Medicolegal Relevance Research Articles

Morphometric measurements of mandible to determine stature and sex: A postmortem study

ObjectivesIdentification of humans has medicolegal relevance in civil issues involving property inheritance, marriage, contested sex, admission to educational institutions, and the disappearance of individuals. To determine the sex of human remains, forensic anthropologists usually use morphologic and metric approaches. This study was conducted to determine stature and sex according to mandibular dimensions in postmortem autopsy samples. MethodsA total of 150 mandibles from people 18–65 years of age were studied. Stature and sex were noted, and six mandibular measurements were taken with Vernier calipers, flexible measuring tape, a protractor, and a graduated autopsy table. Statistical analysis of the measured parameters was conducted in SPSS software. Statistical parameters, such as mean, standard deviation, Spearman's correlation coefficient, multiple linear regression, stepwise regression, and Mann–Whitney U test were analyzed. ResultsBicondylar width was the stature estimation predictor with the strongest correlation (r = 0.439). The other parameters significantly associated with stature were bigonial width (p = 0.000), mandibular angle (p = 0.004), and mandibular arch length (p = 0.000), according to Spearman's correlation coefficient. The mandibular angle had the greatest dimorphic statistical significance (p = 0.004) according to the Mann–Whitney U test. ConclusionBicondylar width may serve as a valuable tool for estimating stature, and mandibular angle can be used to identify sex. Our findings may help forensic anthropologists estimate stature and identify human remains.

Trauma and sporadic desmoid tumor development: An approach toward real incidence and aspects of causality.

The development of desmoid tumors (DT) is associated with trauma, which is an aspect with medicolegal relevance. The objective of this study was to analyze the proportion and type of trauma (surgical, blunt/fracture, implants), its lag time, and mutations of the CTNNB1 gene in patients with sporadic DT. We analyzed a prospectively kept database of 381 females and 171 males, median age at disease onset 37.7years (females) and 39.3 years (males) with a histologically confirmed DT. Patients with germline mutation of the APC gene were excluded. Details of the history particularly of traumatic injuries to the site of DT were provided by 501 patients. In 164 patients (32.7%), a trauma anteceding DT could be verified with a median lag time of 22.9months (SD, 7.7months; range, 9-44months). A prior surgical procedure was relevant in 98 patients, a blunt trauma in 35 patients, a punctuated trauma (injections, trocar) in 18 patients, and site of an implant in 10 patients. In 220 patients, no trauma was reported (43.9%), and 58 females (11.6%) had a postpregnancy DT in the rectus abdominis muscle. In 42 patients (8.4%), data were inconclusive. The distribution of mutations in the CTNNB1 gene (codon 41 vs. 45) was similar in patients with and without a history of trauma before DT development. A significant subgroup of patients suffers from a trauma-associated DT, predominantly at a prior surgical site including implants to breast or groin, accounting for 77.9% of the cases, whereas blunt trauma was responsible in 22.1%. We found no data to support that trauma-associated DT have different molecular features in the CTNNB1 gene.

'Having regard to the findings made by the referrer': medicolegal implications of case SC (2020) for hospital clinicians.

A case concerning the management of a child with meningitis in a hospital paediatrics department provided a judgement that has significant potential implications for medical practice. The case establishes that the examination findings of a previous clinician must be taken into account when investigating and treating patients. This case is of medicolegal relevance to clinicians practising in tertiary centres and who receive patients from other hospitals. This article highlights the medicolegal implications of this case, using an example of cauda equina syndrome for neurosurgeons, a condition that can have fluctuating symptomatology and that already has a high burden of litigation.

