Are autopsies on minors a taboo?: The experience of Milan in a 19-year retrospective study.

Forensic autopsy is an important tool for the proper management of non-natural deaths in minors. However, it seems that autopsy in minors is a practice which may not be performed routinely. In this framework, we conducted a study analyzing autopsies of minors (under 18 years of age in Italy) performed at the Institute of Forensic Medicine in Milan in the period 2001-2019. For the period 2015-2019, we extrapolated all deaths due to non-natural causes in minors to investigate how many and which of these deaths were not subjected to forensic autopsy. Of the total, 344 minors (235 males and 109 females) underwent autopsies, with an overall downward trend of about 80% since 2004. Most autopsies occurred between the ages of 0 and 1 year, and the fewest between the ages of 5 and 9 years. The place of death was home in most cases, and accidental death was most common, followed by natural death, suicide, and homicide, with prevalence varying by age group. Blunt force trauma predominated among accidental death in all age groups, followed by asphyxia. Similar findings were observed for suicides, although there was a more differentiated pattern for suicides between the ages of 15 and 17 years. Among homicides, blunt force trauma, asphyxia, and gunshot wounds were fairly evenly distributed across all age groups. Between 2015 and 2019, a total of 86 minors died of a non-natural cause, and a forensic autopsy was performed in only 33 cases (38%). Our data shows that fewer and fewer autopsies are being performed over the last years, which indicates a dangerous lack of forensic investigation of children and adolescent deaths, with enormous implications for prevention of child abuse.

Elastic fiber degradation as a possible indicator for PMI estimation on mummified and corified skin: a pilot study.

Mummified and corified bodies are particularly complex scenarios to investigate, starting from identifying the post-mortem interval (PMI), even more so in indoor environments. In these bodies, the skin has the peculiar feature to resist for a long time. Among its components, there are elastic fibers, which are characterized by intrinsic resistance to post-mortem degenerative phenomena. Starting from these considerations, we investigated microscopically the persistence, detectability, and changes of elastic fibers in the skin of mummified and corified bodies with different known PMI. The aim was to evaluate whether they could provide an additional tool to aid in PMI estimation in these cases. Therefore, we collected skin samples from mummified or corified bodies found in a domestic environment with different known PMI, as well as from corified bodies that had been exhumed after 11 years of burial. Histochemical staining specific for elastic fibers, namely, Weigert's resorcin fuchsin, showed their prolonged persistence and a progressive and different degradation between mummified and corified skin as a function of PMI. Moreover, on the whole, we observed greater preservation of elastic fibers in mummified skin than in corified one at the same PMI. Therefore, histological analysis of elastic fibers in mummified and corified skin may help to provide valuable aid in estimating PMI, especially in those particular cases where more reliable alternatives are lacking.

Correlation of soft tissue and skeletal injuries in cases of violent death: A retrospective study of autopsy cases for forensic anthropology.

In forensic pathology, deaths due to mechanical injuries (blunt, sharp, and gunshot) require an autopsy in order to determine the cause and manner of death through a detailed examination of viscera, soft tissues, and the skeletal system. Sometimes, such as in cases of severe putrefaction, only the skeleton is observable. In such cases, the absence of bony defects does not mean that a trauma-related death should not be considered: yet, how often will a lethal mechanical death produce a defect in the skeletal system? The present study involved a retrospective review of autopsy reports to investigate the frequencies of soft tissue and related skeletal injuries in cases of violent deaths. A total of 200 autopsy reports for cases of four mechanisms of injury including sharp force trauma (n = 50), gunshot (n = 50), blunt force trauma (n = 50), and mechanical asphyxia (n = 50) were examined. Manner of death, localization of bone fractures, and correspondence between external injuries and bone fractures were reported. Frequencies of bone fractures and degree of correspondence with soft tissue injuries for each trauma group were evaluated. The result showed that lethal blunt trauma always caused bone fractures; 94.0% of violent deaths by gunshot involved bones; 48.0% of sharp force soft tissue injuries involved the bone tissue; and hyoid bone fractures were observed in 20.0% of cases of mechanical asphyxia.

