Consequences of the lack of clinical forensic medicine in emergency departments.

Most victims of physical violence sooner or later will access a hospital or medical cabinet because of that violence, and in particular emergency departments (EDs). This paper aims to analyze the performance of emergency ward clinicians in the forensic management of such victims by examining the activities carried out and the data reported. A total of 991 medical records were extrapolated from the database of the ED of the Policlinico of Milan in an average pre-pandemic 1-year activity. For each medical record, 16 parameters were analyzed in-depth including epidemiological data, information on the type of violent actions, injuries, and time between the infliction of the lesion and access to the ED. In the vast majority of cases, all the actions with medicolegal implications had been neglected by health professionals causing loss of data not only for the justice system but especially for correctly interpreting what happened and taking appropriate measures to protect the patient/victim. Hence, given that clinicians in EDs are busy with non-forensic clinical tasks (and rightly so), it should be ensured that there be specific forensic clinical personnel. However, it is crucial that when unfortunately there can be no forensic staff, at least the clinicians who work in the ED are properly trained to correctly apply essential medicolegal measures. Overall, timely and informed medical and forensic intervention is possible and necessary for the improvement and maintenance of the mental and physical health of victims of violence.

Transcending time: the forensic anthropological case study of three unidentified transgender women in Italy in the early 1990s.

In forensic anthropology, the estimation of skeletal sex results in a dichotomous outcome: male or female. This poses challenges when dealing with transgender individuals. Italy has the highest rate per capita of transgender murders, making their identification a compelling issue. This study presents three cases of unidentified skeletal remains of transgender women (MtF) that underwent autopsies in the 1990s at the Institute of Legal Medicine of Milan. The transgender status of the individuals was determined from the autopsy records which indicated the co-existence of breast implants and male genitalia. The biological profile was created by estimating sex, age, ancestry, and stature, and the bones were investigated looking for evidence of Facial Feminization Surgery (FFS). Anthropological estimations revealed that the skeletons belong to male, adults, European individuals, between 164 and 184 cm. Fragmented gelatinous masses were found in association with two skeletons, which were interpreted as remnants of breast implants. In two cases, signs of remodeling of the cortical surface were observed on the zygomatic bones, although the bone marks observed here were not specific enough to link them to FFS. Despite some limitations, this study highlights the need for greater awareness among practitioners about this limitedly addressed issue, advocating for a more inclusive forensic anthropology that strives to improve methods and interpretation of evidence for the identification of transgender individuals.

Forensic pilot application of rehydrating solutions on human cadaveric skin: what are the effects on hemorrhagic infiltrates?

The microscopic evaluation of hemorrhagic infiltrates is crucial in forensic diagnostics, but it proves challenging in corificated and mummified cadavers. In these cases, pre-treatment with rehydrating solutions is recommended, although their effects on the hemorrhagic infiltrate are not well understood. In this pilot study, we microscopically investigated the effect of two different rehydrating solutions-Sandison's solution and fabric softener-on well-preserved human cadaveric skin samples taken from areas affected by an ecchymotic lesion, comparing them with direct fixation in formalin. Specifically, we examined the topographic distribution of the hemorrhagic infiltrate in each layer of the skin by assigning a semi-quantitative score, conducted mutual comparisons, and performed statistical analysis. Histologically, compared to direct fixation in formalin, a slight and statistically non-significant reduction in the hemorrhagic infiltrate was observed in samples pre-treated with fabric softener. On the other hand, a more pronounced and statistically significant decrease in scores was observed in samples pre-treated with Sandison's solution. This effect is likely due to the fact that Sandison's solution, due to its components, exerts an osmotic effect, partially inducing osmotic lysis of red blood cells. Overall, extensive areas of hemorrhagic infiltrates were preserved, although to a lesser extent, while smaller foci were markedly reduced, sometimes even disappearing. The findings suggest that Sandison's solution has a detrimental effect on cutaneous hemorrhagic infiltrates, emphasizing the importance of being cautious and conducting dual sampling, using both formalin and a rehydrating solution, for forensic examination of mummified or corificated skin samples.

