Mustafa Karapirli

Forensic and clinical carbon monoxide (CO) poisonings in Turkey: A detailed analysis

Carbon monoxide (CO) is produced by incomplete combustion of organic compounds. Its intoxication usually results from inhalation of fumes from improper heating stoves, motor vehicles, or smoke from fires. It can reversibly bind various heme-containing proteins such as hemoglobin, myoglobin, cytochrome p450 and cytochrome oxidases. Among them, it has a high affinity for hemoglobin (230-270 times more avidly than oxygen) with which it forms carboxy-hemoglobin (HbCO) leading to decrease in oxygen-carrying capacity followed by end-organ hypoxia. A tissue hypoxia may then result in transient or permanent damage of important organs like central nervous system and even death. CO poisonings from different reasons are an important cause of morbidity and mortality in Turkey. The purpose of this study on CO poisonings in Turkey is to sum up and analyze the best available researches in both forensic and clinical toxicology fields. This was achieved by synthesizing the results of Turkish and English papers on forensic and clinical CO poisoning cases conducted in universities, institutes, hospitals and other official or private organizations in Turkey. Total of 47,523 medico-legal autopsy data collected from 9 different forensic medicine branches and emergency rooms in different year intervals were reviewed and 980 CO poisoning cases were determined. To calculate the frequency of CO poisoning within all the autopsies carried out and fatal poisoning cases, the number of cases was divided by the total number of medico-legal autopsies and total fatal poisoning cases. The mean age of cases, the source of CO gas, the most common seasons and months, gender, and blood HbCO levels were also taken into consideration if the data is available. Under the light of the findings, we may suggest that determination of affecting factors in CO poisoning is going to be one of the key subjects for planning preventive interventions.

The review of autopsy cases of accidental childhood deaths in Istanbul

Children are at increased risk for various causes of injury from accidents. Accidents are, by far, the leading cause of death among children and adolescents. The aim of this study is to evaluate the lethal childhood accidents in İstanbul by age groups. Reports of autopsies performed between 2001 and 2005 in the Morgue Department of the Council of Forensic. Medicine in Istanbul (n :16853) are examined retrospectively. 833 deaths from accidents in children aged 0-18 years are investigated into the study. The parameters of age, gender, types of accidents and causes of death are evaluated. The accidents account for 47.3% of the deaths among children aged 0-18 years. Of 833 cases, 601 (73%) are male and 232 (27%) are female. The female to male ratio is 1/2.6. The highest rate of death from accidents is at the group of 15-18 years. The primary causes of accidental childhood deaths are motor vehicle accidents (23.1%), followed by drowning (20,1%), poisoning (15.7%), and fall from height (15.5%). The incidence and types of trauma vary with socio-economic status and culture. İstanbul, where this study is conducted in, has approximately 3000 autopsy number annually. Therefore, it provides an important database.

Comparison of the clinical diagnosis and subsequent autopsy findings in medical malpractice.

The rate of diagnostic error has not declined over the last 30 years despite the improvement in diagnosis methods. Today, the probability to encounter a major diagnostic change in autopsy is still high. The special autopsy that provides clinicians the necessary feedback is performed seldom in our country. This study has been started upon the claim that the malpractice cases in scope of forensic cases could be a very useful database. About 525 cases with faulty medical application that resulted in death have been encountered according to the cases that have been sent to the Forensic Medical Institution, which has been the consultative authority of the Ministry of Justice between the years 2001 and 2005. Among these, 375 cases on which autopsies have been conducted are included in the scope of the study. The cases with and without major diagnostic changes have been compared in aspects of gender, age groups, and period spent in health units. When the concordance between autopsy and clinical diagnosis for the 375 cases that were included in the study is examined, it can be seen that clinical diagnosis is verified with autopsy in 49.1% of the cases whereas neither autopsy nor clinical diagnosis was encountered in 14.7% of them. The diseases where diagnostic faults are mostly encountered are ruptured aortic aneurysm, myocardial infarction and pneumonia. The majority of the cases without a clinical diagnosis comprises of complications that occur after operations. In the study, considerable major diagnostic changes were realized after autopsy, which shows that autopsy has an important place in Turkey in spite of the improved methods of diagnosis. Also, in the cases with major diagnostic changes, the medical malpractice rate was high. This shows that autopsy is influential in revealing medical malpractice failures. In the study, we found out that the number of autopsies was high in the cases with a malpractice claim. We aim to increase this number. We are sure that such increment would increase decision accuracy.

