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Purpose The aim of this systematic review was to provide a comprehensive overview of micro-CT current applications in forensic pathology, anthropology, odontology, and neonatology. Methods A bibliographic research on the electronic databases Pubmed and Scopus was conducted in the time frame 01/01/2001–31/12/2021 without any language restrictions and applying the following free-text search strategy: “(micro-computed tomography OR micro-CT) AND (forensic OR legal)”. The following inclusion criteria were used: (A) English language; (B) Application of micro-CT to biological and/or non-biological materials to address at least one forensic issue (e.g., age estimation, identification of post-mortem interval). The papers selected by three independent investigators have been then classified according to the investigated materials. Results The bibliographic search provided 651 records, duplicates excluded. After screening for title and/or abstracts, according to criteria A and B, 157 full-text papers were evaluated for eligibility. Ninety-three papers, mostly (64) published between 2017 and 2021, were included; considering that two papers investigated several materials, an overall amount of 99 classifiable items was counted when referring to the materials investigated. It emerged that bones and cartilages (54.55%), followed by teeth (13.13%), were the most frequently analyzed materials. Moreover, micro-CT allowed the collection of structural, qualitative and/or quantitative information also for soft tissues, fetuses, insects, and foreign materials. Conclusion Forensic applications of micro-CT progressively increased in the last 5 years with very promising results. According to this evidence, we might expect in the near future a shift of its use from research purposes to clinical forensic cases.

The DNA contamination of evidentiary trace samples, included those collected in the autopsy room, has significant detrimental consequences for forensic genetics investigation. After the COVID-19 pandemic, methods to prevent environmental contamination in the autopsy room have been developed and intensified. This study aimed to evaluate the level of human DNA contamination of a postmortem examination facility before and after the introduction of COVID-19-related disinfection and cleaning procedures. Ninety-one swabs were collected from the surfaces and the dissecting instruments, analyzed by real-time quantitative PCR (q-PCR) and typed for 21 autosomal STRs. Sixty-seven out of 91 samples resulted in quantifiable human DNA, ranging from 1 pg/μl to 12.4 ng/μl, including all the samples collected before the implementation of COVID-19 cleaning procedures (n = 38) and 29 out of 53 (54.7%) samples taken afterward. All samples containing human DNA were amplified, resulting in mixed (83.6%), single (13.4%), and incomplete (3%) profiles. A statistically significant decrease in DNA contamination was found for dissecting instruments after treatment with chlorhexidine and autoclave (p 0.05). Environmental decontamination strategies adopted during COVID-19 pandemic only partially solved the long-standing issue of DNA contamination of postmortem examination facilities. The pandemic represents an opportunity to further stress the need for standardized evidence-based protocols targeted to overcome the problem of DNA contamination in the autopsy room.

The most common pulmonary findings in opiate-related fatalities are congestion and oedema, as well as acute and/or chronic alveolar haemorrhage, the cause of which is thought to be a damage to the capillary endothelium related to ischemia. Human vascular mesenchymal stromal cells (vMSCs) play a fundamental role in tissue regeneration and repair after endothelial cell injury, and they express opioid receptors. The aim of this study was to assess the effect of in vitro morphine exposure on the physiological activity and maintenance of human vMSCs. vMSCs were obtained from abdominal aorta fragments collected during surgery repair and were exposed to incremental doses (0.1 mM, 0.4 mM, 0.8 mM and 1 mM) of morphine sulphate for 7 days. The effect was investigated through cell viability assessment, proliferation assay, reactive oxygen species (ROS) detection assay, senescence-associated β-galactosidase assay, senescent-related markers (p21WAF1/CIP1 and p16INK4) and the apoptosis-related marker caspase 3. Moreover, an ultrastructural analysis by transmission electron microscopy and in vitro vascular differentiation were evaluated. Results showed a decrease of the cellular metabolic activity, a pro-oxidant and pro-senescence effect, an increase in intracellular ROS and the activation of the apoptosis signalling, as well as ultrastructural modifications and impairment of vascular differentiation after morphine treatment of vMSC. Although confirmation studies are required on real fatal opiate intoxications, the approach based on morphological and immunofluorescence methodologies may have a high potential also as a useful tool or as a complementary method in forensic pathology. The application of these techniques in the future may lead to the identification of new markers and morphological parameters useful as complementary investigations for drug-related deaths.

