Forensic Analysis and Identification Processes in Mass Disasters: Explosion of Gun Powder in the Fireworks Factory.

A mass disaster is a situation that involves criticality between the number of victims and resources, in terms of both men and means, present on the site of an event that is mostly unexpected and sudden. In the multidisciplinary teams that intervene, the role of forensic pathologists, who are responsible for the direction and coordination of post-mortem operations, is central, and must remain so. The authors report the case of an explosion of a pyrotechnic artifice factory, as a result of which numerous victims and injuries are recorded. So, the team completed the autopsies and created a protocol to obtain biological samples (bones, blood, teeth, muscles), while the forensic pathologists contacted the families of the alleged victims and each provided a blood sample that was collected for the DNA. The geneticist, using the method of gene extraction and amplification, obtained the DNA from each bone, tooth, and muscle of blood taken from the victims and then compared it with that extracted from the blood samples of the relatives; the electropherograms showed at least one allele for each genetic marker of the "Combined DNA Index System" in common between the victims and the families, thus allowing to establish the identity of all the subjects involved in the event. Having established the identity of all workers, it was possible to determine their whereabouts in the environment at the time of the location of fires and explosions. The results of the various forensic analyzes (autopsies, genetic investigations and even traumatological investigations) have allowed us to validate a scientific method useful in all mass disasters even when any type of anthropological or forensic dental research is difficult.

Death Related to a Congenital Vascular Anomaly of Pulmonary Hamartoma Type: Malpractice or Tragic Fatality?

In forensic pathology, apparently straightforward cases can often hide rarities that, if not correctly interpreted, can alter the results of the entire investigation, leading to misinterpretations. This occurs when the investigation is conducted to assess medical malpractice. An unexpected death, with no known apparent cause, is often linked to an underlying disease process of unclear etiological origin whose nature can, unfortunately, be properly investigated only post-mortem. This presentation shows a case study, in which it was possible to reconduct the death of a patient to a natural pathology and not to medical treatment. Here, the authors illustrate a case with a hamartoma developed in chronic inflammatory conditions (bronchiectasis) that was difficult to differentiate from lung cancer due to the inability to perform specific instrumental examinations. The hamartoma, usually benign and identifiable by standard instrumental investigations, in this case, led to the patient's death precisely during the execution of a bronchoscopy. However, in the absence of a certain cause of death, public opinion unanimously attributes a patient's disease to medical error. Indeed, a routine practice such as bronchoscopy should not cause death and consequently, the doctor must have made a mistake. Fortunately, the autopsy not only demonstrated the origin of the bleeding but also unveiled the reason for this, as rare congenital lung disease. Fate, one might say.

Hypostasis and time since death: state of the art in Italy and a novel approach for an operative instrumental protocol.

Hypostasis is a common postmortem change, whose presence or absence is used by forensic pathologists as a means of determining the approximate time of death. This assessment plays a primary role in Italian forensic practice, but blanching of hypostasis is still estimated only on the basis of subjective impressions. To understand how forensic pathologists test livor mortis on the crime scene and during forensic daily practice in Italy, an inquiry was made into lividity testing. Subsequently, with the aim of proposing a more objective approach, a study on postmortem lividity was performed; 101 cadavers were analyzed, and the color of hypostasis was measured by a colorimeter. Different conditions of time and pressure on hypostasis were tested. Linear regression analysis was performed to determine the relationship between postmortem interval and the color of the skin after a predefined intensity and duration of pressure. Herein we propose a novel operative instrumental protocol using new, more standardized conditions for the analysis of hypostasis, thus providing pathologists with a more rigorous approach to postmortem interval estimation.

The Noble Suicide: The Case of a Self-Contained Dagger in the Heart and a Literal Raw.

According to WHO estimates, more than 700,000 people die each year due to suicide and suicides performed with a bladed weapon account for approximately 1.6%-3% of all suicides. It is statistically more common to find injuries to the heart, lungs, and thoracic vessels in homicides, whereas in suicides there is a higher frequency of vascular injuries to the extremities of the limbs. Also in suicides, the presence of "hesitation marks," related to the attempts the victim makes before having the courage to kill himself, can often be found. In the case presented by the authors, these parameters are subverted: There was only one injury and it was the fatal one, it was located on the chest and reached the heart. But it was suicide. The circumstantial data, the psychological explanation, and the previous similar suicide attempt left no doubt about it. The man decided to commit suicide because he could no longer find meaning in his life after losing hope for a career as a pianist, having been diagnosed with a degenerative disease in his hands. The man hated himself and his existence: The future appeared extremely negative and the only escape was self-suppression. This case report makes an essential contribution to the already existing Literature as it shows a suicide that occurred in an unusual manner.

