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Locci E, Stocchero M, Gottardo R, Chighine A, De-Giorgio F, Ferino G, Nioi M, Demontis R, Tagliaro F, d'Aloja E. PMI estimation through metabolomics and potassium analysis on animal vitreous humour. Int J Legal Med 2023; 137:887-895. [PMID: 36799966 PMCID: PMC10085955 DOI: 10.1007/s00414-023-02975-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 02/08/2023] [Indexed: 02/18/2023]
Abstract
INTRODUCTION The estimation of post-mortem interval (PMI) remains a major challenge in forensic science. Most of the proposed approaches lack the reliability required to meet the rigorous forensic standards. OBJECTIVES We applied 1H NMR metabolomics to estimate PMI on ovine vitreous humour comparing the results with the actual scientific gold standard, namely vitreous potassium concentrations. METHODS Vitreous humour samples were collected in a time frame ranging from 6 to 86 h after death. Experiments were performed by using 1H NMR metabolomics and ion capillary analysis. Data were submitted to multivariate statistical data analysis. RESULTS A multivariate calibration model was built to estimate PMI based on 47 vitreous humour samples. The model was validated with an independent test set of 24 samples, obtaining a prediction error on the entire range of 6.9 h for PMI < 24 h, 7.4 h for PMI between 24 and 48 h, and 10.3 h for PMI > 48 h. Time-related modifications of the 1H NMR vitreous metabolomic profile could predict PMI better than potassium up to 48 h after death, whilst a combination of the two is better than the single approach for higher PMI estimation. CONCLUSION The present study, although in a proof-of-concept animal model, shows that vitreous metabolomics can be a powerful tool to predict PMI providing a more accurate estimation compared to the widely studied approach based on vitreous potassium concentrations.
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Affiliation(s)
- Emanuela Locci
- Department of Medical Sciences and Public Health, Section of Legal Medicine, University of Cagliari, Cittadella Universitaria di Monserrato, 09042, Monserrato, Cagliari, Italy
| | - Matteo Stocchero
- Department of Women's and Children's Health, University of Padova, Padua, Italy
| | - Rossella Gottardo
- Department of Diagnostics and Public Health, Unit of Forensic Medicine, University of Verona, Verona, Italy
| | - Alberto Chighine
- Department of Medical Sciences and Public Health, Section of Legal Medicine, University of Cagliari, Cittadella Universitaria di Monserrato, 09042, Monserrato, Cagliari, Italy.
| | - Fabio De-Giorgio
- Department of Health Surveillance and Bioethics, Section of Legal Medicine, Catholic University of Rome, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giulio Ferino
- Department of Medical Sciences and Public Health, Section of Legal Medicine, University of Cagliari, Cittadella Universitaria di Monserrato, 09042, Monserrato, Cagliari, Italy
| | - Matteo Nioi
- Department of Medical Sciences and Public Health, Section of Legal Medicine, University of Cagliari, Cittadella Universitaria di Monserrato, 09042, Monserrato, Cagliari, Italy
| | - Roberto Demontis
- Department of Medical Sciences and Public Health, Section of Legal Medicine, University of Cagliari, Cittadella Universitaria di Monserrato, 09042, Monserrato, Cagliari, Italy
| | - Franco Tagliaro
- Department of Diagnostics and Public Health, Unit of Forensic Medicine, University of Verona, Verona, Italy
| | - Ernesto d'Aloja
- Department of Medical Sciences and Public Health, Section of Legal Medicine, University of Cagliari, Cittadella Universitaria di Monserrato, 09042, Monserrato, Cagliari, Italy
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A novel method for determining postmortem interval based on the metabolomics of multiple organs combined with ensemble learning techniques. Int J Legal Med 2023; 137:237-249. [PMID: 35661238 DOI: 10.1007/s00414-022-02844-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 05/18/2022] [Indexed: 01/10/2023]
Abstract
Determining postmortem interval (PMI) is one of the most challenging and essential endeavors in forensic science. Developments in PMI estimation can take advantage of machine learning techniques. Currently, applying an algorithm to obtain information on multiple organs and conducting joint analysis to accurately estimate PMI are still in the early stages. This study aimed to establish a multi-organ stacking model that estimates PMI by analyzing differential compounds of four organs in rats. In a total of 140 rats, skeletal muscle, liver, lung, and kidney tissue samples were collected at each time point after death. Ultra-performance liquid chromatography coupled with high-resolution mass spectrometry was used to determine the compound profiles of the samples. The original data were preprocessed using multivariate statistical analysis to determine discriminant compounds. In addition, three interrelated and increasingly complex patterns (single organ optimal model, single organ stacking model, multi-organ stacking model) were established to estimate PMI. The accuracy and generalized area under the receiver operating characteristic curve of the multi-organ stacking model were the highest at 93% and 0.96, respectively. Only 1 of the 14 external validation samples was misclassified by the multi-organ stacking model. The results demonstrate that the application of the multi-organ combination to the stacking algorithm is a potential forensic tool for the accurate estimation of PMI.
