Multiple nail gun injuries: suicide or homicide?

Nail gun injuries are a forensic problem; it can be difficult to distinguish self-inflicted injuries from accident and homicide instances. This kind of injuries shares some characteristics with both gunshot and puncture wounds. We describe a peculiar case of a man who committed suicide driving nails into his skull using a pneumatic nail gun. Entrance wounds were found on both temporal regions of the head. Reviewing scientific literature, this is the first case in Italy reporting the macroscopic data of bilateral head and brain nail gun injuries during an autopsy. Circumstantial elements were not sufficient to clarify if these lesions were self-inflicted, inflicted by accident, or else. Radiological examination can be helpful to show the exact location of the nails, but it has also its own limitations. We firmly believe that autopsy, especially the head section, is crucial to identify the nature and the extension of these lesions, thus giving us much more information about the mechanism of death and the circumstances in which it occurred.

Spectrophotometric evaluation of postmortem lividity: a proposal of a model for negroid ethnic race.

The interpretation of tanatochronological data is a fundamental aspect of the medico legal diagnosis, because it allows to trace back the interval of death. Traditionally, the evaluation of the hypostasis plays a relevant role in the interpretation of such information, despite its well-known limits and fallacies. In order to evaluate the degree of hypostatic area discoloration, the methodology currently used is highly subjective and influenced by several variables. The hypostasis pattern in individuals with V-VI phototype is useless because their post-mortem lividity is not estimable due to the color of the skin. This makes much harder to estimate the interval between the death and the detection of the tanatochronological data. This study is aimed at defining a highly accurate procedure to develop an objective method to estimate the hypostasis' degree of fixation with scientific accuracy on people with darker skin. The technology used is spectrophotometry Antera3D: this device is able to analyse the hypostasis by measuring the mean hemoglobin quantitative level in the skin either before and after a standardized compression, thus obtaining a numerical value that is directly related to the time of death. The method here presented allows analysing the hemoglobin amount in the skin of a dead body, without the influence of the melanin pigment in the definition of the hypostatic area color, therefore enabling us to overcome the objective limits of the direct and empiric estimation of the hypostasis decoloration. By creating a standardized method it's possible to reduce the operator-dependent error and to introduce a valid and applicable procedure in order to estimate the post-mortem interval.

Necrotizing Fasciitis of the Thigh as Unusual Colonoscopic Polypectomy Complication: Review of the Literature with Case Presentation.

Necrotizing fasciitis (NF) is an infection characterized by necrosis of the superficial muscle fascia and surrounding soft tissues. It usually occurs following skin breaches from penetrating traumas or high-degree burns. Less frequently, it could be related to major abdominal surgery. However, no cases of thigh NF after minor abdominal procedures have ever been reported. A previously healthy 59-year-old male patient underwent a colonoscopic polypectomy. After the procedure, the patient developed an increasing right groin pain. The CT scan showed a gas collection in the right retroperitoneum space and in the right thigh soft tissues. Thus, a right colon perforation was hypothesized, and the patient was moved to the nearest surgery department and underwent a right hemicolectomy procedure. During surgery, the right thigh was also incised and drained, with gas and pus leakage. Nevertheless, the right lower limb continued to swell, and signs of systemic infection appeared. Afterward, clinical conditions continued to worsen despite the drainage of the thigh and antibiotic therapy, and the patient died of septic shock after just two days. This case shows that, although rare, lower limb NF should be considered among the causes of early post-operative local painful symptoms.

A Comparison of 3 Established Skeletal Age Estimation Methods in an African Group From Benin and an Italian Group From Southern Italy.

