Taser-Related Ocular Injuries: A Review of the Literature and Medico-Legal Implications.

PURPOSE: Electric weapons have dangers associated with their use, such as burns and trauma related with the impacts of uncontrolled falls, even though they often minimize morbidity and mortality. The exact visual outcome of the damage inflicted is unknown, even though numerous studies have been documented in the literature about the ocular damage induced by the use of these tools. METHODS: We present a narrative review of types of eye damage associated with the use of the Taser. The following search terms were used to identify eligible articles through the PubMed database: "TASER", "Conducted Electric Weapons", "CEWs". RESULTS: A total of 15 articles were included with information about 38 patients with eye damage associated with the use of taser. The majority of patients were males. In most cases the mechanism of injury was the penetration of the probe inside the eye. Clinical manifestations of ocular damage were present in only 18 out of 38 cases and varied according to the type of damage mechanism. Indeed, the cases in which the probe had penetrated the eye showed more severe clinical manifestations with a poor visual outcome. CONCLUSION: In conclusion, the introduction of taser use for law enforcement requires serious consideration and adequate training for officers.

Bicycle-related accidents in Rome: Investigating clinical patterns, demographics, injury contexts, and health outcomes for enhanced public safety.

INTRODUCTION: This study aims to analyze the clinical characteristics, demographic features, and injury circumstances of patients admitted to the Emergency Department (ED) at Fondazione Policlinico Universitario A. Gemelli (IRCCS) in Rome, Italy, due to bicycle accidents. METHODS: Data on clinical characteristics, accident timing, injury circumstances, and helmet use were collected for ED patients involved in bicycle accidents from January 2019 to December 2022. Subsequently, Abbreviated Injury Scale codes of all diagnoses were recorded and the Injury Severity Score was calculated. RESULTS: Over the study period, 763 patients were admitted to the ED following bicycle accidents, with a 0.3 % fatality rate and a 30.4 % frequency of multitrauma. Multivariate analysis revealed that collisions with other vehicles increased trauma severity and the risk of ICU admission. Conversely, helmet use was associated with reduced severity of head trauma and a lower likelihood of ICU admission. Notably, toxicological investigations were not conducted for any ED-admitted patients. CONCLUSIONS: Although a low mortality rate and a low incidence of multi-trauma have been shown in comparison to other nations, it is necessary to adopt prevention strategies like safety devices, more cycle paths, and better infrastructures on the one hand, and stricter laws on the other. It is essential to require toxicological testing in Italy for all accidents involving this means of transport, and to make helmet use compulsory for all ages.

Comparative Impact Analysis of Low-Deductible Insurance Versus In-house Hospital Assumption of Risk and Management on Medical Malpractice Claims.

OBJECTIVES: Claims management is critical to ensure the safe and high-quality medical care for which liability insurers and/or hospitals are responsible. The aim of this research is to determine whether increasing hospital malpractice risk exposure, with increasing deductibles, has an impact on malpractice claims and payouts. METHODS: The study was conducted at a single tertiary hospital, the Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy. Payouts on closed reported and registered claims were analyzed during 4-study periods, which ranged from 1.5 million euro annual aggregate deductibles entirely managed by the insurance company to 5 million euro annual aggregate deductibles entirely managed by the hospital. We retrospectively analyzed 2034 medical malpractice claims submitted between January 1, 2007, and August 31, 2021. Four periods were examined depending on the claims management model adopted, ranging from total outsourcing to the insurer (period A) to an almost total hospital assumption of risk method (period D). RESULTS: We found that progressive hospital assumption of risk is associated with a decrease in the incidence of medical malpractice claims (average variation per year: -3.7%; P = 0.0029 if the 2 initial periods and the 2 last periods-characterized by the highest risk retention-are respectively aggregated and compared), an initial decrease in the mean claims cost followed by an increase that is still lower than the national increase (-5.4% on average), and an increase in the total claims cost (when compared with the period where the insurer solely managed claims). We also found that the rate of increase in payouts was less than the national average. CONCLUSIONS: The assumption of more malpractice risk by the hospital was associated with the adoption of numerous patient safety and risk management initiatives. The decrease in claims incidence could be due to the implementation of patient safety policies, while the cost increase could be attributed to inflation and rising costs of healthcare services and claims. Notably, only the hospital assumption of risk model with a high-deductible insurance coverage is sustainable for the studied hospital, while also being profitable for the insurer. In conclusion, as hospitals progressively assumed more risk and management responsibility of malpractice claims, there was a progressive decrease in the total number of claims, and a less rapid rise in claim payouts as compared with the national average. Even a small assumption of risk appeared to elicit meaningful changes in claim filings and payouts.

