Suitability of electroencephalography in brain death determination: a monocentric, 10-year retrospective, observational investigation of 428 cases.

BACKGROUND: We aimed to verify the usefulness of electroencephalographic (EEG) activity recording (that is mandatory according to the Italian law), in addition to two clinical evaluations spaced 6 h, among the procedures of brain death determination (BDD) in adult individuals. METHODS: The study is a monocentric, retrospective analysis of all BDDs performed in the last 10 years at Policlinico Le Scotte in Siena (Italy). RESULTS: Of the 428 cases revised (mean age 67.6 ± 15.03 years; range 24-92 years), 225 were males and 203 females. In total, 212 out of 428 patients (49.5%) were donors. None of the BDD procedures were interrupted due to the reappearance of EEG activity (neither for clinical reasons) at any sampling time, with the exception of one case that was considered a false negative at critical reinspection of the EEG. In 6/428 cases (1.4%), a cardiac arrest occurred during the 6 h between the first and second evaluation, thus missing the opportunity to take organs from these patients because the BDD procedure was not completed. CONCLUSIONS: Once the initial clinical examination before convening the BDD Commission has ascertained the absence of brainstem reflexes and of spontaneous breathing, and these clinical findings are supported by a flat EEG recording, the repetition of a 30-min EEG twice over a 6 h period seems not to add additional useful information to clinical findings. Current data, if confirmed in other centers and possibly in prospective studies, may help to promote a scientific and bioethical debate in Italy, as well as in other countries where the EEG is still mandatory, for eventually updating the procedures of BDD.

Cannabis and Driving: Developing Guidelines for Safety Policies.

INTRODUCTION: The dynamism in the regulatory frameworks concerning the consumption of cannabinoids has placed their effects on cognitive and psychomotor skills at the center of the scientific debate. In consideration of the potential repercussions on public safety, particular attention has been focused on the impairment of driving skills, opening up the need to specifically regulate driving under the effects of cannabinoids. PHARMACOKINETICS: Both native cannabinoids and metabolites show a long positivity at low concentrations in the biological fluids, especially in the case of chronic consumption. Qualitative positivity to cannabinoids does not itself prove the presence of detrimental effects, which require the presence of active substances at relevant concentrations. Driving Skill Impairment: Multiple studies highlight a tetrahydrocannabinol (THC) concentration- based alteration of driving skills mainly affecting automatisms, whereas skills subjected to cognitive control are preserved up to higher dosages. The evidence relating to associations with other substances, chronic consumption and other cannabinoids, on the other hand, is still burdened by a high degree of uncertainty. Regulation Policies: Different models can be adopted in the regulation of driving under the effects of cannabinoids: sanctions can be applied in case of qualitative positivity, cannabinoids concentration above a defined threshold, or in presence of a demonstrated state of cognitive alteration. CONCLUSION: "Per se limit" with a quantitative THC cut-off between 3.5 and 5 ng/ml can currently be considered the most balanced choice. Finally, the analysis carried out allowed to identify pitfalls in both scientific and legislative fields for the improvement of safety policies.

How long can SARS-CoV-2 persist in human corpses?

We report the finding of the SARS-CoV-2 genome in the corpse of an exhumed infected person, one month after her death. The viral gene targets were still present in her lungs and heart, however, the virus was no longer alive. Infectious risks from human corpses should be considered.

Access to social security benefits among multiple sclerosis patients in Italy: A cross-sectional study.

BACKGROUND: Knowledge concerning the predictors of social security benefits and the proportion of Multiple Sclerosis (MS) patients receiving these benefits is very limited. OBJECTIVE: To estimate the likelihood of receiving social security benefits for Italian MS patients. METHODS: From September 2014 to November 2015, we interviewed MS outpatients from two Italian MS clinics to collect information regarding their personal data, clinical and working history, and access to social security benefits. We performed both univariate and multivariable analyses to evaluate the predictors for receiving social security benefits. RESULTS: We interviewed 297 patients, with a mean age of 49.5 (±â€¯10.7) years; 71.4% were females. About 73% of patients had a relapsing-remitting (RR) course and the median EDSS score was 2.5 (IQR 1.5-6). About 75% of MS patients received a full exemption from co-payments, while the proportions of people who enjoyed each of the other social security benefits were lower, ranging from 8.8% (car adaptation) to 32% (disable badge). At multivariable analysis, the probability of obtaining each of the benefits was significantly associated with the EDSS score: walking aids (OR 3.9), care allowance (OR 3.6), disabled badge (OR 2.4), exemption from co-payment (OR 1.6) and allowed off work permit (OR 1.7). Only the probability of obtaining an allowed off work permit was also influenced by comorbidities (OR 2.9) and a higher education (OR 2.2). CONCLUSION: Except for full exemption from co-payments, the proportions of MS patients who enjoyed social security benefits seem to be limited in our study sample. The EDSS score is the strongest predictor of the probability of receiving all the benefits. Only a small proportion of patients received care allowance and working permits, probably because such benefits are only granted to people with a high level of disability. On the other hand, the low proportion of patients who enjoyed fiscal benefits for home and car adaptations could have been influenced by the way such benefits are granted in our country.

