The Role of DNA Degradation in the Estimation of Post-Mortem Interval: A Systematic Review of the Current Literature.

The determination of the post-mortal interval (PMI) is an extremely discussed topic in the literature and of deep forensic interest, for which various types of methods have been proposed. The aim of the manuscript is to provide a review of the studies on the post-mortem DNA degradation used for estimating PMI. This review has been performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the PRISMA Guidelines. Several analytical techniques have been proposed to analyse the post-mortem DNA degradation in order to use it to estimate the PMI. Studies focused mainly on animal models and on particular tissues. The results have been mixed: while on the one hand literature data in this field have confirmed that in the post-mortem several degradation processes involve nucleic acids, on the other hand some fundamental aspects are still little explored: the influence of ante and post-mortem factors on DNA degradation, the feasibility and applicability of a multiparametric mathematical model that takes into account DNA degradation and the definition of one or more target organs in order to standardize the results on human cases under standard conditions.

Analysis of RNA in the estimation of post-mortem interval: a review of current evidence.

Post-mortem interval (PMI) determination is one of the most important issues in forensic sciences. In the past, forensic scientists provided different approaches (physical, chemical, and entomological) for the estimation of PMI without success.However, advances in molecular biology over the last two decades have allowed us to assess the time-dependent degradation of biological markers (e.g., proteins, DNA, and RNA). Thus, the aim of the manuscript is to provide a review of the recent progress in the estimation of PMI using molecular biology methods, mainly focusing on the potential usefulness of RNA markers. To this end, 29 studies have been systematically reviewed, each one chosen according to specific inclusion/exclusion criteria. The selected studies evaluated the contribution of endogenous reference genes in different biological samples in order to determine the PMI based on post-mortem RNA degradation as a function of other influencing factors such as time, cause of death, and environmental conditions.

Proposal for the Application of a Quality Indicator to Medico-legal Consultations in the Field of Medical Liability.

INTRODUCTION: In recent decades, the number of professional liability disputes has increased, especially in the civil sector. In these liability assessments, medico-legal experts have become the linchpin. Law No. 24/2017, concerning professional liability in Italy, requires that guidelines and best practices be established to identify the necessary elements for writing expert reports in the legal sector. MATERIALS AND METHODS: The authors have created a numerical indicator to be applied to 150 legal expert reports on professional liability, enabling them to evaluate the methodological quality of those reports. The results are then compared with the outcome of the legal proceedings in order to establish the suitability of this quality index for evaluating the work of medico-legal experts. RESULTS: Of the 150 reports considered, 14 were scored inadequate, 75 adequate and 31 good. These inadequate (according to the indicator) reports presented a higher probability of being scored inadequate in court proceedings, compared to the risk of inadequacy of all the reports; OR 4.6 (95% CI 1.25-16.90). This probability significantly increased on comparing the inadequate reports with the adequate; OR 5.6 (95% CI 1.28-24.41), and the inadequate with the good; OR 7.73 (95% CI 1.50- 39.87). DISCUSSION: Application of the proposed indicator is simple and produces a high-quality result, thus ensuring an accurate and tenable appraisal of methodological quality. CONCLUSION: The indicator proposed serves as a useful starting point for creating the necessary methodological standards for medico-legal experts in the field of professional liability as recommended by Law No. 24/2017.

Seventeen-Year Medical Professional Liability Experience in a Level III University Hospital.

INTRODUCTION: In recent decades, the number of medical professional liability disputes has grown exponentially, becoming a well-studied aspect of public healthcare. Legal medicine is an essential tool in managing this phenomenon. METHODS: This article reports the results of the analysis of disputes for medical professional liability in a Level III University Hospital in Italy. The study covers the time period from 01.01.2003 to 31.12.2019. RESULTS: About 33% of claims have been compensated. Those claims fall within the following categories: 37% in the surgical field, 17% in the field of internal medicine, and 35% in the emergency care field. As for the types of a medical mistake, compensation was awarded in 30% of diagnostic error cases, 26% of therapeutic error cases, 47% of execution error cases, and 55% of organizational deficiency cases. DISCUSSION: The difference in the rate of compensation between the various medical fields or types of error depends on specific medico-legal characteristics. The aim of advanced healthcare systems is to prevent medical liability disputes by analyzing this phenomenon and improving clinical risk management programs. In particular, according to our study, events related to organizational deficiencies are the most preventable. In addition, through the use of a dedicated reporting procedure, medico-legal analysis of malpractice cases may be the key to risk reduction. CONCLUSION: Every major hospital should set up a medico-legal watchdog responsible for collecting and analyzing information on professional medical liability disputes in order to prevent and manage such events.

A case of lethal varicose vein rupture caused by massive leiomyoma.