Age estimation is a crucial matter in several forensic and legal instances. The literature recommends carrying out hand and wrist radiograph to assess skeletal age. Much research has been conducted to examine the application of various methods in different categories. Our study aims to evaluate the reliability of Greulich and Pyle, Tanner-Whitehouse 2, and FELS methods in Beninese and Italian samples, with a total of 204 subjects, 102 (51 were male and 51 were female) from Benin and 102 (51 were male and 51 were female) from Italy, aged between 4 and 19 years. Hand-wrist radiographs were carried out at Saint Luc Hospital in Cotonou for the African sample and in 2 hospitals in Southern Italy for Italian sample. Skeletal maturity was obtained, applying the 3 methodologies. The arithmetic mean of the 3 ages obtained was calculated, as well as the possible difference between the known chronological age and the estimated mean skeletal age. Data were analyzed statistically using the χ test, Student t test, and Bland-Altman plots. There are no significant statistical differences between real age and skeletal age calculated using the Greulich and Pyle and FELS methods. Comparison between Tanner-Whitehouse 2 and the average of the methods used results in statistically significant, but clinically insignificant, differences.

Using simulation to design control strategies for robotic no-scar surgery.

No-scar surgery, which aims at performing surgical operations without visible scars, is the vanguard in the field of Minimally Invasive Surgery. No-scar surgery can be performed with flexible instruments, carried by a guide under the vision of an endoscopic camera. This technique brings many benefits for the patient, but also introduces several difficulties for the surgeon. We aim at developing a teleoperated robotic system for assisting surgeons in this kind of operations. In this paper, we present a virtual simulator of the system that allows to assess different control strategies for our robot and to study possible mechanical issues.

Extraction of DNA from bones in cases where expectations for success are low.

To resolve cases involving unidentified cadavers, the study of polymorphic DNA markers of old bones is an invaluable but often challenging tool used in forensic genetics. Some of the difficulties encountered involve the limited quantity of endogenous DNA, its subsequent degradation (a result of elapsed time, environmental conditions, and the microorganisms that develop during the postmortem phase), and the coextraction of substances that inhibit amplification reactions. For these reasons, it is necessary to direct research toward the development of new extraction techniques with the goal of obtaining adequate quantities of high-quality DNA.The aim of this study was to improve the collection of extracted DNA compared with the amount of DNA obtained with the NucleoSpin DNA Trace Kit (Macherey Nagel) protocol for the extraction of genomic DNA from human bones. A modified version of the standard protocol is presented.The modified method for the extraction of genomic DNA, followed by amplification reaction, allowed for identification of 4 cadavers and typification of 1 cadaver. The study carried out involved unidentified cadavers, or their remains, discovered after a long period from time of death.

Dental evidence of human remains of a Slavic soldier population deported in concentration camps during World War II.

Aims: The aim of this paper was to analyse post-mortem dental records of a collection of 93 skeletal remains exhumed from the ossuary of Bari Municipal Cemetery, Apulia, Italy. These skeletal remains belonged to Slavic soldiers deported in 1941 during World War II in two Italian concentration camps and who died in 1946-1947. Methods: A total number of 1949 teeth were analysed according to the American Board of Forensic Odontology and the WHO methods. The majority of the victims were men (95%) between the age of 18 and 62. Results: The results showed the dental health situation of a population of soldiers of World War II, in particular the high rate of caries (35%), periodontal disease (61%), and dental wear (65%) according to the high stress level of the soldiers during the armed conflict and the subsequent deportation. Conclusions: This is the first study reported in literature that analyses the effects of war and deportation on soldiers' pathological conditions of the oral cavity. This analysis also confirmed the usefulness of teeth for anthropological and forensic research thanks to their high resistance and preservation even after post-mortem modifications and different environmental factors.

Spectrophotometric analysis of post-mortem lividity: A new objective measure to define time of death.

