Explosion-related deaths: An overview on forensic evaluation and implications.

PURPOSE: Explosion-related deaths are uncommon events which require expertise and confidence so that an appropriate death investigation can be performed. The present study aims to provide a detailed forensic analysis of the issues and implications arising in the event of an explosion. METHODS: A retrospective review of casualty data was conducted on electronic literature databases. Cases concerning deadly explosions registered at the Milan Institute of Legal Medicine were examined and analyzed altogether. RESULTS: Explosions may involve closed or open systems. A security assessment of the site is always necessary. Alterations of the site due to rescue procedures can occur; thus, on-site forensic investigation should be adapted to the environment. Then, a study protocol based on autopsy procedures is presented. Application of the postmortem radiology enforces forensic procedures both for the analysis of blast injuries and skeleton fractures, and for identification purposes. Blast injuries typically cause lacerations of the lungs, intestine and major vessels; moreover, hyoid fractures can be documented. Histopathology may help to define blast injuries effectively. Forensic chemistry, toxicology and ballistics provide useful investigative evidence as well as anthropology and genetics. Different forensic topics regarding explosions are discussed through five possible scenarios that forensic pathologists may come across. Scenarios include self-inflicted explosion deaths, domestic explosions, work-related explosions, terrorist events, and explosions caused by accidents involving heavy vehicles. CONCLUSION: The scenarios presented offer a useful instrument to avoid misinterpretations and evaluation errors. Procedural notes and technical aspects are provided to the readers, with an insight on collaboration with other forensic experts.

Asbestos Lung Burden in Necroscopic Samples from the General Population of Milan, Italy.

The present study analysed the asbestos lung burden in necroscopic samples from 55 subjects free from asbestos-related diseases, collected between 2009 and 2011 in Milan, Italy. Multiple lung samples were analysed by light microscopy (asbestos bodies, AB) and EDXA-scanning electron microscopy (asbestos fibres and other inorganic fibres). Asbestos fibres were detected in 35 (63.6%) subjects, with a higher frequency for amphiboles than for chrysotile. Commercial (CA) and non-commercial amphiboles (NCA) were found in roughly similar frequencies. The estimated median value was 0.11 million fibres per gram of dry lung tissue (mf g(-1)) for all asbestos, 0.09 mf g(-1) for amphiboles. In 44 (80.0%) subjects no chrysotile fibres were detected. A negative relationship between asbestos mass-weighted fibre count and year of birth (and a corresponding positive increase with age) was observed for amphiboles [-4.15%, 95% confidence interval (CI) = -5.89 to -2.37], talc (-2.12%, 95% CI = -3.94 to -0.28), and Ti-rich fibres (-3.10%, 95% CI = -5.54 to -0.60), but not for chrysotile (-2.84%, 95% CI = -7.69 to 2.27). Residential district, birthplace, and smoking habit did not affect the lung burden of asbestos or inorganic fibres. Females showed higher burden only for amphiboles (0.12 versus 0.03 mf g(-1) in males, P = 0.07) and talc fibres (0.14 versus 0 mf g(-1) in males, P = 0.03). Chrysotile fibres were shorter and thinner than amphibole fibres and NCA fibres were thicker than CA ones. The AB prevalence was 16.4% (nine subjects) with concentrations ranging from 10 to 110 AB g(-1) dry, well below the 1000 AB g(-1) threshold for establishing occupational exposure. No AB were found in subjects younger than 30 years. Our study demonstrated detectable levels of asbestos fibres in a sample taken from the general population. The significant increase with age confirmed that amphibole fibres are the most representative of cumulative exposure.

Lethal pulmonary thromboembolism: an autopsy-based study on a rare but legally relevant event.

