Oral health professional intervention and child physical abuse-European legal approach

Physical violence against children and adolescents is an issue of Global Public Health. This study aims to identify traumatic injuries and the medicolegal temporary framework of the victim's profile in the European legal approach. Participants and setting include the following: the clinical reports of a Portuguese European Clinical Academic Center database were analysed. An observational and prospective cohort study was performed. A descriptive analysis of the variables was conducted, considering gender, bimodal age groups, place of residence, offender data, place of occurrence, aetiology, localization, type of injuries, personal injury assessment by Quantum doloris, and injury time. The statistical analysis was performed by Spearman's rho and Kendall's tau-b correlation tests, Pearson's chi-square test of independence (χ2), and Mann-Whitney and Kruskal-Wallis nonparametric tests (P < 0.05). The relationship between age groups and the place of occurrence was statistically significant (P = 0.001). Orofacial and nonorofacial injuries were related (P = 0.035). The General Data Protection Regulation is not a barrier to the treatment and sharing of justified data but a framework for safeguarding individuals' fundamental rights, including the Right to Health. Meticulous reporting of the clinical situation involves the victim, the occurrence, and the potential offender.

Key points

An oral health professional's notification of the event is a fundamental step of the judicial process.The timeline is the core of traumatic injury assessment in a child physical abuse scenario.Medicolegal evaluation impacts disability prevention, imputability, and notification of the crime.

IPMICALC: an Integrated Post-mortem Interval Calculator

Correctly estimating the post-mortem interval (PMI) is essential in forensic practice. In recent decades, the measurement of vitreous humor analyte concentrations - especially of hypoxanthine and potassium - and their correlation with the PMI have returned good results. However, calculating the PMI from the data collected can be quite complex. The present paper describes a web resource ( http://modestya.usc.es:3838/Forensic/ ) that simplifies the procedure. The PMI is determined (with its 95% confidence interval) in a rapid, easy, and reliable manner based on the use of mathematical models, the biochemistry of the vitreous humor, and physical variables such as the ambient temperature, the rectal temperature, and bodyweight. The application is entirely free to use.

DiatomNet v1.0: A novel approach for automatic diatom testing for drowning diagnosis in forensically biomedical application

BACKGROUND AND OBJECTIVE

Diatom testing is supportive for drowning diagnosis in forensic medicine. However, it is very time-consuming and labor-intensive for technicians to identify microscopically a handful of diatoms in sample smears, especially under complex observable backgrounds. Recently, we successfully developed a software, named DiatomNet v1.0 intended to automatically identify diatom frustules in a whole slide under a clear background. Here, we introduced this new software and performed a validation study to elucidate how DiatomNet v1.0 improved its performance with the influence of visible impurities.

METHODS

DiatomNet v1.0 has an intuitive, user-friendly and easy-to-learn graphical user interface (GUI) built in the Drupal and its core architecture for slide analysis including a convolutional neural network (CNN) is written in Python language. The build-in CNN model was evaluated for diatom identification under very complex observable backgrounds with mixtures of common impurities, including carbon pigments and sand sediments. Compared to the original model, the enhanced model following optimization with limited new datasets was evaluated systematically by independent testing and random control trials (RCTs).

RESULTS

In independent testing, the original DiatomNet v1.0 was moderately affected, especially when higher densities of impurities existed, and achieved a low recall of 0.817 and F1 score of 0.858 but good precision of 0.905. Following transfer learning with limited new datasets, the enhanced version had better results, with recall and F1 score values of 0.968. A comparative study on real slides showed that the upgraded DiatomNet v1.0 obtained F1 scores of 0.86 and 0.84 for carbon pigment and sand sediment, respectively, slightly worse than manual identification (carbon pigment: 0.91; sand sediment: 0.86), but much less time was needed.

CONCLUSIONS

The study verified that forensic diatom testing with aid of DiatomNet v1.0 is much more efficient than traditionally manual identification even under complex observable backgrounds. In terms of forensic diatom testing, we proposed a suggested standard on build-in model optimization and evaluation to strengthen the software's generalization in potentially complex conditions.

Development and Validation of a GC-MS-EI Method to Determine α-PHP in Blood: Application to Samples Collected during Medico-Legal Autopsies

New psychoactive substances (NPSs) still represent an issue of great concern worldwide despite efforts made by national and international control systems to limit the spread of these substances. Alpha-pyrrolidinohexanophenone (α-PHP) is a fairly recent synthetic cathinone (the second largest group of monitored substances in Europe) with only a few published studies on the substance. Though there is a low incidence of NPS consumption in Portugal, a recent increase in apprehensions and detections in biological matrices of the substance was verified. An analytical methodology was developed and validated for determining and quantitating α-PHP in blood. Solid-phase extraction was employed for sample preparation (500 μL), which was further analyzed by gas chromatography--mass spectrometry-electron ionization in single-ion monitoring mode with cocaine-d3 as the internal standard. Method validation followed the guidelines of the American National Standards Institute/AAFS Standards Board (ANSI/ASB Standard 036). The procedure was linear between 10 and 1,000 ng/mL, with determination coefficients (r2) higher than 0.999. Carryover was not observed. A limit of detection of 5 ng/mL and a limit of quantitation of 10 ng/mL were achieved. Intraday and intermediate precision and bias assessment showed satisfactory results (coefficient of variation <17.7%; bias <11.6%), and extraction efficiency ranged from 98.5% to 103.3%. The stability of the substance was considered acceptable for at least 6 h at room temperature, 48 h in the autosampler and 21 days after five freeze/thaw cycles. The developed methodology was applied to 15 real samples from the Laboratory of Chemistry and Forensic Toxicology, Centre Branch of the National Institute of Legal Medicine and Forensic Sciences, Portugal, with drug concentrations ranging from 15 to 227 ng/mL. Available information for each case is also detailed in the present article.

