Intoxications involving methoxyacetylfentanyl and U-47700: a study of 3 polydrug fatalities.

Novel synthetic opioids (NSOs) represent an emerging group of novel psychoactive substances, acting as agonists at the opioid receptors. NSOs include fentanyl-related compounds, e.g. methoxyacetylfentanyl (MeACF), and non-fentanyl analogs, e.g. "U compounds" including U-47700. Here we present three cases of death involving MeACF and U-47700, with particular reference to preliminary data on pharmacokinetics and tissue distribution.After a complete post-mortem examination, general unknown screenings and analysis of drugs of abuse were performed on postmortem samples by immunoassays, gas chromatography-mass spectrometry and liquid chromatography-mass spectrometry. To quantify the analytes of interest in post-mortem blood and tissues, the standard addition method was used. A toxicological significance score (TSS), weighing the role of the NSO in each death case, was assigned.Case 1 died at the hospital after consumption of U-47700, methadone (serum levels: 2,600 ng/ml and 37 ng/ml), tilidine and benzodiazepines. In case 2, U-47700 (204 ng/ml) together with methadone (290 ng/ml), flubromazepam (480 ng/ml) and diazepam (300 ng/ml) were detected in peripheral blood. In case 3, methoxyacetylfentanyl (266 ng/ml), furanylfentanyl (4.3 ng/ml) 4-ANPP (15 ng/ml) and alprazolam (69 ng/ml) were quantified in femoral blood. In all cases, the NSO likely contributed to the death (TSS = 3).NSOs appear to be often consumed in the setting of polydrug intoxications, especially in combination with other opioids and benzodiazepines, which often exert synergistic effects. The standard addition method remains the most reliable in post-mortem analysis and toxicological results should always be evaluated together with circumstantial and autopsy data.

Gastric ischemia as an under-reported cause of death in older people.

Acute gastric ischemia is a rare condition due to the rich vascular supply of the stomach. Here we present a case of fatal gastric ischemia associated with bowel ischemia, only diagnosed at autopsy, which was requested for the suspicion of medical liability. A complete post-mortem examination was conducted, along with a macroscopic analysis of the superior mesenteric artery and detailed histological analyses. Past clinical data was also reviewed. The macroscopic blackish discoloration of the stomach and the bowel, coupled with the presence of neutrophils in the mucosa and submucosal non-occlusive thrombi, were consistent with gastric and bowel ischemia, despite the presence of confounding putrefactive changes. The unique aspect of this case resides in the ante-mortem peculiar vascularization of the stomach, supplied by small collateral vessels. No mechanical occlusion was identified, and the cause of the ischemia was deemed as non-occlusive, likely due to systemic hypoperfusion. The analysis of clinical data and documentation of associated comorbidities are strongly recommended, especially when a rare cause of death is suspected. With the aging population, especially among women, and the prevalence of risk factors, the forensic pathologist could increasingly encounter rare cases of gastric ischemia.

Motorcycle injuries: a systematic review for forensic evaluation.

The intricate interplay of exposure and speed leave motorcyclists vulnerable, leading to high mortality rates. During the collision, the driver and the passenger are usually projected away from the motorcycle, with variable trajectories or final positions. Injuries resulting from the crash can exhibit distinct and specific characteristics depending on the circumstances of the occurrence.The aim of this study is to provide a systematic review of the literature on injuries sustained by motorcyclists involved in road accidents describing and analyzing elements that are useful for forensic assessment.The literature search was performed using PubMed, Scopus and Web of Science from January 1970 to June 2023. Eligible studies have investigated issues of interest to forensic medicine about during traffic accidents involving motorcycle. A total of 142 studies met the inclusion criteria and were classified and analyzed based on the anatomical regions of the body affected (head, neck, thoraco-abdominal, pelvis, and limb injuries). Moreover, also the strategies for preventing lesions and assessing injuries in the reconstruction of motorcycle accidents were examined and discussed.This review highlights that, beyond injuries commonly associated with motorcycle accidents, such as head injuries, there are also unique lesions linked to the specific dynamics of accidents. These include factors like the seating position of the passenger or impact with the helmet or motorbike components. The forensic assessment of injury distribution could serve as support in reconstructing the sequence of events leading to the crash and defining the cause of death in trauma fatalities.

