Application of Digital Analysis for Assessment of Coronary Sub-Occlusions in Autopsy Pathology: It Is Time to Move beyond Histology Alone.

Background: Coronary artery disease (CAD) underlies most cases of myocardial infarction (MI), causing or at least contributing to oxygen supply-demand mismatch and myocardial injury, so a careful and reliable evaluation of the main coronary arteries and large branches is a key moment of autopsy in order to establish the cause of death. The aim of this study is to evaluate the application of digital image analysis in the assessment of coronary artery sub-occlusions. Methods: A total of 50 coronary sections sampled during 11 consecutive autopsies, regardless of the cause of death, were analyzed. The ideal lumen and the percentage of the residual lumen were evaluated by digital pathology using QuPath v 4.3 and by an expert pathologist. The evaluations performed were compared using Lin's concordance correlation coefficient. Results: The Lin agreement index between the two evaluation methods for all measurements showed an excellent agreement rate [0.923, with confidence interval (0.866, 0.956)]. However, in the case of critical stenosis, from 60% to 80% and from 65% to 75%, the Lin agreement index between the two evaluation methods was, respectively, 0.798 [0.603, 0.904], corresponding to good agreement, and 0.516 [0.071, 0.725], corresponding to slight agreement. The digital system has superior performance in cases where lumen occlusion falls between 60% and 80% and provides an objective assessment of the residual lumen area. Conclusions: According to the widespread availability and ease of use of these technologies, we suggest that image analysis should be considered a routine tool and established as the diagnostic gold standard in this field.

Colorectal Cancer and Asbestos Exposure: A Women's Health Perspective.

BACKGROUND: Colorectal cancer (CRC) is considered a "man's disease". However, emerging data show that females may have a higher prevalence of certain risk factors. A potential causal role of asbestos in CRC carcinogenesis has been suggested. This relationship is controversial, and only a few studies have focused on exposed female populations. The aim of this study was to review the scientific literature related to asbestos-related CRC incidence and mortality rates in female populations to address gender bias in the existing research. METHODS: A systematic review was performed following PRISMA statement. RESULTS: Fourteen studies reporting 92 cases in total were included. Most women were aged 50 years or older and were employed in occupational activities with high asbestos exposure (steel, textile, and asbestos-cement industry) for at least 10 years. In one single case, household asbestos exposure was reported. The colon was the primary location of the tumor in 47 out of 92 cases. Three women were also affected by synchronous or metachronous peritoneal mesotheliomas. CONCLUSIONS: This study revealed a general methodological "gender bias" in scientific research. A significantly higher representation of women in clinical studies is needed to clarify the link between asbestos exposure and the development of colorectal cancer.

Neonatal chemical burns and child neglect.

Differential diagnosis of agents of chemical burns can be challenging in neonates, especially in absence of a clear history of the event. A wide variety of chemical agents, from acids to basics, can be involved. Massive chemical burns over 21% of the body surface of a four-day-old male neonate were observed. At the physical examination, lower chest, abdomen, genital area and upper limbs showed full-thickness contact burns with a clear demarcation line of the skin breakdown related to necrosis of the subcutaneous layer. Head and fingers exhibited small hard brownish eschars. No clear history was referred by the parents, raising the suspect of a child neglect. Due to the critical conditions, it was not possible to identify the chemical agents causing the burns. The prompt excision and synthetic skin grafting was successfull and the baby survived. Considering all the different chemical agents found in the domestic environment, a combination of acid-basic agents may have been involved. Both parents were sentenced to nine years imprisonment for child neglect and wounding with intent.

Pathological alterations and COHb evaluations as tools for investigating fire-related deaths in veterinary forensic pathology.