Pesticide poisoning cases in Ankara and nearby cities in Turkey: An 11-year retrospective analysis

Since they are available in open markets and pharmacies, pesticides have been widely used all over the country. (Un)intentional poisoning with these compounds is one of the most common causes of chemical poisoning, especially in rural agricultural areas. Pesticide poisonings reported by various countries showed that it is a worldwide health problem with 250,000-370,000 associated deaths each year. In this study, medico-legal deaths between the years 2001 and 2011 in Ankara and nearby cities in Turkey were investigated retrospectively. The autopsies were partly carried out by Ankara Branch of Council of Forensic Medicine. Data were collected from reports of the Morgue Department whose toxicological analyses were performed in the Chemistry Department. The data revealed that 70 cases out of 10,720 autopsied ones had been attributed to fatal pesticide poisoning. The age range was 1-80 years (mean ± SD, 41.33 ± 17.42 years). Most of the cases (60%) were reported from Ankara. Insecticides were the most common (94%) cause of fatal pesticide poisonings, most of them (63%) being organophosphate insecticides. The percentages of pesticide-induced deaths are quite high in our society and should therefore not be underestimated. Accordingly, intensive efforts to reduce occupational and intentional pesticide poisonings are urgently needed in Ankara and nearby cities.

The Fatal Poisoning Pattern of Ankara (Turkey) and Nearby Cities from 2007 to June 2011: A Retrospective Study in Forensic Autopsies

We aimed to obtain an outline of the nature and number of fatal poisonings which still appear to affect widely the population in Turkey. A total of 5921 forensic autopsies were performed between 2007 and 2011 in Ankara and nearby cities and 366 of them were fatal poisonings (219 male, 147 female). Most of the cases were between 41 and 60 years old (n = 84). Most of the fatalities were reported during winter months (48.1%). Carbon monoxide exposure was the most common reason (66.7%) within all the causes followed by medicine and narcotics (13.9%). Postmortem blood alcohol concentrations in ethyl and methyl alcohol poisonings were 385.1 ± 61.9 and 206.8 ± 138.9 mg/dL, respectively. The most common location of deaths was home (71.3%). Fatal poisonings have been a growing global problem because of some shortcomings about the socioeconomic conditions and increasing illicit drug abuse. The level of education, socioeconomic conditions, and legal approaches are very important for the prevention fatal poisonings.

Carbon monoxide-related deaths in Ankara between 2001 and 2011.

Abstract Objective: The aim of the present study was to describe the epidemiology of unintentional carbon monoxide (CO) poisonings (between 2001 and 2011) in Ankara, Turkey. Methods: Data were collected from the records of Ankara Branch of Council of Forensic Medicine and the licensed official institutes and hospitals for medico-legal autopsies. A total of 10 720 medico-legal autopsy reports were obtained and reviewed by the authors. Results: Among 622 fatal poisoning cases during the period, 380 deaths were due to unintentional CO poisoning. The mean CO saturation of the groups was 55.4 ± 13.4 (% saturation). The minimum and maximum levels of CO in blood was 3.6 and 86.5 (% saturation), respectively. Of all the fatal poisonings determined by Ankara Branch of Council of Forensic Medicine, CO poisoning was the most common mortality cause (61.1%). Among the cases, 301 (79.2%) were found to be death in their houses, 43 (11.3%) in hospitals, 15 (3.9%) in their workplaces and 11 (2.9%) in some public places such as park and garden. Most of the cases were from the capital city of Turkey, Ankara (n = 203, 53.4%). When we compared the cities according to their population, it was realized that the highest death rate due to CO poisoning was in Kirikkale (12.3/100 000), followed by Karabuk (8.3/100 000), Cankiri (7.8/100 000) and Kirsehir (5.0/100 000). Discussion and conclusion: These findings add new data to the pool of knowledge in terms of the need of safety, proper heating system instructions and more education on CO poisoning in Turkey.

