Fentanyl-related deaths: demographics, circumstances, and toxicology of 112 cases

Since 1979, the potent narcotic analgesic fentanyl and its analogs have been synthesized in clandestine laboratories and sold as heroin substitutes. At least 112 overdose deaths have been associated with their use. In this study, toxicology data, autopsy findings, and coroners' investigative reports were reviewed in order to construct a profile of the typical fentanyl overdose victim and to identify any factors that might heighten the risk of death from fentanyl use. The "typical" fentanyl overdose victim was 32.5 +/- 6.7 years of age (range, 19 to 57 years), male (78%, compared with 22% female), and Caucasian (50%, compared with 29% Hispanic, 20% Black, and 0.9% Asian). With the exception of his or her age, the typical fentanyl overdose victim is quite similar to the typical heroin user. Nearly all the deaths (94%) occurred in California, yet within the state they were widely distributed throughout 17 counties and 44 cities. Pulmonary edema and congestion and needle puncture sites were consistent postmortem findings. No preexisting medical conditions were identified as possible risk factors. Although most of the fentanyl victims had a prior history of intravenous drug use, morphine or codeine were not commonly found, which suggests that the victims had little or no opiate tolerance. Ethanol was present in 38% of the cases and is thought to be a significant risk factor. Mean fentanyl concentrations in the body fluids were quite low: 3.0 +/- 3.1 ng/mL (0.3 +/- 0.31 micrograms/dL) in blood and 3.9 +/- 4.3 ng/mL (0.39 +/- 0.43 micrograms/dL) in urine, measured by radioimmunoassay. Although the potency of the analogs and the purity of street samples varies considerably, it is probably the general availability of the drug rather than the potency of a particular analog that determines the incidence of overdose deaths.     

Traumatic asphyxial deaths in car crush: Report of 3 autopsy cases

Traumatic asphyxia is a rare syndrome due to compression of thorax, abdomen or both. The diagnosis of traumatic asphyxia is based on typical findings consisting of cervico-facial congestion with swelling, multiple petechial hemorrhages in skin and conjunctiva with a history of traumatic compression. The authors report three cases of traumatic asphyxia in car crash to illustrate few unusual findings along with the typical autopsy findings. All three cases showed the typical findings of traumatic asphyxia. Regarding unusual findings, blisters containing hemorrhagic fluid were observed in two cases over areas subjected to traumatic compression. One case showed the peculiar skin pattern in the form of absent congestion corresponding to the tight-fitting strap of banyan. Subcutaneous emphysema was noted in two cases in presence of intact visceral pleura. These unusual findings could be used as additional markers of traumatic asphyxia in conjunction with characteristic features to support the diagnosis of traumatic asphyxia.     

Patho-anatomic findings in neck structures in asphyxiation due to hanging: a survey of 80 cases

By examining 80 consecutive cases of death due to hanging, fractures of the thyroid cartilage or the hyoid bone or both, were noted in 45%. Fracture of the cricoid cartilage did not occur. No fracture occurred below the age of 25, and the frequency was slightly increasing with increasing age. There was a preponderance of fractures in males. The highest incidence of fractures was noted in typical hangings, while incomplete hanging to a very great extent was combined with congestion to the face, especially if the location of the ligature was atypical. Typical hanging in general did not produce congestion. The lividity in the declivous areas became fixed at the earliest after 5-6 h suspension time, while after 12 h almost all the cases demonstrated fixed lividity in the distal parts, especially in the legs. There is slight indication that the frequency of fractures increases with the length of suspension time.     

Macro- and microscopic findings of cord marks in 2 cases of delayed death by hanging

Two cases of delayed death after suicidal or accidental hanging are reported. Despite equally long survival times (33 and 27 days, respectively) and macroscopically very similar cord furrows, segmental granulation tissue was present histologically in one case (suicide) below the cord furrow, and in the other case there was a normal corium. The main cause for the divergent ultrastructural findings consists in the variable degree of strangulation.     

