An LC-MS-MS Method for the Analysis of Carfentanil, 3-Methylfentanyl, 2-Furanyl Fentanyl, Acetyl Fentanyl, Fentanyl and Norfentanyl in Postmortem and Impaired-Driving Cases.

In July of 2016, carfentanil (CF) emerged in Northeast Ohio resulting in over 25 deaths within a 30-day period. A total of 125 deaths have occurred in Summit County and Cuyahoga County has reported 40 deaths, relating to the presence of CF either alone, or in combinations with heroin and fentanyl. Prior to this surge in CF cases, positive fentanyl enzyme-linked immunosorbent assay (ELISA) screening results were increasing in number.

Opioid Toxicity.

In recent years, there has been a substantial increase in opioid use and abuse, and in opioid-related fatal overdoses. The increase in opioid use has resulted at least in part from individuals transitioning from prescribed opioids to heroin and fentanyl, which can cause significant respiratory depression that can progress to apnea and death. Heroin and fentanyl may be used individually, together, or in combination with other substances such as ethanol, benzodiazepines, or other drugs that can have additional deleterious effects on respiration.

Evaluating infant core temperature response in a hot car using a heat balance model.

Purpose: Using a 1-year old male infant as the model subject, the objectives of this study were to measure increased body temperature of an infant inside an enclosed vehicle during the work day (8:00 am-4:00 pm) during four seasons and model the time to un-compensable heating, heat stroke [>40 °C (>104 °F)], and critical thermal maximum [>42 °C (>107.6 °F)].

Methods: A human heat balance model was used to simulate a child's physiological response to extreme heat exposure within an enclosed vehicle.

Microscopic and spectroscopic features of gunpowder and its documentation in gunshot wounds in charred bodies.

Determining the direction and range of fire of gunshot wounds in charred bodies can be difficult because soot resulting from thermal injury can grossly be identical to soot arising from a contact or close-range firearm discharge. Two charred bodies had gunshot wounds of the head and neck region that were distorted by thermal effect, precluding determination of the direction and range of fire by gross findings alone. By microscopy, deep wound tissue from each charred body had foreign material suggestive of gunpowder.

Review of the significance of various low force fractures in the elderly.

The elderly are more prone to sustain fractures with low force injury because they have an increased incidence of falls, and because their bones are often more fragile secondary to osteoporosis and other conditions. Cases with fracture are routinely reported to medical examiner and coroner offices because fracture reflects traumatic injury. If a fracture is judged to be a significant factor in a person's death, then the manner of death must reflect how the injury was sustained, which is "accidental" in most of these cases.

Metastatic cancer of the urinary bladder: can it be a nonnatural death?

Deaths from metastatic carcinoma are almost exclusively viewed as wholly natural deaths. However, if it can be shown that a cancer has arisen as a result of a prior traumatic injury and the body's healing response to the injury, or treatment thereof, then in select cases, the manner of death shall reflect that of the precipitating injury. This case report is that of a woman who was rendered quadriplegic from spinal cord injury sustained in a motor vehicle crash when she was 22 years old.

Rib fractures in infants due to cardiopulmonary resuscitation efforts.

Although it is widely known that adults may sustain fractures of the anterior and/or lateral aspects of the ribs due to cardiopulmonary resuscitation (CPR) efforts, relatively little is written about the generation of CPR-related rib fractures in the infant age range. In a series of 70 consecutive autopsies in infants ranging in age from 2 weeks to 8 months, with no history or indications of injury, the parietal pleura of the thoracic cage was stripped and the ribs carefully examined for fracture. Subtle fractures of the anterolateral aspects of the ribs were discovered in 8 (11%) of the 70 cases.

Autonomic dysreflexia and sudden death in people with traumatic spinal cord injury.

Autonomic dysreflexia (AD) is an uncommon but potentially life-threatening clinical syndrome consisting of acute episodes of excessive, uncontrolled sympathetic output that may occur in quadriplegics and in paraplegics whose spinal cord lesions are above the level of T6. These uncontrolled bouts of sympathetic output can cause transient and pronounced elevations of blood pressure that on occasion can lead to serious sequela such as the precipitation of a hypertensive intracerebral hemorrhage. The episodes of AD are often triggered by some type of noxious stimulus such as a distended urinary bladder or a fecal impaction.

An overview of inflicted head injury in infants and young children, with a review of beta-amyloid precursor protein immunohistochemistry.

Context: Inflicted traumatic brain injury of infants and young children results in a complex array of autopsy findings. In many cases, immunostains for beta-amyloid precursor protein are used to detect axonal injury. Interpretation of the gross, microscopic, and immunostaining results requires the integration of the many facets of the individual case.

Beta-amyloid precursor protein immunohistochemistry in the evaluation of pediatric traumatic optic nerve injury.

Objective: The pathologic markers of nonaccidental injury (NAI) of the central nervous system (CNS) of infants and young children include subdural, subarachnoid, and retinal hemorrhages. Immunohistochemical staining for beta-amyloid precursor protein (betaAPP) has been used to investigate traumatic axonal injury of the brain, brain stem, and spinal cord injuries, and has potential as an additional indicator of traumatic head injury. A single study has reported that betaAPP immunostaining of the optic nerve in CNS NAI reveals axonal damage.

Sudden unexpected death due to a brainstem glioma in an adult.

Sudden death due to undiagnosed central nervous system tumors is an uncommon, but well-described occurrence. Most of the tumors in these circumstances are supratentorial and occur in a wide spectrum of ages. Brainstem tumors are more rare and occur predominantly in the pediatric and adolescent populations.

Beta-amyloid precursor protein staining of nonaccidental central nervous system injury in pediatric autopsies.

Immunohistochemical staining for beta-amyloid precursor protein (betaAPP) is a well-established marker of traumatic axonal injury in adults. Recent studies have used similar techniques to evaluate nonaccidental central nervous system injury (NAI) in infants and young children. In this prospective study, we report the results of betaAPP immunohistochemistry on the brain and spinal cord in 28 pediatric cases of NAI.

Beta-amyloid precursor protein staining in nonhomicidal pediatric medicolegal autopsies.

Immunohistochemical staining for beta-amyloid precursor protein (betaAPP) has been validated as a marker for axonal injury in adults surviving > or = 2 hours after white matter damage. The significance of betaAPP staining in pediatric brains and spinal cords is not as well established. We evaluated the white matter immunoreactivity for betaAPP from a variety of pediatric medicolegal autopsies: natural disease (non-Sudden Infant Death Syndrome [SIDS]), SIDS, motor vehicle accidents, drowning, near-drowning, overlay, carbon monoxide toxicity, miscellaneous trauma, and mechanical asphyxia.