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Intravascular large B-cell lymphoma (IVLBCL) is a rare form of lymphomas with poor prognosis, characterized by atypical lymphocytes selectively growing within the lumen of small or medium-sized vessels. Here, we report a case of intracerebral IVLBCL in a 54-year-old man who died three months after symptom onset. The diagnosis was made by postmortem pathological examination, based on the identification of multiple ischemic lesions, with small or medium-sized vessels filled with malignant B-cells, in the cerebral hemispheres, cerebellum, midbrain, and medulla oblongata, including the external cuneate nucleus and trigeminal spinal tract nucleus. Apart from necrotic lesions, specific histopathological search for occluded vessels in the other brain stem structures permitted identification of significant involvement of the cuneate nucleus, solitary tract nucleus, hypoglossal nucleus, and inferior olivary complex. Small vessels affected by IVLBCL were also found in the trunks of the oculomotor, trigeminal, glossopharyngeal, vagal, and hypoglossal nerves. These histopathological findings were consistent with some cranial nerve symptoms/signs ascertained during hospitalization, such as diplopia, dysphonia, and asymmetry/hypomotility of the palatal veil. The case study presented here reports novel insights on radiological, anatomical, and clinical correlations of the IVLBCL, including the possible involvement of nuclei and trunks of multiple cranial nerves. The reported findings may help clinicians in the early identification of this rapidly progressive disease that can be easily misdiagnosed, through integrated neuroradiological, neurological and neuropathological approaches.

Rathke cleft cysts (RCCs) are asymptomatic benign sellar cysts. Their surgical treatment may lead to a series of well known complications, many of which can be interpreted as failed surgical interventions. We present a retrospective study on patients with treated RCCs that filed a claim for compensation for medical professional liability, with the aim of reporting the medico-legal issues related to the surgical resection of RCC. A retrospective analysis was performed between 1999 and 2016 on patients diagnosed with RCCs and who underwent surgical resection. The clinical experience of the patients alleging medical liability was analysed by an interdisciplinary group following the European Guidelines proposed by the European Academy of Legal Medicine. Eight patients developed late complications and made a claim for compensation. Only in one case a prognostic error was detected. The pre- and postoperative conditions, as well as the onset of early and late complications are reported and discussed in the paper, as well as the differentiation between “error-free” vs “error-related” complications. Understanding the underlying causes of the increase in compensation claims, as in the specific case, can help not only in the reduction of errors, but also in the prevention of compensation claims, which result in an increase in public and private spending. One of the main causes of the disproportion between the request for compensation and actual compensation is the expectation regarding surgery and the onset of complications, which could be solved through the appropriateness of consent submitted before the intervention.

A 55-year-old man affected by a psychotic disorder suddenly died during a quarrel with his father. The autopsy excluded traumatic causes of death, and the cardiac examination identified a severe cardiomegaly with biventricular dilatation of very likely multifactorial origin. Toxicological and pharmacogenetic analyses excluded a fatal intoxication and identified the presence of the antipsychotic drug fluphenazine in the therapeutic range in a normal metabolizer. The screening for genetic variations highlighted a novel heterozygous single-nucleotide variant in the exon 36: c 0.4750C>A (p.Pro1584Thr) of the Ryanodine Receptor Type 2 (RYR2) gene. The mutation detected can be classified as Likely Pathogenic according to the American College of Medical Genetics and Genomics (ACMG) criteria. RYR2 variation has been associated to catecholaminergic polymorphic ventricular tachycardia (CPVT), a disease currently recognized as one of the most malignant cardiac channelopathies, expressed mostly in young patients, normally in the absence of structural heart disease. The victim late middle age, compared to juvenile onset of CPVT reported in literature, his clinical history, his structurally altered heart, circumstances at death and the absence of phenotype-related variations of dilated cardiomyopathy genes, suggested that the fatal arrhythmia could have been caused by an acquired form of dilated cardiopathy/cardiomyopathy. However, the contribution of the genetic variant to death cannot be completely ruled out, since the significance of a VUS or of a novel variant depends on the data available at the time of investigation, and should be periodically evaluated. We discuss the contribution of the structural alteration and of the variant detected, as well as the role of the molecular autopsy in forensic examination, which can make a significant contribution for inferring both cause and manner of death.

