Forensic value of soft tissue detachments from the hyoid bone in death due to strangulation asphyxia.

BACKGROUND: There are no unequivocal histopathological findings for the diagnosis of fatal asphyxia due to neck compression. From the observation of a series of asphyxiation cases, we noted, during microscopic analysis, a high frequency of "detachment" of soft tissues from the hyoid bone. This specifically refers to the presence of an optical space between the surface of the hyoid bone and soft tissues. OBJECTIVES: We aimed to evaluate the detachment of soft tissues from the hyoid bone as specific histological evidence of death due to strangulation asphyxia. MATERIAL AND METHODS: Ten blocks were taken from deaths due to external mechanical compression of the neck (strangulation asphyxia, group A), 22 blocks were taken from deaths for other causes without trauma to the neck (group B), and 38 blocks were obtained from living subjects that have undergone laryngectomies (group C). The presence/absence of detachments were compared between the 3 groups (A, B and C) using Fisher's exact test. RESULTS: The detachment of soft tissues from the hyoid bone was observed in 5 cases (50%) in group A, 6 cases (27.2%) in group B, and 17 cases (44.3%) in group C. The sensitivity and specificity of the presence of the detachment in group A were 0.5 (95% confidence interval (95% CI): 0.38-0.62) and 0.57 (95% CI: 0.45-0.69), respectively. The comparison between the 3 groups and the presence/absence of soft tissue detachment showed no statistically significant differences between the groups (p = 0.329), clarifying that soft tissue detachment is a nonspecific variable for all 3 situations. CONCLUSIONS: Detachment of soft tissues has poor value as a single element to favor the diagnosis of asphyxia due to violent compression of the neck and should be interpreted as an artifactual finding, unrelated to the neck injury or injury vitality.

Carbon monoxide related deaths: A Verona case series. When cooperation becomes compulsory.

INTRODUCTION: Carbon monoxide (CO) poisoning is a significant concern in forensic medicine, as it often presents unique challenges in terms of diagnosis, investigation, and determination of the cause of death. CO is a colourless, odourless, and tasteless gas that can be lethal when inhaled in high concentrations. It binds strongly to haemoglobin, forming carboxyhaemoglobin (COHb), which reduces the oxygen-carrying capacity of the blood, leading to tissue hypoxia and ultimately death. MATERIALS AND METHODS: Circumstantial data, medical history information, autopsy findings, and toxicological analysis results related to 24 CO poisoning cases at the Institute of Legal Medicine in Verona were collected and analysed. The data were examined in an integrated manner to identify correlations and common patterns. A comparison was also made with the data available in the literature. RESULTS: The male gender was confirmed to be the most frequently involved. COHb levels were found to be less than 50% in 6 cases. Three individuals had concurrent cardiovascular pathologies, while 11 subjects tested positive for various substances, including alcohol, benzodiazepines, and morphine. In most cases, the manner of fatal intoxication was accidental, although 6 suicides and 1 homicide are reported. CONCLUSIONS: The Verona case series demonstrates that deaths due to CO poisoning require a multidisciplinary approach. The integration of diverse expertise is essential for assessing the manner of death. This approach enables a comprehensive evaluation of the available data, aids in distinguishing between accidental, suicidal, and homicidal deaths, and ensures accurate and reliable forensic conclusions.

Incomplete decapitation in suicidal vehicle-assisted ligature strangulation: A case report and a review of the literature.

Vehicle-assisted ligature strangulation is an extremely rare suicide method. We report a case of a 43-year-old man who secured one end of a nylon rope to a tree and the other end around his neck, then got inside his vehicle and stepped on the gas, leading to an incomplete decapitation. A sharply demarcated encircling ligature mark was found upon external examination, along with a deep laceration in the anterior region of the neck. The severance plane passed between the third and fourth cervical vertebrae, with diffuse haemorrhagic infiltration of the cervical muscles, in accordance with autopsy findings reported in the literature. The lung histological examination described a large amount of red blood cells and pulmonary oedema. A review of the literature concerning suicidal vehicle-assisted ligature strangulation cases allowed us to investigate some common autopsy findings, as well as the rope features relevant to the beheading.

Preliminary Study on the Possibility to Detect Virus Nucleic Acids in Post-Mortem Blood Samples.

