"When something goes wrong".

Background: Aspiration of food or liquids can result in suffocation, evolving in coughing, difficulty breathing and forced exhalation. Asphyxia occurs when the aspirated material occludes the upper airways, either in the proximal or distal tract, resulting in the inability to breathe. The risk of asphyxiation death, is increased if a person makes sudden movements while eating, walks or runs while eating, or even becomes distracted or frightened. It is higher in individuals with neurological diseases, intellectual disability (ID), cognitive impairment, psychiatric pathologies or their pharmacological treatments and people carrying additional physiological impairments, which can cause oral dysfunction and dysphagia. Protective mechanisms may sometimes lack or fail to expel food fragments stuck in the airways, which completely obstruct them. Case series: The authors present some peculiar cases of subjects who died from food bolus choking, namely a case of mozzarella-cheese clogging in a young subject (25 years old) undergoing rehabilitation treatment following a stroke; a 38-year-old man with middle-grade mental retardation died from first airway food bolus (mush of bread) clogging; a 26-year-old subject with epilepsy died from tripe clogging in the course of a seizure; a 38-year-old subject in psychiatric treatment for depressive disorder who died from clogging with octopus tentacles. Conclusion: Food bolus clogging asphyctic deaths generally occur in subjects with psychic/neurological pathologies, resulting in altered deglutition mechanisms or lack of protective reflexes. Foodstuff, especially if large or viscous, obstruct the proximal or distal airways, leading to acute respiratory failure and death. Autopsy is diriment in ascertain the cause of death.

Interrupted aortic arch: from a singular forensic case to clinical and diagnostic cue.

Background: Abnormalities of aortic arch include variables related to structure, location, anatomical relationships and collateral vessels. This group includes the malformation known as "interrupted aortic arch". During fetal life, oxygenated blood is provided by materno-fetal circulation and own fetal circulation. Case report.: This work discuss of female fetus born without any vital signs at 38th week by 34-years-old primigravida affected by gestational diabetes and anemia gravidarum. Pregnancy was regular. Labor and cardiotocographic tracings were regular, natural delivery; however, at the time of umbilical cord severing the baby went into cardiocirculatory arrest. Autopsy findings were: - hypertrophied right ventricle; - no morphological changes in interventricular septum, - ascending aorta physiologically arose from the left ventricle; after the emergence of the left subclavian artery and the anonymous trunk, it suddenly stopped at cul de sac. Thoracic tract arose as a collateral branch of the pulmonary artery. In addition, Botallo duct was patent. Thus, the diagnosis of death was interruption of aortic arch resulting in cardiogenic shock and irreversible cardiovascular collapse. Conclusion: In filed case, newborn presented "type B" interruption. Interruption manifests itself between left common carotid artery and the left subclavian artery. Descending aorta arose from the pulmonary trunk. So that, in this case, right ventricle provided systemic circulation. At delivery, with the severing of the umbilical cord and physiological closure of the Botallo ductus, acute right heart failure and shock occurred. This work aims to be a cue for scientific community, in order to assist clinical and diagnostic knowledge using autopsy data with expost perspective.

Psychosis in cocaine intoxication.

Background: Cocaine overdose is a condition in which an increase in blood pressure, heart rate and depth of breath is observed. Cocaine consumption also causes a wide and well-known neuropsychiatric symptomatology that is characterized by incomprehensible behavior, confused and disordered thoughts, and paranoia. Cocaine addiction is a worldwide public health problem, which has somatic, psychological, psychiatric, socio-economic, and judicial complications. Case series: This work shows three cases in which cocaine poisoning and overdose caused a psychotic and extremely violent behavior in the hours leading up to the death of the subjects. Conclusion: The aim of this brief case series is to suggest some diagnostic criteria for the correct definition of this psychosis in order to make an early diagnosis crucial to prevent deaths related to it.

Postmortem or Perimortem Injury? Presentation of an incredible court case in which flames are the protagonists of a murder.

