Identification issues in bodies maimed by train fatalities: The role of the forensic pathologist.

Traffic accident injuries are relevant causes of mortality in industrialized countries. Among traffic accidents, the most destructive effect on the victim's body is produced by trains, which in a very short time provoke a complete distortion of the normal anatomical profiles and extensive amputations of the body. Deaths by severe body mutilation and/or decapitation require complex forensic investigation, as the victims' identification and the recognition of their body are not often feasible. In this study, a retrospective analysis of a series of cases of railway accidents is presented, with the aim of showing potential identification strategies, including a systematic physical re-assembling of the body. Among the railway fatalities assessed at the University Institute of Legal Medicine of Milan from 2016 until 2020, 61 cases were analyzed, focusing on the collection of postmortem data to improve accuracy for the identification of the victims. The results showed that the identification could be based on elements traditionally called "secondary identifiers" which, however, are becoming more and more important for positive identification, especially when dealing with migrants, vagrants, and homeless people. However, several issues need to be considered such as the limitations of the public prosecutors to perform expensive analyses (i.e., genetic testing), and the lack of antemortem data to be compared with postmortem findings, both odontological and fingerprint. In cases where it is not possible to proceed with identification or formal recognition of victims of railroad accidents with severe mutilations, a systematic physical re-assembling of the body is critical to reaching positive identification.

A case of medical liability involving an unexpected systemic amyloidosis.

The authors present a case of fatal amyloid cardiomyopathy, which was diagnosed only upon autopsy. A 57-year-old man was admitted to the hospital for scheduled percutaneous cardiac procedure of transcatheter radiofrequency ablation due to persistent atrial fibrillation and atrial flutter. Ventricular fibrillation was recorded in the monitor 2 h after the surgical procedure. Therefore, he was defibrillated and intubated, but he died for nosocomial pneumonia 26 days after being admitted. A judicial autopsy was ordered by the prosecutor due to an alleged medical malpractice. The autopsy confirmed the cause of death being pneumonia, but also revealed an occult restrictive cardiomyopathy with a thick and firm myocardium. Viscera samples were then collected for microscopic examination. Histopathologic analysis showed diffuse amyloid deposits in the myocardium, especially in the perivascular and subendocardial spaces. Amyloid deposits were also detected in all the other organs, except for the brain. Furthermore, immunohistochemistry for light chains was performed on the heart tissue sample, resulting to be positive. In the case presented herein, autopsy and histopathologic examination were crucial to diagnose an occult systemic amyloidosis (AL-type). In fact, it has been observed that the rarity of systematic amyloidosis and its unusual clinical onset were at first mistakenly perceived as a medical malpractice due to a technical error within the catheter ablation for atrial fibrillation. As a consequence, upon discussing the clinical and medicolegal implications concerning the case, the focus was placed on the undiagnosed systemic amyloidosis and on the causality between surgical procedure and the patient's death.

A unique case of death by MDPHP with no other co-ingestion: a forensic toxicology case.

Synthetic cathinones are a class of psychoactive drugs that have become, in recent years, of quite common observation in medical and toxicological forensic field. MDPHP (3,4-methylenedioxy-α-pyrrolidinohexanophenone) belongs to this class of substances but lethal acute intoxication caused by this specific substance without other co-ingestions has never been described in literature. We are presenting the unique case of a fatal acute intoxication caused by MDPHP in a 48-year-old man carried to the A&E department of a big Milanese hospital where he suddenly deceased after brief time. Clinical records, autopsy examination, histological findings, and toxicological analysis, assessed via a Q-Exactive Orbitrap with a HPLC system and LC/MS-MS system, are discussed. This case report may represent the first case of this type of intoxication and might help in improving recognition and treatment of these particular cases.

Sexual assault and abuse committed against family members: An analysis of 1342 legal outcomes and their motivations.

