A case of fatal multidrug intoxication involving flualprazolam: distribution in body fluids and solid tissues.

PURPOSE: Designer benzodiazepines (DBZDs) increasingly emerged on the novel psychoactive substance (NPS) market in the last few years. They are usually sold as readily available alternatives to prescription benzodiazepines (BZDs) or added to counterfeit medicines. BZDs are generally considered relatively safe drugs due to the low risk of serious acute adverse effects in mono-intoxication, though e.g., alprazolam seems to display an elevated risk of respiratory depression. Here we report on a fatal intoxication involving the novel DBZD flualprazolam. METHODS: A complete postmortem examination was performed. General unknown screenings and analysis of drugs of abuse were performed on postmortem samples by immunoassay, gas chromatography-mass spectrometry and liquid chromatography-mass spectrometry. The standard addition method was employed to quantify flualprazolam in postmortem blood and tissues. Finally, a toxicological significance score (TSS) was assigned. RESULTS: Flualprazolam was detected in heart serum (25.4 ng/mL) and peripheral blood (21.9 ng/mL) as well as in urine, stomach contents, brain, liver and kidney (65.2-323 ng/g). The cause of death was deemed as central nervous system (CNS) and respiratory depression with agonal aspiration of stomach contents, in the setting of a multiple drug intake. Given the concentration levels of the co-consumed CNS depressants, the contribution of flualprazolam to the death was considered likely (TSS of 3). CONCLUSIONS: Our results support that highly potent DBZDs like flualprazolam carry an elevated risk for unintended toxicity, especially in association with other CNS depressants. A multidisciplinary evaluation of fatalities remains mandatory, especially when pharmacological/toxicological data on intoxicating compounds are lacking. To our knowledge this is the first report of flualprazolam concentrations in solid tissues in human.

Arrow entrance wounds with blackened margins simulating bullet wipe.

Crossbows are ancient distance weapons, which in modern times have been largely replaced by guns. Nowadays, they are used for target shooting and in some countries also for hunting. Bolts/arrows fired from a crossbow have a rather low initial velocity but a high penetration capacity comparable to bullets shot from firearms. A considerable number of homicidal, suicidal, and accidental crossbow injuries have been reported up to the present day both under clinical and medicolegal aspects. A recent suicide case gave rise to a systematic study of entrance wounds from field-tipped arrows with shafts made of carbon. Composite models (ballistic gelatin covered with pig skin) served as targets. As found in the suicide case presented, the roundish entrance wounds were characterized by a slit-like severance of the skin surrounded by a pronounced blackish ring resembling the bullet wipe in gunshots. The material deposited circularly on the margins was subjected to the sodium rhodizonate test, SEM/EDX analysis, histological examination, and Raman spectroscopy. As expected, the elements typical of gunshot residues could not be detected. The element pattern of the black deposits was consistent with that of the arrows' tips and carbon shafts. Histological examination revealed that the carbonaceous material was deposited on the abraded wound margins suggesting a mechanism of friction causing the transfer of material. In conclusion, the presence of a black-margined roundish skin wound does not necessarily mean a bullet wipe. The casuistic part of the paper deals with a suicidal shot to the chest in a 48-year-old man, inflicted with a field-tipped carbon arrow which perforated both the heart and the thoracic aorta. In addition, a review of the literature on fatal crossbow injuries is presented.

The transcription factor c-Jun/AP-1 promotes liver fibrosis during non-alcoholic steatohepatitis by regulating Osteopontin expression.

