Asbestos exposure determined 357 days after death through autopsy: a report of a multidisciplinary approach.

Asbestosis is an interstitial lung disease caused by the inhalation of asbestos fibers and poses a significant risk to individuals working in construction, shipping, mining, and related industries. In a forensic context, postmortem investigations are crucial for accurate diagnosis, for which the gold standard is the histopathological examination. This case report describes the autopsy and related investigations conducted on an 84-year-old man, nearly one year (357 days) after his death. After a post-mortem CT scan, an autoptic investigation was performed, followed by histopathological, immunohistochemical, and scanning electron microscopy examinations. The integration of the evidence from these examinations with previously available personal and clinical information conclusively confirmed the diagnosis of asbestosis. We demonstrated the efficacy and reliability of our diagnostic protocol in detecting asbestosis and asbestos fibers and excluding mesothelioma even in decomposed tissues. According to our findings autopsy remains the diagnostic gold standard in cases of suspected asbestosis within a forensic context, even 1 year after death, therefore it is always highly recommended, even in cases where the body has decomposed.

An Overview on the Use of miRNAs as Possible Forensic Biomarkers for the Diagnosis of Traumatic Brain Injury.

Determining the cause of death is one of the main goals of forensic pathology. However, conditions can occur in which common approaches-external inspection, autopsy, histology, etc.-might not be conclusive. With the advancement of molecular biology, several investigative techniques have been developed over the years, and the application as approaches complementary to routine procedures has proved useful in these cases. In this context, microRNA (miRNA) profiling has attracted increasing interest due to these molecules' ability to regulate physiological and pathological processes. The evidence of differential miRNA expression in both animal models and human samples of traumatic brain injury (TBI) has laid the basis for comprehension of the underlying pathophysiological mechanisms, thus allowing us to identify some of them as possible TBI diagnostic biomarkers. The present narrative review aims to explore the primary miRNAs involved in the mechanisms underlying TBI, which could be considered for future evaluation as possible markers in a post mortem setting.

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.

Preventable fatal injury during rally race: a multidisciplinary approach.

INTRODUCTION: The motor vehicle crash (MVC) constitutes an important challenge for forensic pathology in order to identify the manner and cause of death. Our study focuses on a fatal accident during a rally race corresponding to MVC sub-category. MATERIALS AND METHOD: Postmortem computed tomography (PMCT) was performed before the conventional autopsy. Autoptic and PMCT data were compared. Data collection allowed analyzing biomechanical dynamics of the incident and post-traumatic injuries through qualitative-statistics and solicitation quantitative indices. RESULTS: Photo and circumstantial evidence analysis showed a wrong installation of double shoulder belt system of head and neck support (HANS) collar. PMTC clearly highlighted multiple and bilateral fractures involving roof and base of skull; a displaced fracture of the right acetabulum was also encountered. Autopsy confirmed PMCT data and revealed a brainstem laceration. AIS (Abbreviated Injury Scale) achieved a maximum score in consideration of fatal injuries. DISCUSSION: The injuries analysis resulting from photographic surveys examination, conventional autopsy, and PMCT has led us to confirm a fatal front collision with a tree trunk. Head trauma represents a major injury in the present case. In this case, head injuries, related to whiplash trauma, are a consequence of a double shoulder belt system (HANS collar component) wrong installation. CONCLUSION: MVC and especially high-speed motor racing represent an important death cause. There was, for this reason, a marked development of cars and occupants' safety systems, such as HANS collar. PMCT improves the diagnostic performance of conventional autopsy and increases forensic medical knowledge related to traumatic injuries.

Self-inflicted long bone fractures for insurance fraud.

