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

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

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

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

Sex estimation from patellar measurements in a contemporary Italian population: a machine learning approach.

Biological sex estimation in forensic anthropology is a crucial topic, and the patella has shown promise in this regard due to its sexual dimorphism. This study uses 12 machine learning models for sex estimation based on three patellar measurements (maximum height, breadth, and thickness). Data was collected from 180 skeletons of a contemporary Italian population (83 males and 97 females) as well as from an independent sample of 21 forensic cases (13 males and 8 females). Statistical analyses indicated that each of the variables exhibited significant sexual dimorphism. To predict biological sex, the classifiers were built using 70% of a reference sample, then tested on the remaining 30% of the original sample and then tested again on the independent sample. The different classifiers generated accuracies varied between 0.85 and 0.91 on the reference sample and between 0.71 and 0.95 for the validation sample. SVM classifier stood out with the highest accuracy and seemed the best model for our study.This study contributes to the growing application of machine learning in forensic anthropology by being the first to apply such techniques to patellar measurements in an Italian population. It aims to enhance the accuracy and efficiency of biological sex estimation from the patella, building on promising results observed with other skeletal elements.

Clinical forensic medicine in emergency departments: a pilot study of a forensic training and evaluation of its effectiveness in an Italian hospital.

Because emergency departments are often the first point of contact for victims of violence, it is critical to provide the appropriate treatment in compliance with all necessary medicolegal precautions. For this reason, a randomized controlled trial was conducted at the Policlinico Hospital of Milan (Italy) in which an intervention group (12 physicians) received a 6-h course on clinical forensic medicine and their performance in medicolegal procedures in claimed cases of violence was compared with that of a control group (13 physicians) by means of a 16-item assessment scale over the 3 months before and the 3 months after the course. Overall, 195 medical records were included in the statistical analysis. Out of these cases, 105 occurred before the course (60 analyzed by the control group and 45 by the intervention group) and 90 occurred after the course (45 analyzed by the control group and 45 by the intervention group). The results showed that the overall mean score of physicians who participated to the course increased from 14.0 (IQR 7.0) to 19.0 (IQR 8.0) with a p-value < 0.0001 and that the comparison between the intervention group and the control group after the course was 19.0 (IQR = 8.0) and 14.0 (IQR = 7.0), respectively, with a p-value < 0.0001. The improvement was very little and below the expectations pointing out that educational courses, although they can be a first step towards raising the ED physicians' awareness of clinical forensics, may not be enough and that more structured training and new strategies should be implemented.

Investigating gunshot wounds in charred bone with XRF spectroscopy: a technical note.

The analysis of traces of injuries can be difficult in cases of charred human remains since the alteration and fragmentation are high. The aim of this study is to explore the use of X-Ray Fluorescence (XRF) technique as a screening tool for detecting and analyzing gunshot residues (GSR) on cremated and highly fragmented materials, as it is a technique that allows for fast qualitative investigations without altering the sample or requiring sample preparation. The study was carried out on two steps: firstly, on completed skeletonized bones to verify if GSR survive to burning; secondly, we considered a more realistic situation, in which soft tissues were present before the shooting. To this aim, nine adult bovine ribs, four retaining soft tissue, five completely skeletonized, were subjected to a shooting test using two types of 9 mm projectiles (jacketed and unjacketed bullets). The ribs were then burnt until complete calcination in an electric furnace. The entry wound of each rib was analyzed using XRF, revealing traces of GSR. The XRF analysis showed that all samples, except for one, contain Pb and/or Sb near the lesion. Furthermore, the samples hit by unjacketed bullets had a more significant presence of Pb in macroscopic yellow areas, which persisted when moving away from the gunshot. These findings could pave the way for the use of XRF technology, mostly when a fast and immediate scan must be done on osteologic materials by a conservative method.

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

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

Skin surface debris as an archive of environmental traces: an investigation through the naked eye, episcopic microscope, ED-XRF, and SEM-EDX.