Medicolegal relevance of the transient loss of consciousness

Transient and hardly traceable signs of diminished consciousness might be the only signs that are apparent and reported during the scrutinous care of intensive care unit (ICU) staff. Unfortunately, most transient loss of consciousness (TLoC) episodes occur elsewhere. This review aims to help recognize TLoC and identify situations when these conditions mean that certain legal privileges should be held. With this aim, the current literature was scoped for conceptualizing consciousness, its alterations, and loss as regarded in the legal system. This review was partly inceptive for increasing the use of unconsciousness as a defense against criminal charges. This paper tackles working ability and the legal liability of individuals suffering from TLoC. What has been most discussed is so-called syncope—a TLoC without actual focal neurological deficit which occurs due to hypoperfusion of the brain. Therefore, it is a symptom of the nervous system indicating a cardiovascular condition. Unlike stroke or transient ischemic attack (TIA), hypoperfusion affects the entire brain. The sudden loss of consciousness in everyday workplace situations can lead to dangerous situations. Likewise, as a result of avoiding these situations, being aware of the possible loss of consciousness can preclude a patient from performing the duties of occupation—or any activity.

Child maltreatment and management of pediatric patients during COVID-19 pandemic: Knowledge, awareness, and attitudes among students of medicine and surgery. A survey-based analysis.

Purpose of the studyTo assess perception, awareness, and attitudes regarding the medico-legal relevance of child maltreatment and management of pediatric patients during the COVID-19 pandemic in a cohort of medicine and surgery students, with a particular focus on child safety and maltreatment.MethodsA cross-sectional, web-based survey was conducted through an anonymous questionnaire on the personal websites of Università Cattolica del Sacro Cuore medical students.ResultsThe study included 1,166 participants, the majority of whom were experienced with child maltreatment and defensive medicine; only a small percentage was aware of the government's efforts to prevent child maltreatment and safeguard vaccination physicians. Moreover, there was no agreement on the use of telemedicine for non-serious pediatric patients or on the consequences it might have on their health. Finally, the detrimental impacts of lockdown on children's mental health are a major worry.ConclusionsKnowledge of these themes is mainly implemented by deepening these concepts during the undergraduate studies since a high level of knowledge on child maltreatment and on the management of COVID-19 pandemic was significantly associated with clinical years of course. Specific seminars analyzing telemedicine and legislative protections concerning minors and those concerning vaccination doctors should be included in the study plan to raise awareness these concepts.

Ethanol and putrefaction: Medicolegal relevance of the study of different biological samples

Alcohol is the most determined substance in postmortem toxicology and its interpretation is especially complicated. Although the determination and quantification of ethanol is preferably carried out on blood samples, the determination of this parameter in other biological matrices can prove to be quite important. This may be true, for example, in cases where the blood sample available is insufficient or is in a state deemed unsuitable (e.g. putrefaction or contamination by other biological fluids such as gastric contents). Among the biological samples which can be considered as an alternative to blood in the determination of ethanol, the vitreous humor (VH) appears as the most interesting. Therefore, it is of high relevance the analysis of other biological samples, as urine and VH, that in normal situations are only positive for alcohol when antemortem ingestion has occurred. This is important mostly when the blood alcohol concentration (BAC) is lower than 0.5 g/L. Another study reported that with a BAC of 0.5 g/L there is an 87% probability of a positive result for alcohol in VH and with the increase of this concentration the probability goes up to 99%. In the present study, the authors made a statistical survey, within the period of three years, of the cases that indicated putrefaction in which the medical expert required the analyses of the BAC. From all the cases evaluated, three forensic cases were selected, which represent situations that might occur when studying the BAC of a putrefied corpse. These cases were chosen to highlight the possible benefits of analyzing multiple biological samples, when present, for confirmation of the BAC. The samples analysis was made using an Agilent 6890N gas chromatograph equipped with a flame ionization detector and coupled to an Agilent G1888 headspace injector of fixed volume (1 mL) (HS-GC/FID). Prior to gas-chromatography analysis, all specimens, including the calibrators, were diluted 1:10. With this purpose, 100 μL vitreous humor, urine and blood were diluted with 1 mL aqueous solution of n-propanol (100 mg/L), used as internal standard. In the period of 3 years (2018–2020), there were 4264 medical-legal autopsies executed in which the medical expert required the determination of the BAC. Of these cases, a total of 130 had information stating the presence of putrefaction. They were related to different causes of death (intoxication, drowning, trauma, natural deaths and undetermined cause) and had a postmortem interval between one and six days. BAC measured determined 64 cases with a negative result and 66 with a positive result. Of these, 66.7% had a BAC between 0.1 g/L and 0.5 g/L, relevant as endogenous production might have happened, making the interpretation of these values challenging. However, this interpretation can benefit from the integration of the available case information, especially the search for alcohol in other biological samples. Using this data, it was determined how many cases presented one, two and three biological samples and three forensic cases were selected, representing each of these categories, exemplifying situations that can easily occur when studying the BAC of putrefied corpses. In this study we discussed how the determination of the alcohol concentration in urine and VH can be a valuable tool, especially in the presence of putrefied corpses and low concentrations of alcohol in the blood, when trying to determine whether the BAC was of exogenous origin, endogenous production or both. This suggests that the analysis of these three types of biological samples (blood, urine, VH) can be of use in reaching a conclusion regarding the origin of the alcohol and making it less susceptible to dispute.