Background: Establishing the cause of death when analysing burnt human remains is limiting due to thermal degradation. The heat generated by high combustion degrades the bone structure, definitively hiding the perimortem trauma in most cases, which is crucial for solving a court case. Case report: In November 2019, a completely burnt corpse was found inside a car set on fire near a location in Reggio Calabria, Italy. The corpse was subsequently subjected to an initial radiodiagnostic examination and an anthropological/medico-legal investigation, in order to confirm the biological profile of the unidentified subject, define the cause of death and assess the presence of perimortal lesions through macroscopic analysis of skull fragments subjected to fleshing. Conclusions: The soft tissue fleshing of the burnt skull fragments allowed the reconstruction of a partial calotte. Macroscopic analysis of the consolidated shell identified in the left fronto-parietal region a clear linear fracture, perimortal in nature, compatible with blunt trauma. Autopsy examination revealed the presence of carbonaceous residues within the larynx and especially the trachea, confirming ante-mortem combustion.The results of the autopsy examination and the anthropological analysis allowed us to state that the net linear fracture, perimortal in nature, caused the subject a complex encephalic trauma, resulting in loss of consciousness and subsequent death due to carbon monoxide inhalation. This result not only confirms the malicious hypothesis, but reveals a deliberate burning of the victim in order to conceal the evidence necessary to solve the forensic case.

Child abuse and neglect: oral and dental signs and the role of the dentist.

Historically, the law, dental and forensic literature has included numerous articles concerning abused children. The orofacial structures are injured frequently in the maltreated child. Injuries of the neck, head, face, and oral cavity represent the most affected areas of the victim's body that routinely sustain physical trauma in child maltreatment cases. This literature review aimed to report the state of art of child abuse from the point of view of the dentist with focus on studies in dental aspects of child abuse and neglect of the last ten years. Considering the time slot, 20 papers were included with the following inclusion criteria: papers published in English, all keywords included in the title, articles available on PubMed. Many of the injuries are within the scope of dentistry or easily observed by the dental professional during routine dental treatment, and it is essential that the dentist recognizes them. Concerning neglect, it is appropriate to make a distinction between deliberate parental behavior that has the consequence of unavoidable and voluntary neglect towards their children and those conditions of involuntary carelessness determined by socio-economic and cultural factors such as family isolation, lack of finances, parental ignorance, or lack of perceived value of oral health. Therefore, it is relevant that the dentist pays attention to the cases to report and those that only need help.

Reverse engineering in forensic investigations: a new approach to bite mark analysis.

The study of bite marks provides crucial elements that contribute towards identifying the biter. In many cases, it assumes importance when bite marks are detected on the body of a victim of violence, but it could also be relevant when the bite marks are seen on food substances at the crime scene. In both circumstances, comparing the bite marks with a suspect's dentition can be decisive in confirming or excluding the culpability. In this case report, a bun (bread roll) with the sign of a bite was found at the crime scene. We report a pilot study using 3D reproduction of the bite mark on the bun and dental models of the alleged biter and the victim. A reverse engineering process was used to obtain digital 3D models of the bitten bun and the dental models by taking numerous photographs and stitching them together using a software called Metashape by Agisoft. The last step was to compare the bitemark to the two dental models, evaluating the spatial distance, the degree of overlap, and the degree of interpenetration. The results confirmed the usefulness of reverse engineering in forensic investigations showing the compatibility between the victim's teeth and the bite mark on the bun.

Heme Oxygenase-1/High Mobility Group Box 1 Pathway May Have a Possible Role in COVID-19 ARDS (Acute Respiratory Distress Syndrome): A Pilot Histological Study.

COVID-19 is a pandemic disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The persistent and excessive inflammatory response can build up a clinical picture that is difficult to manage and potentially fatal. Potent activators of inflammatory phenomena are damage-associated molecular patterns (DAMPs) and, in particular, the high-mobility group box 1 (HMGB1). HMGB1 is an intranuclear protein that is either passively released during hypoxia-related necrosis or actively released by macrophages. Heme oxygenase (HO-1) has an anti-inflammatory effect by inhibiting HMGB1, which could be a therapeutic target to reduce COVID-19 inflammation. In our study, we evaluated CD3, CD4, CD8, HMGB1 and HO-1 in the COVID-19 lung and correlated it to clinical data.

