Immunohistochemical expression of HMGB1 and related proteins in the skin as a possible tool for determining post-mortem interval: a preclinical study.

Determining the post-mortem interval (PMI) is one of forensic pathology's primary objectives and one of its most challenging tasks. Numerous studies have demonstrated the accuracy of histomorphology and immunohistochemical investigations in determining the time of death. Nevertheless, the skin, a robust and easy-to-remove tissue, has only been partially analyzed so far. By studying 20 adult male mice, we tried to determine whether post-mortem immunohistochemical detection in the skin of HMGB1 proteins and associated components (Beclin1 and RAGE) could be used for this purpose. We discovered that nuclear HMGB1 overexpression indicates that death occurred within the previous 12 h, nuclear HMGB1 negativization with high cytoplasmic HMGB1 intensity indicates that death occurred between 12 and 36 h earlier and cytoplasmic HMGB1 negativization indicates that more than 48 h have passed since death. RAGE and Beclin1 levels in the cytoplasm also decreased with time. The latter proteins' negativization might indicate that more than 24 and 36 h, respectively, have passed from the time of death. These indicators might potentially be helpful in forensic practice for determining the PMI using immunohistochemistry.

Post-mortem Imaging of Brain/Spine Injuries: The Importance of a Comprehensive Forensic Approach.

In forensic investigations, the limitations of the traditional purely autoptic approach can be overcome through post-mortem imaging (virtopsy). Virtospy has several applications to the investigation of brain and spinal injuries, whose analysis can be of forensic interest, especially in cases of suspected malpractice. In this scoping review, we briefly describe the main applications of the two most common post-mortem radiological techniques (computed tomography (CT) and magnetic resonance imaging (MRI)) to the forensic investigation of brain and spinal injuries in cases of medical malpractice or traumatic (accidental/homicidal/suicidal) deaths. Although CT represents the traditional approach to post-mortem imaging, MRI is proving to be a valuable tool to investigate brain and spinal injuries and lesions. These post-mortem radiological techniques can also be used to guide the surgeons in simulated surgical procedures on corpses in the context of training programs, thus helping operators to improve technical and non-technical skills and to reduce the risk of avoidable errors.

Comparative Impact Analysis of Low-Deductible Insurance Versus In-house Hospital Assumption of Risk and Management on Medical Malpractice Claims.

OBJECTIVES: Claims management is critical to ensure the safe and high-quality medical care for which liability insurers and/or hospitals are responsible. The aim of this research is to determine whether increasing hospital malpractice risk exposure, with increasing deductibles, has an impact on malpractice claims and payouts. METHODS: The study was conducted at a single tertiary hospital, the Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy. Payouts on closed reported and registered claims were analyzed during 4-study periods, which ranged from 1.5 million euro annual aggregate deductibles entirely managed by the insurance company to 5 million euro annual aggregate deductibles entirely managed by the hospital. We retrospectively analyzed 2034 medical malpractice claims submitted between January 1, 2007, and August 31, 2021. Four periods were examined depending on the claims management model adopted, ranging from total outsourcing to the insurer (period A) to an almost total hospital assumption of risk method (period D). RESULTS: We found that progressive hospital assumption of risk is associated with a decrease in the incidence of medical malpractice claims (average variation per year: -3.7%; P = 0.0029 if the 2 initial periods and the 2 last periods-characterized by the highest risk retention-are respectively aggregated and compared), an initial decrease in the mean claims cost followed by an increase that is still lower than the national increase (-5.4% on average), and an increase in the total claims cost (when compared with the period where the insurer solely managed claims). We also found that the rate of increase in payouts was less than the national average. CONCLUSIONS: The assumption of more malpractice risk by the hospital was associated with the adoption of numerous patient safety and risk management initiatives. The decrease in claims incidence could be due to the implementation of patient safety policies, while the cost increase could be attributed to inflation and rising costs of healthcare services and claims. Notably, only the hospital assumption of risk model with a high-deductible insurance coverage is sustainable for the studied hospital, while also being profitable for the insurer. In conclusion, as hospitals progressively assumed more risk and management responsibility of malpractice claims, there was a progressive decrease in the total number of claims, and a less rapid rise in claim payouts as compared with the national average. Even a small assumption of risk appeared to elicit meaningful changes in claim filings and payouts.

Post mortem computed tomography meets radiomics: a case series on fractal analysis of post mortem changes in the brain.

