Exploring the role of the human microbiome in forensic identification: opportunities and challenges.

Forensic microbiology is rapidly emerging as a novel tool for human identification. The human microbiome, comprising diverse microbial communities including fungi, bacteria, protozoa, and viruses, is unique to each individual, offering a new dimension to forensic investigations. While traditional identification methods primarily rely on DNA profiling and fingerprint analysis, they face limitations when complete DNA or fingerprints profiles are unattainable or degraded. In this context, the microbial signatures of the human skin microbiome present a promising alternative due to their resilience to environmental stresses and individual-specific composition. This review explores the potential of microbiome analysis in forensic human identification, evaluating its applications, advantages, limitations, and future prospects. The uniqueness of an individual's microbial community, particularly the skin microbiota, can provide distinctive biological markers for identification purposes, while technological advancements like 16 S rRNA sequencing and metagenomic shotgun sequencing are enhancing the specificity of microbial identification, enabling detailed analysis of these complex ecological communities. Despite these promising findings, current research has not yet achieved a level of identification probability that could establish microbial analysis as a stand-alone evidence tool. Therefore, it is presently considered ancillary to traditional methods, contributing to a more comprehensive biological profile of individuals.

Intentional child and adolescent homicides in Milan (Italy): A 30-year interdisciplinary study.

This study aims to discuss the forensic and criminological implications of child homicides in the territory of Milan, Italy. The authors present a retrospective study on all the cases of child and adolescent homicides, that were observed at the Institute of Legal Medicine of Milan (Italy) in the last 30 years (from January 1991 to December 2020). A total of 46 child homicides were collected, focusing on the sociological features, by highlighting peculiar cases, risk factors, potential changing social trends, and comparing our cases with the current literature. The analysis revealed a statistically significant relationship (p < 0.05) for male adolescents and indicated that adolescent homicides were more frequently perpetrated in extrafamilial contexts. In contrast, neonaticides and infanticides were mainly committed at home. Furthermore, the Fisher's Exact test revealed that child murders were mainly committed by immigrants in the Milan district after 2005 (p < 0.05). The two main causes of death were due to sharp and firearm injuries. While the relationship between homicide clusters and homicides committed by sharp objects was not significant, adolescent homicides were mainly committed using firearms (p < 0.05). The present study may help to identify risk factors for homicides against child and adolescent. Consequently, policies that identify, prevent, and minimize this extreme violence should be designed to interrupt the vicious circle of such dreadful murderous events. Child and adolescent homicides deserve additional focus and better education for healthcare professionals and further research should be carried out to develop therapeutic and caring strategies.

Intra-familiar homicides: From 2006 to 2021 in the judicial district of Milan.

INTRODUCTION: The present research aims at analyzing criminological and medico-legal characteristics of intra-familiar homicides occurred in two major Italian cities (Milano and Monza) from the beginning of 2006 to the end of 2021. METHODS: Cases were identified using the Institutional database of the Institute of Legal Medicine of Milan, where all the autopsies of victims were performed. Data about these cases were obtained from autopsies findings, preliminary investigation reports, local papers and victim relatives' interviews. In this period 11,480 autopsies were performed: 392 were homicides and, among these, 94 were confirmed as intra-familiar homicides (as a result of 84 events). Cases were classified according to the classic definition of intimate partner violence (referring only to an intra-familiar context), parricides, filicides, fratricides, familicides and grannicides. Age, sex, nationality and risk factors of the victims and perpetrators, as well as methods of murder were registered for each case. Only in some cases, motives for murder were known. RESULTS: The most frequent type of intra-familiar homicides was intimate partner violence (41.5%), followed by parricides (16%, mainly matricides), filicides (10.7%) and fratricides (6.4%). 9.6% of the total number of events were familicides. Risk factors were frequently involved, in particular among perpetrators and in the group of parricides, while among siblicides they showed minimal relevance. Overall, psychiatric pathologies were the main risk factors involved (at least 23.8%), unlike extrafamiliar homicides, where previous criminal report or involvement in illicit traffics are frequently reported among perpetrators. This finding enlightens the difficulties of caring for a relative with a mental disorder, who can become dangerous for the domestic caregiver. Furthermore, the high number of physical illness and the advanced age of victims points out the tragical consequences of the lack of social support system for these categories of people. METHODS: of murder were mainly cold steel (30-31.9%) and firearms (21-22.3%). However choking/manual ligature (9-9.6%), blunt force trauma inflicted using objects found on the scenario or bare handed (16-17%) and combined methods (11-11.7%) were frequently represented confirming the expected high level of impulsivity related to this kind of crime.

