Child Sexual Abuse: Comparison of Male and Female Victims

ABSTRACT

In the scientific literature, few authors deal with child sexual abuse (CSA) in boys. In addition, these authors debate this phenomenon in most available articles without statistically evaluating the occurrence of different or similar distributions of variables under sex. In light of the above, the authors compared multiple variables between female and male samples. The aim was to explore the characteristics of boys' CSA, identifying the main differences existing compared with the same phenomenon occurring in girls. The authors selected 2 samples for sex: group A, females; group B, males. The authors statistically compared the main variables between the 2 groups. The study yielded the following main results: the population was characterized by 607 children (476 were females-group A; 131 were males-group B); the variables' source of the referral and the type of anogenital findings were statistically significant. These data gave new insights into the CSA phenomenon. Because this study pointed out that sexual abuse does not have the same characteristics in boys and girls, researchers and safeguarding agencies should consider the abovementioned differences when planning preventive strategies against CSA.

Knowledge of child abuse and neglect in nursing students: Assessment and perspectives

Misdiagnosis of child abuse and neglect can delay early treatment. Some authors have pointed out that nurses can miss child abuse and neglect diagnoses due to a lack of knowledge. It is unclear whether the lack of knowledge is due to students' insufficient preparation in nursing school and/or a deficiency in continuing education. An 18-item questionnaire was administered to final-year nursing students to assess their degree of knowledge on child abuse and neglect and to evaluate if the lack of knowledge was due to insufficient teaching/training during nursing school. The students were also asked to evaluate themselves by assigning a score to their knowledge. A statistical comparison was performed to define whether sufficient/insufficient results were associated with the following variables: sex, pediatric or general nursing student, attending pediatric lectures, training in pediatric wards/ambulatories, and attending specific lectures on child abuse and neglect. The study population comprised 175 students (154 females, 20 males, 1 unknown). Exactly 66.3% of the participants had ≤9/18 correct answers. Of all students, 77.7% self-evaluated their level of knowledge as ≤5/10. The comparisons yielded statistically significant differences between the groups with sufficient objective knowledge and those unrelated to training in pediatric wards/ambulatories or pediatric nursing students. Overall, there was little objective knowledge on the subject, which may be related to insufficient teaching/training in nursing schools. Useful corrective strategies include further teaching on child abuse and neglect, preferably using a practical approach. Further, common teaching/training programs should be conducted by both pediatric and general nursing schools.

Artificial Intelligence and Child Abuse and Neglect: A Systematic Review

All societies should carefully address the child abuse and neglect phenomenon due to its acute and chronic sequelae. Even if artificial intelligence (AI) implementation in this field could be helpful, the state of the art of this implementation is not known. No studies have comprehensively reviewed the types of AI models that have been developed/validated. Furthermore, no indications about the risk of bias in these studies are available. For these reasons, the authors conducted a systematic review of the PubMed database to answer the following questions: "what is the state of the art about the development and/or validation of AI predictive models useful to contrast child abuse and neglect phenomenon?"; "which is the risk of bias of the included articles?". The inclusion criteria were: articles written in English and dated from January 1985 to 31 March 2023; publications that used a medical and/or protective service dataset to develop and/or validate AI prediction models. The reviewers screened 413 articles. Among them, seven papers were included. Their analysis showed that: the types of input data were heterogeneous; artificial neural networks, convolutional neural networks, and natural language processing were used; the datasets had a median size of 2600 cases; the risk of bias was high for all studies. The results of the review pointed out that the implementation of AI in the child abuse and neglect field lagged compared to other medical fields. Furthermore, the evaluation of the risk of bias suggested that future studies should provide an appropriate choice of sample size, validation, and management of overfitting, optimism, and missing data.

Traumatic hemorrhage of the thyroid as a work-related injury: a case report and review of the literature

Traumatic hemorrhage of the thyroid gland resulting from blunt injury to the neck is a very rare event. Particular neck positions can expose the thyroid to trauma, especially in motor vehicle collisions, falls, direct blows, or sport activities. Preexisting conditions such as goiters, adenomas, and cysts can increase the risk of bleeding, reducing the force required to rupture the gland and make the thyroid more prone to injury. The authors report the case of a 53-year-old man who was involved in a fire while working on maintenance of a liquid petroleum gas (LPG)-powered car. He subsequently presented to the emergency department with painful swelling of his right anterior neck with a palpable mass. CT scan showed a right thyroid hemorrhagic cyst. The worker reported that he had jumped into the car trunk to extinguish the fire and covered the gas tank nozzle with his own body to prevent dispersal of the accelerant. In this case, the medico-legal evaluation was useful to delineate between natural and traumatic causes of the injury. Medico-legal assessment is key in understanding the dynamics involved in work-related events to identify any legal responsibilities of the worker or the employer.