The multidisciplinary network of Emilia-Romagna for the study of juvenile sudden cardiac death (SCD) was started in Bologna in June 2018 in order to: (1) define the spectrum of etiologies and mechanisms of SCD in young people; (ii) standardize diagnostic terminology and categories; (iii) identify potentially hereditary genetic heart diseases and define the contribution of post-mortem genetic analysis (so-called molecular autopsy) to the overall diagnostic process; (iv) identify preclinical forms of the pathologies in the first-degree relatives of the deceased subject using both phenotypic and genotypic evaluation and, where possible, undertake therapeutic/prophylactic measures (primary prevention).In the first 2 years of activity (01/06/2018-27/08/2020) 50 cases of SCD came to the attention of the Cardiovascular Pathology Unit of the S. Orsola-Malpighi Polyclinic in Bologna, from Centres of Forensic Medicine and Pathological Anatomy in most of the region.Sixty-two percent of cases were sent by forensic pathologists, 36% by clinical pathologists and 2% by the family of the deceased. Medico-legal cases were prompted by autopsies requested by the Judicial Authority in 70% of cases; 55.5% of patients referred by pathologists came from the Cardiovascular Tissue Bank, as part of the regional program for the quality and safety control of organs and tissues from multiorgan-multitissue donors. The average age of the subjects was 35 ± 13.6 years (70% male, range: 1-55 years; median: 38 years). The spectrum of the final diagnoses includes: structurally normal hearts 14%, cardiomyopathies 40%, coronary heart disease 23%, Brugada syndrome 6%, aortic dissection 4%, substance abuse 6%, valvular heart disease 2%, mixed causes 2%.The network is necessarily centered on post-mortem pathological activities, but it does not end with these. If in 60% of cases the pathological autopsy examination was decisive in identifying the cause of death, in the other cases a detailed final diagnosis was reached only with more complex pathways involving molecular genetics, clinical genetics, and toxicology.

Genetic testing of animal biological material has become a valuable tool in forensic investigations, and it is successfully used to identify unknown crime perpetrators, to unmask food frauds, or to clarify cases of animal attacks on humans or other animals. When DNA profiling is not possible due to inadequate amounts of nuclear DNA, mitochondrial DNA (mtDNA) testing is the only viable alternative, as in the case of shed hair samples. In this case, a dog was allegedly killed by wild animals while being hosted in a boarding house. Extraneous hair fragments recovered from the dog’s mouth and paws were subjected to genetic analysis: the cytochrome b gene located on mtDNA was amplified and sequenced in order to determine the species responsible for the killing. The mtDNA analysis provided evidence that the dog was killed by other dogs, thus unmasking a false wild animal attack and putting the case in an entirely different perspective. Electronic supplementary material The online version of this article (10.1007/s00414-020-02388-9) contains supplementary material, which is available to authorized users.

Valproic acid (VPA) is a well-known drug prescribed as anti-epileptic. It has a narrow therapeutic range and shows great individual differences in pharmacodynamics and pharmacokinetics. Consequently, the therapeutical drug monitoring (TDM) in patient's plasma is of crucial importance. Liquid chromatography coupled to mass spectrometry (LC-MS/MS) has gained importance in TDM applications for its features of sensitivity, selectivity and rapidity. However, in case of VPA, the LC-MS/MS selectivity could be hampered by the lack of a sufficient number of multiple reaction monitoring (MRM) transitions describing the molecule. In fact, the product ion scan of deprotonated molecules of VPA does not produce any ion and thus most LC-MS/MS methods are based on the detection of the unique MRM transition m/z 143➔143. In this way, the advantages of selectivity in LC-MS cannot be effectively exploited. In the present method, stable analyte adducts were exploited for the determination of VPA in blood. An Acquity HSS C18 column and mobile phases consisting of 5-mM ammonium formate and acetonitrile both added 0.1% formic acid were used. Source worked in negative acquisition mode and parameters were optimized to increase the adduct (m/z 189) and dimer (m/z 287) stability, and their fragmentation were used to increase the selectivity of MRM detection. The method has been validated according to the toxicological forensic guidelines and successfully applied to 10 real blood samples. Finally, the present method showed suitable for the rapid LC-MS/MS detection of VPA in whole blood, demonstrating the possibility to increase specificity by exploiting stable in-source adducts. This should be considered of utmost importance in the case of forensic applications.