Nonpharmaceutical interventions reduce the incidence and mortality of COVID‐19: A study based on the survey from the International COVID‐19 Research Network (ICRN)

The recently emerged novel coronavirus, “severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2),” caused a highly contagious disease called coronavirus disease 2019 (COVID‐19). It has severely damaged the world's most developed countries and has turned into a major threat for low‐ and middle‐income countries. Since its emergence in late 2019, medical interventions have been substantial, and most countries relied on public health measures collectively known as nonpharmaceutical interventions (NPIs). We aimed to centralize the accumulative knowledge of NPIs against COVID‐19 for each country under one worldwide consortium. International COVID‐19 Research Network collaborators developed a cross‐sectional online survey to assess the implications of NPIs and sanitary supply on the incidence and mortality of COVID‐19. The survey was conducted between January 1 and February 1, 2021, and participants from 92 countries/territories completed it. The association between NPIs, sanitation supplies, and incidence and mortality were examined by multivariate regression, with the log‐transformed value of population as an offset value. The majority of countries/territories applied several preventive strategies, including social distancing (100.0%), quarantine (100.0%), isolation (98.9%), and school closure (97.8%). Individual‐level preventive measures such as personal hygiene (100.0%) and wearing facial masks (94.6% at hospitals; 93.5% at mass transportation; 91.3% in mass gathering facilities) were also frequently applied. Quarantine at a designated place was negatively associated with incidence and mortality compared to home quarantine. Isolation at a designated place was also associated with reduced mortality compared to home isolation. Recommendations to use sanitizer for personal hygiene reduced incidence compared to the recommendation to use soap. Deprivation of masks was associated with increased incidence. Higher incidence and mortality were found in countries/territories with higher economic levels. Mask deprivation was pervasive regardless of economic level. NPIs against COVID‐19 such as using sanitizer, quarantine, and isolation can decrease the incidence and mortality of COVID‐19.

Medico-Legal Examination of Sexual Assaulted Victims Unable to Consent in Portugal: Ethical Decision-Making

Medical decision-making is a complex task in any field. In the medico-legal examination of victims that have (allegedly) been sexually assaulted there are many specific variables and features influencing the decision. It is essential to complement the clinical intervention with a forensic approach. Clinical parameters such as the victim’s physical and cognitive state along with circumstantial information such as the elapsed time from the event and the type of abuse (described or suspected) grant different levels of priority to the forensic medical assessment. In such cases, forensic medical doctors or other medical doctors responsible for attending to the victim may have to decide whether to perform the examination prior to a judicial analysis of the case if consent cannot be obtained. This implies the need to deliberate about performing the examination and/or reporting the case to legal authorities. This article discusses the forensic medical decision-making process in cases of alleged recent sexual assault of victims who are legally unable to consent or unable to consent for other reasons. We aimed to identify possible ethical problems that can arise in this context and discuss which elements should be considered by medical doctors when making decisions about such cases. The Portuguese legal framework of medico-legal examinations is analyzed. The authors also make considerations about reporting these cases from a legal point of view. The discussion turns to an ethical perspective where possible ethical problems arising from medical deliberation are identified. Issues about legally incompetent victims and incompetent victims due to other reasons are addressed. A decision-making tree, based on the problems identified, is proposed.

Nonpharmaceutical interventions reduce the incidence and mortality of COVID-19: A study based on the survey from the International COVID-19 Research Network (ICRN)

The recently emerged novel coronavirus, "severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)," caused a highly contagious disease called coronavirus disease 2019 (COVID-19). It has severely damaged the world's most developed countries and has turned into a major threat for low- and middle-income countries. Since its emergence in late 2019, medical interventions have been substantial, and most countries relied on public health measures collectively known as nonpharmaceutical interventions (NPIs). We aimed to centralize the accumulative knowledge of NPIs against COVID-19 for each country under one worldwide consortium. International COVID-19 Research Network collaborators developed a cross-sectional online survey to assess the implications of NPIs and sanitary supply on the incidence and mortality of COVID-19. The survey was conducted between January 1 and February 1, 2021, and participants from 92 countries/territories completed it. The association between NPIs, sanitation supplies, and incidence and mortality were examined by multivariate regression, with the log-transformed value of population as an offset value. The majority of countries/territories applied several preventive strategies, including social distancing (100.0%), quarantine (100.0%), isolation (98.9%), and school closure (97.8%). Individual-level preventive measures such as personal hygiene (100.0%) and wearing facial masks (94.6% at hospitals; 93.5% at mass transportation; 91.3% in mass gathering facilities) were also frequently applied. Quarantine at a designated place was negatively associated with incidence and mortality compared to home quarantine. Isolation at a designated place was also associated with reduced mortality compared to home isolation. Recommendations to use sanitizer for personal hygiene reduced incidence compared to the recommendation to use soap. Deprivation of masks was associated with increased incidence. Higher incidence and mortality were found in countries/territories with higher economic levels. Mask deprivation was pervasive regardless of economic level. NPIs against COVID-19 such as using sanitizer, quarantine, and isolation can decrease the incidence and mortality of COVID-19.

