Looking for Post-Mortem Metabolomic Standardization: Waiting for Godot-The Importance of Post-Mortem Interval in Forensic Metabolomics.

A growing body of evidence suggests that the post-mortem interval exerts a strong effect on the metabolome, independently of the biological matrix or the cause of death. A sound and shared approach in standardization is mandatory.

Life-threatening danger assessments of penetrating injuries in Eastern Danish clinical forensic medicine.

Clinical forensic assessments of injuries' life-threatening danger may have an impact on the legal aftermath following a violent assault. The pursuit of evidence-based guidelines should ensure a user-independent and reproducible forensic practice. However, does it? The aim of this study was to evaluate the forensic life-threatening danger assessments after a protocol implementation in 2016. The evaluation concerned usability and reproducibility of the protocol, and its influence on assessment severity. We analyzed the level of inter- and intra-rater agreement using 169 blinded, prior-protocol cases that were reassessed by two forensic specialists. We compared assessment made the year before and after protocol implementation (n = 262), and the forensic specialists' reassessments with the prior-protocol cases' original assessments (n = 169). Whether to make an assessment, the levels of agreement varied between weak agreement (inter-rater, Κ = 0.43; assessor 1, Κ = 0.57) and strong agreement (assessor 2, Κ = 0.90). Regarding severity, the levels of agreement varied between strong agreement (inter-rater, Κ = 0.87; assessor 1: Κ = 0.90) and almost perfect agreement (assessor 2: Κ = 0.94). The assessments were statistically significant redistributed after the implementation (chi-square test: p < 0.0001). The proportion of cases assessed as having not been in life-threatening danger increased from 9 to 43%, and moderate severity assessments decreased from 55 to 23%. Of the moderate severity assessments, 55% were reassessed as having not been in life-threatening danger. The protocol ensured independent and reproducible assessments when the forensic specialists agreed on making one. The protocol resulted in less severe assessments. Future studies should examine the reliability of the protocol and its consequences for legal aftermaths.

Forensic evaluation of alleged wrist restraint/handcuff injuries in survivors of torture utilizing the Istanbul Protocol.

Despite being a common form of abuse, there is a paucity of literature describing shackling and wrist restraint injuries among survivors of torture. Forensic evaluation of alleged wrist restraint/handcuff injuries in survivors of torture presents challenges to the evaluator, especially if the injuries are remote and do not leave lasting marks nor neurologic deficits. Thorough history-taking and physical examination are critical to effective forensic documentation. Guidance is provided in The Manual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (Istanbul Protocol), the gold standard for the medicolegal documentation of torture. This guidance relies primarily on physical findings, with less direction provided on how to interpret historical evidence or when historical evidence provided by the patient can be interpreted as highly consistent with alleged injury in the absence of current physical findings. Through a case-based review, we present diagnostic strategies for the evaluation of alleged abuse involving wrist restraints/handcuffs, focusing on skin, neurologic, and osseous injuries. We highlight key findings from both the history and physical examination that will allow the evaluator to improve the accuracy of their expert medical opinion on the degree to which medical findings correlate with the patient's allegations of wrist restraint injuries.

Update on the Diagnostic Pitfalls of Autopsy and Post-Mortem Genetic Testing in Cardiomyopathies.

Inherited cardiomyopathies are frequent causes of sudden cardiac death (SCD), especially in young patients. Despite at the autopsy they usually have distinctive microscopic and/or macroscopic diagnostic features, their phenotypes may be mild or ambiguous, possibly leading to misdiagnoses or missed diagnoses. In this review, the main differential diagnoses of hypertrophic cardiomyopathy (e.g., athlete's heart, idiopathic left ventricular hypertrophy), arrhythmogenic cardiomyopathy (e.g., adipositas cordis, myocarditis) and dilated cardiomyopathy (e.g., acquired forms of dilated cardiomyopathy, left ventricular noncompaction) are discussed. Moreover, the diagnostic issues in SCD victims affected by phenotype-negative hypertrophic cardiomyopathy and the relationship between myocardial bridging and hypertrophic cardiomyopathy are analyzed. Finally, the applications/limits of virtopsy and post-mortem genetic testing in this field are discussed, with particular attention to the issues related to the assessment of the significance of the genetic variants.

Reliability of police reports when assessing health information at the forensic post-mortem examination-using schizophrenia as a model.