Very few studies have examined predictors of Driving Under the Influence (DUI) as a function of gender. This oversight is relevant, because analyzing gender differences prevents generalization of results observed in men, who still currently account for the majority of drivers worldwide, to women. The aim of this study is to analyze the prevalence of DUI of drugs in men and women reported in real case studies published in the last two decades, and to assess gender differences in risky DUI behaviour.PubMed, Scopus, Web of Science were searched for eligible studies in May 2021; a follow-up literature search was conducted in August 2021. Real-case studies of drivers convicted for DUI of psychoactive drugs with positive toxicological confirmatory analysis were included. The extracted outcome was the prevalence of positive findings of men and women for cocaine, cannabinoids, amphetamine-like drugs, opioids, and psychoactive prescription drugs. A meta-analysis of random effects estimates was performed to investigate the change in the size of the overall effect (by Cohen d standardized mean difference test). A Mann Whitney U test was performed to test for differences between genders.Of the 2877 studies screened, 439 were retrieved in full-text and 26 were included. The meta-analysis showed a significant higher prevalence among men for cocaine (1.8% vs 0.9%; p 0.001), cannabinoids (3.5% vs 1.6%; p = 0.01) and amphetamine-like drugs (1.2% vs 0.6%; p 0.01). Surprisingly, no differences were observed in the use of opioids (2.3% vs 2.2%; p = 0.45) and benzodiazepines/Z-drugs (2.9% vs 3.7%; p = 0.52).Contrary to the extraordinary number of real-case studies reported in literature, only a few papers differentiate the prevalence of DUI between men and women. This can lead to an underestimation of the influence of gender in DUI phenomenon or complicate the evaluation of the results for some classes of substances, as observed for medications and opioids. The primary goal in the future will be to collect the data concerning DUI drivers following shared and homogeneous methodologies, in order to allow the analysis of data disaggregated by gender, which can be used for monitoring evolving trends and developing gender-specific targeted prevention and enforcement efforts.

Insects found at a crime scene can produce traces referred to as fly artifacts (FA) due to their movement over the corpse and the manner in which they feed upon it. These can be detrimental for carrying out criminal investigations. Confusing a FA with a genuine bloodspot can lead to misinterpretations, also taking into consideration that FA may contain a human DNA profile. The aim of the present study was to employ scanning electron microscopy (SEM) for the analysis of FA produced by Calliphora vomitoria on hard surfaces and fabrics that are commonly present at crime scenes. FA and control bloodstains were produced under experimental conditions on metal, glass, plaster, cotton, and polyester. After macroscopic analysis, FA were examined at standard low (20–40 ×), medium low (300–600 ×), and high ultrastructural (1200 ×) magnification through a SEM Stereoscan 360, Leica, Cambridge. SEM analysis enabled the identification of distinctive features of FA on hard surfaces, namely, amorphous crystals, micro-crystals with a morphology similar to those of uric or micro-crystals with a comparable morphology to cholesterol, absent in controls. Moreover, red blood cells (RBC) were absent in FA but were always present in controls. On cotton, for both FA and controls, the drop was almost completely absorbed and thus indistinguishable from the underlying fabric texture. On polyester, FA showed amorphous/crystal-like deposits and no RBC, as observed on hard surfaces, except for those showing a completely flat surface. SEM analysis appeared to be suitable for differential diagnosis between FA and genuine bloodstains on hard surfaces, although the results may be inconclusive on tested fabrics.

Biomonitoring of perfluoroalkyl substances (PFASs) in hair is conventionally achieved by SPE extraction and liquid chromatography-triple quadrupole analysis, with sensitivities in the range of ng/g. The aim of this study was to develop and validate a rapid method to detect 20 perfluoroalkyl substances (PFASs) in human hair from general populations by SPE purification and liquid-chromatography coupled to accurate mass measurement (LC-QTOF). The obtained sensitivities (LOQ), linearity and RSD accuracies were respectively in the range of 0.07-0.5 ng/g, 0.1 (or 0.2 or 0.5)-10 ng/g, 1-16%. To verify the applicability of the method, 11 hair samples from volunteers were tested. The detected PFAS were PFBA (range 0.24-14.6 ng/g), PFBS (0.496 ng/g), PFOA (range 0.08-0.178 ng/g) and PFOS (LOQ-0.239 ng/g). The results were compared in terms of detection frequency and abundance with previously published studies. The method proved useful for the determination of the tested PFAS in the hair matrix.

Fly artifacts (FA) are bloodstains resulting from insect activity at a crime scene, usually by feeding on human blood. Whether these artifactual stains might be useful for forensic toxicological investigations in cases of absence of conventional and unconventional matrices, for example, in cases concealment of the body or of extensive putrefaction, has not yet been investigated. The purpose of this study is to understand if FA trace evidence permits toxicological analysis when traditional matrices are not available. To this aim, FA experimentally produced by Calliphora vomitoria feeding on human blood of a cocaine and heroin user were collected from absorptive and non-absorptive material. FA material was analyzed by a new simple and fast LC-MS/MS method. Results were evaluated in terms of presence of the drug and relative amount of the detected molecules. From a qualitative point of view, the analysis of FA revealed all the substances originally detected in post-mortem blood in both cases. The ratios of cocaine/benzoylecgonine, codeine/morphine, and 6-monoacetylmorphine/morphine recovered in FA from cotton-textile materials and from non-absorptive surfaces were consistent with data resulted from original post-mortem blood. The preliminary study herein reported demonstrated that FA are extremely informative in case of cocaine and heroin users and merit further research in order to be applied in real caseworks.