Use of deep learning in forensic sex estimation of virtual pelvic models from the Han population

Accurate sex estimation is crucial to determine the identity of human skeletal remains effectively. Here, we developed convolutional neural network (CNN) models for sex estimation on virtual hemi-pelvic regions, including the ventral pubis (VP), dorsal pubis (DP), greater sciatic notch (GSN), pelvic inlet (PI), ischium, and acetabulum from the Han population and compared these models with two experienced forensic anthropologists using morphological methods. A Computed Tomography (CT) dataset of 862 individuals was divided into the subgroups of training, validation, and testing, respectively. The CT-based virtual hemi-pelvises from the training and validation groups were used to calibrate sex estimation models; and then a testing dataset was used to evaluate the performance of the trained models and two human experts on the sex estimation of specific pelvic regions in terms of overall accuracy, sensitivity, specificity, F1 score, and receiver operating characteristic (ROC) curve. Except for the ischium and acetabulum, the CNN models trained with the VP, DP, GSN, and PI images achieved excellent results with all the prediction metrics over 0.9. All accuracies were superior to those of the two forensic anthropologists in the independent testing. Notably, the heatmap results confirmed that the trained CNN models were focused on traditional sexual anatomic traits for sex classification. This study demonstrates the potential of AI techniques based on the radiological dataset in sex estimation of virtual pelvic models. The excellent sex estimation performance obtained by the CNN models indicates that this method is valuable to proceed with in prospective forensic trials.

European Council of Legal Medicine (ECLM) on-site inspection forms for forensic pathology, anthropology, odontology, genetics, entomology and toxicology for forensic and medico-legal scene and corpse investigation: the Parma form

Further to a previous publication by the European Council of Legal Medicine (ECLM) concerning on-site forensic and medico-legal scene and corpse investigation, this publication provides guidance for forensic medical specialists, pathologists and, where present, coroners' activity at a scene of death inspection and to harmonize the procedures for a correct search, detection, collection, sampling and storage of all elements which may be useful as evidence, and ensure documentation of all these steps. This ECLM's inspection form provides a checklist to be used on-site for the investigation of a corpse present at a crime or suspicious death scene. It permits the collection of all relevant data not only for the pathologist, but also for forensic anthropologists, odontologists, geneticists, entomologists and toxicologists, thus supporting a collaborative work approach. Detailed instructions for the completion of forms are provided.

Trends in microextraction approaches for handling human hair extracts - A review

The complementary role of hair in testing scenarios has expanded across the spectrum of toxicological and clinical monitoring investigations and, over the last 20 years, hair analysis has gained increasing attention and recognition. Moreover, a great deal of attention has been paid to the miniaturisation of extraction procedures, minimising/eliminating toxic organic solvents consumption, making them user-friendly and rapid, in addition to maximising extraction efficiency. The aim of this work is to provide a critical review of the advances observed over the last 5 years in the use of miniaturised approaches for sample clean-up and drug pre-concentration in hair analysis. There have been major improvements in some well-established microextraction approaches, such as liquid phase microextraction, mainly through the use of supramolecular and ionic liquids. In addition, new developments have also been reported in solid phase microextraction, driven by d-SPE applications. In the last 5 years, a total of 69 articles have been published using some type of microextraction technique for hair specimens, thus justifying the relevance of a critical review of innovations, improvements and trends related to these miniaturised approaches for sample preparation.

A potential method for sex estimation of human skeletons using deep learning and three-dimensional surface scanning

Deep learning based on radiological methods has attracted considerable attention in forensic anthropology because of its superior classification capacities over human experts. However, radiological instruments are limited in their nature of high cost and immobility. Here, we integrated a deep learning algorithm and three-dimensional (3D) surface scanning technique into a portable system for pelvic sex estimation. Briefly, the images of the ventral pubis (VP), dorsal pubis (DP), and greater sciatic notch (GSN) were cropped from virtual pelvic samples reconstructed from CT scans of 1000 individuals; 80% of them were used to train and internally evaluate convolutional neural networks (CNNs) that were then evaluated externally with the remaining samples. An additional 105 real pelvises were documented virtually with a handheld 3D surface scanner, and the corresponding snapshots of the VP, DP, and GSN were predicted by the trained CNN models. The CNN models achieved excellent performance in the external testing using CT-based images, with accuracies of 98.0%, 98.5%, and 94.0% for VP, DP, and GSN, respectively. When the CT-based models were applied to 3D scanning images, they obtained satisfactory accuracies above 95% on the VP and DP images compared to the GSN with 73.3%. In a single-blind trial, a multiple design that combined the three CNN models yielded a superior accuracy of 97.1% with 3D surface scanning images over two anthropologists. Our study demonstrates the great potential of deep learning and 3D surface scanning for rapid and accurate sex estimation of skeletal remains.

Acute liver failure requiring transplantation: A possible link to ulipristal acetate treatment?