The panoramic radiograph archive of the human craniological collection housed at the Human Anatomy Museum in Turin

The craniological collection at the Human Anatomy Museum of the University of Turin consists of 1090 skulls and 64 postcranial skeletons prepared mostly during the second half of the nineteenth century. The collection presents individuals of both sexes and of different age groups and includes 712 skulls of known age and sex and 378 of which only the sex is known. Most individuals are associated with a documentation that includes sex, age-at-death, dates of birth and a death certificate. The collection comes from several regions of Italy, between 1880 and 1915, received by the former Anatomical Institute of the University of Turin from city's prisons and hospitals. The whole craniological collection of known age was subjected to panoramic radiographs. The craniological collection combined with the panoramic digital X-ray images represents an important contribution in anthropology and forensic odontology, as there is now no craniological collection available in the world available from a radiological perspective, for investigating dental age assessment and sex dimorphism using radiographs as well as other research and teaching potentials.

The Doppelgänger phenomenon and death: a peculiar case of homicide by a subject with first-episode psychosis

The Doppelgänger phenomenon refers to the experience of a direct encounter with one's self, characteriswed by: (i) the perception of a figure with one's own identical physical features; or (ii) the apprehension that the perceived figure shares the same personality and identity. The Doppelgänger does not only look like the same person, it is his/her double. The perceptual element is usually a hallucination, although occasionally a false perception of an actual figure may be involved. This phenomenon has been described in individuals suffering from overwhelming fear, severe anxiety or intoxication, epilepsy, as well as in the sleep-wakefulness transition. It has also been reported in major psychoses. The fear of imminent death often precedes the Doppelgänger experience. This report presents the case of a 30-year-old man, Mr. Y, who was stabbed to death by Mr. X, his "double". The aggressor and his victim, although not related, were truly doubles; remarkably, they shared the same name and surname, age, professional activity and place of work. Moreover, they attended the same sports center but barely knew each other. The forensic psychiatric evaluations in Mr. X, subsequent to the crime committed, were suggestive of a psychotic condition. This case is unique in the scientific literature. In the most serious psychotic forms, the issue of the "double" calls into question not only the dissociative processes involved in the etiopathogenesis of the disorder, but also bio-psycho-social elements, as well as personal data in this case, which made the victim and the aggressor "identical". In the context of psychopathological functioning, the delusional mood (Wahnstimmung) that precedes the development of delirium is a sort of gateway to an impending psychotic illness, involving delusional awareness or mood (atmosphere). In psychosis, splitting is the main issue and this influence is seen as an evil, foreign, apocalyptic and unknown side no longer recognised as belonging to the self even in a physical sense. In such a situation, it is felt that the only way to survive is by suppressing one's double as a defense against disorganisation of the self.

Unexpected stillbirth from umbilical cord hematoma

Background

Umbilical cord hematomas (UCHs) can cause life-threatening outcomes, although extremely uncommon. They can lead to fetal distress and stillbirth. They have been observed in about 1:5500 pregnancies; they are associated with poor outcome in about the 50% of all cases. UCHs commonly occur due to rupture/lesion of umbilical vein's walls, or less frequently of umbilical arteries' ones.

Case Report

We present a case of a fetal demise which acutely and unexpectedly occurred in the last phases of labor. In this fetus, the identification of the cause of death was made only after post-mortem examination. The present report depicts the uncommon eventuality of umbilical cord hematomas which can cause unexpected fetal demise.

Conclusion

This case points out that in these cases careful examination of umbilical cord's macroscopic/microscopic examination is fundamental to clarify the natural cause of fetal death for statistical purposes; to close parents' mourning process; to ascertain medical malpractice claims.

An Unexpected Death Due to a Subclinical Pheochromocytoma After an Induced Abortion

ABSTRACT

Deaths due to hypertensive crisis can be unexplained because of the impossibility to identify-before the decease-the specific cause of the crisis. In these cases, autopsy and microscopic examinations are needed. It can happen that the request to conduct these examinations can be submitted to forensic pathologists by prosecutors to ascertain medical malpractice claims. Indeed, we report the case of a 36-year-old woman who died after a minimally invasive medical procedure because of the occurrence of a severe hypertensive crisis. After death, the woman's relatives raised formal complaint for medical malpractice. For this reason, the prosecutor ordered to perform an autopsy. Examining the abdominal cavity, the forensic pathologists identified the left adrenal gland as expanded; in correspondence with organ's medulla, there was a gray and noncapsulated mass. Immunohistochemistry was performed: the microscopic samples were diffusely positive for chromogranin A, suggesting the diagnosis of a subclinical pheochromocytoma. In light of the above, medical malpractice was excluded. This case highlights that forensic pathologists should be aware that, in case of unexpected deaths due to hypertensive crisis, adrenal glands should be always accurately evaluated, performing specific immunohistochemistry study to exclude the presence of a pheochromocytoma.

Stillbirth diagnosis and classification: comparison of ReCoDe and ICD-PM systems

OBJECTIVES

The identification of causes of stillbirth (SB) can be a challenge due to several different classification systems of SB causes. In the scientific literature there is a continuous emergence of SB classification systems, not allowing uniform data collection and comparisons between populations from different geographical areas. For these reasons, this study compared two of the most used SB classifications, aiming to identify which of them should be preferable.

