Hyoid Bone Fracture Pattern Assessment in the Forensic Field: The Importance of Post Mortem Radiological Imaging.

Post mortem hyoid bone fracture findings may be attributable to various factors, including both the onset of acute mechanical asphyxia as it happens in manual strangulation and in charred corpses. In forensic practice, the discovery of corpses burned after death to hide their real cause of death is not uncommon: in these cases, the diagnostic challenge is even greater, as the action of flames is capable of both masking previously generated lesions and/or generating new ones, as occurs for hyoid bone fractures. The case concerns a 76-year-old man found charred in his bedroom. Almost complete body charring made it impossible to evaluate any external damage. Post mortem computed tomography (PMCT) was performed, and an evident bilateral fracture of the greater horn of the hyoid bone was detected. Although the absence of typical charring signs had steered the diagnosis towards post mortem exposure to flames, PMCT proved to be very useful in increasing the accuracy in correctly determining the cause of death. In particular, making use of Maximum Intensity Projection (MIP) hyoid bone reconstructions, it was possible to measure the medial dislocation angle of the fracture fragments and then to establish the applied direction of force, which acted in a lateral-medial way. A manual strangulation diagnosis was confirmed. The increasing importance of performing post mortem radiological exams as a corollary for conventional autopsy has been further confirmed.

"Immunohistochemical analysis of Sigma-1 receptor (σ-1R) expression in human pineal gland in relation to different causes of death".

Sigma-1 receptor (σ-1R) modulates cellular signaling pathways, probably acting as a ligand operated chaperone. When activated, the receptor translocates from the interface mitochondrion associated membrane of the endoplasmic reticulum to the cell membrane. σ-1R was demonstrated in some brain regions, including the pineal gland, and was proposed to be involved in several cerebral processes, including neuroprotective responses against homeostasis alterations. On this basis, the immunohistochemical expression of σ-1R in human pineal glands was evaluated, with particular regard to the different causes of death. Thirty-eight pineal glands obtained from forensic autopsies were divided into five groups according to the cause of death: sudden death, drowning, fire fatality, hanging, and hemorrhagic shock, and examined with hematoxylin-eosin stain and immunohistochemistry for σ-1R. Both pinealocytes and perivascular spaces were evaluated. The pineal glands from sudden death were only mildly positive for σ-1R, while a more evident immunopositivity was observed in hanging, fire fatality, hemorrhagic shock, and drowning. These results were confirmed in a two-by-two comparison between the sudden death group and other groups. Our data demonstrate for the first time with immunohistochemical techniques the presence of σ-1R expression in the human pineal gland and propose a direct correlation between σ-1R expression and duration of the death process, in particular when hypoxic conditions and/or excessive psychological stress are present.

Arrhythmogenic Right Ventricular Cardiomyopathy Post-Mortem Assessment: A Systematic Review.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetic disorder characterized by the progressive fibro-fatty replacement of the right ventricular myocardium, leading to myocardial atrophy. Although the structural changes usually affect the right ventricle, the pathology may also manifest with either isolated left ventricular myocardium or biventricular involvement. As ARVC shows an autosomal dominant pattern of inheritance with variable penetrance, the clinical presentation of the disease is highly heterogeneous, with different degrees of severity and patterns of myocardial involvement even in patients of the same familiar group with the same gene mutation: the pathology spectrum ranges from the absence of symptoms to sudden cardiac death (SCD) sustained by ventricular arrhythmias, which may, in some cases, be the first manifestation of an otherwise silent pathology. An evidence-based systematic review of the literature was conducted to evaluate the state of the art of the diagnostic techniques for the correct post-mortem identification of ARVC. The research was performed using the electronic databases PubMed and Scopus. A methodological approach to reach a correct post-mortem diagnosis of ARVC was described, analyzing the main post-mortem peculiar macroscopic, microscopic and radiological alterations. In addition, the importance of performing post-mortem genetic tests has been underlined, which may lead to the correct identification and characterization of the disease, especially in those ARVC forms where anatomopathological investigation does not show evident morphostructural damage. Furthermore, the usefulness of genetic testing is not exclusively limited to the correct diagnosis of the pathology, but is essential for promoting targeted screening programs to the deceased's family members. Nowadays, the post-mortem diagnosis of ARVC performed by forensic pathologist remains very challenging: therefore, the identification of a clear methodological approach may lead to both a reduction in under-diagnoses and to the improvement of knowledge on the disease.

