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In this study, we analyzed blood samples obtained from 169 cadavers subjected to an autopsy from 1 October 2019 to 27 March 2020. The presence of anti-severe acute respiratory syndrome coronavirus 2 (anti-SARS-CoV-2) antibodies was searched by lateral flow immunochromatographic assay (LFIA) and ELISA tests and the SARS-CoV-2 RNA was tested in blood and available lung tissues by real-time PCR (RT-PCR) and droplet digital PCR (ddPCR). Five cases resulted in positives at the serological screening for anti-SARS-CoV-2. Three results were weakly positive for IgM while only one showed strong reactivity for IgG antibodies. The fifth subject (who died in December 2019) resulted positive for the ELISA test. The detection of SARS-CoV-2 RNA resulted in positive only in the blood and lung tissues of such cases. These data suggest that cadaveric blood may be a suitable substrate for the assessment of SARS-CoV-2 infection; moreover, they extend the observations of sporadic cases of SARS-CoV-2 infe...

Severe fungal infections caused by highly invasive fungi such as Aspergillus are not easy to diagnose and often have a poor prognosis. In these cases, the nonspecific symptoms may make clinical diagnosis challenging, and consequently, the autopsy and postmortem histological investigations acquire a crucial role. We report the case of a young man in good health who died of septic shock 3 weeks after having had a tongue piercing. Intravitam investigations did not identify the etiology of the rapidly fatal infectious condition. The autopsy revealed flaccid organs of uniformly diminished consistency with abscesses and granulomatous foci with central necrosis. Histological examination showed the presence of septate mycotic hyphae, with a dichotomous 45-degree bifurcation, typical for Aspergillus, in all the examined organs, including the tongue. The molecular identification confirmed the presence of Aspergillus fumigatus. The observed macroscopic framework and the laboratory findings mad...

Background When the COVID-19 pandemic began there were concerns that suicides might rise, but predicted increases were not generally observed in the pandemic’s early months. However, the picture may be changing and patterns may vary across demographic groups. We aimed to provide an up-to-date, granular picture of the impact of COVID-19 on suicides globally.Methods We identified suicide data from official public-sector sources for countries/areas-within-countries. We used interrupted time series (ITS) analyses to model the association between the pandemic’s emergence and total suicides and suicides by sex-, age- and sex-by-age in each country/area-within-country. We compared the observed number of suicides to the expected number in the pandemic’s first nine and first 10-15 months and used meta-regression to explore sources of variation.Findings We sourced data from 33 countries (24 high-income, six upper-middle-income, three lower-middle-income). There was no evidence of greater-than-expected numbers of suicides in the majority of countries/areas-within-countries in any analysis;more commonly, there was evidence of lower-than-expected numbers. Certain sex, age and sex-by-age groups stood out as potentially concerning, but these were not consistent across countries/areas-within-countries. In the meta-regression, different patterns were not explained by countries’ COVID-19 mortality rate, stringency of public health response, level of economic support, or presence of a national suicide prevention strategy. They were also not explained by countries’ income level, although the meta-regression only included data from high-income and upper-middle-income countries, and there were suggestions from the ITS analyses that lower-middle-income countries fared less well.Interpretation Although there are some countries/areas-within-countries where overall suicide numbers and numbers for certain sex- and age-based groups are greater-than-expected, these are in the minority. Any upward movement in suicide numbers in any place or group is concerning, and we need to remain alert to and respond to changes as the pandemic and its mental health and economic consequences continue.

Nel caso di mancata guarigione di fratture, in una situazione di approccio clinico e terapeutico d\u2019urgenza, l\u2019analisi epicritica medico legale non pu\uf2 esimersi da una dettagliata modulazione sui dati derivanti dall\u2019evidenza scientifica sui singoli motivi di contestazione. Sia per gli aspetti decisionali sia per quelli operativi, soprattutto in casi di politraumatismo, nessuna osservazione inerente i risultati pu\uf2 di per s\ue9 considerarsi un implicito motivo di fondamento del giudizio sulla condotta sanitaria senza una precisa ricostruzione ed un raffronto con le risultanze delle conoscenze scientifiche accertate

Purpose Since the solely certain remnants of a performed autopsy are formalin-fixed paraffin-embedded (FFPE) samples, stored in the archives of every institute of legal medicine, we managed to extract molecules of toxicological interest from these specimens. Methods We assessed the analysis of ten fresh liver samples collected from heroin-related deaths and then histologically processed the same samples. The embedded blocks were then extracted by means of a new extracting method and the eluates were measured. We also selected five toxicological cases of heroin-related fatalities that were examined 20 years ago, collected the toxicological result documents of the analysis that were carried out at the time and then processed the corresponding FFPE liver samples that were stored in the archives. Results We managed to isolate heroine-related metabolites from 20-year-old paraffin-embedded blocks and calculated ratios to evaluate the performance of our new extraction. Conclusions Accordin...

