Streptococcus Pneumoniae Detection Long Time After Death in a Fatal Case of Waterhouse-Friderichsen Syndrome.

We report a fatal case of Waterhouse-Friderichsen syndrome in a 64-year-old man. The diagnosis, suspected during the autopsy (performed 63 hours after death), was confirmed through the successful detection of Streptococcus pneumoniae DNA and antigens in samples (blood and liver) collected during the autopsy. These results conformed with blood cultures performed antemortem, which became available only the day after the autopsy. The case underlines the need to collect biological material (liver and blood samples) during autopsy for microbiological investigations, although the collection is performed a long time after the death, suggesting that a liver sample works for DNA and liver and blood work for Streptococcus pneumoniae antigen detection.

Standard of care and guidelines in prevention and diagnosis of venous thromboembolism: medico-legal implications.

Concerning recent Italian laws and jurisprudential statements, guidelines application involves several difficulties in clinical practice, regarding prevention, diagnosis and therapy of venous thromboembolism. International scientific community systematically developed statements about this disease in order to optimize the available resources in prophylaxis, diagnosis and therapy. Incongruous prevention, missed or delayed diagnosis and/or inadequate treatment of this disease can frequently give rise to medico-legal litigation.

Hanging Deaths: A Retrospective Study Regarding 260 Cases.

Hanging is a form of asphyxia caused by external pressure on the upper airways deriving from a band tightened by the gravitational weight of the body. During a 33-year period from 1983 to 2015, there were 260 hanging deaths examined at the Brescia Institute of Forensic Medicine (Northern Italy), which represented approximately 40% of all the asphyxial deaths recorded during this period. Almost all of the cases were represented by suicidal events, 1 case was a homicide event and there also was a case of sexual asphyxia. Eighty-two percent of the victims were men; 18% were women. There was an increasing tendency in the ages between 20 and 60 years, and the highest number of cases was observed in the 41- to 50-year age group (23% of the cases). The most common place chosen by the victim was the home setting followed by isolated outdoor places. The most common ligature material was a rope. The pathological findings were evaluated in all cases.

REDUCTION OF VITREOUS PROSTAGLANDIN E2 LEVELS AFTER TOPICAL ADMINISTRATION OF INDOMETHACIN 0.5%, BROMFENAC 0.09%, AND NEPAFENAC 0.1.

PURPOSE: To assess vitreous concentrations of nonsteroidal anti-inflammatory drugs (NSAIDs) and prostaglandin E2 (PGE2) in patients treated with NSAIDs before vitrectomy for macular pucker. METHODS: A prospective, investigator-masked, randomized study was performed in 64 patients scheduled to undergo vitrectomy. The patients were randomized 1:1:1:1 to receive indomethacin 0.5%, bromfenac 0.09%, nepafenac 0.1%, or placebo three times a day. NSAIDs and PGE2 levels were evaluated in vitreous samples collected at the beginning of surgery. RESULTS: Mean (SD) vitreous concentrations of the study drugs were 503.13 (241.1) pg/mL for indomethacin, 302.5 (91.03) pg/mL for bromfenac, and 284.38 (128.2) pg/mL for nepafenac. Mean (SD) vitreous PGE2 levels were 247.9 (140.9) pg/mL for indomethacin, 322.12 (228.1) pg/mL for bromfenac, 448.8 (261.1) pg/mL for nepafenac, and 1,133 (323.9) pg/mL for placebo. All three NSAIDs reduced vitreous PGE2 levels to a statistically significant extent, without a significant difference among them. CONCLUSION: All assessed NSAIDs penetrated the vitreous and lowered basal PGE2 levels. A greater penetration was associated with pseudophakic eyes. The important inhibition of prostaglandins in the retina may have a clinical effect on the management of inflammatory retina diseases.

An autopsy study of sudden cardiac death in persons aged 1-40 years in Brescia (Italy).

