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.

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.

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.

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.

The Evaluation of CYP2D6, CYP2C9, CYP2C19, and CYP2B6 Phenoconversion in Post-Mortem Casework: The Challenge of Forensic Toxicogenetics.

In toxicogenetics, an integrative approach including the prediction of phenotype based on post-mortem genotyping of drug-metabolising enzymes might help explain the cause of death (CoD) and manner of death (MoD). The use of concomitant drugs, however, might lead to phenoconversion, a mismatch between the phenotype based on the genotype and the metabolic profile actually observed after phenoconversion. The aim of our study was to evaluate the phenoconversion of CYP2D6, CYP2C9, CYP2C19, and CYP2B6 drug-metabolising enzymes in a series of autopsy cases tested positive for drugs that are substrates, inducers, or inhibitors of these enzymes. Our results showed a high rate of phenoconversion for all enzymes and a statistically significant higher frequency of poor and intermediate metabolisers for CYP2D6, CYP2C9, and CYP2C19 after phenoconversion. No association was found between phenotypes and CoD or MoD, suggesting that, although phenoconversion might be useful for a forensic toxicogenetics approach, more research is needed to overcome the challenges arising from the post-mortem setting.

Quantification of Carbonic Anhydrase Inhibitors and Metabolites in Urine and Hair of Patients and Their Relatives.

Carbonic anhydrase inhibitors (CAIs) are prescription drugs also used in doping to dilute urine samples and tamper with urinalyses. Dorzolamide, brinzolamide, and acetazolamide are prohibited by the World Anti-Doping Agency. Detecting CAIs and their metabolites in biological samples is crucial to documenting misuse in doping. We quantified dorzolamide, brinzolamide, acetazolamide, and their metabolites in the urine and hair of 88 patients under treatment for ocular hypertension or glaucoma. Samples of the patients' relatives were analyzed to assess potential for accidental exposure. After washing, 25 mg hair was incubated with an acidic buffer at 100 °C for 1 h. After cooling and centrifugation, the supernatant was analyzed by ultra-high-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS). Urine (100 µL) was diluted and centrifuged before UHPLC-MS/MS analysis. Run time was 8 min through a reverse-phase column with a mobile phase gradient. MS/MS analysis was performed in a multiple-reaction monitoring mode after positive electrospray ionization. Median urinary concentration was 245 ng/mL (IQR: 116.2-501 ng/mL) for dorzolamide, 81.1 ng/mL (IQR: 35.9-125.3 ng/mL) for N-deethyl-dorzolamide, 0.77 ng/mL (IQR: 0.64 ng/mL-0.84 ng/mL) for N-acetyl-dorzolamide, 38.9 ng/mL (IQR: 20.4-79.2 ng/mL) for brinzolamide, and 72.8 ng/mL (IQR: 20.7-437.3 ng/mL) for acetazolamide. Median hair concentration was 0.48 ng/mg (IQR: 0.1-0.98 ng/mg) for dorzolamide, 0.07 ng/mg (IQR: 0.06-0.08 ng/mg) for N-deethyl-dorzolamide, 0.40 ng/mL (IQR: 0.13-1.95 ng/mL) for brinzolamide. Acetazolamide was detected in only one hair sample. Dorzolamide and brinzolamide were detected in the urine of three and one relatives, respectively. Cutoff concentrations of urinary dorzolamide and brinzolamide are necessary to preclude false positives due to contamination or passive exposure. We reported the first concentrations of brinzolamide in hair.

Development and validation of a fast ultra-high-performance liquid chromatography tandem mass spectrometry method for determining carbonic anhydrase inhibitors and their metabolites in urine and hair.

