Multiple nail gun injuries: suicide or homicide?

Nail gun injuries are a forensic problem; it can be difficult to distinguish self-inflicted injuries from accident and homicide instances. This kind of injuries shares some characteristics with both gunshot and puncture wounds. We describe a peculiar case of a man who committed suicide driving nails into his skull using a pneumatic nail gun. Entrance wounds were found on both temporal regions of the head. Reviewing scientific literature, this is the first case in Italy reporting the macroscopic data of bilateral head and brain nail gun injuries during an autopsy. Circumstantial elements were not sufficient to clarify if these lesions were self-inflicted, inflicted by accident, or else. Radiological examination can be helpful to show the exact location of the nails, but it has also its own limitations. We firmly believe that autopsy, especially the head section, is crucial to identify the nature and the extension of these lesions, thus giving us much more information about the mechanism of death and the circumstances in which it occurred.

The Effects of the COVID-19 Pandemic on Vaccination Hesitancy: A Viewpoint.

Vaccination hesitancy is considered by the World Health Organization as a danger to global health. In recent years, vaccine hesitancy rates to COVID-19 have been studied worldwide. In our study, we aim to provide an overview of the concept of vaccine hesitancy, with regard to the post-COVID era, and to provide prevention and management strategies. A search of the international literature until March 2023 was conducted in the PubMed database. The 5723 papers found were divided into two groups: prior to the COVID-19 era and from 2021 onward. Papers about the vaccine hesitation phenomenon are becoming more common during the SARS-CoV-2 pandemic and following the marketing that the vaccine companies have carried out on the different types of COVID-19 vaccines. It is advisable that healthcare authorities, at the national and international level, as well as healthcare professionals, at the local level, should promote a series of activities to reduce the vaccine hesitancy rate.

Lethal event in diving with self-contained underwater breathing apparatus: A forensic study.

Introduction: In fatal accidents during scuba diving, it is necessary to differentiate a death from primary drowning from a secondary drowning death that is primarily due to other etiopathogenetic factors. The inhalation of water can only be the end point of a series of events capable of causing the diver's exitus. This study aims to demonstrate that even low-risk heart disease in daily life become potentially fatal during scuba diving. Methods: In this case series, we describe all cases of deaths in the course of diving that came to the observation of the Forensic Institute of the University Bari over 20 years (2000-2020). A judicial autopsy was performed on all subjects, with ancillary execution of histological and toxicological investigations. Results: The results of the medicolegal investigations carried out in the complex identified heart failure with acute myocardial infarction as the cause of death in four cases characterized by severe myocardiocoronarosclerosis, a primary drowning in a subject without previous pathological substrate in one case, and a terminal atrial fibrillation induced by acute dynamic heart failure due to functional overload of the right ventricle in one case. Conclusion: Our study demonstrates that lethal events during diving are often related to the presence of unrecognized or subclinical cardiovascular diseases. Such deaths could be prevented and avoided if a greater regulatory sensitivity to preventing and controlling diving was encouraged, considering both the inherent risks of this activity and the possible unrecognized or underestimated pathologies.

'Compressed Baby Head': A New 'Abusive Head Trauma' Entity?

BACKGROUND: Child abuse represents an important issue in the medico-legal and social context. In the last few decades, various aspects and mechanisms have been identified in child abuse case studies; however, constant research is needed in the field. With this paper, the authors will present a case of a new entity of Abusive Head Trauma that has come to the attention of medico-legal experts. DISCUSSION: The trauma analysis performed on the cranio-encephalic district of the baby revealed quite peculiar lesions that led the authors to exclude that the injuries had been solely caused by violent shaking of the baby's head, as suggested by Shaken Baby Syndrome. Instead, the authors hypothesised that another lesion mechanism had been added to this one, namely latero-lateral cranial compression. The comprehensive and exhaustive analysis of the case led the authors to present a new possible entity in child abuse trauma, namely 'Compressed Baby Head'. CONCLUSIONS: To the best of our knowledge, in the current literature, no similar clinical cases have ever been described. Thus, the case's uniqueness deserves to be brought to the attention of experts and the entire scientific community, as well as medical personnel, paediatricians, and reanimators. These professional figures are the first individuals who may encounter complex clinical cases such as the one presented in this paper; thus, they need to know how to properly manage the case and ensure protection for the abused infants and children.

Requests for Compensation in Cases Involving Patients' Falls in Healthcare Settings: A Retrospective Analysis.

