The wounding potential of assault rifles: analysis of the dimensions of entrance and exit wounds and comparison with conventional handguns. A multicentric study.

The appearance of a gunshot wound (GSW) is greatly influenced by the velocity of the projectile, where high-velocity projectiles (HVPs) are defined as ballistic agents reaching a muzzle velocity of > 600 m/s fired from assault rifles. The aim of the study is to present and explain the differences in the dimensions of entrance and exit wounds between the most used handguns and assault rifles and to propose a predictor of HVP, i.e., the ratio of exit and entrance wounds (EX/ENR). The surface area of entrance and exit GSWs and the EX/ENR were calculated. 66 perforating GSWs produced by NATO FMJ 7.62 × 52 mm and 5.56 × 42 mm fired from assault rifles were assigned to the HVP, while 64 lesions produced by conventional projectiles fired from revolvers and semi-automatic pistols were assigned to the low-velocity projectile (LVP) group. The dimensions of the exit wounds of the HVP group were significantly higher when compared to the LVP group (95% CI 0.9886-2.423, p < 0.05). The HVP group showed significantly higher values for the EX/ENR when compared to the LVP group (95% CI 2.617-7.173, p < 0.05). The evaluation of the EX/ENR can be considered an adequate tool to assess the type of weapon involved and to roughly estimate the associated wounding mechanisms, which can guide both the physician in the management and treatment of the patients affected by GSW, and the forensic pathologist in crime investigation.

Anabolic androgenic steroids used as performance and image enhancing drugs in professional and amateur athletes: Toxicological and psychopathological findings.

OBJECTIVE: The use of anabolic androgenic steroids (AASs) as performance and image enhancing drugs (PIEDs), once restricted to professional athletes, now includes amateurs and regular gym visitors. AAS use is associated with psychopathology, yet this relationship is complex and not fully understood. We aimed to assess the presence of AASs and other misused substances in athletes' biological samples and link toxicological to psychopathological findings. METHODS: A multicentre, cross-sectional study in fitness centres in Italy recruited 122 professional and amateur athletes training in several sports (84 men; age range = 18-45 years). Athletes completed questionnaires, interviews, and toxicology testing for AASs, other PIEDs, illicit drugs, and non-prescribed psychotropics. Toxicology was conducted in blood, urine, and hair. RESULTS: Self-reported and toxicologically detected use rates of AASs and other misused substances showed slight-to-fair agreement (Fleiss' κ = 0.104-0.375). There was slight-to-moderate agreement among the three biological samples used for AAS testing (κ = 0.112-0.436). Thirty-one athletes (25.4%) tested positive for AASs. More sport hours/week, narcissistic or antisocial personality disorders, and higher nonplanning impulsiveness scores predicted AAS use (pseudo-R2  = 0.665). AAS users did not differ significantly from non-users in major psychopathology, but their Hypomania Checklist-32 score, which also predicted AAS use, was significantly higher (p < 0.001), suggesting increased odds for cyclothymic disorder or subthreshold hypomania. CONCLUSIONS: Our results have implications for studying AAS users, as they identify a cluster of variables that may be relevant in future understanding of AAS use risks (e.g., personality disorders). Possible disagreements between AAS assessment methods should be considered when implementing harm reduction interventions, such as needle and syringe distribution, health education, and counselling, as well as surveillance programmes.

A systematic review of caffeine-related suicides and an analysis of the controversial role of caffeine consumption in suicidal risk.

Caffeine is the most widely consumed psychoactive compound worldwide. Its mechanisms of action are dose-dependent and when caffeine overdosing occurs, neurologic, cardiovascular and renal systems are mainly affected. Serious toxicities such as seizure and cardiac arrhythmias, seen with caffeine plasma concentrations of 15 mg/L or higher, have caused poisoning or, rarely, death. Caffeine concentrations of 80-100 mg/L are considered lethal. The aim of this systematic review is to summarize data regarding suicides by caffeine administration and analyze the controversial role of caffeine assumption and suicidal risk. We followed the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) indications in the identification and selection of studies and reviewed a series of fatal cases due intentional intoxication by caffeine. A total of 36 cases have been identified. Our results suggests caffeine seems to be negatively correlated with suicide. Even if some observations suggested that the consumption of caffeine may have beneficial effects against depression, and as a consequence against suicide risk, more in-depth studies are required. Data obtained from our study could support both clinicians and forensic pathologists in identifying possible unrecognized cases.

