Firearm ownership and suicide: Has the time come to discuss uniformity of health and social assessments in aid of regulation? Reflection from a retrospective study on a forensic case series.

Background: Firearm-related deaths are an issue of ongoing public interest, from a health and economic perspective. Worldwide, firearm prevalence in suicides varies widely, depending on multiple factors including the availability of weapons in each country. Although several studies have shown that national laws about gun ownership, reducing legal access to guns, decrease the risk of suicide by firearm, the current situation clashes with widely differing legislations. Study design: Retrospective study on a forensic case series. Methods: Autopsy reports assessed at the Section of Legal Medicine of Milan (Italy) from January 2014 to December 2023 were retrospectively documented. Only firearm suicides were considered. For each case, a close analysis of the criminal offence reports has been performed to obtain information about the gender and age of the victim, as well as the legal possession of firearms, psychiatric disorders, alcohol, and illicit drug abuse. Results: Among all the 1,164 suicides assessed at the Section of Legal Medicine of Milan over a 10-year-period, 101 cases (8.7%) were firearm-related. The male to female ratio was therefore about 13:1. No seasonal trends were observed. Most of the individuals owned the firearm license. Of the entire dataset, 35.6% suffered from psychiatric disorders, 4% of alcohol abuse and 2% of drug addiction. Among the owners of a firearm license, 42.3% had psychiatric disorders. Conclusions: Knowledge about firearm suicide and its relation to firearm legal possession is limited and current preventive laws should be reconsidered. Present administrative and clinical examinations required to obtain a firearm license in Italy and in some European territories are dealt with. The evaluation of the firearm-related risk of abuse is an essential but complex procedure, which requires not only clinic-anamnestic data but also in-deep psychiatric information. There is a need to develop and reinvigorate a debate that currently presents very heterogeneous solutions, but which would probably benefit from a common vision of the prevention strategies that can be implemented and enacted for the benefit of the entire community.

Reviewing hereditary connective tissue disorders: Proposals of harmonic medicolegal assessments.

Hereditary connective tissue disorders (HCTDs) are a heterogeneous group of inherited diseases. These disorders show genetic mutations with loss of function of primary components of connective tissue, such as collagen and elastic fibers. There are more than 200 conditions that involve hereditary connective tissue disorders, while the most known are Marfan syndrome, Osteogenesis Imperfecta, and Ehlers-Danlos syndromes. These disorders need continuous updates, multidisciplinary skills, and specific methodologic evaluations sharing many medicolegal issues. Marfan syndrome and Ehlers-Danlos syndromes show a high risk of early sudden death. As a consequence of this, postmortem genetic testing can identify novel genotype-phenotype correlations which help the clinicians to assess personalized cardiovascular screening programs among the ill subjects. Genetic testing is also essential to identify children suffering from Osteogenesis Imperfecta, especially when a physical abuse is clinically suspected. However, this is a well-known clinical problem even though there are still challenges to interpret genetic data and variants of unknown significance due to the current extensive use of new genetic/genomic techniques. Additionally, the more significant applications and complexities of genomic testing raise novel responsibilities on the clinicians, geneticists, and forensic practitioners as well, increasing potential liability and medical malpractice claims. This systematic review provides a detailed overview on how multidisciplinary skills belonging to clinicians, medicolegal consultants, radiologists, and geneticists can cooperate to manage HCTDs from autopsy or clinical findings to genetic testing. Thus, technical aspects need to be addressed to the medicolegal community since there is no consensus works or guidelines which specifically discuss these issues.

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.

Use of a neuro-evacuation device for the endoscopic removal of third ventricle colloid cysts.

Background: Colloid cysts are benign tumors usually located at the level of the foramen of Monro and account for approximately 1% of all intracranial tumors. Endoscopic surgical treatment represents the approach of choice for removal of these tumors and is usually preferred over transcortical or transcallosal microsurgical approaches. Our purpose is to demonstrate the feasibility of endoscopic removal of colloid cysts using a novel aspiration and fragmentation system, currently designed for evacuation of cerebral hematomas. Methods: We performed an evaluation of the results obtained in patients with symptomatic colloid cysts of the third ventricle operated on using an endoscopic neuroevacuation system (Artemis Neuro Evacuation Device, Penumbra, Alameda, California, USA) between April 2020 and April 2022. Instrumentation and surgical technique are described in detail. All patients underwent postoperative MRI to assess the extent of cyst removal. Results: Five patients were included in our study. The predominant symptom at onset was headache. No intraoperative complications related to the technology in use occurred. The surgical time for the cyst removal was significantly shorter than removal via a standard endoscopic technique (80 vs. 120 min). Removal was complete, both content and capsule of the cyst, in all patients. In all cases there was a complete regression of the previously complained symptoms. Conclusion: The Artemis Neuro Evacuation Device has proved to be effective and safe in removal of colloid cysts of the third ventricle and may be proposed as a possible alternative or as a complement of the standard instruments routinely used in neuroendoscopy.

