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

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

The Precision, Inter-Rater Reliability, and Accuracy of a Handheld Scanner Equipped with a Light Detection and Ranging Sensor in Measuring Parts of the Body-A Preliminary Validation Study.

BACKGROUND: Anthropometric measurements play a crucial role in medico-legal practices. Actually, several scanning technologies are employed in post-mortem investigations for forensic anthropological measurements. This study aims to evaluate the precision, inter-rater reliability, and accuracy of a handheld scanner in measuring various body parts. METHODS: Three independent raters measured seven longitudinal distances using an iPad Pro equipped with a LiDAR sensor and specific software. These measurements were statistically compared to manual measurements conducted by an operator using a laser level and a meterstick (considered the gold standard). RESULTS: The Friedman test revealed minimal intra-rater variability in digital measurements. Inter-rater variability analysis yielded an ICC = 1, signifying high agreement among the three independent raters. Additionally, the accuracy of digital measurements displayed errors below 1.5%. CONCLUSIONS: Preliminary findings demonstrate that the pairing of LiDAR technology with the Polycam app (ver. 3.2.11) and subsequent digital measurements with the MeshLab software (ver. 2022.02) exhibits high precision, inter-rater agreement, and accuracy. Handheld scanners show potential in forensic anthropology due to their simplicity, affordability, and portability. However, further validation studies under real-world conditions are essential to establish the reliability and effectiveness of handheld scanners in medico-legal settings.

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.

Impact on touch DNA of an alcohol-based hand sanitizer used in COVID-19 prevention.

In the last years, forensic research has been focused on touch DNA in order to improve its evidential value in criminal activity investigations as well as to understand the variables impacting touch DNA. One of the emerging variables is represented by the use of alcohol-based sanitizers, which was suggested for hand hygiene during the COVID-19 pandemic. The aims of the present study were to assess the effect of a hand sanitizer on touch DNA deposition, transfer, and recovery and also to evaluate STR typing success, quality of DNA profiles, and personal identification. Before and after the use of an alcohol-based hand sanitizer, 20 volunteers deposited on glass surfaces 120 fingerprints, containing skin-derived or salivary DNA. Samples were quantified by real-time quantitative PCR (q-PCR), and 76 samples yielding > 15 pg/µl were typed for 21 autosomal STRs by GlobalFiler® PCR Amplification Kit. DNA profiles were classified into single source, mixed, and inconclusive profiles, and a LR assessment was performed by comparison to the reference samples using LRmix Studio software. After the use of hand sanitizer, samples yielded lower quantities of recovered transferred DNA, especially considering samples containing salivary DNA (p < 0.05 by Friedman test). All the 76 amplified samples (63.3% of the total) showed at least 10 typed loci, and 83-100% of profiles were consistent with the reference ones on the basis of a LR value ≥ 106. Results showed that, although the hand sanitizer reduces the DNA recovering, touch DNA samples might still be useful for forensic personal identification even when hand sanitizers are used.

Insights in opiates toxicity: impairment of human vascular mesenchymal stromal cells.

The most common pulmonary findings in opiate-related fatalities are congestion and oedema, as well as acute and/or chronic alveolar haemorrhage, the cause of which is thought to be a damage to the capillary endothelium related to ischemia. Human vascular mesenchymal stromal cells (vMSCs) play a fundamental role in tissue regeneration and repair after endothelial cell injury, and they express opioid receptors. The aim of this study was to assess the effect of in vitro morphine exposure on the physiological activity and maintenance of human vMSCs. vMSCs were obtained from abdominal aorta fragments collected during surgery repair and were exposed to incremental doses (0.1 mM, 0.4 mM, 0.8 mM and 1 mM) of morphine sulphate for 7 days. The effect was investigated through cell viability assessment, proliferation assay, reactive oxygen species (ROS) detection assay, senescence-associated ß-galactosidase assay, senescent-related markers (p21WAF1/CIP1 and p16INK4) and the apoptosis-related marker caspase 3. Moreover, an ultrastructural analysis by transmission electron microscopy and in vitro vascular differentiation were evaluated. Results showed a decrease of the cellular metabolic activity, a pro-oxidant and pro-senescence effect, an increase in intracellular ROS and the activation of the apoptosis signalling, as well as ultrastructural modifications and impairment of vascular differentiation after morphine treatment of vMSC. Although confirmation studies are required on real fatal opiate intoxications, the approach based on morphological and immunofluorescence methodologies may have a high potential also as a useful tool or as a complementary method in forensic pathology. The application of these techniques in the future may lead to the identification of new markers and morphological parameters useful as complementary investigations for drug-related deaths.