Suicide pacts are unique events, which involve two or more individuals. In such cases, the initiator and the addicted victim decide to end their lives together in the same place and at the same time. In the present research, on the 26,054 autopsy reports assessed at the Milan Institute of Legal Medicine from 1993 to 2020, 4596 suicides were collected. Among them, 6 cases of suicide pacts were registered, which involved two couples of friends, two couples of spouses, one couple of lovers and one couple of identical twins. Gunshots and acute poisonings were the most common suicidal methods that were adopted. Suicidal notes were documented in 4 cases, which reported the reasons and the consent of the victims. Suicidal notes clearly allow the correct identification of suicide pacts. Furthermore, they often explain the reasons which are frequently based on either psychiatric disorders or financial problems. In the other cases, the absence of farewell notes could complicate forensic investigations, especially to establish the differential diagnosis with murder-suicides without the explicit consent of the victims. In this setting, multidisciplinary skills are preferably required, including a full forensic autopsy with ancillary postmortem analyses (e.g., toxicology, histopathology, and forensic genetics). Furthermore, this study aims to discuss the suicide pacts from a medicolegal, criminological, and sociological point of view, providing a review of the literature with a comparison of our forensic cases.

Even if the Amussat's sign is known since the mid-19th century, few studies have been made in order to assess its real occurrence. In particular, the histopathologic examination of the Amussat's sign lacks in the medicolegal literature. The review of the literature shows indeed a significant range of variability (from 1.1 % up to 25 %) regarding the macroscopic detection of the Amussat's sign. In this study, the authors report that the identification of a vital Amussat's sign is important and may require the immunohistochemical staining for the Glycophorin A (a marker of vital reaction). The victim was a 63-year-old man, who was found suspended from the staircase with a rope. Both the carotid arteries were opened in situ by using fine scissors with blunt tips. A horizontal lesion (length 4 mm) of the intima of the left common carotid artery was documented. A sample was obtained; then, a standard post-fixative histopathologic examination and immunohistochemical staining for the Glycophorin A were carried out. The standard histopathologic examination only revealed the intimal laceration with a poor hemorrhagic infiltration. However, the immunohistochemical staining for the Glycophorin A allowed the clear identification of the hemorrhagic infiltration, which was documented both in the intimal laceration and in the periadventitial soft tissues. The immunohistochemical staining for the Glycophorin A can identify the vitality of an Amussat's sign. When an Amussat's sign is documented, the Glycophorin A may therefore help the forensic pathologist to differentiate a hanging death from a postmortem suspension of the body.

The search for diatoms is the test that most of all may contribute to the forensic diagnosis of drowning. Diatoms can be extracted through different methods, which are all complex and long. In this preliminary study, we assessed human vitreous humor as an innovative substrate on which to research diatoms. Sampling and analyses were performed on 3 groups of 10 corpses each. The first one was composed of drowned victims. The second one of victims of traffic accidents with subsequent projection in water; based on the severe traumatic injuries reported at autopsy, we considered such victims as ideally assimilable to bodies immersed in water postmortem. The third group was composed of subjects who died for natural causes and without any relationship with water. The vitreous humor was centrifugated and cytocentrifuged and spotted on two different histological slides: one was left blank and the other one was assessed with hematoxylin and eosin staining. Microscopic observation successfully revealed diatoms in all cases of the first group; in the second group diatoms were not detected in 6 cases; in the third group, no diatoms at all were observed. Diatoms were always qualitatively and quantitatively consistent with those found in the corresponding viscera and waters, which had been investigated through classical acid digestion. Our analyses have demonstrated that the vitreous humor behaves in a completely similar way to the other viscera in cases of drowning. Although further investigations are necessary, vitreous humor has proved to be an innovative, suitable, and reliable substrate for the forensic research of diatoms.