The autobiographical narrative as a damage assessment means: injuries to profound subjective sensitivities - personalization and objectivization of medicolegal relevance.

The article aims to outline and expound upon the impairing aspects of an acoustic lesion involving deafness, analyzing the disabling effects on all aspects of the daily life of the injured person, even in the absence of permanent psychic damage that can be nosographically categorized. Such a form of additional damage, which can hardly be quantified, is certainly immaterial and perhaps cannot even be qualified as biological; although it still falls within the realm of psychic functioning, it must be adequately framed by the forensic doctor, in order to enable the Judge to issue a coherently motivated ruling, fully contextualized within the clinical reality of the patient. This task is strictly medicolegal in nature, and requires the professional to carry out in-depth work thoroughly based on listening for the purpose of providing the courts with a faithful representation.

Recent Medico-Legal Developments on the Issue of Epilepsy and Driver's License Requirements in the Italian and European Legislation.

Epilepsy is a condition that comprises a group of neurological disorders characterized by seizures. Forms of epilepsy that produce abrupt bouts that cause lapses in consciousness may pose a major road safety problem for drivers who, while going through a seizure, could seriously harm themselves as well as others. A fundamental strategy for the purpose of reducing the risk of car accidents caused by epileptic drivers is constituted by prevention, in addition to adequate pharmacological therapies. In that respect, forensic medicine plays a pivotal role, since it deals with the set of requirements that must be met by those who have been diagnosed with epilepsy in order to get a driver's license, and with the obligation to signal such individuals to the national Driver and Vehicle Licensing Agency (in Italian: Motorizzazione Civile). In that regard, the Italian legislative framework is partly hazy in some respects, which the authors have set out to analyze herein, taking into account recently issued European norms. The aim of this paper was to better understand the current Italian legislation in the matter of epilepsy and driver's license requirements, especially regarding the medical criteria that must be met in order to obtain the driving license. The importance of those criteria is underlined by the fact that they directly influence (and are influenced by) the safety for the drivers and for the persons involved in car accidents. Thus, we can consider the issue not only strictly of medico-legal relevance but also from the standpoint of primary prevention. The analysis was conducted by reviewing the most recent documents of medico-legal relevance, in the light of European Union legislation. The authors have ultimately stressed the need for clearer and straightforward regulations, given that professional liability may arise whenever a driver's license is issued, in disregard of legal norms, to an individual who then causes a road accident.