METHODS

A total of 191 SBs were retrospectively classified by a panel composed by three experienced-physicians throughout the ReCoDe and ICD-PM systems to evaluate which classification minimizes unclassified/unspecified cases. In addition, intra and inter-rater agreements were calculated.

RESULTS

ReCoDe defined: the 23.6% of cases as unexplained, placental insufficiency in the 14.1%, lethal congenital anomalies in the 12%, infection in the 9.4%, abruptio in the 7.3%, and chorioamnionitis in the 7.3%. ICD-PM defined: the 20.9% of cases as unspecified, antepartum hypoxia in the 44%, congenital malformations, deformations, and chromosomal abnormalities in the 11.5%, and infection in the 11.5%. For ReCoDe, inter-rater was agreement of 0.58; intra-rater agreements were 0.78 and 0.79. For ICD-PM, inter-rater agreement was 0.54; intra-rater agreements were of 0.76 and 0.71.

CONCLUSIONS

There is no significant difference between ReCoDe and ICD-PM classifications in minimizing unexplained/unspecified cases. Inter and intra-rater agreements were largely suboptimal for both ReCoDe and ICD-PM due to their lack of specific guidelines which can facilitate the interpretation. Thus, the authors suggest correctives strategies: the implementation of specific guidelines and illustrative case reports to easily solve interpretation issues.

Child abuse and neglect: Are future medical doctors prepared?

Diagnosis of child abuse and neglect is a challenging matter: in case of misdiagnosis, the child cannot benefit from an early treatment; erroneous interpretation may generate legal issues. Some studies reported physicians' lack of knowledge in child abuse and neglect. However, it is not clear if the reasons of this lack relay on an insufficient preparation of students during medical school and/or a deficiency in continuing medical education during/after fellowships. For these reasons, the authors of the present manuscript administered a questionnaire to last year medical students to: evaluate the degree of knowledge on this thematic in a medical student sample; understand if the abovementioned lack may be due to insufficient preparation of students during medical school. Study population included 179 students. The 77.7% demonstrated a low knowledge of this thematic, but they showed a high insight of their lack. The authors pointed out that medical school education can represent a weak point in future medical doctor knowledge on child abuse and neglect. It also allowed to identify as study sample's medical students had high awareness of their lacks in this field. In addition, comparison of medical schools from different geographical areas suggested common issues independent of which accreditation system is implemented. Thus - independent of which corrective strategy will be planned - the study highlighted necessity for each medical school to define: its current ability to properly train students in child abuse and neglect; students' awareness of their level of expertise. This can help schools to identify the most suitable correctives.

Risk Assessment and Management for Potential Living Kidney Donors: The Role of “Third-Party” Commission

Living kidney donation is the most common type of living-donor transplant. Italian guidelines allow the living donations from emotionally related donors only after clear and voluntary consent expressed by both the donor and the recipient involved. Living donation raises ethical and legal issues because donors voluntarily undergo a surgical procedure to remove a healthy kidney in order to help another person. According to the Italian standards, the assessment of living donor-recipient pair has to be conducted by a medical “third party”, completely independent from both the patients involved and the medical team treating the recipient. Starting from the Hospital “Città della Salute e della Scienza” of Turin (Italy) experience, including 116 living kidney donations, the Authors divided the evaluation process performed by the “Third-Party” Commission into four stages, with a particular attention to the potential donor. Living donation procedures should reflect fiduciary duties that healthcare providers have toward their patients, originating from the relationship of trust between physician and patient. In addition to that, the social implications are enormous if one considers the worldwide campaigns to promote public awareness about organ donation and transplantation, and to encourage people to register their organ donation decisions. The systematic process proposed here can be a tool that proactively reduces and controls the risks of coercion, organ trafficking, vitiated consent, insufficient weighting of donative choice, that could arise especially in donors involved in living kidney donation.

Survey on postmortem screening and management of COVID-19 related deaths

The COVID-19 pandemic is associated with a high case fatality rate in some countries even thought the majority of cases are asymptomatic. Scientific studies on this novel virus is limited and there is uncertainty regarding the best practices for death investigations both in terms of detection of the disease as well as autopsy safety. An online survey was conducted to identify how different institutions responded to the screening and management of dead bodies during the early phase of the pandemic from January to May. A questionnaire was developed using Google Forms and data was collected from 14 different forensic and pathological institutions in 9 countries. None of the institutions had performed any screening prior to March. Four institutions stated that screening was done routinely. In total, 322 cases had been screened using RT-PCR, out of which 40 positive cases were detected among four institutions. The commonest types of samples obtained were nasopharyngeal and oropharyngeal swabs which also had the highest rates of positivity followed by tracheal swab. Blood, swabs from cut surfaces of lung and lung tissue also gave positive results in some cases. Majority of the positive cases were > 65 years with a history suggestive of respiratory infection and were clinically suspected to have COVID-19 before death. Except for one institution which performed limited dissections, standard autopsies were conducted on all positive cases. Disposal of bodies involved the use of sealed body bags and labelling as COVID positive. Funeral rites were restricted and none of the institutions advocated cremation. There were no reports of disease transmission to those who handled COVID positive bodies.