Review on forensic importance of myiasis: Focus on medicolegal issues on post-mortem interval estimation and neglect evaluation.

Myiasis is the infestation of live vertebrates by dipterous larvae that feed on living or necrotic tissues, liquid body substances or ingested food and develop in or on the vertebrate body. In both animals and humans, myiasis plays a fundamental role in forensic practice because of its implications in the evaluation of cases of neglect and in the mPMI (minimum post-mortem interval) estimation. The present study aims to provide a review of forensic issues related to myiasis. A retrospective analysis was conducted by exploring major electronic literature databases. Methodological evaluation of each study was performed according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) standards. Sixty-one papers were included in this review. Entomology shows great potentiality in forensic investigations, mostly because of its contributory role in mPMI estimation. Such evaluation, however, requires a careful consideration of the possibility of an ante-mortem myiasis infestation, which could complicate the correct assessment of the mPMI. Hence, forensic pathologists should pay attention to the entomological fauna on a corpse, in both fresh and decomposed bodies. Moreover, in cases with poor nutritional or hygienic conditions, myiasis should be carefully evaluated as an indicator of neglect.

Identification issues in bodies maimed by train fatalities: The role of the forensic pathologist.

Traffic accident injuries are relevant causes of mortality in industrialized countries. Among traffic accidents, the most destructive effect on the victim's body is produced by trains, which in a very short time provoke a complete distortion of the normal anatomical profiles and extensive amputations of the body. Deaths by severe body mutilation and/or decapitation require complex forensic investigation, as the victims' identification and the recognition of their body are not often feasible. In this study, a retrospective analysis of a series of cases of railway accidents is presented, with the aim of showing potential identification strategies, including a systematic physical re-assembling of the body. Among the railway fatalities assessed at the University Institute of Legal Medicine of Milan from 2016 until 2020, 61 cases were analyzed, focusing on the collection of postmortem data to improve accuracy for the identification of the victims. The results showed that the identification could be based on elements traditionally called "secondary identifiers" which, however, are becoming more and more important for positive identification, especially when dealing with migrants, vagrants, and homeless people. However, several issues need to be considered such as the limitations of the public prosecutors to perform expensive analyses (i.e., genetic testing), and the lack of antemortem data to be compared with postmortem findings, both odontological and fingerprint. In cases where it is not possible to proceed with identification or formal recognition of victims of railroad accidents with severe mutilations, a systematic physical re-assembling of the body is critical to reaching positive identification.

Applications of artificial intelligence in forensic sciences: Current potential benefits, limitations and perspectives.

In recent years, new studies based on artificial intelligence (AI) have been conducted in the forensic field, posing new challenges and demonstrating the advantages and disadvantages of using AI methodologies to solve forensic well-known problems. Specifically, AI technology has tried to overcome the human subjective bias limitations of the traditional approach of the forensic sciences, which include sex prediction and age estimation from morphometric measurements in forensic anthropology or evaluating the third molar stage of development in forensic odontology. Likewise, AI has been studied as an assisting tool in forensic pathology for a quick and easy identification of the taxonomy of diatoms. The present systematic review follows the PRISMA 2020 statements and aims to explore an emerging topic that has been poorly analyzed in the forensic literature. Benefits, limitations, and forensic implications concerning AI are therefore highlighted, by providing an extensive critical review of its current applications on forensic sciences as well as its future directions. Results are divided into 5 subsections which included forensic anthropology, forensic odontology, forensic pathology, forensic genetics, and other forensic branches. The discussion offers a useful instrument to investigate the potential benefits of AI in the forensic fields as well as to point out the existing open questions and issues concerning its application on real-life scenarios. Procedural notes and technical aspects are also provided to the readers.

Sudden and unexpected deaths due to non-traumatic abdominal disorders: A forensic perspective.