Infective or mycotic intracranial aneurysms are infrequent cerebrovascular lesions (0,7-4,4% of all intracranial aneurysms) that were related (in the pre-antibiotic era) to bacterial endocarditis or to the intravenous use of drugs. Currently they occur asymptomatically and their finding is occasional during autopsies (5-10% of cases). In this case-report, the Authors show the case of a death due to an intracranial haemorrhage caused by a ruptured mycotic aneurysm of the Postero Inferior Cerebellar Arthery (PICA). It occured in a woman submitted to surgical excision of a right acoustic neurinoma; this case came to forensic observation for the suspect of clinical malpractice. The case A 38 years old woman underwent surgical resection of an 8th cranial nerve benign neoplasy showing asthenia and fever after discharge. For these reasons, she was hospitalized in the same structure for further clinical investigations. After ten days, however, she suddenly died. The Judicial Authority ordered the autopsy, in order to investigate possible medical malpractice occurred during surgery. Results The cadaver was in good conditions of preservation; scalp showed surgical sutured cut at the right fronto-parietal area, and a surgical scar of 12 cm at the retromastoid area. Head dissection demonstrated abundant emission of partially coagulated blood from a drill hole of 1 cm, at the right temporoparietal area of the skull. In the epidural area of the right portion of the posterior cranial fossa, hemostatic material and a surgical suture of the dura mater were found, with a massive hemorrhagic blood collection at the clivus. A cerebral hemorrhage with multifocal localization (leptomeningeal cerebellar, peribulbar, tetraventricular, and right pericisternal) was detected and considered as the cause of death. Histopathologic analysis showed a complete aneurysmatic dissection of the right PICA, at almost 0,2 cm from the origin; it was characterized by the presence of mycotic hyphae with a 45\ub0angle pattern, typical of Aspergillus spp. Conclusions This report describes a case of sudden unexpected death due to a ruptured mycotic aneurysm of the PICA; it occurred in a 38 years old woman, previously submitted to a surgical excision of a neurinoma. It has to be considered a rare, occasional event, which is secondary to an aggressive mycotic infection related to invasive neurosurgical procedures. At Authors\u2019 knowledge, it\u2019s the first case involving VIII cranial nerve neurinoma resection

This study aims to examine the phenomenon of homicide with victims under 18 years-old in a wide and multiethnic metropolitanarea in the north of Italy. We’re dealing with a type of crime that generates a widespread alarm and a common concern.The data analysis, approached with a multidisciplinary strategy, presented in this paper is based on forensic reports of the Instituteof Legal Medicine of the University of Milan, to provide a detailed framework of the homicides of minors that took place inthe territorial jurisdiction of Milan and Monza Prosecutor’s Office between 1993 and 2017. Quantitative and qualitative analysiswere conducted regarding victims’ socio-demographic characteristics (gender, age, nationality), weapons used, places and modalityof body discovery, murderers, motives of the killing and type of relationship between offenders and victims. Purpose of thispaper is to compare the present set of data with the ones provided by the international literature, as well as make s...

Considerato che il giudizio medico legale nel contenzioso civile \ue8 finalizzato ad un convincimento giuridico che si inquadra in un contesto giuridico, la ricerca degli elementi di prova tecnica \ue8 un nucleo obbligato della analisi medico forense. Ci\uf2 indipendentemente dal fatto si tratti di un\u2019analisi in assetto contrattuale o aquiliano, in sospetto di responsabilit\ue0 individuali o strutturali. Se si analizzano linee guida e check list di differente origine, si possono con facilit\ue0 individuare tutti i passaggi critici dei quali, da parte dell\u2019oculista citato in giudizio civile, si rende necessaria una dettagliata documentazione ai fini probativi del rispetto dei diversi passaggi. Ci\uf2 attiene anche gli aspetti dell\u2019emergenza per i quali, dall\u2019analisi della letteratura e nel dibattito costante, si osservano posizioni assai differenti quanto a disponibilit\ue0 estesa dello specialista anestesista. Su questi aspetti \ue8 necessario individuare linee di azione comuni e condivise poich\ue9 l\u2019analisi epicritica medico legale dell\u2019evento indesiderato possa fruire di tutti gli elementi di prova che, pi\uf9 concretamente, sostengono la certezza del giudizio

I pi\uf9 recenti sviluppi giurisprudenziali del tema centrale del risarcimento del danno a persona hanno visto rivoluzionare le componenti non patrimoniali inducendo una profonda riflessione anche sul ruolo medico legale nella determinazione di tali componenti del danno. Il pensiero che il contributo medico legale si debba affinare anche in questo ambito per fornire al Magistrato una pi\uf9 ampia prospettiva decisionale e strumenti di quantificazione del danno fondati su parametri omogenei deve essere affermato. Se \ue8 pur vero che le componenti personali di tipo relazionale, individualmente agenti in senso negativo sulla sfera dell\u2019esistenza, quando sono dipendenti da una menomazione psico fisica non possono essere inclusi nel concetto di danno biologico, \ue8 altrettanto vero che in molti sistemi nazionali il giudizio medico sul grado di sofferenza morale rappresenta una componente del danno affermata ampiamente e da tempo in ogni caso nel quale sussista una danno da lesione dell\u2019integrit\ue0 psico fisica. Questi elementi devono indurre ad una profonda modifica (nel senso dell\u2019amplificazione del ruolo) del contributo tecnico medico legale nella valutazione del danno a persona