The correct definition of time of death often represents a key to solving judicial cases. One of the methods for determination of the time interval since death is at present the quantitative and qualitative characteristics of hypostases. However, the simple observation of the degree and fixation of hypostases is based on nonobjective parameters, and is therefore characterized by an intrinsic variability that can compromise their reliability. The purpose of the present study was to define an objective and standardizable method that allows estimation of time since death with good approximation. To achieve this, the instrument used was based on spectrophotometry, to analyze only the hemoglobin contribution to skin color, while excluding the role of melanin. This made it possible to analyze a hypostatic area, with a numerical value defined as a measure of the hemoglobin content before and after application of standardized pressure for a defined time interval. The study was conducted on 100 cadavers in various wards. The variables considered in the study were: Hb-pre (mean hemoglobin measure before weight force application); Hb-post (mean hemoglobin measure after weight force application), ΔHb (change in mean hemoglobin measures from before to after weight force application); and red% Hb (percentage reduction in hemoglobin after weight force application, compared to the mean measure of hemoglobin before weight force application). The analysis showed statistically significant correlations between red% Hb in the skin area analyzed and time from death to examination. This provided a mathematical formula to estimate time since death with good reliability ( ± 4 h, 50 min).

Cerebral venous sinus thrombosis after COVID-19 vaccination and congenital deficiency of coagulation factors: Is there a correlation?

In January 2020, SARS-COV-2 infection spread worldwide and was declared "pandemic" by WHO. Because of the high contagiousness of the virus and devastating effects of the epidemic on public health, numerous efforts have been made to develop suitable vaccines to prevent the infection. Among the side effects developed by patients who undergone vaccination, there are common symptoms but also more serious reactions such as the thrombosis syndromes. This paper presents two cases of thrombosis temporally associated with live-vectored Covid vaccination similar to vaccine-induced thrombocytopenia (VITT) in patients with inherited thrombophilia (respectively, the deficiency of protein S and a Factor II mutation). The clinical manifestation caused by VITT is characterized by widespread thrombosis especially affecting intracranial venous sinus, which may cause massive bleeding and intracranial hemorrhage. Although this condition is widely described in literature, there is no evident correlation between this side effect and inherited condition of thrombophilia. The authors suggest that the presence of inherited thrombophilia should be better investigated and, if necessary, screened during the anamnestic data collection before the vaccine administration, leading the healthcare professional to choose the appropriate vaccine to the patient.

Morphological cardiac changes in electrocution deaths: A literature review.

Electrical injury may lead to damage to the conducting tissue, myocardial changes and even sudden cardiac death. Victims of low-voltage electrocution may have no electric marks, burns or other signs typical of electrical injuries. In these cases, the absence of other specific findings could make the identification of the cause of death very difficult. A broad spectrum of cardiac changes in cases of electrocution has been described in the literature, including the break-up of myocardial fibres, cardiomyolysis, haemorrhagic areas, the separation of myofibres and alternating hypercontracted-hyperdistended myocytes. All the described alterations, however, cannot be exclusively attributed to electrocution, since no specific morphological cardiac findings have so far been identified in electrocution. However, a few histological patterns recur, and their knowledge may be important for the forensic pathologist. This literature review describes the main pathological patterns observed in cases of fatal electrocution based on a literature search carried out up to September 2019 in the databases PubMed and Scopus. The search criteria included the keywords for cardiac lesions and electrocution. On the grounds of the literature data, a list of major and minor diagnostic markers for the passage of the electrical current through the heart tissue was created.

Dental age estimation: Demirjian's versus the other methods in different populations. A literature review.

Age estimation is an important issue in forensic anthropology and odontology, since it is applied to both the living and the dead. Studies have shown that assessing tooth development using radiological methods is a reliable way to estimate age, especially in children. Demirjian's method is the most widely used estimation method for dental age evaluation. Over the years, many methods have been developed in order to asses which one predicts more accurately the age. In the literature, many populations were examined with these different methods and discordant results are described. This review aims to evaluate the studies in which Demirjian's method was compared with Willems', Cameriere's, Nolla's, Smith's, Haavikko's and Chaillet's methods in order to estimate the most accurate dental age estimation method in different populations. Using the methodology described in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement, the authors conducted a review of existing literature using three databases: PubMed, Google Scholar and Google Scopus.

