European Council of Legal Medicine (ECLM) on-site inspection forms for forensic pathology, anthropology, odontology, genetics, entomology and toxicology for forensic and medico-legal scene and corpse investigation: the Parma form.

Further to a previous publication by the European Council of Legal Medicine (ECLM) concerning on-site forensic and medico-legal scene and corpse investigation, this publication provides guidance for forensic medical specialists, pathologists and, where present, coroners' activity at a scene of death inspection and to harmonize the procedures for a correct search, detection, collection, sampling and storage of all elements which may be useful as evidence, and ensure documentation of all these steps. This ECLM's inspection form provides a checklist to be used on-site for the investigation of a corpse present at a crime or suspicious death scene. It permits the collection of all relevant data not only for the pathologist, but also for forensic anthropologists, odontologists, geneticists, entomologists and toxicologists, thus supporting a collaborative work approach. Detailed instructions for the completion of forms are provided.

Markers of mechanical asphyxia: immunohistochemical study on autoptic lung tissues.

Forensic pathologists are often asked to provide evidence of asphyxia death in the trial and a histological marker of asphyxiation would be of great help. Data from the literature indicate that the reaction of lung tissue cells to asphyxia may be of more interest for forensic purposes than migrating cells. The lungs of 62 medico-legal autopsy cases, 34 acute mechanical asphyxia (AMA), and 28 control cases (CC), were immunostained with anti-P-selectin, anti-E-selectin, anti-SP-A, and anti-HIF1-α antibodies, in order to verify if some of them may be used as markers of asphyxia death. Results show that P- and E-selectins expression in lung vessels, being activated by several types of trigger stimuli not specific to hypoxia, cannot be used as indicator of asphyxia. Intra-alveolar granular deposits of SP-A seem to be related to an intense hypoxic stimulus, and when massively present, they can suggest, together with other elements, a severe hypoxia as the mechanism of death. HIF1-α was expressed in small-, medium-, and large-caliber lung vessels of the vast majority of mechanical asphyxia deaths and CO intoxications, with the number and intensity of positive-stained vessels increasing with the duration of the hypoxia. Although further confirmation studies are required, these preliminary data indicate an interesting potential utility of HIF1-α as a screening test for asphyxia deaths.

A novel method for the simultaneous determination of drugs of abuse, ethyl glucuronide and synthetic opioids in human hair through a single digestion, purification and analysis in LC-MS/MS.

Polydrug use is a serious health and social problem worldwide. Over the past several years, there has been an increasing tendency to combine narcotics, alcohol, sedatives, and/or stimulants. To the traditional drugs of abuse and alcohol, an increase of new abuse drugs such as synthetic opioids has been added. In the current study, the development and validation of an innovative and fast analytical procedure has been presented to determine drugs of abuse, ethyl glucuronide and synthetics opioids in 30 mg of human hair through a single digestion, purification and analysis in LC-MS/MS. A combine simple preparation of hair sample followed to a single chromatographic run of 10 min has been proposed. A full validation for 54 target analytes for the parameters of selectivity, linearity, limit of detection, limit of quantification, accuracy, precision, matrix effects, recovery, and dilution integrity was successful completed. The method was linear in different ranges with r values of at least 0.990; the value to the validated LLOQ values were in the range 0.1-100 pg/mg. The method offered satisfactory precisions (CV<15 % and accuracy ± 20 %). In conclusion, a significant reduction in the overall times of the analytical procedure and the reduction of consumables costs make this method extremely advantageous and undoubtedly useful in routine laboratory workflow analyses and open the way to the prospect of a further implementation which also includes other classes of xenobiotics.

Malpratice claims in cardiology and cardiac surgery: A medico-legal issue.

Medical liability has become a challenge in every physician's modern practice with the consequent loss of the physician's autonomy and an increase in "defensive medicine". From this perspective, the role of Legal Medicine in assessing medical liability has become increasingly specific and a homogenization of the methods of ascertainment is increasingly necessary, since such a process can contribute to strengthening the guarantees in professional liability procedures. Focusing on malpractice claims in the field of cardiology, the complexity of the management of cardiac pathologies and the frequency of severe adverse events implies the importance of a multi-disciplinary approach, together with the application of a shared ascertainment methodology. In particular, it is essential for the forensic pathologist to collaborate with experts in cardio-pathology, cardiology and/or cardiac surgery in cases of alleged medical liability in the cardiologic field and to follow the guidelines which have been produced to assist the expert dealing with deaths reflecting cardiac disease, in order to prevent criticism of case analysis in medico-legal environments and to promote the standardization of the structure of the juridical-legislative medical malpractice lawsuits.