Fly artifacts (FA) are bloodstains resulting from insect activity at a crime scene, usually by feeding on human blood. Whether these artifactual stains might be useful for forensic toxicological investigations in cases of absence of conventional and unconventional matrices, for example, in cases concealment of the body or of extensive putrefaction, has not yet been investigated. The purpose of this study is to understand if FA trace evidence permits toxicological analysis when traditional matrices are not available. To this aim, FA experimentally produced by Calliphora vomitoria feeding on human blood of a cocaine and heroin user were collected from absorptive and non-absorptive material. FA material was analyzed by a new simple and fast LC-MS/MS method. Results were evaluated in terms of presence of the drug and relative amount of the detected molecules. From a qualitative point of view, the analysis of FA revealed all the substances originally detected in post-mortem blood in both cases. The ratios of cocaine/benzoylecgonine, codeine/morphine, and 6-monoacetylmorphine/morphine recovered in FA from cotton-textile materials and from non-absorptive surfaces were consistent with data resulted from original post-mortem blood. The preliminary study herein reported demonstrated that FA are extremely informative in case of cocaine and heroin users and merit further research in order to be applied in real caseworks.

Novel psychoactive substances (NPS) represent a severe health risk for drug users. Even though the phenomenon has been growing since the early 2000s, the mechanisms of action of NPS at the receptors and beyond them are still scarcely understood. The aim of the present study was to provide a systematic review of the updated knowledge regarding the molecular mechanisms underlying the toxicity of synthetic opioids, cannabinoids, cathinones, and stimulants. The study was conducted on the PubMed database. Study eligibility criteria included relevance to the topic, English language, and time of publication (2010–2020). A combined Mesh and free-text protocols search was performed. Study selection was performed on the title/abstract and, in doubtful cases, on the full texts of papers. Of the 580 records identified through PubMed searching and reference checking, 307 were excluded by title/abstract and 78 additional papers were excluded after full-text reading, leaving a total of 155 included papers. Molecular mechanisms of synthetic opioids, synthetic cannabinoids, stimulants, psychedelics, and hallucinogens were reviewed and mostly involved both a receptor-mediated and non-receptor mediated cellular modulation with multiple neurotransmitters interactions. The molecular mechanisms underlying the action of NPS are more complex than expected, with a wide range of overlap among activated receptors and neurotransmitter systems. The peculiar action profile of single compounds does not necessarily reflect that of the structural class to which they belong, accounting for possible unexpected toxic reactions.

The combined event of a suicide and the killing of a pet has been hardly explored in forensic literature, but it is not rare at all. In the reported case the dead corpse of a 60-year old mentally ill woman and the carcass of a dog were found on the bed of a private apartment. In light of death scene investigation, necroscopic examination and toxicological analyses death was attributed to licit drug intoxication and self-strangulation after lethal poisoning of the dog. Due to the presence of two lethal means (cervical noose and drugs), acting in chronological order, the event was classified as a secondary complex suicide. Moreover, the woman, although mentally ill, was a psychiatrist. Thus, her professional background, namely the easy access to psychiatric drugs together with her knowledge of drug composition and properties lead to suppose an occupation related suicide. The comprehensive analysis of all the available information, including death scene investigation, occupational, necroscopic and toxicological data, resulted of the utmost importance for a proper reconstruction of the events and are recommended in complex cases such as occupation related planned complex suicides combined to the killing of pets.

Introduction: In 2019, the Italian Supreme Court established that hemp cannot be commercialized for human use, when the “psychotropic effect” of the product or its “offensiveness” can be demonstrated. The aim of the present study is to assess Δ9-tetrahydrocannabinol (Δ9-THC) and cannabidiol (CBD) blood concentrations after smoking cannabis with a low percentage of Δ9-THC, also referred as “light cannabis”, and its effects on young adults’ vigilance, cognitive and motor skills. Materials and methods: Eighteen young adults consumed three light cannabis cigarettes containing 400 mg of inflorescences each, with a percentage of 0.41% of Δ9-THC and of 12.41% of CBD. Blood samples were collected before the experiment (t0), after each light cannabis cigarette (t1→t3), 60 (t4) and 120 (t5) minutes after the beginning of the experiment. Five performance tasks and a subjective scale were employed for measuring cognitive and psychomotor performances the day before the experiment (TT0) and after the third cigarette (TT1). Results: Mean (SD) concentrations (ng/ml) were 1.0 (0.8) in t1, 1.2 (0.9) in t2, 1.0 (0.8) in t3, 0.6 (0.4) in t4 and 0.3 (0.3) in t5 for Δ9-THC; 10.5 (10.3) in t1, 10.3 (13.2) in t2, 15.1 (14.8) in t3, 9.9 (9.2) in t4 and 5.7 (5.7) in t5 for CBD. No significant differences were observed between TT0 and TT1 for all performed psychomotor performance task. None of the subjects declared to feel “high” after the experiment. Discussion: All study participants reported that a higher number of cigarettes, corresponding in this study to 1200 mg of herbal product, could hardly be consumed by smoking in a recreational setting. Δ9-THC and CBD concentrations showed a high inter-subject variability, and the average concentrations were lower than those previously reported. Toxicological results showed a decrease of Δ9-THC and CBD after the third light cannabis cigarette, and a Δ9-THC /CBD ratio always