INTRODUCTION: Sudden cardiac death (SCD), above all when occurring in young people, remains a major clinical problem. We have analysed the clinical and post mortem findings of patients who were evaluated for SCD. METHODS AND RESULTS: We have analysed 54 cases of SCD which occurred in patients aged below 40 years during the period 1993-2012 and were studied at the Institute of Forensic Medicine of Brescia. The following variables were considered: sex, age, medical history, autopsy findings with special reference to macroscopic and histological evaluation of the heart and toxicological investigation. In all cases, we also performed the dissection of the cardiac conduction tissue with subsequent serial sampling and careful microscopic evaluation.Most SCD patients were men (76%), with a mean age of 27 years. The results of post mortem investigations have identified the following abnormalities: coronary artery disease (18.5%), arrhythmogenic right ventricular dysplasia (11.1%), hypertrophic obstructive cardiomyopathy (9.2%), severe valvular heart disease (7.4%) and myocarditis (7.4%). A case of persistence of the inter-atrial communication with cardiomegaly and right and left ventricular hypertrophy was also reported. Examination of the cardiac conduction tissue showed abnormalities in 12 cases (22.2%), in whom the heart was structurally normal at macroscopic examination. Despite all the investigations carried out, any pathogenic substrate that could have justified death was not found in 12 cases (22.2%). CONCLUSION: Our study underlines the value of an accurate routine post mortem investigation that may show an otherwise unsuspected structural heart disease. The serial study of the conduction tissue may provide pathologic substrates that may be responsible for the arrhythmic cause of death. A meaningful percentage of cases (22%) had no evidence of any abnormality. Genetic testing can be indicated in these cases.

Ethyl glucuronide in vitreous humor and blood postmortem specimens: analysis by liquid chromatography-electrospray tandem mass spectrometry and interpreting results of neo-formation of ethanol.

INTRODUCTION: The determination of ethyl glucuronide (EtG), a stable and sensitive marker that is specific to alcohol intake, finds many applications both in the forensic toxicology and clinical fields. AIM: The aim of the study is to examine the possibility of using a cadaveric biological matrix, vitreous humor (VH), to determine EtG as a marker of recent ethanol use. METHODS: The blood, taken from the femoral vein, and the VH were obtained from 63 autopsy cases. Analysis of the EtG was performed using an LC/MS/MS system. Analyses of the ethanol and putrefaction biomarkers, such as acetaldehyde and n-propanol, were performed using the HS-GC/FID technique in both the matrices. RESULTS: In 17 cases, both ethanol and EtG were absent in both matrices.Nineteen cases presented ethanol in blood from 0.05 to 0.30 g/L, EtG-Blood concentration from 0.02 to 3.27 mg/L, and EtG-VH concentration from 0.01 mg/L to 2.88 mg/L. Thirteen cases presented ethanol in blood > 0.05 g/L but EtG concentration in blood and VH lower than 0.01 mg/L, are part of these 8 samples presented acetic aldehyde and n- propanol in blood or VH, means identification of putrefaction indicators. Fourteen cases presented ethanol in blood > 0.46 and EtG concentration in blood and VH higher than 0.01 mg/L. CONCLUSIONS: The determination of EtG in biological material is important in those cases where the intake of ethanol appears doubtful, as it allows us to exclude the possibility of any post-mortem formation of ethanol.

Hydranencephaly in a case of suspected infanticide.

An abandoned fetus with suspicious skin injuries was found dead, lying on the grass of a garden, near a private house. Suspecting infanticide, the prosecutor ordered a medico-legal autopsy. The cause of death was identified as a congenital malformation of the central nervous system such as hydranencephaly, and infanticide was excluded.

Homicide-suicide in Brescia County (Northern Italy): a retrospective study from 1987 to 2012.

From January 1987 to December 2012, 19 homicide-suicide events were registered at the Brescia Institute of Forensic Medicine (Northern Italy), leading to 39 deaths (20 homicide victims and 19 suicide victims). The homicide victims were females in the total of the cases (100%), while perpetrators were exclusively males (100%). Only one event involved foreigners as both victim and perpetrator, all the other cases regarded Italian people. The average age was 37.3 years for the homicide victims and 41.57 years for the offenders. Perpetrators usually used a firearm both for murder (65%) and suicide (84%). In 66% of the cases the homicide-suicide events occurred at home; homicide victims were strictly bound to their perpetrators (husband, boyfriend or ex boyfriend, father) in all the events.

Sharp force injury fatalities: a retrospective study (1982-2012) in Brescia (Italy).

