Medicolegal Death Investigation Research Articles

Detection and characterization of the new synthetic cannabinoid APP-BINACA in forensic casework.

New psychoactive substances (NPS) continue to emerge around the world. APP-BINACA (or APP-BUTINACA), a novel synthetic cannabinoid, was first reported in Europe in January 2019 and later in the United States in March 2019. APP-BINACA was identified in the United States for the first time in blood sample extracts from forensic casework by liquid chromatography quadrupole time-of-flight mass spectrometry (LC-QTOF-MS). To date, APP-BINACA has been identified in 11 forensic toxicology cases from five states and in both medicolegal death investigations and drug impaired driving investigations. APP-BINACA was commonly found in combination with 4F-MDMB-BINACA. Subsequent to its discovery in biological samples, APP-BINACA was detected and characterized in seized drug material by gas chromatography mass spectrometry (GC-MS), LC-QTOF-MS, and nuclear magnetic resonance (NMR) spectroscopy. Further analysis of biological specimens resulted in the identification of five metabolites, including 4-HO-APP-BINACA and APP-BINACA 3-phenylpropanoic acid. The frequency of APP-BINACA detection appears to be increasing and this new synthetic cannabinoid has been identified as a possible contributory factor in adverse events, including death. This is the first literature report regarding the characterization of the new synthetic cannabinoid APP-BINACA in humans. Since it is not widely tested for, it is not yet known the extent to which APP-BINACA is contributing to morbidity and mortality, but forensic scientists, public health officials, and others should be aware of its possible presence and impact. Laboratories should incorporate APP-BINACA into testing workflows for detection and confirmation, where possible.

Elevator-Related Deaths.

Elevators are mechanical transportation devices used to move vertically between different levels of a building. When first developed, elevators lacked the safety features. When safety mechanisms were developed, elevators became a common feature of multistory buildings. Despite their well-regarded safety record, elevators are not without the potential for danger of injury or death. Persons at-risk for elevator-related death include maintenance and construction workers, other employees, and those who are prone to risky behavior. Deaths may be related to asphyxia, blunt force, avulsion injuries, and various forms of environmental trauma. In this review, we report on 48 elevator-related deaths that occurred in nine different medicolegal death investigation jurisdictions within the United States over an approximately 30-year period. The data represents a cross-section of the different types of elevator-related deaths that may be encountered. The review also presents an overview of preventive strategies for the purpose of avoiding future elevator-related fatalities.

The Trouble With Kratom: Analytical and Interpretative Issues Involving Mitragynine.

Mitragynine is the primary active alkaloid in the leaves of the tropical tree Mitragyna speciosa, and goes by the popular names "Kratom", biak-biak and maeng da. Mitragynine is increasingly seen in forensic toxicology casework including driving under the influence of drugs and medicolegal death investigation cases. The toxicity of mitragynine continues to be debated in the scientific community as advocates highlight its long history of use in Southeast Asia and testimonials to its benefits by present-day users, while opponents point to an increasing number of adverse events tied to mitragynine use in Western societies. Quantitative reports of mitragynine in biological specimens from forensic investigations in the literature are sparse and may be influenced by poor analyte stability and inadequate resolution of mitragynine from its diastereomers, which could lead to falsely elevated concentrations and subsequently render those reported concentrations inappropriate for comparison to a reference range. Over the course of 27months, 1,001 blood specimens submitted to our laboratory tested positive for mitragynine using a sensitive and specific quantitative LC-MS/MS method; concentrations ranged from 5.6-29,000ng/mL, with mean and median concentrations of 410±1,124 and 130ng/mL, respectively. Mitragynine presents an analytical challenge that requires a method that appropriately separates and identifies mitragynine itself from its isomers and other related natural products. We describe a validated analytical method and present a short series of case reports that provide examples of apparent adverse events, and the associated range of mitragynine concentrations. This type of analytical specificity is required to appropriately interpret mitragynine concentrations detected in biological specimens from forensic casework and assess its potential toxicity.

