The potential of micro-CT for dating post-cranial bone fractures: a macroscopic, radiographic, and microtomography study of fractures of known post-traumatic ages.

The estimation of the post-traumatic survival time (PTST) in case of bone injuries remains a tricky issue in the forensic field, especially when dealing with dry bones. Newer high-resolution imaging, and in particular microcomputed tomography (micro-CT), has the potential to significantly improve our abilities to interpret antemortem and perimortem lesions and accurately date fractures in a less destructive analysis. In this paper, nine costal fractures of known post-traumatic ages were analyzed through gross examination, conventional radiography, and microcomputed tomography, in order to test the potential of microcomputed tomography for dating fractures. As a result, microcomputed tomography provided images of high quality and definition and allowed the observation of the internal microarchitecture of the fractures and calluses. While microcomputed tomography cannot substitute histological examination for the estimation of the post-traumatic survival time, it constitutes a potent and helpful complementary tool for the analysis of bone trauma.

Radiological investigation of gunshot wounds: a systematic review of published evidence.

INTRODUCTION: Despite the constantly growing popularity of radiological imaging in forensic pathology, a systematic review investigating the efficiency and limits of radiological techniques, in comparison to forensic autopsy, was still missing. AIM: The present review aims at providing an overview on the current role of radiology in the forensic investigation of fatal gunshot wounds without any restriction to specific radiological techniques. MATERIAL AND METHODS: A systematic literature search on three databases (PubMed, Web of Science, and Science Direct) was performed until December 2017. The Oxford Centre for Evidence Based Medicine (OCEBM) grading system for levels of evidence was applied, in order to weigh published evidence. RESULTS AND DISCUSSION: Eighty-six papers (1.64% of the records) were included. Despite the quite limited general level of evidence, which contrasts with the abundance of the scientific literature on this topic, several recommendations/statements, coupled to their OCEBM grade, were distilled as for the identification of retained bullets, gunshot wounds detection, diagnosis of entrance and exit wounds, trajectories and internal injury detection and estimation of the firing distance. CONCLUSIONS: Imaging radiological technologies represent the present and future of wound ballistics. However, traditional, micro and molecular imaging techniques require further validation through blinded cross-sectional studies with appropriate reference standards (e.g. forensic autopsy).

Skin lesions and traditional folk practices: a medico-legal perspective.

The correct assessment of signs of abuse on the skin is a challenge of utmost importance for both clinical and forensic applications. This review aims to investigate how differing cultural behaviors influence the perception of abuse, focusing on the need for a multidisciplinary approach and investigation. A literature search for articles that discussed folk practices from a forensic perspective was performed; articles with reference to abuse in the description of the main folk healing techniques and with reference to the differential diagnosis between physical abuse and skin injuries due to folk healing techniques were selected. A synoptic table of all skin injuries produced by folk healing techniques, divided by geographical area, was created. This table can be used as a tool for the thorough assessment of typical signs detectable on the skin, thus aiding in a differential diagnosis. The first approach to the patient represents a crucial step toward the identification of abuse; forensic practitioners ought to be aware of the existence of folk healing techniques which may mimic signs that can be interpreted as physical abuse in children and adults.

Necrotizing fasciitis: case series and review of the literature on clinical and medico-legal diagnostic challenges.

Necrotizing fasciitis (NF) is a life-threatening infection of soft tissues spreading along the fasciae to the surrounding musculature, subcutaneous fat and overlying skin areas that can rapidly lead to septic shock and death. Due to the pandemic increase of medical malpractice lawsuits, above all in Western countries, the forensic pathologist is frequently asked to investigate post-mortem cases of NF in order to determine the cause of death and to identify any related negligence and/or medical error. Herein, we review the medical literature dealing with cases of NF in a post-mortem setting, present a case series of seven NF fatalities and discuss the main ante-mortem and post-mortem diagnostic challenges of both clinical and forensic interests. In particular, we address the following issues: (1) origin of soft tissue infections, (2) micro-organisms involved, (3) time of progression of the infection to NF, (4) clinical and histological staging of NF and (5) pros and cons of clinical and laboratory scores, specific forensic issues related to the reconstruction of the ideal medical conduct and the evaluation of the causal value/link of any eventual medical error.

