Evaluation of a Set of miRNAs in 26 Cases of Fatal Traumatic Brain Injuries.

In forensic medicine, identifying novel biomarkers for use as diagnostic tools to ascertain causes of death is challenging because of sample degradation. To that aim, a cohort (n = 26) of fatal traumatic brain injuries (TBIs) were tested for three candidate miRNAs (namely, miR-124-3p, miR-138-5p, and miR144-3p). For each case, three FFPE specimens (coup area (CA), contrecoup area (CCA), and the corpus callosum (CC)) were investigated, whereas the FFPE brain tissues of 45 subjects (deceased due to acute cardiovascular events) were used as controls. Relative quantification via the ∆∆Ct method returned significantly higher expression levels of the three candidate miRNAs (p < 0.01) in the TBI cases. No difference was detected in the expression levels of any miRNA investigated in the study among the CA, CCA, and CC. Furthermore, the analyzed miRNAs were unrelated to the TBI samples' post-mortem intervals (PMIs). On the contrary, has-miR-124-3p ahashsa-miR-144-3p were significantly correlated (p < 0.01) with the agonal time in TBI deaths. Since the RNA was highly degraded in autoptic FFPE tissues, it was impossible to analyze the mRNA targets of the miRNAs investigated in the present study, highlighting the necessity of standardizing pre-analytical processes even for autopsy tissues.

A fatal and unusual genital mutilation in an elderly man as a result of sharp force injuries and domestic dog predation.

Cases of genital amputation require a careful investigation, since they may be the result of self-inflicted injuries, assaults, animal predation, or post-mortem body mutilation. In the present case, an 81-year-old man affected by liver cirrhosis and dementia and suffering from sexual disinhibition was found lying half-naked and unconscious in his courtyard; profuse bleeding in the perineal area and the absence of the external genitalia were observed. The victim was transferred to hospital and underwent surgical emergency treatment, but he died 2 days later. No sharp tools were found on the scene. Moreover, the autopsy did not reveal any defense or tentative wound on the body and no blood stains on the hands of the victim. Several linear scratches were detected close to the edges of the wound; according to the surgical report, these scratches were clean-cut in the lower part and crenated and infiltrated by blood in the cranial part. Although the medical history of the man could be consistent with self-mutilation, it was not possible to rule out the involvement of other people, including the possibility of an attempt by his relatives to cover up what may have been a self-amputation. Furthermore, the victim's dog vomited parts of the man's genitalia while being transported to a dog shelter. Similar cases have rarely been published in the current forensic literature.

Medicolegal Implications of Fatalities Because of Entanglement in the Augers of Feed Mixer Wagons.

ABSTRACT: Feed mixer or total mixed ration mixer wagons are powerful agricultural machines used to shred and mix silage with other ingredients and deliver it direct to the feeding troughs on livestock farms. Fatalities involving these feed mixers may occur when operators become trapped in the augers or, less frequently, are crushed by moving wagons. Death can occur very rapidly because of dismemberment, multiple lesions, or crushing. The aim of this review is to focus on the diagnostic evaluations that need to be performed to confirm that the death was accidental and to exclude a hypothesis of murder or suicide. Forensic investigations in such cases must involve the detailed analysis of the death scene and the mechanical characteristics of the machinery with an accurate postmortem and toxicological examination.

Cytokine storm and histopathological findings in 60 cases of COVID-19-related death: from viral load research to immunohistochemical quantification of major players IL-1ß, IL-6, IL-15 and TNF-α.

This study involves the histological analysis of samples taken during autopsies in cases of COVID-19 related death to evaluate the inflammatory cytokine response and the tissue localization of the virus in various organs. In all the selected cases, SARS-CoV-2 RT-PCR on swabs collected from the upper (nasopharynx and oropharynx) and/or the lower respiratory (trachea and primary bronchi) tracts were positive. Tissue localization of SARS-CoV-2 was detected using antibodies against the nucleoprotein and the spike protein. Overall, we tested the hypothesis that the overexpression of proinflammatory cytokines plays an important role in the development of COVID-19-associated pneumonia by estimating the expression of multiple cytokines (IL-1ß, IL-6, IL-10, IL-15, TNF-α, and MCP-1), inflammatory cells (CD4, CD8, CD20, and CD45), and fibrinogen. Immunohistochemical staining showed that endothelial cells expressed IL-1ß in lung samples obtained from the COVID-19 group (p < 0.001). Similarly, alveolar capillary endothelial cells showed strong and diffuse immunoreactivity for IL-6 and IL-15 in the COVID-19 group (p < 0.001). TNF-α showed a higher immunoreactivity in the COVID-19 group than in the control group (p < 0.001). CD8 + T cells where more numerous in the lung samples obtained from the COVID-19 group (p < 0.001). Current evidence suggests that a cytokine storm is the major cause of acute respiratory distress syndrome (ARDS) and multiple organ failure and is consistently linked with fatal outcomes.

