Antigenicity Preservation Is Related to Tissue Characteristics and the Post-Mortem Interval: Immunohistochemical Study and Literature Review.

The main aim of this study was to investigate the post-mortem proteolytic degradation process of selected tissue antigens and correlate it to the post-mortem interval. During the autopsy of 12 cadavers (time interval ranging 1 day-2 years after death) samples of skin, liver, kidney, and spleen were collected. All samples were formalin-fixed and paraffin-embedded. Four µm paraffin sections were used for hematoxylin-eosin staining and immunohistochemical analysis (Ki67, Vimentin, Pan cytokeratin, and CD20). Data reported here show that immunohistochemical reactivity preservation was related to the characteristics of the tissues. In particular, the most resistant tissue was the skin, where the autolysis phenomena were not appreciable before 5 days. On the contrary, the liver and the spleen underwent early autolysis, while the kidney displayed an early autolysis of the tubules and a late one of the glomeruli. As concerns specific antigens, immunoreactivity was lost earliest for nuclear antigens as compared to cytoplasmic ones. In conclusion, our results demonstrate that immunohistochemical detection of specific antigens may be useful in estimating the post-mortem interval, especially when we need to know whether the post-mortem interval is a few days or more than 7-10 days.

A Rapid Fatal Outcome of Iliopsoas Hematoma: Clinical and Autopsy Findings.

A case of massive muscular bleeding of iliopsoas resulting in lethal exsanguination is presented. The intramuscular bleeding occurred spontaneously in an old man with heart failure, presented to the emergency department after the acute onset of shortness of breath, and treated with therapeutic doses of antiplatelets and heparin to prevent thrombosis. On the sixth day of recovery, pain in the left lumbar region develops while there was a decrease in hemoglobin level. Computed tomography (CT) scan revealed a 10 × 3 cm hematoma of the left iliac muscle. The treatment was immediately stopped, but within 6 hours, the death was confirmed. The autopsy revealed that the hematoma, and its increased size since the latest imaging assessment, was the leading cause of death. Particularly in older patients with comorbidity, even in those with clotting parameters in the therapeutic range, the potential for fatal result of iliopsoas muscle bleeding should be considered. Identifying potential patience with increased risk of this complication could be important, especially in pandemic time of COVID-19, when the use of anticoagulant therapy-both for treatment and for prevention of severe disease-has become massive and addressed also to people without previous and specific pathologies.

Post-Mortem RT-PCR Assay for SARS-CoV-2 RNA in COVID-19 Patients' Corneal Epithelium, Conjunctival and Nasopharyngeal Swabs.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease has been described to possibly be associated with ocular surface disturbances. However, whether the virus could invade ocular tissues still remains elusive. In the present study, we tried to investigate the post-mortem presence of SARS-CoV-2 RNA in corneal epithelium gathered by patients with an ante-mortem confirmed diagnosis of Coronavirus disease-19 (COVID-19). Cadavers with an ante-mortem confirmed diagnosis of moderate to severe COVID-19 were examined. Clinical and demographic features were retrieved from hospital patients' notes. For each cadaver, corneal scrapings, conjunctival swabs (CS) and nasopharyngeal swabs (NPS) were collected to perform real-time reverse transcriptase polymerase chain reaction ((RT)-PCR) for SARS-CoV-2. Fourteen consecutive cadavers with an ante-mortem confirmed diagnosis of moderate to severe COVID-19 were examined. The last NPS performed ante-mortem confirmed SARS-CoV-2 infection in 12/14 (85.7%) patients. The mean death-to-swab time (DtS) was 3.15 ± 0.5 (2.10-5.1) h. The post-mortem NPS and CS found positive for SARS-CoV-2 RNA were 9/14 (64.3%) and 3/28 (10.7%), respectively. None of the corneal epithelium scrapes tested positive to RT-PCR for SARS-CoV-2 RNA. These data promote the SARS-CoV-2 as not able to contaminate the post-mortem corneal epithelium, while it can persist in different other structures of the ocular surface (i.e., the conjunctiva). It is reasonable to assume that such a contamination can occur ante-mortem too.

Medical Liability: Review of a Whole Year of Judgments of the Civil Court of Rome.