Facial approximation for identification purposes: soft tissue thickness in a Caucasian population. Sex and age-related variations.

The aim of this study was to collect soft tissue thickness (STT) values of an Italian population from 12 bone landmarks, to improve the facial approximation process for identification purposes. 100 Italian adults (50 males and 50 females), who had undergone head CT for clinical purposes, were analysed in order to expand the database of the Italian population. Average values, standard deviation and range were collected according to gender and age and the obtained values were statistically analysed in order to evaluate any possible significant difference. Only one landmark was statistically significant associated with sex, females showed significantly higher values for para-zygomaxillary. Two landmarks were statistically significant associated with age, upper incisor and pogonion. The obtained results were compared with the existing literature. Such information can be useful in the forensic craniofacial reconstruction process and can facilitate choosing the most suitable STT values according to osteological analysis of the human remains.

Methadone overdose in patients following methadone mainte- nance treatment:A three years overview in the district of Bari (South-Italy).

BACKGROUND: Methadone maintenance treatment (MMT) is reco-gnized as a reference treatment for opioid dependence. According to Italian Law, at the beginning of the treatment patients must receive medication under the supervision of a physician, to avoid overdose. After a period of stability, patients could be allowed to take methadone at home in pre-arranged and personalized concentrations, in order to empower their self-responsibility. The aim of the present investigation is to underline the presence of a "glitch in the system" of the MMT. METHODS: In the last three years, 7 forensic autopsies and toxi-cological analysis on corpses of regular opioid users were performed into the Institute of Legal Medicine of Bari. CONCLUSION: Therefor an improvement of the MMT's guideline is needed to reduce methadone overdose deaths in future. RESULTS: In all these cases very high methadone concentration in blood were found. All the 7 subjects were following a MMT in a Public Health Institute and the cause of death was respiratory depression by overdose of methadone in 6 cases.

Age estimation from dry bone measurements: evidence from a sample of soldiers exiled in two concentration camps in Bari.

The mandible undergoes remodelling and morphological alterations throughout the life of an individual, and it is subjected to sex- and age-related structural changes. Personal identification from skeletal remains represents one of the most difficult challenges for a forensic anthropologist. The study of mandibular morphology is an important aid in determining the sex and age of skeletal remains. The objective of this study was to evaluate the age-related changes of three mandibular dimensions through dry bone measurements: bigonial width, ramus height and gonial angle. A total of 93 skeletal remains were included in this study, from a group of soldiers of Yugoslav origin who lived in two concentration camps in Bari (southern Italy) during World War II. These are included in the collection of the Forensic Anthropology Laboratory of the Institute of Forensic Medicine of Bari. The measurements were recorded after comprehensive examination by a forensic anthropologist and a forensic odonto-stomatologist. The data obtained were analysed statistically using a bivariate test and a multivariate linear regression model, using the Statal 13MP software. The results indicate that the bigonial width and gonial angle vary significantly according to age. In conclusion, this study confirms that the mandible is useful for age estimation in the identification of skeletal remains using these specific mandibular measurements when performed on dry bone without radiological distortion.

The paleoradiology importance in the study of relics: the unique densitometric analysis of a bone relic of Saint Nicholas.

