Intentional child and adolescent homicides in Milan (Italy): A 30-year interdisciplinary study

This study aims to discuss the forensic and criminological implications of child homicides in the territory of Milan, Italy. The authors present a retrospective study on all the cases of child and adolescent homicides, that were observed at the Institute of Legal Medicine of Milan (Italy) in the last 30 years (from January 1991 to December 2020). A total of 46 child homicides were collected, focusing on the sociological features, by highlighting peculiar cases, risk factors, potential changing social trends, and comparing our cases with the current literature. The analysis revealed a statistically significant relationship (p < 0.05) for male adolescents and indicated that adolescent homicides were more frequently perpetrated in extrafamilial contexts. In contrast, neonaticides and infanticides were mainly committed at home. Furthermore, the Fisher's Exact test revealed that child murders were mainly committed by immigrants in the Milan district after 2005 (p < 0.05). The two main causes of death were due to sharp and firearm injuries. While the relationship between homicide clusters and homicides committed by sharp objects was not significant, adolescent homicides were mainly committed using firearms (p < 0.05). The present study may help to identify risk factors for homicides against child and adolescent. Consequently, policies that identify, prevent, and minimize this extreme violence should be designed to interrupt the vicious circle of such dreadful murderous events. Child and adolescent homicides deserve additional focus and better education for healthcare professionals and further research should be carried out to develop therapeutic and caring strategies.

Exploring the role of the human microbiome in forensic identification: opportunities and challenges

Forensic microbiology is rapidly emerging as a novel tool for human identification. The human microbiome, comprising diverse microbial communities including fungi, bacteria, protozoa, and viruses, is unique to each individual, offering a new dimension to forensic investigations. While traditional identification methods primarily rely on DNA profiling and fingerprint analysis, they face limitations when complete DNA or fingerprints profiles are unattainable or degraded. In this context, the microbial signatures of the human skin microbiome present a promising alternative due to their resilience to environmental stresses and individual-specific composition. This review explores the potential of microbiome analysis in forensic human identification, evaluating its applications, advantages, limitations, and future prospects. The uniqueness of an individual's microbial community, particularly the skin microbiota, can provide distinctive biological markers for identification purposes, while technological advancements like 16 S rRNA sequencing and metagenomic shotgun sequencing are enhancing the specificity of microbial identification, enabling detailed analysis of these complex ecological communities. Despite these promising findings, current research has not yet achieved a level of identification probability that could establish microbial analysis as a stand-alone evidence tool. Therefore, it is presently considered ancillary to traditional methods, contributing to a more comprehensive biological profile of individuals.

Work-related and non-work-related fatal road accidents: Assessment of psychoactive substance use in commuting

Commuting road traffic collisions (RTCs) are one of the main causes of occupational death worldwide, including Italy. Among the prominent yet relatively understudied personal risk factors in the subpopulation of workers, there is the use of psychoactive substances. Since the phenomenon of driving under alcohol and drugs effects in the commuter sub-population has so far been poorly studied, we carried out a study by comparing results obtained from the analysis of commuters and non-commuters. The percentage of commuting RTCs victims was 10.4% out of all the RTCs. Commuter victims were mostly men, 51-60 years-old, motorcyclists (32.1%) or car drivers (28.6%), employees, deceased during Fridays and Saturdays, in the afternoon (35.7%) and in the evening (32.1%). It was possible to perform toxicological analyses in 60.7% of commuter cases: approximately 40% tested positive, always and only for ethanol (median Blood Alcohol Concentration, BAC, of about 1.03 g/L). Values above the legal limit were observed in 23.5% of the toxicological samples analyzed from commuter accidents. Our findings contribute to bridging the gap in knowledge in the area of RTCs and commuting and emphasize the importance of carrying out toxicological investigations, with possible repercussions on both insurance issues and public health strategies, which are relevant for analyzing the phenomenon structurally.

Intra-familiar homicides: From 2006 to 2021 in the judicial district of Milan

INTRODUCTION

The present research aims at analyzing criminological and medico-legal characteristics of intra-familiar homicides occurred in two major Italian cities (Milano and Monza) from the beginning of 2006 to the end of 2021.

METHODS

Cases were identified using the Institutional database of the Institute of Legal Medicine of Milan, where all the autopsies of victims were performed. Data about these cases were obtained from autopsies findings, preliminary investigation reports, local papers and victim relatives' interviews. In this period 11,480 autopsies were performed: 392 were homicides and, among these, 94 were confirmed as intra-familiar homicides (as a result of 84 events). Cases were classified according to the classic definition of intimate partner violence (referring only to an intra-familiar context), parricides, filicides, fratricides, familicides and grannicides. Age, sex, nationality and risk factors of the victims and perpetrators, as well as methods of murder were registered for each case. Only in some cases, motives for murder were known.

RESULTS

The most frequent type of intra-familiar homicides was intimate partner violence (41.5%), followed by parricides (16%, mainly matricides), filicides (10.7%) and fratricides (6.4%). 9.6% of the total number of events were familicides. Risk factors were frequently involved, in particular among perpetrators and in the group of parricides, while among siblicides they showed minimal relevance. Overall, psychiatric pathologies were the main risk factors involved (at least 23.8%), unlike extrafamiliar homicides, where previous criminal report or involvement in illicit traffics are frequently reported among perpetrators. This finding enlightens the difficulties of caring for a relative with a mental disorder, who can become dangerous for the domestic caregiver. Furthermore, the high number of physical illness and the advanced age of victims points out the tragical consequences of the lack of social support system for these categories of people.

