Dental superimposition: a pilot study for standardising the method

Dental superimposition is becoming more and more important because of the increasing number of illegal immigrants (at least in Italy), with no clinical history, no personal effects or relatives useful for genetic comparison, whose friends and acquaintances can usually only produce photographs. Very few authors have been involved in devising and using this method. The goal of the present study is to establish whether it is possible, and under which conditions, to identify individuals by dental superimposition of teeth visible in an ante-mortem photograph and dental casts of an unidentified body, and to develop a protocol for the spatial orientation analysis of the dentition and qualitative and semi-quantitative analysis of superimpositions. A non-mathematical scoring system has been applied to each superimposition as a first step towards the optimisation of a cheap, quick, semi-quantitative method of identifying individuals when other more used methods are not applicable.

Fatal hemophagocytic syndrome related to active human herpesvirus-8/Kaposi sarcoma-associated herpesvirus infection in human immunodeficiency virus-negative, non-transplant patients without related malignancies

Hemophagocytic syndrome (HS) may occur as a consequence of herpes viral infections. Human herpesvirus 8 (HHV-8)/Kaposi sarcoma-associated herpesvirus has so far been recognized as a trigger of HS only in immunosuppressed subjects or in patients with Kaposi sarcoma and/or HHV-8-related lymphoproliferative diseases. We report two Italian human immunodeficiency virus (HIV)-negative elderly men who developed an HS with a rapidly fatal course, following treatment with corticosteroids for autoimmune hemolytic anemia. An overwhelming active infection with HHV-8 was unequivocally documented by molecular and immunohistochemical methods, in the absence of HHV-8-related tumors. The occurrence of HHV-8-associated HS, although rare, may be considered, even out of the HIV or the transplantation settings, at least in areas endemic for HHV-8 infection.

Sensitivity of autopsy and radiological examination in detecting bone fractures in an animal model: Implications for the assessment of fatal child physical abuse

Skeletal injuries are often strong indicators of child abuse and their detection is therefore crucial. The aim of this study was to compare the sensitivity of three diagnostic approaches, namely autopsy, traditional (conventional) radiology, and computed tomography on "battered" piglets, in order to verify the sensitivity of each method, with respect to the true number of bone fractures assessed once the piglet was skeletonised (osteological control). Four newborn cadaver piglets who had died from natural causes were severely beaten post-mortem in every district of the body. Traditional radiography, computed tomography (CT) and autopsy were performed. The piglet was then macerated until skeletonised and the number of all fractures present recorded (osteological control). On the cranium, traditional radiology revealed only 35% circa of actual fractures, autopsy detected only 31% (P<0.01 for both comparisons versus osteological control), whereas CT imaging detected all fractures actually present. For ribs, radiology detected only 47% of all fractures present, and autopsy 65% circa (P>0.05 for both comparisons versus osteological control), while CT scans detected 34% (P<0.01). In suspected cases of fatal child abuse, we suggest that the bones of specific districts be directly analysed either at autopsy or by collecting specific diagnostic sites, such as parts of the rib cage, and subjecting them to maceration. The removed areas could be replaced with artificial material for cosmetic purposes. The authors stress the importance of combined radiological, CT scan, autopsy and osteological survey in the detection of perimortem bone fractures.

Symptom relief in Parkinson disease by safinamide: Biochemical and clinical evidence of efficacy beyond MAO-B inhibition

In an open pilot study, doses of safinamide (100, 150, and 200 mg once a day, higher than previously tested) were administered to 13 parkinsonian patients along with a stable dose of dopamine (DA) agonist, causing a significant progressive improvement in motor performance as evaluated by the Unified Parkinson Disease Rating Scale (UPDRS) part III over an 8-week period (4.2 points; P < 0.001). In association with levodopa, the same doses of safinamide in another group of patients (N = 11) induced a significant decrease in motor fluctuations (UPDRS part IV, 2.1 points; P < 0.001), accompanied by a dose-proportional increase of the levodopa AUC, up to 77% from baseline. Because MAO-B was fully inhibited (95%) at all doses tested, we suggest that these biochemical and symptomatic dose-dependent effects must be related to additional mechanisms of action, such as inhibition of glutamate release, increased dopamine release, or inhibition of dopamine re-uptake. These hypotheses are under investigation and will pursue confirmation in controlled clinical trials.