An Insight into Kounis Syndrome: Bridging Clinical Knowledge with Forensic Perspectives.

Kounis syndrome (KS) is an acute coronary syndrome triggered by allergic or hypersensitivity reactions. Incidence rates vary, with studies reporting 19.4 per 100.000 among all admissions and 3.4% among allergy patients. This review explores the expanding understanding of KS, encompassing various manifestations, and focusing on both clinical data and forensic findings useful in performing a diagnosis. The pathophysiology of this syndrome involves a complex interplay between allergic reactions and the cardiovascular system. Mast cell activation, histamine release, leukotrienes, cytokines, and platelet activation can contribute to coronary events. Three types of classification systems (allergic angina, allergic myocardial infarction, allergic stent thrombosis) aid in categorizing presentations. The diagnosis of KS relies on clinical presentation, laboratory findings, and imaging. Postmortem assessment of KS is based on the integration of circumstantial data, autopsy, and histological findings. Biochemical and immunohistochemical analyses also contribute to postmortem diagnosis. In conclusion, a combined, multidisciplinary approach should be used to ease the diagnostic process, which is crucial for forensic practitioners in confirming KS occurrence.

Morphological and Genetic Aspects for Post-Mortem Diagnosis of Hypertrophic Cardiomyopathy: A Systematic Review.

Hypertrophic cardiomyopathy (HCM) is one of the most common genetic cardiovascular diseases, and it shows an autosomal dominant pattern of inheritance. HCM can be clinically silent, and sudden unexpected death due to malignant arrhythmias may be the first manifestation. Thus, the HCM diagnosis could be performed at a clinical and judicial autopsy and offer useful findings on morphological features; moreover, it could integrate the knowledge on the genetic aspect of the disease. This review aims to systematically analyze the literature on the main post-mortem investigations and the related findings of HCM to reach a well-characterized and stringent diagnosis; the review was performed using PubMed and Scopus databases. The articles on the post-mortem evaluation of HCM by gross and microscopic evaluation, imaging, and genetic test were selected; a total of 36 studies were included. HCM was described with a wide range of gross findings, and there were cases without morphological alterations. Myocyte hypertrophy, disarray, fibrosis, and small vessel disease were the main histological findings. The post-mortem genetic tests allowed the diagnosis to be reached in cases without morpho-structural abnormalities; clinical and forensic pathologists have a pivotal role in HCM diagnosis; they contribute to a better definition of the disease and also provide data on the genotype-phenotype correlation, which is useful for clinical research.

Professional liability due to complete esophagus section during thyroidectomy: a rare case report.

Background: Several diagnostic and therapeutic processes are regulated by guidelines and recommendations provided by International and National Societies which offer standardized indications for health-care practitioners, including the treatment of pathologies that may affect the thyroid gland. These documents are very important for patient health promotion and, also, for preventing adverse events associated with patient injuries and related malpractice litigations. Particularly, thyroid surgery can be a cause of professional liability due to complications from surgical errors. Even if the most frequent complications are hypocalcemia and recurrent laryngeal nerve injury, this surgical specialty can be also burdened by other rare and serious adverse events such as esophagus lesions. Case Description: Here a case of alleged medical malpractice involving a 22-year-old woman reporting a complete esophagus section during thyroidectomy was described. The case analysis highlighted that the surgical treatment was performed for an unconfirmed Graves-Basedow disease which was then assessed as Hashimoto thyroiditis by histological exam of the removed gland. The esophagus section was treated by termino-terminal pharyngo-jejunal anastomosis and termino-terminal jejuno-esophagus anastomosis. The medico-legal analysis of the case revealed two different profiles of medical malpractice related, respectively, to the misdiagnosis of the pathology due to an inappropriate diagnostic-therapeutic procedure and the production of the complete section of the esophagus, representing an extremely rare complication of thyroidectomy. Conclusions: Clinicians should ensure an adequate diagnostic-therapeutic path based on guidelines, operational procedures, and evidence-based publications. The non-observance of the "required rules" for diagnosis and treatment of thyroid disease can be associated with a very rare and severe complication that strongly compromises the patient quality of life.