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Tozzo P, Amico I, Delicati A, Toselli F, Caenazzo L. Post-Mortem Interval and Microbiome Analysis through 16S rRNA Analysis: A Systematic Review. Diagnostics (Basel) 2022; 12:2641. [PMID: 36359484 PMCID: PMC9689864 DOI: 10.3390/diagnostics12112641] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 08/12/2023] Open
Abstract
The determination of the Post-Mortem Interval (PMI) is an issue that has always represented a challenge in the field of forensic science. Different innovative approaches, compared to the more traditional ones, have been tried over the years, without succeeding in being validated as successful methods for PMI estimation. In the last two decades, innovations in sequencing technologies have made it possible to generate large volumes of data, allowing all members of a bacterial community to be sequenced. The aim of this manuscript is to provide a review regarding new advances in PMI estimation through cadaveric microbiota identification using 16S rRNA sequencing, in order to correlate specific microbiome profiles obtained from different body sites to PMI. The systematic review was performed according to PRISMA guidelines. For this purpose, 800 studies were identified through database searching (Pubmed). Articles that dealt with PMI estimation in correlation with microbiome composition and contained data about species, body site of sampling, monitoring time and sequencing method were selected and ultimately a total of 25 studies were considered. The selected studies evaluated the contribution of the various body sites to determine PMI, based on microbiome sequencing, in human and animal models. The results of this systematic review highlighted that studies conducted on both animals and humans yielded results that were promising. In order to fully exploit the potential of the microbiome in the estimation of PMI, it would be desirable to identify standardized body sampling sites and specific sampling methods in order to align data obtained by different research groups.
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Affiliation(s)
- Pamela Tozzo
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy
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Nardini M, Ciasca G, Lauria A, Rossi C, Di Giacinto F, Romanò S, Di Santo R, Papi M, Palmieri V, Perini G, Basile U, Alcaro FD, Di Stasio E, Bizzarro A, Masullo C, De Spirito M. Sensing red blood cell nano-mechanics: Toward a novel blood biomarker for Alzheimer's disease. Front Aging Neurosci 2022; 14:932354. [PMID: 36204549 PMCID: PMC9530048 DOI: 10.3389/fnagi.2022.932354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 08/10/2022] [Indexed: 11/13/2022] Open
Abstract
Red blood cells (RBCs) are characterized by a remarkable elasticity, which allows them to undergo very large deformation when passing through small vessels and capillaries. This extreme deformability is altered in various clinical conditions, suggesting that the analysis of red blood cell (RBC) mechanics has potential applications in the search for non-invasive and cost-effective blood biomarkers. Here, we provide a comparative study of the mechanical response of RBCs in patients with Alzheimer's disease (AD) and healthy subjects. For this purpose, RBC viscoelastic response was investigated using atomic force microscopy (AFM) in the force spectroscopy mode. Two types of analyses were performed: (i) a conventional analysis of AFM force-distance (FD) curves, which allowed us to retrieve the apparent Young's modulus, E; and (ii) a more in-depth analysis of time-dependent relaxation curves in the framework of the standard linear solid (SLS) model, which allowed us to estimate cell viscosity and elasticity, independently. Our data demonstrate that, while conventional analysis of AFM FD curves fails in distinguishing the two groups, the mechanical parameters obtained with the SLS model show a very good classification ability. The diagnostic performance of mechanical parameters was assessed using receiving operator characteristic (ROC) curves, showing very large areas under the curves (AUC) for selected biomarkers (AUC > 0.9). Taken all together, the data presented here demonstrate that RBC mechanics are significantly altered in AD, also highlighting the key role played by viscous forces. These RBC abnormalities in AD, which include both a modified elasticity and viscosity, could be considered a potential source of plasmatic biomarkers in the field of liquid biopsy to be used in combination with more established indicators of the pathology.
