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.

Changes in Drug Use Patterns during the COVID-19 Pandemic in Italy: Monitoring a Vulnerable Group by Hair Analysis.

From 22 March until 18 May 2020, a complete lockdown in Italy was ordered as a countermeasure against the COVID-19 pandemic. Social isolation measures affect some populations more than others, and people with drug and/or alcohol disorders (SUDs) are more likely to be adversely affected. This study presents, for the first time, laboratory data on the use of alcohol and drugs in a high-risk population during Italy's first wave of the COVID-19 pandemic. Thirty subjects with SUDs were monitored for the use of illicit drugs and alcohol every 3 months before, during and after the lockdown, by hair analysis. The number of samples positive for heroin, cocaine, MDMA and cannabis fell considerably during the lockdown and then resumed to pre-lockdown levels when the period of confinement was over. Interestingly, the consumption of benzodiazepines and alcohol followed the opposite trend; both the number of benzodiazepine-positive samples and the level of alcohol consumption increased and remained high, even at the end of the lockdown. The confinement measures produced significant changes in drug/alcohol use patterns, with a shift toward the use of substances that were more easily accessible, used as self-medication for negative feelings, and used to alleviate the effects of abstinence from drugs that were no longer readily available.

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.

Application of Infrared Reflectance Spectroscopy on Plastics in Cultural Heritage Collections: A Comparative Assessment of Two Portable Mid-Fourier Transform Infrared Reflection Devices.

Plastics have been increasingly used to create modern and contemporary art and design, and nowadays, museum collections hold numerous objects completely or partially made of plastics. However, the preservation of these materials is still a challenging task in heritage conservation, especially because some plastics show signs of degradation shortly after their production. In addition, different degradation mechanisms can often take place depending on the plastic composition and appropriate environmental and packaging conditions should be adopted. Therefore, methods for in situ and rapid characterization of plastic artifacts' composition are greatly needed to outline proper conservation strategies. Infrared (IR) spectroscopy, such as attenuated total reflection Fourier transform infrared spectroscopy (ATR FT-IR), is a well-established method for polymeric material analysis. However, ATR FT-IR requires an intimate contact with the object, which makes its application less appropriate for the in situ investigation of fragile or brittle degraded plastic objects. Mid-FT-IR reflectance spectroscopy may represent a valid alternative as it allows in situ measurements with minimum or even no contact, and IR data can be acquired rapidly. On the other hand, spectral interpretation of reflectance spectra is usually difficult as IR bands may appear distorted with significant changes in band maximum, shape, and relative intensity, depending on the optical properties and surface texture of the material analyzed. Presently, mid-FT-IR reflection devices working in external reflection (ER FT-IR) and diffuse reflection infrared Fourier transform spectroscopy (DRIFTS) modes have been used in cultural heritage research studies. As the collected vibrational information depends on the optical layout of the measuring system, differences between ER FT-IR and DRIFT spectra are thus expected when the same polymer is analyzed. So far, ER FT-IR and DRIFT spectroscopy have been individually explored for the identification of plastic objects, but comparative studies between the application of two reflectance FT-IR modes have not been presented yet. In this work, the use of two portable FT-IR spectrometers equipped with ER FT-IR and DRIFTS modes were compared for plastics identification purposes for the first time. Both references of polymeric materials and historical plastic objects (from a Portuguese private collection) were studied and the differences between ER FT-IR and DRIFT spectra were discussed. The spectra features were examined considering the two different optical geometries and analytes' properties. This new insight can support a better understanding of both vibrational information acquired and practical aspects in the application of the ER FT-IR and DRIFTS in plastic analysis.

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.

A New System for Assessing Visual Disability Using a Digital Visor.

BACKGROUND: Considering the lack of universally accepted visual requirements for driving and for defining various grades of visual disability, the aim of this study is to propose a new method that provides a numerical score resulting from a combined assessment of the visual field and visual acuity loss obtained using a digital technology visor. METHODS: This study presents a new system for calculating the percentage of visual disability by combining binocular visual acuity and binocular visual field assessments. A new Global Vision Evaluation System digital technology visor uses standardized, reproducible criteria to produce well-defined, numerically expressed test results. Through a specific algorithm, the device produces a numerical value expressing the percentage of visual disability. RESULTS: Eighty-six subjects with various types of visual impairment underwent visual acuity and visual field test examinations carried out employing both traditional methods and the new digital visor. The two methods provided homogeneously similar results regarding the positioning of the subjects on the visual disability scale. CONCLUSIONS: The new digital visor seems to be a valid method to ensure that visual disability assessments are more homogeneous and reliable, and that, consequently, the resources available for this purpose are more fairly distributed.

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.

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.

Pregabalin Abuse in Combination With Other Drugs: Monitoring Among Methadone Patients.