INTRODUCTION: DXA have greatly contributed to the development of paleoradiology, a branch of diagnostic imaging that allows to obtain information about human remains in contexts of archaeological and/or forensic interest. In this manuscript we report the unique experience of DXA performed on the relic of a Saint; in particular we analyzed a skeletal fragment of St. Nicholas, kept in the Basilica of Bari (Italy) since 1087. MATERIALS AND METHODS: The bone to be examined consisted of the posterior arch of the ninth left rib that was 12cm long, 1.2cm maximum width and 1.7cm thick at the body. The data acquired from the densitometric study were performed using the anthropometric measures reported in historical records of St. Nicholas' life: sex (male), age (75 years), weight (70kg), height (167cm), and ethnicity (Caucasian). In addition to the examination of the relic, a comparison assessment was made with the rib of a healthy 60 years old man (height of 170cm, without known skeletal pathologies). This sample had a length of 19cm, maximum width at the head 1cm, and 0.7cm thick at the body. The analysis of bone fragments is different from the analysis of bones in the context of the human body (where soft tissues are placed around the skeleton); for this reason, one of the most critical issues was to create a support that would allow the analysis of bone fragments. We simulated conditions similar to those occurring in patients: a density scale was established, using a specific plexiglass phantom on which the bone fragments to be examined were placed. From the analysis it was calculated the parameter bone mineral density (BMD), express in g/cm2, that indicates the relation between mass of bone mineral content and area of examined bone segment. BMD data was compared to a range normalized by age, sex and ethnicity (BMD-N). RESULTS: The results of the scannnig of St. Nicholas' rib showed a BMD of 0.97g/cm2 with a BMD-N between 0.77 and 1.08g/cm2. Simultaneous measurements of the relic compared with a reference rib showed highlighted BMD of 0.84g/cm2 for the relic and 0.50g/cm2 for the reference rib. The St. Nicholas data are 168% higher than reference bone. All our measurements of the relic indicated a high bone mineral density, most likely due to the presence of a high concentration of calcium salts. A relatively higher mineral density of the relic was seen compared to the healthy subject's rib. From the history of St Nicholas' life, we know of the long imprisonment at the age of 51 in damp and unhealthy environment. The results of this study suggest that a good bone mineral density was maintained by the Saint even in old age. An additional element that can influence bone mineral density is diet, certainly different during the time of St. Nicholas. The good bone densitometry indicates that the Saint maintained a proper diet, with a generally fair state of health. CONCLUSION: For this first DXA analysis of the rib relic of Saint Nicholas was necessary a long and complex experimental work to modify standard technique procedure to particular and unusual sample and Create specific supports and complementary instruments. Perform DXA analysis on relics permit to obtain additional information to living conditions, economical situation, behaviours, diet, diseaes, conservations conditions of remains, change of life style in different age. Our experimental work, the first of its kind, creates the way to analyze precious relics that often include only few bone fragments and data obtained by our work can be useful for a better management and movement of fragile relics. We ourselves are working on a new challenge for the analysis of bone finds from shipwrecks found at the bottom of the sea.

Personal identification through digital photo superimposition of dental profile: a pilot study.

The usefulness of teeth for personal identification lies mainly in their vast individual variability, making them virtually unique for every subject. Odontological identification represents a reliable and important complement to forensic inquiries, in particular in the event of unidentifiable human remains. However, this technique is based on the availability of ante-mortem records containing significant evidence. In the absence of dental records, the only available ante-mortem elements are often photographs. In the present study, dental profile photographs of selected smiling subjects were compared to the relevant plaster study models through digital image analysis. In order to ascertain the reliability of the technique, the comparison was carried out both in a homologous and heterologous manner with the Facecomp software. The results confirm the ability of Facecomp software to identify even the smallest variations in dental elements to reach a positive identification. The method is useful in forensic practice since a forensic inquiry may obtain plaster models from cadavers for comparison with photographs of missing people's anterior teeth.

A singular case of asphyxia by choking on a handkerchief: accidental event or suicide to "shut-up" spirits.

Choking in adults can prove fatal, despite resuscitation attempts. The manner of death can be natural, homicide or accident. When a death is due to choking, one must consider what conditions contributed to or predisposed the person to choking (eg. alcohol, drugs and physical and mental impairments). Homicidal deaths by choking are relatively uncommon, being more frequently accidental. The diagnosis of death by choking is made at autopsy when the airway is found occluded. If the individual had an occluded airway and the object or food was removed during resuscitation, the only way to make the diagnosis would be on the history. Here, we present a case of asphyxia (accidental or suicidal) by choking on a handkerchief in a patient with a long history of schizophrenia. The woman had attempted a previous suicide driven by evil spirits coming from inside her body, especially from the head and throat; in order to "shut-up" the spirit, she was trying to suffocate it with her hands or by a belt from her pants.