Introduction: The concealment of the body following a homicide undermines different moments of the forensic and medico-legal investigations. The aim of the present study is to provide an overview of the literature and the forensic casuistry of the Institute of Legal Medicine of Padova for analyzing and discussing diverse methodological approaches for the forensic pathologist dealing with covered-up homicides. Material and methods: A literature review, updated until September 2019, was performed, and a literature pool of forensic cases was built. In-house cases were included by conducting a retrospective analysis of the forensic caseworks of Padova of the last 20years. Data regarding epidemiology, methodology of assessment, methods of concealment, and answers to medico-legal issues were extracted for both data sets. Results and discussion: Seventy-eight papers were included in the literature review (78.2% being case reports or case series, 17% retrospective studies, and 6% experimental studies or reviews). Literature and in-house data sets consisted of 145 and 13 cases, respectively. Death scene investigation, radiology, toxicology, and additional analyses were performed in 20–54% of literature and 62–77% of in-house cases. Cover-up by multiple methods prevailed. Death was caused by head trauma in about 40% of cases (both data sets), strangulation in 21% of literature, and 7% of in-house cases, and was undetermined in 17% of literature and 7% of in-house cases. Conclusions: The methodology of ascertainment should be case-specific and based on a multidisciplinary and multimodal evaluation of all data, including those gained through novel radiological and/or analytical techniques.

The reconstruction of dynamic of traffic injuries remains a challenge in forensic pathology and is often based on circumstantial data. Dash Cams are digital video recorders which can be located inside a vehicle and continuously record the view through the windscreen, thus providing objective evidence. Here we present the case of a traffic crash in which a pedestrian was hit by an articulated lorry. The analysis of a video recorded from a Dash Cam retrieved inside the vehicle during the death scene investigation (DSI) was crucial in the reconstruction of the manner of death. Indeed, the death, which was initially assumed to be accidental, was finally deemed as a suicide on the basis of the video recording, which showed an intentional and sudden rush of the victim to the middle of the roadway. Advantages and disadvantages of the use of Dash Cams will be discussed, focusing on the profound differences in the related national and international regulations. Based on the present case, in traffic crashes, the search for Dash Cams during the DSI may be recommended and the video recordings should be analyzed in the setting of a multidisciplinary and multimodal evaluation of the case, for a proper reconstruction of the facts. Supplementary Information The online version contains supplementary material available at 10.1007/s12024-021-00382-0.

Per- and polyfluoroalkyl substances (PFAS) are anthropogenic chemicals present in the environment and defined as persistent organic pollutants (POPs). The interest in these forms of contaminants is related to the toxic consequences for health derived from exposures and bioaccumulation processes. The present research aims at assessing differences in the exposure of PFAS in the Italian population by hair analyses. To this aim, 20 compounds of the PFAS family were investigated in hair of 86 Italian subjects distributed across the regions of Veneto, Emilia-Romagna, Lombardy and Marche. The applied method was ad hoc developed in a previous research and included SPE extraction and LC-QTOF analysis. In the analyzed population, 66.4 % had quantifiable amounts of one or more PFAS molecules (up to 4 compounds); mean PFAS content, expressed as sum of PFAS, was 0.1457 ng/g, ranging from “not detected” to 0.85 ng/g (SD 0.1867). PFOA and PFOS were the chemicals most frequently detected, with mean concentrations of 0.1402 ng/g and 0.1155 ng/g, respectively. PFBA was detected in 9.3 % of subjects with a mean concentration of 0.3760 ng/g; PFNA in 3.5 % of subjects with mean concentration 0.12 ng/g; PFDA was found in one subject at the concentration of 0.541 ng/g. PFUnA and PFHxS were detected below the limit of quantification. The overall results displayed differences in the presence and prevalence of PFAS in hair of the Italian population on a geographical base. On the contrary, no significatively differences in the amount of PFAS were observed when considering gender or age classes. On this base, hair can be considered a good diagnostic tool to assess PFAS exposure on a regional-scaled base. Of course, more studies are required to infer PFAS internal dose from hair results due to its peculiar detection window and to interpretative issues derived from external contamination.