Routine Photography of Injuries: A Comparison Between Smartphone Cameras and Digital Single-Lens Camera-A Pilot Study.

ABSTRACT: Ten lesions were photographed with an entry-level (HUAWEI P smart 2019), a midrange (Samsung Galaxy S8) and a high range (Apple Iphone XR) smartphone camera and with a digital single-lens camera (DSLC). Images were independently rated by 3 pathologists, based on comparison to the real lesion and "visual impact." Difference of perceptual lightness coordinates between smartphones and the criterion standard (DSLC) was calculated.The highest ranking for adherence to reality was obtained with DSLC, while the highest ranking for visual impact was obtained with the Iphone. The color representation better reflecting the criterion standard (DSLC) was obtained for the entry-level smartphone.All the devices allow to assess the general features (ie, the color, the shape, and the main characteristics) of an injury during a forensic autopsy. However, results might be different when photos are obtained in suboptimal, such as low-light, conditions. Moreover, images acquired through a smartphone camera might be unsuitable for later image exploitation, such as enlargement of a portion of the image to magnification of a detail, which seemed not relevant when the photo was shot. Only a raw image, acquired using a dedicated camera and deactivating images manipulation software, might allow the preservation of the true data.

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

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

Morphological characterization using scanning electron microscopy of fly artifacts deposited by Calliphora vomitoria (Diptera: Calliphoridae) on household materials.

Insects found at a crime scene can produce traces referred to as fly artifacts (FA) due to their movement over the corpse and the manner in which they feed upon it. These can be detrimental for carrying out criminal investigations. Confusing a FA with a genuine bloodspot can lead to misinterpretations, also taking into consideration that FA may contain a human DNA profile. The aim of the present study was to employ scanning electron microscopy (SEM) for the analysis of FA produced by Calliphora vomitoria on hard surfaces and fabrics that are commonly present at crime scenes. FA and control bloodstains were produced under experimental conditions on metal, glass, plaster, cotton, and polyester. After macroscopic analysis, FA were examined at standard low (20-40 ×), medium low (300-600 ×), and high ultrastructural (1200 ×) magnification through a SEM Stereoscan 360, Leica, Cambridge. SEM analysis enabled the identification of distinctive features of FA on hard surfaces, namely, amorphous crystals, micro-crystals with a morphology similar to those of uric or micro-crystals with a comparable morphology to cholesterol, absent in controls. Moreover, red blood cells (RBC) were absent in FA but were always present in controls. On cotton, for both FA and controls, the drop was almost completely absorbed and thus indistinguishable from the underlying fabric texture. On polyester, FA showed amorphous/crystal-like deposits and no RBC, as observed on hard surfaces, except for those showing a completely flat surface. SEM analysis appeared to be suitable for differential diagnosis between FA and genuine bloodstains on hard surfaces, although the results may be inconclusive on tested fabrics.

When the Hidden Issue of Elder Abuse Leads to Death: Do Not Neglect Elder Neglect.