Consent and Complications in Health Care: The Italian Context.

Informed consent is the manifestation of the will that a patient freely expresses toward a medical treatment. The physician is responsible for acquiring informed consent for both medical and nursing procedures. Informed consent represents a juridical-deontological tool that allows therapeutic choices to be shared with the user after having exhaustively explained the risks and benefits of the procedure itself. In fact, the physician has an obligation to provide the patient with clear and comprehensible information about the type of service, the methods of delivery, the benefits, the risks, even unforeseeable ones, and the complications. According to Italian legal guidelines, in cases of presumed health responsibility, the health professional accused of negligence will have to demonstrate that any complication that has arisen, although foreseeable, was not preventable. Through the analysis of a clinical case relating to the procedure of insertion of a bladder catheter performed by a nurse and a review of the literature, the authors explain the importance of the information that must be provided to the patient before carrying out any invasive procedure, even if not performed by the doctor. The authors describe the problem in the Italian context and propose a possible solution.

Haemorrhage and Survival Times: Medical-Legal Evaluation of the Time of Death and Relative Evidence.

Haemorrhage is the name used to describe the loss of blood from damaged blood vessels (arteries, veins, capillaries). Identifying the time of haemorrhage remains a clinical challenge, knowing that blood perfusion of systemic tissues is poorly correlated with the perfusion of specific tissues. In forensic science, one of the most discussed elements is the time of death. This study aims to provide the forensic scientist with a valid model to establish a precise time-of-death interval in cases of exsanguination following trauma with vascular injury, which can be useful as a technical aid in the investigation of criminal cases. To calculate the calibre and resistance of the vessels, we used an extensive literature review of distributed one-dimensional models of the systemic arterial tree as a reference. We then arrived at a formula that allows us to estimate, based on a subject's total blood volume and the calibre of the injured vessel, a time interval within which a subject's death from haemorrhage from vascular injury falls. We applied the formula to four cases in which death had been caused by the injury of a single arterial vessel and obtained comforting results. The study model we have offered is only a good prospect for future work. In fact, we intend to improve the study by expanding the case and statistical analysis with particular regard to the interference factors to confirm its actual usability in practical cases; in this way, useful corrective factors can be identified.

Healthcare Liability and Thyroidectomy: When Is the Surgeon Wrong?

Thyroid surgeries can often lead to operative complications, sometimes with consequences on the patient's health. This often leads to claims for compensation but the assessments of consultants and judges are not always objective. Based on these considerations, the authors analyzed forty-seven sentences issued between 2013 and 2022 regarding claims of alleged medical malpractice. This analysis aims to examine the cases presented in the sentences and the evaluations proposed by the judges to offer ideas for objective evaluation by the legislation in force in Italy.

Diagnostic Methods in Forensic Pathology: A New Sign in Death from Hanging.

PURPOSE: To evaluate the usefulness of studying vital injuries at the sternal head insertion of the sternocleidomastoid muscle in the medico-legal assessment of death by hanging. MATERIALS AND METHODS: Study material was obtained from eight bodies of people who died from hanging. The control group included as many specimens collected from people who died from traumatic causes other than hanging (precipitation from medium to large heights and traffic accidents). The structures under study were examined histologically with a BX-51 light microscope (Olympus). An analysis of the extravasated erythrocytes was performed by counting the number per mm2 in the histologic section on 10 HPF (400×), and Student's t-test for a comparison of the averages was applied for all parametric values. The authors noted that the key finding, indicative of the subject's viability at the time of discontinuation, was the presence of recent hemorrhagic infiltrate (in the absence of hemosiderin) at the tendon insertion of the sternocleidomastoid muscle and the proximal part of the muscle itself. RESULTS: All specimens tested were positive for the presence of hemorrhagic infiltrate at the portions tested in a statistically significant manner. In contrast, in the control cases there was no or, where present, no statistically significant (p < 0.05) presence of recent hemorrhagic infiltrate. The limitation of the study is the low number of samples examined. In any case, the results obtained are strongly indicative of the possibility of using this type of forensic pathological investigation in cases where there is a doubt in terms of a differential diagnosis between hanging (suicidal type) and suspension of a corpse in a simulation of hanging.

