Secular changes in dental development of Korean children aged 4 to 16 years over a 10-year period.

This study evaluated 10-year secular changes in dental maturity and dental development among Korean children. A retrospective analysis of panoramic radiograph samples from Korean children (4-16 years old) taken in 2010 and 2020 was conducted. The 2010 group consisted of 3491 radiographs (1970 boys and 1521 girls), and the 2020 group included 5133 radiographs (2825 boys and 2308 girls). Using Demirjian's method, dental maturity scores and dental developmental stages were assessed. For intra-observer reliability, Weighted Cohen's kappa was used, and Mann-Whitney U tests were performed to compare the 2020 and 2010 groups. A slight acceleration in dental maturity was observed in both boys and girls, with the difference being more noticeable in boys at an earlier age. Statistically significant differences were noted at ages 4, 5 and 7 for boys, and at age 6 for girls. Despite these differences, the individual dental development stages of 2020 and 2010 showed inconsistent trends with limited differences. Generally, girls demonstrate more advanced dental maturity than boys. A slight acceleration in Korean children's dental maturity was observed over a 10-year period when comparing the 2020 groups to the 2010 groups.

Combining surface-enhanced Raman spectroscopy (SERS) and paper spray mass spectrometry (PS-MS) for illicit drug detection.

There is an ongoing effort in the US illicit drug market to make new psychoactive compounds more potent and addictive. Due to continuous chemical modifications, many fentanyl analogs are developed and mixed with more traditional illicit drugs, such as cocaine and heroin. Detecting fentanyl and fentanyl analogs in these illicit drug mixtures has become more crucial because of the increased potency and associated health risks. Most confirmatory procedures require time-consuming and expensive, highly sophisticated laboratory equipment and experimental procedures, which can delay critical information that might save a victim or find a suspect. In this study, we propose miniaturizing and accelerating this process by combining surface-enhanced Raman spectroscopy (SERS) analysis and paper spray mass spectrometry (PS-MS). For this aim, dual-purposed paper substrates were developed through soaking in Au/Ag nanostars suspensions. These novel, in-house prepared paper SERS substrates showed stability for up to four weeks with and without the presence of drug compounds. Fentanyl analogs with similar SERS spectra were differentiated by coupling with PS-MS. The limit of detection (LOD) for fentanyl on the paper substrates is 34 µg/mL and 0.32 µg/mL for SERS and PS-MS, respectively. Fentanyl and fentanyl analogs show selective SERS enhancement that helped to detect trace amounts of these opioids in heroin and cocaine street samples. In short, we propose the combination of SERS/PS-MS by using modified paper substrates to develop cost-effective, sensitive, rapid, portable, reliable, and reproducible methods to detect illicit drugs, especially trace amounts of fentanyl and fentanyl analogs in illicit drug mixtures. The combination of these two category A techniques allows for the identification of illicit drugs according to the SWGDRUG guidelines.

Death following cylindrical battery ingestion associated with toxic manganese levels.

Cases of battery ingestion are well documented in the scientific literature, especially concerning button cell battery ingestion in children. In this instance, the authors present an atypical case of a young man who voluntarily ingested a cylindrical alkaline battery containing manganese. The patient died approximately a week later, despite not exhibiting any specific symptoms. The battery was found in the cecum during the autopsy, showing deterioration at its positive pole. The cecal mucosa exhibited two ulcerations without perforation. Histological analysis revealed intestinal ischemia in the cecum, with no microscopic lesions in other organs. Toxicology reports indicated high levels of manganese in both cardiac and peripheral blood. Considering all the results from the additional analyses, the experts concluded that the death was likely of multifactorial origin, associated with a toxic blood concentration of manganese. To the best of our knowledge, this is the first recorded death following the ingestion of a cylindrical battery, and the first instance of manganese intoxication resulting from the ingestion of an alkaline battery. The authors will present the case and provide a literature review to assess the extent to which the presence of manganese may have contributed to the fatality.

Selective postmortem arterial angiography of head and neck using digital x-ray or computed tomography: A practical and rapid method to identify vascular injuries.