Traces from bodies can be of various nature, for example of biological or inorganic origin. Some of these historically have received more consideration than others in forensic practice. Samplings of gunshot residues or biological fluid traces are commonly standardized, whereas macroscopically invisible environmental traces are usually ignored. This paper simulated the interaction between a cadaver and a crime scene by placing skin samples on the ground of five different workplaces and inside the trunk of a car. Traces on samples were then investigated through different approaches: the naked eye, episcopic microscope, Scanning Electron Microscopy (SEM) with Energy-dispersive X-ray spectroscopy (EDX) and Energy Dispersive X-Ray Fluorescence (ED-XRF). The purpose is to provide the forensic scientist with the awareness of the value of debris on skin and then to highlight implications for forensic investigations. Results demonstrated that even naked eye observation can reveal useful trace materials, for defining the possible surrounding environment. As a next step, the episcopic microscope can increase the number of visible particulates and their analysis. In parallel, the ED-XRF spectroscopy can be useful to add a first chemical composition to the morphological data. Finally, the SEM-EDX analysis on small samples can provide the greatest morphological detail and the most complete chemical analysis, although limited, like the previous technique, to inorganic matrices. The analysis of debris on the skin, even with the difficulties due to the presence of contaminants, can provide information on the environments involved in criminal events that can add to the investigation framework.

Post-mortem to ante-mortem facial image comparison for deceased migrant identification.

The identification of deceased migrants is a global challenge that is exacerbated by migration distance, post-mortem conditions, access to ante-mortem data for comparison, inconsistent international procedures and lack of communication between arrival and origin countries. Due to low technology requirements, fast speed analysis and ease of transferring digital data, facial image comparison is particularly beneficial in those contexts, especially in challenging scenarios when this may be the only initial ante-mortem data available to identify the deceased. The Facial Identification Scientific Working Group (FISWG) professional guidelines for facial image comparison were developed for living facial appearance, and, therefore, a tailored protocol for the application of post-mortem to ante-mortem facial image comparison was proposed and evaluated in this research. The protocol was investigated via an inter-observer and an accuracy study, using 29 forensic cases (2001-2020) from the University of Milan, provided by the Laboratory of Forensic Anthropology and Odontology. In order to replicate a migrant identification scenario, each post-mortem subject was compared to all 29 ante-mortem targets (841 comparisons). The protocol guided the practitioner through stages of facial image comparison, from broad (phase 1) to more detailed (phase 3), eventually leading to a decision of 'exclusion' or 'potential match' for each post-mortem to ante-mortem case (phase 4). In phase 4, a support scale was also utilised to indicate the level of confidence in a potential match. Each post-mortem subject could be recorded with multiple potential matches. The protocol proved to be useful guide for facial image comparison, especially for less experienced practitioners and the inter-observer study suggested good reproducibility. The majority (82-96%) of ante-mortem subjects were excluded at the first stage of the protocol, and 71 full post-mortem to ante-mortem facial image comparisons were carried out. On average, two or three potential matches were recorded for each post-mortem subject. The overall accuracy rate was 85%, with the majority (79%) of ante-mortem non-targets correctly excluded from the identification process. An increased number and quality of available ante-mortem images produced more successful matches with higher levels of support. All potential matches involving non-targets received low levels of support, and for 73% of the post-mortem subjects, the ante-mortem target was the only recorded potential match. However, two ante-mortem targets were incorrectly excluded (one at the first stage of the protocol) and therefore changes to the protocol were implemented to mitigate these errors. A full protocol and a practical recording chart for practitioner use is included with this paper.

Mood disorders and suicide: pilot study on postmortem toxicologic evidence and adherence to psychiatric therapy by determining blood levels of medications.

Suicide is one of the leading causes of death today, and among all mental illness, mood disorders account for one of the main risk factors. It is well known and proven that suicides are very common among people undergoing treatment and prescribed psychiatric medication. So far, however, there have only been a few studies dealing with this particular phenomenon. For this reason, autopsy patients who died by suicide, suffered from a mood disorder, and were known to be taking psychiatric medication at the time of death were selected for this study. The blood and urine samples taken during the autopsy underwent toxicological analysis and the results were compared with the prescribed therapy. A total of 22 people were included in the study: 12 presenting with depression and 10 with bipolar disorder. The toxicological analysis revealed that only 6 cases (27%) showed a qualitative match with the prescribed medication. In 5 cases (22.7%) the medication was only partially complied with and in 11 cases (50%) it was not complied with at all. Furthermore, even when medication was present, the value was often below the therapeutic range. Overall, more than 70% of the test subjects adhered to their medication only partially or not at all. Since treatment adherence is considered as a key factor in reducing the risk of suicide, this inevitably raises relevant clinical and forensic questions. Against this background, prospective monitoring of post-mortem medication levels in suicidal individuals and synergistic collaboration between clinicians and forensic pathologists could help to evaluate the effectiveness of specific medical interventions, highlight existing critical problems and develop new approaches to suicide prevention.

