Determination of Δ9-tetrahydrocannabinol, 11-nor-carboxy-Δ9-tetrahydrocannabinol and cannabidiol in human plasma and urine after a commercial cannabidiol oil product intake.

PURPOSE: Cannabidiol (CBD) products are widely used for pain relief, sleep improvement, management of seizures etc. Although the concentrations of Δ9-tetrahydrocannabinol (Δ9-THC) in these products are low (≤0.3% w/w), it is important to investigate if its presence and/or that of its metabolite 11-nor-carboxy-Δ9-THC, is traceable in plasma and urine samples of individuals who take CBD oil products. METHODS: A sensitive GC/MS method for the determination of Δ9-THC, 11-nor-carboxy-Δ9-THC and CBD in plasma and urine samples was developed and validated. The sample preparation procedure included protein precipitation for plasma samples and hydrolysis for urine samples, solid-phase extraction and finally derivatization with N,O-bis(trimethylsilyl)trifluoroacetamide) with 1% trimethylchlorosilane. RESULTS: For all analytes, the LOD and LOQ were 0.06 and 0.20 ng/mL, respectively. The calibration curves were linear (R2 ≥ 0.992), and absolute recoveries were ≥91.7%. Accuracy and precision were within the accepted range. From the analysis of biologic samples of 10 human participants who were taking CBD oil, it was realized that Δ9-THC was not detected in urine, while 11-nor-carboxy-Δ9-THC (0.69-23.06 ng/mL) and CBD (0.29-96.78 ng/mL) were found in all urine samples. Regarding plasma samples, Δ9-THC (0.21-0.62 ng/mL) was detected in 10, 11-nor-carboxy-Δ9-THC (0.20-2.44 ng/mL) in 35, while CBD (0.20-1.58 ng/mL) in 25 out of 38 samples, respectively. CONCLUSION: The results showed that Δ9-THC is likely to be found in plasma although at low concentrations. In addition, the detection of 11-nor-carboxy-Δ9-THC in both urine and plasma samples raises questions and concerns for the proper interpretation of toxicological results, especially considering Greece's zero tolerance law applied in DUID and workplace cases.

Domestic and Community Violence in Greece After the First COVID-19 Quarantine: A Clinical Forensic Approach.

Many scientists expressed their concerns regarding the impact of COVID-19-related quarantine measures on interpersonal violence, mainly concerning children and intimate partners, as well as other negative psychological effects. During early 2020, free circulation in Greece was prohibited for 42 days, up until May 4th. The aim of our study was to investigate characteristics of bodily harm allegation cases referred to the Department of Forensic Medicine and Toxicology of the Medical School of the National and Kapodistrian University of Athens, Greece, during the first month succeeding free circulation re-establishment in the broader Attica region. We also aimed to detect any possible differences regarding bodily harm allegations by comparing the corresponding time period of 2019. A decrease in community violence (CV) allegations, especially youth violence incidents, was observed in 2020. Females' victimization, as well as allegations against strangers, were also decreased. No differences were observed concerning the injury mechanism. Victims of 2020 filed the allegations faster and, thus, were examined almost one day earlier than their 2019 counterparts. During lockdown, domestic violence (DV) hotline reporting was significantly increased, but paradoxically DV cases referred to our Department were decreased. In Greece, the legislators did not foresee any specific exemption from circulation restriction for DV victims attempting to escape abuse. Our results revealed a small, but notable, impact on non-fatal interpersonal violence.

The Anaphylactoid Syndrome of Pregnancy: Two Autopsy Cases.

The anaphylactoid syndrome of pregnancy (ASP) is a rare emergency with significant mortality and morbidity, in which the amniotic fluid and fetal cells enter the maternal circulation leading to respiratory failure, altered mental status, hypotension, and disseminated intravascular coagulation. The term ASP was recently introduced to replace the term amniotic fluid embolism since the clinical manifestations of the entity were more similar to a septic or anaphylactic shock rather than that of an embolic event. Two autopsy cases are described, regarding a 35-year-old gravida 2 para 1 and a 34-year-old gravida 1 para 0, where the cause of death was determined to be ASP.

Infant Pneumonitis Due to a Tracheoesophageal Fistula: A Presentation of Two Autopsy Cases.

