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Spectrum of unnatural deaths associated with

positive toxicology findings in Eastern province,

KSA: An autopsy based study

Sahar Y. Issa

a,b,*

, Mohammed El Dossary

c

, M. Abdel Salam

c

,

Maha K. Al-Mazroua

b

, Mostafa A. Hamd

d

, Magdy Kharoshah

c

a

Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Alexandria University, Egypt b

Regional Poison Control Center, MOH, Dammam, Saudi Arabia c

Forensic Medicine, MOH, Dammam, Saudi Arabia d

Forensic Medicine, MOH, Al-Madinah Al-Munawarah, Saudi Arabia

Received 6 November 2015; revised 10 May 2016; accepted 11 May 2016

KEYWORDS Autopsy; Unnatural deaths; Saudi; Poisoning; Suicide; Homicide; Hanging; Strangulation; Violence; Firearm; Forensic; Toxicology

Abstract Background:Mortality statistics are crucial for monitoring changes in death rates, demo-graphics and causes. The importance of autopsy performance and result documentation for mortal-ity statistics has been referred to and debated over a long period in many places all over the world. Objective:To determine the spectrum of unnatural deaths, focusing on toxicological findings with respect to gender susceptibility, inhabitant nationality, manners and causes of death, and weaponry over a period of five years in Eastern province, Saudi Arabia. Methods: The unnatural deaths whether suicidal, homicidal or, accidental fatalities in the period from 2009 to 2013 in the Eastern region, Saudi Arabia were retrospectively studied from autopsy reports. Results: 1335 cases were examined in Dammam forensic center over five years, two hundred twenty unnatural fatalities with alcohol and poison were positive. All positive cases were investigated retrospectively by the Forensic Medical Authority, Eastern province in the five year period starting from 2009 to 2013. Toxicological results in the examined samples were obtained for all studied cases. The subjects were chiefly males (90.9%), most cases were in young age group ranging between 21 and 30 years of age (30.5%). Accidental causes significantly predominated (61.8%) over suicidal and homicidal causes (20.5% and 10.9% respectively). Most of the cases were Saudi (45%), followed by Indian nationals (25.5%) followed by other nationalities. Conclusion: In conclusion, this study highlighted key find-ings of demographic differences in unnatural deaths in Eastern province, Saudi Arabia. Further studies are recommended.

Ó 2016 The International Association of Law and Forensic Sciences (IALFS). Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).

* Corresponding author at: Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Alexandria University, Egypt. Peer review under responsibility of The International Association of Law and Forensic Sciences (IALFS).

H O S T E D BY Contents lists available atScienceDirect

Egyptian Journal of Forensic Sciences

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1. Introduction

Official mortality rates are used to monitor trends, compare causes, manners, and rates across regions, and assess risk fac-tors. More than five million deaths occur annually, with inju-ries and violence accounting for 10% of worldwide mortality. Violence-related deaths are 7.1% more than the number of fatalities that result from infectious diseases combined. Furthermore, most of the leading causes for fatalities in people aging between 15 and 29 years are injury-related. These inju-ries result from acts of violence against oneself or others, road traffic crashes, burns, drowning, falls, and poisonings, among other causes.1–3

Internationally, governments, public and private partners are increasingly attentive of the stresses that violence and injuries place on humanities. In reaction, they are reinforcing data collection schemes, improving services for victims and survivors, and increasing preventive measures that can reduce suffering and save lives.4–6

Autopsy remains the most applicable medical tool of inves-tigation used for observing the failure of the medical care offered to the deceased, or to exclude the aspect of medical negligence of the caring team and to see the role of violence if any.7

There is no precise registry based statistical data on unnat-ural deaths in most of the countries in the world. Universally, homicides represent approximately 1 million deaths, while suicide leads to at least 1.1 million deaths annually. Approximately 1.7 million road traffic accident fatalities occur globally each year as reported by WHO.291% of the world’s deaths due to Road Traffic Accidents (RTA) occurs in the low and middle income countries.8Poisoning deaths account for more than 60% of all undetermined deaths nationwide.9 Many studies revealed that a proportion of undetermined deaths are probably unreported suicidal attempts, and sug-gested that the actual reported suicide rates are underestimated by about 10–30%.10Suicide may be seen in every community, both in ordinary individuals responding to stressful life circumstances, or in patients with severe mental disorders.11 Suicide is still a very controversial matter, for being one of the main reasons for death in recent years.12,13

Antisocial and criminal behavior is known to increase among alcoholics.14It is of great importance to note that mea-suring trends in alcoholics and alcohol-related violent prob-lems is essentially challenging, and this relates to the unreliability of data in most of alcohol related violent behaviors.15

2. Aim of the work

The aim of this study was to determine the spectrum of unnat-ural deaths, focusing on toxicological findings in studied cases regarding; gender susceptibility, inhabitant nationality, man-ners and causes of death, and weaponry over a period of five years in Eastern province, Saudi Arabia.