Are autopsies on minors a taboo?: The experience of Milan in a 19-year retrospective study.

Forensic autopsy is an important tool for the proper management of non-natural deaths in minors. However, it seems that autopsy in minors is a practice which may not be performed routinely. In this framework, we conducted a study analyzing autopsies of minors (under 18 years of age in Italy) performed at the Institute of Forensic Medicine in Milan in the period 2001-2019. For the period 2015-2019, we extrapolated all deaths due to non-natural causes in minors to investigate how many and which of these deaths were not subjected to forensic autopsy. Of the total, 344 minors (235 males and 109 females) underwent autopsies, with an overall downward trend of about 80% since 2004. Most autopsies occurred between the ages of 0 and 1 year, and the fewest between the ages of 5 and 9 years. The place of death was home in most cases, and accidental death was most common, followed by natural death, suicide, and homicide, with prevalence varying by age group. Blunt force trauma predominated among accidental death in all age groups, followed by asphyxia. Similar findings were observed for suicides, although there was a more differentiated pattern for suicides between the ages of 15 and 17 years. Among homicides, blunt force trauma, asphyxia, and gunshot wounds were fairly evenly distributed across all age groups. Between 2015 and 2019, a total of 86 minors died of a non-natural cause, and a forensic autopsy was performed in only 33 cases (38%). Our data shows that fewer and fewer autopsies are being performed over the last years, which indicates a dangerous lack of forensic investigation of children and adolescent deaths, with enormous implications for prevention of child abuse.

Age assessment in unaccompanied minors: assessing uniformity of protocols across Europe.

Age assessment of migrants is crucial, particularly for unaccompanied foreign minors, a population facing legal, social, and humanitarian challenges. Despite existing guidelines, there is no unified protocol in Europe for age assessment.The Forensic Anthropology Society of Europe (FASE) conducted a comprehensive questionnaire to understand age estimation practices in Europe. The questionnaire had sections focusing on the professional background of respondents, annual assessment numbers, requesting parties and reasons, types of examinations conducted (e.g., physical, radiological), followed protocols, age estimation methods, and questions on how age estimates are reported.The questionnaire's findings reveal extensive engagement of the forensic community in age assessment in the living, emphasizing multidisciplinary approaches. However, there seems to be an incomplete appreciation of AGFAD guidelines. Commonalities exist in examination methodologies and imaging tests. However, discrepancies emerged among respondents regarding sexual maturity assessment and reporting assessment results. Given the increasing importance of age assessment, especially for migrant child protection, the study stresses the need for a unified protocol across European countries. This can only be achieved if EU Member States wholeheartedly embrace the fundamental principles outlined in EU Directives and conduct medical age assessments aligned with recognized standards such as the AGFAD guidelines.

A Forensic Case of Suicide Ingestion of Paraquat Herbicide: New Histological Insights and Revision of the Literature.

ABSTRACT: Paraquat (PQ) is one of the most widely used herbicides in the world, and poisoning is generally associated with accidental, suicidal, or homicidal events. Therefore, in the forensic context, PQ could be in various ways involved as a possible cause of death of a subject. However, even though its systemic toxicity is known, the biological effects exerted on individual viscera have been explored only to some extent, especially in case of victim's survival. Therefore, a case concerning a suicidal ingestion of PQ with survival of 3 days was deemed of interest. Clinical toxicological analyses confirmed acute PQ intoxication, and after the death of the victim, an autopsy was performed showing local and systemic signs of ingestion of a caustic substance. Histologic examination revealed marked cellular damage to the major viscera, particularly the gastroesophageal tract, liver, kidneys, and lungs, with initial alveolar fibrosis noted despite the patient's short survival. This finding represents a new element in the context of PQ lung injury, as it has not been previously documented in the literature. Thus, histological findings in lethal intoxications after survival can reveal specific peculiarities still unknown and, therefore, assume transversal relevance not only at forensic but also clinical level.

Pilot Application of SEM/EDX Analysis on Suspected Cigarette Burns in a Forensic Autopsy Case of Child Abuse.