Estimating the post-mortem interval is a fundamental, albeit challenging task in forensic sciences. To this aim, forensic practitioners need to assess post-mortem changes through a plethora of different methods, most of which are inherently qualitative, thus providing broad time intervals rather than precise determinations. This challenging problem is further complicated by the influence of environmental factors, which modify the temporal dynamics of post-mortem changes, sometimes in a rather unpredictable fashion. In this context, the search for quantitative and objective descriptors of post-mortem changes is highly demanded. In this study, we used computed tomography (CT) to assess the post-mortem anatomical modifications occurring in the time interval 0-4 days after death in the brain of four corpses. Our results show that fractal analysis of CT brain slices provides a set of quantitative descriptors able to map post-mortem changes over time throughout the whole brain. Although incapable of producing a direct estimation of the PMI, these descriptors could be used in combination with other more established methods to improve the accuracy and reliability of PMI determination.

Postmortem CT pulmonary findings in SARS-CoV-2-positive cases: correlation with lung histopathological findings and autopsy results.

INTRODUCTION/PURPOSE: Postmortem computed tomography (PMCT) is a valuable tool for analyzing the death of patients with SARS-CoV-2 infection. The purpose of this study was to investigate the correlation between PMCT lung findings in autopsy cadavers positive for SARS-CoV-2 infection and the severity of COVID-19 lung disease by histopathological analysis. MATERIALS AND METHODS: We reviewed chest PMCT findings, paying particular attention to the lung parenchyma, in 8 autopsy cases positive for SARS-CoV-2. Correlations between chest PMCT and histopathological findings were assessed. Clinical conditions and comorbidities were also recorded and discussed. The primary cause of death was finally considered. RESULTS: In 6/8 cases, pulmonary PMCT findings were massive consolidation (4/8) and bilateral diffuse mixed densities with a crazy-paving pattern (2/8). These cases showed severe pulmonary signs of COVID-19 at histopathological analysis. In the remaining 2/8 cases, pulmonary PMCT findings were scant antideclive ground-glass opacities in prevalent gradient densities attributed to hypostasis. In 4/8 cases with massive consolidations, important comorbidities were noted. In 6/8 cases with severe pulmonary histopathological signs of lung COVID-19, autopsy found that the cause of death was cardiorespiratory failure. In the remaining 2/8 cases, histopathological analysis revealed lung alterations due to edema and some signs of SARS-CoV-2 infection; the cause of death was not attributed to SARS-CoV-2 infection (Table 1). DISCUSSION AND CONCLUSION: Chest PMCT findings correlate with the severity of COVID-19 lung disease at histopathology examination. According to our results, there may also be a relationship between cause of death and PMCT findings in COVID-19, which must be critically analyzed considering clinical antemortem data.

A novel computational strategy to predict the value of the evidence in the SNP-based forensic mixtures.

This study introduces a methodology for inferring the weight of the evidence (WoE) in the single nucleotide polymorphism (SNP)-typed DNA mixtures of forensic interest. First, we redefined some algebraic formulae to approach the semi-continuous calculation of likelihoods and likelihood ratios (LRs). To address the allelic dropouts, a peak height ratio index ("h," an index of heterozygous state plausibility) was incorporated into semi-continuous formulae to act as a proxy for the "split-drop" model of calculation. Second, the original ratio at which a person of interest (POI) has entered into the mixture was inferred by evaluating the DNA amounts conferred by unique genotypes to any possible permutation of any locus of the typing protocol (unique genotypes are genotypes that appear just once in the relevant permutation). We compared this expected ratio (MRex) to all the mixing ratios emerging at all other permutations of the mixture (MRobs) using several (1 - χ2) tests to evaluate the probability of each permutation to exist in the mixture according to quantitative criteria. At the level of each permutation state, we multiplied the (1 - χ2) value to the genotype frequencies and the h index. All the products of all the permutation states were finally summed to give a likelihood value that accounts for three independent properties of the mixtures. Owing to the (1 - χ2) index and the h index, this approach qualifies as a fully continuous methodology of LR calculation. We compared the MRs and LRs emerging from our methodology to those generated by the EuroForMix software ver. 3.0.3. When the true contributors were tested as POIs, our procedure generated highly discriminant LRs that, unlike EuroForMix, never overcame the corresponding single-source LRs. When false contributors were tested as POIs, we obtained a much lower LR value than that from EuroForMix. These two findings indicate that our computational method is more reliable and realistic than EuroForMix.

Estimation of the time of death by measuring the variation of lateral cerebral ventricle volume and cerebrospinal fluid radiodensity using postmortem computed tomography.