METHODS

of murder were mainly cold steel (30-31.9%) and firearms (21-22.3%). However choking/manual ligature (9-9.6%), blunt force trauma inflicted using objects found on the scenario or bare handed (16-17%) and combined methods (11-11.7%) were frequently represented confirming the expected high level of impulsivity related to this kind of crime.

Driving under the influence of drugs: Correlation between blood psychoactive drug concentrations and cognitive impairment. A narrative review taking into account forensic issues

Driving under the influence of alcohol has been shown to increase the risk of involvement in road traffic collisions (RTCs) however, less is known about the effects of illicit drugs, and a clear correlation between drug concentrations and RTC risk is still debated. The goal of this narrative review is to assess the current literature regarding the most detected psychoactive drugs in RTC (ethanol, amphetamines, cannabis, opioids and cocaine), in relation to driving performance. Evidence on impaired driving due to psychoactive substances, forensic issues relating to the assessment of the impact of drugs, blood cut-off values proposed to date as well as scientific basis for proposed legislative limits are discussed. At present there is no unequivocal evidence demonstrating a clear dose/concentration dependent impairment in many substances. Per se and zero tolerance approaches seem to have negative effect on drugged driving fatalities. However, the weight of these approaches needs further investigation.

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Driving under the influence of psychotropic substances has become a widespread phenomenon.

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Only a few substances have been reported to have a clear dose/concentration dependent impairment.

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Statistically significant differences should not be considered as clinically significant per se

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There is wide variability in legislative cut-offs.

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Detection limits seems to be the most public safety-oriented legislative approach.

Telemedicine Applications in the Era of COVID-19: Telesurgery Issues

Telemedicine allows for the effective delivery of health care to patients at a distance through the application of information technology to the field of medicine. This is optimal during the COVID-19 pandemic to reduce interpersonal contact to mitigate contagion. Among the possible Telemedicine applications, there is Telesurgery, which involves more and more surgical specialties thanks to the numerous benefits in quality and cost containment. In the growing field of Telesurgery, its technical and legal implications must be considered. In this study, a traditional review of the scientific literature was carried out to identify the most relevant issues of interest in Telesurgery. The problematic legal aspects identified are mainly related to the difference in legislation between different geographical areas, which is critical in the case of malpractice. In addition, there is the possibility of a malicious hacker attack on the transmitted data stream either to steal sensitive data or to harm the patient. Finally, there are inherent difficulties with the technology used, such as latency issues in data transmission. All these critical issues are currently not adequately addressed by current legislation. Therefore, one can only hope for a legislative action to allow Telesurgery to be used safely.

Sexual assault and abuse committed against family members: An analysis of 1342 legal outcomes and their motivations

Background

Over the past years medical centres specifically addressed in gender-based violence have developed protocols for the collections of evidence useful in the courtroom, including accurate documentation of physical and psychological states of the victim and collection of samples. Previous studies showed an association between documented physical trauma and conviction but unfortunately, few studies in the recent literature analysed the factors that influence the legal outcome and final judgement. The present study focused on the elements that appeared of significance in the legal outcome, including medico-legal evaluation, source of the crime report and circumstance of the assault.

Methods

It was conducted a retrospective analysis of all the judgments issued by the Public Prosecutor’s Office at a Court of a Metropolitan Italian city regarding sexual and domestic violence, from January 1^st 2011 to 31st December 31^st 2015. Examination regarded the demographic information of the victim and of the defendant, information on the crime, the circumstances of the aggression and medical information retrieved. Sentences were subsequently divided into two categories based on the legal outcome (conviction vs acquittal) and the different characteristics of the two sub-populations were compared to verify if there were variables significantly associated to the judge’s final judgment.

Results

Over the 5 years taken into consideration, there have been 1342 verdicts regarding crimes of sexual violence (374 cases) and regarding abuses against family members or cohabitants (875): other 93 cases regarded both sexual violence and abuse. 66.3% ended in conviction of the offender and 33.7% in acquittal of the accused. Cases of conviction were more frequent when they involved: use of a weapon by the assailant, as well as if the assailant had a criminal record and had a history of drug abuse or other addictions; duration of proceeding less 22 months and a civil party involved; presence of clinical documentation together with other deposition in addition to victim’s deposition; also frequent episodes of violence and application of precautionary measures were associated to conviction.

Conclusions

Many factors seem able to influence the judge’s judgment, although clearly each case must be singularly evaluated. The mere presence of medical documentation, without the support of other sources of evidence, such as the victim’s statement or further declarations, however, is almost always not definitive for the verdict. Despite so, in cases where there are multiple sources of evidence, clinical documentation can provide useful elements and can give clues on the consistency between the history told and injuries observed.

Prediction model for autopsy diagnosis of driver and front passenger in fatal road traffic collisions

Road traffic collisions (RTC) analysis is almost a daily activity in many autopsy room. Especially when analyzing an RTC with multiple occupants in the car, it can be necessary to distinguish driver from front seat passenger in order to provide the judicial authority with elements useful to understand and to prove who was driving, considering the criminal and civil responsabilities that may derive from it. Despite this, it is beyond doubt that there is enormous difficulty in providing such information. The aim of this paper is then to evaluate whether it is possible to differentiate driver and front seat passenger in case of fatal collisions using a mathematical model based on injury pattern alone. Autopsy reports concerning 90 drivers and 60 front-seat passengers were analyzed. Statistical analysis was used to detect injuries capable of discriminating between driver and passenger, considering skin, skeletal and visceral injuries. Results show that certain skin injuries, fractures and internal organ lesions are possibly associated with drivers and front seat passenger status and the overall injury pattern seems to be able to provide useful information. A mathematical model is presented. The process to distinguishing driver from front seat passenger following fatal motor vehicle collision may use multiple sources of information, including autopsy injury pattern analysis.

