Negative Outcomes of Blepharoplasty and Thyroid Disorders: Is Compensation Always Due? A Case Report with a Literature Review.

BACKGROUND: Plastic surgery is one of the medical specialties with the highest risk of recurrent medical malpractice claims. The frequency of civil lawsuits represents an issue for the micro- and macro-economy of practitioners of these health treatments. This paper aims to discuss the medico-legal aspects and claim path in a case of a cosmetic blepharoplasty complicated by lagophthalmos wrongly related to the procedure but due to missed hyperthyroidism. CASE DESCRIPTION AND LITERATURE REVIEW: A 48-year-old woman who underwent cosmetic blepharoplasty with undiagnosed hyperthyroidism claimed that the lagophthalmos that occurred some months after the procedure was due to medical malpractice, due to an over-resection of the exuberant lower eyelid tissue. The review question was, "Are thyroid disfunctions usually considered contraindications to be communicated to patients who undergo blepharoplasty?", and the databases MEDLINE via PubMed, Embase, Scopus, Ovid, ISI Web of Science, Cochrane, and Google Scholar were used. RESULTS AND DISCUSSION: There were 21 eligible papers. The case highlights the importance and complexity of causal inference (such as unknown thyroid dysfunctions), related informed consent involving information on possible complications unrelated to malpractice, and guidelines recommending endocrinological consultation for cosmetic/functional blepharoplasty in patients at risk (e.g., female patients with a known history of thyroid disease).

Biomarkers of traumatic brain injury in vitreous humor: A pilot study.

BACKGROUND: Traumatic brain injury (TBI) is one of the major causes of morbidity and mortality worldwide. The patients' and injuries' heterogeneity associated with TBI, alongside with its variable clinical manifestations, make it challenging to make diagnosis and predict prognosis. Therefore, the identification of reliable prognostic markers would be relevant both to support clinical decision-making and forensic evaluation of polytraumatic deaths and cases of medical malpractice. This pilot study aimed to evaluate some of the main biomarkers specific for brain damage in sTBI and mmTBI deaths in samples of vitreous humor (VH) in order to verify whether predictors of prognosis in TBI can be found in this matrix. METHODS: VH were obtained from both eyes (right and left) of 30 cadavers (20 sTBI and 10 mmTBI) and analysed. These factors were evaluated: NSE (neuron-specific enolase), S100 calcium-binding protein (S100), glial fibrillary acidic protein (GFAP), Brain-derived neurotrophic factor (BDNF), Copeptin, Interleukin 6 (IL-6), Ferritin, Lactate dehydrogenase (LDH), C-Reactive Protein (CRP), Procalcitonin (PCT), Glucose and Neutrophil gelatinase-associated lipocalin (N-Gal). RESULTS: Four of the analysed proteins (LDH, ferritin, S100 and NSE) proved to be particularly promising. In particular, logistic regression analysis found a good discriminatory power. CONCLUSIONS: Given the peculiarity of the matrix and the poor standardization of the sampling, such promising results need to be furtherly investigated in serum before being implemented in the forensic practice.

A Semi-Automatic Method on a Small Italian Sample for Estimating Sex Based on the Shape of the Crown of the Maxillary Posterior Teeth.

Teeth are known to be reliable substrates for human identification and are endowed with significant sexual dimorphism not only in the size but also in the shape of the crowns. In the preliminary phase of our study (already published in 2021), a novel sex estimation method based on dental morphometric geometric (GMA) analysis combined with the artificial neural network (ANN) was developed and validated on a single dental element (first upper premolar) with an accuracy rate of 80%. This study aims to experiment and validate the combination of GMA-ANN on the upper first and second left premolars and the upper left first molar to obtain a reliable classification model based on the sexual dimorphic traits of multiple maxillary teeth of Caucasian Italian adults (115 males and 115 females). A general procrustes superimposition (GPS) and principal component analysis (PCA) were performed to study the shape variance between the sexes and to reduce the data variations. The "set-aside" approach was used to validate the accuracy of the proposed ANN. As the main findings, the proposed method correctly classified 94% of females and 68% of males from the test sample and the overall accuracy gained was 82%, higher than the odontometric methods that similarly consider multiple teeth. The shape variation between male and female premolars represents the best dimorphic feature compared with the first upper molar. Future research could overcome some limitations by considering a larger sample of subjects and experimenting with the use of computer vision for automatic landmark positioning and should verify the present evidence in samples with different ancestry.

A Survey on forensic odontologists' activity in Italy during the COVID-19 pandemic.

