Clinical and forensic signs related to ethanol abuse: a mechanistic approach

Bisphosphonates and osteonecrosis of the jaws: Clinical and forensic aspects

OBJECTIVE

This manuscript aims to provide a comprehensive review of the current knowledge in the pathophysiology, diagnosis, prevention, and other relevant clinical and forensic aspects of a potentially severe complication known as medication-related osteonecrosis of the jaw (MRONJ) while synthesizing state-of-the-art information on bisphosphonates and introducing a possible differential diagnosis.

DESIGN

An extensive search was conducted in PubMed (U.S. National Library of Medicine) without a time or language constraint, focusing on the epidemiology, pathophysiology, risk factors, site specificity, signs and symptoms, differential diagnosis, prevention, and forensic aspects of MRONJ. All types of original articles, reviews, case reports, short communications, opinion articles, guidelines, and letters to editors were considered to produce a complete review on this subject.

RESULTS

MRONJ prevention relies on a multidisciplinary approach and is critical since truly effective treatments are lacking. This therapeutic challenge is partly due to uncertainty regarding this condition's pathophysiology. Differential diagnosis of osteonecrosis of the jaws associated with krokodil abuse, one of the most dangerous and homemade psychoactive illicit substances, should be considered.

CONCLUSIONS

Further research into the etiology and site specificity of MRONJ is encouraged, aiming to develop novel treatment prospects. Indeed, comprehending this would allow for increased efficacy and therapeutic options while emphasizing the importance of prevention. In addition, we advocate for greater consensus among the various societies regarding MRONJ's treatment and management.

Clinical and Forensic Signs Resulting from Exposure to Heavy Metals and Other Chemical Elements of the Periodic Table

Several heavy metals and other chemical elements are natural components of the Earth's crust and their properties and toxicity have been recognized for thousands of years. Moreover, their use in industries presents a major source of environmental and occupational pollution. Therefore, this ubiquity in daily life may result in several potential exposures coming from natural sources (e.g., through food and water contamination), industrial processes, and commercial products, among others. The toxicity of most chemical elements of the periodic table accrues from their highly reactive nature, resulting in the formation of complexes with intracellular compounds that impair cellular pathways, leading to dysfunction, necrosis, and apoptosis. Nervous, gastrointestinal, hematopoietic, renal, and dermatological systems are the main targets. This manuscript aims to collect the clinical and forensic signs related to poisoning from heavy metals, such as thallium, lead, copper, mercury, iron, cadmium, and bismuth, as well as other chemical elements such as arsenic, selenium, and fluorine. Furthermore, their main sources of occupational and environmental exposure are highlighted in this review. The importance of rapid recognition is related to the fact that, through a high degree of suspicion, the clinician could rapidly initiate treatment even before the toxicological results are available, which can make a huge difference in these patients' outcomes.

One image is worth more than a thousand words: producing an atlas of medical signs for teaching clinical and forensic toxicology

Clinical and forensic toxicology are critically involved in the acquisition of basic skills to correctly suspect intoxication, collect biological and non-biological materials for toxicological analysis, comprehend the complexities inherent to laboratory activity, and understand the fundamentals of toxicokinetics and toxicodynamics that underlie the interpretation of results. This works presents a pedagogical innovation proposal for the teaching of clinical and forensic toxicology based on a compilation of more than 3 000 cases where the image was fulcra for suspicion. The experience in this article follows the model practiced in bachelors, masters, and PhD degrees, as well as in other continuing training courses, where we are teaching toxicology for more than 15 years. All these levels of education are considered fundamental to the sound development of this science. This approach aims also to offer strength to the intervention of the true toxicologist in all the toxicological phases, besides the classic analytical chemistry. Indeed, it is impossible to provide effective clinical and forensic toxicological interpretations without a proper and broad education, and not thinking exclusively in terms of laboratory techniques. In the future, it will be interesting to evaluate knowledge retention and to propose a database of videos of signs related to intoxications.