The present case describes in detail a 55-year-old woman diagnosed with acute liver injury 3 days after completion of the first treatment course with ulipristal acetate (UPA), 5 mg/day orally for uterine fibroids causing persistent bleeding (treatment duration of 109 days). Liver transplantation was performed approximately 6 weeks after UPA suspension, and a photograph of the explanted liver is presented. Of note, other common causes of acute liver injury, such as history of alcohol or other psychoactive substances abuse, viral hepatitis and autoimmune hepatitis or preexisting liver disease were all excluded. This case was reported to the European Medicines Agency (EMA) and contributed to the final recommendations of the Pharmacovigilance Risk Assessment Committee (PRAC) disclosed in January 2021. The causality assessment considered a probable case of drug-induced liver injury as a consequence of UPA treatment, and the Roussel Uclaf Causality Assessment Method (RUCAM) was scored as unlikely. Although further studies are needed aiming to avoid confounding factors, this case suggests that liver function tests should be monitored during treatment with UPA.

An efficient method for building a database of diatom populations for drowning site inference using a deep learning algorithm

Seasonal or monthly databases of the diatom populations in specific bodies of water are needed to infer the drowning site of a drowned body. However, existing diatom testing methods are laborious, time-consuming, and costly and usually require specific expertise. In this study, we developed an artificial intelligence (AI)-based system as a substitute for manual morphological examination capable of identifying and classifying diatoms at the species level. Within two days, the system collected information on diatom profiles in the Huangpu and Suzhou Rivers of Shanghai, China. In an animal experiment, the similarities of diatom profiles between lung tissues and water samples were evaluated through a modified Jensen-Shannon (JS) divergence measure for drowning site inference, reaching a prediction accuracy of 92.31%. Considering its high efficiency and simplicity, our proposed method is believed to be more applicable than existing methods for seasonal or monthly water monitoring of diatom populations from sections of interconnected rivers, which would help police narrow the investigation scope to confirm the identity of an immersed body.

Socialization During the COVID-19 Pandemic: The Role of Social and Scientific Networks During Social Distancing

In the COVID-19 era, while we are encouraged to be physically far away from each other, social and scientific networking is needed more than ever. The dire consequences of social distancing can be diminished by social networking. Social media, a quintessential component of social networking, facilitates the dissemination of reliable information and fighting against misinformation by health authorities. Distance learning, telemedicine, and telehealth are among the most prominent applications of networking during this pandemic. Additionally, the COVID-19 pandemic highlights the importance of collaborative scientific efforts. In this chapter, we summarize the advantages of harnessing both social and scientific networking in minimizing the harms of this pandemic. We also discuss the extra collaborative measures we can take in our fight against COVID-19, particularly in the scientific field.

Microextraction by Packed Sorbent as a Novel Strategy for Sample Clean-Up in the Determination of Methadone and EDDP in Hair

A microextraction by packed sorbent (MEPS) procedure for rapid concentration of methadone and its primary metabolite (EDDP) in hair samples was developed. The miniaturized approach coupled to gas chromatography with tandem mass spectrometry (GC-MS-MS) was successfully validated. Hair samples (50 mg) were incubated with 1 mL of 1 M sodium hydroxide for 45 min at 50°C, time after which the extract was neutralized by adding 100 μL of 20% formic acid. Subsequently, MEPS was applied using a M1 sorbent (4 mg; 80% C8 and 20% strong cation-exchange (SCX)), first conditioned with three 250-μL cycles of methanol and three 250-μL cycles of 2% formic acid. The extract load occurred with nine 150-μL cycles followed by a washing step involving three 50-μL cycles with 3.36% formic acid. For the elution of the analytes, six 100-μL cycles of 2.36% ammonium hydroxide in methanol were applied. The method was linear from 0.01 to 5 ng/mg, for both compounds, presenting determination coefficients greater than 0.99. Precision and accuracy were in accordance with the statements of international guidelines for method validation. This new miniaturized approach allowed obtaining recoveries ranging from 73 to 109% for methadone and 84 to 110% for EDDP, proving to be an excellent alternative to classic approaches, as well as other miniaturized procedures.

U100: An Innovative USERN Platform for Education and Research Without Borders

The article's abstract is no available.

All together to Fight COVID-19

Novel coronavirus disease (COVID-19), named a pandemic by the WHO, is the current global health crisis. National and international collaboration are indispensable for combating COVID-19 and other similar potential outbreaks. International efforts to tackle this complex problem have led to remarkable scientific advances. Yet, as a global society, we can and must take additional measures to fight this pandemic. Undoubtedly, our approach toward COVID-19 was not perfect, and testing has not been deployed fast enough to arrest the epidemic early on. It is critical that we revise our approaches to be more prepared for pandemics as a united body by promoting global cooperation and commitment.

