Self‐Embedding Behavior in Adults: A Report of Two Cases and a Systematic Review

Self‐embedding behavior (SEB) is the repeated insertion of sharp objects, such as needles or pins, into the soft tissues of abdomen, limbs, and other body parts. In this study, two cases of SEB were reported and the scientific worldwide literature reviewed. Thirty‐two cases of SEB were identified through systematic searches in the main bibliographic databases. Mean age was 35 years (SD = 8.97). Just over two‐thirds of the patients were female. Although the number of embedded objects could be as high as 200, major clinical and surgical complications were uncommon and mortality was null. Patients with SEB presented three major diagnoses: psychotic (25%), personality (21.9%), and factitious (28.1%) disorders. The practice of SEB largely went undetected as the patients themselves did not bring it to the attention of family members or physicians and usually denied they have engaged in SEB. A high level of suspicion is required to avoid a missed diagnosis.     

Self‐harm Risk Among Adolescents and the Phenomenon of the “Blue Whale Challenge”: Case Series and Review of the Literature

The “Blue Whale Challenge” is a dangerous Internet phenomenon. As per media reports, it involves a series of life‐threatening tasks imposed by a “curator” to “players,” who must fulfill the whole list, and it ends with the suicide of the player. The authors report the data of five suspected cases of “Blue Whales” managed from January 2016 to December 2017 by the staff of a unit (the “Bambi Unit” of the Pediatric Hospital “Regina Margherita” of Turin, Italy) that is dedicated to the evaluation of suspected abused children. Then, they analyzed this data in the light of the literature regarding self‐harm. This comparison highlights the role of the Internet in the spreading of self‐harm behavior among vulnerable adolescents who are characterized by epidemiological, psychological, psychiatric, social, and cultural risk factors. In conclusion, the authors suggest a multidisciplinary and specialized approach in the evaluation of adolescents who committed self‐harm activities.     

Shark‐Inflicted Trauma: A Case Study of Unidentified Remains Recovered from the Gulf of Mexico*

Abstract: Here, we present a case of an unidentified male whose remains, except for the right arm, were recovered from the Gulf of Mexico 10 years prior to osteological analysis by forensic anthropologists. After the poorly preserved soft tissue was removed and the bones cleaned, forensic analysis revealed an unusual series of hard tissue trauma later attributed by a shark expert as shark scavenging and/or predation. Identified were five unique hard tissue trauma patterns that are bite mark artifacts produced by sharks: punctures without fractures, punctures with associated fractures, striations with bone shaving, overlapping striations, and incised bone gouges. The cooperation among experts provided a comprehensive death case analysis and a better understanding of shark‐inflicted trauma on human skeletal remains.     

Identification of Risk Factors for Self‐Injurious Behavior in Male Prisoners*

Abstract: Male prisoners with (n = 132) and without (n = 132) histories of engaging in self‐injurious behavior (SIB) were matched on conviction prefix and custody level. Conditional logistic regression revealed that a combination of risk factors from domains defined by developmental, offense history, mental health, and institutional functioning factors correctly classified 93% of the prisoners in the sample (ROC AUC = 0.89, S.E. = 0.005, p < 0.0001). Model specificity was 92.6% and sensitivity was 95.3%. False positive and false negative rates were 2.3% and 3.4%, respectively. Implications for the assessment of prisoners at risk for SIB as well as suggested future directions for SIB prisoner research are discussed.     

Relationship Between Self‐Injurious Behaviors and Levels of Aggression in Children and Adolescents Who Were Subject to Medicolegal Examination,

Aggression, which is defined as a behavior causing harm or pain, is a behavioral pattern typically expected in children and adolescents who are involved in criminal activities. The aim of this study was to examine the relationship between aggression and self‐injurious behavior (SIB) in children and adolescents. The study was performed in 295 cases which were sent for medicolegal examination. The mean age of the subjects was 14.27 ± 1.05 years (age range 10–18 years). The aggression levels of the subjects were determined using the Aggression Questionnaire (AQ), which is an updated form of the Buss‐Durkee Hostility Inventory. The mean total AQ score of the subjects with and without SIB was 78.04 ± 21.0 and 62.75 ± 18.05, respectively (p < 0.01). There were significant statistical differences between the two groups with respect to their subscale scores (p < 0.01). It was concluded that the levels of aggression increased in children and adolescents who were involved in criminal activities when the SIBs increased.     