Progression of non-alcoholic fatty liver disease (NAFLD) from steatosis to non-alcoholic steatohepatitis (NASH) is a key step of NASH pathogenesis. The AP-1 transcription factor c-Jun is an important regulator of hepatic stress responses, but its contribution to NASH pathogenesis remains poorly defined. We therefore addressed c-Jun expression in liver biopsies of patients with steatosis and NASH. The role of c-Jun during NASH pathogenesis was analyzed mechanistically in c-Jun mutant mice fed with a methionine- and choline-deficient diet (MCDD). Disease progression from steatosis to NASH in patients correlated with increased c-Jun expression in hepatocytes, while its expression in non-parenchymal liver cells (NPLCs) particularly correlated with fibrosis. Analysis of untreated and MCDD-fed mice lacking c-Jun in hepatocytes (c-Jun∆li) revealed that c-Jun promotes hepatocyte survival, thereby protecting against the regenerative ductular reaction (DR) of Sox9/Osteopontin (Opn) co-expressing NPLCs, expression of the Opn receptor CD44 and fibrosis, which were all exacerbated in c-Jun∆li mice. Since Opn and c-Jun were co-expressed by NPLCs in mice and patients with NASH, we wondered whether the increased fibrosis observed in c-Jun∆li mice could be rescued by additional c-Jun deletion in NPLCs (c-Jun∆li*). c-Jun∆li* mice with NASH indeed exhibited reduced expression of Opn and CD44 in NPLCs, impaired DR and reduced fibrosis. A similar phenotype was observed in Opn knockout mice, suggesting that the observed functions of c-Jun were indeed Opn-dependent. In conclusion, c-Jun expression correlates with disease progression from steatosis to NASH in patients and exerts cell-type-specific functions in mice: In hepatocytes, it promotes cell survival thereby limiting the DR and fibrogenesis. In NPLCs, it rather promotes the DR and fibrogenesis by regulating expression of Opn and CD44.

Rearward movement of the slide in semi-automatic pistols: a factor potentially influencing the configuration of muzzle imprint marks in contact shots.

A muzzle imprint mark is a highly diagnostic finding, which indicates a contact shot. In many cases, it also provides additional information on the type of the weapon used and on the way in which it was held at the time of firing. In semi-automatic pistols, some constructional elements constituting the muzzle plane move to the rear together with the slide, which may prevent them from causing a corresponding imprint close to the bullet entrance hole. The present study comprises 30 consecutive autopsy cases of fatal contact shots to the head inflicted with semi-automatic pistols. The imprint marks accompanying the entrance wounds were compared with the muzzle ends of the respective weapons both before and after retracting the slide. It turned out that in a considerable number of cases (3 out of 30), the retractable parts were not depicted or only to a minor degree as components of the imprint mark. In order to validate the presumed correlation, experimental shots were fired to composite models using pistols in which the movable and the stationary parts forming the muzzle plane were dyed with different paints. Thus, it could be demonstrated that the muzzle imprint preferentially mirrors the front sides of the stationary parts such as the barrel end, the recoil guide, and the gun housing. Immediately after discharge, the slide and the ballooning skin of the bullet entrance site move in the same direction. The stationary parts of the weapon block the expansion of the skin bulging towards the muzzle, so that the skin gets firmly pressed against them. The dynamic interaction between the gun and the entrance region resulting in a characteristic imprint mark could be visualized by the use of a high-speed motion camera recording test shots to different composite models.

The influence of the bullet shape on the width of abrasion collars and the size of gunshot entrance holes.

To investigate if there is any correlation between the bullet design and the respective dimensions of the abrasion collar and the skin defect in gunshot entrance wounds, experimental studies were performed on dyed pig skin. For the test shots, .38 Special revolver cartridges with three different bullet designs (round nose, wadcutter, and truncated cone) were used. With the help of an image editing program in combination with an image analyzing system, the area size of the abrasion rings and the skin defects was calculated automatically. The measured values differed significantly depending on the bullet type: the abrasion ring areas were largest in shots with round nose bullets and smallest with wadcutter projectiles. With regard to the entrance hole size, the relationship was inverse. The results are discussed with reference to the pertinent literature concerning the dynamic interaction between bullet and skin.

Electrothermic damage to the nail due to arcing in high-voltage discharge.