ABSTRACT: It is well known that elder neglect entails a number of physical and psychological consequences, as well as being an independent risk factor for death. In the present study, we describe 5 forensic cases of death of older adults where the diagnosis of neglect only emerged postmortem through the combination of the scene investigation, the often-scarce circumstantial data, and the autopsy findings. The gathering of this information allowed the presence of risk factors-not previously assessed or reported-to be identified. Nevertheless, complete medical information was lacking both for the isolation of the victims with their caregivers and for the absence of every social and health support in self-neglect. More research is needed also in the forensic pathology field with standardized methods to contribute to prevention strategies and to avoid that victims of elder neglect remain hidden also after death.

A DNA-based method for distinction of fly artifacts from human bloodstains.

Fly artifacts resulting from insect activity could act as confounding factors on a crime scene and interfere with bloodstain pattern analysis interpretation. Several techniques have been proposed to distinguish fly artifacts from human bloodstains based on morphological approach and immunological assay, but a DNA-based method has not been developed so far. Even if in forensic genetic investigations the detection of human DNA is generally the primary goal, fly artifacts can provide useful information on the dynamics of crime events. The present study provides a molecular method to detect fly DNA from artifacts deposited by Calliphora vomitoria after feeding on human blood through the analysis of the mitochondrial cytochrome oxidase gene subunit I (COI). Fly artifacts originated from digestive process and of different morphology spanning from red and brownish/light brown, circular and elliptical stains to artifacts with sperm-like tail or a tear-shaped body were collected. The COI amplification was successfully obtained in 94% of fly artifact samples. The method showed high sensitivity and reproducibility, and no human DNA contamination was observed, offering specificity for use in confirmatory test. This molecular approach permits the distinction of fly artifacts from genuine bloodstains and the identification of fly's species through the COI region sequencing by protocols usually applied in forensic genetic laboratories.

Homicide and concealment of the corpse. Autopsy case series and review of the literature.

INTRODUCTION: The concealment of the body following a homicide undermines different moments of the forensic and medico-legal investigations. The aim of the present study is to provide an overview of the literature and the forensic casuistry of the Institute of Legal Medicine of Padova for analyzing and discussing diverse methodological approaches for the forensic pathologist dealing with covered-up homicides. MATERIAL AND METHODS: A literature review, updated until September 2019, was performed, and a literature pool of forensic cases was built. In-house cases were included by conducting a retrospective analysis of the forensic caseworks of Padova of the last 20 years. Data regarding epidemiology, methodology of assessment, methods of concealment, and answers to medico-legal issues were extracted for both data sets. RESULTS AND DISCUSSION: Seventy-eight papers were included in the literature review (78.2% being case reports or case series, 17% retrospective studies, and 6% experimental studies or reviews). Literature and in-house data sets consisted of 145 and 13 cases, respectively. Death scene investigation, radiology, toxicology, and additional analyses were performed in 20-54% of literature and 62-77% of in-house cases. Cover-up by multiple methods prevailed. Death was caused by head trauma in about 40% of cases (both data sets), strangulation in 21% of literature, and 7% of in-house cases, and was undetermined in 17% of literature and 7% of in-house cases. CONCLUSIONS: The methodology of ascertainment should be case-specific and based on a multidisciplinary and multimodal evaluation of all data, including those gained through novel radiological and/or analytical techniques.

Importance of dashboard camera (Dash Cam) analysis in fatal vehicle-pedestrian crash reconstruction.

The reconstruction of dynamic of traffic injuries remains a challenge in forensic pathology and is often based on circumstantial data. Dash Cams are digital video recorders which can be located inside a vehicle and continuously record the view through the windscreen, thus providing objective evidence. Here we present the case of a traffic crash in which a pedestrian was hit by an articulated lorry. The analysis of a video recorded from a Dash Cam retrieved inside the vehicle during the death scene investigation (DSI) was crucial in the reconstruction of the manner of death. Indeed, the death, which was initially assumed to be accidental, was finally deemed as a suicide on the basis of the video recording, which showed an intentional and sudden rush of the victim to the middle of the roadway. Advantages and disadvantages of the use of Dash Cams will be discussed, focusing on the profound differences in the related national and international regulations. Based on the present case, in traffic crashes, the search for Dash Cams during the DSI may be recommended and the video recordings should be analyzed in the setting of a multidisciplinary and multimodal evaluation of the case, for a proper reconstruction of the facts.