Predictors of success for Brugada syndrome epicardial ablation

 

Epicardial right ventricular outflow tract (RVOT) ablation has been described for the treatement of Brugada syndrome (BrS) high risk patients.

Purpose

Success evaluation of epicardial ablation for BrS.

Methods

Type 1 ECG was defined as spontaneous if recorded in absence of drugs and/or specific conditions. BrS patients were scheduled for ablation if presented at least one of: spontaneous type 1 ECG, syncope, ventricular arrhythmias (VA).

Programmed electrical stimulation (PES) was performed (2 extrastimuli, 2 sites) in basal conditions and after ajmaline infusion. Epicardial subxifoid access and electroanatomical endo-epicardial maps were obtained during sinus rhythm. Delayed fragmented/low-frequency, low-voltage electrograms (EGM) were targeted: substrate area measured in basal conditions and after ajmaline.

Epicardial ablation

Radiofrequency (RF) was delivered (50 W power control mode) till complete elimination of targeted EGM and BrS-ECG pattern after ajmaline. Eventually PES repeated: if positive a repeated PES scheduled at follow-up (fu).

Success was defined as absence of type 1 ECG either spontaneous or with ajmaline challenge at 3 month. Recurrences were scheduled to redo ablation.

Results

55 patients were submitted to 58 ablation procedures. 38 spontaneous type 1 ECG: 18 symptomatic for syncope/polimorphic VT/VF or appropriate ICD shock; 13 had VA induction at PES. 4 patients with ajmaline-type 1 ECG had VA induction. 36% of the symptomatic patients and 26% of asymptomatic had PES-VA induction. In all patients abnormal EGM area (cm2) was detected in epicardial RVOT (table 1).

Acute success: No patient had ECG type 1 with ajmaline. 5 patients had PES induction of VA. Complications: 1 cardiac tamponade, 16 mild pericarditis.

At FU of 1,1±0,6 yrs no patient had spontaneous ECG type 1 nor arrhythmic events. 50 had negative ajmaline challenge (90% success rate after single procedure), 3 underwent redo: 2 had negative ajmaline challenge at FU, 1 had persistence type 1-ajmaline induction; 2 are scheduled for redo. No patient had VT induction at PES.

Multivariate analysis: Single procedure success was not related either to history (symptoms, VA, type 1 ECG) or to procedural findings (PES results, substrate area).

Conclusion

Epicardial substrate ablation was safe end effective in BrS. No clinical or procedural findings were related to success

Funding Acknowledgement

Type of funding source: None

The pathological diagnosis of the height of fatal falls: A mathematical approach

The authors analyzed the injury pattern of 385 victims of fall from a height which underwent a complete autopsy, with the objective to investigate whether it was possible to construct a mathematical model to be used for height of the fall diagnosis. The cases were selected and enrolled according to a balanced stratification of the heights of the fall, allowing a subdivision into seven classes consisting of 55 subjects each: 6m or less, 9m, 12m, 15m, 18m, 21m, 24m or more (maximum 36m). For each case anthropologic and necroscopic data was collected and analyzed to obtain a standardized description of the injury pattern was obtained, dividing the body into 4 major anatomical areas (Head, Thorax, Abdomen, Skeleton), each of them further divided in 5 major organs. Every organ was finally divided into 5 objective degrees of injury. Statistical analysis was performed on all the available data using IBM SPSS Statistics 20, to test the performance of the "injury pattern assessment table" in the diagnosis of the height of the fall and to develop a related mathematical model. Our findings confirm that the height of the fall is significantly associated with age, weight of the body and the injury pattern. An Injury Pattern Assessment Table and two mathematical models which correlates the height of the fall with analyzed variables are presented.

Valorization of agro-industrial wastes to produce hydrolytic enzymes by fungal solid-state fermentation

Nowadays, significant amounts of agro-industrial wastes are discarded by industries; however, they represent interesting raw materials for the production of high-added value products. In this regard, orange peels (ORA) and exhausted sugar beet cossettes (ESBC) have turned out to be promising raw materials for hydrolytic enzymes production by solid state fermentation (SSF) and also a source of sugars which could be fermented to different high-added value products. The maximum activities of xylanase and exo-polygalacturonase (exo-PG) measured in the enzymatic extracts obtained after the SSF of ORA were 31,000 U·kg^-1 and 17,600 U·kg^-1, respectively; while for ESBC the maximum values reached were 35,000 U·kg^-1 and 28,000 U·kg^-1, respectively. The enzymatic extracts obtained in the SSF experiments were also employed for the hydrolysis of ORA and ESBC. Furthermore, it was found that extracts obtained from SSF of ORA, supplemented with commercial cellulase, were more efficient for the hydrolysis of ORA and ESBC than a commercial enzyme cocktail typically used for this purpose. In this case, maximum reducing sugars concentrations of 57 and 47 g·L^-1 were measured after the enzymatic hydrolysis of ESBC and ORA, respectively.

Alleged malpractice in orthopaedics. Analysis of a series of medmal insurance claims

Background

Medical malpractice is an important topic worldwide, and orthopedics is a clinical branch that is considered to be at a high risk for claims. The analysis of a series of medmal insurance claims allows forensic pathologists, clinicians, and insurance companies to probe the risk of a specific clinical branch for medical malpractice claims and highlights areas where care may be improved. We investigated the main features of a major Italian insurance broker’s archive in order to identify recurrent pitfalls in this field.