Self-inflicted fractures simulating traffic accident represent a new social fraud opportunity for criminality. Recognising scams through an increase of awareness of existence of self-inflicted arm fractures for insurance fraud could help community health workers to report these injuries to the competent authorities. In this article, authors have recognised an unusual but consistent pattern of upper and lower limb fractures whose incidence does not coincide in numerical terms with what is reported in literature. The aim of the present study is to describe fracture patterns observed over the past 2 years. Further, authors describe clinical presentations of these fractures and attempt to define a possible mechanism of these types of injuries.

Occupational accidents and the use of PPE: a global meta-analysis.

Occupational accidents, despite continuous safety updates, are still a scourge in the occupational and forensic spheres, constituting, among other things, the subject of a large share of litigation. Demographic data can help to understand the areas where the application of health surveillance is lacking. This meta-analysis sets out to analyse data from studies on accidents at work, focusing on the correlation between the areas in which accidents occur and whether or not personal safety equipment is used, in relation to the different regulations in force. For the selection of the data, a systematic review was carried out according to the PRISMA guidelines, with the primary objective of identifying the trend of occupational accidents in specific geographical areas, which differ in terms of the attention paid to preventive aspects. The data we highlighted showed, regarding the type of accident, substantial differences between low-income countries and industrialised countries (stratified according to the Human Development Index) and, an overall indifference as to whether or not individual safety devices were used, revealing that, despite the continuous normative evolution in the field of safety at work, even today, the investigative data on the actual application of the regulations, during accidents at work, is underestimated and little researched.

Delayed Traumatic Rupture of the Spleen in a Patient with Mantle Cell Non-Hodgkin Lymphoma after an In-Hospital Fall: A Fatal Case.

Splenic rupture and hematoma are significant complications that can occur in patients with non-Hodgkin lymphoma (NHL). Understanding these associated complications is essential for optimal patient management and enhanced patient outcomes. Histopathological and immunohistochemical analyses are crucial in diagnosing NHL and assessing splenic involvement. In this study, a judicial autopsy had been requested by the Prosecutor's Office for a malpractice claim due to a fall in the hospital. In the Emergency Department, a 72-year-old man fell from a gurney and reported sustaining a wound to his forehead. No other symptoms were reported. A face and brain CT scan showed no abnormalities. Nine days after discharge, the patient presented with abdominal pain. An abdominal CT revealed splenic rupture and hemoperitoneum. The patient underwent open splenectomy but showed signs of hemodynamic shock and subsequently died. The evidence from the autopsy allowed us to diagnose mantle cell non-Hodgkin lymphoma with spleen involvement, previously unknown. Histopathological and immunohistochemical analyses were performed to assess the diagnosis of splenic rupture and estimate its timing. The findings strongly suggest that the splenic rupture was associated with the patient's fall and the pre-existing malignancy. This case highlights the importance of considering an underlying hematological malignancy when investigating delayed splenic rupture. An immunohistochemical study of spleen samples allowed the timing of splenic hematoma and rupture to be assessed, leading to the establishment of a causal relationship with trauma.

A Comprehensive Review on Alcohol Abuse Disorder Fatality, from Alcohol Binges to Alcoholic Cardiomyopathy.

Frequent and excessive consumption of alcohol, be it episodic or sustained misuse, ranks among the top causes of mortality globally. This comprehensive analysis seeks to elucidate how alcohol misuse precipitates death, with a particular focus on associated cardiac anomalies. Notably, the phenomenon of "Holiday Heart Syndrome", linked to binge drinking, is recognized for inducing potentially fatal cardiac arrhythmias. Moreover, persistent alcohol consumption is implicated in the development of alcoholic cardiomyopathy, a condition that underlies heart failure and arrhythmic disturbances of the heart. Additionally, individuals undergoing withdrawal from alcohol frequently exhibit disruptions in normal heart rhythm, posing a risk of death. This review further delves into additional alcohol-related mortality factors, including the heightened likelihood of hypertension, cerebrovascular accidents (strokes), and the connection between excessive alcohol use and Takotsubo syndrome.

Femicide Circumstances and Harmfulness: Case Report and Focusing Review.

