Dura mater and survival time determination in individuals who died after traumatic brain injury: a preliminary study.

BACKGROUND: Traumatic brain injury (TBI) is one of the major causes of morbidity and mortality among young people and is a matter of concern for forensic pathologists. Many authors have tried to estimate a person's survival time (ST) after TBI using different approaches. OBJECTIVE: The present study aimed to present an innovative workflow to estimate the ST after TBI by observing the inflammatory reaction of the dura mater (DM). METHODS: The authors collected DM samples from 36 cadavers (20 with TBI and 16 with no history or signs of TBI). Each sample was labelled via immunohistochemistry with three different primary antibodies, CD15, CD68, and CD3, yielding 108 slides in total. The slides were digitalized and analysed using QuPath software. RESULTS: The DM is involved in the inflammatory response after TBI. CD15 immunoreactivity allowed us to distinguish between subjects who died immediately after TBI and those with an ST of minutes or hours. CD3 immunoreactivity can be used to differentiate subjects with an ST of days from those with other STs. Moreover, the DM samples showed an acceptable diagnostic yield even in samples with signs of putrefaction.

Informed consent and biological agents in rheumatology and internal medicine.

BACKGROUND: The need for highly effective therapies in rheumatologic diseases has led to the widespread and growing use of a heterogeneous class of molecules called biological agents. The increasing experience with biological agents has raised concerns about safety and efficacy issues that need to be discussed in the informed consent acquisition process. METHODS: The authors performed a review of the literature on biological agents focusing on their most important characteristics concerning the informed consent procedures. RESULTS: No studies specifically addressed the issue of informed consent in patients receiving biological agents. Several studies reported data about off-label use of biological agents usually with no obvious attention to informed consent shortcomings. CONCLUSION: The reported association between biological agents and serious infections or malignancies, including reactivation of latent tuberculosis, needs specific disclosure in informed consent acquisition, together with information about the possible efficacy in clinical contexts often characterized by resistance to previous treatments. Ethical and clinical issues bound to the need for experimenting with new agents with potentially serious adverse effects deserve specific attention. Studies aimed at evaluating mental capacity to consent in subjects receiving biological agents are required.

Reporting Incidents in the Psychiatric Intensive Care Unit: A Retrospective Study in an Italian University Hospital.

ABSTRACT: To evaluate the characteristics of the reported workplace violence in a psychiatric intensive care unit (PICU) by analyzing an electronic hospital incident reporting system (IRS). One hundred thirty reports were retrieved from January 2017 to June 2020, referring to assaults committed by patients (71% males) with an average age of 29.8 years (SD, 14.9). The most frequent psychiatric diagnosis was a neurodevelopmental disorder (33%). Physical aggression (84%) was more frequent than the other types of aggression. Nurses and unlicensed assistive personnel were the most frequent victims (65%). Aggressions were more frequent on Friday (18%) and between 4 p.m. and 8 p.m. (35%). A total of 64.9% of the incidents happened in the first 5 days of hospitalization. A significant association between physical aggression and diagnosis of neurodevelopmental disorder emerged. IRS could be helpful to identify high-risk patient groups and develop clinical strategies to reduce adverse events in clinical practice.

Patricide and overkill: a review of the literature and case report of a murder with Capgras delusion.

Despite being an infrequent crime, parental homicide has been associated with schizophrenia spectrum disorders in adult perpetrators and a history of child abuse and family violence in adolescent perpetrators. Among severe psychiatric disorders there is initial evidence that delusional misidentification might also play a role in parricide. Parricides are often committed with undue violence and may result in overkill. The authors present the case of an adult male affected by schizoaffective disorder and Capgras syndrome who committed patricide. Forensic pathologists classify such cases as overkill by multiple fatal means comprising stabbing, blunt trauma and choking. Accurate crime scene investigations coupled with psychiatric examinations of perpetrator allow reconstruction of the murder stages. This overkill case is discussed in the context of a broad review of the literature.

Role and Tasks of the Occupational Physician during the COVID-19 Pandemic.