A multicentre and prospective study of suspected cases of child physical abuse

In this multicentre prospective study, the authors aim to describe the social and clinical characteristics of a population of children who arrived with a suspicion of physical abuse at five Emergency Services across France and who underwent clinical and thorough radiological screening according to a common predetermined protocol. A total of 185 cases of children seen at the Emergency units of five French hospitals over a 4-year period was assessed via a specific protocol and included in this study. The results of this study show socio-cultural factors consistent with previous reports on abused populations, and in particular give interesting data concerning the type and severity of lesions present, on the whole, in 80% of the population studied. In particular this study revealed a high prevalence (30%) of bone fractures. Apart from giving a perspective on the French population, this study adds some information to the too few preexisting studies of its kind-and stresses the importance of effective identification of possible cases of child abuse and of a thorough and sensitive screening protocol.

Improvement of motor function in early Parkinson disease by safinamide

A median safinamide (SAF) dose of 70 mg/day (range 40 to 90 mg/day) increased the percentage of parkinsonian patients improving their motor scores by > or =30% from baseline (responders) after 3 months from 21.4% (placebo) to 37.5% (p < 0.05, calculated by logistic regression analysis). In a subgroup of 101 patients under stable treatment with a single dopamine agonist, addition of SAF magnified the response (47.1% responders, mean 4.7-point motor score decrease; p > or = 0.05). These results suggest that doses of SAF exerting ion channel block and glutamate release inhibition add to its symptomatic effect and warrant exploration of higher doses.

Wider recognition in peripheral vision common to different subtypes of dyslexia

Italian children (n = 125) were classified into dyslexics, poor readers and ordinary readers. The dyslexics were further classified into the Boder and Bakker subtypes. The children were tested with the form-resolving field (FRF), which measures central and peripheral visual recognition. Dyslexics show higher correct identification of letters in the periphery, supporting the notion of a different distribution of lateral masking. A numerical characterization of individual FRFs--C2R--reliably distinguishes between dyslexics and ordinary readers. The wider distribution of recognition, similar across the various subtypes of dyslexia, suggests a general characteristic of visual perception, and possibly a different visual-attentional mode.

International collaboration in mass disasters involving foreign nationals within the EU: medico-legal investigation of Finnish victims of the Milan Linate airport SAS SK 686 aircraft accident on 8 October 2001

Identification of and investigation into the cause of death of foreign nationals in mass disasters are generally conducted according to the jurisdiction of the country in which the disaster occurs. However, such identification can be achieved only through co-operation with the authorities of the victims' countries of residence. On October 8th 2001 at Linate airport in Milan, Italy, an MD87 SAS airplane with 110 crew members and passengers on board collided on the ground with a Cessna Citation II jet with 2 pilots and 2 passengers. The plane then caught fire after having crashed into an airport baggage hangar causing the death of 4 other victims among the groundstaff. The accident claimed a total of 118 victims of 9 nationalities. Based on our experience from investigation of the Finnish victims, we explore how current national legislations of the EU member states and varying compliance with existing recommendations may influence the medico-legal investigation of a mass disaster. Legislative measures and further harmonisation of medico-legal procedures in connection with mass disasters within the EU are needed.

The detection of morphine and codeine in human teeth: an aid in the identification and study of human skeletal remains

When studying unidentified putrefied or skeletonised human remains it may be difficult to obtain information on drug habits which may prove important for the construction of a biological profile or lead to hypotheses on the manner of death. The detection of morphine and codeine in teeth from human remains may prove crucial in obtaining such information and thus give forensic odontology and anthropology a further tool for identification. Because teeth can be an important deposit of exogenous substances accumulated both in the pulp and in the calcified tissues, they are an invaluable source of data from a toxicological point of view. The authors therefore tested 3 groups of teeth for morphine and codeine: the first group consisted of artificially aged teeth from individuals known to have died of heroin overdose; the second, of teeth from individuals with no history of drug abuse; the third, of teeth from cases of burnt, putrefied and skeletonised remains found in conditions strongly suggestive of a drug-related death. Results showed that in groups 1 and 3 morphine and codeine could still be identified in the teeth, proving that these tissues may be a reliable source for toxicological information concerning the history of the individual. Further studies are needed to verify whether the substances detected reflect drugs in circulation in an acute phase (and therefore present in blood vessels in the pulp) or whether they represent drugs which have percolated and been stored in dentine and enamel and thus denote a history of drug abuse. Nonetheless this study shows that teeth may be an important source of toxicological information in the forensic scenario.