Micro-CT features of intermediate gunshot wounds covered by textiles.

The analysis of gunshot residue (GSR) on the clothing and the underlying skin of the victim may play an important role in the reconstruction of the shooting incident. The aim of the present study was to test micro-computed tomography (micro-CT) for the analysis of firearm wounds experimentally produced on human skin covered by textiles. Firing trials were performed on 60 sections of human calves enveloped by a single layer of fabric (cotton or jeans or leather or nylon) and 15 controls consisting of bare calves. Experimental firings were conducted in a ballistic laboratory at three different muzzle-to-target distances (5, 15, and 30 cm), using a .32 ACP pistol (Beretta Mod. 81) loaded with full-jacketed bullets coming from the same production lot (7.65 × 17 mm, Browning SR). The visual inspection revealed the classic pattern of GSR distribution on the fabrics and the skin of control samples, while only a dark ring around the entrance lesion was identified on the skin beneath the fabrics. Micro-CT analysis showed the presence of radiopaque material on all entrance wounds, with a statistically significant difference between cases and controls. No differences were found among specimens covered by fabrics, with regard to the firing distance and the type of clothing. No GSR-like deposits were detected in exit wounds. Our results suggest that micro-CT analysis may be a useful screening tool for differentiating entry from exit gunshot wounds when the covering textiles are contaminated, damaged, or missing.

Micro-CT evaluation of morphological degenerative features of sterno-clavicular joint for age-at-death estimation in forensic anthropology - A qualitative analysis.

The analysis of the sternoclavicular joint holds significant importance in forensic anthropology, especially through the evaluation of medial clavicular ossification stage, which, however, is helpful only in subjects younger than 30 years of age. Given this limitation, the aim of the present work was to examine, through micro-CT, the surface of sternoclavicular joints of deceased individuals across various age groups, aiming to identify age-related degenerative changes applicable to age estimation in adults over 30 years old. A total of 41 deceased subjects were categorized into three age groups (20-39 years; 40-59 years; ≥60 years) for the analysis. Degenerative morphological features on both clavicular and sternal articular surfaces, including topography, porosity, and presence of osteophytes, were evaluated using a composite scoring system based on a modified "Falys-Prangle method.", which assigns to each parameter specific score ranges: 1-3 for surface topography (smooth, slightly irregular, markedly irregular), 1-6 for porosity (absent, micro- and macroporosity for <50 % or >50 % of surface, surface breakdown), 1-3 for osteophytes (absent, present, not evaluable). The findings revealed a positive correlation between degenerative morphological features and age for both clavicular (rs = 0.719) and sternal articular surfaces (rs = 0.750). Additionally, the combined assessment of the clavicle and sternum, or the evaluation of the clavicle alone, exhibited better differentiation among the three age groups. The micro-CT evaluation of degenerative alterations affecting the sternoclavicular joint proves to be a reliable and efficient method for age estimation in adults.

Intimate partner femicide (IPF): Medico-legal investigation at the Institutes of Legal Medicine of Freiburg (Germany) and Padova (Italy).

Violence against women is a significant public health concern, with femicide as its most extreme manifestation. This crime is often perpetrated by current or former intimate partners, thus taking the name of intimate partner femicide (IPF). Although international comparisons are essential for prevention policies, cross-country comparative studies are scarce in this context. The aim of this study was to evaluate and compare clinical, epidemiological and medico-legal characteristics of IPF autopsy cases investigated at the Institutes of Legal Medicine of two Western European cities, in order to identify a potential medico-legal pattern of IPF. Autopsy and police reports of IPF cases occurred in the judicial district of Freiburg (Germany) and Padova (Italy) from 2000 to 2022 were analyzed. Data relating to victims, perpetrators, relationship context, and circumstantial and pathological-forensic characteristics of the homicide were collected. Statistical analyses were performed to explore potential relationships between the data collected. Additionally, a review of the literature dealing with autopsy-based studies on IPF was performed. Overall, 82 cases of IPF were analyzed, 39 from Freiburg and 43 from Padova. A total of 6 papers fulfilled the review inclusion criteria. Our study identified a medico-legal pattern of IPF and demonstrated that it did not vary substantially between the two European Countries considered, suggesting that certain IPF characteristics are shared at the European level. However, a significant finding emerged regarding the higher prevalence of firearm-related IPFs in Italy compared to Germany. Forensic pathology research might contribute to developing targeted prevention policies to protect women from this lethal form of violence.