Are carboxyhaemoglobin levels and distance of the corpse from the site of explosion linked? Results from the retrospective analysis of a terroristic attack.

We present a retrospective analysis of a terrorist attack with incendiary grenades. We tried to analyse the correlation between carboxyhaemoglobin levels and distance of the corpse from the explosion site to check whether there is a direct relationship between them. In most fatal cases caused by grenade explosions reported in literature, death results from disruptive injuries or following multiorgan complications of the trauma, but here the terrorists used incendiary grenades causing serious burns to the victims with flames at the site of explosion. As a result, the external injuries were not fatal for most victims, especially those further from the explosion site where the flames and carbon monoxide from the fire played a significant role in causing death. The convergence of circumstantial data, autopsy results, and toxicological data led us to conclude that a direct link between the carboxyhaemoglobin level and distance from the site of explosion could not be made. Understanding the limitation of the value of linking such data is important both for police and forensic pathologists as this can reduce potential errors in reconstructing the dynamics of the event.

Trauma- and stressor-related disorders in survivors from a shipwreck: a short report on forensic implications.

On January 2012 the Costa Concordia cruise ship sank after hitting an underwater rock off Isola del Giglio, in Tuscany, this resulting in a number of deaths and injuries. After the disaster, several survivors developed psychological disturbances. This led to medico-legal evaluations aimed at assessing the psychiatric sequelae of the accident in order to quantify the permanent biological impairment and the related compensations. In the present manuscript we provide an overview of the results of clinical and medico-legal evaluations performed between 2013 and 2019 on 177 survivors complaining psychological disturbances. The most frequently diagnosed condition was Post-Traumatic Stress Disorder (PTSD; n=90), followed by Acute Stress Disorder (n=37), Adjustment Disorders (n=29) and Generalized Anxiety Disorder (n=5). The results of such evaluations are consistent with evidence indicating the risk of developing PTSD and other trauma- and stressor-related disorders among disaster survivors; further, they highlight the potential relevance in the forensic context of individual elements increasing or decreasing the possibility to develop PTSD among subjects exposed to similar life threatening experiences.

A systematic review of radiological and histological findings of septic myocardial calcifications.

Myocardial calcification is a life-threatening condition that is a recognised complication of ischaemic heart disease, cardiac surgery, rheumatic fever, myocarditis and sepsis. Only sparse data, reporting the clinical symptoms, the anatomo-pathological findings, the imaging findings have been published and no exhaustive analysis of all these factors exists in literature. To date, there have been 26 published cases in the medical literature in which myocardial calcifications is the consequence of a septic status. In this review, we will describe the main imaging and histological findings, with particular attention to the known and hypothesized mechanisms of myocardial calcifications. The results of this study may help clinicians and forensic pathologists to identify possible unrecognized cases and inspire the development of an international registry by which to coordinate further research.

Aggression and Violence Toward Healthcare Workers in a Psychiatric Service in Italy: A Retrospective Questionnaire-Based Survey.

Workplace violence and aggression are receiving increasing attention, especially when perpetrated in at-risk services such as psychiatric and emergency departments. Many healthcare providers have been victims of verbal aggressions (VAs) and physical aggressions (PAs), as well as injuries (INs), at the hands of patients. We conducted a 1-year retrospective questionnaire-based survey to assess workplace violence and aggression experienced by staff working at the Psychiatric Service of the Health District of Bolzano-Bozen (Italy). We performed parametric statistics. Logistic regression estimated the size of the association between PA occurrence and staff characteristics. Our psychiatric service's employees were frequent victims (91.5%) of 1 or more aggression/injury in the previous year. VAs and INs showed comparable frequencies among the three sites of our service, that is, the inpatient (INP), the outpatient (OUTP), and the rehabilitation (REHAB) units, differently from PAs, which were more common at INP (p < 0.001). The logistic regression model showed that female sex, working at INP, and a shorter psychiatry work experience predicted PAs occurrence. Most of the staff felt they could benefit from aggression management. Findings show that VAs, PAs, and INs are common among our psychiatric service's employees and point to the need to provide staff training on de-escalation.

