Congenital heart diseases (CHDs) and forensic investigations: Searching for the cause of death.

Congenital Heart Diseases (CHDs) are a group of structural abnormalities or defects of the heart that are present at birth. CHDs could be connected to sudden death (SD), defined by the WHO (World Health Organization) as "death occurring within 24 h after the onset of the symptoms" in an apparently "healthy" subject. These conditions can range from relatively mild defects to severe, life-threatening anomalies. The prevalence of CHDs varies across populations, but they affect millions of individuals worldwide. This article aims to discuss the post-mortem investigation of death related to CHDs, exploring the forensic approach, current methodologies, challenges, and potential advancements in this challenging field. A further goal of this article is to provide a guide for understanding these complex diseases, highlighting the pivotal role of autopsy, histopathology, and genetic investigations in defining the cause of death, and providing evidence about the translational use of autopsy reports. Forensic investigations play a crucial role in understanding the complexities of CHDs and determining the cause of death accurately. Through collaboration between medical professionals and forensic experts, meticulous examinations, and analysis of evidence, valuable insights can be gained. These insights not only provide closure to the families affected but also contribute to the prevention of future tragedies.

Respect for bioethical principles and human rights in prisons: a systematic review on the state of the art.

BACKGROUND: Respect for human rights and bioethical principles in prisons is a crucial aspect of society and is proportional to the well-being of the general population. To date, these ethical principles have been lacking in prisons and prisoners are victims of abuse with strong repercussions on their physical and mental health. METHODS: A systematic review was performed, through a MESH of the following words (bioethics) AND (prison), (ethics) AND (prison), (bioethics) AND (jail), (ethics) AND (jail), (bioethics) AND (penitentiary), (ethics) AND (penitentiary), (prison) AND (human rights). Inclusion and exclusion criteria were defined and after PRISMA, 17 articles were included in the systematic review. RESULTS: Of the 17 articles, most were prevalence studies (n.5) or surveys (n.4), followed by cross-sectional studies (n.3), qualitative studies (n.1), retrospective (n.1) and an explanatory sequential mixed-methods study design (n.1). In most cases, the studies associated bioethics with prisoners' access to treatment for various pathologies such as vaccinations, tuberculosis, hepatitis, HIV, it was also found that bioethics in prisons was related to the mental health of prisoners, disability, ageing, the condition of women, the risk of suicide or with the request for end-of-life by prisoners. The results showed shortcomings in the system of maintaining bioethical principles and respect for human rights. CONCLUSIONS: Prisoners, in fact, find it difficult to access care, and have an increased risk of suicide and disability. Furthermore, they are often used as improper organ donors and have constrained autonomy that also compromises their willingness to have end-of-life treatments. In conclusion, prison staff (doctors, nurses, warders, managers) must undergo continuous refresher courses to ensure compliance with ethical principles and human rights in prisons.

The dating of thrombus organization in cases of pulmonary embolism: an autopsy study.

BACKGROUND: Pulmonary embolism (PE) is associated to high mortality rate worldwide. However, the diagnosis of PE often results inaccurate. Many cases of PE are incorrectly diagnosed or missed and they are often associated to sudden unexpected death (SUD). In forensic practice, it is important to establish the time of thrombus formation in order to determine the precise moment of death. The autopsy remains the gold standard method for the identification of death cause allowing the determination of discrepancies between clinical and autopsy diagnoses. The aim of our study was to verify the morphological and histological criteria of fatal cases of PE and evaluate the dating of thrombus formation considering 5 ranges of time. METHODS: Pulmonary vessels sections were collected from January 2010 to December 2017. Sections of thrombus sampling were stained with hematoxylin and eosin. The content of infiltrated cells, fibroblasts and collagen fibers were scored using a semi-quantitative three-point scale of range values. RESULTS: The 30 autopsies included 19 males (63.3%) and 11 females (36.7%) with an average age of 64.5 ± 12.3 years. The time intervals were as follows: early (≤1 h), recent (> 1 h to 24 h), recent-medium (> 24 h to 48 h), medium (> 48 h to 72 h) and old (> 72 h). In the first hour, we histologically observed the presence of platelet aggregation by immunofluorescence method for factor VIII and fibrinogen. The presence of lymphocytes has been identified from recent thrombus (> 1 h to 24 h) and the fibroblast cells were peripherally located in vascular tissue between 48 and 72 h, whereas they resulted central and copious after 72 h. CONCLUSIONS: After a macroscopic observation and a good sampling traditional histology, it is important to identify the time of thrombus formation. We identified histologically a range of time in the physiopathology of the thrombus (early, recent, recent-medium, medium, old), allowing to determine the dating of thrombus formation and the exact time of death. CLINICAL TRIAL NUMBER: NCT03887819. TRIAL REGISTRATION: The trial registry is Cliniclatrials.gov, with the unique identifying number NCT03887819. The date of registration was 03/23/2019 and it was "Retrospectively registered".