An Autopsy Case in Which Self‐Bloodletting Via a Cervical Blood Access Led to a Fatal Outcome*

Abstract: A 48‐year‐old woman was found dead on a chair in her living room. She had received dialysis every day because of chronic renal failure for the past 15 years. On a table beside her, there was a mirror and 10‐mL syringe on a napkin. A stopper was out of place in a portion of a three‐way blood access tube established in the right cervical region, and blood coagulation was noted in the lumen. There was a bloodstained measuring cup on the floor. Autopsy findings included a large number of shunt traces in the bilateral infraclavicular fossae and upper limbs, as well as the cervical blood access terminal reaching the right atrium via the internal jugular vein to superior vena cava. Various organs showed anemia. Neither a fatal lesion nor injury was noted in the main organs. Therefore, this patient may have committed suicide by self‐bloodletting via a cervical blood access.     

Alcohol‐Induced Osteopenia Among In‐Custody and Homicide Deaths from the Harris County Institute of Forensic Sciences

Four cases of in‐custody or unlawful death are presented as examples of increased bone fragility with an associated increase in fracture rates due to ethanol‐induced osteopenia. In addition, one of the individuals suffered fractures several weeks premortem, allowing some healing to take place. Using radiographs and physical examination, the ribs from these individuals are compared with those retained from three individuals with no history of alcoholism to illustrate diagnostic characteristics that will be notable using standard autopsy and anthropological procedures. Trabecular bone mass is notably decreased in the alcoholic group leading to a greater chance of fracture occurring during conflict, including arrest and in‐custody situations. The average number of perimortem fractures among the alcoholic individuals is 15, while the control group is six. In the case of the individual with healing, the degree of bone repair on the ribs was less than is expected considering the interval between injury and death.     

A Fatality Following Ingestion of the Designer Drug Meta‐Chlorophenylpiperazine (mCPP) in an Asthmatic—HPLC‐MS/MS Detection in Biofluids and Hair

A 20‐year‐old man, a cocaine addict and regular ecstasy user, with a medical history of allergic asthma died after ingesting half a tablet earlier the same day. The white tablet, stamped with a “smiling sun” logo looked very much like an ecstasy tablet and was sold as such. He experienced a severe asthma attack just after ingesting the half tablet and it evolved over the next few hours into fatal cardiorespiratory arrest. Biological samples, taken after embalming, were analyzed by high‐performance liquid chromatography tandem mass spectrometry (HPLC‐MS/MS). Analysis revealed meta‐chlorophenylpiperazine (mCPP) in concentrations of 45.8 mg in a similar tablet obtained later from the drug dealer, 5.1 ng/mL in the bile, 0.3 ng/g in the liver, 15.0 ng/mL in the urine, and its absence in a hair sample (<0.02 ng/mg), which indicated he was not a regular user (whereas strong concentrations of MDMA and cocaine were found in the hair). Interrogated by the police after his arrest, the dealer said that he had sold the victim and for the very first time two tablets with the same “smiling sun” logo. The tablet used for analysis was from the same brand as the one ingested by the victim. The autopsy excluded other causes of death, while the histological analyses showed a large number of polynuclear eosinophils in the bronchial walls, confirming the asthmatic pathology. None of the other organs examined (larynx, liver, heart, adrenal glands, and kidneys) showed any distinctive signs, and in particular no inflammatory infiltrate. The death was the result of an asthma attack in an asthmatic person, violently decompensated following ingestion of approximately 20 mg of mCPP.     

Postmortem Blood Concentrations of R‐ and S‐Enantiomers of Methadone and EDDP in Drug Users: Influence of Co‐Medication and P‐glycoprotein Genotype

Abstract: We investigated toxicological and pharmacogenetic factors that could influence methadone toxicity using postmortem samples. R‐ and S‐methadone were measured in femoral blood from 90 postmortem cases, mainly drug users. The R‐enantiomer concentrations significantly exceeded that of the S‐enantiomers (Wilcoxon’s test, p < 0.001). The samples were divided into four groups according to other drugs detected (methadone only, methadone and strong analgesics, methadone and benzodiazepines, or methadone and other drugs). There was no significant difference in any of the R‐methadone/total methadone ratios among the four groups. The median R/S ratio was 1.38, which tends to be higher than that reported for the plasma of living subjects. In addition, we investigated whether small nucleotide polymorphisms in the MDR1 gene that encode the drug transporter P‐glycoprotein were associated with the concentrations of R‐ and S‐methadone and its metabolite 2‐ethylidene‐1,5‐dimethyl‐3,3‐diphenylpyrrolidine. No significant association was detected.     

Distribution of Venlafaxine,O‐desmethylvenlafaxine,and O‐desmethylvenlafaxine to Venlafaxine Ratio in Postmortem Human Brain Tissue

Venlafaxine (VEN) and its metabolite O‐desmethylvenlafaxine (ODV) inhibit reuptake of serotonin and norepinephrine. This study examines whether VEN is differentially distributed in postmortem brain and examines relationships between brain and femoral blood concentrations from donors prescribed VEN for treatment of depression. Using high‐pressure liquid chromatography‐ultraviolet detection, VEN and ODV concentrations were measured in temporal, occipital, and cerebellar cortex of six postmortem brains. The ODV/VEN ratio was calculated as a relative measure of drug metabolism within each region where higher ratios indicated a greater conversion of VEN to ODV. Compared to the other regions examined, the cerebellum showed decreased VEN (p = 0.056), ODV (p = 0.006), and ODV/VEN (p = 0.027) ratios. In parts per million, VEN was higher in temporal and occipital cortex, but not cerebellum, as compared to femoral blood concentration. These observations suggest that VEN and ODV are differentially distributed in the brain, and metabolism of VEN to ODV may vary across brain regions.     