Non-transferrin-bound iron in myelodysplastic syndromes: a marker of ineffective erythropoiesis?

INTRODUCTION

Iron overload is usually observed in patients (even untransfused) with myelodysplastic syndromes (MDS), and contributes towards the generation of low molecular weight iron complexes or non-transferrin-bound iron (NTBI), which in turn favors oxidative DNA damage and consequent apoptosis.

MATERIALS AND METHODS

Levels of NTBI and lipid peroxidation were evaluated by means of free serum malondyaldehyde (MDA) in untransfused MDS patients and we tried to correlate them with ineffective erythropoiesis, apoptosis and the pattern of in vitro growth.

RESULTS

NTBI levels were found to be significantly higher in low-risk than in high-risk MDS patients, as well as in patients with a lower myeloid/erythroid ratio. MDA was found to be uniformly higher in the MDS patients as a whole than in normal controls. The bone marrow progenitor cells in the MDS patients with high NTBI levels showed a higher degree of apoptosis, but this difference was not statistically significant. Patients with a leukemic growth pattern had lower NTBI levels than those with a non-leukemic pattern.

CONCLUSION

These data suggest that NTBI is related to the degree of ineffective erythropoiesis and that it contributes towards inducing apoptosis in MDS bone marrow precursors. The presence of leukemic growth is associated with low NTBI levels, probably due to increased iron consumption by blast cells.

Cronkhite-Canada syndrome. A case of sustained partial-remission

A case of Cronkhite-Canada syndrome is described. Few cases have been published and in most patients the prognosis is poor. A variety of medical measures have been attempted in those in whom remission has been reported. In the patient presented here, a sustained partial-remission has been achieved with steroids.

Hodgkin disease developing in patients infected by human immunodeficiency virus results in clinical features and a prognosis similar to those in patients with human immunodeficiency virus-related non-Hodgkin lymphoma

BACKGROUND

Unlike aggressive non-Hodgkin lymphoma (NHL), Hodgkin disease (HD) develops rarely in patients who are infected by human immunodeficiency virus (HIV), and its characteristics are not well defined. The authors analyzed the clinicopathologic and prognostic features from a consecutive series of patients with HIV-associated HD who were observed at their institution and compared them with the features observed in a concurrent series of patients with systemic HIV-related NHL.

METHODS

Eighteen patients with HIV infection who were diagnosed and treated uniformly from 1985 to 1999 at a single primary referral center were analyzed. Their demographic, immunologic, and clinicopathologic features; responses to treatment; and outcomes were compared with those of 98 patients with systemic NHL of aggressive histology who were diagnosed during the same period and with 165 HIV negative patients with HD.

RESULTS

HIV-associated HD and NHL occurred in patients with similar age, gender, HIV risk factors, degree of immunodeficiency, and incidence of previous acquired immunodeficiency syndrome. The clinical presentation of HIV-associated HD was atypical and was more aggressive than in HIV negative patients (mediastinal involvement, 11%; Stage III-IV, 84%; B symptoms, 83%). It was similar to HIV-related NHL, except for the frequency of extralymph node disease, which was seen less frequently in patients who had HD (56%) compared with patients who had NHL (82%; P = 0.025), and the frequency of bone marrow involvement, which was unexpectedly higher in patients who had HD (50%) compared with patients who had NHL (20%; P = 0.011). Potentially curative treatment was administered to 77% of patients with HD and 66% of patients with NHL. Complete remission and disease recurrence rates as well as disease free and overall survival rates did not differ significantly, with estimated overall survival at 5 years of 24% in patients with HD and 23% in patients with NHL.

CONCLUSIONS

HIV-associated HD is an aggressive disease with demographic, clinical, and prognostic features nearly identical to those of HIV-related NHL.

