Search

Fat embolism syndrome (FES) can be challenging to diagnose by forensic pathologists. For the diagnosis of FES, there is no benchmark test. Postmortem diagnosis requires a full autopsy and specific ancillary examination. However, the high variability in the clinical presentation of FES represents a relevant issue, and there is no consensus on the postmortem assessment. This is the case of a 33-year-old man who died of FES one week after a car accident. He suffered multiple fractures, but was hemodynamically stable and showed no neurological changes. The patient died a few days after hospital discharge. Additionally, he had osteogenesis imperfecta type III, a genetic disorder associated with bone fragility. To the best of our knowledge, no study has assessed whether and how osteogenesis imperfecta contributes to the onset of FES. Despite the heterogeneous manifestations of FES, the present case met many of the proposed clinical and histological diagnostic criteria. Therefore, we briefly review FES diagnostic criteria, show the postmortem diagnostic workup, and discuss the hypothetical link between osteogenesis imperfecta and FES. [ABSTRACT FROM AUTHOR]

Establishing the manner of death is one of the most challenging tasks for forensic pathologists. We present the case of a 24-year-old woman found dead in the early morning on a flyover. The body was sitting on the ground with the back leaning against a wall. The neck was encircled by a white phone charger cable knotted to the staircase's handrail. The victim had argued with her boyfriend and tried to jump out of his car while coming home from a wedding party the night before. After that, she left home alone with her phone charger in her hand. Due to self-harm behaviors, the first hypothesis was suicide by hanging. However, the ligature crossed immediately beneath the thyroid cartilage and encircled the neck twice horizontally; the two ends of the cable overlapped, forming a cross-over point in the front-right of the neck. Then, the ligature passed obliquely through the nape, gradually disappearing, forming a gap in the mark. The mark was sharply defined, stiff, yellow, and parchment-like. The investigators performed a three-dimensional scene reconstruction using the Trimble X7 Laser Scanner and the PC-Crash Multibody System. Even though the geometry of the ligature mark in the present case raised doubts about the manner of death, the three-dimensional reconstruction confirmed that the hanging was feasible without any external intervention. [ABSTRACT FROM AUTHOR]

Restrictions imposed during the COVID-19 pandemic might have changed recreational habits. In this study, the results of toxicological tests for alcohol and drugs in blood were compared among drivers stopped at roadside checks in the periods before (1 January 2018 to 8 March 2020) and after the lockdown measures (9 March 2020 to 31 December 2021). A total of 123 (20.7%) subjects had a blood alcohol level above the legal limit for driving of 0.5 g/l, 21 (3.9%) subjects tested positive for cocaine, and 29 (5.4%) subjects positive for cannabis. In the COVID-19 period, the mean blood alcohol level was significantly higher than in the previous period. Cannabis use, which was more frequent among younger subjects, was statistically associated with cocaine use. There has also been a quantitative increase in alcohol levels in the population with values above the legal limits, indicative of greater use of alcohol in the population predisposed to its intake. [ABSTRACT FROM AUTHOR]

One of the cornerstones for enhancing the patient safety culture is the incident reporting system (IRS). It is a process for detecting, reporting, collecting, and summarizing adverse events (AEs) and near-misses in healthcare, and so it represents a vital tool for clinical risk management. We analyzed the 5-year experience of a third-level hospital's IRSs, showing its trends and highlighting its main strengths and weaknesses. Patients' falls and physical or verbal aggression toward the providers or between patients are the most reported events. Underreporting is the main limitation of the system, especially among nurses. Visible actions, forceful analysis of the reports, operators' education, no-blame culture promotion, and organizational adjustments may improve operators' adherence to IRS. Providers do not willingly inform patients' relatives about fatal incidents. Despite that, the IRS is far from its potential, and the number of data collected has increased. [ABSTRACT FROM AUTHOR]