Overview of clinical forensic services in various countries of the European Union

Examination of a person who has been a victim of a physical or sexual assault may be very important for upcoming legal proceedings. In the context of a clinical forensic examination, physical findings are recorded and biological trace material is gathered and secured. Ideally, all forensic findings are documented in a detailed report combined with photographic documentation, which employs a forensic scale to depict the size of the injuries. However, the integrity of such forensic findings depends particularly on two factors. First, the examination needs to be conducted professionally to ensure that the findings are properly admissible as court evidence. Second, the examination should take place as soon as possible because the opportunity to successfully secure biological samples declines rapidly with time. Access to low-threshold clinical forensic examinations is not evenly provided in all member states of the European Union (EU); in some states, they are not available at all. As part of the JUST_eU! (Juridical standards for clinical forensic examinations of victims of violence in Europe) project, the Ludwig Boltzmann Institute for Clinical Forensic Imaging in Graz, Austria created (in cooperation with its international partner consortium) a questionnaire: the purpose was to collect information about support for victims of physical and/or sexual assault in obtaining a low-threshold clinical forensic examination in various countries of the EU. Our paper provides a summary of the responses and an overview of the current situation concerning provided clinical forensic services.

Deoxyribonucleic Acid Extraction and Quantification from Human Saliva Deposited on Foods with Bitemarks

AIM

The aim of this study is to evaluate the potential of deoxyribonucleic acid (DNA) recovery from bite marks in foods, in different collection types, from DNA quantification.

MATERIALS AND METHODS

The sample consisted of 80 swabs, obtained from 20 cheese pieces, bitten by the same person, using the double-swab technique in the center and the periphery of the bite. A statistical analysis was carried out using Statistical Package for the Social Sciences (SPSS) statistical software version 20.0, with values of p < 0.05 being considered statistically significant.

RESULTS

The DNA was recovered in all cheese pieces, regardless of the collection types and the bite region. However, the comparative analysis of DNA recovery potential in the four swabs allowed us to infer that the collections in the central region of the bite (DC and WC) were the ones that presented better precision, in addition to extracting a higher DNA concentration, the dry swab being in the center of the bite which presented better results.

CONCLUSION

The results proved the effectiveness of the double-swab technique for collecting genetic materials in bite marks; however, in the food used, a single collection at the center of the bite would be enough, optimizing the resources and time needed for the analysis.

CLINICAL SIGNIFICANCE

Due to the difficulties of physically comparing a site of a skin lesion and the dental arches of the suspect, the evidence of DNA in saliva has been used to indicate the perpetrator of the bite. In addition, the collection, preservation, and isolation of saliva DNA can be done at low cost and provide flexibility for clinical and laboratory workflow.

Determination of Selected Opiates in Hair Samples Using Microextraction by Packed Sorbent: A New Approach for Sample Clean-up

In this article the development and validation of an analytical method using microextraction by packed sorbent (MEPS) to determine tramadol (TRM), codeine (COD), morphine (MOR), 6-acetylcodeine (6-AC), 6-monoacetylmorphine (6-MAM) and fentanyl (FNT) in hair samples by gas chromatography coupled to tandem mass spectrometry (GC–MS-MS) is presented. The MEPS used a mixed mode sorbent, and the steps for sample cleanup were conditioning (three cycles of 250 μL of methanol and three cycles of 250 μL formic acid 2%); sample load (15 cycles of 150 μL); wash (150 μL of 3.36% formic acid); and elution (eight cycles of 100 μL of ammonium hydroxide 2.36% (in methanol)). Linearity was obtained from the lower limit of quantitation (LLOQ) up to 5 ng/mg, with all target compounds revealing determination coefficients >0.99. The LLOQs achieved were 0.01 ng/mg for TRM, COD and 6-AC, and 0.025 ng/mg for MOR, 6-MAM and FNT. The recoveries ranged from 74 to 90% (TRM), 51 to 59% (COD), 22 to 36% (MOR), 69 to 99% (6-AC), 53 to 61% (6-MAM) and 75 to 86% (FNT). Precision and accuracy revealed coefficients of variation typically below 15% and relative errors within a ±15% interval, respectively. This new approach has proven to be an excellent alternative to classic procedures, reducing the volumes of organic solvents required.

A reliable method for estimating the postmortem interval from the biochemistry of the vitreous humor, temperature and body weight

The estimation of the time elapsed since death is of paramount importance in the field of forensic sciences and criminal investigation, owing, among other factors, to the possible legal repercussions. Over the past few years various formulae have been developed to calculate this interval using a combination of different statistical methods and the concentrations of substances found in the vitreous humor. Corrective factors, such as ambient temperature, cause of death or age, which can modify the concentration of these substances and therefore the estimation of the postmortem interval, have been incorporated into models. In this paper five simple and reliable models to estimate PMI based the on the analysis of potassium, hypoxanthine and urea in the vitreous humor are presented. Corrective factors, such as body weight, rectal temperature and ambient temperature, which can influence the estimation of this interval have been incorporated into the formulae. Finally, the R2 and the mean squared error have been calculated for each model in order to select the best of the five. A free software program which calculates the PMI from the model and parameters used is available from the authors. It provides quick and reliable results as well as the error committed and R2 for each case.