Plasma Risperidone-related Measures in Children and Adolescents with Oppositional Defiant/Conduct Disorders.

OBJECTIVE: Therapeutic drug monitoring helps clinicians in choosing the right drug and adjust its dose in specific patients. To this end, we aimed to assess time patterns of risperidone and its metabolite, 9-hydroxyrisperidone, in children and adolescents with oppositional defiant and/or conduct disorder. METHODS: We measured plasma concentrations of risperidone and 9-hydroxyrisperidone, their sum (active moiety, AM) and ratio, as well as plasma concentrations corrected for daily dose (C/D), from 140 children/adolescents with the above-mentioned disorders. We used Student's t test to compare females versus males, patients under versus over 16-year-old, patients with lower versus higher than the median body weight, and patients with lower versus higher than the median body mass index (BMI). Two mixed-effects logistic regression models were fitted for risperidone/9- hydroxyrisperidone ratio and AM, respectively, by considering risperidone daily dose and patients' demographic characteristics. RESULTS: Females had higher 9-hydroxyrisperidone and AM plasma concentrations than males (p = 0.004 and p = 0.034). Younger patients had lower risperidone plasma concentration and risperidone/9-hydroxyrisperidone ratio (p = 0.02 and p = 0.021), but higher C/D 9-hydroxyrisperidone and AM than older patients (p = 0.013 and p = 0.043). Lower-weight patients had lower plasma risperidone and risperidone/9-hydroxyrisperidone ratio (p = 0.014 and p = 0.019), but higher C/D 9-hydroxyrisperidone concentration than heavier patients (p = 0.03). All these results could be accounted for by daily dose. Patients with lower and higher BMI did not differ significantly. Regression analyses showed that only risperidone daily dose predicted risperidone/9-hydroxyrisperidone ratio, whereas risperidone daily dose, sex, and age predicted AM. CONCLUSION: Clinicians prescribing risperidone need to consider sex, age, and weight, but not BMI when adjusting daily doses.

Mercuric chloride poisoning: symptoms, analysis, therapies, and autoptic findings. A review of the literature.

Among mercury-related intoxications, the re-emerging of mercuric chloride poisoning has been recently described in literature. Only sparse data, reporting the clinical symptoms, the anatomo-pathological findings, the analytical procedures or the treatment have been published and no exhaustive analysis of all these factors exists in literature. The classic symptoms associated with toxicity of mercuric chloride is a combination of renal, gastrointestinal (GI) and central nervous system (CNS) damages, eventually leading to death. Fatalities related to exposure to mercuric chloride have been reported since the nineteenth century. To date, there have been 45 published cases in the medical literature in which the intoxication or the death is attributed to mercuric chloride. In this review, we will describe the modern medical treatments, with particular attenztion to the developments of the lasts two decades, in order to provide an exhaustive description of the clinical symptoms, the post-mortem findings, and the analytical procedures to act out when mercuric chloride intoxication occurs. The analysis of the data obtained permitted us to accurately describe all the organs and apparatus involved in mercuric chloride intoxication. The target organs were the kidneys, the GI tract and the CNS. A description of the analytical procedures for the determination of mercuric chloride in biological materials, to carry out in vivo and in post-mortem samples has also been described.

New Rules on Patient's Safety and Professional Liability for the Italian Health Service.

