Post-mortem CT radiomics for the prediction of time since death.

OBJECTIVES: Post-mortem interval (PMI) estimation has long been relying on sequential post-mortem changes on the body as a function of extrinsic, intrinsic, and environmental factors. Such factors are difficult to account for in complicated death scenes; thus, PMI estimation can be compromised. Herein, we aimed to evaluate the use of post-mortem CT (PMCT) radiomics for the differentiation between early and late PMI. METHODS: Consecutive whole-body PMCT examinations performed between 2016 and 2021 were retrospectively included (n = 120), excluding corpses without an accurately reported PMI (n = 23). Radiomics data were extracted from liver and pancreas tissue and randomly split into training and validation sets (70:30%). Following data preprocessing, significant features were selected (Boruta selection) and three XGBoost classifiers were built (liver, pancreas, combined) to differentiate between early (< 12 h) and late (> 12 h) PMI. Classifier performance was assessed with receiver operating characteristics (ROC) curves and areas under the curves (AUC), which were compared by bootstrapping. RESULTS: A total of 97 PMCTs were included, representing individuals (23 females and 74 males) with a mean age of 47.1 ± 23.38 years. The combined model achieved the highest AUC reaching 75% (95%CI 58.4-91.6%) (p = 0.03 compared to liver and p = 0.18 compared to pancreas). The liver-based and pancreas-based XGBoost models achieved AUCs of 53.6% (95%CI 34.8-72.3%) and 64.3% (95%CI 46.7-81.9%) respectively (p > 0.05 for the comparison between liver- and pancreas-based models). CONCLUSION: The use of radiomics analysis on PMCT examinations differentiated early from late PMI, unveiling a novel image-based method with important repercussions in forensic casework. CLINICAL RELEVANCE STATEMENT: This paper introduces the employment of radiomics in forensic diagnosis by presenting an effective automated alternative method of estimating post-mortem interval from targeted tissues, thus paving the way for improvement in speed and quality of forensic investigations. KEY POINTS: • A combined liver-pancreas radiomics model differentiated early from late post-mortem intervals (using a 12-h threshold) with an area under the curve of 75% (95%CI 58.4-91.6%). • XGBoost models based on liver-only or pancreas-only radiomics demonstrated inferior performance to the combined model in predicting the post-mortem interval.

Age estimation for two Mediterranean populations: rib histomorphometry applied to forensic identification and bone remodelling research.

Numerous intrinsic and extrinsic factors influence bone remodelling rates and have shown to affect the accuracy of histological aging methods. The present study investigates the rib cortex from two Mediterranean skeletal collections exploring the development of population-specific standards for histomorphometric age-at-death estimation. Eighty-eight standard ribs from two samples, Cretans and Greek-Cypriots, were processed histologically. Thirteen raw and composite histomorphometric parameters were assessed and observer error tested. The correlation between age and the parameters and the differences between sex and population subsamples were explored through group comparisons and analysis of covariance. General linear models assessed through data fit indicators and cross-validation were generated from the total dataset, and by sex and population subsamples. Most of the histological variables showed a statistically significant correlation with age with some differences observed by sex and by sample. From the twelve models generated, the optimal model for the whole sample included osteon population density (OPD), osteon perimeter, and osteon circularity producing an error of 10.71 years. When sex and samples were separated, the best model selected included OPD and osteon perimeter producing an error of 8.07 years for Greek-Cypriots. This research demonstrates the feasibility of quantitative bone histology to estimate age, obtaining errors rates in accordance with macroscopic ageing techniques. Sex and sample population differences need further investigation and inter-population variation in remodelling rates is suggested. Moreover, this study contributes to the creation of population-specific standards for Cretans and Greek-Cypriots.

Pair-Matching Digital 3D Models of Temporomandibular Fragments Using Mesh-To-Mesh Value Comparison and Implications for Commingled Human Remain Assemblages.