Background and Objectives: The first clusters of SARS-CoV-2 infection were identified in an occupational setting, and to date, a significant portion of the cases may result from occupational exposure; thus, COVID-19 should also be considered a new occupational risk that both directly and indirectly impacts the health of workers. Given the significance of occupational-exposure-related infections and deaths, this study aims to assess the roles and tasks of occupational physicians (OPs) in countering the spread of the infection. Indeed, despite the OP's centrality in risk management in the workplace, its activity in the current epidemic context has rarely been mentioned. Materials and Methods: Three different databases (PubMed, Google Scholar, and Embase) were questioned using the main keywords "COVID-19" and "SARS-CoV-2" that were crossed, according to different needs, with the terms "occupational medicine", "occupational physician", "workplace", and "risk assessment" using, when possible, the MeSH database research. Additionally, a systematic research of the regulatory changes of workplaces health surveillance was performed on reference sites of international, European, and Italian authorities. Results: Fundamental tasks and duties of OPs in the current COVID-19 outbreak are highlighted by examining their clinical activity and technical action. A risk assessment and management workflow is proposed, and medico-legal implications in case of infection at work are also discussed in the light of recent regulatory changes that clearly attribute to OPs an important role in safeguarding public health. Conclusion: The proposed approach can provide new instruments to contrast the spread of the infection as part of a comprehensive system response to the current pandemic, for which OPs are called to assume full responsibility.

Post-mortem persistence of SARS-CoV-2: a preliminary study.

Since the beginning of March 2020, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has been the cause of millions of deaths worldwide. The need to better define the pathogenesis of coronavirus disease 19 (Covid-19) as well as to provide the correct statistical records concerning deaths related to this virus, inevitably involves the role of forensic pathology and routine autopsy practice. Currently, some data on macroscopic and microscopic features in autopsies performed in suspected Covid-19 cases are reported in the literature. The persistence of SARS-CoV-2 in cadavers has not yet been elucidated and only a few reports have emphasized the importance of evaluating the Virus RNA in post-mortem tissues. In this preliminary study, we observed that SARS-CoV-2 survives in multiple cadaver tissues many days after death despite some extreme conditions of post-mortem body preservation. The results of this on-going analysis could help improve the safety of working practices for pathologists as well as understanding the possible interaction between microbiological agents and the cadaver tissue's supravital reactions.

Patterned bruising indicating a complete renal artery transection in a fatal occupational accident.

Blunt renal artery injury (BRAI) is a rare finding with incidence ranging from 0.05% to 0.08% among blunt abdominal trauma patients. BRAI occurs in 1% to 4% of patients with renal injury, and the most common cause is motor vehicle accidents. An unusual case of BRAI in a 47-year-old man at work is reported. The victim accidentally fell from a scaffold (approximately 3 m in height). He was transported to the hospital where he was intubated, but he died after 30 min despite the cardio-pulmonary resuscitation. Surveillance cameras showed the man falling from the scaffold, but his impact with the ground was not captured. At autopsy, except for an oval bruise on the left hypochondrium, no external injury was found. The same mark was noticed on the shirt worn by the victim. Bilateral ribs fractures were found. The abdominal cavity was filled with 2 l of fresh blood and clots as a consequence of a complete transection of the left renal artery. Investigation of the workplace revealed a partial footprint on the external side of the scaffold, matching shoes worn by the victim. On the ground, a metallic pedestrian gate with a 1 m high post was found placed just below the scaffold. It was concluded that the man hit the gate's post as intermediate impact after the fall, which caused the oval bruise, ribs fractures, and the rupture of the left renal artery without injury of the internal organs.

Ethical Challenges in Health Care Policy during COVID-19 Pandemic in Italy.

Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, Italy has proven to be one of the countries with the highest coronavirus-linked death rate. To reduce the impact of SARS-CoV-2 coronavirus, the Italian Government decision-makers issued a series of law decrees that imposed measures limiting social contacts, stopped non-essential production activities, and restructured public health care in order to privilege assistance to patients infected with SARS-CoV-2. Health care services were substantially limited including planned hospitalization and elective surgeries. These substantial measures were criticized due to their impact on individual rights including freedom and autonomy, but were justified by the awareness that hospitals would have been unable to cope with the surge of infected people who needed treatment for COVID-19. The imbalance between the need to guarantee ordinary care and to deal with the pandemic, in a context of limited health resources, raises ethical concerns as well as clinical management issues. The emergency scenario caused by the COVID-19 pandemic, especially in the lockdown phase, led the Government and health care decision-makers to prioritize community safety above the individuals' rights. This new community-centered approach to clinical care has created tension among the practitioners and exposed health workers to malpractice claims. Reducing the morbidity and mortality rates of the COVID-19 pandemic is the priority of every government, but the legitimate question remains whether the policy that supports this measure could be less harmful for the health care system.

Fatal mauling by tigers.

Lethal injuries due to large animal attack are uncommon in routine forensic practice in Europe. Specifically, few incidents are reported concerning tiger/lion attacks that usually involve captive circus or zoo animals. We present the case of a 61-year old animal tamer who was mauled to death by four tigers while he was training them for a circus performance. Careful investigation of the circumstances surrounding the fatality revealed that the tamer had most likely been struck with a tiger paw and then mauled by additional tigers resulting in serious and fatal injuries. Although a full medico-legal autopsy was not authorized, total body CT scan coupled with post-mortem external examination allowed a reconstruction of events.