Is there a lesser value type of violence? Older people abuse: "The silence of the lambs".

The World Health Organization (WHO) describes gender violence as a real global health problem with a major impact not only on the victims' physical and mental health, but also on the economics of the National Health System. Gender-based violence has been also extended to all types of subjects defined as fragile: children, elderly, women, men and disabled people. Older people abuse, more frequent in women, is a far less socially debated issue, with many forms: physical, sexual, psychological, abandonment, neglect, economic-financial, pharmaceutical, discriminatory, institutional. An electronic literature research was carried out search using the keywords "elderly abuse" on various online sources. The research showed low number of results and little attention to this topic in the scientific literature. The paper highlights how the theme of older people abuse is little reported and not adequately addressed in scientific literature and in real life, being a form of violence certainly underestimated by the public.

The forensic value of the gastric content in head trauma injuries: A case report.

We present the case of a 69 years old man who was hit by a car while crossing the road. A CT scan of the skull and brain showed fracture of the left occipital bone, bilateral hemispheric subarachnoid hemorrhage, right frontal-temporal-parietal subdural hematoma with a shift of midline structures of 18 mm and complete obliteration of the third ventricle. He showed signs of anisocoria, absence of mobility of all 4 limbs and was immediately intubated and admitted to intensive care. The neurosurgeon was immediately consulted. He underwent drainage of subdural hematoma and two decompressive craniotomies, but died 15 days after the initial trauma. At autopsy, the stomach was full of a greenish poltaceous material. This gave us vital information in reconducting the actual brain death of the man to the immediacy of the investment, helping in the process of ruling out any possible profiles of professional liability.

Vehicular homicide or cardiovascular event? The importance of the autopsy findings.

We present the case of a 61 years old woman who was hit by a car, resulting in fractures of the pubic bone, left ischium-pubis ramus and right femur, with need of hip replacement surgery. In the next days she was affected by two episodes of acute coronary syndrome, treated with coronary angioplasty surgery. After undergoing total hip replacement surgery an episode of asystole caused her death. A full autopsy showed coronary stenosis and chronic ischemic heart disease associated with a recent myocardial infarction. The pre-existing condition of T.L. could not be ignored but the initial traumatic event and the subsequent fractures played a further co-occurrent causal role. The initial trauma represented the first step of the phenomenological chain that led to a series of adverse cardiological events and to an irreversible asystole, so that the car driver should be partly considered accountable for the death of the woman.

Child Abuse: Adherence of Clinical Management to Guidelines for Diagnosis of Physical Maltreatment and Neglect in Emergency Settings.

Child maltreatment is a phenomenon of great importance due to the significant socio-health implications related to it. Purpose of the study is assessing compliance child abuse clinical management with guidelines and suggest corrective actions to avoid false negative or false positive judgments. The data come from 34 medical records of child victims of suspected abuse hospitalized in a pediatric clinic. We examined diagnostic and medico-legal management through the analysis of pediatric, dermatological, ophthalmological (including fundus examination), and gynecological (only in some cases) consultations, brain and skeletal imaging, laboratory tests (with reference to the study of hemostasis), and medico-legal advice. Of 34 patients, the average age was 23 months, ranging from 1 month to 8 years. The judgment was positive for abuse for 20 patients and negative for 12 patients; in two cases it was not possible to express a conclusive judgment. Two children died because of the injuries sustained. We underline the need of clinical-diagnostic standardized protocols, coroner in emergency settings, short-distance follow-up, social worker support. We also suggest objectifying in a descriptive way (using a common and repeatable language) and with photographic documentation the results of all the investigations carried out, to evaluate signs of physical maltreatment and neglect.

Diquat Poisoning: Care Management and Medico-Legal Implications.

