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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]

Blunt renal artery injury (BRAI) is a rare finding with incidence ranging from 0.05% to 0.08% among blunt abdominal trauma patients. BRAI occurs in 1% to 4% of patients with renal injury, and the most common cause is motor vehicle accidents. An unusual case of BRAI in a 47-year-old man at work is reported. The victim accidentally fell from a scaffold (approximately 3 m in height). He was transported to the hospital where he was intubated, but he died after 30 min despite the cardio-pulmonary resuscitation. Surveillance cameras showed the man falling from the scaffold, but his impact with the ground was not captured. At autopsy, except for an oval bruise on the left hypochondrium, no external injury was found. The same mark was noticed on the shirt worn by the victim. Bilateral ribs fractures were found. The abdominal cavity was filled with 2 l of fresh blood and clots as a consequence of a complete transection of the left renal artery. Investigation of the workplace revealed a partial footprint on the external side of the scaffold, matching shoes worn by the victim. On the ground, a metallic pedestrian gate with a 1 m high post was found placed just below the scaffold. It was concluded that the man hit the gate's post as intermediate impact after the fall, which caused the oval bruise, ribs fractures, and the rupture of the left renal artery without injury of the internal organs. [ABSTRACT FROM AUTHOR]

The term overkill usually indicates the infliction of massive injuries by far exceeding the extent necessary to kill the victim. Only few articles or textbooks report this term that is mostly associated with sex-motivated homicides where injuries, generally stabbing, are directed to significant sexual parts of the body. The aim of this study is to shed light on the phenomenon of overkill by reviewing some cases personally analyzed by the authors from both a forensic pathology rather than forensic psychiatry views. The reported results coupled with the literature revision confirmed the importance of a complete analysis of all criminological elements for better defining overkill cases. [ABSTRACT FROM AUTHOR]

The article presents two case studies of autoerotic deaths in middle-aged males. Particular focus is given to the cause of death, which is usually through oxygen depletion resulting from autoerotic asphyxia caused by actions such as self-strangulation, hanging and use of gas or volatile chemicals, the equipment used by both victims and the forensic findings. Photographs from both cases are included.

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]

Background: Clarithromycin is a widely used antibiotic, especially prescribed for the treatment of respiratory tract infections, The drug is generally well tolerated. It is described as a very rare cause of fulminant liver failure. Case presentation: Herein we report a case of fatal fulminant hepatitis in a young patient. In his past history the patient presented documented episodes of hypertransaminasemia. Conclusions: This case confirms that clarithromycin although very rarely, can be a cause of fulminant hepatitis, especially in patients with pre-existing liver damage. Although the presumption that clarithromycin hepatotoxicity is dose related is reasonable, an immune-toxicologic hypothesis cannot be excluded. [ABSTRACT FROM AUTHOR]

Background: Ethical issues regarding patient care have recently been raised in Italy by the case of Eluana Englaro, a 36-year-old woman who remained in a persistent vegetative state (PVS) for 17 years. There are no specific laws on the books in Italy regarding euthanasia and physician-assisted suicide. In November 2008, a controversial decision by the Italian Supreme Court granted the woman's father his wish to discontinue nutrition and hydration provided to her. Because of this historic decision, the authors carried out a survey of Italian physicians' beliefs regarding end-of-life practices. Methods: A questionnaire was e-mailed to 70,000 physicians working for the Italian Public Health System and University Medical Hospitals. Results: A total of 22,219 doctors responded to the questionnaire (32.3%), of whom 17,252 (77.6%) had some experience in treating PVS patients. Nearly 70% of responding doctors were aware of PVS diagnostic criteria; most of them (61%) considered tube feeding to be a medical therapy, and 66% of respondents believed that withdrawal of assisted nutrition and hydration (ANH) might be appropriate depending on the patient's wishes. Moreover, even though 50% of doctors surveyed were not in favor of euthanasia, a significant percentage (42%) did approve of it, while 8% of this sample was uncertain. Conclusions: Italian doctors probably have the least experience in end-of-life decisions in Europe, therefore this national survey is a great chance to understand their authentic opinions regarding such remarkable issues. There is broad consensus that a clear legislative position regarding euthanasia and ANH is needed. [ABSTRACT FROM AUTHOR]