Sudden death during hip replacement surgery: A case series

Hip arthroplasty (hip replacement) surgery is a very common procedure and is particularly common in elderly individuals, where it is typically performed following traumatic hip fracture. As with any surgical procedure, hip arthroplasties are associated with a certain degree of morbidity and mortality, with many deaths occurring in the post-operative period. As most of these cases result from trauma (fractured hips), they are typically referred for medicolegal death investigation. Occasionally, sudden cardiorespiratory collapse and death occurs during hip arthroplasty surgery. In certain medicolegal jurisdictions, all intra-operative deaths must be investigated. Although many post-operative arthroplasty-related deaths might not require autopsy, those that occur intra-operatively may require autopsy. While clinical decision-making during recent years has resulted in fewer arthroplasty-related deaths, intraoperative deaths may still occur. In this review, the authors present their experience with three intra-operative arthroplasty-related deaths, followed by a discussion related to possible mechanisms involved in the deaths.

4F-MDMB-BINACA: A New Synthetic Cannabinoid Widely Implicated in Forensic Casework.

This is the first report regarding the characterization of the new synthetic cannabinoid 4F-MDMB-BINACA. 4F-MDMB-BINACA was first analytically confirmed in seized drug material using gas chromatography-mass spectrometry (GC-MS), liquid chromatography-quadrupole time-of-flight mass spectrometry (LC-QTOF), and nuclear magnetic resonance (NMR) spectroscopy. Subsequent to this characterization, 4F-MDMB-BINACA was detected in biological specimens collected as part of forensically relevant casework, including medicolegal death investigations and drug impaired driving investigations, from a variety of regions in the United States. Further analysis of biological specimens resulted in the identification of the metabolites 4F-MDMB-BINACA 3,3-dimethylbutanoic acid and 4-OH-MDMB-BINACA. 4F-MDMB-BINACA is appearing with increasing frequency as a contributory factor in deaths, creating morbidity and mortality risks for drug users. Laboratories must be aware of its presence and impact, incorporating 4F-MDMB-BINACA into workflows for detection and confirmation.

Identification of the abuse of performance-enhancing agents in medico-legal investigations; based on a death of a body-builder

Sportsmen abuse Performance-enhancing agents (PEA) to enhance their muscle mass and strength, while the side effects PEA may cause consequences and sudden deaths. However, the relatives usually are not aware of PEA-abuse, because most PEAs are purchased by the sportsmen from black-market. Therefore, the pathologists might miss PEA-abuse and may dispose of the postmortem with a wrong cause of death. This concept introduces a guideline to identify PEA-abuse and to give recommendations for the proper medico-legal investigation of deaths due to PEA-abuse. A 37-year-old bodybuilder who had a healthy-lifestyle died suddenly. Though the relatives were unaware, the Forensic pathologist profiled the findings and suspected PEA-abuse. The scene was visited but did not find PEA. Family physician revealed the abuse of PEA such as testosterone, cutting steroids, insulin-like growth factor and caffeine, and has had elevated liver enzymes. A high-risk autopsy was conducted. The face had acne and heart had concentric hypertrophy. Histopathology showed hypertrophy of the cardiac muscle and lung parenchyma and fatty liver. Therefore, we propose a postmortem guideline to identify PEA-abuse among sportsmen; (1) Establish seven PEA-abuse profiles; Social, physical, psychological, clinical, sports, pathological and toxicological, (2) Before autopsy, to identify the types of PEA (i) Contact the physicians and (ii) visit the scene, (3) At the autopsy, use special approaches; (i) Consider as high-risk autopsy and (ii) If gene doping is suspected, do molecular autopsy. (4) To ascertain COD, consider abuse profiles, scene and autopsy findings. (5) For prevention, organize awareness programmes and (6) to prevent premature deaths recommend to employ a clinical screening tool.

Evaluation of a Novel Medicolegal Death Investigator-Based Suicide Surveillance System to the National Violent Death Reporting System.