(1) Background: Femicide is an increasing phenomenon consisting of the murder of a woman for gender-related reasons. Despite the enactment of new laws aimed at controlling the phenomenon by toughening the penalties and introducing aggravating circumstances, there is an increasing trend that testifies to the persistence of a flaw in the actual measures. (2) Case Presentation. We report the case of the murder of a 32-year-old woman-perpetrated by an ex-husband who refused to accept the end of the marriage-the analysis of which allowed us to frame the case as femicide. (3) Discussion. Despite global awareness of this phenomenon, the identification of risk factors to predict and prevent femicide is of utmost importance. This can be achieved by a multidisciplinary approach involving police officers, legal professionals, hospitals, governmental and nongovernmental organizations, and medico-legal departments aimed at promoting standardized methodologies. (4) Conclusions. We evaluate the contribution of forensic investigations to the identification of key elements that can help frame the murder of a woman as a femicide. Considering the devastating consequences for children who witness this kind of violence within the domestic setting, the planning of more impactful preventive actions is, thus, mandatory to minimize effects on public health.

Systematic Review of Fatal Sodium Nitrite Ingestion Cases: Toxicological and Forensic Implications.

Documented cases of sodium nitrite toxicity are almost exclusively caused by accidental ingestion; however, self-poisoning with sodium nitrite represents an increasing trend in nitrate-related deaths. This systematic review summarizes the most crucial evidence regarding the fatal toxicity of sodium nitrite. It identifies gaps and differences in the diagnostic forensic approaches and the detection methods of sodium nitrite intoxication. A total of eleven research articles were selected for qualitative and quantitative data. Most of the studies (6/11) were case reports. Fifty-three cases of fatal intoxication with sodium nitrite were chosen for the review. More research is required to develop cost-effective techniques and uniform cutoffs for blood nitrite and nitrate levels in the event of deadly sodium nitrite poisoning. There is still a lack of critical information on other matrices and the impact of time since death on toxicological results in such situations. The available evidence provides useful recommendations for forensic pathologists and health practitioners engaged in instances of sodium nitrite poisoning or death. The data should also set off alarm bells in the public health system, in prosecutor's offices, and for policymakers so that they may undertake preventative measures to stop and restrict the unregulated market for these substances.

THC and THC-COOH hair concentrations: Influence of age, gender, consumption habits, cosmetics treatment, and hair features.

Evaluation of Cannabis consumption is required for many purposes (i.e., workplace drug testing and driving license renewal). Hair analysis represents the most adopted and reliable approach for the investigation of repeated or chronic exposure to Cannabis. The main markers are the Δ9-tetrahydrocannabinol (THC) and its main metabolite, 11-nor-9-carboxy-Δ9-tetrahydrocannabinol (THC-COOH), as stated by the Society of Hair Testing (SoHT) and the European Workplace Drug Testing Society (EWDTS). In this paper we presented an observational study on the hair concentrations of THC and THC-COOH and influences due to age, gender, consumption habits, and hair features. Data were collected from analysis of scalp hair samples (3-cm proximal segment) provided by subjects tested for THC consumption for personal purposes (i.e., workplace drug testing, personal use proving). The subjects provided an informed consent and a short questionnaire. A new analytical method was previously developed and then adopted. It consisted in a hydrolysis (1 mL of 1 M NaOH at 65 °C, 20 min) and a liquid-liquid extraction (with hexane/ethyl acetate,90/10, v/v in presence of 1.5 mL of H2SO4 1 M) of 25 mg of hair. A liquid chromatograph - tandem mass spectrometer (LC-MS/MS) equipped with a C18 column was used. The acquisition was in multiple reaction monitoring for the following transitions: 315→259, 193 m/z, for THC; 318→196, 123 m/z, for THC-d3; 345→299, 193 m/z for THC-COOH; 348→196, 302 m/z for THC-COOH-d3. Correlation between THC and THC-COOH hair concentrations was analyzed by Spearman's rank correlation coefficient. In order to study the influences of several variables, a new value, Sqrt(THC*THCCOOH), was adopted. Its effectiveness and reliability were proved by the Principal Component Analysis. Relationships between the Sqrt(THC*THCCOOH) and the variables were studied through the Stepwise regression (p = 0.05). The normality of data distribution was tested by the Shapiro-Wilk test. The Lower limits of quantification were 10.0 (THC) and 0.2 (THC-COOH) pg/mg. Accuracy and precision always met the acceptable criteria. Recoveries were > 78% and ion suppression was observed for both the compounds. Data from 126 hair samples were included in this study: 54 subjects(42.9%) were positive both for THC and THC-COOH; none of the samples was positive for a single substance. Concentrations ranged from 0.18 to 1.75 ng/mg (median: 0.78 ng/mg) for THC and from 0.04 to 0.85 ng/mg (median: 0.31 ng/mg) for THC-COOH. Cannabinoids levels seemed to decrease with the age, with lower amounts in the subjects aged > 40 years (p < 0.05). Also years of consumption seemed to have a significant impact on hair concentrations, as higher levels were observed in consumers from > 10 years (p = 0.013). Moreover, this study further provided evidences of a significant reduction of THC and THC-COOH in bleached hair (p = 0.042).