The intestinal mucosa contains a highly specialized immune system which plays a central role in the induction of immune reactions. In the small bowel, Gut-Associated Lymphoid Tissue (GALT) is organized in lymphoid aggregates which are known as Peyer’s Patches (PP). Even though human PP involvement in systemic immunity has been described, little is known about their anatomy and morphology and viability. The aim of this study was to examine PP according to their macroscopic anatomy, distribution and cell viability after death. Specimens from the distal ileum were obtained from 72 serial autopsy cases: PP were identified and, parts of them were analyzed for histological examination. Moreover, viability of recovered PP cells was assessed by the trypan blue exclusion test. Most of the PP (90%) were situated on the antimesenteric border of ileum, and the greatest density of PP occurred in the most distal segment. The number of PP varied with age, with the maximum number observed in 21- to 30-years old cadavers. Histological examination showed their remarkable architectural preservation at different post-mortem intervals (PMI), while the mucosal surface underwent autolysis. In 56% of cases PP cells were still viable, especially at PMI < 24 hours after death. These data confirm that human PP are still well preserved in a remarkable percentage of cadavers also several hours after death, and their availability may be helpful in various fields of research. [ABSTRACT FROM AUTHOR]

Pro-inflammatory mediators hold important functions in human body in response to infection, trauma and vascular disease. However, their action is down regulated by the release of anti-inflammatory cytokines, thus restoring a balance which reflects the immune status of a given individual. Recent studies have stressed out the importance of circulating levels of cytokines for forensic purposes even if there is a lack of studies regarding the role of post-mortem mucosa-associated lymphoid tissue. In this respect, Peyer’s patches (PP), represent one of the most important immunological site of the body and the major component of the gut -associated lymphoid tissue. The aim of this study was to evaluate post-mortem PP immune response in 40 serial autopsy cases of people who died from natural and traumatic death. The study examined spontaneous release of the following cytokines by fresh isolated PP cells: interleukin (IL)-12, tumor necrosis factor (TNF)-α, IL-10, IL-6, IL-1β, and IL-8. Results will show that higher levels of TNF-α, IL-6, IL-1β, and IL-8 are statistically correlated with the traumatic death group. From a forensic point of view these data demonstrate that fundamental lymphoid organs, such as PP, may have a potential in diagnosing the cause of death. [ABSTRACT FROM AUTHOR]

Conclusions. Patients affected by whiplash-associated disorder presented alterations of vestibular evoked myogenic potentials (VEMPs). VEMP testing may be an important 'forensic' diagnostic tool in the assessment of cervical spine injury. Objectives. The purpose of this prospective study was to evaluate changes in VEMPs in the assessment of whiplash injuries. Patients and methods. Fourteen patients complaining of whiplash injury were examined and compared with 15 controls. All patients underwent VEMP testing within 7 days from the injury and 90 days after whiplash injury. Beside VEMPs, standard investigation consisted of pure-tone and speech audiometry, impedance audiometry and evaluation of the vestibular system. Results. All subjects presented normal hearing, normal impedence audiometry findings, and normal vestibular function. VEMPs were present both in patients affected by whiplash injury and in the control group at time 0. At 90 days VEMPs were absent in two cases (14.3%). Statistical analysis showed that at time 0 and at time 90 days p1 latency was significantly higher in whiplash patients compared with healthy subjects on both sides (p<0.002). The amplitude of p1-n1 was significantly lower in whiplash patients at time 0 (p = 0.003 on the right and p = 0.018 on the left), but not at 90 days. [ABSTRACT FROM AUTHOR]