The abundance of actionable information available in a medicolegal suicide investigation is often inaccessible and underutilized in public health to the detriment of prevention efforts. Epidemiologists obtained the Washington County subset of the Oregon Violent Death Reporting System (OR-VDRS). To determine if additional information beyond the OR-VDRS was available through a standard death investigation, an epidemiologist shadowed medicolegal death investigators (MDIs) for nearly 2 years. The MDIs and epidemiologist developed a novel, real-time, MDI-entered surveillance system, the Suicide Risk Factor Surveillance System (SRFSS), to capture suicide risk factor data with greater timeliness and accuracy than available through the OR-VDRS. To evaluate the performance of each surveillance system, differences in the prevalence of suicide risk factor data from SRFSS were compared with the county OR-VDRS subset for the same 133 suicides occurring in 2014-2015. Across 27 suicide risk factors and circumstances, the median difference in prevalence was 10.5 percentage points between the OR-VDRS and the SRFSS, with the higher prevalence in SRFSS. The prevalence was significantly different between the 2 surveillance systems for 21 (78%) of 27 variables. This study demonstrates the truly exceptional data quality and timeliness of MDI information over traditional sources.

A Descriptive and Geospatial Analysis of Environmental Factors Attributing to Sudden Unexpected Infant Death.

This study examined medicolegal death investigation records and autopsy reports of a medical examiner's office to identify the circumstances surrounding sudden unexpected infant deaths (SUID) and geospatial analyses to pinpoint areas of infant death concentration. Analysis of 732 records of SUID deaths occurring in a 10-year span resulted in the conclusion that environmental factors associated with the sudden death were to some extent modifiable. Co-sleeping (sharing a sleeping surface, or bed-sharing) on various surfaces (mattress, pallet, couch) occurred in 53.4% of the infant deaths. Geographic areas where the largest number of deaths occurred were characterized as areas of high poverty level. The inclusion of additional information at the time of investigation (eg, alcohol and tobacco use of co-sleepers, illness of others in household, exceptions to normal sleep routine of infant) may aid in identifying modifiable circumstances to reduce infant mortality attributable to sudden infant death.

Improving risk factor identification for opioid overdose deaths in Tennessee

ObjectiveTo examine specific drugs present based on postmortem toxicology for prescription opioid, heroin, and fentanyl overdoses classified based on ICD-10 coding. To compare drugs identified from postmortem toxicology with those listed on the death certificate for opioid overdoses.IntroductionUsing death certificates alone to identify contributing substances in drug overdose deaths may result in misclassification and underestimation of the burden of illicit and prescription opioids and other drugs in drug-related deaths. To enable timely and targeted prevention in Tennessee (TN), the identification and monitoring of new drugs and trends in use should utilize toxicology and medicolegal death investigation data directly, as recommended by others 1-3. These data can inform mortality outcome definitions for improved surveillance and risk factor identification 4-7. To our knowledge, this is the first analysis to use statewide linked toxicology and death certificate data in TN.MethodsWe identified 615 opioid involved overdose deaths in TN of unintentional (underlying ICD-10 codes: X40-X44) or undetermined (underlying ICD-10 codes: Y10-Y14) intent during June 1st to December 31st 2017. Utilizing the Interim Medical Examiner Database (I-MED), we identified postmortem toxicology reports for 454 cases, which were from one of three national laboratories used by a state Regional Forensic Center. Toxicology data were abstracted and independently verified by two co-authors and linked to the TN death statistical file that included cause of death information (literal text and ICD-10 codes) and demographics. The analysis focuses on cases with an available toxicology report.ResultsWe identified 171 prescription opioid overdoses, 221 fentanyl overdoses, and 113 heroin overdoses. Table 1 displays postmortem toxicology profiles for major drugs/classes. For prescription opioid deaths (excluding fentanyl and heroin), positive toxicology results for prescription opioids were as follows: methadone (11%), buprenorphine (14%), hydrocodone (14%), oxycodone (36%) and oxymorphone (also a metabolite, 47%). Benzodiazepines were present in close to 58% of prescription opioid overdoses; stimulants (cocaine, amphetamines, methamphetamines) in about 25%. For fentanyl and heroin deaths, prescription opioids were detected in about 26% and 34%, respectively; stimulants in about 57.9% and 52.2%, respectively, and benzodiazepines 36-37%. Fentanyl was present on toxicology in about half of heroin overdoses, and 6–monoacetylmorphine in 72.6%.ConclusionsUsing medical examiners’ data, including toxicology data, improves estimation of contributing drugs involved in opioid deaths. This analysis provides jurisdiction-specific data on drugs that can help with monitoring trends and informs risk factor identification. Future work includes adding information on prescribed opioid and benzodiazepines using TN’s Prescription Drug Monitoring Database and evaluating demographic variation in contributing drugs between toxicology and DC data to identify susceptible populations.