Acute chemical intoxication represents one of the major causes of Emergency Room admittance, and possible errors in diagnosis are extremely frequent, especially when patients present generic and non-specific symptoms. Diquat, a bipyridyl class of herbicides, exerts high intrinsic toxicity as a consequence of free oxygen radicals, leading to cellular death and organ dysfunctions. Following ingestion, with the major source of absorption for suicidal purposes, the chemical induces local irritating effects; systemic symptoms appear later, while specific symptoms can occur in the following 48 h. A smoker and hypertensive 50-year-old man arrives at the E.R., reporting that an episode of herbicide inhalation occurred few hours earlier. Physical examination evidenced alkalosis with hypoxemia, leucocytosis, mild hyperglycaemia and moderate increase in creatine kinase and myoglobin. Despite blood creatine kinase and myoglobin values that were higher than normal, he was prescribed with hydration and anti-pain therapy. During the night, the man left the hospital; he returned the next morning at 8:45 a.m., with cardiorespiratory arrest, medium fixed non-reactive mydriasis, diffused cyanosis of the skin and of the mucous membranes, as well as imperceptible pulse and peripheral pressure. Despite resuscitation attempts, the patient died at 9:30 a.m.; the body was immediately transferred to the morgue. Autopsy and toxicological analyses were carried out nine days later, evidencing paraquat ingestion for suicidal purposes. GC/MS analyses to verify the presence of diquat were performed on body fluids and gastric and colon contents; all specimens resulted positive, thus confirming the cause of death as herbicide ingestion (blood diquat concentration of 1.2 mg/L; more than twice the minimum to observe a systemic poisoning). The procedure followed for patient management resulted to be not in line with the provisions of both guidelines and good clinical practices. Staff did not perform clinical-diagnostical monitoring of the patient's condition or ask for more specific analyses (i.e., serum creatine phosphokinase monitoring). This misconduct led to a decrease in the patient's chances to survive.

Medico-Legal Issues in Cremation: Comparative Analysis of International Legislation.

Cremation has seen a constant increase in popularity all around the world. Because of its extensively destructive nature, however, a series of medico-legal issues arise concerning identification, forensic autopsy, external examination, histological, toxicological and genetic exams to be performed not in the immediacy of death. The aim of this study is to compare the international legislation on cremation, seeking the response of various countries to their medico-legal issues. Several affinities but also some differences were found. Similarities include the need for a certificate by a medical examiner excluding any medico-legal issues and non-natural causes of death and the expression of consent to cremation given by the deceased when still alive otherwise by relatives. Significant differences were found in German law, which provides for a second medical examination prior to cremation and in Italian law providing for the medical examiner to collect biological samples from the body and store them for a minimum of ten years for any future purpose of justice. The Italian approach could give a plausible solution to the medico-legal issues raised by cremation with the imperative premise, however, we need to look deeply into its privacy and consent implications, cost-benefits rate, sample collection and storage protocol.

Infections Are a Very Dangerous Affair: Enterobiasis and Death.

BACKGROUND: Enterobiasis or oxyuriasis from Enterobius vermicularis is an infection usually localized in the large bowel and cecum. Generally, the symptoms are characterized by anal itching, and intestinal or nervous disorders. Rarely, it is responsible for death. METHODS: A forensic autopsy of a 52-year-old white male inmate who died 5 days after hospitalization was performed. Histological and toxicological analyses were also performed. RESULTS: The death occurred by localization of Enterobius vermicularis in the duodenum and in the proximal ileum, with intestinal haemorrhage, inflammation, and peritonitis documented by histological examination. CONCLUSION: This is a common infectious disease, and can rarely occur with a fatal outcome, even in advanced populations. The lack of knowledge related to the rarity of death from enterobiasis disease can determine a dangerous concern.

Autoptic findings of sudden cardiac death (SCD) in patients with arrhythmogenic ventricular cardiomiopathy (AVC) from left ventricle and biventricular involvement.

OBJECTIVES: To evaluate autoptic histopathological findings of arrhythmogenic ventricular cardiomyopathy (AVC) as major cause of sudden cardiac death (SCD) in young adults. BACKGROUND: According to Heart Rhythm Society (HRS)'s international consensus, histological criteria for AVC diagnosis include a progressive myocardial atrophy of the right ventricle characterized by a transmural fatty or fibrofatty replacement in a segmental or diffuse pattern (residual myocytes <60 % vs 60-75 % by morphometric analysis) explaining the electrical instability with increased risk of SCD. However, there is increasing evidence for atypical patterns of localizations and percentage of fibrofatty replacement suggesting the need to update histopathological features of AVC. METHODS: Histology examination of ventricles, atria, and septum was performed on 10 autopsy of SCD due to AVC. Staining with hematoxylin-eosin and PicroSirius Red/Fast Green were performed on the heart samples to identify specific fibrofatty patterns. RESULTS: Our analysis showed that: 1) myocardial replacement by a diffuse segmental fatty or fibro-fatty tissue characterized right and left ventricles as well as atrial walls; 2) the degree of fibrofatty tissue replacement was less than 40 % both in left ventricle (n = 4, 40 %) and biventricular (n = 6, 60 %) localization; 3) perivascular fibrosis, inflammatory infiltrate, areas of hypertrophy and/or areas of coagulative necrosis as signs of hypoxic damage in the first stage. CONCLUSIONS: We confirmed prior evidence for fibrofatty replacement both in biventricular and septal localizations. Importantly, we observed a less degree (<40 %) of fibrofatty replacement as compared to current guidelines. This supports the need to further explore the histological patterns of fibrofatty infiltration in a larger study population to improve the histological diagnostic criteria of AVC.

