Child Sexual Abuse: Comparison of Male and Female Victims.

ABSTRACT: In the scientific literature, few authors deal with child sexual abuse (CSA) in boys. In addition, these authors debate this phenomenon in most available articles without statistically evaluating the occurrence of different or similar distributions of variables under sex. In light of the above, the authors compared multiple variables between female and male samples. The aim was to explore the characteristics of boys' CSA, identifying the main differences existing compared with the same phenomenon occurring in girls. The authors selected 2 samples for sex: group A, females; group B, males. The authors statistically compared the main variables between the 2 groups. The study yielded the following main results: the population was characterized by 607 children (476 were females-group A; 131 were males-group B); the variables' source of the referral and the type of anogenital findings were statistically significant. These data gave new insights into the CSA phenomenon. Because this study pointed out that sexual abuse does not have the same characteristics in boys and girls, researchers and safeguarding agencies should consider the abovementioned differences when planning preventive strategies against CSA.

Traumatic hemorrhage of the thyroid as a work-related injury: a case report and review of the literature.

Traumatic hemorrhage of the thyroid gland resulting from blunt injury to the neck is a very rare event. Particular neck positions can expose the thyroid to trauma, especially in motor vehicle collisions, falls, direct blows, or sport activities. Preexisting conditions such as goiters, adenomas, and cysts can increase the risk of bleeding, reducing the force required to rupture the gland and make the thyroid more prone to injury. The authors report the case of a 53-year-old man who was involved in a fire while working on maintenance of a liquid petroleum gas (LPG)-powered car. He subsequently presented to the emergency department with painful swelling of his right anterior neck with a palpable mass. CT scan showed a right thyroid hemorrhagic cyst. The worker reported that he had jumped into the car trunk to extinguish the fire and covered the gas tank nozzle with his own body to prevent dispersal of the accelerant. In this case, the medico-legal evaluation was useful to delineate between natural and traumatic causes of the injury. Medico-legal assessment is key in understanding the dynamics involved in work-related events to identify any legal responsibilities of the worker or the employer.

Stillbirth diagnosis and classification: comparison of ReCoDe and ICD-PM systems.

OBJECTIVES: The identification of causes of stillbirth (SB) can be a challenge due to several different classification systems of SB causes. In the scientific literature there is a continuous emergence of SB classification systems, not allowing uniform data collection and comparisons between populations from different geographical areas. For these reasons, this study compared two of the most used SB classifications, aiming to identify which of them should be preferable. METHODS: A total of 191 SBs were retrospectively classified by a panel composed by three experienced-physicians throughout the ReCoDe and ICD-PM systems to evaluate which classification minimizes unclassified/unspecified cases. In addition, intra and inter-rater agreements were calculated. RESULTS: ReCoDe defined: the 23.6% of cases as unexplained, placental insufficiency in the 14.1%, lethal congenital anomalies in the 12%, infection in the 9.4%, abruptio in the 7.3%, and chorioamnionitis in the 7.3%. ICD-PM defined: the 20.9% of cases as unspecified, antepartum hypoxia in the 44%, congenital malformations, deformations, and chromosomal abnormalities in the 11.5%, and infection in the 11.5%. For ReCoDe, inter-rater was agreement of 0.58; intra-rater agreements were 0.78 and 0.79. For ICD-PM, inter-rater agreement was 0.54; intra-rater agreements were of 0.76 and 0.71. CONCLUSIONS: There is no significant difference between ReCoDe and ICD-PM classifications in minimizing unexplained/unspecified cases. Inter and intra-rater agreements were largely suboptimal for both ReCoDe and ICD-PM due to their lack of specific guidelines which can facilitate the interpretation. Thus, the authors suggest correctives strategies: the implementation of specific guidelines and illustrative case reports to easily solve interpretation issues.

An Unexpected Death Due to a Subclinical Pheochromocytoma After an Induced Abortion.