Why identification matters: an explorative study on six cases of family reunification.

The escalating phenomenon of migration, accompanied by a disturbing surge in associated tragedies, has persistently violated internationally protected human rights. Absence of physical evidence, namely the presence of adequately identified corpses, may impede the full enjoyment of human rights and-in some cases-the course of justice as it obstructs the initiation of legal proceedings against individuals implicated in causing such catastrophes. It also presents administrative obstacles, as death certificates are indispensable in legitimizing statuses like orphanhood and widowhood. Family reunification, particularly for orphans, plays a significant role for those attempting to reconnect with their relatives all over the world. Likewise, for mothers, the acknowledgment of their marital status or widowhood can be a pathway to regain their marginalized right to social life. To elucidate this issue, we analyzed six representative cases from the tragic October 3, 2013, shipwreck near the Italian island of Lampedusa, where 366 individuals were retrieved dead from the sea. These cases underscore the practical challenges involved, highlighting the compelling need for continued efforts to ensure that this burdensome problem transcends from being a mere ethical, moral, and legal discourse. Although considerable progresses, these cases also reveal that substantial work still lies ahead. There is a pressing need for improved mechanisms to certify kinship ties, which are often the limiting factor in many reunifications, and can hinder the granting of custody to children. The severity and far-reaching implications of this problem necessitate thoughtful attention and action, especially considering the ongoing escalation in migration and related fatalities.

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

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

Photoanthropometric study: are non-professional photographs suitable for objective and reliable analysis of facial features?

BACKGROUND: The face has been widely investigated using professionally taken frontal and lateral photographs, however, there is a lack of studies of non-professional facial photographs. It is not known if they could be suitable for facial analysis. The analysis of non-professional photographs could allow the performance of cost- effective longitudinal studies. AIM: To determine if non-professional photographs could be used for a reliable analysis of facial features. SUBJECTS AND METHODS: The frontal profiles of 18-21-year-olds (35 males, 39 females) were measured by direct anthropometry, in addition, professional photographs were taken and non-professional photographs were obtained. Anthropometric landmarks were superimposed on those photographs. The indices calculated on the basis of the measurements of direct anthropometry and both types of photographs were compared. RESULTS: The comparison of the measurements of direct anthropometry and professional photographs showed no difference between 14 out of 25 male and 10 out of 25 female facial indices (p > 0.05) after comparing the results of direct anthropometry with those of non-professional photographs, no difference was found in 8 out of 25 male and 7 out of 25 female indices. These indices were mostly composed of vertical parameters and eye measurements. CONCLUSION: Vertical facial dimensions and eye measurements may not only be used interchangeably for both facial photographs and direct anthropometry, but may also be suitable for objective and reliable facial analyses.

Assessing wound vitality in decomposed bodies: a review of the literature.

The capability of discriminating between a vital and a post-mortem injury has always been a central theme in forensic pathology, particularly when the corpse is an advanced state of decomposition. Post-mortem decay of the body can mask or disrupt the classical features of a skin lesion, making it difficult to establish the cause and manner of death. Taphonomically challenging situations pose several interpretative issues of skin lesions which need to be addressed with scientifically recent methods that are still limited in the forensic literature. For that reason, the present research aims at resuming what is currently available in the attempt to provide some insight regarding this topic. This review considers only original researches, in which the markers of vitality were studied a significant amount of time after death, in order to test post-mortem persistency of these markers over time. A number of 132 original articles and reviews were considered, and the most significant results are resumed in an overview table and in two intuitive figures. Though many researchers tried to establish the vitality of lesions in specimen, few analysed samples from bodies when a significant degree of putrefaction or burning had occurred. The most significant marker proved to be GPA, which sowed a satisfying persistence over time (up to 6 months in air putrefaction and 15 days in water). However, what clearly emerged is that further studies are needed to address the challenges of taphonomically transformed specimen and to possibly neutralize the variability of experimental conditions, which affect the reproducibility of results. In conclusion, this study could be a starting point for providing food for thoughts about the most useful markers to search for in unusually tricky autopsy cases.