Toxicological and pathological findings in a series of buprenorphine related deaths. Possible risk factors for fatal outcome

Buprenorphine is considered to have little respiratory side effects at therapeutic doses and the partial agonistic properties should produce a "ceiling effect" for respiratory depression at higher doses. Still, there are several reports on buprenorphine related deaths. Most deaths involve drug users and the co-administration of other CNS depressant drugs as well as reduced tolerance have been suggested to be risk factors. The primary aims were to investigate if lack of tolerance and/or co-ingestion of other psychotropic drugs are significant risk factors in buprenorphine fatalities. From July 2005 to September 2009, all autopsy cases where buprenorphine or norbuprenorphine had been detected in femoral blood and where analysis of buprenorphine had been performed in urine were selected. Results from the postmortem examination and toxicology were compiled. Postmortem toxicology was performed using the routine methodology at the laboratory. In total, 97 subjects were included in the study. These were divided into four groups; Intoxication with buprenorphine (N=41), Possible intoxication with buprenorphine (N=24), Control cases where buprenorphine was not the cause of death (N=14), and Unclear (N=18). The metabolite to parent compound ratios in both blood and urine in the Intoxication group were significantly different from those in the Control and Unclear groups. An extensive poly-drug use was seen in all groups with several additional opioids in the Possible group (54%) and in the Unclear group (78%) and hypnotics or sedatives in more than 75% of the Intoxication, Possible, and Unclear cases. Illicit drugs were present in all groups but not to a great extent with amphetamine and tetrahydrocannabinol as the main findings. Interestingly, 4 cases in the Intoxication group presented with no other significant drugs in blood other than buprenorphine. We conclude that a lethal concentration of buprenorphine in blood cannot be defined. Instead the analysis of blood as well as urine can be an important tool to show that the drug was taken shortly before death and to rule out a continuous use of buprenorphine supporting the notion that abstinence is an important risk factor. The presence of alprazolam in more than 40% of the Intoxications and the presence of hypnotics and sedatives in 75% of the Intoxications suggests that these drugs interact with buprenorphine producing toxic effects that buprenorphine alone would not have produced. Still, in 10% of the Intoxications no other drugs were found indicating that under certain circumstances buprenorphine alone may produce respiratory depression resulting in death.     

Toxicological findings in deaths due to ingestion of pentazocine: A report of two cases

Two cases of fatal suicidal ingestion of pentazocine are presented. Toxicological findings in these deaths are compared to those of twelve similar pentazocine fatalities gleaned from various compilation of toxicology data. Pentazocine blood and liver concentrations in the presented cases were 3.3 and 9.2 mg/l, and 34 and 43 mg/kg, respectively. Blood and liver concentrations in references cases ranged from 0.8 – 38 mg/l and 3 – 197 mg/kg, respectively. The interpretation of toxicology findings following the ingestion of pentazocine is discussed.     

Asphyxiation by hanging in two young Hispanic children--homicide, suicide, or accidental deaths? A review of pediatric hangings

Case reports of asphyxiation by hanging in two young children are presented along with a review of the literature to determine the incidence and manner of death by hanging in the younger pediatric population.     

Petechiae in hanging: a retrospective study of contributing variables

Petechiae, one of the classic signs of asphyxia, are thought to be more frequently observed in cases of hanging where part of the body is supporting the victim's weight, ie, cases of incomplete hanging. However, there is very little evidence-based medicine to support this claim. The present study is intended to evaluate the relationship between petechiae and the type of hanging (complete vs. incomplete). Furthermore, several other variables were analyzed to determine if they contribute significantly to the presence of petechiae. An 8.5-year retrospective study of 206 cases of death by hanging reviewed autopsy reports for the presence of petechiae. For each case, the following information was also compiled: gender and age, height and weight, body mass index, the type of hanging (complete or incomplete suspension), the type of ligature used (narrow or wide), and whether or not the victim had received cardiopulmonary resuscitation maneuvers. Statistical analysis revealed that the incidence was higher among incomplete hanging victims compared with cases of complete suspension and that the incidence of petechiae varied inversely with the height of the victims. The other factors were not shown to contribute significantly to the presence of petechiae.     