3. Methods

1335 cases were examined in Dammam forensic center over five years, two hundred twenty unnatural fatalities with

alcohol and poison were positive. This study involved all the fatalities due to any form of violence or unnatural causes (N = 220) in the time period from 2009 to 2013. Cases were submitted for autopsy in the mortuary of Department of Forensic Medicine, Eastern province, Saudi Arabia including suicidal, homicidal, accidental or, undetermined causes includ-ing fatal occupational injuries, accidental falls, fire related deaths, accidental drowning, and fatal alcohol poisoning.

Cases of apparently natural causes and cases of infanticide, and maternal deaths were excluded from the study. The dead bodies were examined in a definite prearranged order namely; clothes and, external body examination, followed by autopsy performance to find out the cause, mode, time of death, and the weapon used if any. Suspected tissues and body fluids were collected and submitted for thorough toxicological analysis. Deceased’s sex, cause or manner of death, in addition to region from where the bodies were brought, and year of incidence were reported. 10–15 ml of peripheral blood - being the most reliable specimen for toxicological testing – was withdrawn from the femoral vein in the leg, the iliac vein, accessible from the body cavity during internal examination, or from the sub-clavian vein in the chest. 10–15 ml of urine were collected with a syringe, through a simple incision allowing visualization of the bladder. Vitreous was collected with a hypodermic syringe by inserting the needle into each eye. Comprehensive examina-tion of the collected samples was done for all collected samples using the following protocol: Blood and urine samples of each subject were screened for ethanol and, drugs of abuse (Amphe-tamine, barbiturates, benzodiazepine, cannabis, cocaine, and opiates) using fluorescence polarization immunoassay (FPIA) principle on ARCHITECT system c4000, model i1000 SR by Abbott laboratories. Using Gas Chromatography – Head space GC ultra-model K0C33B730000000, Milano, Italy, all samples were analyzed for all volatiles including ethanol. Extraction and analysis by Gas Chromatography–Mass spec-trometer GC–MS–QP2010, Shimadzu for weakly acidic and neutral drugs, is then performed. This includes acetamino-phen, non-steroidal anti-inflammatory drugs, barbiturates, phenytoin, and Carbamazepine. Finally extraction and analy-sis was done by the same GC–MS for alkaloid and basic drugs, including most common centrally acting therapeutic drugs with the exception of those checked for in weakly acidic and neutral extract. This includes antidepressants, stimulants, nar-cotics, antihistamines, decongestants, muscle relaxants, anti-convulsants, organic poisons, and antipsychotics. Finally analysis for detection of carbon monoxide, or other specific tests which would have to be specially requested or suggested by the circumstances of the death might be done. Ethanol anal-ysis was performed by static headspace analanal-ysis.

3.1. Analysis of ethanol

As the limits for ethanol might be low, thus, a three-point calibration curve covering the ethanol concentration range between 0.01 mg/dl and 10 mg/dl was constructed. Ethanol standards, quality control samples and internal standards (n-propanol, 10 mg/dl) were prepared in distilled water from HPLC grade solvents. A resolution mixture of ethanol, n-propanol, acetaldehyde, methanol and acetone were prepared in distilled water from HPLC grade solvents at a concentration of 100 mg/dl each.

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3.2. Headspace procedure

The samples were placed in 20 ml headspace vials by adding 1.0 ml of samples, standards or quality control samples and 1 ml of internal standard. The samples were sealed using crimp top vial caps with septa and were placed in the headspace rack. Operation parameters are given in (Table 1).

3.3. Gas chromatography analysis

The quantitative analysis of ethanol and its separation from other low-molecular volatiles were done with a TRACETM

Ultra Gas Chromatograph.