Intimate Partner Violence in the COVID-19 Era: A Health, Psychological, Forensic and Legal Perspective.

This commentary aims to provide a multidisciplinary framework on intimate partner violence (IPV) during the COVID-19 pandemic (with a specific focus on the most predominant form of gender-based violence, i.e., male violence towards women), commenting on the multiple negative consequences of the pandemic on gender violence and providing elements of effective practice. We searched literature for reports/studies on the issue of IPV during the COVID-19 pandemic, focusing on health, psychological, forensic, and legal aspects. The combined effects of lockdowns, isolation at home with abusive partners, quarantine, and economic worries/loss of a job could significantly facilitate violence against women and, at the same time, diminish women's chances to seek for help, with a strong negative impact on their life. The continued offer of clinical, psychological, forensic, and legal services for survivors of violence, despite the modifications to the provision of these services due to the new needs related to the COVID-19 pandemic, appears of utmost importance. All actions to support survivors of IPV are expected to be multidisciplinary, including the involvement of social and/or legal services and health systems, and woman-centred. Implementing these measures in the COVID-19 era appears challenging but is of primary importance.

Utility of micro-CT for dating post-cranial fractures of known post-traumatic ages through 3D measurements of the trabecular inner morphology.

Fracture dating is an issue at the forefront of forensic sciences. While dating fracture is crucial to understanding and verifying the chronology of events in cases of abuse and violent death, its application is the subject of considerable discussion in the scientific community, filled with limitations and difficulties. Current methods for fracture dating are mainly based on a qualitative assessment through macroscopy, microscopy, and imaging and subject to variations depending on the experience of the observer. In this paper, we investigated the potential of quantifiable micro-CT analysis for fracture dating. Five histomorphometric parameters commonly used for the study of the 3D bone trabecular microarchitecture with micro-CT were calculated based on nine fractures of known post-traumatic ages, including the degree of anisotropy, connectivity density, bone volume fraction, trabecular thickness, and trabecular separation. As a result, trends in the evolution of the microarchitecture of the bone relative to age of the callus could be identified, in particular concerning anisotropy, trabecular separation and connectivity density, consistent with the healing bone process. The findings obtained in this pilot study encourage further research in quantifiable parameters of the bone microarchitecture as they could represent useful features for the construction of objective models for fracture dating.

Cigarette Smoking as a Predictor of Male DUI Recidivism.

This study aimed to investigate the predictors of recidivism in first-time driving under the influence (DUI) offenders, analyzing variables derived from medico-legal and toxicological examinations. The research was structured as a comparative study for the period 2012-2019. DUI offenders with a blood alcohol concentration >0.5 were included in the study. The case group consisted of recidivist offenders, while the comparison group consisted of first-time offenders. Personal data, socioeconomics, and parameters linked to the DUI were compared between the two groups. Significance was determined by chi-square and Mann-Whitney tests. To prevent confounding effects, multivariate binary logistic regression analysis was performed. Our sample encompassed 1678 subjects (196 in the case group, 1482 in the comparison group). Gender, driving license category, education, and tobacco use resulted in significant differences between the groups. In a model including age at DUI, education, and smoking habit as independent variables, higher educational levels (high school, bachelor's) and older age protected against recidivism, whereas smoking >20 cigarettes/day was an independent risk factor for recidivism. Recidivist offenders have specific characteristics indicating different therapeutic programs and carefulness in driving license regranting. A higher tobacco consumption in recidivists suggests that the use of this substance could influence the risk of DUI for reasons that will need to be explored.

Reconstruction of the dynamic in a fatal traffic accident with prolonged dragging of the victim.

