Original Article

Role of Diffusion-Weighted MRI (DWI-MRI) in the Diagnosis of Brain Complications caused by Heroin Substance Abuse

Y Davoudi, A Ghaderi, B Dadpour, R Afshari, M Afzalaghaee, L Ameri, O Mehrpour

International Journal of Medical Toxicology and Forensic Medicine, Vol. 6 No. 4(Autumn) (2016), 3 February 2017, Page 193-199

Background: Magnetic resonance imaging (MRI) offers higher diagnostic accuracy for brain lesions caused by heroin abuse compared to compute tomography (CT) scan. These lesions have a low signal on T1-weighted (T1W) images and a high signal on T2-weighted (T2W) and fluid-attenuated inversion recovery (FLAIR) images. This study aimed to evaluate the role of diffusion-weighted MRI (DWI-MRI) in heroin addicts.

Methods: This cross-sectional study was conducted on 20 patients with heroin addiction (vapor inhalation/injection) referring to Imam Reza Hospital of Mashhad, Iran. Patients in whom heroin abuse was only cause of consciousness, loss and neurological symptoms were enrolled in this study. Demographic data of the patients were recorded, including MRI, FLAIR, T1W and T2W images. In addition, DWI of axial and sagittal sections of the brain was performed in the following sequences.

Results: In this study, mean age of patients was 40.15±7.673 years, and 95% of patients were male. The most common mode of heroin use was inhalation, and mean duration of addiction was 5.48±3.393 years. Mean daily intake of heroin was 13.4±15.30 grams, and mean duration of heroin abuse was 10.3 and 4.6 years in patients with and without MRI changes, respectively. A significant correlation was observed between MRI changes and duration of heroin use (r=0.721) (p=0.001). In addition, a significant correlation was observed between MRI changes and daily intake of heroin (p=0.006).

Conclusion: According to the results of this study, brain lesions caused by heroin abuse have a low signal on T1W images and a high signal on T2W and FLAIR images. Therefore, it could be concluded that heroin intake has significant effects on the brain of users.

Review of Fall Injuries and Related Factors in Patients Admitted to a Trauma Referral Hospital in Tehran, Iran

S Soltani, K Aghakhani, S Rismantab Sani, M Asgari, Fardin Fallah

International Journal of Medical Toxicology and Forensic Medicine, Vol. 6 No. 4(Autumn) (2016), 3 February 2017, Page 200-208

Background: Falls are important causes of mortality and morbidity in urban areas and put a high burden on societies. We investigated patterns of fall traumas and related factors in a referral trauma hospital in Tehran, Iran.

Methods: In this routine-data-based study, all documents of fall cases in Hazrate-Rasool hospital, Tehran, Iran, during October 2014-2015 were investigated. Information on demographic factors of patients, fall conditions and outcomes were collected. Data were analyzed by SPSS 11.5. The statistically significant level was considered ≤ 0.05.

Results: Of the 307 cases, 70% were male. Median (interquartile range) age was 32 (22-51) years. Of cases, 91% were undergraduates. The mortality rate was 2.6%. Suicide attempts reported in 17 (5.5%) cases and only 2 (12%) of them were successful. Injured body organs in order of frequency were extremities, head and neck, thorax, vertebras, abdomen and pelvis. Outcome (in terms of injured body organs) was related to age and gender of patients alongside with height and reason of the fall. Falls at workplaces, in suicide attempts and among males happened for significantly higher distances. High distance falls and low GCS at admission were related to higher mortality. Majority of falls on a same level happened at home among old women.

Conclusion: In our region, fall was a problem of people with low socioeconomic status. Our mortality rate is similar to the highest mortality rates in the world. Personal characteristics along with trauma-related factors are both important in the outcomes of fall cases. Safety equipment at high risk jobs is essential to prevent falls.

Assessment of Aspiration-Induced lung Injuries among Acute Drug Poisoning Patients; Loghman Hakim Hospital, Poisoning center

F Khodabandeh, Kh Agin

International Journal of Medical Toxicology and Forensic Medicine, Vol. 6 No. 4(Autumn) (2016), 3 February 2017, Page 209-216

Background: Following pulmonary aspiration of gastric contents, a variety of conditions occurs ranging from the acute inflammatory response (aspiration pneumonitis) to an infectious process (aspiration pneumonia). They cause due to the failure of protecting mechanism of airway patency following poisoning toxicity.

Methods: Patients with acute drug poisoning for assessment of aspiration-induced lung injury evaluated during the twelfth months.