Work-related and non-work-related fatal road accidents: Assessment of psychoactive substance use in commuting.

Commuting road traffic collisions (RTCs) are one of the main causes of occupational death worldwide, including Italy. Among the prominent yet relatively understudied personal risk factors in the subpopulation of workers, there is the use of psychoactive substances. Since the phenomenon of driving under alcohol and drugs effects in the commuter sub-population has so far been poorly studied, we carried out a study by comparing results obtained from the analysis of commuters and non-commuters. The percentage of commuting RTCs victims was 10.4% out of all the RTCs. Commuter victims were mostly men, 51-60 years-old, motorcyclists (32.1%) or car drivers (28.6%), employees, deceased during Fridays and Saturdays, in the afternoon (35.7%) and in the evening (32.1%). It was possible to perform toxicological analyses in 60.7% of commuter cases: approximately 40% tested positive, always and only for ethanol (median Blood Alcohol Concentration, BAC, of about 1.03 g/L). Values above the legal limit were observed in 23.5% of the toxicological samples analyzed from commuter accidents. Our findings contribute to bridging the gap in knowledge in the area of RTCs and commuting and emphasize the importance of carrying out toxicological investigations, with possible repercussions on both insurance issues and public health strategies, which are relevant for analyzing the phenomenon structurally.

Driving under the influence of drugs: Correlation between blood psychoactive drug concentrations and cognitive impairment. A narrative review taking into account forensic issues.

Driving under the influence of alcohol has been shown to increase the risk of involvement in road traffic collisions (RTCs) however, less is known about the effects of illicit drugs, and a clear correlation between drug concentrations and RTC risk is still debated. The goal of this narrative review is to assess the current literature regarding the most detected psychoactive drugs in RTC (ethanol, amphetamines, cannabis, opioids and cocaine), in relation to driving performance. Evidence on impaired driving due to psychoactive substances, forensic issues relating to the assessment of the impact of drugs, blood cut-off values proposed to date as well as scientific basis for proposed legislative limits are discussed. At present there is no unequivocal evidence demonstrating a clear dose/concentration dependent impairment in many substances. Per se and zero tolerance approaches seem to have negative effect on drugged driving fatalities. However, the weight of these approaches needs further investigation.

A pilot study for investigating the feasibility of supervised machine learning approaches for the classification of pedestrians struck by vehicles.

This research focuses on the application of Artificial Intelligence (AI) methodologies to the problem of classifying vehicles involved in lethal pedestrian collisions. Specifically, the vehicle type is predicted on the basis of traumatic injury suffered by casualties, exploiting machine learning algorithms. In the present study, AI-assisted diagnosis was shown to have correct prediction about 70% of the time. In pedestrians struck by trucks, more severe injuries were appreciated in the facial skeleton, lungs, major airways, liver, and spleen as well as in the sternum/clavicle/rib complex, whereas the lower extremities were more affected by fractures in pedestrians struck by cars. Although the distinction of the striking vehicle should develop beyond autopsy evidence alone, the presented approach which is novel in the realm of forensic science, is shown to be effective in building automated decision support systems. Outcomes from this system can provide valuable information after the execution of autoptic examinations supporting the forensic investigation. Preliminary results from the application of machine learning algorithms with real-world datasets seem to highlight the efficacy of the proposed approach, which could be used for further studies concerning this topic.

Prediction model for autopsy diagnosis of driver and front passenger in fatal road traffic collisions.