Sudden and unexpected deaths due to non-traumatic abdominal disorders are a disregarded topic in the forensic field. These conditions are very heterogenous, accounting for 1-5% of sudden deaths. Specifically, acute gastrointestinal hemorrhages, bowel obstructions, liver cirrhosis, and necrotizing pancreatitis are frequently reported, whereas there are also unusual conditions which deserve careful analysis. Furthermore, the postmortem examinations of such disorders are not straightforward in the forensic setting since advanced putrefaction of the body, alleged medical malpractice, or the absence of any medical records could complicate autopsy procedures. Thus, the use of forensic histopathology, toxicology, microbiology, and postmortem radiology may help the pathologists to identify the abdominal cause of death. In this paper, the authors aim to discuss most of congenital and acquired abdominal conditions that have resulted in sudden and unexpected deaths. Hence, the discussion of the pathological features of each abdominal organ or system is prefaced with practical examples from caseworks of the Milan Institute of Legal Medicine. However, this paper also shows an extensive literature review with selected medicolegal articles to detailly describe the lethal mechanisms related to each condition, along with any associated risk factors or other diseases. Finally, each section shows a focus on either novel forensic approach (when available) or medicolegal implications, such as the use of postmortem radiology, peculiar histopathologic findings, or allegations in medical malpractices.

A case of medical liability involving an unexpected systemic amyloidosis.

The authors present a case of fatal amyloid cardiomyopathy, which was diagnosed only upon autopsy. A 57-year-old man was admitted to the hospital for scheduled percutaneous cardiac procedure of transcatheter radiofrequency ablation due to persistent atrial fibrillation and atrial flutter. Ventricular fibrillation was recorded in the monitor 2 h after the surgical procedure. Therefore, he was defibrillated and intubated, but he died for nosocomial pneumonia 26 days after being admitted. A judicial autopsy was ordered by the prosecutor due to an alleged medical malpractice. The autopsy confirmed the cause of death being pneumonia, but also revealed an occult restrictive cardiomyopathy with a thick and firm myocardium. Viscera samples were then collected for microscopic examination. Histopathologic analysis showed diffuse amyloid deposits in the myocardium, especially in the perivascular and subendocardial spaces. Amyloid deposits were also detected in all the other organs, except for the brain. Furthermore, immunohistochemistry for light chains was performed on the heart tissue sample, resulting to be positive. In the case presented herein, autopsy and histopathologic examination were crucial to diagnose an occult systemic amyloidosis (AL-type). In fact, it has been observed that the rarity of systematic amyloidosis and its unusual clinical onset were at first mistakenly perceived as a medical malpractice due to a technical error within the catheter ablation for atrial fibrillation. As a consequence, upon discussing the clinical and medicolegal implications concerning the case, the focus was placed on the undiagnosed systemic amyloidosis and on the causality between surgical procedure and the patient's death.

Suicide pacts in the Milan district (Italy): A retrospective autopsy-based study with literature review.

Suicide pacts are unique events, which involve two or more individuals. In such cases, the initiator and the addicted victim decide to end their lives together in the same place and at the same time. In the present research, on the 26,054 autopsy reports assessed at the Milan Institute of Legal Medicine from 1993 to 2020, 4596 suicides were collected. Among them, 6 cases of suicide pacts were registered, which involved two couples of friends, two couples of spouses, one couple of lovers and one couple of identical twins. Gunshots and acute poisonings were the most common suicidal methods that were adopted. Suicidal notes were documented in 4 cases, which reported the reasons and the consent of the victims. Suicidal notes clearly allow the correct identification of suicide pacts. Furthermore, they often explain the reasons which are frequently based on either psychiatric disorders or financial problems. In the other cases, the absence of farewell notes could complicate forensic investigations, especially to establish the differential diagnosis with murder-suicides without the explicit consent of the victims. In this setting, multidisciplinary skills are preferably required, including a full forensic autopsy with ancillary postmortem analyses (e.g., toxicology, histopathology, and forensic genetics). Furthermore, this study aims to discuss the suicide pacts from a medicolegal, criminological, and sociological point of view, providing a review of the literature with a comparison of our forensic cases.

Histological microaggregates as a sign of systemic dissemination due to oral ingestion of povidone-iodine (Betadine®).