Materials and methods

A retrospective study was carried out on orthopedics claims. The archive covered claims from 2002 to 2013 that targeted 1980 orthopedists.

Results

635 claims were found and analyzed with a focus on the clinical activity invocked in the claim, the presence of alleged team malpractice, the clinical outcome of the case, and the final forensic decision regarding the claim. 299 orthopedists had at least one malpractice claim made against them during the available period; 146 orthopedists were subject to more than one malpractice claim. Most of the claims regarded perioperative and operative cases, usually originating from civil litigation. The anatomical sites most commonly involved were the hip or knees, and sciatic nerve lesions were the main contributor.

Conclusions

Orthopedics is a medical specialty with a high risk for malpractice claims. In our study, medical malpractice was observed in nearly 50% of the cases—typically in surgery-linked cases resulting in permanent impairment of the patient. Death from orthopedics malpractice seemed to be rare.

Level of Evidence

IV.

The expert and the foreigner: Reflections of forensic transcultural psychopathology on a total of 86 reports by experts on criminal liability

In recent times Italy has been experiencing massive migration flows, therefore the attention on the issue of crimes committed by foreigners is increasing. But within trials, in the evaluation of criminal liability of foreigners, how do experts deal with them? Do the performed evaluations take cultural diversity into account? The present study took origin from these questions and examined a total of 86 reports by experts on criminal liability of foreign persons (16 females and 70 males). Examinees have been declared indictable in 31 cases (36%), totally mentally ill in 40 cases (45%) and with diminished liability in 15 cases (17%); when liability was excluded, examinees were diagnosed in 11 cases with mood disorders, in 23 cases with personality disorders, in 4 cases with adaptation disorders and post-traumatic stress disorder and in 10 cases with different diagnoses (in some cases more than one diagnosis was present). None of the reports used the section of the DSM concerning "cultural framing". Tests were used in 48 surveys (56% of cases), with more tests for each examinee, for a total of 39 Rorschach, 14 Raven test, 8 Minnesota Multiphasic Personality Inventory - MMPI - 4 Wechsler Adult Intelligence Scale - WAIS - level test, 8 Thematic Apperception test. When subjects were diagnosed with mental disorder and with diminished liability, 42 (79%) were also socially dangerous. Results highlight the importance of the relationship between the expert and the foreigner. Many factors ought to be critically considered by experts dealing with foreigners, like cultural awareness, knowledge of verbal communication, critical consideration of meanings and diagnosis, knowledge of the foreigners' personal story, presence of tests with inexact information and cultural fallacy.

Valorization of exhausted sugar beet cossettes by successive hydrolysis and two fermentations for the production of bio-products

Exhausted sugar beet cossettes (ESBC) show an enormous potential as a source of sugars for the production of bio-products. Enzyme hydrolysis with the combined effect of mainly cellulases, xylanases and pectinases, turned out to be very efficient, obtaining almost double the concentration of sugars measured with the sole action of Celluclast® and β-glucosidase, and increasing 5 times the hydrolysis rate. As the sole pretreatment, ESBC soaked in the hydrolysis buffer were autoclaved, avoiding the application of severe conventional biomass pretreatments. Moreover, a promising alternative for the complete utilization of glucose, xylose, arabinose, mannose and maltose contained in ESBC is proposed in this paper. It consists of sequential fermentation of sugars released in the hydrolysis step to produce bioethanol and lactic acid as main bio-products. Compared to separate fermentations, with this strategy glucose and hemicellulose derived sugars were completely consumed and the 44% of pectin derived sugars.

MR pyelography in 115 patients with a dilated renal collecting system

Purpose: To evaluate the accuracy of MR pyelography in the assessment of hydroureteronephrosis.

Material and Methods: One hundred and fifteen patients, with variable degree of hydroureteronephrosis demonstrated by US and urography were subjected to MR pyelography obtained by means of two ultra-fast sequences.

Results: Of the 228 kidneys examined, the collecting systems of 130 kidneys were dilated and correctly identified on MR pyelography, with only 2 false-positive results. The specificity of MR pyelography in detecting hydronephrosis was 98%. Accuracy in revealing level of obstruction was 100%. Sensitivity in detecting stones, strictures and congenital ureteropelvic junction obstructions was respectively 68.9%, 98.5% and 100%.

Conclusion: MR pyelography can rapidly and accurately depict the morphological features of dilated urinary tracts with information regarding the degree and level of obstruction, without using contrast medium or ionizing radiation.

The Fatty Disc: An Unusual Cause of Bright Intervertebral Disc on T1-Weighted Conventional Spin-Echo MR: A Case Report

A hyperintense intervertebral disc on T1-weighted spin-echo MR image, the “bright disc”, is described in a patient with a long-standing ankylosing spondylitis.

The high signal intensity was due to the fatty infiltration of the discal tissue, as was clearly demonstrated by the comparison of MR and CT scan of the lumbar spine, probably due to progressive endochondral ossification with subsequent bone marrow metaplasia in the ossified disc.

Alleged malpractice in anesthesiology: analysis of a series of private insurance claims

BACKGROUND

Medical malpractice is currently a crucial topic and anesthesia is a key specialty for the improvement of patient safety. However, death and permanent impairment due to anesthesia still occur and studies of insurance analysis data are increasing. We investigated the main features of a major Italian insurance broker's archive in order to identify possible recurrent pitfalls in this critical field of medicine.

