Circumstances Of Death Research Articles

End-of-life management of multiple myeloma patients in the era of CD38 and immunotherapy.

In spite of spectacular advances in the treatment of multiple myeloma, a majority of patients will die from this disease or related complications. While a great amount of focus has been dedicated to the development of novel therapies, little attention has been paid to latter stages of patient follow-up. In order to describe patient management during this critical period as well as the immediate causes and circumstances of death, we have analyzed a single center series of 100 patients diagnosed with myeloma who died between 2016 and 2021. Patients received a median of 3 lines of treatment, including 2 during their last year of life. Sixty per cent of patients had received daratumumab. Fifty patients had obtained complete remission or very good partial response at some time during the course of disease but 75 were refractory to the last treatment line. Eighteen patients died while their disease was stable or in remission while 77 had confirmed progressive disease at time of death. Thirty six patients had uncontrolled sepsis, 49 were in renal failure and 24 had hypercalcemia at the time of death. Seventy three patients presented with lymphopenia. Disease progression was documented in a majority of MM patients at the time of death and was associated with disease-related complications in a significant number of patients. Disease progression remains the main cause of death in patients with multiple myeloma.

Baclofen-related deaths in Australia 2000–2022

In Australia, the therapeutic indication of baclofen (oral tablets) is for the treatment of muscle spasm. Deaths related to baclofen have been reported, as well as misuse, dependence and self-poisoning. This national retrospective study aimed to investigate the number, characteristics, circumstances, and toxicology of baclofen-related deaths in Australia, 2000–2022. We identified 102 baclofen-related deaths, with a mean age of 45.6 years and 51 % being male. Circumstances of death were: intentional toxicity (54.9 %), unintentional toxicity (30.4 %), unintentional toxicity/disease (9.8 %), and accidental injury (4.9 %). Multiple sclerosis or spinal injury was documented in 15.7 % of cases, substance use problems in 43.1 % and specifically alcohol use problems in 38.2 %. Mental health problems were documented in 73.5 %, a previous self-harm or suicide attempt in 30.4 %, and chronic pain in 37.3 %. The median baclofen blood concentration for all cases was 3.10 mg/L (25th 0.70, 75th 8.10, range 0.04–110.00), unintentional toxicity 1.95 mg/L (25th 0.70, 75th 4.35, range 0.04–24.0), intentional toxicity 6.00 mg/L (25th 1.10, 75th 13.0, range 0.05–110.0). Concomitant substance use was seen in 93.8 %, with antidepressants (69.8 %) and benzodiazepines (64.6 %) most frequently detected. In conclusion, the ‘typical’ case was middle-aged, most dying due to intentional toxicity, and likely to have a history of mental health and substance use problems. We suggest caution is needed in prescribing baclofen given its potential to be used in intentional and non-intentional overdose.

Maternal Mortality in the Governorate of Tunis between 2017 and 2023: evolution of Maternal Mortality Ratio and the main causes of death

Background Maternal mortality is the main indicator of maternal health worldwide. The aims of your study were to determine the Maternal Mortality Ratio (MMR) in the governorate of Tunis and to identify the main causes of maternal death. Methods We included all maternal deaths between January 2017 and December 2023, reported to the Tunis Regional Health Directorate. The data collected included the MMR per 100000 live birth, sociodemographic characteristics, causes of death, circumstances of death, autopsy findings, and preventability. Results Sixty one maternal deaths were recorded. The average of MMR was 46, 88 per 100000 live births. Two peaks in the MMR were noted in 2017 and 2020. The average age of the patients was 34, 1 years (±5.1). We noted that 43, 75 % of the patients were not residents of the governorate of Tunis. The postpartum period was the most critical. In fact, 83, 33 % of maternal deaths occurred postpartum. Hemorrhage was the main etiology in 20.8% of cases. The second cause was COVID- 19complicationsin 16, 6% of cases. Conclusion This study of maternal mortality in Tunis opens the debate on the effectiveness of maternal health policies in Tunisia and the areas for improvement.

Psychosocial and pandemic-related circumstances of suicide deaths in 2020: Evidence from the National Violent Death Reporting System.

