The effect of the medico-legal evaluation on asylum seekers in the Metropolitan City of Milan, Italy: a pilot study.

In the present-day situation, the clinical forensic documentation of an asylum seeker's narrative and his or her examination, together with the physical and psychological findings, may have very important effects on the outcome of the request for political asylum. Since 2012, the Municipality of Milan, the University Institute of Legal Medicine, and other institutions have assembled a team with the task of examining vulnerable asylum seekers and preparing a medical report for the Territorial Commission for International Protection (Prefecture, Ministry of Interiors), who will assess the application. We compared medico-legal reports and outcomes of 57 cases which were evaluated by the Commission after having undergone a medico-legal evaluation through the Istanbul Protocol criteria and examined, in particular, which medico-legal variables seem associated to the outcome. The results show that forensic assessment seems to have a significant and interesting correlation with the final assessment given by the Commission. For example, the higher the level of consistency, according to the Istanbul Protocol, the more frequently protection is granted. These data show how important clinical forensic medicine can be in such scenarios and how the presence of clinical forensic experts should be encouraged in such evaluations, as has been recently enshrined in Italy in the guidelines of a Ministerial Decree of April 3rd, 2017 for the assistance and the rehabilitation as well as the treatment of psychiatric disorders in refugees and asylum seekers who have undergone torture, rape, and other severe forms of psychological, physical, or sexual violence.

Skeletal idiopathic osteosclerosis helps to perform personal identification of unknown decedents: A novel contribution from anatomical variants through CT scan.

Personal identification consists of the comparison of ante-mortem information from a missing person with post-mortem data obtained from an unidentified corpse. Such procedure is based on the assessment of individualizing features which may help in providing a conclusive identification between ante-mortem and post-mortem material. Anatomical variants may provide important clues to correctly identify human remains. Areas of idiopathic osteosclerosis (IO), or dense bone islands (DBIs) characterized by radiopaque areas of dense, trabeculated, non-inflamed vital bone represent one of these, potentially individualizing, anatomical features. This study presents a case where the finding of DBI was crucial for a positive identification through CT-scan. A decomposed body was found in an apartment in June 2014 in advanced decomposition and no dental records were available to perform a comparison for positive identification. Genetic tests were not applicable because of the lack of relatives in a direct line. The analysis of the only ante-mortem documentation, a CT-scan to the deceased dating back to August 2009, showed the presence of three DBIs within the trabecular bone of the proximal portion of the right femur. The same bony district was removed from the corpse during the autopsy and analysed by CT-scan, which verified the presence of the same features. Forensic practitioners should therefore be aware of the great importance of anatomical bone variants, such as dense bone islands for identification purposes, and the importance of advanced radiological technique for addressing the individualizing potential of such variants. We propose that anatomical variants of the human skeleton should be considered as being "primary identification characteristics" similar to dental status, fingerprints and DNA.

Application of age estimation methods based on teeth eruption: how easy is Olze method to use?

The development of new methods for age estimation has become with time an urgent issue because of the increasing immigration, in order to estimate accurately the age of those subjects who lack valid identity documents. Methods of age estimation are divided in skeletal and dental ones, and among the latter, Olze's method is one of the most recent, since it was introduced in 2010 with the aim to identify the legal age of 18 and 21 years by evaluating the different stages of development of the periodontal ligament of the third molars with closed root apices. The present study aims at verifying the applicability of the method to the daily forensic practice, with special focus on the interobserver repeatability. Olze's method was applied by three different observers (two physicians and one dentist without a specific training in Olze's method) to 61 orthopantomograms from subjects of mixed ethnicity aged between 16 and 51 years. The analysis took into consideration the lower third molars. The results provided by the different observers were then compared in order to verify the interobserver error. Results showed that interobserver error varies between 43 and 57 % for the right lower third molar (M48) and between 23 and 49 % for the left lower third molar (M38). Chi-square test did not show significant differences according to the side of teeth and type of professional figure. The results prove that Olze's method is not easy to apply when used by not adequately trained personnel, because of an intrinsic interobserver error. Since it is however a crucial method in age determination, it should be used only by experienced observers after an intensive and specific training.