INTRODUCTION: In recent years, there has been an increase in the non-medical use of psychoactive prescription drugs including pregabalin (PGB). Studies have shown that multiple drug users and patients in methadone treatment programs administered PGB at high dosages in order to achieve euphoria, reduce withdrawal symptoms, or potentiate the effects of methadone. For these reasons, accurate toxicological monitoring is required for these high-risk individuals. MATERIALS AND METHODS: The present study investigated whether PGB could be detected in the hair samples of 250 patients with a history of opiate dependency, and under toxicological surveillance assess their compliance with methadone maintenance therapy. RESULTS: Opiates were found in 54/250 of all hair samples, while cannabis was present in 74/250 patients, cocaine was detected in 21/250 patients, and benzodiazepines without prescription were identified in 49/250 patients. As expected, methadone was present in all 250 patients (100%). PGB without prescription was found in the hair samples of 35/250 patients (14%). Of these, 91.43% were male, 48.57% were <30 y old, and 45.71% were between ages 30 and 50 y. There were no apparent associations among PGB use, daily methadone dosage, and duration of methadone maintenance therapy. Psychiatric comorbidities were present in 25.71% of the patients abusing PGB. Anxiety (55.56%) and depression (33.33%) were the most prevalent psychiatric disorders. DISCUSSION: Most of the patients taking PGB (57.14%) used other drugs (especially opiates) concurrently. The utility of hair analysis is explained by easy and rapid sample collection and the ability of the hair to reflect long-term drug use and incorporate drug metabolites. The findings of this study suggested that PGB has significant potential for abuse by high-risk populations such as opioid users and patients with dual diagnosis. These risks are particularly high in cases of poly-drug use and drug intake that are not in compliance with prescription guidelines.

GC-MS/MS detects potential pregabalin abuse in susceptible subjects' hair.

Pregabalin, a GABA analogue, binds to the alpha 2 delta subunit of voltage-dependent calcium channels. It is recognised as efficacious in pathologies such as epilepsy, neuropathic pain, and anxiety disorders. Since pregabalin prescriptions have increased worldwide, reports of its abuse have been accumulating, mainly in patients with opioid abuse disorders. The present study investigated potential pregabalin abuse by means of hair analysis, a matrix that provides valuable retrospective information. Half of the pool of 280 susceptible patients had been occasional drug users and were being monitored for driving licence renewals. The other 140 patients had a history of opiate dependency and were monitored to assess compliance with methadone therapy. In view of determining pregabalin in hair samples, it was extracted in methanol, successfully derivatised to give the ethyl chloroformate derivative, and finally pregabalin was analysed by gas chromatography-tandem mass spectrometry. Selectivity, linearity, limit of detection, limit of quantification, recovery, intra- and inter-day precision, and accuracy of the quantification procedure were appraised. Pregabalin limits of detection and quantification were 30 pg/mg and 50 pg/mg, respectively. We found 10.7% of hair samples from methadone patients and 4.29% from occasional drug users were positive to pregabalin without medical prescription. The mean pregabalin concentration in hair was higher than in consumers with medical indications (1.45 ng/mg vs 0.74 ng/mg). These results suggest that pregabalin possesses a significant abuse potential particularly among individuals attending opiate dependence services and that pregabalin abuse is a serious emerging issue, which should be carefully monitored.

A crossbow suicide.

The crossbow is an ancient ranged weapon originally conceived for war and hunting. Although nowadays its use in warfare has been surpassed by firearms, it continues to be used in hunting, sports and recreation. The authors present the case of a 40-year-old man who suffered from severe depression. When his condition further deteriorated, doctors ordered a forced hospitalization but, just a few hours before the measure became effective, the man committed suicide using a crossbow. The autopsy and police investigation showed possession of the crossbow darts which the man used to shoot himself in the head. The forensic pathologist found the dart stuck in the skull: the entry wound was in the suprahyoid region while the arrow tip emerged in the left parietal region meaning the arrow crossed the tongue, the middle fossa, the brain and the cranial wall. All the wounds presented a three-pointed star shape consistent with the three sharp blades of the dart. An extensive blood infiltration affected the subdural and subarachnoid space, particularly where the dart had passed. The severe brain injury, extensive subdural and subarachnoid bleeding and brain swelling following the trauma caused the death. Even though the use of the crossbow is only permitted in sporting/hunting contexts, the reported case highlights the sharp contrast between its potential for harm and the easy access to this kind of weapon, even for those affected by mental illness.

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.

Suicide behaviour and arsenic levels in drinking water: a possible association?: A review of the literature about the effects of arsenic contamination in drinking water on suicides.

BACKGROUND: A considerable part of the global population is exposed to arsenic-contaminated drinking water which is the main source of inorganic arsenic(As) exposure in humans. Arsenic exposure interferes with the action of enzymes, essential cations, and transcriptional events in cells throughout the body, and a multitude of multisystemic non-cancer effects might ensue. The aim of our review was to evaluate the effects of arsenic contamination in drinking water on suicides rates. METHODS: A systematic literature search (English written literature) was conducted in electronic databases MEDLINE, SCOPUS. Evidences dating from 1999 till 2016 have been collected. A manual search of reference lists of included studies and review articles was successively performed. All references of the retrieved studies were also reviewed to avoid missing relevant publications. The key search terms included: "arsenic AND water AND suicide". RESULTS: The literature search yielded 13 publications, but we identified 2 manuscripts available for this systematic review. The 2 studies included in the review, were published in 2015 and in 2017 and settled in Italy and Hungary. The levels of arsenic in the waters ranged from 0.016 µg/l to >50 µg/l. The findings of the two studies are conflicting, in fact Pompili et al. reported an apparently beneficial effect of arsenic on suicides rates, with an inverse correlation of arsenic concentration and local suicide rates, in contrast to a positive correlation with natural-cause mortality rates. CONCLUSIONS: Our review led to conflicting results, so the diatribe about the real effects of arsenic intake of suicidal behaviors is still open. Therefore, we encourage other colleagues to conduct further studies in other locations in order to have more reliable results.

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.