Bicycle injuries: A systematic review for forensic evaluation.

Bicycles are employed as means of transportation across various age groups, from young students to the elderly, for work, education, health, and leisure trips. Despite not achieving high speeds, bicyclists remain vulnerable to severe and even fatal injuries when they are involved in traffic accidents. Although the rising awareness of ecological issues and traffic law enforcement mean that cyclists are increasingly susceptible to road traffic crashes and injuries. Injuries resulting from a traffic accident involving cyclists can show distinct and specific characteristics depending on the manner of occurrence. The aim of this study is to provide a systematic review of the literature on injuries sustained in cyclists involved in road accidents describing and analysing elements useful for forensic assessment. The literature search was performed using PubMed, Scopus, and Web of Science from January 1970 to March 2023. Eligible studies have investigated issues of interest to forensic medicine about traffic accidents involving bicycles. A total of 128 studies satisfied the inclusion criteria and were categorized and analyzed according to the anatomical regions of the body affected (head, neck, thoraco-abdominal, and limb injuries), and the assessment of lesions in reconstruction of the bicycle accident was examined and discussed. This review highlights that injuries resulting from a traffic accident involving cyclists can show distinct and specific characteristics depending on the manner of occurrence and the energy levels involved in the crash. The assessment of injuries offers valuable insights that integrated with circumstantial and engineering data perform the reconstruction of accident dynamics.

Reliability in distinguishing murder from accidental event with current forensic criteria in traumatic head injury.

Discovering a body displaying signs of multiple head trauma requires a thorough examination by the forensic pathologist, and a multidisciplinary approach is recommended. However, determining the manner of death is not always possible. We present a case in which the body of a 60-year-old man was discovered lying face down on the floor of his apartment, partially unclothed, surrounded by blood and vomit, and presenting numerous head injuries. The autopsy concluded that the cause of death was a result of post-traumatic brain injury. Nevertheless, applying current criteria made it challenging to ascertain whether the trauma stemmed from an accidental event or an assault.

Validation and application of a method for the quantification of 137 drugs of abuse and new psychoactive substances in hair.

INTRODUCTION: In the dynamic universe of new psychoactive substances (NPS), the identification of multiple and chemically diverse compounds remains a challenge for forensic laboratories. Since hair analysis represents a gold-standard to assess the prevalence of NPS, which are commonly detected together with classical drugs of abuse (DoA), our study aimed at developing a wide-screen method to detect and quantify 127 NPS and 15 DoA on hair. MATERIALS AND METHODS: A multi-analyte ultra-high performance liquid chromatography mass spectrometry method for the identification and quantification of 127 NPS (phenethylamines, arylcyclohexylamines, synthetic opioids, tryptamines, synthetic cannabinoids, synthetic cathinones, designer benzodiazepines) and 15 DoA in hair samples was developed. A full validation was performed according to the European medicines Agency (EMA) guidelines, by assessing selectivity, linearity, accuracy, precision, limit of quantification (LOQ), limit of detection (LOD), matrix effect and recovery. As a proof of the applicability, the method was applied to 22 authentic hair samples collected for forensic purposes. RESULTS: Successful validation was achieved, by meeting the required technical parameters, for 137 compounds (122 NPS and 15 DoA), with LOQ set at 4 pg/mg for 129 compounds, at 10 pg/mg for 6 and at 40 pg/mg for 2. The method was not considered validated for 5 NPS, as LLOQ resulted too high for a forensic analysis (80 pg/mg). Among authentic forensic samples, 17 tested positive for DoA, and 10 to NPS, most samples showing positivity for both. Detected NPS were ketamine and norketamine, 5-MMPA, ritalinic acid, methoxyacetyl fentanyl, methylone and RCS-4. CONCLUSION: The present methodology represents an easy, low cost, wide-panel method for the quantification of 122 NPS and 15 DoA, for a total of 137 analytes, in hair samples. The method can be profitably applied by forensic laboratories. Similar multi-analyte methods on the hair matrix might be useful in the future to study the prevalence of NPS and the co-occurrence of NPS-DoA abuse.