Quantitative Analysis of Gamma‐Hydroxybutyrate at Endogenous Concentrations in Hair using Liquid Chromatography Tandem Mass Spectrometry

Abstract: A method capable of quantifying endogenous concentrations of gamma‐hydroxybutyrate (GHB) in human head hair was developed and validated using liquid chromatography/mass spectrometry/mass spectrometry (LC/MS/MS). Hair was digested under alkaline conditions, and GHB was isolated using liquid–liquid extraction. LC/MS/MS was performed using atmospheric pressure chemical ionization in the negative mode, multiple reaction monitoring, and deuterated internal standard (GHB‐D₆). Linearity was observed between 0.1 and 100 ng/mg GHB (R² = 1.000). The limits of detection and quantitation in human hair were 0.2 and 0.4 ng/mg, respectively. Accuracy at 2 ng/mg and 10 ng/mg was determined to be 97% and 94%, and intra‐assay CVs at these concentrations were 5.2% and 7.4% (n = 4). Beta‐hydroxybutyrate (BHB), alpha‐hydroxybutyrate, gamma‐butyrolactone, and 1,4‐butanediol did not produce an interference, and there was negligible ion suppression or enhancement from the matrix.     

Deaths Due to Child Abuse: A 6‐Year Review of Cases in The Cook County Medical Examiner's Office

Case files from the Cook County Medical Examiner's Office from 2007 to 2012 were reviewed to analyze homicides due to physical child abuse in children <3 years old. Fatal cases mostly involved younger subjects. Intracranial injuries were the leading cause of death, while death due to extracranial injuries was uncommon. Eyes were involved in most of the cases. Spinal cord was involved in about 1/3 of the cases, mostly in the thoracic area. In some cases, previous injuries were present. There were significant differences in the pattern of injuries between age groups. Subjects showing signs of impact to the head and subjects with no evidence of an impact showed no significant difference in internal injuries. The association of multiple injuries is highly suggestive of child abuse. In suspected child abuse, a postmortem examination including neuropathological, ophthalmological, and radiological information should be always evaluated, together with investigative reports and the medical history.     

Analyses of Beverage Remains in Drug Rape Cases Revealing Drug Residues ‐ The Possibility of Contamination from Drug Concentrated Oral Fluid or Oral Cavity Contained Tablets

In drug‐facilitated sexual assault (DFSA) cases, drug residues may be detected in beverage remains found in cups or glasses known to have been used by the victims. In this small naturalistic study, the possibility of beverages being contaminated, either by drug concentrated oral fluid or by oral cavity contained tablets, was investigated. Analysis of residues from cups containing soft drinks was performed by immunoassay and ultra‐performance liquid chromatography‐mass spectrometry (UPLC‐MS/MS). Beverage with both added tablets and spiked oral fluid was investigated, as well as simulation of swallowing tablets. Only the residues from added tablets were positive with immunoassay, while drugs were detectable in all cups using more sensitive UPLC‐MS/MS. In conclusion, the possibility of detecting drug residues in beverages due to a contamination, from either drug concentrated oral fluid or oral cavity contained tablets at a time of consumption, should be kept in mind when performing sensitive analysis.     

Potency Trends of Δ9‐THC and Other Cannabinoids in Confiscated Cannabis Preparations from 1993 to 2008*

Abstract: The University of Mississippi has a contract with the National Institute on Drug Abuse (NIDA) to carry out a variety of research activities dealing with cannabis, including the Potency Monitoring (PM) program, which provides analytical potency data on cannabis preparations confiscated in the United States. This report provides data on 46,211 samples seized and analyzed by gas chromatography‐flame ionization detection (GC‐FID) during 1993–2008. The data showed an upward trend in the mean Δ⁹‐tetrahydrocannabinol (Δ⁹‐THC) content of all confiscated cannabis preparations, which increased from 3.4% in 1993 to 8.8% in 2008. Hashish potencies did not increase consistently during this period; however, the mean yearly potency varied from 2.5–9.2% (1993–2003) to 12.0–29.3% (2004–2008). Hash oil potencies also varied considerably during this period (16.8 ± 16.3%). The increase in cannabis preparation potency is mainly due to the increase in the potency of nondomestic versus domestic samples.