The Effects of the COVID-19 Pandemic on Vaccination Hesitancy: A Viewpoint.

Vaccination hesitancy is considered by the World Health Organization as a danger to global health. In recent years, vaccine hesitancy rates to COVID-19 have been studied worldwide. In our study, we aim to provide an overview of the concept of vaccine hesitancy, with regard to the post-COVID era, and to provide prevention and management strategies. A search of the international literature until March 2023 was conducted in the PubMed database. The 5723 papers found were divided into two groups: prior to the COVID-19 era and from 2021 onward. Papers about the vaccine hesitation phenomenon are becoming more common during the SARS-CoV-2 pandemic and following the marketing that the vaccine companies have carried out on the different types of COVID-19 vaccines. It is advisable that healthcare authorities, at the national and international level, as well as healthcare professionals, at the local level, should promote a series of activities to reduce the vaccine hesitancy rate.

How Much Is an Abortion Worth? Was a Human "Not Formed"? An Italian Proposal.

INTRODUCTION: "Human capital" is defined as an integration of innate skills and knowledge acquired by investing in the formation of an individual; it is a real "capital" that pays off in the long term. In the Italian legal system, a human being is recognised as a "person" from the moment of birth. This determines the acquisition of the personal rights of an individual. Necessarily, therefore, by law, a fetus does not own such rights; nevertheless, it has an innate "potential" to acquire such rights after birth. OBJECTIVE: In Italian jurisprudence, in general, the damage from a loss of a parental relationship is justified by the condition of existential emptiness caused in the family by the loss of a child. Compensation for this damage in the event of abortion due to third-party responsibility presents a non-uniform recognition in the judgements of the Italian courts, but in any case, it is almost always recognised with limitations since the emotional relationship with the lost individual is defined only in terms of "potential". Consequently, in this matter, at least two questions can be raised: (i) Is the economic estimate of abortion based on objective and standardised criteria, or is it heavily influenced by subjective evaluation? (ii) Is it possible to find standard criteria that may act as guidelines to quantify the loss of that human capital "in progress"? METHODOLOGY: The authors try to answer these questions by analysing the different approaches to this issue adopted at an international level. CONCLUSIONS: In conclusion, the authors propose homogeneous criteria to quantify the damage caused by abortion.

The Job that Kills the Worker: Analysis of Two Case Reports on Work-Related Stress Deaths in the COVID-19 Era.

The COVID-19 pandemic caused an increasing number of corporate layoffs and downsizing, as well as causing many employees to be absent due to illness, with inevitable consequences on the health of active workers both from a physical point of view, due to the need to make up for staff and organizational shortages, and from a mental point of view, due to the inevitable consequences related to the uncertainty of the social context. This context has certainly caused an increase in work-related stress, which is the pathological outcome of a process that affects workers who are subjected to excessive (emotional-relational or high or low or inadequate activity) or improper work loads. The purpose of this paper is to evaluate the main aspects of this issue, through the analysis proposed by two case reports, both of which occurred during the COVID-19 pandemic, in which occupational stress emerged as an etiological agent in the determinism of death.

Alcohol and Drug Consumption among Drivers before and during the COVID-19 Pandemic: An Observational Study.

Restrictions imposed during the COVID-19 pandemic might have changed recreational habits. In this study, the results of toxicological tests for alcohol and drugs in blood were compared among drivers stopped at roadside checks in the periods before (1 January 2018 to 8 March 2020) and after the lockdown measures (9 March 2020 to 31 December 2021). A total of 123 (20.7%) subjects had a blood alcohol level above the legal limit for driving of 0.5 g/l, 21 (3.9%) subjects tested positive for cocaine, and 29 (5.4%) subjects positive for cannabis. In the COVID-19 period, the mean blood alcohol level was significantly higher than in the previous period. Cannabis use, which was more frequent among younger subjects, was statistically associated with cocaine use. There has also been a quantitative increase in alcohol levels in the population with values above the legal limits, indicative of greater use of alcohol in the population predisposed to its intake.

Requests for Compensation in Cases Involving Patients' Falls in Healthcare Settings: A Retrospective Analysis.

