Consultation between forensic and clinical pathologists for histopathology examination after forensic autopsy.

The magnitude of the diagnostic benefit conferred by performing histopathological examinations after medico-legal/forensic autopsies remains debatable. We have tried to address this issue by reviewing a series of histopathology referrals concerning medico-legal autopsies in real-world routine practice. We present an audit of the consultations provided to forensics by clinical pathologists at our institute between 2015 and 2018. Over this period, 493 post-mortem examinations were performed by forensic pathologists. Of these cases, 52 (11%) were referred for histopathology. Gross assessment was requested in 22/52 (42%) cases. Histopathology examination was performed on single organs in 15/52 (29%) cases, primarily on the lung and heart, whereas parenchymatous multi-organ analysis was carried out in 14/52 (27%) cases. Bone-marrow sampling was studied in 4/52 (8%) cases. Immunohistochemistry was needed in 16/52 (31%) cases, special stains in 9/52 (21%) cases and molecular analysis in 4/52 (8%) cases. Focusing on technical processes, standard methodology on pre-analytical procedures was changed in 10/52 (19%) cases in order to answer specific diagnostic questions. We showed that although most of the time the diagnosis is clear by the end of dissection on the basis of the macroscopic findings, histopathology can provide, modify or confirm the cause of death in many medico-legal/forensic cases. Therefore, it is desirable that forensic pathologists and clinical pathologists establish robust working relationships in a cooperative environment. We conclude that it is important to implement guidelines based on real-world routine practice in order to identify cases where histopathology can provide useful contributions, which in our experience applied to 11% of forensic cases.

Is the Italian consent to transfusion really informed? A medico-legal analysis between old ghosts and new evidence.

In healthcare systems of developed countries, obtaining informed consent is a necessary and fundamental requirement for the administration of any medical treatment. In Italy, for the administration of the recipient's informed consent for a blood transfusion, a pre-printed form is used in line with the Decree of the Ministry of Health dated 2 November 2015. This paper aims to analyse this form in light of the European legal provisions and following the enactment of Italian Law No. 219 of 2017 on informed consent and advance treatment directives. Our review shows that the structure of the form can be improved in light of the new direction provided by Italian law, the scientific advancement on transfusion risks, and the potential to reduce the use of blood components. Revising this form could be the opportune time to include written information on Patient Blood Management strategies. Though not exhaustive, this proposal may stimulate debate on the point and produce further contributions.

Septic cardiomyopathy: The value of lactoferrin and CD15 as specific markers to corroborate a definitive diagnosis.

Current scientific consensus about the physiopathology in the progression from severe sepsis to septic shock and death focuses on myocardial contractile dysfunction. Nevertheless, objective parameters to establish a pathological correlate of a fatal outcome are lacking; then a cause of death due to sepsis can remain an unsolved problem. We first reviewed all death cases recorded at our institutions during the period from 2007 until 2015. Then, we conducted a retrospective study of a selected autopsy series of people who had received "sepsis" as cause of death. Two pathologists re-examined the heart sections while the most suitable myocardial sample for each case was stained for immunohistochemistry with antibodies targeted for specific inflammatory-related molecules. We used specific antibodies for the following markers: alpha-smooth muscle actin (alpha-SMA); fibronectin; matrix metallopeptidase 9 (MMP-9); intercellular adhesion molecule 1 (ICAM-1); caspase-3; lactoferrin (LF); cluster differentiation 15 (CD15). The statistical significance of differences was assessed using student's t-test for unpaired data or non-parametric Mann-Whitney or Wilcoxon tests for skewed variables or one-way analysis of variance and post hoc Scheffe's test for continuous variables and Pearson's χ2-test for discrete variables. Linear regression analysis was used to determine the presence of a correlation between continuous variables. At our institutions, 2220 deaths have been recorded during the period study. Sepsis accounted as a cause of death for the 20% of total. We finally enrolled 56 cases; of these, only 20 were positive for microbiological analysis. At histological examination, clear inflammation was detectable in the 32% of cases; otherwise, immunohistochemical reaction showed a positive reaction for LF and CD15 in more than a half cases (56%). We still ignore all the underlying mechanisms of sepsis and all its pathophysiological connections with cardiac metabolism; in this sense, we aim to corroborate the diagnostic value of anti-LF and anti-CD15 staining for the post-mortem detection of myocardial inflammation.

Delayed splenic rupture: dating the sub-capsular hemorrhage as a useful task to evaluate causal relationships with trauma.

The aim of the paper was to perform a chronological assessment of the phenomenon of delayed rupture of the spleen, to assess the phenomenological order about the sub-capsular hematoma transformation to determine the causal relationship with trauma as hypothetical cause of death. 80 cases of blunt trauma with splenic capsular hematoma and subsequent rupture of the spleen were evaluated: 38 had an acute rupture of the spleen, 42 presented a break in days or weeks after the traumatic injury. Time between the traumatic event and delayed rupture of the spleen is within a range of time from one day to more than one month. Data recorded included age, sex, type of trauma, injury severity score, grade of splenic injury, associated intra-abdominal injuries, pathologic specimen evaluation. Immunohistochemical investigation of perisplenic hematoma or laceration was performed utilizing polyclonal antibodies anti-fibrinogen, CD61 and CD68, and showed structural chronological differences of sub-capsular hematoma. Expression of modification and organization of erythrocytes, fibrinogen, platelets and macrophages provides an informative picture of the progression of reparative phenomena associated with sub-capsular hematoma and subsequent delayed splenic rupture. Sub-capsular splenic hematoma dating, which we divided into 4 phases, is representing a task in both clinical practice and forensic pathology.