3.4. Capillary gas chromatography/mass spectrometry analysis (GC/MS)

The quantitative analysis of ethanol and its separation from other low-molecular volatiles was done with a TRACETMUltra

Gas Chromatograph. Injections were made in the split mode. The column temperature program was isothermal at 90°C. Helium was used as the carrier gas. The injector and transfer line temperatures were 230°C and the split ratio was 10:1 with each sample lot, a calibration curve, a blank (distilled water) and quality control samples were run. The resolution mixture was first run in a scan mode in the mass range of m/z 20 to m/z 120 to identify the compounds and subsequently the mixture was run in a SIM mode for the samples. The methods were lin-ear in the concentration range used.

Blood and urine samples were analyzed for ethyl glu-curonide and ethyl sulfate (EtG and EtS) by Liquid Chromatography Tandem Mass Spectrometry using method-ology described by Helander et al.16and only cases with EtG levels P0.5 lg/mL (positive cut-off for EtG), and EtS P0.1 lg ng/mL (positive cut-off for EtS) were included in the study.

4. Statistical analysis

All data obtained for the investigated cases were submitted to statistical evaluation by SPSS program, version 22 and the results were compared with similar studies.

5. Results

Figs. 1 and 2reveal that the males (N = 200, 90.9%) much prevailed over females (N = 20, 9.1%), and the Saudi nation-als (N = 99, 45%) prevailed over non-Saudi cases. The highest incidence of non-Saudi cases was among Indians (N = 56, 25.5%).

As seen inFig. 3, the highest incidence of cases (N = 67, 30.5%) was detected among victims in the age group (21–30 years), followed by age group (31–40 years), with a total number of 54(24.5%). 56 (25.5%) of the cases in domi-nant age group were males, and 11(5%) were females, with dominance of Non-Saudi nationals (34, 15.5%) as seen in Table 2. The highest incidence of unnatural female deaths was seen in this dominant age group as seen inTable 2.

Eastern region of Saudi Arabia is a vast area comprised of many cities. The highest incidence of fatalities (N = 71, 32.3%) were encountered in Dammam which is the largest city in Eastern Region of Saudi Arabia, as seen inFig. 4.

As seen inTable 3poisoning comprised the highest cause of death among the studied cases (N = 72, 32.7%). 12.3% (N = 27) of the poisoning cases was due to carbon monoxide. The second leading cause of death in the poisoning group was due to overdose of drugs of abuse as seen in 25 of the cases (11.3%), followed by pharmaceutical and pesticide poisoning (N = 20, 9.1%). Hanging as a cause of death accounted for 10.9% (N = 24), followed by road traffic accidents (21, 9.5%). As regards the detailed toxicological findings, 94 (42.7%) of the studied cases revealed ethanol in their analytical results, followed by carbon monoxide (27, 12.3%), amphetamine (25, 11.3%), Cannabis (19, 8.6%), morphine (17, 7.7%) and heroin (12, 5.4%) as shown inFig. 5.

Ethanol was the sole toxicological finding in 26 (27.7%) cases, but was a cofounding with other compounds in 68 (72.3%) of the positive 94 ethanol cases, as shown inTable 4. Based on the data fromFig. 6, the accidental manner of death was observed in 136 cases (61.8%), followed by suicidal, Table 1 Parameters of head-space chromatography.

Parameter Temperature

Initial temp 45°C

Max temp 350°C

Ram 1 initial temperature 90°C

Inlet temperature 230°C

MS transfer line 250°C

Ion source 220°C

Syringe temperature 60°C

Parameter Time

Hold time 00.00 min

Prep run timeout 99.00 min

Equilibrium time 00.50 min

Ram 1 hold time 01.00 min

Prep run timeout 99.00 min

Equilibrium time 00.50 min

Gas saver time 03.00 min

Parameter Volume Sample volume 01.00 ml [CATEGO RY NAME] 90.9% [CATEGO RY NAME] 9.1%

Distribuon of cases by Gender

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homicidal and undetermined manners consecutively, while the highest frequency of the cases, was during the year 2013 (54, 25%), followed by the year 2010 (53, 24%) as shown in Fig. 7. Deaths due to most common causes of poisoning versus the studied year are presented inFig. 8, with the highest num-ber of poisoning due to carbon monoxide inhalation, drugs of abuse and pharmaceuticals or pesticide exposures recorded in the years 2012, 2011 and 2013 consecutively. As seen in Fig. 9, ethanol was the most detected substance in accidental, suicidal and homicidal deaths.

