Forensic remarks regarding 35 cases of complex suicides and 4 cases of complicated suicides investigated at the Institute of Legal Medicine of Brescia during the period 1983-2022.

The role of the forensic pathologist is central to both identifying the cause and determining the manner of death. Distinguishing a suicide from a homicide or accidental event is essential to define whether third parties are involved in death. Suicides are most frequently performed using a single method; therefore, they can be defined as simple. The term "complex suicide" refers to a form of suicide in which two or more methods are applied by the victim, simultaneously or in chronological succession, to achieve the death. The different methods may have been planned in advance to prevent failure of the first method or may occur because the first method was not effective or was too painful, so the victim quickly seeks another way to complete the suicide. "Complicated suicides", on the other hand, are characterised by an unintentional secondary trauma following the suicidal act. This study analyses 35 complex suicides and 4 complicated suicides investigated at the Institute of Forensic Medicine in Brescia (Italy) during the period 1983-2022. Some data about the cases are discussed. This study aims to demonstrate how multiple lesions on the victim's body are not in themselves indicative of the intervention of third parties in their production, but complex and complicated suicides must always be considered.

Complementary and Alternative Medicine Use in Rheumatoid Arthritis.

PURPOSE OF REVIEW: Despite advances in pharmacologic management of rheumatoid arthritis (RA), complementary and alternative medicine (CAM) remains popular adjuncts to therapy among patients for ongoing symptomatology. RECENT FINDINGS: Mind-body interventions are becoming increasingly popular, including yoga and meditation. Randomized controlled trials have found these interventions to be helpful regarding pain, mood, and energy in RA patients. Other CAM modalities, such as natural products, special diets, acupuncture, and body-based therapies, also continue to be used by RA patients with limited evidence for efficacy and safety. While there are numerous CAM interventions available, the data is very limited at this time with only low-quality evidence supporting various therapies. Medical providers are more open to the addition of CAM in their patients and require increased education on the topic. Additional research needs to be conducted in order to provide evidence-based recommendations to our patients.

Inflammatory muscle disease - An update.

Idiopathic inflammatory myopathies (IIM) are a heterogeneous group of inflammatory myopathies whose common feature is immune-mediated muscle injury. There are distinct subgroups including dermatomyositis (DM), polymyositis (PM), inclusion body myositis, and immune-mediated necrotizing myopathy. Antisynthetase syndrome is also emerging as a distinct subgroup with its unique muscle histopathological characteristic of perifascicular necrosis. While the newly updated EULAR/ACR Classification Criteria for IIM have brought advancements in diagnosis and the exclusion of mimickers, the use of only one autoantibody in the derivation of the schema limits its use. Similarly, while the advent of multiple novel therapeutics in the treatment of myositis has been exciting, it has also highlighted the scarcity of validated outcome measures. The purpose of our review is to highlight the updated classification criteria of myositis, newly reported clinical phenotypes associated with myositis autoantibodies, the measurement of outcomes, and emerging treatments in the field.

Safety of retrievable inferior vena cava filters in patients with the antiphospholipid syndrome.

OBJECTIVE: Consideration for placement of an inferior cava filter arises in patients with APS where cessation of anticoagulation is necessary or thrombotic complications continue despite maximal anticoagulation. Permanent IVC filters are recommended to be avoided. We evaluated the safety of placement and removal of retrievable inferior vena cava filters in patients with APS. METHODS: Case series of 5 patients with APS and aPL antibodies who had placement and removal of retrievable IVC filter (because of contraindication to anticoagulation or ongoing thrombosis despite full anticoagulation) to assess for safety, presence of clots in the vena cava or on the filter while in the body, evidence of PE, or clot on the explanted filter. RESULTS: Insertion and removal, even while on anticoagulation, was safe. There was no evidence of clot in the vena cava, on the filter or pulmonary embolism in all cases. CONCLUSION: Where necessary, retrievable IVC filters may be safer in APS patients but should not be left in for long periods of time.

Prognostic variables for clinical outcomes in valvular heart disease patients with moderate to severe secondary tricuspid regurgitation.

BACKGROUND AND AIM OF THE STUDY: Secondary tricuspid regurgitation (STR) is frequently seen in cardiology practice. Currently, few data are available on the prognostic variables associated with moderate or severe STR on death and progression to valve surgery. Hence, the study aim was to identify these prognostic variables. METHODS: In this retrospective study, patients with at least moderate STR were identified from an ongoing database and followed until death, any valvular heart surgery, or the end of the study. Clinical and echocardiographic variables including age, gender, coronary artery disease, device implantation (defibrillator or pacemaker), pulmonary disease, left ventricular ejection fraction, right ventricular size, right ventricular systolic pressure (RVSP), STR severity and concomitant valve disease were recorded. End-points were death and valve surgery. RESULTS: The average age of the 92 study participants was 68 +/- 16 years. During a mean follow up of 43 +/- 24 months, there were 13 deaths (14%) and 12 surgeries (13%). In multivariate analysis, both an elevated RVSP and device implantation were significant predictors of death (p = 0.0038 and 0.0487, respectively). Only an elevated RVSP was predictive of surgery (p = 0.05) and surgery-free survival (p = 0.0005). A RVSP > 48 mmHg had a hazard ratio of 3.93 (p = 0.0012) and a high diagnostic accuracy for predicting death, with an area under the receiver operating characteristic curve of 0.73. CONCLUSION: In patients with valvular heart disease and at least moderate STR, an elevated RVSP of at least 48 mmHg was associated with significantly increased mortality and decreased surgery-free survival.