The burn effects in high-voltage electrocutions are manifold ranging from inconspicuous marks to deep charring. Apart from lesions caused by direct contact with a live conductor, the victim's body may suffer flash burns from arcing resulting in extensive scattered or confluent heat damage of the skin. In such cases, the nail plates of fingers and toes may undergo thermal changes which up to now have not been mentioned in the pertinent literature. Macroscopically, the nail shows a yellowish discoloration with tiny and closely arranged verruciform elevations. Histologically, the uppermost layer of the nail plate is interspersed with small vacuoles resembling micro-blisters as seen in the corneal layer of common electric marks. The surface of the nail is coated with a thin film of carbonaceous material. Based on an accidental high-voltage electrocution recently observed by the authors, attention is also drawn to the possible occurrence of contact burns from metal objects heated by the current as this finding is usually described only in victims of lightning strikes and not in the context of high-voltage discharges of technical electricity.

[Postmortem detection of accidental methadone intoxication in a 10-year-old girl]. / Postmortale Aufdeckung einer akzidentellen Methadon-Intoxikation bei einem 10-jährigen Mädchen.

Intoxications in children still account for a large part of the cases reported to poison control centres. Among drug intoxications, substitution drugs have gained in importance lately. Careless storage of take-home medications puts children living in the same household at risk. The authors report on a fatal case of a 10-year-old girl who died from intoxication with methadone belonging to a carer. The accidental intoxication had not been diagnosed at the hospital where the girl was treated for suspected meningitis. The question of medical malpractice is discussed.

Suicide by multiple blunt head traumatisation using a stone.

Apart from collisions with road or rail vehicles and falls from height, self inflicted blunt force is a rare suicide method and mainly seen in psychiatric patients. The paper presents a rare case of suicide by active blunt force. A 68-year-old man committed suicide by repeatedly hitting his head with a stone. He sustained a craniocerebral trauma and finally died from hypothermia due to the low outdoor temperature. According to the relatives, the man was not diagnosed with a mental disorder or suicidal tendencies. Uncommon manners of self-harm are challenging for those involved in the investigation, and a differentiation between suicide, accident and homicide can only be made in synopsis of all findings.

Intracranial impalement with entrance site in the mandibular region: postmortem elucidation of an accidental fall on a wooden plant stick.

A 78-year-old woman with a history of transient ischemic attacks was found in the doorway of her house in a somnolent and unresponsive condition. In the right mandibular region, a small skin wound was localized, which was surgically treated. Six days after admission to the hospital, an exploratory craniotomy was performed because of abnormal CT findings. Apart from tissue lesions and hemorrhages a small bone fragment was detected in the right cerebral cortex, which was removed. After 11 days in hospital, the patient died from failure of central regulatory functions. At the forensic autopsy, a 15 cm long wound track running upward from the skin wound in the right mandibular region through the bony skull base to the right parietal lobe of the brain was noted. Apparently, the surgically removed bone fragment had been displaced from the right middle cranial fossa. The site of the incident in the deceased's house was inspected again and a bamboo pole used to stabilize a potted plant standing on the floor was found and sent to the trace evidence laboratory. Analysis showed blood and tissue deposits from the victim. On the basis of all the findings and the circumstances of the case, a fatal impalement injury caused by an accidental fall could be assumed.

Ethyl sulphate and ethyl glucuronide in vitreous humor as postmortem evidence marker for ethanol consumption prior to death.

To clarify the circumstances of death, the degree of inebriation is of importance in many cases, but for several reasons the determination of the ethanol concentration in post-mortem samples can be challenging and the synopsis of ethanol and the direct consumption markers ethyl glucuronide (EtG) and ethyl sulphate (EtS) has proved to be useful. The use of a rather stable matrix like vitreous humor offers further advantages. The aim of this study was to determine the concentrations of ethanol and the biomarkers in the robust matrix of vitreous humor and to compare them with the respective levels in peripheral venous blood and urine. Samples of urine, blood from the femoral vein and vitreous humor were taken from 26 deceased with suspected ethanol consumption prior to death and analyzed for ethanol, EtS and EtG. In the urine samples creatinine was also determined. The personal data, the circumstances of death, the post-mortem interval and the information about ethanol consumption prior to death were recorded. EtG and EtS analysis in urine was performed by LC-ESI-MS/MS, creatinine concentration was determined using the Jaffé reaction and ethanol was detected by HS-GC-FID and by an ADH-based method. In general, the highest concentrations of the analytes were found in urine and showed statistical significance. The mean concentrations of EtG were 62.8mg/L (EtG100 206.5mg/L) in urine, 4.3mg/L in blood and 2.1mg/L in vitreous humor. EtS was found in the following mean concentrations: 54.6mg/L in urine (EtS100 123.1mg/L), 1.8mg/L in blood and 0.9mg/L in vitreous humor. Ethanol was detected in more vitreous humor samples (mean concentration 2.0g/kg) than in blood and urine (mean concentration 1.6g/kg and 2.1g/kg respectively). There was no correlation between the ethanol and the marker concentrations and no statistical conclusions could be drawn between the markers and matrices.