Road traffic collisions (RTC) analysis is almost a daily activity in many autopsy room. Especially when analyzing an RTC with multiple occupants in the car, it can be necessary to distinguish driver from front seat passenger in order to provide the judicial authority with elements useful to understand and to prove who was driving, considering the criminal and civil responsabilities that may derive from it. Despite this, it is beyond doubt that there is enormous difficulty in providing such information. The aim of this paper is then to evaluate whether it is possible to differentiate driver and front seat passenger in case of fatal collisions using a mathematical model based on injury pattern alone. Autopsy reports concerning 90 drivers and 60 front-seat passengers were analyzed. Statistical analysis was used to detect injuries capable of discriminating between driver and passenger, considering skin, skeletal and visceral injuries. Results show that certain skin injuries, fractures and internal organ lesions are possibly associated with drivers and front seat passenger status and the overall injury pattern seems to be able to provide useful information. A mathematical model is presented. The process to distinguishing driver from front seat passenger following fatal motor vehicle collision may use multiple sources of information, including autopsy injury pattern analysis.

Sexual assault and abuse committed against family members: An analysis of 1342 legal outcomes and their motivations.

BACKGROUND: Over the past years medical centres specifically addressed in gender-based violence have developed protocols for the collections of evidence useful in the courtroom, including accurate documentation of physical and psychological states of the victim and collection of samples. Previous studies showed an association between documented physical trauma and conviction but unfortunately, few studies in the recent literature analysed the factors that influence the legal outcome and final judgement. The present study focused on the elements that appeared of significance in the legal outcome, including medico-legal evaluation, source of the crime report and circumstance of the assault. METHODS: It was conducted a retrospective analysis of all the judgments issued by the Public Prosecutor's Office at a Court of a Metropolitan Italian city regarding sexual and domestic violence, from January 1st 2011 to 31st December 31st 2015. Examination regarded the demographic information of the victim and of the defendant, information on the crime, the circumstances of the aggression and medical information retrieved. Sentences were subsequently divided into two categories based on the legal outcome (conviction vs acquittal) and the different characteristics of the two sub-populations were compared to verify if there were variables significantly associated to the judge's final judgment. RESULTS: Over the 5 years taken into consideration, there have been 1342 verdicts regarding crimes of sexual violence (374 cases) and regarding abuses against family members or cohabitants (875): other 93 cases regarded both sexual violence and abuse. 66.3% ended in conviction of the offender and 33.7% in acquittal of the accused. Cases of conviction were more frequent when they involved: use of a weapon by the assailant, as well as if the assailant had a criminal record and had a history of drug abuse or other addictions; duration of proceeding less 22 months and a civil party involved; presence of clinical documentation together with other deposition in addition to victim's deposition; also frequent episodes of violence and application of precautionary measures were associated to conviction. CONCLUSIONS: Many factors seem able to influence the judge's judgment, although clearly each case must be singularly evaluated. The mere presence of medical documentation, without the support of other sources of evidence, such as the victim's statement or further declarations, however, is almost always not definitive for the verdict. Despite so, in cases where there are multiple sources of evidence, clinical documentation can provide useful elements and can give clues on the consistency between the history told and injuries observed.

Telemedicine Applications in the Era of COVID-19: Telesurgery Issues.

Telemedicine allows for the effective delivery of health care to patients at a distance through the application of information technology to the field of medicine. This is optimal during the COVID-19 pandemic to reduce interpersonal contact to mitigate contagion. Among the possible Telemedicine applications, there is Telesurgery, which involves more and more surgical specialties thanks to the numerous benefits in quality and cost containment. In the growing field of Telesurgery, its technical and legal implications must be considered. In this study, a traditional review of the scientific literature was carried out to identify the most relevant issues of interest in Telesurgery. The problematic legal aspects identified are mainly related to the difference in legislation between different geographical areas, which is critical in the case of malpractice. In addition, there is the possibility of a malicious hacker attack on the transmitted data stream either to steal sensitive data or to harm the patient. Finally, there are inherent difficulties with the technology used, such as latency issues in data transmission. All these critical issues are currently not adequately addressed by current legislation. Therefore, one can only hope for a legislative action to allow Telesurgery to be used safely.

The pathological diagnosis of the height of fatal falls: A mathematical approach.