Unusual case of a fatal upper esophageal trauma caused by a toothpick

The authors report the case of the unexpected death of a fifty-year-old female found by her partner in the bathroom floor. External examination revealed some contusions dispersed by different corporal areas and an unusually placed green discoloration of the anterior cervical region. After neck dissection and opening the esophagus, a three and a half centimeter wooden toothpick fragment was found at the upper region, covered by a purulent substance associated with puncture wounds. Histopathological and microbiological studies revealed "acute bilateral cervical cellulitis" and Klebsiella Oxytoca, respectively. Further investigation revealed that during the five days prior to her death, the victim was observed twice in an emergency department with complains of throat discomfort after eating some bread with salami. X-Ray and a laryngoscopy were performed but did not reveal any significant findings. Due to the victim's medical history, she was evaluated by a psychiatrist that dismissed a non-somatic setting due to the type of complains and the elevation of blood inflammatory parameters. Rinopharyngitis was then assumed as the most likely diagnosis and was treated accordingly. The victim died the following day. This case reports an unusual fatal traumatic lesion to the upper esophagus that is a very important remainder, particularly for clinical practitioners, to maintain a high degree of suspicion, avoid diagnostic biases such as those related to psychiatric disorders and meticulously evaluate patients in order to deliver the most evidence-based diagnosis possible. To the best of the authors' knowledge there are no other cases described in the literature of a death caused by esophageal toothpick lesion.

European council of legal medicine (ECLM) guidelines for the examination of suspected elder abuse

Article 25 of the Charter of Fundamental Rights of the European Union (adopted in Nice on 7 December 2000) recognizes and respects the rights of older people to lead a life of dignity and independence and to participate in social and cultural life. It also highlights the importance of prevention and recognition of elder abuse, especially since exposure to violence is likely as the population ages, either in familial or in institutional settings. Elder abuse has some issues in common with child abuse but in spite of this fact currently is less recognized. Health professionals have a major role to play in early detection and management of cases of elder abuse. This protocol summarizes some key concepts and approaches to assist in the timely detection and investigation of elder abuse cases by healthcare professionals and forensic practitioners.

Tri-dimensional pattern analysis of foodstuff bitemarks - A pilot study of tomographic database

The analysis of bitemarks has been mostly done through analogical methods. The advent of current technologies brings new and more reliable tools for analyzing evidence. Bitemarks can now be turned into more consistent evidence by using a digital tridimensional (3D) analysis. The aim of this study is to propose a reliable, accurate and monitorized approach of 3D bitemark analysis. 12 cranium Cone Beam Computed Tomographic (CBCT) files were randomly selected from a clinical database (Coimbra Hospital and University Center/Faculty of Medicine of the University of Coimbra). The individuals were recalled to bite an apple (golden delicious 65/80) immediately subjected to a CBCT scan. The 3D rendering of every bitemark was compared with the 3D upper dental arches obtained from the CBCT cranium scans of the simulated suspects. The research team was composed by 5 elements. The matching process consists of corresponding landmark points, in both the bitemark and the suspects' dentition (upper dental arch). 144 comparisons were obtained. The Kappa statistics analysis was performed. Cohen's Kappa values were obtained between 0,690 and 0,910. Fleiss Kappa obtained a value of 0,767. The Friedman's test was performed and the normality assumption was not verified (p>0,05). A non-destructive protocol of bitemark study by 3D analysis of tomographic volumes was presented. The statistic analysis supports its accuracy and reliability. This experimental study opens doors to a future where bitemark analysis could be done through software that searches for matching dentitions in a CBCT database.

Guidelines examination of victims of sexual assault harmonization of forensic and medico-legal examination of persons

Sexual assault is a complex situation with medical, psychological, and legal aspects. Forensic experts play a major role in terms of forensic and gynecological medical examination and evidence collection in order to maintain the chain of custody. Victims should be examined by a specially trained medico-legal examiner in order to avoid multiple examinations in the surroundings that do not meet minimum health standards. The evolution and treatment of sexual assault victims are time-intensive and should optimally be provided by a team that includes a forensic medical doctor. These guidelines will be of interest to forensic medical doctors who will have responsibility for the examination and assessment of victims of sexual violence and can be used as a day-to-day service document and/or a guide to develop health service for victims of sexual violence.

Study of mortality from infectious diseases in Brazil from 2005 to 2010: risks involved in handling corpses

In the wake of disasters, the lack of information on how to handle and dispose of corpses leads the professionals involved in emergency operations to uncertainty about associated risks and safety precautions. The article seeks to establish the risks of the etiologic agents involved in Brazilian mortality due to infectious diseases and identify and discuss the main protection measures for professionals involved in handling of corpses in disaster situations. It involved a survey of deaths by infectious diseases in Brazil between 2005 and 2010, using data from the Mortality Information System. Of the 171,223 deaths analyzed, the pathogens leading to the greatest number of deaths were: HIV, Mycobacterium tuberculosis and Trypanosoma cruzi. 59% belonged to risk class 3 and 40.6% to risk class 2. Eight deaths were caused by risk class 4 pathogens, which represent high risk. The professionals involved in the handling of corpses may be exposed to chronic risks, such as viruses transmitted via blood, gastrointestinal infections and tuberculosis. These findings indicate the importance of investment in the preparation of measures to reduce the risk of infection associated with the handling of corpses.

Cardiac injuries caused by trauma: Review and case reports

Assessment of suspected cardiac injuries in a trauma setting is a challenging and time-critical matter, with clinical and imaging findings having complementary roles in the formation of an accurate diagnosis. In this article, we review the supporting literature for the pathophysiology, classification and evaluation of cardiac injuries caused by trauma. We also describe 4 cardiac trauma patients seen at a tertiary referral hospital.