Using postmortem CT (PMCT), changes in the volume of the lateral cerebral ventricles (LCVs) and modifications of the radiodensity of cerebrospinal fluid (CSF) have been examined to identify a possible relationship between these changes and the time of death. Subsequent periodical CT scans termed "sequential scans" for ten corpses at known time of death were obtained, and a 3D segmentation of the entire LCV was carried out to measure its volume and radiodensity over time from ~ 5.5- h up to 273-h postmortem. A linear decrease of the LCV volume for all the cases was observed in the investigated time range, together with an overall logarithmic increase of radiodensity. Although a larger sampling should be performed to improve the result reliability, our finding suggests that the postmortem variation of CSF radiodensity can be a potentially useful tool in determining postmortem interval, a finding that is worthy of further investigation.

Use of post-mortem chest computed tomography in Covid-19 pneumonia.

BACKGROUND AND AIM: COVID-19 is an extremely challenging disease, both from a clinical and forensic point of view, and performing autopsies of COVID-19 deceased requires adequately equipped sectorial rooms and exposes health professionals to the risk of contagion. Among one of the categories that are most affected by SARS-Cov-2 infection are the elderly residents. Despite the need for prompt diagnoses, which are essential to implement all isolation measures necessary to contain the infection spread, deceased subjects in long-term care facilities are still are often diagnosed post-mortem. In this context, our study focuses on the use of post-mortem computed tomography for the diagnosis of COVID-19 infection, in conjunction with post-mortem swabs. The aim of this study was to assess the usefulness of post-mortem whole CT-scanning in identifying COVID-19 pneumonia as a cause of death, by comparing chest CT-findings of confirmed COVID-19 fatalities to control cases. MATERIALS AND METHODS: The study included 24 deceased subjects: 13 subjects coming from long-term care facility and 11 subjects died at home. Whole body CT scans were performed within 48 h from death in all subjects to evaluate the presence and distribution of pulmonary abnormalities typical of COVID-19-pneumonia, including: ground-glass opacities (GGO), consolidation, and pleural effusion to confirm the post-mortem diagnosis. RESULTS: Whole-body CT scans was feasible and allowed a complete diagnosis in all subjects. In 9 (69%) of the 13 cases from long-term care facility the cause of death was severe COVID 19 pneumonia, while GGO were present in 100% of the study population. CONCLUSION: In the context of rapidly escalating COVID-19 outbreaks, given that laboratory tests for the novel coronavirus is time-consuming and can be falsely negative, the post-mortem CT can be considered as a reliable and safe modality to confirm COVID-19 pneumonia. This is especially true for specific postmortem chest CT-findings that are rather characteristic of COVID-19 fatalities.

Post-mortem ocular changes and time since death: Scoping review and future perspective.

The forensics literature on the relationship between ocular changes and the postmortem interval (PMI) has traditionally focused on time-related variations in concentrations of metabolites and elements within the eye. However, structural changes within the eye over time deserve the same attention because there is significant evidence of their importance in determining the time since death. Therefore, we reviewed publications that provided substantial evidence on this issue. In light of our inclusion and exclusion criteria, 26 papers were eligible for review. On the basis of the ocular parameters considered, we grouped the reviewed evidence into eight thematic areas: corneal opacities, corneal thickness, drug-induced pupil diameter variations, retinal changes, segmentation of retinal vessels, intraocular pressure reduction, globe temperature and crystalline alterations. The most important and common limitations of the reviewed studies were small study populations (many were monocentric studies), absence of robust statistical methodology, use of mathematical models valid only in ideal conditions and validation only for short PMIs. Although many phenomena cannot be used to reliably estimate PMI, there is rigorous evidence suggesting that promising factors, including corneal thickness, require methodological innovations for application to forensics practice but could be used in the near future to reliably estimate the time since death.

Postmortem CT and autopsy findings in nine victims of terrorist attack.

In a foreign country, a religious terrorist group raided a restaurant, using pipe bombs, sharp-edged weapons, and various types of firearms (handguns, submachine guns, and AK-47 assault rifles) loaded with normal and prohibited bullets to kill foreigner customers, some of whom were Italian tourists. Local pathologists performed forensic autopsies on the bodies, but we were asked to perform additional external examinations, postmortem computed tomography (PMCT) scans, and then a second round of complete autopsies on nine victims (5 females and 4 males). Four victims had slash wounds inflicted by sharp-edged weapons, mostly localized in the head and neck. All but two victims had gunshot wounds. Finally, three casualties had injuries caused by the explosion of improvised explosive devices. In all cases, PMCT was a reliable source of information and provided strategic guide during autopsies, helping identify and describe the injuries and thus reconstruct the events. Therefore, in these cases, we suggest integrating the autopsy findings with the postmortem radiological data.