Povidone-iodine (PVP-I) in the formulation of Betadine® is widely used in several medical fields, whereas its suicidal ingestion is an unusual occurrence. Therefore, the biological signs of this fatal poisoning remain unclear and elusive, similarly to the histological lesions induced by PVP-I. In fact, there are no forensic articles concerning the histological signs of PVP-I acute poisoning. Specifically, this short communication reports the unique case of a man who ingested 125 ml of Betadine® 10% to commit suicide, for which he died three days later. The autopsy examination showed either local or systemic signs of caustic ingestion; moreover, the histological analysis showed both intra- and extra-cytoplasmic amorphous and brownish microaggregates in almost all the organs. Histological and histochemical techniques resulted to be negative for the detection of physiological and known pigments (e.g., formalin, lipofuscin, hemosiderin). Likewise, such pigments were not associated neither with the man's diseases nor with his medications. Therefore, the authors supposed that they were povidone-iodine microaggregates, which have been deposited in the organs through the blood circulation. In conclusion, the complete postmortem histological examination could allow the identification and the characterization of PVP-I microaggregates as evidence of systemic toxicity from Betadine®, when dealing with a forensic case of ingestion of povidone-iodine.

The forensic application of the Glycophorin A on the Amussat's sign with a brief review of the literature.

Even if the Amussat's sign is known since the mid-19th century, few studies have been made in order to assess its real occurrence. In particular, the histopathologic examination of the Amussat's sign lacks in the medicolegal literature. The review of the literature shows indeed a significant range of variability (from 1.1 % up to 25 %) regarding the macroscopic detection of the Amussat's sign. In this study, the authors report that the identification of a vital Amussat's sign is important and may require the immunohistochemical staining for the Glycophorin A (a marker of vital reaction). The victim was a 63-year-old man, who was found suspended from the staircase with a rope. Both the carotid arteries were opened in situ by using fine scissors with blunt tips. A horizontal lesion (length 4 mm) of the intima of the left common carotid artery was documented. A sample was obtained; then, a standard post-fixative histopathologic examination and immunohistochemical staining for the Glycophorin A were carried out. The standard histopathologic examination only revealed the intimal laceration with a poor hemorrhagic infiltration. However, the immunohistochemical staining for the Glycophorin A allowed the clear identification of the hemorrhagic infiltration, which was documented both in the intimal laceration and in the periadventitial soft tissues. The immunohistochemical staining for the Glycophorin A can identify the vitality of an Amussat's sign. When an Amussat's sign is documented, the Glycophorin A may therefore help the forensic pathologist to differentiate a hanging death from a postmortem suspension of the body.

Explosion-related deaths: An overview on forensic evaluation and implications.

PURPOSE: Explosion-related deaths are uncommon events which require expertise and confidence so that an appropriate death investigation can be performed. The present study aims to provide a detailed forensic analysis of the issues and implications arising in the event of an explosion. METHODS: A retrospective review of casualty data was conducted on electronic literature databases. Cases concerning deadly explosions registered at the Milan Institute of Legal Medicine were examined and analyzed altogether. RESULTS: Explosions may involve closed or open systems. A security assessment of the site is always necessary. Alterations of the site due to rescue procedures can occur; thus, on-site forensic investigation should be adapted to the environment. Then, a study protocol based on autopsy procedures is presented. Application of the postmortem radiology enforces forensic procedures both for the analysis of blast injuries and skeleton fractures, and for identification purposes. Blast injuries typically cause lacerations of the lungs, intestine and major vessels; moreover, hyoid fractures can be documented. Histopathology may help to define blast injuries effectively. Forensic chemistry, toxicology and ballistics provide useful investigative evidence as well as anthropology and genetics. Different forensic topics regarding explosions are discussed through five possible scenarios that forensic pathologists may come across. Scenarios include self-inflicted explosion deaths, domestic explosions, work-related explosions, terrorist events, and explosions caused by accidents involving heavy vehicles. CONCLUSION: The scenarios presented offer a useful instrument to avoid misinterpretations and evaluation errors. Procedural notes and technical aspects are provided to the readers, with an insight on collaboration with other forensic experts.

Forensic considerations on the two major civilian terrorist events occurred in Milan: A retrospective autopsy-based study.