Guidelines for Collection of Biological Samples for Clinical and Forensic Toxicological Analysis

This article aims to review general procedures for sampling of routinely collected as well as on alternative samples that may provide additional information regarding intoxication. These approaches may be applied whenever sample collection for clinical and forensic toxicology is required and should be considered as general guidelines that must be adapted to each specific case. It is expected that this article will help toxicologists and other forensic experts to accomplish their mission, since the toxicological result is first influenced by the quality and quantity of the sample available for analysis. These guidelines were approved by the European Council of Legal Medicine.

Bacillus anthracis como ameaça terrorista

Após 2001, a utilização de patógenos reforçou seu emprego como arma de guerra. Este estudo descritivo tem por objetivo discutir estratégias de contingenciamento em ataque por anthrax, auxiliando no reconhecimento precoce e estabelecimento de medidas de contenção. Profissionais de saúde necessitam reconhecer a infecção, pois em atentados, o elemento-chave é médico e não militar. O anthrax por inalação é a forma de atentado mais provável com 100% de mortalidade, caso não haja tratamento imediato. É altamente resistente; tem período de incubação de um a seis dias; seus sintomas iniciais são similares à influenza; só permite diagnóstico em NB3; a vacina é aquela recomendada para ocupações de risco, de disponibilidade restrita; e requer profilaxia antibiótica longa.

Detection and Intervention Strategies by Primary Health Care Professionals in Suspected Elder Abuse

INTRODUCTION

Primary health care professionals are in a privileged position to recognize and manage cases of suspected elder abuse. The purpose of this study was to provide some insight of these professionals' views and knowledge on this subject.

MATERIAL AND METHODS

A questionnaire was elaborated and sent to physicians and nursing staff practicing in 12 different health care units in Coimbra. The data collected included parameters related to demography, perception of abuse and management strategies, personal experience and training on this subject.

RESULTS

The global response rate was 67.9% corresponding to 127 validated questionnaires. From the results found, we highlight the following: there was a significant contact between these professionals and older people; most (64.6%) considered the abuse as more prevalent in the familiar context and 32.3% signed negligence as the most common type; the majority of professionals considered themselves as useful (97.6%); the uncertainty in the diagnosis was one of the most important causes for non-reporting; there were doubts concerning mandatory report of abuse to judicial authorities. It was also found that 87.4% of the respondents stated they would feel more comfortable having formal protocol to handle these cases and this subject was not included in the training curriculum of 70.9% of the respondents.

DISCUSSION

The significant contact between older population and health care professionals allows for an early diagnose and intervention. The professionals showed knowledge in accordance to some studies, namely, as to the context and prevalence of abuse. Doubts as to the best way to manage these cases could be solved by implementing protocols and by specific training, which is a fundamental cornerstone for preparing professionals to deal with these kind of cases.

CONCLUSION

Health care professionals seemed to be aware of the relevance of elder abuse, as well as the importance of their role in preventing and diagnosing these abuses. However, a more extensive approach on this subject during clinical training and the definition of general clinical guidelines are important to increase the professionals' confidence in managing suspected cases.

Medico-legal litigation in Obstetrics: a characterization analysis of a decade in Portugal

PURPOSE

It was to analyse the most critical areas in Obstetrics and to suggest measures to reduce or avoid the situations most often involved in these disputes.

METHODS

Obstetrics cases submitted to the Medico-legal Council since the creation of the National Institute of Legal Medicine and Forensic Sciences in 2001 until 2011 were evaluated. A comprehensive characterization, determination of absolute/relative frequencies, hypothesis of a linear trend over the years and the association between each parameter was done.

RESULTS

The analysis has shown no significantly linear trend. The most common reasons for disputes were perinatal asphyxia (50%), traumatic injuries of the newborn (24%), maternal sequelae (19%) and issues related to prenatal diagnosis and/or obstetric ultrasound (5.4%). Perinatal asphyxia showed no significantly linear trend (p=0.58) and was usually related to perinatal deaths or permanent neurologic sequelae in newborn children. Traumatic injuries of the newborn, mostly related to instrumented deliveries, shoulder dystocia or vaginal delivery in breech presentation, has shown a significantly increased linear trend (p<0.001), especially related to instrumented deliveries. The delay/absence of cesarean section was the clinical procedure questioned in a significantly higher number of cases of perinatal asphyxia (68.7%) and of traumatic lesions of the newborn due to instrumented deliveries (20.5%).

CONCLUSION

It is important to improve and correct theoretical/practical daily clinical performance in these highlighted areas, in order to reduce or even avoid situations that could end up in medico-legal litigations.

Estudo sobre pessoas idosas vítimas de violência em Portugal: sociografia da ocorrência

O presente artigo apresenta dados sobre violência contra pessoas com 60 e mais anos residentes em Portugal há mais de 12 meses. O estudo transversal e descritivo recolheu dados por meio de um questionário aplicado presencialmente a vítimas que recorreram a três entidades governamentais e a uma instituição não-governamental de apoio a vítimas. A amostra não probabilística foi constituída por 510 vítimas de violência em contexto familiar. A violência física e a psicológica foram os tipos mais reportados, afetando 87,8% e 69,6% das pessoas estudadas, seguindo-se a violência financeira (47,5%), sexual (7,5%) e a negligência (6,5%). A maioria (74,1%) dos respondentes indicou mais de um tipo de violência. As vítimas, na maioria mulheres, tinham uma média de idade de 70,7 anos. A maioria dos agressores pertencia à família nuclear, nomeadamente, cônjuges ou companheiros, filhos/enteados e filhas/enteadas. Contudo, observaram-se diferenças no agressor consoante o gênero da vítima. Os resultados indicam que a violência não é um fenômeno uniforme, apresentando-se sob diferentes configurações.