Postmortem Biochemistry and Immunohistochemistry in Anaphylactic Death Due to Hymenoptera Sting: A Forensic Case Report.

BACKGROUND: Postmortem assessment of anaphylactic death is a challenge for forensic pathologists. One of the most frequent elicitors of anaphylaxis is insect venom. Here, a case of anaphylactic death due to Hymenoptera stings is reported to highlight the contribution of postmortem biochemistry and immunohistochemistry in assessing the cause of death. CASE REPORT: A 59-year-old Caucasian man working on his farm was presumably stung by a bee and died. He had a history of previous sensitization to insect venom. The autopsy revealed no signs of insect puncture, mild edema of the larynx, and foamy edema in the bronchial tree and lungs. Routine histology showed endo-alveolar edema and hemorrhage, bronchospasm, and scattered bronchial obstruction due to mucus hyperproduction. Biochemical analysis was performed, and serum tryptase was equal to 189 µg/L, total IgE was 200 kU/L, and specific IgE dosage was positive for bee and yellow jacket species. Immunohistochemistry for tryptase detection was carried out, revealing mast cells and degranulated tryptase expression in the larynx, lungs, spleen, and heart. These findings led to the diagnosis of anaphylactic death due to Hymenoptera stings. CONCLUSIONS: The case highlights that the role of biochemistry and immunohistochemistry in the postmortem assessment of anaphylactic reactions should be stressed by forensic practitioners.

Multidisciplinary Forensic Approach in "Complex" Bodies: Systematic Review and Procedural Proposal.

The recovery of severely altered cadavers (i.e., extensively decomposed, mummified, charred or dismembered) can be a challenge for forensic pathologists due to the difficulties in identification, PMI estimation and manner and cause of death determination. In such cases, integrating routine approaches (autopsy, histology, toxicology) to more specific forensic branches can be fundamental to improving the investigative process. In this paper a systematic review using PubMed, Scopus and Web of Science databases has been performed. The aim was to evaluate the forensic approaches implemented in the management of severely altered bodies due to decomposition, mummification, skeletonization, charring or dismemberment (to which we refer to as "complex"), and the role of each approach in the solution of a case. Then, the literature revision results were used to propose a schematic flowchart summarizing the post mortem activities that can be performed in forensic practice, adaptable in relation to each case.

Suicide, depression and thyroid dysregulation: An unusual case of unplanned complex suicide.

Complex suicides are rare events pursued by the victims by means of two or more different fatal methods and can be further classified in planned or unplanned depending on the simultaneous or sequential application of the methods, respectively. The multiplicity of the injuries detected can frequently lead to misinterpretations, thus making a multidisciplinary approach of utmost importance. Here an unusual unplanned complex suicide was described discussing the post-mortem data leading to the forensic diagnosis; moreover, a focus on the depression cause was reported. The case regarded a 48-year-old man with a recent diagnosis of depression who self-stabbed his neck and, subsequentially, fallen from height. Data obtained from autopsy, histology, radiology and toxicology were described, highlighting the main findings for achieving the differential diagnosis between suicide and homicide. Moreover, microscopic findings compatible with an unrecognized thyroiditis led to consider the thyroid dysfunction as a possible substrate of depression, suggesting it potential effect on suicidal behaviour.

Application of Third Molar Maturity Index (I3M) for Assessing Adult Age of 18 Years in a Southern Italian Population Sample.

OBJECTIVE: Age estimation of living or dead individuals has a strategic importance in medicine, anthropology, and forensic science, in the context of mass disasters and in civil or criminal matters such as adoption or asylum. Teeth play a major role in this context in particular, the third molars are useful for determining whether an individual has reached the legal age of 18 years because they are still in development from the age of 14. MATERIALS AND METHODS: In this study, a sample of 307 panoramic radiographs performed on healthy subjects aged between 13 and 23 was analyzed to consider the correlation between the maturity index of the third molar (I3M) and age to verify the reliability of the cutoff 0.08 indicated by Cameriere et al in a sample of Italian subjects living in the Province of Messina (Sicily, South Italy) to discern the adult subjects from the minors. STATISTICAL ANALYSIS: The analysis of 307 panoramic radiographs resulted in a sensitivity of 89.2% with a confidence interval of 95%, a specificity of 96.5% with a confidence interval of 95%, and a positive predictive value of 96.7%. RESULTS: The method proved itself reliable in estimating adulthood in the population of the Messina- Sicily, but the I3M should not be used as the sole indicator to determine whether a person is younger or older than 18 years because age estimation based on dental methods alone has limitations as the third molars suffer from many variations related to their morphology, their location, and their development. CONCLUSION: We recommend a combination of several methods that are available to increase accuracy of age estimation, depending on the different legal requirements in civil or criminal cases.