Sexual Harassments Related to Alcohol and Drugs Intake: The Experience of the Rape Centre of Turin.

A cross-sectional study was conducted that describes the characteristics of sexual violence episodes related to the intake of alcohol and drugs observed among women that turned to the "Centro Soccorso Violenza Sessuale" (SVS) of the Sant'Anna Hospital in Turin between 1 January 2008, and 31 December 2017. Two hundred twenty-two patients were enrolled, 25 of which were minors, 141 were Italians, and most of them knew their aggressor and were raped in a private home. One hundred and fifty-five of them declared to the healthcare personnel to have taken alcoholic substances and/or drugs in conjunction with the event (86 reported having drunk alcohol, 36 having taken drugs and 33 disclosed both alcohol and drug abuse). If the woman knew her abuser, alcohol consumption was described as voluntary in more than 80% of cases, while in relation to drugs the consumption was equally voluntary or fraudulent. About 73% of women who reported having drunk alcohol just had amnesia or amnesia related to other symptoms, while amnesia was present in about 63% of women who reported only drug use. Physicians observed physical injuries on 156 women. Patients who reported to have assumed alcohol presented a significantly higher risk to suffer any physical injury and have a significantly increased risk to suffer injuries to their head and/or neck. The results obtained underline how even in Northern Italy alcohol intake represents the most widespread psychoactive substance in case of drug-facilitated sexual assault. There is therefore a need to promote education and prevention campaigns among citizens, especially among the youngest.

An Italian single-center retrospective analysis of 1106 consecutive cases of child and adolescent abuse: key elements of effective practices.

BACKGROUND: Child and adolescent maltreatment refer to several forms of abuse and neglect, with negative and harmful consequences on children's and adolescents' physical and psychological health. METHODS: This study aims to provide a wide perspective on child and adolescents maltreatment from a large, public, anti-violence center located in a university hospital (SVSeD, Sexual and Domestic Violence Service) and to suggest models of tailored therapeutic interventions and proposals for effective clinical practice. RESULTS: The sample study was obtained by analyzing 1106 medical records of victims aged 0 to 17 referring to SVSeD for all types of abuse. Our findings confirm that almost in one third (28.2%) of the cases children and adolescents are victims of multiple different types of violence. In our experience, sexual violence plays a leading role (66% of cases), being the most frequent type of child and adolescent abuse. CONCLUSIONS: This study confirms that child and adolescent abuse could manifest in many different ways, which are often not so easily detected, as the violence usually occurs inside the family. Institutional educational programs should be implemented to increase the health practitioners' skills and competence for detecting and reporting children and adolescents who are victims of abuse.

Sexual assault and abuse committed against family members: An analysis of 1342 legal outcomes and their motivations.

BACKGROUND: Over the past years medical centres specifically addressed in gender-based violence have developed protocols for the collections of evidence useful in the courtroom, including accurate documentation of physical and psychological states of the victim and collection of samples. Previous studies showed an association between documented physical trauma and conviction but unfortunately, few studies in the recent literature analysed the factors that influence the legal outcome and final judgement. The present study focused on the elements that appeared of significance in the legal outcome, including medico-legal evaluation, source of the crime report and circumstance of the assault. METHODS: It was conducted a retrospective analysis of all the judgments issued by the Public Prosecutor's Office at a Court of a Metropolitan Italian city regarding sexual and domestic violence, from January 1st 2011 to 31st December 31st 2015. Examination regarded the demographic information of the victim and of the defendant, information on the crime, the circumstances of the aggression and medical information retrieved. Sentences were subsequently divided into two categories based on the legal outcome (conviction vs acquittal) and the different characteristics of the two sub-populations were compared to verify if there were variables significantly associated to the judge's final judgment. RESULTS: Over the 5 years taken into consideration, there have been 1342 verdicts regarding crimes of sexual violence (374 cases) and regarding abuses against family members or cohabitants (875): other 93 cases regarded both sexual violence and abuse. 66.3% ended in conviction of the offender and 33.7% in acquittal of the accused. Cases of conviction were more frequent when they involved: use of a weapon by the assailant, as well as if the assailant had a criminal record and had a history of drug abuse or other addictions; duration of proceeding less 22 months and a civil party involved; presence of clinical documentation together with other deposition in addition to victim's deposition; also frequent episodes of violence and application of precautionary measures were associated to conviction. CONCLUSIONS: Many factors seem able to influence the judge's judgment, although clearly each case must be singularly evaluated. The mere presence of medical documentation, without the support of other sources of evidence, such as the victim's statement or further declarations, however, is almost always not definitive for the verdict. Despite so, in cases where there are multiple sources of evidence, clinical documentation can provide useful elements and can give clues on the consistency between the history told and injuries observed.

