Ethyl Glucuronide and Ethyl Sulphate in Urine: Caution in their use as markers of recent alcohol use.

AIM: To clarify the role of the ethanol metabolites, ethyl glucuronide (EtG) and ethyl sulfate (EtS), in monitoring alcohol consumption. METHOD: We recruited 7 female and 17 male volunteers who were instructed to consume a quantity of beer (containing 48 gm ethanol) with food in one session. We examined urinary excretion of EtG and EtS over time and looked for correlations between the concentrations of the metabolites EtG and EtS. RESULTS: EtG concentrations in urine varied between 0.026 and 430.372 µg/ml with average values between 11.85 µg/ml (SD 19.75), 30 min after alcohol intake, and 100.39 µg/ml (SD 101.34), 4.5 h after alcohol intake. EtS urinary concentration ranged from 0.006 to 101.432 µg/ml with average values between 4.77 µg/ml (SD 5.42), 30 min after alcohol intake, and 30.14 µg/ml (SD 27.20), 4.5 h after alcohol intake. Spearman's test showed that urinary EtG and EtS correlated significantly at several time points. CONCLUSION: The great interindividual variability in their excretion suggests caution in the use of urinary measurement of these metabolites in forensic investigations.

An Unusual Case of Homicide by Impalement With a Battering Ram.

Impalement injuries occur when a large foreign body traverses or penetrates a body cavity or extremity. Nowadays, impalement injuries are uncommon and are usually a consequence of a fall onto a blunt object or a road accident. The authors report a case of a woman found dead in her apartment, seemingly killed by a firearm injury to the abdomen. However, after the autopsy was carried out, it became clear that the injuries had the features of an impalement. After the inquiry, the murder weapon was identified as a battering ram, used by the robbers to break into the house of the woman. This is the first case ever described in literature where a battering ram has been used to impale someone. This case emphasizes the importance of an accurate description of injuries, also with photographs, in order to achieve effective recognition of the wound patterns as they may correspond to specific and unusual weapons.

A Case of Bilateral Extracranial Internal Carotid Artery Dissection Due to the Helmet Strap After Motorcycle Crash.

The authors report a case of a man who developed stroke symptoms a few days after a road accident on his motorcycle. Radiographic examinations revealed the presence of bilateral dissection of the extracranial internal carotid arteries with signs of involvement of the brain parenchyma.The location, timing, and presentation lead to the conclusion that the carotid lesions were secondary to the motorcycle collision; in particular, we suppose that it is due to the pressure exerted by the helmet strap worn. Although helmets have undoubtedly prevented serious injuries, this report highlights that the helmets themselves may cause injuries, especially to cervical soft tissues and vessels.

Significance of Morphine Concentration in Bile, Liver, and Blood: Analysis of 52 Cases of Heroin Overdoses.

Forensic pathologists are requested to select matrices alternative to blood in cases of toxicological interest in which blood is not available for different reasons. We evaluated morphine concentrations in blood, bile, and liver samples in 52 cases of heroin overdoses, relating them to each other, to understand the information that could be derived from their analysis. Gas chromatography/mass spectrometry analysis was performed for all the samples positive on screening for opiates. Shapiro-Wilk test, nonparametric Mann-Whitney test, linear regression analysis, and Bland-Altman test were used for analysis. Linear regression demonstrated that there was not a statistically significant association in morphine concentrations between blood and bile and blood and liver. Mean liver/blood ratio was 2.76, varying from 0.131 to 13.379, and bile/blood ratio was 28.79, varying from 0.28 to 559.16. According to these results, bile analysis is a "screening test"; biliary or hepatic concentration of morphine cannot provide information on hematic concentration at the time of death, having no forensic value taken individually.

Cocaine contamination of banknotes: a review.

Background: The analysis of drug traces on banknotes with different validated techniques can provide important information about the types of substances that are used in a geographical region. The aim of our review was to investigate banknotes' contamination by cocaine, by its metabolite, but also by other drugs. Methods: A systematic literature search (English written literature) was conducted in MEDLINE, and Scopus, collecting studies from 1974 till 2017. The Key search terms included: 'banknote AND drug'; 'banknote AND cocaine'. Results: The literature search yielded 88 publications; 9 were included in our review. In six studies that showed banknotes' positivity to cocaine, the percentage ranged from 2.5% to 100%. The concentration of cocaine ranged from 0.09 ng/note to 889 µg/note. Benzoylecgonine was indentified only in three studies with a range from 0.71 to 130 ng/note. Other indentified drugs were: amphetamine derivatives, opiates, benzodiazepines. Conclusions: Circulating banknotes could be used to indicate substances used in a population, and those recently introduced in a geographical macro-area. The identification of very high amounts of cocaine can provide important information for the identification of banknotes used in illegal trafficking.