Fire-related deaths are usually a consequence of carbon monoxide (CO) poisoning or shock from thermal injuries. In humans, high levels of carboxyhemoglobin (COHb) concentrations in the blood can support a diagnosis of CO poisoning. In veterinary medicine, few studies investigated the pathological changes and blood COHb% in fire victims, and no data are available on post-mortem changes in blood gas composition due to fire. This study aims to investigate the pathological changes and COHb levels in both animal victims of fire and cadavers experimentally exposed to fire. For this purpose, dogs were selected and subdivided into three groups. Group A comprised 9 adult dogs, and Group B comprised 7 puppies that died under fire-related conditions. Group C was represented by 4 dog cadavers experimentally exposed to heat and smoke. A complete macroscopic, histological, and COHb evaluation were performed on each animal. Animals in Groups A and B showed cherry-red discoloration, thermal-injuries and soot deposits along the respiratory tract. Animals in Group C showed thermal injuries and soot deposits limited to the upper respiratory tract. The mean COHb% values in cadavers in Group C were lower than those observed in the other groups but higher compared to the values detected before the heat and smoke treatment. These findings suggest that both pathological changes and COHb analysis are valid tools for investigating fire-related deaths in dogs. However, the increase of COHb levels in cadavers exposed post-mortem to heat and smoke highlights how the COHb analysis should always be evaluated together with macroscopical and microscopical findings to avoid significant misjudgments in investigating fire-related fatalities in veterinary forensic practice.

Suicide by ligature strangulation and/or hanging inside a motor vehicle: a comprehensive review.

Suicide by ligature strangulation/hanging inside vehicles is uncommon, and only few cases have been reported in the literature. This study aimed to conduct a comprehensive review of reported cases of suicide by ligature strangulation/hanging inside vehicles, analyzing the features of the death scene, of the ligature and furrow, autopsy findings, and causes of death. The comprehensive review was performed following the PRISMA guidelines by using the most common scientific databases. According to inclusion criteria, a total of 20 cases of vehicle-assisted strangulation/hanging were reviewed: 13 cases were assessed as ligature strangulation resulting in 7 complete decapitations and 7 other cases as hanging. All victims were young or adult males, except for one 48-year-old female. Death was assessed as suicide in all cases, except for a possible accidental autoerotic death. In 8 cases, a history of depression or other psychiatric disorders was reported. Toxicological analysis were positive in 7 cases. Hard ligature materials (nylon, steel, plastic, hemp ropes) were used in most cases, but only 13 cases had a well-demarcated furrow. In 2 cases, no internal findings of asphyxia were found. An additional case of ligature strangulation inside a motor vehicle off is also presented, where no autopsy findings of asphyxia were observed, except for a broad pale furrow and monolateral conjunctival petechiae. This study highlights the challenges in classifying suicidal hanging and ligature strangulation in motor vehicles.

Age assessment in unaccompanied minors: assessing uniformity of protocols across Europe.

Age assessment of migrants is crucial, particularly for unaccompanied foreign minors, a population facing legal, social, and humanitarian challenges. Despite existing guidelines, there is no unified protocol in Europe for age assessment.The Forensic Anthropology Society of Europe (FASE) conducted a comprehensive questionnaire to understand age estimation practices in Europe. The questionnaire had sections focusing on the professional background of respondents, annual assessment numbers, requesting parties and reasons, types of examinations conducted (e.g., physical, radiological), followed protocols, age estimation methods, and questions on how age estimates are reported.The questionnaire's findings reveal extensive engagement of the forensic community in age assessment in the living, emphasizing multidisciplinary approaches. However, there seems to be an incomplete appreciation of AGFAD guidelines. Commonalities exist in examination methodologies and imaging tests. However, discrepancies emerged among respondents regarding sexual maturity assessment and reporting assessment results. Given the increasing importance of age assessment, especially for migrant child protection, the study stresses the need for a unified protocol across European countries. This can only be achieved if EU Member States wholeheartedly embrace the fundamental principles outlined in EU Directives and conduct medical age assessments aligned with recognized standards such as the AGFAD guidelines.

Atypical Postmortem "Incaprettamento" After an Honor Homicide.