To describe and explore variation in 'pandemic-related circumstances' among suicide decedents during the first year of the COVID-19 pandemic. We identified pandemic-related circumstances using decedents' text narratives in the 2020 National Violent Death Reporting System. We use time-series analysis to compare other psychosocial characteristics (e.g., mental health history, interpersonal difficulties, financial strain) of decedents pre-pandemic (2017/2018: n = 56,968 suicide and n = 7,551 undetermined deaths) to those in 2020 (n = 31,887 suicide and n = 4,100 undetermined). We characterize common themes in the narratives with pandemic-related circumstances using topic modeling, and explore variation in topics by age and other psychosocial circumstances. In 2020, n = 2,502 (6.98%) narratives described pandemic-related circumstances. Compared to other deaths in 2020 and to the pre-pandemic period, decedents with pandemic-related circumstances were older and more highly educated. Common themes of pandemic-related circumstances narratives included: concerns about shutdown restrictions, financial losses, and infection risk. Relative to decedents of the same age that did not have pandemic-related circumstances in 2020, those with pandemic-related circumstances were more likely to also have financial (e.g., for 25-44 years, 43% vs. 12%) and mental health (76% vs. 66%) psychosocial circumstances, but had similar or lower prevalence of substance abuse (47% vs. 49%) and interpersonal (40% vs. 42%) circumstances. While descriptive, these findings help contextualize suicide mortality during the acute phase of the COVID-19 pandemic and can inform mental health promotion efforts during similar public health emergencies.

Intracranial injuries in the autopsy material of the Department of Forensic Medicine of the Medical University of Lodz with analysis of anatomical lesions caused by traumatic brain injuries

BackgroundIn 2022, 408 autopsies were performed in the Department of Forensic Medicine of the Lodz Medical University, of which as many as 82 concerned deaths with intracranial injuries, which represents about 20 % of all performed autopsies. AimThe article presents a comparative analysis of deaths of people with intracranial injuries in terms of frequency, the structure of victims (gender, age, sobriety), type of injury (intracranial bleeding, bruises of nerve tissue, nerve tissue tears, posttraumatic brain oedema, etc.), causes and circumstances of death, place of death (house, hospital, street) survival time, type of tool/object used, and the obtained data were compared with publications from other departments of forensic medicine. ResultsThe victims were definitely male. Regarding age, deaths mainly concerned people between 31 and 70. The most common cause of death was multi-organ injuries, craniocerebral, intracranial and the least other injuries. Regarding the circumstances of the deaths, most of the cases were accidents; the fewest were homicides.

Predictors of ICU Surrogates' States of Concurrent Prolonged Grief, Post-Traumatic Stress, and Depression Symptoms.

Scarce research explores factors of concurrent psychologic distress (prolonged grief disorder [PGD], post-traumatic stress disorder [PTSD], and depression). This study models surrogates' longitudinal, heterogenous grief-related reactions and multidimensional risk factors drawing from the integrative framework of predictors for bereavement outcomes (intrapersonal, interpersonal, bereavement-related, and death-circumstance factors), emphasizing clinical modifiability. Prospective cohort study. Medical ICUs of two Taiwanese medical centers. Two hundred eighty-eight family surrogates. None. Factors associated with four previously identified PGD-PTSD-depressive-symptom states (resilient, subthreshold depression-dominant, PGD-dominant, and PGD-PTSD-depression concurrent) were examined by multinomial logistic regression modeling (resilient state as reference). Intrapersonal: Prior use of mood medications correlated with the subthreshold depression-dominant state. Financial hardship and emergency department visits correlated with the PGD-PTSD-depression concurrent state. Higher anxiety symptoms correlated with the three more profound psychologic-distress states (adjusted odds ratio [95% CI] = 1.781 [1.562-2.031] to 2.768 [2.288-3.347]). Interpersonal: Better perceived social support was associated with the subthreshold depression-dominant state. Bereavement-related: Spousal loss correlated with the PGD-dominant state. Death circumstances: Provision of palliative care (8.750 [1.603-47.768]) was associated with the PGD-PTSD-depression concurrent state. Surrogate-perceived quality of patient dying and death as poor-to-uncertain (4.063 [1.531-10.784]) correlated with the subthreshold depression-dominant state, poor-to-uncertain (12.833 [1.231-133.775]), and worst (12.820 [1.806-91.013]) correlated with the PGD-PTSD-depression concurrent state. Modifiable social-worker involvement (0.004 [0.001-0.097]) and a do-not-resuscitate order issued before death (0.177 [0.032-0.978]) were negatively associated with the PGD-PTSD-depression concurrent and the subthreshold depression-dominant state, respectively. Apparent unmodifiable buffering factors included surrogates' higher educational attainment, married status, and longer time since loss. Surrogates' concurrent bereavement distress was positively associated with clinically modifiable factors: poor quality dying and death, higher surrogate anxiety, and palliative care-commonly provided late in the terminal-illness trajectory worldwide. Social-worker involvement and a do-not-resuscitate order appeared to mitigate risk.