Two Fatal Intoxications Due to Tramadol Alone: Autopsy Case Reports and Review of the Literature.

Since tramadol was marketed, it has been widely prescribed as a pain killer because of its relatively safe profile among opioids.Nevertheless, intoxication can occur: overdose can lead to fatal outcomes mostly in association with other drugs, via the potential interaction with serotonergic antidepressant medications, as well as the potential for increased central nervous system (CNS) depression.Fatal outcomes only attributable to tramadol are a rare entity. In this case report, 2 fatal cases are described due to tramadol stand-alone intoxication with peculiar characteristics.In case 1, gas chromatography - mass spectrometry analysis detected tramadol in all specimens (32 µg/mL in the heart blood, 23.9 µg/mL in the femoral blood, 3.3 µg/mL in the bile, and 1.4 µg/mL in the urine). No other CNS depressants were detected by toxicological analysis.In case 2, gas chromatography - mass spectrometry analysis detected tramadol in all specimens (7.5 µg/mL in the heart blood, 5.8 µg/mL in the femoral blood, and 18 µg/mL in the urine). No other CNS depressants were detected by toxicological analysis.Review of the literature was performed to clarify the actual knowledge on this topic.

Cannabis Use Surveillance by Sweat Analysis.

BACKGROUND: Sweat testing, an alternative matrix for establishing drug abuse, offers additional benefits to the more common biological samples. The authors developed a procedure using gas chromatography-mass spectrometry to test for Δ9-tetrahydrocannabinol, 11-nor-Δ9-tetrahydrocannabinol-9-carboxylic acid, cannabinol (CBN), and cannabidiol (CBD) in a sweat patch. The results were compared with urine and hair sample results. METHODS: Urine, hair, and sweat samples were simultaneously collected from 12 patients who were involved, respectively, in forensic case and monitoring abuse. Selectivity, linearity, limit of detection (LOD), limit of quantification (LOQ), recovery, intraday and interday imprecision, and inaccuracy of the quantification procedure were validated. LODs in hair were 0.05 ng/mg for Δ9-tetrahydrocannabinol, CBN, and CBD, and 0.005 ng/mg for 11-nor-Δ9-tetrahydrocannabinol-9-carboxylic acid. The LOD for sweat was 0.30 ng/patch for all substances. The LOQ in hair was 0.1 ng/mg for Δ9-tetrahydrocannabinol, CBN, and CBD, and 0.01 ng/mg for 11-nor-Δ9-tetrahydrocannabinol-9-carboxylic acid. The LOQ was 0.4 ng/patch in sweat for each analyte. Cannabinoid in urine was determined by means of immunochemical screening (cutoff 11-nor-Δ-tetrahydrocannabinol-9-carboxylic acid 50 ng/mL). RESULTS: All subjects tested positive for 11-nor-Δ9-tetrahydrocannabinol-9-carboxylic acid and Δ9-tetrahydrocannabinol in urine and hair. In sweat samples, Δ9-tetrahydrocannabinol was found in all patches (0.4-2.0 ng/patch); 6 cases were positive for CBN (0.4-0.5 ng/patch) and 3 for CBD (0.4-0.6 ng/patch); 11-nor-Δ9-tetrahydrocannabinol-9-carboxylic acid was never detected in patches. CONCLUSIONS: Present sweat analysis results integrated the information from hair and urine and showed that sweat analysis is a suitable, noninvasive method for monitoring compliance with rehabilitation therapy and for detecting recent cumulative use of cannabinoids.

A Fatal Case of Acute Butane-Propane Poisoning in a Prisoner Under Psychiatric Treatment: Do These 2 Factors Have an Arrhythmogenic Interaction, Thus Increasing the Cardiovascular Risk Profile?