ABSTRACT: Honor killing is a murder carried out to protect the family's reputation by actions that are perceived as shameful. Usually, honor killing occurs to preserve family's honor, which has been violated by adulteries, premarital pregnancies, or inappropriate relationships. In Southern Italy, the culture of honor is quite strong especially among the local criminal organizations. Honor crimes by Italian Mafia are intended to have an admonitory significance, and they can be carried out following a macabre ritual of "incaprettamento." The aim is to humiliate the victim treating him like an animal, a bonded young goat where the victim is secured by a rope passing behind the back from the upper to lower extremities. In this case study, the honor homicide was perpetrated against the lover of a butcher's wife by sharp weapon, followed by a postmortem atypical incaprettamento of the corpse. The wrists and ankles were tied together by ropes, and the extremities were fixed to the abdomen with a string. The body was also wrapped in a plastic tape after penile amputation. According to killer's confession, the mutilation and the incaprettamento were expressions of revenge and contempt for the victim to restore the honor lost.

COVID-19: detection methods in post-mortem samples.

COVID-19 identification is routinely performed on fresh samples, such as nasopharyngeal and oropharyngeal swabs, even if, the detection of the virus in formalin-fixed paraffin-embedded (FFPE) autopsy tissues could help to underlie mechanisms of the pathogenesis that are not well understood.The gold standard for COVID-19 detection in FFPE samples remains the qRT-PCR as in swab samples, contextually other methods have been developed, including immunohistochemistry (IHC), and in situ hybridization (ISH). In this manuscript, we summarize the main data regarding the methods of COVID-19 detection in pulmonary and extra-pulmonary post-mortem samples, and especially the sensitivity and specificity of these assays will be discussed.

Colorectal Cancer: 35 Cases in Asbestos-Exposed Workers.

BACKGROUND: Asbestos is considered one of the major global work-related carcinogens. Some studies suggest a potential causal relationship between asbestos exposure and colorectal cancer (CRC). However, the role of asbestos in CRC carcinogenesis is still controversial. METHODS: 35 claims of occupational CRC among asbestos-exposed workers were reviewed. All claims were rejected by the Italian National Institute for Insurance against Accidents (INAIL) due to the "lack of scientific evidence in the causality" between asbestos exposure and CRC; causality was finally assessed in civil trials. All cases were categorized by age, gender, industry type, task, exposure and latency periods, anatomical location, and histopathological characteristics of CRC and concomitant respiratory diseases. RESULTS: Most workers were males aged 60 years or more and employed in occupational activities with extensive use of asbestos for over 20 years. In 31 out of 35 cases, CRC was diagnosed over 39 years after employment. Right-sided colic adenocarcinoma was diagnosed in nine cases; rectum was involved in eight cases. Respiratory comorbidities were observed in 22 workers. CONCLUSIONS: Our study provides some interesting points in the assessment of the causal relationship between asbestos exposure and CRC.

Choking in patients with neurological disorders and role of drug-induced dysphagia.

Choking is a type of asphyxia due to the internal obstruction of airways by foreign material, quite always food. Most choking deaths are accidental and occur so quickly that may mimic a heart attack. This scenario is also known as "Cafè coronary syndrome" or "bolus death". At autopsy, pieces of under-chewed food are commonly lodged at, above, or in the tracheal space adjacent to the laryngeal inlet. In these fatal events mechanisms other than asphyxia can be also involved, such as a vasovagal episode (by stimulation of the autonomic nerve plexus of the laryngeal inlet) or swallowing impairment. Swallowing is a complex, semi-automatic process that can be affected by various disorders (i.e. dementia, Parkinson, neurological injuries, etc.), senility and external factors causing oropharyngeal dysphagia (OD). Among these factors, several drugs have been also associated with impaired swallowing, including drugs acting on the CNS like antipsychotics and antiepileptics. Three cases of witnessed bolus deaths are reported. All victims were affected by neurological defects and took medications acting on CNS. In all cases, at autopsy pieces of food were found distributed from the laryngeal inlet along the main axis of the trachea up to the large bronchi over the bifurcation. Additional autopsy findings were represented by facial congestion and cyanosis, subepicardial petechiae and pulmonary emphysema.

Matricide and psychiatric evaluation: An update.