6. Discussion

Un-natural deaths entail fatalities caused due to criminal intent of an offender to oneself or to others, as well as deaths resulting from negligence or deliberate omission of some per-son. It involves deaths encountered due to accidents or disas-ters as well.7Detection of toxic substances plays a significant role in any forensic investigation. It is essential to reveal whether or not the deceased was under the influence of ethanol or other substances of abuse at the moment of an accident or criminal offense.17,18

Postmortem toxicology testing is a vital part of the forensic autopsy. Intentional violent drug-related deaths are a major percentage of any forensic pathologist or medical examiner’s workload. Poisoning, including ethanol, prescription and illicit drugs, is considered the second leading cause of fatal injuries.19

In line with many other studies, poisoning was the most fre-quent leading cause of death.3,20,21

Usually, investigation of deaths include investigation of the death or crime scene noting the presence and types of all drugs, reviewing medical records, performing autopsy examination, followed by testing of collected post-mortem fluids and tissues for qualitative and quantitative analysis of drugs and chemi-cals. Less frequently, an external examination of the body with collection of post-mortem samples for toxicology testing instead of a complete autopsy is performed. Toxicology test results are interpreted in conjunction with autopsy findings and circumstantial evidences of a death scene.22

Suicide is one of the commonest leading causes of death worldwide. Many have considered suicide to be an innately violent act. Except for few neurobiological researches much of the investigation on the interrelationship of suicide and N=99, 45% N=56, 25.5% 6% 6% 3% 2% 2% 2% 1% 7%

Distribution of cases by nationalities

Saudi Indian Pakistani Nepali Filipino Sirilanki Bangladeshi Indonesian Sudanese Others

Figure 2 Distribution of cases as regards nationalities.

4.1% 2.7% 30.7% 24.5% 23.6% 7.7% 3.2% 3.6% 0 10 20 30 40 50 60 70 80 Fr equency Age groups

Distribution of cases by age groups

0-10 11--20 21-30 31-40 41-50 51-60 61-70 >70

Figure 3 Distribution of cases as regards age groups.

Table 2 Distribution of cases by age group versus gender & nationality.

Age groups Gender Nationality Total

Male Female Saudi Non-Saudi

0–10 Count 8 1 9 0 9 % of total 3.6% 0.5% 4.1% 0.0% 4.1% 11–20 Count 4 2 6 0 6 % of total 1.8% 0.9% 2.7% 0.0% 2.7% 21–30 Count 56 11 33 34 67 % of total 25.5% 5.0% 15.0% 15.5% 30.5% 31–40 Count 51 3 18 36 54 % of total 23.2% 1.4% 8.2% 16.4% 24.5% 41–50 Count 49 3 19 33 52 % of total 22.3% 1.4% 8.6% 15.0% 23.6% 51–60 Count 17 0 7 10 17 % of total 7.7% 0.0% 3.2% 4.5% 7.7% 61–70 Count 7 0 3 4 7 % of total 3.2% 0.0% 1.4% 1.8% 3.2% >70 Count 8 0 4 4 8 % of total 3.6% 0.0% 1.8% 1.8% 3.6% Total Count 200 20 99 121 220 % of total 90.9% 9.1% 45.0% 55.0% 100% Dammam 32.3% Khobar 18.6% Jubail 15.9% Qatif 9.1% Dhahran 6.4% Naireyah 5% Sihat 3.6% Hafr El Baten 2.3% Safwa 1.8% Ras Tanorah 1.4% Khafji 1.4% Alqareya Alolya 0.9% Tarot 0.9% Abqaiq 0.5% Distribution of cases by Region

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violence has focused on personality traits and psychiatric abnormalities related to self-reported harm and aggression, and it is terrifying to account for alcohol abuse in surveys of

the possible role of ethanol in violence ending into suicide or homicide.23,24 In accordance with other studies ethanol was the most frequently detected poison either solely or together with other drugs.25–27

Males (N = 200, 90.9%) prevailed over females (N = 20, 9.1%) in the current study of unnatural fatalities. This obser-vation is in accordance with other authors’ findings.28,29This might be attributed to more work stresses, activities, Table 3 Distribution of cases by cause of death.