ABSTRACT: Deaths due to hypertensive crisis can be unexplained because of the impossibility to identify-before the decease-the specific cause of the crisis. In these cases, autopsy and microscopic examinations are needed. It can happen that the request to conduct these examinations can be submitted to forensic pathologists by prosecutors to ascertain medical malpractice claims. Indeed, we report the case of a 36-year-old woman who died after a minimally invasive medical procedure because of the occurrence of a severe hypertensive crisis. After death, the woman's relatives raised formal complaint for medical malpractice. For this reason, the prosecutor ordered to perform an autopsy. Examining the abdominal cavity, the forensic pathologists identified the left adrenal gland as expanded; in correspondence with organ's medulla, there was a gray and noncapsulated mass. Immunohistochemistry was performed: the microscopic samples were diffusely positive for chromogranin A, suggesting the diagnosis of a subclinical pheochromocytoma. In light of the above, medical malpractice was excluded. This case highlights that forensic pathologists should be aware that, in case of unexpected deaths due to hypertensive crisis, adrenal glands should be always accurately evaluated, performing specific immunohistochemistry study to exclude the presence of a pheochromocytoma.

Fuel tank injury in a fatal motorcycle accident.

Vehicular trauma is the most common cause of pelvic fractures. In motorcycle collisions, the driver strikes or is struck by a fixed object, and is subjected to blunt trauma and deceleration forces. Injuries around the scrotum and perineum of victims in motorcycle accidents are known as a fuel tank injuries (FTI). We report the case of a 26-year-old male motorcyclist involved in a fatal high-speed head-on collision with a car. At autopsy, purple bruising distributed symmetrically over both hips with scrotal lacerations were found. Partial bowel evisceration through an abdominal lacerated wound, extensive abdominal organ injuries and multiple fractures were also found. Considering the dynamics of the accident and the type of motorcycle he had been riding, the pelvic bruising and the scrotal injury were related to violent deceleration following the impact, leading the driver to slide forward against the fuel tank of the motorcycle.FTI is comparatively rare in motorcycle accidents because it only occurs in cases involving a head-on collision, and most drivers try to swerve or correct their direction just prior to the collision. Nevertheless, the most frequent cause of pelvic injuries in motorcyclists is caused by contact with the vehicles fuel tank during the crash. Forensic pathologists should have a better knowledge of FTIs as they are helpful in understand the dynamics of the accident and in distinguishing the driver from the passenger in two-rider motorcycle crashes.

Survey on postmortem screening and management of COVID-19 related deaths.

The COVID-19 pandemic is associated with a high case fatality rate in some countries even thought the majority of cases are asymptomatic. Scientific studies on this novel virus is limited and there is uncertainty regarding the best practices for death investigations both in terms of detection of the disease as well as autopsy safety. An online survey was conducted to identify how different institutions responded to the screening and management of dead bodies during the early phase of the pandemic from January to May. A questionnaire was developed using Google Forms and data was collected from 14 different forensic and pathological institutions in 9 countries. None of the institutions had performed any screening prior to March. Four institutions stated that screening was done routinely. In total, 322 cases had been screened using RT-PCR, out of which 40 positive cases were detected among four institutions. The commonest types of samples obtained were nasopharyngeal and oropharyngeal swabs which also had the highest rates of positivity followed by tracheal swab. Blood, swabs from cut surfaces of lung and lung tissue also gave positive results in some cases. Majority of the positive cases were > 65 years with a history suggestive of respiratory infection and were clinically suspected to have COVID-19 before death. Except for one institution which performed limited dissections, standard autopsies were conducted on all positive cases. Disposal of bodies involved the use of sealed body bags and labelling as COVID positive. Funeral rites were restricted and none of the institutions advocated cremation. There were no reports of disease transmission to those who handled COVID positive bodies.

Forensic and Clinical Issues in a Case of Motorcycle Blunt Trauma and Bilateral Carotid Artery Dissection.