The analysis of macro- and microscopic characteristics of saw marks on bones can provide useful information about the class of the tool utilized to produce the injury. The aim of the present study was to test micro-computed tomography (micro-CT) for the analysis of false starts experimentally produced on 32 human bone sections using 4 different hand-saws in order to verify the potential utility of micro-CT for distinguishing false starts produced by different saws and to correlate the morphology of the tool with that of the bone mark. Each sample was analysed through stereomicroscopy and micro-CT. Stereomicroscopic analysis allowed the identification of the false starts and the detection of the number of tool marks left by each saw. Micro-CT scans, through the integration of 3D renders and multiplanar reconstructions (MPR), allowed the identification of the shape of each false start correlating it to the injuring tool. Our results suggest that micro-CT could be a useful technique for assessing false starts produced by different classes of saws, providing accurate morphological profiles of the bone marks with all the advantages of high resolution 3D imaging (e.g., high accuracy, non-destructive analysis, preservation and documentation of evidence). However, further studies are necessary to integrate qualitative data with quantitative metrical analysis in order to further characterize the false start and the related injuring tool.

Introduction Psychoactive medicines, such as benzodiazepines and Z-drugs (BdZ), antidepressants and antipsychotics (AA) and medical opioids (MO), have an impairing effect on driving ability. In previous epidemiological studies performed on impaired and/or injured drivers, not all relevant psychoactive substances were included in the toxicological assessment, and their prevalence may be underestimated. This study aims to assess the prevalence of a large set of psychoactive substances (n = 53) in Italian drivers involved in a road traffic crash and in predefined population subgroups. Materials and methods The toxicological analyses were performed on the whole blood of 1026 drivers involved in a road traffic crash in the area of Bologna, Italy, from January 2017 to March 2018. Analyses were performed using GC-FID (alcohol), GC MS (illicit drugs) and LC/HRMS (psychoactive drugs). The population was divided into subgroups according to gender, age and crash time. Descriptive statistics were used in order to assess differences among sub-groups. Results The highest prevalence was found for alcohol (17.3%), followed by medicinal drugs (13.6%) and illicit drugs (5.5%). The prevalence of BdZ, AA and MO were 7.3%, 7.2% and 3.1%, respectively. The frequency of BDZ and AA was significantly higher in female drivers and showed higher prevalence at increasing age. The presence of medicinal drugs was significantly higher during the week and in crashes occurring during the day. Conclusion Results for alcohol and illicit drugs partially overlap with those reported in previous European and Italian studies, but the prevalence of BdZ was much higher. We also found a high prevalence of AA, which are rarely investigated in epidemiological studies performed on drivers, but may cause impairment of the ability to drive, especially when taken in combination with alcohol or other drugs. The pattern of medication use differs from that involving drugs of abuse, since it is mainly observed in female subjects and older drivers and does not follow the same weekly trend observed for alcohol and other illicit drugs.

Introduction Among the several techniques proposed for the estimation of the Post Mortem Interval (PMI), the analysis of odorous amines has been applied in the past, with conflicting results. The aims of this study are: (i) to develop and validate a GC–MS method for the determination of putrescine (PUT) and cadaverine (CAD) in the human brain (validation study) and (ii) to study the relation of PUT and CAD concentration in the human brain and the PMI (decomposition study). Materials and methods Validation study. Analysis has been performed through GC–MS after a liquid-liquid extraction and a single step-derivatization for the identification and quantification of odorous amines in brain cortex samples. The standard protocol used in forensic toxicology, slightly modified for endogenous compounds according to recent guidelines, was used for validation. Decomposition study. Three uninjured human brains were sampled during the autopsy of three fatal traumatic cases. Along a 120-hour period of decomposition under experimental conditions, each brain was sampled along predetermined time intervals. Results Validation study. Both PUT and CAD validation parameters were within the acceptable values defined by the Scientific Working Group for Forensic Toxicology (SWGTOX), with better selectivity, linearity, accuracy and precision values for PUT. Decomposition study. A significant relationship between PUT and CAD levels and PMI has been demonstrated through statistical analysis with a correlation coefficient of 0.98 for PUT and 0.93 for CAD (p Conclusion Although further experimental studies on a wider number of samples are necessary, the results of this study suggest a possible role of polyamine levels in brain cortex for the estimation of PMI.