BACKGROUND: The phenomenon of clinical negligence claims has rapidly spread to United States, Canada and Europe assuming the dimensions and the severity of a pandemia. Consequently, the issues related to medical malpractice need to be studied from a transnational perspective since they raise similar problems in different legal systems. METHODS: Over the last two decades, medical liability has become a prominent issue in healthcare policy and a major concern for healthcare economics in Italy. The failures of the liability system and the high cost of healthcare have led to considerable legislative activity concerning medical malpractice liability, and a law was enacted in 2012 (Law no. 189/2012), known as the "Balduzzi Law". RESULTS: The law tackles the mounting concern over litigation related to medical malpractice and calls for Italian physicians to follow guidelines. Briefly, the law provided for the decriminalisation of simple negligence of a physician on condition that he/she followed the guidelines and "good medical practice" while carrying out his/her duties, whilst the obligation for compensation, as defined by the Italian Civil Code, remained. Judges had to consider that the physician followed the provisions of the guidelines but nevertheless caused injury to the patient. CONCLUSION: However, since the emission of the law, thorny questions remain which have attracted renewed interest and criticism both in the Italian courts and legal literature. Since then, several bills have been presented on the topic and these have been merged into a single text entitled "Regulations for healthcare and patient safety and for the professional responsibility of healthcare providers".

Pharmacotherapy for Hoarding Disorder: How did the Picture Change since its Excision from OCD?

This brief review deals with the various issues that contributed to the creation of the new Diagnostic and Statistical Manual condition of hoarding disorder (HD) and attempts at reviewing its pharmacotherapy. It appears that after the newly founded diagnosis appeared in the literature as an autonomous entity, distinct from obsessive-compulsive disorder, drug trials are not being conducted and the disorder is left in the hands of psychotherapists, who on their part, report fair results in some core dimensions of HD. The few trials on HD specifically regard the serotonin-noradrenaline reuptake inhibitor venlafaxine, and, possibly due to the suggestion of a common biological background of HD with attention-deficit/hyperactivity disorder, the psychostimulant methylphenidate and the noradrenaline reuptake inhibitor atomoxetine. For all these drugs, positive results have been reported, but the evidence level of these studies is low, due to small samples and non-blind designs. Regretfully, there are currently no future studies aiming at seriously testing drugs in HD.

Systematic Review of Drug Packaging Methods in Body Packing and Pushing: A Need for a New Classification.

A systematic review of the literature regarding drug packaging methods in body packing and materials used is presented, with the aim (a) to summarize data regarding the packaging methods adopted by drug trafficking organizations, (b) to support forensic pathologists and police forces to classify and describe drug packages, (c) to propose a new classification for drug packaging techniques, and (d) to better clarify the impact of packaging methods on radiological detectability.Packaging methods have been described in 2981 cases, permitting us to summarize the different materials used and to propose a new classification for packaging method based on the materials used. Information concerning the affiliation of body packers and pushers with major (or not) drug trafficking organizations and techniques used to reduce the radiological detectability of the concealed drugs have also been collected.Besides the packaging methods described over the years, our study suggests a standardized approach for the description of drug packages based on the use of different materials and packaging procedures, which provide a possible insight to the type of drug trafficking organization involved.

A lethal case of hoarding due to the combination of traumatic and confined space asphyxia.

Hoarding is defined as the acquisition of, and failure to discard, possessions of little use or value to others, usually associated with a significant degree of clutter in the individual's home. We describe a case of a woman who died from a combined traumatic and confined space asphyxia, after being trapped under some of the objects amassed in her apartment. The event was considered to be accidental; by taking into account the information gathered during assessment of the scene, we believe that the accident took place while entering or exiting the apartment. It appears that the woman, who was trying to open or close the door, could have been using her leg to keep the objects piled behind the door from falling. Unfortunately the pile of hoarded objects collapsed and the woman was fatally trapped underneath them. The age and strength of the woman played an important role in the fatal incident, she was too old and weak to remove the items that had collapsed over her body. The scarcity of space between the collapsed objects and the woman, as well as the absence of external or internal signs of violent asphyxiation, or other causes of death, allowed us to establish that the death resulted from a combined mechanism of both the traumatic and the confined space asphyxiation.