Pediatric motor vehicle crashes injuries: A systematic review for forensic evaluation.

Children involved in car crashes can experience either direct trauma or inertial injuries resulting from interactions with external objects, such as other vehicles, or with the restraint system. Furthermore, improper use of restraint systems can lead to additional severe injuries. Recent reports from international institutions underscored the persistent prevalence of inadequate restraint systems utilization and this widespread issue increases children's vulnerability and risk of injuries.The aim of this study is to provide a systematic review of the literature on injuries sustained in children involved in road accidents describing and analyzing elements useful for forensic assessment.The literature search was performed using PubMed, Scopus and Web of Science from January 1970 to March 2023. Eligible studies have investigated issues of interest to forensic medicine about traffic accidents involving pediatric passengers. A total of 69 studies satisfied the inclusion criteria and were categorized and analyzed according to the anatomical regions of the body affected (head, neck, thoraco-abdominal, and limb injuries), and the assessment of lesions in reconstruction of the accident was examined and discussed.The review highlights that in motor vehicle accidents involving children, the forensic evaluation of both the cause of death and accident dynamics needs to consider several factors, such as the child's age, the type of restraint system employed, and the specific passenger seat occupied. Considering the complexity of the factors that can be involved in this road accident, it is crucial that there is a comprehensive exchange of information between the judge and the medical expert.

On tackling abuse of older people: The forensic challenges in fatal cases investigation.

The World Health Organization recently presented the priorities for tackling abuse of older people in a coordinated and strategic way. However, data on the forensic scenario is still lacking. In this context, the aim of the present work was to provide a comprehensive literature review of this inherently complex phenomenon in the post-mortem setting, in order to better characterize it from a forensic point of view. A comprehensive literature search was performed in three electronic databases following the PRISMA guidelines. Sociodemographic and medical data of victims and perpetrators, post-mortem data, types of abuse and risk factors were extracted from non-aggregated data. Forty-eight papers dealing with abuse in the post-mortem setting were included, with a predominance of case reports and case series. The review showed that neglect was the most common type of abuse and victims are predominantly older women who are abused in a domestic setting by trusted family member. To generate more and better data, expanded research in the forensic field requires standardized methods and the raise of professional awareness about abuse of older people.

Diagnostic challenges and forensic implications in a case of infantile fatal myocarditis.

We present the case of a 23-month-old child who died less than 24 h after the onset of cardiac symptoms, despite being admitted to the hospital 72 h earlier. Autopsy revealed no significant macroscopic changes, and histologic examination revealed focal lymphocytic myocarditis with myocyte disruption, diffuse alveolar damage in the exudative phase, and generalized lymphocytic immune activation in other organs. Ante-mortem and post-mortem microbiological exams did not clearly prove a causative role of infectious agents. The peculiarity of this case was characterized by the contrast between the severe clinical features and the mild cardiac histological findings. This discrepancy, coupled with the suspicion of a viral causative role based on both ante-mortem and post-mortem microbiological examinations, presented significant challenges in reaching an etiological diagnosis. This case also confirms that the diagnosis of myocarditis in children cannot be made solely on the basis of histological cut-offs or microbiological results. Using abductive reasoning, various diagnostic hypotheses were formulated and evaluated to arrive at the final diagnosis of fatal myocarditis of viral or post-viral origin. Data from post-mortem examination are often the only source of information that is available to the experts, especially in cases of sudden infant death syndrome. In such cases, the forensic pathologists should accurately evaluate findings that may appear to indicate a different etiology, and, in the absence of clinical or radiological data, interpret post-mortem data in a logically correct manner. The autopsy is the first essential step to evaluate the cause of death and must be integrated with the results of ante- and post-mortem diagnostic tests in a holistic approach, which is crucial to allow forensic pathologists to provide an appropriate and relevant opinion.

Homicide or suicide? A probabilistic approach for the evaluation of the manner of death in sharp force fatalities.