Dinitrogen (N2) has been increasingly connected to suicidal deaths. The analysis of N2 in post-mortem cases still represents a major challenge in forensic toxicology and circumstantial data has so far played a major role for the determination of the cause of death. In this paper, after presenting a review of cases of N2 intoxication described in forensic literature, we report the application of two approaches in order to quantify an excess of N2 in post-mortem whole blood collected from a case of suicide by nitrogen inhalation. N2 analyses were performed by GC–MS on the suicidal case and on controls taken from 10 autopsy cases with similar PMI (5 traumatic deaths and 5 deaths by asphyxia). The percentage of N2 was estimated by building a five-point N2 peak area calibration curve (0, 15.6 %, 62.4 % 78.1 %, 100 %) and through an external QC, assessing linearity, accuracy and precision, LLOQ, specificity and stability of N2 in the sample vial. Percentage of N2 of the case was significantly higher than the post-mortem controls (p < 0.05). The N2/O2 ratio of the case and controls was also calculated as an additional indicator, and was significantly higher in the case (p < 0.05). The strengths and the limitation of both methods are reported in the paper. Toxicological confirmation for N2 are rarely performed when the cause of death is evident, probably due to the lack of validated methods and the complexity of the interpretation of N2 concentration in biological fluids. The presented methods can be rapidly and profitably applied with instrumentation normally available in forensic laboratories.

Introduction Immunoassay (IA) tests are not widely applied in post-mortem samples, since they are based on technologies requiring relatively non-viscous specimens, and compounds originating from the degradation of proteins and lipids during the post-mortem interval can alter the efficiency of the test. However, since the extraction techniques for IA tests are normally rapid and low-cost, IA could be used as near-body drug-screening for the classes of drugs most commonly found in Italy and Europe. In this study, semi-quantitative results on post-mortem whole blood samples obtained through CEDIA analysis (cannabinoids, cocaine, amphetamine compounds, opiates and methadone), were compared with results of confirmatory analysis obtained using GC–MS. Screening cut-offs for all drugs were retrospectively optimized. Methods Post-mortem whole blood samples from autopsy cases of suspected fatal intoxication were collected over 3 years. Samples were initially analyzed through CEDIA (CEDIA, ILab 650, Werfen). Confirmatory analyses were then performed by GC–MS (QP 2010 Plus, Shimadzu). Screening cut-offs were retrospectively optimized using Receiver Operating Characteristic (ROC) analysis. Results CEDIA results were available for 125 samples. Two-hundred-eighty-nine (289) positive screening results were found. Among these, 162 positive confirmation results were obtained. Optimized screening cut-offs were as follows: 6.5 ng/ml for THC; 4.2 ng/ml for THC-COOH; 12.0 ng/ml for cocaine; 6.6 ng/ml for benzoylecgonine; 6.4 ng/ml for opiates; 2.0 ng/ml for methadone. Analysis of ROC-curves showed a satisfying degree of separation in all tests except for amphetamine compounds, with areas under the curve (AUC) between 0.915 (THC) and 0.999 (for benzoylecgonine and methadone). Discussion The results of the study showed that CEDIA screening at the optimized cut-offs exhibits a very high sensitivity and good specificity and positive predictive value (PPV) for cannabinoids, cocaine and metabolites, opiates and methadone. A high number of false positives (n = 19) for amphetamine compounds was observed at the optimized cut-off, resulting in a very low PPV, which is also influenced by the very low number of TP (n = 4). Conclusion The results of the study show that the CEDIA is a valuable screening test on post-mortem whole blood for cannabinoids, cocaine and metabolites, opiates and methadone, but it is not recommended for amphetamine compounds, due to the high number of false positives. The strengths of the study are the large sample size, the inclusion of post-mortem cases only and the high level of sensitivity and specificity obtained at the optimized cut-offs.