[Differential diagnostics of stomach contents showing blue discoloration]. / Zur Differentialdiagnose des blau Verfärbten Mageninhalts.

A 42-year-old man evidently had died from an intoxication. On the basis of the findings at scene it was primarily assumed that the man had ingested a larger quantity of an ethylene glycol-containing antifreeze for suicidal purposes. The man was said to have had an alcohol problem and did not only consume drinking alcohol, but also other alcoholic liquids. At autopsy, a bluish liquid with an aromatic smell was found in the oesophagus and stomach. However, toxicological analyses did not furnish evidence of ethylene glycol--as expected--but a potentially fatal concentration of ethanol (blood alcohol concentration 4.01 per mille). The blue colour (patent blue C.I.42051) came from a liquid used in the wind-screen washer system in winter, which now contains ethanol (denatured with 2-butanone) instead of ethylene glycol. The results of the toxicological findings including the analysis of congener alcohols and the differential diagnostics of blue-coloured stomach contents are discussed.

Hemorrhage from a cavernous hemangioma with fatal blood aspiration: A rare cause of sudden unexpected death.

Blood aspiration may be fatal, even when caused by a minor hemorrhage, and then it is important to localize and identify the source of bleeding in order to determine its origin as traumatic, spontaneous or iatrogenic. The present case deals with the clinically unexpected sudden death of a 73-year-old woman who underwent pulmonary artery catheterization (PAC) 11 days before because of known pulmonary hypertension. The forensic autopsy revealed a previously undiagnosed cavernous hemangioma of the right lung which had led to a local intrapulmonary hemorrhage with secondary bleeding into the bronchial tree. The fatal blood aspiration was preceded by recurrent episodes of hemoptysis, and its occurrence was probably promoted by the pre-existing pulmonary hypertension. The present case and other reports in the medical literature suggest that vessel malformations of the lung have to be considered as a potential cause of unexpected sudden death. Careful investigation is needed for post-mortem identification of the bleeding site.

Urine tested positive for ethyl glucuronide and ethyl sulfate after the consumption of yeast and sugar.

BACKGROUND: To an increasing degree, EtG and EtS are routinely used for the proof of abstinence for purposes of traffic, occupational, addiction and social medicine. This routine use demands further investigations on the sensitivity and specificity of these analytes and the examination of possible genesis of positive EtG and EtS concentrations even without the consumption of ethanol. In vivo fermentation with consecutive formation of EtG and EtS was addressed by experiments with yeast products. METHODS: Two experiments with baker's yeast and brewer's yeast tablets were performed. The ethanol concentrations in urine of the 2 and 4 volunteers, respectively, were detected by HS-GC-FID, EtG and EtS analysis was performed by LC-ESI-MS/MS, and the creatinine concentration was determined using a method based on the Jaffé reaction. RESULTS AND CONCLUSIONS: After the consumption of baker's yeast the maximum concentrations of EtG and EtS normalised to creatinine were found to be 0.67 and 1.41mg/L, respectively, and therefore clearly above the commonly applied cut-off value for the proof of abstinence of 0.1mg/L. In contrast, in this study the, uptake of yeast tablets did not result in a detection of EtG and EtS in urine.

Urine tested positive for ethyl glucuronide and ethyl sulphate after the consumption of "non-alcoholic" beer.