The punched-out tissue complex (skin-bone "imprimatum") in shots from captive-bolt guns: does it act as a secondary projectile?

From the first half of the twentieth century to the present day, injuries and fatalities from captive-bolt livestock stunners are a major topic in forensic medicine. The vast majority of cases account for suicides with the frontal, temporal, parietal, and occipital regions being the most common sites of entrance (in descending order of frequency). Due to the limited length of the bolt, the corresponding wound channel within the braincase is only several centimeters long. It has been a controversial subject for a long time, whether the skin-bone complex punched out by the conically grooved end of the steel rod may act as a "secondary projectile" being propelled beyond the actual path of the bolt. To answer this question, experimental shots from various types of captive bolt-guns were fired to simulants. Video-documentation employing a high-speed motion camera showed that the punched-out pieces of skin and bone did not move further than the bolt. Thus, a secondary extension of the total wound channel could not be observed. However, the suction effect caused by the bolt's rearward movement may induce a slight retrograde displacement of the skin-bone complex.

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.

Intra-class and inter-class tool discrimination through micro-CT analysis of false starts on bone.

Micro-CT has successfully been applied to the characterization of false starts (FSs) and, among several parameters, kerf width seems to correlate to the tool blade. The aim of the present study was to evaluate the diagnostic value of micro-CT for the differentiation of saw marks produced by different classes of saws and by saws belonging to the same class and differing only in number of teeth per inches (TPI). A morphological and morphometric analysis of 84 marks, produced by 6 saws belonging to 3 morphological classes, was performed. In the experimental cohort, for each parameter, statistically significant differences in intra- and inter-class analysis were searched for and cut-offs were established. The diagnostic accuracy of cut-offs was assessed through statistical analyses on the validation cohort. The morphological assessment did not allow to differentiate saws differing only in TPI. Angle 1 and top kerf width, respectively for cross-cut and rip-cut saws with alternating set, allowed a good discrimination between FSs produced by tools belonging to the same morphological class. High positive predictive values were found in intra-class analyses, while results in inter-class analyses were less encouraging. In cases of dismemberment, a micro-CT-based analysis of FSs is strongly suggested as a part of a multistep and multimodal methodology of assessment, which includes scanning electron microscopy and stereomicroscopy. A morphological assessment should be followed by an experimental trial and by a morphometric analysis. Further studies are needed to evaluate hampering factors, such as damage by physico-chemical agents.

Radiological investigation of gunshot wounds: a systematic review of published evidence.

INTRODUCTION: Despite the constantly growing popularity of radiological imaging in forensic pathology, a systematic review investigating the efficiency and limits of radiological techniques, in comparison to forensic autopsy, was still missing. AIM: The present review aims at providing an overview on the current role of radiology in the forensic investigation of fatal gunshot wounds without any restriction to specific radiological techniques. MATERIAL AND METHODS: A systematic literature search on three databases (PubMed, Web of Science, and Science Direct) was performed until December 2017. The Oxford Centre for Evidence Based Medicine (OCEBM) grading system for levels of evidence was applied, in order to weigh published evidence. RESULTS AND DISCUSSION: Eighty-six papers (1.64% of the records) were included. Despite the quite limited general level of evidence, which contrasts with the abundance of the scientific literature on this topic, several recommendations/statements, coupled to their OCEBM grade, were distilled as for the identification of retained bullets, gunshot wounds detection, diagnosis of entrance and exit wounds, trajectories and internal injury detection and estimation of the firing distance. CONCLUSIONS: Imaging radiological technologies represent the present and future of wound ballistics. However, traditional, micro and molecular imaging techniques require further validation through blinded cross-sectional studies with appropriate reference standards (e.g. forensic autopsy).