Abstract: Fatal gunshot injuries are routinely encountered by forensic pathologists practicing in Southern Italy. Bari, the capital city of the Italian region known as Apulia, is a leader with regard to the number of firearm deaths in Italy. This is mainly attributable to local organized crime groups which control a variety of illicit activities. This retrospective study analyzes autopsy data related to fatal firearm wounds, handled by the Institute of Legal Medicine [University of Bari], between 1988 and 2003. A total of 717 cases were selected and classified as follows: firearm homicides (634); suicides (82); and accidental death (1). A significant number of variables have been reviewed such as: month in which the violent event took place; the victims’ nationalities; gender and age of victims; site and number of entrance wounds; weapon type used; and manner of death (i.e. homicide; suicide; accidental). Analysis has revealed a homicide versus suicide ratio of almost 8:1. Victims were mostly male with a lower mean age than in other similar studies. Homicides with multiple gunshot wounds were more common than ones with single entrance wounds. For example, in one case, 30 entrance wounds were identified in the murder of a gang boss. Four suicides with two entrance gunshot wounds were identified. Handguns were the most frequently used weapon in all groups (i.e. homicide, suicide, and accidental), with 7.65mm and 9mm being the most common calibres. This study revealed a very low incidence of suicide among females. Mental and other types of illness, as well as financial stress were the apparent motives which prompted most of the suicide victims. The homicide cases described were most often related to continual, ongoing fights among local criminal gangs (75%). [Copyright &y& Elsevier]

Traumatic brain injury is the leading cause of morbidity and mortality among children suspected of child abuse. Penetrating cranio-facial injuries are generally rare in the pediatric age group and are caused by both accidental and inflicted mechanisms. We report an unusual case of a 2-year-old female who was admitted to a pediatric emergency room with an industrial stainless steel coat hanger impaled in her skull. Pertinent clinical forensic medicine examination, coupled with home inspection and interviews by the local law enforcement, revealed a horrible episode of domestic violence. [ABSTRACT FROM AUTHOR]

Hospital falls are a frequent sentinel event worldwide, yet prevention remains challenging. There is a need to standardize hospital fall management in healthcare facilities. This study aimed to analyze policies and procedures used by Italian healthcare facilities to reduce hospital falls.The Italian hospitals’ public procedures on patients’ falls issued between November 2011 and June 2022 were retrieved by a web search using the Google search engine and further evaluated according to their compliance with the 2011 Italian Ministerial recommendation for the prevention of patients’ falls.We found 37 official online procedures, of which 45.6% showed full compliance with the 2011 Ministerial recommendation. All the documents explicitly addressed the issue of identifying patient-related fall risk profiles, whereas 28 set appropriate environmental risk factors. More than 80% of the retrieved procedures used the Conley scale. Forty-three percent of the procedures did not provide for national monitoring and reporting of patient falls.Public procedures for preventing patient falls in Italian hospitals are scarcely compliant with the 2011 Ministerial recommendation. Local monitoring, compliance, and reporting of hospital falls are needed to improve patient outcomes and reduce the risk of litigation for staff and organizations. Additionally, standardized tools for evaluating the risk of falls, healthcare professionals’ training, and implementing environmental prevention strategies are needed to contrast this issue. [ABSTRACT FROM AUTHOR]

A response by Biagio Solarino and colleagues to a letter to the editor regarding their article "A national survey of Italian physicians' attitudes towards end-of-life decisions following the death of Eluana Englaro" in the 2011 issue is presented.

Lethal injuries due to large animal attack are uncommon in routine forensic practice in Europe. Specifically, few incidents are reported concerning tiger/lion attacks that usually involve captive circus or zoo animals. We present the case of a 61-year old animal tamer who was mauled to death by four tigers while he was training them for a circus performance. Careful investigation of the circumstances surrounding the fatality revealed that the tamer had most likely been struck with a tiger paw and then mauled by additional tigers resulting in serious and fatal injuries. Although a full medico-legal autopsy was not authorized, total body CT scan coupled with post-mortem external examination allowed a reconstruction of events. [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]