Pulmonary embolisation of bone fragments from penetrating cranial gunshot wounds.

Bone embolism is a very rare event that usually occurs in trauma-induced septic bone lesions, after bone surgery or after bone marrow transplantation, and normally remains silent. To our knowledge, there are no previous reports of bone embolism after a gunshot to the head. We describe a case of pulmonary embolism associated with bone fragments after a gunshot to the head in which bone fragments surrounded by leukocytes, interstitial and intra-alveolar oedema and haemorrhage around the embolised vessels, leukostasis and fat and bone marrow embolism suggest that the survival time from the gunshot was sufficiently long to allow changes in lung microcirculation and lung tissue.

Death due to crush injuries in a compactor truck: vitality assessment by immunohistochemistry.

We present a case in which the timing of injuries was requested to determine whether the death of a man found in a landfill was due to homicide or accident. The use of immunohistochemistry to detect P-selectin and E-selectin on endothelial cells of vessels in damaged skin samples, and compare them with intact skin samples, as well as the presence of lung adipose embolism provide information on the timing of the injury, thereby helping substantially to identify the dynamics of death.

Road traffic deaths: A retrospective analysis (2009-2019) in the north of the Italian region Emilia Romagna.

OBJECTIVE: International literature and several national studies demonstrate that alcohol and illicit drugs impair driving abilities, diminishing the level of attention, and cause traffic accidents. In Italy, driving under the influence of alcohol or drugs is regulated by Articles 186 and 187 of the National Street Code, which defines penalties and fines for the convicted. The aim of this study was the collection of all available data from 2009 to 2019 focusing on deaths related to road accidents in the Unit of Legal Medicine of Department of Medicine and Surgery at the University of Parma, in order to assess any consumption of alcohol, illicit drugs, and medicinal drugs among drivers. METHODS: Data were retrieved from autopsy reports found at the Unit of Legal Medicine of Parma University related to 327 subjects who died following road accidents in the Italian areas of Parma, Reggio-Emilia, and Piacenza. The population was divided into subgroups according to age, gender, crash time, and drug positivity. RESULTS: Those in the age group 46 to 65 years old were involved in the most accidents, whereas the category with fewest members included subjects under 26 years old. The majority of road accidents occurred during the daytime and on weekends. Among the toxicological investigations carried out (only for drivers), the highest prevalence was found for alcohol (43.1%), followed by illicit drugs (14.4%) and medicinal drugs (7.8%). The prevalence of alcohol and illicit drugs in combination was 11.8%. Regarding subjects positive for alcohol and illicit drugs in combination, 44.4% had a blood alcohol concentration (BAC) > 1.5 g/L and overall, in 61.1% of the total cases a BAC > 0.81 g/L was detected. CONCLUSIONS: Our results are in line with national and international studies highlighting the prevalence of high BAC levels in most of the cases. Confirmation analyses on blood collected from people who died following road accidents showed levels of BAC above 0.8 g/L (threshold for penal sanctions) in the majority of the subjects who tested positive for alcohol. They also revealed cocaine, cannabis, and benzodiazepines as the most common illicit drugs and medicinal drugs used, respectively, as demonstrated in several international studies.

A medico-legal definition of femicide.

Femicide refers to the extreme form of violence against someone belonging to the female gender, i.e. the killing of a woman. Research shows that, to date, gender-based violence remains largely a hidden phenomenon with prevalence often being underestimated by official statistics and data missing in numerous countries. It can be argued that the under-reporting may be suggestive of a legislative gap that needs addressing. This work aims to reach a shared medico-legal definition of femicide stemming from a comprehensive review of the current legislation of countries around the world. In addition, it appraises forensic pathology studies focusing on the murder of women as well as the most relevant documents published by prominent international organizations fighting violence against women. Review of the literature shows a scarcity of national legislations concerning specifically femicide, despite the attention given to this phenomenon by international organizations fighting violence against women. Additionally, a non-homogeneous framing of the term femicide arises from the forensic pathology literature and national laws. Starting from one of the funding principle of medical ethics - autonomy - authors propose to define femicide as a murder perpetrated because of a failure to recognize the victim's right to self-determination. This definition would give the forensic pathologist a central role in identifying femicide cases among the murders of women. A shared forensic approach is needed, ideally employing standardized methodology to compare international data and to standardize scientific research in the field.