A new, rapid, sensitive, and comprehensive ultra-high-performance liquid chromatography tandem mass spectrometry (UHPLC-MS/MS) method for quantifying diuretics (acetazolamide, brinzolamide, dorzolamide, and their metabolites) in human urine and hair was developed and fully validated. Twenty-five milligrams of hair were incubated with 500-µl M3® buffer reagent at 100°C for 1 h for complete digestion. After cooling, 1-µl supernatant was injected onto chromatography system. Urine samples were simply diluted before injection. The chromatographic run time was short (8 min) through a column with a mobile phase gradient. The method was linear (determination coefficients always higher than 0.99) from limit of quantification (LOQ) to 500 ng/ml in urine and from LOQ to 10 ng/mg in hair. LOQs ranged from 0.07 to 1.16 ng/ml in urine and from 0.02 to 0.15 ng/mg in hair. No significant ion suppression due to matrix effect was observed, and process efficiency was always higher than 80%. Intra- and inter-assay precision was lower than 15%. The suitability of the methods was tested with six urine and hair specimens from patients treated with acetazolamide, dorzolamide, or brinzolamide for ocular diseases or systemic hypertension. Average urine concentrations were 266.32 ng/ml for dorzolamide and 47.61 ng/ml for N-deethyl-dorzolamide (n = 3), 109.27 ng/ml for brinzolamide and 1.02 ng/ml for O-desmethyl-brinzolamide (n = 2), and finally, 12.63 ng/ml for acetazolamide. Average hair concentrations were 5.94 ng/mg for dorzolamide and 0.048 ng/mg for N-deethyl-dorzolamide (n = 3), 3.26 ng/mg for brinzolamide (n = 2), and 2.3 ng/mg for acetazolamide (n = 1). The developed method was simple and fast both in the extraction procedures making it eligible in high-throughput analysis for clinical forensic and doping purposes.

Died with or Died of? Development and Testing of a SARS CoV-2 Significance Score to Assess the Role of COVID-19 in the Deaths of Affected Patients.

Since December 2019, a new form of coronavirus, SARS-CoV-2, has spread from China to the whole word, raising concerns regarding Coronavirus Disease 2019 (COVID-19) endangering public health and life. Over 1.5 million deaths related with COVID-19 have been recorded worldwide, with wide variations among countries affected by the pandemic and continuously growing numbers. The aim of this paper was to provide an overview of the literature cases of deaths involving COVID-19 and to evaluate the application of the COVID-19 Significance Score (CSS) in the classification of SARS CoV-2-related fatalities, comparing it with the Hamburg rating scale. The results obtained allowed us to highlight that CSS used after a complete accurate post-mortem examination, coupled to the retrieval of in vivo data, post-mortem radiology, histology and toxicology, as well as to additional required analyses (e.g., electronic microscopy) is a useful and concise tool in the assessment of the cause of death and the role played by this virus. A shared use of this scale might hopefully lower the inhomogeneities in forensic evaluation of SARS CoV-2-related fatalities.

A 2017-2019 Update on Acute Intoxications and Fatalities from Illicit Fentanyl and Analogs.

The aim of this review was to report the most recent cases of acute intoxication, fatalities and "driving under the influence" cases, involving illicit fentanyl and its newest analogs. When available, information on age, sex, circumstances of exposure, intoxication symptoms, cause of death (if applicable) and toxicology results from biological fluid testing was described. Scientific publications reporting fatalities or acute intoxications involving use of fentanyl derivatives were identified from PubMed, Scopus and institutional/governmental websites from January 2017 up to December 2019. The search terms, used alone and in combination, were as follows: fentanyl, street fentanyl, analogs, compounds, derivatives, abuse, fatality, fatalities, death, toxicity, intoxication and adverse effects. When considered relevant, reports not captured by the initial search but cited in other publications were also included. Of the 2890 sources initially found, only 44 were suitable for the review. Emergent data showed that the most common analogs detected in biological samples and seized materials are acetylfentanyl, acrylfentanyl, butyrfentanyl, carfentanil, cyclopropylfentanyl, fluorofentanyl, 4-fluorobutyrfentanyl, 4-fluoroisobutyrfentanyl, furanylfentanyl, 2-methoxyacetylfentanyl, 3-methylfentanyl and ocfentanil. These compounds were frequently administered in association with other illicit substances, medicinal drugs and/or alcohol; patients and the victims often had a previous history of drug abuse. The trend of fentanyl analogs is rapidly evolving with illicit market fluctuations. Since information about potency and lethal dosage are frequently unknown, it is important to identify the new trends for further investigation on therapeutic use, toxicity and fatal doses, and implement public health measures. Recently marketed fentanyl analogs such as crotonylfentanyl and valerylfentanyl were not involved in intoxications to date, but should be carefully monitored. Many intoxications and fatalities might have gone unnoticed, and research efforts should focus on metabolite identification studies and the implementation of updated and comprehensive analytical methods.