Sudden death due to inhalation of aliphatic hydrocarbons such as butane and propane is well described in the literature. The main mechanism involved is the induction of a fatal cardiac arrhythmia. This phenomenon is frequently associated with prisoners who accidentally die while sniffing these volatile substances with an abuse purpose. Furthermore, such prisoners are often under psychiatric treatment; specific drugs belonging to this pharmacological class lead to a drug-related QT interval prolongation, setting the stage for torsade de pointes. In this article, we present the case of a prisoner died after sniffing a butane-propane gas mixture from a prefilled camping stove gas canister. The man was under psychiatric drugs due to mental disorders. He was constantly subjected to electrocardiogram to monitor the QTc (corrected QT interval), which was 460 milliseconds long. Toxicological analysis on cadaveric samples was performed by means of gas chromatography (head space) and revealed the presence of butane and propane at low levels. The aim of this article was to discuss a possible arrhythmogenic interaction of QT interval prolongation induced by psychiatric drugs and butane-propane inhalations, increasing the cardiovascular risk profile. In other words, evidence may suggest that prisoners, under these circumstances, are more likely to experience cardiovascular adverse effects. We believe that this study underlines the need to take this hypothesis into account to reduce death risk in prison and any medical-related responsibilities. Further studies are needed to validate the hypothesis.

An Enigmatic Death in Farm Chopping Machine: Is This the Perfect Murder?

Forensic autopsy, like the other sectors in medicine, has benefited from the technological progress and the creation of multidisciplinary teams to unveil more and more finely planned criminal intents.Forensic pathologists, however, can sometimes deal with very enigmatic cases, meeting so with the limits of their own knowledge. Therefore, in these cases, they must not allow themselves to be pressured by inquiring agencies, remaining instead always faithful to empiric observations.With regard to that, we present a peculiar case of death by shredding inside a grinding machinery. The magistrature consequently opened a dossier for willful murder. Lots of figures were appointed to solve the case and among them is the forensic pathologist. However, a great number of obstacles were put in the investigators' inquiries.Was it a perfect murder?

Cocaine Addiction Treatment and Home Remedies: Use of the Scopolamine Transdermal Patch.

Recently, there has been an enormous increase in the number of people seeking treatment for cocaine addiction. Fifteen male cocaine users aged 20-30 years who requested hair analysis from our forensic toxicology laboratory (Perugia, Italy) from March to June 2012, reported using scopolamine without medical supervision to reduce the anxiety associated with cocaine withdrawal. Self-reports were verified with the results obtained from the hair analysis. We discuss whether the use of scopolamine in cocaine abusers could be supported by a neurobiological and pharmacological point of view.

Report of a fatal case of pulmonary thromboembolism in a long-distance truck driver.

Long-distance truck drivers have been found to be associated with many medical problems because of their lifestyle and work environment. Many studies have revealed an increased risk in sexually transmitted infections, musculoskeletal disease, sleep disorders, hypertension, gastrointestinal disease, substance abuse and alcoholism, lung cancer, as well as human immunodeficiency virus infection. To our knowledge, there are no any articles about a fatal case of pulmonary thromboembolism. We report a case of a 45-year-old truck driver, who was found dead in his truck at a service station along the A1 motorway in Umbria, Italy. Autopsy findings revealed pulmonary thromboembolism as cause of death. Our report underlies that future actions must be addressed to provide health care access to this vulnerable, medically underserved population.

Instantaneous death due to transorbital reverse penetration of a screw in an accidental fall: unusual autopsy case report and review of the literature.

We present a peculiar autopsy case of a transorbital penetrating head injury, in a male worker, after an accidental fall onto a screw not completely stuck into a wooden board. A 13-cm screw entered the cranium 9.5 cm deep, penetrating with the flat end, a condition defined in literature as "reverse penetration." The death was instantaneous and caused by a neurogenic shock due to injuries to the brain stem and the right cerebellar hemisphere. These injuries, enabled by the length of the screw, are generally described in literature as due to nontransorbital penetrations, frequently associated with posterior entry and a large intracranial injury. The ocular globe has been, furthermore, perfectly preserved thanks to its mobility in the orbit. Even the dynamic of the incident is peculiar because of the stationary nature of the penetrating object, which the victim actively fell on by accident. To the best of our knowledge, the matter is therefore a very peculiar mortal case of transorbital intracranial penetration, whose verified injuries and dynamics are absolutely atypical. The case is now under discussion, and a review of pertinent literature is performed.