ABSTRACT: Cigarette burn lesions present forensic scenarios that are often difficult to investigate, both from a morphological diagnostic point of view and with regard to the mode of infliction, especially if the victim is unable to speak or has died. Although there may be the suspicion for a lesion to be produced by a lit cigarette, to date one can only rely on the morphological aspects that characterize it, and there is a lack of tools to reach the most evidence-based diagnosis possible. This limitation arose when managing a forensic autopsy case of possible child abuse that resulted in the death of the child, characterized by the presence of 3 suspicious cigarette burn lesions. We therefore decided to perform scanning electron microscopy/energy-dispersive x-ray (SEM/EDX) spectrometry analysis on these lesions and on the cigarette butt found at the crime scene. At the same time, SEM/EDX was applied to the analysis of an unlit cigarette in its entirety (obtained from the same source package as the cigarette butt), a positive control skin sample with an iatrogenic cigarette burn injury, and a negative control skin sample. Among the various compounds highlighted on compositional analysis, only sulfuric anhydride (SO 3 ) and phosphoric anhydride (P 2 O 5 ) showed a highly significant distribution pattern by being found in the autopsy samples, the cigarette butt, the tobacco of the unlit cigarette, and the positive skin control. Considering this, cigarette burns appear to follow Locard's principle as well, and similarly to other lesions, SEM/EDX allowed the diagnosis of cigarette burn lesions, already suspected morphologically, to be corroborated. Therefore, SEM/EDX is confirmed as a helpful tool in forensic pathology investigations.

Elastic fiber degradation as a possible indicator for PMI estimation on mummified and corified skin: a pilot study.

Mummified and corified bodies are particularly complex scenarios to investigate, starting from identifying the post-mortem interval (PMI), even more so in indoor environments. In these bodies, the skin has the peculiar feature to resist for a long time. Among its components, there are elastic fibers, which are characterized by intrinsic resistance to post-mortem degenerative phenomena. Starting from these considerations, we investigated microscopically the persistence, detectability, and changes of elastic fibers in the skin of mummified and corified bodies with different known PMI. The aim was to evaluate whether they could provide an additional tool to aid in PMI estimation in these cases. Therefore, we collected skin samples from mummified or corified bodies found in a domestic environment with different known PMI, as well as from corified bodies that had been exhumed after 11 years of burial. Histochemical staining specific for elastic fibers, namely, Weigert's resorcin fuchsin, showed their prolonged persistence and a progressive and different degradation between mummified and corified skin as a function of PMI. Moreover, on the whole, we observed greater preservation of elastic fibers in mummified skin than in corified one at the same PMI. Therefore, histological analysis of elastic fibers in mummified and corified skin may help to provide valuable aid in estimating PMI, especially in those particular cases where more reliable alternatives are lacking.

Trends in mortality from non-natural causes in children and adolescents (0-19 years) in Europe from 2000 to 2018.

BACKGROUND: Non-natural mortality in children and adolescents is a global public health problem that varies widely from country to country. Data on child and adolescent maltreatment are not readily available, and mortality due to violent causes is also underestimated. METHODS: Injury-related mortality rates (overall and by specific causes) from 2000 to 2018 in selected European countries were analysed to observe mortality patterns in children and adolescents using data from the Eurostat database. Age-standardized mortality rates per 100,000 person-years were calculated for each country. Joinpoint regression analysis with a significance level of 0.05 and 95% confidence intervals was performed for mortality trends. RESULTS: Children and adolescent mortality from non-natural causes decreased significantly in Europe from 10.48 around 2005 to 5.91 around 2015. The Eastern countries (Romania, Bulgaria, Poland, Slovakia, Czech Republic) had higher rates; while Spain, Denmark, Italy, and the United Kingdom had the lowest. Rates for European Country declined by 5.10% per year over the entire period. Larger downward trends were observed in Ireland, Spain and Portugal; smaller downward trends were observed for Eastern countries (Bulgaria, Czech Republic, Poland, Slovakia) and Finland. Among specific causes of death, the largest decreases were observed for accidental causes (-5.9%) and traffic accidents (-6.8%). CONCLUSIONS: Mortality among children and adolescents due to non-natural causes has decreased significantly over the past two decades. Accidental events and transport accidents recorded the greatest decline in mortality rates, although there are still some European countries where the number of deaths among children and adolescents from non-natural causes is high. Social, cultural, and health-related reasons may explain the observed differences between countries.