Predictors of early mortality in patients age 80 and older receiving implantable defibrillators.

BACKGROUND: There are no upper age restrictions for implantable defibrillators (ICDs) but their benefit may be limited in patients > or = 80 years with strong competing risks of early mortality. Risk factors for early (1-year) mortality in ICD recipients > or = 80 years of age have not been established. METHODS: Two-center retrospective cohort study to assess predictors of one-year mortality in ICD recipients > or = 80 years of age. RESULTS: Of 2,967 ICDs implanted in the two centers from 1990-2006, 225 (7.6%) patients were > or =80 years of age and followed-up at one of the two centers. Mean age was 83.3 +/- 3.1 years and follow-up time 3.3 +/- 2.6 years. Median survival was 3.6 years (95% confidence interval 2.3-4.9). Multivariate predictors of 1-year mortality included ejection fraction (EF) < or = 20% and the absence of beta-blocker use. Actuarial 1-year mortality of ICD recipients > or = 80 with an EF < or = 20% was 38.2% versus 13.1% in patients 80+ years with an EF > 20% and 10.6% for patients < 80 years with an EF < or = 20% (P < 0.001 for both). There was no significant difference in the risk of appropriate ICD therapy between those patients 80+ years with EF above and below 20%. CONCLUSION: In general, patients > or = 80 years of age who meet current indications for ICD implantation live sufficiently long to warrant device implantation based on anticipated survival alone. However, those with an EF < or = 20% have a markedly elevated 1-year mortality with no observed increase in appropriate ICD therapy, thus reducing the benefit of device implantation in this population.

Catheter ablation of atrial fibrillation.

Atrial fibrillation, the most common cardiac arrhythmia requiring treatment, has significant morbidity and mortality consequences. Pharmacologic therapy consisting of anticoagulants, AV nodal blocking agents and antiarrhythmics, remain the primary treatment. However, several nonpharmacologic therapies for the treatment of atrial fibrillation have been developed. In this review, we provide a detailed discussion of the most promising nonpharmacologic approach to the treatment of atrial fibrillation-catheter-based ablation.

Management of coronary artery disease in patients with chronic kidney disease.

Patients with chronic kidney disease (CKD) are considered to belong to the highest risk group for the development of cardiovascular events. These patients should be subject to aggressive risk-factor modification. However, management of coronary artery disease in patients with CKD can be uniquely challenging. Many of the medications used in the treatment and prevention of coronary artery disease are metabolized or excreted by the kidney. Thus, patients with CKD are more likely to experience adverse effects from any attempt to aggressively modify risk factors for coronary artery disease. Little is known regarding revascularization in patients with CKD. Patients with CKD may benefit from off-pump strategies during coronary artery bypass. Percutaneous coronary intervention in patients with CKD is associated with lower procedural success and increased peri-procedural myocardial infarction, ischemia, and target vessel revascularization. In this review, we discuss the unique challenges of managing coronary artery disease in patients with CKD.

Utility of echocardiography in the evaluation of coronary artery disease in patients with end-stage renal disease.

Patients with chronic kidney disease (CKD) are at increased risk of cardiovascular events. Echocardiography is an integral part of the evaluation of coronary artery disease. Chronic kidney disease has a predictable and unique effect on the myocardium and the epicardial circulation that may be detected by echocardiography. In particular dobutamine stress echocardiography has proved to be an invaluable tool in the detection of cardiovascular disease in patients with CKD. Here, we review the usefulness of echocardiography in the detection and evaluation of coronary artery disease in patients with CKD.

Assessing cardiovascular disease in the dialysis patient.

Cardiac causes account for nearly half of all deaths in patients with end-stage renal disease (ESRD). Coronary artery disease (CAD) is present in 38% - 40% of patients starting dialysis. Both traditional and chronic kidney disease-related cardiovascular risk factors contribute to this high prevalence rate. In patients with ESRD, CAD--particularly acute myocardial infarction--is underdiagnosed. Dobutamine stress echocardiography and, to a lesser extent, stress myocardial perfusion imaging have proved useful in screening for CAD in such patients. Coronary artery calcium scoring is less useful. Acute myocardial infarction is associated with high short- and long-term mortality in dialysis patients. Cardiac troponin I appears to be more specific than cardiac troponin T or CK-MB in the diagnosis of acute myocardial infarction.