Blood alcohol concentration and road accidents: Underestimation due to time of the arrival to the emergency department (ED) or delay in blood sampling. A 4-Year Retrospective Study in Rome.

Alcohol is a significant public health issue, according to the World Health Organization. Our study aims to analyze the correlation between blood alcohol concentrations (BACs) of drivers, their demographic features, and the possible underestimation of BACs due to the time elapsed between hospital admission and blood sampling. Methods: This study includes patients evaluated for BAC levels in the emergency department (ED) of Fondazione Policlinico Universitario A. Gemelli IRCCS from January 2013 to December 2016. BAC levels were compared in patients involved in road crashes according to age group, sex, and time of the accident. The delays in blood sampling and BAC measurement in the ED were recorded for each patient. The time between the accident and access to the hospital in most cases was unknown. Results: A total of 398 patients were included in the analysis, 107 of them had BACs more than 0.05 g/L., and 86 of these individuals had BAC levels more than 0.5 g/L. Road accident patients had higher rates of positive BAC readings at night and on weekends. A significant delay in blood sampling for BAC determination was observed. Discussion: This study demonstrates a critical bias due to the arrival time at the ED and the delay in blood sampling that inevitably influences and underestimates the BAC, resulting in possible false negative results (BAC values below the cutoff). Zero tolerance or a retrospective BAC calculation could mitigate this bias. It is necessary to implement preventive strategies to reduce instances of driving under the influence (DUI) of alcohol.

Electric scooter-related accidents: a possible protective effect of helmet use on the head injury severity.

Despite electric scooter use has proliferated in Italy since 2019, actionable data regarding injury incidence and patterns associated with electric scooter accidents are limited. This study aims at analyzing the rate, clinical, and demographic features of electric scooter accidents accessed to the Emergency Department (ED) of Fondazione Policlinico Universitario A. Gemelli IRCSS (Rome, Italy). This retrospective study included all patients older than 18 years riding an electric scooter in the ED from June 2019 to April 2022. Personal data, injury circumstances, helmet use, and health data were collected. Abbreviated Injury Scale (AIS) codes of all diagnoses were recorded, and the Injury Severity Score (ISS) was calculated for each patient. The analysis includes 92 patients admitted to the ED due to an e-scooter accident during the study period, with an increase in years. Thirty-two patients presented bone fractures especially concerning the extremities and the face districts. The median Injury Severity Score in the study cohort was 3, with the highest AIS represented by AIS Pelvic-Extremity and AIS External. Moreover, statistical significance was found between AIS Head-Neck and severity of trauma. E-scooters have become a familiar sight in cities worldwide recently, with many new companies renting them for use. But their arrival has also brought new safety concerns. Although most injuries reported are minor, the meager rate of helmet use is critical. Implementing compulsory helmet use for electric scooters for all ages could be a protective factor for being patient with head trauma on urban streets.

Drug-impaired driving and traffic collisions: Study on a cross section of the Italian population.

The present study focuses on the association between road accidents and the presence of drugs of abuse markers in the biological fluids of the drivers. Biological fluids collected from 1236 drivers involved in road accidents (54 fatal and 1182 non-fatal crashes) in the Rome area were analyzed for alcohol and psychotropic drugs, as required by judicial authorities. The substance most frequently detected was alcohol (in 19% of non-fatal and 32% of fatal crashes), followed by cannabinoids (12% of non-fatal crashes) and cocaine (9% of non-fatal and 20% of fatal crashes). The results obtained for cocaine and cannabinoids in blood and urine were compared. We observed the absence or low concentrations of the active drug in blood (cocaine was often below 5 ng/ml and THC below 1 ng/ml), whereas urinary concentrations of metabolites were generally high (benzoylecgonine 250-above 5000 ng/ml, THCCOOH 15-270 ng/ml). The risk of being involved in a road accident if cocaine or cannabis markers were present in the urine specimens was evaluated compared to a control population. The odds ratios calculated, being 8.13 for cannabis and 5.32 for cocaine, suggest a strong association between the presence of these drugs in the urine of drivers and traffic accidents, regardless of their presence in blood samples. The present data suggest that the chance of being involved in a road accident is higher than in the control population even if the subject is no longer "under the influence" of cannabis or cocaine at the time of the accident.

A cranio-encephalic trauma due to electric-scooter accident: could the wearing of a helmet reduce this risk?