The Credibility of Cephalogram Parameters in Gender Identification From Medico-Legal Relevance Among the Iranian Populatio

Background: Normal cephalogram parameters seem to be gender discriminative and thus applicable in forensic medicine. We assessed validity of cephalogram parameters in gender identification among the Iranian population. Methods: This cross-sectional study was conducted on 75 Iranian men and 75 Iranian women aged 25 to 54 years. On their first admission, the physicians requested for simple lateral skull X-ray for all participants. Results: Using area under the ROC curve, gonion-gonion index (AUC=0.741) and vertex- mention index (AUC=0.697) had a moderate value to discriminate male from female gender, while other parameters lacked enough power to differentiate gender. The best cut-off point in gonion-gonion index for discriminating male from female gender was 103.75 with a sensitivity of 74.7% and a specificity of 65.3%. Also, the best cut-off value for vertex-mention index to differentiate two genders was 244.75 with a sensitivity of 74.7% and a specificity of 62.7%. By considering two parameters of gonion-gonion and vertex-mention, it is possible to differentiate males from females with a sensitivity of 82.6% and a specificity of 71.8%. Conclusion: The two gonion-gonion and vertex-mention indices on cephalogram are applicable for gender discrimination.

Trisomy 21 in forensic autopsies: Review of a 20-year period

BackgroundTrisomy 21 is the most common human chromosomal abnormality. Its manifestation includes intellectual impairment and more or less typical anatomical malformations and functional deficiencies that can cause sudden or unexpected deaths. Typical medicolegal questions at autopsy are related to medical malpractice, improper care, neglect, or abuse, and, depending on the cause of death, whether the death might have been avoidable. The aim of this study was to examine whether the causes of death in individuals with trisomy 21 were linked to the known health risks for this condition and to consider how these deaths might have been prevented. Material and methodsA retrospective study was performed at the Institutes for Legal Medicine in Giessen and Frankfurt am Main, Hesse, Germany. All records for forensic autopsy cases within a 20-year period from 1998 to 2017 were reviewed for the diagnosis trisomy 21”, respectively, “Down’s syndrome”. ResultsTwenty-three cases complied with the inclusion criteria trisomy 21 and autopsy. The age of the deceased ranged from 23 days to 61 years. Infectious diseases, mainly respiratory, were the leading cause of death, followed by accidental deaths. ConclusionThe medicolegal relevance of the known health risks in Down’s syndrome could be illustrated by the autopsy findings and the results of the additional examinations. The known high susceptibility to infections, with an increased risk of a rapid course and lethal outcome, in individuals with Down’s syndrome could be confirmed in our study. A sound knowledge of the risks and abnormalities associated with trisomy 21 are helpful in medicolegal assessments, particularly, in relation to medical malpractice charges.

A novel use of infra-red spectroscopy (NIRS and ATR-FTIR) coupled with variable selection algorithms for the identification of insect species (Diptera: Sarcophagidae) of medico-legal relevance

Unequivocal identification of fly specimens is an essential requirement in forensic entomology. Herein, a simple, non-destructive and rapid method based on two vibrational spectroscopy techniques [Near-Infrared Spectroscopy (NIRS) and attenuated total reflection Fourier-transform infrared (ATR-FTIR) spectroscopy] coupled with variable selection techniques such as genetic algorithm-linear discriminant analysis (GA-LDA) and successive projection algorithm-linear discriminant analysis (SPA-LDA) were applied for identifying and discriminating six species of flesh flies (Diptera: Sarcophagidae) native to Neotropical regions. This novel approach is based on the unique spectral “fingerprints” of their biochemical composition. One hundred sixty (160) NIRS and FT-IR specimens (120 male, 40 female) were acquired; different pre-processing methods such as baseline correction, derivative and Savitzky-Golay smoothing were also performed. In addition, the multivariate classification accuracy results were tested based on sensitivity, specificity, positive (or precision) and negative predictive values, Youden index, positive and negative likelihood ratios. Principal components analysis (PCA) was employed for male vs. female category using NIRS, strongly showing the separation between the classes with only three principal components and 99% explained variance. Differentiation between the genera Oxysarcodexia, Peckia and Ravinia was efficiently confirmed by both techniques. In comparison with other biological methods, this approach represents an effective choice for fast and non-destructive identification in forensic entomology.