Identification of vascular injuries is crucial for complete postmortem evaluation and understanding of trauma deaths by the Medical Examiner. Some vascular injuries are difficult to evaluate due to challenging anatomic locations, especially in the head and neck. Documenting injuries of the facial and vertebral arteries is challenging and necessitates time-consuming dissections that can create artifacts and disfigurement. In busy medical examiner offices with a significant number of traumatic injuries, finding a creative solution to employ reliable postmortem angiography is desirable. At the Office of the Chief Medical Examiner for the State of Maryland (OCME), we created and effectively implemented a selective angiography procedure using traditional indwelling Foley catheters and water-soluble barium swallow contrast to evaluate arterial injuries using either digital radiography or computed tomography imaging modalities. This technique and imaging interpretation can be performed by a medical examiner or forensic pathology fellow after basic technical training and basic radiology training. This study outlines the technique, methods, and utilization of the procedure and describes the findings of six deaths due to vascular lesions from different injury mechanisms and disease processes and describes the ease of implementation on a broader scale in busy Medical Examiner's offices.

A retrospective study of 29 fatal cases of insulin overdose.

PURPOSE: To summarize recent cases of fatal insulin poisoning both domestically and internationally, thereby offering valuable insights for the forensic identification of insulin overdose cases. METHODS: Literature published since 2000 on fatal insulin overdose were systematically searched and screened. Data encompassing variables such as year, age, sex, cause of death, scene conditions, occupations, medical histories of victims and perpetrators, autopsy timing, dosage and administration methods, forensic pathology, and toxicological analysis, were compiled for rigorous statistical analysis. RESULTS: Among the 29 fatal cases of insulin poisoning, suicides and homicides accounted for 55.2 % and 41.4 %, respectively. Precisely 34.5 % of victims or perpetrators were associated with the medical industry, 27.6 % had diabetes, and 24.1 % had mental illnesses such as depression. Intravenous injection resulted in quicker death than did subcutaneous injection. In some cases, immunohistochemical staining of insulin and protamine at injection sites yielded positive results. The average molar ratio of insulin to C-peptide in post-mortem blood was 13.76 ± 5.167, indicating a significant diagnostic value for insulin poisoning. CONCLUSION: Assessment of cases of fatal insulin overdose should be thorough, incorporating case investigation, scene examination, medical records review, autopsy findings, pathological examinations, and laboratory tests, alongside considering the condition of the body and timing of death autopsy. Using mass spectrometry to detect insulin proves valuable, particularly in cases of poor body preservation.

The analysis of methylamphetamine and para-hydroxy-methylamphetamine in post-mortem hair samples using liquid chromatography-tandem mass spectrometry.

External contamination is a well-recognized limitation of hair analysis for drugs of abuse like methylamphetamine (MA), and there are no guidelines regarding the analysis of specific metabolites of MA to assist interpretation. We developed an analytical method to detect MA, amphetamine (AMP), and para-hydroxy-methylamphetamine (p-OH-MA) in hair and present their concentrations among a cohort of deceased persons positive for MA in blood (n = 63). Hair samples (≤ 3 cm) were washed with dichloromethane and water prior to extraction using a methanolic micro-pulverization. The reconstituted hair extracts were separated on a UCT Selectra® Aqueous C18 HPLC Column (100 × 2.1 mm, 3 µm) by gradient elution and detected using a Sciex Triple Quad 6500+ system. Validation was satisfactory, and the lower limits of quantitation were 0.01 ng/mg for MA and AMP and 0.001 ng/mg for p-OH-MA. The median hair concentrations of MA, AMP, and p-OH-MA were 13 ng/mg (range = 0.015-49; n = 51), 1.1 ng/mg (range = 0.018-44; n = 60), and 0.020 ng/mg (range = 0.0012-0.38, n = 62), respectively. These concentrations in hair were strongly positively correlated (r = .7202 to .8641, p < .001), suggesting similar modes of incorporation. Moreover, the wash/hair ratios were indicative of external contamination, especially among the soiled group of hair samples. Therefore, further studies are necessary to determine concentrations of p-OH-MA in living MA users and confirm if this metabolite constitutes a potential marker of MA consumption.

Review of the lethal mechanism of insulin poisoning and the characteristic of forensic identification.

Insulin, as the only hypoglycemic hormone in the body, plays a key role in blood sugar control. However, excessive insulin intake can lead to insulin poisoning and even death, which often occurs in clinical and forensic work. At present, some researches on insulin poisoning have been carried out at home and abroad, however, it seems that the mechanism and forensic characteristics of insulin poisoning are not clear and complete. Therefore, in this paper, we reviewed the potential mechanism of insulin poisoning, the methods of insulin detection and the forensic identification of poisoning cases, aiming at providing services for the forensic identification of insulin poisoning.