Results: 410 participants followed the study. Of those, 249 (61 %) were male and 161 (39%) female. They ranged between 17-55 years. The mode was 25-39 years with frequency of 38%.  The mean±SD of age was 32.3±14.5 (Female 34% and Male 27% respectively). The mean age ±SD of females was lower than males (27.3±12.4 vs. 34.4±14.4 years old). An episode of vomiting was recorded positive in 62% (254) of patients. They were recorded by self-reported or witnessed by someone else within the first hours of poisoning. The chest radiograph abnormality was observed mostly in both lungs (45%, 185). They consisted of multifocal patchy infiltrates in lungs 44% (178), diffuse bilateral infiltration 35% (144), and bilateral perihilar consolidation 18% (72) and lobular consolidation 4% (16) mainly in both lung fields (45%, 185). Aspiration related pulmonary complications attributed to pneumonitis 43.5% (178) including ARDS 35% (144), pneumonia 18% (72), and lung abscess 4% (16). There was a significant relationship with vomiting (P=0. 04).

Conclusion: Aspiration pulmonary abnormalities were the commonest lung manifestation of drug toxicities. Chest x-ray abnormalities associated with vomiting presentation are clues to finding pulmonary complications of acute drug toxicity.

Anxiety Level of Pregnant Women from Ahwaz Exposed to Domestic Violence

F Pazandeh, M Beheshtinasab, MA Emamhadi, A Safarzadeh, MH Haghighizadeh

International Journal of Medical Toxicology and Forensic Medicine, Vol. 6 No. 4(Autumn) (2016), 3 February 2017, Page 217-224

Background: Domestic violence is a concern in the communities and need a wide attention. Violence against women can cause all kinds of physical and mental illness. This is a threat to woman’s and family member’s health. Stress, anxiety and depression during pregnancy are risk factors for adverse consequences. Little is known about the level of the mental illnesses in women who exposed to domestic violence during pregnancy. This study reported the level of anxiety in women who were victims of domestic violence in health centers in Ahwaz.

Methods: This was a cross-sectional study in which a sample of 110 pregnant women with domestic violence and pregnant women without violence were recruited.  The data were collected using the demographic questionnaire, World Health Organization standardized domestic violence questionnaire, and the Beck Anxiety Inventory (BAI). The data entered in SPSS 21 and were analyzed using Chi-Square, Independent-t and Multiple Logistic Regression.

Results: The pregnant women in the domestic violence group had a higher mean score of anxiety (P<0.05). Women exposed to violence experienced psychological violence (57.75%), physical violence (37.73%) and sexual violence (33.88%). The psychological violence was the greatest influence on the level of anxiety in pregnant women.

Conclusion: This study demonstrated the impact of domestic violence on the level of anxiety in pregnant women and confirmed its treat to women's mental health.

Review Article

Different Types of Death from the Viewpoint of Quran and Forensic Medicine

B Mostafazadeh, F Najari, I Baradaran Kial

International Journal of Medical Toxicology and Forensic Medicine, Vol. 6 No. 4(Autumn) (2016), 3 February 2017, Page 225-230

Background: The word death has been brought in several verses of Quran. The purpose of this study is to discuss and compare similarities and differences between Quran’s and forensics’ perspective in terms of death.

Methods: The present study is carried out by library studies on multiple interpretations of Quran, interpretation of juridical references and comparing them with current forensics knowledge.

Results: Holy Quran has mentioned different types of death: 1- certain death: death is inevitable; 2- Suspended death: occurrence of death is conditioned; 3- Optional death: optionally giving up on deeds, properties and void thoughts; 4- Ambiguous death. On the other hand, different types of death from the perspective of forensics include: 1- Apparent death: a state in which breathing and functions of the heart are slowed down; 2- Cellular death: certain and imminent death; 3- Somatic death: irreparable loss of cognitive potency which is in fact the same as Brain death; 4- Instant death: roughly instantaneous deterioration of the entire cells. From the view of forensics, manners of death are divided into two groups including natural death and unnatural death. The latter includes committing suicide, killing and accidents.

Conclusion: Quran is the equivalent of Natural death in forensics. In addition, the equivalent of Suspended death in forensics is death resulted by illnesses, accidents and incidents which may appear as certain death or brain death.

Jurisprudential and Legal Investigation of Effectiveness of the Muslim’s will on Using Bodily Organs of the Testator

F Najari, M Khalilzadeh

International Journal of Medical Toxicology and Forensic Medicine, Vol. 6 No. 4(Autumn) (2016), 3 February 2017, Page 231-236

Background: Human being is owned by God and is allowed to own him/herself and make a decision on his/her organs after demise, including the right of making will on using his/her organs in the case of death.

Methods: This study is a review of Jurisprudential and legal investigation of the effectiveness of the Muslim’s will on using bodily organs of the testator in Iran. The findings that used, based on the studies were carried down in Iran and published in databases such as Google scholar, religious book and request for opinion emulation searching is done by using valid keywords.

Results: This study concluded that using of organs of the deceased is acceptable for solving the problems of another live Muslim person. The legal department of the judiciary has declared also that organ donation is acceptable, but no organ may be sold since it is not included as a property.