Characteristics of drug-related deaths where individuals are found submerged in a bath or hot tub in the United Kingdom, 1997-2023.

Recent media reports highlight that drug-related fatalities can occur while individuals are immersed in water in domestic settings. We aimed to determine the case characteristics, circumstances of death and type of implicated drugs among individuals dying due to unintentional drug-related causes found immersed in a bath or hot tub. Retrospective cohort study in the United Kingdom using coronial records from the National Programme on Substance Abuse Deaths, 1997-2023. Information was available on decedent socio-demographics, characteristics of death and drugs implicated in death. One hundred fifty-six decedents were found immersed in the bath and six in a hot tub, a mean of 6.4 deaths per year (SD 3.7; range 1-13). Overall decedents were predominantly male (n = 94, 58.0%), of White ethnicity (n = 98, 60.5%) with a mean age of 40 years (SD 13; range 19-74). Only 12 decedents had any physical contributory factor to death other than poisoning or drowning. The median number of drugs detected at post-mortem was 3 (interquartile range 2, 5) with multiple drug toxicity implicated in the majority of cases (n = 90, 55.6%). The most common implicated drugs were heroin (n = 53, 32.7%), alcohol (n = 46, 28.4%) and cocaine (n = 33, 20.4%). Over the last two decades in the United Kingdom there have been consistent numbers of unintentional drug-related deaths each year where individuals were found in a bath or hot tub. Polysubstance, opioid and alcohol use are overrepresented. Targeted advice to avoid bathing while intoxicated would appear to be an appropriate harm reduction message.

Analysis of miRNA Expression Profiles in Traumatic Brain Injury (TBI) and Their Correlation with Survival and Severity of Injury.

Traumatic brain injury (TBI) is the leading cause of traumatic death worldwide and is a public health problem associated with high mortality and morbidity rates, with a significant socioeconomic burden. The diagnosis of brain injury may be difficult in some cases or may leave diagnostic doubts, especially in mild trauma with insignificant pathological brain changes or in cases where instrumental tests are negative. Therefore, in recent years, an important area of research has been directed towards the study of new biomarkers, such as micro-RNAs (miRNAs), which can assist clinicians in the diagnosis, staging, and prognostic evaluation of TBI, as well as forensic pathologists in the assessment of TBI and in the estimation of additional relevant data, such as survival time. The aim of this study is to investigate the expression profiles (down- and upregulation) of a panel of miRNAs in subjects deceased with TBI in order to assess, verify, and define the role played by non-coding RNA molecules in the different pathophysiological mechanisms of brain damage. This study also aims to correlate the detected expression profiles with survival time, defined as the time elapsed between the traumatic event and death, and with the severity of the trauma. This study was conducted on 40 cases of subjects deceased with TBI (study group) and 10 cases of subjects deceased suddenly from non-traumatic causes (control group). The study group was stratified according to the survival time and the severity of the trauma. The selection of miRNAs to be examined was based on a thorough literature review. Analyses were performed on formalin-fixed, paraffin-embedded (FFPE) brain tissue samples, with a first step of total RNA extraction and a second step of quantification of the selected miRNAs of interest. This study showed higher expression levels in cases compared to controls for miR-16, miR-21, miR-130a, and miR-155. In contrast, lower expression levels were found in cases compared to controls for miR-23a-3p. There were no statistically significant differences in the expression levels between cases and controls for miR-19a. In cases with short survival, the expression levels of miR-16-5p and miR-21-5p were significantly higher. In cases with long survival, miR-21-5p was significantly lower. The expression levels of miR-130a were significantly higher in TBI cases with short and middle survival. In relation to TBI severity, miR-16-5p and miR-21-5p expression levels were significantly higher in the critical-fatal TBI subgroup. Conclusions: This study provides evidence for the potential of the investigated miRNAs as predictive biomarkers to discriminate between TBI cases and controls. These miRNAs could improve the postmortem diagnosis of TBI and also offer the possibility to define the survival time and the severity of the trauma. The analysis of miRNAs could become a key tool in forensic investigations, providing more precise and detailed information on the nature and extent of TBI and helping to define the circumstances of death.