Nonsex offenses committed by child molesters: findings from a longitudinal study

This study, which used a prospective as well as a retrospective methodology, examined the criminal records of 30 child molesters prior to, and up to 10 years after an index event of sexual abuse for which they were convicted: 73% had convictions for other offenses, 60% had convictions for offenses other than sex offenses, 50% had convictions for property offenses, 27% had convictions for offenses involving violence, and 23% had convictions for drug offenses. Offending levels for nonsex offenses were significantly higher than the general adult male population. Any theory concerning the dynamics of sex offending against children needs to account for the level of nonsex offenses committed by child molesters.     

急性心肌缺血猝死心肌中血红素加氧酶-1的表达

目的观察血红素加氧酶-1（HO-1）在急性心肌缺血猝死心肌细胞胞浆中的表达情况。方法应用免疫组织化学技术（SP法）,对27例可疑早期心肌缺血猝死（早期梗死组）、10例心肌梗死猝死（心肌梗死组）、11例冠心病非心性猝死（对照组1）以及10例正常心肌（对照组2）中HO-1的表达进行观察分析。结果早期梗死组与心肌梗死组在心肌细胞胞浆中HO-1均呈强阳性表达,对照组1和对照组2心肌细胞胞浆中HO-1弱阳性表达或无表达。早期梗死组和心肌梗死组与对照组1和对照组2之间心肌细胞内HO-1表达的差异有显著性意义（P（0.01）;镜下各组心肌细胞胞浆内HO-1表达的阳性面积率及平均光密度差别明显。结论 HO-1可以作为急性心肌缺血所致心性猝死的一个诊断指标。     

A retrospective analysis of cardiovascular deaths: A 5-year autopsy study of 1045 cases in Antalya,Turkey

This study aims to identify the macroscopic and microscopic changes that occur in the heart in different causes of cardiovascular death and sudden cardiac death in autopsy cases and evaluate the difficulties that a forensic practitioner may encounter during autopsies. All forensic autopsy cases in the Morgue Department of the Council of Forensic Medicine, Antalya Group Administration between January 1, 2015, and December 31, 2019, were examined, retrospectively. The cases were chosen according to inclusion and exclusion criteria, and their autopsy reports were examined in detail. It was determined that 1045 cases met the study criteria, 735 of which were also met the sudden cardiac death criteria. The top three common causes of death were ischemic heart disease (n = 719, 68.8%), left ventricular hypertrophy (n = 105, 10%), and aortic dissection (n = 58, 5.5%). The frequency of myocardial interstitial fibrosis was significantly higher in deaths due to left ventricular hypertrophy than in deaths due to ischemic heart disease and other causes (χ²(2) = 33.365, p < 0.001). Despite detailed autopsy and histopathological examinations, some heart diseases that cause sudden death may still not be detected.     

Agonal sequences in a filmed suicidal hanging: analysis of respiratory and movement responses to asphyxia by hanging

The forensic literature on the pathophysiology of human hanging is still limited. Therefore, forensic pathologists often feel uncomfortable when confronted with related questions. Here presented is the filmed suicidal hanging of a 37-year-old man. This recording allows a unique analysis of agonal movement sequences: loss of consciousness (13 sec), convulsions (15 sec), decortication rigidity (21 sec), decerebration rigidity (46 sec), second decortication rigidity (1 min 11 sec), loss of muscle tone, (1 min 38 sec) and last isolated muscle movement (4 min 10 sec). As for respiratory responses, very deep respiratory attempts started at 20 sec. Respiratory movements progressively decreased and completely stopped at 2 min. Despite the fact that extending the presented data on all cases of hanging asphyxia would be a mistake, this case gives a very interesting insight into movement and respiratory response to asphyxia by hanging.     