Genetic identification by using short tandem repeats analysis in a case of suicide by self-incineration: a case report.

Suicide by self-incineration is an uncommon method of suicide in the western world in contrast with Asian countries, where this type of suicide is more common. If there is a lack of witnesses, genetic analysis for identification is mandatory, especially when anthropologic or dental identification is barely significant.The authors report a case of self-incineration of a 55-year-old white man, which occurred near Siena, Tuscany, Italy.The recovered bones were classified according to the Crow-Glassman scale and assigned to category 5 (the highest extent of combustion according to this scale). Therefore, because of the extent of the bone damage, analyzing the residual soft tissue around the pelvic bones was the only way to reach a genetic identification.The authors report this case to emphasize that even if the highest level of burn injury to human body is reached, an accurate analysis of the findings may lead to a genetic identification. In these cases, an efficient cooperation among police, fire experts, and forensics is necessary, especially because it is the only way to determine if the modality of death was accidental, suicidal, or homicidal.

An unusual autopsy case of incomplete decapitation of a motorcyclist with herniation of thoracic organs through a helmet-related neck wound.

The authors report an unusual autopsy case of a motorcyclist who wore a full-face type helmet and had incomplete decapitation and herniation of the heart and a portion of the right lung through an extensive lacerate wound on the front of the neck after his motorcycle crashed. The authors identified 2 main offensive dynamics that occurred simultaneously: First, partial decapitation with a extensive gaping wound on the neck caused by the chin strap after a violent angular movement of the head; second, the translocation of the abdominal organs into the thorax and the herniation of the thoracic organs through the neck wound generated by a compressive trauma of the thorax and abdomen. This singular case, like few others in forensic literature, shows the possibility of helmet chin strap-related traumas and highlights the limitations of modern protective helmets. If the postulated mechanism is confirmed despite the massive benefits derived from the compulsory use of protective helmets, the properties of the helmet chin strap would need to be reassessed to improve the protection of the soft tissue and bones in the neck.

A fatal work-related poisoning by hydrogen sulfide: report on a case.

Hydrogen sulfide (H2S) is a colorless and potentially deadly gas that may cause rapid loss of consciousness and respiratory depression without warning. Although occupational exposure to H2S and the medical management of H2S-associated toxicity are widely established, it remains a problem in the sour gas industry and in other industrial settings, predominantly in new workers. In this article, the authors report a fatal case of a factory worker who died after breathing in H2S while undertaking a task that he was not trained to perform. Toxicological assessment supported by autopsy findings and circumstantial data was essential to clarify the cause of death, determined as H2S poisoning. This case emphasizes the need to develop work safety initiatives, improve on-the-job training, and introduce more consciousness to put on protective equipment for workers; indeed, correct training and education for workers regarding safety in the workplace may help to reduce worker fatalities.

Cytokines, chaperones and neuroinflammatory responses in heroin-related death: what can we learn from different patterns of cellular expression?

Heroin (3,6-diacetylmorphine) has various effects on the central nervous system with several neuropathological alterations including hypoxic-ischemic brain damage from respiratory depressing effects and neuroinflammatory response. Both of these mechanisms induce the release of cytokines, chemokines and other inflammatory mediators by the activation of many cell types such as leucocytes and endothelial and glial cells, especially microglia, the predominant immunocompetent cell type within the central nervous system. The aim of this study is to clarify the correlation between intravenous heroin administration in heroin related death and the neuroinflammatory response. We selected 45 cases among autopsies executed for heroin-related death (358 total cases); immunohistochemical studies and Western blotting analyses were used to investigate the expression of brain markers such as tumor necrosis factor-α, oxygen-regulated protein 150, (interleukins) IL-1ß, IL-6, IL-8, IL-10, IL-15, cyclooxygenase-2, heat shock protein 70, and CD68 (MAC387). Findings demonstrated that morphine induces inflammatory response and cytokine release. In particular, oxygen-regulated protein 150, cyclooxygenase-2, heat shock protein 70, IL-6 and IL-15 cytokines were over-expressed with different patterns of cellular expression.

Patterns of Prescription Medicine, Illicit Drugs, and Alcohol Misuse among High-Risk Population: A Factor Analysis to Delineate Profiles of Polydrug Users.