Two cases in a row demonstrate the importance of autopsy in the investigation of the cause of death, even when circumstantial information and preliminary examinations suggest potentially lethal pathology, such as sub-arachnoidal or intracranial haemorrhage, arteriovenous malformation (AVM) rupture, sudden cardiac death, aortic dissection, pulmonary embolism, intoxication, etc. These two cases show how every sudden death needs further investigation to figure out what the real cause is because there are so many fatal pathologies that can cause it. Indeed, the duodenal ulcer detected in these cases cannot be diagnosed without an autopsy. External examination only may be insufficient or too generic being able, if not followed by an autopsy, to direct towards incorrect causes of death. [ABSTRACT FROM AUTHOR]

Background: The need for highly effective therapies in rheumatologic diseases has led to the widespread and growing use of a heterogeneous class of molecules called biological agents. The increasing experience with biological agents has raised concerns about safety and efficacy issues that need to be discussed in the informed consent acquisition process. Methods: The authors performed a review of the literature on biological agents focusing on their most important characteristics concerning the informed consent procedures. Results: No studies specifically addressed the issue of informed consent in patients receiving biological agents. Several studies reported data about off‐label use of biological agents usually with no obvious attention to informed consent shortcomings. Conclusion: The reported association between biological agents and serious infections or malignancies, including reactivation of latent tuberculosis, needs specific disclosure in informed consent acquisition, together with information about the possible efficacy in clinical contexts often characterized by resistance to previous treatments. Ethical and clinical issues bound to the need for experimenting with new agents with potentially serious adverse effects deserve specific attention. Studies aimed at evaluating mental capacity to consent in subjects receiving biological agents are required. [ABSTRACT FROM AUTHOR]

SARS-CoV-2 vaccination campaigns initially targeted the adult population. After the authorization of the main agencies, including the EMA (European Medicines Agency), the European Vaccination Plan now involves young people between the ages of 12–17 and 5–11. In assessing the child's "best interests", the refusal of vaccination by parents or guardians, in addition to the increased circulation of the virus, is responsible for the risk of social distancing. This reduction in social contacts, particularly during very sensitive ages such as adolescence, has been linked to the increased incidence of psychiatric illness, a significant reason for extending vaccination against SARS-CoV-2 in these younger children. One may consider that government should issue a law that allows the child to decide on the vaccination plan, even without the consent of the parents or guardians, without the need for a judge's ruling. The availability of the child should be the point of reference, according to the National Bioethics Committee, for consent to vaccination. The authors investigate the subject in depth in order to counteract vaccination hesitation, and promote the dissemination of correct scientific information, using every different possible communication tool, as well as social networks and schools. [ABSTRACT FROM AUTHOR]

Since the beginning of March 2020, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has been the cause of millions of deaths worldwide. The need to better define the pathogenesis of coronavirus disease 19 (Covid-19) as well as to provide the correct statistical records concerning deaths related to this virus, inevitably involves the role of forensic pathology and routine autopsy practice. Currently, some data on macroscopic and microscopic features in autopsies performed in suspected Covid-19 cases are reported in the literature. The persistence of SARS-CoV-2 in cadavers has not yet been elucidated and only a few reports have emphasized the importance of evaluating the Virus RNA in post-mortem tissues. In this preliminary study, we observed that SARS-CoV-2 survives in multiple cadaver tissues many days after death despite some extreme conditions of post-mortem body preservation. The results of this on-going analysis could help improve the safety of working practices for pathologists as well as understanding the possible interaction between microbiological agents and the cadaver tissue's supravital reactions. [ABSTRACT FROM AUTHOR]