Autopsies continue to be the most reliable source of mortality statistics; however, more and more death certificates are based on the post-mortem external examination (PME) alone. Forensic PMEs differ from clinical PMEs, because the forensic pathologist usually has no preceding knowledge of the health of the decedent and must rely on information from authorities in the form of the police report. It is useful at the forensic PME to know whether the decedent suffered from a mental illness; however, it is unknown how valid such a diagnosis is, when based upon information in the police report alone. This study compared tentative diagnoses of schizophrenia from 500 forensic PMEs with a reference database based on the Danish National Patient Registry. We found that 19.3% of schizophrenia cases were missed, and 9.1 % of identified cases were false positives. Overall, 11.4% of all assessments were incorrect. Subgroup analysis showed that marital status as 'single' and the finding of illegal substances at the scene were predictors for both correctly identified and overlooked schizophrenia cases. The most reliable source of information was the decedent's general practitioner, whereas friends and neighbors were the most unreliable. Future studies should be aware of the risk of assigning a wrong diagnosis and use as many sources of information as possible. Taking the decedent's social history and observations about the scene into account may add to the diagnostic accuracy.

Emergency Department Management of the Sexual Assault Victim in the COVID Era: A Model SAFET-I Guideline From San Diego County.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has contributed to an increase in intimate partner violence (IPV), posing challenges to health care providers who must protect themselves and others during sexual assault examinations. Victims of sexual assault encountered in prehospital and emergency department (ED) settings have legal as well as medical needs. A series of procedures must be carefully followed to facilitate forensic evidence collection and law enforcement investigation. A literature review detected a paucity of published guidance on the management of sexual assault patients in the ED, and no information specific to COVID-19. OBJECTIVE: Investigators sought to update the San Diego County sexual assault guidelines, created in collaboration with health care professionals, forensic specialists, and law enforcement, through a consensus iterative review process. An additional objective was to create a SAFET-I Tool for use by frontline providers during the COVID-19 pandemic. DISCUSSION: The authors present a novel SAFET-I Tool that outlines the following five components of effective sexual assault patient care: stabilization, alert system activation, forensic evidence consideration, expedited post-assault treatment, and trauma-informed care. This framework can be used as an educational tool and template for agencies interested in developing or adapting existing sexual assault policies. CONCLUSIONS: There is a lack of clinical guidance for ED providers that integrates the many aspects of sexual assault patient care, particularly during the COVID-19 pandemic. A SAFET-I Tool is presented to assist emergency health care providers in the treatment and advocacy of sexual assault patients during a period with increasing rates of IPV.

Joint European Society of Paediatric Radiology (ESPR) and International Society for Forensic Radiology and Imaging (ISFRI) guidelines: paediatric postmortem computed tomography imaging protocol.

Postmortem CT for investigating childhood deaths is increasingly utilised as a noninvasive adjunct or alternative to standard autopsy; however there are no standardised published imaging protocols. This article describes a standardised imaging protocol that has been developed based on current practices of international postmortem imaging practitioners and experts. This recommendation is expected to be useful for postmortem imaging centres wishing to update their existing practices and for those starting paediatric postmortem CT as a new service.

Boundary-making in the medico-legal context: examining doctor-nurse dynamics in post-sexual assault forensic medical intervention.

A key dimension of the institutional response to sexual assault is the forensic medical examination of a victim's body conducted for purpose of documenting, collecting and testifying to corroborative evidence. Drawing upon in-depth interviews with forensic examiners and forensic nurse practitioners in one region of England, this study addresses a gap in the existing research on medico-legal processes, and critically examines the nature and dynamics of the relationship between doctors and nurses involved in this intervention. Using an analytic framework based on Thomas Gieryn's notion of 'boundary-work', we explore how this historically gendered dyadic relationship is experienced and understood in a context influenced by both medicine and law. We demonstrate very clear boundaries demarcating (i) physicians as experts and nurses as non-experts in the collection and representation of medical evidence, and, (ii) physicians as equated with technical competence and nurses with 'caring' duties. We conclude by positing implications that may stem from these professional relations with respect to sexual assault evidence, professionals and victims.

[Evaluation of injunction to care practices: A study of 119 cases]. / Évaluation des pratiques de l'injonction de soins : étude sur 119 sujets.