Water-related atmospheric agents and solubility: two parameters of validation in toxicological screening on clothing worn by skeletal remains.

In forensic toxicology, when conventional matrices are no longer available, alternative matrices can be used to assess toxicological investigations. Clothes worn by skeletal remains may be a good unconventional matrix for toxicological analyses considering that they have absorbed decomposition fluids and blood from a body. We hypothesized a scenario in which a skeleton, wearing clothes, was discovered in an open environment. From this starting point, an experimental study was developed on different textiles (cotton, wool, and polyester) to evaluate whether water-related atmospheric agents and molecule solubility can largely influence the detection of molecules of toxicological interest on this specific matrix, together with the characteristics of different garments chosen. The experimental study was performed on blood spots, previously spiked with 6-monoacetylmorphine and morphine, accurately placed on different textiles and washed with different quantities of deionized water adjusted at pH 5.6 with formic acid to simulate different rainfall conditions. Toxicological analyses were performed via Solid-Phase Extraction and High-Performance Liquid Chromatography-Tandem Mass Spectrometry analyses (Thermo Scientific™ TSQ Fortis™ II Triple-Quadrupole Mass Spectrometer). From the experimental study morphine could not be detected on 100% cotton and 100% wool fabric after the passing of 500 mL of deionized water and in 100% synthetic polyester textile after washing with 250 mL of deionized water. In conclusion, when toxicological analyses are carried out on unconventional matrices as textiles worn by corpses exposed to different environmental conditions, it is of great importance, in using such substrates as evidence for the presence of molecules of toxicological interest, to evaluate chemical-physical characteristics of each analyte under investigation in order to correctly interpret the toxicological data obtained.

Digital pair-matching of iliac bones: pilot study on a three-dimensional approach with models acquired through stereophotogrammetry.

Three-dimensional (3D) pair-matching has brought about an innovative approach for the analysis of commingled skeletal remains, and it has been tested on bone models acquired through CT and laser scans. Here, 3D models of 40 innominate bones (20 left and 20 right) of 20 documented male individuals from a cemeterial skeletal collection were acquired through a stereophotogrammetric device (VECTRA M3, Canfield Scientific, Inc.). The ventral iliac surface was chosen as the anatomical region of interest (ROI) for the analysis. Each left ROI was mirrored and superimposed on the matching right ROI (contralateral element from the same individual) and mismatching ROIs (contralateral elements from different individuals). The point-to-point distance between models was calculated through the Vectra Analysis Module (VAM) software and the root mean square (RMS) point-to-point distance value was used to evaluate the sorting performance of the method, in terms of sensitivity and specificity rates. Differences in RMS between matches and mismatches were investigated through a Student's t test (p < 0.05). The state of preservation of the remains was assessed following an index of anatomical completeness and differences in RMS distances of true matches according to different anatomical completeness were assessed through the Mann-Whitney test (p < 0.05). RMS point-to-point distances of matches and mismatches were significantly different (p < 0.01), being the matches lower than mismatches. The RMS threshold of 2.9 mm identified all the true pairs; the test was 100% sensitive and 51% specific. The RMS of matches with a better state of preservation are significantly lower than the less preserved matches (p < 0.05). In general, a low RMS distance value may indicate a true match, being it to be further verified. The 3D approach for sorting innominate bones provides a valid screening test that could complete subjective and osteometric methods with numerical evidence of the match. Preliminary data suggest a possible relation between RMS distance values and taphonomic condition, which would benefit from further research.

The rights of migrants to the identification of their dead: an attempt at an identification strategy from Italy.