Medico-legal perspectives on sudden cardiac death in young athletes.

Sudden cardiac death (SCD) in a young athlete represents a dramatic event, and an increasing number of medico-legal cases have addressed this topic. In addition to representing an ethical and medico-legal responsibility, prevention of SCD is directly correlated with accurate eligibility/disqualification decisions, with an inappropriate pronouncement in either direction potentially leading to legal controversy. This review summarizes the common causes of SCD in young athletes, divided into structural (hypertrophic cardiomyopathy, arrhythmogenic cardiomyopathy, congenital coronary artery anomalies, etc.), electrical (Brugada, congenital LQT, Wolf-Parkinson-White syndrome, etc.), and acquired cardiac abnormalities (myocarditis, etc.). In addition, the roles of hereditary cardiac anomalies in SCD in athletes and the effects of a positive result on them and their families are discussed. The medico-legal relevance of pre-participation screening is analyzed, and recommendations from the American Heart Association and European Society of Cardiology are compared. Finally, the main issues concerning the differentiation between physiologic cardiac adaptation in athletes and pathologic findings and, thereby, definition of the so-called gray zone, which is based on exact knowledge of the mechanism of cardiac remodeling including structural or functional adaptions, will be addressed.

Criminality, narrative and the expert witness in American biohistory

This article considers forensic anthropologists’ roles in negotiating the concept of criminality in biohistorical cases, those investigations of the famous and infamous dead that are driven by public interest rather than traditional medicolegal relevance. We review three biohistorical cases from the United States: the purported skull of a martyred Catholic priest from sixteenth century Georgia, the Mountain Meadows Massacre that occurred in Utah in the mid-nineteenth century, and the search for Billy the Kid’s grave in New Mexico. We find that anthropologists have active and passive roles in the manufacture, assignment, and sometimes denial of criminality in these cases. Additionally we explore how the analysis and discussion of violence in these biohistorical cases reflects two concepts that are distinctive to United States’ history, notably manifest destiny and the idea of closure in historical narratives. The perception that the present order is a natural culmination of history, and that the past is truly past underestimates the relevance and impact of labelling past personages as criminals to contemporary culture. As a result, forensic anthropologists’ negotiation of criminality in U.S. biohistorical cases is fraught with nebulous ethical challenges and tangible consequences.

Tension pneumothorax in unsuccessful cardiopulmonary resuscitation

Background. A well-known complication of cardiopulmonary resuscitation (CPR) and a potentially reversible cause of cardiac arrest (CA) is tension pneumothorax (TP). In TP external cardiac massage is ineffective because increased intrathoracic pressures hamper passive diastolic filling of the heart. Case Reports. As forensic practice reveals repeated cases of unsuccessful CPR with co-existing TP, we exemplarily describe 4 cases of unsuccessful CPR from different origins with TP, which prevented CPR from positive outcome. Why should a forensic pathologist be aware of this? Not only complications of medical therapies are of medico-legal relevance, but also omission of procedures. Autopsy cases with TP after CPR should be discussed regarding medical malpractice. Bilateral chest decompression before termination of CPR must be considered in all patients with CA and blunt chest trauma, i.e. external

PP.42 Investigation of Neonatal Encephalopathy: The Lost Placental ‘Black Box’

BackgroundAfter an aeroplane crash, recovery of the ‘black box’ is a high priority for investigators; analysis of recorded parameters frequently identifies cause or contributing factors. The placenta likewise provides an...

Mesh in prolapse surgery: an imaging perspective

Mesh in prolapse surgery: an imaging perspective

The role of clinical neurophysiology in urogynecology

Clinical neurophysiological methods remain interesting research tools in urogynecology; their diagnostic role in the individual "pelvic floor" patient is, however, minor. The methods are diagnostically useful particularly in patients suspected to have a lesion involving the sphincters or the peripheral sacral nervous system, the diagnosis of which will influence management decisions or have prognostic or medicolegal relevance. Most helpful tests are the concentric needle EMG and bulbocavernosus reflex testing.

