Bio-medicolegal guidelines and protocols: survey and future perspectives in Europe

Questionnaire survey for the International Journal of Legal Medicine on the occassion of the 26th triennal meeting of the International Academy of Legal Medicine

A questionnaire was prepared in advance of the 26th triennial conference of the International Academy of Legal Medicine (IALM) and sent to 474 email addresses included in the IALM mailing list. The questionnaire addressed three current challenges faced by the International Journal of Legal Medicine (IJLM): the publication of guidelines and validation studies in the field of legal medicine, the publication ethics of case reports, and the recruitment of new reviewers for the IJLM. The response rate was 20%. The survey results highlight the need for international guidelines in various areas of legal medicine. Some desired guidelines already exist. To provide visibility and knowledge of the existing national guidelines, the IJLM has launched a Topical Collection on Quality Assurance in Legal Medicine. This collection aims to inform readers about country-specific characteristics of legal medicine structures and the existing national guidelines.Around 80% of the participants stated that there are legal or ethical requirements for the publication of forensic case reports or case series. Various options for obtaining consent for publication are discussed. Eighty-six of the 97 participants indicated their willingness to review manuscripts for the IJLM. It is emphasized that the contributions of reviewers should be duly recognized and valued.

From Deutsche Zeitschrift to International journal of legal medicine-100 years of legal medicine through the lens of journal articles, Part 4: International journal of legal medicine from 1990 to 2022

This is the fourth and final paper in a series related to the analysis of articles published in this journal during its first 100 years of activity. This article covers the time span from 1990 to 2022. It is important to note that, given the period covered by this analysis, it does not aim to provide a historical overview but rather an examination of the most recent trends in our discipline compared to the past. Between 1990 (Volume 104) and 2022 (Volume 136), 4004 articles were published in the International Journal of Legal Medicine (IJLM) across 33 volumes. This corresponds to 53% of all the articles published since the launch of the journal. When compared to the period from 1970 to 1990, some categories no longer appear to be as relevant (e.g., sexual medicine, 1 article; social medicine, 0 articles; biography, 3 articles; history, 4 articles). Conversely, the most recent period has shown an increasing importance in forensic genetics (1388 articles) and the emergence of new significant topics that merit their own classification, such as age estimation (286 articles), forensic anthropology (189 articles), forensic imaging (150 articles), and forensic entomology (90 articles).

Malpratice claims in cardiology and cardiac surgery: A medico-legal issue

Medical liability has become a challenge in every physician's modern practice with the consequent loss of the physician's autonomy and an increase in "defensive medicine". From this perspective, the role of Legal Medicine in assessing medical liability has become increasingly specific and a homogenization of the methods of ascertainment is increasingly necessary, since such a process can contribute to strengthening the guarantees in professional liability procedures. Focusing on malpractice claims in the field of cardiology, the complexity of the management of cardiac pathologies and the frequency of severe adverse events implies the importance of a multi-disciplinary approach, together with the application of a shared ascertainment methodology. In particular, it is essential for the forensic pathologist to collaborate with experts in cardio-pathology, cardiology and/or cardiac surgery in cases of alleged medical liability in the cardiologic field and to follow the guidelines which have been produced to assist the expert dealing with deaths reflecting cardiac disease, in order to prevent criticism of case analysis in medico-legal environments and to promote the standardization of the structure of the juridical-legislative medical malpractice lawsuits.

Evaluating Patient Preferences in Benign Prostatic Hyperplasia Treatment Using Conjoint Analysis

OBJECTIVE

To quantify BPH patient preferences to promote guidelines-compliant, patient-centered care. Discordance between patient and urologist priorities for the treatment of benign prostatic hyperplasia (BPH) hinders patient-centered care. Physician assumptions regarding patient preferences lead to dissatisfied patients; a poor outcome in any quality of life surgery. American Urologic Association guidelines urge urologists to consider patient preferences when recommending a BPH treatment.

METHODS

In this cross-sectional, online survey study using researchmatch.org, participants were required to decide between theoretical BPH treatments in a balanced, choice-based conjoint analysis. The treatments had varying levels of four attributes: efficacy, recovery difficulty, risk of complications (Clavien-Dindo 2+), and risk of de novo ejaculatory dysfunction. Demographic information and International Prostate Symptom Score (IPSS) were collected and analyzed using comparative statistics. Each attribute was analyzed using a conditional logit model, and attribute importance (range in utility between attribute-levels) was calculated.