METHODS

Three hundred seventeen Italian claims were analyzed, filling out a standardized form that recorded information on patient and physician's characteristics, procedures, sequence and location of events and outcomes. The operative setting, the type of anesthesia performed the origin of the multidisciplinary team malpractice hypothesis, the final clinical outcome and the malpractice investigation results were also analyzed.

RESULTS

In 225 malpractice claims, the adverse event was surgery-linked, either intraoperatively (114 cases) or postoperatively (111 cases): abdominal surgery (26%), orthopedics (22%), gynecology (20%), heart surgery (11%) and neurosurgery (9.5%) were the most frequently involved surgical specialties. In 92 cases, the claim was unlinked to a surgeon's activity, with dental damage in oral intubation procedures as the greatest contributor (42.3%). Anesthetists' malpractice was technically ascertained in 39% of cases, 74.8% resulting in permanent impairment.

CONCLUSIONS

Malpractice was mainly suspected in surgery-linked procedures. Most of the claims were settled for procedural error in performing locoregional anesthesia and oral intubation procedures. 60% of all closed claims resulted in no malpractice ascertained. Confirmed malpractice typically deals with non surgery-linked and non multidisciplinary team cases, causing permanent impairment.

The injury pattern in fatal suicidal falls from a height: an examination of 307 cases

Falls from a height are a common cause of suicidal death in urban settings. The aim of the present work is to describe and discuss a specific set of 307 autopsies performed in a metropolitan city such as Milan, Italy from 2006 to 2011, with a special focus on the relationship between the injury pattern and height of the fall, age at death and weight at death. The rib cage (92%), the lungs (76%), the heart (53%) and the liver (58%) turned out to be the most injured structures in the whole population. Age resulted statistically significant for heart, thoracic aorta, mesentery, kidney hilus, hip bones and right forearm injuries. Weight resulted statistically significant for subtentorial brain, facial skull, rib cage, lungs and liver injuries. Height was significant for the facial skull (including the jaw), lungs, heart, thoracic aorta, diaphragm, liver, cervical spine, sacroiliac joints, pubic symphysis, right arm and left leg. A simple Injury Extension Score was also calculated which showed a correlation with height. A great variability does exist across all the available forensic literature concerning falls from a height. As a strong common denominator for the injury pattern across all the available literature there is however the very low prevalence of neck injuries, the very high prevalence of rib cage fractures and a definite thorax and upper abdomen injury.

The medical malpractice in Milan-Italy. A retrospective survey on 14 years of judicial autopsies

The medical malpractice is a rising and central topic for the forensic pathologist and forensic autopsies are a mandatory step in the judicial evaluation of the suspected medical malpractice. Reliable national and international registers about the medical malpractice are still missing and nowadays the necroscopic archives are therefore one of the best sources of data about such a complex phenomenon. We analyzed the archive of the Institute of Forensic Medicine of the Milan University from 1996 to 2009 and selected 317 lethal cases of suspected medical malpractice. The mean age of our cases was 60±18 years for males and 58±19 years for the females. In 70% of such cases the patient death occurred in a hospital setting. The first 24h of hospitalization turned out to be the hottest period for deaths followed by malpractice claims. The surgical branches were obviously the most involved, with abdominal surgery, orthopedics, neurosurgery and gynecology as the main contributors. Just 12% of the total amount of cases came from all the internistic branches put together. Non-hospital malpractice was typically caused by misdiagnosed myocardial infarctions and aortic ruptures. A full forensic report was present in 71 cases (all belonging to the 2007-2009 period): in 69% of cases the judicial autopsy revealed as a sufficient tool for diagnosing the cause of death; medical malpractice was confirmed in only 17% of the whole cases and a causal link between the ascertained malpractice and the patient death was recognized in only 12.7% cases.

Single-phase dual-energy CT urography in the evaluation of haematuria

AIM

To assess the value of a single-phase dual-energy computed tomography (DECT) urography protocol with synchronous nephrographic-excretory phase enhancement and to calculate the potential dose reduction by omitting the unenhanced scan.

MATERIALS AND METHODS

Eighty-four patients referred for haematuria underwent CT urography using a protocol that included single-energy unenhanced and dual-energy contrast-enhanced with synchronous nephrographic-excretory phase scans. DECT-based images [virtual unenhanced (VUE), weighted average, and colour-coded iodine overlay] were reconstructed. Opacification degree by contrast media of the upper urinary tract, and image quality of virtual unenhanced images were independently evaluated using a four-point scale. The diagnostic accuracy in detecting urothelial tumours on DECT-based images was determined. The dose of a theoretical dual-phase single-energy protocol was obtained by multiplying the effective dose of the unenhanced single-energy acquisition by two. Radiation dose saving by omitting the unenhanced scan was calculated.

RESULTS

The degree of opacification was scored as optimal or good in 86.9% of cases (k = 0.72); VUE image quality was excellent or good in 83.3% of cases (k = 0.82). Sensitivity, specificity, positive predictive value, and negative predictive value for urothelial tumours detection were 85.7, 98.6, 92.3, and 97.1%. Omission of the unenhanced scan led to a mean dose reduction of 42.7 ± 5%.

CONCLUSION

Single-phase DECT urography with synchronous nephrographic-excretory phase enhancement represents an accurate "all-in-one'' approach with a radiation dose saving up to 45% compared with a standard dual-phase protocol.

Computed tomography coronary angiography in asymptomatic patients

PURPOSE

This study assessed the accuracy of computed tomography coronary angiography (CT-CA) for detecting significant coronary artery disease (CAD; ≥50% lumen reduction) in intermediate/high-risk asymptomatic patients.