Matricide is an infrequent crime that has often raised to the suspicion that the offender could suffer from a pathological mental status. Although it is hard to establish a relationship between mental disorders and specific forms of homicide, several studies suggest that matricide offender frequently suffers from schizophrenia or other psychotic disorders. Aim of the study was to review the literature in order to explore epidemiologic and psychiatric characteristics of matricide offenders with a focus on the cause of death and crime circumstances. According to the PRISMA statement, 16 out of 225 studies were included. Main findings were the following: 80 victims were reported in total, killed by 81 offenders. In one case two brothers were responsible for the matricide. 81.5% of the offenders were young males. The most represented psychiatric pattern of the offenders was schizophrenia and psychotic disorders (43.2%). 6.2% of victims had also psychiatric disorders. Sharp force injuries were the first cause of death (55%), followed by blunt trauma (15%) and asphyxia (15%). In 12% of cases overkilling was also reported. 13.6% of offenders were considered not guilty for reason of insanity while 25.9% of the offenders had diminished criminal responsibility. A case study of a young homicide offender suffering from personality disorder is reported. In this case the victim also suffered from psychiatric disorders and an overkilling occurred as she was stabbed multiple times post-mortem. In a second case of matricide, the victim was dismembered and the human remains were concealed in several plastic bags.

Hypoplastic Left Heart Syndrome: About a Postnatal Death.

BACKGROUND: Hypoplastic left heart syndrome (HLHS) is a congenital heart disease that is associated with high mortality rates in the early neonatal period and during surgical treatments. This is mainly due to missed prenatal diagnosis, delayed diagnostic suspicion, and consequent unsuccessful therapeutic intervention. CASE REPORT: twenty-six hours after birth, a female newborn died of severe respiratory failure. No cardiac abnormalities and no genetic diseases had been evidenced or documented during intrauterine life. The case became of medico-legal concern for the assessment of alleged medical malpractice. Therefore, a forensic autopsy was performed. RESULTS: the macroscopic study of the heart revealed the hypoplasia of the left cardiac cavities with the left ventricle (LV) reduced to a slot and a right ventricular cavity that simulated the presence of a single and unique ventricular chamber. The predominance of the left heart was evident. CONCLUSIONS: HLHS is a rare condition that is incompatible with life, with very high mortality from cardiorespiratory insufficiency that occurs soon after birth. The prompt diagnosis of HLHS during pregnancy is crucial in managing the disease with surgery.

Evaluation of Muscle Proteins for Estimating the Post-Mortem Interval in Veterinary Forensic Pathology.

Postmortem cadaveric changes are commonly used to estimate the postmortem interval (PMI) in humans and animals. However, these modifications have been poorly investigated in animals of interest to veterinary forensic pathology. The aim of this study was to investigate the potential use of muscle proteins (desmin and dystrophin) as biomarkers for estimating the PMI in dogs. For this study, 10 dead adult dogs were evaluated for 4 days in a temperature-controlled room at 19 ± 1 °C. For each animal, at 3, 24, 48, 72, and 96 h after death, a 1 × 1 × 1 cm cube of muscle tissue was removed from the vastus lateralis and triceps brachii. Protein expression levels were analyzed by immunohistochemical examination and immunoblot analysis. The obtained results showed rapid dystrophin degradation, with complete disappearance at 72 h after death. In contrast, desmin-positive fibers and desmin protein bands detected by immunoblot were observed on all 4 days of observation. Our findings suggest the potential use of muscle proteins as biomarkers for estimating the PMI in dogs.

Gunshot injuries in Campania (Italy): A retrospective thirty-years (1981-2011) study.