BACKGROUND: Over the past years medical centres specifically addressed in gender-based violence have developed protocols for the collections of evidence useful in the courtroom, including accurate documentation of physical and psychological states of the victim and collection of samples. Previous studies showed an association between documented physical trauma and conviction but unfortunately, few studies in the recent literature analysed the factors that influence the legal outcome and final judgement. The present study focused on the elements that appeared of significance in the legal outcome, including medico-legal evaluation, source of the crime report and circumstance of the assault. METHODS: It was conducted a retrospective analysis of all the judgments issued by the Public Prosecutor's Office at a Court of a Metropolitan Italian city regarding sexual and domestic violence, from January 1st 2011 to 31st December 31st 2015. Examination regarded the demographic information of the victim and of the defendant, information on the crime, the circumstances of the aggression and medical information retrieved. Sentences were subsequently divided into two categories based on the legal outcome (conviction vs acquittal) and the different characteristics of the two sub-populations were compared to verify if there were variables significantly associated to the judge's final judgment. RESULTS: Over the 5 years taken into consideration, there have been 1342 verdicts regarding crimes of sexual violence (374 cases) and regarding abuses against family members or cohabitants (875): other 93 cases regarded both sexual violence and abuse. 66.3% ended in conviction of the offender and 33.7% in acquittal of the accused. Cases of conviction were more frequent when they involved: use of a weapon by the assailant, as well as if the assailant had a criminal record and had a history of drug abuse or other addictions; duration of proceeding less 22 months and a civil party involved; presence of clinical documentation together with other deposition in addition to victim's deposition; also frequent episodes of violence and application of precautionary measures were associated to conviction. CONCLUSIONS: Many factors seem able to influence the judge's judgment, although clearly each case must be singularly evaluated. The mere presence of medical documentation, without the support of other sources of evidence, such as the victim's statement or further declarations, however, is almost always not definitive for the verdict. Despite so, in cases where there are multiple sources of evidence, clinical documentation can provide useful elements and can give clues on the consistency between the history told and injuries observed.

Multi-Rater Agreement Using the Adapted Fracture Healing Scale (AFHS) for the Assessment of Tubular Bones on Conventional Radiographs: Preliminary Study.

Better understanding of the timing of fracture healing may help in cases of interpersonal violence but also of personal identification. The intra- and inter-rater agreement for the adapted fracture healing scale (AFHS) assessing the post-traumatic time interval on radiographs were tested. This is a preliminary study, providing essential information on method reliability for upcoming studies using the AFHS. Five raters (two radiologists, a forensic pathologist, an orthopedist, and an anthropologist) were presented with a test in three parts consisting of 85 radiographs (from 30 adults) of fractures of tubular bones in different stages of healing purposefully selected from more than 1500 radiographs. The raters were firstly asked to assess 15 features describing fracture healing as present, absent, or not assessable. Thereafter, the raters were asked to choose from the AFHS a single-stage best representing the observed healing pattern. The intra- and inter-rater agreement were assessed using single-rating, absolute agreement, two-way mixed-effects intra-class correlation (ICC) coefficients. The intra-rater ICC of radiologist 1 ranged from 0.80 to 0.94. The radiologists' inter-rater ICC ranged from 0.68 to 0.74, while it ranged from -0.01 to 0.90 for the other raters. The good to excellent ICC among the radiologists and forensic anthropologist provides good foundation for the use of the AFHS in forensic cases of trauma dating. The poor to good results for the other physicians indicate that using the AFHS requires training in skeletal anatomy and radiology.

Mechanical asphyxia by accidental compression of the neck during a theft: A case report.

Death by accidental mechanical asphyxia in adults is infrequent and usually results from chocking/aspiration, entrapment, ligature strangulation by clothes catching in machinery (especially as occupational deaths) and, more frequently, sexual asphyxia. Except for autoerotic deaths, accidental hanging almost never occurs in adults, and compression of the neck by solid unmovable structures is also rarely reported. The authors report an unusual case of death by mechanical asphyxia due to accidental compression of the neck in combination with suspension of the body, observed in a thief who was found hanging from the ceiling of a room, having his neck compressed by the panels of the floor and his body suspended half a meter from the ground.

A 10-year single-center experience on 708 lung metastasectomies: the evidence of the "international registry of lung metastases".

INTRODUCTION: The International Registry of Lung Metastases defined a new staging system based on identified prognostic factors for long-term survival after metastasectomy. The aim of our study was to confirm the validity of the International Registry of Lung Metastases classification system in patients who underwent curative lung metastasectomy in a single center. METHODS: We retrospectively reviewed 575 patients who underwent 708 lung metastasectomies from January 1998 to October 2008. Complete curative pulmonary resections were performed in 490 cases (85%). Three hundred seventy-two patients developed lung metastases from epithelial tumors, 80 from sarcomas, 27 from melanomas, and 11 from germ cell tumors. The mean disease-free interval (DFI) was 46.6 months. Open surgical resection was performed in 479 patients. One hundred eighty-five patients had a single-lung metastasis. Lymph node dissection was performed in 353 cases. RESULTS: After a mean follow-up of 34 months, 247 patients (43%) had died. Multivariate analysis disclosed that completeness of resection (p < 0.0001), patients with germ cell tumors (p = 0.04), and DFI ≥36 months (p = 0.01) were also associated with a better prognosis. The actuarial survival after complete metastasectomy was 74% at 2 years and 46% at 5 years. CONCLUSIONS: We confirmed completeness of surgery, histology, and DFI ≥36 months as independent prognostic factors. Number of metastases, presence of lymph node metastases, surgical approach, and number of metastasectomies did not statistically influence long-term survival.