The authors analyzed the injury pattern of 385 victims of fall from a height which underwent a complete autopsy, with the objective to investigate whether it was possible to construct a mathematical model to be used for height of the fall diagnosis. The cases were selected and enrolled according to a balanced stratification of the heights of the fall, allowing a subdivision into seven classes consisting of 55 subjects each: 6m or less, 9m, 12m, 15m, 18m, 21m, 24m or more (maximum 36m). For each case anthropologic and necroscopic data was collected and analyzed to obtain a standardized description of the injury pattern was obtained, dividing the body into 4 major anatomical areas (Head, Thorax, Abdomen, Skeleton), each of them further divided in 5 major organs. Every organ was finally divided into 5 objective degrees of injury. Statistical analysis was performed on all the available data using IBM SPSS Statistics 20, to test the performance of the "injury pattern assessment table" in the diagnosis of the height of the fall and to develop a related mathematical model. Our findings confirm that the height of the fall is significantly associated with age, weight of the body and the injury pattern. An Injury Pattern Assessment Table and two mathematical models which correlates the height of the fall with analyzed variables are presented.

Skin lesions and traditional folk practices: a medico-legal perspective.

The correct assessment of signs of abuse on the skin is a challenge of utmost importance for both clinical and forensic applications. This review aims to investigate how differing cultural behaviors influence the perception of abuse, focusing on the need for a multidisciplinary approach and investigation. A literature search for articles that discussed folk practices from a forensic perspective was performed; articles with reference to abuse in the description of the main folk healing techniques and with reference to the differential diagnosis between physical abuse and skin injuries due to folk healing techniques were selected. A synoptic table of all skin injuries produced by folk healing techniques, divided by geographical area, was created. This table can be used as a tool for the thorough assessment of typical signs detectable on the skin, thus aiding in a differential diagnosis. The first approach to the patient represents a crucial step toward the identification of abuse; forensic practitioners ought to be aware of the existence of folk healing techniques which may mimic signs that can be interpreted as physical abuse in children and adults.

The expert and the foreigner: Reflections of forensic transcultural psychopathology on a total of 86 reports by experts on criminal liability.

In recent times Italy has been experiencing massive migration flows, therefore the attention on the issue of crimes committed by foreigners is increasing. But within trials, in the evaluation of criminal liability of foreigners, how do experts deal with them? Do the performed evaluations take cultural diversity into account? The present study took origin from these questions and examined a total of 86 reports by experts on criminal liability of foreign persons (16 females and 70 males). Examinees have been declared indictable in 31 cases (36%), totally mentally ill in 40 cases (45%) and with diminished liability in 15 cases (17%); when liability was excluded, examinees were diagnosed in 11 cases with mood disorders, in 23 cases with personality disorders, in 4 cases with adaptation disorders and post-traumatic stress disorder and in 10 cases with different diagnoses (in some cases more than one diagnosis was present). None of the reports used the section of the DSM concerning "cultural framing". Tests were used in 48 surveys (56% of cases), with more tests for each examinee, for a total of 39 Rorschach, 14 Raven test, 8 Minnesota Multiphasic Personality Inventory - MMPI - 4 Wechsler Adult Intelligence Scale - WAIS - level test, 8 Thematic Apperception test. When subjects were diagnosed with mental disorder and with diminished liability, 42 (79%) were also socially dangerous. Results highlight the importance of the relationship between the expert and the foreigner. Many factors ought to be critically considered by experts dealing with foreigners, like cultural awareness, knowledge of verbal communication, critical consideration of meanings and diagnosis, knowledge of the foreigners' personal story, presence of tests with inexact information and cultural fallacy.

The Adult Male Rape Victim: Forensic Description of a Series of 57 Cases.

A retrospective analysis on 57 adult male victims of sexual violence has been performed. Age, nationality and anamnesis of the victims, location of the assault, type of violence, number and identity of the assailants, presence of physical injuries, lapse of time between the assault and the request of medical assistance, and toxicological and semen detection tests were analyzed. Victims were mostly in the 31- to 40-year age group. Ten victims referred themselves as either active homosexuals or bisexuals. Forced oral and/or anal penetration was registered in 86.8% of cases, mostly performed by a single assailant. Anogenital injuries were recorded in 61.4% of cases, whereas extragenital injuries in 35.1%: abrasions and perianal reddening were the most frequent acute anogenital marks, whereas the head and lower limbs were the body parts most commonly affected by blunt trauma. No clinically severe injuries were found. Anal and perianal swabs for semen detection tested positive in less than 20% cases, whereas oral swabs always tested negative. When performed, nearly 50% of cases tested positive in drug tests, above all for psychoactive substances. No definite forensic diagnosis in terms of confirmation of rape was possible on the basis of type and topography of injuries.

