Distinguishing injury patterns in fatal falls from heights versus pedestrian impacts: an autopsy study for differential diagnosis in ambiguous cases.

This study investigated the injury patterns associated with fatal falls from heights compared to individuals struck by cars, aiming to enhance the differential diagnosis in ambiguous cases, where it is unclear whether the body fell from nearby building or was left on the street following a road traffic incident. A retrospective review of comprehensive forensic reports from the Institute of Legal Medicine of the University of Rome "Tor Vergata" between 2012 and 2023 was conducted. The analysis included 232 cases, gathering data on internal organ injuries, skeletal fractures, external skin injuries, as well as pleural, peritoneal, and pericardial effusions. Bilateral lung injuries were significantly more common in falls from height (33.3%) compared to pedestrians (13.6%, p < 0.001). Liver injuries also occurred more frequently in fall victims (49.6%) than in pedestrians (28.2%, p < 0.001). Skull fractures were more frequent in falls from height (68.2%) versus individuals struck by cars (55.3%, p = 0.044), while unilateral leg fractures were more common in pedestrians (28.2%) compared to fall victims (16.3%, p = 0.029). External injuries, notably to the head and legs, were more frequent in pedestrians. The "Total Injured Skin Area" analysis revealed a significant discriminative power with an optimal cut-off of 84.2 cm², suggesting that injuries exceeding this threshold may be indicative of a pedestrian road fatality.

Obesity as a social phenomenon: A narrative review.

BACKGROUND: obesity is one of the most prevalent diseases all over the world. Because of its high social impact, the broadest possible approach on several levels - and not limited only to clinical aspect - is needed to better understand and face the challenges obesity poses to public health. OBJECTIVES: to analyse, through the main evidence, the social impact of weight excess in the general population and the actions aimed at mitigating its negative effects. DESIGN: narrative review. SETTING: data obtained from the sources included in the study were gathered and analyzed in five macroareas: Health Inequality, Society, Work, Impact on Social Medicine (focused on the Italian model), and Social Costs. RESULTS: each category showed a bilateral relationship with obesity having a significant impact for the community. CONCLUSIONS: for each field, various actions should be taken at institutional level. Many recommendations and actions have already been taken worldwide, but they alone seem to be not enough. This work points out that, in order to combat obesity and bring about a slowdown of this pandemic, the entire scientific community and institutions must work together to identify and design programmes that are truly effective.

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.

[Regulatory aspects and medicolegal considerations regarding clinical drug trials]. / Aspetti normativi e considerazioni medico-legali sulla sperimentazione farmacologica clinica.

This article aims to explore the regulatory and medicolegal aspects of experimental drug trials. Firstly, the authors provide definitions of drug according to WHO, the European Community and our official Pharmacopoeia, and that of experimental studies. They then explain the distinction between pure or basic research and drug trials and explain the various phases of the latter. Besides providing definitions, and exploring doctrinal, theoretical but also practical aspects of drug trials, the authors also discuss and analyze legislative aspects, with particular reference to the Italian legislative framework, and medicolegal issues, including informed consent, effects on humans, and professional responsibility.

Autopsy findings of fatal retroperitoneal hemorrhage after traumatic rupture of bilateral renal angiomyolipoma.

The present work reports the autopsy findings of a unique case characterized by fatal retroperitoneal hemorrhage following the traumatic rupture of bilateral renal angiomyolipomas. Renal angiomyolipomas are generally benign tumors with an unpredictable clinical course, ranging from asymptomatic to sudden rupture and hemorrhagic shock. They may be associated with genetic disorders such as tuberous sclerosis complex. The case under investigation is unprecedented in the medical literature due to its bilateral nature and fatal outcome. Autopsy analysis revealed an extensive retroperitoneal hemorrhage originating from bilateral ruptured tumors. Microscopic examination found features consistent with bilateral renal angiomyolipoma. Circumstantial information identified a traffic accident before the death, considering it as the cause of the tumors' traumatic rupture. In this case, due to the severity of the situation, immediate medical measures-such as fluid resuscitation, coagulopathy correction, and surgical treatment, which are usually lifesaving-could not be performed. This led to the patient being declared dead at the scene of the crash.

A Retrospective Analysis of Familicide in Latium (Italy): A Criminological Profile of the Victims and Offenders Involved in 29 Cases and a Comparison with the Literature.