Fentanyl novel derivative-related deaths.

OBJECTIVE: Fentanyl (FEN) is a potent, synthetic narcotic used as an anaesthetic and a pain reliever, but also illegally manufactured. For diversion purpose, it is being steadily modified to produce new analogous compounds and derivatives (FENS), categorised as novel psychoactive substances. While potential FEN abuse is already known, even in the absence of a clear lethal dosage, there is still a shortage of data on its derivatives. METHODS: A literature review of FENS-related deaths was performed, to better understand potential damage and future perspectives of FEN congeners. RESULTS: Epidemiological data, pathological findings, administration routes, average concentrations and lethal doses, toxicological issues, trends in misuses, comparison among FENS, and possible explanation for FENS abuse are reviewed and discussed in depth. CONCLUSIONS: This study provides a medical-legal and toxicological assessment of this phenomenon in order to understand the role of illegal fentanyl and its congeners in deaths from FENS overdose.

Profiling online recreational/prescription drugs' customers and overview of drug vending virtual marketplaces.

OBJECTIVES: Internet and social networking sites play a significant role in the marketing and distribution of recreational/prescription drugs without restrictions. We aimed here at reviewing data relating to the profile of the online drug customer and at describing drug vending websites. METHODS: The PubMed, Google Scholar, and Scopus databases were searched here in order to elicit data on the socio-demographic characteristics of the recreational marketplaces/online pharmacies' customers and the determinants relating to online drug purchasing activities. RESULTS: Typical online recreational drugs' customers seem to be Caucasian, men, in their 20s, highly educated, and using the web to impact as minimally as possible on their existing work/professional status. Conversely, people without any health insurance seemed to look at the web as a source of more affordable prescription medicines. Drug vending websites are typically presented here with a "no prescription required" approach, together with aggressive marketing strategies. CONCLUSIONS: The online availability of recreational/prescriptions drugs remains a public health concern. A more precise understanding of online vending sites' customers may well facilitate the drafting and implementation of proper prevention campaigns aimed at counteracting the increasing levels of online drug acquisition and hence intake activities.

Death after smoking of fentanyl, 5F-ADB, 5F-MDMB-P7AICA and other synthetic cannabinoids with a bucket bong.

PURPOSE: We report a case of a polydrug user who consumed various synthetic cannabinoids and fentanyl from a transdermal patch via a bucket bong. Toxicological results from postmortem matrices with special focus on synthetic cannabinoids are discussed in terms of their relevance to the death. METHODS: The samples were analyzed by toxicological screening procedures involving immunoassays and gas chromatography-mass spectrometry (GC-MS) as well as quantitative analyses by means of GC-MS and high-performance liquid chromatography-tandem mass spectrometry (LC-MS/MS). RESULTS: At the autopsy, coronary artery disease and signs of liver congestion were noted, in the absence of acute myocardial ischemic changes. Femoral blood concentrations of fentanyl and pregabalin were 14 ng/mL and 3,200 ng/mL, respectively. In addition, 2.7 ng/mL 5F-ADB and 13 ng/mL 5F-MDMB-P7AICA were detected together with relatively low amounts of 5 other synthetic cannabinoids in cardiac blood. A total number of up to 17 synthetic cannabinoids were detected in kidney, liver, urine and hair. Fentanyl and 5F-ADB were also detected in the water of the bucket bong. CONCLUSIONS: The cause of death could be attributed to an acute mixed intoxication by fentanyl and 5F-ADB (both Toxicological Significance Score (TSS) = 3) with a contribution of pregabalin and 5F-MDMB-P7AICA (TSS = 2), in a subject suffering from pre-existing heart damage. The most plausible mechanism of death consists in a respiratory depression. This case report demonstrates that use of opioids in combination with synthetic cannabinoids might be particularly dangerous.