Falls are the most frequent adverse events recorded in healthcare facilities. By employing a multifaceted strategy to ensure prevention interventions that are specific to the patient type and environmental risk management, risk factor evaluation may help to reduce falls in the hospital setting. Patient falls are one of the main causes of lawsuits against hospitals, which has led to the development of validated instruments that are beneficial in treating the patient after the incident and effective in minimizing the frequency of falls. The aim of our study is to evaluate compensation claims asserting healthcare culpability in situations where a patient fell in a hospital setting. The collected data relate to judgments issued in Italy until December 2022 regarding 30 episodes of falls that occurred between 2003 and 2018. Our research revealed that approximately 50% of Italian healthcare organizations lose the case in court when a patient falls in a hospital setting and dies or is injured. In half of these cases, the failure of the medical staff to use protective equipment against falls is what led to the court's acceptance of the compensation claim. In order to improve the quality of healthcare services, fall prevention techniques must continue to be implemented.

Photography as the Sole Means of Proof: Medical Liability in Dermatology.

Malignant melanoma is a cutaneous malignancy resulting from the uncontrolled proliferation of melanocytes and poses a challenge diagnostically because neoplastic lesions can mimic benign lesions, which are much more common in the population. Doctors, when they suspect the presence of melanoma, arrange for its removal and the performance of a histological examination to ascertain its diagnosis; in cases where the dermatoscopic examination is indicative of benignity, however, after the lesion is removed, histological examination is not always performed, a very dangerous occurrence and a harbinger of further medico-legal problems. The authors present a court litigation case of an "alleged" failure to diagnose malignant melanoma in a patient who died of brain metastases from melanoma in the absence of a certain location of the primary tumor: the physician who had removed a benign lesion a few months earlier was sued, and only thanks to the presence of photographic documentation was the health care provider able to prove his extraneousness. The aim of this paper is to formulate a proposal for a dermatological protocol to be followed in cases of excisions of benign skin lesions with a twofold purpose: on the one hand, to be able to prove, in a judicial context, the right action on the part of the sanitarians; on the other hand, to avoid the rise of so-called "defensive medicine".

Heat Stroke in the Work Environment: Case Report of an Underestimated Phenomenon.

Average global temperatures continue to trend upward, and this phenomenon is part of the more complex climate change taking place on our planet over the past century. Human health is directly affected by environmental conditions, not only because of communicable diseases that are clearly affected by climate, but also because of the relationship between rising temperatures and increased morbidity for psychiatric diseases. As global temperatures and the number of extreme days increase, so does the risk associated with all those acute illnesses related to these factors. For example, there is a correlation between out-of-hospital cardiac arrest and heat. Then, there are pathologies that recognize excessive heat as the main etiological agent. This is the case with so-called "heat stroke", a form of hyperthermia accompanied by a systemic inflammatory response, which causes multi-organ dysfunction and sometimes death. Starting with a case that came to their attention of a young man in good general health who died while working unloading fruit crates from a truck, the authors wanted to express some thoughts on the need to adapt the world of work, including work-specific hazards, in order to protect the worker exposed to this "new risk" and develop multidisciplinary adaptation strategies that incorporate climatology, indoor/building environments, energy use, regulatory perfection of work and human thermal comfort.

A Multi-Institutional Informed Consent Proposal as a Prevention Tool for Combined Oral Contraceptive Intake and Thrombotic Risk.

Combined oral contraceptives (COC), are among the most widely used contraceptive methods in the world today. Despite the different changes in terms of estrogen/progestogen combinations and dosages, the thromboembolic risk for a woman who takes combined oral contraceptives persists to date. METHODS: The review of relevant literature and international guidelines on prescription of combined oral contraceptives made it possible to create a proposal for informed consent to be used for prescribing. RESULTS: The several sections of our consent proposal were designed according to a rationale in order to cover all the aspects presented by worldwide guidelines: how to take, adverse effects, advertisements, extra-contraceptive benefits and effects, a checklist for condition at risk of thromboembolism, the signature of the woman. CONCLUSIONS: An informed consent to standardize combined oral contraceptives prescription can improve women's eligibility, mitigate thromboembolic risk, and assure legal protection to healthcare providers. In this systematic review in particular, we refer to the Italian medical-legal scenario, to which our group of researchers belongs. However, the model proposed was designed in the respect of main healthcare organization guidelines, and it could be easily used by any center in the world.