Polydrug use is a serious health and social problem worldwide. Treatment remains a challenge because it requires planning based on estimates of the nature and extent of drug consumption and the characteristics of the population in need. To this end, 103 subjects, who voluntarily asked to begin rehabilitation treatment, were monitored through hair analysis to investigate the nature and extent of their polydrug use. A factor analysis was carried out to delineate polydrug user profiles based on the following variables: age, sex, type of illicit drug use, type of prescription drug misuse, and amount of alcohol consumption. Twenty-three percent of subjects tested positive to more than one illicit drug (mainly cocaine), 44% to unprescribed drugs (mainly benzodiazepines), and 66% were hard drinkers. The profiles of drug users outlined included "single drug cocaine user", and "single drug opiate user". Moreover, a particularly problematic profile of cocaine users, common between genders and age groups, who combine high levels of alcohol and unprescribed benzodiazepines and opiates, emerged ("hard polydrug abusers"). From a treatment policy perspective, these findings support the importance of preventive analysis before rehabilitation treatment begins in order to identify different patterns of drug abusers to implement personalized multidisciplinary measures.

Establishing a missing person DNA Biobank as a form of human rights protection.

Nowadays, organ transplantation is considered an established medical practice that, every year, improves the quality of life of thousands of patients. However, the increasing demands for kidney transplantation are in contrast with the global lack of organs. The imbalance between supply and demand for organs has created the basis for a highly profitable black market, placing illicit organ trafficking in the broader context of human trafficking. Currently, thanks to the advancements of the analytical techniques used in laboratories, forensic genetics is able to discriminate the geographical origin of genetically distinct populations. The recent availability of genetic data regarding many populations of the world and the concomitant development of technologies and methodologies that are appropriate for the study of panels of STRs and SNPs are fundamental resources in this direction. This type of analyses, together with the creation of missing person DNA databases, may be used in cases of dubious origin of organs or in transplantation cases in which clear and comprehensive medical records of patients and donors are not available. It can also establish a scientific tool useful to contrast the illegal traffic of human kidneys. In this article, we will discuss biological and ethical aspects of this interesting perspective.

Drug Checking as Strategy for Harm Reduction in Recreational Contests: Evaluation of Two Different Drug Analysis Methodologies.

Introduction: Drug checking as a part of drug harm-reduction strategies represents an essential aspect of public health policies. It focuses on rapid identification of drugs that individuals intend to use during night events, in order to implement health-protective behaviors. Chemical drug analysis techniques vary considerably, from simple colorimetric reagents to advanced forensic methods such as gas chromatography/mass spectrometry (GC/MS). Materials and Methods: In 2019, drug-check services were offered at some night events in Umbria (Central Italy). One hundred and twenty attendees directly delivered unidentified substances to a harm-reduction worker, who collected a few milligrams of the substances on ceramic plates and added a drop of colorimetric reagent. Multiple reagents were used to increase the diagnostic capacity of a substance, which may react with a specific drug or a few drugs. Later, a fraction of the samples was analyzed by GC/MS. The concordance of the results obtained using these two methodologies and the intended behaviors of consumers after being informed of the test result was evaluated. Results: We analyzed 120 samples by colorimetric test: 32 MDMA, 25 ketamine, 10 amphetamine, 11 cocaine, 8 heroin, and 4 LSD samples. The results were inconclusive for 29 samples. The GS/MS analysis confirmed MDMA in 84%, ketamine in 78%, amphetamine in 91%, cocaine in 92%, heroin in 88%, and LSD in 100% of the samples. The results of samples with inconclusive results were as follows: 2, MDMA; 7, ketamine; 2, amphetamine; 2, cocaine; 2, heroin; 2, mephedrone; 6, mixes; 1, debris; and 5, adulterants as the main component. Twenty-one of 29 participants reported that they had no intention of consuming the unidentified substance. Discussion: The high percentage of individuals who claimed no intention of consuming the unidentified drugs indicates that drug checking is viable as a part of drug harm-reduction strategies. Overall, colorimetric reagents showed a good performance with regard to samples being unadulterated (LSD) or minimal in quantity, but failed to identify mixtures of substances and the adulterants present in them. Therefore, the use of more discriminatory on-site methods such as Raman or infrared spectrometry is strongly recommended.