The impact of COVID-19 on Italian dentists: A cross-sectional survey on 2443 participants.

OBJECTIVE: To evaluate the impact of COVID-19 pandemic among a sample of Italian dentists in terms of infection, strategies for infection control, organization of the dental clinic, attitude, and behavior. MATERIAL AND METHODS: This was a cross-sectional survey. The sample consisted of 8000 Italian dentists selected among 63,375 using a computerized random sampling method. An electronic informed consent had to be signed. The questionnaire categories were on demographic, infection risk management, organization, and dentists' attitude and behavior. Geographic macro-areas were used for subgroup analysis. RESULTS: Among 8000 invited dentists, 2443 agreed to participate to the survey (30.6%). Mean age was 51.2 years, women were 34.5%. A total of 6.1% self-reported COVID-19 experience and higher rate of infection was reported in north Italy compared to the south (p < 0.05). FFP2/FFP3 respirators (97.1%) and visors (97.4%) were used by almost all dentists. While, natural ventilation and mouthwashes were the most frequent approaches used to reduce the infection risk. Most of the dentists reported positive attitude, nevertheless 83.6% felt an increased responsibility. CONCLUSION: The self-reported COVID-19 prevalence was 6.1% with some differences among geographic areas. COVID 19 had a deep impact on preventive strategies, dental office organization, and behavior within this sample.

Professional liability subsequent to the Cartabia Reform: implications for pathologists.

The Cartabia Reform modifies the standard used by the Public Prosecutor for the submission of requests for filing or referral for trial. The standard has shifted to the "reasonable prediction of conviction" by moving the principle of in dubio pro reo to the investigation phase. The scope of the legislative amendment is focused on protecting the rights of investigated individuals, who are too often brought to trial without adequate supporting evidence. The implications that this reform has on legal proceedings concerning the criminal liability of healthcare professionals, including pathologists, is discussed.

Aerosol transmission for SARS-CoV-2 in the dental practice. A review by SIdP Covid-19 task-force.

Current evidence suggests that SARS-CoV-2, the virus that causes COVID-19, is predominantly spread from person to person. Aim of this narrative review is to explore transmission modality of SARS-CoV-2 to provide appropriate advice to stakeholders, in order to support the implementation of effective public health measures and protect healthcare workers that primary face the disease. "In vivo" and "in vitro" studies from laboratories and hospitals confirmed the presence of surface contamination and provided insight of SARS-CoV-2 detection in the air, particularly in indoor settings with poor ventilation where aerosol-generating procedures were performed. Measures for aerosol reduction, in conjunction with other effective infection control strategies, are needed to prevent the spread of SARS-CoV-2 in dental setting.

Surface disinfection and protective masks for SARS-CoV-2 and other respiratory viruses: A review by SIdP COVID-19 task force.

OBJECTIVES: Primary focused question for this systematic review (SR) was "Which is the evidence about surfaces decontamination and protection masks for SARS-Cov-2 in dental practice?" Secondary question was "Which is the evidence about surfaces decontamination and protection masks against airborne pathogens and directly transmitted viral pathogens causing respiratory infections?" MATERIALS AND METHODS: PRISMA guidelines were used. Studies on surface decontamination and protective masks for SARS-CoV-2 in dental practice were considered. Studies on other respiratory viruses were considered for the secondary question. RESULTS: No studies are available for SARS-CoV-2. Four studies on surface disinfection against respiratory viruses were included. Ethanol 70% and sodium hypochlorite 0,5% seem to be effective in reducing infectivity by > 3log TCID. Four RCTs compared different types of masks on HCW. The single studies reported no difference for laboratory-diagnosed influenza, laboratory-diagnosed respiratory infection, and influenza-like illness. A meta-analysis was not considered appropriate. CONCLUSIONS: There is lack of evidence on the efficacy of surface disinfection and protective masks to reduce the spread of SARS-CoV-2 or other respiratory viruses in dentistry. However, the consistent use of respirator and routine surface disinfection is strongly suggested. There is urgent need of data on the efficacy of specific protection protocols for dental HCW against viral infections.

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.

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.

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.

Postmortem CT and autopsy findings in nine victims of terrorist attack.

In a foreign country, a religious terrorist group raided a restaurant, using pipe bombs, sharp-edged weapons, and various types of firearms (handguns, submachine guns, and AK-47 assault rifles) loaded with normal and prohibited bullets to kill foreigner customers, some of whom were Italian tourists. Local pathologists performed forensic autopsies on the bodies, but we were asked to perform additional external examinations, postmortem computed tomography (PMCT) scans, and then a second round of complete autopsies on nine victims (5 females and 4 males). Four victims had slash wounds inflicted by sharp-edged weapons, mostly localized in the head and neck. All but two victims had gunshot wounds. Finally, three casualties had injuries caused by the explosion of improvised explosive devices. In all cases, PMCT was a reliable source of information and provided strategic guide during autopsies, helping identify and describe the injuries and thus reconstruct the events. Therefore, in these cases, we suggest integrating the autopsy findings with the postmortem radiological data.