Post‌-Mortem Serum level of Cortisol and its Relation with the Cause, the Time, and circumstances of Death: A Cross-sectional Cadaveric Study

Post‌-Mortem Serum level of Cortisol and its Relation with the Cause, the Time, and circumstances of Death: A Cross-sectional Cadaveric Study

An Arachnoid Cyst Incidentally Found in a Young Man Who Died of Sudden Cardiac Death

An arachnoid cyst is a rare cerebrospinal fluid–filled non-neoplastic cystic lesion. Most arachnoid cysts are asymptomatic; however, depending on their location and size, they may show various clinical symptoms and rarely can cause serious complications. We report a case of an arachnoid cyst incidentally found in a 25-year-old male soldier, which was not the cause of death. A 2.3×1.7 cm unilocular cystic lesion filled with colorless serous fluid was observed near the interpeduncular fossa of the brain. Microscopy revealed the cyst membrane to be lined by a single layer of meningothelial cells with no edema or inflammatory reaction in the surrounding structures. Considering the medical history, circumstances of death, and autopsy findings, the cause of death was determined to be sudden cardiac death, and the cyst found in the brain was consistent with an arachnoid cyst. Reviewing this case and related literature would help to determine the cause and manner of death if an arachnoid cyst is incidentally found during an autopsy.

Police arrest-related death: about four cases and review of the literature.

Unexpected deaths may occur in individuals during a police arrest. These individuals usually have had both physical and emotional exertion, associated or not with agitation and restraint by police. Further investigations in these cases often show an impregnation with drugs. Autopsy findings may raise medico-legal problems in these cases.We report four cases of deaths during police arrest in which multiple factors contributed to the death. In the first two cases, there was a combination of emotional and physical stress due to police pursuit and, the presence of mechanical asphyxia. We noticed the presence of cannabis and amphetamine; however, we couldn't relate the death to a drug intoxication. In the third case, the deceased lost consciousness when he was arrested by the police with no link to the intervention of law enforcement authorities. Death in this case was due to sepsis complicating endocarditis. The fourth case reports a rare cause of asphyxia that can occur in a police arrest related to a drug package. Death was due to upper airway obstruction in this case.The forensic pathologist should take into consideration every factor when explaining these deaths. Thorough autopsy and investigations are critical to understand the cause and circumstances of death.

Public Perceptions of Memory Failures in Infant ‘Hot Car’ Deaths

Caregivers can forget young children in the back of the car, thereby resulting in the tragic circumstance of infant death. The current exploratory study examined whether the public (N = 171) believes a memory explanation when the defendant caregiver relationship to the child is varied and when expert witness testimony is and is not provided regarding the processes by which these memory failures can occur. Adult participants believed that a memory failure played a role when the defendant caregiver was the grandfather as opposed to when the caregiver was the father. Expert witness testimony did not impact this belief. Other memory-related variables impacted perceptions of defendant guilt when defendant guilt was measured continuously but not dichotomously. Numerous non-memory related outcome variables were also studied. Defendant relationship and expert witness testimony impacted different memory-related and non-memory related outcome variables. Results are discussed in terms of age-related forgetting and collective vulnerability versus prospective memory failures. Implications regarding the legal system are considered.

Changes in Human Vulnerability to Flood and Landslide: Evidences from Historical Data

Human impact by floods and landslides (FLs) is a significant concern, necessitating a deeper understanding to implement effective reduction measures, in line with the Sendai Framework for Disaster Risk Reduction’s goal to reduce disaster mortality between 2020 and 2030. This study examines the evolution of human interaction with FLs over the past 70 years in Calabria, Italy. By systematically analyzing regional newspapers and historical archives from 1951–1960 and 2011–2020, a database was created documenting fatalities, injuries, and the involvement of people in FL incidents. For each victim, the database includes demographic details, accident time and place, circumstances of death or injury, and whether the victim’s behavior was hazardous or protective. Results indicate a drastic reduction in both the total number of fatalities (196 versus 20) and high mortality events from 1951–1960 to 2011–2020 (6 versus 1). However, the number of people involved in incidents has increased (202 versus 1102), although this may be partly due to improved dissemination of information. Changes in population habits and the construction of more robust houses have significantly reduced high-fatality events, enhancing security. The study highlights the importance of data collection for developing locally tailored risk reduction strategies, increasing community resilience by addressing specific vulnerabilities and strengths.