MATERIALS AND METHODS

A total of 183 consecutive asymptomatic individuals (92 men; mean age 54±11 years) with more than one major risk factor (obesity, hypertension, diabetes, hypercholesterolaemia, family history, smoking) and an inconclusive or nonfeasible noninvasive stress test result (stress electrocardiography, stress echocardiography, nuclear stress scintigraphy) underwent CT-CA in an outpatient setting. All patients underwent conventional coronary angiography (CAG) within 4 weeks. Data from CT-CA were compared with CAG regarding the presence of significant CAD (≥50% lumen reduction).

RESULTS

Mean calcium score was 177±432, mean heart rate during the CT-CA scan was 58±8 bpm and the prevalence (per-patient) of obstructive CAD was 19%. CT-CA showed single-vessel CAD in 9% of patients, two-vessel CAD in 9% and three-vessel CAD in 0%. Per-patient sensitivity, specificity, positive predictive value and negative predictive value of CT-CA were 100% (90-100), 98% (96-99), 97% (85-99), 100% (97-100), respectively. Positive and negative likelihood ratios were 151 and 0, respectively.

CONCLUSIONS

CT-CA is an excellent noninvasive imaging modality for excluding significant CAD in intermediate/ high-risk asymptomatic patients with inconclusive or nonfeasible noninvasive stress test.

Magnetic resonance cholangio-pancreatography versus endoscopic retrograde cholangio-pancreatography in the diagnosis of common bile duct stones: a prospective comparative study

AIM

As it is a non-invasive method, magnetic resonance cholangiography (MRCP) has almost completely replaced endoscopic retrograde cholangiography (ERCP) in the diagnosis of pancreato-biliary diseases. The aim of this study was to evaluate sensitivity, specificity, diagnostic accuracy, positive predictive value (PPV) and negative predictive value (NPV) of MRCP in diagnosis of choledocholithiasis using ERCP/endoscopic sphincterotomy (ES) as gold standard.

METHODS

For this study 140 individuals, suspected for lithiasis of the common bile duct (CBD), were enrolled. After a clinical and biochemical evaluation, patients underwent upper abdominal ultrasonography, then MRCP and diagnostic and/or operative ERCP.

RESULTS

Only 120 out of 140 patients completed the study. MRCP diagnosed lithiasis of CBD in 84. ERCP confirmed the lithiasis in 73/84 patients who were submitted to ES. Eleven were negative after ES. ERCP documented stones in 10 patients among the 36 negative at MRCP; stones were detected only in four patients after ES. In 26 out of 36 patients negative at MRCP, ERCP confirmed this response: only 12 out of 26 patients underwent ES. The sensitivity, specificity, diagnostic accuracy, PPV and NPV of MRCP were: 88%, 72%, 83%, 87%, 72%.

CONCLUSIONS

As the MRCP diagnostic yield is still limited with small stones, the question of which patient is the best candidate to ERCP/ES is still unsolved.

Neuropathic pain in temporomandibular joint disorders: case-control analysis by MR imaging

BACKGROUND AND PURPOSE

Temporomandibular joint disorders (TMJ-D) may be associated with the onset of neuropathic pain. The purpose of this study was to prospectively assess if, at the open-mouth position, the distance between the temporomandibular joint (TMJ) disk and the mandibular nerve is shorter in patients with TMJ-D and neuropathic pain vs patients with TMJ-D without neuropathic pain or in healthy people.

MATERIALS AND METHODS

After ethical committee approval, we evaluated by MR imaging 16 TMJs with TMJ-D and neuropathic pain, 16 TMJs with TMJ-D without neuropathic pain, and 16 TMJs of healthy volunteers. All of the subjects were informed about the study procedure. We evaluated the distance between the TMJ disk and the mandibular nerve at the oval foramen level. Furthermore, the presence within the TMJs of internal derangement, osteoarthrosis, joint effusion, and bone marrow edema was evaluated.

RESULTS

At the maximal open-mouth position, the distance between the TMJ disk and the mandibular nerve is shorter in patients with TMJ-D and neuropathic pain than in patients with TMJ-D without neuropathic pain or in healthy volunteers (P < .05). The imaging findings of TMJ internal derangement, effusion, osteoarthrosis, and bone marrow edema were present both in patients with TMJ-D without neuropathic pain and in patients with TMJ-D and neuropathic pain.

CONCLUSIONS

We suggest that a closer proximity between the TMJ disk and the mandibular nerve could be one of the causes of the onset of neuropathic pain in patients with TMJ-D and neuropathic pain.

Arteriovenous fistula of the mandible simulating an odontogenic cyst. A case report

SUMMARY

We describe a rare case of mandibular highflow arteriovenous malformation (AVM) mimicking an odontogenic cyst in a young man. The diagnosis of mandibular AVM was made by CT angiography and confirmed by digital subtraction angiography. CT scan showed the extent of mandibular bone alteration and a double enlarged mandibular canal on the same side. An AVM containing a large aneurysm was demonstrated by CT angiography.The mandibular AVM was successfully treated by endovascular therapy with Guglielmi detachable coils. On panoramic radiogram, mandibular AVMs can appear as cystic lesions without pathognomonic features. Several benign and malignant tumours of this anatomical region must be considered in the differential diagnosis.We emphasize the radiological sign of double enlarged mandibular canal and the diagnostic role of CT, particularly CT angiography, to discriminate a mandibular AVM from neoplastic entities of this region, sparing the risks of a needle biopsy.