Abstract: “Autoerotic asphyxia” typically involves an individual hanging or ligature, resulting in self-induced oxygen deprivation brought about by neck compression during sexual activity. Little about the so-called “atypical forms” of autoerotic asphyxia, which also involve compression of the chest or abdomen, has been published in forensic literature. When death results from such practices, they are usually deemed accidental, however, suicide or homicide must also be considered. The authors present a single case of accidental fatal asphyxia by the simultaneous compression of the neck, chest, and abdomen using a chair-bed. The victim was known to have had masochistic tendencies. In order to confirm the hypothesis of accidental death, the results of crime scene investigations, and autopsy findings, including histological and toxicological analysis, are summarized here. [ABSTRACT FROM AUTHOR]

Abstract: Nicotine, a lipid-soluble alkaloid obtained from the dried leaves of Nicotiana, is most frequently encountered in tobacco products for smoking, chewing or sniffing as well as in a limited number of pesticides. Though nicotine is one of the most toxic drugs of abuse, it has rarely led to fatalities. Sudden death can be caused by cardiovascular arrest, respiratory muscle paralysis and/or central respiratory failure. A 42-year-old man was found dead by his wife. He was lying on the floor, next to a box containing many empty bottles of beer and vodka. Some labeled chemical bottles found at the scene contained various substances, including nicotine and brucine. Gross examination of the organs at autopsy revealed no specific findings. The toxicological examination failed to disclose any lethal toxic agents other than a high concentration of nicotine and its primary metabolite cotinine in femoral venous blood (2.2μg/mL). Blood alcohol was determined to be 2.1g/L in femoral venous blood. Only a paucity of fatal cases of nicotine poisoning has been reported in the literature so far. [Copyright &y& Elsevier]

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 6.6μg/mL in femoral venous blood, while levels of nicotine and its primary metabolite cotinine were determined to be 0.6 and 2.0μg/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. [Copyright &y& Elsevier]

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]

Abstract: To evaluate the characteristics of the reported workplace violence in a psychiatric intensive care unit (PICU) by analyzing an electronic hospital incident reporting system (IRS). One hundred thirty reports were retrieved from January 2017 to June 2020, referring to assaults committed by patients (71% males) with an average age of 29.8 years (SD, 14.9). The most frequent psychiatric diagnosis was a neurodevelopmental disorder (33%). Physical aggression (84%) was more frequent than the other types of aggression. Nurses and unlicensed assistive personnel were the most frequent victims (65%). Aggressions were more frequent on Friday (18%) and between 4 p.m. and 8 p.m. (35%). A total of 64.9% of the incidents happened in the first 5 days of hospitalization. A significant association between physical aggression and diagnosis of neurodevelopmental disorder emerged. IRS could be helpful to identify high-risk patient groups and develop clinical strategies to reduce adverse events in clinical practice. [ABSTRACT FROM AUTHOR]