Alleged malpractice in anesthesiology: analysis of a series of private insurance claims.

BACKGROUND: Medical malpractice is currently a crucial topic and anesthesia is a key specialty for the improvement of patient safety. However, death and permanent impairment due to anesthesia still occur and studies of insurance analysis data are increasing. We investigated the main features of a major Italian insurance broker's archive in order to identify possible recurrent pitfalls in this critical field of medicine. METHODS: Three hundred seventeen Italian claims were analyzed, filling out a standardized form that recorded information on patient and physician's characteristics, procedures, sequence and location of events and outcomes. The operative setting, the type of anesthesia performed the origin of the multidisciplinary team malpractice hypothesis, the final clinical outcome and the malpractice investigation results were also analyzed. RESULTS: In 225 malpractice claims, the adverse event was surgery-linked, either intraoperatively (114 cases) or postoperatively (111 cases): abdominal surgery (26%), orthopedics (22%), gynecology (20%), heart surgery (11%) and neurosurgery (9.5%) were the most frequently involved surgical specialties. In 92 cases, the claim was unlinked to a surgeon's activity, with dental damage in oral intubation procedures as the greatest contributor (42.3%). Anesthetists' malpractice was technically ascertained in 39% of cases, 74.8% resulting in permanent impairment. CONCLUSIONS: Malpractice was mainly suspected in surgery-linked procedures. Most of the claims were settled for procedural error in performing locoregional anesthesia and oral intubation procedures. 60% of all closed claims resulted in no malpractice ascertained. Confirmed malpractice typically deals with non surgery-linked and non multidisciplinary team cases, causing permanent impairment.

The toll of traffic-related fatalities in a metropolitan Italian area through the experience of the Department of Legal Medicine.

Despite the introduction of new traffic laws in Italy, traffic-related deaths are still a huge burden. The study presents data and medico-legal issues behind traffic deaths in Milan between 2001 and 2012 (1506 traffic-related deaths). Data were collected from the database of the Department of Legal Medicine: 79.4% males and 20.6% females (mean age 44.14). The target group concerned traumatic deaths as a consequence of the accident as well as deaths not directly related to an accident. Although 6.1% were non-traumatic deaths (cause of death unconnected to the accident, i.e. because of a heart attack, or when death occurred after survival and cause of death was not related certainly to the accident), multiple skeletal/visceral injuries were the main cause of death (57.9%), occurring in motorcyclists the most (63.7%). Injuries to the skull and brain were the second cause of death (25.9%). Victims were mostly males (79.4%) and drivers (77.6%). Fifty-five per cent were deaths on-scene, while 45% survived. Other variables were also considered: medications, medical history, and drugs/alcohol/smoke. A downward trend in traffic-related fatalities was evident, but the toll is still high. This study should be a glimpse at the actual situation, since it is indicative of a metropolitan area where autopsies are systematically performed.

How reliable are parenchymal tissues for the evaluation of carbon monoxide poisoning? A pilot study.

Dealing with burnt bodies, the forensic pathologist must first of all answer the question whether the victim was alive at the moment of the fire. This study aims at clarifying whether some human solid tissues may be reliably used for the forensic diagnosis of Co poisoning on burnt bodies providing no collectable blood during the autopsy. From 34 selected cases, both cardiac blood and parenchymal samples were collected to perform CO-oxymeter, spectrophotometry, and gas chromatography tests: blood CO estimations (blood COHb% and blood[CO]) and parenchymal[CO] values have been compared with special focus on R values. The solid tissues having the best correlations with blood CO amount turned out to be the lung (R 0.84), the liver (R 0.83), the kidney (R 0.79), and the spleen (R 0.92).