The role of forensic science can be defined as providing relevant opinions to assist investigators and courts of law in answering questions. The Likelihood Ratio (LR) provides a quantitative and logical approach to communicating the strength of expert evidence. We reviewed existing forensic literature on sharp force fatalities, focusing on studies reporting the manner of death and the frequency of some characteristics that are traditionally assessed. Four studies were included, resulting in a database of 173 suicides and 354 homicides. The LR of each of the characteristic under both hypotheses (suicide and homicide) was obtained. Subsequently, the LR was computed in six fatalities with known manner of death, three suicides and three homicides, by multiplying the corresponding LR of each individual characteristic. LR ranged from 115 to 140,250 in suicidal cases and from 9 to 2728 in homicidal cases. Compared to other fields of forensic science where LR is used extensively, the values obtained in our cases of sharp force fatalities is low. However, in forensic pathology there is evidence that is outside the expert's opinion, and it is for the trier of fact, such as the judge or jury, to draw conclusions. Nevertheless, the LR serves as a tool for interpreting and weighing evidence while maintaining the distinct roles of the trier of fact and the expert. To comprehensively apply the LR in the field of sharp force deaths, it will be necessary to standardize the methodology of investigation and data collection in descriptive studies.

Homicide, suicide, or accident? Complex differential diagnosis. A case series.

Distinguishing between homicides, suicides, and accidental deaths remains a challenging task. The examination of actual cases, which involve a multitude of variables, significantly contributes to our understanding of these matters. In this context, we present three distinct cases that required the involvement of various specialists to conduct a thorough analysis of the manner of death. In the first case, the integration of on-site inspection, autopsy, radiological, and kinematic data enabled the identification of a homicidal death. In the second case, the combination of circumstantial evidence, autopsy findings, toxicological analysis, and meteorological data revealed an atypical accidental death resulting from an attempted suicide. In the third case, radiological findings, supplemented with criteria from forensic science, indicated an accidental manner of death. In all reported cases, a multidisciplinary approach played a pivotal role in the differential diagnosis of the manner of death.

Human metabolism and basic pharmacokinetic evaluation of AP-238: A recently emerged acylpiperazine opioid.

As a consequence of recently implemented legal restrictions on fentanyl analogs, a new generation of acylpiperazine opioids appeared on the illicit drug market. AP-238 was the latest opioid in this series to be notified by the European Early Warning System in 2020 and was involved in an increasing number of acute intoxications. AP-238 metabolism was investigated to provide useful markers of consumption. For the tentative identification of the main phase I metabolites, a pooled human liver microsome assay was performed. Further, four whole blood and two urine samples collected during post-mortem examinations and samples from a controlled oral self-administration study were screened for anticipated metabolites. In total, 12 AP-238 phase I metabolites were identified through liquid chromatography-quadrupole time-of-flight mass spectrometry in the in vitro assay. All of these were confirmed in vivo, and additionally, 15 phase I and five phase II metabolites were detected in the human urine samples, adding up to a total of 32 metabolites. Most of these metabolites were also detected in the blood samples, although mostly with lower abundances. The main in vivo metabolites were built by hydroxylation combined with further metabolic reactions such as O-methylation or N-deacylation. The controlled oral self-administration allowed us to confirm the usefulness of these metabolites as proof of intake in abstinence control. The detection of metabolites is often crucial to documenting consumption, especially when small traces of the parent drug can be found in real samples. The in vitro assay proved to be suitable for the prediction of valid biomarkers of novel synthetic opioid intake.

Fatal coronary perforation during percutaneous coronary intervention: The medico-legal interest in establishing the correlation between in vivo imaging and post-mortem histopathology.