Neltenexine tablets in smoking and non-smoking patients with COPD. A double-blind, randomised, controlled study versus placebo

BACKGROUND

The aim of this double-blind, randomised, controlled study vs placebo was to evaluate the efficacy and tolerability of neltenexine (tablets) versus placebo (tablets), administered to smoking and non-smoking patients with chronic obstructive pulmonary disease (COPD).

METHODS

Sixty patients with mild stable COPD were recruited. The exclusion criteria were lung cancer, pulmonary tuberculosis, asthma, cystic fibrosis, bronchiectasis, community-acquired pneumonia (CAP), intercurrent infections, concomitant treatment with corticosteroids, antitussives, beta2 agonists, anticholinergic and other mucolytic agents. The patients were allocated randomly to receive neltenexine (20 smokers and 20 non-smokers) or a matching placebo (20 smokers), 1 tablet twice daily for 20 days. The efficacy criteria were sputum characteristics and volume, difficulty in expectorating, cough, dyspnoea, pulmonary auscultation, forced expiratory volume in one second (FEV1), vital capacity and arterial partial oxygen pressure (PO2). Tolerability was monitored and adverse events were reported.

RESULTS

At the study end, the improvement of patients treated with neltenexine (smokers and non-smokers) was greater and statistically significant as compared with the patients in the placebo group in terms of improvement of dyspnoea (p<0.02), cough (p<0.02), pulmonary auscultation (p<0.02), and difficulty in expectorating (p<0.02). Furthermore, a significant improvement of the sputum characteristics (p<0.02) and volume (p<0.01) was evidenced, as compared with patients treated with placebo, in non smoking patients treated with neltenexine and in smoking patients treated with neltenexine.

CONCLUSIONS

The study confirmed earlier clinical experiences showing that neltenexine is effective in the treatment of COPD patients and highlighted the correlation between abstention from smoking and the efficacy of mucoactive treatment.

Quality assurance in age estimation based on aspartic acid racemisation

Estimates of the age of living and dead individuals, obtained in order to answer legal or social questions, require minimum quality standards in order to guarantee data quality. We present an outline strategy (with recommendations) for the attainment of quality assurance in age estimation based on aspartic acid racemisation. The strategy is based on a definition of minimum standards for laboratories, including documentation of procedures, methodology and levels of expertise, and the formulation of guidelines for intralaboratory and interlaboratory quality control.

Age estimation: the state of the art in relation to the specific demands of forensic practise

Age estimation in cadavers, human remains and living individuals may clarify issues with significant legal and social ramifications for individuals as well as for the community. In such cases methods for estimating age should fulfil the following specific demands: (1) they must have been presented to the scientific community, as a rule by publication in peer-reviewed journals, (2) clear information concerning accuracy of age estimation by the method should be available, (3) the methods need to be sufficiently accurate and (4) in cases of age estimation in living individuals principles of medical ethics and legal regulations have to be considered. We have identified and summarized the methods that essentially fulfil these specific demands. In childhood and adolescence morphological methods based on the radiological examination of dental and skeletal development are to be recommended. In adulthood, the accuracy of most morphological methods is much reduced. Here a biochemical method based on aspartic acid racemization in dentine provides the most accurate estimates of age, followed by special morphological dental and skeletal methods. The choice of method has to take account of the individual circumstances of each case. Most methods require either the consultation of specialised and trained scientists or an adequate calibration by the "user". Very few attempts have been made to find common standardisation, calibration and evaluation procedures or to develop means of quality assurance for methods of age estimation. Efforts in these directions are necessary to guarantee quality standards and adequate answers to the important legal and social issue of age estimation in forensic medicine.

[Acute renal failure. Epidemiologic observations in the Piedmont region]

BACKGROUND

The use of ICD9-CM for the classification of disease has been introduced in Italy. A retrospective study has been performed to evaluate the incidence of Acute Renal Failure Dialysis treated (ARFD) in Piedmont (4,500,000 inhabitants) and to evaluate the use of ICD9-CM for the classification of Acute Renal Failure (ARF) in the compilation of Hospital Discharge Sheets (SDOs).

METHODS

The Piedmont Renal Transplant Registry was used to look for episodes of ARFD in the Region in 1997. All cases of ARF (584,5,6,7,8,9- 997.5- 958.5- 788.9- 634.3-639,3-669.3) were looked for in SDOs of all admissions to hospitals in the Region in the same period.