The Authors propose a detailed description of the pathologic findings, macroscopic and histological, of two cases of juvenile sudden death in association with the results of genetic tests, such as diagnostic protocol for medico-legal definition of sudden cardiac death caused by arrhythmogenic right ventricular cardiomyopathy (ARVC). The analysis of the circumstances of acquisition judicial, forensic investigations and diagnostic judgments reached, allow us to highlight the importance of monitoring the territory of Milan and its province; it is based on performing the autopsy conducted in accordance with strict research protocols aimed, as well as legal interests, at the prevention of new episodes lethal, related to conditions such as arrhythmogenic right ventricular cardiomyopathy genetically determined and familial transmitted

Introduzione L\u2019interpretazione di preparati istologici cutanei allestiti da materiale cadaverico in avanzato stato di decomposizione rappresenta un\u2019ardua sfida nella comune pratica autoptica medico-legale. Infatti, lo studio isto-patologico di tessuti prelevati da cadaveri in avanzato stato di decomposizione \ue8 quanto mai difficoltoso a causa di alterazioni organiche che, avvenendo in presenza di ossigeno e dei cosiddetti \u201corganismi decompositori\u201d (funghi, batteri, lieviti e, a seconda dei casi, insetti), comportano una degradazione e degenerazione delle strutture tissutali, rendendole scarsamente interpretabili. Tuttavia, esistono diverse colorazioni isto-morfologiche che si possono utilizzare in laboratorio per meglio studiare e caratterizzare le diverse tipologie lesive riscontrate durante un\u2019autopsia, in questi casi. L\u2019uso della soluzione reidratante di Sandison su cadaveri mummificati \ue8 gi\ue0 stato utilizzato con successo in alcuni studi di interesse sia paleopatologico sia patologico forense. Le colorazioni tricromiche, invece, vengono utilizzate in ambito forense per studiare la reazione vitale cutanea, grazie alla loro capacit\ue0 di colorare diversamente le componenti connettivali all\u2019interno di un tessuto. In questo studio presentiamo i risultati dell'applicazione combinata della soluzione di reidratazione di Sandison e della tricromica di Masson su cute di cadaveri sottoposti ad autopsia giudiziaria, con lo scopo di differenziare aree di tessuto indenne da aree interessate da lesivit\ue0 a diversa origine e a diverso stadio di decomposizione. Materiali e metodi Sono stati selezionati 10 cadaveri, sottoposti ad autopsia giudiziaria tra gennaio 2015 e dicembre 2016 presso la Sezione di Medicina Legale dell\u2019Universit\ue0 degli Studi di Milano, rinvenuti in diverso stato di decomposizione, ad un tempo dalla morte compreso tra 1 e 4 mesi. La casistica ha incluso 2 vittime con lesivit\ue0 da arma da fuoco, 2 con lesivit\ue0 elettrica, 2 con lesivit\ue0 termica e, infine, 4 morti per asfissia meccanica da impiccamento. In tutti i casi \ue8 stata prelevata una losanga di cute apparentemente lesionata. Questa \ue8 stata suddivisa poi in due sezioni: una, direttamente fissata in formalina al 10%, mentre l'altra, preliminarmente veniva trattata con soluzione di reidratazione di Sandison e successivamente fissata in formalina al 10%. Tutti i campioni sono stati quindi avviati alla preparazione istologica di routine e le sezioni cos\uec ottenute sono state colorate con Ematossilina-Eosina e Tricromica di Masson secondo Goldner. Risultati All\u2019osservazione microscopica i campioni direttamente fissati in formalina, hanno mostrato alterazioni delle diverse strutture di grado pi\uf9 severo rispetto a quelli preliminarmente reidratati con soluzione di Sandison che, viceversa, ha permesso un riconoscimento strutturale maggiormente distintivo. La colorazione Tricromica di Masson ha presentato un\u2019anomala inversione dell\u2019affinit\ue0 tintoriale del connettivo, apparso di colore rosso, invece che verde, in corrispondenza delle sedi cutanee lesionate, con un effetto pi\uf9 marcato, nei campioni fissati subito in formalina, e di minore entit\ue0 o con disposizione \u201ca macchia di leopardo\u201d in quelli pretrattati in Sandison. Conclusioni Su campioni di cute in diverso stato di decomposizione l'uso combinato della soluzione di reidratazione di Sandison e della colorazione Tricromica \u2013 che si presenta con alterato effetto cromatico \u2013 rappresenta un\u2019utile procedura per lo studio di alcune modalit\ue0 lesive. Attraverso l\u2019inversione dell\u2019affinit\ue0 tintoriale del connettivo \u2013 rosso, anzich\ue9 verde \u2013 \ue8 possibile individuare aree lesionate caratterizzate da effetti di compressione/disidratazione, occultate dallo stato trasformativo avanzato del cadavere, evidenziando aree molto danneggiate, in cui la normo-tintorialit\ue0 cutanea non \ue8 pi\uf9 ripristinabile