Internal carotid artery dissection (ICAD) after motorcycle accidents is unusual but life threatening if not promptly diagnosed and treated. We report the case of a motorcyclist involved in a frontal collision with a car, suffering injuries due to direct blunt trauma and indirect trauma by sudden deceleration force. Bilateral ICAD was diagnosed by computed tomography angiogram 5 days after the accident. Here in, starting from a medicolegal case, we emphasized some clinical criteria to make a prompt diagnosis to prevent permanent neurological deficit in this pathology whose best management is still under the debate. An unusual case of ICAD is described with regard to both forensic and promptly diagnostic therapeutic management.

Death Shortly after Delivery Caused by Congenital High Airway Obstruction Syndrome.

Background: Congenital High Airway Obstruction Syndrome (CHAOS) is an uncommon anomaly. Prenatal ultrasonography allows a prenatal diagnosis to prepare for immediate surgical correction at birth. If the obstruction is severe and a correct therapeutic approach is not planned, CHAOS can cause neonatal death shortly after delivery from a potentially surgically correctable lesion.Case report: This neonate died unexpectedly shortly after delivery due to CHAOS. Ultrasonographic findings of enlarged echogenic lungs, dilated airways distal to the obstruction, flattened or inverted diaphragms, or ascites were absent. This was due to a type-II laryngeal-atresia and a type-C esophageal-atresia, with a resultant distal fistula that allowed intrauterine decompression of the fluid in the lungs.Conclusions: The absence of prenatal ultrasonographic findings of CHAOS may be due to a lower fistula between respiratory and gastrointestinal tracts. This set of associations may not be a surgically correctable cause of CHAOS.

Infantile Hypertrophic Cardiomyopathy and Bronchopneumonia as Causes of an Unexpected Death in an 11-Month-Old Child.

Background: Hypertrophic cardiomyopathy is characterized by intrinsic myocardial hypertrophy that is not consequent to hemodynamic stimuli. Infantile hypertrophic cardiomyopathy (<1 year of age) has a frequency of about 3.6 per 1 million children, is usually diagnosed in utero, at birth, or in the first months of life. The most common outcome of this form is heart failure that may result in the death of the child. Case Report: We present an 11-month old infant with hypertrophic cardiomyopathy, complicated by terminal bronchopneumonia, without the typical clinical signs/symptoms in which the diagnosis was made only after postmortem examination. Conclusion: The present report depicts that IHCM may present with the unexpected death of an infant.

Two autopsy cases of siblings with alveolar capillary dysplasia: clinical and post-mortem issues.

Alveolar capillary dysplasia with misalignment of pulmonary veins (ACD/MPV) is a rare but fatal lung disorder, which causes persistent pulmonary hypertension of the newborn (PPHN) and which is unresponsive to treatment. We report the case of two siblings, both of whom died a few hours after birth because of severe pulmonary failure. Post-mortem histology confirmed ACD/MPV as the cause of death in both cases, and genetic analysis identified the same 16p13.3 deletion. ACD/MPV can occur suddenly in apparently healthy newborns after a regular pregnancy, and always leads to death. Nevertheless, an autopsy is not always performed after the death of an infant. For these reasons ACD/MPV represents a challenge for diagnosis and therapeutic management with medicolegal implications. Prenatal assessment of ACD/MPV is very difficult, and it should be suspected when irreversible and persistent fetal circulation occurs rapidly in newborns. An early diagnosis during pregnancy would facilitate adequate counselling regarding treatment and prognosis. When death occurs, a complete autopsy with histological and genetic investigations is recommended in order to define the exact cause of death, and potentially inform appropriate genetic counselling of family members who could be affected by hereditary disorders.

Occult cardiac amyloidosis: the last chapter of a 2-year long story.