A forensic case of abdominal cocoon syndrome.

The term "cocoon syndrome" defines a sclerosing encapsulating peritonitis (SEP) that involves a chronic fibrotic inflammatory reaction of the parietal peritoneum and of the viscera leading to a complete sclerosis. The cocoon that is formed causes an incarceration of the intestinal loops with severe complications leading to high mortality. We are presenting the case of a 15-year-old young man that underwent surgery for appendectomy and that was evaluated for having a regular abdominal state. During the post-surgery period, however, several episodes of intestinal occlusion required further surgical interventions leading to a right hemicolectomy. The presence of a fibrotic-adhesive ligneous peritonitis with blended intestinal loops, severely thickened walls, and intestinal scaring stenosis was observed during his second surgical operation. A stenosis of the colostomy led to a worsening of the vital signs of the young man with the onset of a cardiac failure and subsequent decease. Macroscopic autopsy examination and histological analysis confirmed the severe obstructive adhesive encapsulating abdominal context allowing to trace back the cause of death to a cocoon syndrome. Since no predisposing factor could be found, we hypothesized that this case could be characterized by an excessive peritoneal reactivity due to surgical appendectomy. Cocoon syndrome is a rare pathology, and its microscopic features are seldomly observed and could be underestimated. We present a directly observed case with a very substantial macroscopic and microscopic context.

Use of cadaveric vitreous humor as an innovative substrate for diatoms research and forensic diagnosis of drowning.

The search for diatoms is the test that most of all may contribute to the forensic diagnosis of drowning. Diatoms can be extracted through different methods, which are all complex and long. In this preliminary study, we assessed human vitreous humor as an innovative substrate on which to research diatoms. Sampling and analyses were performed on 3 groups of 10 corpses each. The first one was composed of drowned victims. The second one of victims of traffic accidents with subsequent projection in water; based on the severe traumatic injuries reported at autopsy, we considered such victims as ideally assimilable to bodies immersed in water postmortem. The third group was composed of subjects who died for natural causes and without any relationship with water. The vitreous humor was centrifugated and cytocentrifuged and spotted on two different histological slides: one was left blank and the other one was assessed with hematoxylin and eosin staining. Microscopic observation successfully revealed diatoms in all cases of the first group; in the second group diatoms were not detected in 6 cases; in the third group, no diatoms at all were observed. Diatoms were always qualitatively and quantitatively consistent with those found in the corresponding viscera and waters, which had been investigated through classical acid digestion. Our analyses have demonstrated that the vitreous humor behaves in a completely similar way to the other viscera in cases of drowning. Although further investigations are necessary, vitreous humor has proved to be an innovative, suitable, and reliable substrate for the forensic research of diatoms.

Technical note: A comparison between rehydrating solutions in the pretreatment of mummified and corified skin for forensic microscopic examination.

Microscopic examination of mummified or corified skin may be of extreme importance for forensic purposes. However, standard histological samples in these cases are low-end, and preparation is burdened by several problems and so are diagnostic results: an improvement of these types of specimens is therefore advantageous. This study aims to identify the best performing rehydration solution among a fabric softener, a body lotion, and Sandison's rehydrating solution. Samples of skin undergoing mummification or corification were collected from 25 corpses and each sample was divided into 4 fragments: one of these fragments was directly fixated in 4% formalin, one was previously treated with a tissue softener, another one was previously treated with a body lotion, and the last one was treated with Sandison's solution. After 72 h, the pretreated samples were post-fixated in 4% formalin and then prepared for standard histological examination staining the histological slides with hematoxylin-eosin and Masson's trichrome. At the microscopic examination, samples directly fixated in formalin were characterized by usual marked structural alterations and altered stainability, typical of such dry tissues. Vice versa, those previously treated appeared to be better-preserved even though with different improvement levels: body lotion made a medium-low-grade restoration of the tissues, and fabric softener a high-grade restoration, while Sandison's rehydrating solution produced an optimal grade restoration. Sandison's rehydrating solution was confirmed to be the best rehydrating substance for mummified and corified skin. Fabric softener could be, however, considered a valid substitute, being productive of high-grade microscopic yield.