Liability of Health Care Professionals and Institutions During COVID-19 Pandemic in Italy: Symposium Proceedings and Position Statement.

BACKGROUND: On May 12, 2020, a symposium titled "Liability of healthcare professionals and institutions during COVID-19 pandemic" was held in Italy with the participation of national experts in malpractice law, hospital management, legal medicine, and clinical risk management. The symposium's rationale was the highly likely inflation of criminal and civil proceedings concerning alleged errors committed by health care professionals and decision makers during the COVID-19 pandemic. Its aim was to identify and discuss the main issues of legal and medicolegal interest and thus to find solid solutions in the spirit of preparedness planning. METHODS: There were 5 main points of discussion: (A) how to judge errors committed during the pandemic because of the application of protocols and therapies based on no or weak evidence of efficacy, (B) whether hospital managers can be considered liable for infected health care professionals who were not given adequate personal protective equipment, (C) whether health care professionals and institutions can be considered liable for cases of infected inpatients who claim that the infection was transmitted in a hospital setting, (D) whether health care institutions and hospital managers can be considered liable for the hotspots in long-term care facilities/care homes, and (E) whether health care institutions and hospital managers can be considered liable for the worsening of chronic diseases. RESULTS AND CONCLUSION: Limitation of the liability to the cases of gross negligence (with an explicit definition of this term), a no-fault system with statal indemnities for infected cases, and a rigorous methodology for the expert witnesses were proposed as key interventions for successfully facing future proceedings.

A 360° Approach to the Craniovertebral Junction in a Cadaveric Laboratory Setting: Historical Insights, Current, and Future Perspectives in a Comparative Study.

BACKGROUND: We herein outline the experience matured in our equipped Cranio-Vertebral Junction Laboratory for anatomic dissection. METHODS: An extreme lateral approach (ELA) was performed on 4 fresh cadavers and submandibular approach was performed on 5. An endoscope and navigation-assisted far lateral approach (FLA) was performed in 5 injected specimens. In these specimens, a transoral approach was also performed, as well as a neuronavigation-assisted comparison between transoral and transnasal explorable distances. RESULTS: As calculated with neuronavigation, statistically significant differences both in the explored craniocaudal (P = 0.003) and lateral (P = 0.008) distances were observed between the transoral approach and endoscopic endonasal approach. In FLA, neuronavigation facilitated identification and partial removal of the occipital condyle; in one case, during endoscopic intradural exploration, tearing of the emerging roots of the 11th cranial nerve occurred. In ELA, the site where the accessory nerve pierces into the sternocleidomastoid muscle was found at a distance from the tip of the mastoid between 3 and 4 cm. CONCLUSIONS: During dissections, as in the clinical setting, endoscope and image guidance give the surgeon a constant orientation, increasing the accuracy and the safety of the approach. Nonetheless, the encumbrance of the endoscope could represent a limit in deep and narrow corridors as those running across the craniovertebral junction, especially in "oblique" FLA and ELA, in which the surgical target is often hidden by a delicate tangle of nerves and vessels. Its use appears more suitable and safer in "straight" approaches as transoral and transnasal in which there are no neurovascular structures interposed.

An evaluation of the objectivity and reproducibility of shear wave elastography in estimating the post-mortem interval: a tissue biomechanical perspective.

Cadaveric rigidity-also referred to as rigor mortis-is a valuable source of information for estimating the time of death, which is a fundamental and challenging task in forensic sciences. Despite its relevance, assessing the level of cadaveric rigidity still relies on qualitative and often subjective observations, and the development of a more quantitative approach is highly demanded. In this context, ultrasound shear wave elastography (US SWE) appears to be a particularly well-suited technique for grading cadaveric rigidity, as it allows non-invasive quantification of muscle stiffness in terms of Young's modulus (E), which is a widely used parameter in tissue biomechanics. In this pilot study, we measured, for the first time in the literature, changes in the mechanical response of muscular tissues from 0 to 60 h post-mortem (hpm) using SWE, with the aim of investigating its applicability to forensic practice. For this purpose, 26 corpses were included in the study, and the muscle mechanical response was measured at random times in the 0-60 hpm range. Despite the preliminary nature of this study, our data indicate a promising role of SWE in the quantitative determination of cadaveric rigidity, which is still currently based on qualitative and semiquantitative methods. A more in-depth study is required to confirm SWE applicability in this field in order to overcome some of the inherent limitations of the present work, such as the rather low number of cases and the non-systematic approach of the measurements.