BACKGROUND: In many forensic cases, the medical records of the deceased are not available at the time of the autopsy; therefore, no information about the deceased's state of health, including any infectious diseases contracted during life, is accessible. The detection of some of the principal viral infections, such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus type 1 (HIV-1), could contribute to determining causes of death and interesting applications could be found in medico-legal practice, such as occupational risk assessment. To date, accurate and sensitive serological and molecular assays capable of detecting these viruses have been validated on biological samples taken from living beings, while their efficiency on forensic post-mortem biological samples has yet to be thoroughly assessed. To further this aim, this study evaluated whether the nucleic acid amplification techniques (NAATs) for the detection of viral genomes that are applied in clinical settings can be used, with the same success rate, for these latter samples. METHODS: Manual viral nucleic acid extraction processes and fully-automated amplification-based detection techniques developed in-house were evaluated on blood samples taken during the routine autopsies of 21 cadavers performed 2 to 9 days after death. Information on HBV, HCV, and HIV-1 seropositive status was previously known for only four of these cadavers. RESULTS: Using automated quantitative real-time PCR (qPCR) and qualitative PCR (end-point) analyses, it was possible to confirm the presence of viral genomes in the four post-mortem whole blood samples with previously reported specific serological positivity. In addition, the genomes of HCV and/or HIV-1 genomes were detected in three other blood samples with unknown serological status at the time of autopsy. CONCLUSIONS: Therefore, our findings suggest that molecular assays may detect the presence of viral genomes in forensic post-mortem blood samples up to five days after death. This provides an additional means of investigation that can contribute to the determination of the deceased's cause of death.

Unusual Lichtenberg figures in a lightning strike's victim: Case report and literature review.

Lichtenberg figures are pathognomonic markings commonly described as transient pink-red fractal pattern marks on the skin of people struck by a lightning. Their nature and the underlying physiopathology are still largely unknown. Here we describe a Lichtenberg figure in a 45-year-old woman who died due to a lightning strike during a thunderstorm. On autopsy, five days after the fatal event, she presented atypical green Lichtenberg figures on the skin of her abdomen. This appearance has not previously been described in the scientific literature, so a review of literature was done to support our observation.

A hard way to die: when multiple lethal gunshots mean suicide.

Multiple suicidal gunshot wounds are rare and often present a challenging issue for forensic pathologists in determining the manner of death.We describe three cases of suicidal multiple gunshot wounds in which crime scene investigation, cadaveric examination, and autopsy were provided. In all cases, integration of circumstantial data and crime scene investigation suggested a suicidal event.Firstly, we describe the self-infliction of two gunshots to the chest and head in a 90-year-old man by a revolver with wounds to the left lung and lethal wound to both frontal and temporal lobes. The second case concerns a 97-year-old man found dead with two gunshot wounds to the chest by a semi-automatic weapon and bullets penetrated to the left lung and heart. The last case, exceptional in literature, is a 41-year-old man with three self-inflicted gunshots, all-penetrating the left lung and the heart, using a revolver. This paper illustrates that immediate incapacitation can lack even in case of multiple fatal gunshot wounds on instantaneously lethal targets. Therefore, a complete investigation is required for a correct interpretation of the manner of death.An extensive review of literature is also provided.

Policies and practice in the disclosure of medical error: Insights from leading countries to address the issue in Italy.

The relationship between physician and patient has undergone profound changes in recent years. Patients increasingly insist on being thoroughly informed with detailed information about treatments and procedures suggested for their best care. This is also due to the growing suspicion towards doctors and the health-care system in general. Therefore, it is no longer possible to hide a medical error. To satisfy the request for honesty and safety of patients and society, it is necessary to enhance the skills and tools that physicians can use when disclosing and explaining an error to the patient. All modern codes of medical conduct acknowledge the importance of strengthening communication between physician and patient, which is the only way to save a relationship under constant threat of rupture and to improve the quality and safety of the treatment. The disclosure and explanation of the error has become not only an ethical duty but also a prudent way of avoiding negligence lawsuits. In this context, in 2013, Germany approved a law known as Patientenrechtegesetz, which we consider a good compromise between patient expectations and the need for doctors to work without the constant fear of being sued for malpractice. This work seeks to provide an overview of the most important issues pertaining to disclosure of medical error and of practice in other countries, with the aim of offering a contribution to the debate on this subject in Italy.

Consultation between forensic and clinical pathologists for histopathology examination after forensic autopsy.

The magnitude of the diagnostic benefit conferred by performing histopathological examinations after medico-legal/forensic autopsies remains debatable. We have tried to address this issue by reviewing a series of histopathology referrals concerning medico-legal autopsies in real-world routine practice. We present an audit of the consultations provided to forensics by clinical pathologists at our institute between 2015 and 2018. Over this period, 493 post-mortem examinations were performed by forensic pathologists. Of these cases, 52 (11%) were referred for histopathology. Gross assessment was requested in 22/52 (42%) cases. Histopathology examination was performed on single organs in 15/52 (29%) cases, primarily on the lung and heart, whereas parenchymatous multi-organ analysis was carried out in 14/52 (27%) cases. Bone-marrow sampling was studied in 4/52 (8%) cases. Immunohistochemistry was needed in 16/52 (31%) cases, special stains in 9/52 (21%) cases and molecular analysis in 4/52 (8%) cases. Focusing on technical processes, standard methodology on pre-analytical procedures was changed in 10/52 (19%) cases in order to answer specific diagnostic questions. We showed that although most of the time the diagnosis is clear by the end of dissection on the basis of the macroscopic findings, histopathology can provide, modify or confirm the cause of death in many medico-legal/forensic cases. Therefore, it is desirable that forensic pathologists and clinical pathologists establish robust working relationships in a cooperative environment. We conclude that it is important to implement guidelines based on real-world routine practice in order to identify cases where histopathology can provide useful contributions, which in our experience applied to 11% of forensic cases.