Forensic age estimation of adolescents using computed tomography of the clavicles.

In forensic age estimation, CT imaging of the clavicles is used to determine an age over completed 21 years. If ossification of the medial clavicular epiphysis is complete, young men are assumed to be over 21 years of age. The aim of this study is to check the statistical parameters (specificity, predictive probability) for the characteristic "completed ossification of the medial clavicles". 285 male patients who, for various reasons, received a chest CT at the Medical Center of the University of Freiburg between 1st December 2019 and 6th December 2022 were screened for the study, of whom 203 patients were included in the study. The stage of clavicular ossification was classified as stage 1 - 5 according to Schmeling. While 70 out of 71 patients under 21 years of age were correctly estimated to be under 21 years of age, there was one patient whose ossification on one side was classified as stage 4 and who would therefore have been estimated to be over 21 years of age. If only subjects whose ossification stage was the same on both sides are included, the specificity of the test method is 100% and the positive predictive probability is 100%. If patients for whom only one side is stage 4 are also included, the specificity is 98.6%. Thus, only the complete and symmetrical ossification of both clavicles (stage 4 according to the Schmeling classification) in a standardised thin-layer CT can be classified as a reliable indicator of an age over 21 years in young men. In the case of asymmetric ossification of the medial clavicles (stage 4 is not reached on one side), false positive evaluations and the incorrect assumption of an age over 21 years can occur.

Forensic age estimation by MRI of the knee - comparison of two classifications for ossification stages in a German population.

AIM AND OBJECTIVES: In forensic age estimation e.g. for judicial proceedings surpassed age thresholds can be legally relevant. To examine age related differences in skeletal development the recommendations by the Study Group on Forensic Age Diagnostics (AGFAD) are based on ionizing radiation (among others orthopantomograms, plain x-rays of the hand). Vieth et al. and Ottow et al. proposed MRI-classifications for the epiphyseal-diaphyseal fusion of the knee joint to define different age groups in healthy volunteers. The aim of the present study was to directly compare these two classifications in a large German patient population. MATERIALS AND METHODS: MRI of the knee joint of 900 patients (405 female, 495 male) from 10 to 28 years of age were retrospectively analyzed. Acquired T1-weighted turbo spin-echo sequence (TSE) and T2-weighted sequence with fat suppression by turbo inversion recovery magnitude (TIRM) were analyzed for the two classifications. The different bony fusion stages of the two classifications were determined and the corresponding chronological ages assigned. Differences between the sexes were analyzed. Intra- and inter-observer agreements were determined using Cohen's kappa. RESULTS: With the classification of Ottow et al. it was possible to determine completion of the 18th and 21st year of life in both sexes. With the classification of Vieth et al. completion of the 18th year of life for female patients and the 14th and 21st year of life in both sexes could be determined. The intra- and inter-observer agreement levels were very good (κ > 0.82). CONCLUSION: In the large German patient cohort of this study it was possible to determine the 18th year of life with for both sexes with the classification of Ottow et al. and for female patients with the classification of Vieth et al. It was also possible to determine the 21st year of life for all bones with the classification of Ottow et al. and for the distal femur with the classification of Vieth et al.

Cardiac rhabdomyoma: an uncommon culprit in sudden infant death.

Sudden death in infants remains a common and poorly understood cause of childhood mortality in the USA. Pediatric cardiac tumors, although rare, may underlie some cases of unexplained sudden infant death. Autopsy is a crucial diagnostic step in these cases, as both gross and microscopic examination of the heart may uncover occult cardiac tumors. Rhabdomyomas are the most common cardiac tumors in childhood and may result in arrythmia and sudden death. We present a case of sudden death in a healthy 5-month-old infant which initially appeared "SIDS-like" until thorough histological analysis revealed an underlying cardiac rhabdomyoma. The case is of particular importance in that the gross examination of the heart was considered completely normal, and the tumor only involved certain portions of the heart microscopically. Had a single random section of myocardium been the only heart section examined microscopically, the diagnosis might have been missed. This case emphasizes the importance of thorough microscopic examination in infant cases, especially in cases where the heart appears grossly normal.

Rethinking scientific communication in courts: A question of credibility.