Soft-tissue thickness values using cone beam computed tomography: A literature review.

When human remains are found, with no evidence of identity, facial approximation can be a useful technique to employ. The reconstruction of the ante-mortem appearance can reproduce the likely features of the face, starting from the skull, based on the overlying soft-tissue thickness. Over the years, many techniques have been developed to achieve soft-tissue thickness measurements, one of which is based on the use of cone beam computed tomography. This study aimed to review the status of this technique and to evaluate heterogeneity among studies undertaken in this field, with particular regard to determination of landmarks, sex and body mass index.

Suspension of Care for Patients With Spasticity During COVID-19 Pandemic: Ethical and Medico-Legal Point of View Starting From an Italian Study.

The COVID-19 pandemic has revolutionized the habits of entire communities, having even more profound negative effects on assistance for the chronically ill. The sudden demand for extraordinary resources caught all worldwide countries unprepared, highlighting shortages in provision of care services. This applies to all patients, affected by COVID-19 or not, as many need continuing access to chronic diseases treatments. Almost all of the energy available has been directed toward care of COVID-19 patients, and almost nothing has been done to continue therapy for patients with spasticity. This study builds on a recent article and discusses its results as a basis for highlighting the ethical dilemmas and unintended consequences of health systems changing their priorities during the pandemic. The above mentioned study has shown increased patient-perceived spasticity during lockdown (72.2%) with reductions in perceived quality of life (70.9%). Telemedicine tools have proved insufficient, with access by only 7.3% of these patients. Despite the health emergency, it cannot be denied that this situation is a violation of these patients' rights and dignity. The healthcare system will also have to bear increased costs in the future to recover the loss of previous therapies benefits, because of their interruption. The real challenge will be to exploit the critical issues emerged during the pandemic, and to resolve the measures needed to take the care to the patient, and not vice versa. This applies particularly to fragile patients, to respect their dignity and right to care.

Torkildsen's Ventriculocisternostomy First Applications: The Anthropological Evidence of a Young Slavic Soldier Who Died in the Torre Tresca Concentration Camp (Bari, Italy) in 1946.

Human skeletal remains are considered as real biological archives of each subject's life. Generally, traumas, wounds, surgical interventions, and many human pathologies suffered in life leave identifiable marks on the skeleton, and their correct interpretation is possible only through a meticulous anthropological investigation of skeletal remains. The study here presented concerns the analysis of a young Slavic soldier's skeleton who died, after his imprisonment, in the concentration camp of Torre Tresca (Bari, Italy), during the Second World War (1946). In particular, the skull exhibited signs of surgical activity on the posterior cranial fossa and the parieto-occipital bones. They could be attributed to surgical procedures performed at different times, showing various degrees of bone edge remodeling. Overall, it was possible to correlate the surgical outcomes highlighted on the skull to the Torkildsen's ventriculocisternostomy (VCS), the first clinically successful shunt for cerebrospinal fluid (CSF) diversion in hydrocephalus, which gained widespread use in the 1940s. For this reason, the skeleton we examined represents a rare, precious, and historical testimony of an emerging and revolutionary neurosurgical technique, which differed from other operations for treating hydrocephalus before the Second World War and was internationally recognized as an efficient procedure before the introduction of extracranial shunts.

Sex determination through the evaluation of sella turcica measurements using head CT scan.