The mesh-to-mesh value comparison (MVC) method developed by Karell et al. (Int J Legal Med 130(5):1315-1322, 2016) facilitates the digital comparison of three-dimensional mesh geometries obtained from laser-scanned or computed tomography data of osteological materials. This method has been employed with great success to pair-matching geometries of intact skeletal antimeres, that is, left and right sides. However, as is frequently the case for archaeological materials, there are few circumstances which proffer complete skeletal remains and fewer still when considering contexts of commingling. Prior to the present research, there existed a paucity of sorting techniques for the diverse taphonomic conditions of skeletal materials found within commingled assemblages, especially regarding fragmentary remains. The present chapter details a study in which the MVC method was adapted to encompass comparisons of isolated components of bone in lieu of entire bone geometries in order to address this dearth. Using post-mortem computed tomography data from 35 individuals, three-dimensional models of 70 mandibular fossae and 69 mandibular condyles were created and then compared using Viewbox 4, to produce numerical mesh-to-mesh values which indicate the geometrical and spatial relationship between any two given models. An all-to-all comparison was used to determine if the MVC method, using an automated Trimmed Iterative Closest Point (TrICP) algorithm, could be utilized to (1) match corresponding bilateral pairs of condyles and fossae and (2) match same-sided articular correlates. The pair-matching of both the condyles and the fossae generally produced high sensitivity and specificity rates. However, the articulation results were much poorer and are not currently recommended.

Forensic Recreation and Visual Representation of Greek Orthodox Church Saint Eftychios of Crete.

Facial reconstruction is employed in medical science and archaeology. Though quite popular as anthropological method, it has not so far been used in the orthodox ecclesiastical tradition. This work presents the facial reconstruction of St Eftychios of Crete, who lived between the ninth and tenth centuries. Computed tomography and reverse engineering methods were employed to complete the task. Reconstruction of the mandible and the missing left zygomatic arch was implemented following the Sassouni method. The American method was followed for the soft tissues, with clay deposition of appropriate thickness, on the surface of the skull model. The eyes, nose, and lips were added based on the dimensions of the underlying bone structures. Long hair and beard were added, according to the classic Byzantine tradition pattern of the time period. The final bust developed was then digitized, using a 3D non-contact laser scanner. The 3D geometry produced was employed to produce a mold with vacuum casting techniques. This mold provides the ability to produce copies of the bust, if needed. At the same time, a realistic 3D representation of the Saint's bust was developed, with the aid of special software, in order to compare the traditional forensic reconstruction to the pure digital one. This work is the first case of a Saint's facial reconstruction in the Orthodox Church. The facial reconstruction process, with all the limitations considered, offers the ability to present a realistic aspect of a Greek Orthodox Church Saint, in a form that is easily accessible. Both physical and digital facial reconstruction processes were based on scientific data, so they were as accurate as possible, considering that the mandible was missing in the skull. The facial reconstruction was entirely implemented in Greece creating the basis for similar work in the future. The final bust developed was donated to the Odigitria Monastery, to be exhibited to its visitors.

Virtual Trauma Analysis of the Nineteenth-Century Severed Head of the Greek Outlaw Stavrou.

Human remains have been displayed in museums in Europe since many centuries for historical, cultural, and educational reasons. Of particular interest are skeletal remains and body parts that have suffered violent deaths and such remains often feature in Criminology Museums. Despite the well-acknowledged value of human remains in medical education, bioarchaeology, and research, the display of human remains still raises ethical considerations ranging in severity depending on the cultural substrate and legal framework of each country. Recent developments in medical imaging and visualisation are offering an alternative way. Taking into account the emerging issues regarding exhibition and handling of human remains, this research project aims to use virtual methods to reconstruct the circumstances of the death of a nineteenth-century outlaw comprising one of the human exhibits at the Criminology Museum of Athens in Greece.For the purpose of the project, the severed head of the outlaw Stavrou was CT scanned, and the data were used to reconstruct and to evaluate the ballistic trauma sustained at the time of his death. From the scans, it was possible to determine the minimum number of shots, entrance and exit wounds, approximate calibre of the bullets, approximate distance from which they were fired, and general velocity of the round.Shots are fired from the lateral left and backside of the head and bullets exited from the right frontal and temporal area causing extensive damage to the right craniofacial region. The direction of the shots coming from the back and left suggests that Stavrou was more likely ambushed by gendarmerie squads and not shot in a fair fight which would have caused entry wounds in the anterior surface of the body. This is in agreement with historical evidence that placed him in gunfire with his fellow gang member Karapanos against a government squad. On the other hand, the possibility of being captured alive and executed cannot be rejected based only on wound ballistics.This work would be excellent supplementary material to the actual human exhibit for the accurate presentation of Stavrou's history at the Criminology Museum. In addition, it would allow the virtual exhibition of the material for historical and teaching purposes to museums and universities anywhere in Greece and along the globe, thus overcoming the obstacles of moving the actual remains.