Asphyxial deaths caused by automobile exhaust inhalation not attributable to carbon monoxide toxicity: study of 2 cases

The authors report two suicides that resulted from the intentional inhalation of automobile exhaust gases in which death occurred without the formation of physiologically significant amounts of carboxyhemoglobin. These circumstances are correlated with measurements of the involved vehicles' exhaust gases, which showed reduced concentrations of carbon monoxide present, reflecting improvements in automobile engine technology. In the absence of carbon monoxide toxicity, the authors attribute death in these cases to asphyxia caused by carbon dioxide intoxication and diminished atmospheric oxygen concentrations.     

Drug prevalence in drowning deaths in Cuyahoga County, Ohio: a ten-year retrospective study

Previous studies have shown that up to 50% of adult drownings are related to the consumption of alcohol. Little information is available in the literature regarding the possible contribution of ethanol and other drugs to drownings.All records of deaths occurring in Cuyahoga County, Ohio, from 1994-2003, in which drowning was listed as the cause of death, were reviewed. Toxicology analysis was performed on cases where specimens were submitted. Review of the 187 cases showed that the majority (78%) of drowning deaths were ruled as accidents, 26 (14%) as suicide, 5 (3%) as homicide, and 11 (6%) as undetermined.Among the accidental deaths (n=141), 97 (69%) were negative for all drugs, including ethanol, and 30 cases (21%) were positive for ethanol only. Illicit drugs were detected in 4 of the cases (3%). In the suicides (n=26), 16 (62%) were negative for all drugs, including ethanol, and 7 cases (27%) were positive for ethanol only (mean blood alcohol concentration [BAC] 0.03 g/dL). Illicit drugs were detected in 3 of the cases (12%). Two of the 5 homicide cases (40%) were positive for ethanol. There were no cases in which the victim tested positive for illicit drugs.Of the 11 cases ruled as undetermined, 64% (n=7) were negative for all drugs, including ethanol. The remainder of the cases tested positive for ethanol only. There were no cases in which illicit drugs were detected. This study demonstrates that the majority of drowning deaths in Cuyahoga County, Ohio, were not drug related. Deaths in which drugs were detected were typically accidental deaths, with ethanol the most common drug detected.     

The prevalence of drugs in carbon monoxide-related deaths: a retrospective study, 2000-2003

The objective of this study was to review demographic characteristics and drugs detected in carbon monoxide (CO)-related deaths from cases received by the Office of the Cuyahoga County Coroner in Cleveland, Ohio, from 2000-2003. Postmortem reports were reviewed, and decedents for which CO was listed as the cause of death were included. The data were compiled into 3 groups according to the official coroner's verdict as to the manner of death: accident, suicide, and homicide. Included in this study were 122 cases: 84 (69%) accidental, 31 (25%) suicide, and 7 (6%) homicide. Accident decedents were typically white males, aged 40-59 years, residing in Cleveland. Suicide decedents were also middle-aged, white males but residing in the suburbs. Homicide decedents under the age of 6 were characteristically black (N=2), while decedents over the age of 39 were predominately white (N=3). Carboxyhemoglobin (COHb) levels in suicide cases were higher than concentrations measured in accidental deaths. The highest percentage of suicide decedents (36%) had a COHb level>70% saturation, accident decedents (36%) between 50% and 69% saturation, and homicide decedents (71%) below 50% saturation. Ethanol (N=34) was detected in 28% of deaths, and therapeutic and/or abused drugs (N=50) were detected in 41% of deaths. Illicit drugs were detected in 11% of cases (cocaine/metabolites; THC/metabolites), other drug positives were therapeutic medications. The most common drugs detected were antidepressants and antihistamines in suicides and pain medications and antihistamines in accidents.     

Acute ethanol poisoning: a two-year study of deaths in North Carolina

A 24-month study of fatalities in North Carolina with high blood ethanol levels (300 mg/100 ml or over) revealed 502 cases with either acute alcoholism or the effects of this range of blood ethanol concentration having caused or contributed to death. This investigation reassessed the criteria for ethanol poisoning, including its cause and manner of death, and revealed recurrent patterns common to this syndrome. This inquiry also contrasted the frequency of ethanol poisoning in different areas of the country.     