The high value placed on forensic information in the criminal justice process is demonstrated by the fallout resulting when questions are raised as to the validity of methods used, deficiencies in the understanding of the limitations of results, or uncertainties around the professional expertise or ethical practices of the provider of the information. To effectively act as the "speaker" for the scientific evidence in court, forensic science needs to have credibility. The workshop "Rethinking scientific communication in courts" held at the Australian National University College of Law in November 2023 explored the subject of science communication in the legal context through the lens of philosophy, law, forensic service provision and meta-science, demonstrating the unique challenges placed on the field of forensic science as a scientific profession confined and defined within a non-scientific system. Stemming from the discussions at the workshop, this paper examines the notion of credibility in science, how forensic science aligns with the hallmarks of a credible scientific community and the influence this has on our understandings of scientific communication in courts.

A Three-Year Investigation on Corpses Referred to Legal Medicine Organization from An Iranian General Hospital: A Cross-Sectional Study.

Background: A Medical Certificate of Cause of Death (MCCD) is a legal and enforceable document issued by the attending physician. However, according to the instructions, in many cases such as sudden, unexplained, and extraordinary deaths, along with some uncommon causes, such as cases suspicious of murder, the deceased patient must be referred to the Iranian Legal Medicine Organization (ILMO). Moreover, the unnecessary referral of corpses to ILMO can increase the workload of the staff, finally confronting the family of the deceased with high emotional and financial costs. Methods: In this cross-sectional study, the medical records of all deceased patients referred from Hazrat Rasool Hospital to the ILMO (565 cases) in a three-year period from April 2016 to March 2019 were investigated and analyzed using SPSS22 software with chi-squared and T-test. Results: Among all the patients who passed away during this time (4,239 patients), 565 were referred to ILMO, accounting for 13.3% of deaths. The most common causes of referral were car and motorcycle accidents, with a total prevalence of 27.1%, dead-on-arrival (DOA) prevalence of 21.3%, and death with an unknown cause prevalence of 15.3%. Significant correlation was also detected between causes of referral with gender, time of death, and age. For example, Car accidents and lawsuits against medical staff were more common in men and women, respectively. Conclusion: Car and motorcycle accidents, DOA, and unknown causes were the most prevalent causes of referral in this study. In general, few studies have been conducted regarding the causes of referral of the deceased to the Legal Medicine Organization. In this study, we collected relevant variables to investigate this issue thoroughly.

Forensic Assessment of Alcohol Intoxication in Cases of Fatal Road Traffic Accidents in Lithuania.

Background: There is strong evidence that alcohol consumption is a significant risk factor for fatal road traffic accidents. It is estimated that the number of alcohol-related road accidents remains high in the past few years in Lithuania. This study aims to examine the prevalence of alcohol in blood samples collected from the autopsy results of road traffic accident victims. Materials and methods: A retrospective study of 136 road traffic accident victims was performed in State Forensic Medicine Service of Lithuania in the period of 2013 to 2023. We analyzed blood alcohol concentration (BAC) in relation to sex, age, road user type, place and time of the day at death. Results: 31% of the victims were under influence of alcohol at the time of death, with mean BAC 1.99 ± 0.92‰. The mean BAC was 2.16 ± 0.8‰ in male and 1.18 ± 1.12‰ in female group. By the type of road users, 23% of the pedestrians (mean BAC 2.45 ± 0.71‰), 32% of car drivers (mean BAC 2.13 ± 0.75‰), 41% of vehicle passengers (mean BAC of 1.73 ± 1.19‰), 37% of the motorcycle riders (mean BAC of 1.28 ± 0.53‰), 37% of the cyclists (mean BAC of 1.15 ± 0.75‰) were found to be intoxicated during the time of accident. Highest mean blood alcohol concentration was found during the night time hours (9 p. m. - 5 a. m.) 2.28 ± 0.91, comparing to in afternoon hours (12 p. m. - 5 p. m.) 1.49 ± 0.99, evening hours (5 p. m. - 9 p. m.) 2.10 ± 0.73 and morning hours (5 a. m. - 12 p. m.) 1.94 ± 1.00. The mean BAC in road traffic accidents during summer was 1.48 ± 0.71‰, spring 2.25 ± 0.76‰, autumn 2.12 ± 1‰, winter 2.42 ± 1‰. Conclusions: Alcohol consumption by road users is a significant contributing factor in road traffic accidents and their outcomes in Lithuania.