Background: Traumatic brain injury (TBI) is one of the major causes of morbidity and mortality among young people and is a matter of concern for forensic pathologists. Many authors have tried to estimate a person’s survival time (ST) after TBI using different approaches.The present study aimed to present an innovative workflow to estimate the ST after TBI by observing the inflammatory reaction of the dura mater (DM).The authors collected DM samples from 36 cadavers (20 with TBI and 16 with no history or signs of TBI). Each sample was labelled via immunohistochemistry with three different primary antibodies, CD15, CD68, and CD3, yielding 108 slides in total. The slides were digitalized and analysed using QuPath software.The DM is involved in the inflammatory response after TBI. CD15 immunoreactivity allowed us to distinguish between subjects who died immediately after TBI and those with an ST of minutes or hours. CD3 immunoreactivity can be used to differentiate subjects with an ST of days from those with other STs. Moreover, the DM samples showed an acceptable diagnostic yield even in samples with signs of putrefaction.Objective: Traumatic brain injury (TBI) is one of the major causes of morbidity and mortality among young people and is a matter of concern for forensic pathologists. Many authors have tried to estimate a person’s survival time (ST) after TBI using different approaches.The present study aimed to present an innovative workflow to estimate the ST after TBI by observing the inflammatory reaction of the dura mater (DM).The authors collected DM samples from 36 cadavers (20 with TBI and 16 with no history or signs of TBI). Each sample was labelled via immunohistochemistry with three different primary antibodies, CD15, CD68, and CD3, yielding 108 slides in total. The slides were digitalized and analysed using QuPath software.The DM is involved in the inflammatory response after TBI. CD15 immunoreactivity allowed us to distinguish between subjects who died immediately after TBI and those with an ST of minutes or hours. CD3 immunoreactivity can be used to differentiate subjects with an ST of days from those with other STs. Moreover, the DM samples showed an acceptable diagnostic yield even in samples with signs of putrefaction.Methods: Traumatic brain injury (TBI) is one of the major causes of morbidity and mortality among young people and is a matter of concern for forensic pathologists. Many authors have tried to estimate a person’s survival time (ST) after TBI using different approaches.The present study aimed to present an innovative workflow to estimate the ST after TBI by observing the inflammatory reaction of the dura mater (DM).The authors collected DM samples from 36 cadavers (20 with TBI and 16 with no history or signs of TBI). Each sample was labelled via immunohistochemistry with three different primary antibodies, CD15, CD68, and CD3, yielding 108 slides in total. The slides were digitalized and analysed using QuPath software.The DM is involved in the inflammatory response after TBI. CD15 immunoreactivity allowed us to distinguish between subjects who died immediately after TBI and those with an ST of minutes or hours. CD3 immunoreactivity can be used to differentiate subjects with an ST of days from those with other STs. Moreover, the DM samples showed an acceptable diagnostic yield even in samples with signs of putrefaction.Results: Traumatic brain injury (TBI) is one of the major causes of morbidity and mortality among young people and is a matter of concern for forensic pathologists. Many authors have tried to estimate a person’s survival time (ST) after TBI using different approaches.The present study aimed to present an innovative workflow to estimate the ST after TBI by observing the inflammatory reaction of the dura mater (DM).The authors collected DM samples from 36 cadavers (20 with TBI and 16 with no history or signs of TBI). Each sample was labelled via immunohistochemistry with three different primary antibodies, CD15, CD68, and CD3, yielding 108 slides in total. The slides were digitalized and analysed using QuPath software.The DM is involved in the inflammatory response after TBI. CD15 immunoreactivity allowed us to distinguish between subjects who died immediately after TBI and those with an ST of minutes or hours. CD3 immunoreactivity can be used to differentiate subjects with an ST of days from those with other STs. Moreover, the DM samples showed an acceptable diagnostic yield even in samples with signs of putrefaction. [ABSTRACT FROM AUTHOR]

Despite being an infrequent crime, parental homicide has been associated with schizophrenia spectrum disorders in adult perpetrators and a history of child abuse and family violence in adolescent perpetrators. Among severe psychiatric disorders there is initial evidence that delusional misidentification might also play a role in parricide. Parricides are often committed with undue violence and may result in overkill. The authors present the case of an adult male affected by schizoaffective disorder and Capgras syndrome who committed patricide. Forensic pathologists classify such cases as overkill by multiple fatal means comprising stabbing, blunt trauma and choking. Accurate crime scene investigations coupled with psychiatric examinations of perpetrator allow reconstruction of the murder stages. This overkill case is discussed in the context of a broad review of the literature. [ABSTRACT FROM AUTHOR]