Analysis of a DNA mixture involving Romani reference populations.

Here we present an Italian criminal case that shows how statistical methods can be used to extract information from a series of mixed DNA profiles. The case involves several different individuals and a set of different DNA traces. The case possibly involves persons of interest of a small population of Romani origin. First, a brief description of the case is provided. Secondly, we introduce some heuristic tools that can be used to evaluate the data and we also briefly outline the statistical model used for analysing DNA mixtures. Finally, we illustrate some of the findings on the case and discuss further directions of research. The results show how the use of different population database allele frequencies for analysing the DNA mixtures can lead to very different results, some seemingly inculpatory and some seemingly exculpatory. We also illustrate the results obtained from combining the evidence from different samples.

A novel method for post-mortem interval estimation based on tissue nano-mechanics.

Forensic estimation of post-mortem interval relies on different methods, most of which, however, have practical limitations or provide insufficient results, still lacking a gold standard method. In order to better understand the phenomenon of rigor mortis and its applicability to the post-mortem interval estimation, we decided to use atomic force microscopy, a tool often employed to measure mechanical properties of adherent cells. Thus, we surgically removed skeletal muscle samples of three forensic cases from 0 to 120 h post-mortem and quantitatively evaluate two parameters: the Young's modulus (E), which gives information about the sample stiffness, and the hysteresis (H), which estimates the contribution of viscous forces. Despite being a preliminary study, the obtained results show that the temporal behavior of E well correlates with the expected evolution of rigor mortis between 0 and 48 h post-mortem, and then monotonically decreases over time. Unfortunately, it is strongly affected by inter-individual variability. However, we found that H provides measurable data along a time-dependent curve back to the starting point, and these data measured on different subjects collapse onto a single master curve, getting rid of the inter-individual variability. Although a larger sampling should be performed to improve the result reliability, this finding is strongly suggestive that the evaluation of rigor mortis should involve the measure of the nanoscale dissipative behavior of muscular tissues.

Mastering Craniovertebral Junction Surgical Approaches: The Dissection Laboratory Experience at the Catholic University of Rome.

The craniovertebral junction is an intricate anatomical region frequently affected by neoplastic, vascular, traumatic, congenital and degenerative pathology. Because the topography of this region is complex, direct knowledge and full mastery of craniocervical anatomy is mainly obtained through anatomical dissections performed in neuroanatomical laboratories.

Perspectives on Patient Safety and Medical Malpractice: A Comparison of Medical and Legal Systems in Italy and the United States.

OBJECTIVES: Italy is experiencing a crisis of malpractice litigation with important repercussions on the insurance industry (e.g., lower profits), physicians (e.g., defensive medicine), and the courts (e.g., work backlog, lengthy proceedings). We searched for common ground between legal systems in Italy and the United States and considered the implications for international collaborations in patient safety. METHODS: We examined the judicial frameworks of medical malpractice litigation in two countries with different legal foundations: the United States (a public-private system governed by common law) and Italy (a publicly financed healthcare system governed by civil law). RESULTS: We found important differences and similarities across the two systems that suggest a high compatibility for future comparisons and collaborations. Although many Italian hospitals maintain risk management programs, the U.S. emphasis on patient safety and quality has not yet been integrated into Italian healthcare systems. CONCLUSIONS: Based on our findings, we propose that the Italian system might benefit from assertively adopting some concepts from the U.S. system. In particular, we consider the role of the law and Italian medicolegal experts as key facilitators for the integration of patient safety and risk management units within Italian healthcare facilities.

A Fatal Mediastinitis Due to a Neck Trauma from an Undeclared Assault.

History of neck trauma should be promptly investigated in patients with severe infections of the chest as mediastinitis. We present a forensic case of a death due to a mediastinitis in a patient with an undetected fracture of the superior horn of the thyroid cartilage that was exclusively revealed at autopsy examination. Histological analyses of the neck tissues showed signs of pharyngeal mucosal microperforation caused by the fracture and surrounded by an inflammatory reaction. The fracture was caused by a not declared manual strangulation attempt, happened several days before medical evaluations. We share our experience to emphasize the importance of revealing the etiologies of fatal infections of the mediastinum both for clinical and forensic purposes.