Are cranial peri-mortem fractures identifiable in cremated remains? A study on 38 known cases.

Accurate identification and analysis of signs of trauma on human bone is one of the mainstays of forensic pathology. However, when a forensic pathologist has to deal with charred remains, the task become extremely difficult, because tissues are subjected to severe morphological alterations and their assessment can be critically distorted. We analyzed 38 individuals with peri-mortem skull fractures due to falls from height (17 cases), traffic accidents (16 cases), gunshots wounds (5 cases), of which we had the demographic and clinical data and the autopsy report with the description and photographic records of the fracture lines. After autopsy, the bodies were cremated in gas furnaces and the analysis of cremated cranial remains was conducted in order to verify if it was possible to reconstruct the original peri-mortem fractures and verify differences between known peri-mortem and post-mortem fractures. After 90 min and exposure to temperatures up to 1280 °C, in less than a third of cases (11-29%) the original peri-mortem fracture pattern could be found and reconstructed. The edges and the surface of the fractures can preserve their proper morphology, or they can be affected by post-mortem heat-induced fractures and deformations. Interestingly whenever peri-mortem fracture margins showed the evidence of yellow/brownish colouration, a matte appearance was observed, much different from post-mortem fractures, which may provide further food for thought for the identification of peri-mortem fractures after the cremation process.

Histomorphological aspects of cadaveric skin and its possible use in forensic genetics.

The skin is rarely considered as good biological material for successful DNA typing when a corpse is found in a leathery, mummified or partially skeletonised state, as bones and teeth are the gold standard in these cases. This study evaluates the histomorphological aspects of nuclear chromatin (Lillie's staining) in leathery and mummified skin samples as an indicator for possible successful DNA typing. Chromatin was found in samples that underwent mummification or partial skeletonisation but not in samples in a wet type of post-mortem transformation, such as saponification or leathery transformation. As a preliminary result, a positive detection of DNA profiles was only observed in 1-year-old mummified or partially skeletonised samples. These findings suggest that specific areas of skin, even from severely deteriorated cadavers, can show nuclear chromatin and DNA. These preliminary results raise the potential use of skin samples as an alternative source of DNA in highly degraded corpses.

Similarity and Differences in Sexual Violence Against Adolescents and Adult Women: The Need to Focus on Adolescent Victims.

STUDY OBJECTIVE: To explore whether there are differences in characteristics, clinical findings and management in cases of sexual violence in adolescent and adult women. DESIGN: Retrospective study. SETTING: SVSeD-Service for Sexual and Domestic Violence, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy. PARTICIPANTS: Female victims of sexual violence aged 10 years and older. Two study groups were analysed: an adolescent group and an adult group. INTERVENTIONS: None; this was an observational study. MAIN OUTCOME MEASURES: Characteristics of the perpetrator, time spent between the episode of sexual violence and the access to SVSeD, presence of genital and/or extragenital injuries; tests for sexually transmitted diseases, spermatozoa research; and toxicological screening; RESULTS: Adolescent victims of sexual violence requested help later than the adult victims. The majority of the perpetrators were well known to the victims in both groups. In both groups, we observed genital injuries in 1 of 3 patients. We found a strong association between the presence of genital injuries and a positive screening test for sexually transmitted diseases, in particular with regard to the adolescent victims. CONCLUSION: Adolescents' delayed disclosure of sexual violence may affect the ability to properly manage these crimes. Prevention programs and public awareness campaigns should be implemented to highlight the importance of a prompt disclosure after sexual assault has occurred. Gynecologists should be made increasingly aware of this delicate issue, to better assist victims of sexual violence, especially adolescent victims.