Methadone-related deaths are characterized by a wide range of post-mortem blood concentrations, due to the high pharmacokinetic/dynamic inter-individual variability, the potential subjective tolerance state and to other risk factors or comorbidities, which might enhance methadone acute toxicity. In the present study, the association among pre-existing and external conditions and diseases and the resultant methadone death capacity have been investigated. Beside a systematic literature review, a retrospective case-control study was done, dividing cases in which methadone was the only cause of death (controls), and those with associated clinical-circumstantial (naive/non-tolerant state), pathological (pulmonary or cardiovascular diseases) or toxicological (other drugs detected) conditions. Methadone concentrations were compared between the two groups and the association with conditions/diseases was assessed by multiple linear and binomial logistic regressions. Literature cases were 139, in house 35, consisting of 22 controls and 152 cases with associated conditions/diseases. Mean methadone concentrations were 2122 ng/mL and 715 ng/mL in controls and cases respectively, with a statistically significant difference (p &lt, 0.05). Lower methadone concentrations (by 24, 19 and 33% respectively) were detected in association with naive/non-tolerant state, pulmonary diseases and presence of other drugs, and low levels of methadone (&lt, 600 ng/mL) might lead to death in the presence of the above conditions/diseases.

Novel psychoactive substances (NPS) represent a severe health risk for drug users. Even though the phenomenon has been growing since the early 2000s, the mechanisms of action of NPS at the receptors and beyond them are still scarcely understood. The aim of the present study was to provide a systematic review of the updated knowledge regarding the molecular mechanisms underlying the toxicity of synthetic opioids, cannabinoids, cathinones, and stimulants. The study was conducted on the PubMed database. Study eligibility criteria included relevance to the topic, English language, and time of publication (2010–2020). A combined Mesh and free-text protocols search was performed. Study selection was performed on the title/abstract and, in doubtful cases, on the full texts of papers. Of the 580 records identified through PubMed searching and reference checking, 307 were excluded by title/abstract and 78 additional papers were excluded after full-text reading, leaving a total of 155 included papers. Molecular mechanisms of synthetic opioids, synthetic cannabinoids, stimulants, psychedelics, and hallucinogens were reviewed and mostly involved both a receptor-mediated and non-receptor mediated cellular modulation with multiple neurotransmitters interactions. The molecular mechanisms underlying the action of NPS are more complex than expected, with a wide range of overlap among activated receptors and neurotransmitter systems. The peculiar action profile of single compounds does not necessarily reflect that of the structural class to which they belong, accounting for possible unexpected toxic reactions.

This article was published online with an error. Given names and family names of the authors were interchanged. The correct author names are presented above. The original article has been corrected.

Femicide is defined as the gender-related killings of women and girls or as an any intentional murder of women and it represents a worldwide health issue. Although it has gained a growing attention across the public and the media, true data on its prevalence and a characterization of the phenomenon are still scarce. The aim of the present study was to evaluate the characteristics of female homicides and femicides, which are necessary to design and monitor effective preventive efforts. Post-mortem examination reports of female homicides occurred in the judicial district of Bologna over a period of 70 years were revised. Characteristics of victims and perpetrators, circumstantial and post-mortem data were extracted. Overall, 172 female homicides were observed, including 103 femicides, with no significant changes over time. The mean age of victims increased over time and showed a statistically significant association with the victim-perpetrator relationship. Homicides committed by non-intimate partner family members increased. Our study unveiled that, in the past decades, femicide was a hidden but constant social phenomenon, despite the social, cultural and juridical changes. The research in forensic pathology could help bring to light trends, characteristics and risk factors to be considered for strategies to counteract violence against women.

An 85-year-old man was found deceased floating in an irrigation ditch 18days after his disappearance. During crime scene investigation, specimens of the red swamp crayfish Procambarus clarkii were found in proximity of the body. The feeding activity of these nonendemic crayfishes contributed to the formation of specific injuries on the body and in the production of a large substance defects inside the corpse. The aim of this paper was to illustrate the scavenging activity of P.clarkii on a human body and highlight the potential postmortem artefacts caused by this species. This is the first report on a real case of postmortem injuries produced by P.clarkii crayfishes on a submerged human body. So far, crustaceans are not considered useful for the estimation of the minimum postmortem interval. However, the important modifications on the corpses deriving from the activity of these animals should be kept in consideration.

The combined event of a suicide and the killing of a pet has been hardly explored in forensic literature, but it is not rare at all. In the reported case the dead corpse of a 60-year old mentally ill woman and the carcass of a dog were found on the bed of a private apartment. In light of death scene investigation, necroscopic examination and toxicological analyses death was attributed to licit drug intoxication and self-strangulation after lethal poisoning of the dog. Due to the presence of two lethal means (cervical noose and drugs), acting in chronological order, the event was classified as a secondary complex suicide. Moreover, the woman, although mentally ill, was a psychiatrist. Thus, her professional background, namely the easy access to psychiatric drugs together with her knowledge of drug composition and properties lead to suppose an occupation related suicide. The comprehensive analysis of all the available information, including death scene investigation, occupational, necroscopic and toxicological data, resulted of the utmost importance for a proper reconstruction of the events and are recommended in complex cases such as occupation related planned complex suicides combined to the killing of pets.