Postmortem Diagnosis of Invasive Disseminated Aspergillosis After Tongue Piercing.

ABSTRACT: Severe fungal infections caused by highly invasive fungi such as Aspergillus are not easy to diagnose and often have a poor prognosis. In these cases, the nonspecific symptoms may make clinical diagnosis challenging, and consequently, the autopsy and postmortem histological investigations acquire a crucial role. We report the case of a young man in good health who died of septic shock 3 weeks after having had a tongue piercing. Intravitam investigations did not identify the etiology of the rapidly fatal infectious condition. The autopsy revealed flaccid organs of uniformly diminished consistency with abscesses and granulomatous foci with central necrosis. Histological examination showed the presence of septate mycotic hyphae, with a dichotomous 45-degree bifurcation, typical for Aspergillus , in all the examined organs, including the tongue. The molecular identification confirmed the presence of Aspergillus fumigatus. The observed macroscopic framework and the laboratory findings made it possible to diagnose pseudomembranous invasive tracheobronchial aspergillosis and to attribute the death to fatal invasive disseminated aspergillosis. The consistency and concordance of all the findings in our possession led us to suspect the practice of piercing as the triggering cause of the man's pathology.

An unusual suicide by self-waterboarding: forensic pathological issues.

The authors present the first case, to the best of our knowledge, of a preplanned suicide by self-waterboarding. Waterboarding (WB) is a military method of torture in which water is poured into the nostrils and the mouth of a victim, to evoke the sensation of asphyxiation by drowning. The victim was a 22-year-old male student, who was found dead and naked in the bathtub. His head was covered by a soaked canvas bag, and his hands were tied with two nylon ropes and a padlock. The water jet of the showerhead was specifically directed at the victim's head, so that the canvas bag could be soaked with water. The cause of death was defined as the combination of asphyxiation by drowning with the direct suffocation provoked by the soaked canvas bag in the context of the waterboarding practice. Finally, the authors discuss the differential diagnosis regarding the modality (suicide versus homicide) through which this case of waterboarding was performed. The case is intended to be used as source data for similar forensic cases, where a multidisciplinary approach is advisable in such complex cases.

Common and much less common scenarios in which botany is crucial for forensic pathologist and anthropologists: a series of eight case studies.

It is commonly accepted that crime scene recovery and recording are key moments of any judicial inspection in which investigators must decide on the correct strategies to put into place. Complex outdoor scenarios, presenting partially or entirely skeletonised remains, can benefit more than others by the intervention of environmental specialists (forensic anthropologists, archaeologists, entomologists and botanists). These experts are capable of singling out, correctly recording and recovering environmental evidence that can lead to a more comprehensive reconstruction of a given criminal episode. If human remains are discovered in an outdoor scenario, the on-site presence of a botanist will guarantee a correct approach to the identification, recording and recovery of any botanical evidence. If an on-site botanist is not available, the operators must be capable of both the botanical evaluation of a scene and the implementation of correct botanical sampling protocols.The following collection of unusual case histories that aim at underlining the efficacy of forensic botany will examine the determination of post mortem or the post depositional interval, evidence for a victim's post mortem transfer, evidence for the identification of a primary crime scene and evidence for the identification of a victim's dismemberment site. In another two cases, one, we will illustrate the important role that forensic botany played in the discrimination between botanical material used to voluntarily conceal a victim and vegetation that had grown naturally above a disposal site, whereas the other will highlight the protocols implemented for the identification of a murder weapon.

Postmortem diagnostics of assumed suicidal food anaphylaxis in prison: a unique case of anaphylactic death due to peach ingestion.