his study aims to investigate the prevalence of alcohol and drugs of abuse in Italian drivers involved in road traffic crashes between 2011 and 2018. Toxicological analyses were performed on the whole blood of 7593 injured drivers. Alcohol and illicit drugs, namely tetrahydrocannabinol (THC; cut-off 2ng/ml), cocaine (cut-off 10ng/ml), illicit opiates (cut-off 10ng/ml) and amphetamines (amphetamine, methamphetamine, MDMA, MDA; cut-off 20ng/ml) were investigated. The age and gender of the driver, the time of the crash (weekend/weekday and day/night), the road crash year and Blood Alcohol Concentration (BAC) were also considered. The 16.2% of samples tested positive for alcohol, 2.5% for cocaine, followed by opiates (2.0%), cannabinoids (1.5%), and amphetamines (0.5%). The overall prevalence of alcohol and drugs was lower than those reported in previous epidemiological studies of the DRUID project. The year 2011 showed the highest prevalence of drug-positive cases (24.1%), while the lowest prevalence was found in 2016 (16.8%), after the update of the Road Traffic Law (RTL) that increased punishments for driving under the influence. A progressive increase in the number of alcohol-positive female drivers was observed from 2011 to 2018, and the highest prevalence was found in the 26-35-year-old age range. Illicit drugs showed the highest overall prevalence in drivers

Toxicological analyses are often performed in drug-facilitated sexual assaults (DFSA), when the victim shows or reports impaired consciousness and reduced ability. However, in other crimes or fatalities, especially in cases of concurrent natural disease or when another likely cause of death has been established, the involvement of drugs can be overlooked. The aim of this study is to report a series of cases of (i) victims of drug-facilitated crimes (DFC) other than DFSA and (ii) victims of acute intoxications, in which "licit" psychoactive drugs were found in blood samples, with the aim of understanding in which circumstances and to what extent prescription drugs have been used for non-medical purposes in recent Italian casuistry. Circumstantial, autopsy, and toxicological data were collected through a retrospective analysis performed between 2013 and 2017 in the Forensic Toxicology Unit of the University of Bologna. Cases of "DFC other than DFSA" and "Acute Intoxication" in which "psychoactive drugs" or "prescription drugs" or "licit drugs" were found in the blood samples of the victims were included in the study. Nine cases of DFC other than DFSA, and 11 cases of acute intoxication, were identified. Different categories of "licit" psychoactive drugs (e.g. hypnotics, antipsychotics, antidepressants, anticonvulsants) had been used to facilitate diverse types of crime (homicide, robberies, elder abuse, fatal poisoning) or acute intoxication (suicide, attempted suicide, accidental death). The circumstances of these cases, as well as toxicological findings in blood samples and other relevant forensic elements, are reported, summarized and discussed in this paper. The non-medical use of pharmaceuticals has been identified by recent forensic literature and the present study as a significant and growing phenomenon, and its implication in fatalities should be taken into consideration and accurately investigated through appropriate toxicological analysis. Our study presents an overview of the circumstances of non-medical use of prescription drugs, usually considered "safe drugs", and their involvement in cases of DFC, suicides and accidental intoxication. In order to estimate the real incidence of these medications in DFC and acute intoxication, and thus collect more analytical and contextual data, further studies are needed, along with effective cooperation among police officers, clinicians, forensic pathologists, and toxicologists.

Introduction Immunoassay (IA) tests should be able to detect low concentrations of illegal drugs when used for the screening of drugs in drivers. False negatives should be avoided, and false positives should be reduced as far as possible. In this study, semi-quantitative results for blood samples containing illicit drugs (cannabinoids, cocaine, amphetamines/methamphetamines, opiates and methadone) obtained with cloned enzyme donor immunoassay (CEDIA), were compared with results of confirmatory analysis performed through gas chromatography-mass spectrometry (GC–MS). Screening cut-off points for each class of drugs were retrospectively optimized. Methods Whole blood samples from drivers involved in road accidents in the period from January 2013-December 2017 were analyzed with CEDIA (4200 samples). Confirmatory analyses were performed through (GC–MS) on: (i) all samples with screening concentrations above 1 ng/ml for at least one drug (positive screening results); (ii) 800 samples with screening concentration lower than 1 ng/ml (negative screening results). Recommended per se limits in relation to driving under the influence of drugs were set as fixed values. Sensitivity, specificity, positive and negative predictive values were evaluated by contingency tables and compared to ROC-analysis in order to obtain ideal screening cut-offs. Results CEDIA results were available for 4200 blood samples and 1172 positive screening results were found. Among these, 1008 confirmation analysis were obtained through GC–MS. Optimized screening cut-offs obtained through ROC analysis were as follows: 8.0 ng/ml for THC; 5.5 ng/ml for THC-COOH; 21.1 ng/ml for cocaine; 6.9 ng/ml for benzoylecgonine; 33.1 ng/ml for opiates; 61.6 ng/ml for amphetamines; 5.0 ng/ml for methadone. Using these cut-offs, sensitivity was above 97% for THC-COOH, cocaine, benzoylecgonine, amphetamines, opiates and methadone, and 92% for THC; specificity was above 90% for cocaine, benzoylecgonine, amphetamines, opiates and methadone, 80% for THC and 89% for THC-COOH; negative predictive value was above 99% for all drugs and metabolites. Conclusion Previous studies have shown that CEDIA tests are useful for preliminary screening of serum and urine. Its implementation in whole blood is of primary importance for the assessment of impaired driving, since the per se limits of many European countries refer to whole blood, and preparation of the serum and/or the collection of urine is not always possible in the hospital emergency department, where blood samples are withdrawn. Our study shows that CEDIA tests on whole blood permit the definition of cut-off values with optimal sensitivity and negative predictive values for all analytes (near to 100%), including very good specificity.