Amyloidosis is characterized by deposition of insoluble fibrillar proteins in organs and tissues. The prognosis depends on where in the body amyloid deposition occurs, the amount of deposition, and the symptoms, which are often unspecific. Cardiac involvement is commonly associated with the immunoglobulin light-chain amyloidosis (AL) and may lead to sudden death. The case of a 53-year-old man's death due to unsuspected, undiagnosed AL predominantly involving the myocardium has been reported. His medical history had begun with gastroenterological symptoms. Angina pectoris and brain stroke occurred in the following years. He died after two years during the surgical implantation of a cardioverter-defibrillator because of cardiogenic shock. Post-mortem histologic examination revealed the presence of amyloid material in the lymph nodes, lungs, liver, spleen, kidneys, adrenal glands, stomach, and heart. The cause of death was cardiac failure secondary to primary systemic amyloidosis predominantly involving the heart. This case demonstrates that amyloidosis should be considered within the differential diagnoses and actively investigated in patients with unspecific and long-lasting symptoms; medical liability may also be suspected.

Differential diagnosis between physical maltreatment and cupping practices in a suspected child abuse case.

Physical maltreatment is one of the most common forms of child abuse. Cutaneous injuries often raise the suspicion of child maltreatment. Nevertheless, among health professionals there is still uncertainty in the evaluation of such injuries. In the literature, there are few indications about the most important factors that allow the differentiation of physical abuse findings from signs/lesions that are caused by "folk medicine practices" with similar presentations. We report the case of two brothers who were brought to the Emergency Department of a pediatric hospital by their father because each of them showed one painful, circular and red-purple bruise on their back. Suspecting child abuse, the emergency physicians reported the case to a multidisciplinary unit (dedicated to child abuse). After a careful physical examination, psychological interviews, as well as the evaluation of their medical history, the operators pointed out that the lesions were the result of cupping practices (a form of folk medicine). This case highlights the need for a multidisciplinary approach and demonstrates the importance of a careful evaluation of the cultural background of the family.

An unusual work-related fatality: the importance of scene investigation combined with autopsy findings.

Transorbital penetrating intracranial injuries are uncommon amongst the civilian population, but they can be found in fatal work-related accidents. An unusual case of accidental fatal penetrating intracranial injury in a 44-year-old man at work is reported. He was working in a building site driving a tractor with a rear- mounted flail mower. While he was mowing grass close to a crane, he became unconscious and then comatose. A cranium X-Ray and a brain CAT scan taken before he died revealed the presence of a metallic foreign body in the left occipital area that had penetrated the left eyelid and orbital bone. At autopsy, a fragment of a frayed electrical copper cable was found stuck in the brain. Investigation at the scene found a cable with the same characteristics of the fragment recovered from the victim's brain protruding from the ground just beneath the tractor. It was concluded that the mower blades had severed the cable and propelled a fragment of it upwards, striking the man in the head.

Positional asphyxia in a work-related fatality.

Positional or postural asphyxia occurs when a particular body position interferes with adequate respiratory movements for a lengthy period of time. Death is usually accidental and associated with alcohol or drug intoxication, disability, or restraint. We report on the case of a 42-year-old man found unresponsive while working on farmland. The upper part of his body (head and upper limbs) was trapped in the highest and largest opening of the atomizer of a high-volume sprayer tank while his legs were hanging down. Bruises and abrasions were found on both suprascapular regions. Tramline bruises encircled the body between the abdominal and thoracic regions in line with the morphology of the tank's opening where the body was found. Cyanosis and petechial hemorrhages were found on his face, conjunctives, neck, and superior chest; the lungs were edematous. Toxicological analyses of body fluids were negative. The cause of death was postural asphyxia, and the manner of death was certified as a fatal accident at work. Work-related postural asphyxia has rarely been described in the literature. Scene investigation, autopsy, and toxicological analyses play a key role in the reconstruction of the dynamics involved in occupational events, in turn allowing the identification of any legal responsibilities of the worker or the employer.