The effect of diet and sociopolitical change on physiological stress and behavior in late Roman-Early Byzantine (300-700 AD) and Islamic (902-1,235 AD) populations from Ibiza, Spain.

OBJECTIVES: This study evaluated chronological changes in physiological stress and levels of habitual loading of Ibizan populations from the Late Roman-Early Byzantine (LREB) to the Islamic period (300-1,235 AD) using measures of body size and bone cross-sectional properties to compare Urban LREB, Urban Medieval Islamic, and Rural Medieval Islamic groups. It also explored the effect of diet, modeled using stable isotopes, on physiological stress levels and behavior. MATERIALS AND METHODS: The sample comprised individuals from three archeological populations: Urban Late Roman- Early Byzantine (LREB) (300-700 AD), Medieval Urban Islamic (902-1,235 AD), and Medieval Rural Islamic. Bone lengths, femoral head dimensions, and cross-sectional properties, diaphyseal products and circumferences, were compared to assess differences in body size and habitual loading in 222 adult individuals. Ordinary least squares regression evaluated the correlations between these measures and carbon (δ13 C) and nitrogen (δ15 N) stable isotope ratios in 115 individuals for whom both isotope values and osteological measures are available. RESULTS: The Medieval Rural Islamic group had shorter stature and reduced lower limb cross-sectional properties compared to the two urban groups. Limb shape differs between Urban LREB and Urban Medieval Islamic groups. Measures of body size length were positively correlated with δ13 C values in all individuals and separately in the Urban LREB and Rural Medieval Islamic groups. δ15 N showed a positive correlation with left humerus shape in the Urban LREB sample. CONCLUSIONS: The low stature and cross-sectional properties of the Medieval Rural Islamic group may be an indicator of greater physiological stress, potentially due to poorer diet. Positive correlations between measures of body size and δ13 C values further suggest that greater access to C4 resources improved diet quality. Alternatively, this relationship could indicate greater body size among migrants from areas where individuals consumed more C4 resources.

Applicability of T1-weighted MRI in the assessment of forensic age based on the epiphyseal closure of the humeral head.

This work investigates the value of magnetic resonance imaging analysis of proximal epiphyseal fusion in research examining the growth and development of the humerus and its potential utility in establishing forensic age estimation. In this study, 428 proximal humeral epiphyses (patient age, 12-30 years) were evaluated with T1-weighted turbo spin echo (T1 TSE) sequences in coronal oblique orientation on shoulder MRI images. A scoring system was created following a combination of the Schmeling and Kellinghaus methods. Spearman's rank correlation analysis revealed a significant positive relationship between age and ossification stage of the proximal humeral epiphysis (all subjects: rho = 0.664, p < 0.001; males: 0.631, p < 0.001; females: rho = 0.651, p < 0.001). The intra- and inter-observer reliability assessed using Cohen's kappa statistic was κ = 0.898 and κ = 0.828, respectively. The earliest age of epiphysis closure was 17 years for females and 18 years for males. MRI of the proximal humeral epiphysis can be considered advantageous for forensic age estimation of living individuals in a variety of situations, ranging from monitoring public health to estimating the age of illegal immigrants/asylum seekers, minors engaged in criminal activities, and illegal participants in competitive sports, without the danger of radiation exposure.

Forensic age diagnostics by magnetic resonance imaging of the proximal humeral epiphysis.

The most commonly used radiological method for age estimation of living individuals is X-ray. Computed tomography is not commonly used due to high radiation exposure, which raises ethical concerns. This problem can be solved with the use of magnetic resonance imaging (MRI), which avoids the use of ionizing radiation. The purpose of the present study was to evaluate the utility of MRI analysis of the proximal humeral epiphyses for forensic age estimations of living individuals. In this study, 395 left proximal humeral epiphyses (patient age 12-30 years) were evaluated with fast-spin-echo proton density-weighted image (FSE PD) sequences in a coronal oblique orientation on shoulder MRI images. A five-stage scoring system was used following the method of Dedouit et al. The intra- and interobserver reliabilities assessed using Cohen's kappa statistic were κ = 0.818 and κ = 0.798, respectively. According to this study, stage five first appeared at 20 and 21 years of age in males and females, respectively. These results are not directly comparable to any other published study due to the lack of MRI data on proximal humeral head development. These findings may provide valuable information for legally important age thresholds using shoulder MRI. The current study demonstrates that MRI of the proximal humerus can support forensic age estimation. Further research is needed to establish a standardized protocol that can be applied worldwide.