From 1981 to 2011, 200 firearm deaths were autopsied in Naples, at the Institute of Legal Medicine of the University of Campania "Luigi Vanvitelli". 188 cases were homicides and most of them (116) were related to the local organized crime. The majority of victims were young Italian males in the 20-39 age fired in outdoor environments. The reason for choosing outdoor environments can be related to the opportunity for the killer run from the crime scene immediately after the murder. Only 11 of the bodies autopsied were suicide victims, mostly older individuals, over 50 years -old with history of mental illness. All the suicides occurred in indoor environments in order to protect their domestic intimacy. Only two female victims were accounted in this historical series which is quite impressive if compared to recent phenomenon of feminicides occurring mostly in domestic environments. A total of 772 entry wounds were observed: 658 fired from single-charge handguns and 114 from multiple-charge firearms. 9x21 pistol cartridge was the most common ammo used, followed by the 7.65 Parabellum. The head was the most common anatomical site injured (in 81.8% of the suicides cases and in 68.6% of homicides). Most of the victims of homicide died before arriving at an Emergency Service. Only a minority of victims lived from few hours up to less than a week, after being shot, and very few victims remained alive up to a couple of months.

Accidental Injury or "Shaken Elderly Syndrome"? Insights from a Case Report.

Subdural haemorrhage (SDH) as result of a traumatic brain injury (TBI) is a common cause of death in cases of fatal physical abuse. Since intracranial bleeding is a common finding in elderly due to age-related intracranial changes or increasing prevalence of anticoagulant medication, differential diagnosis between inflicted and non-inflicted head injury is challenging. A case of an elderly woman's death caused by TBI is reported. Autopsy showed multiple polychromatic bruises and a frontoparietal hematoma with bilateral subacute SDH. History excluded paraphysiological or pathological non-traumatic conditions that could justify SDH, while iatrogenic factors only played a contributory role. Since polychromatic bruises distributed on the face, the upper extremities and the chest were consistent with forceful grasping/gripping or repeated blows and SDH can form in absence of impact or by mild/minor blows, SDH was considered the result of repeated physical abuses. Differential diagnosis between traumatic and non-traumatic SDH is still challenging for forensic pathologists. As largely accepted in the pediatric population and occasionally described also in adults, however, violent shaking should be also considered as a possible mechanism of SDH-especially in elderly who do not have any sign of impact to the head.

Chronic Encapsulated Intracerebral Hematoma as an Occasional Finding in Sudden Cardiac Death.

Chronic encapsulated intracerebral hematoma (CEIH) is a rare solid mass characterized by the presence of a fibrotic capsule that can present a variety of signs and symptoms due to the mass effect and hydrocephalus. It may be caused by post-traumatic or spontaneous bleeding as related to an adjacent aneurysm, angiomas or neoplasms. Differential diagnosis must be applied in order for it to mimic neoplasm or a vascular malformation. Several cases of CEIH have been reported but only a few of them have an intraventricular localization. A forensic autopsy of a 50-year-old male who died suddenly while driving is discussed. Gross analysis, histology and toxicology were performed and a CEIH of the right lateral ventricle was found in a case of acute coronary death.

Toxicological Analysis of Illicit Drugs Seized in Naples (Italy) and First Detection of Synthetic Cannabinoids during COVID-19 Pandemic.

The COVID-19 pandemic has consistently raised the number of drug seizures, in United States as in Europe. The COVID-19 pandemic has also changed the typology of seizures from "more traditional" drugs to New Psychoactive Substances (NPSs), depending on geographical area. In Europe, the most frequent NPSs are synthetic cannabinoids (SCs) and cathinones, nonetheless synthetic opioids and phenethylamines are widely used. The aim of the study is the detection of NPS and other substances of abuse available in the black market, by quali/quantitative methods in LC-MS/MS and GC-MS. From 2018 to 2021, 268 seizures occurred in total and were analyzed by the Forensic Toxicology Laboratory (FTL) of Naples (Italy). The distribution of analyzed seizures over the years is the following: 53 in 2018, 61 in 2019, 89 in 2020 and 65 during the first semester of 2021. Cannabis was the most detected drug both in hashish and marijuana seizures, followed by cocaine > heroine > prescribed drugs > ketamine−amphetamine MDMA. No NPSs were seized until June 2021, when NPSs were found in two different seizures: Case #1 showed a bar of Cannabis resin containing a low level of Δ9THC = 0.57% associated to SC AB-FUBINACA in 4.5%; Case #2 showed a vegetal resinous substance (Δ9THC = 0.27%) with SC 5F-APINACA (4.1%) associated with methadone (1.0%). The detection of NPSs is alarming evidence that can lead to an increase in the risk of overdose or other negative and unpredictable consequences, such as violent or self-harming behavior in unaware users of cannabis derivatives considered of "natural" origin.