INTRODUCTION: The injunction to care (IC) is a new compulsory treatment created by the Act of June 17, 1998. Initially, this judicial tool concerned mainly sex offenders, but then the number of overall crimes requiring an IC began to dramatically rise. The judge can order this measure only if a psychiatric expertise has concluded to its potential opportunity. Then the convict must undergo a psychiatric follow-up after having served the sentence. The creation of a court-ordered treatment is based on the premise that many offenders are affected by psychiatric disorders. For the lawmaker, the aim is to lower the risk of recidivism. PURPOSES: The main purpose of this study is to assess the convicts concerned by the IC describing their sociodemographic characteristics, psychiatric diagnostics and criminal characteristics. The second purpose is to assess the efficiency of this measure regarding re-offending and specifically legal recidivism. METHODS: This is a retrospective and descriptive study concerning 119 subjects followed-up by two "coordinating doctors" in the department of Sarthe who could assess their psychiatric diagnostics and sociodemographic characteristics. They could also compare medical data with the judicial data for 78 of the subjects. RESULTS: The population was composed of 117 men (98.3%) aged 45 years old on average. They had a job in 37% of cases (n=44) and were single in 56.3% of cases (n=67). According to the DSM-IV-TR, only 29 subjects (24.4%) had an axis I disorder and 37.8% of the population had a pathological personality trait (non DSM-IV-TR categorized disorder). Furthermore, 51.3% (n=61) of the subjects were addicted (mainly alcohol). The medical follow-up was carried out by a psychiatrist in 83.2% of cases (n=99). The average duration of follow-up was five years. Among the 78 subjects for whom there was access to juridical data, 13 (16.7%) had committed a new offense during follow-up. Among them, seven had recidivated six of whom were initially sentenced for sexual offense. CONCLUSIONS: Most of the subjects in injunction to care had no axis I disorder but addictions and/or pathological personality traits. Nevertheless, the expert concluded the need of an IC. Personality and behavior disorders do not always require psychiatric care, and the management must be multidisciplinary. In France, the psychiatrist remains at the center of injunction to care measure. The addictology care is not developed whereas it is a population at risk and there is a lack of interactions between professionals (medical, social and judicial professionals). The IC is a measure that needs to be improved by means of better communication among the different professionals and a better global assessment of the subjects. Medical care must be a possible option but not a systematic treatment.

Discussion on Standardization of Forensic Assessment of Olfactory Dysfunction.

ABSTRACT: With the development of society, the improvement of living standards and the advancement of research methods, olfactory function has been paid more and more attention. Therefore, higher requirements for the forensic identification of olfactory function have also been put forward. Standardization construction of forensic medical examination and identification of olfactory dysfunction is urgently needed. Based on a comprehensive review of olfactory function and forensic assessment of olfactory dysfunction, this paper elaborates on problems related to the principles and timing of forensic assessment of olfactory dysfunction, the requirements of identification of traumatic olfactory dysfunction, the subjective and objective methods of examination of olfactory function. Strict control of the above issues is an important mean of standardization of forensic assessment of olfactory dysfunction.

Comparison of Evaluation Results of Different Disability Standards of Long Bone Fracture.

ABSTRACT: Objective To provide reference for further perfection and revision of standards relevant to limb injury by comparing the evaluation results of different disability standards of long bone fracture. Methods Thirty cases were selected from the long bone fracture cases accepted by our institution in 2018. These cases include 5 cases of shoulder, elbow, wrist, hip, knee, ankle joints, respectively, to investigate the degree of loss of function of joints after long bone fracture. Disability evaluation was made according to Classification of the Impairment Related To Injury （hereinafter referred to as Classification）, Assessment for Body Impairment of the injured in road traffic accidents （now repealed, hereinafter referred to as original Road Standard） and Identifying Work Ability-Gradation of Disability Caused by Work-related Injuries and Occupational Diseases （hereinafter referred to as Work Standard）. The disability evaluation results of every domestic standard were compared with the joint damage rate of Guides to the Evaluation of Permanent Impairment （hereinafter referred to as GEPI）. Results The functional loss rate of joints （except ankle） was 26%-48%，and the ankle functional loss rate was 51%-64%. The mean value of GEPI joint impairment rate of the joints was 13%-22%, with the fluctuation range less than 10%. The rate of level 10 disability was 100% according to the Classification. The rate of level 10 disability was 27%, the rate of level 9 disability was 6% and 67% were not disabled according to the original Road Standard. The rate of level 10 disability was 10% according to the Work Standard and 90% had a disability above level 10 （47% were classified as level 7 disability）. Conclusion The people with limb joint dysfunction in this study had evaluation results with a smaller fluctuation range and better consistency according to the Classification and GEPI. The evaluation results according to the original Road Standard and the Work Standard has a less consistency. The Classification is more similar to GEPI and is more reasonable.

Comparative Analysis of Visual System Disability Evaluation Criteria between China and the United States.