Fatal Rupture of Brachial Pseudoaneurysm in a Drug Abuser: Case Report and Review of the Literature.

The injection of drugs of abuse causes many millions of deaths each year; deaths are mostly due to fatal overdose and the trauma and infection caused by repeated injections. The scientific literature widely reports cases of infected pseudoaneurysm in injecting drug abusers; however, most of these autopsy cases deal with the rupture of pseudoaneurysm of the femoral artery. We present fatal hemorrhagic shock in a heroin-cocaine abuser subsequent to rupture of pseudoaneurysm of the brachial artery; the man collapsed just before injecting himself with a dose of heroin-cocaine (speedball).

Lethal endomyocarditis caused by chronic "Krokodil" intoxication.

"Krokodil" is a home-made opioid drug obtained by synthesizing desomorphine from codeine and combining it with other low-cost additives. Initially introduced in the former Soviet countries, it was then imported to Western Europe as a heroin substitute. To our knowledge, this is the first report of an Italian case of lethal krokodil abuse, that occurred in a 39-year-old man, who died suddenly after transportation to the Emergency Department (ED) for hyperthermia associated with sweating, dyspnoea and tachycardia. Post-mortem examination revealed extensive necrotic ulcerative lesions on the forearms, and autopsy showed a hypertrophic heart with ample endocardial vegetation on the aortic valve and patency of the foramen ovale. Histopathological examination of the heart showed ulcero-vegetative lesions of the aortic valve with an abscess on the annulus and extension to the periaortic adipose tissue, as well as diffuse myocardial interstitial inflammatory neutrophilic infiltrates. Toxicological analysis demonstrated a desomorphine metabolite in urine. On the basis of all these findings the cause of death was ruled to be congestive heart failure caused by endocarditis and myocarditis, correlated with chronic abuse of krokodil.

Off-label and unlicensed drug use among neonatal intensive care units in Southern Italy.

BACKGROUND: Many drugs used for neonates are unlicensed or off-label. An increased risk of medication errors and unexpected adverse drug reactions is associated with their use. This risk is even higher in preterm newborns, because of their physiological immaturity and the exposure to many different medicines. The objective of this study was to evaluate the use of unlicensed or off-label drugs in eight tertiary-level neonatal intensive care units (NICU) from two different southern Italian regions. METHODS: All drugs prescribed to newborns admitted to each NICU, during 1 month of observation, were recorded and classified as licensed, unlicensed or off-label, according, respectively, first, to their license status and, then, their indications, dose, treatment route, and duration of treatment specified in each specific marketing authorization. RESULTS: A total of 126 newborns were treated with at least one drug during the observation period. A total of 483 prescriptions referred to 87 different drugs, classified as licensed, unlicensed or off-label. Each newborn was exposed to three (median) different drugs; 88.6% were licensed and 11.4% unlicensed (range, according to different NICU, 1.9-26.7%). Among licensed drugs, 37.4% were used as off-label (range, 27.3-53.4%). CONCLUSIONS: The use of unlicensed or off-label drugs use is common practice in NICU, with wide variation in local policies and newborn characteristics. Well-designed and -conducted pharmaceutical studies in newborns are needed to increase the number of licensed drugs, thereby reducing any risk for patients due to over- or under-treatment, and also legal issues for clinicians.

Fatal fulminant hepatitis following administration of clarithromycin in a patient chronically treated with antipsycotic drugs.

BACKGROUND: Clarithromycin is a widely used antibiotic, especially prescribed for the treatment of respiratory tract infections, The drug is generally well tolerated. It is described as a very rare cause of fulminant liver failure. CASE PRESENTATION: Herein we report a case of fatal fulminant hepatitis in a young patient. In his past history the patient presented documented episodes of hypertransaminasemia. CONCLUSIONS: This case confirms that clarithromycin although very rarely, can be a cause of fulminant hepatitis, especially in patients with pre-existing liver damage. Although the presumption that clarithromycin hepatotoxicity is dose related is reasonable, an immune-toxicologic hypothesis cannot be excluded.

Measuring the willingness to share personal health information: a systematic review.