• The diagnosis of myocarditis is challenging at Emergency Department. • D.A.M.E. score may provide fast identification of patients with myocarditis. • DAME score is composed by fever, chest pain, ESR, hs-CRP, troponin, and LVEF. • A score>7 showed higher sensibility, specificity and NPV in myocarditis diagnosis. . The final diagnosis of myocarditis is challenging. The aim of our study was to provide the D.A.M.E. (D iagnosis of A cute M yocarditis in E mergency) Score for the fast identification of patients suffering from myocarditis at Emergency Department (ED). . This was a multicenter, retrospective study involving three centers. All medical records from January 2010 to December 2014 reporting a final discharge diagnosis of myocarditis were considered. One hundred-four patients (mean age: 40.2±16.5 years) were enrolled. Clinical, biochemical and instrumental data were gathered. Data were analysed by means of logistic regression model and factorial analysis. A validation cohort from a fourth center was enrolled. . The final determinants of the DAME score were six: fever, chest pain, erythrocyte sedimentation rate (ESR) > 20 mm/h, C-reactive protein (hs-CRP) >3 mg/L, troponin serum levels >3 ng/L, and left ventricle ejection fraction < 50%. All of them received a specified score ranging from 0 to 4. A score > 4 was related to 75% probability of myocarditis; a final score ranging between 1 and 4 was related to 57% probability of myocarditis. ROC curve on the validation cohort (289 patients, 27 with myocarditis) demonstrated the best cut-off to be 7: AUC 0.958 (p< 0.001), sensibility: 100%, specificity: 85.11%, PPV: 40.9%, NPV: 100% (LR+: 6.72; LR-: 0.00). Logistic regression analysis revealed Odds Ratio equal to 2.83 (95% CI 1.90 – 4.20, p < 0.0001). . DAME score can offer a reliable tool in ED setting for the evaluation of patients suffering from suspected myocarditis. [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]

Traumatic injuries in pregnancy such as abdominal trauma, pelvic fractures and penetrating trauma are major causes of maternal and neonatal morbidity and mortality. The most common causes of trauma during pregnancy are motor vehicle accidents, falls, assaults, gunshots, and burns. Pregnancy itself has been identified as a risk factor for trauma, together with a younger age, drug use, alcohol use, and domestic violence. We report the case of a 46-year-old woman, 34 weeks pregnant, who attempted suicide by jumping from a flyover, immediately after a probably deliberate traffic collision with the guardrail. She had fractures of five lumbar vertebrae and three ribs with pulmonary contusions, but was without other injuries. Following the mother's stabilization, the fetal heart tones were detected as abnormal and the patient had an emergency caesarean section delivering a still-born male infant. Neither alcohol nor drugs were found in the mother who had been diagnosed with an unspecified episodic mood disorder. She recovered completely from her injuries. At autopsy of the newborn, a massive subarachnoid hemorrhage with deformity of the skull was found, caused by maternal blunt abdominal trauma following car accident and fall. This case is an outstanding example of fetal head trauma which occurred with no life-threatening maternal injury due to attempted suicide. It is important for clinicians and forensic pathologists to have adequate knowledge and practical experience of these cases, because pregnancy is a special risk factor for self-inflicted injuries among females, with significant adverse effects on the fetus even with minor injuries to the mother. [ABSTRACT FROM AUTHOR]

“Krokodil” is a home-made opioid drug obtained by synthesizing desomorphine from codeine and combining it with other low-cost additives. Initially introduced in the former Soviet countries, it was then imported to Western Europe as a heroin substitute. To our knowledge, this is the first report of an Italian case of lethal krokodil abuse, that occurred in a 39-year-old man, who died suddenly after transportation to the Emergency Department (ED) for hyperthermia associated with sweating, dyspnoea and tachycardia. Post-mortem examination revealed extensive necrotic ulcerative lesions on the forearms, and autopsy showed a hypertrophic heart with ample endocardial vegetation on the aortic valve and patency of the foramen ovale. Histopathological examination of the heart showed ulcero-vegetative lesions of the aortic valve with an abscess on the annulus and extension to the periaortic adipose tissue, as well as diffuse myocardial interstitial inflammatory neutrophilic infiltrates. Toxicological analysis demonstrated a desomorphine metabolite in urine. On the basis of all these findings the cause of death was ruled to be congestive heart failure caused by endocarditis and myocarditis, correlated with chronic abuse of krokodil. [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]