Juvenile sudden cardiac death due to congenital coronary ostial valve-like ridges: A case report and literature review.

Coronary artery anomalies are a heterogeneous group of congenital disorders affecting the coronary pattern with a characteristic (origin, number, number of hosts, course, etc.). They are rarely found in the population. We report the case of a 21-year-old male who died from sudden cardiac death caused by an isolated coronary ostial obstruction, secondary to a rare anomaly, the presence of a valve-like ridge consisting of a small fold in the Valsalva aortic sinus. The study provides a brief literature review on the pathophysiology, diagnosis, and clinical and medico-legal issues in coronary artery anomaly cases that may be helpful in forensic practice when dealing with sudden cardiac death in young people and highlights key points for further research and public health measures.

The Chain of Custody in the Era of Modern Forensics: From the Classic Procedures for Gathering Evidence to the New Challenges Related to Digital Data.

The purpose of this work is to renew the interest and attention for the chain of custody in forensic medicine, its establishment and maintenance, protecting the integrity and validity of evidence as well as to analyze how over time the establishment of the chain of custody and the collection of evidence has evolved also in function of the advent of technology and the use of electronic devices connected to the network. The analysis of the various aspects of the chain of custody demonstrates how necessary it is for the professional figures involved in the phases of the investigation (especially those who manage the evidence and who have, therefore, designated the assignment) to know the procedures to follow, trace the movement and the handling of objects subjected to seizure, also for the purposes of toxicological and/or histological investigations. The knowledge of interferences or complications helps to reduce errors and safeguard the validity of the evidence, assuring the proceeding judicial authority that the evidence is authentic and that it is, in other words, the same evidence seized at the scene of the crime. Furthermore, the issue is particularly felt today, with the recent need to guarantee the originality of digital data. Following a careful review and analysis of the literature currently available in this regard, it is worth adding that further efforts are needed to formulate internationally validated guidelines, harmonizing the different reference criteria in forensic science and medical areas, given the current absence of good international practices valid in the field and applicable both in the case of physical evidence and in the case of seizure of digital evidence.

Focus on Liability of Residences for Elderly and Sick People: A Case Series and Medico-Legal Issues.

Residences for elderly and sick people, self-sufficient or dependent, are varied. To date, the liability profiles of these structures are not clearly delineated, and increasingly often, their operating and organization criteria are entrusted to subnational, regional, or local regulations. Among the various deficits, there is the keeping of a complete and detailed documentation/diary of the patient, the lack of which can generate medico-legal problems. In this paper, we present three cases of guests in residences for a dependent person brought to the attention of the Institute of Forensic Medicine of the University Hospital of Palermo due to criminal proceedings, where the lack of existing documentation in the structure and, in some cases, the behavior of the professionals working there, led the evaluator to deduce the organization's culpability.