The injury pattern in fatal suicidal falls from a height: an examination of 307 cases.

Falls from a height are a common cause of suicidal death in urban settings. The aim of the present work is to describe and discuss a specific set of 307 autopsies performed in a metropolitan city such as Milan, Italy from 2006 to 2011, with a special focus on the relationship between the injury pattern and height of the fall, age at death and weight at death. The rib cage (92%), the lungs (76%), the heart (53%) and the liver (58%) turned out to be the most injured structures in the whole population. Age resulted statistically significant for heart, thoracic aorta, mesentery, kidney hilus, hip bones and right forearm injuries. Weight resulted statistically significant for subtentorial brain, facial skull, rib cage, lungs and liver injuries. Height was significant for the facial skull (including the jaw), lungs, heart, thoracic aorta, diaphragm, liver, cervical spine, sacroiliac joints, pubic symphysis, right arm and left leg. A simple Injury Extension Score was also calculated which showed a correlation with height. A great variability does exist across all the available forensic literature concerning falls from a height. As a strong common denominator for the injury pattern across all the available literature there is however the very low prevalence of neck injuries, the very high prevalence of rib cage fractures and a definite thorax and upper abdomen injury.

The medical malpractice in Milan-Italy. A retrospective survey on 14 years of judicial autopsies.

The medical malpractice is a rising and central topic for the forensic pathologist and forensic autopsies are a mandatory step in the judicial evaluation of the suspected medical malpractice. Reliable national and international registers about the medical malpractice are still missing and nowadays the necroscopic archives are therefore one of the best sources of data about such a complex phenomenon. We analyzed the archive of the Institute of Forensic Medicine of the Milan University from 1996 to 2009 and selected 317 lethal cases of suspected medical malpractice. The mean age of our cases was 60±18 years for males and 58±19 years for the females. In 70% of such cases the patient death occurred in a hospital setting. The first 24h of hospitalization turned out to be the hottest period for deaths followed by malpractice claims. The surgical branches were obviously the most involved, with abdominal surgery, orthopedics, neurosurgery and gynecology as the main contributors. Just 12% of the total amount of cases came from all the internistic branches put together. Non-hospital malpractice was typically caused by misdiagnosed myocardial infarctions and aortic ruptures. A full forensic report was present in 71 cases (all belonging to the 2007-2009 period): in 69% of cases the judicial autopsy revealed as a sufficient tool for diagnosing the cause of death; medical malpractice was confirmed in only 17% of the whole cases and a causal link between the ascertained malpractice and the patient death was recognized in only 12.7% cases.

Forensic grading of myocarditis: an experimental contribution to the distinction between lethal myocarditis and incidental myocarditis.

Myocarditis can be either the cause of the death of a person or just an incidental finding during the autopsy and the following histological examinations. To establish whether a single myocarditis is a lethal or just an incidental pathology a very careful grading is always mandatory. The aim of the present work is thus to test the hypothesis about the reliability of an evidence-based distinction between the lethal myocarditis and the incidental myocarditis. The present work compares clinical and histological features from two different groups of myocarditis. Group A is composed of patients having myocarditis at the time of death, who certainly died from other reasons (i.e.: death by head gunshot with no survival time). Group B is composed of patients who died having a myocarditis as the only pathological evidence at the autopsy and the following histological and toxicological examinations and then who died because of the myocarditis. The lethal myocarditis and the incidental myocarditis differ statistically about last days' anamnesis, acute findings in the macroscopic analysis of the heart, neutrophilic infiltration, myocite necrosis, multiple sites interstitial oedema and perivascular cuffs. Such variables can be summarized in a scoring system able to quantitatively separate the lethal myocarditis from the incidental myocarditis. Such a reliable scoring system develops far behind the isolated grading of the myocite necrosis, even though the myocite necrosis should always be considered as a pivot variable for distinguishing lethal myocarditis from incidental myocarditis. The proposed scoring system is very easy to use and it is also appreciably money-sparing with its foundations in the simple combination of clinical anamnesis, autopsy and basic histology. Its routinary application could implement the objectivity in the forensic grading of myocarditis.