Cause of death Frequency Percent

Poisoning 72 32.7

Type N %

Carbon monoxide poisoning 27 12.3

DOA overdose 25 11.3

Pharmaceutical & pesticide poisoning

20 9.1

Hanging 24 10.9

Road traffic accidents (RTA) 21 9.5

Undetermined 20 9.1 Burn 14 6.3 Firearm injury 13 6 Strangulation 13 6 Stab wound 9 4.1 Drowning 9 4.1

Falling from height 9 4.1

Head Injury 8 3.6 Cut throat 6 2.7 Traumatic asphyxia 2 0.9 Total 220 100.0 Ethyl Alcohol 42.7% Carbon monoxide 12.3% Amphetamine 11.3% Cannabis 8.6% Morphine 7.7% Di-acetyl Morphine-Heroin 5.4% Organophosphat e Pescides 3.2% Codeine 1.4% Hydrogen Sulphide 1.4% Acetone 1.4% Tramadol 0.9% Aluminium phosphide 0.9% Methanol 0.9% Acetaminophen 0.5% Ephedrine 0.5% Ibuprofen 0.5% Carbamate Pescides 0.5%

Toxicological findings in studied cases

Figure 5 Distribution of cases by toxicological findings.

Table 4 Distribution of ethanol positive cases by nationality, and co-occurrence of other toxicological findings.

Nationality Toxicological results Total

Ethanol with other drugs Ethanol alone Saudi Count 8 18 26 % of total 8.5% 19.2% 27.7% Non-Saudi Count 58 10 68 % of total 61.7% 10.6% 72.3% Total Count 66 28 94 % of total 70.2% 29.8% 100.0% 61.8% 20.5% 10.9% 6.8%

Distribuon of cases by manner

of death

Accidental Suicidal Homicidal Undetermined

Figure 6 Distribution of cases as regards manner of death.

2009 2010 2011 2012 2013 44, 20% 53, 24% 27, 12% 42, 19% 54, 25% 2009 2010 2011 2012 2013 0 10 20 30 40 50 60

Frequency of studied cases per

year

Figure 7 Frequency of studied cases per each year of the study.

0 2 4 6 8 10 12 2009 2010 2011 2012 2013 CO DOA Pharmaceucal & pescides Figure 8 Deaths due to most common causes of poisoning versus the studied year.

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movements, as well as increased incidence of exposure to exter-nal environments and contacts with other members of society. Greater physical strength, more rapid anger, egoism, mind-set for vengeance are other reasons which lastly lead him to be a victim or assailant.30

The present study revealed that highest incidence of cases (N = 67, 30.5%) was detected among victims in the age group (21–30 years), followed by age group (31–40 years), which was similar to other relevant studies.31–33 Dammam, the largest and most popular city in Eastern province, Saudi Arabia, has dominance of immigrant workers from Southeast Asia, mainly Indians, which explains the higher incidence of Indian victims (56, 25.5%).34

In accordance with our results hanging was found to be the second leading cause of death following poisoning in unnatural fatalities as in India35, but in many other countries, including Japan and Germany it was the chief manner in unnatural deaths.36,37

Ethanol was solely detected in only 27.7% of the ethanol positive cases, while in 72.3% of the cases alcohol was detected together with other drugs or chemicals, which is in accordance with other studies.25–27The actual underlying cause of death in these cases is not ethanol or drug alone but the additive central nervous system depression with concurrent use of both of them can lead to fatal overdose and death. This finding is in accor-dance with other studies stating that drug use with alcohol is usually associated with lethal poisoning.38

The highest frequency of unnatural deaths, was during the year 2013 (54, 25%), followed by the year 2010 (53, 24%), which is still markedly less than other countries.39,40 This low frequency of unnatural fatalities can be ascribed to reli-gious factors, as well as relatively better, and strict law and order condition in Saudi Arabia. Better intra personal and familial bonds, behavior and harmonious relationship among the communities in this country are also important contribut-ing factors.34,41This impression is further strengthened when it is observed that the accidental causes in our study predomi-nated the manners of unnatural deaths, and the percentage of homicidal deaths is only 10.9% in comparison to what has been reported by the other researchers which show a higher rate of homicidal deaths.42,43

7. Conclusions

It is concluded that the precise statistical mortality database for unnatural deaths may provide an enormous support for the effect of different factors on aggressive behavior, human health and mortality. Poisoning deaths pose a distinctive diffi-culty in defining the intent of death to medical examiners and coroners. Violence is attributed to a variety of fatal outcomes and it is critical to examine demographically which groups are most affected. Such data will consequently help to better tailor preventive efforts. Our findings call for an instant mandatory regular testing program to thoroughly demographically and toxicologically interpret findings in all post-mortem settings of unnatural fatalities. Funding None. Conflict of interest None declared. Ethical approval

Necessary ethical approval was obtained from the institute ethics committee.

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