Postmortem Otorrhagia in Positional Asphyxia.

Otorrhagia is generally associated with basilar skull fractures or diving accidents. In routine forensic medical practice, an accurate knowledge of the etiology of otorrhagia may have a key role to distinguish between traumatic and atraumatic causes and accidental, homicidal, or suicidal manners. The authors present the case of an unusual cause of atraumatic otorrhagia occurred in an elderly farmer found dead in a barn. He remained entrapped in a narrow tunnel created by some hay bales. The autopsy findings revealed only an intense polyvisceral congestion and subpleural petechiae, with no signs of traumatic injuries and no fractures of skull base or temporal pyramid. The cause of death was determined to be positional asphyxia, and the manner of death was deemed accidental. In fact, the head-down position resulted in diaphragm compression causing respiratory failure in combination with the stasis of the upper venous circle districts. Mechanical and gravitational forces related to upside-down position and increased vascular pressure also caused postmortem otorrhagia. In this case, the death scene investigation and circumstantial information allowed for reconstruction of the unique dynamics of the death. At the death scene, the position of the corpse must be accurately investigated because it can explain some cadaveric findings such as the ear bleeding or other markers of increased cephalic venous pressure like pink teeth, facial and conjunctival petechiae, or Tardieu spots. Therefore, forensic pathologists should consider that ear bleeding in dead bodies is not always the evidence of severe head blunt trauma or diving accidents, but it might be a postmortem phenomenon mostly related to body position.

Fatal entrapment in a pool drainage system: a case report.

Swimming pool suction injuries are rarely encountered in forensic medicine. Infants under 8 years of age are most frequently involved in such accidents with high risk of serious injuries and fatal consequences due to drowning. We report, for the first time, a case of a 13-year-old boy trapped at the abdomen by an uncovered suction drainage hole. External examination of the body revealed a round ecchymosis which had the same diameter as the pool drain. Post-mortem examination established that death had occurred due to drowning, possibly in combination with traumatic shock from the suction mechanism involving the intestinal loops. Furthermore, this case may be remarkable as it raises other medico-legal issues regarding the safety standards at swimming pools, including pool management and lifeguard attendance. Preventative measures are needed in order to make sure this sort of injury or death does not occur. Moreover, the awareness of the occurrence of these accidents should be increased.

Age estimation by assessment of pulp chamber volume: a Bayesian network for the evaluation of dental evidence.

PURPOSE: The present study aimed to investigate the performance of a Bayesian method in the evaluation of dental age-related evidence collected by means of a geometrical approximation procedure of the pulp chamber volume. Measurement of this volume was based on three-dimensional cone beam computed tomography images. METHODS: The Bayesian method was applied by means of a probabilistic graphical model, namely a Bayesian network. Performance of that method was investigated in terms of accuracy and bias of the decisional outcomes. Influence of an informed elicitation of the prior belief of chronological age was also studied by means of a sensitivity analysis. RESULTS: Outcomes in terms of accuracy were adequate with standard requirements for forensic adult age estimation. Findings also indicated that the Bayesian method does not show a particular tendency towards under- or overestimation of the age variable. Outcomes of the sensitivity analysis showed that results on estimation are improved with a ration elicitation of the prior probabilities of age.

The iliac crest in forensic age estimation: evaluation of three methods in pelvis X-rays.

Age assessment in children and young adults is a relevant forensic issue. It is requested not only in evaluating criminal responsibility in youths without proper identification documents, often in relation to age thresholds, but also for release of a residency permit, and asylum seekers of minors. The analysis of the Risser sign and the iliac crest ossification process has been proposed as a useful tool for forensic age estimation. We evaluated the applicability of three different age estimation methods on a sample of 497 pelvic radiographs of Italian individuals between 10 and 25 years of age. Each method showed high reliability for both reproducibility and repeatability. The staging technique inspired by Kreitner and Kellinghaus methods (KK-MS) is easier than the Risser method in applicability, as it is not affected by the variations of ossification. We observed that all subjects who attained stage 3c of KK-MS and 5 of Risser Fr were >14 years, suggesting the benefits of these methods for that age threshold. The applicability of the area measurement method, inspired by Cameriere's approach, ranged between 12 and 20 years, but the statistical analysis showed only a moderate correlation with age. In order to evaluate the possible use of this approach it is therefore necessary to clarify and exclude external factors influencing the parameter. In conclusion, the iliac crest ossification is of interest in age estimation for forensic purposes. The evaluation of the pelvis X-ray, in addition to the other common dental and skeletal methods, could become a useful supplementary tool in age estimation for the 14 year threshold in order to fulfill forensic-level requirements.