Differences Between Readmitted and Non-readmitted Women in an Italian Forensic Unit: A Retrospective Study

The main objective of this study was to compare readmitted (RW) and non-readmitted (NRW) female psychiatric patients after being conditionally or unconditionally released from Italian inpatient forensic psychiatry services, in order to identify variables that were significantly linked with readmission. This study included all patients who were discharged from the female Residences for the Execution of the Security Measure (REMS) of Castiglione delle Stiviere from January 2008 to June 2015 who were not readmitted until December 31, 2018 (48). In addition, data were collected on female patients who were discharged from the same REMS before 2008 and readmitted from January 2008 to December 2018 (42). A key finding of our study was that the readmission into a female REMS was positively associated with the presence of substance use disorders (SUD) and a primary diagnosis on Axis II. To a lesser extent, younger age, being unconditionally discharged when first released, having had a shorter length of inpatient stay and having committed a crime against property for the first REMS admission was also variables that were apparently linked with readmission. The present research continues the previous research on gender-specific mentally ill offenders. Hence, the decision to proceed separately with a sample of men only and one of women only. For all these reasons, young female patients with personality disorder and SUD perhaps should remain longer in REMS and be released with conditions. In most European countries, the length of stay depends on the clinical condition and risk assessment, with some exceptions where the courts set a maximum length of stay at the outset, as in Italy. All the factors listed above influence the risk assessment. Finally, from integrating these findings into the increasing international literature on conditional release and considering the recent changes in the Italian forensic treatment model, we recommend continuing research on individual risk and protective factors as well as risk assessment instruments on conditionally and unconditionally released inpatients with genders studied separately.

Micro-CT processing's effects on microscopic appearance of human fetal cardiac samples

Higher resolution than common computed tomography has been reached through Micro-Computed Tomography (micro-CT) on small samples. Emerging forensic applications of micro-CT are the study of fetal/infant organs and whole fetuses, and their two/three-dimension reconstruction; it allows: to facilitate pathologists' role in the identification of causes of fetal stillbirth and of infant death; to create digital two and/or three-dimension representations of fetal/infant organs and whole fetuses which can be easily discussed in civil and/or penal courts. Micro-CT reconstructs cardiac anatomy of animal and human sample. There are no studies that are specifically aimed to evaluate possible effects of micro-CT processing on cardiac microscopic evaluation. This study analyzed microscopic effects of micro-CT processing on human-fetal-hearts. After processing with Lugol-solution or Microfil-MV-122-injection in coronary branches, fetal hearts underwent micro-CT scan. Then, hearts were microscopically analyzed using hematoxylin/eosin, trichrome, immunohistochemistry (IHC) for actin-protein, and IHC for desmin-intermediate-filament stains. In all cases staining was present in all fields. In all slides, disarranged myocardial proteins with increase of inter filaments and inter cellular spaces was reported. This manuscript allowed to observe post micro-CT appropriate staining and antigenic reactivity, and to identify cytoarchitecture modifications that could compromise slides' microscopic evaluation. It also highlighted a possible role of micro-CT determining this cytoarchitecture phenomenon.

Immunohistochemistry patterns of SARS-CoV-2 deaths in forensic autopsies

SARS-CoV-2 infection was a leading cause of death in 2020 worldwide. It can evolve determining sudden dyspnea and death without hospitalization and/or a nasopharyngeal swab. These cases can need the intervention of forensic pathologists in order to identify causes of death and to clarify malpractice claims. For these reasons, it would be useful to identify immunohistochemistry patterns of SARS-CoV-2 deaths. Thus, the authors described immunohistochemistry findings of two Patients: perivascular recruitment of T-cells in lung parenchyma, massive activation of cytotoxic cells (especially in spleen's parenchyma), and diffuse platelet aggregation in medium/small vessels. In addition, they analyzed these data in the light of the scientific literature, pointing out meaningful immunohistochemistry patterns in order to better understand SARS-CoV-2 pathophysiology process and to clearly identify causes/contributing factors of death in forensic routine.

Infantile Hypertrophic Cardiomyopathy and Bronchopneumonia as Causes of an Unexpected Death in an 11-Month-Old Child

Background: Hypertrophic cardiomyopathy is characterized by intrinsic myocardial hypertrophy that is not consequent to hemodynamic stimuli. Infantile hypertrophic cardiomyopathy (<1 year of age) has a frequency of about 3.6 per 1 million children, is usually diagnosed in utero, at birth, or in the first months of life. The most common outcome of this form is heart failure that may result in the death of the child. Case Report: We present an 11-month old infant with hypertrophic cardiomyopathy, complicated by terminal bronchopneumonia, without the typical clinical signs/symptoms in which the diagnosis was made only after postmortem examination. Conclusion: The present report depicts that IHCM may present with the unexpected death of an infant.