In abstinence maintenance programs, for reissuing the driving licence and in workplace monitoring programs abstinence from ethanol and its proof are demanded. Various monitoring programs that mainly use ethyl glucuronide (EtG) as alcohol consumption marker have been established. To abstain from ethanol, but not from the taste of alcoholic beverages, in particular non-alcoholic beer has become more and more popular. In Germany, these "alcohol-free" beverages may still have an ethanol content of up to 0.5vol.% without the duty of declaration. Due to severe negative consequences resulting from positive EtG tests, a drinking experiment with 2.5L of non-alcoholic beer per person was performed to address the question of measurable concentrations of the direct metabolites EtG and EtS (ethyl sulphate) in urine and blood. Both alcohol consumption markers - determined by LC-MS/MS - were found in high concentrations: maximum concentrations in urine found in three volunteers were EtG 0.30-0.87mg/L and EtS 0.04-0.07mg/L, i.e., above the often applied cut-off value for the proof of abstinence of 0.1mg EtG/L. In the urine samples of one further volunteer, EtG and EtS concentrations cumulated over-night and reached up to 14.1mg/L EtG and 16.1mg/L EtS in the next morning's urine. Ethanol concentrations in blood and urine samples were negative (determined by HS-GC-FID and by an ADH-based method).

Secondary skull fractures in head wounds inflicted by captive bolt guns: autopsy findings and experimental simulation.

Apart from one article published by Rabl and Sigrist in 1992 (Rechtsmedizin 2:156-158), there are no further reports on secondary skull fractures in shots from captive bolt guns. Up to now, the pertinent literature places particular emphasis on the absence of indirect lesions away from the impact point, when dealing with the wounding capacity of slaughterer's guns. The recent observation of two suicidal head injuries accompanied by skull fractures far away from the bolt's path gave occasion to experimental studies using simulants (glycerin soap, balls from gelatin) and skull­brain models. As far as ballistic soap was concerned, the dimensions of the bolt's channel were assessed by multi-slice computed tomography before cutting the blocks open. The test shots to gelatin balls and to skull-brain models were documented by means of a high-speed motion camera. As expected, the typical temporary cavity effect of bullets fired from conventional guns could not be observed when captive bolt stunners were discharged. Nevertheless, the visualized transfer of kinetic energy justifies the assumption that the secondary fractures seen in thin parts of the skull were caused by a hydraulic burst effect.

Immunohistochemistry of catecholamines in the hypothalamic-pituitary-adrenal system with special regard to fatal hypothermia and hyperthermia.

Catecholamines are involved in various stress responses. Previous studies have suggested applicability of the postmortem blood levels to investigations of physical stress responses or toxic/hyperthermic neuronal dysfunction during death process. The present study investigated cellular immunopositivity for adrenaline (Adr), noradrenaline (Nad) and dopamine (DA) in the hypothalamus, adenohypophysis and adrenal medulla with special regard to fatal hypothermia (cold exposure) and hyperthermia (heat stroke) to examine forensic pathological significance. Medicolegal autopsy cases (n=290, within 3 days postmortem) were examined. The proportions of catecholamine (Adr, Nad and DA)-positive cells (% positivity) in each tissue were quantitatively estimated using immunostaining. Hyperthermia cases (n=12) showed a lower neuronal DA-immunopositivity in the hypothalamus than hypothermia cases (n=20), while Nad- and DA-immunopositivities in the adrenal medulla were higher for hyperthermia than for hypothermia. Rates of Nad-immunopositivity in the adrenal medulla were very low for hypothermia. No such difference between hypothermia and hyperthermia was seen in the adenohypophysis. In hypothermia cases, cellular Nad-immunopositivity in the adrenal medulla correlated with the Nad level in cerebrospinal fluid (r=0.591, p<0.01). These observations suggest a characteristic immunohistochemical pattern of systemic stress response to fatal hypothermia and hyperthermia, involving the hypothalamus and adrenal medulla.

Medicolegal evaluation of suicidal deaths exemplified by the situation in Germany.