Hemidiaphragm Paralysis after Robotic Prostatectomy: Medical Malpractice or Unforeseeable Event?

The authors present a case of suspected malpractice linked to the onset of hemidiaphragm paralysis after robot-assisted radical prostatectomy (RARP). The approach to the case is shown from a medico-legal point of view. It is demonstrated how, after a thorough review of the literature, this was not a case of medical malpractice but an unforeseeable event. This paper aims at contributing to the very few reports dealing with the onset of hemidiaphragm paralysis after RARP, thus fostering clinical knowledge of these rare events and meanwhile providing useful data for the medico-legal handling in case of alleged negligence of surgeons.

Padova Charter on personal injury and damage under civil-tort law : Medico-legal guidelines on methods of ascertainment and criteria of evaluation.

Compensation for personal damage, defined as any pecuniary or non-pecuniary loss causally related to a personal injury under civil-tort law, is strictly based on the local jurisdiction and therefore varies significantly across the world. This manuscript presents the first "International Guidelines on Medico-Legal Methods of Ascertainment and Criteria of Evaluation of Personal Injury and Damage under Civil-Tort Law". This consensus document, which includes a step-by-step illustrated explanation of flow charts articulated in eight sequential steps and a comprehensive description of the ascertainment methodology and the criteria of evaluation, has been developed by an International Working Group composed of juridical and medico-legal experts and adopted as Guidelines by the International Academy of Legal Medicine (IALM).

Age estimation for forensic purposes in Italy: ethical issues.

Age assessment in children and young adults is a relevant medicolegal issue due to the gradual increase of persons devoid of proper identification documents in European countries. Because of the illegal immigration and growing crime rates among children and adolescents, age estimation for forensic purposes is often required. The scientific research and the extensive experience of forensic experts in the last decades focused on the use of radiographic methods addressed to evaluate the degree of skeletal or dental development as the most accurate parameters to estimate the chronological age of children and adolescents. This paper analyzes the ethical issues related to age estimation procedures based on radiographic methods, showing how the ethical principles of beneficence, nonmalevolence, justice, and autonomy may be guaranteed during the execution of the age assessment in forensic practice. The procedure might be conducted in accordance with international guidelines and protocols, though they need a higher homogenization and standardization. A strong collaboration between various scientific societies of professionals (forensic odontologists, forensic pathologists, forensic anthropologist, radiologists, pediatricians, and psychologists), who have been involved in age estimation for years, is needed to reach this goal.

Ethical implications of Italian legislation on 'epilepsy and driving'.

The laws concerning driving licences and epilepsy in different countries are very diverse with regard to the criteria for issuance or renewal of licences, and also the methods of evaluating fitness. In 2011, a law was issued in Italy implementing the European directives on driving licences, including provisions for mandatory notification that a driver is epileptic. This was established regardless of the European rules that require compulsory notification only of patients. The Federation of Italian Boards of Physicians has made recommendations against mandated physician reporting, resulting in a current confusion between legal and ethical recommendations to medical doctors. The mandatory notification enacted by Italian law raises ethical concerns about disparities in access to care and possible violations of the right to confidentiality of patient information. Moreover, the law discussed here fails to emphasise the importance of physicians ensuring compliance by the patient, by sharing the correct information about the risks associated with illegal driving and by obtaining information from the patient through regular check-ups. An urgent revision of the law is required to implement the duty of the physician to provide information and to ensure that the rule about mandatory notification should be erased in favour of optional self-reporting by epileptics as the preferred way to notify the licensing authority. The implementation of these measures could correct the dichotomy between the law and the ethical recommendations for medical doctors and protect the rights of people with epilepsy as well as those of any other patients whose pathology or impairment could imply a risk to the community.

An unusual case of incaprettamento.

Incaprettamento is a ritual strangulation that represents a method of homicide typical of the Italian Mafia. While the victim is in the prone position, he/she is bound by one end of a rope, creating a slipknot around the throat, while the other end is used to tie the limbs behind the back. Forensic investigations reveal that in most cases, the binding of the extremities and the positioning of the victim are carried out after death due to others means and are intended to hold somebody in contempt and to punish betrayers. When the victim is tied while alive, the death is caused by self-strangulation because it is impossible to maintain the legs in this forced position. Here, we describe in detail a case with a lot of similarities to incaprettamento, although we define it as atypical because of the unusual methods of the actual binding and the circumstances in which death occurred. In fact, the investigation of the crime scene, the external and internal findings, and the histologic examination result show that this is a crime of passion.