Chest skeletal injuries are the most frequent complications of external chest massage ( ECM) during cardiopulmonary resuscitation, but heart and great vessels lacerations that are indeed very rare. We report the case of a 35-year-old workman who collapsed and underwent ECM by his co-workers for almost 30 min. At autopsy, no external injuries, fractures or bruises of the ribs or sternum, were observed. A hemopericardium with a rupture of the heart was found, with no signs of pre-existent cardiac disease. Bruises of thoracic aortic wall, lung petechiae, a contusion of the liver, and bruises of lumbar muscles were found. The cause of death was due to sudden cardiac death with an extensive cardiac rupture. This is an unusual report of massive heart damage without any skeletal or muscle chest injuries, secondary to cardiopulmonary resuscitation. This kind of cardiac lesions may be considered when thoracic-abdominal trauma, or medical history, is unclear. [ABSTRACT FROM AUTHOR]

Folie à deux is a rare clinical syndrome characterized by the transference of delusional ideas from one person to one or more other people in close association with the primary affected patient. Mummification indicates the preservation of the corpse of a person for a variable period of time. A brief review of the literature in this field is presented, and an exceptional case is described, characterized by the association of both these rare phenomena. The case is an example of folie à fammille which developed out of a condition of extreme religiousness and seclusion of an entire family. The shared psychosis led to the horrible death of some of the family members, while the last surviving member of the family lived for more than a year and a half with their mummified remains. The Judge commissioned a forensic psychiatry assessment to verify the survivor's ability to bear witness. The development of the psychiatric syndrome and its consequences are extensively discussed. [ABSTRACT FROM AUTHOR]

In forensic sciences, bone marrow (BM) is an alternative matrix in postmortem toxicology because of its good resistance to autolysis and contaminations. Nevertheless, few studies have been focused on postmortem BM morphological changes after pathological stimuli. We examined 73 BM samples from forensic autopsies; causes of death were both natural and traumatic. BM samples were collected from the sternum by needle aspiration and biopsy; in selected cases, immunohistochemistry was performed. Few autolytic changes were found; BM cellularity decreased with increasing age and postmortem interval. Notable cell changes were detected in 45 cases (61.64%): neoplastic (n = 4), and non-neoplastic BM findings (n = 41), including multiorgan failure/sepsis (n = 26), myelodisplastic-like conditions (n = 11), and anaphylactic reactions (n = 4). The results showed that BM cellularity supported circumstantial and autopsy findings, suggesting that BM samples could be a useful tool in forensic science applications. [ABSTRACT FROM AUTHOR]

Determination of time since death is one of the most difficult and crucial issue in forensic medicine. Apart from body cooling, which is commonly used in the early postmortem interval (PMI), supravital reactions are the most interesting postmortem changes for time of death estimation. Nasal ciliary motility has been occasionally observed in postmortem period although no studies have focused on this phenomenon for forensic purposes. We aimed to evaluate the diagnostic usefulness of ciliary motility as a potential tool in estimating the time of death. Specimens of ciliated epithelium from 100 consecutive cadavers were obtained by scraping the nasal mucosa at three different postmortem intervals. The samples were then smeared on a slide, and an in vitro evaluation of ciliary movement was analyzed by phase-contrast microscopy. A postmortem nasal ciliary motility was observed, and a statistically significant relationship between decreasing ciliary movements and increasing postmortem interval was detected even in presence of putrefactive changes of nasal ultrastructure integrity. Some peculiar causes of death seem to influence ciliary motility in the early PMI, while no significant correlations with sex or age were observed. According to the results of this study, postmortem evaluation of nasal ciliary motility may be a bona fide and a feasible option for estimating the time of death. [ABSTRACT FROM AUTHOR]