Aim To estimate the prevalence of drug and polydrug use among drunk-drivers during the driving license regranting program, in order to assess the inclusion of toxicological tests on hair and urine samples in the systematic methodology in this category of subjects. Short summary A total of 2160 drunk-drivers were tested for alcohol and drugs during driving license regranting. Thirty-one subjects showed alcohol use, 212 illicit drug use and, among these, 131 were polydrug users. Nineteen different patterns of drug and polydrug use were found. Cocaine was detected in 165 subjects. Methods The study was performed on 2160 drunk-drivers examined at Legal Medicine and Toxicology Unit of the University of Padova, in a 3-year-period (2014-2017). The positivity for one or more illicit drugs in hair or urine samples was confirmed by LC/MS and GC/MS methods. Chi-square test, Fischer's exact test and Cochran-Armitage Trend test were used to study the correlation between general characteristics of the examined sample and the presence of drug/polydrug use. Results Thirty-one subjects showed alcohol use, 212 illicit drug use and, among these, 131 were polydrug users. Nineteen different patterns of drug and polydrug use were found. Cocaine was detected in 165 subjects in whom 122 showed a concurrent use of alcohol and cocaine, identified through the detection of cocaethylene in hair samples. No significant association and/or trends between drug/polydrug use and the general characteristics of the sample were detected. Conclusions The results show that drug and polydrug use among drunk-drivers should be subjected to toxicological as well as alcohological monitoring, especially in the regranting procedure. The implementation of this procedure could improve the knowledge of dimensions of the issue, providing a powerful means for the reduction of phenomenon of driving under the influence of alcohol and drugs.

The term "€œplanned complex suicideâ€" means the combination of more than one method of suicide, planned to prevent failure of the first method to ensure a fatal outcome. Professional skills and tools are sometimes used to plan and perpetrate the suicide. A case of planned complex suicide of a mechanical engineer working with furnaces in a tube factory is herein reported. The suicide was committed in a rudimental furnace set up in the victim’s apartment using his professional skills, by assembling furniture, mattresses, books and flammable liquid present in the house. Three-dimensional models of the crime scene before and after the realization of the “homemade furnace” are proposed. The discussion will focus on the importance of a comprehensive analysis of the professional background of the victim to infer the manner of death for the identification of complex and occupation-related suicides.

Toluene, a liquid aromatic hydrocarbon, is one of the most widely used industrial solvents, and is present in numerous paints, paint thinners, glues and other industrial and household products. It has become the most abused solvent in the world due to its rapid effects following inhalation. However, the numerous cases of fatal and non-fatal toluene-related intoxication reported in the literature have not yet been collected and discussed in the forensic setting. In this paper we aim to provide a review of the cases of toluene abuse and intoxication and the state of the art of the forensic toxicological analysis of toluene intoxications in the living and in the dead subject, from the early identification to the medico-legal interpretation of the toxicological result. We have identified a total of 45 papers regarding different aspects of toluene abuse, and divided them into three sections, namely sampling, storage and techniques of analysis, assessment in living subjects and post-mortem assessment. This article reports toluene concentrations in blood from 202 living subjects, 23 fatal toluene intoxications and 85 toluene related deaths. Toxicological results are discussed in relation to the clinical presentation (living subjects, including impaired drivers), and the manner of death according to the medical examiner reports (post-mortem examinations). Finally, we discuss the strengths and limitations of the review.