Iatrogenic damage to the mandibular nerves as assessed by the masseter inhibitory reflex.

Iatrogenic injury of the inferior alveolar or lingual nerves frequently leads to legal actions for damage and compensation for personal suffering. The masseter inhibitory reflex (MIR) is the most used neurophysiological tool for the functional assessment of the trigeminal mandibular division. Aiming at measuring the MIR sensitivity and specificity, we recorded this reflex after mental and tongue stimulations in a controlled, blinded study in 160 consecutive patients with sensory disturbances following dental procedures. The MIR latency was longer on the affected than the contralateral side (P < 0.0001). The overall specificity and sensitivity were 99 and 51%. Our findings indicate that MIR testing, showing an almost absolute specificity, reliably demonstrates nerve damage beyond doubt, whereas the relatively low sensitivity makes the finding of a normal MIR by no means sufficient to exclude nerve damage. Probably, the dysfunction of a small number of nerve fibres, insufficient to produce a MIR abnormality, may still engender important sensory disturbances. We propose that MIR testing, when used for legal purposes, be considered reliable in one direction only, i.e. abnormality does prove nerve damage, normality does not disprove it.

Surgical margin marking for high-risk basal cell carcinomas of the cephalic region: a single-centre experience.

AIM: Mohs micrographic surgery is the treatment of choice for basal cell carcinomas (BCCs) at high risk for local recurrence. This procedure is scarcely employed in Italy, even when it appears necessary, for different causes, including high costs, organization problems, or low professional experience with the technique. Aim of this study is to report our experience with the "surgical margin marking", as alternative to standard Mohs micrographic surgery in the management of high-risk BCCs of the head and neck region. METHODS: A retrospective analysis on 102 (64 males and 38 females; mean age: 66.8 years; median: 68 years; range: 53-87 years) of 208 patients with high-risk basal cell carcinomas of the head and neck region, submitted to surgical margin marking has been made. All cases had completed a 3-year follow-up. Primary tumours were 52 (51%), recurrent tumours were 50 (49%). RESULTS: The mean number of micrographic surgery stages for a complete tumour clearance was 1.65 (range: 1-4 stages). In 47% (N.=49) of cases the tumours were removed by a single stage, while in 42.1% (N.=43) of patients two stages were required. Only 2 patients (2%) showed recurrences during a mean follow-up of 61.2 months (median: 62 months; range: 37-84 months). CONCLUSION: Our experience supports the effectiveness of the surgical margin marking technique in the treatment of high-risk basal cell carcinomas of the cephalic region. It may represent an alternative approach to Mohs micrographic surgery in dermatologic departments of many hospitals, where standard Mohs micrographic surgery is more difficult to perform.

Mephedrone and chemsex: a case report.

The chemsex or slamsex phenomenon has attracted attention worldwide, with concerns also expressed by health professionals for the spread of sexually transmitted diseases. Mephedrone or 4-methylmethcathinone, a substituted cathinone homolog of ephedrine, is one of the most popular substances used as a cheaper alternative to other traditional drugs. Fatal cases of chemsex are still rare. We present here the first case-report to the best of our knowledge of a mephedrone-related acute toxicity case in Parma (Italy) detected and quantitated in biological specimens (2.0 mg/L in urine sample, 1.1 mg/L in bile and 1.0 mg/L in central blood while 0.8 mg/L in peripheral blood). None of the other most common drugs of abuse could be detected. Autopsy findings such as facies edematosa, oedema and polyvisceral congestion, interstitial petechiae are compatible elements with a death from acute cardio-respiratory failure, with peri-mortem agony of few minutes in which the cardiac hypertrophy, the moderate aortocoronary sclerosis and mephedrone injection have played a substantial role in the evaluation of the final cause due to an accidental acute intoxication with mephedrone.