Pharmacological Aspects and Biological Effects of Cannabigerol and Its Synthetic Derivatives.

Cannabigerol (CBG) is a cannabinoid from the plant Cannabis sativa that lacks psychotomimetic effects. Its precursor is the acidic form, cannabigerolic acid (CBGA), which is, in turn, a biosynthetic precursor of the compounds cannabidiol (CBD) and Δ9-tetrahydrocannabinol (THC). CBGA decarboxylation leads to the formation of neutral cannabinoid CBG, through a chemical reaction catalyzed by heat. On the basis of the growing interest in CBG and with the aim of highlighting scientific information on this phytocannabinoid, we focused the content of this article on its pharmacokinetic and pharmacodynamic characteristics and on its principal pharmacological effects. CBG is metabolized in the liver by the enzyme CYP2J2 to produce hydroxyl and di-oxygenated products. CBG is considered a partial agonist at the CB1 receptor (R) and CB2R, as well as a regulator of endocannabinoid signaling. Potential pharmacological targets for CBG include transient receptor potential (TRP) channels, cyclooxygenase (COX-1 and COX-2) enzymes, cannabinoid, 5-HT1A, and alpha-2 receptors. Pre-clinical findings show that CBG reduces intraocular pressure, possesses antioxidant, anti-inflammatory, and anti-tumoral activities, and has anti-anxiety, neuroprotective, dermatological, and appetite-stimulating effects. Several findings suggest that research on CBG deserves to be deepened, as it could be used, alone or in association, for novel therapeutic approaches for several disorders.

State of the Art on the Role of Postmortem Computed Tomography Angiography and Magnetic Resonance Imaging in the Diagnosis of Cardiac Causes of Death: A Narrative Review.

The need of a minimally invasive approach, especially in cases of cultural or religious oppositions to the internal examination of the body, has led over the years to the introduction of postmortem CT (PMCT) methodologies within forensic investigations for the comprehension of the cause of death in selected cases (e.g., traumatic deaths, acute hemorrhages, etc.), as well as for personal identification. The impossibility to yield clear information concerning the coronary arteries due to the lack of an active circulation to adequately distribute contrast agents has been subsequently overcome by the introduction of coronary-targeted PMCT Angiography (PMCTA), which has revealed useful in the detection of stenoses related to calcifications and/or atherosclerotic plaques, as well as in the suspicion of thrombosis. In parallel, due to the best ability to study the soft tissues, cardiac postmortem MR (PMMR) methodologies have been further implemented, which proved suitable for the detection and aging of infarcted areas, and for cardiomyopathies. Hence, the purpose of the present work to shed light on the state of the art concerning the value of both coronary-targeted PMCTA and PMMR in the diagnosis of coronary artery disease and/or myocardial infarction as causes of death, further evaluating their suitability as alternatives or complementary approaches to standard autopsy and histologic investigations.

The role of PMCT for the assessment of the cause of death in natural disaster (landslide and flood): a Sicilian experience.

In this report, the authors provide a contribution of PMCT in assessing the cause of death due to natural disasters. Here, the PMCT findings of 43 subjects who died during both landslide and flood were described. The post-mortem imaging revealed, clearly, traumatic injuries and/or the presence of foreign material in airways allowing to assess the cause of death of each subject, together with external inspection and the collected circumstantial data. Particularly, the PMCT has been helpful for characterization and localization of the clogging substance in airways providing findings on bronchial branches involvement. Moreover, the investigation offered detailed data on skeletal injuries in all anatomic districts and put in evidence both the precise fracturing site and the characteristics of fracture stubs for each bone fracture. This report supports the recommendation of the virtual autopsy in a case with several victims, as in natural disasters, and its role as an alternative diagnostic investigation when the standard autopsy is not feasible.