Thermal imaging (TI) allows the detection of thermal patterns emitted from objects as a function of their temperature in the long-infrared spectrum and produces visible images displaying temperature differences. The aim of this pilot study was to test TI to visualize the coronary circulation of swine hearts. Thirty swine hearts were prepared for ex situ coronarography, and thermal images were acquired through a FlirOne thermal camera (FLIR Systems®) paired with a Google Android Smartphone. Coronary arteries were cannulated, namely the anterior interventricular artery, the circumflex branch of the left coronary artery, and the right coronary artery. The heart was cooled, and contrast medium (CM) consisting of distilled water heated to 40°C was injected in a coronary vessel, while thermal images were captured. These steps were repeated for each coronary vessel and under experimentally simulated coronary heart disease. Thermal imaging coronarography (TIC) allowed a clear representation of the morphology and course of the coronary vessels and of experimentally simulated coronary heart disease, moreover, demonstrated to be easy to perform during or after autopsies on ex situ hearts, non-destructive, reproducible, and cheap. On the basis of these preliminary results, TIC might allow a subsequent more focused and comprehensive cardiopathological examination of the heart, which remains mandatory for the definitive diagnosis of coronary heart disease. Although these preliminary results seem encouraging, further systematic studies on human hearts, both normal and pathological, are necessary for estimating the sensitivity and specificity of the proposed method and to draw any definitive conclusion.

The primary Varicella Zoster Virus (VZV) infection results in varicella, a generally benign, self-limiting disease in immunocompetent children. Despite the usual course a possible fatal evolution of the primary infection is observed predominantly in immunocompromised subjects and in adults, especially emigrating from tropical regions. Two cases of fatal varicella have been investigated and discussed. Death occurred in two patients over 40 years of age, coming from South Asia and receiving chronic immunosuppressive therapy. The forensic expert must be cautious and consider all clinical records in managing fatal varicella cases, bearing in mind risk factors and pre-existing conditions such as age, geographical provenance and pathological comorbidity, which may lead to a bad prognosis irrespective of therapies. Based on the severe and fatal course observed in the reported cases, an extension of the immunization program appears advisable for immigrants from tropical countries, especially before scheduled immunotherapy.

Necrotizing fasciitis (NF) is a life-threatening infection of soft tissues spreading along the fasciae to the surrounding musculature, subcutaneous fat and overlying skin areas that can rapidly lead to septic shock and death. Due to the pandemic increase of medical malpractice lawsuits, above all in Western countries, the forensic pathologist is frequently asked to investigate post-mortem cases of NF in order to determine the cause of death and to identify any related negligence and/or medical error. Herein, we review the medical literature dealing with cases of NF in a post-mortem setting, present a case series of seven NF fatalities and discuss the main ante-mortem and post-mortem diagnostic challenges of both clinical and forensic interests. In particular, we address the following issues: (1) origin of soft tissue infections, (2) micro-organisms involved, (3) time of progression of the infection to NF, (4) clinical and histological staging of NF and (5) pros and cons of clinical and laboratory scores, specific forensic issues related to the reconstruction of the ideal medical conduct and the evaluation of the causal value/link of any eventual medical error.

Introduction: In 2019, the Italian Supreme Court established that hemp cannot be commercialized for human use, when the “psychotropic effect” of the product or its “offensiveness” can be demonstrated. The aim of the present study is to assess Δ9-tetrahydrocannabinol (Δ9-THC) and cannabidiol (CBD) blood concentrations after smoking cannabis with a low percentage of Δ9-THC, also referred as “light cannabis”, and its effects on young adults’ vigilance, cognitive and motor skills. Materials and methods: Eighteen young adults consumed three light cannabis cigarettes containing 400 mg of inflorescences each, with a percentage of 0.41% of Δ9-THC and of 12.41% of CBD. Blood samples were collected before the experiment (t0), after each light cannabis cigarette (t1→t3), 60 (t4) and 120 (t5) minutes after the beginning of the experiment. Five performance tasks and a subjective scale were employed for measuring cognitive and psychomotor performances the day before the experiment (TT0) and after the third cigarette (TT1). Results: Mean (SD) concentrations (ng/ml) were 1.0 (0.8) in t1, 1.2 (0.9) in t2, 1.0 (0.8) in t3, 0.6 (0.4) in t4 and 0.3 (0.3) in t5 for Δ9-THC; 10.5 (10.3) in t1, 10.3 (13.2) in t2, 15.1 (14.8) in t3, 9.9 (9.2) in t4 and 5.7 (5.7) in t5 for CBD. No significant differences were observed between TT0 and TT1 for all performed psychomotor performance task. None of the subjects declared to feel “high” after the experiment. Discussion: All study participants reported that a higher number of cigarettes, corresponding in this study to 1200 mg of herbal product, could hardly be consumed by smoking in a recreational setting. Δ9-THC and CBD concentrations showed a high inter-subject variability, and the average concentrations were lower than those previously reported. Toxicological results showed a decrease of Δ9-THC and CBD after the third light cannabis cigarette, and a Δ9-THC /CBD ratio always