Caffeine-Related Deaths: Manner of Deaths and Categories at Risk.

Caffeine is the most widely consumed psychoactive compound worldwide. It is mostly found in coffee, tea, energizing drinks and in some drugs. However, it has become really easy to obtain pure caffeine (powder or tablets) on the Internet markets. Mechanisms of action are dose-dependent. Serious toxicities such as seizure and cardiac arrhythmias, seen with caffeine plasma concentrations of 15 mg/L or higher, have caused poisoning or, rarely, death; otherwise concentrations of 3⁻6 mg/kg are considered safe. Caffeine concentrations of 80⁻100 mg/L are considered lethal. The aim of this systematic review, performed following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement for the identification and selection of studies, is to review fatal cases in which caffeine has been recognized as the only cause of death in order to identify potential categories at risk. A total of 92 cases have been identified. These events happened more frequently in infants, psychiatric patients, and athletes. Although caffeine intoxication is relatively uncommon, raising awareness about its lethal consequences could be useful for both clinicians and pathologists to identify possible unrecognized cases and prevent related severe health conditions and deaths.

Drug importation into Italy by body packing: An analysis of the UNODC Individual Drug Seizures Database.

Internal concealment and transportation of illegal substances by body packing is a major business with very high profits, attracting criminals all over the world. As body packers are rarely arrested, it is difficult to quantify their proportion in the general population and, consequently, identify the countries involved in this kind of drug traffic; as a consequence, the percentage of undetected cases is undoubtedly high. The aim of this study is to provide useful information concerning the country of origin of body packers travelling to Italy through the analysis of the United Nations Office on Drugs and Crime Individual Drug Seizures Report database in the period 2010-2015. Results of our study highlighted a total of 85 cases, producing a total of 52.4 kg of drugs transported through body packing towards Italy. Data obtained from our analysis could represent an useful starting point to: (a) enhance police controls on people coming from targeted countries and improve collaborations between Italian Police Forces and those of other countries; (b) understand the reason why some cities/airports are so frequently used in drug trafficking through body packing and, as a consequence, enhance police controls in these places; and (c) train airport security staffs in international airports recognized as important departure points for body packers travelling to Italy.

Time since death in a case of simultaneous demise due to a single gunshot: an issue concerning the use of Henssge's nomogram.

We report a case of a double homicide in which the victims, a man and his daughter, were simultaneously killed by a single gunshot. The temperature-based nomogram method for estimation of the time since death was used to ascertain the reliability of the method in a case of simultaneous demise, where the exact time of death was obtained from the analysis of security cameras.In the case presented, the victims differed for a great number of parameters (e.g., atmospheric conditions, thermal insulation of lower trunk, and, above all, body weight), except for the time of death, that was simultaneous. The correct application of the method permitted us to conclude that the estimated time since death was fully consistent with the circumstantial data obtained by the analysis of security cameras.No previous papers reporting the use of the nomogram method in a case of ascertained simultaneously death exists in literature; issues concerning the use of the nomogram method have been presented as well.

Volatile lipophilic substances management in case of fatal sniffing.

Death due to inhalation of aliphatic hydrocarbons such as butane and propane is a particularly serious problem worldwide, resulting in several fatal cases of sniffing these volatile substances in order to "get high". Despite the number of cases published, there is not a unique approach to case management of fatal sniffing. In this paper we illustrate the volatile lipophilic substances management in a case of a prisoner died after sniffing a butane-propane gas mixture from prefilled camping stove gas canisters, discussing the comprehensive approach of the crime scene, the autopsy, histology and toxicology. A large set of accurate values of both butane and propane was obtained by gas chromatography-mass spectrometry analyzing the following post-mortem biological samples: peripheral blood, heart blood, vitreous humor, liver, lung, heart, brain/cerebral cortex, fat tissue, kidney, and allowed an in depth discussion about the cause of death. A key role is played by following the proper sampling approach during autopsy.