Does cone beam CT actually ameliorate stab wound analysis in bone?

This study aims at verifying the potential of a recent radiological technology, cone beam CT (CBCT), for the reproduction of digital 3D models which may allow the user to verify the inner morphology of sharp force wounds within the bone tissue. Several sharp force wounds were produced by both single and double cutting edge weapons on cancellous and cortical bone, and then acquired by cone beam CT scan. The lesions were analysed by different software (a DICOM file viewer and reverse engineering software). Results verified the limited performances of such technology for lesions made on cortical bone, whereas on cancellous bone reliable models were obtained, and the precise morphology within the bone tissues was visible. On the basis of such results, a method for differential diagnosis between cutmarks by sharp tools with a single and two cutting edges can be proposed. On the other hand, the metrical computerised analysis of lesions highlights a clear increase of error range for measurements under 3 mm. Metric data taken by different operators shows a strong dispersion (% relative standard deviation). This pilot study shows that the use of CBCT technology can improve the investigation of morphological stab wounds on cancellous bone. Conversely metric analysis of the lesions as well as morphological analysis of wound dimension under 3 mm do not seem to be reliable.

The persistence of ligature marks: towards a new protocol for victims of abuse and torture.

One of the most frequently observed lesions in clinical forensic practice concerns the patterned abrasion on skin due to constriction by various types of ligature. Detection of ligature marks and their patterns may be fundamental for reconstructing events and supporting testimony of an aggression, sexual abuse, or maltreatment. But very little actually exists in literature concerning their detectability and how long they last. This study aims at evaluating the time of persistence and detectability of skin signs left by different types of ligatures in living persons: on the arms of three volunteers, eight different ligatures were applied; 123 tests were performed, with time of contact ranging between 1 min and 2 h and 45 min. In addition, the persistence of the shape and pattern of the ligature was evaluated 15, 30, and 60 min after a 5- and 15-min compression. Polyvinyl siloxane, applied by a gun dispenser, was used to perform a cast of the skin mark. The results show that the pattern was less distinguishable with the decrease of time of contact, going from 75 % after 10 and 15 min of contact, to 45.8 % after 1 min. Above 15 min, the specific pattern was always recognizable. In addition, a progressive decrease of the detectability of the pattern with time, respectively, up to 12.5 and 37.5 % in 5- and 15-min tests was observed. This study provides useful results for the assessment of patterned injuries in forensic pathology and clinical forensic medicine, both on dead and living persons: in addition, the use of silicone casts seems to be a reliable and cheap method for easily recording and preserving the morphological profile of skin lesions.

The juvenile face as a suitable age indicator in child pornography cases: a pilot study on the reliability of automated and visual estimation approaches.

OBJECTIVE: In cases of suspected child pornography, the age of the victim represents a crucial factor for legal prosecution. The conventional methods for age estimation provide unreliable age estimates, particularly if teenage victims are concerned. In this pilot study, the potential of age estimation for screening purposes is explored for juvenile faces. In addition to a visual approach, an automated procedure is introduced, which has the ability to rapidly scan through large numbers of suspicious image data in order to trace juvenile faces. METHODS: Age estimations were performed by experts, non-experts and the Demonstrator of a developed software on frontal facial images of 50 females aged 10-19 years from Germany, Italy, and Lithuania. To test the accuracy, the mean absolute error (MAE) between the estimates and the real ages was calculated for each examiner and the Demonstrator. RESULTS: The Demonstrator achieved the lowest MAE (1.47 years) for the 50 test images. Decreased image quality had no significant impact on the performance and classification results. The experts delivered slightly less accurate MAE (1.63 years). Throughout the tested age range, both the manual and the automated approach led to reliable age estimates within the limits of natural biological variability. CONCLUSIONS: The visual analysis of the face produces reasonably accurate age estimates up to the age of 18 years, which is the legally relevant age threshold for victims in cases of pedo-pornography. This approach can be applied in conjunction with the conventional methods for a preliminary age estimation of juveniles depicted on images.

Persistence of spermatozoa on decomposing human skin: a scanning electron microscopy study.