A retrospective study was carried out on postmortem examination data of 131 sharp force-related casualties recorded by the Brescia Institute of Forensic Medicine between 1982 and 2012. The objective was to identify relevant parameters that may be used to distinguish the manner of deaths between homicide, suicide, and accident. The following variables were considered: manner of death; demographic data; scene; type of sharp object; location and numbers of wounds; the presence of hesitation marks/defense wounds; toxicological findings; psychiatric history. There were 92 homicides, 28 suicides, and 11 accidents. Most victims were male, with an average age of 43. Injuries in isolation were present in 9.8% of homicides, in 35.7% of suicides, and in 54.5% of accidents. Most injuries involved the left anterior chest in homicides and the forearms in suicides. This study underlines the importance of a meticulous postmortem examination of injuries on the body and their relationship with other results from the death scene investigation.

Homicide in Brescia County (Northern Italy): a thirty-year review.

This retrospective study analyses post-mortem examination data of 251 homicide victims recorded by the Brescia Institute of Forensic Medicine between the years 1982 and 2012. The following variables were considered: year, month and day of death; gender, age and nationality of the victim; type of injurious mean; cause of death; homicide-suicides events; multiple murders; scene of death; toxicological data. Victims were usually young (30% was in the 21-30 years class) and males (64%). Although the victims were mostly Italians (73%), from 1990's more and more foreign victims appeared, following the migratory flow that affected Brescia County. The offenders frequently used firearms to kill their victims (41%), in particular for multiple murders. Sharp instruments were used mostly by foreigners. The study also emphasized 20 homicide-suicide events, mostly committed between intimates and family members.

Homicide by blunt trauma in Brescia county (northern Italy) between 1982 and 2012.

Blunt force injuries are produced by a variety of objects, including hands and feet (which is human strength) and many different weapons. Some of these objects produce distinctive patterns of injury of potential evidentiary value. This article presents a series of 53 homicides by blunt trauma along the period from 1982 to 2012, representing 16% of all homicides treated by the University Institute of Forensic Medicine in Brescia (northern Italy). Fifty-seven percent (30 cases) of the victims were male. The mean age of the victims was 47.9 years. The weapon most frequently involved was human strength. Not surprisingly, head trauma was the most common cause of death (66%). Forty-seven percent (25 cases) of the victims survived their assaults for varying periods. Homicides due to blunt trauma are still a relevant challenge for the forensic pathologist, who must obtain a complete and accurate history of the crime (including details regarding the crime scene), interpret patterns of injury and other findings at autopsy, and correlate all of the findings to make an accurate ruling of the cause and manner of death.

Age-at-death estimation in Caucasian females from the morphological analysis of the sternal end of the fourth rib.

The morphology evaluation of the sternal end of the fourth rib through the Iscan's "phases method" is considered one of the most reliable method for age-at-death estimation of corpses of unknown identity. This study aims to develop a component model for age estimation alternative to Iscan's method. A numerical score, ranging from 3 to 9, was assigned based on the morphology of surface (S), antero/posterior walls (W) and articular margins (M) of the sternal end of the fourth rib in 71 white female corpse. For each component a regression formula was determined. The best correlation between end rib morphology and age-at-death was obtained through the formula of multiple regression with two independent variables (articular surface and antero/posterior walls): Age (years)=6.37(S)+5.33(W)-17.15±3.3.

HIV-positive status and preservation of privacy: a recent decision from the Italian Data Protection Authority on the procedure of gathering personal patient data in the dental office.

The processing of sensitive information in the health field is subject to rigorous standards that guarantee the protection of information confidentiality. Recently, the Italian Data Protection Authority (Garante per la Protezione dei Dati Personali) stated their formal opinion on a standard procedure in dental offices involving the submission of a questionnaire that includes the patient's health status. HIV infection status is included on the form. The Authority has stated that all health data collection must be in accordance with the current Italian normative framework for personal data protection and respect the patient's freedom. This freedom allows the patient to decide, in a conscious and responsible way, whether to share health information with health personnel without experiencing any prejudice in the provision of healthcare requested. Moreover, data collection must be relevant and cannot exceed the principles of treatment goals with reference to the specific care of the concerned person. However, the need for recording information regarding HIV infection at the first appointment, regardless of the clinical intervention or therapeutic plan that needs to be conducted, should not alter the standard protection measures of the healthcare staff. In fact, these measures are adopted for every patient.