The estimation of age and sex is mandatory in forensic identification of unknown skeletal remains and it could be reached analyzing different bones' features. The morphometric evaluation of Sella turcica is less described in literature. Many studies have been published in this field for age estimation but none of them based on head CT scan measurement. Previous studies were carried out for age estimation on different populations, but any study has been carried out on the Italian population. Furthermore, no studies were carried out with CT scan technology for the correlation between sex and Sella turcica. Thanks to CT scan technology it has been possible to measure sella turcica's dimensions in an easier way than previous methods, to detect more accurate parameters and even introduce a new one. In this study, the sample was composed of 115 adults, 53 males, and 62 females. Five different measurements of the sellae turcicae were taken. The purpose of this study was to find new elements for sex assessment with the evaluation of sella turcica measurements, improving previous studies, analyzing an Italian European sample. In this study, results of the statistical analysis showed correlation between sex and sella turcica's parameter "Length of Sella Turcica" for which grater values are related to male gender. In conclusion, the Authors consider this unexpected result useful for sex determination in association with other parameters.

DNA extraction from sternum bone for identification of a saponified body: use of a modified protocol.

This paper discusses our approach and results obtained when attempting to identify a saponified human body recovered from the sea, without arms and legs. Bones, especially the long ones, are the only sources of DNA available in several cases involving unidentified bodies in advanced state of putrefaction. In this case, since the body was found without limbs, attempts were made to extract DNA from the sternum bone. The DNA was extracted using a modified version of the NucleoSpin® DNA Trace Kit (Macherey Nagel™) protocol and an STR analysis was performed. Thanks to this modified protocol a complete DNA profile was obtained from the sternum bone, while only partial results were obtained from blood and teeth. The DNA profile obtained from the sternum was compared with the DNA of the putative son searching for a genetic match. Five incompatibilities were detected so it was possible to exclude the kinship. In conclusion this could be a useful technique in personal identification through DNA analysis in case of poor quality and quantity of bone.

High tension electrocution death: New histopathological cardiac tools by Confocal Laser Scanning Microscope.

In deaths due to electrocution intraepidermal separation, vacuolation of epidermal cells, "swiss cheese" aspect of the superficial part of epidermis (swollen and with multiple vescicles), metallization, necrosis of collagenous fibers, cardiomyocytes alterations are microscopically described. No cardiac nerve damage due to electricity is actually reported in literature. In this work we tried to find new morphological signs in the hearts of deaths due to electrocution. In three cases of deaths due to electrocution, in which forensic autopsies were performed within 36 h of the death, heart specimens were taken at the level of common trunk of the left coronary artery. The myocardium histological examination at optical microscope and Confocal Laser Scanning Microscope (CLSM) revealed fragmentation of cardiomyocytes, nerve trunks damage with hydropic swelling of the nerve fibers, interstitial and sub-nerve-sheath edema, very dishomogenous distribution of the natural fluorescence of the neurofilaments, coarctation of epicardial gangliar cells with cytoplasmic cleft and irregular fluorescence pattern. Identification of S-100 protein by immunohistochemistry can help to better observe the hydropic swelling of the nerve fibers and the central cytoplasmic clefts. These alterations could be used in future as specific signs of the passage of the electrical current through the heart. We recommend heart specimens at the level of common trunk of the left coronary artery in all the cases of suspected electrocution, to better evaluate cardiac nerve trunks damages and alterations.

Facial approximation: Soft tissue thickness values for Caucasian males using cone beam computer tomography.

The aim of this study was to obtain soft tissue thickness (STTs) of Caucasian males starting from 12 bone landmarks, to allow facial reconstruction and assign an identity to skeletal remains. When a skeleton is found without any circumstantial evidence of identity, through anthropological investigations it is possible to estimate age, sex, and race studying specific characteristics of bones. This first step of identification process helps investigators to narrow down the identity suppositions, but not always forensic analysis guarantees a final positive identification. Moreover, it is possible to rely on facial reconstruction trying to reproduce the likely features of the face from the skull. The obtained images could be used as a support in recognition by relatives who could provide photos and other data to carry out a comparative analysis. Furthermore, identity can be confirmed by conventional identification methods such as DNA profiling, odontological identification, and radiological comparison. Forensic facial reconstruction (FFR) is based on the bone surface that conditions the facial physiognomy. Analyzing cone beam CT (CBCT) scans of 30 Caucasian males, average STTs values were obtained. CBCT, compared with the conventional spiral CT, has much lower radiation doses, lower costs, high spatial resolution and focuses on head and neck. The obtained results were compared with existing literature and databases and were analyzed by descriptive statistics. Two researchers repeated measurements in different times to assess the reliability of the method.