Histological Diagnosis of Myocardial Sarcoidosis in a Fatal Fall from a Height

The major issues of medico-legal relevance in fatal falls from a height are the manner of death and the reconstruction of the event. We present a peculiar case of a fatal fall from a height of about 9 m, involving a 27-year-old woman. At the death scene investigation, no suicide notes, housebreaking marks, or signs of fight were found, thus weakening both the suicide and homicide hypotheses. Combining circumstantial, autopsy and toxicology data, the kinematic analysis of the jump/fall, and the histological evidence of a myocardial sarcoidosis involving the left ventricle, we hypothesized that the young woman might have accidentally fallen from the window because of a sudden loss of consciousness related to cardiac disease undiagnosed during life. We believe that our brief report is a good example of the powerful additional information that histological investigations can offer for reconstructing the dynamics of the event in falls from a height and other traumatic fatalities.

Errors in Birth Registrations and Coding of Twins and Higher Order Multiples

AbstractDizygotic compared with monozygotic conceptions are at decreased risk of fetal and infant death and serious morbidity in surviving infants. Different sex twin maternities must be dizygotic but miscoding and incorrect registration of sex and number of fetuses may lead to an incorrect assignment of zygosity. The aim of the study was to validate the coding and registration of number and sex of births in multiple pregnancies. Fetal and infant death registrations from all multiple maternities in England and Wales 1993–1998 were examined. There were 51,792 twin, 1627 triplet and 51 higher order multiple maternities that were registered. Among these there were 1926 fetal deaths, 58 of which were registered as being of indeterminate sex but were coded as male in 56 and female in 2 cases. A fetus papyraceous was registered as male in 19 and as female in 19 cases. Other fetal deaths weighing ≤100g, with no mention of papyraceous on the death certificate, nevertheless, likely to be of indeterminate sex, were registered as male in 26 and as female in 23 cases. In 13 maternities, the number of infants registered at birth was less than the number mentioned on the registration certificate. It cannot be assumed that multiple births of different registered sex are dizygotic. As surviving infants from a monozygotic multiple birth are at much greater risk of infant death and serious morbidity than dizygotic multiple births, incorrect assignment of sex has important implications for parental counselling and may have medicolegal relevance when attributing negligence as the cause of morbidity in a survivor from a multiple pregnancy.

Errors in birth registrations and coding of twins and higher order multiples.

Dizygotic compared with monozygotic conceptions are at decreased risk of fetal and infant death and serious morbidity in surviving infants. Different sex twin maternities must be dizygotic but miscoding and incorrect registration of sex and number of fetuses may lead to an incorrect assignment of zygosity. The aim of the study was to validate the coding and registration of number and sex of births in multiple pregnancies. Fetal and infant death registrations from all multiple maternities in England and Wales 1993-1998 were examined. There were 51,792 twin, 1627 triplet and 51 higher order multiple maternities that were registered. Among these there were 1926 fetal deaths, 58 of which were registered as being of indeterminate sex but were coded as male in 56 and female in 2 cases. A fetus papyraceous was registered as male in 19 and as female in 19 cases. Other fetal deaths weighing >/= 100g, with no mention of papyraceous on the death certificate, nevertheless, likely to be of indeterminate sex, were registered as male in 26 and as female in 23 cases. In 13 maternities, the number of infants registered at birth was less than the number mentioned on the registration certificate. It cannot be assumed that multiple births of different registered sex are dizygotic. As surviving infants from a monozygotic multiple birth are at much greater risk of infant death and serious morbidity than dizygotic multiple births, incorrect assignment of sex has important implications for parental counselling and may have medico-legal relevance when attributing negligence as the cause of morbidity in a survivor from a multiple pregnancy.