Environmental Deaths in the Northern Territory of Australia, 2003–2018

The Northern Territory is sparsely populated with a distinctive climate, geography, and wildlife compared with other states and territories in Australia. Environmental deaths (including drowning, heat-related deaths or environmental exposure, fatal animal attacks or envenomation, and lightning deaths) are reportable to the Northern Territory coroner for further investigation. Databases of the Northern Territory coroner's office and the Royal Darwin Hospital Forensic Pathology Unit were searched to identify all environmental deaths over a 15-y period (July 1, 2003-June 30, 2018). A total of 4535 cases were reported to the Northern Territory coroner's office during the studied period, of which 167 (4%) were environmental deaths. Drowning was the most common type of environmental death, followed by heat-related deaths and fatal crocodile attacks. Deaths resulting from lightning and animals other than crocodiles are rare. Local resident, male victims in rural locations were the most commonly affected. Alcohol intoxication played a role in about one-third of cases, and in approximately one-third of cases a known underlying medical condition was identified. The Northern Territory has a challenging environment that is hot, humid, remote, and isolated. Circumstantial information and thorough police investigations are essential in the medicolegal investigation of environmental deaths.

A 25-Year Review of Pediatric Suicides: Distinguishing Features and Risk Factors.

Childhood and adolescent suicides have been increasing worldwide in recent years, and the investigation of such deaths is often complex. Forensic pathologists frequently find themselves having to opine as to the manner of death in these difficult cases. The present study was undertaken to identify distinguishing features in childhood and adolescent suicides to assist in the investigation and prevention of these deaths. A 25-year review of pediatric suicides in a metropolitan area was performed, which showed a steady increase in pediatric suicides over time. Male pediatric suicides were more common than female, with both having an average age of 15 years. Gunshots wounds and hanging were the most common methodologies seen, with drug toxicity being more common in females and gunshot wounds more common in males. Approximately 20% of decedents had a psychiatric history, 25% had a previous history of a suicide attempt or ideation, and 24% had a history of drug use. Only a minority of decedents made their intentions known prior to the suicidal act (16%) or left a note of intent (16%). In 62% of cases, a temporal, precipitating event could be identified, of which conflict with a significant other (boyfriend or girlfriend) was the most common. No specific trends over time were identified. While these features may assist forensic pathologists in assessing a possible suicidal death in the pediatric age group, medicolegal death investigators must approach these deaths as they would any violent death in an attempt to accurately determine the manner of death regardless of the societal and familial implications of such a determination.

Impact of a Drug Overdose Decedent Toxicology Testing Legislative Mandate on Informing Coroner Death Investigation and Certification Practices.

To (a) determine the impact of Kentucky's (KY's) mandate requiring postmortem toxicology testing of coroner cases; (b) identify the influence of coroner experience and training, jurisdiction size, budget, and location on postmortem testing requests; (c) identify facilitators/barriers for postmortem toxicology testing requests and listing the specific drugs involved in drug-poisoning deaths on death certificates. A modified Dillman approach was used to deliver the survey to KY's elected coroners between April and May 2016. Responses stratified by identified influence factors were compared using χ2 tests and Fisher exact tests. Fifty-eight percent of coroners reported that drug overdose investigations had changed since the mandate was enacted. Statistically significant differences in responses were found when stratified. Sixty-three percent of coroners reported always using testing results to complete death certificates. Uptake of the mandate for postmortem toxicology testing of all decedents is not yet complete. Without uptake of the mandate, surveillance efforts may result in undercounting of drug overdose deaths and the involvement of specific drugs. Mandates for enhanced training and modification of funding structure for medico-legal death investigations could facilitate uptake.