Bodies in sequestered and non-sequestered aquatic environments: a comparative taphonomic study using decompositional scoring system.

The study of decomposition by using accumulated degree days (ADDs) has been suggested not only in terrestrial decay but also for water-related deaths. Previous studies have demonstrated that the accumulation of thermal energy as a function of the post-mortem submersion interval (PMSI) can be derived from a descriptive decompositional scoring system (DSS). In order to verify how useful can the total aquatic decomposition score (TADS) for ADD prediction be, a comparative taphonomic study has been performed between two series of bodies: 16 corpses found floating in shallower waters with a presumptive PMSI from 3 to 118 days and exposed to water temperatures (Tw) between 10.5 and 20.3 °C approximately equating from a minimum of 46 to 1.392 ADD; 52 bodies, all victims of a single shipwreck, found in sequestered environments and subjected to constant Tw of 4 °C for 210 days approximately equating to 840 ADD. The two series of bodies have revealed different stages of decay and a large DSS variability. In most of bodies, freshly formed adipocere was able to delay the appearance of later decompositional stages explaining why most of the bodies were in relatively good condition. Although promising, the accuracy of the TADS model can be affected by adipocere and animal activity. The TADS model suffers of the same limitations for ADD calculations as they can give a false perception of accuracy due to the complexity of integrating all changing factors affecting human decay in sequestered and non-sequestered marine environments (currents, animal activity, water temperatures, depth of submersion).

Early childhood caries (ECC) and neglect in child care: analysis of an Italian sample.

AIM: Dental caries was identified as the single most common chronic childhood disease; its prevention should be a priority for dentists. With the aim of describing the correlation between early childhood caries (ECC) and the phenomenon of child neglect, a questionnaire which recorded socio-economic and dental service use data was provided to a randomly chosen sample of parents at three pediatric health service centers in Bari (Italy). MATERIALS AND METHODS: In order to evaluate the association among risk factors and ECC, contingency tables were created and the value of the Odds Ratio (OR) was calculated, indicating the confidence intervals and chi square values. A student's t-test for independent samples was performed to evaluate the differences between the averages. A value of p≤0.5 was considered to be significant for all tests used. RESULTS: Of the 63 children examined, 61.9% (n=39; 95%CL=49.9- 73.9) presented with ECC, of which 47.6% (n=30; 95%CL=34.9-60.6) were classified as Wyne's Type I; 12.7% (n=8; 95%CL=5.6-23.5) were classified as Type II; and 1.6% (n=1; 95%CL=0-8.5) as Type III. Interestingly, the frequency of Types II and III were shown to be higher in low-income families (chi-square=8.50; p=0.03). CONCLUSION: Dentists should recognize children's susceptibility to ECC and their exposure to risk factors for neglect, thus facilitating a primary prevention visit.

Death in head-down position in a heavily intoxicated obese man.