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Affiliation(s)
- Matteo Nardini
- Dipartimento di Neuroscienze, Sezione di Fisica, Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Gabriele Ciasca
- Dipartimento di Neuroscienze, Sezione di Fisica, Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alessandra Lauria
- Unitá Operativa Complessa Neuroriabilitazione ad Alta Intensitá, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Cristina Rossi
- Department of Laboratory Diagnostic and Infectious Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Flavio Di Giacinto
- Dipartimento di Neuroscienze, Sezione di Fisica, Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Sabrina Romanò
- Dipartimento di Neuroscienze, Sezione di Fisica, Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Riccardo Di Santo
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Massimiliano Papi
- Dipartimento di Neuroscienze, Sezione di Fisica, Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Valentina Palmieri
- Dipartimento di Neuroscienze, Sezione di Fisica, Università Cattolica del Sacro Cuore, Rome, Italy
- Istituto dei Sistemi Complessi (ISC), Consiglio Nazionale delle Ricerche (CNR), Rome, Italy
| | - Giordano Perini
- Dipartimento di Neuroscienze, Sezione di Fisica, Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Umberto Basile
- Department of Laboratory Diagnostic and Infectious Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesca D. Alcaro
- Department of Laboratory Diagnostic and Infectious Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Enrico Di Stasio
- Department of Laboratory Diagnostic and Infectious Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alessandra Bizzarro
- Unitáă Operativa Complessa Continuità assistenziale, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Carlo Masullo
- Dipartimento di Neuroscienze, Sezione di Fisica, Università Cattolica del Sacro Cuore, Rome, Italy
- Sezione di Neurologia, Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marco De Spirito
- Dipartimento di Neuroscienze, Sezione di Fisica, Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Mosadegh M, Khazaei M, Abdollahpour ZD, Alahyari S, Moharamzad Y, Emamhadi M, Aram S, Abolbaghaei M, Sanei Taheri M. Ultrasound shear-wave elastography applicability in estimation of post-mortem time. ULTRASOUND (LEEDS, ENGLAND) 2022; 30:134-140. [PMID: 35509295 PMCID: PMC9058388 DOI: 10.1177/1742271x211035810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/07/2021] [Indexed: 05/03/2023]
Abstract
Introduction Post-mortem rigidity of the tissues is one of the basic principles in forensic medicine to estimate the time of death. Qualitative methods to determine the stiffness of the corpse may have some limitations. Methods that provide quantitative values may be useful. We intended to evaluate the applicability of ultrasound shear-wave elastography of the tissues to estimate the post-mortem interval (PMI). Methods For 80 corpses, shear-wave elastography of the liver, sartorius muscle, testis, thyroid and parotid was performed before autopsy. Based on the forensic reports as the reference method to define post-mortem interval, the corpses were divided into four groups: group 0 (PMI < 24 hours), group 1 (PMI ≥24 hours and <48 hours), group 2 (PMI ≥ 48 hours and <72 hours), and group 3 (PMI ≥ 72 hours). There were 24, 38, 13, and 5 corpses, respectively, in groups 0, 1, 2, and 3. Results A significant rise in the elasticity values in comparison to elasticity of normal tissues in live adults was seen very early in the post-mortem period. Between-group comparisons showed that a significant difference in the liver elasticity was present among the groups. The mean (SD) liver elasticity was 10.29 (±0.83) in group 0, 14.98 (±1.56) in group 1, 12.49 (±1.09) in group 2, and 15.64 (±1.68) kilopascals (kPa) in group 3 (P = 0.035). Nevertheless, elasticity measurements in other tissues were not helpful in distinguishing post-mortem interval groups. Conclusion It is possible to use liver quantitative shear-wave elastography to estimate the time of death.
