Perioperative and anesthetic deaths: toxicological and medico legal aspects

Background: Anesthesia has become safer during decades, though there is still a preventable mortality; the complexity of medical and surgical interventions, increasingly older and sicker patients, has created a host of new hazards in anesthesiology. In this paper, some of these perioperative (PO) fatal adverse events are investigated in terms of health responsibility. Selective literature research in several data bases, concerning perioperative and anesthetic deaths and medical responsibility, was performed. Main text: A generally accepted definition of the anesthesia and perioperatory-related death still remains one of the major concerns in forensic pathology, and the terms “operative deaths” and “anesthetic deaths” are usually applied inaccurately within the medico-legal literature. Such events involve comprehensively PO fatalities and allow for subtle separation of natural and unnatural death, at least from the prospective of forensic pathology. Iatrogenic deaths in this field can be separated into some major categories, as attributable to previous patient’s unfavorable conditions or depending from surgical procedure per se (such as PO cardiac and cerebrovascular events). In this review, the authors carried out syntheses of specific research areas regarding epidemiology, complications of general and spinal anesthetic, failure in airway management and patient’s circulatory homeostasis, and adverse drugs reactions; analysis considering the challenge of anesthetic-related mortality, epidemiology and classifications, by indicating causal chain of death, in respect of both contributing and associated anesthetic and surgery facts. Conclusions: Perioperative quality control programs and its relevance for medico-legal evaluation are emphasized as, although mortality rates have decreased worldwide over the last decades, however, preventable drug-related deaths still happen. Such fatal events have to be considered within the field of forensic pathology experts, with regard of malpractice claims, to implement a strategy for preventing potentially fatal complications

Work activities at increased risk of traumatic injuries: an integrated preventive approach

Included in the scope of workplace safety is that relating to potential accidents, i.e. the harmful consequences for human health crossed with the work environment factor. In the study of the determinism of these accidental events, it is important to achieve a biomechanical balance between two main elements: the human and the work environment (consisting of the physical, chemical and environmental factors, i.e. the equipment and what generates its use). Considering the most recent statistically recorded incidents, our analysis has focused on the accident sphere proper, where an imbalance in the above-mentioned binomial triggers the activation of multiple disciplines that actively and pro-actively study the event and assess its sequelae, in all possible facets (economic, engineering, clinical, medical-legal)

Heavy metal removal from aqueous solutions by sorption using natural clays from Burkina Faso

The acid-base properties of two raw and purified mixed clays from Burkina Faso were studied, as well as their potential to remove copper(II), lead(II) and chromium(III), and thereby their ability to be used to purify water from heavy metals. The purification procedure of the clays involved removal of carbonates, iron oxides and organic matter. A determination of the elemental composition of the mixed clays revealed the presence of aluminum, iron and silicon as main constituents. The high alkaline pH in one of the samples is attributable to the presence of carbonate in the raw clay. The point of zero charge (pHpzc) values of the clays, as determined by potentiometric titrations, were 6.79 and 9.52 for the raw clays, while after purification they were 6.87 and 6.76, respectively. Metal adsorption to the clay surfaces started at pH values below pHpzc, strongly indicating formation of inner-sphere complexes. With contact time of 48 h, complete removal of copper(II) was achieved at pH 8 for all samples. More than 90% of the lead(II) removal was attributed to adsorption while for chromium(III), it was 85%. Adsorption to organic matter and iron oxides, and precipitation of metal hydroxides gave significant contributions to the removal of metal ions in aqueous systems.Key words: Mixed clays, potentiometric titration, heavy metals, pHpzc

Utility of post mortem computed tomography in clivus fracture diagnosis. Case illustration and literature review

Clivus fractures are usually associated with head blunt trauma due to traffic accident and falls. A 23–year-old man died immediately after a smash-up while he was stopping on his motorcycle. Post-mortem Computed tomography (PMCT), performed before autopsy, revealed a complex basilar skull base fractures associated with brainstem and cranio-vertebral junction injuries, improving the diagnostic performance of conventional autopsy. Imaging data were re-assessable and PMCT offers the possibility to perform multiplanar and volume rendered reconstructions, increasing forensic medicine knowledge related to traumatic injuries

The role of vitamin deficiency in liver disease: To supplement or not supplement?