Objective Letrozole is an aromatase inhibitor, used to treat post-menopausal women with hormone receptor-positive or advanced breast cancer. It is prohibited in sport because it is used together with androgen anabolizing steroids to avoid their adverse effects. In case of adverse analytical finding, it may be important to distinguish between repetitive use due to voluntary administration and occasional use, possibly due to involuntary intake. With the objective to identify the dose capable of producing a positive hair testing, this study aims at investigating the incorporation into hair of single or repeated doses of letrozole. Methods Four subjects were recruited to investigate the incorporation in hair after ingestion of letrozole. Hair samples were obtained from: (i) 2 subjects (A and B) in chronic therapy with 2.5 mg of letrozole/day and (ii) 2 subjects (C and D) who ingested one dosage of 2.5 mg and 0.62 mg of letrozole, respectively. From subject A and B a whole length hair sample was collected, and segmental analysis was performed on 1 cm long segments. From subjects C and D, beard hair was sampled by shaving before administration (t = 0), 3 days after administration, and 6 days after administration. Head hairs were cut close to the scalp 10 and 90 days after administration. Analysis were performed through HPLC–HRMS. Results Letrozole was present in concentration higher than 160 pg/mg in all segments from subjects A and B. In subject C a detectable amount of the analyte in beard of the first 3 days (160 pg/mg in 0–3 days), up to the 6th day (130 pg/mg in 3–6 days) after ingestion and in head hair collected 10 days after ingestion (60 pg/mg) were found. In subject D, a lower amount of letrozole both in beard (100 and 85 pg/mg) and in head hair (30 pg/mg) was determined. Letrozole was detected also in head hair collected 90 days after the drug administration (30 pg/mg in C and 17 pg/mg in subject D). Conclusion This preliminary study shows that a single administration of a therapeutic dose (2.5 mg) or less than a dose (0.62 mg) of the drug produces a positive hair sample. Moreover, the results highlight large differences between concentrations in hair of subjects who consumed a single dose and hair of subjects in chronic therapy and suggest a positive correlation between frequency and/or dose ingested and hair concentration. The relatively higher amount identified in beard when compared to head hair suggests a mixed mode of incorporation in beard through sweat and blood.

Many studies have focused on the importance of post-mortem computed tomography (PMCT) prior to or in substitution of standard forensic autopsies in case of firearm death. However, due to the fact that PMCT is not routinely performed in all countries, in cases of death abroad it can happen that a CT scan is performed only after a first autopsy. A case of post-mortem re-examination, including the external examination and a post-autopsy computed tomography (PACT), of a gunshot victim of homicide in a foreign country is presented, and the pros and cons of imaging in post-autopsy setting are discussed. PACT could be a tool for carrying out more complete investigations and for obtaining information on bone injuries and foreign bodies trapped within peripheral soft tissues that can be re-analyzed after the arrival of the first autopsy report. Given that the value of information derived may be strongly influenced by the previously performed autopsy, in order to process the definitive considerations it is necessary to compare and interpret the data obtained through PACT with the results of the first autopsy, and to continue the international cooperation effort and the application of international guidelines in order to share information at the repatriation of the corpse.

Traumatic fatal aortic rupture (FAR) is a common finding in victims of motor vehicle crashes (MVC), but its aetiology and mechanisms of production remain an issue of major concern, above all in motorcyclists. This study reports a series of cases obtained from a retrospective analysis of traumatic FARs occurring in motorcycle drivers, with the aim of defining the injury patterns and correlating them with the mechanisms of FAR production. Circumstantial, autopsy and histology data were collected through a retrospective analysis of post mortem examinations performed at the Institute of Legal Medicine of the University of Padova between 2014 and 2016. Among 151 traffic related victims, 8 were motorcycle drivers and displayed traumatic FAR and were thus included in the study. In 7 cases, the presence of abdominal/thoracic injuries suggested that the external compression due to the accident was at least a concurrent cause of FAR, being the predominant mechanism of aortic injury in 4 cases, through the “osseous pinch” or the “waterhammer effect” mechanisms. Our study highlights the well-known role of “preventative forensic pathology”, which has become routinary in traffic medicine since many years, also for defining the points of impact and the injury patterns of motorcyclists sustaining traumatic FAR, thereby facilitating the development of new prevention strategies and devices. Further studies, however, are needed in order to widen the investigated population and to estimate the real number of victims for which traumatic FAR might hypothetically be prevented with specific countermeasures.