The post-mortem examination of victims of fatal road crashes and the reconstruction of the dynamic of traffic accidents are fundamental in vehicular homicides, where the degree of negligence/careless of the driver has to be established. Here we present a case in which a pedestrian was dragged along an SUV for 3.5 km, until the vehicle was parked at the house of the driver, arising the suspect of vehicular manslaughter and failure to provide assistance. On the basis of death scene investigation, analysis of video recording from a surveillance camera, post-mortem computerized tomography (PMCT) and complete post-mortem examination, including gross and microscopical findings, the accident was reconstructed as a frontal collision between the right portion of the bumper and the right side of the body of a standing pedestrian, with deformation of the bumper and production of a metal sheet hook; secondary run-over the right feet, cranio-facial trauma against the bodywork of the vehicle and hooking of the right hand of the victim to the metal sheet; prolonged dragging of the pedestrian over the road surface and severe bleeding. A multidisciplinary-multimodal methodology, including PMCT, allowed to assess the cause of death as hemorrhagic shock, suggested that the victim would have likely survived if the vehicle had stopped, and is increasingly recommendable in fatal road accidents.

Legal scenarios in the coronavirus time: Medico legal implications in the aspects of governance.

Along with rising levels of the infection around the world, the state of emergency prompted by the COVID-19 pandemic has also been having a heavy legal impact. The situation is posing important criminal challenges, as well as an ocean of social and public health issues around the world. It has not only directly affected constitutionally-guaranteed rights and individual freedoms, but also brought to the fore certain types of criminal offence that had previously been of little practical importance, such as the crime of 'maliciously or unintentionally causing an epidemic'. Different countries and states have introduced policies to manage the emergency at different times and in different ways. The measures adopted have been the object of much criticism, also raising questions of constitutional legitimacy in countries like Italy. The present contribution begins with a brief outline of the different international scenarios. Then we examine some of the medicolegal aspects of criminal offences previously envisaged and newly introduced since the arrival of the pandemic. We suggest the need for a sort of 'code of public health laws for the time of coronavirus', that could also be applied to other public health emergencies, pandemic or otherwise. The idea is to give operators in the sector and the general population the opportunity to identify clear and simple rules to follow in the current complex global situation. We need a new, appropriate interpretation of the 'boundaries' of our individual rights in relation to the need to safeguard the wider community and its more vulnerable members.

The Role of Risk or Contributory Death Factors in Methadone-Related Fatalities: A Review and Pooled Analysis.

Methadone-related deaths are characterized by a wide range of post-mortem blood concentrations, due to the high pharmacokinetic/dynamic inter-individual variability, the potential subjective tolerance state and to other risk factors or comorbidities, which might enhance methadone acute toxicity. In the present study, the association among pre-existing and external conditions and diseases and the resultant methadone death capacity have been investigated. Beside a systematic literature review, a retrospective case-control study was done, dividing cases in which methadone was the only cause of death (controls), and those with associated clinical-circumstantial (naive/non-tolerant state), pathological (pulmonary or cardiovascular diseases) or toxicological (other drugs detected) conditions. Methadone concentrations were compared between the two groups and the association with conditions/diseases was assessed by multiple linear and binomial logistic regressions. Literature cases were 139, in house 35, consisting of 22 controls and 152 cases with associated conditions/diseases. Mean methadone concentrations were 2122 ng/mL and 715 ng/mL in controls and cases respectively, with a statistically significant difference (p < 0.05). Lower methadone concentrations (by 24, 19 and 33% respectively) were detected in association with naive/non-tolerant state, pulmonary diseases and presence of other drugs, and low levels of methadone (<600 ng/mL) might lead to death in the presence of the above conditions/diseases.

The problem of dating fractures: A retrospective observational study of radiologic features of fracture healing in adults.