Identification of Skeletal Remains Using Genetic Profiling: A Case Linking Italy and Poland.

Forensic genetics is a rapidly evolving science thanks to the growing variety of genetic markers, the establishment of faster, less error-prone sequencing technologies, and the engineering of bioinformatics models, methods, and structures. In the early 2000s, the need emerged to create an international genetic database for forensic purposes. This paper describes a judicial investigation of skeletal remains to identify the subject using various methods. The anthropological examination of the remains allowed identification of the Caucasoid (European) ethnic group, a height of 156 ± 4 cm, and an age between 47 and 50 years. The genetic profiles obtained from typing several microsatellites made it possible to evaluate the compatibility between the skeletal remains and the suspected decedent. To identify the remains, the two extrapolated genetic profiles were compared. The case described highlights the central role of forensic genetics in identifying skeleton remains by means of comparison.

Impact of a Pro-Active Infectious Disease Consultation on the Management of a Multidrug-Resistant Organisms Outbreak in a COVID-19 Hospital: A Three-Months Quasi-Experimental Study.

BACKGROUND: Antimicrobial and diagnostic stewardship (AS/DS) principles are crucial for the management of multidrug-resistant organisms (MDROs) infections. We evaluated the impact of a pro-active Infectious Disease (ID) consultation on the mortality risk of patients during an MDROs outbreak in a COVID-19 hospital. METHODS: A quasi-experimental study was performed in a dedicated COVID-19 hospital, including patients with suspected/confirmed infection and/or colonization by MDROs, which were managed as follows: (i) according to the standard of care during the pre-phase and (ii) in collaboration with a dedicated ID team performing a pro-active bedside evaluation every 48-72 h in the post-phase. RESULTS: Overall, 112 patients were included (pre-phase = 89 and post-phase = 45). The AS interventions included the following: therapy optimization (33%), de-escalation to narrow the spectrum (24%) or to lessen toxic drugs (20%), and discontinuation of antimicrobials (64%). DS included the request of additional microbiologic tests (82%) and instrumental exams (16%). With the Cox model, after adjusting for age, sex, COVID-19 severity, infection source, etiological agents, and post-phase attendance, only age predicted an increased risk of mortality, while attendance in the post-phase resulted in a decreased risk of mortality. CONCLUSIONS: Implementation of AS and DS intervention through a pro-active ID consultation may reduce the risk of 28-day mortality of COVID-19 patients with MDROs infections.

COVID-19 Vaccination Policies: Ethical Issues and Responsibility.

The World Health Organization (WHO) declared coronavirus 2 (SARS-CoV-2, COVID-19) a global pandemic on 11 March 2020. The emergence of the reliability of vaccines, the fear of possible vaccination-related side effects, and mass-media information created situations in which families and even health professionals developed hesitations regarding the need for vaccines, with a consequent decrease in vaccination coverage. This study discusses ethical issues and responsibility for the possible side effects of SARS-CoV-2 vaccination raised by vaccination policies.

Italian Legal Euthanasia: Unconstitutionality of the Referendum and Analysis of the "Italian" Problem.

The term "euthanasia" refers to medical interventions that involve the direct administration of a lethal drug to the patient who requests it and meets certain requirements. Currently in Italy euthanasia constitutes a crime and falls within the hypotheses foreseen and punished by Article 579 (Murder of consenting person) or by article 580 (Instigation or aid to suicide) of the penal code. On the contrary, medically assisted suicide in some cases and the suspension of treatment constitute an inviolable right pursuant to art. Thirty two of the Constitution and Law 219/2017. Thanks to the sentence 242/2019 of the Constitutional Court, in Italy it is instead possible to request medically assisted suicide, that is, the indirect help of a doctor to die. There are four conditions required: whoever requests it must be fully capable of understanding and willing, must have an irreversible pathology that is the bearer of severe physical or mental disease, and must survive thanks to life-saving treatments. The Italian referendum "Free until the end" aims to introduce legal euthanasia through the partial repeal of art. 579 c.p. which punishes the murder of the consenting party. The authors analyze the reasons for the referendum in the light of the Italian and European scenario, analyzing the first Italian case of assisted suicide immediately after the referendum which inevitably becomes a starting point for ethical and medico-legal reflection on the issue. On 02.15.2022 the Italian Constitutional Court declared the Referendum on Legal Euthanasia inadmissible.