Medicolegal Implications of Biphasic Anaphylaxis.

ABSTRACT: Biphasic anaphylaxis is an uncommon IgE-mediated condition whose pathophysiological mechanisms, risk factors, and predictive signs are not properly understood. Fortunately, the lethality of biphasic anaphylaxis, although probably underestimated, is low. Preventive clinical measures for biphasic anaphylaxis are neither standardized nor commonly applied. Furthermore, there are no laboratory protocols or anaphylactic markers to help identify the onset of biphasic anaphylaxis in clinical settings. The aim of this review is to highlight the medicolegal difficulties facing coroners and forensic pathologists in terms of the diagnosis and assessment of harm for victims and survivors of biphasic anaphylaxis.

Medicolegal Investigations in Cases of Double Suicidal Gunshots to the Head Using 2 Different Handguns: A Report of an Unusual Case.

Suicides committed by firing 2 gunshots to the head are rare events and pose a significant challenge for coroners and forensic pathologists. The evaluation of the victim's ability to fire 2 shots simultaneously, or to act after a first gunshot, is crucial for the reconstruction of the death scene and to differentiate between homicide and suicide. We report an unusual case of suicide involving 2 gunshot wounds to the head. The medicolegal investigations hypothesized that the victim had either fired 2 shots near simultaneously or he suffered from rapid incapacitation after the first gunshot but was still able to fire a second consecutive and fatal shot to the head. This article focuses on the diagnostic difficulties involved, together with analysis of the death scene and autopsy findings, in cases where the courts demand confirmation that a double gunshot to the head is in fact a case of suicide.

Medicolegal Investigations Into Deaths Due to Crush Asphyxia After Tractor Side Rollovers.

Farm tractors are large, heavy, powerful vehicles with a high center of gravity. When driven carelessly on sloping, irregular, or slippery ground, tractors can overturn sideways and cause the death by crush asphyxia of the driver or passengers, especially if appropriate safety equipment is not fitted or used. The aim of this review is to focus on the diagnostic difficulties with which coroners and forensic pathologists have to cope when a confirmation of crush asphyxia after tractor side rollover is required by judicial authorities. Forensic investigations in such cases must involve the meticulous analysis of the death scene and the mechanical characteristics of the vehicle together with accurate postmortem and toxicological examination.

Diffuse pulmonary ossification in permanent vegetative state.

Diffuse pulmonary ossification (DPO) is a rare condition characterized by diffuse metaplastic bone formation in the lungs. Two patterns have been described: dendriform, with a coral-like network of bone spiculae along the alveolar septa; and nodular, with lobulated fragments in the alveolar spaces. Dendriform DPO is frequently associated with chronic pulmonary pathologies. We present here the first case of DPO associated with a long-lasting vegetative state. Micro-computed tomography (MicroCT) was applied to analyze the distribution of pulmonary ossification in volumes of lung samples. It showed a mean volume percentage of ossification of 0.79% and 3-D reconstructions permitted to reveal the branching pattern and internal cavities of some ossifications. The occurrence of DPO in a persistent vegetative state (PVS) may be favored by recurrent pulmonary infections, due to aspiration and immunological defects, and respiratory instability, due to brain damage and the fact of being bedridden. Fibrotic reactions probably represent a preliminary step in bone formation. Further studies could examine the incidence and clinical significance of DPO in subjects in PVS or patients who are bedridden for other reasons. MicroCT may facilitate analysis of more case histories, with greater sensitivity with respect to classic microscopic analyses.

Sudden death of an athlete due to concealed arrhythmogenic cardiomyopathy: Why preparticipation screening did fail.