Few information on virus contagion at the beginning of the covid-19 pandemic led to severe restrictions in the dental and forensic activity in Italy, the introduction of procedural guidelines and implementation of preventive measures. A specific survey on Italian forensic odontologists (FOds) activity was conducted to investigate the COVD-19 pandemic impact on daily practices, the preventive measures adopted to manage the risks of contagion procedures performed on living and dead people and the possible peculiar cases that required the intervention of a medical examiner. A total of 122 FOds answered, mostly males over 46 years coming from northern Italy. The results highlight the lack of specific guidelines for the procedures on living people compared to those on the dead but the regulations for the daily clinical practice resulted more than sufficient: in fact, more than 80% of FOds adopted the preventive and safety measures provided for dental practices. The forensic activity significantly decreased during the initial period (more than 75%) and gradually normalized to pre-pandemic numbers in approximately 50% of cases after the implementation of the vaccination campaign. 13 cases of occupational contagion have been reported, most of them (more than 85%) in northern and central Italy. In two cases members of the dental staff sued the employer for responsibility in the contagion. The decrease of the overall ID activity during the pandemic time can be more likely attributed to the of the dental data than the real impact of the pandemic regulations. The use of telematic tools, such as teleconferences, for many procedures proved to be an important resource useful for application even in post-pandemic times.

Third molar maturity index (I3M) assessment according to different geographical zones: a large multi-ethnic study sample.

Identification of living undocumented individuals highlights the need for accurate, precise, and reproducible age estimation methods, especially in those cases involving minors. However, when their country of origin is unknown, or it can be only roughly estimated, it is extremely difficult to apply assessment policies, procedures, and practices that are accurate and child-sensitive. The main aim of this research is to optimize the correct classification of adults and minors by establishing new cut-off values for four different continents (Africa, America, Asia, and Europe). For this purpose, a vast sample of 10,701 orthopantomographs (OPTs) from four continents was evaluated. For determination and subsequent validation of the new third molar maturity index (I3M) cut-off values by world regions, a cross-validation by holdout method was used and contingency tables (confusion matrices) were generated. The lower third molar maturity indexes, from both left and right side (I3ML and I3MR) and the combination of both sides (I3ML_I3MR) were calculated. The new cut-off values, that aim to differentiate between a minor and an adult, with more than 74.00% accuracy for all populations were as follows (I3ML; I3MR; I3ML_I3MR, respectively): Africa = (0.10; 0.10; 0.10), America = (0.10; 0.09; 0.09), Asia = (0.15; 0.17; 0.14), and Europe = (0.09; 0.09; 0.09). The higher sensitivity (Se) was detected for the I3ML for male African people (91%) and the higher specificity (Sp) of all the parameters (I3ML; I3MR; I3ML_I3MR) for Europeans both male and female (> 91%). The original cut-off value (0.08) is still useful, especially in discriminating individuals younger than 18 years old which is the goal of the forensic methods used for justice.

Dental DNA as an Indicator of Post-Mortem Interval (PMI): A Pilot Research.

Teeth have proven to be a reliable source of DNA for forensic analysis as the pulp is rich in cells and protected from damaging factors and contamination by dental hard tissues. The pilot study aims to evaluate the feasibility of Next-Generation sequencing analysis on dental pulp to detect genetic mutations in DNA caused by post-mortem cell necrosis. We used a 56-gene oncopanel kit on a sample of 17 teeth extracted from living patients. Time of the tooth avulsion was assumed as death of the individual and Post-mortem Interval (PMI) was the time elapse since the DNA extraction and analysis. Days and Accumulated Degree Days (ADD) were assumed as measures of PMI that ranged between 0 to 34 days. Only 38 of the 56 considered genes proved to be affected by mutations (101), thus being of forensic interest. More specifically, 14 mutations occurred only in a specific range of PMIs/ADD; 67 were detected (alone or as clusters of the same gene) at specific PMI/ADD; 22 occurred at every PMI/ADD, except for some specific intervals. Since dental pulp was not targeted by any oncological diseases and all teeth were intact, vital, and from patients with unremarkable medical history, it could be assumed that mutations were due to post-mortem DNA changes induced by pulp death and the increasing time elapse since death. This pilot study found encouraging results in the application of NGS analysis on dental DNA, especially for PMIs of several days for which the traditional tools for PMI estimation have limitations. Further research on a larger sample of PMI and validation research on a larger sample of PMI and validation of the results are indeed necessary.

Trend in 167 cases of minors witnessing violence: The role played by COVID-19 pandemic.

Background: There currently is no evidence that COVID-19 has had an impact on the rates of psychological abuses occurring when a minor witnesses interpersonal violence. Aim: Our aim was to describe the accesses of the last four years to the Emergency Department of a tertiary hospital (Careggi University Hospital-Florence, Italy) due to this issue and then to evaluate whether the COVID-19 has had an impact on this trend. Methods: We collected data regarding cases of abuse in which at least a minor had reportedly witnessed the event. Medical records stored between January 1, 2018 to January 1, 2022 were analyzed, extracting sex, age and nationality of the victim; sex of the perpetrator and relationship with the victim; known previous episodes of abuse in the medical history of the victim; setting of the abuse (domestic vs. non-domestic); type of abuse (physical, psychological, sexual); whether the perpetrator was under the influence of alcohol/drugs; whether the victim was hospitalized; prognosis of the victim; number, relation with the victim and involvement in the abuse (as co-victim) of the minor(s) who witnessed the abuse. Results: A total of 167 eligible cases were registered. 69% of victims had previous episodes of abuse. The perpetrators were all known and mainly males (96%).The abuses were mainly domestic (79%). In 74% of the cases only a type of violence was perpetrated. In 12% of the cases, the minors were also victims of physical abuse. No statistically significant relationships were found between the start of the COVID-19 pandemic and the changes in the number of cases of domestic abuse (p = 0.07), physical abuse (p = 0.62), psychological abuse (p = 0.83) or sexual abuse (p = 0.88). However, during the institutional lockdown in Italy (March-May 2022) only two cases occurred - a number that did not allow period-specific statistical inference. Conclusions: Empowering the hospital policies specifically aimed at identifying and protecting the victims of violence/witnessed violence remains a critical goal from both a public health and medico-legal point of view.