The authors present the first case, to the best of our knowledge, of a preplanned suicide by self-waterboarding. Waterboarding (WB) is a military method of torture in which water is poured into the nostrils and the mouth of a victim, to evoke the sensation of asphyxiation by drowning. The victim was a 22-year-old male student, who was found dead and naked in the bathtub. His head was covered by a soaked canvas bag, and his hands were tied with two nylon ropes and a padlock. The water jet of the showerhead was specifically directed at the victim’s head, so that the canvas bag could be soaked with water. The cause of death was defined as the combination of asphyxiation by drowning with the direct suffocation provoked by the soaked canvas bag in the context of the waterboarding practice. Finally, the authors discuss the differential diagnosis regarding the modality (suicide versus homicide) through which this case of waterboarding was performed. The case is intended to be used as sourc...

... divergenze o convergenze.Risultati e Conclusioni - Sebbene una struttura universitaria come quella del settorato milanese offra la possibilità di osservare tutti i decessi da causa violenta in Milano e provincia, il monitoraggio dei parametri tanatologici fin dalla prima ora dal ...

Suicide in cancer patients has always been a subject of clinical studies, but the contribution of forensic pathology to this phenomenon is poorly reported. With the aim of at least partially filling this gap in information, at the Institute of Forensic Medicine of Milan, Italy, we assessed all suicides that occurred in cancer patients. A descriptive and retrospective analysis was carried out by examining the database of the Institute and autopsy reports. We included 288 suicide cases with proven cancer diseases. For each suicide, sex, age, country of origin, body area affected by cancer, further pathological history, medications, previous suicide attempts and suicidal communications, as well as the place where the suicide occurred, were assessed. Furthermore, from a forensic point of view, we considered the chosen suicide method and any involved means. The majority of cases were male older adults affected by lung, colon and prostate cancer. Violent suicide methods were prevalent, an...

Vascular injuries that occur during traffic accidents are a commonly neglected aspect that can add more detail to the framework of a case. In this study, we analysed a case series of 150 traffic accidents, 39 of which were marked by microscopically identifiable vascular lesions. The purpose was to identify the presence of carotid injuries in individuals who died due to traffic accidents and had nonpenetrating trauma of the neck. We focused on the discrepancies regarding the macroscopical aspect and the histology and demonstrated how histological analysis of the carotids in cases of trauma can reveal injuries that are attributable to the trauma itself. We conducted a histological analysis of the lesions to describe their distribution and type and investigate potential correlations. The study offers insight on how to examine road accidents that involve traumatic injury of the carotid arteries. Indeed the main task of the forensic pathologist in the case of death is to establish the existence of a causal relationship between the micro- or macroscopic alterations observed in the autopsy and the traumatic event that led to the death of the subject. Thus, further morphological elements were provided to the forensic practitioners that may reveal injuries attributable to the trauma itself and should be evaluated in cases of trauma in traffic accidents.