We report the case of a professional soccer athlete who died suddenly for arrhythmogenic cardiomyopathy that was not diagnosed at the time of preparticipation screening. Exercise testing had repeatedly shown effort-induced premature ventricular beats with normal echocardiography, which was considered reassuring. However, there is emerging evidence that cardiac diseases characterized by focal ventricular scarring may not cause wall motion abnormalities and can be revealed only by tissue characterization with cardiac magnetic resonance. Modern interpretation of premature ventricular beats features is essential to select athletes who should undergo advanced cardiac imaging investigations, to achieve a correct diagnosis and allow safe sport participation.

Spread of COVID-19 Infection in Long-Term Care Facilities of Trieste (Italy) during the Pre-Vaccination Era, Integrating Findings of 41 Forensic Autopsies with Geriatric Comorbidity Index as a Valid Option for the Assessment of Strength of Causation.

BACKGROUND: in 2020, a new form of coronavirus spread around the world starting from China. The older people were the population most affected by the virus worldwide, in particular in Italy where more than 90% of deaths were people over 65 years. In these people, the definition of the cause of death is tricky due to the presence of numerous comorbidities. OBJECTIVE: to determine whether COVID-19 was the cause of death in a series of older adults residents of nursing care homes. METHODS: 41 autopsies were performed from May to June 2020. External examination, swabs, and macroscopic and microscopic examination were performed. RESULTS: the case series consisted of nursing home guests; 15 men and 26 women, with a mean age of 87 years. The average number of comorbidities was 4. Based only on the autopsy results, the defined cause of death was acute respiratory failure due to diffuse alveolar damage (8%) or (31%) bronchopneumonia with one or more positive swabs for SARS-CoV-2. Acute cardiac failure with one or more positive swabs for SARS-CoV-2 was indicated as the cause of death in in symptomatic (37%) and asymptomatic (10%) patients. Few patients died for septic shock (three cases), malignant neoplastic diseases (two cases), and massive digestive bleeding (one case). CONCLUSIONS: Data from post-mortem investigation were integrated with previously generated Geriatric Index of Comorbidity (GIC), resulting in four different degrees of probabilities: high (12%), intermediate (10%), low (59%), and none (19%), which define the level of strength of causation and the role of COVID-19 disease in determining death.

Determinants of surgeon choice in cases of suspected implant rupture following mastectomy or aesthetic breast surgery: Clinical implications.

Implant ruptures may be diagnosed by physical examination, ultrasound (US), and magnetic resonance imaging (MRI). The absence of standard guidelines to approach to implant ruptures may cause unnecessary surgical revisions in the absence of radiological confirmation of prosthetic damages.The purpose of this study was to analyze the diagnostic procedures applied to patients with suspected prosthetic rupture and surgeon choices to perform a revision or to plan a clinical and radiological follow-up.We conducted a retrospective study on 62 women submitted to revision surgery due to radiological diagnosis of suspected implant rupture, following mastectomy or aesthetic reconstruction, and admitted to a Plastic Surgery Department between 2008 and 2018.Seventy-three implants, believed to be ruptured, were explanted. One-third of these were intact and unnecessarily explanted. US associated with MRI evaluation resulted in the most helpful diagnostical method.A standardized clinical and radiological approach is essential to manage breast implant ruptures successfully. An innovative protocol is proposed in order to: ensure the appropriate management of implant ruptures and prevent unnecessary surgical revisions; reduce the risk of claims for medical malpractice in cases of unsatisfactory final aesthetic results or worse than before.

Medico legal aspects of self-injection of metallic mercury in cases of suicide or self-harming.

Metallic mercury may be self-injected for suicidal or self-harm purposes or sometimes for superstitious or other inadvisable reasons. Local tissue or systemic consequences such as mercurialism can frequently occur in cases of subcutaneous or deep injection, while death due to pulmonary embolism and cardiac, brain, hepatic or renal toxicity may occur in cases of high dosage intravenous administration. The aim of this review is to focus on the diagnostic difficulties facing coroners and forensic pathologists when the courts require confirmation that evidence of self-injection of metallic mercury is the result of suicide or self-harming. Forensic examination performed on the corpses of victims who died in or out of hospital or on surviving injured or intoxicated victims showing signs of mercurialism, demands the careful evaluation of the death scene, of all related circumstances and of the clinical and autopsy data. Close interaction between forensic pathologists and toxicologists is also needed to identify and quantify mercury levels in blood, urine and tissue.

Medico legal and epidemiological aspects of femicide in a judicial district of north eastern Italy.