Use of corneas for transplant after self-inflicted eyeballs enucleation in the Italian law.

The authors analyze from an ethical and legal point of view the case of a 37 year old man, hospitalized for four days because of a 'dissociative syndrome', who had introduced in both his orbits a portable radio antenna. Most likely, he completed the self-enuclation using his own hands. He was brought to the Ophtalmic Hospital by nurses who handed the two eyeballs to the physicians who ascertained that the corneas were intact. Then, they performed the conservative extraction. In the following days those corneas were transplanted (keratoplasty) on two subjects on the waiting list at that hospital. The case raises the question of whether it is lawful and ethically acceptable to take, for transplant use, the corneas of a mentally incapable patient who has excised his own eyeballs. The authors analyze the case from the angle of the Italian law and Oviedo Convention. Neither of them has a specific regulation on this topic. It is therefore necessary to apply general principles that holdvalidfor Italy and a variety of countries worldwide. Particularly, the choice to use the corneas for transplant did not prejudice the physical integrity of the patient, who could no longer utilize his own eyeballs. His self-determination has not been affected; in fact, he was not in the position to make a conscious decision. Additionally, the so-called "implied consent" could be applied. Therefore, the principle of human solidarity, which is the moral duty to benefit others, seems to prevail in the case at hand.

Italian law on the vehicular homicide: medical legal issues and comparative analysis.

Law no. 41/2016, enacted after a parliamentary debate characterized by a strong media pressure, intends to give a strong response to the growing social alarm caused by road accidents causing deaths. In this perspective, it introduced the categories of road homicide and road injuries within the Penal Code and the new hypotheses of mandatory and facultative arrest in flagrante delicto. This paper aims at comparing the rules by which the United Kingdom, France, Spain, Germany and Italy protect people's lives and safety of vehicular traffic in order to highlight strengths and weaknesses with a view to future reforms. A survey on the European legislature highlights that, while other countries tend to criminally sanction several dangerous driving conducts, Italy has preferred, on the one hand, to punish only with administrative sanctions some violations related to reckless driving (with the exception of driving under the influence of alcohol and drugs) and, on the other, to provide for particularly harsh prison sentences in the case of vehicular homicide. The authors criticize this approach and other aspects of the new law. Moreover, it seems that the legislator's aim has not been achieved because traffic accidents have not decreased. They also believe that better results could be obtained by increasing controls on the roads and developing a policy of economical investments which improves road safety.

Demonstration of Ollulanus tricuspis in the stomach of domestic cats by biopsy.

Ollulanus tricuspis is a small nematode of the family Ollulanidae, found in the stomach of domestic cats and other felids. Of 131 gastric biopsy samples collected at endoscopic examination, four were shown to contain the parasite. Vomiting was the main presenting sign in three cats and weight loss in the fourth. The stomachs were grossly normal on endoscopic examination. Chronic gastritis was observed histologically in two cases, while the remaining cases were microscopically normal. The significance of the parasite remained undetermined. To our knowledge, this is the first report of O. tricuspis infection in domestic cats in which the diagnosis was made by examining routine endoscopic biopsy samples.

Postanaesthetic tracheal strictures in three rabbits.

Within an 11-day period, three rabbits were anaesthetized for neutering. All were endotracheally intubated with 12 cm long, 2.5 mm (inner diameter [ID]) polyvinylchloride (PVC) tubes. All rabbits developed clinical signs of dyspnoea and upper respiratory tract obstruction, 17-21 days later. One rabbit was found dead; the other two were treated, but one was euthanized and one died. At necropsy examination, focal chronic inflammation and significant localized narrowing of the tracheal lumen was found in all cases. The affected sites corresponded to the position of the bevel of the endotracheal tube (ETT) during anaesthesia. Histopathology could not differentiate between a traumatic or chemical cause for the narrowing. Possible causes include trauma by the bevel of the ETT when turning the rabbit or preparing the surgical site or a chemical burn from incorrect disinfection or inadequate rinsing of the tubes. Iatrogenic tracheitis should be considered as a cause of dyspnoea, when clinical signs arise 2-3 weeks after anaesthesia.

Synthesis and pharmacological evaluation of poly(oxyethylene) derivatives of 4-isobutylphenyl-2-propionic acid (ibuprofen).