Using histology to evaluate micro-CT findings of trauma in three post-mortem samples — First steps towards method validation

Forensic imaging technology has rapidly advanced over the past several decades and is gaining increasing significance in medico-legal death investigations. Medical-grade computed tomography (CT) is now routinely used in post-mortem examinations at numerous institutions across the globe. However, the resolution of medical-grade CT is limited and unsuitable when used to depict some smaller anatomical structures or micro-trauma. High-resolution micro-CT offers up to 100× the resolution to overcome this problem but is a very recent addition to the field of forensic radiology. Few studies so far have attempted to validate the results which is an essential prerequisite for it to be used in the criminal justice process as demanded by regulatory bodies. This study directly compares micro-CT images with histology, the current gold standard. Three cases were examined: two larynges from suspected strangulations and one ribcage of a case of fatal child abuse. A strong correlation was observed between histology and micro-CT as the majority of skeletal injuries were identified correctly. This paper discusses the forensic implications of the results and how micro-CT is complementary to histology.

Radiology in the witness box: manipulation or clarification?

Post-mortem imaging especially CT scanning has become common practice in medico-legal death investigation. Inevitably these images are being used in court proceedings. How the content of those images should be presented to court is uncertain notwithstanding the ability to so-called post-process the data to produce 3-D reconstructions and the like. This requires the input of a specialist to view the images and highlight the salient features; a process the courts initially found difficult with photography but which is now generally accepted since the introduction of digital photography. To a greater extent post-mortem CT images can be altered to show with greater clarity the postulated areas of interest for the benefit of the court. Clearly, safeguards must be in place to prevent unscrupulous or overzealous manipulation although in reality at this time there would seem to be an unfair advantage in the use of such imagery by the often better resourced Crown.

Social Media and Medicolegal Death Investigation: Logged in…To the Morgue

Social media (SM) represent a global consumer phenomenon with an exponential rise in usage within the last few years. The various applications and websites are relatively easy and fast to access, and the number of users increases continuously. SM are an incredible source of freely available, public information about their users. The purpose of this study is to provide information about the usefulness of SM in forensic practice. The electronic database of the Cook County of Medical Examiner's Office ("CCMEO") in Illinois was searched for investigative narratives that included specific SM keywords, in the period from August 2014 to January 2018. A total of 48 cases met the study's criteria. Among these, "Facebook" has been found to be the most helpful SM for medicolegal investigation purposes. Information obtained by SM can play an important role in forensic practice since it can be used to clarify certain aspects of the medicolegal death investigation, with particular regard to time and manner of death.

Surge in Fentanyl Toxicity Deaths in Jefferson Parish, LA, 2013-2018.

Background: The opioid epidemic in the United States has resulted in a significant increase in fentanyl-related overdoses nationwide since 2013. Because of an increased rate of fentanyl-related overdoses seen in Jefferson Parish, LA, the Jefferson Parish Coroner's Office (JPCO) hypothesized that the opioid epidemic, specifically related to fentanyl, had reached this region. To test this hypothesis, JPCO analyzed fentanyl overdose deaths to determine if the deaths had increased during a 6-year period and if the change met the definition of an epidemic.Methods: In the toxicology laboratory at JPCO, enzyme-linked immunosorbent assay screening and gas chromatography/mass spectrometry are used in-house to determine the presence of drugs. Drug-positive samples are sent to National Medical Services (NMS) Labs to quantify the analyte concentration in each sample. Data for each decedent were extracted from the Medicolegal Death Investigation Log (MDILog) database for the years 2013 through 2018.Results: A slow increase in fentanyl-related deaths during the first 3 years of the study period was followed by a near doubling of cases in 2016, a tripling of cases in 2017, and a 6-fold increase in incidence in 2018. During the 6-year study period, fentanyl-related deaths increased from 6 in 2013, to 8 in 2014, to 14 in 2015. Twenty-five deaths in 2016 spiked to 66 in 2017 and increased to 78 fentanyl-related overdose deaths in 2018. The percentage of fentanyl-related overdose deaths increased from 4% of all drug deaths in 2013 to 45% in 2018.Conclusion: The data validate the hypothesis that the fentanyl epidemic has affected Jefferson Parish in southeast Louisiana.

