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.

Lethal event in diving with self-contained underwater breathing apparatus: A forensic study.

Introduction: In fatal accidents during scuba diving, it is necessary to differentiate a death from primary drowning from a secondary drowning death that is primarily due to other etiopathogenetic factors. The inhalation of water can only be the end point of a series of events capable of causing the diver's exitus. This study aims to demonstrate that even low-risk heart disease in daily life become potentially fatal during scuba diving. Methods: In this case series, we describe all cases of deaths in the course of diving that came to the observation of the Forensic Institute of the University Bari over 20 years (2000-2020). A judicial autopsy was performed on all subjects, with ancillary execution of histological and toxicological investigations. Results: The results of the medicolegal investigations carried out in the complex identified heart failure with acute myocardial infarction as the cause of death in four cases characterized by severe myocardiocoronarosclerosis, a primary drowning in a subject without previous pathological substrate in one case, and a terminal atrial fibrillation induced by acute dynamic heart failure due to functional overload of the right ventricle in one case. Conclusion: Our study demonstrates that lethal events during diving are often related to the presence of unrecognized or subclinical cardiovascular diseases. Such deaths could be prevented and avoided if a greater regulatory sensitivity to preventing and controlling diving was encouraged, considering both the inherent risks of this activity and the possible unrecognized or underestimated pathologies.

Basosquamous Cell Carcinoma of the Nipple-Areola Complex-Report of a Case.

Basosquamous cell carcinoma (BSCC) is a rare malignancy usually arising on sun-exposed areas of the skin. BSCC is described as a rare variant of Basal cell carcinoma (BCC) which shows clinical and microscopic features of both BCC and of Squamous cell carcinoma (SCC). We report the case of a 70-year-old male with a cutaneous lesion of the nipple-areola complex (NAC); to the best of our knowledge, this is the first ever reported patient with BSCC in this area. The lesion had a fast growth, but, due to the COVID19 crisis, the patient only came to our observation one year after onset of this condition. Physical examination showed a bleeding red ulcerated lesion that involved the NAC, measuring 27 mm × 20 mm. Biopsy showed a BSCC. Pre-operative breast ultrasound scan, mammogram and MRI were all performed before surgery, which consisted of simple mastectomy and sentinel lymph-node biopsy. The patient was discharged home on the 4th post-operative day, and at 18-month follow-up there are no signs or clinical evidence of local recurrence or metastases. Diagnosis of BSCC of the nipple-areola complex requires high index of suspicion and a thorough differential diagnosis, management, and suitable radical treatment due to well described high rates of recurrence and of metastases. Differential diagnosis with similar lesions (e.g., Paget's disease, Bowen's disease, BCC, and SCC) should also be taken into account.

Cosmetic Outcomes of Simple Pediatric Facial Lacerations Repaired With Skin Adhesive Compared With Skin Adhesive With Underlying Adhesive Strips: A Randomized Controlled Trial.

OBJECTIVES: A randomized controlled trial was designed to compare 2 methods of repairing simple pediatric facial lacerations. We hypothesized that wounds repaired with skin adhesive and underlying adhesive strips compared with skin adhesive alone would be superior in regard to cosmetic outcome. METHODS: Patients aged younger than 18 years presenting to the emergency department with simple facial lacerations requiring repair were eligible for enrollment. Patients were randomly assigned to repair with either skin adhesive alone or skin adhesive with underlying adhesive strips. Families were contacted by phone 1 week after enrollment to discuss short-term complications. The cosmetic appearance of photographs of the scars at 2 months was analyzed using a visual analog scale by a blinded pediatric emergency physician and pediatric plastic surgeon. RESULTS: One hundred twenty patients were enrolled, with 92 returning for the 2-month follow-up. The visual analog scale scores for the skin adhesive with adhesive strips group were similar to the skin adhesive alone group (60 mm vs 58 mm, P = 0.540). Spearman ρ correlation coefficient between the raters was 0.669, indicating strong agreement. There was no significant difference in rates of return visits, wound dehiscence, or infection. The skin adhesive with adhesive strips group had a longer time to perform the repair (195 seconds vs 107 seconds, P < 0.001). CONCLUSIONS: Using adhesive strips to first approximate a wound before applying skin adhesive leads to a similar cosmetic outcome compared with simple facial lacerations repaired with skin adhesive alone. Although the study showed longer time to complete the repair, this approach may still be useful in settings where approximation is difficult to obtain manually.