Deaths during Sexual Activity.

Background: Deaths during sexual activities are rarely identified phenomena in forensic medicine practice. Most often, such deaths are classified as accidents or deaths due to the manifestation of certain diseases during sexual activity. It is important to rule out homicide or suicide as the cause of death when investigating sexual deaths. Determining the cause of death requires a comprehensive assessment of the evidence and circumstances and should not be based solely on autopsy findings. When determining the cause of death, it is necessary to evaluate the circumstances of the discovery, important evidence found near the body, the position of the deceased, the place where the deceased was found, and the characteristics of the environment. Cases: Case 1: A 65-year-old male was clothed in women's underwear and was found hanging in a noose in a bedroom after a house fire. The autopsy revealed a ligature mark on the neck, bruises in neck muscles, tears in carotid arteries, and signs of acute pulmonary distension. The cause of death was determined to be suffocation due to neck compression by a ligature, compounded by significant alcohol intoxication, with additional postmortem burns covering 30% of the body surface area likely occurring after death.Case 2: A 55-year-old naked male was found without external injuries but with a plastic tube inserted into the rectum, causing a 2.5 cm rupture in the ileum. The perforation led to complications, including purulent diffuse peritonitis, intoxication, and acute cardiac and respiratory failure, resulting in death within 3-6 hours after insertion. Concurrent findings included atherosclerotic changes in the heart, internal organ hyperemia and edema, hepatic steatosis, renal cyst, and a lack of ethyl alcohol in blood but 0.17 ‰ presence in urine according to toxicology analysis. Conclusions: A detailed evaluation of all the evidence is very important in the forensic examination of the deceased during sexual activity. Therefore, to determine the cause of death, not only the autopsy data, toxicological and microscopic examinations of the deceased are important, but also the evaluation of all findings at the scene. The most common cause of death of an autoerotic nature is asphyxia, and the most commonly identified group of the dead are men aged around 40 years.

Hiding the evidence: Preliminary investigation of heat-induced alterations to pre-existing saw mark trauma.

Dismemberment and subsequent burning are common methods employed in an attempt to conceal or destroy evidence. While kerf characteristics can be utilised to identify tool(s) used for dismemberment, further research is necessary to assess the effect of burning on these characteristics. In this study, a back (tenon) saw (13 teeth per inch) was used to manually inflict trauma on Ovis aries de-fleshed femur bones (n = 18). Three different cut marks (shallow false start, incomplete cut and complete transection) were made on the mid-shaft of each bone. Subsequently, the bones were burned for 20 minutes in a muffle furnace. Three burn temperatures were assessed: 400 °C, 600 °C and 800 °C. Saw mark characteristics of each cut type were assessed and compared pre- and post-burning. All pre-existing trauma was recognisable post-burning; however, metric and morphological alterations were apparent. An increase in kerf width was observed at 600 °C in false start lesions and 800 °C in incomplete cuts. Breakaway spur thickness decreased post-burning (at 400 °C and 800 °C) but length was not significantly affected. Mean inter-striation distance decreased post burning at all temperature groups. Saw marks were distinguishable from heat-related fractures across all temperature groups. One false start lesion was obliterated at 800 °C. Exit chipping, pull-out striae as well as striation regularity appeared to be more enhanced after heat exposure. These alterations indicate a temperature-dependent impact on these characteristics. Further research is necessary to assess the role of burn duration.

A systematic approach to the analysis of illicit drugs for DNA with an overview of the problems encountered.