Accurate dating of bone fractures can be crucial in the context of forensic trauma analysis since it may provide essential information for the corroboration or contradiction of statements by victims or suspects in cases of domestic abuse or torture. The different stages of bone healing have been well described in the existing literature, and some previous studies attempted to define related timelines particularly in the paediatric population. However, the bone healing process can be very variable and despite the importance of the topic in the forensic field, so far little is known about the radiological appearance of bone fractures at different healing stages, and how this correlates with time, especially in an adult population. The aim of this retrospective observational study was to describe the temporal aspect of pre-defined healing stages as they appear on radiographs of tubular bone fractures in adults, and explore the effect of potential cofounding variables. A dynamic nomogram was developed as a user-friendly tool to be eventually applied in clinical or medico-legal settings. This study showed that the posttraumatic time interval (PTTI) increased progressively with the pre-defined healing stages. However, confounding factors, such as patients' age, sex, and location of the fracture need to be accounted for in the final estimation model. Further studies are needed to explore more potentially confounding variables to refine the presented outcomes. Better knowledge of the effect of different confounding variables in the dating of fracture healing will contribute to greater accuracy of PTTI estimation of bone fractures in adults.

Criminological and Medico-legal Aspects in Homicidal and Suicidal Sharp Force Fatalities.

The interpretation of sharp force fatality dynamics may be difficult in some cases, but a contribution to analysis of the phenomenon may be provided by case studies. Therefore, the purpose of our study is focused on identifying, in observed sharp force fatalities, reliable parameters that can differentiate a homicidal and suicidal manner of death, with particular reference to criminological parameters. Data derived from sharp force fatality cases in Padua and Venice from 1997 to 2019, anonymized and collected in Excel, included personal, circumstantial, clinical, and psychopathological-criminological data, as well as crime scene investigation, necroscopic, and toxicological data. Statistical analyses were performed using chi-square and Wilcoxon rank-sum tests. Possible predictors of homicide were analyzed by logistic regression. Six parameters (bloodstains distant from the body, clothing lacerations, hesitation/defense wounds, number of injuries, and potential motives) were significantly different in the two groups (p < 0.05). An independent statistical association between potential motives explaining the crime (p < 0.001; OR 27.533) and homicide on multiple logistic regression analysis was highlighted. The absence of clothing lacerations was inversely related to homicide (p = 0.002, OR 0.092). To the best of our knowledge, this is one of very few Italian studies concerning the differential diagnosis between homicidal and suicidal sharp force fatalities. The dynamics of the event is established in most cases by the integrated evaluation of data from crime scene investigation and the autopsy. Nevertheless, in an atypical scenario, a psychopathological-criminological analysis may provide essential elements, and particular attention should be given to the identification of potential explanatory motives.

Multi-Rater Agreement Using the Adapted Fracture Healing Scale (AFHS) for the Assessment of Tubular Bones on Conventional Radiographs: Preliminary Study.

Better understanding of the timing of fracture healing may help in cases of interpersonal violence but also of personal identification. The intra- and inter-rater agreement for the adapted fracture healing scale (AFHS) assessing the post-traumatic time interval on radiographs were tested. This is a preliminary study, providing essential information on method reliability for upcoming studies using the AFHS. Five raters (two radiologists, a forensic pathologist, an orthopedist, and an anthropologist) were presented with a test in three parts consisting of 85 radiographs (from 30 adults) of fractures of tubular bones in different stages of healing purposefully selected from more than 1500 radiographs. The raters were firstly asked to assess 15 features describing fracture healing as present, absent, or not assessable. Thereafter, the raters were asked to choose from the AFHS a single-stage best representing the observed healing pattern. The intra- and inter-rater agreement were assessed using single-rating, absolute agreement, two-way mixed-effects intra-class correlation (ICC) coefficients. The intra-rater ICC of radiologist 1 ranged from 0.80 to 0.94. The radiologists' inter-rater ICC ranged from 0.68 to 0.74, while it ranged from -0.01 to 0.90 for the other raters. The good to excellent ICC among the radiologists and forensic anthropologist provides good foundation for the use of the AFHS in forensic cases of trauma dating. The poor to good results for the other physicians indicate that using the AFHS requires training in skeletal anatomy and radiology.

Accuracy, precision and inter-rater reliability of micro-CT analysis of false starts on bones. A preliminary validation study.