CONTEXT: Pulmonary thromboembolism (PTE) is the severe end stage of many different diseases producing prolonged patient immobilization or a hypercoagulative state. Lethal PTE is also one of the most frequent topics for suspected medical malpractice, especially when dealing with patients originally affected by non-critical illnesses and suddenly killed by a non-prevented embolic event. The crucial forensic question about a lethal PTE is the following one: was this lethal PTE an unpreventable complication or was it a consequence of real medical malpractice? MATERIALS AND METHODS: The authors analyzed the 1999-2009 autopsy archive of the Institute of Forensic Medicine of Milan University and selected all the cases where PTE was the cause of death. For every selected case, the authors also collected all the available demographic and clinical data. Statistical analysis was performed using SPSS V.16.00. RESULTS: In the period 1999-2009, 129 (1.25%) cases out of a total of 10,288 autopsies were diagnosed as having suffered lethal PTE. The male to female ratio was 1:2 (34.1% versus 65.9%). The mean age at death was 67 ± 18 years. In 41% of cases the death occurred outside of the hospital and in the absence of any medical support; in 36.5% of cases it occurred during the territorial paramedical support or during the very first evaluation in the emergency; and in the remaining 22.5% of cases it occurred during a period of hospitalization. In 33.4% of the selected cases, a typical preliminary event was positively identified: a pure major trauma (18.6%); a trauma followed by a major surgery (7%); a major non post-traumatic surgery (7%); and a non-surgical delivery. Symptoms suggesting PTE were detected in 46 cases (35.7%). Nine cases underwent a judicial autopsy in the same original hypothesis of a medical malpractice for incorrect prophylaxis in acutely bed-restricted patients. CONCLUSIONS: Post-surgical PTE cannot be automatically labeled a consequence of medical malpractice. The combination of correct prophylaxis, careful diagnostic monitoring of the high-risk patient and the correct therapy surely reduces the occurrence of lethal PTE, but it does not completely erase such an insidious pathology. In the hypothesis of a causative medical malpractice, only careful analysis by an experienced forensic pathologist can make a reliable distinction between an unpreventable complication and real medical malpractice.

[Digital Pen & Paper® technology to manage clinical risk and to prevent medical malpractice claims]. / La tecnologia Digital Pen & Paper nel Clinical Risk Management e nella prevenzione del contenzioso medico-legale.

The use of innovative technologies in the health sector can be a key element in clinical risk management. In order to reduce errors in medical recording and to provide medico-legal evidence, Digital Pen & Paper technology has been adopted by medical staff of a hospital in Milan. The Authors introduce the first results of this trial: notable advantages have been reported in compilation, transmission and storage of medical records. Furthermore, this technology could provide evidence in evaluating medical malpractice claims.

Defensive medicine and outcomes for medical malpractice liability.

Defensive medicine is a significant force driving the high costs of healthcare systems and has a substantial influence on physicians' behavior because they primarily concern about malpractice liability and not patient's health protection. This attitude disagrees with deontological duties and could impair physicians' ability of judgment and clinical reasoning. Reducing defensive medicine also could mean improving the quality in healthcare systems and eliminating unnecessary costs.

Acute respiratory distress syndrome in the pediatric age: an update on advanced treatment.

Acute respiratory distress syndrome (ARDS) is a heterogeneous syndrome that lacks definitive treatment. The cornerstone of management is sound intensive care treatment and early anticipatory ventilation support. A mechanical ventilation strategy aiming at optimal alveolar recruitment, judicious use of positive end-respiratory pressure (PEEP) and low tidal volumes (VT) remains the mainstay for managing this lung disease. Several treatments have been proposed in rescue settings, but confirmation is needed from large controlled clinical trials before they be recommended for routine care. Non-invasive ventilation (NIV) is suggested with a cautious approach and a strict selection of candidates for treatment. Mild and moderate cases can be efficiently treated by NIV, but this is contra-indicated with severe ARDS. The extra-corporeal carbon dioxide removal (ECCO2 R), used as an integrated tool with conventional ventilation, is playing a new role in adjusting respiratory acidosis and CO2. The proposed benefits of ECCO2 R over extra-corporeal membrane oxygenation (ECMO) consist in a reduction of artificial surface contact, avoidance of pump-related side effects and technical complications, as well as lower costs. The advantages and disadvantages of inhaled nitric oxide (iNO) are better recognized today and iNO is not recommended for ARDS and acute lung injury (ALI) in children and adults because iNO results in a transient improvement in oxygenation but does not reduce mortality, and may be harmful. Several trials have found no clinical benefit from various surfactant supplementation methods in adult patients with ARDS. However, studies which are still controversial have shown that surfactant supplementation can improve oxygenation and decrease mortality in pediatric and adolescent patients in specific conditions and, when applied in different modes and doses, also in neonatal respiratory distress syndrome (RDS) of preemies. Management of ARDS remains supportive, aimed at improving gas exchange and preventing complications. Progress in the treatment of ARDS must be addressed toward the new paradigm of the disease pathobiology to be applied to the disease definition and to predict the treatment outcome, also with the perspective to develop predictive and personalized medicine that highlights new and challenging opportunities in terms of benefit for patient's safety and doctor's responsibility, with further medico-legal implication.