A Case of Fatal Cerebral Air Embolism After Blunt Lung Trauma: Postmortem Computed Tomography and Autopsy Findings.

Cerebral air embolism is caused by gas bubbles in the vascular system. These bubbles can cause cerebral ischemia by obstructing encephalic blood vessels. It is frequently associated with blunt and penetrating chest trauma as well as iatrogenic interventions. Lung trauma involving laceration of the respiratory tract, lung parenchyma, and blood vessels may result in direct communication of these structures, driving air or gas into the pulmonary venous system. We report a case of a blunt chest trauma that led to massive arterial air embolism that was possible to recognize with the help of postmortem computed tomographic scan examination.

[Duties and liabilities for psychiatrists]. / La responsabilità dello psichiatra.

This paper evaluates forensic duties and liabilities for psychiatrists, based on the current literature and based on our experience over several years of forensic medicine practice, involving both criminal and civil cases. We evaluated different scenarios, including cases of patients dangerous to themselves or others. We highlighted the importance to keep adequate and detailed clinical records, both in the inpatient and outpatient setting, given the absence of other objective items (e.g., laboratory records or other instrumental assessments) that may be of help for the judge and his/her counselors.

Sexual Masochism Disorder with Asphyxiophilia: A Deadly yet Underrecognized Disease.

DSM-5 distinguishes between paraphilias and paraphilic disorders. Paraphilias are defined as atypical, yet not necessarily disordered, sexual practices. Paraphilic disorders are instead diseases, which include distress, impairment in functioning, or entail risk of harm one's self or others. Hence, DSM-5 new approach to paraphilias demedicalizes and destigmatizes unusual sexual behaviors, provided they are not distressing or detrimental to self or others. Asphyxiophilia, a dangerous and potentially deadly form of sexual masochism involving sexual arousal by oxygen deprivation, are clearly described as disorders. Although autoerotic asphyxia has been associated with estimated mortality rates ranging from 250 to 1000 deaths per year in the United States, in Italy, knowledge on this condition is very poor. Episodes of death caused by autoerotic asphyxia seem to be underestimated because it often can be confounded with suicide cases, particularly in the Italian context where family members of the victim often try to disguise autoerotic behaviors of the victims. The current paper provides a review on sexual masochism disorder with asphyxiophilia and discusses one specific case as an example to examine those conditions that may or may not influence the likelihood that death from autoerotic asphyxia be erroneously reported as suicide or accidental injury.

[Burnout syndrome. Legal medicine: analysis and evaluation INAIL protection in cases of suicide induced by burnout within the helping professions]. / Analisi e valutazione medico-legale della sindrome da burnout nell'ambito delle helping profession e della tutela INAIL per i casi di malattia e suicidio.

After a survey of the definition and etiopathogenesis of burnout syndrome (BOS) carried out with the support of the most reliable available literature on the subject, the essay focuses on clinical evaluation (psychometric identification and quantification) of burn-out. In accordance with Circular 71/2003 of INAIL, it is assumed to be essential both legally and scientifically knowledge that the syndrome of burnout, knowledge, which involves an analysis of the case conducted with objective strictness and critical sensibility. It is carried out by collecting data on work history, physiological history, remote and proximal pathological history and performing a physical examination including neuro-psychiatric and psycho-diagnostic tests surveys. Only after the ascertainment of an effective existence of a psychiatric syndrome related to burnout phenomenon indeed, it will be possible (and necessary) to quantify the period of illness and the potential temporary biological damage or, more rarely, a permanent one. Given the difficulty of applying the forensic methodology to BOS (among which: the evaluation of the previous state of the person, the assessment of the causal link, the difficulties of nosographic of mental illness, the near impossibility of adequate prognostic evaluation, the difficulty to identify suitable criteria for establishing the importance and nature of limitations of daily living), in order to quantify the damage as objective as possible, it will be necessary to: 1) reconstruct the previous mental state of the subject; 2) assess the psychopathological condition following the event which the action of recognition focuses on; 3) express the clinical severity graduation judgment of the framework as well as a prognosis regarding the mental disorder found. The second part of the analysis focuses on the relationship between BOS and "helping profession"; specific attention is paid, in this section of work, to the analysis of the relationship between a typical BOS work-related stress and suicide.

Death by electrocution: Histological technique for copper detection on the electric mark.