Housing status and accidental substance-related acute toxicity deaths in Canada, 2016-2017.

There is a complex relationship between housing status and substance use, where substance use reduces housing opportunities and being unhoused increases reasons to use substances, and the associated risks and stigma. In this descriptive analysis of people without housing who died of accidental substance-related acute toxicity in Canada, we used death investigation data from a national chart review study of substance-related acute toxicity deaths in 2016 and 2017 to compare sociodemographic factors, health histories, circumstances of death and substances contributing to death of people who were unhoused and people not identified as unhoused, using Pearson chi-square test. The demographic distribution of people who died of acute toxicity was compared with the 2016 Nationally Coordinated Point-In-Time Count of Homelessness in Canadian Communities and the 2016 Census. People without housing were substantially overrepresented among those who died of acute toxicity in 2016 and 2017 (8.9% versus <1% of the overall population). The acute toxicity event leading to death of people without housing occurred more often in an outdoor setting (24%); an opioid and/or stimulant was identified as contributing to their death more frequently (68%-82%; both contributed in 59% of their deaths); and they were more frequently discharged from an institution in the month before their death (7%). We identified several potential opportunities to reduce acute toxicity deaths among people who are unhoused, including during contacts with health care and other institutions, through harm reduction supports for opioid and stimulant use, and by creating safer environments for people without housing.

A comparison of the characteristics of accidental substance-related acute toxicity deaths in Canada across life stages, 2016-2017.

The acute toxicity (sometimes called "overdose" or "poisoning") crisis has affected Canadians across all stages of life, including youth, adults and older adults. Our biological risks and exposures to substances change as we age. Based on a national chart review study of coroner and medical examiner data on acute toxicity deaths in 2016 and 2017, this analysis compares the burden of deaths and circumstances of death, locations of acute toxicity event and death, health history and substances contributing to death of people, by sex and life stage.

ANALYSIS OF THE POSSIBILITIES OF MODERN RESEARCH METHODS FOR THE DIAGNOSTIC OF HEMORRAGE IN THE SUBSTANCE OF THE HUMAN BRAIN (LITERATURE REVIEW)

Traumatic brain injury is one of the most widespread and complex types of mechanical injury today, which involves many fields of medical practice, including neurosurgery, neurology, rehabilitation, forensic medicine, etc., and requires a multidisciplinary approach to its solution. Aim of the work: to analyse, on the basis of data from literary sources, the possibilities of modern research methods for the diagnosis of haemorrhages in the substance of the human brain and their genesis. Research results. The gold standard for verification of the diagnosis in forensic medicine is a forensic histological examination, however, the classical technique of histological differential diagnosis of the genesis and time of formation of a haemorrhage in the brain substance is not effective. The diagnosis of traumatic brain injury can be complicated in cases where there are no macroscopic signs of head trauma and little information is available about the circumstances of death. Therefore, a number of researchers have explored the possibility of using biomarkers to provide objective evidence of traumatic brain injury as the cause of death or to estimate the survival and post-mortem time of the deceased. Biophysical studies using a laser have shown potential success in the field of traumatic brain injury diagnostics. Preliminary conclusions regarding the possibility of differentiating the genesis of cerebral haemorrhage using the method of reconstructing distributions of the magnitude of linear dichroism fluctuations gave positive results. Conclusion. It was found that biochemical studies show significant success in the diagnosis of traumatic brain injury, some markers even make it possible to differentiate the genesis of brain haemorrhage, but forensic medical practice requires the development of easy-to-use, highly effective methods to verify the type of human brain injury. This role can potentially be fulfilled by physical-optical methods based on laser irradiation of biological objects followed by mathematical and statistical processing of the obtained data.

Opioid-related deaths in Northern Ontario in the early COVID-19 pandemic period.