Introduction: by a medico-legal point of view it is important to identify a gunshot injury when the characteristics of a penetrating wounds are not obvious to the naked eye. In these cases can be very useful a histological study of both the wounded skin and the injured organs [1, 2, 3]. Sodium rhodizonate has been used as a specific histochemical marker for the detection of gunshot residues on skin, due to its property to form a coloured complex in presence of lead, antimony and barium [4, 5], but it has never been tested on organs. This study proposes a histochemical staining technique with sodium rhodizonate and light green SF yellowish for the detection of gunshot residues in injured brain and dura mater, in order to determine if sodium rhodizonate can be consider a useful histological marker even when it is applied on organs. Methods: the study has been performed on subjects who died of close range gunshot head injury; samples of brain and dura mater were taken, in proximity of the injury, both near the entrance and the exit wound, fixed in 10% neutral buffered formalin and later underwent histological routine procedures; 5-\u3bcm-thick sections were obtained. All sections were first stained with sodium rhodizonate, then contrasted with light green SF yellowish, in order to detect gunshot residues and define their characteristics. Samples of integral brain and dura mater have been used as control sections. Results: a brown-blackish particulate has been detected in injured brain and dura mater sections stained with sodium rhodizonate and light green SF yellowish, mostly located in the areas of greater hemorrhage infiltration near the entrance wound, on a well-contrasted connective tissue. The intensity of staining appeared to be proportional to the concentration of gunshot residues, being brighter in the areas where the tissue was most affected by disruptive processes and where, most likely, particles had deposited in greater amounts. However, greater particulate dispersion could be observed also near the exit wound. Control samples were completely free from any brown-blackish particulate. Conclusions: sodium rhodizonate has proven extremely useful in detecting gunshot residues on brain and dura mater sections. The presence of a brown-blackish particulate within the injured tissues demonstrates that in close range gunshot injuries there is a carriage of gunshot residues and/or substances from the bullet for the entire length of the internal lesion, and these substances can be easily detectable with a histochemical exam. The negativity of control sections (brain and dura mater) confirms the histological specificity of sodium rhodizonate as a marker for lead, antimony and barium, even when it is tested on organs. The histological study of injured organs can be consider as a useful and specific medico-legal instrument applicable to difficult cases, also due to its cheapness and simplicity

Drowning asphyxia correlated to submersion of the vehicles, although globally widespread, is an infrequent manner of death1, characterized by the causal correlation between two events: trauma and asphyxia. Aim of the Authors is to illustrate, through retrospective survey, the incidence of the phenomenon in more than two decades, analyzing damage and impact mechanisms.Out of 22108 autopsies performed at the Institute of Legal Medicine of Milan (1st of January 1993 to 31st of December 2014), the Authors selected all cases of death occurred in traffic accidents with the vehicle fallen into water, dividing them according to different parameters: role of the victim on the vehicle, location of the event, dynamics of the accident, objective injuries and cause of death. For these victims, all the specimens of organs and organic fluids available in the Archives of the Institute of Legal Medicine underwent histopathological and toxicological testing.Cases useful to this research resulted to be 16 (0.07% of all autopsies and 0.38% of the 4153 traffic accidents occurred in the considered period). The \u201ctypical victim" is a young male driver of a car rather than a motorcycle, never surviving to the impact. The dynamics of 88% of these accidents consisted in the car running off the road with the subsequent fall in the water, directly adjacent to roads or falling from bridges, while in the remaining two cases regarding motorcycles, both had previously impacted, respectively, with a truck or with a car. Toxicological tests showed a positive BAC in 47% of cases and just one victim resulted positive for antidepressants and caffeine. Histopathological evidences showed significant microscopic findings in the lungs, and the pursuit of diatoms, performed in all cases, corroborated the cause of death, identified in drowning. Only two victims reported traumatic lesions ascribable to the impact of the vehicle, not sufficient to justify the exitus. The Authors presented the autopsic records of a rare and complex manner of death, characterized by a peculiar forensic-pathological profile resulting from the combination of two events: traffic accident and drowning asphyxia. In these cases, a correct diagnosis of the cause of death, quite difficult due to the possible overlap of these two different harmful manners, is identified on basis of non-lethal traumatic evidences and positive diatoms findings, this last procedure considered as a gold-standard in these kind of events