Femicide is the intentional killing of a woman because she is female, and often occurs when there are pre-existing relations, intimate or otherwise, between the victim and the murderer. A retrospective epidemiological study was made of 34 female homicides recorded in a university departmental register of post-mortems, pertaining to a judicial district of about 700,000 inhabitants in north eastern Italy, during a 21-year period from January 1st 1993 to December 31st 2013. The temporal trend, the socio-demographic characteristics of victims and perpetrators, the circumstances surrounding the crime and the risk factors for femicide were studied with the aim of identifying and developing preventive strategies.

[Clinical practice guidelines: juridical and medico legal issues in health care malpractice liability]. / Linee guida: aspetti giuridici e medico legali nella valutazione della colpa professionale in ambito sanitario.

Clinical Practice Guidelines are clinical tools addressed to medical and health professionals and are normally employed to improve quality and safety of diagnostic and therapeutical procedures but may sometimes limit the autonomy of medical and other health care professionals. The adherence to Clinical Practice Guidelines should not be an exclusive step to evaluate the liability and respect of standards of care in case of medico-legal investigations being each clinical case very specific. Medical liability and respect of standards of care should be evaluated with the support of Clinical Practice Guidelines and the extensive examination of all specific features, professional background and experience requested to treat each single patient.

Neck injury patterns resulting from the use of petrol and electric chainsaws in suicides. Report on two cases.

Suicides due to neck injuries caused by chainsaws are uncommon events. The cutting elements of petrol and electric chainsaws produce different features in lethal neck injuries. The accurate evaluation of the death scene, of the power and mechanical characteristics of the chainsaw and of wound morphology are all essential in distinguishing a case of suicide.

Medico-legal implications of traumatic cataract.

Traumatic cataract is due to lens damage when mechanical, irradiative, electrical or chemical agents injury the globe. The appearance of a traumatic cataract is typically short and unilateral with rare spontaneous resolution and often involves other ocular anatomical areas. Medico-legal evaluation of the appearance and the consequences of a traumatic cataract requires a correct methodological approach with the support of qualified ophthalmological competences.

The Eluana Englaro Case: cause of death after the withdrawal of artificial nutrition and hydration in a subject in a permanent vegetative state and with quadriplegia.

A 38-year-old woman, who had been in a permanent vegetative state with quadriplegia for 17 years following a motor vehicle accident, died 87 h after the judicially authorised suspension of artificial nutrition and hydration. Medico-legal investigations, requested by the Judicial Authorities and focusing on the evaluation of clinical and necroscopic data, aimed to explain the cause of death, to exclude any lethal cause other than one deriving from the withdrawal of artificial nutrition and hydration and to verify the level of perceived discomfort and the correctness in the application of the supportive protocol during the end of life phase. The inability of quadriplegic patients to compensate critical hyperthermic and haemodynamic disturbances induced by dehydration was considered to be the cause of a rapid demise after the withdrawal of artificial sustenance.

Post-mortem diagnosis of anaphylaxis: A difficult task in forensic medicine.

The lack of reliable laboratory biomarkers and common standard definitions of signs and symptoms represents the main problem for clinicians when a suspected anaphylactic event must be diagnosed, while a post-mortem diagnosis of anaphylaxis is often a very difficult task in forensic medicine. Significant necroscopic signs as well as the data reported from witnesses or medical records may be absent, biological fluids as blood or urine may be unavailable or under thanatological modifications. The aim of this review is to focus on the diagnostic difficulties with which coroners and forensic pathologists have to cope when a confirmation of anaphylactic death is required by judicial authorities. Investigation methods for a prudent forensic diagnosis of anaphylactic death as well as the need of new potential laboratory or histological investigation techniques coming from immunological research are discussed too.

Paradoxical air embolism through patent foramen ovale during consensual intercourse in a non-pregnant young female.

Sudden vaginal bleeding and a cardiac arrest occurred in a 18-year-old female during consensual intercourse. Resuscitation procedures, applied at the arrival of a medical emergency team, restored the cardiac function allowing admission to hospital, where two vaginal mucosal lacerations were diagnosed and sutured. Cardiological investigations diagnosed a left ventricle myocardial infarction and a patent foramen ovale while a brain CT scan showed ischemic signs and intravascular air images. Death occurred after 48 h, due to heart failure, cerebral anoxia and multiorgan failure. Autopsy confirmed a patent foramen ovale considered as responsible for a paradoxical air embolism. Judicial Authority evaluated the fatal paradoxical air embolism as a consequence of an unpredictable accident occurred during consensual intercourse without sexual violence.