Suicide and homicide before and during the COVID-19 pandemic in Milan, Italy.

Background: The COVID-19 pandemic has been postulated to account for inflated rates of either suicides or homicides. Nonetheless, results are discordant, in particular concerning suicide. We aimed to perform a retrospective analysis of suicides and homicides in the region of Lombardy, Northern Italy (districts of Milan and Monza Brianza), the Italian region most seriously impacted by the pandemic outbreak. Methods: Data were collected during the autopsies performed at the Institute of Forensic Medicine in Milan. We presented suicides and homicides in the years 2015-2021 and compared the year 2021 to 2019, a pre-COVID-19 year. Results: Data may allow us to cautiously hypothesize a normalization of trends ("regression" to the mean effect) as time passes from the COVID-19 outbreak. Limitations: Limited number of events, in particular, homicides. Conclusions: Recording historical reports from the same region is warranted besides the comparisons across different countries.

Evidence of SARS-CoV-2 Antibodies and RNA on Autopsy Cases in the Pre-Pandemic Period in Milan (Italy).

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 infection in North Italy prior to the first confirmed cases.

Survey on postmortem screening and management of COVID-19 related deaths.

The COVID-19 pandemic is associated with a high case fatality rate in some countries even thought the majority of cases are asymptomatic. Scientific studies on this novel virus is limited and there is uncertainty regarding the best practices for death investigations both in terms of detection of the disease as well as autopsy safety. An online survey was conducted to identify how different institutions responded to the screening and management of dead bodies during the early phase of the pandemic from January to May. A questionnaire was developed using Google Forms and data was collected from 14 different forensic and pathological institutions in 9 countries. None of the institutions had performed any screening prior to March. Four institutions stated that screening was done routinely. In total, 322 cases had been screened using RT-PCR, out of which 40 positive cases were detected among four institutions. The commonest types of samples obtained were nasopharyngeal and oropharyngeal swabs which also had the highest rates of positivity followed by tracheal swab. Blood, swabs from cut surfaces of lung and lung tissue also gave positive results in some cases. Majority of the positive cases were > 65 years with a history suggestive of respiratory infection and were clinically suspected to have COVID-19 before death. Except for one institution which performed limited dissections, standard autopsies were conducted on all positive cases. Disposal of bodies involved the use of sealed body bags and labelling as COVID positive. Funeral rites were restricted and none of the institutions advocated cremation. There were no reports of disease transmission to those who handled COVID positive bodies.

Telemedicine Applications in the Era of COVID-19: Telesurgery Issues.

Telemedicine allows for the effective delivery of health care to patients at a distance through the application of information technology to the field of medicine. This is optimal during the COVID-19 pandemic to reduce interpersonal contact to mitigate contagion. Among the possible Telemedicine applications, there is Telesurgery, which involves more and more surgical specialties thanks to the numerous benefits in quality and cost containment. In the growing field of Telesurgery, its technical and legal implications must be considered. In this study, a traditional review of the scientific literature was carried out to identify the most relevant issues of interest in Telesurgery. The problematic legal aspects identified are mainly related to the difference in legislation between different geographical areas, which is critical in the case of malpractice. In addition, there is the possibility of a malicious hacker attack on the transmitted data stream either to steal sensitive data or to harm the patient. Finally, there are inherent difficulties with the technology used, such as latency issues in data transmission. All these critical issues are currently not adequately addressed by current legislation. Therefore, one can only hope for a legislative action to allow Telesurgery to be used safely.

Preliminary suicide trends during the COVID-19 pandemic in Milan, Italy.

Europe was the second most affected continent by the 2019 coronavirus disease (COVID-19) pandemic, with Italy paying very high death tolls, especially in Lombardy, a region in Northern Italy. The pandemic profoundly impacted mental health and the world's rates of suicide since its outbreak. COVID-19-related suicide rates nonetheless followed a non-linear trend over the pandemic, decreasing after the COVID-19 outbreak, then raising during an extended follow-up period. Thus, we aimed to further assess the suicide rates in Lombardy. We carried out a retrospective analysis of all the autopsies performed in the year 2020 and within the first four months of the year 2021 through the database of the Institute of Forensic Medicine in Milan. In the year 2020, the recorded suicides decreased in comparison to 2016-2019 (21.19-22.97% of the autopsies), being 98 (18.08% out of 542 autopsies), while, in the first 4 months of the year 2021, 35 suicides were documented (185 autopsies, overall). Since the region of Lombardy was severely affected by COVID-19 since the early months of the year 2020, the extended retrospective follow-up allowed for firmer conclusions and insights about the need to extend the follow-up of COVID-19 pandemic beyond the first months after the outbreak, worldwide. This is with special emphasis towards the need to allocate the proper funds for mental health prevention for the general population as well as the most vulnerable ones, such as people with severe mental illness and caregivers, frontline health workers, and others bereaved by COVID-19.

The Italian document: decisions for intensive care when there is an imbalance between care needs and resources during the COVID-19 pandemic.

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 Italian scientific or technical-professional societies and other stakeholders (i.e., associations of citizens, patients and caregivers; religious communities; industry; public institutions; universities and research institutes). Individual healthcare providers, lay people, or other associations could address their comments by e-mail. RESULTS: Eight stakeholders (including scientific societies, ethics organizations, and a religious community), and 8 individuals (including medical experts, ethicists and an association) participated to the public consultation. The stakeholders' agreement with statements was on average very high (ranging from 4.1 to 4.9, on a scale from 1-full disagreement to 5-full agreement). The 4 statements concerning triage stated that in case of saturation of care resources, the intensive care triage had to be oriented to ensuring life-sustaining treatments to as many patients as possible who could benefit from them. The decision should follow full assessment of each patient, taking into account comorbidities, previous functional status and frailty, current clinical condition, likely impact of intensive treatment, and the patient's wishes. Age should be considered as part of the global assessment of the patient. CONCLUSIONS: Lacking national guidelines, the document is the reference standard for healthcare professionals in case of imbalance between care needs and available resources during a COVID-19 pandemic in Italy, and a point of reference for the medico-legal assessment in cases of dispute.