Finding spermatozoa is of the utmost importance in judicial cases involving both the living and the dead; however, most of literature actually deals with inner genitalia and does not take into consideration the chance of external deposition of semen on skin, which is not rare. In addition, the most advanced microscopic technologies such as scanning electron microscopy (SEM) have not been thoroughly investigated within this specific field of research. This study aims at applying SEM analysis to samples of decomposed skin in order to test its potential in detecting spermatozoa particularly in decomposed cadavers. A sample of skin was obtained at autopsy and divided into two thin strips; one of the samples was used as a negative control. Semen was then taken from a "donor" (with a normal spermiogram) and was spread onto the other skin sample. Every 3 days for the first 15 days (for a total of six samples), a standard slide was prepared from swabs on the treated and control skin and analyzed by standard light microscopy. In addition, every 7 days up to 91 days (3 months circa), a skin sample was taken from the positive and negative control and examined by SEM for a total of 14 samples. Results show that after 12 days, light microscopy failed in detecting spermatozoa, whereas they were still visible up to 84 days by SEM analysis. This study therefore suggests the persistence of sperm structures in time and in decomposing material as well as the possible application of SEM technology to decomposed skin in order to detect semen.

The application of cone-beam CT in the aging of bone calluses: a new perspective?

In the forensic and anthropological fields, the assessment of the age of a bone callus can be crucial for a correct analysis of injuries in the skeleton. To our knowledge, the studies which have focused on this topic are mainly clinical and still leave much to be desired for forensic purposes, particularly in looking for better methods for aging calluses in view of criminalistic applications. This study aims at evaluating the aid cone-beam CT can give in the investigation of the inner structure of fractures and calluses, thus acquiring a better knowledge of the process of bone remodeling. A total of 13 fractures (three without callus formation and ten with visible callus) of known age from cadavers were subjected to radiological investigations with digital radiography (DR) (conventional radiography) and cone-beam CT with the major aim of investigating the differences between DR and tomographic images when studying the inner and outer structures of bone healing. Results showed how with cone-beam CT the structure of the callus is clearly visible with higher specificity and definition and much more information on mineralization in different sections and planes. These results could lay the foundation for new perspectives on bone callus evaluation and aging with cone-beam CT, a user-friendly and skillful technique which in some instances can also be used extensively on the living (e.g., in cases of child abuse) with reduced exposition to radiation.

Pitfalls at the root of facial assessment on photographs: a quantitative study of accuracy in positioning facial landmarks.

In the last years, facial analysis has gained great interest also for forensic anthropology. The application of facial landmarks may bring about relevant advantages for the analysis of 2D images by measuring distances and extracting quantitative indices. However, this is a complex task which depends upon the variability in positioning facial landmarks. In addition, literature provides only general indications concerning the reliability in positioning facial landmarks on photographic material, and no study is available concerning the specific errors which may be encountered in such an operation. The aim of this study is to analyze the inter- and intra-observer error in defining facial landmarks on photographs by using a software specifically developed for this purpose. Twenty-four operators were requested to define 22 facial landmarks on frontal view photographs and 11 on lateral view images; in addition, three operators repeated the procedure on the same photographs 20 times (at distance of 24 h). In the frontal view, the landmarks with less dispersion were the pupil, cheilion, endocanthion, and stomion (sto), and the landmarks with the highest dispersion were gonion, zygion, frontotemporale, tragion, and selion (se). In the lateral view, the landmarks with the least dispersion were se, pronasale, subnasale, and sto, whereas landmarks with the highest dispersion were gnathion, pogonion, and tragion. Results confirm that few anatomical points can be defined with the highest accuracy and show the importance of the preliminary investigation of reliability in positioning facial landmarks.

The risk of misinterpreting genital signs of sexual abuse in cadavers: a case report.

The significance of genital findings in a case of suspected child sexual abuse has been widely debated in the past decades, as shown by the different classifications available in literature. In the case of postmortem examination, the search for signs of sexual abuse is considerably more difficult because of the superimposition of postmortem modifications, which may determine tissue modifications that can be mistaken for traumatic lesions. This study aims at reporting a case where presumed findings of the first autopsy were denied by histological analysis; in detail, what looked like a possible bruise of the hymen was correctly recognized as hypostasis (livor) of the hymenal tissue by histological analysis. This case report suggests caution in the analysis and discussion of genital lesions found during postmortem examination since the superimposition of cadaveric modifications may radically modify the morphology of soft tissues.