Both esophageal atresia (EA) and tracheoesophageal fistula (TEF) represent a rather uncommon congenital abnormality that is the result of abnormal tracheoesophageal organogenesis. Although EA, with or without TEF, is relatively uncommon, it represents the most common upper gastrointestinal birth defect. Esophageal atresia and tracheoesophageal fistula are anatomically classified into five types according to the Gross classification (types A, B, C, D, E/H). As in type E/H, the continuity of the esophagus is not interrupted, the symptom onset is consequently delayed, and therefore diagnosis is difficult. Aspiration pneumonitis is a chemical injury caused by inhaled sterile gastric contents, while aspiration pneumonia is, in part, an infectious process because the inhaled oropharyngeal secretions are rich in bacteria. This paper aims to report two infant autopsy cases of aspiration pneumonitis with TEF involvement. The main histopathological finding was interstitial pneumonitis. Upon histopathological examination, lymphocytes, plasma cells, and macrophages were discovered on the alveolar walls, which were compatible with the chemical origin of interstitial pneumonitis. No eosinophils were detected; therefore, hypersensitivity-originating interstitial pneumonitis was ruled out. The cause of death in both cases was interstitial pneumonitis.

Ballistic Simulation of a Head Wound Inflicted by a Homemade Gun Used in a Suicide Case.

Homemade guns may inflict serious injuries mainly depending on the shooting distance. A case of a male victim discovered dead with a head wound thought to be inflicted by a homemade gun firing modified ammunition is presented. Upon completion of the postmortem examination, the question of whether the homemade gun recovered on site was able to inflict such a wound arose. An experimental approach was employed to evaluate the ballistic characteristics and wounding pattern of the homemade gun and then compare it with the actual case. Ballistic gelatin with an incorporated bone simulant was used to model and approximate the behavior of the projectile when striking and penetrating the victim's head. The retention of the bullets' path in gelatin was verified through experimental shootings using the same homemade gun and similar type of projectiles. Analysis of the experimental shootings allowed for improved observation and documentation of the wounding pattern, thus confirming the initial hypothesis that the recovered homemade gun did in fact inflict the wound observed during the autopsy of the victim.

Non-Fatal Attacks by Dogs: Characteristics of Victims and Attacking Dogs, From the Forensic Perspective: A Series of 106 Cases From Athens, Greece, and Brief Review of the Literature.

INTRODUCTION: The close association of dogs with humans may explain the fact that dog bites are possibly the most common animal bites recorded. The relevant data concerning Greece is scarce. We aimed to study this phenomenon by describing its characteristics. METHODS: We performed a retrospective analysis of cases concerning dog attack victims, examined our Department, between 2011 and 2019. Recorded variables included sex, age, nationality, occupation, marital status, medical history, ownership status of the dog, injury anatomic location, incident time, the timing of clinical forensic examination, incapacitation time, and medical care provided. Statistical analysis was performed using Stata/MP 13 (Stata Corp., College Station, TX) and IBM SPSS Statistics Version 20 (IBM, Armonk, NY). Statistical significance was defined as a two-sided p value of <0.05. RESULTS: Most incidents involved male victims (54.2%). The victim's mean age was 44.9 years. The dog involved was unowned in 19.8% of cases. The most frequent anatomical site of injury was the legs (48.1%). Older victims suffered injuries in more sensitive areas of the body (head and neck), when compared to younger adults. Only 1.9% of victims required hospitalization. The mean incapacitation time was estimated at 5.39 days. CONCLUSIONS: Per our results, males tend more often to be victims of dog attacks. Typically, victims are of increased age and are attacked by a dog already known to them. Most incidents take place during late winter and spring, more specifically during February and during May. The most frequently affected anatomical sites were the legs. Older people suffered injuries in more sensitive areas of the body.

Cardiac Involvement and Subsequent Death due to Extranodal NK/T Cell Cutaneous T-Cell Lymphoma: An Autopsy Case and Brief Review of the Literature.

Cardiac tumors range from benign to high grade malignancies. The incidence of cardiac involvement either by primary, or secondary tumors during autopsy is reported to be extremely low. Extranodal NK/T-cell lymphoma (ENKTL), nasal type is an unusual type of lymphoma. The skin is the second most common site of involvement after the respiratory tract. We present a case of a 63-year-old male, who was recently diagnosed with ENKTL, nasal type, who received chemotherapy, and died without any evident cause. The corpse was referred for routine medicolegal examination. Macroscopical determination of the cause of death was not feasible and subsequent histopathological examination revealed heart infiltration by ENKTL that was found in vivo in cutaneous lesions. Similar infiltrations existed in the pancreatic tissue. To the best of our knowledge, myocardial infiltration of ENKTL, inducing severe myocardial lesions that eventually caused death, is rare, with limited cases reported in the literature.