Torture and Maltreatment in Prison: A Medico-Legal Perspective.

The maltreatment and torture of prisoners constitute a global problem. Methods of maltreatment are classified as the psychological and the physical, and physical methods inevitably lead to psychological sequelae. Our review offers an analysis from the medico-legal perspective of the literature on the torture and physical and sexual abuse experienced by prisoners and their psychological sequelae and aims to investigate the medico-legal issues of investigating maltreatment in prison so as to suggest methodologies and updated approaches for dealing with such cases in a forensic context. We performed a comprehensive literature search of peer-reviewed publications (articles and reviews), research reports, case studies, books, service models, protocols, and institutional documents available online using key electronic databases (Scopus, PubMed) and search engines (Google Scholar) with the following keywords: physical violence, psychological violence, torture, maltreatment, physical abuse, psychological abuse AND prison OR prisoner OR jail OR custody. In the medical literature, most of the publications on torture are based on retrospective studies of torture among survivors and often refer to asylum seekers. Forensic evaluation is crucial for assessing the determinant elements of torture and maltreatment. A multidisciplinary approach and standardized and updated methodologies are needed to support policymakers, national institutions, and public health system initiatives in this field.

A fatal suicidal sodium nitrite ingestion determined six days after death.

Sodium nitrite (SN) is an inorganic salt that appears as a slightly yellowish crystalline solid, odorless, and highly soluble in water at room temperature. It is highly toxic to humans at specific doses because it can oxidize hemoglobin to methemoglobin, causing severe tissue hypoxia. A 20-year-old woman was unconscious in her bedroom and died shortly after that. Two days later, following the discovery of a jar of SN and a paper in which were written instructions on how to take it (and the website from which the procedure was learned) in the same room were death occurred, the Judicial Authority ordered the execution of the autopsy on the exhumed body of the young woman. The autopsy procedure was performed ∼ 2h after exhumation. It showed greyish-purple hypostasis, labial cyanosis, stomach distension and greenish color but empty, subpleural petechiae, brownish fluid in the pleural cavities (∼300 ml), congested and edematous lungs and diffuse visceral congestion. At autopsy, foamy liquid was observed at the lung section and subsequent squeezing. In addition, the autopsy showed edema and hemorrhagic petechiae of the laryngeal, glottal, and tracheal submucosa and green-brownish foamy liquid in the tracheal lumen. The cause of death was attributed tocardiac arrest induced by anoxia resulting from acute methemoglobinemia caused by sodium nitrite poisoning, intensified by severe malnutrition. Manner of death was suicidal.

Ethical and Forensic Issues in the Medico-Legal and Psychological Assessment of Women Asylum Seekers.

Asylum-seeking migrants represent a vulnerable segment of the population, and among them, women constitute an even more vulnerable group. Most of these women and girls have been exposed to threats, coercion, and violence of many kinds, including rape, forced prostitution, harassment, sexual slavery, forced marriage and pregnancy, female genital mutilation/excision, and/or other violations of their rights (e.g., deprivation of education, prohibition to work, etc.). The perpetrators of the violence from which they flee are often their own families, partners, and even institutional figures who should be in charge of their protection (such as police officers). In the process for the acceptance/rejection of an asylum application, the forensic and psychological certification can make the difference between successful and unsuccessful applications, as it can support the credibility of the asylum seeker through an assessment of the degree of compatibility between the story told and the diagnostic and forensic evidence. This is why constant and renewed reflection on the ethical, forensic, and methodological issues surrounding medico-legal and psychological certification is essential. This article aims to propose some reflections on these issues, starting from the experience of the inward healthcare service dedicated to Migrant Victims of Maltreatment, Torture, and Female Genital Mutilation operating since 2018 at the Institute of Forensic Medicine of the University Hospital of Palermo.