The risk of assault against mental health professionals: a fatal case report and literature review.

Assaults by patients against healthcare providers are an increasing phenomenon worldwide. Mental health professionals in acute facilities and rehabilitation wards have the highest risk of being attacked at work. Verbal abuse or intimidating behaviors represent the most common types of violence. Fatal assault by psychiatric patients has been rarely reported in the literature. We present a case of a female psychiatrist who was fatally stabbed in her office in a Mental Health Center. At autopsy seventy stab wounds were found: four wounds of the neck, fifty penetrating wounds of the thorax, three wounds of the abdomen, six wounds of the lumbar region, and seven wounds of the upper arms including defense injuries. The cause of death was massive blood loss due to multiple stab wounds. The perpetrator was a 44-year-old male patient who had been referred to the victim after a previous admission to hospital following experiences of suicidal ideation and confusion. The extreme and unmotivated violence in a non-acute setting were notable. A borderline-antisocial personality disorder was later diagnosed by forensic experts. This case emphasizes the significant occupational risk for mental healthcare staff to sustain life threatening injuries or death, with implications for training of clinicians, and strategies for preventing aggressive behaviors.

Diagnostic Criteria for Commotio Cordis Caused by Violent Attack: Review of the Literature.

The diagnosis of lethal commotio cordis (CC) is really complex. The forensic pathologist's task is even more relevant when he/she has to explain a CC diagnosis caused by an assault in a trial. The purpose of this study was to analyze the literature on lethal CC as a result of violent attacks and identify relevant parameters that may help in the diagnosis. A review of the relevant articles was performed. Fifty-two cases of CC caused by violent attacks were identified. The collected data allowed to confirm the following literature's criteria for CC diagnosis in case of assaults: witnessed occurrence of a blunt, nonpenetrating blow to the chest preceding cardiovascular collapse; absence of structural damage to the sternum, ribs, or heart itself; and absence of any underlying cardiovascular abnormalities (such as other causes of sudden death). Regarding the assessment of the third criterion, the authors suggest that the pathologist should always specify the scientific autopsy guidelines that he/she used to differentiate CC from the other causes of sudden death. In addition, the authors highlight the importance of a multidisciplinary approach for a correct interpretation of clinical, autopsy, and laboratory findings.

Virtopsy shows a high status funerary treatment in an early 18th Dynasty non-royal individual.

This work presents the multidisciplinary investigation of the head of Nebiri (Museo Egizio, Turin S_5109), Chief of Stables, a high status elite person from the 18th Dynasty involving MDCT, 3D brain surface and facial reconstructions accompanied by a consideration of previously presented chemical analysis of the embalming materials found in fragments of bandages used on the head and viscera (lung) found in one of the four canopic jars. Comparison of the techniques used for the cosmetic treatment of Nebiri with those used in other elite and high status non-royal persons confirms the validity of the use of the term "high status elite" in the case of Nebiri. This case highlights the importance of using modern forensic techniques both to enhance new technologies of retrospective diagnosis on altered human remains and to increase knowledge of past populations.

Supporting health and social care professionals in serious illness conversations: Development, validation, and preliminary evaluation of an educational booklet.