The current observation of deaths by electrocution, both for domestic and work-related accidents as well as those in other contexts, has deepened the scope of investigation into electric marks, especially from the histological point of view. This is one of the few investigation tools that may lead to the diagnosis of death by electrocution in this distinct area, bearing in mind the diagnostic difficulties that this type of fatality presents. Our attention has been placed on the phenomenon of metallization. In particular, we focused on using the Timm's method [1] to locate the copper deposits. The phenomenon of metallization, usually could be caused by the copper deposit, this happens due to the copper debris released onto the skin by the live conductor. To date, this technique has only been used in the pathological field. Nevertheless, we tried to assess its application in seven selected cases, after partially modifying the technique, comparing it with the most common staining detection techniques and analysing the specificity, sensitivity as well as the potential for its application in the routine.

Giant Diaphragmatic Lipoma: Two Autopsy Case Reports and Review of the Literature.

Lipomas are common benign tumors most frequently found within the subcutaneous areas of the body. Deep-seated lipomas are rare and tend to be larger than cutaneous ones. Lipomas are rarely seen in the thoracic cavity, and they are usually located in the mediastinum, bronchiole, and lungs. Diaphragmatic lipomas have been occasionally reported in the literature, the first being described by Clark et al. in 1886. The authors report two rare cases of giant diaphragmatic lipoma incidentally found during forensic autopsies. In the first case, a Caucasian 85-year-old woman burned to death with another passenger, after her methane-fueled car collided with another car on a highway near Terni, Umbria, Italy. In the second case, a Caucasian 45-year-old man collapsed while walking through the countryside of Perugia. In either case, a large mass in the thorax was observed. The definitive pathologic diagnosis was giant intrathoracic diaphragmatic lipoma without evidence of malignancy. The authors also review the relevant literature and discuss differential diagnoses. These case reports contribute to the establishment of the actual incidence of diaphragmatic lipomas.

Forensic botany as a useful tool in the crime scene: Report of a case.

The ubiquitous presence of plant species makes forensic botany useful for many criminal cases. Particularly, bryophytes are useful for forensic investigations because many of them are clonal and largely distributed. Bryophyte shoots can easily become attached to shoes and clothes and it is possible to be found on footwear, providing links between crime scene and individuals. We report a case of suicide of a young girl happened in Siena, Tuscany, Italia. The cause of traumatic injuries could be ascribed to suicide, to homicide, or to accident. In absence of eyewitnesses who could testify the dynamics of the event, the crime scene investigation was fundamental to clarify the accident. During the scene analysis, some fragments of Tortula muralis Hedw. and Bryum capillare Hedw were found. The fragments were analyzed by a bryologists in order to compare them with the moss present on the stairs that the victim used immediately before the death. The analysis of these bryophytes found at the crime scene allowed to reconstruct the accident. Even if this evidence, of course, is circumstantial, it can be useful in forensic cases, together with the other evidences, to reconstruct the dynamics of events.

Report of a fatal case of pulmonary thromboembolism in a long-distance truck driver.

Long-distance truck drivers have been found to be associated with many medical problems because of their lifestyle and work environment. Many studies have revealed an increased risk in sexually transmitted infections, musculoskeletal disease, sleep disorders, hypertension, gastrointestinal disease, substance abuse and alcoholism, lung cancer, as well as human immunodeficiency virus infection. To our knowledge, there are no any articles about a fatal case of pulmonary thromboembolism. We report a case of a 45-year-old truck driver, who was found dead in his truck at a service station along the A1 motorway in Umbria, Italy. Autopsy findings revealed pulmonary thromboembolism as cause of death. Our report underlies that future actions must be addressed to provide health care access to this vulnerable, medically underserved population.

Genetic identification by using short tandem repeats analysis in a case of suicide by self-incineration: a case report.

Suicide by self-incineration is an uncommon method of suicide in the western world in contrast with Asian countries, where this type of suicide is more common. If there is a lack of witnesses, genetic analysis for identification is mandatory, especially when anthropologic or dental identification is barely significant.The authors report a case of self-incineration of a 55-year-old white man, which occurred near Siena, Tuscany, Italy.The recovered bones were classified according to the Crow-Glassman scale and assigned to category 5 (the highest extent of combustion according to this scale). Therefore, because of the extent of the bone damage, analyzing the residual soft tissue around the pelvic bones was the only way to reach a genetic identification.The authors report this case to emphasize that even if the highest level of burn injury to human body is reached, an accurate analysis of the findings may lead to a genetic identification. In these cases, an efficient cooperation among police, fire experts, and forensics is necessary, especially because it is the only way to determine if the modality of death was accidental, suicidal, or homicidal.

Case report of a homicide by a shotgun loaded with unusual ammunition.

Reported is the case of a man killed by a neighbor with a shotgun loaded with a unusual ammunition. The cartridge contained several shots chained together by metallic wires. Such ammunition has been used for hunting purposes but is now banned, so it can be handmade only. The joined pellets produce a wound with features that are different from those of a wound made by a regular load of pellets. Several interpretive problems are caused by the unknown number of pellets contained in the shell and the effects of the wire holding the shot together.