RESULTS

646 episodes of ARFD were found in the Piedmont Registry, that is an incidence of 142 episodes/million/year. 830 episodes of ARF (184 episodes/million/year) were found in an analysis of SDOs. It is impossible to find cases of ARFD from an analysis of SDO data.

CONCLUSIONS

The ICD9-CM system, in Piedmont, in 1997, wasn't well utilized and the data are not useful for epidemiological studies unless further education in their use has been carried out. The analysis of the Piedmont Registry evidences that in the Region all the cases of advanced ARF (creatinine > 5 mg%) are treated by Dialysis. This may indicate a good performance of nephrological care, but the data have to be confirmed, because the incidence of ARFD is higher than in other European countries.

Efficacy of N-acetylcysteine and all-trans retinoic acid in restoring in vitro effective hemopoiesis in myelodysplastic syndromes

We evaluated the in vitro effect on clonogenic potential (CFU-GM) and apoptosis in myelodysplastic syndromes (MDS) progenitors of an anti-oxidant (N-acetylcysteine, NAC) and/or a differentiating (all-trans retinoic acid, ATRA) agent. NAC significantly reduced apoptosis, both NAC and ATRA induced an increase in CFU-GM, but NAC seemed to be particularly effective in the high risk (HR) MDS. NAC + ATRA conferred a significant advantage in terms of CFU-GM with respect to NAC and ATRA alone. Tumor Necrosis Factor-alpha (TNF-alpha) levels decreased after incubation with NAC in the MDS samples. This study shows that ineffective hemopoiesis in MDS could benefit from both NAC and ATRA, suggesting that anti-oxidant treatment may play a role in guaranteeing MDS cell survival, predisposing them towards differentiation.

A review of the methodological aspects of aspartic acid racemization analysis for use in forensic science

Accurate age determination of adult cadavers and human remains is a key requirement in forensic practice. The current morphological methods lack accuracy and precision, require specialist training and are costly. The use of aspartic acid racemization (AAR) in human dentine provides a simple, cost-effective solution and the method can achieve accuracies of +/- 3 years at best. Currently, there are differences in AAR methodology between laboratories which produce different results on the rate of racemization in teeth. These inconsistencies must be resolved if the technique is to be successfully applied to age determinations in forensic cases. This paper reviews the differences in protocol which have been used, discusses how each method will affect the results obtained from AAR analysis and gives recommendations for optimization of the methological protocol as a first step towards international standardization.

Determining the human origin of fragments of burnt bone: a comparative study of histological, immunological and DNA techniques

In situations where badly burnt fragments of bone are found, identification of their human or non-human origin may be impossible by gross morphology alone and other techniques have to be employed. In order to determine whether histological methods were redundant and should be superseded by biomolecular analyses, small fragments of artificially burnt bone (human and non-human) were examined by quantitative and standard light microscopy, and the findings compared with newer biomolecular analyses based on identifying specific human albumin by ELISA and amplifying human mitochondrial DNA by PCR. For quantitative microscopy, reference data were first created using burnt bones from 15 human and 20 common domestic and farm animals. Measured osteon and Haversian canal parameters were analysed using multivariate statistical methods. Highly significant differences were found between values for human and non-human bone, and a canonical discriminant function equation was derived, giving a predicted correct classification of 79%. For the main study, samples of cortical bone were taken from three fresh cadavers, six human skeletons and ten freshly slaughtered animals and burnt by exposure to temperatures ranging from 800 to 1200 degrees C; charred fragments of human cortical bone from two forensic cases were also tested. Quantitative microscopy and canonical discriminant function gave the correct origin of every sample. Standard microscopy falsely assigned burnt bone from one human skeleton and one forensic case to a non-human source, but otherwise gave correct results. Human albumin was identified in five individuals, including one of the forensic cases, but mitochondrial DNA could not be amplified from any of the human bone. No false positive test results were seen with either biomolecular method; and human albumin and mitochondrial DNA were correctly identified in all unburnt control specimens. It was concluded that histological methods were not redundant and that quantitative microscopy provided an accurate and consistent means of determining the human or non-human origin of burnt bone and was more reliable than standard microscopy or the newer immunological and DNA techniques tested here.