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Affiliation(s)
- Mohsen Mosadegh
- Radiology Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehdi Khazaei
- Radiology Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Sam Alahyari
- Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Yashar Moharamzad
- Radiology Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammadali Emamhadi
- Forensic Medicine Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Samira Aram
- Legal Medicine Research Center, Legal Medicine Organization, Tehran, Iran
| | | | - Morteza Sanei Taheri
- Radiology Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Morteza Sanei Taheri, Radiology Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Post mortem computed tomography meets radiomics: a case series on fractal analysis of post mortem changes in the brain. Int J Legal Med 2022; 136:719-727. [PMID: 35239030 PMCID: PMC9005394 DOI: 10.1007/s00414-022-02801-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 02/14/2022] [Indexed: 10/26/2022]
Abstract
Estimating the post-mortem interval is a fundamental, albeit challenging task in forensic sciences. To this aim, forensic practitioners need to assess post-mortem changes through a plethora of different methods, most of which are inherently qualitative, thus providing broad time intervals rather than precise determinations. This challenging problem is further complicated by the influence of environmental factors, which modify the temporal dynamics of post-mortem changes, sometimes in a rather unpredictable fashion. In this context, the search for quantitative and objective descriptors of post-mortem changes is highly demanded. In this study, we used computed tomography (CT) to assess the post-mortem anatomical modifications occurring in the time interval 0-4 days after death in the brain of four corpses. Our results show that fractal analysis of CT brain slices provides a set of quantitative descriptors able to map post-mortem changes over time throughout the whole brain. Although incapable of producing a direct estimation of the PMI, these descriptors could be used in combination with other more established methods to improve the accuracy and reliability of PMI determination.
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De-Giorgio F, Ciasca G, Fecondo G, Mazzini A, De Spirito M, Pascali VL. Estimation of the time of death by measuring the variation of lateral cerebral ventricle volume and cerebrospinal fluid radiodensity using postmortem computed tomography. Int J Legal Med 2021; 135:2615-2623. [PMID: 34562107 PMCID: PMC8523388 DOI: 10.1007/s00414-021-02698-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/27/2021] [Indexed: 12/21/2022]
Abstract
Using postmortem CT (PMCT), changes in the volume of the lateral cerebral ventricles (LCVs) and modifications of the radiodensity of cerebrospinal fluid (CSF) have been examined to identify a possible relationship between these changes and the time of death. Subsequent periodical CT scans termed "sequential scans" for ten corpses at known time of death were obtained, and a 3D segmentation of the entire LCV was carried out to measure its volume and radiodensity over time from ~ 5.5- h up to 273-h postmortem. A linear decrease of the LCV volume for all the cases was observed in the investigated time range, together with an overall logarithmic increase of radiodensity. Although a larger sampling should be performed to improve the result reliability, our finding suggests that the postmortem variation of CSF radiodensity can be a potentially useful tool in determining postmortem interval, a finding that is worthy of further investigation.