BACKGROUND: Complaints about medical malpractice have increased over time in Italy, as well as other countries around the world. This scenario, perceived by some as a "malpractice crisis", is a subject of debate in health law and medical law. The costs arising from medical liability lawsuits weigh not only on individual professionals but also on the budgets of healthcare facilities, many of which in Italy are supported by public funds. A full understanding of the phenomenon of medical malpractice appears necessary in order to manage this spreading issue and possibly to reduce the health liability costs. METHODS: The retrospective review concerned all the judgments drawn up by the Judges of the Civil Court of Rome, XIII Chamber (competent and specialized section for professional liability trials) published between January 2018 and February 2019. RESULTS: The analysis of data concerning the involved parties showed that in 84.6% of the judgments taken into account, one or more health facilities were sued, while in 58.2% of cases, one or more health workers were present among the defendants. When healthcare providers are the only ones to be summoned, it is dentists and aesthetic doctors/plastic surgeons who undergo most of the claims. In the overall period analyzed, the amount paid was 23,489,254.08 EUR with an average of 163,119.82 EUR. CONCLUSION: The evidence provided by the reported data is a useful tool to understand medical malpractice in Italy, especially with regard to the occurrence of the phenomenon at a legal level, an aspect still hardly mentioned by existing literature.

Persistence of SARS-CoV-2 Viral RNA in Nasopharyngeal Swabs after Death: An Observational Study.

The aim of this study was to investigate the persistence of SARS-CoV-2 in post-mortem swabs of subjects who died from SARS-CoV-2 infection. The presence of the virus was evaluated post-mortem from airways of 27 SARS-CoV-2 positive patients at three different time points (T1 2 h; T2 12 h; T3 24 h) by real-time PCR. Detection of antibodies to SARS-CoV-2 was performed by Maglumi 2019-nCoV IgM/IgG chemiluminescence assay. SARS-CoV-2 viral RNA was still detectable in 70.3% of cases within 2 h after death and in 66,6% of cases up to 24 h after death. Our data showed an increase of the viral load in 78,6% of positive individuals 24 h post-mortem (T3) in comparison to that evaluated 2 h after death (T1). Noteworthy, we detected a positive T3 post-mortem swab (24 h after death) from 4 subjects who were negative at T1 (2 h after death). The results of our study may have an important value in the management of deceased subjects not only with a suspected or confirmed diagnosis of SARS-CoV-2, but also for unspecified causes and in the absence of clinical documentation or medical assistance.

Morphological evaluation of sympathetic renal innervation in patients with autosomal dominant polycystic kidney disease.

Several evidences support the hypothesis that patients affected by autosomal dominant polycystic kidney disease (ASPKD) show a sympathetic renal hyperactivity. Nevertheless, no morphological evidences are available yet. Therefore, the aim of the study was to demonstrate that an increase in sympathetic renal artery innervation was present in the ADPKD patients by using histological methods. In addition, here we correlated the sympathetic renal artery innervation with the evolutionary state of ADPKD (increase in volume of kidney, onset of chronic renal failure and hypertension). To this end, peri-adventitial innervation of renal arteries was studied using morphological methods from 49 patients in total: 29 underwent surgical nephrectomies for ADPKD and 20 non-dialysis patients (CTRL group) undergoing nephrectomy for other diseases. Nerve density (number of nerves per mm2) was evaluated in the peri-adventitial tissue in a concentric ring that was located within 2 mm from the beginning of the adventitia by using immunohistochemistry. The total nerve density was significantly increased in the ADPKD group (1.26 ± 0.82 × mm2) as compared to controls (0.78 ± 0.40 × mm2) (p = 0.02). Hypertensive patients with ADPKD showed a greater nerve density than control hypertensives. However, the increase in renal sympathetic innervation in the ADPKD patients was found to be independent of hypertension, resistance to antihypertensive therapy, age, sex and kidney volume, as demonstrated by the uni and multivariate analysis. In conclusion, our study better clarifies the effect of sympathetic hyperactivity in the progression of polycystic disease.

Plaque calcification is driven by different mechanisms of mineralization associated with specific cardiovascular risk factors.