Implementation of A Year-Long Antimicrobial Stewardship Program in A 227-Bed Community Hospital in Southern Italy.

BACKGROUND: Healthcare-Acquired Infections (HAIs) are serious healthcare complications affecting hospital stay, in-hospital mortality, and costs. Root cause analysis has identified the inappropriate use of antibiotics as the main causative factor in the expansion of multi-drug-resistant organisms (MDRO) in our hospital. An Antimicrobial Stewardship (AMS) program was implemented to optimize antibiotic use, limit the development of resistance, improve therapeutic efficacy and clinical outcomes, and reduce costs. METHODS: The stewardship strategies were: antimicrobial oversight on "critical" antibiotics; the development of hospital guidelines on antibiotic selection with the production of a consensus document; the implementation of clinical and management control algorithms with visual impact and Business Intelligence methods; training and updating; and the monitoring of outcome measures and process indicators. RESULTS: Clinical outcomes: length of stay reduced by 0.23 days, hospital readmission/first month rates decreased by 19%, and mortality for infections reduced by 8.8%. Microbiological Outcomes: Clostridium Difficile colitis incidence reduced by 9.1%.Economic Outcomes: Reduction in antimicrobial costs by 35% on average fee/discharged patient. CONCLUSIONS: The systematic application of the AMS program in a small hospital led to multiple improvements in clinical, microbiological, and economic outcome measures. The analysis of the core indicators for our hospital AMS program showed a significant adherence to the model and hospital recommendations.

Intrauterine and Neonatal Exposure to Opioids: Toxicological, Clinical, and Medico-Legal Issues.

Opioids have a rapid transplacental passage (i.e., less than 60 min); furthermore, symptoms characterize the maternal and fetal withdrawal syndrome. Opioid withdrawal significantly impacts the fetus, inducing worse outcomes and a risk of mortality. Moreover, neonatal abstinence syndrome (NAS) follows the delivery, lasts up to 10 weeks, and requires intensive management. Therefore, the prevention and adequate management of NAS are relevant public health issues. This review aims to summarize the most updated evidence in the literature regarding toxicological, clinical, and forensic issues of intrauterine exposure to opioids to provide a multidisciplinary, evidence-based approach for managing such issues. Further research is required to standardize testing and to better understand the distribution of opioid derivatives in each specimen type, as well as the clinically relevant cutoff concentrations in quantitative testing results. A multidisciplinary approach is required, with obstetricians, pediatricians, nurses, forensic doctors and toxicologists, social workers, addiction specialists, and politicians all working together to implement social welfare and social services for the baby when needed. The healthcare system should encourage multidisciplinary activity in this field and direct suspected maternal and neonatal opioid intoxication cases to local referral centers.

Useful Evidence by Post-Mortem CT and Stereomicroscopy in Bone Injury: A Case Series from Forensic Practice.

The investigation of bone injuries is an essential topic in forensics. We sometimes have to deal with charred or dismembered human remains that have lost soft tissue, making it difficult to diagnose the mechanisms of injury that led to death. Our contribution aims to share with the scientific community how we approached two cases of very different bone injuries and the techniques used to differentiate relevant pathology findings of bone fragments. Two cases are analyzed from the case history of the forensic medicine institute of Palermo. PMCT made it possible to differentiate heat bone lesions from traumatic lesions. The stereomicroscope was superior to PMCT in being able to better characterize and evaluate shear injuries, allowing a more accurate measurement of acute lesions. Injury to bone remains can be appropriately investigated with rapid techniques such as PMCT and stereomicroscopy. The presented methodology shows the importance of a multidisciplinary approach when dealing with bone injuries in forensics that could find further applications in other circumstances to answer forensic questions.