The analysis of macro- and microscopic characteristics of saw marks on bones can provide useful information about the class of the tool utilized to produce the injury. The aim of the present study was to test micro-computed tomography (micro-CT) for the analysis of false starts experimentally produced on 32 human bone sections using 4 different hand-saws in order to verify the potential utility of micro-CT for distinguishing false starts produced by different saws and to correlate the morphology of the tool with that of the bone mark. Each sample was analysed through stereomicroscopy and micro-CT. Stereomicroscopic analysis allowed the identification of the false starts and the detection of the number of tool marks left by each saw. Micro-CT scans, through the integration of 3D renders and multiplanar reconstructions (MPR), allowed the identification of the shape of each false start correlating it to the injuring tool. Our results suggest that micro-CT could be a useful technique for assessing false starts produced by different classes of saws, providing accurate morphological profiles of the bone marks with all the advantages of high resolution 3D imaging (e.g., high accuracy, non-destructive analysis, preservation and documentation of evidence). However, further studies are necessary to integrate qualitative data with quantitative metrical analysis in order to further characterize the false start and the related injuring tool.

Micro-CT has successfully been applied to the characterization of false starts (FSs) and, among several parameters, kerf width seems to correlate to the tool blade. The aim of the present study was to evaluate the diagnostic value of micro-CT for the differentiation of saw marks produced by different classes of saws and by saws belonging to the same class and differing only in number of teeth per inches (TPI). A morphological and morphometric analysis of 84 marks, produced by 6 saws belonging to 3 morphological classes, was performed. In the experimental cohort, for each parameter, statistically significant differences in intra- and inter-class analysis were searched for and cut-offs were established. The diagnostic accuracy of cut-offs was assessed through statistical analyses on the validation cohort. The morphological assessment did not allow to differentiate saws differing only in TPI. Angle 1 and top kerf width, respectively for cross-cut and rip-cut saws with alternating set, allowed a good discrimination between FSs produced by tools belonging to the same morphological class. High positive predictive values were found in intra-class analyses, while results in inter-class analyses were less encouraging. In cases of dismemberment, a micro-CT-based analysis of FSs is strongly suggested as a part of a multistep and multimodal methodology of assessment, which includes scanning electron microscopy and stereomicroscopy. A morphological assessment should be followed by an experimental trial and by a morphometric analysis. Further studies are needed to evaluate hampering factors, such as damage by physico-chemical agents.

The estimation of the post mortem interval (PMI) is still one of the most challenging variables to determine and the different approaches currently used in its estimation generally yield to large post mortem windows. In the present study we combined morphological and immunohistochemical analysis in order to reach a more detailed knowledge on tissue organization and degradation after death. Ultrastructural cellular changes and the extracellular matrix of gingival tissues, collected at different post mortem intervals, were observed by a Transmission Electron Microscopy (TEM), in combination with the immunohistochemical detection of extracellular matrix proteins (i.e. collagen type I and collagen type III) as potential post mortem biochemical markers. The final goal was to find a correlation between morphological modifications, biomarkers expression and the time of death. Samples of gingival tissues obtained from 10 cadavers at different post mortem intervals (short post mortem interval, 1–3 days; mid post mortem interval, 4–6 days; long post mortem interval, 7–9 days) were processed for light microscopy and TEM and they were also immunostained with anti-collagen type I and type III antibodies. Results showed gradual degradation of extracellular matrix in the suboral connective tissue in relation to the different time of death. Moreover PMI was related to an increase of nuclear chromatin condensation and cytoplasmic vacuolization both in epithelial and connective tissues. In conclusion, in addition to traditional forensic approaches to estimate PMI, the combined analyses of cellular morphology, ultrastructure and immunohistochemical expression of collagen proteins allow to better infer the PMI.