Lessons from a decade of technical-scientific opinions in obstetrical litigation

The authors aimed to assess the Portuguese circumstances concerning situations of medico-legal dispute in Obstetrics, evaluate the conclusions of technical-scientific opinions and analyze their consequences. The analysis of all cases of Obstetrics medical responsibility examined in Medico-legal Council since the creation of the National Institute of Legal Medicine was performed. Technical-scientific opinions of those files were examined according to the existence of a causal link and of infringement of the 'leges artis'. The most common reasons for dispute in Obstetrics were perinatal asphyxia (50%), traumatic injuries of the newborn (24%), maternal sequelae (19%) and issues related to prenatal diagnosis and/or obstetric ultrasound (5.4%). In the technical-scientific opinions of files examined, the existence of a causal link was established in 17.4%, and the infringement of the 'leges artis' was suggested in 15.5% of cases, numbers which have grown significantly over the years and which are particularly relevant in the proceedings of perinatal asphyxia and traumatic lesions of the newborn. In 11% of cases the opinion was inconclusive due to the poor quality of the clinical process sent for analysis. These results highlight the impact that litigation can have on the professional activity and personal lives of obstetricians. It should alert them for the need to better fulfill medical clinical files in order to reduce or avoid medico-legal conflicts, as well as to the fact of the increasing practice of defensive medicine and its consequences in daily clinical routine for doctors and patients.

O Respeito pela Autonomia da Criança na Regulação das Responsabilidades Parentais

Child custody decisions are among the most difficult is one of the most difficult for judges to make. The possibility of child abuse allegations or parents’ deviant/psychopathologic behaviours within this context, make the decision further complicated. Based on jurisprudence the listening of children opinion is a way to protect their best interest. In fact children have the right to express an opinion in all matters affecting their life. It should be given proper consideration to children opinion according with his/her age and maturity. Nonetheless custody disputes are emotionally draining issues. Asking the child to express an opinion during a public hearing, most likely in the presence of both parents, its not recommended because this is a potential stressful experience. Child interviews should take place in a proper environment and be set to their age. Medicine and Psychology have an important role in assessing children cognitive, emotional and volitional abilities, which is essential to properly account their opinions according to autonomy degree. This essay analyses the contribution of medico-legal and/or psychological exams to respect the autonomy of the child in cases of regulation of parental responsibilities. The conclusion is the need to establish a symbiotic relationship between the medical and legal perspectives of the (open) concept of child’s best interests.

[Respecting minors' autonomy in child custody cases]

Child custody decisions are among the most difficult for judges to make. The possibility of child abuse allegations or parents' deviant/ psychopathologic behaviours within this context, make the decision further complicated. Based on jurisprudence the listening of children opinion is a way to protect their best interest. In fact children have the right to express an opinion in all matters affecting their life. It should be given proper consideration to children opinion according with his/her age and maturity. Nonetheless custody disputes are emotionally draining issues. Asking the child to express an opinion during a public hearing, most likely in the presence of both parents, its not recommended because this is a potential stressful experience. Child interviews should take place in a proper environment and be set to their age. Medicine and Psychology have an important role in assessing children cognitive, emotional and volitional abilities, which is essential to properly account their opinions according to autonomy degree. This essay analyses the contribution of medico-legal and/or psychological exams to respect the autonomy of the child in cases of regulation of parental responsibilities. The conclusion is the need to establish a symbiotic relationship between the medical and legal perspectives of the (open) concept of child's best interests.

Fatal intimate partner violence against women in Portugal: a forensic medical national study

Intimate partner violence (IPV) is an important cause of women's health and socio-familial severe problems, the most extreme being the victims' homicide. This is the first nationwide Portuguese autopsy-based and judicial-proven study about female intimate partner homicide. At least 62 women over 15 years old were killed by current or former men-intimate partners, corresponding to an IPV-related female mortality rate of 0.44/100.000 women; intimate partner violence was the reason of homicide in 60.8% of all autopsied women. The typical Portuguese victim showed to be a young adult woman, employed, killed by a current husband in a long-term relationship, usually with children in common and with a history of previous IPV. The typical Portuguese perpetrator showed to be older than the victim, employed, owning a firearm and without criminal records. At the time of the fatal event 59.7% of the relationships were current. In 57.9% of the former relationships women were killed during the 1st year after its terminus. Near half of the perpetrators attempted or committed suicide afterward. Most women were killed by gunshot wounds (45.2%), especially in the thorax (48.4%), with multiple fatal injuries; 56.5% also presented non-fatal injuries. The detection of prior IPV and the risk evaluation seems to be fundamental to decrease these fatal outcomes, but also, the prevention of perpetrators' alcohol abuse and carrying weapons. This work emphasizes the need to deepen the research on this issue, aiming to contribute to prevent both fatal and non-fatal IPV-related cases.