Application of aquatic decomposition scores for the determination of the Post Mortem Submersion Interval on human bodies recovered from the Northern Adriatic Sea.

PURPOSE: The decomposition process of human bodies in marine environment is not well understood, and it is influenced by external variables related to the geographical area where the body is submerged. We report the application of two decomposition scores, the Heaton's score and the van Daalen's score, on a casuistry of human bodies recovered from the Northern Adriatic Sea. The aims of this study are to verify whether the marine environment of a Mediterranean climate area may affect the applicability of both scores and to develop a prediction model that can be applied on bodies recovered in salt water. METHODS: A retrospective study was performed on 61 human bodies recovered between 2005 and 2019 from coastal water of the Northern Adriatic Sea nearby the Italian regions Emilia-Romagna and Marche. For each of the 61 cases included, the Total Aquatic Decomposition Score (TADS) was calculated with the Heaton's score and the Van Daalen's score. The prediction model was assessed through multiple regression analyses, and the determination coefficients (r2) between TADS and PMSI (expressed in days) and between TADS and Accumulate Degrees Days (ADD) were studied. The prediction model was applied to the entire case sample, to bodies recovered during the warm season and to bodies recovered during the cold season. RESULTS: All bodies were recovered floating, and a very poor scavenging activity was observed. The regression analyses showed a strong correlation between the TADS and the total case sample using both scores and both independent variables (PMSI and ADD). The determination coefficients were greater than 0.95 also when considering the total case sample. DISCUSSION: The proposed prediction models are not significantly influenced by seasonality, contrarily to what observed on bodies recovered in fresh water in the same climate area. However, the ADD model, which also consider the water temperature, should be preferred for higher decomposition stages. This study helps increase the accuracy of PMSI estimation in bodies recovered from a marine environment of the Northern Adriatic Sea.

Pharmacology and legal status of cannabidiol.

Cannabidiol (CBD) is the second most abundant cannabinoid present in Cannabis sativa L. It is not associated with psychotropic activity and is capable to mitigate the psychotomimetic effects produced by tetrahydrocannabinol (THC). The latest cannabis decriminalization policies and the high applicability in therapeutic and technologic-industrial fields, have determined an exponential marketing growth of foods, cosmetics and in particularly medicinal products containing CBD, which are easily available for consumers. Most importantly, on 2018 United States Food and Drug Administration approved CBD oral solution with the trade name of Epidiolex® for the treatment of two rare and severe forms of epilepsy, "Lennox-Gastaut syndrome" and "Dravet syndrome", in pediatric patients. The aim of this review was to focus on pharmacology and on legal status of CBD, to highlight the lack of harmonization of international regulatory laws over the marketing authorization of CBD-based products.

A Comprehensive HPLC-MS-MS Screening Method for 77 New Psychoactive Substances, 24 Classic Drugs and 18 Related Metabolites in Blood, Urine and Oral Fluid.

To date, more than 800 molecules are classified as New Psychoactive Substances (NPS), and it is reported that this number increases every year. Whereas several cases of polydrug consumption that led to acute intoxication and death are reported, a lack of effective analytical screening method to detect NPS and classical drug of abuse in human matrices affects the prompt identification of the probable cause of intoxication in emergency department of hospitals. In this concern, a fast, simple and comprehensive high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS-MS) screening method to detect and quantify 77 NPS, 24 classic drugs and 18 related metabolites has been successfully developed and validated in blood, urine and oral fluid. A small volume (100 µL) of whole blood samples spiked with internal standard deuterated mixture was added to 70 µL of M3® buffer, and after precipitation of blood proteins, the supernatant was evaporated to dryness and reconstituted in 1 mL of mobile phase. Same volume (100 µL) of urine and oral fluid samples spiked with internal standard deuterated mix were only diluted with 500 µL of M3® reagent. One microliter of samples of each matrix was injected into HPLC-MS-MS equipment. The run time lasted 10 min with a gradient mobile phase. Mass spectrometric analysis was performed in positive ion multiple reaction monitoring mode. The method was linear for all analytes under investigation with a determination coefficient always better than 0.99. The calibration range for blood and oral fluid was from limits of quantification (LOQs) to 200 ng/mL, whereas that for urine was LOQs to 1000 ng/mL. Recovery and matrix effect were always higher than 80%, whereas intra-assay and inter-assay precision were always better than 19% and accuracy was always within 19% of target in every matrix. Applicability of the method was verified by analysis of samples from real cases.