Palatal rugae as an individualising marker: reliability for forensic odontology and personal identification.

Personal identification is based on the comparison between ante mortem and post mortem data which can be considered unique for each individual: palatal rugae represent a useful element for such a comparison, thanks to their apparent low variability with time and unique patterns. Literature however is scarce. This pilot study aims at assessing the reliability of palatal rugae in time and at developing an identification method based on their comparison. Two casts from the upper dental arch of 39 subjects were obtained in different periods of time; at their first cast, 85.2% of patients were less than 16 years old. The second cast was performed after a period of time which varied between 4 and 65 months later than the first cast. The first cast can be taken to simulate ante mortem information, the second post mortem information. Every cast was then digitised with a scanner. In the digital images the palatal rugae were highlighted by using Adobe® Photoshop® 7.0 software; each image was coded and a comparison between "simulated" ante mortem and post mortem data was performed. In all cases ante mortem and post mortem data from the same individual were correctly matched. The study seems to indicate that this technique is highly reliable and user friendly, even on subadults, where growth processes seem not to affect the specific morphology of palatal rugae.

Forensic radiology and personal identification of unidentified bodies: a review.

Personal identification of unidentified bodies is crucial for ethical, juridical and civil reasons and is performed through comparison between biological data obtained from the cadaver and antemortem material from one or more missing persons to whom the body may have belonged in life. The increasing applications of forensic radiology and the wide use of conventional radiography and computed tomography (CT) in routine clinical practice demonstrate the potential of these technologies as tools for verifying the correspondence between an unidentified body and an identity suspect. This paper reviews the literature concerning the application of forensic radiology to the difficult issue of personal identification. Despite the increasing importance of the comparison between radiographic and CT findings, numerous limitations still need to be overcome, including the fact that few forensic centres have access to sophisticated X-ray technologies and that the reliability of those technologies for detecting specific morphological traits and bone lesions is a matter of intense debate. In addition, as with other morphological methods for identification, comparisons between antemortem and postmortem data require standardisation and statistical analysis, especially in Europe where there are very few indications concerning the admission in court of evidence obtained by anthropological and radiological methods. In the future, with developments in radiographic technologies and increasing numbers of studies on their application to the forensic setting, radiology will become one of the most useful tools in the field of personal identification.

The "blind age assessment": applicability of Greulich and Pyle, Demirjian and Mincer aging methods to a population of unknown ethnic origin.

PURPOSE: Age estimation is one of the most crucial issues in case of unknown deceased as well as in the living and is very frequently of radiological interest. Three methods for age estimation have been designated as the most reliable among the others: Greulich and Pyle, Demirjian and Mincer. The literature provides several studies concerning their applicability in different geographic contexts. However, not always can ancestry be ascertained, for example, in the case of badly preserved corpses. In these cases, age assessment must be performed without the corrections suggested by the literature for different ethnic groups. One may therefore wonder how reliable the result of age assessment performed without knowing the racial group to which the subject belongs may be. This study aimed at testing the applicability of the Greulich and Pyle Atlas, the Demirjian and the Mincer methods on a mixed population to compare skeletal and dental methods of age estimation. MATERIALS AND METHODS: X-ray films of 167 subjects aged between 4 and 31 years from more than 18 countries were recruited. One hundred and nine orthopantomographs (OPG) of children aged between 4 and 15.5 years were evaluated by Demirjian's method; whenever the highest Demirjian score was reached (31 cases), the Mincer method was applied. The skeletal maturation of 54 subjects aged between 7 and 19 years was determined by the Greulich and Pyle method. RESULTS: The lowest average variance from chronological age was shown by the Greulich and Pyle method, followed by Demirjian. The Mincer method showed very high mean variances. CONCLUSIONS: Mean variances from the different methods do not significantly differ from data reported in the literature and demonstrate that the reliability of Demirjian, and Greulich and Pyle as they stand may be applied satisfactorily to remains or individuals of unknown ethnic origin.