During the COVID-19 pandemic, the number of accesses to the Pediatric Emergency Department (pED) in Italy sharply decreased by 30%. The purpose of this study is to evaluate how this novel setting impacted on management of children with trauma, and the use and appropriateness of imaging studies in such patients at the pED. All imaging studies performed in patients with trauma at the pED of a tertiary children’s Hospital during the first wave of the COVID-19 pandemic (between March and May 2020) were reviewed, in comparison with a control time interval (March to May 2019). In the pre-COVID control era, 669 imaging studies documented bone fractures in 145/568 children (25.5%). In the COVID-era, 79/177 (44.6%) pediatric patients showed bone fractures on 193 imaging studies. Comparative analysis shows a 71% decrease in imaging studies, and the proportion of negative imaging studies (with no evidence of bone fractures) dropped in 2020 by 19% compared to the 2019 control era (p < 0.001). The sharp decrease of negative studies suggests that the rate of appropriateness was higher during COVID-era, suggesting some attitude toward defensive medicine in the previous control year, as a result of some degree of imaging inappropriateness. The impact of a pandemic on emergency medicine may offer a unique opportunity to revisit diagnostic and therapeutic protocols in pediatrics. [ABSTRACT FROM AUTHOR]

The figure of the junior doctor is defined in different ways depending on age, educational path, and contract terms related to the conditions of the work contract. The issues related to this particular professional figure should be considered one of the greatest tests to which Health Systems have to respond. In this paper, these aspects are discussed together with practical advice that could be tailored to individual working situations in order to adequately address these issues. Cornerstones and common practices of clinical risk management which may be successfully applied in these contexts are also discussed. The application of Risk Management tools can both provide proactive solutions to reduce the risk of litigation, and create an environment based on trust and one in which junior doctors feel encouraged to signal adverse events and to learn from them. This could result in overall growth in the system, also from a cultural perspective, and better healthcare both for staff and patients. [ABSTRACT FROM AUTHOR]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.forsciint.2009.12.058 Byline: D. Poli (a)(b), B. Solarino (c), G. Di Vella (c), L. Tattoli (c), G. Strisciullo (c), M. Goldoni (a)(b), A. Mutti (b), R. Gagliano-Candela (c) Keywords: Work related death; Environmental findings; Toxicological analyses; Hydrogen sulfide Abstract: During a routine truck-tank washing operation, five healthy workers were found motionless inside an empty tanker. Four of them died inside the tanker while the fifth died the following day in hospital. Since the true nature of the fatal compound(s) were not known, a rigorous environmental and toxicological approach supported by autopsy findings was essential to clarify the cause of death. Environmental results indicated that H.sub.2S fumes arising from the liquid sulfur previously shipped were responsible for the serial deaths, also confirmed by a simulation performed on two similar truck-tanks. These environmental findings were supported by toxicological analyses through the measurement of thiosulfate, one of the main H.sub.2S metabolites. Abnormal thiosulfate concentrations from 1.1 to 186.2mg/kg were revealed in all post-mortem biological samples (blood, lung, liver, kidney, brain and fat). Finally, the cluster analysis performed on thiosulfate body distribution contributed to establishing the time of death according to the accident scene reconstruction. This report presents valuable findings in correctly identifying the cause of death in gas asphyxiation cases by unknown compound(s). Author Affiliation: (a) National Institute of Occupational Safety and Prevention Research Center at the University of Parma, via Gramsci 14, 43100 Parma, Italy (b) Laboratory of Industrial Toxicology, Dept. of Clinical Medicine, Nephrology and Health Sciences, University of Parma, via Gramsci 14, 43100 Parma, Italy (c) Section of Legal Medicine (DiMIMP), Department of Internal Medicine and Public Medicine, University of Bari, Policlinico Piazza G. Cesare 11, 70124 Bari, Italy Article History: Received 3 June 2009; Revised 15 December 2009; Accepted 18 December 2009