ABSTRACT: Gradation of Disability in Human Body Injuries （hereinafter referred to as Gradation） has been released and used since January 2017, and has become the most widely used standard in forensic science practice. This paper calculates and rates the visual system evaluation provisions of the current domestic disability evaluation criteria represented by the Gradation which used the methods of Guides to the Evaluation of Permanent Impairment （hereinafter referred to as GEPI） issued by American Medical Association （AMA）. Through comparing, a good correlation between the provisions in Gradation and whole person impairment rating index in GEPI was shown. On the basis of this, suggestions are put forward to amend some provisions of Gradation, in order to provide reference for the revision and further improvement of domestic standards and provisions.

[The comprehensive forensic expertise of the images of the human physical appearance]. / Kompleksnaia sudebnaia ékspertiza izobrazhenii vneshnego oblika cheloveka.

The present study addresses the complicated borderline problems facing researchers of human images obtained with the use of photographic and videotechnical means and methods that imply the necessity of the combined application of the knowledge of different aspects of forensic medical and criminalistics expertises. The fundamental principles of comprehensive investigations and expertises are defined. The theoretical substantiation is provided for the performance of the combined forensic medical expertises and forensic facial reconstruction based on the concrete examples from expert practice. Special attention is given to the schedule and conduction of such examinations. It is demonstrated that only the joint analysis of all characteristic features revealed by different specialists allows for a definitive expert conclusion of evidentiary value.

[Some questions regarding the administration and conduct of comprehensive accident investigations and forensic medical examinations]. / Nekotorye voprosy naznacheniia i proizvodstva kompleksnykh transportno-tekhnicheskikh i sudebno-meditsinskikh ékspertiz.

The purpose of the study is to consider the theoretical and practical questions of the administration and conduct of comprehensive forensic medical accident investigations, and on the basis of a determination of their particular characteristics, to outline prospects for their further development. The record of investigations of transportation accidents which we studied demonstrates that comprehensive technical and medical forensic investigations are generally called for. In this regard there is a need for an expansion of knowledge of investigations of transportation accidents that are not only limited to the specified forensic investigations. Technical and forensic medical investigations in aviation, marine, and railroad accidents should also be developed.

Guidelines examination of victims of sexual assault harmonization of forensic and medico-legal examination of persons.

Sexual assault is a complex situation with medical, psychological, and legal aspects. Forensic experts play a major role in terms of forensic and gynecological medical examination and evidence collection in order to maintain the chain of custody. Victims should be examined by a specially trained medico-legal examiner in order to avoid multiple examinations in the surroundings that do not meet minimum health standards. The evolution and treatment of sexual assault victims are time-intensive and should optimally be provided by a team that includes a forensic medical doctor. These guidelines will be of interest to forensic medical doctors who will have responsibility for the examination and assessment of victims of sexual violence and can be used as a day-to-day service document and/or a guide to develop health service for victims of sexual violence.

Evaluation of a CIAP session for students in Medicine, Pediatrics module.

BACKGROUND: Teaching by the Clarification, Illustration, Application and Participation of Students (CIAP) approach is a method of participatory pedagogy that helps active learning to help the learner understand and integrate the new Knowledge to be able to apply them. The objectives of this work were to describe the conduct of a CIAP session and to evaluate this method of learning among students. METHODS: The session took place in a room in the Forensic Medicine Department of the Charles Nicolle Hospital in Tunis on April 18, 2017 for 60 minutes. Our population was made up of DCEM2 students undergoing pediatrics and neonatology at the Charles Nicolle Hospital. The chosen topic was post-infectious acute glomerulonephritis. The assessment consisted in a written test given at baseline before the teaching sessions and repeated immediately afterwards. Students were also asked to grade the quality of the teaching received. RESULTS: In total, 13/22 students were present. Clarifications were given at the request of the students. The illustration showed capillary proliferation and extra-capillary proliferation. Clinical cases have sparked a lot of interaction. All the students participated in the session: seven of them participated actively, the other six were solicited to participate. Pre-test scores varied from 2/10 to 7/10. Post-test scores ranged from 4/10 to 10/10. The mean score for the pre-test was 4.61 ± 1.6 and, the mean score for the post-test was 8.23 ± 2.31 / 10, the difference being statistically significant (p = 0.03). For students, the choices of educational objectives were relevant and were achieved, the session was coherent with the professional reality and brought new knowledge. The majority of students felt that there was good interaction. All students were satisfied with listening to the teacher and her answers to their questions. All students reported that the CIAP session provided them with a better clarification of the theoretical course, a sufficient illustration, and enabled them to participate actively in teaching. The students reported that there was a good application of the theoretical course. CONCLUSION: The CIAP session improved student knowledge. The students were generally satisfied with this teaching.

[Organization of quality control of the forensic medical investigations]. / Organizatsiia kontrolia kachestva sudebno-khimicheskikh issledovanii.