Reliability of optical devices for three-dimensional facial anatomy description: a systematic review and meta-analysis.

The use of three-dimensional (3D) optical instruments to measure soft tissue facial characteristics is increasing, but systematic assessments of their reliability, practical use in research and clinics, outcome measurements, and advantages and limitations are not fully established. Therefore, a review of the current literature was performed on the reliability of facial anthropometric measurements obtained by 3D optical facial reproductions as compared to conventional anthropometry or other optical devices. The systematic literature search was conducted in electronic databases following the PRISMA guidelines (PROSPERO registration: CRD42018085473). Overall, 815 studies were identified, with 27 final papers included. Two meta-analyses were conducted. Tested devices included conventional cameras, laser scanning, stereophotogrammetry, and structured light. Studies measured living people or inanimate objects. Overall, the optical devices were considered reliable for the measurement of linear distances. Some caution is needed for surface assessments. All instruments are suitable for the analysis of inanimate objects, but fast scan devices should be preferred for living subjects to avoid motion artefacts in the orbital and nasolabial areas. Prior facial landmarking is suggested to improve measurement accuracy. Practical needs and economic means should direct the choice of the most appropriate instrument. Considering the increasing interest in surface-to-surface measurements, fast scan devices should be preferred, and dedicated protocols devised.

Three-dimensional assessment of restored smiling mobility after reanimation of unilateral facial palsy by triple innervation technique.

The aim of this study was to assess surgically restored facial mobility using an optical 3D instrument. Eleven patients (age range 42-76 years) with unilateral facial palsy, treated by triple innervation procedure (masseteric and partial hypoglossal reinnervation, plus double cross-face facial grafting), performed five facial animations: rest position, smiling by contracting the healthy side, clenching the teeth, and pushing the tongue against the lower incisors and Mona Lisa smiling. These were recorded by stereophotogrammetry. Sixty healthy subjects were also recorded. The 3D reconstruction of each facial expression was registered onto the rest position scan, and the root mean square (RMS) point-to-point distance between the two 3D surfaces was calculated automatically for the facial thirds. RMS values on the rehabilitated hemiface were 74.8% (upper third), 46.6% (middle third), and 54.1% (lower third) of those recorded in healthy subjects. RMS values were higher in the middle and lower thirds than in the upper third, and during smile provided by masseteric stimulus (P<0.05). The rehabilitated hemiface differed more from healthy subject values than the healthy hemiface did (P<0.05). On average, patients were more asymmetric than healthy subjects (P=0.004). The proposed method is non-invasive and non-contact, and it can quantify localized facial movements after surgical procedures.

Three-dimensional superimposition for patients with facial palsy: an innovative method for assessing the success of facial reanimation procedures.

Facial palsy is a severe condition that may be ameliorated by facial reanimation, but there is no consensus about how to judge its success. In this study we aimed to test a new method for assessing facial movements based on 3-dimensional analysis of the facial surfaces. Eleven patients aged between 42 and 77 years who had recently been affected by facial palsy (onset between 6 and 18 months) were treated by an operation based on triple innervation: the masseteric to temporofacial nerve branch, 30% of the hypoglossal fibres to the cervicofacial nerve branch, and the contralateral facial nerve through two cross-face sural nerve grafts. Each patient had five stereophotogrammetric scans: at rest, smiling on the healthy side (facial stimulus), biting (masseteric stimulus), moving the tongue (hypoglossal stimulus), and corner-of-the-mouth smile (Mona Lisa). Each scan was superimposed onto the facial model of the "rest" position, and the point-to-point root mean square (RMS) value was automatically calculated on both the paralysed and the healthy side, together with an index of asymmetry. One-way and two-way ANOVA tests, respectively, were applied to verify the significance of possible differences in the RMS and asymmetry index according to the type of stimulus (p=0.0329) and side (p<0.0001). RMS differed significantly according to side between the facial stimulus and the masseteric one on the paralysed side (p=0.0316). Facial stimulus evoked the most asymmetrical movement, whereas the masseteric produced the most symmetrical expression. The method can be used for assessing facial movements after facial reanimation.