Work-related and non-work-related fatal road accidents: Assessment of psychoactive substance use in commuting.

Commuting road traffic collisions (RTCs) are one of the main causes of occupational death worldwide, including Italy. Among the prominent yet relatively understudied personal risk factors in the subpopulation of workers, there is the use of psychoactive substances. Since the phenomenon of driving under alcohol and drugs effects in the commuter sub-population has so far been poorly studied, we carried out a study by comparing results obtained from the analysis of commuters and non-commuters. The percentage of commuting RTCs victims was 10.4% out of all the RTCs. Commuter victims were mostly men, 51-60 years-old, motorcyclists (32.1%) or car drivers (28.6%), employees, deceased during Fridays and Saturdays, in the afternoon (35.7%) and in the evening (32.1%). It was possible to perform toxicological analyses in 60.7% of commuter cases: approximately 40% tested positive, always and only for ethanol (median Blood Alcohol Concentration, BAC, of about 1.03 g/L). Values above the legal limit were observed in 23.5% of the toxicological samples analyzed from commuter accidents. Our findings contribute to bridging the gap in knowledge in the area of RTCs and commuting and emphasize the importance of carrying out toxicological investigations, with possible repercussions on both insurance issues and public health strategies, which are relevant for analyzing the phenomenon structurally.

Environment, Environmental Crimes, Environmental Forensic Medicine, Environmental Risk Management and Environmental Criminology.

Forensic medicine has always held the human environment, either seen as a source for pathological agents or the background of judicial events, in great consideration. The concept of the environment has evolved through time, expanding itself to include all the physical and virtual sub-spaces in which we exist. We can nowadays talk of technoenvironmental reality; virtual spaces exploded because of the COVID-19 pandemic making us come to terms with the fact that those are the places where we work, where we socialize and, even, where we meet our doctors and can be cured. Artificial Intelligence (AI) has contributed to shaping new virtual realities that have got their own rules yet to be discovered, carved and respected. We already fight a daily battle to save our natural environment: along with the danger of green crimes, comes the need for environmental justice and environmental forensic medicine that will probably develop a forensic branch and an experimental branch, to implement our technical culture leading to definition of the real dimension of the risk itself to improve the role of legal medicine in the Environmental Risk Management. While green criminology addresses widespread green crimes, a virtual environment criminology will also develop, maybe with a contribution of AI in the justice field. For a sustainable life, the environmental revolution must rapidly take place, and there is the need for a new justice, a new forensic medicine and a new criminology too.

Driving under the influence of drugs: Correlation between blood psychoactive drug concentrations and cognitive impairment. A narrative review taking into account forensic issues.

Driving under the influence of alcohol has been shown to increase the risk of involvement in road traffic collisions (RTCs) however, less is known about the effects of illicit drugs, and a clear correlation between drug concentrations and RTC risk is still debated. The goal of this narrative review is to assess the current literature regarding the most detected psychoactive drugs in RTC (ethanol, amphetamines, cannabis, opioids and cocaine), in relation to driving performance. Evidence on impaired driving due to psychoactive substances, forensic issues relating to the assessment of the impact of drugs, blood cut-off values proposed to date as well as scientific basis for proposed legislative limits are discussed. At present there is no unequivocal evidence demonstrating a clear dose/concentration dependent impairment in many substances. Per se and zero tolerance approaches seem to have negative effect on drugged driving fatalities. However, the weight of these approaches needs further investigation.