BACKGROUND AND AIMS: The aim of this study was to investigate possible associations among markers of mineralization, plaque instability and the main risk factors of atherosclerosis. METHODS AND RESULTS: A Tissue MicroArray containing 52 samples of calcified carotid plaques from 52 symptomatic and asymptomatic patients were built. TMA serial sections were used to study the expression of inflammatory and mineralization markers (BMP-2, BMP-4, VDR, RANKL, Osteopontin, Sclerostin, ß-catenin and calmodulin) by immunohistochemistry. Our data clearly demonstrated the expression of mineralization markers in atheromatic plaques. Indeed, with the exception of RANKL, all investigated markers were expressed in at least 60% of cases. Specifically, multivariate analysis displayed significant associations between both the expression of BMP-2 and the presence of unstable plaques as well as between the expression of ß-catenin and the presence of stable plaques. We also found a significant inverse association between both a) the presence of hypertension and VDR and b) smoking habits and calmodulin expression. Finally, we noted a higher density of RANKL positive cells in plaques from diabetic patients as compared to non-diabetic ones and a significant positive association between hypertriglyceridemia and BMP-4 expression. CONCLUSION: Our results support the hypothesis that the process of atherosclerotic plaque calcification presents a number of similarities with the physiological processes that occur in bone, involving both osteoblasts- and osteoclasts-like arterial cells. Finally, the present study suggests that risk factors, such as hypertension, cigarette smoke and diabetes, can cause the destabilization of the atheromatic plaque acting on calcification process as well as inflammation.

Application of Precision Medicine in Neurodegenerative Diseases.

One of the main challenges for healthcare systems is the increasing prevalence of neurodegenerative pathologies together with the rapidly aging populations. The enormous progresses made in the field of biomedical research and informatics have been crucial for improving the knowledge of how genes, epigenetic modifications, aging, nutrition, drugs and microbiome impact health and disease. In fact, the availability of high technology and computational facilities for large-scale analysis enabled a deeper investigation of neurodegenerative disorders, providing a more comprehensive overview of disease and encouraging the development of a precision medicine approach for these pathologies. On this subject, the creation of collaborative networks among medical centers, research institutes and highly qualified specialists can be decisive for moving the precision medicine from the bench to the bedside. To this purpose, the present review has been thought to discuss the main components which may be part of precise and personalized treatment programs applied to neurodegenerative disorders. Parkinson Disease will be taken as an example to understand how precision medicine approach can be clinically useful and provide substantial benefit to patients. In this perspective, the realization of web-based networks can be decisive for the implementation of precision medicine strategies across different specialized centers as well as for supporting clinical/therapeutical decisions and promoting a more preventive and participative medicine for neurodegenerative disorders. These collaborative networks are essentially addressed to find innovative, sustainable and effective strategies able to provide optimal and safer therapies, discriminate at risk individuals, identify patients at preclinical or early stage of disease, set-up individualized and preventative strategies for improving prognosis and patient's quality of life.

The diagnostic delay of oral carcinoma.

This paper describes the results of a retrospective study that analyzed the extent and role of diagnostic delays on the development and prognosis of oral cancer. We consulted the digital archives of the Anatomy and Pathology Department of the University Hospital of Modena and Reggio Emilia for the period from 2000 to 2016, to identify all patients with oral cavity lesions according to the SNOMED coding system. In total, 645 reports of squamous cell carcinoma of the oral cavity were retrieved. Data collected from the reports was supplemented with clinical information, with particular reference to the time of onset of the first signs and/or symptoms and the time elapsed between biopsy and definitive histological diagnosis following surgery. The average delay of patients from onset of signs and/or symptoms and seeking medical care was 112 days, or about 4 months. A longer delay was found for male with respect to female patients (151 days versus 82 days respectively; p < 0.015). An average delay of 40 days was observed between the first biopsy and the postoperative histological diagnosis. Results indicate that diagnostic delays occur frequently in oral tumours and can due to both the patient's wait-and-see conduct upon appearance of the first signs and/or symptoms, and to the organizational and communicative deficiencies among the different medical specialties. In light of these results, we make the recommendation to organize information campaigns through the Public Health Departments and specific screening programs, and to introduce an operational protocol for the prevention and early diagnosis of oral cancer, involving general medicine practitioners and dentists as the main promoters.

Uncovering genetic and non-genetic biomarkers specific for exudative age-related macular degeneration: significant association of twelve variants.