Asylum seekers often experience situations of vulnerability, being frequently exposed to a heightened risk of harm, and thus require special care, support and protection. The categories of “vulnerable persons”, identified by International Legislation, and an individual’s classification as a “vulnerable asylum seeker”, have important implications in the reception procedures, in the decision-making phase and in the definition of therapeutic needs and rehabilitation. The Istanbul Protocol, the first international guideline approved by the United Nations and applied in different contexts, is not applicable for the assessment of the totality of the conditions (medical and otherwise), and therefore, the identification and assessment of conditions of vulnerability is largely delegated to questionnaires administered by non-medical personnel. The proposed methodology, based on the modificatory reworking of the Guidelines of the International Academy of Legal Medicine concerning the “medicolegal ascertainment of personal injury and damage on the living person”, takes into consideration all the medical issues relevant for the decision concerning the applicant, both in the reception procedures and in the outcome of the asylum application.

Micro computed tomography (micro-CT) has already been proposed as a useful technique for the qualitative analysis of false starts (FS) produced on human bones, although the reliability and the error rate of this technique have not been tested yet, neither for qualitative nor for quantitative assessments. The aim of the present study was to test the morphological agreement, accuracy, precision and inter-rater reliability of micro-CT analysis of FS on bones. The morphological agreement was assessed through the degree of concordance among the 3 independent blind raters in the identification of the shape of 24 FS manually produced on bones by 3 different saws (8 FS for each saw). The accuracy was calculated through the percentage of error in the automatic and manual measurement of the diameter of a reference object. The precision was calculated as CV% of multiple measurements performed by 3 independent blind raters on the reference object and one bone sample acquired 20 times. The inter-rater reliability was assessed as intraclass correlation coefficient (ICC) among measurements performed by 3 independent blind raters, assessing 24 FS produced using 3 different saws. The results demonstrated that both qualitative and quantitative analysis were reproducible and robust. Micro-CT analysis showed a 100% morphological agreement, a high level of accuracy (percentage error < 0,5%), precision (CV% < 5%) and inter-rater reliability (ICC > 0.995), when FS were analyzed by forensic pathologists and/or radiologists with adequate expertise. Obviously, further validation studies are needed, including a higher number of samples produced by a wider variety of saws and multiple operators.

Strong experimental and clinical evidences have definitely linked occupational vinyl chloride exposure to development of angiosarcoma of the liver. In contrast, despite the International Agency for Research on Cancer having included vinyl chloride among the causes of hepatocellular carcinoma, the association between vinyl chloride exposure and hepatocellular carcinoma remains debated. This issue is relevant, because occupational exposure to high levels of vinyl chloride may still occur. We report a unique case of sequential occurrences of hepatocellular carcinoma and angiosarcoma of the liver, in a vinyl chloride–exposed worker without cirrhosis and any known risk factor for chronic liver disease. Both the hepatocellular carcinoma and the surrounding normal liver showed micronucleus formation, which reflects genotoxic effect of vinyl chloride. Angiosarcoma showed a KRAS G12D point mutation, which is considered to be characteristic of vinyl chloride–induced angiosarcoma. This case supports the pathogenic role of vinyl chloride in both hepatocellular carcinoma and angiosarcoma development.

In sudden cardiac deaths (SCD), the identification of the cause(s) of death at autopsy may be challenging, especially in some conditions where the border between physiological and pathological changes is not defined. This paper describes a case of SCD in an 18-month-old child with two abnormalities of uncertain significance. The multi-disciplinary approach included PMCT, autopsy, histological, toxicological and genetic analysis. Parental screening and targeted genetic testing were performed. Two potentially pathogenic abnormalities were detected: a high take-off origin of the left coronary artery from the tubular aorta and a heterozygous variant, harbored by the mother and the grandfather, within exon 1 of the KCNQ1 (potassium voltage-gated channel subfamily Q member 1) gene (p.Ala46Thr). The clinical examination, basal ECG and Holter ECG were normal, except for a single borderline QTc interval measurement in the mother. The high coronary origin is classified by the International Guidelines for autopsy investigation in SCD as an “uncertain” cause of death and the genetic variant is classified as of “uncertain” or “likely pathogenic” significance in Clinvar and Varsome, respectively. The possibility to perform an extended family screening revealed the lack of a solid genotype-phenotype correlation, and the KCNQ1 variant cannot with any certainty be regarded as disease-causing. When autopsy findings fall into the grey zone between physiological and pathological changes, as well as post-mortem genetic analysis, the standardized clinical testing of families should be emphasized in order to understand the role of gene variants, and to produce evidences for the realization of personalized medicine.