Familicide, an extreme form of domestic violence where one family member kills another, is a complex criminological issue. We analyzed autopsy files from the Institute of Legal Medicine, University of Rome Tor Vergata (1995-2022), to understand familicide better. The study focused on victim profiles, offender characteristics, and case dynamics. From 29 analyzed cases, 31 victims emerged, with 2 instances of double homicide. The perpetrators were mostly male (79.31%) and the victims were primarily female (54.84%). The familial ties ranged from parent-child to siblings and spouses. A significant number of crimes happened at private residences (70.97%) using bladed weapons (48.39%), with the injuries being concentrated on the head and chest. Half of the cases showed struggle signs, and 24.14% of the perpetrators had identifiable psychiatric disorders, which often served as the motive. Post-crime actions included self-reporting, suicide attempts, and successful suicides. A comparison with literature confirmed the typical familicide offender as a middle-aged male with potential social stressors and a history of domestic violence, with the victims often being female family members. Mental health conditions including depression, bipolar disorder, and schizophrenia significantly impacted these events. These findings underline the need for customized approaches to comprehending and preventing familicide.

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.

Health Management in Italian Prisons during COVID-19 Outbreak: A Focus on the Second and Third Wave.

The SARS-CoV-2 spread is a threatening and challenging issue for correctional systems worldwide because of many factors, particularly overcrowding and of the intrinsic characteristics of the population. The prevention measures adopted by the Italian Government were aimed to protect and preserve both inmates' and prison workers' health. The present study aimed to evaluate the efficacy of the adopted strategies. METHODS: Data regarding Italian prisons' occupation and prisoners' population from January 2019 to June 2021, as well as the cumulative weekly increase of confirmed cases and the number of doses of vaccine administered among the population of inmates, the prison workers, and Italian population from November 2020 to the end of June 2021, were collected. RESULTS: Prisons' occupation dropped from 120% to 106% after the beginning of the pandemics. The confirmed cases between inmates were consistently lower than among the Italian population and prison workers. A time-series chart showed a time lag of one week between the peaks of the different population. CONCLUSIONS: The containing strategies adopted by the Italian correctional system have proved their effectiveness in terms of the prevention and protection of both inmate and staff health.

Profiling Players Involved in Overkill: An Analysis of 71 Cases in Central Italy.

"Overkill" is characterized by the finding of excessive wounds on the victim's body. Despite the large use of this term, it does not have a definition in the literature yet. Our study aimed to analyze the information related to the dynamics of overkill cases, collecting objective variables, and producing a profile of the players involved in this type of homicides. Data on 71 overkill cases from reports of the autopsies performed in the Section of Legal Medicine of the University of Rome Tor Vergata from 1 January 2000 to 31 December 2020 were collected. The victims and the perpetrators of overkill shared similar characteristics: they were usually male aged between 20 and 50 years, more likely in the 20-35 years range; victims however also showed another age peak in the range 50-55 years. The type of damage can be linked to the sole action of a cold weapon or the simultaneous use of multiple harmful tools with no significant differences. The most common motive proved to be a dispute for futile reasons; however, in the case of a single perpetrator of the crime, the economic and passionate motives are as frequent as the previous one. Implications of the findings and avenues for future research are discussed.

From overkill to beheading: A case report of a schizophrenic matricide.

Initial evidence exists on a subtype of matricide committed by subjects suffering from severe mental disorders. Matricide perpetrators often undergo a forensic psychiatric evaluation during the subsequent criminal trial because of supposed legal insanity. The few studies on matricide by mentally disordered perpetrators suggested a possible association between such extreme form of violence and schizophrenia spectrum disorders, especially in case of active delusions or hallucinations. METHODS: we analyze a case of a young male with a recent diagnosis of psychotic disorder who committed matricide by inflicting multiple injuries and beheading. Data emerging from the forensic pathological analysis of the victim, as well as the forensic psychiatric analysis of the matricide perpetrator are discussed within an interdisciplinary perspective. RESULTS: the autopsy revealed multiple stab wounds in the regions of the upper limbs, abdomen, chest, and neck, the latter determining beheading. The forensic psychiatric evaluation yielded a diagnosis of schizophrenia and clarified the causal role in the homicidal behavioral of active psychotic symptoms. CONCLUSION: the specific type of delusional content, and perpetrator-victim relationship might contribute explaining a subtype of extremely violent homicide in recent onset schizophrenia.

Inhalation of helium in plastic bag suffocation with suicidal purpose: Observation and differences of two cases.