The mourning process and "living with the dead": Two case reports and a review of the literature

The discovery of mummified bodies in domestic settings is not unusual in the medico-legal context. It is often a marker of social isolation, even in our urban modern society, and usually occurs among elderly people living alone or in precarious conditions. However, bereaved subjects can sometimes be found managing their grief by deliberately keeping the corpses of their loved ones at home. Investigation of these atypical cases can be challenging and often requires a multidisciplinary effort by different forensic specialists. We report two cases of people who lived for several months with the mummified remains of a relative. In both cases, the judge ordered a forensic psychiatry assessment of the survivors' competency and the reasons for this peculiar behavior, which is regarded as abnormal in our society. Case 1 describes a shared psychosis, which developed out of a condition of extreme seclusion of the entire family. Case 2 shows that even a mild personality disorder on which a series of traumatic events operates can trigger psychotic decompensation, causing extreme denial of the reality of death. The analysis of these cases contributes to our knowledge of the scantly studied phenomenon of "Living with the Dead" and raises questions about the psychopathology behind it. It is useful to identify subjects who are more prone to developing this "deviant" behavior, in order to distinguish people with mental illness from those who merely want to profit from the death of a loved one.

Death Shortly after Delivery Caused by Congenital High Airway Obstruction Syndrome

Background: Congenital High Airway Obstruction Syndrome (CHAOS) is an uncommon anomaly. Prenatal ultrasonography allows a prenatal diagnosis to prepare for immediate surgical correction at birth. If the obstruction is severe and a correct therapeutic approach is not planned, CHAOS can cause neonatal death shortly after delivery from a potentially surgically correctable lesion.Case report: This neonate died unexpectedly shortly after delivery due to CHAOS. Ultrasonographic findings of enlarged echogenic lungs, dilated airways distal to the obstruction, flattened or inverted diaphragms, or ascites were absent. This was due to a type-II laryngeal-atresia and a type-C esophageal-atresia, with a resultant distal fistula that allowed intrauterine decompression of the fluid in the lungs.Conclusions: The absence of prenatal ultrasonographic findings of CHAOS may be due to a lower fistula between respiratory and gastrointestinal tracts. This set of associations may not be a surgically correctable cause of CHAOS.

Forensic and Clinical Issues in a Case of Motorcycle Blunt Trauma and Bilateral Carotid Artery Dissection

Internal carotid artery dissection (ICAD) after motorcycle accidents is unusual but life threatening if not promptly diagnosed and treated. We report the case of a motorcyclist involved in a frontal collision with a car, suffering injuries due to direct blunt trauma and indirect trauma by sudden deceleration force. Bilateral ICAD was diagnosed by computed tomography angiogram 5 days after the accident. Here in, starting from a medicolegal case, we emphasized some clinical criteria to make a prompt diagnosis to prevent permanent neurological deficit in this pathology whose best management is still under the debate. An unusual case of ICAD is described with regard to both forensic and promptly diagnostic therapeutic management.

Two autopsy cases of siblings with alveolar capillary dysplasia: clinical and post-mortem issues

Alveolar capillary dysplasia with misalignment of pulmonary veins (ACD/MPV) is a rare but fatal lung disorder, which causes persistent pulmonary hypertension of the newborn (PPHN) and which is unresponsive to treatment. We report the case of two siblings, both of whom died a few hours after birth because of severe pulmonary failure. Post-mortem histology confirmed ACD/MPV as the cause of death in both cases, and genetic analysis identified the same 16p13.3 deletion. ACD/MPV can occur suddenly in apparently healthy newborns after a regular pregnancy, and always leads to death. Nevertheless, an autopsy is not always performed after the death of an infant. For these reasons ACD/MPV represents a challenge for diagnosis and therapeutic management with medicolegal implications. Prenatal assessment of ACD/MPV is very difficult, and it should be suspected when irreversible and persistent fetal circulation occurs rapidly in newborns. An early diagnosis during pregnancy would facilitate adequate counselling regarding treatment and prognosis. When death occurs, a complete autopsy with histological and genetic investigations is recommended in order to define the exact cause of death, and potentially inform appropriate genetic counselling of family members who could be affected by hereditary disorders.

Differential diagnosis between physical maltreatment and cupping practices in a suspected child abuse case

Physical maltreatment is one of the most common forms of child abuse. Cutaneous injuries often raise the suspicion of child maltreatment. Nevertheless, among health professionals there is still uncertainty in the evaluation of such injuries. In the literature, there are few indications about the most important factors that allow the differentiation of physical abuse findings from signs/lesions that are caused by "folk medicine practices" with similar presentations. We report the case of two brothers who were brought to the Emergency Department of a pediatric hospital by their father because each of them showed one painful, circular and red-purple bruise on their back. Suspecting child abuse, the emergency physicians reported the case to a multidisciplinary unit (dedicated to child abuse). After a careful physical examination, psychological interviews, as well as the evaluation of their medical history, the operators pointed out that the lesions were the result of cupping practices (a form of folk medicine). This case highlights the need for a multidisciplinary approach and demonstrates the importance of a careful evaluation of the cultural background of the family.