Now a day’s forensic entomology is considered as important tool in medico-legal cases

Forensic entomology is the use of arthropod evidence in legal investigations is becoming increasingly more important in such investigations. Most often, forensic entomologists assist homicide investigations by estimating the time of death using information on the biology and ecology of arthropods. In murder investigations it deals with which insect’s eggs appear, their location on the body and in what order they appear. In medico-legal death investigations one of the most critical question is, ‘‘When did the death take place?’’ An accurate estimation of the post mortem interval has special relevance in a homicide case because this information can narrow the field of possible suspects in a crime. Forensic entomology helpful in determining a post mortem interval (PMI) and location of a death in question. Since many insects exhibit a degree of endemism (occurring only in certain places), or have a well-defined phenology (active only at a certain season, or time of day), their presence in association with other evidence can demonstrate potential links to times and locations where other events may have occurred. Another area covered by medico legal forensic entomology is the relatively new field of entomotoxicology. This particular branch involves the utilization of entomological specimens found at a scene in order to test for different drugs that may have possibly played a role in the death of the victim. Forensic entomology is recognized in many countries as an important tool for legal investigations. Unfortunately, it has not received much attention in Bangladesh as an important investigative tool. This paper reviews the various types of insect’s behavior on corpse also important information we will find from them. This is helpful for the investigators, law personnel and researchers aware of the importance of entomology in criminal investigations. Correct estimation of the post mortem interval is one of the most important aspects of legal medicine.

Corrigendum.

[This corrects the article DOI: 10.1177/192536211700700405.].

Toxological Viscera Analysis in India: Current Scenario, Problems & Suggestions- One Year Study of Autopsy Cases Where Viscera Had Been Preserved

Chemical and Toxoclogical analysis of viscera is conducted in a Medicolegal Death investigation to rule out poisoning/intoxication in the death of the deceased. The analysis is done only in Forensic Science Laboratories established by Indian Government. The Viscera reports are usually received after a period of considerable delay and opinion about the case is kept pending till then. Keeping the same thing into consideration, this study was undertaken to analyze the system of Viscera analysis after autopsy and identifying the factors and problems hampering the timely Chemical Analysis. The study was conducted in Department of Forensic Medicine, All India Institute of Medical sciences, New Delhi. All the Medicolegal Autopsy Cases in the period of one year from 1st January 2013 to 31st December 2013 where viscera was preserved were studied. Data was collected and analyzed from the PM reports and the subsequent viscera reports from FSLs received in the Department till 30th April 2017. The viscera analysis report was received in only 45.5% cases till 30th April 2017 and only 6.2% cases analysis reports were received within six months of conduction of postmortem. Poisons and Drugs were detected in 134 (41.5%) case out of which Ethyl and Methyl Alcohol constitutes 78.6% cases and only in those cases quantification was performed. The reasons of the delay in analysis of viscera and its effects on Medicolegal Death Investigation are discussed. It was concluded that there is a need of establishing Toxological Laboratories associated with the district hospitals and Medical Colleges where postmortem are being conducted.

Unnatural Deaths of the Elderly Population of Sri Lanka

As people age, they may become more vulnerable to injury because of frailty, ill health, or dependency on others. Data from medicolegal death investigation including autopsy and statements from cases reported to 3 medicolegal units in Sri Lanka were analyzed in this study under the strict ethical framework. Of the study population, 265 were male and 75 were female. Mean age was 71.14 years. Commonest manner of death was accidental (62.1%) followed by suicide (32.1%) and homicide (5.6%). Commonest types of incidents were road traffic accidents (26.5%), falls (22.6%), and poisoning (21.2%). Among the road traffic accidents, pedestrians (77.9%) were the majority. Poisoning (59.6%) was the commonest method of suicide. The commonest weapons used in homicides were blunt weapons (47.3%). Association with alcohol was seen in more than 10% of suicidal and accidental deaths. More attention should be given to the elderly people who are using the roads while developing policies by the state. Furthermore, it is high time to think about psychological aspect in the elderly care management specially alcohol abuse and suicidal ideation among them.