The use of helium in plastic bag suffocation is a suicide method recently found in forensic cases. Although it is not common practice, there has been a strong increase in its use during the past 20 years, thanks to the accessibility of information on the web and materials needed to implement it. From a pathophysiological point of view, there are various theories on how helium can change the timing and, also, the cause of death when the head is inside a plastic bag. We report two cases where we believe that the action of helium, whose unequivocal use is demonstrated by the circumstantial data, has unfolded in a different way. In the first case, the discovery of an intense cyanosis of the face, blood leakage from the respiratory orifices and the destruction of numerous alveolar septa with histologically demonstrated blood extravasation, was left for a longer agonic period and a no negligible rate of pulmonary barotrauma in determination of death. In the second case, the total absence of external pathological phenomena, internal and histological, allows us to hypothesise an onset of death that is faster and catalysed by helium and explained by the known sympathetic hyperactivation and consequent cardiac arrhythmic death described in similar plastic bag suffocation cases.

Drug detection in decomposed cadavers confirms testimonial evidence in a case of serial homicides.

Toxicology investigation on human's buried dead bodies is a rare and challenging task in the forensic field. As requested by the Judicial Authority, this work aimed to verify testimonial evidence that emerged during a criminal investigation involving multiple murder cases. The statements indicated an improper medical administration of one or more alleged drugs (propofol, morphine, diazepam, and midazolam) which presumably caused the deaths. Since the supposed crimes took place several years before, the task of the present work was to obtain results to support the charges. The analyses involved 18 biological samples taken from four exhumed bodies, three of which were female and one male, each buried in a different date and mode. Each sample was treated with specific purification and extraction techniques (LLE - SPE) after the addition of the deuterated analogs of the searched analytes (propofol-d17, morphine-d3, diazepam-d5, midazolam-d4) as internal standards. Afterwards, the extracts were subjected to qualitative analysis by gas chromatography-mass spectrometry-Electron Impact (GC/MS - EI), both in full scan and SIM mode. Propofol, morphine, and diazepam were identified in the corpses. It supports testimonials that were administered just before the deaths occurred.

Snakebite Envenoming a Challenging Diagnosis for the Forensic Pathologist: A Systematic Review.

Snakebite envenoming (SBE) is a public health issue in developing countries. The estimated annual global incidence of snakebites is about 5.4 million snakebites per year, resulting from 1.8 to 2.7 million cases of SBE and from 81,000 to 138,000 deaths with 400,000 survivors suffering permanent physical and psychological disabilities. There are more than 3000 species of snakes around the world: 600 are venomous and over 200 are considered to be medically important because of their clinical effects. The severity of SBE depends on several factors among which bite localization, snake's size, condition of glands and teeth, bite angle and bite duration, the microflora of the snake's mouth and victim's skin, age of the victim, weight, health status, and victim's activity after a bite. Snake venoms are mixtures of protein families, and each of these families contains many different toxins or toxin isoforms. Based on their effects, snake venoms can be classified as hemotoxic, neurotoxic, or cytotoxic and they can all act together involving multiple tissues and organs. When the bite is fatal, the mechanism of death is primarily related to the paralysis of respiratory muscles, which causes asphyxia and hypoxic-ischemic encephalopathy, but also anaphylactic shock, hemorrhagic shock, cardiomyopathy, acute tubular necrosis (ATN). The purpose of this literature review is to evaluate epidemiological and post-mortem examination findings in fatal SBEs in order to better understand the pathophysiological mechanisms, thus helping pathologists in defining the correct diagnosis.

Autopsy findings of fatal retroperitoneal hemorrhage after traumatic rupture of bilateral renal angiomyolipoma

ABSTRACT The present work reports the autopsy findings of a unique case characterized by fatal retroperitoneal hemorrhage following the traumatic rupture of bilateral renal angiomyolipomas. Renal angiomyolipomas are generally benign tumors with an unpredictable clinical course, ranging from asymptomatic to sudden rupture and hemorrhagic shock. They may be associated with genetic disorders such as tuberous sclerosis complex. The case under investigation is unprecedented in the medical literature due to its bilateral nature and fatal outcome. Autopsy analysis revealed an extensive retroperitoneal hemorrhage originating from bilateral ruptured tumors. Microscopic examination found features consistent with bilateral renal angiomyolipoma. Circumstantial information identified a traffic accident before the death, considering it as the cause of the tumors' traumatic rupture. In this case, due to the severity of the situation, immediate medical measures—such as fluid resuscitation, coagulopathy correction, and surgical treatment, which are usually lifesaving—could not be performed. This led to the patient being declared dead at the scene of the crash.

Necrotizing fasciitis. Possible profiles of professional liability with reference to two cases.