Forensic considerations on the two major civilian terrorist events occurred in Milan: A retrospective autopsy-based study.

Explosion-related deaths are a disregarded topic of forensic sciences, despite the pivotal role of the forensic pathologist in such investigations. In fact, very few scientific articles have been published up to now, even if there is a considerable increase of terrorist attacks worldwide due to the use of improvised explosive devices (IEDs). In this paper, the authors show a retrospective autopsy-based study on the two major civilian terrorist events which occurred in Milan (Italy). The first one took place in a closed system, where a gelignite bomb was set inside the National Agriculture Bank in December 1969. 17 people were killed, and all of them underwent forensic autopsies, which were performed at the Milan Institute of Legal Medicine. The second event took place in an open system, where a car bomb exploded in Palestro Street in July 1993. 5 people were killed, forensic autopsies were performed as well. A total of 22 explosion-related deaths were assessed in this study. For each victim, the analysis of clothes, external and internal examinations were reported; furthermore, a statistical analysis using Fisher's exact test was carried out in order to show differences among blast injuries that occurred in a closed system versus an open system. The analysis of the autopsy reports, which included the descriptions of clothes, and the injury patterns allowed a possible reconstruction of the bodily exposure side of the victims in relation to the origin site of the explosive devices.

A pilot study for investigating the feasibility of supervised machine learning approaches for the classification of pedestrians struck by vehicles.

This research focuses on the application of Artificial Intelligence (AI) methodologies to the problem of classifying vehicles involved in lethal pedestrian collisions. Specifically, the vehicle type is predicted on the basis of traumatic injury suffered by casualties, exploiting machine learning algorithms. In the present study, AI-assisted diagnosis was shown to have correct prediction about 70% of the time. In pedestrians struck by trucks, more severe injuries were appreciated in the facial skeleton, lungs, major airways, liver, and spleen as well as in the sternum/clavicle/rib complex, whereas the lower extremities were more affected by fractures in pedestrians struck by cars. Although the distinction of the striking vehicle should develop beyond autopsy evidence alone, the presented approach which is novel in the realm of forensic science, is shown to be effective in building automated decision support systems. Outcomes from this system can provide valuable information after the execution of autoptic examinations supporting the forensic investigation. Preliminary results from the application of machine learning algorithms with real-world datasets seem to highlight the efficacy of the proposed approach, which could be used for further studies concerning this topic.

The pathological diagnosis of the height of fatal falls: A mathematical approach.

The authors analyzed the injury pattern of 385 victims of fall from a height which underwent a complete autopsy, with the objective to investigate whether it was possible to construct a mathematical model to be used for height of the fall diagnosis. The cases were selected and enrolled according to a balanced stratification of the heights of the fall, allowing a subdivision into seven classes consisting of 55 subjects each: 6m or less, 9m, 12m, 15m, 18m, 21m, 24m or more (maximum 36m). For each case anthropologic and necroscopic data was collected and analyzed to obtain a standardized description of the injury pattern was obtained, dividing the body into 4 major anatomical areas (Head, Thorax, Abdomen, Skeleton), each of them further divided in 5 major organs. Every organ was finally divided into 5 objective degrees of injury. Statistical analysis was performed on all the available data using IBM SPSS Statistics 20, to test the performance of the "injury pattern assessment table" in the diagnosis of the height of the fall and to develop a related mathematical model. Our findings confirm that the height of the fall is significantly associated with age, weight of the body and the injury pattern. An Injury Pattern Assessment Table and two mathematical models which correlates the height of the fall with analyzed variables are presented.

Alleged malpractice in anesthesiology: analysis of a series of private insurance claims.

