Guido Viel

Phosphatidylethanol in Blood as a Marker of Chronic Alcohol Use: A Systematic Review and Meta-Analysis

The present paper aims at a systematic review of the current knowledge on phosphatidylethanol (PEth) in blood as a direct marker of chronic alcohol use and abuse. In March 2012, the search through “MeSH” and “free-text” protocols in the databases Medline/PubMed, SCOPUS, Web of Science, and Ovid/Embase, combining the terms phosphatidylethanol and alcohol, provided 444 records, 58 of which fulfilled the inclusion criteria and were used to summarize the current evidence on the formation, distribution and degradation of PEth in human blood: (1), the presence and distribution of different PEth molecular species (2), the most diffused analytical methods devoted to PEth identification and quantization (3), the clinical efficiency of total PEth quantification as a marker of chronic excessive drinking (4), and the potential utility of this marker for identifying binge drinking behaviors (5). Twelve papers were included in the meta-analysis and the mean (M) and 95% confidence interval (CI) of total PEth concentrations in social drinkers (DAI ≤ 60 g/die; M = 0.288 μM; CI 0.208–0.367 μM) and heavy drinkers (DAI > 60 g/die; M = 3.897 μM; CI 2.404–5.391 μM) were calculated. The present analysis demonstrates a good clinical efficiency of PEth for detecting chronic heavy drinking.

Validation of a fast screening method for the detection of cocaine in hair by MALDI-MS

The sensitivity and specificity of a novel method of screening for cocaine in hair, based on matrix-assisted laser desorption/ionisation (MALDI) mass spectrometry (MS), have been evaluated. The method entails a rapid extraction procedure consisting of shaking 2.5xa0mg pulverised hair at high frequency in the presence of an acidic solution (160xa0µL of water, 20xa0µL of acetonitrile and 20xa0µL of 1xa0M trifluoroacetic acid) and a stainless-steel bullet. Following centrifugation, the supernatant is dried under a nitrogen stream, and the residue is reconstituted in 10xa0µL of methanol/trifluoroacetic acid (7:3; v/v). One microlitre of the extract is deposed on a MALDI sample holder previously scrubbed with graphite; an α-cyano-4-hydroxycinnamic acid (matrix) solution is electrosprayed over the dried sample surface to achieve a uniform distribution of matrix crystals. The identification of cocaine is obtained by post-source decay experiments performed on its MH+ ion (m/z 304), with a limit of detection of 0.1xa0ng/mg of cocaine. A total of 304 hair samples were analysed in parallel by MALDI-MS and a reference gas chromatography-MS method. The obtained results demonstrate specificity and sensitivity of 100% for MALDI-MS. Evidence of cocaine presence was easily obtained even when hair samples exhibiting particularly low cocaine levels (<0.5xa0ng/mg) were analysed.

Ethyl glucuronide concentration in hair for detecting heavy drinking and/or abstinence: a meta-analysis

In both clinical and forensic settings, hair analysis for ethyl glucuronide (HEtG) has been increasingly employed for diagnosing chronic excessive drinking and, more recently, for monitoring abstinence. This paper aims at meta-analysing published data on HEtG concentrations in teetotallers, social drinkers and heavy drinkers in order to evaluate the use of this marker in hair for identifying chronic excessive drinking and for monitoring abstinence. In May 2012, a systematic multi-database search retrieved 366 records related to HEtG and further screened for relevant publications in the field. Fifteen (4.1xa0%) records matched the selection criteria and were included in the meta-analysis. The mean and 95xa0% confidence intervals (CI) of HEtG concentrations in social drinkers (mean 7.5xa0pg/mg; 95xa0% CI 4.7–10.2xa0pg/mg; pu2009<u20090.001), heavy drinkers (mean 142.7xa0pg/mg; 95xa0% CI 99.9–185.5xa0pg/mg; pu2009<u20090.001) and deceased subjects with a known history of chronic excessive drinking (mean 586.1xa0pg/mg; 95xa0% CI 177.2–995.0xa0pg/mg; pu2009<u20090.01) were calculated. The ranges of mean values and 95xa0% confidence intervals for single studies involving teetotallers/social or social/heavy drinkers showed a partial overlap with a down-trespassing of both the 7 and 30xa0pg/mg thresholds for social and heavy drinkers, respectively. Although larger and well-designed population studies are required to draw any definitive conclusion, our data show that the cut-off of 30xa0pg/mg limits the false-negative effect in differentiating heavy from social drinkers, whereas the recently proposed 7xa0pg/mg cut-off value might only be used for suspecting an active alcohol use, and not for proving complete abstinence.

Bio-medicolegal scientific research in Europe: a comprehensive bibliometric overview.