Medical Imaging and Facial Soft Tissue Thickness Studies for Forensic Craniofacial Approximation: A Pilot Study on Modern Cretans.

Forensic cases may require craniofacial approximations for unidentifiable victims. The accuracy of these approximations is improved by using population-specific average soft tissue depths. This study used CT scans from 64 Cretan adults (32 male and 32 female) to produce three-dimensional models of each individual's cranium and skin surface. Using the models, the soft tissue depths were measured at 36 craniofacial landmarks; the means and standard deviations were calculated for the general Cretan population, and for male and female Cretans separately. Cretan facial soft tissue depths were then compared to those of French, Slovak, and Korean adults. 16 of the 36 landmarks exhibited sex differences among Cretans, with males having consistently thicker depths than females. The facial soft tissue depths of Cretan adults also presented significant differences when compared to other populations. Overall, the average soft tissue depths obtained represent the first database for the craniofacial approximation of Cretan (Greek) adults.

Three-Dimensional Geometry of Phalanges as a Proxy for Pair-Matching: Mesh Comparison Using an ICP Algorithm.

Forensic anthropologists are frequently faced with the challenge of individualizing and sorting commingled remains in a variety of scenarios. A number of protocols have been proposed to standardize the methodological approach to individuating commingled remains, some of which are focused on pair-matching. A recent study by Karell et al. (2016) proposed a virtual method for pair-matching humeri using a semi-automatic procedure that gave encouraging results. With regards to the phalanges, there are only a handful of studies focusing on identifying and siding phalanges, as well as exploring their directional and functional asymmetry. Yet, they are still as important as every other bone when sorting commingled human remains in various situations, such as archaeological common burials and mass graves, commingled decomposed remains resulting from atrocities, accidents or natural disasters. This study investigates a new method for pair-matching, a common individualization technique, using digital three-dimensional models of bone: mesh-to-mesh value comparison (MVC) as proposed by Karell et al. (2016). The MVC method digitally compares the entire three-dimensional geometry of two bones using an iterative closest point (ICP) algorithm to produce a single value as a proxy for their similarity. The method is automated with the use of Viewbox software 4.1 beta for a simultaneous comparison of all possible pairs. For this study, 515 phalanges from 24 individuals of mixed ancestry were digitized using CT scans and the 3D modeling program AMIRA 5.3.3. The models were also hollowed (internal information of compact and trabecular bone removed) to test the method with simulated surface scan models. The subsequent data-over 73,000 comparisons-were assessed using sensitivity and specificity rates via ROC analysis to indicate how well the automated version of MVC pair-matched phalanges. The best bone in terms of pair-matching was the proximal phalanx of Digit 3 with 87.5% sensitivity and 92.4% specificity rates at a threshold value of 0.488 for the unhollowed bones. The specificity drops slightly (91.1%) when the hollowed models are compared. To compare the performance of the method in all phalanges, the specificity was set to 95%-allowing for a 5% acceptable error-and the adjusted sensitivity was compared. The highest sensitivity, namely 68.8%, was noted for Digit 2 proximal phalanx for both unhollowed and hollowed models. Thus far, our preliminary results indicate that the MVC method performs well when pair-matching phalanges, though it is less accurate than pair-matching other types of bones. The introduction of 95% specificity threshold allows for rejecting pairs in great confidence, which could, for instance, significantly reduce the number of DNA comparisons required for the remaining possible matches. In addition, the similar results obtained from hollowed and unhollowed models indicate that the internal information included in the unhollowed models adds little to the identification of true pairs. This means that if a CT scan is not available, the method could be applied to surface models produced by light and laser scanners as well. While additional work needs to be done to verify these preliminary results, this research has the potential to expand the repertoire of individualization methods.

Applicability of 3D-dental reconstruction in cervical odontometrics.