Objective Shared decision-making (SDM) may help to reduce the rate of Cesarean Delivery (CD). The aim of the study was to evaluate the extent to which pregnant women are involved in SDM about the mode of delivery, applying the Italian version of the OPTION 12 scale to obstetric consultations. Methods Fifty-eight outpatient consultations were rated; statistical associations between OPTION 12 scores and sociodemographic data of both patient and physicians were determined. Results The OPTION 12 total scores showed a skewed distribution in the lower range of total scores. Total scores in a percentage basis ranged from 0 to 69, with a mean of 21.2 (±19.84) and a median of 13.5. Mean and median scores for all the 12 OPTION 12 items never reached the minimum skill level. Conclusion A low level of patient involvement in deciding between a CD and a Vaginal Delivery (VD) was demonstrated. Interventions aiming at educating obstetricians as well as the adoption of decision aids are requested. Practice implications The OPTION 12 scale may prove useful for testing the extent of pregnant women’s involvement in deciding between CD and VD. The awareness of a low patient involvement seems mandatory to improve SDM and may lead to medico-legal protection.

In this work, the physical and chemical properties of a novel zwitterionic LC stationary phase are applied to the development, validation and application of a new fast and reliable method devoted to the analysis of GHB (gamma-hydroxybutyric acid) and its relatively new discovered glucuronide metabolite in hair. The obtained sensitivity, expressed as limit of detection (LOD) and quantification (LOQ), were 0.033 and 0.10 ng/mg for GHB and 0.11 and 0.37 ng/mg, for GHB-glucuronide respectively. Linearity was assessed between LOQ and 50 ng/mg for both compounds. GHB and GHB-glucuronide extraction from hair matrix was maintained simple and consisted in an acidified-solvent incubation. No samples purification was required before LC–MS/MS analysis. The method was finally applied to 65 real hair sample, 60 adults and 5 children below 2 years old. The obtained results highlighted that GHB concentrations were in the range 0.11–0.96 ng/mg (average 0.38 ± 0.25 ng/mg) in 44 cases (68%) while in 21 samples GHB concentrations were in the range between LOD and LOQ (0.033–0.1 ng/mg). GHB-glucuronide was detected in few samples (n. 3) at levels below LOQ. The interest on these molecules relies on the fact that GHB is both a naturally occurring inhibitory neurotransmitter in the central nervous system and an illicit drug often experienced by victims of drug-facilitated sexual assault. GHB-glucuronide was firstly identified in urine by the group of Petersen in 2013 and, as per analogy to ethyl glucuronide, it was proposed as a longer biomarker for GHB intoxication.

Background Ethyl chloride (EC) or chloroethane is a colourless halogenated hydrocarbon gas regularly employed as a topical anaesthetic spray for pain-related injuries and muscle spasm in athletes. However, EC became also popular as a street drug in the 1980s. Brief inhalations of EC vapour can result in dizziness, euphoria, confusion, incoordination, hallucinosis, impairment of short-term memory and narcosis. Inhalation of higher doses, usually employed to “get high”, may be related to severe depression of the central nervous system. Indeed, toxicity and deaths have been reported so far. Case presentation A 40-year-old man was found unresponsive after EC inhalation. EC determination was performed by dynamic headspace gas chromatography coupled to mass spectrometry. EC was detected in the peripheral blood (0.156 g/L), central blood concentration (0.203 g/L) and the lung and brain (19 and 25 mg/kg). EC in the vitreous humour showed a sensitively lower respect to blood (0.018 vs 0.203 g/L). Conclusions Considering the results of toxicological analyses of investigations on the death scene besides the absence of any signs of trauma, death was attributed to inhalation of ethyl chloride.

Bloodstain pattern analysis has a key role in crime scene reconstruction; however, it can be hampered by diverse confounding factors, such as insect activity which may lead to the production of small artifactual bloodstains, commonly referred to as fly artifacts (FA). Although several techniques aimed at distinguishing human bloodstains and FA have been developed, actually, no standardized and reproducible methodology is available. The aim of our study was to test the use of scanning electron microscopy (SEM) to distinguish human bloodstains from FA produced by Sarcophaga carnaria. FA and bloodstains have been produced on five different deposition surfaces under experimental conditions. After visual analysis, bloodstains and FA were analyzed at standard low (× 40–× 300) and high (× 600–× 1200) magnification through a Philips SEM 515. Although differential diagnosis between bloodstains and FA resulted often inconclusive at visual analysis, SEM analysis allowed the identification of additional key distinctive morphological features. In particular, on the surface of FA, small crystal-like and/or amorphous material deposits were observed. Such deposits were absent on bloodstains which, on the other hand, displayed red blood cells stacked in “rouleaux.” Basing on these results and under our experimental conditions, SEM analysis resulted suitable to perform a differential diagnosis between bloodstains and FA produced from the insect activity of Sarcophaga carnaria.