Interpersonal Violence Against Children and Adolescents: A Forensic Study From Greece.

OBJECTIVE: To investigate differences in victimization of minors after allegations of domestic violence and community violence. METHODS: This retrospective study was conducted by reviewing the archive of clinical examinations after allegations for interpersonal violence against minors that were performed at the Department of Forensic Medicine and Toxicology of our Medical School from 2012 to 2016. RESULTS: 216 cases of allegations for victimization of minors' were referred to our department, representing 8.8% of all clinical forensic examinations. Boys community violence victims were affected mainly on the head, whilst girls mainly on the genital area. Upper limbs were the predominant site of injuries on domestic violence victims of both sexes. CONCLUSIONS: Adolescents were in greater danger of sustaining injuries than younger children. Upper limb injuries may prove to be a useful screening tool for domestic violence in school-age children and adolescents, while trunk injuries may indicate domestic violence in preschool children.

Biological rhythms of fatal myocardial infarction in Greece: an autopsy study.

BACKGROUND: Biological rhythms, acting as an endogenous clock, prepare and assist the organism to function optimally during predictable seasonal and daily cycles. Many elements of the cardiovascular system exhibit specific rhythmical patterns. Besides genetic mechanisms, external stimuli may alter biological rhythms. METHODS: The aim of this study was to investigate the patterns of biological rhythms in patients who suffered a fatal myocardial Infarction (MI), ascertained by macroscopical or histopathological examination. Cases of fatal MI examined during the time 2010-2017 were included in our study sample (827 cases in total). Medical History was also obtained for each case. The assessment of seasonal variation of fatal MI was accomplished by employing three different methods, Rayleigh Uniformity Test, X2 Goodness-of-fit test and Edward's Seasonality Test. Statistical significance was defined as a 2-sided p value of <0.05. RESULTS: Regarding the distribution of total cases, fatal MIs onset occurs more often during winter, with higher incidence in December and January. The weekly distribution of cases seems uniform. The circadian pattern presents higher frequencies of fatal MIs between 08:00 and 12:00 with the acrophase between 11:00 and 12:00. Further analysis was conducted separately, depending on the method of time-of-death reporting. CONCLUSIONS: Taking under consideration the variation of the occurrence of MI related deaths, in accordance with the respective biological rhythms, public health policies more suitable to the individual requirements of every country's population may be adopted.

Impact of Covid-19 lockdown on characteristics of autopsy cases in Greece. Comparison between 2019 and 2020.

In order to reduce transmission of COVID-19, social distancing measures were proposed, including spatial distancing (2m distance), or even generalized lockdown. Main concern was to prevent overwhelming of the healthcare systems, mainly of the intensive care units (ICUs) by decreasing the spreading of the disease. In Greece, the Government, after consulting with experts in the fields of infectious disease and epidemiology, implemented a rather aggressive stance with an early lockdown. Aim of our study, is to identify and compare the characteristics of cases referred for autopsy during the first month of the lockdown period for the COVID-19 outbreak, versus the cases referred during the same period in 2019. 231 autopsy cases were included in our study, 125 in 2019 and 106 in 2020. Regarding gender, age and nationality, no significant differences were detected between the two time periods. Age subgroup analysis demonstrated increased number of cases within the age group 70-79 years, in 2020. As to the place of death, the increase in the percentage of out-of-hospital deaths was not confirmed as statistically significant. Regarding type of death (violent, sudden/unexpected), the drop of violent deaths in the 2020 examined period, was not confirmed as statistically significant; however, further subgroup analysis showed a significant drop of fatal injuries resulting from road traffic accidents in the 2020 period. The slight increase of sudden/unexpected deaths, especially myocardial infarction cases, did not reach statistical significance. One month after lockdown, we cannot detect significant differences in the two time periods examined. Further study should be conducted soon when more data will become available. Frequency of fatal myocardial infarction seems to remain unaffected by the COVID-19 pandemic while deaths resulting from road traffic accidents exhibit a significant decrease. Homicides and suicides remain at low levels, in our jurisdiction area, seemingly unaffected by the COVID-19 outbreak and the subsequent lockdown. It appears that since sudden/unexpected deaths, statistically remain unaffected, the preventive measures taken by the Greek authorities prevented overwhelming of the healthcare system, which could function properly.