Evolution of Italian laws banning trafficking, use and abuse of psychotropic drugs.

The penalty system implemented by Italian law still represents a barrier against psychoactive drugs and drug addiction, especially at a time when the age of first consumption has considerably dropped. Presidential Decree n. 309 of October 9, 1990 entitled "Consolidation of the laws governing drugs and psychotropic substances, the prevention, treatment and rehabilitation of drug addicts", and referred to as Presidential Decree 309/90, is the reference text for the cultivation, production, trade and use of narcotics and other psychoactive substances in Italy. The Presidential Decree has its origins in the now-forgotten law of December 22, 1975, n. 685, amended by law 162/90, which provided a draft of the current Presidential Decree 309/90. The current text has been amended numerous times over the years.

Δ9-Tetrahydrocannabinol and Cannabidiol Time Courses in the Sera of "Light Cannabis" Smokers: Discriminating Light Cannabis Use from Illegal and Medical Cannabis Use.

BACKGROUND: Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD) time courses in serum and physiological and behavioral effects associated with smoking 1 or 4 "light cannabis" cigarettes were studied. Biomarkers to differentiate light cannabis versus illegal and medical cannabis use were also investigated. METHODS: Sera were obtained at different times from 6 healthy light cannabis consumers and 6 individuals who smoked 1 and 4 cigarettes, within 4 hours through a liquid-liquid method and analyzed by liquid chromatography-tandem mass spectrometry. RESULTS: In serum, minimal THC concentration was observed after a single cigarette smoke, while repeated smoking increased it by 1 order of magnitude. CBD concentrations were higher, but did not increase linearly, probably because it does not preferentially volatilize compared with THC. The highest THC and CBD concentrations were observed 0.5 hours after the start of the smoking of 1 cigarette. Serum THC ranged from 2.7 to 5.9 ng/mL, while serum CBD varied from 5.7 to 48.2 ng/mL. Similarly, the highest THC and CBD concentrations were observed 0.5 hours after the smoking of 4 cigarettes. Specifically, the ranges were THC: 11.0-21.8 ng/mL and CBD: 19.4-35.3 ng/mL. In both cases, the mean THC/CBD concentration ratio ranged from 0.2 to 0.9. There were no significant changes in blood pressure, heart rate, and body temperature, but participants who smoked 4 cigarettes experienced severe drowsiness. CONCLUSIONS: THC and CBD time courses in the sera of light cannabis smokers were similar to those previously observed in oral fluid and blood. Serum THC/CBD concentration ratio not higher than the mean value of 0.9 might be a useful biomarker to identify use of light cannabis versus that of illegal THC cannabis (where THC/CBD concentration ratios are generally greater than 10) or versus that of medical cannabis (where ratios are greater than 1). Consumers should be advised of possible drowsiness after he repeated smoking of light cannabis cigarettes.

Fatal inhalation of nitrogen inside a closed environment: Toxicological issues about the cause of death.

Asphyxia due to inhalation of nitrogen, as accidental or suicidal event, has been seldom reported in the forensic field. Death usually occurs because of a displacement and decrease of environmental and alveolar oxygen concentrations, but taking into account that nitrogen is a normal component of atmosphere, autopsy findings, which may be in certain cases unremarkable, must be corroborated with a careful scene investigation in order to determine the cause of death. We present a case of a 37-year old male found unresponsive inside his car with five liquid nitrogen tanks placed in the trunk, three of them with clear losses because of incomplete lock. Resuscitation efforts were unsuccessful. Autopsy findings and histological analyses were unremarkable, but toxicological analyses were crucial. Percentages of nitrogen were high in blood collected from the inferior vena cava (85.2%), left ventricle (81.01%) and the right lung (80.73%). Concentrations of nitrogen were higher than those detected in control samples: 14 autopsy cases, room air and water. The cause of death was identified as an inert gas asphyxiation, which was classified as accidental in accordance with the police report.