooms of private households. We show that significant CO concentrations can build up even when these rooms are ventilated in accordance with the regulations and that such levels may cause the death of healthy persons, as described in the following. As the safety recommendations from the wood pellet industry are inadequate, we consider that further fatal accidents are likely to occur and recommend urgent revision of the safety regulations.

Suicide tourism: a pilot study on the Swiss phenomenon

While assisted suicide (AS) is strictly restricted in many countries, it is not clearly regulated by law in Switzerland. This imbalance leads to an influx of people—‘suicide tourists’—coming to Switzerland, mainly to the Canton of Zurich, for the sole purpose of committing suicide. Political debate regarding ‘suicide tourism’ is taking place in many countries. Swiss medicolegal experts are confronted with these cases almost daily, which prompted our scientific investigation of the phenomenon. The present study has three aims: (1) to determine selected details about AS in the study group (age, gender and country of residence of the suicide tourists, the organisation involved, the ingested substance leading to death and any diseases that were the main reason for AS); (2) to find out the countries from which suicide tourists come and to review existing laws in the top three in order to test the hypothesis that suicide tourism leads to the amendment of existing regulations in foreign countries; and (3) to compare our results with those of earlier studies in Zurich. We did a retrospective data analysis of the Zurich Institute of Legal Medicine database on AS of non-Swiss residents in the last 5 years (2008–2012), and internet research for current legislation and political debate in the three foreign countries most concerned. We analysed 611 cases from 31 countries all over the world. Non-terminal conditions such as neurological and rheumatic diseases are increasing among suicide tourists. The unique phenomenon of suicide tourism in Switzerland may indeed result in the amendment or supplementary guidelines to existing regulations in foreign countries.

No association of serotonin transporter gene variation with sudden infant death syndrome (SIDS) in Caucasians

Genetic studies on SIDS have been motivated by clinical, epidemiological, and/or neuropathological observations made of SIDS victims. One of the candidate genes is the serotonin transporter (5-HTT) gene, based on decreased serotonergic receptor binding observed in the brain-stems of SIDS victims. Two polymorphisms in the regulatory region of the 5-HTT gene differentially modulate gene expression (promoter, intron 2). The promoter allelic variants long (L) and extra long (XL) and the intron 2 12-repeat allele seem to be associated with SIDS; however, the 5-HTT promoter allele distribution varies widely by ethnicity. We investigated the DNA of 145 Caucasian SIDS cases and 58 controls and could find no significant association between our Caucasian SIDS cases and controls either for the promoter L allele and the intron 2 12-repeat allele, or for the combined L-12 haplotype as well as the L- or 12-containing genotypes.

Minimally invasive, imaging guided virtual autopsy compared to conventional autopsy in foetal, newborn and infant cases: study protocol for the paediatric virtual autopsy trial.

BackgroundIn light of declining autopsy rates around the world, post-mortem MR imaging is a promising alternative to conventional autopsy in the investigation of infant death. A major drawback of this non-invasive autopsy approach is the fact that histopathological and microbiological examination of the tissue is not possible. The objective of this prospective study is to compare the performance of minimally invasive, virtual autopsy, including CT-guided biopsy, with conventional autopsy procedures in a paediatric population.Methods/DesignFoetuses, newborns and infants that are referred for autopsy at three different institutions associated with the University of Zurich will be eligible for recruitment. All bodies will be examined with a commercial CT and a 3 Tesla MRI scanner, masked to the results of conventional autopsy. After cross-sectional imaging, CT-guided tissue sampling will be performed by a multifunctional robotic system (Virtobot) allowing for automated post-mortem biopsies. Virtual autopsy results will be classified with regards to the likely final diagnosis and major pathological findings and compared to the results of conventional autopsy, which remains the diagnostic gold standard.DiscussionThere is an urgent need for the development of alternative post-mortem examination methods, not only as a counselling tool for families and as a quality control measure for clinical diagnosis and treatment but also as an instrument to advance medical knowledge and clinical practice. This interdisciplinary study will determine whether virtual autopsy will narrow the gap in information between non-invasive and traditional autopsy procedures.Trial RegistrationClinicalTrials.gov: NCT01888380

Self-burning – A rare suicide method in Switzerland and other industrialised nations – A review

News items reporting self-immolation by Tibetans have been on the increase in recent years. After examining the corpse of a Swiss man who had committed suicide by deliberate self-burning, we wondered how often this occurs in Switzerland. The Federal Statistics Office (FSO) does not register self-burning specifically so no official national data on this form of suicide are available. However, we had access to the data from a Swiss National Science Foundation (SNSF) project Suicides in Switzerland between 2000 and 2010, which collected information on all (4885) cases of suicide investigated by the various institutes of forensic medicine. From this data pool we extracted 50 cases (1.02%) of suicide by self-burning, in order to determine the details and to identify the possible reasons for choosing this method. To look at our results in the light of studies from other countries, we searched the literature for studies that had also retrospectively examined suicide by self-immolation based on forensic records. Our results showed that, on the whole, personal aspects of self-burning in Switzerland do not differ from those in other industrialised nations. Some data, including religious and sociocultural background, were unfortunately missing - not only from our study but also from the similar ones. In our opinion, the most important prevention strategy is to make healthcare professionals more aware of this rare method of suicide.