Nowadays, one of the most important health and social policy issues concerning all countries is the problem of road accident rates. Traffic is one of the most important risk factors. For this reason, ridesharing companies have been launching electric scooters in Rome since June 2019 with the aim of reducing car traffic. In the absence of relevant legislations, the risk is that of facing an increase in deaths due to electric scooter crashes. We report the case of an electric scooter accident victim with cranio-encephalic trauma associated with limb injuries that caused immediate death. This case report emphasizes how the obligation of using helmets must be extended to all ages, in order to reduce the risk of increasing the number of deaths. Compulsory helmet use can reduce fatalities in all cases where high-speed crashes are not involved.

Use of post-mortem chest computed tomography in Covid-19 pneumonia.

BACKGROUND AND AIM: COVID-19 is an extremely challenging disease, both from a clinical and forensic point of view, and performing autopsies of COVID-19 deceased requires adequately equipped sectorial rooms and exposes health professionals to the risk of contagion. Among one of the categories that are most affected by SARS-Cov-2 infection are the elderly residents. Despite the need for prompt diagnoses, which are essential to implement all isolation measures necessary to contain the infection spread, deceased subjects in long-term care facilities are still are often diagnosed post-mortem. In this context, our study focuses on the use of post-mortem computed tomography for the diagnosis of COVID-19 infection, in conjunction with post-mortem swabs. The aim of this study was to assess the usefulness of post-mortem whole CT-scanning in identifying COVID-19 pneumonia as a cause of death, by comparing chest CT-findings of confirmed COVID-19 fatalities to control cases. MATERIALS AND METHODS: The study included 24 deceased subjects: 13 subjects coming from long-term care facility and 11 subjects died at home. Whole body CT scans were performed within 48 h from death in all subjects to evaluate the presence and distribution of pulmonary abnormalities typical of COVID-19-pneumonia, including: ground-glass opacities (GGO), consolidation, and pleural effusion to confirm the post-mortem diagnosis. RESULTS: Whole-body CT scans was feasible and allowed a complete diagnosis in all subjects. In 9 (69%) of the 13 cases from long-term care facility the cause of death was severe COVID 19 pneumonia, while GGO were present in 100% of the study population. CONCLUSION: In the context of rapidly escalating COVID-19 outbreaks, given that laboratory tests for the novel coronavirus is time-consuming and can be falsely negative, the post-mortem CT can be considered as a reliable and safe modality to confirm COVID-19 pneumonia. This is especially true for specific postmortem chest CT-findings that are rather characteristic of COVID-19 fatalities.

Method development for the identification of methoxpropamine, 2-fluoro-deschloroketamine and deschloroketamine and their main metabolites in blood and hair and forensic application.

The constant increase of new psychoactive substances, often available on the illicit drug market as 'research chemicals', poses a concern for public health and a significant analytical and legislative challenge. Β-keto-arylcyclohexamines represent a class of dissociative anesthetics recently introduced on the market of New Psychoactive Substances (NPS). There is still a lack of information about the pharmacological activity of many of such substances, usually depending on the potential chemical modifications introduced to circumvent the law. Furthermore, their intake may not be fully intentional, since consumers do not always have knowledge of the content of online purchases. The present study describes the characterization by liquid chromatography-high resolution mass spectrometry (LC-HRMS), using a benchtop Orbitrap instrument, of the novel ketamine analogues methoxpropamine, 2-fluoro-deschloroketamine and deschloroketamine, found in the post-mortem blood and hair samples from a forensic case of suicide by fall from height, and of some of their metabolites. This allowed the development of analytical methods for the determination of both the ß-keto-arylcyclohexamines and the metabolites in LC-HRMS and in LC-MS/MS, providing a starting point for studying their toxicokinetics.

Did poisoning play a role in Napoleon's death? A systematic review.

INTRODUCTION: On 5 May 2021 we celebrate the bicentenary of Napoleon's death. Despite autopsy findings of a "gastric cancer" and, more importantly, gastric perforated ulcer complicated with bleeding, the questions about the illness that tormented Napoleon at St. Helena and whether the death was a consequence of a poisoning, maintain an unbroken fascination. PubMed/MEDLINE lists hundreds of articles. We also consulted Index-Cat library for articles dating back to the eighteenth century. The present paper presents for the first time a systematic review on this topic. METHODS: The authors divided the selected articles according to the methodology of the papers: (a) illness and autopsy evidence revised by current pathological knowledge; (b) toxicological tests on Napoleon's hair performed by modern analytical techniques. RESULTS: None of the articles denied the toxicological evidence from Napoleon's hair, although analytical papers did not offer homogeneous results due to several biases. Few of them refuted the hypothesis of death due to primary toxic substances. Most considered gastric bleeding is the primary cause of Napoleon's death due to solely or nearly completely gastric cancer or to medications containing antimony, mercury, or arsenic. CONCLUSIONS: Upon review of the contemporary and modern evidence, we classify Napoleon's 1821 death as "unnatural" with massive gastric bleeding due to primary involvement of toxic substances that may have precipitated or exacerbated an underlying "natural" pathological condition or a disease as likely could be a stomach carcinoma; it does not imply criminal intent.