The risk of assault against mental health professionals: a fatal case report and literature review

Assaults by patients against healthcare providers are an increasing phenomenon worldwide. Mental health professionals in acute facilities and rehabilitation wards have the highest risk of being attacked at work. Verbal abuse or intimidating behaviors represent the most common types of violence. Fatal assault by psychiatric patients has been rarely reported in the literature. We present a case of a female psychiatrist who was fatally stabbed in her office in a Mental Health Center. At autopsy seventy stab wounds were found: four wounds of the neck, fifty penetrating wounds of the thorax, three wounds of the abdomen, six wounds of the lumbar region, and seven wounds of the upper arms including defense injuries. The cause of death was massive blood loss due to multiple stab wounds. The perpetrator was a 44-year-old male patient who had been referred to the victim after a previous admission to hospital following experiences of suicidal ideation and confusion. The extreme and unmotivated violence in a non-acute setting were notable. A borderline-antisocial personality disorder was later diagnosed by forensic experts. This case emphasizes the significant occupational risk for mental healthcare staff to sustain life threatening injuries or death, with implications for training of clinicians, and strategies for preventing aggressive behaviors.

Juvenile Facial Growth and Mimicry: A Preliminary 3D Study

Studies focused on facial development during childhood have been conducted by means of 3D technology to provide modifications of anthropometric parameters. Facial mobility was also considered. This study proposed a 3D approach to facial growth changes. Facial surface data of 6 subjects were acquired in T1 (age 7-14 years) and after 7 years (T2), in rest position, and during voluntary movements, by a 3D laser scanner. Linear and angular measurements on rest position scans at T1 and T2 were compared. Each mimic scan was superimposed with the corresponding rest scan. Displacement of significant anthropometric points was measured for each facial gesture and at T1 and T2 statistically compared. Vertical measurements were those most influenced by aging. Some measurements of central facial area were consistent over time. The pattern of soft tissues displacement for each expression was consistent in T1 and T2. These results may be helpful for missing children identification.

Child Sexual Abuse Perpetrated by Women: Case Series and Review of the Literature

The literature on child sexual abuse (CSA) perpetrated by female sexual offenders (FSOs) is exiguous, and many studies have focused on judicial databases. The present retrospective study, instead, analyzed clinical and judicial data of a group of both victims and alleged FSOs, to additionally include women who have not been convicted by the criminal justice system, but who hold strong clinical suspicions of being perpetrators of CSA. The medical records and the Court files of 11 children and their eight suspected FSOs have been collected and critically reviewed in light of the literature to date. This approach allowed for a deeper understanding of the relationship between child and FSO. The authors hypothesize that the victims' severe psychopathological outcomes were a result of a failure to develop appropriate attachments with their prospective caregivers, which could have been damaged by the pathological relationship with FSOs, who were the victims' caregivers.

Diagnostic Criteria for Commotio Cordis Caused by Violent Attack: Review of the Literature

The diagnosis of lethal commotio cordis (CC) is really complex. The forensic pathologist's task is even more relevant when he/she has to explain a CC diagnosis caused by an assault in a trial. The purpose of this study was to analyze the literature on lethal CC as a result of violent attacks and identify relevant parameters that may help in the diagnosis. A review of the relevant articles was performed. Fifty-two cases of CC caused by violent attacks were identified. The collected data allowed to confirm the following literature's criteria for CC diagnosis in case of assaults: witnessed occurrence of a blunt, nonpenetrating blow to the chest preceding cardiovascular collapse; absence of structural damage to the sternum, ribs, or heart itself; and absence of any underlying cardiovascular abnormalities (such as other causes of sudden death). Regarding the assessment of the third criterion, the authors suggest that the pathologist should always specify the scientific autopsy guidelines that he/she used to differentiate CC from the other causes of sudden death. In addition, the authors highlight the importance of a multidisciplinary approach for a correct interpretation of clinical, autopsy, and laboratory findings.

Self-harm Risk Among Adolescents and the Phenomenon of the "Blue Whale Challenge": Case Series and Review of the Literature

The "Blue Whale Challenge" is a dangerous Internet phenomenon. As per media reports, it involves a series of life-threatening tasks imposed by a "curator" to "players," who must fulfill the whole list, and it ends with the suicide of the player. The authors report the data of five suspected cases of "Blue Whales" managed from January 2016 to December 2017 by the staff of a unit (the "Bambi Unit" of the Pediatric Hospital "Regina Margherita" of Turin, Italy) that is dedicated to the evaluation of suspected abused children. Then, they analyzed this data in the light of the literature regarding self-harm. This comparison highlights the role of the Internet in the spreading of self-harm behavior among vulnerable adolescents who are characterized by epidemiological, psychological, psychiatric, social, and cultural risk factors. In conclusion, the authors suggest a multidisciplinary and specialized approach in the evaluation of adolescents who committed self-harm activities.

Staged crime scene determination by handling physical and digital evidence: Reports and review of the literature

Geberth in 2006 stated that "staging is a conscious criminal action on the part of an offender to thwart an investigation." In the present paper two crime scenes staged by handling digital evidence are reported. The first case involves a 50-year-old woman who had been living with the offender for three years before he murdered her at the end of their relationship. He staged the scene as a sex-related crime committed by an unknown perpetrator. The second case concerns a young woman who was found dead in Southern Italy in January 2004 with a gunshot on the forehead. The boyfriend, responsible for the murder, had staged the crime scene as a suicide. Three years earlier in Germany, he had also murdered the victim's mother. In both cases, the correlation of physical and digital forensic evidence was crucial in the definition of the manner of death.