Suicidal ingestion of food which the victim is aware they are allergic to is an exceptional occurrence in the forensic field. To the best of our knowledge, no cases of suicidal food anaphylaxis have been reported to date. Therefore we present the first case described in the literature. A 30-year-old prisoner was found dead inside his cell with the remains of a peach remains next to his body, and a handwritten farewell note in his pocket. The autopsy revealed only non-specific findings, while laboratory investigations (serological, toxicological, histological, and immunohistochemical) played a pivotal role in determing the cause and manner of death. In particular, a high titer of both total and specific IgE antibodies was detected, as well as an increase of the tryptase level in cadaveric blood. Moreover, a massive concentration of salicylates was measured in the gastric contents. Microscopically, cellular residues characterized by a vegetal structure were observed in the gastric contents and elements suggestive of mast cells were detected in the glottis, lungs, and myocardium. The immunohistochemical investigation with anti-CD117 and anti-tryptase antibodies showed positivity for mast cells, some of which appeared degranulated. Such findings were entirely consistent with an acute systemic anaphylactic reaction triggered by allergy. Therefore, the prisoner's death was attributed to self-induced food anaphylaxis caused by the ingestion of peaches. This conclusion was achieved based only on circumstantial data, anamnestic information, autopsy findings, and multiple laboratory results. This integrated approach should be used to pursue a post-mortem diagnosis of anaphylaxis.

Technical note-stabilization of cadaveric corified and mummified skin thanks to prolonged temperature.

Microscopic study and interpretation of skin samples obtained from mummified/corified cadavers request the adoption of special laboratory techniques in order to avoid that the histological samples may detach from the slide during staining processes. We have assessed an experimental and extended drying of corified and mummified skin samples in order to evaluate an eventual improvement after staining procedures. Samples of skin undergoing different post-mortem putrefactive phenomena-from parchment-like to mummification-were collected from 16 corpses and divided in halves: one half was fixated in buffered formalin while the other half was previously treated with Sandison's rehydrating solution. The so-obtained sections were subsequently dried for one night at 37 °C and stained with Hematoxylin & Eosin staining and Masson's Trichrome staining according to Goldner. At microscope observation, 69% of the dyed sections stained with H&E and 53% of the sections stained with Masson's Trichrome was lost during different steps of the coloring procedures. We then proceeded with a new cutting of the slides and decided to experimentally dry them for 5 days at a mean temperature of 37 °C: purpose of this procedure was to gradually remove the possible liquid component of the samples probably culpable of the detachment. With this modified procedure, all the sections resulted to be preserved in the following staining steps and showed, moreover, an improvement of the morphological structure, especially in those previously treated with Sandison's rehydrating solution. In those cases where a histological examination is requested on skin samples collected from corified or mummified cadavers, this technique is highly recommended in order to obtain microscopic slide of high quality.

A Brief Review of Scanning Electron Microscopy With Energy-Dispersive X-ray Use in Forensic Medicine.

Scanning electron microscopy with energy-dispersive x-ray (SEM/EDX) analysis is an investigation whose potential has become increasingly important in the field of forensic research and diagnosis. We present the procedure to perform a well-carried-out SEM/EDX analysis on corpses affected by different types of injuries, such as blunt force trauma, ligature strangulation, electrocution, sharp force trauma, gunshot wounds, and intoxication. After the areas of forensic interest have been macroscopically identified, the sampling can be performed in 2 different ways: apposition of the double-sided graphite tape on the damaged area or performing the excision of a biological sample. In both cases, a proper negative control sample is required. In all cases, SEM/EDX analysis can detect exogenous microtraces consistent with the types of injuries involved. In blunt force trauma, microparticles of different nature deriving from the contact of the blunt instrument with the victim may be observed; in sharp force trauma, metal microtraces (Fe, Cr, Al, Ti) can be identified. In ligature strangulation, exogenous microtraces may be found in the cutaneous furrow. In electrocution, it allows to identify the pathognomonic metal pattern (Cu, Zn, Fe) of the "electric mark." In gunshot wounds, the main applications regards the detection of metal particles (Pb, Ba, Sb) of gunshot residues. Finally, in the analysis of intoxicants, it may identify traces of toxic substances. Thus, the authors conclude that SEM/EDX analysis can provide essential information to assist in the medicolegal investigation of death.