Multi-Rater Agreement Using the Adapted Fracture Healing Scale (AFHS) for the Assessment of Tubular Bones on Conventional Radiographs: Preliminary Study.

Better understanding of the timing of fracture healing may help in cases of interpersonal violence but also of personal identification. The intra- and inter-rater agreement for the adapted fracture healing scale (AFHS) assessing the post-traumatic time interval on radiographs were tested. This is a preliminary study, providing essential information on method reliability for upcoming studies using the AFHS. Five raters (two radiologists, a forensic pathologist, an orthopedist, and an anthropologist) were presented with a test in three parts consisting of 85 radiographs (from 30 adults) of fractures of tubular bones in different stages of healing purposefully selected from more than 1500 radiographs. The raters were firstly asked to assess 15 features describing fracture healing as present, absent, or not assessable. Thereafter, the raters were asked to choose from the AFHS a single-stage best representing the observed healing pattern. The intra- and inter-rater agreement were assessed using single-rating, absolute agreement, two-way mixed-effects intra-class correlation (ICC) coefficients. The intra-rater ICC of radiologist 1 ranged from 0.80 to 0.94. The radiologists' inter-rater ICC ranged from 0.68 to 0.74, while it ranged from -0.01 to 0.90 for the other raters. The good to excellent ICC among the radiologists and forensic anthropologist provides good foundation for the use of the AFHS in forensic cases of trauma dating. The poor to good results for the other physicians indicate that using the AFHS requires training in skeletal anatomy and radiology.

Can cadaverous pollution from environmental lead misguide to false positive results in the histochemical determination of Gunshot Residues? In-depth study using ultra-sensitive ICP-MS analysis on cadaveric skin samples.

INTRODUCTION: In a previous work, we wanted to evaluate if the histochemical determination of lead in Gunshot Residues (GSR) on firearm wounds could be misled due to possible environmental contamination produced by heavy metals and, in particular, by lead. The Sodium Rhodizonate test and its confirmation test with 5% HCl Sodium Rhodizonate resulted to be negative and therefore we wanted to verify if these techniques were sensible enough in order to evaluate this element. We have assessed, on these same samples, a more sensitive technique, as inductive coupled plasma mass spectrometry (ICP-MS) is. This technique is able to detect elements in solution at concentrations as low as 10-15gL-1. MATERIALS AND METHODS: Skin samples taken from two groups of victims, whose cause of death was not related to gunshot wounds were analyzed using ICP-MS: group A included 25 corpses found in open spaces after a long time; group B included 16 corpses exhumed after a period of 11 years. As a positive control group we used skin samples from two subjects that had died due to firearm wounds: as a negative control group we used three different types of plain paraffin slides without included biological material. RESULTS: At the analysis by ICP-MS, the evaluation of the samples belonging to groups A, B and for the negative control groups resulted to be negative for traces of lead (Pb), barium (Ba) and antimony (Sb). On the other hand, high concentrations of GSR could be found in the positive control group were victims died for firearm wounds. CONCLUSIONS: On these basis, we can state that environmental Pb does not contaminate cadavers exposed to open air nor those buried in soil, as confirmed using to ICP-MS technique. Sodium Rhodizonate and 5% HCl Sodium Rhodizonate confirmation test have therefore a high sensitivity, highlighting GSRs, for the diagnosis of death caused by firearm wounds.

Can cadaverous pollution from environmental lead misguide to false positive results in the histochemical determination of gunshot residues? Study on cadaveric skin samples.