OBJECTIVES: The objective of this study was to assess the accuracy, reliability, and reproducibility of computed tomography (CT) images in measuring cervical mesiodistal and buccolingual tooth sizes, by comparing the values obtained by 3D virtual models from CT images with those obtained using digital calipers. MATERIALS AND METHODS: In total, 530 maxillary and mandibular teeth of 51 individuals from two Iron Age sites were scanned using a Siemens Somatom sensation 64-slice computed tomography machine, and the images were reconstructed and measured. Values obtained by direct measurement served as the primary reference for cervical measurements. Intra- and inter-observer reliability was assessed by calculating technical error of measurements (TEM), relative technical error of measurements (rTEM), and the coefficient of reliability (R). RESULTS: Results showed that virtual cervical measurements were not significantly different from the actual measurements, and the correlation of the two measurement methods shows that the methods are comparable. Inter- and intra-observer error analysis also indicated high replicability of measurements with both measuring methods (R > 0.99). The rTEM values for all the measurements were below the 5% standards for anthropometric studies. DISCUSSION: CT is a non-invasive technique that allows for an accurate and detailed visualization of morphological features without causing any damage to teeth. Our findings indicate that virtual odontometric analysis is a reliable method, similar to traditional physical odontometric analysis. Currently, the virtual system is likely to be more suitable for fragile specimens, such as archaeological samples.

A novel method for pair-matching using three-dimensional digital models of bone: mesh-to-mesh value comparison.

The commingling of human remains often hinders forensic/physical anthropologists during the identification process, as there are limited methods to accurately sort these remains. This study investigates a new method for pair-matching, a common individualization technique, which uses digital three-dimensional models of bone: mesh-to-mesh value comparison (MVC). The MVC method digitally compares the entire three-dimensional geometry of two bones at once to produce a single value to indicate their similarity. Two different versions of this method, one manual and the other automated, were created and then tested for how well they accurately pair-matched humeri. Each version was assessed using sensitivity and specificity. The manual mesh-to-mesh value comparison method was 100 % sensitive and 100 % specific. The automated mesh-to-mesh value comparison method was 95 % sensitive and 60 % specific. Our results indicate that the mesh-to-mesh value comparison method overall is a powerful new tool for accurately pair-matching commingled skeletal elements, although the automated version still needs improvement.

Inner ear morphology of the cioclovina early modern European calvaria from Romania.

OBJECTIVES: The morphology of the human bony labyrinth is thought to preserve a strong phylogenetic signal and to be minimally, if at all, affected by postnatal processes. The form of the semicircular canals is considered a derived feature of Neanderthals and different from the modern human anatomy. Among other hominins, European Middle Pleistocene humans have been found to be most similar to Neanderthals. Early modern humans have been proposed to show a pattern that is distinct, but most similar to that of Holocene people. Here we examine the inner ear structures of the Cioclovina calvaria, one of the earliest reliably dated and relatively complete modern human crania from Europe, in the context of recent and fossil human variation. MATERIALS AND METHODS: Bony labyrinths were virtually extracted from CT scans of recent Europeans and Cioclovina. Using univariate and multivariate methods, measurements of the semicircular canals were compared with published measurements of other fossil specimens. RESULTS: Our results show that Cioclovina's inner ear morphology falls within the range of modern variation, with affinities to both Late Pleistocene modern humans and recent Europeans. Using discriminant functions, the sex of the Cioclovina specimen is estimated as male. DISCUSSION: Results agree with previous work showing that Cioclovina exhibits fully modern cranial morphology.

Sexual dimorphism of the tibia in contemporary Greeks, Italians, and Spanish: forensic implications.

There are many population-specific studies around the world on sex estimation from skeletal remains. Of the long bones, the tibia has been an important one because it is commonly studied to assess population specificity of a long bone. However, the studies in Europe that use this bone for sex estimation remain limited. The aim of this study is to analyse the tibia in different populations of the southern Europe such as Greece, Italy, and Spain providing standards for sex estimation in a forensic context. In total, we analyzed tibiae of 157 Greek, 190 Italian, and 105 Spanish individuals. Standard osteometric measurements were taken and the data was analyzed using discriminant function statistics. Posterior probabilities were calculated for all produced formulae. Statistical analysis was performed using SPSS subroutines. All measurements were significantly different between the sexes in all three populations and in the pooled sample. A discriminant function of the pooled sample for Southern Europeans resulted in about 88 % accuracy using all three variables. Over 43 % of the individuals were correctly classified at a 0.95 threshold. More work should be done including other Southern European populations to this database to further test the applicability of the method.

Advanced bronchogenic carcinoma presented as cardiac tamponade: a case report and a review of the literature.