Micro computed tomography (micro-CT) has already been proposed as a useful technique for the qualitative analysis of false starts (FS) produced on human bones, although the reliability and the error rate of this technique have not been tested yet, neither for qualitative nor for quantitative assessments. The aim of the present study was to test the morphological agreement, accuracy, precision and inter-rater reliability of micro-CT analysis of FS on bones. The morphological agreement was assessed through the degree of concordance among the 3 independent blind raters in the identification of the shape of 24 FS manually produced on bones by 3 different saws (8 FS for each saw). The accuracy was calculated through the percentage of error in the automatic and manual measurement of the diameter of a reference object. The precision was calculated as CV% of multiple measurements performed by 3 independent blind raters on the reference object and one bone sample acquired 20 times. The inter-rater reliability was assessed as intraclass correlation coefficient (ICC) among measurements performed by 3 independent blind raters, assessing 24 FS produced using 3 different saws. The results demonstrated that both qualitative and quantitative analysis were reproducible and robust. Micro-CT analysis showed a 100% morphological agreement, a high level of accuracy (percentage error < 0,5%), precision (CV% < 5%) and inter-rater reliability (ICC > 0.995), when FS were analyzed by forensic pathologists and/or radiologists with adequate expertise. Obviously, further validation studies are needed, including a higher number of samples produced by a wider variety of saws and multiple operators.

Traumatic fatal aortic rupture in motorcycle drivers.

Traumatic fatal aortic rupture (FAR) is a common finding in victims of motor vehicle crashes (MVC), but its aetiology and mechanisms of production remain an issue of major concern, above all in motorcyclists. This study reports a series of cases obtained from a retrospective analysis of traumatic FARs occurring in motorcycle drivers, with the aim of defining the injury patterns and correlating them with the mechanisms of FAR production. Circumstantial, autopsy and histology data were collected through a retrospective analysis of post mortem examinations performed at the Institute of Legal Medicine of the University of Padova between 2014 and 2016. Among 151 traffic related victims, 8 were motorcycle drivers and displayed traumatic FAR and were thus included in the study. In 7 cases, the presence of abdominal/thoracic injuries suggested that the external compression due to the accident was at least a concurrent cause of FAR, being the predominant mechanism of aortic injury in 4 cases, through the "osseous pinch" or the "waterhammer effect" mechanisms. Our study highlights the well-known role of "preventative forensic pathology", which has become routinary in traffic medicine since many years, also for defining the points of impact and the injury patterns of motorcyclists sustaining traumatic FAR, thereby facilitating the development of new prevention strategies and devices. Further studies, however, are needed in order to widen the investigated population and to estimate the real number of victims for which traumatic FAR might hypothetically be prevented with specific countermeasures.

Micro-computed tomography of false starts produced on bone by different hand-saws.

The analysis of macro- and microscopic characteristics of saw marks on bones can provide useful information about the class of the tool utilized to produce the injury. The aim of the present study was to test micro-computed tomography (micro-CT) for the analysis of false starts experimentally produced on 32 human bone sections using 4 different hand-saws in order to verify the potential utility of micro-CT for distinguishing false starts produced by different saws and to correlate the morphology of the tool with that of the bone mark. Each sample was analysed through stereomicroscopy and micro-CT. Stereomicroscopic analysis allowed the identification of the false starts and the detection of the number of tool marks left by each saw. Micro-CT scans, through the integration of 3D renders and multiplanar reconstructions (MPR), allowed the identification of the shape of each false start correlating it to the injuring tool. Our results suggest that micro-CT could be a useful technique for assessing false starts produced by different classes of saws, providing accurate morphological profiles of the bone marks with all the advantages of high resolution 3D imaging (e.g., high accuracy, non-destructive analysis, preservation and documentation of evidence). However, further studies are necessary to integrate qualitative data with quantitative metrical analysis in order to further characterize the false start and the related injuring tool.

Suicidal Smothering by Rubber Latex Gloves and Handkerchief.

Asphyxial deaths are common in forensic practice, being sustained by a variety of mechanisms that cause an oxygen deficiency to the brain. Several classification models have been proposed in the literature, the most recent one being that of the International Network for Forensic Research Group (INFOR). This report describes an unusual case of suffocation where the obstruction of the airways was caused by a gag formed of three latex gloves and a handkerchief. The manner of death (differential diagnosis between homicide and suicide) and the different alternatives of classification are discussed.