Eye-opening in brain death: A case report and review of the literature.

Background: According to Italian law, brain death is diagnosed when the patient is in a coma, showing the absence of respiratory drive under specific clinical conditions, and without any brain stem reflexes. On the other hand, presence of spinal reflexes, when correctly identified, does not hamper the diagnosis. Case report: We present a case of eyelid elevation two seconds after thoracic pain stimulation in a patient who otherwise fulfilled all clinical and instrumental brain-death criteria due to a residual preserved function of the superior cervical ganglion. Conclusion: Although the observed reflex is to be considered extracerebral, and therefore it should not hamper the diagnosis of BD, the authors propose implementing cerebral flow evaluation, considered "prudential", as a preliminary assessment before determining BD.

Tortures alleged by migrants in Italy: compatibility and other medicolegal challenges.

BACKGROUND: Illegal immigration to Europe is a well-known phenomenon whose numbers are being steadily increasing in recent years. Most of the immigrants in Italy come from war zones, and many of them submit an asylum application supported by the complaint to have been victims of persecutory acts in their home countries. MATERIAL AND METHODS: One hundred ninety-six medicolegal reports are analyzed considering the different country of origin, the type of the lesions claimed, tools used, evidenced effects, location of the perpetration of the physical abuses, and the possible motivation of the alleged torture. RESULTS: Greater than 80% of the assessed asylum seekers are over 18-year males coming from African countries. Fifty-eight percent of migrants were tortured or abused in countries of transit, 95% in Libya. Economic, familial, politic, and ethnic reasons prevail in some countries of origin, while tortures or abuses perpetrated in transit countries are mainly linked to forced labor and detention. In the 42.2% of cases, no physical evidence of tortures was detected. The Istanbul Protocol resulted to have been only partly applicable and about 40% of the medicolegal reports are "inconclusive" about the compatibility of physical evidence with the alleged tortures. CONCLUSIONS: The medicolegal and forensic experts involved in torture and ill-treatment cases should seek specific education and training to lower the risks of underestimation and the rate of inconclusive reports. More extensive implementation of the Istanbul Protocol in daily practice should be pursued by the authorities in charge of asylum or protection releasement.

Three-Dimensional Dental Analysis for Sex Estimation in the Italian Population: A Pilot Study Based on a Geometric Morphometric and Artificial Neural Network Approach.

Dental dimorphism can be used for discriminating sex in forensic contexts. Geometric morphometric analysis (GMA) allows the evaluation of the shape and size, separately, of uneven 3D objects. This study presents experiments using a novel combination of GMA and an artificial neural network (ANN) for sex classification, applied to premolars of Caucasian Italian adults (50 females and 50 males). General Procrustes superimposition (GPS) and the partial least square (PLS) method were performed, respectively, to study the shape variance between sexes and to eliminate landmark variations. The "set-aside" approach was used to assess the accuracy of the proposed neural networks. As the main findings of the pilot study, the proposed method applied to the first upper premolar correctly classified 90% of females and 73% of males of the test sample. The accuracy was 0.84 and 0.80 for the training and test samples, respectively. The sexual dimorphism resulting from GMA was low, although statistically significant. GMA combined with the ANN demonstrated better sex classification ability than previous odontometric or dental morphometric methods. Future research could overcome some limitations by considering a larger sample of subjects and other kinds of teeth and experimenting with the use of computer vision for automatic landmark positioning.

Dental age estimation in children affected by juvenile rheumatoid arthritis.

Dental root calcification has proven to be a reliable biological evidence to estimate chronological age of children. The development of structures usually examined in the age estimation forensic practice (e.g. skeleton, teeth) is supposed to be influenced by diseases and nutritional, environmental, ethnic, and ultimately even socioeconomic factors. This research aims to study the age estimation in children affected by juvenile rheumatoid arthritis (JRA) with and without steroids treatment and compared with healthy subjects. MATERIAL AND METHODS: Dental age estimations based on 752 OPGs, 420 girls and 332 boys, aged from 3.3 to 15.99 years, were provided by applying Demirjian and Willems' original methods. Of the whole sample, 103 individuals were affected by JRA and 40 received a continuous corticosteroid therapy, over 1 year long. CONCLUSIONS: Willems' and Demirjian's original methods, as methods commonly applied to estimate age for sub-adults with unremarkable medical history, can be used for medico-legal purposes to children affected by JRA. Willems' method tended to underestimate age while Demirjian's method resulted to be prone to overestimation for both healthy and JRA-affected children. JRA showed to have no influence on root calcification process even in children that received steroid treatment for 1 year or longer.