In the first year of pandemic measures, opioid-related deaths across Ontario's (ON) 34 public health units (PHUs) increased by 60%. Death rates for all seven Northern ON PHUs were above the provincial average. This study describes and compares factors surrounding opioid-related deaths before and after pandemic measures were introduced, for Northern ON compared to the rest of ON. Aggregate data were provided for Northern ON and the rest of the province by the Office of the Chief Coroner/Ontario Forensic Pathology Services. Opioid-related deaths were cohorted by date of death for the year before and after pandemic measures were introduced on March 16, 2020. Chi-square tests were used to compare between cohorts and geographies to determine significant differences for each variable, and for dichotomized levels within variables. P-values < 0.05 were considered statistically significant a priori. In Northern ON, the number of opioid-related deaths approximately doubled from the pre-pandemic cohort (n = 185) to the early pandemic cohort (n = 365). Compared to the rest of ON, higher proportions of deaths occurred in Northern ON among individuals who lived and died in private residences, among women (although the majority of decedents were male) and among individuals employed in mining, quarrying, and oil and gas industries. Compared to the pre-pandemic year, in Northern ON, higher proportions of opioid-related deaths involved fentanyl and stimulants as direct contributors, and the majority involved evidence of inhaled drugs. Differences between the circumstances of death in Northern ON andin the rest of ON suggest opportunities to tailor interventions.

Homicides of American Indians/Alaska Natives in urban versus rural areas: United States National Violent Death Reporting System, 2003–2020

BackgroundMissing and Murdered Indigenous People is a historic and contemporary issue that has gained national attention. In 2021, homicide was the eighth leading cause of death among American Indian/Alaska Native...

Pathological Grief in Geriatric Age Group Affected by COVID-19 Deaths: A Community-Based Study

Background: Deaths by COVID-19 have left behind nearly 12 million recent bereaved individuals worldwide and researchers have raised concerns that the circumstances of COVID-19 related deaths will lead to a rise in prevalence of prolonged grief disorder (PGD) cases. Nevertheless, no research has looked at the PGD incidence among older Indians who have lost a loved one to COVID-19. The aim this research is to determine the prevalence of PGD and the demographics of older people who have experienced COVID-19-related bereavement. Methods: This is a cross-sectional study and house to house survey was conducted between August 2022 and August 2023. Forty geriatric adults aged above 60 years, who consented to participate were assessed for PGD. Demographic details and loss-related information were collected. Self-reported prolonged grief symptoms were measured using Pandemic Grief Scale (PGS) and Traumatic Grief Inventory Self Report (TGI-SR). Anxiety and depression were measured using Hamilton Rating Scale for Anxiety (HAM-A) and Hamilton Rating Scale for Depression (HAM-D). Multiple linear regression analysis was used to determine the associated factors of grief symptoms. Results: Our study indicates that individuals who experienced loss due to COVID-19 exhibited higher levels of grief. Most of the participants were females (65%). Prevalence of PGD was 10% by TGI-SR. HAM-A scores (14.28 +/- 1.42) were higher than HAM-D scores (12.02 +/- 1.58). Conclusion: It is essential to counsel families early and offer supportive services to prevent pathological grief associated with COVID-19 deaths.

Fentanyl-related deaths in Ontario, Canada: toxicological findings and circumstances of death in 4395 cases (2020-22).

Over the last 20 years, there has been a significant increase in fentanyl-related deaths in Ontario, Canada. This report examines toxicological findings in a series of death investigations in which fentanyl was quantitated to identify the prevalence, trends, and demographic data associated with fentanyl in Ontario, Canada, and to highlight the changes in these trends since fentanyl began appearing in casework in Ontario in the early 2000s. A retrospective study of all cases in which fentanyl was quantitated in blood, using liquid chromatography (LC)-tandem mass spectrometry (MS-MS), was conducted for the time period between 1 January 2020 and 31 December 2022. A total of 4395 cases were included; 77% of the decedents were male, and 23% was female with ages ranging from 0 to 95 years. The most frequently classified cause of death was mixed drug toxicity (69%) followed by fentanyl intoxication at 19%. Less than 10% of cases where fentanyl was quantitated were classified as nondrug-related deaths. Fentanyl concentrations in all cases ranged from 1.3 to >2000 ng/mL. Other drugs were frequently detected with fentanyl. In mixed drug toxicity cases, stimulants were the most frequently encountered class of drugs: cocaine was identified in 51.8%, and methamphetamine was observed in 43.0% of cases. Detailed reports for select cases were included to provide additional insight into the different case types and to show the difficulty in interpreting blood concentrations without additional detailed case histories. This study provides valuable information for the scientific and medical community regarding the continued use of fentanyl and how patterns of fentanyl use have evolved since it began to appear in forensic casework.