Serious illness conversations aim to align the care process with the goals and preferences of adult patients suffering from any advanced disease. They represent a challenge for healthcare professionals and require specific skills. Conversation guides consistent with task-centered instructional strategies may be particularly helpful to improve the quality of communication. This study aims to develop, validate, and preliminarily evaluate an educational booklet to support Italian social and healthcare professionals in serious illness conversations. A three-step approach, including development, validation, and evaluation, was followed. A co-creation process with meaningful stakeholders led to the development of the booklet, validated by 15 experts on clarity, completeness, coherence, and relevance. It underwent testing on readability (Gulpease index, 0 = lowest-100 = maximum) and design (Baker Able Leaflet Design criteria, 0 = worst to 32 = best). Twenty-two professionals with different scope of practice and care settings evaluated acceptability (acceptable if score ≥30), usefulness, feasibility to use (1 = not at all to 10 = extremely), and perceived acquired knowledge (1 = not at all to 5 = extremely). After four rounds of adjustments, the booklet scored 97% for relevance, 60 for readability, and 25/32 for design. In all, 18 (81.8%), 19 (86.4%) and 17 (77.3%) professionals deemed the booklet acceptable, moderate to highly useful, and feasible to use, respectively; 18/22 perceived gain in knowledge and all would recommend it to colleagues. The booklet has good readability, excellent design, high content validity, and a high degree of perceived usefulness and acquired knowledge. The booklet is tailored to users' priorities, mirrors their most frequent daily practice challenges, and offers 1-minute, 2-minute and 5-minute solutions for each scenario. The co-creation process ensured the development of an educational resource that could be useful regardless of the scope of practice and the care setting to support professionals in serious illness conversations.

Migrant deaths and the Kater Radez I wreck: from recovery of the relict to marine taphonomic findings and identification of the victims.

On March 1997, during a naval blockade imposed by Italy to prevent illegal immigration, the motorboat Kater Radez I full of Albanian refugees clashed with an Italian warship with 120 people approximately on board. The boat sank quickly after the collision just in the middle of the Otranto Canal (Mediterranean Sea). Only 34 individuals survived the accident; 58 died, mostly women and children, and dozens were missing. After 7 months spent at depth of 800 m approximately underwater to constant temperature of 4 °C, the motorboat was rescued, and totally, 52 bodies were recovered from the holds. The management of the mass disaster is summarized focusing on the procedures applied in the recovery of the boat and victims, and the identification process. The purpose of the article is to present the unique taphonomic model of decomposition dealing with marine sequestered environments. The postmortem changes have been revised according with a skeletonization scoring system. Surprisingly, most of the victims were in good condition with soft tissues still present except at the head/neck region and the hands resulting in the body parts mostly pre-skeletonized. Closed compartments as well as heavy clothing in multiple layers protected the bodies from animal activity of marine scavengers. Presumptive positive identification was obtained in 49 out of 52 bodies based on the correspondence between ante- and postmortem data. An additional purpose of the article is also to focus on the practice of coercive actions disproportionate to the risk of unauthorized entry criticized by several international organizations for migration and recently condemned by the European Court in Strasbourg.

Knowledge of child abuse and neglect in nursing students: Assessment and perspectives.

Misdiagnosis of child abuse and neglect can delay early treatment. Some authors have pointed out that nurses can miss child abuse and neglect diagnoses due to a lack of knowledge. It is unclear whether the lack of knowledge is due to students' insufficient preparation in nursing school and/or a deficiency in continuing education. An 18-item questionnaire was administered to final-year nursing students to assess their degree of knowledge on child abuse and neglect and to evaluate if the lack of knowledge was due to insufficient teaching/training during nursing school. The students were also asked to evaluate themselves by assigning a score to their knowledge. A statistical comparison was performed to define whether sufficient/insufficient results were associated with the following variables: sex, pediatric or general nursing student, attending pediatric lectures, training in pediatric wards/ambulatories, and attending specific lectures on child abuse and neglect. The study population comprised 175 students (154 females, 20 males, 1 unknown). Exactly 66.3% of the participants had ≤9/18 correct answers. Of all students, 77.7% self-evaluated their level of knowledge as ≤5/10. The comparisons yielded statistically significant differences between the groups with sufficient objective knowledge and those unrelated to training in pediatric wards/ambulatories or pediatric nursing students. Overall, there was little objective knowledge on the subject, which may be related to insufficient teaching/training in nursing schools. Useful corrective strategies include further teaching on child abuse and neglect, preferably using a practical approach. Further, common teaching/training programs should be conducted by both pediatric and general nursing schools.