Europe is turning a blind eye on a humanitarian disaster unfolding at its doorsteps, with thousands of migrants dying unidentified in Mediterranean waters. Since 2014, Italy has been struggling in an almost indifferent international scenario to identify its dead migrants. Despite the lack of sufficient resources, of the difficulties in collecting post mortem data from the disseminated bodies, and of the problems of contacting and collecting ante mortem information from relatives, it has been proven, with a series of pilot studies, that not only can these bodies be identified but that relatives are also looking for their loved ones and need death certificates. This article focuses on the administrative limbo and lack of regulations obliging single states to engage in appropriate procedures to maximise identification.

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

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

Identification issues in bodies maimed by train fatalities: The role of the forensic pathologist.

Traffic accident injuries are relevant causes of mortality in industrialized countries. Among traffic accidents, the most destructive effect on the victim's body is produced by trains, which in a very short time provoke a complete distortion of the normal anatomical profiles and extensive amputations of the body. Deaths by severe body mutilation and/or decapitation require complex forensic investigation, as the victims' identification and the recognition of their body are not often feasible. In this study, a retrospective analysis of a series of cases of railway accidents is presented, with the aim of showing potential identification strategies, including a systematic physical re-assembling of the body. Among the railway fatalities assessed at the University Institute of Legal Medicine of Milan from 2016 until 2020, 61 cases were analyzed, focusing on the collection of postmortem data to improve accuracy for the identification of the victims. The results showed that the identification could be based on elements traditionally called "secondary identifiers" which, however, are becoming more and more important for positive identification, especially when dealing with migrants, vagrants, and homeless people. However, several issues need to be considered such as the limitations of the public prosecutors to perform expensive analyses (i.e., genetic testing), and the lack of antemortem data to be compared with postmortem findings, both odontological and fingerprint. In cases where it is not possible to proceed with identification or formal recognition of victims of railroad accidents with severe mutilations, a systematic physical re-assembling of the body is critical to reaching positive identification.

Two peculiar cases of cranial fractures running through craniotomy burr holes: may this be a kind of "exception" to the Puppe rule.

A correct assessment on the position, path, and direction of fracture lines is crucial when the sequence of different injuries on the skull has to be ascertained. In this context, the so-called Puppe's rule on intersecting fracture lines has always been considered a cornerstone of such an investigation. However, there is one factor that has never been previously considered: how do fracture lines behave when they reach the edges of an old and remodeled hole from a previous craniotomy? Two peculiar cases are presented of subjects undergoing cranial fractures due to blunt force trauma (case 1) and gunshot (case 2). Both previously underwent neurosurgical operations with persistence of the burr holes produced by the craniotomy drill (15 and 20 years before death). What was arguable, according to Puppe's rule, was that the fracture lines, when at the edge of the craniotomy hole, stopped. However, what has been detected was different than what expected: fracture lines continued exactly in the opposite direction, as though they were "skipping" the hole, following the same direction and the same axis and stopping a few centimeters over on the opposite side of the craniotomy hole. Puppe's rule has never been refuted, but these cases are the closest to an exception ever seen in forensic anthropology.

Analysis of interrater reliability in age assessment of minors: how does expertise influence the evaluation?

Nowadays, the clinical forensic medical management of migration flows comprises the age assessment of unaccompanied minors. The process of age estimation is a fundamental pillar for legally ensuring the minors' rights and their protection needs. The procedure is complex and involves different phases and actors, from medical doctors to law enforcement officers. The present study aimed to investigate the performance of Greulich and Pyle, Demirjian, and Mincer methods when performed by raters both trained and without training. Also, the interrater reliability within groups of raters from different areas of expertise was evaluated. A total of 36 participants were enrolled for this study, divided in two groups according to their level of experience with age estimation methods. Each rater was asked to allocate stages and standards for age assessment, evaluating ten orthopantomograms and ten hand-wrist roentgenograms. The interrater reliability expressed through the Fleiss Kappa coefficient and the agreement with the reference standard were calculated. The results showed that none of the categories analyzed could reach a good interrater reliability (ĸ > 0.8) for both methods. The study results highlighted variation and disagreement in the interpretation of the sample among raters and in the subsequent stages and standards allocation. In conclusion, the results of this study highlight that expertise does influence the reliability of the most utilized methods of age estimation of living individuals and stress the importance of proper training and practice, which could greatly increase the accuracy of age assessments.