Autophagy pathways in drug abusers after forensic autopsy: LC3B, ph-mTOR and p70S6K analysis.

INTRODUCTION: Autophagy plays a role in various central nervous system diseases. Little is known about its molecular activation in drug addiction. Our aim was to investigate the signalling pathways of autophagy in brain tissues from drug abusers. METHODS: Twenty-five drug abusers with acute lethal intoxication and 10 controls were medico-legally autopsied. Brain-tissue samples from the parietal cortex and cerebellum were obtained. Expression of LC3B, phospho-mTOR (ph-mTOR) and phospho70S6 Kinase (p70S6K) was identified in tissue microarrays, with three tissue spots per case. Blood, urine or vitreous humour were tested in all cases to identify the acute intoxication. Hair analysis was performed in 14 cases to confirm chronic intoxication; the remaining cases had a documented medical history of chronic abuse. RESULTS: The autophagy marker LC3B was always positive on both the cortex and the cerebellum, stratified as strongly in 18 (72%) cases and weakly positive in seven (28%) cases. ph-mTOR was negative in all cases. The p70S6K molecule showed positivity in 14 (56%) cases on cortex tissue. The cerebellum was always negative, except for Purkinje cells. Drug abusers had statistically more double positive cases (LC3B-p70S6K) than controls ( p=0.0094). CONCLUSION: Autophagy pathways were activated in our series, and 56% of drug abusers showed simultaneous LC3B-p70S6K immunoexpression on tissue from the parietal cortex and cerebellum. This may be of value in autopsy practice as an indicator of brain damage due to drug abuse and could serve as alternative or additional double sensitive diagnostic method to detect drug-related deaths using a tissue-based rationale.

Development of a low cost gas diffusion device for ammonia detection in the vitreous humor and its preliminary application for estimation of the time since death.

A simple and low cost analytical device is described for the determination of ammonium in the vitreous humor suitable for inferring the post mortem interval in forensic cases. The device is based on ammonia formation from ammonium ion by means of NaOH addition to the vitreous humor sample and its detection with a pH chemical indicator in the gas phase above the vitreous humor sample. From the gas phase, ammonia diffuses through a polymeric membrane and it is trapped and detected with a droplet of pH indicator thymol blue. The color change of the droplet is measured using a smartphone camera. Under optimal conditions, the device showed a limit of detection of 0.2mM, with between days precision of ≤ 15% expressed as relative standard deviation, and an accuracy between days from 88.3% to 114.5%. This homemade gas diffusion analytical device was successfully used for the determination of ammonia in vitreous humor samples from forensic autopsies. The results obtained with the proposed method, although for a limited number, showed a close correlation with the data obtained with an instrumental analysis based on capillary electrophoresis. Moreover a significant correlation was also found between the results of the present method and the time elapsed since death by a simple evaluation of the color intensity. In conclusion, this preliminary study showed that the proposed device, after adequate validation, could be a promising tool for a presumptive estimation of the time since death directly at the crime scene.

Necrotizing fasciitis: case series and review of the literature on clinical and medico-legal diagnostic challenges.

Necrotizing fasciitis (NF) is a life-threatening infection of soft tissues spreading along the fasciae to the surrounding musculature, subcutaneous fat and overlying skin areas that can rapidly lead to septic shock and death. Due to the pandemic increase of medical malpractice lawsuits, above all in Western countries, the forensic pathologist is frequently asked to investigate post-mortem cases of NF in order to determine the cause of death and to identify any related negligence and/or medical error. Herein, we review the medical literature dealing with cases of NF in a post-mortem setting, present a case series of seven NF fatalities and discuss the main ante-mortem and post-mortem diagnostic challenges of both clinical and forensic interests. In particular, we address the following issues: (1) origin of soft tissue infections, (2) micro-organisms involved, (3) time of progression of the infection to NF, (4) clinical and histological staging of NF and (5) pros and cons of clinical and laboratory scores, specific forensic issues related to the reconstruction of the ideal medical conduct and the evaluation of the causal value/link of any eventual medical error.

Current trends in disability claims due to fibromyalgia syndrome.

Fibromyalgia syndrome (FMS) affects 0.4-8% of the general population predominantly in the female population with a F:M ratio of 3-9:1. It is characterised by persistent widespread pain and other associated clinical conditions such as chronic fatigue, irritable bowel syndrome (IBS), temporomandibular joint dysfunction (TMJD), sleep disorders and cognitive impairment. FMS diagnosis at present is purely clinical because no medical or laboratory examinations are able to identify it with certainty. FMS is not fully recognised worldwide, and patients often do not receive the treatment and disability benefits planned for other chronic diseases even though it gives rise to a very significant social burden due to direct and indirect healthcare costs and the loss of productivity and work. This article describes the medico-legal situation of FMS patients around the world, particularly issues related to the recognition of the disease by health institutions and the provision of disability benefits. We also discuss the current means of assessing disabilities in the medico-legal context, and their possible future improvements.