Intimate partner violence in Greece: a study of 664 consecutive forensic clinical examinations.

BACKGROUND: Intimate partner violence (IPV) is a well-known phenomenon, which affects mostly women. While IPV victims may attend emergency departments (EDs) seeking medical care, not all of them will make an allegation against their abusers. OBJECTIVE: The aim of this study was to examine the prevalence and the characteristics of the victims, who had made an allegation about the violent incident and had been examined by a forensic pathologist for judicial purposes, and had attended EDs seeking medical care, before the forensic examination. METHODS: We reviewed the archives of clinical examinations that were conducted at the Department of Forensic Medicine and Toxicology of National and Kapodistrian University of Athens during a 5-year period (2012-16). RESULTS: Six hundred sixty-four clinical examinations were conducted at our Department for IPV allegations. According to our findings, women were more likely to seek medical care than men. Victims who have attended EDs were more likely to have sustained injuries located at least on the head or on the lower limbs. CONCLUSION: The majority of IPV victims in the broader region of Attica (Greece) were women, usually married, and aged between 30 and 49 years old. Despite the fact that the majority of IPV incidents are not reported to police, every person who is engaged in the process of dealing with IPV victims has to be educated and adequately informed about this phenomenon, its implications and the possible ways to deal with it. Furthermore, victims need to be educated and informed adequately in waiting rooms of EDs.

Traumatic complete outer ear amputation by human bite, a forensic case report and review of the literature.

We present a case of a complete external ear amputation, caused by a human bite, that took place during a quarrel in a local farmers' market. The male victim was transferred to the Hospital. After surgical reattachment of the auricle, a forensic clinical examination was performed, as per legal obligation. During examination, the victim was found to have sustained: contusions of the orbital regions (lower eyelids), bilaterally, soft tissue oedema of the forehead (to the left of the middle line), and contusion of the right neck area. He also sustained multiple soft tissue injuries (contusions, abrasions) on the torso and on both upper and lower extremities. Clinical forensic examination of human bite injuries requires thorough description of the wound, proper photography and possibly collection of swabs for DNA identification (in case of unknown perpetrator). Nevertheless, the Forensic Pathologist is often required to perform clinical examination, only after medical care has been provided. Therefore, clinicians should be aware of the need of proper documentation and act accordingly.

Unusual Elevator-Related Deaths: A Report of Two Cases.

We present two cases of elevator-related deaths that occurred in two different elevators, and deaths were caused by a similar, but unusual, mechanism. An elevator is a platform or compartment housed in a shaft for raising and lowering people or things to different levels. Elevator-related deaths and injuries are rarely reported in the literature. In most of these cases, cause of death was attributed to falls. It seems that most of the elevator accidents may be attributed to factors related to device maintenance inadequacies or even to device malfunctioning. In our cases, both elevator cars were not equipped with full-length inner doors, thus allowing both accidents to occur. Since 2014, the European Union adopted a relative directive, which imposes the need to equip all elevators with such full-length doors. The enforcement of the above-mentioned EU Directive is crucial, in order to prevent similar accidents in the future.

Death by Ram Attack: A Case Report from Greece and a Brief Review of the Literature.

A case of a ram attack that caused injuries to a 73-year-old man is presented. The deceased survived the attack and had the opportunity to speak with a friend over the phone before being transferred to the hospital. After a 21-day hospitalization, the patient passed away. A postmortem examination was performed to ascertain the cause of death. The autopsy findings are presented along with a brief review of the literature. Attacks by agricultural animals (or livestock) around the world are reported in the scientific literature. Fatalities from ram attacks are extremely rare. The need to implement specific codes in the ICD system, relevant to each animal attack, appears to be of great importance, in order to allow tracking of animal-related deaths.

Does history of childhood maltreatment make a difference in prison? A hierarchical approach on early family events and personality traits.