Preservation of neurons in an AD 79 vitrified human brain.

Detecting the ultrastructure of brain tissue in human archaeological remains is a rare event that can offer unique insights into the structure of the ancient central nervous system (CNS). Yet ancient brains reported in the literature show only poor preservation of neuronal structures. Using scanning electron microscopy (SEM) and advanced image processing tools, we describe the direct visualization of neuronal tissue in vitrified brain and spinal cord remains which we discovered in a male victim of the AD 79 eruption in Herculaneum. We show exceptionally well preserved ancient neurons from different regions of the human CNS at unprecedented resolution. This tissue typically consists of organic matter, as detected using energy-dispersive X-ray spectroscopy. By means of a self-developed neural image processing network, we also show specific details of the neuronal nanomorphology, like the typical myelin periodicity evidenced in the brain axons. The perfect state of preservation of these structures is due to the unique process of vitrification which occurred at Herculaneum. The discovery of proteins whose genes are expressed in the different region of the human adult brain further agree with the neuronal origin of the unusual archaeological find. The conversion of human tissue into glass is the result of sudden exposure to scorching volcanic ash and the concomitant rapid drop in temperature. The eruptive-induced process of natural vitrification, locking the cellular structure of the CNS, allowed us to study possibly the best known example in archaeology of extraordinarily well-preserved human neuronal tissue from the brain and spinal cord.

Mass spectrometry-based proteomics for the forensic identification of vomit traces.

Proteomics was exploited to assess the nature of possible traces of vomit found on the scene of an alleged sexual assault. In the case in point, a woman reported to the police to be raped five days before by a cousin of hers in his car. The woman declared she had vomited in the car before fainting definitely, due to alcohol or possible drugs covertly slipped in her drinks. The suspect confirmed the sexual intercourse, but he claimed consensual sex while the woman was fully conscious. To establish consent and hence subsistence of the crime, the Magistrate requested toxicological analyses on items sampled from the car and from woman's boots. Negative results obtained from toxicological analyses could not exclude the actual assumption of psychoactive substances by the alleged victim, due to sample aging. On the contrary, proteomic analysis disclosed a pattern of 249 gene products including signature endogenous and food-derived proteins along with a multitude of peptide digests, clearly indicative of vomit, thereby supporting the victim's report in the case under examination. Proteomics also provided detailed information about the nature of meal, which might contribute to frame the crime scene in similar cases. SIGNIFICANCE: The identification of traces of vomit supported the report of the victim's report according to which she vomited before definitely losing consciousness, so providing key contribution to establish consent for the sexual intercourse. This is the first time that proteomics is used to identify traces of vomit for forensic purposes. In spite of the scantiness of the biological specimen available, proteomics was successful to define a panel of characteristic endogenous proteins as well as to identify partly digested food-proteins arising from a complex meal. Proteomics is increasingly used as a forensic technique, well complementing the existing tools. In general, assessing traces of vomit in biological specimens and characterizing the nature of food ingested at the molecular level could afford probative elements to frame a crime scene.

Unreasonable obstinacy: Ethical, deontological and forensic medical problems.

Especially in oncology and in critical care, the provision of medical care can require therapeutic choices that could go beyond the patient's will or intentions of the protection of his health, with the possible adoption of medical behaviors interpreted as unreasonable obstinacy or, at the opposite extreme, as euthanasia. In some cases, the demand for obstinate therapeutic services could come from the patient or from his relatives, in which case the dilemma arises for the health professional between rejecting such a request, in respect of their professional autonomy, or abiding by it for fear of a professional care responsibility for therapeutic abandonment. We analyzed and commented on emblematic clinical cases brought to court for alleged wrong medical conduct due to breach of the prohibition of unreasonable obstinacy. In healthcare it is impossible to fix a general rule defining any therapeutic act as appropriate, because on one hand there are technical assessments of medical competence, and on the other the perception of the patient and of his family members of the usefulness of the health care provided, which may be in contrast. The medical act cannot make treatments that are inappropriate for the needs of care or even be unreasonable; conversely, before the request by the patient or by his family members for disproportionate health services in relation to the results they may give in practice, in compliance with the legislative and deontological provisions, the doctor can refuse them, thus safeguarding both his decision-making autonomy and, therefore, his professional dignity.