Suicide is a significant form of unnatural death and must be differentiated as such from other violent manners of death (homicide, accident), but also from unexpected deaths due to natural causes. The distinction is made on the basis of a careful collection and correct interpretation of post-mortem forensic findings on the one hand, the general background of the case and the criminal investigation at the scene on the other. For competent assessment by the post-mortem medical examiner and/or forensic pathologist, a thorough knowledge of the numerous methods of committing suicide and their pathomorphological correlates is indispensable. This not only includes the constellation of findings and injury patterns typical of suicide, but also unusual manifestations. Highly conspicuous are complex suicides, in which several methods are applied simultaneously, or one after the other, as well as joint suicides and homicide-suicides involving several persons. Certain settings also deserve special attention. Moreover, simulated or dissimulated suicide is a possibility that must always be borne in mind in forensic practice.

[Confusing injury findings in a suicidal gunshot fired to the chest from a carbine with a sawed-off barrel]. / Irritierende Verletzungsbefunde bei einem suizidalen Brustschuss aus einem Karabiner mit gekürztem Lauf.

The stellate bullet entrance wound is one of the facultative features of a contact shot. For the formation of a star-shaped wound two factors are of special importance: first, an extensive bony support underlying the skin in the entrance region, and second, a strong propellant charge of the cartridge fired. Contact shots to the precordial region usually do not cause stellate entrance wounds, even if high-powered rifle ammunition is used. In the reported case, an injury pattern was observed that was not in line with normal findings and seemed confusing at first. Following a suicidal gunshot to the chest from a sawed-off carbine 98a (cal. 8 x 57 Js), a 4.5 cm wide, gaping bullet entrance wound with radiating tears was found. Instead of the usual pocket, the anterior thoracic wall showed a fist-sized area of destruction with extensive undermining of the subcutis. Not far from the entrance hole, a rib fragment had become displaced retrogradely thus perforating the skin from the inside out. The unusual pattern of findings could be explained by the fact that the barrel had been sawed off: as a result of this manipulation, a considerable part of the propellant charge had been converted outside the barrel, i.e. in the initial section of the bullet path.

[Suicide with multiple graze shots]. / Suizid mit multiplen Streifschussverletzungen.

A 77-year-old man was found in his flat with a shot to the right temple. In spite of hospital treatment he died from the head injury the next day. The weapon at the scene used for committing the suicide was a pistol, make Kaba Special (calibre 6.35 mm). At autopsy, the right temporal region showed a surgically treated, originally stellate gunshot entrance wound with a powder cavity. Close to this penetrating gunshot wound there were 3 parallel graze shot injuries of the scalp. The autopsy findings were consistent with the assumption that all the shots had been fired by the victim himself with suicidal intent. The injury pattern is presented and discussed in relation to the results of the technical investigation of the weapon and the findings at the scene.

[Homicide with postmortem opening of the thoracic and abdominal cavity--morphological, criminological and forensic-psychiatric aspects]. / Tötungsdelikt mit postmortaler Offnung von Brust- und Bauchhöhle--morphologische, kriminalistische und forensisch-psychiatrische Aspekte.

During a walk a man found the partially unclothed body of a 16-year-old girl in a field near a village in South Baden. The body showed numerous injuries caused by sharp force. Several stab wounds were discernible on the neck, the chest, the genital region, the back and the right thigh. Postmortem, the anterior wall of the trunk had been severed with one long cut reaching from the mons pubis to the jugular fossa. The injuries and the scene suggested homicide with a sexual motive. Already on the next day a male suspect was ascertained. Blood traces of the victim could be demonstrated on his car. The man confessed the homicide, but did not describe the course of events in detail. He denied a sexual motive for the homicide. The psychiatric examination did not furnish any clues to internal, neurological or psychiatric disorders. The perpetrator did not claim intoxication for the time of the offence, which might have been relevant for the question of criminal responsibility. Psychodiagnostically, it was found that he had a narcissistic personality structure with a pronounced lack of self-esteem, deficits in affect processing and control as well as anxiety and aggression problems. The man was sentenced to life imprisonment for murder.