Objective To identify the incidence and risk factors of haemorrhoids and fissures during pregnancy and after childbirth.Design Prospective observational cohort study.Setting University hospital and outpatient clinics in Lithuania.Population A total of 280 pregnant women followed up until 1 month after delivery.Methods Women were examined four times through pregnancy and after delivery; those that developed peri-anal diseases were compared with those that did not.Main outcome measures Incidence, time and risk factors of haemorrhoids and fissures.Results In all, 123 (43.9%) women developed peri-anal disease: 1.6% in the first trimester, 61% during the third trimester, 34.1% after delivery and 3.3% 1 month after delivery; 114 (40.7%) women were diagnosed with haemorrhoids, seven (2.5%) with haemorrhoids and anal fissure and two (0.71%) with anal fissure. Ninety-nine (80.5%) women had vaginal delivery and 24 (19.5%) women had undergone caesarean section. Multivariate analysis identified personal history of peri-anal diseases (odds ratio [OR] 11.93; 95% confidence interval [95% CI] 2.18-65.30), constipation (OR 18.98; 95% CI 7.13-50.54), straining during delivery for more than 20 minutes (OR 29.75; 95% CI 4.00-221.23) and birthweight of newborn >3800 g (OR 17.99; 95% CI 3.29-98.49) as significant predictors of haemorrhoids and anal fissures during pregnancy and perinatal period.Conclusions Haemorrhoids and fissures are common during the last trimester of pregnancy and 1 month after delivery, with constipation, personal history of haemorrhoids or fissures, birthweight of newborn >3800 g, straining during delivery for more than 20 minutes being independently associated risk factors.

Carfentanyl, an ultra-potent synthetic opioid, is approved for use only in veterinary medicine as a tranquilizing agent. However, many cases of human poisoning with carfentanyl have recently appeared in the news with limited information given and scientific literature provides only 1 case of documented human exposure to carfentanyl.Fifteen cases of death from drug overdoses with carfentanyl involvement are being presented. Fifteen blood and urine samples have been taken for alcohol and drug testing. Headspace gas chromatography was used for alcohol detection. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) and liquid chromatography–time-of-flight mass spectrometry (LC/MS TOF) system was used for drug detection.Sixty-three cases of death from poisoning with drugs have been tested for carfentanyl in the State Forensic Medicine Service. Fifteen of them were positive for carfentanyl.The cases mentioned above show that carfentanyl exposure causes signs and symptoms similar to other opioid toxicity. Carfentanyl intoxication may even be fatal if appropriate treatment is not available. Therefore, nowadays it is very important to draw forensic medicine expert's attention to new substances in drug trade.

Rationale:Positional asphyxia is a rare cause of sudden death and a difficult diagnosis, based mostly on the circumstances of the incident, along with particular external and internal findings, frequent in asphyxia (signs of sudden death).Patient concerns:In this report, we are describing one case of adult who was found positioned in a way that led to eventual asphyxiation.Diagnoses:The final diagnosis of positional asphyxia was determined after the autopsy.Interventions:In a head-down position, gravitation and mechanical forces lead to an increased pressure on the diaphragm from the weight of the abdominal organs. Abdominal breathing, and later, chest breathing were hindered by the raised diaphragm and the difference between abdominal and breathing pressures.Outcomes:It is known that death from positional asphyxia can emerge in several ways, such as the external breathing suppression when the victim‘s torso is compressed or deformed.Lessons:Therefore, the current criteria for positional asphyxia are based on the obstruction of normal gas exchange caused by the body position, the impossibility to move to another position, and the exclusion of other causes of death. The forensic medical examination must also be started at the scene of the incident.

Rationale:Hemochromatosis is a disorder, associated with an abnormal accumulation of iron leading to toxic organ damage. Clinical symptoms develop during a long period of time, thus, determining accidental or late diagnosis, usually when complications are evident.Patient concerns:A 53-year-old man was brought to the emergency unit with symptoms of hypovolemic shock without any apparent cause, which ultimately led to multiple organ failure, severe metabolic acidosis.Diagnoses:The final diagnosis of hemochromatosis was determined after the autopsy.Interventions:Abnormal findings included a black-grayish pancreas, without any surrounding tissue reaction, and a dilated congestive cardiomyopathy. Histological findings revealed significant hemosiderin deposits in the internal organs, which were more distinct in the pancreas, liver, and kidneys.Outcomes:Patient death in less than 12 hours.Lessons:The necessity of a genetic examination after the autopsy, regarding this case was undeniable, especially focusing on the first-degree relatives, helping to diagnose and prescribe an adequate and early treatment.