The synthesis of three oligomeric derivatives of 4-isobutylphenyl-2-propionic acid (ibuprofen), namely, the monoester of tetraethylene glycol (I) and the diesters of poly(oxyethylene) samples having molecular weights of 1000 (+/- 50) and 2000 (+/- 150) (II and III), has been performed via the imidazolide method. The antiinflammatory activity of I-III, and of equivalent amounts of free drug, was determined in the carrageenan-induced rat paw edema assay at different times after oral administration and found to be considerably prolonged in the case of the three derivatives. The lowest molecular weight derivative (I) also had an enhanced initial activity with regard to 4-isobutylphenyl-2-propionic acid. These results were confirmed by measuring the plasma levels of 4-isobutylphenyl-2-propionic acid in rats at different times after oral administration.

Functional identification of rat atypical beta-adrenoceptors by the first beta 3-selective antagonists, aryloxypropanolaminotetralins.

1. We have assessed the relative abilities of compounds belonging to the new aryloxypropanolaminotetralin (APAT) class and of the reference beta-adrenoceptor-blocking agent, alprenolol, to antagonize functional responses in vitro and in vivo involving atypical (beta 3) or conventional (beta 1 and beta 2) beta-adrenoceptors. 2. The range of pA2 values for three representative APATs against inhibition of spontaneous motility in the rat isolated colon by the selective beta 3-adrenoceptor agonist, SR 58611A (8.1-8.8), was well above similarly calculated values for non-competitive antagonism of guinea-pig trachea relaxation by salbutamol (beta 2, 6.5-6.9) and the atrial chronotropic response by isoprenaline (beta 1, 6.7-7.3). Alprenolol, however, was substantially more potent in antagonizing atrial (pA2, 8.2) and tracheal (pA2, 8.9) responses than SR 58611A mediated inhibition of colonic motility (pA2, 6.8). 3. Several APAT isomers with different configurations at the chiral carbons, when tested on isolated organs, presented stringent stereochemical requirements for beta 3-selectivity, including high antagonist potency-ratios between active and inactive enantiomers. 4. In vivo, the inhibition of colonic motility and the thermogenic response of brown adipose tissue elicited in rats by the selective beta 3-adrenoceptor agonists SR 58611A and BRL 37344 respectively were substantially diminished by the representative APAT, SR 59230A, at oral doses (< or = 5 mg kg-1) well below those half maximally effective (ID50) for preventing beta 1-(isoprenaline tachycardia > or = 80 mg kg-1) or beta 2-(salbutamol bronchodilatation, 44 mg kg-1) mediated responses. Alprenolol, as expected, was a less potent and nonselective antagonist of the putative beta 3-responses. 5. These findings support APATs as the first potent, orally effective selective antagonists at beta 3-adrenoceptors, and provide final unambiguous evidence that beta 3-adrenoceptors underlie inhibition of colonic motility and brown adipose tissue thermogenesis in rats.

Detection and significance of adenoviruses in cases of sudden infant death.

Respiratory tract infections have been thought to act as a trigger mechanism in sudden infant death. In 118 autopsy cases of infant death, paraffin-embedded or frozen lung tissues were investigated by means of a nested polymerase chain reaction (PCR) to detect adenovirus (AV) DNA. The primers used are general primers and allow the detection of most pathogenic adenoviruses with high specificity and sensitivity and independently of devitalization of viruses or degradation of viral DNA. For the investigation three groups were established: there were 13 cases of unnatural death, 78 cases of natural death without histological signs of interstitial pneumonia, and 27 cases with interstitial pneumonia. The first group was AV negative. In the group without interstitial pneumonia AV was detected in 10.2% of the cases. In the group with interstitial pneumonia the frequency of AV detection was almost 26%. The results obtained demonstrate an association between interstitial pneumonia and detection of AV DNA, indicating that AV may play an important part in pulmonary infection in infants. Histological evidence of interstitial pneumonia was not observed in all AV-positive cases, perhaps because nonspecific virus-related changes occurred only in early stages of viral infection. Comparison of the AV frequency in SIDS (25%) and non-SIDS cases (4%) indicates an association between pulmonary AV infections and sudden death. These results support the working hypothesis of respiratory infections acting as a trigger mechanism in sudden infant death.