A 64-year-old man diagnosed with chronic coronary syndrome (CCS) underwent elective percutaneous coronary intervention (PCI) to place a stent in a branch of the first diagonal artery. Fifteen minutes after the procedure, the patient suffered a cardiac arrest, which was subsequently determined to be caused by cardiac tamponade identified through ultrasound examination. Despite an hour of cardiopulmonary resuscitation, the patient died and a forensic investigation was requested by the public prosecutor. On review of the coronary angiography images, an extravasation of contrast was noted, which was classified as a type II perforation according to the Ellis classification. Autopsy revealed a hemorrhagic suffusion area on the anterior surface of the left ventricle with suspected epicardial discontinuity. Histopathological examination confirmed a complete rupture of the vessel wall in the distal section of the branch where the stent was placed, accompanied by adjacent hemorrhagic and fibrin-platelet material. The diagnosis of coronary perforation is typically made through imaging and histological confirmation is rarely obtained. In the present case, the correlation between in vivo imaging and post-mortem histopathology not only facilitated the precise localization of the coronary perforation but also had significant medico-legal implications in the assessment of presumed medical liability.

Postmortem histological freeze-thaw artifacts: a case report of a frozen infant and literature review.

Freezing and thawing have the potential to alter the gross and histologic appearance of tissues, causing damage to individual cells and disrupting the overall architecture. In forensic investigations, freezing and thawing can play a crucial role in cases of unknown cause of death. Perpetrators may use freezing preservation to conceal the body or obscure the time of death. Freezing can also occur naturally when a body is exposed to the elements, sometimes even leading to death itself. We present a case report involving an autopsy performed on an infant, who died of natural causes, after undergoing freezing and thawing. The objective of this study was to identify and discuss the histological artifacts observed in different tissues as a result of the freeze-thaw process. Histologically, the infant's tissues exhibited the most common features described in the literature. Ice crystal artifacts, characterized by expansion of the extracellular space and tissue clefts, were found in the heart, brain, liver, lungs, and kidneys. On the contrary, adipose tissue was not affected, likely due to the scarcity of water. Freeze-thaw artifacts should be taken into account whether a body is known to have been frozen or to add further data if found already defrosted.

Medico-legal implications of dog bite injuries: A systematic review.

Dog bites pose a significant global public health issue and are the most common type of injury caused by animals. While most dog bites result in minor harm, they can also lead to severe or even fatal consequences. In cases involving serious injury or death, forensic pathologists investigate various aspects, including the crime scene, the injuries sustained by the victim, and the characteristics of the dog suspected to have caused the bite. The aim of this study is to provide a systematic review of the literature on the medical-legal implications of dog bites in forensic practice, in order to recognize the dog bite victim features, the injuries and their consequences related to, and to identify the offending dogs. The literature search was performed using PubMed, Scopus and Web of Science from January 1980 to March 2023. Eligible studies have investigated issues of interest to forensic medicine about dog bites to humans. A total of 116 studies met the inclusion criteria and were included in the review and they were organized and discussed by issue of interest (biting dog features, dog bite victim features, anatomical distribution of dog bites, injuries related to dog bites, cause of death, bite features, dog identification and post-mortem dog depredation). The findings of this systematic review highlight the importance of bite mark analysis in reconstructing the events leading to the attack and identifying the dog responsible. In medical forensic evaluations of dog bite cases, a multidisciplinary approach is crucial. This approach involves thorough analysis of the crime scene, identification of risk factors, examination of dog characteristics, and assessment of the victim's injuries. By combining expertise from both human and veterinary forensic fields, a comprehensive understanding can be achieved in dog bite cases.

Determination of ethyl glucuronide in hair and self-reported alcohol consumption in university students.

Young individuals constitute an intriguing population, as their drinking habits are notably shaped by their perception of their peers' alcohol consumption. Nonetheless, excessive alcohol intake can have detrimental effects on academic performance, interpersonal relationships, and the risk and severity of accidents. This study reported the first data involving students enrolled from three universities on a voluntary basis for alcohol consumption evaluation. Alcohol consumption was assessed through questionnaires and EtG quantification in hair (hEtG) carried out by liquid chromatography-mass spectrometry (LC-MS/MS) analysis after a solid-phase extraction (SPE) purification step. The results of our study demonstrated that 77.1% of samples tested negative for hEtG or displayed hEtG ≤ 5 pg/mg. Particularly, the student population was not characterized by samples with hEtG indicative of chronic excessive consumption (hEtG ≥ 30 pg/mg). No significant association was identified between biological sex, among the degree course/the year attended, nor in relation to BMI or smoking/coffee consumption. Among the obtained results, it was worth noting that the comparison of self-reporting abstinence from tobacco and coffee accounted for 65.3% and 16.7%, respectively, while only 2.8% of the total declared abstinence from alcohol. The current study has uncovered a significant level of interest among students in this analysis and its interpretation. This suggests that implementing public health promotion activities within a university setting could be beneficial.