The article describes the system of quality control at all stages of forensic chemical investigations (including pre-analytical, analytical, and post-analytical ones) carried out by the Saint-Petersburg Bureau of Forensic Medical Expertise It is shown that standardization and control taken together make up a solid foundation for obtaining the reliable and reproducible results of forensic chemical investigations. Responsibility for the quality control at all stages of forensic chemical investigations lies on the heads of the respective departments. Special staff members are appointed to supervise performing each concrete form of control and keeping the relevant documentation.

[The analysis of the results of the medical criminalistics expertises of the blood stains performed at the Bureau of Forensic Medical Expertise of the Moscow Health Department during the period from 2011 till 2015]. / Analiz mediko-kriminalisticheskikh ékspertiz sledov krovi, vypolnennykh v Biuro sudebno-meditsinskoi ékspertizy Departamenta zdravookhraneniia Moskvy za period 2011-2015 gg.

The objective of the present study was the analysis of the results of the medical criminalistics expertises of the blood stains with reference to their different characteristics including the occurrence across the years, variability, the forms and parameters of the traumatizing impacts, the properties of the objects with which the injuries were inflicted, etc. The majority of the data necessary for the analysis were extracted from the archive materials of the Medical and Criminalistic Department of the Bureau of Forensic Medical Expertise of the Moscow Health Department for the period from 2011 till 2015. A total of 5749 expertises performed during this time included 107 analyses of blood stains, 98 trace-evidence and 9 situational analyses. The specific features of such expertises include a large number of objects carrying blood stains available for the analysis. In the majority of the cases, such objects are stained with blood of several types differing in the mechanisms of their formation. 3D-scanning of the scene of the event with the subsequent three-dimensional computer-assisted simulation of the actions of each participant of the accident is considered to be the most promising method for the medical criminalistic expertise of the blood stains. The application of this approach is believed to make the work of the forensic medical experts significantly easier.

[The significance of student competitions for the development of motivation for education and the acquisition of professional competences in the students the Department of Forensic Medical Expertise of the Sechenovsky University]. / Znachenie studencheskikh olimpiad dlia formirovaniia obrazovatel'noi motivatsii i osvoeniia professional'nykh kompetentsii u obuchaiushchikhsia na kafedre sudebnoi meditsiny Sechenovskogo universiteta.

Russia joined the Bologna process in 2003 and since that time has become integrated into the unified European educational space. The key element of the new form of the higher education process is the self-guided unsupervised work of the students. Motivation is needed to promote the involvement of the students in the educational process which implies the necessity of the goal-oriented initiative for the acquisition of professional knowledge and practical experience in the field of forensic medicine. To achieve this goal, the Department of Forensic Medicine of I.M. Sechenov First Moscow State Medical University places special emphasis on the experience with carrying out student competitions. Each such competition consists of several contests focused on the solution of a specific problem, e.g. the inspection of the place of occurrence under investigation with a gunshot or punctured-and-incised wound, forensic medical autopsy, problem studies, and intelligence tests. All the contests and problem studies are held in the form of an interactive game. The experience gained in the course of the student competitions gives practical evidence that the interdepartmental intelligence contests contribute to raising the interest of students in forensic medicine. The open competition provides a highly efficient tool for the popularization of scientific knowledge and the promotion of interest in the participation in the forensic medical research activities. Moreover, the student competitions facilitate formation of the earlier professional skills indispensable for team working and the development of abilities for making decisions under the extreme conditions. In addition, the contests teach the participants the art of public appearance. They improve the quality of vocational training in forensic medicine and help to establish the first professional contacts at the interinstitutional (including international) level.

Methodology for the identification of vulnerable asylum seekers.

Asylum seekers often experience situations of vulnerability, being frequently exposed to a heightened risk of harm, and thus require special care, support and protection. The categories of "vulnerable persons", identified by International Legislation, and an individual's classification as a "vulnerable asylum seeker", have important implications in the reception procedures, in the decision-making phase and in the definition of therapeutic needs and rehabilitation. The Istanbul Protocol, the first international guideline approved by the United Nations and applied in different contexts, is not applicable for the assessment of the totality of the conditions (medical and otherwise), and therefore, the identification and assessment of conditions of vulnerability is largely delegated to questionnaires administered by non-medical personnel. The proposed methodology, based on the modificatory reworking of the Guidelines of the International Academy of Legal Medicine concerning the "medicolegal ascertainment of personal injury and damage on the living person", takes into consideration all the medical issues relevant for the decision concerning the applicant, both in the reception procedures and in the outcome of the asylum application.