Dying in a head-down position is rare, and autopsy may reveal no morphological findings which can sufficiently explain the cause of death. The authors describe a case of positional asphyxia of a 78-year-old man, found dead hanging in head-down position inside a blackberry bush. The subject was suspended by his left leg and wedged inside a thick blackberry bush, while his right leg was free and inflected. Investigation revealed that the elderly man had last been seen after lunch in the early afternoon (about 2.00 p.m.), two days before being found. The subject had no pre-existing physical or mental condition which might have explained his death. He was 164 cm tall and weighed 90 kg (BMI: 33.4). External examination of the body revealed abrasions on the head and multiple superficial scratch marks on the hands; no external signs of violence were observed. The deceased's head was cyanotic and revealed marked petechial haemorrhages of the conjunctiva. Rigor mortis was fully developed and reddish fixed livor was observed on the face, neck and upper chest. The distribution of livor was consistent with the position of the body at the scene. Autopsy revealed marked pulmonary and cerebral oedema; the liver showed fatty vacuolization with a mild increase of connective tissue and thickening of the walls of the central veins and centrilobular sinusoids. The heart was enlarged, particularly the left ventricle, with a slight, calcified, diffuse and increased thickness of the aortic and coronary arteries. The remains of meat and vegetables in the initial phase of digestion were found inside the stomach, and there was a strong smell of alcohol. The blood alcohol concentration, ascertained by GC (Gas Chromatography), was 2.10 g/l. Toxicological assays for addictive drugs (cocaine, heroin, THC) yielded negative results. There were no features suggesting that the deceased had been the victim of an assault. The authors of this case report illustrate the main pathophysiological and diagnostic features of positional asphyxia and possible relevant co-causes of death, with an emphasis on the combined role of acute alcoholic intoxication and obesity in the hastened demise of a subject in the head-down position.

Esthetics and implantology: medico-legal aspects.

In recent years the high number of malpractice lawsuits in dentistry has attracted closer attention of dental practitioners to its medico-legal aspects. Implantology, in particular, presents many points of medico-legal concern connected with the difficulties inherent to dental procedures and objectives (both functional and esthetic), as well as full patient collaboration as an essential part of successful treatment. An accurate assessment of each case by the clinician is fundamental, especially in circumstances where esthetic considerations are preponderant as, for instance, in the frontal sectors. In such cases, the options of implantology or of a traditional fixed prosthesis need to be carefully weighed in light of the patient's anatomic condition. The patient should therefore receive complete information and be made fully aware of the risk of treatment failure, as well as possible complications, limits to the procedures, and the fact that successful outcome will also depend on her/his scrupulous observance of the practitioner's instructions. In short, the aim is to make the patient an active ''accomplice'' in treatment. To this end, the use of an extremely detailed information leaflet is strongly advised; after careful clarification of any doubts the patient may have, the patient's written informed consent should be obtained. Nevertheless, there is the risk that excessive intrusion of bureaucracy into medical procedures in defence of the practitioner against malpractice suits may hinder the principal aim of traditional medicine, i.e. to provide the best care for the patient through mutual trust fostered within the doctor-patient relationship.

Poor reliability of facial indices for comparative metric facial identification without parametrical superimposition.

The relationship between the craniometric indices that can be evinced from the comparison of two faces for identification purposes is considered a reliable method for the personal identification of faces. Our study aims to assess whether facial indices are susceptible to substantial variations even if the two faces being compared are a different size, looking in a different direction, or differently angled. Our results showed high variability as regards both the facial indices thus obtained and the relative relations. This underlines the fact that regardless of the validity of the metric analysis method used, no numerical comparison can be reliable unless prior parametrical somato-physical superimposition of the images of the subjects has been performed to assess the complete comparability of the faces of the suspects. In conclusion, no reliable identification can be made with the simplified techniques that bypass this difficult, demanding and time-consuming phase of parametric superimposition, as we have shown that they can lead to gross errors.

Reverse engineering techniques applied to a human skull, for CAD 3D reconstruction and physical replication by rapid prototyping.

The production of a copy of an existing object of complex shape is one of the typical applications of the integration between two modern computer-based technologies, reverse engineering (RE) and rapid prototyping (RP). The method is extremely versatile and can be used in various applicative domains (e.g. replacement of anatomical parts with artificial prostheses, replication of skeletal remains). Two different acquisition techniques of images of a skull, by laser and by CT scan, were compared to ascertain which enabled more accurate reproduction of the original specimen. The skull was chosen due to it being the body part most often used in medico-legal investigations (for personal identification, skull-photo superimposition techniques, forensic art, etc). Comparison between the copy and the original yielded satisfactory results for both techniques. However, CT scanning demonstrated some advantages over the laser technique, as it provided a cleaner point cloud, enabling shorter pre-reproduction processing times, as well as data on the internal parts, which resulted in the reproduction of a more faithful copy.