An mRNA Profiling Study of Vaginal Swabs from Pre- and Postmenopausal Women.

Body fluid identification by means of mRNA profiling provides valuable supplementary information in forensic investigations. In particular, the detection of vaginal mucosa mRNA markers is highly relevant in sexual assault cases. Although the vagina undergoes characteristic age-related physiological changes over a lifetime, few studies have evaluated the efficacy of vaginal mRNA markers in women of different ages. In this multicentric study, a 19-plex mRNA profiling assay including vaginal-specific markers (CYP2B7P1, MUC4, MYOZ1) was tested in a collection of 6-20-month-old vaginal swabs obtained from pre- (n = 84) and postmenopausal (n = 55) female volunteer donors. Overall, participating laboratories were able to correctly identify ~85% of samples as vaginal mucosa by mRNA profiling. The assay's success rate did not differ between the two age groups and was not affected by the time interval between swab collection and RNA analysis. MYOZ1 resulted a less sensitive vaginal marker compared to MUC4 and CYP2B7P1. A significant relative increase in the contribution to the total amplification signal was observed for MUC4, compared to CYP2B7P1 and MYOZ1, in postmenopausal women. Observation of other body fluids and tissues different from vaginal mucosa was also evaluated in connection to information on previous sexual activity and menstrual cycle phase at the time of sampling.

Pembrolizumab-Induced Fatal Myasthenia, Myocarditis, and Myositis in a Patient with Metastatic Melanoma: Autopsy, Histological, and Immunohistochemical Findings-A Case Report and Literature Review.

Immune checkpoint inhibitors (ICIs) represent a major advance in cancer treatment. The lowered immune tolerance induced by ICIs brought to light a series of immune-related adverse events (irAEs). Pembrolizumab belongs to the ICI class and is a humanized IgG4 anti-PD-1 antibody that blocks the interaction between PD-1 and PD-L1. The ICI-related irAEs involving various organ systems and myocarditis are uncommon (incidence of 0.04% to 1.14%), but they are associated with a high reported mortality. Unlike idiopathic inflammatory myositis, ICI-related myositis has been reported to frequently co-occur with myocarditis. The triad of myasthenia, myositis, and myocarditis must not be underestimated as they can rapidly deteriorate, leading to death. Herein we report a case of a patient with metastatic melanoma who fatally developed myasthenia gravis, myocarditis, and myositis, after a single cycle of pembrolizumab. Considering evidence from the literature review, autopsy, histological, and immunohistochemical investigations on heart and skeletal muscle are presented and discussed, also from a medical-legal perspective.

A Genome-Wide Analysis of a Sudden Cardiac Death Cohort: Identifying Novel Target Variants in the Era of Molecular Autopsy.

Sudden cardiac death (SCD) is an unexpected natural death due to cardiac causes, usually happening within one hour of symptom manifestation or in individuals in good health up to 24 h before the event. Genomic screening has been increasingly applied as a useful approach to detecting the genetic variants that potentially contribute to SCD and helping the evaluation of SCD cases in the post-mortem setting. Our aim was to identify the genetic markers associated with SCD, which might enable its target screening and prevention. In this scope, a case-control analysis through the post-mortem genome-wide screening of 30 autopsy cases was performed. We identified a high number of novel genetic variants associated with SCD, of which 25 polymorphisms were consistent with a previous link to cardiovascular diseases. We ascertained that many genes have been already linked to cardiovascular system functioning and diseases and that the metabolisms most implicated in SCD are the lipid, cholesterol, arachidonic acid, and drug metabolisms, suggesting their roles as potential risk factors. Overall, the genetic variants pinpointed herein might be useful markers of SCD, but the novelty of these results requires further investigations.