Age-related Macular Degeneration (AMD) represents one of the most sight-threatening diseases in developed countries that substantially impacts the patients' lifestyle by compromising everyday activities, such as reading and driving. In this context, understanding the prevalence, burden, and population-specific risk/protective factors of AMD is essential for adequate health care planning and provision. Our work aimed to characterize exudative AMD in Italian population and to identify the susceptibility/protective factors (genetic variants, age, sex, smoking and dietary habits) which are specific for the onset of disease. Our study involved a cohort of 1976 subjects, including 976 patients affected with exudative AMD and 1000 control subjects. In particular, the sample cohort has been subjected to a large genotyping analysis of 20 genetic variants which are known to be associated with AMD among European and Asiatic populations. This analysis revealed that 8 genetic variants (CFH, ARMS2, IL-8, TIMP3, SLC16A8, RAD51B, VEGFA and COL8A1) were significantly associated with AMD susceptibility. Successively, we performed a multivariate analysis, considering both genetic and non-genetic data available for our sample cohort. The multivariate analysis showed that age, smoking, dietary habits and sex, together with the genetic variants, were significantly associated with AMD in our population. Altogether, these data represent a starting point for the set-up of adequate preventive and personalized strategies aimed to decrease the burden of disease and improve the patients' quality of life.

An unusual case of suicidal double ligature strangulation.

As suicide by ligature strangulation is rare, the correct medico-legal diagnosis may be difficult to establish if there is no clear supporting circumstantial evidence. We report an unusual case of suicide by strangulation with a double ligature. Investigation of the scene of death and pathological findings at autopsy are reported and discussed. We emphasise the importance of an external examination and an on-the-spot investigation.

Cortical Expression of the Polysialylated Isoform of the Neural Cell Adhesion Molecule on Brain Tissue to Recognize Drug-Related Death: An Exploratory Analysis.

The polysialylated isoform of the neural cell adhesion molecule (PSA-NCAM) has been shown to be a key player in neuroplastic changes and is expressed in various disorders. We investigated the PSA-NCAM expression on brain cortical tissue in a cohort of drug-related deaths. Brains from 25 drug abusers and 10 control subjects were removed at autopsy, and 2 samples of the right parietal lobe of each case were obtained. The polysialylated isoform of NCAM was evaluated on formalin-fixed and paraffin-embedded tissues. Eleven patients were polydrug abusers; 14 used a single substance. The mechanisms of death were acute respiratory failure (n = 19), cardiorespiratory failure (n = 4), acute heart failure (n = 1), and brain injury (n = 1). Toxicological analyses of blood were available for all cases, and urine and bile analyses for 19 of 25 cases. The polysialylated isoform of NCAM immunoexpression in the neuronal soma and dendritic spines was observed in 18 (72%) of 25 drug abusers and in 2 (20%) of 10 control subjects. Drug abusers were statistically more positive for PSA-NCAM than control subjects (P = 0.0082). The expression of PSA-NCAM in the parietal cortex could be an indicator of brain damage due to drug abuse, and its availability could allow the forensic pathologists to develop rapid and low-cost additional or alternative method to improve detection of drug-related deaths.

Towards the application of precision medicine in Age-Related Macular Degeneration.

The review essentially describes genetic and non-genetic variables contributing to the onset and progression of exudative Age-related Macular Degeneration (AMD) in Italian population. In particular, AMD susceptibility within Italian population is contributed to by genetic variants, accounting for 23% of disease and non-genetic variants, accounting for 10% of AMD. Our data highlighted prominent differences concerning genetic and non-genetic contributors to AMD in our cohort with respect to worldwide populations. Among genetic variables, SNPs of CFH, ARMS2, IL-8, TIMP3, SLC16A8, RAD51B, VEGFA and COL8A1 were significantly associated with the risk of AMD in the Italian cohort. Surprisingly, other susceptibility variants described in European, American and Asiatic populations, did not reach the significance threshold in our cohort. As expected, advanced age, smoking and dietary habits were associated with the disease. In addition, we also describe a number of gene-gene and gene-phenotype interactions. In fact, AMD-associated genes may be involved in the alteration of Bruch's membrane and induction of angiogenesis, contributing to exacerbate the damage caused by aging and environmental factors. Our review provides an overview of genetic and non-genetic factors characterizing AMD susceptibility in Italian population, outlining the differences with respect to the worldwide populations. Altogether, these data reflect historical, geographic, demographic and lifestyle peculiarities of Italian population. The role of epigenetics, pharmacogenetics, comorbities and genetic counseling in the management of AMD patients have been described, in the perspective of the application of a "population-specific precision medicine" approach addressed to prevent AMD onset and improve patients' quality of life.