Falls are the most frequent adverse events recorded in healthcare facilities. By employing a multifaceted strategy to ensure prevention interventions that are specific to the patient type and environmental risk management, risk factor evaluation may help to reduce falls in the hospital setting. Patient falls are one of the main causes of lawsuits against hospitals, which has led to the development of validated instruments that are beneficial in treating the patient after the incident and effective in minimizing the frequency of falls. The aim of our study is to evaluate compensation claims asserting healthcare culpability in situations where a patient fell in a hospital setting. The collected data relate to judgments issued in Italy until December 2022 regarding 30 episodes of falls that occurred between 2003 and 2018. Our research revealed that approximately 50% of Italian healthcare organizations lose the case in court when a patient falls in a hospital setting and dies or is injured. In half of these cases, the failure of the medical staff to use protective equipment against falls is what led to the court's acceptance of the compensation claim. In order to improve the quality of healthcare services, fall prevention techniques must continue to be implemented.

Cerebral venous sinus thrombosis after COVID-19 vaccination and congenital deficiency of coagulation factors: Is there a correlation?

In January 2020, SARS-COV-2 infection spread worldwide and was declared "pandemic" by WHO. Because of the high contagiousness of the virus and devastating effects of the epidemic on public health, numerous efforts have been made to develop suitable vaccines to prevent the infection. Among the side effects developed by patients who undergone vaccination, there are common symptoms but also more serious reactions such as the thrombosis syndromes. This paper presents two cases of thrombosis temporally associated with live-vectored Covid vaccination similar to vaccine-induced thrombocytopenia (VITT) in patients with inherited thrombophilia (respectively, the deficiency of protein S and a Factor II mutation). The clinical manifestation caused by VITT is characterized by widespread thrombosis especially affecting intracranial venous sinus, which may cause massive bleeding and intracranial hemorrhage. Although this condition is widely described in literature, there is no evident correlation between this side effect and inherited condition of thrombophilia. The authors suggest that the presence of inherited thrombophilia should be better investigated and, if necessary, screened during the anamnestic data collection before the vaccine administration, leading the healthcare professional to choose the appropriate vaccine to the patient.

COVID-19 Variants in Critically Ill Patients: A Comparison of the Delta and Omicron Variant Profiles.

BACKGROUND: Coronavirus disease is a pandemic that has disrupted many human lives, threatening people's physical and mental health. Each pandemic wave struck in different ways, infectiveness-wise and mortality-wise. This investigation focuses on critically ill patients affected by the last two variants, Delta and Omicron, and aims to analyse if any difference exists between the two groups. METHODS: intensive care unit (ICU) COVID-19 consecutive admissions between 1 October 2021 and 31 March 2022 were recorded daily, and data concerning the patients' demographics, variants, main comorbidities, ICU parameters on admission, and the outcome were analysed by a univariate procedure and by a multivariate analysis. RESULTS: 65 patients were enrolled, 31 (47.69%) belonging to the Omicron versus 34 (52.31%) to the Delta group. The mortality rate was 52.94% for the Omicron group versus 41.9% for the Delta group. A univariate analysis showed that the Omicron variant was associated with total comorbidities number, Charlson Comorbidity Index (CCI), pre-existing pulmonary disease, vaccination status, and acute kidney injury (AKI). In stepwise multivariate analysis, the total number of comorbidities was positively associated with the Omicron group, while pulmonary embolism was negatively correlated with the Omicron group. CONCLUSION: Omicron appears to have lost some of the hallmarks of the Delta variant, such as endothelialitis and more limited cellular tropism when it comes to the patients in the ICU. Further studies are encouraged to explore different therapeutic approaches to treat critical patients with COVID-19.

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.

Dental evidence of human remains of a Slavic soldier population deported in concentration camps during World War II.

Aims: The aim of this paper was to analyse post-mortem dental records of a collection of 93 skeletal remains exhumed from the ossuary of Bari Municipal Cemetery, Apulia, Italy. These skeletal remains belonged to Slavic soldiers deported in 1941 during World War II in two Italian concentration camps and who died in 1946-1947. Methods: A total number of 1949 teeth were analysed according to the American Board of Forensic Odontology and the WHO methods. The majority of the victims were men (95%) between the age of 18 and 62. Results: The results showed the dental health situation of a population of soldiers of World War II, in particular the high rate of caries (35%), periodontal disease (61%), and dental wear (65%) according to the high stress level of the soldiers during the armed conflict and the subsequent deportation. Conclusions: This is the first study reported in literature that analyses the effects of war and deportation on soldiers' pathological conditions of the oral cavity. This analysis also confirmed the usefulness of teeth for anthropological and forensic research thanks to their high resistance and preservation even after post-mortem modifications and different environmental factors.