Over the past few years, growing interest has been shown for the impact of dietary requirements and nutritional factors on chronic diseases. As a result, nutritional programs have been reinforced by public health policies. The precise role of micronutrients in chronic liver disease is currently receiving particular attention since abnormalities in vitamin levels are often detected. At present, treatment programs are focused on correcting vitamin deficiencies, which are frequently correlated to higher rates of comorbidities with poor outcomes. The literature reviewed here indicates that liver diseases are often related to vitamin disorders, due to both liver impairment and abnormal intake. More specific knowledge about the role of vitamins in liver disease is currently emerging from various results and recent evidence. The most significant benefits in this area may be observed when improved vitamin intake is combined with a pharmacological treatment that may also affect the progression of the liver disease, especially in the case of liver tumors. However, further studies are needed

Medico legal procedures related to sexual assault: a 10-year retrospective experience of a Daphne protocol application

Background: Sexual assault is a worldwide problem that has not yet been sufficiently acknowledged as confirmed by the literature. Italian law n.96, 1996, foreseeing norms regarding rape and sexual abuse, finally gave significant relevance to sex crimes. In 2004, the European Commission for Justice Internal Affairs and Social Politics promoted the Daphne II program to support victims of rape and abuse, and the Violence and Operative Healthcare Networks (Ve.R.S.O.) project started at the Policlinico \ue2\u80\u9cP. Giaccone\ue2\u80\u9d University Hospital of Palermo in 2006. Aim: data analysis emerging from 10 years experience of Daphne protocol utilization for the management of sexual assault victims. Methods: From October 2006 since December 2016 a total of 90 victims of sexual assault were retrospectively investigated. Patients are divided into groups in relation to: gender, age, place of SA, number and type of assailant, nature of sexual assault, presence/absence of physical or genital injuries. Results: Among victims 88 were females (97%) and 2 males (3%); 68 Italians (75.5%) and 22 foreigners (24.5%). At the time the events occurred, 42% (n = 38) of the victims were minors aged less than 16\uc2 years. In 11 cases, the age of the victim is not indicated. The assailant was an acquaintance of the victim in 65% of the cases (in 73% of these cases, the assailant was a family member). In 26 cases (28%) happened indoor, 44 cases happened outdoor and in 20 cases there were no data. Evidence of recent acute general body trauma (abrasions, bruises, lacerations) was found in 38 cases (42%); other types of injuries include: genital trauma (14 cases, 15%), genital and body traumas (49 cases, 54%) (tab. 1\ue2\u80\u932-). In 24 cases (26%) there were no injuries. Among genital trauma, we distinguished vulvo-vaginal lesions (68.5%) and anal lesions (31.5%). We have classified the minor victims using first Adam\ue2\u80\u99s classification and based on Adam\ue2\u80\u99s classification revised in 2015. Conclusion: Application of the Ve.R.S.O project protocol changed and greatly improved health management of victims of violence. By following these procedures, violence and abuse are analyzed from every point of view, also for an appropriate assessment of the medium and long term health consequences of sexual assault. Only in this way are citizens provided with a high level of protection against gender violence, psychological support and prevention from any form of violence which takes place in respect of such vulnerable people

Palatal Rugae as a Discriminating Factor in Determining Sex: A New Method Applicable in Forensic Odontology?

The purpose of this study is a new method that can help to identify the sex through the study of palatal rugae, comparing sagittal sections of the hard palate using Cartesian coordinates and evaluating the assistance given by digital technology and its applicability in this method. In this study, 57 digital impressions were examined and divided in two groups based on sex. Results: 2223 impression sections were studied and 145 coordinates that were present with a frequency greater than 50% in one or both groups were obtained: 52 discriminating traits (DT) in the male group, 29 discriminating traits in the female group, and 64 common traits (CT). The DTs in the female group showed no statistically significant difference from the same coordinates in the male one (p = 0.832). Statistically significant differences were observed in the DTs in the male group compared to the same coordinates in the female group (p = 0.018). No statistically significant differences were observed in the frequency of DTs in both sexes (p = 0.056). Further research in forensic odontology is needed to determine its scientific certainty. It is certain that digital technology may one day be a valuable support for the forensic odontologist but to date the lack of dedicated and certified programs limits its reliability