Selfie identification app as a forensic tool for missing and unidentified persons

Social media applications can be valuable investigative tools in the search for missing and unidentified persons. As yet, no forensic App exists with the aim of assisting the human identification process, through the search of antemortem data to be used as adjunct data in the comparison with postmortem data collected. The aim of this article is to introduce a new application for Smartphones called “Selfie Forensic ID” App which will employ selfie and face photographs as an archive of dental data and dental features of the front teeth of missing persons sharing with Instagram, Tumblr, and Twitter Social Networks (available for free download from both Android and Apple store at http://onelink.to/selfieforensic). Features such as diastema rotated or wrongly positioned teeth, lip anomalies, recognizable fixed prosthetics, dental crown discolorations, dental or cutis piercing could represent strong identifiers in the comparison of AM and PM data. The increased number of terrorist attacks and natural disasters which result in the premature death of innocent people underlines the importance of storing personal identification data to avoid bodies remaining unidentified. The authors believe there will be an increased public willingness to share personal ID information through understanding of the ethical and administrative consequences to the families of deceased persons should bodies remain unidentified.

Death Investigation and Certification in Italy

The certification of cause and manner of death is fundamental for legal and epidemiological purposes. In Italy, as in several other European countries, the death certificate is legal proof of an individual's death. The incorrect assessment of cause and manner of death can have serious implications for public health and the judicial system. Unnatural deaths can be erroneously reported as natural deaths, leaving accidents or homicides undetected. Many reasons can explain such inaccuracy, such as the level of training of medical practitioners involved in death investigations or a lack of information regarding the decedent's medical history. In January of 2011, the Italian death certificate changed to conform to European rules dealing with statistical recording. This paper discusses the concept of manner of death in the Italian death investigation system, along with a brief history of Italian legislation, and discussion of the professionals involved in the certification of death, responsibilities for the determination of cause and manner, and how the manner of death is used.

Complete cardiac rupture associated with closed chest cardiac massage: case report and review of the literature

Chest skeletal injuries are the most frequent complications of external chest massage (ECM) during cardiopulmonary resuscitation, but heart and great vessels lacerations that are indeed very rare. We report the case of a 35-year-old workman who collapsed and underwent ECM by his co-workers for almost 30 min. At autopsy, no external injuries, fractures or bruises of the ribs or sternum, were observed. A hemopericardium with a rupture of the heart was found, with no signs of pre-existent cardiac disease. Bruises of thoracic aortic wall, lung petechiae, a contusion of the liver, and bruises of lumbar muscles were found. The cause of death was due to sudden cardiac death with an extensive cardiac rupture. This is an unusual report of massive heart damage without any skeletal or muscle chest injuries, secondary to cardiopulmonary resuscitation. This kind of cardiac lesions may be considered when thoracic–abdominal trauma, or medical history, is unclear.

Posttraumatic stress disorder: protective and risk factors in 18 survivors of a plane crash

The aim of this study is to identify protective and risk factors related to the development of posttraumatic stress disorder (PTSD) on a sample of survivors from a single plane crash. Eighteen survivors were examined 6 months following the event. The subjects all underwent psychiatric interviews, Clinician-Administered PTSD Scale structured interviews, personality and cognitive tests. Only 38.9% of them presented with all of the symptoms of PTSD; 22.2% showed no symptoms for PTSD; remaining survivors exhibited emotional/affective symptoms related to the event. In addition to the severity of the traumatic event itself, other risk factors identified were the loss of a relative, the manifestation of depressive symptoms, and the severity of physical injuries sustained. Low levels of hostility and high levels of self-efficacy represented protective factors against developing PTSD.

Postmortem morphology and viability of human Peyer's patches in distal ileum: a technical note

The intestinal mucosa contains a highly specialized immune system which plays a central role in the induction of immune reactions. In the small bowel, Gut-Associated Lymphoid Tissue (GALT) is organized in lymphoid aggregates which are known as Peyer's Patches (PP). Even though human PP involvement in systemic immunity has been described, little is known about their anatomy and morphology and viability. The aim of this study was to examine PP according to their macroscopic anatomy, distribution and cell viability after death. Specimens from the distal ileum were obtained from 72 serial autopsy cases: PP were identified and, parts of them were analyzed for histological examination. Moreover, viability of recovered PP cells was assessed by the trypan blue exclusion test. Most of the PP (90%) were situated on the antimesenteric border of ileum, and the greatest density of PP occurred in the most distal segment. The number of PP varied with age, with the maximum number observed in 21- to 30-years old cadavers. Histological examination showed their remarkable architectural preservation at different post-mortem intervals (PMI), while the mucosal surface underwent autolysis. In 56% of cases PP cells were still viable, especially at PMI < 24 hours after death. These data confirm that human PP are still well preserved in a remarkable percentage of cadavers also several hours after death, and their availability may be helpful in various fields of research.