Sucralfate as an Adjunct to Analgesia to Improve Oral Intake in Children With Infectious Oral Ulcers: A Randomized, Double-Blind, Placebo-Controlled Trial.

STUDY HYPOTHESIS: We hypothesized that sucralfate along with oral analgesics (acetaminophen or ibuprofen) administered in the emergency department leads to a clinically significant improvement in oral intake in children with acute infectious oral ulcers. METHODS: This was a randomized, double-blind, placebo-controlled trial of sucralfate versus placebo conducted between 2017 and 2018 in an urban pediatric emergency department. Children aged 6 months to 5 years with acute, infectious oral ulcers and poor oral intake received either acetaminophen at 15 mg/kg or ibuprofen at 10 mg/kg and were then randomized to receive sucralfate at 20 mg/kg per dose up to 1 g or a placebo solution. The primary outcome was oral fluid intake within 60 minutes of medication administration. The secondary outcomes were repeat ED visits, length of stay in ED, intravenous hydration rate, admission rate, adverse event rate, and emergency physician's determination of the adequacy of oral intake. RESULTS: One hundred subjects with mild dehydration (clinical dehydration score of 1) and a median age of 1.38 years were enrolled and analyzed (49 in the sucralfate group and 51 in the placebo group). Oral intake 1 hour after drug administration was similar in both the groups: the median intake in the sucralfate group was 9.7 mL/kg and 10.7 mL/kg in the placebo group (difference -1 mL/kg; 95% confidence interval [CI] -2.0 to 4.8). According to the emergency physician's report, the secondary outcomes were significant only for adequate oral intake: 71% in the sucralfate group versus 88% in the placebo group (difference -16.8%; 95% CI -32.2 to -1.4). CONCLUSION: Sucralfate as an adjunct to oral analgesics was not superior to placebo in improving oral intake in children with acute oral infectious ulcers.

Virtual reality distraction during pediatric intravenous line placement in the emergency department: A prospective randomized comparison study.

OBJECTIVE: To evaluate the efficacy of virtual reality distraction (VR) during intravenous line (IV) placement in a pediatric emergency department to increase first-attempt IV success. Secondary endpoints included median time to successful IV placement, patient pain and anxiety scores, and an evaluation of characteristics of patients in whom VR is well tolerated. STUDY DESIGN: This was a randomized controlled trial at a tertiary pediatric emergency department, enrolling patients aged 4-17 years who required IV placement. Patients were enrolled only when child life specialists were unavailable. The primary endpoint was first attempt IV success. RESULTS: A total of 116 subjects were enrolled, 58 were randomly assigned to the VR group and 58 were assigned to the standard of care (SOC) group. 115 subjects completed the trial and were analyzed. First attempt IV success rates were similar between the groups (VR = 81%, standard = 84.2%, p = .65). Number of IV attempts and changes in pain and anxiety scores were also similar between the groups. The median time to successful IV placement was shorter in the VR group (78 vs 104 seconds) but this difference was not statistically significant (p = .21). Overall the VR headset was tolerated by 79% of subjects assigned to that group. The only significant predictor of headset tolerance was older age (P = .02). CONCLUSIONS: VR distraction for IV placement in the Pediatric Emergency Department shows similar efficacy to standard distraction techniques and appears to be well tolerated.

'Compressed Baby Head': A New 'Abusive Head Trauma' Entity?

BACKGROUND: Child abuse represents an important issue in the medico-legal and social context. In the last few decades, various aspects and mechanisms have been identified in child abuse case studies; however, constant research is needed in the field. With this paper, the authors will present a case of a new entity of Abusive Head Trauma that has come to the attention of medico-legal experts. DISCUSSION: The trauma analysis performed on the cranio-encephalic district of the baby revealed quite peculiar lesions that led the authors to exclude that the injuries had been solely caused by violent shaking of the baby's head, as suggested by Shaken Baby Syndrome. Instead, the authors hypothesised that another lesion mechanism had been added to this one, namely latero-lateral cranial compression. The comprehensive and exhaustive analysis of the case led the authors to present a new possible entity in child abuse trauma, namely 'Compressed Baby Head'. CONCLUSIONS: To the best of our knowledge, in the current literature, no similar clinical cases have ever been described. Thus, the case's uniqueness deserves to be brought to the attention of experts and the entire scientific community, as well as medical personnel, paediatricians, and reanimators. These professional figures are the first individuals who may encounter complex clinical cases such as the one presented in this paper; thus, they need to know how to properly manage the case and ensure protection for the abused infants and children.

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.