RESULTS

Out of 1235 recruited participants, 812 (66%) completed the study. Median IPSS and age was 6 (IQR 3-12) and 56 (IQR 38-67), respectively. Complication risk was the most important attribute, followed by efficacy, recovery difficulty, and risk of ejaculatory dysfunction. In a subgroup analysis of age quartiles, participants age <38 and >67 held efficacy (31%) and complication risk (47%) to the highest relative importance, respectively.

CONCLUSIONS

Males valued BPH treatments that minimize complication risks, while ejaculatory dysfunction was least impactful. Variation in results between age subgroups emphasizes the need for individualized care to maximize patient satisfaction.

[Forensic autopsies and pathological examination: Current practice in Montpellier's jurisdiction. A retrospective study of 630 autopsies]

INTRODUCTION

In France, pathological examination is not systematically required in forensic autopsies. The factors affecting the decision to carry out a pathological expertise have not yet been defined. The aim of this study was to describe in which conditions a pathological expertise was required after forensic autopsy by the high court of Montpellier.

METHODS

This study included and analyzed retrospectively all of the autopsy elements, of all forensic autopsies carried out over a year. These elements were classified: pre-autopsy, per-autopsy, and post-autopsy.

RESULTS

A pathological expertise was required in 19.2% of 630 cases, among which 31% in a context of undetermined cause of death and in 14% of cases of determined causes of death. The forensic practitioner recommended a pathological expertise in 10 to 31% of autopsies. Overall, 64 pathological examinations were realized out of 121 recommended examinations (52.9%), this rate varied from 25 to 73% depending on the court. The magistrate tended to favor anatomopathological expertise in cases of determined causes of death, and in certain manner of death (80% homicide versus 35% natural). The pathologist's expertise enabled to change the cause of death in 22% of cases and the manner of death in 19%. The pathological approach was a major asset in the 65% of unknown manner of deaths and in the 20% of natural, whereas the expertise did not help in cases of homicides, suicides and accidents. The cause of death was modified in 5.6% of initially determined causes of death, against 42.9% in case of initially unknown cause.

CONCLUSION

The use of pathologic examination in forensic autopsies is scarce and uneven. The factors resulting to its request are not directly linked to its scientific assets. A conjoint work between forensic and pathologist practitioners would be beneficial.

The Role of Risk or Contributory Death Factors in Methadone-Related Fatalities: A Review and Pooled Analysis

Methadone-related deaths are characterized by a wide range of post-mortem blood concentrations, due to the high pharmacokinetic/dynamic inter-individual variability, the potential subjective tolerance state and to other risk factors or comorbidities, which might enhance methadone acute toxicity. In the present study, the association among pre-existing and external conditions and diseases and the resultant methadone death capacity have been investigated. Beside a systematic literature review, a retrospective case-control study was done, dividing cases in which methadone was the only cause of death (controls), and those with associated clinical-circumstantial (naive/non-tolerant state), pathological (pulmonary or cardiovascular diseases) or toxicological (other drugs detected) conditions. Methadone concentrations were compared between the two groups and the association with conditions/diseases was assessed by multiple linear and binomial logistic regressions. Literature cases were 139, in house 35, consisting of 22 controls and 152 cases with associated conditions/diseases. Mean methadone concentrations were 2122 ng/mL and 715 ng/mL in controls and cases respectively, with a statistically significant difference (p < 0.05). Lower methadone concentrations (by 24, 19 and 33% respectively) were detected in association with naive/non-tolerant state, pulmonary diseases and presence of other drugs, and low levels of methadone (<600 ng/mL) might lead to death in the presence of the above conditions/diseases.

Post-autopsy computed tomography. Pros and cons in a firearm death

Many studies have focused on the importance of post-mortem computed tomography (PMCT) prior to or in substitution of standard forensic autopsies in case of firearm death. However, due to the fact that PMCT is not routinely performed in all countries, in cases of death abroad it can happen that a CT scan is performed only after a first autopsy. A case of post-mortem re-examination, including the external examination and a post-autopsy computed tomography (PACT), of a gunshot victim of homicide in a foreign country is presented, and the pros and cons of imaging in post-autopsy setting are discussed. PACT could be a tool for carrying out more complete investigations and for obtaining information on bone injuries and foreign bodies trapped within peripheral soft tissues that can be re-analyzed after the arrival of the first autopsy report. Given that the value of information derived may be strongly influenced by the previously performed autopsy, in order to process the definitive considerations it is necessary to compare and interpret the data obtained through PACT with the results of the first autopsy, and to continue the international cooperation effort and the application of international guidelines in order to share information at the repatriation of the corpse.