Seminal vesicle cysts with unilateral renal agenesis and contralateral ureteral stenosis in a beta-thalassemic patient: an unknown association by incomplete development of the mesonephric duct

We report the case of a 13-year-old male patient with beta-thalassemic trait who presented for a colic pain. An ultrasound of the abdomen revealed absence of the right kidney with a complex hypoechogenic pelvic mass causing mild pressure on the posterior bladder wall. Urography showed hypertrophy of the left kidney with moderate ureteral enlargement of the distal third due to an insertion defect in the bladder suggestive of a primary segmental nonobstructing megaureter. MR studies showed right multilocular seminal vesicle cysts. One year later an MR examination of the pelvis showed an increase in size of seminal vesicle cysts and open surgery was performed to remove the cystic retrovesical mass. Our case represents a very rare association of seminal vesicle cysts, unilateral renal agenesis and alteration in contralateral ureteral insertion in a patient with beta-thalassemic trait.

Use of sulesomab in the diagnosis of brucellar spondylitis

Twenty-two patients with suspected brucellar spondylitis were investigated to evaluate the possible diagnostic role of Sulesomab, a (99m)Tc-antigranulocyte antibody Fab' fragment. Sensitivity and specificity were compared with those of magnetic resonance imaging (MRI). Skeletal involvement was detected by MRI in 11 cases, while leukoscintigraphy indicated normal vertebral uptake in seven of these patients, increased uptake in two patients, and decreased uptake in two patients. Leukoscintigraphy of the 11 patients negative by MRI demonstrated increased uptake in two cases. The sensitivity and specificity of leukoscintigraphy were 27.2% and 81.1%, respectively. Based on these results, leukoscintigraphy is not indicated for the management of patients with suspected brucellar spondylitis.

Lithiasic Obstructive Uropathy

OBJECTIVES

The purpose of this study was to evaluate the role of magnetic resonance (MR) pyelography in patients affected by hydronephrosis due to ureteric stones, in order to identify a pyonephrotic condition.

MATERIALS AND METHODS

In the last 3 years, 315 patients, who had originally been investigated by ultrasonography, were evaluated with MR pyelography in order to define the etiology of obstruction. In 67 patients hydronephrosis was referred as caused by lithiasis.

RESULTS

MR pyelography not only confirmed urinary tract dilatation in all patients, but also identified grade and site of obstruction, both in acute dilatation (25 patients) and in chronic obstructions (42 patients). In 7 patients, MR pyelography documented pyonephrosis that was obviously confirmed by nephrostomic drainage.

CONCLUSION

MR pyelography, made with ultrafast breath-hold sequences, has a great value in identifying hydronephrosis in patients with ureteric stones. Furthermore, it provides the chance to identify pyonephrosis requiring an immediate drainage of the kidney before major complications develop.

Hepatic artery aneurysm, an unusual cause of obstructive jaundice: MR cholangiography findings

Hepatic artery aneurysms are rare vascular lesions, often with a nonspecific clinical presentation, and difficult to diagnose before rupture. We report the case of a patient with obstructive jaundice caused by a compression on the right biliary duct by a right hepatic artery aneurysm in which the diagnosis was suggested by magnetic resonance cholangiography and confirmed by Doppler sonography and preoperative digital subtraction angiography.

Calcium alginate gel as encapsulation matrix for coimmobilized enzyme systems

Encapsulation within calcium alginate gel capsules was used to produce a coimmobilized enzyme system. Glucose oxidase (GOD) and catalase (CAT) were chosen as model enzymes. The same values of Vmax and Km app for the GOD encapsulated system and for the GOD-CAT coencapsulated system were calculated. When gel beads and capsules were compared, the same catalyst deactivation sequence for the two enzymes was observed. However, when capsules were employed as immobilization support, GOD efficiencies were higher than for the gel beads. These results were explained in terms of the structure of the capsules.

MR pyelography in the assessment of hydroureteronephrosis: single-shot thick-slab RARE versus multislice HASTE sequences

BACKGROUND

We used magnetic resonance (MR) pyelography to compare the value of thick-slab single-shot rapid acquisition with relaxation enhancement (RARE) sequence with that of multislice half-Fourier acquisition single-shot turbo-spin-echo (HASTE) sequence in evaluating the full spectrum of morphologic features in a group of patients with hydronephrosis.

METHODS

MR pyelographic images, with the use of thick-slab RARE and multislice HASTE sequences in 90 patients, were evaluated for image quality, presence of hydronephrosis, and level and cause of obstruction.

RESULTS

HASTE sequences provided images of better quality than did RARE sequences (p < 0.001). There was no statistically significant difference in demonstrating the presence of hydronephrosis (p = 0.5) and level of obstruction (p = 0.125). Sensitivity, specificity, and accuracy in diagnosing cause of obstruction were 61.7%, 62.5%, and 62%, respectively, for RARE sequences and 80%, 82.5%, and 81%, respectively, for HASTE sequences, with a statistically significant difference (all p < 0.05).

CONCLUSION

Multislice HASTE sequence provides better diagnostic information than does thick-slab RARE sequence, particularly in evaluating the cause of obstruction.