The identification of living persons on images: A literature review.

Personal identification in the forensic context commonly concerns unknown decedents. However, recently there has been an increase in cases which require identification of living persons, especially from surveillance systems. These cases bring about a relatively new challenge for forensic anthropologists and pathologists concerning the selection of the most suitable methodological approaches with regard to the limitations of the photographic representation of a given person for individualization and identity. Facial features are instinctively the primary focus for identification approaches. However, other body parts (e.g. hands), and body height and gait (on videos) have been considered in cases of personal identification. This review aims at summarizing the state-of-the-art concerning the identification of the living on images and videos, including a critical evaluation of the advantages and limitations of different methods. Recommendations are given in order to aid forensic practitioners who face cases of identification of living persons.

MEPROCS framework for Craniofacial Superimposition: Validation study.

Craniofacial Superimposition (CFS) involves the process of overlaying a skull with a number of ante-mortem images of an individual and the analysis of their morphological correspondence. The lack of unified working protocols and the absence of commonly accepted standards, led to contradictory consensus regarding its reliability. One of the more important aims of 'New Methodologies and Protocols of Forensic Identification by Craniofacial Superimposition (MEPROCS)' project was to propose a common framework for CFS, what can be considered the first international standard in the field. The framework aimed to serve as a roadmap for avoiding particular assumptions that could bias the process. At the same time, it provides some empirical support to certain practices, technological means, and morphological criteria expected to facilitate the application of the CFS task and to improve its reliability. In order to confirm the utility and potential benefits of the framework use, there is a need to empirically evaluate it in CFS identification scenarios as close as possible to the reality. Thus, the purpose of this study is to validate the CFS framework developed. For that aim 12 participants were asked to report about a variable number of CFS following all the recommendations of the framework. The results are analysed and discussed according to the framework understanding and fulfilment, the participants' performance, and the correlation between expected decisions and those given by the participants. In view of the quantitative results and qualitative examination criteria we can conclude that those who follow the MEPROCS recommendations improve their performance.

Animal experimentation in forensic sciences: How far have we come?

In the third millennium where ethical, ethological and cultural evolution seem to be leading more and more towards an inter-species society, the issue of animal experimentation is a moral dilemma. Speaking from a self-interested human perspective, avoiding all animal testing where human disease and therapy are concerned may be very difficult or even impossible; such testing may not be so easily justifiable when suffering-or killing-of non human animals is inflicted for forensic research. In order to verify how forensic scientists are evolving in this ethical issue, we undertook a systematic review of the current literature. We investigated the frequency of animal experimentation in forensic studies in the past 15 years and trends in publication in the main forensic science journals. Types of species, lesions inflicted, manner of sedation or anesthesia and euthanasia were examined in a total of 404 articles reviewed, among which 279 (69.1%) concerned studies involving animals sacrificed exclusively for the sake of the experiment. Killing still frequently includes painful methods such as blunt trauma, electrocution, mechanical asphyxia, hypothermia, and even exsanguination; of all these animals, apparently only 60.8% were anesthetized. The most recent call for a severe reduction if not a total halt to the use of animals in forensic sciences was made by Bernard Knight in 1992. In fact the principle of reduction and replacement, frequently respected in clinical research, must be considered the basis for forensic science research needing animals.

Radiological pitfalls of age estimation in adopted children: a case report.

Age estimation has a relevant importance in assessing adopted children, also in cases where the age of the minor seems unquestioned, since pathological conditions may radically alter bodily growth. This may lead to an incorrect age evaluation, with consequent social and psychological problems linked to an inadequate collocation in public school. This study aims at exposing a case report concerning age estimation for a newly adopted child from Cambodia; previous clinical documentation reported information suggesting possible malnutrition, which was verified by the observation of a general disalignment of bone and dental structures. This example shows the importance of a thorough forensic evaluation of adopted children from other countries in order to verify the possible environmental modification of physiological growth even where it seems not to be needed, and represents a caveat for clinical and social personnel dealing with adoption procedures.