Due to the restricted nature of illicit drugs, it is difficult to conduct research surrounding the analysis of this drug material for any potential DNA in sufficient quantities acceptable for high numbers of replicates. Therefore, the current research available in peer reviewed journals thus far regarding analysing illicit drugs for DNA has been performed under varying experimental conditions, often using surrogate chemicals in place of illicit drugs. The data presented within this study originated from the analysis of genuine illicit drugs prepared both in controlled environments and those seized at the Australian border (and therefore from an uncontrolled environment) to determine if DNA can be obtained from this type of material. This study has been separated into three main parts (total n=114 samples): firstly, methamphetamine synthesised within a controlled environment was spiked with both saliva and trace DNA to determine the yield following DNA extraction; secondly, methamphetamine also synthesised in a controlled environment but on a larger scale was tested for the amount of DNA added incidentally throughout the synthesis, including the additional steps of recrystallising, homogenising and "cutting" the drug material to simulate preparation for distribution; and thirdly, the detection of human DNA within samples of cocaine and heroin seized at the Australian border. The DNA Fast Flow Microcon Device was utilised to concentrate all replicates from the same source into one combined extract to improve the DNA profiles for the samples where no DNA spiking occurred. Full STR profiles were successfully obtained from drug samples spiked with both saliva and trace DNA. Methamphetamine was present in the final DNA extracts and caused incompatibilities with the quantification of DNA using Qubit. The yields of DNA from drugs not spiked with DNA sources were much lower, resulting in 36 % of samples yielding alleles where all others did not. These results were not unexpected given these were realistic drug samples where the history of the drug material was unknown. This is the first study to obtain DNA profiles from genuine illicit drug material in both controlled and uncontrolled environments and indicates that the analysis of illicit drugs for DNA is an avenue worth pursuing to provide information which can in turn assist with disrupting the supply of these drugs. Given that DNA profiling is carried out worldwide using essentially the same systems as described within this study, the potential for impact is on a national and international scale.

A medico-legal perspective on postictal violence: A case study and systematic review of postictal delirium.

Detailed descriptions of violent postictal episodes are rare. We provide evidence from an index case and from a systematic review of violent postictal episodes that demonstrates the encephalopathic features of some violent postictal behaviors. We discuss how these cases may fit in the legal framework of culpability. The data support the view that some episodes of violent postictal behavior are more accurately classified as a neurological delirium or encephalopathy rather than as a postictal psychosis. Current medical terminology may present unwarranted (and presumably unintended) barriers to exculpation for patients who exhibit post-ictal violence during an episode of delirium during which the patient was unaware of his or her violent conduct.

Microscopic fungi on the corpse - Promising tool requiring further research.

Forensic microbiology is a relatively new area of forensic sciences. It considers the potential of microorganisms to be used in criminal investigations. As most studies involve the role of bacteria in fields like post-mortem interval estimation, personal identification or geolocation, the data on the role of fungi is comparatively scarce. Forensic mycology involves the application of fungi and their structures in forensic cases. The aim of this review is the evaluation of the current state of knowledge on fungi associated with human cadavers and their possible role in estimating the time since death. In accordance with the available reports, we focused on the relation between microscopic fungi isolated from human corpses and the cadaver condition e.g., the stage of decomposition. We also emphasised the contrast between the reported methodologies and attempted to standardise research methods in forensic mycology from sample collection to its storage, mycological analysis and identification of the obtained fungal cultures. Moreover, the potential usage of microscopic fungi in criminal cases was discussed based on various case reports.

Loperamide positive deaths in Sweden 2012-2022 and Finland 2017-2022: Fatal loperamide intoxication exclusively for Sweden.

Loperamide, a potent µ-opioid receptor agonist used as an antidiarrheal drug, exhibits increased bioavailability at supratherapeutic doses, causing potential central nervous system effects. Its misuse for opioid withdrawal relief and euphoria can lead to dangerously elevated blood levels, causing severe cardiac dysrhythmias and death. This study aimed to compare loperamide positive autopsy cases in Sweden and Finland after the introduction of postmortem toxicological analysis of loperamide, focusing on loperamide's role in fatalities and identifying common characteristics among those affected. All cases with detected loperamide in femoral blood at forensic autopsies in Sweden (2012-2022) and Finland (2017-2022) were included. In Sweden, loperamide was detected in 126 individuals, and in Finland, in 111 individuals. The incidence of individuals positive for loperamide in postmortem femoral blood increased steadily over the study duration in both Sweden and Finland. Loperamide related fatalities were observed exclusively in Sweden (n=80), predominantly involving younger males with histories of substance abuse, typically classified as accidental deaths. The group of loperamide nonrelated deaths in Sweden mirrored the entirety of cases in Finland. The concentration of loperamide in postmortem femoral blood was significantly higher in cases where loperamide was considered the cause of death (median 0.140 µg/g) compared to cases where loperamide contributed (median 0.080 µg/g), as well as in deaths unrelated to loperamide in both countries (Sweden: median 0.029 µg/g; Finland: median 0.010 µg/ml). The high limit of quantification for loperamide in Sweden may underestimate therapeutic users in epidemiological assessments. This study underscores the absence of loperamide misuse in Finland and indicates a rising trend of loperamide abuse in Sweden.