Explosion-related deaths are a disregarded topic of forensic sciences, despite the pivotal role of the forensic pathologist in such investigations. In fact, very few scientific articles have been published up to now, even if there is a considerable increase of terrorist attacks worldwide due to the use of improvised explosive devices (IEDs). In this paper, the authors show a retrospective autopsy-based study on the two major civilian terrorist events which occurred in Milan (Italy). The first one took place in a closed system, where a gelignite bomb was set inside the National Agriculture Bank in December 1969. 17 people were killed, and all of them underwent forensic autopsies, which were performed at the Milan Institute of Legal Medicine. The second event took place in an open system, where a car bomb exploded in Palestro Street in July 1993. 5 people were killed, forensic autopsies were performed as well. A total of 22 explosion-related deaths were assessed in this study. For each victim, the analysis of clothes, external and internal examinations were reported; furthermore, a statistical analysis using Fisher's exact test was carried out in order to show differences among blast injuries that occurred in a closed system versus an open system. The analysis of the autopsy reports, which included the descriptions of clothes, and the injury patterns allowed a possible reconstruction of the bodily exposure side of the victims in relation to the origin site of the explosive devices.

An unusual suicide by self-waterboarding: forensic pathological issues.

The authors present the first case, to the best of our knowledge, of a preplanned suicide by self-waterboarding. Waterboarding (WB) is a military method of torture in which water is poured into the nostrils and the mouth of a victim, to evoke the sensation of asphyxiation by drowning. The victim was a 22-year-old male student, who was found dead and naked in the bathtub. His head was covered by a soaked canvas bag, and his hands were tied with two nylon ropes and a padlock. The water jet of the showerhead was specifically directed at the victim's head, so that the canvas bag could be soaked with water. The cause of death was defined as the combination of asphyxiation by drowning with the direct suffocation provoked by the soaked canvas bag in the context of the waterboarding practice. Finally, the authors discuss the differential diagnosis regarding the modality (suicide versus homicide) through which this case of waterboarding was performed. The case is intended to be used as source data for similar forensic cases, where a multidisciplinary approach is advisable in such complex cases.

Brain Arteriovenous Malformations Classifications: A Surgical Point of View.

Brain arteriovenous malformations (AVMs) classification has been the subject of extensive discussion. The aim of our work was to review the main classification schemes proposed in the literature, which can be summarized in four main groups: (a) traditional schemes oriented to evaluate the operability of AVMs have been joined by (b) specific classifications that evaluate the outcome and the predictability of obliteration of other treatment modalities and (c) others that evaluate the outcome of intracerebral hemorrhages in ruptured AVMs. Eventually, (d) topographical classifications that categorize the subtypes of AVMs located in specific anatomical regions have been drawn. For each classification, we discuss the implications on surgical management.

Cirsoid aneurysm rupture of the splenic artery as a rare cause of fatal hemoperitoneum.

Cirsoid aneurysms are rare arteriovenous malformations without any capillaries interposed and almost always observed in the scalp region. These types of aneurysms are so-called "cirsoid" because of their serpiginous appearance. In this report, the authors present the first case of a lethal spontaneous rupture of a cirsoid aneurysm of the splenic artery, which could be diagnosed only by post-mortem histologic examination. The victim was a 70-year-old man who was suddenly found dead in bed while he was hospitalized and waiting for a scheduled cardiac surgery. A forensic autopsy was ordered due to the suspicion that the man's death could have been related to medical malpractice. An accurate autopsy and a complete forensic histologic examination could clarify the cause of death, which was identified in the spontaneous rupture of a cirsoid aneurysm of the splenic artery. The case is intended to be used as source data for similar forensic cases, where the cause of a massive hemoperitoneum is difficult to be identified.

A forensic analysis on 53 cases of complex suicides and one complicated assessed at the Bureau of Legal Medicine of Milan (Italy).

Complex suicides are highly uncommon suicides in which multiple detrimental methods are used simultaneously or in chronological succession. We retrospectively analyzed through our database the 25512 autopsy reports registered at the Bureau of Legal Medicine of Milan in the last 27 years from 1993 until 2019, where 4498 suicides were documented. We assessed 53 cases of complex suicides and only one case of complicated suicide: for all of them we analyzed both data collected during the on-site investigation and the autopsy. In our case series, we identified a total number of 113 methods chosen and variably combined by the victims, which were classified into 17 categories. On the whole the most frequent association of suicide methods resulted in the combination of the plastic bag suffocation with inert gas inhalation (13 out of 53 complex suicides; 24.5%). We also analyzed our cases of simple suicides (1993-2019), to compare them with the complex suicides. In this study, we present a complete analysis regarding our cases of complex suicides, discussing the challenges and the interpretative issues which a forensic pathologist might deal with. A thorough on-site judicial inspection and a careful autopsy examination are crucial in such cases. Moreover, the clinical history of the victims and laboratory findings are supplemental elements to be necessarily considered to establish the actual manner of death and avoid any misinterpretations.