BACKGROUND: Medical malpractice is currently a crucial topic and anesthesia is a key specialty for the improvement of patient safety. However, death and permanent impairment due to anesthesia still occur and studies of insurance analysis data are increasing. We investigated the main features of a major Italian insurance broker's archive in order to identify possible recurrent pitfalls in this critical field of medicine. METHODS: Three hundred seventeen Italian claims were analyzed, filling out a standardized form that recorded information on patient and physician's characteristics, procedures, sequence and location of events and outcomes. The operative setting, the type of anesthesia performed the origin of the multidisciplinary team malpractice hypothesis, the final clinical outcome and the malpractice investigation results were also analyzed. RESULTS: In 225 malpractice claims, the adverse event was surgery-linked, either intraoperatively (114 cases) or postoperatively (111 cases): abdominal surgery (26%), orthopedics (22%), gynecology (20%), heart surgery (11%) and neurosurgery (9.5%) were the most frequently involved surgical specialties. In 92 cases, the claim was unlinked to a surgeon's activity, with dental damage in oral intubation procedures as the greatest contributor (42.3%). Anesthetists' malpractice was technically ascertained in 39% of cases, 74.8% resulting in permanent impairment. CONCLUSIONS: Malpractice was mainly suspected in surgery-linked procedures. Most of the claims were settled for procedural error in performing locoregional anesthesia and oral intubation procedures. 60% of all closed claims resulted in no malpractice ascertained. Confirmed malpractice typically deals with non surgery-linked and non multidisciplinary team cases, causing permanent impairment.

The challenging definition of naïve patient for biological drug use.

Biosimilar is defined by The European Medical Agency as a biological medicinal product, which is similar but not identical to the biological drug already authorized. The biosimilar and its reference product are expected to display the same safety and efficacy profile and are generally used to treat the same conditions. The Italian Medicines Agency considers biosimilars as a valid therapeutic option with an economic advantage, especially in primary naïve patients with no previous exposure to the originator or with a sufficiently long wash-out period ("secondary naïve"). The identification of "secondary naïve" is not well defined and can be subjected to different variables, mainly the drug biologic effect and its immunogenicity. The first one depends on the type of biologics and on their mechanism of action. The second one is related to the fact that biologicals may be immunogenic and can trigger an anti-drug antibody response (ADA). ADA may behave as neutralizing antibodies blocking the active site of the biological but can also recognize other epitopes favoring the formation of immune-complexes that eventually affect the pharmacodynamics. Moreover, the concomitant immune-suppressive treatment can affect the immunogenicity, even if the exact mechanism remains unknown. In conclusion, the development and use of biosimilars represent a tool for increasing health system sustainability. However it is of paramount importance to distinguish between the pharmacodynamics of a given drug and its immunogenicity being the two aspects unrelated. Thus a detailed definition of "secondary naïve" patients is challenging, and may be related to both the two parameters.

The medical malpractice in Milan-Italy. A retrospective survey on 14 years of judicial autopsies.

The medical malpractice is a rising and central topic for the forensic pathologist and forensic autopsies are a mandatory step in the judicial evaluation of the suspected medical malpractice. Reliable national and international registers about the medical malpractice are still missing and nowadays the necroscopic archives are therefore one of the best sources of data about such a complex phenomenon. We analyzed the archive of the Institute of Forensic Medicine of the Milan University from 1996 to 2009 and selected 317 lethal cases of suspected medical malpractice. The mean age of our cases was 60±18 years for males and 58±19 years for the females. In 70% of such cases the patient death occurred in a hospital setting. The first 24h of hospitalization turned out to be the hottest period for deaths followed by malpractice claims. The surgical branches were obviously the most involved, with abdominal surgery, orthopedics, neurosurgery and gynecology as the main contributors. Just 12% of the total amount of cases came from all the internistic branches put together. Non-hospital malpractice was typically caused by misdiagnosed myocardial infarctions and aortic ruptures. A full forensic report was present in 71 cases (all belonging to the 2007-2009 period): in 69% of cases the judicial autopsy revealed as a sufficient tool for diagnosing the cause of death; medical malpractice was confirmed in only 17% of the whole cases and a causal link between the ascertained malpractice and the patient death was recognized in only 12.7% cases.