Helium Suicide, a Rapid and Painless Asphyxia: Toxicological Findings.

Suicide by helium inhalation has become increasingly common in the last few decades in Europe and the US because it produces a quick and painless death. Inhaled-gas suicides can easily be assessed through death scene investigation and autopsy. However, helium is a colorless and odorless inert gas that unfortunately cannot be detected using standard toxicological analysis. A successful gas analysis was performed following the suicide of a 17-year-old female. For the detection of helium, central/peripheral blood samples and gaseous samples from the esophagus, stomach, and upper and lower respiratory airways (from the trachea and the primary left and right bronchia) were collected with a gastight syringe, ensuring minimal dilution. Qualitative analyses were positive in all gaseous samples. Quantitative analyses were performed using a special gas-inlet system with a vacuum by which the sample can be transferred to a mass spectrometer, reducing the risk of contamination. Helium concentrations were 20.16% from the trachea, 12.33% from the right lung, and 1.5% from the stomach. Based on the high levels of helium, the cause and manner of death were assessed as asphyxia suicide by inhalation of helium. Therefore, toxicological analyses should always be applied in order to gain evidence of inhaled gas in gaseous samples.

Relationship between COVID-19 Mortality, Hospital Beds, and Primary Care by Italian Regions: A Lesson for the Future.

One of the characteristics of the SARS-CoV-2 infection in Italy is the significant regional difference in terms of lethality and mortality. These geographical variances were clear in the first wave and confirmed in the second one as well. The study aimed to analyze the correlation between regional differences in COVID-19 mortality and different regional care models, by retrospectively analyzing the association between the Italian COVID-19 deaths and the number of hospital beds, long-term care facilities, general practitioners (GPs), and the health expenditure per capita. The period considered was from 1 March 2020 to 1 March 2021. The number of hospital beds (p < 0.0001) and the number of GPs (p = 0.0094) significantly predicted the COVID-19 death rate. The Italian regions with a higher number of hospital beds and a lower number of GPs showed a higher number of deaths. Multivariate analyses confirmed the results. The Italian regions with a higher amount of centralized healthcare, as represented by the number of hospital beds, experienced a higher number of deaths, while the regions with greater community support, as exemplified by the number of the GPs, faced higher survival. These results suggest the need for a change in the current healthcare system organization.

PD-L1 Overexpression in the Lungs of Subjects Who Died from COVID-19: Are We on the Way to Understanding the Immune System Exhaustion Induced by SARS-CoV-2?

Knowledge of the pathogenic mechanisms of severe acute respiratory syndrome-associated coronavirus 2 (SARS-CoV-2) is certainly a priority for the scientific community. Two main elements are involved in the biology of the most severe forms of coronavirus disease 2019 (COVID-19): the direct cytopathic effect of the virus against the host tissues, and a dysfunction of the immune system, characterized by the exhaustion of T lymphocytes. The exhaustion of T cells in COVID-19 is poorly understand, but some data could suggest a possible role of PD-1/PD-L1 axis. The aim of this study was to evaluate the possible role of PD-L1 expression in the pulmonary tissue in subjects affected by COVID-19. The presence of SARS-CoV-2 in the pulmonary tissue, and its exact location, was indagated by in situ hybridization; the expression of PD-L1 and CD8 in the same tissue was indagated by immunohistochemistry. Overall, PD-L1 resulted diffusely expressed in 70% of the cases, and an intense expression was observed in 43.5% of cases. Diffuse and intense presence of SARS-CoV-2 by in situ hybridization significantly correlated with an intense PD-L1 expression, and with expression of PD-L1 by pneumocytes. PD-L1 is overexpressed in the pulmonary tissue of subjects died from COVID-19, and mainly in subjects with a high viral load. These data suggest a possible role of PD-L1 in the immune system exhaustion at the basis of the severe forms of the disease.