Contrast-enhanced MR imaging with fat suppression in adult-onset septic spondylodiscitis

Spinal infections typically involve vertebrae as well as discs, and for this reason they are called septic spondylodiscitis. Magnetic resonance imaging is the most sensitive imaging method for the evaluation of this group of spinal diseases. The use of contrast-enhanced T1-weighted sequences with fat suppression, if correctly applied, may increase information provided by MRI. Firstly, this technique allows the primary vertebral focus, which often precedes disc involvement, to be identified at a very early stage. When the disease spreads, T1-weighted fat-suppressed gadolinium dimeglumine (Gd-DTPA) enhanced images provide macroscopic details of the primary vertebral focus, disc involvement patterns, and pathways of infection diffusion. All this information, when correlated with laboratory tests, may be useful in identifying the infectious agents (tuberculous vs piogenic forms), thus enabling a suitable therapy to be started. This technique is also useful in the assessment of the real extension of the disease, providing a clear depiction of paravertebral space involvement and of psoas muscle abscesses. Dangerous complications, such as meningitis, myelitis, and epidural abscesses, may be more promptly diagnosed and fully evaluated with fat-suppressed post-contrast T1-weighted images. Finally, this imaging technique may help to differentiate infectious processes from degenerative disorders, extradural neoplastic processes, and rheumatic diseases.

Cerebral angiography in the rat with mammographic equipment: a simple, cost-effective method for assessing vasospasm in experimental subarachnoid haemorrhage

We report quantification of vasospasm following subarachnoid haemorrhage (SAH) and the effect of a new antivasospastic free radical scavenger (AVS) in rats, using an angiographic technique developed in our laboratory. We acquired single-exposure angiograms with mammographic equipment, using a 0.1 mm diameter focal spot and single-emulsion mammographic films. Contrast medium was injected through a PE50 catheter in the common carotid artery, after the external carotid artery had been ligated to divert flow towards the internal carotid artery territory. Measurements of the M1 and A1 segments and of the middle third of the basilar artery were made by projecting the angiograms directly as slides and using the endovascular catheter as an internal reference. We tested the technique on 40 male albino Sprague-Dawley rats divided into four groups: sham-operated+saline, SAH+saline, sham-operated+AVS and SAH+AVS. We were able to measure the diameter of the principal intracranial arteries in all the animals. With our technique, which is cost-effective when compared to many of those reported recently, we could detect intracranial vasospasm in all untreated rats with SAH, and confirm antivasospastic effects of AVS.

Polygalacturonase production by Aspergillus awamori on wheat in solid-state fermentation

The production of exo-polygalacturonase (exo-PG) and endo-PG by Aspergillus awamori grown on wheat in solid-state fermentation was studied. Endo- and exo-PG activities were detected after 24 h of inoculation. Glucose released from starch hydrolysis acted as a catabolite repressor for the exo-PG enzyme. In contrast, endo-PG production was not affected by glucose repression. When milled grains were used, the particle-size distribution and the chemical composition of the medium influenced the rate of micro-organism growth and therefore the trend followed by endo- and exo-PG production. However, these two parameters did not affect the maximum production of exo-PG and endo-PG. For one of the milled samples, three different moisture contents were used (50, 55, 60%). Moisture contents of 60% provide a higher yield of pectinases by A. awamori.

Twisted ovarian fibroma with high signal intensity on T1-weighted MR image: a new sign of torsion of ovarian tumors?

Torsion of ovarian tumors is often difficult to diagnose, because of non-specific clinical, laboratory, and imaging findings. We report a case of twisted ovarian fibroma whose main characteristic was the presence of large areas of high signal intensity on both T1- and T2-weighted MR images due to the passive congestion of the mass. This previously unreported finding should be considered a sign of ovarian torsion and may facilitate prompt surgical intervention.

Ossifying lipoma of the parapharyngeal space: CT and MRI findings

Ossifying lipomas independent of bone tissue are very rare. A literature review revealed that only few cases of ossifying lipoma independent of bone tissue have been reported. None of the cases have been reported in the international radiology literature. In addition, there are no reports concerning the MRI features of this entity. We describe CT and MRI findings in a case of ossifying lipoma of the parapharyngeal space.

MR white lung sign: incidence and significance in pulmonary consolidations

PURPOSE

The presence of a pulmonary consolidation with a signal intensity comparable with that of the static fluid on heavily T2-weighted MR images has been named the "MR white lung sign." This sign has been described in mucinous bronchioloalveolar carcinoma (BAC). Our purpose was to establish the frequency and significance of this sign in pulmonary consolidations of varied causes.

METHOD

In this prospective study, 83 patients with pulmonary consolidation underwent MR examination between January and December 1999. Segmental or lobar consolidations were due to pneumonia without central obstruction (n = 22), pneumonitis with central obstruction (n = 21), cicatricial atelectasis (n = 8), passive atelectasis (n = 10), radiation pneumonitis (n = 8), mucinous BAC (n = 5), infarction (n = 3), bronchiolitis obliterans organizing pneumonia (n = 3), nonmucinous BAC (n = 2), and lymphoma (n = 1). The MR white lung sign was considered present when the signal intensity of a pulmonary consolidation was comparable with that of the static fluid on heavily T2-weighted images obtained with MR hydrography sequences. Interobserver agreement, sensitivity, and specificity of the white lung sign in diagnosing mucinous BAC were calculated.

RESULTS

The MR white lung sign was present in 7 (8%) of 83 consolidations, including 5 (100%) of 5 cases of mucinous BAC and 2 (10%) of 21 cases of obstructive pneumonitis. The frequency of the white lung sign was 100% in mucinous BAC and 2.6% in consolidations due to other causes. The difference was statistically significant (p < 0.05).

CONCLUSION

The white lung sign is an uncommon finding in pulmonary consolidations evaluated with heavily T2-weighted sequences. However, the sign is characteristic of mucinous BAC and adds specificity to the radiologic diagnosis.

Perineural spread in a case of sinonasal sarcoidosis: case report

We report a case of sinonasal sarcoidosis with perineural spread along the trigeminal and vidian nerves in which primarily MR imaging but also CT allowed excellent visualization of this infiltration.