Placenta as alternative specimen to detect in utero cannabis exposure: A systematic review of the literature.

The use of cannabis during pregnancy and lactation is widely recognized as a health concern. The placenta is one of the several biological matrices that can be used to detect in utero drug exposure with the distinct advantage of easy and noninvasive collection. We conducted a PubMed search of selected literature published to June 30, 2016 to investigate the pharmacokinetics of cannabinoids, the active constituent of cannabis, in the placenta. The majority of the selected twelve papers was before 1990 and concerned animals at term gestation with great variability of experimental conditions. Only three were about human population and two of them reported equivocal findings on pre- term placenta. Our systematic review confirms that placental cannabis pharmacokinetics has been scarcely investigated and that further research is needed to determine advantages and disadvantages for monitoring maternal THC use or the degree of in utero exposure.

The usefulness of biomarkers of alcohol abuse in hair and serum carbohydrate-deficient transferrin: a case report.

The detection of carbohydrate-deficient transferrin (CDT) in serum is widely accepted to identify chronic alcohol consumption over the previous two weeks, but minor ethanol metabolites detected in hair often complete the information obtained. In particular, ethylglucuronide and cocaethylene (a marker of simultaneous intake of cocaine and alcohol) allow correct interpretation of data obtained in forensic cases. We refer to a negative CDT value obtained from a serum sample collected during hospitalization of a man admitted for cardiac arrest who died about 14 h later. Clinical analysis performed on admission showed a high ethanol level and a positive urinary screening for cocaine. The toxicological analyses of post-mortem samples found cocaine metabolites in his urine and blood. The negative CDT level suggested the ethanol concentration at admission to be an acute episode. Cocaine and cocaethylene well above the cut-off suggested by the literature were found in hair analyzed for the entire length (about 1 cm). Ethylglucuronide detected on the same hair sample confirmed chronic abuse of ethanol in the previous month, at least. The present report suggests caution in the interpretation of biomarkers of alcohol abuse, encouraging the detection of more than one marker to avoid misinterpretation.

Genetic and toxicologic investigation of Sudden Cardiac Death in a patient with Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) under cocaine and alcohol effects.

Cocaine and alcohol toxicity is well known, especially when simultaneously abused. These drugs perform both acute and chronic harmfulness, with significant cardiac events such as ventricular arrhythmias, tachycardia, systemic hypertension, acute myocardial infarction, ventricular hypertrophy, and acute coronary syndrome. The present report refers about a patient who died after a documented episode of psychomotor agitation followed by cardiac arrest. At the autopsy investigation, arrhythmogenic right ventricular cardiomyopathy (ARVC) was diagnosed and confirmed by postmortem molecular analysis revealing a mutation in the DSG2 gene. Postmortem toxicological analysis demonstrated a recent intake of cocaine, and the death was attributed to cardiac arrhythmias. The detection of cocaine and cocaethylene in hair samples proved chronic simultaneous intake of cocaine and alcohol at least in the last month. The authors discuss the role of these drugs and genetic predisposition of the ARVC in causing the death of the patient.

A case of toxic shock due to clandestine abortion by misoprostol self-administration.

Maternal mortality and morbidity are the leading causes of death and illness, respectively, among women of reproductive age in many countries throughout the world. Of all maternal deaths, those related to unsafe abortions are the most widely underestimated, but they are also the most largely preventable. Medical abortion is a safe and reliable method for termination of a pregnancy in early gestation, although it is important to be aware of signs and symptoms of severe infection and toxic shock syndrome after the medical termination of pregnancy; case studies in literature are rarely fatal events. We report the first case of septic shock syndrome following a clandestine pregnancy termination with a misoprostol-only regimen (12 tablets 200 µg each). Autopsy findings and histopathological examination proved that the woman died from septic shock. This case suggests to improve the forensic investigations in case of unsafe, often clandestine, abortion is suspected.