Abstract: The aim of this study was to ascertain if a relationship between weapon choice and psychopathology existed. The perpetrators (103) were evaluated at the Department of Criminology and Forensic Psychiatry of the University of Bari in southern Italy. Psychiatric examination and psycho-diagnostic tests were administered for each of the perpetrators and a database was subsequently formulated. The results showed a significant correlation between some types of mental disorder and weapon choice. A strong correlation was found between delusional disorders and the use of sharp weapons, whereas depressive disorders were more strongly associated with asphyxia. Organic disorders were found to be highly correlated with the use of blunt instruments. In cases where the homicide was the result of an impulsive reaction, the use of sharp weapons was most often observed. [Copyright &y& Elsevier]

Myocarditis is an inflammatory disease of myocardium, associated with nonischemic necrosis and degeneration of myocytes. Although the clinical course is rapid, myocarditis can lead to dilated cardiomyopathy with chambers dilatation and ventricular dysfunction. The pathophysiology of myocarditis in humans is not completely understood. There are several etiological agents implicated, mainly viral agents. The clinical presentation is extremely various, with nonspecific systemic symptoms until sudden death. The great variability of symptoms makes the diagnosis, therefore, extremely difficult. We report the case of a 40-year-old woman who developed, after childbirth, hyperthermia associated with neck and left arm pain; initially treated with acetaminophen, without any benefit, the young woman, after few days, died suddenly. The autopsy documented the presence of edematous lungs and enlarged and congested liver. The microbiological tests performed 4 days after death were negative. The heart was normal in shape and volume; a section of the left ventricle wall showed subendocardial discromic areas histologically characterized by multifocal perivascular and interstitial inflammatory infiltrates. These infiltrates consisted mainly of neutrophils with eosinophil component associated with myocyte necrosis and hemorrhagic interstitial infiltration. [ABSTRACT FROM AUTHOR]

• Dog bites are still a major health problem and may cause injuries or even death. • Italian law establishes the responsibility for any dog aggression lies with its owner. • A technical multidisciplinary evaluation of bite marks may help to identify the dogs involved in the attack. Lethal injuries by animal attacks are a matter of concern for the forensic pathologist; the presented case illustrates a two dogs attack on a 61-year-old man. The authors have focused on a multidisciplinary approach involving forensic pathologists and veterinarians. The victim was cycling in the countryside when he was attacked by two dogs that came out of a large house. He was found lying in the street by the homeowners who called for help. The victim was transported to the hospital where he died five days later. According to recovery data and medico-legal autopsy findings the cause of death was septic shock. Forensic pathologists and veterinarians multidisciplinary evaluation revealed lacerations, abrasions, and multiple small punctures constituting bite marks over the entire body. Six skin dowels with bite marks were taken and compared with the dental cast of the dogs. A comparison of the dog dental casts and the bite marks on the victim's body allowed the identification of the animals involved in the attack. [ABSTRACT FROM AUTHOR]

Background Many drugs used for neonates are unlicensed or off-label. An increased risk of medication errors and unexpected adverse drug reactions is associated with their use. This risk is even higher in preterm newborns, because of their physiological immaturity and the exposure to many different medicines. The objective of this study was to evaluate the use of unlicensed or off-label drugs in eight tertiary-level neonatal intensive care units ( NICU) from two different southern Italian regions. Methods All drugs prescribed to newborns admitted to each NICU, during 1 month of observation, were recorded and classified as licensed, unlicensed or off-label, according, respectively, first, to their license status and, then, their indications, dose, treatment route, and duration of treatment specified in each specific marketing authorization. Results A total of 126 newborns were treated with at least one drug during the observation period. A total of 483 prescriptions referred to 87 different drugs, classified as licensed, unlicensed or off-label. Each newborn was exposed to three (median) different drugs; 88.6% were licensed and 11.4% unlicensed (range, according to different NICU, 1.9-26.7%). Among licensed drugs, 37.4% were used as off-label (range, 27.3-53.4%). Conclusions The use of unlicensed or off-label drugs use is common practice in NICU, with wide variation in local policies and newborn characteristics. Well-designed and -conducted pharmaceutical studies in newborns are needed to increase the number of licensed drugs, thereby reducing any risk for patients due to over- or under-treatment, and also legal issues for clinicians. [ABSTRACT FROM AUTHOR]