Raising Awareness on the Clinical and Forensic Aspects of Jellyfish Stings: A Worldwide Increasing Threat

Jellyfish are ubiquitous animals registering a high and increasing number of contacts with humans in coastal areas. These encounters result in a multitude of symptoms, ranging from mild erythema to death. This work aims to review the state-of-the-art regarding pathophysiology, diagnosis, treatment, and relevant clinical and forensic aspects of jellyfish stings. There are three major classes of jellyfish, causing various clinical scenarios. Most envenomations result in an erythematous lesion with morphological characteristics that may help identify the class of jellyfish responsible. In rare cases, the sting may result in delayed, persistent, or systemic symptoms. Lethal encounters have been described, but most of those cases happened in the Indo-Pacific region, where cubozoans, the deadliest jellyfish class, can be found. The diagnosis is mostly clinical but can be aided by dermoscopy, skin scrapings/sticky tape, confocal reflectance microscopy, immunological essays, among others. Treatment is currently based on preventing further envenomation, inactivating the venom, and alleviating local and systemic symptoms. However, the strategy used to achieve these effects remains under debate. Only one antivenom is currently used and covers merely one species (Chironex fleckeri). Other antivenoms have been produced experimentally but were not tested on human envenomation settings. The increased number of cases, especially due to climate changes, justifies further research in the study of clinical aspects of jellyfish envenoming.

The Application of Metabolomics in Forensic Science with Focus on Forensic Toxicology and Time-of-Death Estimation

Recently, the diagnostic methods used by scientists in forensic examinations have enormously expanded. Metabolomics provides an important contribution to analytical method development. The main purpose of this review was to investigate and summarize the most recent applications of metabolomics in forensic science. The primary research method was an extensive review of available international literature in PubMed. The keywords “forensic” and “metabolomics” were used as search criteria for the PubMed database scan. Most authors emphasized the analysis of different biological sample types using chromatography methods. The presented review is a summary of recently published implementations of metabolomics in forensic science and types of biological material used and techniques applied. Possible opportunities for valuable metabolomics’ applications are discussed to emphasize the essential necessities resulting in numerous nontargeted metabolomics’ assays.

The Auto-Brewery Syndrome: A Perfect Metabolic "Storm" with Clinical and Forensic Implications

Auto-brewery syndrome (ABS) is a rare, unstudied, unknown, and underreported phenomenon in modern medicine. Patients with this syndrome become inebriated and may suffer the medical and social implications of alcoholism, including arrest for inebriated driving. The pathophysiology of ABS is reportedly due to a fungal type dysbiosis of the gut that ferments some carbohydrates into ethanol and may mimic a food allergy or intolerance. This syndrome should be considered in patients with chronic obstruction or hypomotility presenting with elevated breath and blood alcohol concentrations, especially after a high carbohydrate intake. A glucose challenge test should be performed as the confirmatory test. Treatment typically includes antifungal drugs combined with changes in lifestyle and nutrition. Additional studies are particularly needed on the human microbiome to shed light on how imbalances of commensal bacteria in the gut allow yeast to colonize on a pathological level.

Drug Overdose-Induced Coma Blisters: Pathophysiology and Clinical and Forensic Diagnosis

BACKGROUND

Coma blisters or coma bullae are bullous lesions that have been associated with cases of drug overdose-induced coma. Previous history of suicide attempt by administering benzodiazepines, barbiturates, ethanol, antipsychotics, antidepressants or opioids have been particularly implicated. Patients may present also painful deep skin and soft tissue involvement, edema and functional impairment. The pathophysiology remains unknown and lesions are usually self-limited and typically resolve without scarring.

OBJECTIVE

This work aims to fully review the state of the art regarding the causes pathophysiology, diagnosis and treatment of drug overdose-induced coma blisters.

CONCLUSION

Coma blisters are a benign, self-limiting condition that should be suspected in patients who develop pressure blisters several hours after an altered state of consciousness.

Prevalence and determinants of seborrhoeic dermatitis in a middle-aged and elderly population: the Rotterdam Study

BACKGROUND

Seborrhoeic dermatitis is a chronic relapsing inflammatory skin disease with unclear pathophysiological mechanisms.

OBJECTIVES

To establish which lifestyle and physiological determinants are associated with seborrhoeic dermatitis.

METHODS

Seborrhoeic dermatitis was diagnosed by a trained physician during a full-body skin examination within the Rotterdam Study, a prospective population-based cohort study in middle-aged and elderly people. The current design is a comparative cross-sectional study embedded in the Rotterdam Study. Potential factors were identified from the literature and analysed in a multivariable logistic regression, including: age, sex, obesity, skin colour, stress, depression, education level, hypertension, climate, xerosis cutis, alcohol and tobacco use.