Conclusion: According to different religions and laws in the different countries similar studies are limited also in the Islamic countries, too. But there is disagreement on the studies in our country. There is a fundamental difference between the view of the proponents and that of the opponents of removing organs.

Case Report

Diagnostic Dilemma with Interval Death in a Road-Traffic Accident Victim

R Mandal, K Mondal, K Khan, P Kumar Mandal, M Gaha Mallik Sinha

International Journal of Medical Toxicology and Forensic Medicine, Vol. 6 No. 4(Autumn) (2016), 3 February 2017, Page 237-241

Background: The cause of death is difficult to interpret in a road-traffic accident (RTA) victim, because multiple injuries make it difficult to decide on the most fatal lesion, particularly when death is delayed by prompt medical intervention; and secondary haemorrhage, renal failure, fat embolism, systemic infections, myocardial or cerebral infarction – all comes under the potential differential threats.

Case Report: A 20 year-old RTA victim was hospitalized in a comatose state and died after surviving 21 days on intermittent positive pressure ventilation. Post-mortem examination of different organs revealed pneumonic consolidation in lung, fatty changes in liver and acute tubular necrosis in kidney; in addition to haemorrhage and congestion in these organs and brain.

Conclusion: Acute contusions of various internal organs, compounded by hospital-acquired infection and medical interventions turn the overall diagnostic scenario messy in a resuscitated RTA victim. In such condition notification about all lethal organic defects, instead of mentioning mere ‘multiorgan failure’, is the best way to sign out an ‘autopsy report.


Successful Suicide in a Child: Depression-Related or Paroxetine-Induced?

K Aghakhani, S Soltani, N Farhidnia, F Fallah

International Journal of Medical Toxicology and Forensic Medicine, Vol. 6 No. 4(Autumn) (2016), 3 February 2017, Page 242-246

Background: Children and adolescents are prone to develop psychiatric problems after stressful life events. These problems need appropriate treatment because of negative consequences like disease-related suicide. Antidepressants (especially "Serotonin Selective Reuptake Inhibitors") are common treatments for psychiatric problems of children and adolescents; but different side effects, including drug-induced suicide, have been reported.

Case Report: In this article, we describe a nine-year-old girl who developed depression after parental divorce and was prescribed paroxetine. During pharmacotherapy, she had suicidal thoughts and several unsuccessful attempts which have been neglected and finally last attempt was successful. This report is an evidence for physicians to prescribe antidepressants cautiously with reasonable indication. As still there is no certain contraindication of using antidepressants in pediatric patients, importance of follow-ups and screening of suicide in pediatric patients during treatment with antidepressants seems essential.

Conclusion: This study discloses the magnitude of explaining the side effects of antidepressants to caregivers of children with psychiatric problems.

A Rare Case of Homicide by Dual Method-Strangulation with Cut Throat: A Case Report

UK Choudhary, S N Darandale, R Nanaji Wasnik, G D Nithurkar, K U Zine

International Journal of Medical Toxicology and Forensic Medicine, Vol. 6 No. 4(Autumn) (2016), 3 February 2017, Page 247-250

Background: Homicide is killing of a human being by another human being. Various methods like strangulation, cut throat, stabbing etc may be used for homicide; however combination of two mechanisms is rare.

Case Report: hereby we present a rare case with unexpected appearance of two different mechanisms of homicide applied over same region, wherein body of a female was referred to us with history of cut throat. Body of the deceased was found near her house with cut throat injuries over front of neck, on examination cut throat injuries were present over neck along with ligature mark intermingling with them.

Conclusion: The present case represents an unexpected rare association of two methods of homicide, as in this case of strangulation followed by cut throat. Correct Interpretation of cause of death with its manner in such case is very important, which needs meticulous post-mortem examination along with proper correlation with other information.

Delayed Onset Brain Hypoxia and Subsequent Seizures: a Rare Fatal Consequence of Undiagnosed Foreign Body Aspiration

K Aghakhani, M Asgari, S Soltani, N Farhidnia, F Fallah

International Journal of Medical Toxicology and Forensic Medicine, Vol. 6 No. 4(Autumn) (2016), 3 February 2017, Page 251-255

Background: Foreign body aspiration is a common medical emergency among children that can lead to lethal complications especially in neglected or misdiagnosed cases.

Case Report: This article is a report of a 15-month-old child who aspirated food materials and after chocking crisis, she presented with unspecific respiratory symptoms and treated for respiratory tract infections. After five days, sudden airway obstruction led to hypoxic brain damage and seizure. Due to unavailability of bronchoscopic facilities, extraction of foreign body was postponed and persistent hypoxia led to irreversible brain damage, seizures and finally death. This report reveals the key role of physicians in prompt diagnosis and the importance of early extraction of aspirated foreign bodies, even in asymptomatic cases, to prevent later complications and related mortality and morbidity.

Conclusion: This report contains warning hints for professionals in different fields of medicine that deal with pediatric patients.