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Affiliation(s)
- Fabio De-Giorgio
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
- Department of Healthcare Surveillance and Bioethics, Section of Legal Medicine, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Gabriele Ciasca
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Neuroscience Department, Section of Physics, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gennaro Fecondo
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Healthcare Surveillance and Bioethics, Section of Legal Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alberto Mazzini
- Neuroscience Department, Section of Physics, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marco De Spirito
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Neuroscience Department, Section of Physics, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vincenzo L Pascali
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Healthcare Surveillance and Bioethics, Section of Legal Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
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Rippy JR, Singh M, Aglyamov SR, Larin KV. Ultrasound Shear Wave Elastography and Transient Optical Coherence Elastography: Side-by-Side Comparison of Repeatability and Accuracy. IEEE OPEN JOURNAL OF ENGINEERING IN MEDICINE AND BIOLOGY 2021; 2:179-186. [PMID: 34179823 PMCID: PMC8224461 DOI: 10.1109/ojemb.2021.3075569] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objective: We compare the repeatability and accuracy of ultrasound shear wave elastography (USE) and transient optical coherence elastography (OCE). Methods: Elastic wave speed in gelatin phantoms and chicken breast was measured with USE and OCE and compared with uniaxial mechanical compression testing. Intra- and Inter-repeatability were analyzed using Bland-Altman plots and intraclass correlation coefficients (ICC). Results: OCE and USE differed from uniaxial testing by a mean absolute percent error of 8.92% and 16.9%, respectively, across eight phantoms of varying stiffness. Upper and lower limits of agreement for intrasample repeatability for USE and OCE were ±0.075 m/s and −0.14 m/s and 0.13 m/s, respectively. OCE and USE both had ICCs of 0.9991. In chicken breast, ICC for USE was 0.9385 and for OCE was 0.9924. Conclusion: OCE and USE can detect small speed changes and give comparable measurements. These measurements correspond well with uniaxial testing.
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De-Giorgio F, Grassi S, d'Aloja E, Pascali VL. Post-mortem ocular changes and time since death: Scoping review and future perspective. Leg Med (Tokyo) 2021; 50:101862. [PMID: 33610931 DOI: 10.1016/j.legalmed.2021.101862] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 12/10/2020] [Accepted: 02/07/2021] [Indexed: 11/30/2022]
Abstract
The forensics literature on the relationship between ocular changes and the postmortem interval (PMI) has traditionally focused on time-related variations in concentrations of metabolites and elements within the eye. However, structural changes within the eye over time deserve the same attention because there is significant evidence of their importance in determining the time since death. Therefore, we reviewed publications that provided substantial evidence on this issue. In light of our inclusion and exclusion criteria, 26 papers were eligible for review. On the basis of the ocular parameters considered, we grouped the reviewed evidence into eight thematic areas: corneal opacities, corneal thickness, drug-induced pupil diameter variations, retinal changes, segmentation of retinal vessels, intraocular pressure reduction, globe temperature and crystalline alterations. The most important and common limitations of the reviewed studies were small study populations (many were monocentric studies), absence of robust statistical methodology, use of mathematical models valid only in ideal conditions and validation only for short PMIs. Although many phenomena cannot be used to reliably estimate PMI, there is rigorous evidence suggesting that promising factors, including corneal thickness, require methodological innovations for application to forensics practice but could be used in the near future to reliably estimate the time since death.
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Affiliation(s)
- Fabio De-Giorgio
- Department of Health Care Surveillance and Bioethics, Section of Legal Medicine, Università Cattolica del S. Cuore, Rome, Italy; Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Simone Grassi
- Department of Health Care Surveillance and Bioethics, Section of Legal Medicine, Università Cattolica del S. Cuore, Rome, Italy; Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Ernesto d'Aloja
- Department of Clinical Sciences and Public Health, Forensic Medicine Unit, University of Cagliari, Cagliari, Italy
| | - Vincenzo L Pascali
- Department of Health Care Surveillance and Bioethics, Section of Legal Medicine, Università Cattolica del S. Cuore, Rome, Italy; Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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