The Multidisciplinary Approach for the Diagnosis of Laryngohyoid Lesions: a Systematic Literature Review and Meta-Analysis

Background: The diagnosis of neck lesions remains a medico-legal diagnostic challenge because of the complexity of the anatomical relationship of the neck's organs and their anthropometric morphological variability. We compared the multidisciplinary approach using autopsy and postmortem computed tomography (PMCT), postmortem fine preparation (PMFP), postmortem micro-computed tomography (micro-CT), and postmortem magnetic resonance (PMMR) with the performance of a single diagnostic method among them evaluating the significance of different results. The multidisciplinary approach significantly reduced the number of unidentified neck lesions. The analysis demonstrates the need to better define the scan protocols and compose forensic guidelines for radiological application. The results of this study point out the need to compare the different diagnostic approaches in deceased subjects to better define the radiological scan protocol based on a multidisciplinary approach, including autopsy and radiological methods and the radiological scan protocols. Methods: We performed a systematic electronic search of retrospective scientific articles in PubMed, the Scopus database, and the Cochrane Library. The following combinations of words were used: "hyoid fracture"; "comparison between PMCT AND autopsy"; "hyoid fracture PMCT AND autopsy"; "hyoid bone fracture AND forensic imaging"; "hyoid fracture AND PMCT"; "neck fracture PMCT AND autopsy"; "laryngohyoid lesions"; "postmortem CT AND autopsy in strangulation"; "postmortem AND strangulation Signs "; "strangulation virtopsy"; and "strangulation AND MRI". We selected 16 articles that were published between March 2003 and June 2020. We conducted a meta-analysis with R software to evaluate the rates. We obtained related confidence intervals and a forest plot. Results: Thyroid cartilage damages were significantly more common than hyoid bone fractures (61.7% vs 42.2%) in a sample of 128 subjects. The synergic uses of autopsy/PMCT, autopsy/PMFP, autopsy/microCT, and autopsy/PMMR revealed significantly higher rates than a single investigation. We analyzed the PMCT scan data. The scan parameters evaluated were as follows: row, scan sample, reconstruction, kernel, slice thickness, kVp, and mAs. A lack of uniformity in the application of the protocol was observed. Conclusion: Further studies are needed to better define the radiological scan protocols and to draw guidelines to identify the appropriate radiological methods in relation to the specific case

Preventable fatal injury during rally race: a multidisciplinary approach

Introduction: The motor vehicle crash (MVC) constitutes an important challenge for forensic pathology in order to identify the manner and cause of death. Our study focuses on a fatal accident during a rally race corresponding to MVC sub-category. Materials and method: Postmortem computed tomography (PMCT) was performed before the conventional autopsy. Autoptic and PMCT data were compared. Data collection allowed analyzing biomechanical dynamics of the incident and post-traumatic injuries through qualitative-statistics and solicitation quantitative indices. Results: Photo and circumstantial evidence analysis showed a wrong installation of double shoulder belt system of head and neck support (HANS) collar. PMTC clearly highlighted multiple and bilateral fractures involving roof and base of skull; a displaced fracture of the right acetabulum was also encountered. Autopsy confirmed PMCT data and revealed a brainstem laceration. AIS (Abbreviated Injury Scale) achieved a maximum score in consideration of fatal injuries. Discussion: The injuries analysis resulting from photographic surveys examination, conventional autopsy, and PMCT has led us to confirm a fatal front collision with a tree trunk. Head trauma represents a major injury in the present case. In this case, head injuries, related to whiplash trauma, are a consequence of a double shoulder belt system (HANS collar component) wrong installation. Conclusion: MVC and especially high-speed motor racing represent an important death cause. There was, for this reason, a marked development of cars and occupants’ safety systems, such as HANS collar. PMCT improves the diagnostic performance of conventional autopsy and increases forensic medical knowledge related to traumatic injuries