Genetic Risk in Insurance Field.

The risk-delimiting tools available to insurance companies are therefore substantial and it is also possible to argue that a margin of uncertainty is a natural component of the insurance contract. Despite this, businesses look at the potential of predictive medicine, and in particular the growing understanding of genetic mechanisms that support many common diseases. In particular, the rapid development of genetics has led many insurance companies to glimpse in the predictive diagnosis of disease by genetic testing the possibility of extending the calculation of the individual risk of developing a particular disease to appropriate premiums or even denying insurance coverage.

Genetic Testing and Professional Responsibility: The Italian Experience.

Responsibility means responding to the damaging consequences of technical work and in this binding perspective the general principles of guilt in genetic diagnostics and related activities are not different from any other medical performance. Performing a genetic test however, especially when it has predictive characteristics, offers absolutely peculiar technical deontological issues. It is not and should not be considered as a mere habitual laboratory test but as a complex set of interactions that presupposes adequate information as a valid consensus to formalize absolutely in written form.

Blood Transfusion in Children: The Refusal of Jehovah's Witness Parents'.

In Italy, both parents have parental responsibility; as a general principle they have the power to give or withhold consent to medical procedures on their children, including consent for blood transfusion; however these rights are not absolute and exist only to promote the welfare of children. METHODS: The Authors discuss ethical and legal framework for Jehovah's Witness parents' refusal of blood transfusion in Italy. They searched national judgments concerning Jehovah's Witness parents' refusal of blood transfusion - and related comments - in national legal databases and national legal journals, and literature on medical literature databases. RESULTS: In the case of Jehovah's Witness parents' refusal of blood transfusion for their child, Italian Courts adopt measures that prevents the parents from exercise their parental responsibility not in the child's best interest. DISCUSSION: In the event that refusal by the parents, outside of emergency situations, exposes the child's health to serious risk, health workers must proceed by notifying the competent authority, according also to the Italian Code of Medical Ethics. CONCLUSION: When the patient is a minor, the child's best interest always come first.

Aesthetic Dental Procedures: Legal and Medico-legal Implications.

Dental treatments, as well as simple anatomical and functional repair work, can also be for aesthetic purposes. This is because the anatomical area concerned, i.e. the oral cavity, has a great power of attraction. Aesthetic treatments in general - in particular dental treatments - have been on the rise in recent years, and this has also meant an increase in claims due to patient dissatisfaction with the results obtained. Numerous laws have been introduced that emphasise the need for comprehensive prior information in order to acquire valid consent. This has resulted in the elimination of the distinction between the obligation of means and obligation of result, with achievement of the normally expected result required in any case.

Ethical and Legal Issues in Gestational Surrogacy.

This study originated from events that occurred in 2014 in an Italian hospital, where the embryos of a couple, obtained by means of homologous insemination, were mistakenly implanted into the uterus of another woman who, along with her husband, underwent the same treatment. Faced with this serious adverse circumstance, that gives rise to ethical and legal issues, the authors conducted a comparative examination of how to consider the division of maternity (between biological mother and uterine mother) and the related division of paternity (between genetic father and legal father, husband or partner of the gestational mother). Some preliminary observations are made concerning parenthood and filiation within the context of currently applicable Italian law. The following is a detailed analysis of the arguments in favour of the parental figures involved (gestational mother/genetic mother).

Piercing and Tattoos in Adolescents: Legal and Medico-legal Implications.

Non-therapeutic body modification interventions are permitted within the limits of the use of one's own body that can be specified in the legal system. The authors take into consideration Italian regulation on tattooing and piercing, in particular in relation to adolescents. RESULTS: In Italy, several regions have therefore issued acts aimed at regulating the activities of tattoo and piercing also in reference to minors. Discussion. With regard to minors, the rules taken into account set precise limits in relation to the age criterion and subordinate the implementation of such practices to the provision of consent by legal representatives. CONCLUSION: If such practices are of an aesthetic nature, we cannot avoid considering the implications they have on health protection, and then adopt appropriate measures to protect the person who intends to undergo them, particularly in the case of minors.