Analysis of Italian requests for compensation in cases of responsibility for healthcare-related infections: A retrospective study.

Introduction: The aim of this study was to examine the type of compensation claims for alleged medical malpractice in the field of healthcare-related infections in Italy. Methods: It was analyzed which was the most frequent clinical context, the characteristics of the disputes established, which were the alleged damages most often complained of, which were the possibly censurable behaviors of the health professionals, and which were the reasons for acceptance or rejection of the request for compensation. Results: In 90.2%, the issue questioned regarded surgical site infections. The most common pathogens involved were coagulase-negative Staphylococci (34.1%) and Staphylococcus aureus (24.4%). The lack or non-adherence to protocols of prophylaxis and/or prevention of healthcare-related infections was the most reported cause of acceptance of the request of compensation. Discussion: According to our data, a stronger effort should be made in terms of risk management perspective in order to ensure the develop and application of protocols for prevention of Gram-positive healthcare-related infections and strengthen infection control and antimicrobial stewardship programs.

Sex determination through the evaluation of sella turcica measurements using head CT scan.

The estimation of age and sex is mandatory in forensic identification of unknown skeletal remains and it could be reached analyzing different bones' features. The morphometric evaluation of Sella turcica is less described in literature. Many studies have been published in this field for age estimation but none of them based on head CT scan measurement. Previous studies were carried out for age estimation on different populations, but any study has been carried out on the Italian population. Furthermore, no studies were carried out with CT scan technology for the correlation between sex and Sella turcica. Thanks to CT scan technology it has been possible to measure sella turcica's dimensions in an easier way than previous methods, to detect more accurate parameters and even introduce a new one. In this study, the sample was composed of 115 adults, 53 males, and 62 females. Five different measurements of the sellae turcicae were taken. The purpose of this study was to find new elements for sex assessment with the evaluation of sella turcica measurements, improving previous studies, analyzing an Italian European sample. In this study, results of the statistical analysis showed correlation between sex and sella turcica's parameter "Length of Sella Turcica" for which grater values are related to male gender. In conclusion, the Authors consider this unexpected result useful for sex determination in association with other parameters.

Morphological cardiac changes in electrocution deaths: A literature review.

Electrical injury may lead to damage to the conducting tissue, myocardial changes and even sudden cardiac death. Victims of low-voltage electrocution may have no electric marks, burns or other signs typical of electrical injuries. In these cases, the absence of other specific findings could make the identification of the cause of death very difficult. A broad spectrum of cardiac changes in cases of electrocution has been described in the literature, including the break-up of myocardial fibres, cardiomyolysis, haemorrhagic areas, the separation of myofibres and alternating hypercontracted-hyperdistended myocytes. All the described alterations, however, cannot be exclusively attributed to electrocution, since no specific morphological cardiac findings have so far been identified in electrocution. However, a few histological patterns recur, and their knowledge may be important for the forensic pathologist. This literature review describes the main pathological patterns observed in cases of fatal electrocution based on a literature search carried out up to September 2019 in the databases PubMed and Scopus. The search criteria included the keywords for cardiac lesions and electrocution. On the grounds of the literature data, a list of major and minor diagnostic markers for the passage of the electrical current through the heart tissue was created.

Dental age estimation: Demirjian's versus the other methods in different populations. A literature review.

Age estimation is an important issue in forensic anthropology and odontology, since it is applied to both the living and the dead. Studies have shown that assessing tooth development using radiological methods is a reliable way to estimate age, especially in children. Demirjian's method is the most widely used estimation method for dental age evaluation. Over the years, many methods have been developed in order to asses which one predicts more accurately the age. In the literature, many populations were examined with these different methods and discordant results are described. This review aims to evaluate the studies in which Demirjian's method was compared with Willems', Cameriere's, Nolla's, Smith's, Haavikko's and Chaillet's methods in order to estimate the most accurate dental age estimation method in different populations. Using the methodology described in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement, the authors conducted a review of existing literature using three databases: PubMed, Google Scholar and Google Scopus.

Soft-tissue thickness values using cone beam computed tomography: A literature review.

When human remains are found, with no evidence of identity, facial approximation can be a useful technique to employ. The reconstruction of the ante-mortem appearance can reproduce the likely features of the face, starting from the skull, based on the overlying soft-tissue thickness. Over the years, many techniques have been developed to achieve soft-tissue thickness measurements, one of which is based on the use of cone beam computed tomography. This study aimed to review the status of this technique and to evaluate heterogeneity among studies undertaken in this field, with particular regard to determination of landmarks, sex and body mass index.