Although most fatal lung tumors are well diagnosed before a patient's death, occasionally forensic pathologists encounter cases of sudden death in which the presence of a primary small cell lung carcinoma was not suspected. We present the case of a 49-year-old man asymptomatic until 2 days before his death. The autopsy revealed a huge tumorous mass originating from the central bronchus, infiltrating the large vessels, pulmonary parenchyma, pericardium, and the right ventricle of the heart. Pericardial sac was distended due to pericardial effusion (700 mL). Examination also revealed metastases to the liver, pancreas, and right adrenal gland. Microscopic examination identified the primary neoplasm as a small cell lung carcinoma after common stain of hematoxylin-eosin, and additional immunohistochemistry were performed.

Sexual dimorphism of the bony labyrinth: a new age-independent method.

Currently in physical anthropology there is a need for reliable methods of sex estimation for immature individuals and highly fragmented remains. This study develops a sex estimation technique from discriminant function analysis of the bony labyrinth as it matures before puberty and can survive taphonomic conditions that would destroy most other skeletal material. The bony labyrinth contains the organs of hearing and balance. For this reason biologists and paleoanthropologists have undertaken research in this area to understand evolutionary changes in locomotion. Prior studies have found clear differences between species, but within-species variation has not been satisfactorily investigated. 3D segmentations of the left and right labyrinths of 94 individuals from a Cretan collection were generated and measured. Mean measurements of height, width, size, and shape indices were analyzed for sexual dimorphism, bilateral asymmetry, and measurement error. Significant sexual dimorphism was detected for several measurements. For sex estimation, the single best variable was the radius of curvature of the posterior semicircular canal, which achieved 76% accuracy. Two multivariate functions increased accuracy to 84%. Although these equations are less accurate than equations for complete long bones and crania, they appear to be as accurate as or better than other techniques for sexing immature individuals and temporal bones.

Nitrogen-plastic bag suicide: a case report.

The use of pure nitrogen gas to commit suicide has recently become more popular, although suicides involving nitrogen oxide fumes have been occasionally reported in the past. The cause of death in such cases is attributed to asphyxia due to forced depletion of oxygen, a subcategory of a phenomenon dubbed environmental hypoxia. A case of a 26-year-old man who committed suicide by inhaling nitrogen through a plastic bag is reported. The exact method of suicide used here is one of the many described in detail on the Web.

Human bony labyrinth as a sex indicator in subadults.

Due to the durability and good preservation of the petrous bone in archaeological and forensic contexts, the value of the inner ear as a sex indicator has been evaluated in various studies. Previous findings suggest that the morphology of the bony labyrinth is not stable in the postnatal period. In this study, we aim to assess the sexual dimorphism of the bony labyrinth via analysis of computed tomography (CT) data obtained from 170 subadults (birth to 20 y.o.) and test whether the postnatal changes of the bony labyrinth affect the level of dimorphism in the inner ear. A set of 10 linear measurements of 3D labyrinth models as well as 10 size and shape indices were analyzed. Sexually dimorphic variables were used to produce sex estimation formulae with discriminant function analysis. The produced formulae allowed for the correct classification of up to 75.3 % of individuals aged from birth to 15 years old. Sexual dimorphism was not significant for individuals between 16 and 20 years of age. This study suggests that the morphology of the subadult bony labyrinth exhibits significant sexual dimorphism in individuals under 16 years of age, which can aid the forensic identification process. Although postnatal growth of the temporal bone seems to affect the level of sexual dimorphism present in the inner ear, the formulae created in this study could be used as an additional tool for sex estimation of subadult (<16 y.o.) remains.

IPPASOS: The first digital forensic information system in Greece.

OBJECTIVE: This article describes the first digital clinical information system tailored to support the operational needs of a forensic unit in Greece and to maintain its archives. METHOD: The development of our system was initiated towards the end of 2018, as a close collaboration between the Medical School of the University of Crete and the Forensic Medicine Unit of the University Hospital of Heraklion, Crete, where forensic pathologists assumed active roles during the specification and testing of the system. RESULTS: The final prototype of the system was able to manage the life cycle of any forensic case by allowing users to create new records, assign them to forensic pathologists, upload reports, multimedia and any required files; mark the end of processing, issue certificates or appropriate legal documents, produce reports and generate statistics. For the first 4 years of digitised data (2017-2021), the system recorded 2936 forensic examinations categorised as 106 crime scene investigations, 259 external examinations, 912 autopsies, 102 post-mortem CT examinations, 804 histological examinations, 116 clinical examinations, 12 anthropological examinations and 625 embalmings. CONCLUSION: This research represents the first systematic effort to record forensic cases through a digital clinical information system in Greece, and to demonstrate its effectiveness, daily usability and vast potential for data extraction and for future research.