L\u2019asfissia da inalazione di gas volatili \ue8 un\u2019evenienza di non raro riscontro nell\u2019ambito forense, sia come evenienza di tipo accidentale, sia come mezzo utilizzato a scopo suicida. Tali composti volatili possono essere normalmente presenti nell\u2019ambiente come componenti dell\u2019atmosfera o essere invece il risultato di processi di sintesi in ambito commerciale. Un certa quota di questi gas \ue8 normalmente presente all\u2019interno dell\u2019organismo umano, ma un aumento delle loro concentrazioni, specie se all\u2019interno di un ambiente chiuso, \ue8 in grado di determinare il decesso con meccanismo asfittico considerato \u201cda confinamento\u201d, a causa del progressivo decremento della concentrazione di ossigeno e contestuale aumento dell\u2019anidride carbonica fino a valori incompatibili con la vita. Materiali e metodi: vengono presentati 5 casi, osservati presso l\u2019Istituto di Medicina Legale di Milano, di decesso conseguente ad asfissia acuta da gas volatili. I primi due rappresentano evenienze accidentali mentre altri due rappresentano casi di suicidio. Ne vengono presentate le relative caratteristiche circostanziali, le risultanze autoptiche e tossicologiche. Risultati: il primo caso riguarda una asfissia da gas Azoto (inodore, incolore, insapore ed inerte) verificatosi in maniera accidentale a causa di una malocclusione di una bombola di azoto liquido all\u2019interno di un\u2019autovettura. Il proprietario, non avvedendosene, veniva a decedere rapidamente all\u2019interno dell\u2019ambiente saturo di tale gas e quindi ormai povero di ossigeno. Di fronte a risultanze autoptiche totalmente non dirimenti dal punto di vista anatomo-patologico, le analisi tossicologiche con metodiche innovative nel campo, data l\u2019ubiquitariet\ue0 del gas negli organismi viventi e nella stessa atmosfera, avevano consentito di rilevare concentrazioni di azoto all\u2019interno dei tessuti ampiamente giustificative dell\u2019azione del gas nel determinismo della morte. Una adeguata disamina dei dati circostanziali aveva infatti avvalorato tale ipotesi. Il secondo caso coinvolge invece il gas Argon (gas nobile, costituente dello 0.94% dell\u2019atmosfera terrestre) e riguarda un operaio impegnato all\u2019interno di una conduttura idraulica in fase di realizzazione mentre sulla superficie esterna della stessa venivano effettate operazioni di saldatura al titanio ed al suo interno veniva convogliato gas Argon, saturando quindi l\u2019ambiente. All\u2019evento era poi seguito un periodo di ricovero ospedaliero in stato vegetativo per coma post-anossico, con exitus in terza giornata. Anche in questo caso l\u2019esame autoptico non risult\uf2 dirimente, cos\uec come le specifiche indagini di tipo tossicologico a causa del \u201cwash-out\u201d del gas dai tessuti e dai liquidi biologici. I dati circostanziali ebbero quindi un ruolo decisivo nella ricostruzione della modalit\ue0 lesiva e dei meccanismi letiferi. Il terzo caso riguarda l\u2019utilizzo di propano (idrocarburo alcano e alifatico saturo) come metodo suicidario associato ad un meccanismo combinato di plastic bag suffocation, considerato come metodo \u201cclassico\u201d a scopo suicida, soprattutto nell\u2019ambiente carcerario. Il caso riguarda un uomo rinvenuto propria abitazione con un sacchetto fissato al capo con nastro adesivo, all\u2019interno del quale era stato fatto passare un tubo di gomma a sua volta collegato con una bombola di propano. Le indagini tossicologiche sui campioni di liquidi biologici e tessuti della vittima diedero esito positivo per concentrazioni di propano considerate incompatibili con la vita. Il quarto risulta sostanzialmente analogo al precedente e riguarda l\u2019utilizzo di butano (idrocarburo alifatico gassoso, principale costituente di una miscela che, compressa in bombole, trova impiego come combustibile per uso domestico ed industriale) come meccanismo asfittico a scopo suicida da parte di un carcerato. Le indagini tossicologiche rilevarono elevate concentrazioni di butano all\u2019interno dei tessuti fornendo un fondamentale ausilio alla ricostruzione degli eventi e alla determinazione della causa di morte. Il quinto ed ultimo caso riguarda un\u2019evenienza di sempre pi\uf9 frequente riscontro in tempi recenti, ovvero l\u2019asfissia acuta a scopo suicida mediante gas elio. Tale modalit\ue0 suicida \ue8 stata riscontrata in diversi casi osservati di recente anche nella provincia di Milano. Il caso discusso riguarda due giovani rinvenuti all\u2019interno dell\u2019abitazione di uno dei due, entrambi supini su due letti attigui, con il capo avvolto da un sacchetto di plastica all\u2019interno del quale era stato fatto passare un tubo collegato ad una bombola contenente gas elio. Tale modalit\ue0 di asfissia chimica, per la facile reperibilit\ue0 dei componenti e per la metodica lesiva considerata pressoch\ue9 \u201cindolore\u201d, rappresenta una modalit\ue0 sempre pi\uf9 utilizzata anche delle…

Attraverso un\u2019analisi di casi giudiziari riguardanti i trattamenti terapeutici oculari vengono analizzate le salienti tematiche medico legali in relazione a consenso alla prestazione oculistica, trattamento chirurgico dei difetti refrattivi, complicanze infettive, documentazione sanitaria in oculistica, valore di protocolli i linee guida nel giudizio medico legale sulla condotta specialistica oculistica

We present a case of a 48-year-old man's unexpected death affected by a relapsed clivalchordoma. After partial excision surgery of the neoplasm, he manifested 5 days later, in conditions of well-being, a sudden lethal extracranial hemorrhage from nose and mouth. The autopsy examination and the subsequent histological investigations did not allow us to clarify the exact origin of the bleeding. Based on the negativity of the accurate examinations performed, the extent of the bleeding, and the findings highlighted by the means of the nuclear magnetic resonance (NMR) carried out a few days before death, we have considered reasonable to localize the source of hemorrhage in the intrapetrous tract of the left internal carotid artery. Since this is a unique event, never previously documented, we believe that our report may be of interest to the scientific community.