Back to the Future - Part 2. Post-mortem assessment and evolutionary role of the bio-medicolegal sciences

Part 2 of the review "Back to the Future" is dedicated to the evolutionary role of the bio-medicolegal sciences, reporting the historical profiles, the state of the art, and prospects for future development of the main related techniques and methods of the ancillary disciplines that have risen to the role of "autonomous" sciences, namely, Genetics and Genomics, Toxicology, Radiology, and Imaging, involved in historic synergy in the "post-mortem assessment," together with the mother discipline Legal Medicine, by way of its primary fundament, universally denominated as Forensic Pathology. The evolution of the scientific research and the increased accuracy of the various disciplines will be oriented towards the elaboration of an "algorithm," able to weigh the value of "evidence" placed at the disposal of the "justice system" as real truth and proof.

Back to the Future - Part 1. The medico-legal autopsy from ancient civilization to the post-genomic era

Part 1 of the review "Back to the Future" examines the historical evolution of the medico-legal autopsy and microscopy techniques, from Ancient Civilization to the Post-Genomic Era. In the section focusing on "The Past", the study of historical sources concerning the origins and development of the medico-legal autopsy, from the Bronze Age until the Middle Ages, shows how, as early as 2000 BC, the performance of autopsies for medico-legal purposes was a known and widespread practice in some ancient civilizations in Egypt, the Far East and later in Europe. In the section focusing on "The Present", the improvement of autopsy techniques by Friedrich Albert Zenker and Rudolf Virchow and the contemporary development of optical microscopy techniques for forensic purposes during the 19th and 20th centuries are reported, emphasizing, the regulation of medico-legal autopsies in diverse nations around the world and the publication of international guidelines or best practices elaborated by International Scientific Societies. Finally, in "The Future" section, innovative robotized and advanced microscopy systems and techniques, including their possible use in the bio-medicolegal field, are reported, which should lead to the improvement and standardization of the autopsy methodology, thereby achieving a more precise identification of natural and traumatic pathologies.

The role of histopathology in forensic practice: an overview

The role of forensic histopathology in routine practice is to establish the cause of death in particular cases. This is achieved on the basis of microscopic analysis of representative cell and tissue samples taken from the major internal organs and from abnormal findings made at autopsy. A prerequisite of this is adherence to the quality standards set out for conventional histological/cytological staining and enzyme histochemical and immunohistochemical methods. The interpretation of histological findings is performed by taking into account macroscopic autopsy findings and information on previous history. Histological analysis may prompt postmortem biochemical and chemical-toxicological investigations. The results of histological analysis need to be classified by experts in the context of the available information and the need to withstand the scrutiny of other experts.

Malpractice and medical liability. European Guidelines on Methods of Ascertainment and Criteria of Evaluation

The manuscript presents the European Guidelines on medico-legal Methods of Ascertainment and Criteria of Evaluation in cases of suspected subjective "Medical Responsibility and/or Liability" developed by an international working group under the patronage of the European Academy of Legal Medicine. It includes a step-by-step illustrated explanation of approved Flow Charts, articulated in 18 sequential steps and comprehensive of both Methods of Ascertainment and Evaluation Criteria.

Phosphatidylethanol in blood as a marker of chronic alcohol use: a systematic review and meta-analysis

The present paper aims at a systematic review of the current knowledge on phosphatidylethanol (PEth) in blood as a direct marker of chronic alcohol use and abuse. In March 2012, the search through “MeSH” and “free-text” protocols in the databases Medline/PubMed, SCOPUS, Web of Science, and Ovid/Embase, combining the terms phosphatidylethanol and alcohol, provided 444 records, 58 of which fulfilled the inclusion criteria and were used to summarize the current evidence on the formation, distribution and degradation of PEth in human blood: (1), the presence and distribution of different PEth molecular species (2), the most diffused analytical methods devoted to PEth identification and quantization (3), the clinical efficiency of total PEth quantification as a marker of chronic excessive drinking (4), and the potential utility of this marker for identifying binge drinking behaviors (5). Twelve papers were included in the meta-analysis and the mean (M) and 95% confidence interval (CI) of total PEth concentrations in social drinkers (DAI ≤ 60 g/die; M = 0.288 μM; CI 0.208–0.367 μM) and heavy drinkers (DAI > 60 g/die; M = 3.897 μM; CI 2.404–5.391 μM) were calculated. The present analysis demonstrates a good clinical efficiency of PEth for detecting chronic heavy drinking.