Histochemical determination of lead in gunshot residues (GSR) raises the question of possible environmental contamination by heavy metals. Authors assess the specificity of the Sodium Rhodizonate Test in the search of lead derived from environmental pollution. Sodium Rhodizonate Test and 5% HCl Sodium Rhodizonate test were applied to skin samples taken from two groups of victims, whose cause of death was not related to gunshot wounds: group A included 25 corpses found in open spaces after a long time; group B included 16 corpses exhumed after a period of 11 years. The use of these histochemical tests to skin samples from these two groups did not show metal debris histochemically similar to the lead present in GSR. These tests were confirmed to be specific in highlighting the GSR coming from gunshot, without being affected by the potential environmental contamination of the heavy metal pollutants, coming from air or soil.

Sexual Violence Against Adolescent Girls: Labeling It to Avoid Normalization.

Violence against women is a pervasive complex phenomenon that destroys women's feelings of love, trust, and self-esteem. In this commentary, we specifically focus on sexual violence against adolescent girls, whose impact is particularly harmful since it may lead to impaired mental health, social functioning, and neurodevelopment. Between 12% and 25% of adolescent girls throughout the world experience sexual violence, very often perpetrated by a family member or a friend. Moreover, for an alarming proportion of girls, the first sexual experience is coerced. In this article, we review the multiple negative effects of sexual violence against adolescent girls. We also report data derived from our practice in a public Italian referral Centre for Sexual and Domestic Violence (SVSeD) and address the importance of a multidisciplinary clinical approach with adolescent victims of sexual violence.

Analysis of metallic medical devices after cremation: The importance in identification.

The recovery of a charred cadaver raises many issues concerning personal identification; the presence of prosthetic materials may provide very important and decisive information. Who is involved in the recovery of a charred body or of burnt human fragments, should therefore be able to recognize medical devices even if modified by fire effects. Metallic residues (585kg) that came from 2785 cremations were studied. Medical devices were then divided by type and material in order to esteem the representativeness of each typology. The study illustrates the great presence of metal medical devices that could be of great help in identifying bodies and underlines that metallic medical devices types and morphology should be known by forensic practitioner involved in identification cases and that this kind of material can still be identified by physician and dentists, even if exposed to very high temperatures.

The Issue of Age Estimation in a Modern Skeletal Population: Are Even the More Modern Current Aging Methods Satisfactory for the Elderly?

The main idea behind age assessment in adults is related to the analysis of the physiological degeneration of particular skeletal structures with age. The main issues with these procedures are due to the fact that they have not been tested on different modern populations and in different taphonomic contexts and that they tend to underestimate the age of older individuals. The purpose of this study was to test the applicability and the reliability of these methods on a contemporary population of skeletal remains of 145 elderly individuals of known sex and age. The results show that, due to taphonomic influences, some skeletal sites showed a lower survival. Therefore, the methods with the highest percentage of applicability were Lovejoy (89.6%) and Rougé-Maillart (81.3%), followed by Suchey-Brooks (59.3%), and those with the lowest percentage of applicability were Beauthier (26.2%) and Iscan (22.7%). In addition, this research has shown how for older adults the study of both acetabulum and auricular surface may be more reliable for aging. This is also in accordance with the fact that auricular surface and the acetabulum are the areas more frequently surviving taphonomic insult.

Study on the criteria for assessing skull-face correspondence in craniofacial superimposition.

Craniofacial superimposition has the potential to be used as an identification method when other traditional biological techniques are not applicable due to insufficient quality or absence of ante-mortem and post-mortem data. Despite having been used in many countries as a method of inclusion and exclusion for over a century it lacks standards. Thus, the purpose of this research is to provide forensic practitioners with standard criteria for analysing skull-face relationships. Thirty-seven experts from 16 different institutions participated in this study, which consisted of evaluating 65 criteria for assessing skull-face anatomical consistency on a sample of 24 different skull-face superimpositions. An unbiased statistical analysis established the most objective and discriminative criteria. Results did not show strong associations, however, important insights to address lack of standards were provided. In addition, a novel methodology for understanding and standardizing identification methods based on the observation of morphological patterns has been proposed.