BACKGROUND : Suicide cases usually report a unique kind of lesion: either stab injuries, or gunshot lesions, or hanging, or poisoning, or precipitation and so forth. Sometimes, suicide victims perform a strange complex ritual involving several different self-inflicted lesions, to reach their purpose. Since the beginning of 2012, two very peculiar cases have come to the attention of the Institute of Legal Medicine in Milan. CASE 1: a 36-years-old transexual women was found dead in her home, with a knife stuck in the thorax and another stab injury beside the previous one. A pajama sleeve was tied tightly around the neck and the gas stove was open. At autopsy, the neck groove was depressed but there was no evidence of excoriation; both thyroid horns were fractured, with blood infiltration. Stabbing injuries involved the left lung, diaphragm, stomach and spleen. Toxicological analysis showed a small amount of alcohol (0.29 g/l) in the blood and the presence of benzodiazepines in blood and urine. Instead, the presence of carbon monoxid in cardiac blood was very low (2,7%).In the gastric content there were chemicals such as methylpalmitoleate, ammonium laurate and so on, normally used in detergents, which she had presumably swallowed. CASE 2: The latter concerns a 49-year-old woman, who jumped from the sixth floor and was found dead on the sidewalk beside her house. Law enforcement officers found in her flat a farewell letter; a plastic chair on a table in the terrace, probably used to climb over the wall and reach the roof; an almost empty plastic bottle containing sodium hydroxide, and a kitchen knife on the roof. At autopsy the presence of multiple stab injuries in neck, chest and abdomen were found, causing a lesion to the jugular vein. The stomach contained 500ml of a brownish-blackfowl-smelling liquid, conditioning the presence of a blackish mucosal surface and a hypertrophic plicature. However the cause of death were the multiple skeletal and visceral lesions due to the contusive mechanism of the fall. CONCLUSION: Literature contains many case-reports of complex suicides: they account for 1,5-5% of all suicides. In most cases a double-modality of combined suicides is described; three-modality ones are more rarely observed. We report a four-modality-combined suicide (described only once in literature), in which there is more than one deep stab wounds: even cases of multiple stab wounds in suicides are reported few times in literatur

Background In early 2020, the Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) published clinical ethics recommendations for the allocation of intensive care during COVID-19 pandemic emergency. Later the Italian National Institute of Health (ISS) invited SIAARTI and the Italian Society of Legal and Insurance Medicine to prepare a draft document for the definition of triage criteria for intensive care during the emergency, to be implemented in case of complete saturation of care resources. Methods Following formal methods, including two Delphi rounds, a multidisciplinary group with expertise in intensive care, legal medicine and law developed 12 statements addressing: (1) principles and responsibilities; (2) triage; (3) previously expressed wishes; (4) reassessment and shifting to palliative care; (5) collegiality and transparency of decisions. The draft of the statements, with their explanatory comments, underwent a public consultation opened to Ita...

BACKGROUND Suicide outcomes in cancer patients represent a major public health concern. We performed an umbrella review (UR) including all meta-analyses (MAs) and systematic reviews (SRs) published on the association between cancer and suicide outcomes. METHODS Eligible studies were searched in the main scientific databases up to January 23rd, 2021. Eligible MAs/SRs focused on all suicide phenotypes among cancer patients. Evidence of the association was extracted; the credibility and quality of the included studies were evaluated using ad-hoc tools, including "A MeaSurement Tool to Assess systematic Reviews-2-Revised" (AMSTAR-2-R). RESULTS Six MAs and 6 SRs were included. The standardized mortality ratio of suicide in cancer patients was 1.5 to 1.7-fold higher than in the general population. Risk factors for suicide outcomes among cancer patients were male sex and older age, a cancer diagnosis within the prior year, and some specific cancer sites. Among 107 associations, 90 (84.1%) were supported by high credibility of evidence (class II). However, all studies reported a large heterogeneity (I2> 50%) and the majority of them reported considerable heterogeneity (I2> 75%). All MAs used random-effects measures. All MAs but one assessed publication bias and only one disclosed it. The majority of MAs/SRs showed critically low quality based on AMSTAR-2-R. LIMITATIONS We could not perform additional analyses due to the limited number of MAs. CONCLUSIONS This UR underlines the inflated risk for suicide among cancer patients. Upcoming, well-designed studies are needed to account for a broader set of variables. Several methodological issues likewise warrant attention.