Agalactorrhoea following reductive mastoplasty: a case of permanent impairment evaluation.

A woman of fertile age who had been suffering from agalactorrhoea since undergoing reductive mastoplasty was referred to us for forensic evaluation. As the impairment rating criteria listed within the main Italian assessment guidelines did not provide us with any helpful clues, we turned our attention to a selection of French, Spanish and Portuguese rating tables either legally binding or merely indicative in nature, to the barème (table) formulated by the CEREDOC (Confédération Européenne d'Experts en Evaluation et Réparation du Dommage Corporel) and to the American Medical Association guidelines, the only ones contemplating rating criteria specific for agalactorrhoea with an impairment score range of 0-5 percentage points. In light of the woman's young age and in subsequent consideration of the implications agalactorrhoea typically has both for nursing mothers and for their newborn babies, we estimated her physical impairment at five percentage points.

Age estimation from the rib by components method analysis in white males.

Changes at the sternal extremity of the fourth rib have already been established as reliable indicators of age at death. Still now, the Iscan "phase method," based on the morphologic changes at the sternal extremity of the fourth rib, is one of the best effective for age estimation at death. The present study was carried out to develop an alternative method considering the morphologic characteristics of articular surface (A), anterior/posterior walls (B), and superior/inferior edges (C) of the sternal extremity of the fourth rib. For each parameter a numerical score was assigned and some regression formulae was elaborated. The best correlation between morphologic characteristics and age was obtained through the formula Age = 10.43 (AB)(0.53). The sample consisted of sternal extremities of the fourth rib obtained at autopsy from 49 white males of known age.

Firearm-related deaths in Brescia (Northern Italy) between 1994 and 2006: a retrospective study.

This retrospective study analyzes post-mortem examination data of 164 firearm-related casualties recorded by the Brescia, Italy Institute of Forensic Medicine between the years 1994 and 2006. The following variables were considered: year, month and day of death, gender and age of the victim, manner of death (homicide, suicide, accidental), type of weapon used, anatomical site and number of wounds, scene of death, and, whenever requested by the local District Attorney's Office, results of the toxicological examinations conducted on the corpses of the deceased. In the County of Brescia, Italy, the 2006 firearm-related mortality rate amounted to 0.84 per 100,000 residents, with an average of 12.6 cases per year. The most common manner of death was suicide (60.4%), followed by homicide (35.9%) and accidental death (3.7%). Most victims were male, with an average age of 47.2 in cases of suicide, 37.9 in cases of homicide, and 47.5 in cases of accidental death. Considering all of the death manners contemplated in this study, the weapon types most frequently resorted to were single-action, short-barrelled guns, followed by multiple-action, long-barrelled ones. In cases of suicide, entry wounds were primarily situated on the head (right temple) and chest (precordium), while in cases of homicide no conclusions could be drawn as to the entry wounds' predominant location.

Population data for 15 autosomal STRs loci and 12 Y chromosome STRs loci in a population sample from the Sardinia island (Italy).

One hundred twenty-five unrelated individuals (69 females and 56 males) from Sassari (Northern Sardinia) and Orgosolo (Central Sardinia) were typed for 15 STRs loci. The 56 males were typed for 12 Y chromosome STRs loci too. Frequency distribution is described.

X-chromosome polymorphism on DXS8378, DXS7132, HPRTB and DXS7423 loci in 130 individuals from Brescia (northern Italy).

One hundred and thirty unrelated individuals (80 females and 50 males) from Brescia (northern Italy) were typed for DXS8378, DXS7132, HPRTB and DXS7423 loci. Allele, genotype and haplotype frequencies were calculated. A comparison between our population data and others from Caucasians and Asians populations was performed.

Population data for 12 Y-chromosome STRs in a sample from Brescia (northern Italy).

Twelve Y-chromosome STRs--DYS19, DYS389-I, DYS389-II, DYS390, DYS391, DYS392, DYS393, DYS385, DYS437, DYS438, DYS439--were typed in a population sample (n=104) of unrelated males from Brescia (northern Italy). A total of 91 haplotypes were identified by the 12 Y-STR loci. The haplotype diversity (98.68%), discrimination capacity (87.50%) and gene diversity were calculated.