DNA extraction from sternum bone for identification of a saponified body: use of a modified protocol.

This paper discusses our approach and results obtained when attempting to identify a saponified human body recovered from the sea, without arms and legs. Bones, especially the long ones, are the only sources of DNA available in several cases involving unidentified bodies in advanced state of putrefaction. In this case, since the body was found without limbs, attempts were made to extract DNA from the sternum bone. The DNA was extracted using a modified version of the NucleoSpin® DNA Trace Kit (Macherey Nagel™) protocol and an STR analysis was performed. Thanks to this modified protocol a complete DNA profile was obtained from the sternum bone, while only partial results were obtained from blood and teeth. The DNA profile obtained from the sternum was compared with the DNA of the putative son searching for a genetic match. Five incompatibilities were detected so it was possible to exclude the kinship. In conclusion this could be a useful technique in personal identification through DNA analysis in case of poor quality and quantity of bone.

Head CT scan in emergency room: Is it still abused? Quantification and causes analysis of overprescription in an Italian Emergency Department.

In recent years, the increasing prescription of diagnostic imaging has been noted, due to advances in imaging technology and the development of defensive medicine. Overuse of diagnostic imaging significantly impacts the quality and costs of health care. Therefore, the purpose of this study was to quantify overprescription and investigate its causes through the evaluation of head computer tomography (CT) scan prescriptions. In this study, a set of 100 requests of CT scans was collected and analysed by three experts in guidelines and scientific evidences, evaluating prescription appropriateness. Then, the rate of overprescription was quantified and its causes identified as incorrect adoption of guidelines indications (32%) and as defensive medicine (6%). Therefore, in order to reduce inappropriate investigations, the findings of the present study suggest that the reduction in overprescription could be reached through the improvement of training of health personnel and the propagation of a no-blame culture aimed at minimizing defensive medicine.

High tension electrocution death: New histopathological cardiac tools by Confocal Laser Scanning Microscope.

In deaths due to electrocution intraepidermal separation, vacuolation of epidermal cells, "swiss cheese" aspect of the superficial part of epidermis (swollen and with multiple vescicles), metallization, necrosis of collagenous fibers, cardiomyocytes alterations are microscopically described. No cardiac nerve damage due to electricity is actually reported in literature. In this work we tried to find new morphological signs in the hearts of deaths due to electrocution. In three cases of deaths due to electrocution, in which forensic autopsies were performed within 36 h of the death, heart specimens were taken at the level of common trunk of the left coronary artery. The myocardium histological examination at optical microscope and Confocal Laser Scanning Microscope (CLSM) revealed fragmentation of cardiomyocytes, nerve trunks damage with hydropic swelling of the nerve fibers, interstitial and sub-nerve-sheath edema, very dishomogenous distribution of the natural fluorescence of the neurofilaments, coarctation of epicardial gangliar cells with cytoplasmic cleft and irregular fluorescence pattern. Identification of S-100 protein by immunohistochemistry can help to better observe the hydropic swelling of the nerve fibers and the central cytoplasmic clefts. These alterations could be used in future as specific signs of the passage of the electrical current through the heart. We recommend heart specimens at the level of common trunk of the left coronary artery in all the cases of suspected electrocution, to better evaluate cardiac nerve trunks damages and alterations.

Facial approximation: Soft tissue thickness values for Caucasian males using cone beam computer tomography.

The aim of this study was to obtain soft tissue thickness (STTs) of Caucasian males starting from 12 bone landmarks, to allow facial reconstruction and assign an identity to skeletal remains. When a skeleton is found without any circumstantial evidence of identity, through anthropological investigations it is possible to estimate age, sex, and race studying specific characteristics of bones. This first step of identification process helps investigators to narrow down the identity suppositions, but not always forensic analysis guarantees a final positive identification. Moreover, it is possible to rely on facial reconstruction trying to reproduce the likely features of the face from the skull. The obtained images could be used as a support in recognition by relatives who could provide photos and other data to carry out a comparative analysis. Furthermore, identity can be confirmed by conventional identification methods such as DNA profiling, odontological identification, and radiological comparison. Forensic facial reconstruction (FFR) is based on the bone surface that conditions the facial physiognomy. Analyzing cone beam CT (CBCT) scans of 30 Caucasian males, average STTs values were obtained. CBCT, compared with the conventional spiral CT, has much lower radiation doses, lower costs, high spatial resolution and focuses on head and neck. The obtained results were compared with existing literature and databases and were analyzed by descriptive statistics. Two researchers repeated measurements in different times to assess the reliability of the method.