An Insight into the Role of Postmortem Immunohistochemistry in the Comprehension of the Inflammatory Pathophysiology of COVID-19 Disease and Vaccine-Related Thrombotic Adverse Events: A Narrative Review.

On 11 March 2020, the World Health Organization (WHO) declared a pandemic due to the spread of COVID-19 from Wuhan, China, causing high mortality rates all over the world. The related disease, which mainly affects the lungs, is responsible for the onset of Diffuse Alveolar Damage (DAD) and a hypercoagulability state, frequently leading to Severe Acute Respiratory Syndrome (SARS) and multiorgan failure, particularly in old and severe-critically ill patients. In order to find effective therapeutic strategies, many efforts have been made aiming to shed light on the pathophysiology of COVID-19 disease. Moreover, following the late advent of vaccination campaigns, the need for the comprehension of the pathophysiology of the fatal, although rare, thrombotic adverse events has become mandatory as well. The achievement of such purposes needs a multidisciplinary approach, depending on a correct interpretation of clinical, biochemical, biomolecular, and forensic findings. In this scenario, autopsies have helped in defining, on both gross and histologic examinations, the main changes to which the affected organs undergo and the role in assessing whether a patient is dead "from" or "with" COVID-19, not to mention whether the existence of a causal link exists between vaccination and thrombotic adverse events. In the present work, we explored the role of postmortem immunohistochemistry, and the increasingly used ancillary technique, in helping to understand the mechanism underlying the pathophysiology of both COVID-19 disease and COVID-19 vaccine-related adverse and rare effects.

Post-Mastectomy Pain: An Updated Overview on Risk Factors, Predictors, and Markers.

After breast surgery, women frequently develop chronic post-mastectomy pain (PMP). PMP refers to the occurrence of pain in and around the area of the mastectomy lasting beyond three months after surgery. The nature of factors leading to PMP is not well known. When PMP is refractory to analgesic treatment, it negatively impacts the lives of patients, increasing emotional stress and disability. For this reason, optimizing the quality of life of patients treated for this pathology has gained more importance. On the basis of the findings and opinions above, we present an overview of risk factors and predictors to be used as potential biomarkers in the personalized management of individual PMP. For this overview, we discuss scientific articles published in peer-reviewed journals written in the English language describing risk factors, predictors, and potential biomarkers associated with chronic pain after breast surgery. Our overview confirms that the identification of women at risk for PMP is fundamental to setting up the best treatment to prevent this outcome. Clinical practice can be planned through the interpretation of genotyping data, choosing drugs, and tailoring doses for each patient with the aim to provide safer and more effective individual analgesic treatment.

Caspase 9 and Caspase 3 Immunohistochemical Pattern in Skeletal and Cardiac Muscles at Different Times after Death: An Experimental Study on PMI Estimation.

(1) Background: The estimation of the post mortem interval (PMI) is a challenge for forensic pathologists because data emerging from methods commonly applied are not always conclusive, since several conditions exist that may affect the reliability of these parameters. Thus, new approaches have been proposed to overcome such a limit. In recent years, several studies have been performed on proteins analyzing their expression/degradation patterns in relation to the progressing of the post mortem interval. (2) Methods: The immunoreactivity patterns of two apoptosis mediators-Caspase 9 and Caspase 3-have been tested in order to evaluate their potential role as markers of the post mortem interval. The immunohistochemical analysis was performed on samples of skeletal and cardiac muscles obtained from rats at 0, 4, 8, 12, 24 and 72 h after death. (3) Results: The observed immunoreactivity patterns of both Caspase 9 and Caspase 3 showed a significant correlation with increasing post mortem interval either in skeletal or cardiac muscles, while the comparison of the immunoreactivity patterns of the two apoptotic mediators within each tissue appeared consistent with a preliminary activation of the "initiator" Caspase 9, which, in turn, subsequently activates the "executioner" Caspase 3. (4) Conclusion: The different expressions and decrease immunohistochemically observed on both caspases with progressing PMI support the usefulness of the combined analysis for post mortem interval estimation.

Dystrophin and metalloproteinase 9 in myocardial ischemia: A post-mortem immunohistochemical study.