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.forsciint.2009.09.019 Byline: Biagio Solarino (a)(b), Benno RieAelmann (c), Claas T. Buschmann (a), Michael Tsokos (a) Keywords: Tramadol; Nicotine; Multiple transdermal patches; Forensic toxicology Abstract: A fatal case of multidrug poisoning by tramadol and nicotine is reported. Tramadol is a centrally acting analgesic used in the treatment of moderate to severe acute or chronic pain. Nicotine, a lipid-soluble alkaloid, is one of the most readily available drugs in modern society. A 46-year-old man was found dead in his bed, and a suicide note was discovered near the body. He had 25 transdermal nicotine patches attached to his thorax and abdomen. Two half emptied bottles were found on the bedside table; the toxicological examination revealed that they contained tobacco and nicotine as well as other drugs such as diphenhydramine. At autopsy, areas of fresh and old myocardial infarction as well as diffuse pulmonary congestion and edema were present. The tramadol concentration was 6.6[mu]g/mL in femoral venous blood, while levels of nicotine and its primary metabolite cotinine were determined to be 0.6 and 2.0[mu]g/mL in femoral venous blood. Based on these results, we determined the cause of death to be cardiorespiratory failure induced by the additive effects of tramadol and nicotine shortly after consumption. Author Affiliation: (a) Institute of Legal Medicine and Forensic Sciences, University Medical Centre Charite, University of Berlin, Turmstr. 21, Building L, 10559 Berlin, Germany (b) Section of Legal Medicine, Department of Internal Medicine and Public Medicine, University of Bari, P.zza Giulio Cesare 11, 70124 Bari, Italy (c) Governmental Institute of Legal Medicine and Forensic Sciences, University Medical Centre Charite, Turmstr. 21, 10559 Berlin, Germany Article History: Received 26 May 2009; Revised 15 September 2009; Accepted 21 September 2009

Objectives: This study aimed to standardize and rationalize the handover, a critical and essential moment in common health care practices, through the realization of an efficient and standardized checklist, which could be used daily to ensure complete, thorough and effective handover. The principal purpose of the implementation of the handover is to reduce errors due to superficial and insufficient communication. Methods: The "operative group" defined the phases to the realization of the delineated aims: at first, the direct observation and the consequent realization of a handover checklist model and then, the experimental phases (trials). The handover checklist model was used for a month and it was daily and duly completed by the doctors who took part in the trial. To prove the success of the study, three questionnaires were distributed on different occasions. Results: Analyzing the answers to the questionnaires, the importance of the handover has come to light and that for the most part, the doctors consider it an essential and irreplaceable moment in daily health care work. Moreover, it became obvious that the use of the handover checklist guaranteed a considerable improvement in the traditional handover in terms of security, completeness, care continuity and clarity. The handover checklist was completely appreciated by the majority of the participant doctors who agree with the definitive introduction of it in their unit. Conclusions: Our study indicated the consistency of the handover checklist as an instrument to implement the handover and, indirectly, to improve the quality of the care. [ABSTRACT FROM AUTHOR]

It is our view that the Russian tactic to destroy telecommunications and hinder access to healthcare for civilians, should be considered a crime against humanity. Dear Editor: In the Ukrainian conflict, healthcare for civilians has become a relative concept though the international community considered it a fundamental right that even the invaders should guarantee. [Extracted from the article]

A rare case of lethal idiopathic plasmacytic lymphadenopathy ( IPL) with polyclonal hyperimmunoglobulinemia with chronic renal failure is described. A 40-year-old woman who had suffered from upper airways disease was admitted to the Emergency Room with acute renal failure and hypergammaglobulinemia. She developed pericardial effusion, a pruritic rash, splenomegaly and fell into a coma after 6 days. Multiple myeloma, infection, collagenopathy, and coagulopathy were ruled out. Finally, a form of malignant hypergammapathy was suspected. At autopsy, lymph nodes were infiltrated by polyclonal plasma cells and lymphocytes, with erythrophagocytosis features; immunohistochemistry confirmed the plasma cells (CD138+), with a prevalence of kappa-positive cells, B (CD20+) and T (CD3+) cells. Kidneys showed advanced glomerulosclerosis containing similar infiltrates. The cause of death was IPL with polyclonal hypergammaglobulinemia and advanced renal failure. Similar cases are unusual, and possible medical liability associated with failure to diagnose and treat idiopathic plasmacytic lymphadenopathy deserves discussion and further studies. [ABSTRACT FROM AUTHOR]