Can subclavian blood be equated with a peripheral blood sample? A series of 50 cases

Drug overdose deaths during prison riots and mental states of prisoners: a case study

Prison riots, though often sensationalized in the media, have profound consequences, with a significant death toll. Prison populations, historically plagued by psychiatric disorders, witness high rates of suicide, particularly linked to turbulent events like riots. This study examines three drug overdose deaths resulting from a prison riot during the initial wave of the SARS-CoV-2 pandemic in Italy. To ascertain the nature of these deaths, a comprehensive toxicological analysis was conducted. Immunochemical screening and gas chromatography-mass spectrometry were employed to detect a spectrum of drugs, including MDMA, methadone, morphine, cannabis derivatives, benzodiazepines, and others. The toxicological findings revealed high concentrations of various substances in the biological fluids of the deceased inmates. Tramadol and mirtazapine were implicated in one case, while methadone was a common factor in the deaths of two inmates, one of whom also ingested diazepam. The synergistic effects of substances were explored, with methadone identified as a leading cause of death in two cases. Prison riots exacerbate drug abuse issues within prisons, leading to mass intoxication and overdose, as witnessed in historic incidents globally. The study underscores the challenges in determining whether such deaths are accidental, intentional (suicidal), or a consequence of uncontrollable drug consumption during a riot. The prison environment also amplifies pre-existing psychiatric disorders, and incidents like riots can trigger a cascade of uncontrollable psychological reactions. The three potential scenarios are drug dependence, accidental overdose in recreational drug use, and suicide attempts through substance ingestion.

Preanalytical factors influencing the results of ethanol analysis in postmortem specimens

Excessive drinking and drunkenness are underlying factors in many fatal accidents, which make the quantitative determination of ethanol in postmortem (PM) specimens an essential part of all unnatural death investigations. The same analytical methods are used to determine ethanol in blood taken from living and deceased persons although the interpretation of the results is more complicated in medical examiner cases owing to various preanalytical factors. The biggest problem is that under anaerobic conditions ethanol can be produced naturally in decomposed bodies by microbial activity and fermentation of blood glucose. Ways are needed to differentiate antemortem ingestion of ethanol from PM synthesis. One approach involves the determination of ethanol in alternative specimens, such as bile, cerebrospinal fluid, vitreous humor and/or urine, and comparison of results with blood alcohol concentration (BAC). Another approach involves the analysis of various alcohol biomarkers, such as ethyl glucuronide, ethyl sulfate and/or phosphatidylethanol or the urinary metabolites of serotonin 5-hydroxytryptophol/5-hydroxyindoleacetic acid (5-HTOL/5-HIAA). If ethanol had been produced in the body by microbial activity, the blood samples should also contain other low-molecular volatiles, such as acetaldehyde, n-propanol and/or n-butanol. The inclusion of 1-2% w/v sodium or potassium fluoride, as an enzyme inhibitor, in all PM specimens is essential to diminish the risk of ethanol being generated after sampling, such as during shipment and storage prior to analysis. Furthermore, much might be gained if the analytical cut-off for reporting positive BAC was raised from 0.01 to 0.02 g% when PM blood is analyzed. During putrefaction low BACs are more often produced after death than high BACs. Therefore, when the cadaver is obviously decomposed, a pragmatic approach would be to subtract 0.05 g% from the mean analytical result. Any remaining BAC is expected to give a more reliable indication of whether alcohol had been consumed before death.

Postmortem Ethanol Concentrations and Postmortem Ethanol Production

A review of the literature was conducted in reference to postmortem blood ethanol concentrations and the issue of postmortem production of ethanol. Ethanol in postmortem specimens may occur as a result of antemortem consumption (most common), postmortem production in the body or in vitro by microorganisms (less common), and endogenous production by microorganisms during life (rare). The portion of ethanol-positive postmortem cases in which postmortem production of ethanol is thought to have occurred is small, as is the portion of cases in which postmortem production of ethanol is a potentially important issue. It is unusual for postmortem production of ethanol to account for more than a 70 mg/dL concentration, but cases with higher concentrations occasionally occur. Cases in which blood ethanol is positive but vitreous ethanol concentration is much lower or negative, and/or in which the urine: blood ethanol concentration ratio is less than one are supportive of postmortem ethanol production. The presence of other alcohols such as n-propanol and/or n-butanol is suggestive of postmortem microbial production of ethanol. The ratio of serotonin metabolites in urine may be helpful in distinguishing postmortem production of ethanol from antemortem consumption, as may the concentration of ethyl glucuronide in blood. Candida and some other species may produce ethanol in urine antemortem and postmortem. In rare instances such as infections, endogenous ethanol production may occur in a living person. Recommendations are made concerning samples to collect and tests that may be helpful in distinguishing antemortem ethanol consumption from postmortem production of ethanol.