The presented study evaluated the expression of dystrophin and MMP-9 in cases of sudden cardiac death (SCD) due to coronary atherosclerotic disease (CAD) in order to analyze the characteristics and the chronology of their expression, providing evidence on the possible role in post-mortem diagnosis of myocardial ischemia. The expression of these proteins was also compared to C5b-9 complex and fibronectin expression to evaluate any differences. Two groups of CAD-related SCD, respectively group 1 with gross and/or histological evidence and group 2 with no specific histological signs of myocardial ischemia, were used. A third group formed by cases of acute mechanical asphyxiation was used as a control. The immunohistochemical staining by dystrophin, MMP-9, C5b-9, and fibronectin antibodies was performed. The study revealed that dystrophin and MMP-9 showed different expression in group 1 and group 2 as, respectively, different degree of sarcolemmal staining depletion and increasing of interstitial and granulocytes immunopositivity. Moreover, loss of dystrophin staining and C5b-9 immunopositivity were more significant when compared to MMP-9 increasing. Dystrophin and MMP-9 seemed to be useful immunohistochemical markers for the detection of myocardial ischemic damage. However, the comparison of the four markers suggested that loss of dystrophin could be considered as an earlier marker.

Investigation of the skin lesions in lightning strike death.

Lightning strike-related deaths are unusual, and the victim bodies can present different lesions due to the different injury mechanisms associated with this event. Since the post mortem assessment can be challenging, the evaluation of the characteristics of the skin lesions becomes fundamental to reconstruct the event. Due to the paucity of literature on this topic, the authors report the case of a 59-year-old man found dead near his home after a thunderstorm. Initially considered a murder by gunshot, the autopsy revealed the typical lightning strike lesions, also known as Lichtenberg figures. The adequate interpretation of the autopsy data and the histological evidences allowed to reconstruct the death dynamic and to relate it to a lightning strike. The main lesions due to lightening are here reported and discussed in order to provide a workflow for the identification of lightening as cause of death in unwitnessed cases.

Forensic investigative issues in a fireworks production factory explosion.

Since their discovery in ancient China, fireworks rapidly spread throughout the world, where they have always been used to celebrate either popular or private events. Their use is nonetheless related to several risks, especially within production factories, since several injuries or even death can occur following an accidental ignition. In cases of major disasters related to fireworks explosions, stating the accidental or intentional nature of the event might prove challenging, thus raising the need of a multidisciplinary approach. In this regard, we here discuss the case of an accidental explosion that occurred in a fireworks production factory, accountable for five deaths and two hospitalisations.

Pathological Findings in COVID-19 as a Tool to Define SARS-CoV-2 Pathogenesis. A Systematic Review.

Introduction: The World Health Organization declared the COVID-19 pandemic in March 2020. COVID-19 still represents a worldwide health emergency, which causesa severe disease that has led to the death of many patients. The pathophysiological mechanism of SARS-CoV-2 determining the tissue damage is not clear and autopsycan be auseful tool to improve the knowledge of this infection and, thus, it can help achieve a timely diagnosis and develop an appropriate therapy. This is an overview of the main post-mortem findings reporting data on the infection effects on several organs. Methods: A systematic literature search was conducted in the PubMed database searching for articles from 1 January to August 31, 2020. Thearticles were selected identifying words/concepts in the titles and/or abstracts that indicated the analysis of the morphological/pathological tissue injuries related to SARS-CoV-2 disease by several investigations. Results: A total of 63 articles were selected. The main investigated tissue was the lung showing a diffuse alveolar damage (DAD) frequently associated with pulmonary thrombotic microangiopathy. Inflammatory findings and vascular damage were observed in other organs such as heart, liver, kidney, brain, spleen, skin and adrenal gland. The immunohistochemical analysis showed tissue inflammatory cells infiltrates. The virus presence was detected by several investigations such as RT-PCR, immunohistochemistry and electron microscope, showing the effect ofSARS-CoV-2not exclusively in the lung. Discussion: The evidence emerging from this review highlighted the importance of autopsy to provide a fundamental base in the process of understanding the consequences ofSARS-CoV-2 infection. COVID-19 is strictly related to a hyper inflammatory state that seems to start with DAD and immuno-thrombotic microangiopathy. Massive activation of the immune system and microvascular damage might also be responsible for indirect damage to other organs, even if the direct effect of the virus on these tissues cannot be excluded.