Lethal effect of a single dose of rasburicase in a preterm newborn infant.

This case report describes a preterm newborn infant who was treated with a single dose of rasburicase for an increase in uric acid level. He died on the third day as a result of complications of hemolysis, which appeared to be precipitated by rasburicase. The patient's death was preceded by progressive respiratory insufficiency, lactic acidosis, and hyperbilirubinemia, culminating in refractory hypoxia and hypotension. A postmortem assay for glucose-6-phosphate dehydrogenase showed deficiency and the glucose-6-phosphate dehydrogenase Mediterranean genotype.

Sudden cardiac death, borderline myocarditis and molecular diagnosis: evidence or assumption?

PURPOSE: Sudden unexpected death autopsy is sometimes non-conclusive both from a macroscopic and from a histological point of view, even if carried out according to the guidelines for sudden cardiac death examination. Molecular biology techniques are required in this setting and may play a crucial role in reaching the final diagnosis. A CASE REPORT: The postmortem examination and toxicology findings of the body of a young monk found dead in his cell were negative. Rare focal myocardial lymphocytic infiltrates were seen microscopically, associated with interstitial oedema. The findings were not sufficient to diagnose a myocarditis as the certain final cause of cardiac arrest. According to the recent guidelines for sudden cardiac death, a molecular investigation by polymerase chain reaction analysis was performed on samples of myocardium and spleen, with detection of parvovirus B19 DNA in the myocardium. Accordingly, a diagnosis of parvovirus B19 borderline acute myocarditis was put forward as the possible cause of sudden cardiac death. CONCLUSION: In sudden death cases in which there is lack of a cause-effect relationship with the postmortem findings, the final report should be expressed as a descriptive association of evidence, not providing unreliable certainty, as the Association for European Cardiovascular Pathology recommends.

A devastating case of purpura fulminans in a young adult seven years after a splenectomy: a case report.

It is well known that asplenic patients can suffer immediate and long-term infective sequelae, most of all from capsulated bacteria, whereas appropriate immunization can reduce the incidence of postsplenectomy sepsis. We discuss the case of a young adult developing an overwhelming post-splenectomy sepsis (OPSS) due to streptococcus pneumoniae seven years after the splenectomy for a traumatic injury. Neither immunoprophylaxis nor antibiotic therapy, whose value is underlined by literature data and international guidelines, was ever administered, either by the hospital physicians or by the general practitioner.

Third mandibular molar radiological development as an indicator of chronological age in a European population.

Assessing biological age in the youth nearby legal age has always represented a stimulating issue for the Italian forensic scientist as far as he deals with matter of imputability and legal or illegal immigration of uncertain age subjects. Since any method of evaluation should of course be accurate, not invasive, reproducible and, as possible, easily exploitable, radiological investigation of age dependent features is the most appropriate instrument to the purpose. Dental development is slower and delayed compared with skeletal bone one, occurring according to a known, regular pattern from whose evaluation a biological age can be assessed with a reasonably restricted span for a certain radiological image. This is the assumption which inspired since 1941 (Schour e Massler) so many anthropologists and forensic and clinic odontologist in investigating biological age by the study of radiological dental morphology. Demirjian and Goldstein [New systems for dental maturity based on seven and four teeth, Ann. Hum. Biol. 3 (1976) 411-421] obtained no differences between two groups of subjects whose age was extimated by the evaluation of 14 teeth in one case and 7 teeth in another, the last being greatly simpler. Afterwards, Thorson (1991), Mincer et al. [The A.B.F.O. study of third molar development and its use as estimator of chronological age, J. Forensic Sci. 38 (1993) 379], Solari and Abramovitc [The accuracy and precision of third molar development as an indicator of chronological age in Hispanic, J. Forensic Sci. (3) (2002) 531-535] and then Prieto Carrero [Evaluation of Chronological Age Based on Third Molar Development in the Spanish Population, Atti del XIX Congresso IALM, Milano, 2003], developed a method based on the evaluation of the radiological development of the alone third molar, according to Demirjian's schematic definitions of crown and root formation. Eight stages of development of the third molar are defined from the time of mineralization appearance of the cusp tips up to complete closing of the apexes. In order to achieve grater precision in discriminating stages F and G, Solari added two stages (F1 and G1), determining 10 stages of maturation of root and crown. Prieto tested the accuracy and precision of this method by the evaluation of about 1300 orthopantomographs of juveniles and young Spanish adults of known age, divided for gender. We analyzed a total of 400 orthopantograms of young Spanish dental patients to evaluate the chronology of the right mandibular third molar development and to assess its correlation with the biological age of the tested. Biological age is attributed with a maximum standard deviation of 2.47 from the mean in the eight stages outline. The greatest limit of the method seems to be the operator experience in determining the dental stage of development. We think that age data coming from such evaluation method should be clearly explained to the magistrate in their true statistical significance and limits.