Severe generalised rhabdomyolysis with fatal outcome associated with isotretinoin

Isotretinoin is considered to be a safe and effective therapy in otherwise therapy-resistant acne. Elevated serum creatine phosphokinase values with or without muscle-related symptoms in isotretinoin-treated patients have been reported and interpreted as benign phenomena, lethal cases have not been described yet. We present the case of a 20-year-old male who died from severe generalised rhabdomyolysis associated with isotretinoin treatment.

Journals publishing bio-medicolegal research in Europe

Fragmentation of bio-medicolegal knowledge has led to a proliferation of ultra-specialised sub-disciplines and branches, often published in 'field-oriented' scientific journals.The aim of this work is to provide an in-depth analytical picture of bio-medicolegal sources of publication, within and outside the traditional conception of legal medicine. An extensive search of bio-medicolegal articles published in the last five and a half years was performed on the MEDLINE database according to MeSH terms combined with free-text protocols. We performed a systematic analysis of targeted journals after merging, selecting and categorising all retrieved records, taking into account data from the 2009 JCR Science Edition (released on June 2010); 1,037 different journals were identified, of which only 48 (4.6%) focus specifically on bio-medicolegal matters, and of which only seven (14.6%) have an impact factor (IF). Despite this apparent dispersion, 47% of articles were published in bio-medicolegal journals (BML), of which 70.2% were in journals with IF (BML-IF). Articles published in BML-IF journals (33% of total papers) reach almost 50%, mainly in "Forensic Science International", "International Journal of Legal Medicine" and "Journal of Forensic Sciences". Instead, publications in not specifically bio-medicolegal journals (Not BML-IF) are greatly scattered and even fragmented in about 650 journals.The sub-disciplines that appear most frequently in Not BML-IF rather than BML-IF journals are Forensic Psychiatry (48.2% vs. 5.1%), Criminology (37.1% vs. 8.3%), Malpractice (50.7% vs. 4.0%), Medical Law and Ethics (46.4% vs. 6.9%) and Clinical Forensic Medicine (39.5% vs. 21.3%). The proposed bibliometric analysis revealed the preference of Forensic Pathology, Criminalistics (Biological), Forensic Genetics, Forensic Anthropology and Forensic Entomology for journals traditionally considered pertinent to the medico-legal discipline, with a considerable dispersion involving Toxicology, Psychiatry, Criminology and Malpractice, which were published in less well-known journals. This dispersion could be reduced adapting specialised forensic sections and increasing the IF of forensic journals, in order to respond suitably to the present demand for visibility by bio-medicolegal scientists, clearly oriented towards enhancing the objective impact of their curricula and attempting to attract funding to their research projects.

Bio-medicolegal scientific research in Europe. A country-based analysis

The European mosaic of socio-cultural, economic and legal realities is reflected in forensic and legal medicine, in which a great variety of operational modes of forensic medical services, organisational systems, structures, functional competences and scientific research strategies can be observed. The present work analyses the European bio-medicolegal scientific output of the last 5.5 years (exact time window, January 1, 2005-June 1, 2010), categorising papers by nationality of the corresponding author and forensic sub-discipline in question, in order to identify the peculiarities of national sub-specialised competences and to build up international research projects. This country-based bibliometric analysis, based on the number of articles and the impact factor produced by each European country, also considering its economic profile (gross domestic product and per capita gross domestic product), highlights the prevailing productive role of Western and Southern Europe (Germany, Great Britain, Italy, Switzerland, Spain and France). Categorising scientific output by forensic sub-discipline and branch, significant in terms of impact factor are contributions from Germany (coming first in Pathology, Toxicology, Genetics, Anthropology and Biological Criminalistics), Great Britain (first in Clinical Forensic Medicine, Malpractice and Invalidity-Social Insurance), Switzerland (first in Criminology), Italy (second in Toxicology, Anthropology and Invalidity-Social Insurance), The Netherlands (third in Clinical Forensic Medicine and Medical Law and Ethics), Spain (third in Genetics, Criminalistics and Invalidity-Social Insurance) and France (third in Toxicology and Malpractice). Interestingly, several countries with low gross domestic product, such as Poland, Turkey and other Eastern European nations, show notable scientific production in specific sub-disciplines such as Pathology, Toxicology and Forensic Genetics, suggesting that fruitful international cooperation could be planned and be of interest to funding sources within the European Community, also taking into account funds reserved for depressed areas undergoing development.