RESULTS

Of the 5498 participants, 788 participants were diagnosed with seborrhoeic dermatitis (14·3%). We found associations between seborrhoeic dermatitis and male sex [adjusted odds ratio (OR) 2·09, 95% confidence interval (CI) 1·77-2·47], darker skin (adjusted OR 0·39, 95% CI 0·22-0·69), season (summer vs. winter: adjusted OR 0·63, 95% CI 0·48-0·82) and generalized xerosis cutis (adjusted OR 1·41, 95% CI 1·11-1·80).

CONCLUSIONS

Seborrhoeic dermatitis is one of the most common inflammatory dermatoses in middle-aged and elderly individuals, especially during winter. Men, and people with a light and dry skin were most likely to have seborrhoeic dermatitis.

Sudden cardiac death in young adult

Cardiovascular disease represents one of the most important public health problem in the Western countries, with sudden cardiac death (SCD) being the most common cause of death in adults under 65 years of age. The objective of the present study is to evaluate the leading causes of SCD in young adults who died suddenly in Northern Portugal between 2007 and 2012. This study included 288 cases of 20- to 45-year-old adults who died suddenly of a cardiac cause and whose forensic autopsy was performed in the North Branch of the National Institute of Legal Medicine and Forensic Sciences between 2007 and 2012. Data included the cause of death, forensic autopsy findings, previous medical history and cardiovascular risk factors. The mean age of the population was 37.36 years. Coronary artery disease (CAD) was the leading cause of death, representing 55.6 % of all cases (92.5 % of men and 7.5 % of women). Females died mostly from probable primary arrhythmia. From those who died of coronary disease, 72 (25 % of total cases) had histological evidence of a fatal acute infarction. Age, previous coronary disease, hypercholesterolemia, smoking habits and alcohol consumption seem to be associated with an increased risk of SCD by CAD. A total of 55.6 % of deaths were attributed to CAD. Prevention of cardiovascular risk factors should therefore be considered to prevent atherosclerosis in young adults.

Clinical and forensic signs related to chemical burns: a mechanistic approach

This manuscript highlights and critically analyses clinical and forensic signs related to chemical burns. Signs that may lead to suspicion of a particular chemical are thoroughly discussed regarding its underlying mechanisms. Burns due to sulfuric, hydrofluoric, nitric, hydrochloric (muriatic) and acetic (including derivatives) acids, hydrogen sulphide, sodium (caustic soda) and calcium (cement) hydroxides, paraquat, burns after inflation and rupture of airbags, povidone-iodine, chlorhexidine/alcohol (in preterm infants), laxatives, and vesicants (warfare agents), will be reviewed since these are the most common agents found in daily practice, for which relevant and timed information may be helpful in formulating an emergency treatment protocols and toxicological analysis.

Heterogeneous and homogeneous immunoassays for drug analysis

Immunoassays are very useful techniques to perform screening and semi-quantitative analysis of hundreds of different xenobiotics. Small sample volumes are required and pretreatment is usually unnecessary (e.g., homogeneous immunoassays). Fully automated and high-throughput systems are available, which help physicians to take timely decisions. However, immunoassays do suffer from interference from both endogenous and exogenous factors that limit their application in quantitative analysis. These assays use different labels (e.g., colorimetric, fluorescent, chemiluminescent or electrochemiluminescent) and different methods for generating and measuring signals, but the basic principles are usually similar. This review outlines the practical aspects of immunoassays in bioanalysis and describes their application in clinical chemistry for xenobiotic analysis, namely medicines and drugs of abuse.

Pedestrian fatalities resulting from train-person collisions

OBJECTIVE

Train-person collisions have a significant impact in our society, due to their negative economic and psychological effects. This work aims to study fatalities resulting from train-person collisions in Portugal.

METHODS

A retrospective study was conducted based on the analysis of autopsy reports related to train-person fatalities performed in the North Branch of the National Institute of Legal Medicine and Forensic Sciences.

RESULTS

Suicide was responsible for most of the cases, and males were more often involved in train-person collisions than females. Victims, between 40 and 59 years old, were found to be involved in a high percentage (39%) of the cases, and people older than 65 accounted for a significant percentage (40%) of the accidents. No seasonality was observed in suicide cases, but a decrease in accident numbers was registered in summer. Regarding weekday and time of day, afternoon and non-rush hour were the times when most suicides were observed, whereas accidents did not showed a specific weekday or time of day, except for rush hour, during which they were more frequent. Alcohol-positive blood analysis accounting for 25% of the cases.

CONCLUSIONS

Differences from other European studies were found, which may be related to the different cultures of the countries/regions, as well as to the differences in the railway systems. More extensive studies must be performed in order to develop strategies to prevent train-person collisions.