Varicose veins are a common and benign disease, especially affecting the lower limbs of the elderly. This pathology can exhibit several complications, which in the majority of cases do not require medical treatment; life-threatening conditions are possible but extremely rare. We present here a suspected murder case in which a woman was found dead in her home with a large amount of blood soiling the floor and the furniture of her house. Death scene investigation (DSI) with body inspection and bloodstain pattern analysis (BPA) were not exhaustive in excluding a homicide, and the prosecutor asked for a forensic autopsy. During the dissection, a uterine neoplasia, which altered the lower limb venous system, was detected, thus allowing to reconstruct the physio-pathological mechanism of the formation and rupture of the varicose vein.

Mycobacterium Chimaera: Clinical and medico-legal considerations starting from a case of sudden acoustic damage.

Mycobacterium Chimaera is a microorganism that can cause nosocomial infections particularly in patients undergoing cardiac surgery. The specific case presented herein shows an original clinical presentation of the infection: sudden unilateral deafness as a result of septic embolization. Medico-legal experts appointed by the court in a civil liability dispute analyzed the case and submitted their expert opinion. This article analyzes the peculiar and innovative aspect of professional liability that can be attributed to the healthcare facility and the manufacturer of the equipment used in the operating room from a medical-legal point of view.

The clinical legal medicine: a need for quality of care and patient's safety. A single center five-year experience.

INTRODUCTION: Clinical legal medicine is a branch of legal medicine that takes place in a clinical setting approaching the patient's bedside and using a particular attention not only for conceptual or normative references but also for every possible medical and social aspect. MATERIAL AND METHODS: The requests of medico-legal opinions received by the Department of Legal Medicine of a large university hospital were retrospectively collected over a 5-years period. The analysis focused on the recurrence rate of the requests and the most common medico-legal issues to be solved in a clinical context, differentiating between adult and minor patients. RESULTS: The collected medico-legal advices amounted to 448. The most clearly involved clinical area was Medicine (54%) followed by Gynecology and Obstetrics (15.6%), Pediatrics and Surgery (10.7%). The requests concerning patient's self-determination in therapeutics choices, including refusal of proposed treatments, covered almost one-half of total casuistry. The designation of support administrator represented also a relevant issue (20.5%). In case of minors, the queries related to reporting crimes were three times higher than in adults, while the appointment of a support administrator was never requested. CONCLUSION: Clinical legal medicine, through medico-legal advices, plays a primary role in contributing to the safeguarding of health and to the decision-making process of clinicians.

The state of knowledge of young Italian medicolegal doctors on the law of provisions for informed consent and advance treatment directives: a multi-centric survey two years after the enactment of Law 219 of 2017.

BACKGROUND: On 22 December 2017, Law number 219 was approved in Italy entitled "Provisions for informed consent and advance treatment directives". We aim to examine the knowledge of these provisions of Italian medico legal fellows, and the ability of Italian university healthcare facilities to implement the principles of the new law. METHODS: A survey was conducted by means of a questionnaire sent to members of a scientific society. The society had 357 members and represents more than 75% of the Italian doctors in training and 32 university healthcare facilities in Italy. 27 facilities and 45% of the society's members participated in this enquiry. RESULTS: The majority (68%) of those interviewed felt they had acquired an adequate knowledge of the Law but only 60% of them were able to indicate how for filing legally valid advance directives (60% vs. 40%) and only 37% knew how drafting a shared care plan. 89% of the pool felt that legal recognition of a patient's self-determination was useful for enhancing the care relationship. The 74% of the facilities analyzed have organized training activities regarding the contents of the law but only 26% have updated their procedures on the practical implementation of the law and their informed consent forms. 60% of the facilities perform medico legal consultation activities and in 15% of the facilities, there has been resistance to the application of the law. CONCLUSION: Many of the facilities have performed training activities but lack effective implementation of the activities required. With increased knowledge and organization this could be overcome.

Genetic identification of endoscopic biopsies after unnecessary gastrectomy: Case report and medico-legal evaluation.

INTRODUCTION: Forensic genetic laboratories analyse samples included in paraffin to verify the genetic correspondence of histological samples, from living subjects or cadavers, in cases where there is a suspicion of contamination of samples with tissues of other patients. PRESENTATION OF THE CASE: A case of a man subjected to a gastrectomy as a result of a histological diagnosis of gastric adenocarcinoma after endoscopic biopsies is reported. The microscopic analysis on the gastric tissue after the gastrectomy excluded the presence of cancer. Having suspected a diagnostic error, a microscopic revision of the biopsies was performed and confirmed the presence of cancer cells but led to a hypothesis that there had been contamination with foreign intestinal tissue. The genetic analysis performed on various pieces of tissue, despite the reduced amount of biological material, succeeded in identifying the presence of two incomplete genetic profiles, one of which belonged to a subject of the opposite sex. DISCUSSION: The case raised many questions about the process of setting up histological specimens. Even though it is impossible to identify the healthcare professionals responsible for contamination, the organizational error during the management of biopsies has significantly affected the clinical case of the patient, who underwent a gastrectomy for cancer that was not present. CONCLUSION: This case is not simply an example of diagnostic error and related unnecessary surgery, but it has raised some doubts about patient management and it has led us to some medical-legal cause for reflection in the field of professional liability.