Childhood deaths due to suicide

Suicide has been reported as the second or third most common cause of death in children and adolescents all over the world. The aim of the study was to investigate the general properties of suicide in childhood and adolescents, and to evaluate the results in the light of literature. Reports of autopsies performed between 2001 and 2005 in the Morgue Department of the Council of Forensic Medicine in Istanbul (n = 16853) were examined retrospectively. Deaths between 0–18 years of age doubtlessly considered as suicide were included in the study. Childhood and adolescent (0–18 years) deaths comprised 10.4% (n = 1761) of all medico-legal autopsy cases. 136 cases of suicidal origin were evaluated in terms of age, gender, and method of suicide. The ages ranged between 7 and 18, with a mean of 15.54 ± 2.691(SD). The most common method of suicide was hanging (59.2%) in both genders. Older adolescents (16–18 age group) constituted the overwhelming number (63.2%, n = 86) of all cases. Seven cases of 10 years of age and below were determined, and hanging was the method of suicide in five of these cases. In order to prevent childhood suicides, families and society should be aware of their responsibilities.

Autopsy profiles of malpractice cases.

Claims for medical malpractice and the number of lawsuits filed thereafter are increasing in Turkey as is the case throughout the world. In the present study all files issued by the associated boards of the Council of Forensic Medicine between 2001 and 2005 were studied and of those, 525 death cases in which there was a medical malpractice claim were included. 303 of the cases (57.7%) were male, 215 (41%) were female, while no gender was mentioned in seven cases (1.3%). The age of the subjects ranged between 0 and 90, with an average of 26.8. 147 cases (28%) were related to Emergency Units. 92% of the cases (482 cases) were resolved in the Council of Forensic Medicine, Ministry of Justice. 167 of the resolved cases were concluded as medical malpractice.

Fatal aorto-esophageal fistula in child: A case report

Esophageal foreign body ingestion is especially frequent in childhood and may cause fatal complications in case of late diagnosis and delayed treatment. We present a case of 2-year old girl who was admitted to emergency department with massive bleeding. However, she died due to an unrecognized foreign body resulted an aorto-esophageal fistula. At autopsy an aorto-esophageal fistula was detected by gross examination. Tissue samples were obtained from the organs and fistula region. In histopathological examination, a calcified body with multinucleated giant cell and surrounding granulation tissue was detected at the bleeding site. An ulcerated fistula tract ran from the intima to the adventitia, passing through layers of esophageal wall was also noticed. The mortality rate for foreign body ingestion is less than 1%, except in cases of perforation. Therefore the presented case is among rare examples of fatal foreign body ingestions.

Idiopathic giant cell myocarditis in a newborn: case report

Idiopathic giant cell myocarditis (IGCM) is a rare cause of arrhythmia, heart failure and death in children. The etiology of IGCM is unknown. Endomyocardial biopsy and histological examination are essential for diagnosis. In our case, a one-month-old baby boy with no prior medical history died during breast-feeding. The gross autopsy and drug screen failed to disclose a cause of death. Hemotoxylen Eosin (H&E) stained cardiac tissue slides showed widespread and multifocal necrosis accompanied by mixed inflammatory infiltrate. Admixed with the infiltrate were fibroblastic proliferation and multinucleated giant cells in the absence of sarcoid like granuloma. Although myocarditis is usually thought to be a disease of older children, infants can also be affected. This entity can be the cause of some cases of sudden unexpected death in infancy.