Vestibular evoked myogenic potentials (VEMPs) in whiplash injury: a prospective study

CONCLUSIONS

Patients affected by whiplash-associated disorder presented alterations of vestibular evoked myogenic potentials (VEMPs). VEMP testing may be an important 'forensic' diagnostic tool in the assessment of cervical spine injury.

OBJECTIVES

The purpose of this prospective study was to evaluate changes in VEMPs in the assessment of whiplash injuries.

PATIENTS AND METHODS

Fourteen patients complaining of whiplash injury were examined and compared with 15 controls. All patients underwent VEMP testing within 7 days from the injury and 90 days after whiplash injury. Beside VEMPs, standard investigation consisted of pure-tone and speech audiometry, impedance audiometry and evaluation of the vestibular system.

RESULTS

All subjects presented normal hearing, normal impedence audiometry findings, and normal vestibular function. VEMPs were present both in patients affected by whiplash injury and in the control group at time 0. At 90 days VEMPs were absent in two cases (14.3%). Statistical analysis showed that at time 0 and at time 90 days p1 latency was significantly higher in whiplash patients compared with healthy subjects on both sides (p < 0.002). The amplitude of p1-n1 was significantly lower in whiplash patients at time 0 (p = 0.003 on the right and p = 0.018 on the left), but not at 90 days.

Craniofacial identification by comparison of antemortem and postmortem radiographs: two case reports dealing with burnt bodies

Two cases of positive identification of burnt bodies by radiographic comparison are reported. They emphasize that antemortem radiographs of the head are an important but sometimes overlooked source of information which can frequently provide useful objective data for comparison purposes. A positive identification can easily be achieved by medical examiners through visual comparison of the antemortem with the postmortem cranial and facial structures, even of bodies severely damaged by fire. In these bodies the radiographs of the skull can graphically depict structures which are often unique to the individual, such as the frontal sinus pattern and the morphology of dental restorations. However, the process of identification through radiographs is appropriate only in burnt bodies in which antemortem radiographs of the alleged deceased are available for comparison and unique craniofacial structures are still present on the body in a well-preserved state or at least not completely destroyed by fire, depending on the extent of the burn injury. Matching of corresponding features seems preferable to other methods of personal identification such as skull-photo superimposition, morphometric analysis, and/or other computer-aided methods since these techniques need trained personnel, as well as expensive equipment which is not invariably available in the medical examiner's office or department of anthropology.

Rupture of the spleen or splenic vessels (splenic emergency syndrome) in late pregnancy: a report of two autopsy cases

Emergencies of splenic origin in pregnancy involving rupture of the splenic artery or hemorrhage are rare events that can present suddenly and unexpectedly. We report two cases of young women, both in the third trimester of gestation, who suffered sudden malaise while at home and were admitted to the ER. On arrival, both were in severe hemorrhagic shock due to gross hemoperitoneum and they died in the operating theatre during emergency surgery. To better clarify the causes and sequence of these mortalities, forensic autopsy was requested in each case. In the first (a 26-year-old primigravida in the 40th week of pregnancy), cadaveric section demonstrated the rupture of an aneurysm of the splenic artery. In the second (a 28-year-old multipara in the 33rd week of pregnancy), the clinical and anatomopathological data suggested splenic hemorrhage. In both cases histology showed a fibrodysplasia of the arterial wall involving the splenic artery in one case and the hilar branches in the other. In agreement with the data in literature, in such cases particular importance must be attributed to examination of the arterial wall. In pregnancy a synergic effect between hemodynamic and endocrine factors can cause degeneration of the arteries resulting in dramatic hemorrhage. From the forensic pathologist's viewpoint, these cases underline the importance of histopathological study of the splenic artery in the interpretation of the pathogenesis of splenic vessel rupture or hemorrhage.

Future project concerning Mass Disaster Management: a forensic odontology prospectus

The world has experienced a plethora of mass disasters in recent years: acts of terrorism, bombings, earthquakes, hurricanes, typhoons, air crashes and other transportation mishaps, not to mention armed conflicts and migrants drowned in the Mediterranean Sea. In reviewing mass disasters to date, the principal difficulties have not changed: (1) large numbers of humans fragmented, co-mingled, and burned remains; (2) difficulty in determining who was involved in the disaster; (3) acquisition of useful medical and dental records and radiographs; (4) legal, jurisdictional, organisational, and political issues; (5) internal and external documentation and communication problems; (6) application of universal human forensic identification codes. Forensic dentistry plays a major role in victim identification. DNA and dental identification of human remains depends on sufficient availability of ante mortem information, existence of sufficient post mortem material and a comparison or match between ante and post mortem details. Forensic odontology is a specialty with a specific training, and cannot simply be carried out by dentists without such training. Strategies for developing an international forensic odontology capacity and resources are needed for the management of dead bodies following a mass disaster, together with universal guidelines and codes. To this end, Interpol's forms have proved to be a good starting point to meet these requirements.