In times of globalisation, the future of bio-medicolegal sciences in Europe depends on the scientific community’s ability to develop new strategies for research, to introduce new and generally accepted standards, to develop new analytical methods, all in order to draw up inter-site, multidisciplinary and interdisciplinary long-term research projects, eligible for European Union (EU) funding. To analyse the scientific output and to identify the topics of greatest interest and appeal in these sciences, an innovative method has been developed to select and analyse publications. This method has been applied to analyse a total of 21,176 records from PubMed out of which 5,826 papers were suitable for further analysis because they were published in national and international journals in the time between January 1, 2005 and June 1, 2010 by European authors in the field of interest. In 69% of all manuscripts, authors presented results of systematic research (original articles); 84% of the papers were written in English language. The cumulative impact factor increased from 1,670 points in 2005 to 1,878 in 2009, and extrapolated 2,812 points in 2010. The most frequent topics were the description of new analytical methods in forensic toxicology (5.7% of all papers), the analysis of short tandem repeat systems (STR, 5.6%) as well as the analysis of injury mechanisms in forensic pathology and clinical forensic medicine (4.9%). If the impact factor related potential of different topics is calculated (ratio of frequency of papers and frequency of impact points achieved), SIDS research reaches 1.64 points, followed by studies on mtDNA (1.59) and the development of new analytical methods in forensic toxicology (1.49). The findings made in the present bibliometric analysis reveal a clear and interesting overall picture of the European scientific production and productivity and could be used to identify the most innovative research lines.

Bio-medicolegal guidelines and protocols: survey and future perspectives in Europe

The preservation of uniqueness and the enhancement of the value of evidence in legal medicine is based on the implementation and development of a “quality management system,” which includes a continuous education of specialists, the introduction and application of guidelines and protocols, as well as mechanisms of internal quality control. This ongoing process shows differences with regard to various fields of knowledge such as forensic genetics, toxicology, forensic pathology or forensic psychiatry, especially if different European countries are compared. To get an overview on the development of legal medicine in different European countries, a questionnaire was developed and sent to representatives of 42 European countries to verify the existence of bio-medicolegal guidelines and protocols. A National Society of Legal Medicine is established in 27 out of 32 countries (84%) which could be included in the final analyses. In 25 countries (78%), a specialisation is necessary as a prerequisite of inclusion in a national register, and 30 of the countries (94%) have guidelines in at least one field of legal medicine. The most common guidelines concern forensic pathology (in the fields of professional qualification and sudden death), forensic toxicology (driving under the influence of drugs and substance testing) and forensic genetics (paternity testing and personal identification). The findings of this study show that comparison is possible and can be a basis for further consensus in the European medicolegal community. The process of harmonisation of the medicolegal autopsy rules in Europe initiated in 1990 was a first step on this way. Further consensus is necessary and might be gained by developing European guidelines for each field within the subdisciplines, based on a standard European Guideline Format.

Planned complex suicide by penetrating captive-bolt gunshot and hanging: Case study and review of the literature

Captive-bolt guns or slaughterers guns are devices widely used in meat industry and private farmer households for slaughtering animal stocks. They consist of a simple cylindrical metal tube (barrel) with a metal bolt placed in their centre (around 9-15cm long and 1-1.5cm wide). The bolt is actuated by a trigger pull and is propelled forward by compressed air or by the discharge of a blank powder gun cartridge. Violent deaths inflicted by captive-bolt guns are rarely encountered in forensic practice and are predominantly suicidal events. We report an unusual complex suicide by hanging and self-shooting with a slaughterers gun in a 21-year-old boy. The victim after putting a ceiling fixed rope around his neck shot himself in the head (occipital region) with a Kerner captive-bolt gun. He used two mirrors (a cosmetic mirror and a man-sized one) in order to properly visualize his back and to target the occipital region of his head. Radiological data (computed tomography with three dimensional reconstruction) and autopsy findings are discussed according to the clinical and forensic literature. A brief review on planned complex suicides is also given.

Sensitivity and specificity of EtG in hair as a marker of chronic excessive drinking: pooled analysis of raw data and meta-analysis of diagnostic accuracy studies.

Background: To assess the debated diagnostic performance of ethyl glucuronide in the 3-cm proximal scalp hair fraction (HEtG) as a marker of chronic excessive drinking. Methods: In July 2012/May 2013, after a systematic search through the MEDLINE, OVID/EMBASE, WEB OF SCIENCE, and SCOPUS databases, 8 studies were included in the pooled analysis that report raw single data on HEtG concentration and self-reported daily alcohol intake (SDAI). A receiver operating characteristic curve analysis and a Spearman rank-order correlation test were used. A meta-analysis was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane recommendations, comprising quality and bias assessments. Results: The pooled analysis showed that 30 pg/mg could be a useful cutoff value for HEtG to detect an SDAI >60 g/d and demonstrated a parabolic direct correlation between HEtG and SDAI data [rho 0.79; 95% confidence interval (CI), 0.69–0.87; P < 0.001]. The meta-analysis found an overall HEtG sensitivity of 0.96 (95% CI, 0.72–1.00) and a specificity of 0.99 (95% CI, 0.92–1.00); a nomogram to predict the posttest probability of exhibiting the targeted condition in the general population was built. Significant variability among the included studies was detected, which was mainly explained by true heterogeneity in the presence of publication bias. Conclusions: With the available data, we conclude that HEtG is a promising marker for identifying chronic excessive drinking. Nonetheless, larger and well-designed population studies are required to draw any definitive conclusions on the significance and appropriateness of its application in the forensic setting.