Chances and limits of method restriction: a detailed analysis of suicide methods in Switzerland

The objective of this study was to estimate the potential of method restriction as a public health strategy in suicide prevention. Data from the Swiss Federal Statistical Office and the Swiss Institutes of Forensic Medicine from 2004 were gathered and categorized into suicide submethods according to accessibility to restriction of means. Of suicides in Switzerland, 39.2% are accessible to method restriction. The highest proportions were found in private weapons (13.2%), army weapons (10.4%), and jumps from hot-spots (4.6%). The presented method permits the estimation of the suicide prevention potential of a country by method restriction and the comparison of restriction potentials between suicide methods. In Switzerland, reduction of firearm suicides has the highest potential to reduce the total number of suicides.

Erratum to: Post-mortem whole-exome sequencing (WES) with a focus on cardiac disease-associated genes in five young sudden unexplained death (SUD) cases

The original version of this article contained an error.

Investigation of pacemaker position, lead configuration, and sensitivity setting in pacemakers of 579 deceased patients.

AIMS The position of the pacemaker (PM) system (right or left-sided, pectoral, or abdominal), the ventricular lead configuration (unipolar or bipolar), the programmed ventricular sensitivity setting (SS), and the ventricular sensitivity of the pulse generator (PG) against electromagnetic interference (EMI) are decisive parameters with respect to EMI behaviour of PGs. Three of these ventricular parameters were investigated in PM of 579 deceased patients. MATERIAL AND METHODS We investigated PM function provided a regular stimulation pattern in 878 deceased PM patients before cremation. The PG was explanted and then measured in a bench test in the laboratory with respect to the programmed parameters. Further investigations were restricted to 579 patients with PGs implanted between 1998 and 2004. The following parameters were evaluated: (i) position of the PG, (ii) lead configuration, and (iii) programmed SS of the ventricular channel. SS was measured according to the European Pacemaker Standards. Out of 579 patients, 556 PMs were implanted pectorally, with 172 on the left side (30.9%) and 384 on the right side (69.1%). In 23 cases, the implantation site was unknown. Out of 579 PMs, 282 ventricular leads were unipolar (48.7%). Of the 297 bipolar leads (51.3%), 61 (20.5%) had a unipolar sensing function so that a total majority of 343 PM (59.2%) had unipolar sensing. The mean value of SS was 3.24 mV (range: 1.2-8.1 mV) for unipolar leads and 3.55 mV (range: 1.05-10.9 mV) for bipolar ones. The PGs with unipolarized bipolar leads were even more sensitive at 3.0 mV. Of the 579 PM systems, 0.67% possessed a combination of parameters: left side, unipolar and with SS < 2 mV. CONCLUSIONS The results seemed to be paradoxical in that unipolar sensitivity was more sensitive than bipolar sensitivity. Less than 0.67% of patients possessed a worst case PM system with respect to EMI: a unipolar, left-sided PG with a ventricular SS < 2 mV. This implies that ∼2345 PM patients in Germany could be at risk. Out of the 61 PGs with unipolarized bipolar leads, 14 had never been programmed as they still possessed the shipping programming. Unipolar leads can be used with left-side implantation if the SS is 3 mV (median value of all leads in our study) or higher. This would largely improve the immunity of PGs to EMI in the future. This study also demonstrates that there is a need for educational measures.

Why We Need Postmortem Analysis of Cardiac Implantable Electronic Devices.

The prevalence of cardiac implantable electronic devices (CIEDs), pacemakers and implantable cardioverter defibrillators (ICDs) is increasing. However, postmortem analysis of CIEDs is not performed routinely. Fourteen consecutive CIEDs were analyzed. The indication for and date of implantation, technical data, CIED reprogramming, heart rhythm disturbances, patient demographics and medical consultations were investigated. Death during the first year after implantation was seen in 54%, whereof 71% consulted a physician within 10 days before death. The time of death was attributed to a particular day in 29%. There was a relationship between CIEDs and cause/manner of death in 50%. Although limited by a small sample size, this study advocates the routine postmortem CIED analysis for forensic and clinical purposes in selected cases. Patients with CIEDs seem to show an increased risk of death during the first year after implantation. The analysis of CIEDs can be helpful in evaluating the time/cause/manner of death.

Road traffic suicide in Switzerland

Objective: To determine details of road traffic suicides in Switzerland between 2000 and 2010 and to look at our results in relation to studies from other countries. Methods: Retrospective data analysis of road traffic suicides extracted from the database of all suicides investigated by Swiss institutes of forensic medicine between 2000 and 2010 using a standardized assessment sheet. Results: Out of 4,885 suicides in Switzerland, we identified 76 cases (1.56%) of road traffic suicide. Twenty-three cases had to be excluded because, although the forensic medical experts suspected suicide, they could not establish it for sure. That left 53 cases (1.02% of all suicides), mostly unmarried men, who were on average 9 years younger than the study population as a whole. Most collided with other vehicles, mainly other cars, and usually on main highways or country roads. In most cases, the cause of death was multiple injuries. Other persons were killed 4 times more often than with other suicide methods. Toxicology screening was performed significantly more frequently than with other methods but more often proved negative. Acute psychiatric problems were commonly assumed to be the underlying reasons. Suicide notes were left by only 20%, a lower proportion than in the study population as a whole. Conclusions: Road traffic suicides account for approximately 1% of all suicide methods used in Switzerland, although unclassifiable cases indicate that the rate might be higher. Every road traffic crash should therefore be routinely investigated by an interdisciplinary team and suicide should be considered as the possible cause.