Necrotizing fasciitis is one of the most dangerous complication of an abscess and it is still a disease with a high mortality. In this work, we decided to consider two cases: the first one concerns a male subject, aged 66, deceased because of a fatal necrotizing fasciitis associated to a cervical descending mediastinitis, which evolved from a primary peritonsillar abscess; the second is about a 50-year-old woman with a perineal abscess, then evolved into necrotizing fasciitis associated to a fatal septis shock. After a systematic consideration of necrotizing fasciitis as pathology and an analysis of the possible related risks to a diagnostic or therapeutic delay, we analyzed the particular history of both cases to underline the possible critical issues in professional behavior of the medical staff intervened. KEY WORDS: Abscess, Medical malpractice, Mortality, Necrotizing fasciitis, Professional liability.

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.

Digenic Inheritance of Shortened Repeat Units of the D4Z4 Region and a Loss-of-Function Variant in SMCHD1 in a Family With FSHD.

Facioscapulohumeral muscular dystrophy (FSHD) is a neuromuscular disorder which is typically transmitted by an autosomal dominant pattern, although reduced penetrance and sporadic cases caused by de novo mutations, are often observed. FSHD may be caused by a contraction of a repetitive element, located on chromosome 4 (4q35). This locus is named D4Z4 and consists of 11 to more than 100 repeated units (RU). The D4Z4 is normally hypermethylated and the genes located on this locus are silenced. In case of FSHD, the D4Z4 region is characterized by 1-10 repeats and results in the region being hypomethylated. However, 5% of FSHD cases do not carry the short allele of D4Z4 region. To date, two forms of FSHD (FSHD1 and FSHD2) are known. FSHD2 is usually observed in patients without the D4Z4 fragment contraction and carrying variants in SMCHD1 (18p11.32) gene. We report the case of a young adult patient who shows severe symptoms of FSHD. Preliminary genetic analysis did not clarify the phenotype, therefore we decided to study the family members by genetic and epigenetic approaches. The analysis of D4Z4 fragment resulted to be 8 RU in the affected proband and in his father; 26 RU in the mother and 25 RU in the maternal uncle. SMCHD1 analysis revealed a heterozygous variation within the exon 41. The variant was detected in the proband, her mother and the uncle. Furthermore, epigenetic analysis of CpG6 methylation regions showed significant hypomethylation in the affected patient (54%) and in the mother (56%), in contrast to the father (88%) and the uncle (81%) carrying higher methylation levels. The analysis of DR1 methylation levels reported hypomethylation for the proband (19%), the mother (11%), and the uncle (16%). The father showed normal DR1 methylation levels (>30%). Given these results, the combined inheritance of SMCHD1 variant and the short fragment might explain the severe FSHD phenotype displayed by the proband. On this subject, SMCHD1 analysis should be promoted in a larger number of patients, even in presence of D4Z4 contractions, to facilitate the genotype-phenotype correlation as well as, to enable a more precise diagnosis and prognosis of the disease.

A case of fulminant subacute sclerosing panencephalitis presenting with acute myoclonic-astatic epilepsy.

The neurologic sequelae post-measles are less common than other complications measles-related and can lead to severe disability or death: primary measles encephalitis (PME), acute post-infectious measles encephalomyelitis (APME), measles inclusion body encephalitis (MIBE), and subacute sclerosing panencephalitis (SSPE). SSPE syndrome can affect people years from the acute measles virus infection, as result of the persistence of defective viral particles in brain cells. Clinical onset typically manifests with progressive intellectual deterioration, behavioral changes, and myoclonic jerks. The course of SSPE in the majority of affected children is that of a progressive worsening with fatal outcome within two years. This report described an Italian case of fulminant SSPE syndrome that led to death within few months from the initial onset.

A case of "precocious" mummification.

Mummification is a peculiar transformative process consisting of the total drying of the body soft tissues. It is produced, in particular conditions, between 6 and 12 months after death. "Precocious" mummification has been reported in countries where recorded weather conditions are more extreme than in Italy, in a confined environment, or with particular micro-climate conditions. Here we present a case of mummification produced in a central region of Italy in four weeks. We also analyze conditions allowing for the rapidity of this phenomenon.

Differential diagnosis between cranial fractures of traumatic origin and explosion fractures in burned cadavers.

Interpreting the damages on a cadaver which has been exposed to the action of fire is a challenge for the forensic pathologist. The finding of a burned body gives in fact the opportunity to make a series of inquiries which deal with the whole medical-legal practice. In our case, the victim has been hit over the head with a blunt object and has been then carbonized. The medical-legal problems implied lie in the definition of the exact manner and cause of death, and therefore in the analysis of vital, perimortal and postmortal injuries, as to formulate a differential diagnosis between the former traumatic originated and the latter caused by combustion.