Morphologic analysis of third-molar maturity by digital orthopantomographic assessment.

Accurate timing of the eruption of first and permanent teeth is an important parameter in forensic odontology to establish the age of dead or live individuals. Determination of adulthood may determine, for example, whether an individual convicted of a crime is sentenced as an adult and incarcerated in a state penal institution or as a juvenile and sent to a juvenile camp. At present, there is a large immigrant population in Italy, and young foreign criminals sometimes have false passports bearing a later birth date, with the aim of evading punishment. In such circumstances, age determination is becoming a significant forensic issue.Late in adolescence, after formation of the premolars and canines, only the third molars continue to develop. According to several studies, although the third molars are the most variable teeth in the dentition, they remain the most reliable biologic indicator available for estimation of age during the middle teens and early twenties.In this study, the authors test the possibilities offered by orthopantomography executed by means of digital technology, with the aim of exploiting the advantages of the computerized digital technique compared with the conventional technique, to determine adult age on the basis of root development of the third molar.Digital radiography is simple to use, quick, and effective, allowing superimposition and enlargement; the images can be electronically stored and transported. In comparison with traditional orthopantomography, the digital technique features greater diagnostic accuracy of some anatomic structures: upper and lower front teeth, root apexes, floor of the nasal fossa and maxillary sinus, nasal septum, mandibular condylus. Moreover, digital orthopantomography suffers less from artifacts.The digital orthopantomographies of 83 Caucasian subjects (43 females and 40 males) aged between 16 and 22 years were analyzed in standard conditions, assessing the degree of maturation of the upper and lower third molars. A standardized computer procedure was used to acquire the x-ray images, recording 3 per plate: the overall orthopantomography and 2 enlargements of optical type of the left and right sides, to reveal the third molars while maintaining unaltered the image resolution.For the analysis, the authors adopted Demirjian's staging system that classifies development of the third molar in 8 stages (A, B, C, D, E, F, G, H) on the basis of morphologic criteria. This has been statistically proved to feature notable precision and high predictive ability.To assess any sex-related variations in mineralization speed, the series was subdivided by gender. The study demonstrated that such differences are more evident under the age of 18 years.Overall, the observation of 245 third molars showed faster development of the upper than the lower third molars, a prevalence of stages D to G in the age range between 16 and 18 years, and a clear predominance of stage H in individuals over 18 years of age. Finally, an intermediate stage between G and H was demonstrated in subjects aged between 17 and 21 years.

Photogrammetric 3D skull/photo superimposition: A pilot study.

The identification of bodies through the examination of skeletal remains holds a prominent place in the field of forensic investigations. Technological advancements in 3D facial acquisition techniques have led to the proposal of a new body identification technique that involves a combination of craniofacial superimposition and photogrammetry. The aim of this study was to test the method by superimposing various computerized 3D images of skulls onto various photographs of missing people taken while they were still alive in cases when there was a suspicion that the skulls in question belonged to them. The technique is divided into four phases: preparatory phase, 3d acquisition phase, superimposition phase, and metric image analysis 3d. The actual superimposition of the images was carried out in the fourth step. and was done so by comparing the skull images with the selected photos. Using a specific software, the two images (i.e. the 3D avatar and the photo of the missing person) were superimposed. Cross-comparisons of 5 skulls discovered in a mass grave, and of 2 skulls retrieved in the crawlspace of a house were performed. The morphologyc phase reveals a full overlap between skulls and photos of disappeared persons. Metric phase reveals that correlation coefficients of this values, higher than 0.998-0,997 allow to confirm identification hypothesis.