This study attempts to assess childhood maltreatment in prison through a hierarchical approach. The hierarchical approach principally aims to disentangle the independent effects of childhood maltreatment upon psychiatric morbidity/personality traits, if any, from the burden that the adverse family conditions have already imposed to the mental health of the maltreated individual-prisoner. To this direction, a conceptual framework with five hierarchical levels was constructed, namely: immutable demographic factors; family conditions; childhood maltreatment (physical abuse, neglect and sexual abuse); personality traits, habits and psychiatric morbidity; prison-related variables. A self-administered, anonymous set (battery) of questionnaires was administered to 173 male prisoners in the Chalkida prison, Greece; 26% of prisoners disclosed childhood maltreatment. Psychiatric condition in the family, parental alcoholism and parental divorce correlated with childhood maltreatment. After adjustment for immutable demographic factors and family conditions, childhood maltreatment was associated with aggression (both in terms of Lifetime History of Aggression and Buss­Perry Aggression Questionnaire scores), illicit substance use, personal history of psychiatric condition, current smoking, impulsivity and alcohol abuse. In conclusion, childhood maltreatment represents a pivotal, determining factor in the life course of male prisoners. Delinquents seem to suffer from long-term consequences of childhood maltreatment in terms of numerous mental health aspects.

Current aspects of penal surgical liability in Greece.

The surgeon may face in every day practice issues that may render him liable. The legal liability usually emerges due to the negligence exhibited during the preoperative, the operative and the postoperative stage. The surgeon, as any doctor, isn't liable for the result, but he is responsible for the correct diagnosis and therapeutic treatment, always according to the principles of the Medical science and to the possibilities available to him in every specific case (facilities and time). The continuous education about the issues of his speciality, the adaptation of scientifically approved techniques, the correct monitoring of the patient, both preoperatively and postoperatively, and finally the good communication with the patient are necessary for the proper practice of Medicine; but also constitute the "shield" of the surgeon against any possible legal conflict.

Smoking in prison: a hierarchical approach at the crossroad of personality and childhood events.

BACKGROUND: Smoking has long been considered part of prison culture and studies have shown a high prevalence of smoking within correctional facilities. METHODS: A self-administered, anonymous questionnaire was administered to 173 male prisoners in the Chalkida prison, Greece. To assess current smoking habits, a hierarchical approach was adopted. The underlying conceptual framework included: (i) demographic parameters, (ii) adverse childhood history (physical abuse, parental neglect, parental divorce, alcoholism in the family, sexual abuse and psychiatric condition in the family), (iii) education, personality traits, such as impulsivity (Barrat Impulsivity Scale-11), aggression (Buss-Perry Aggression Questionnaire and Lifetime History of Aggression), and personal history of mental disease, (iv) prison-related features (duration of sentence, sentence already served and change in smoking habits during imprisonment). RESULTS: Eighty percentage of the study sample reported current smoking; 43.4% disclosed deterioration in their smoking habits during imprisonment. The hierarchical approach pointed to: (i) adverse childhood events, i.e. alcoholism in the family [adjusted odds ratio (OR) = 6.29, 95% confidence interval (CI): 2.44-16.25], psychiatric condition in the family (adjusted OR = 4.10, 95% CI: 1.31-12.84), physical abuse (adjusted OR = 2.90, 95% CI: 1.30-6.46), parental neglect (adjusted OR = 2.66, 95% CI: 1.19-5.95), parental divorce (adjusted OR = 2.14, 95% CI: 1.00-4.56), and (ii) impulsivity (adjusted OR = 2.26, 95% CI: 1.12-4.58) as independent risk factors. In addition, deterioration of smoking habits during imprisonment exerted an effect of borderline significance (adjusted OR = 2.02, 95% CI: 0.97-4.24). CONCLUSIONS: Heavy smoking in prison principally integrates two components: unfavourable childhood and current personality traits (impulsivity).

Forensic investigation of child victim with sexual abuse.

Sexual abuse includes any activity with a child, before the age of legal consent, that is for the sexual gratification of an adult or a significantly older child. Sexual mistreatment of children by family members (incest) and nonrelatives known to the child is the most common type of sexual abuse. Intrafamiliar sexual abuse is difficult to document and manage, because the child must be protected from additional abuse and coercion not to reveal or to deny the abuse, while attempts are made to preserve the family unit. The role of a comprehensive forensic medical examination is of major importance in the full investigation of such cases and the building of an effective prosecution in the court. The protection of the sexually abused child from any additional emotional trauma during the physical examination is of great importance. A brief assessment of the developmental, behavioral, mental and emotional status should also be obtained. The physical examination includes inspection of the whole body with special attention to the mouth, breasts, genitals, perineal region, buttocks and anus. The next concern for the doctor is the collection of biologic evidence, provided that the alleged sexual abuse has occurred within the last 72 hours. Cultures and serologic tests for sexually transmitted diseases are decided by the doctor according to the special circumstances of each case. Pregnancy test should also be performed in each case of a girl in reproductive age.