Background: In the age of digitalization and big data, personal health information is a key resource for health care and clinical research. This study aimed to analyze the determinants and describe the measurement of the willingness to disclose personal health information. Methods: The study conducted a systematic review of articles assessing willingness to share personal health information as a primary or secondary outcome. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol. English and Italian peer-reviewed research articles were included with no restrictions for publication years. Findings were narratively synthesized. Results: The search strategy found 1,087 papers, 89 of which passed the screening for title and abstract and the full-text assessment. Conclusion: No validated measurement tool has been developed for willingness to share personal health information. The reviewed papers measured it through surveys, interviews, and questionnaires, which were mutually incomparable. The secondary use of data was the most important determinant of willingness to share, whereas clinical and socioeconomic variables had a slight effect. The main concern discouraging data sharing was privacy, although good data anonymization and the high perceived benefits of sharing may overcome this issue.

Alcohol and Drug Consumption among Drivers before and during the COVID-19 Pandemic: An Observational Study.

Restrictions imposed during the COVID-19 pandemic might have changed recreational habits. In this study, the results of toxicological tests for alcohol and drugs in blood were compared among drivers stopped at roadside checks in the periods before (1 January 2018 to 8 March 2020) and after the lockdown measures (9 March 2020 to 31 December 2021). A total of 123 (20.7%) subjects had a blood alcohol level above the legal limit for driving of 0.5 g/l, 21 (3.9%) subjects tested positive for cocaine, and 29 (5.4%) subjects positive for cannabis. In the COVID-19 period, the mean blood alcohol level was significantly higher than in the previous period. Cannabis use, which was more frequent among younger subjects, was statistically associated with cocaine use. There has also been a quantitative increase in alcohol levels in the population with values above the legal limits, indicative of greater use of alcohol in the population predisposed to its intake.

Nasal ciliary motility: a new tool in estimating the time of death.

Determination of time since death is one of the most difficult and crucial issue in forensic medicine. Apart from body cooling, which is commonly used in the early postmortem interval (PMI), supravital reactions are the most interesting postmortem changes for time of death estimation. Nasal ciliary motility has been occasionally observed in postmortem period although no studies have focused on this phenomenon for forensic purposes. We aimed to evaluate the diagnostic usefulness of ciliary motility as a potential tool in estimating the time of death. Specimens of ciliated epithelium from 100 consecutive cadavers were obtained by scraping the nasal mucosa at three different postmortem intervals. The samples were then smeared on a slide, and an in vitro evaluation of ciliary movement was analyzed by phase-contrast microscopy. A postmortem nasal ciliary motility was observed, and a statistically significant relationship between decreasing ciliary movements and increasing postmortem interval was detected even in presence of putrefactive changes of nasal ultrastructure integrity. Some peculiar causes of death seem to influence ciliary motility in the early PMI, while no significant correlations with sex or age were observed. According to the results of this study, postmortem evaluation of nasal ciliary motility may be a bona fide and a feasible option for estimating the time of death.

[An extreme case of family violence against a child]. / Un caso estremo di violenza familiare su un minore.

An extreme case of family violence against a child. Marianna is a child dead by hardships. The case, apparently far from nursing daily practice, is the occasion for reflecting how often the nursing profession witnesses situations at risk of remaining invisible unless somebody decides to take them on by collecting data, reporting signals, carefully observing.

Off-Label Use of Cardiovascular Drugs in the Home Therapy of Children With Congenital or Acquired Heart Disease.

Most medications are not labeled for use in the pediatric population because they have not been formally studied in children. Data on off-label use of cardiovascular (CV) drugs in the home therapy of children with CV disease are scanty. The study included 325 pediatric patients with CV disease and on ≥1 CV medication who underwent ≥1 visit during 2019 at the Pediatric Cardiology outpatient clinic of Giovanni XXIII Pediatric Hospital in Bari, Italy. A total of 287 patients (88.3%) received ≥1 off-label medication, whereas 113 patients (34.7%) received ≥2 off-label medications, and 22 patients (6.7%) ≥3 off-label medications. In CV medications (n = 27) 85% were used off-label in all cases, and 92.5% were used off-label in ≥50% of patients. Adverse events occurred in 8 patients, leading to drug discontinuation in 2 of them. In all 8 cases, medications were used off-label. In multivariate analysis, congenital heart disease patients with single-ventricle physiology (odds ratio 8.4, 95% confidence interval 2.25 to 54.4) and those with heart failure (odds ratio 2.0, 95% confidence interval 1.1 to 3.6) were at higher risk for receiving ≥2 off-label drugs. The off-label use of CV drugs in the home therapy of children with congenital or acquired heart disease is common and adverse events may occur. Patients with congenital heart disease with single-ventricle physiology and those with heart failure have a higher probability to receive ≥2 off-label medications. This study highlights the need for larger safety and efficacy trials in this specific cohort of pediatric patients.