Bio-medicolegal scientific research in Europe. A country-based analysis

The European mosaic of socio-cultural, economic and legal realities is reflected in forensic and legal medicine, in which a great variety of operational modes of forensic medical services, organisational systems, structures, functional competences and scientific research strategies can be observed. The present work analyses the European bio-medicolegal scientific output of the last 5.5xa0years (exact time window, January 1, 2005–June 1, 2010), categorising papers by nationality of the corresponding author and forensic sub-discipline in question, in order to identify the peculiarities of national sub-specialised competences and to build up international research projects. This country-based bibliometric analysis, based on the number of articles and the impact factor produced by each European country, also considering its economic profile (gross domestic product and per capita gross domestic product), highlights the prevailing productive role of Western and Southern Europe (Germany, Great Britain, Italy, Switzerland, Spain and France). Categorising scientific output by forensic sub-discipline and branch, significant in terms of impact factor are contributions from Germany (coming first in Pathology, Toxicology, Genetics, Anthropology and Biological Criminalistics), Great Britain (first in Clinical Forensic Medicine, Malpractice and Invalidity-Social Insurance), Switzerland (first in Criminology), Italy (second in Toxicology, Anthropology and Invalidity-Social Insurance), The Netherlands (third in Clinical Forensic Medicine and Medical Law and Ethics), Spain (third in Genetics, Criminalistics and Invalidity-Social Insurance) and France (third in Toxicology and Malpractice). Interestingly, several countries with low gross domestic product, such as Poland, Turkey and other Eastern European nations, show notable scientific production in specific sub-disciplines such as Pathology, Toxicology and Forensic Genetics, suggesting that fruitful international cooperation could be planned and be of interest to funding sources within the European Community, also taking into account funds reserved for depressed areas undergoing development.

Journals publishing bio-medicolegal research in Europe.

Fragmentation of bio-medicolegal knowledge has led to a proliferation of ultra-specialised sub-disciplines and branches, often published in ‘field-oriented’ scientific journals.The aim of this work is to provide an in-depth analytical picture of bio-medicolegal sources of publication, within and outside the traditional conception of legal medicine. An extensive search of bio-medicolegal articles published in the last five and a half years was performed on the MEDLINE database according to MeSH terms combined with free-text protocols. We performed a systematic analysis of targeted journals after merging, selecting and categorising all retrieved records, taking into account data from the 2009 JCR Science Edition (released on June 2010); 1,037 different journals were identified, of which only 48 (4.6%) focus specifically on bio-medicolegal matters, and of which only seven (14.6%) have an impact factor (IF). Despite this apparent dispersion, 47% of articles were published in bio-medicolegal journals (BML), of which 70.2% were in journals with IF (BML-IF). Articles published in BML-IF journals (33% of total papers) reach almost 50%, mainly in “Forensic Science International”, “International Journal of Legal Medicine” and “Journal of Forensic Sciences”. Instead, publications in not specifically bio-medicolegal journals (Not BML-IF) are greatly scattered and even fragmented in about 650 journals.The sub-disciplines that appear most frequently in Not BML-IF rather than BML-IF journals are Forensic Psychiatry (48.2% vs. 5.1%), Criminology (37.1% vs. 8.3%), Malpractice (50.7% vs. 4.0%), Medical Law and Ethics (46.4% vs. 6.9%) and Clinical Forensic Medicine (39.5% vs. 21.3%). The proposed bibliometric analysis revealed the preference of Forensic Pathology, Criminalistics (Biological), Forensic Genetics, Forensic Anthropology and Forensic Entomology for journals traditionally considered pertinent to the medico-legal discipline, with a considerable dispersion involving Toxicology, Psychiatry, Criminology and Malpractice, which were published in less well-known journals. This dispersion could be reduced adapting specialised forensic sections and increasing the IF of forensic journals, in order to respond suitably to the present demand for visibility by bio-medicolegal scientists, clearly oriented towards enhancing the objective impact of their curricula and attempting to attract funding to their research projects.

Intersecting fractures of the skull and gunshot wounds. Case report and literature review

When two fracture lines of a solid surface (ice, glass, eggshell, etc.) intersect, it is always possible to tell which one has been made first. Indeed pre-existing damage of the surface arrests all the fracture lines produced by subsequent impacts. This well-known principle (established by Puppe in 1903) has been largely used in glass fracture analysis, but can be applied also to the examination of skull fractures. It can help sequencing blunt force or gunshot injuries determining the direction of fire and differentiating entrance from exit wounds in the absence of specific distinguishing features (i.e., internal/external beveling of the skull or overlying skin indicators). In this context, we report the case of a 76-year-old man who shot himself in the mouth with a Walther PPK 7.65 handgun and highlight the utility of the application of both Puppe’s Rule and Multislice Computed Tomography (MSCT) in the examination of gunshot wounds to the skull.