Biostatistical evaluation of HLA-A, B findings in cases with suspected recombination

In a given case with two or more siblings the bloodgroup findings may yield a high plausibility of paternity for the alleged father of the children whilst the HLA-A,B characteristics may exhibit an exclusion of fatherhood of one or other of the siblings. But this "exclusion" may disappear assuming an HLA-A,B recombination of a father's (or mother's) gamete. In such cases simple calculations (i.e., by hand) can provide the serostatistical characteristic L = Y/X (after Essen-M?ller) for the given HLA-A,B constellation. In two-child cases with HLA-A,B findings for the putative father, the two pedigrees for the counterhypothesis Y are Yg1 and Yg2. The one holds for the case where the putative father is the father of child 1 and the other for the case where he is the father of child 2; in each case an unknown man is the father of the other child. The likelihood ratio is calculated as follows: L = Y/X = 1/r.p(3,3).p(3,4).[p(4,4) + p(4,3)]/[p(3,3).p(4,4) + p(3,4).p(4,3)], where p(3,3) and p(4,4) are the frequencies of the putative father's HLA-A,B haplotypes in the pedigree YH1, p(3,4) and p(4,3) those in pedigree YH2, and where r is the recombination rate. In three-child cases and others in which the putative father is deceased and HLA results from legitimate children or siblings are available, and in which fatherhood is only possible if a recombinant haplotype interferes, only one counter-hypothesis exists. In these cases, the likelihood ratio is represented by L = Y/X = 2/r.p(HR).2I, where p(HR) means the frequency of the recombinant HLA-A,B haplotype, r the recombination rate and I(0, 1 or 2) the "difference in determined types."     

草鱼胆汁提取物急性中毒的实验病理

研究草鱼胆汁提取物（鲤醇硫酸酯钠）对小鼠毒性作用的病理变化及其作用机制。按1．5LD50、1．0LD50和0．5LD50的剂量给昆明小鼠1次腹腔注射1％鲤醇硫酸酯钠溶液和按0．5LD50的剂量给昆明小鼠多次腹腔注射1％的鲤醇硫酸酯钠溶液,观察中毒小鼠各主要脏器的病理变化。中毒小鼠主要脏器的病理变化与草鱼胆汁中毒十分相似：心肌细胞水肿,严重者可见灶性肌溶解坏死;肾小管上皮细胞变性、坏死,肾小球滤过膜各层均有不同程度的病变。通过酶组织化学方法发现鲤醇硫酸酯钠对心肌SDH及CCO有明显的抑制作用。鲤醇硫酸酯钠是草鱼胆汁的主要毒性成分之一。     

Poisoning deaths in Central China (Hubei): A 10-year retrospective study of forensic autopsy cases

A retrospective study of autopsy cases was conducted at the Department of Forensic Medicine, Tongji Medical College (DFM-TMC), in Hubei, China to describe the characteristics of poisoning deaths from 1999 to 2008. A total of 212 poisoning deaths were investigated by DFM-TMC during the 10-year period. The poisoning deaths ranged from 17 cases in 1999 to 27 cases in 2008. Of the 212 cases, 82 deaths (38.7%) were from pesticides, 36 deaths (17.0%) from carbon monoxide, 34 deaths (16.0%) from drugs, 22 deaths (10.4%) from alcohol, 17 deaths (8.0%) from other chemicals, 15 deaths (7.1%) from poisonous plants and animals, and six deaths (2.8%) from heavy metals. Of the 82 pesticide poisoning deaths, 43 (52.4%) cases were caused by rodenticides, mainly tetramine (N = 39). The majority of poisoning deaths were accidents (63.7%), followed by suicides (25.9%) and homicides (3.8%). The manner of death could not be determined in 14 cases (6.6%).