Allochrony is shaped by foraging niche segregation rather than adaptation to the windscape in long-ranging seabirds

BACKGROUND

Ecological segregation allows populations to reduce competition and coexist in sympatry. Using as model organisms two closely related gadfly petrels endemic to the Madeira archipelago and breeding with a two month allochrony, we investigated how movement and foraging preferences shape ecological segregation in sympatric species. We tested the hypothesis that the breeding allochrony is underpinned by foraging niche segregation. Additionally, we investigated whether our data supported the hypothesis that allochrony is driven by species-specific adaptations to different windscapes.

METHODS

We present contemporaneous tracking and stable isotopes datasets for Zino's (Pterodroma madeira) and Desertas (Pterodroma deserta) petrels. We quantified the year-round distribution of the petrels, characterised their isotopic niches and quantified their habitat preferences using machine learning (boosted regression trees). Hidden-Markov-models were used to investigate the effect of wind on the central-place movement speed, and a simulation framework was developed to investigate whether each species breeds at times when the windscape is most favourable to sustain their trips.

RESULTS

Despite substantial spatial overlap throughout the year, the petrels exhibited diverging isotopic niches and habitat preferences during breeding. Both species used a vast pelagic region in the North Atlantic, but targeted two different mesopelagic ecoregions and showed a preference for habitats mostly differing in sea surface temperature values. Based on our simulation framework, we found that both species would perform trips of similar speed during the other species' breeding season.

CONCLUSIONS

The different breeding schedules between the species are underpinned by differences in foraging habitat preferences and adaptation to the local environment, rather than to the windscape. Nevertheless, the larger Desertas petrels exploited significantly windier conditions, potentially unsustainable for the smaller Zino's petrels. Furthermore, due to larger mass and likely higher fasting endurance, Desertas petrels engaged in central-place-foraging movements that covered more ground and lasted longer than those of Zino's petrels. Ultimately, patterns of ecological segregation in sympatric seabirds are shaped by a complex interplay between foraging and movement ecology, where morphology, foraging trip regulation and fasting endurance have an important- yet poorly understood- role.

Chronic sacroiliac joint dysfunction and CT-guided percutaneous fixation: a 6-year experience

PURPOSE

Reporting the clinical outcomes, patient satisfaction, and complications following an imaging-guided percutaneous screw fixation in the treatment of sacroiliac joint dysfunction and evaluating the safety and effectiveness of this method.

METHODS

We performed a retrospective study on a prospectively gathered cohort of patients with physiotherapy-resistant pain due to sacroiliac joint incompetence that underwent percutaneous screw fixation, between 2016 and 2022 in our center. A minimum of two screws were used in all patients to obtain fixation of the sacroiliac joint, using percutaneous screw insertion under CT guidance, coupled with a C-arm fluoroscopy unit.

RESULTS

The mean visual analog scale significantly improved at 6 months of follow-up (p < 0.05). One hundred percent of the patients reported significant improvement in pain scores at the final follow-up. None of our patients experienced intraoperative or postoperative complications.

CONCLUSION

The use of percutaneous sacroiliac screws provides a safe and effective technique for the treatment of sacroiliac joint dysfunction in patients with chronic resistant pain.

Fatal diving accidents in Genoa (North-West Italy) from 1968 to 2021: Forensic approach and literature review

Scuba diving is one of the most common and practised water sport activities in Genoa, especially in the more recent years. Although scuba diving is generally considered a safe activity, this does not exclude the possibility of serious or fatal accidents from happening. This retrospective study investigates the case history of deaths resulting from diving accidents recorded by the Municipal Morgue of Genoa over a period of 53 years, specifically from 1968 to 2021. Of the total 52 deaths covered by the study, 48 were male with an age range of 16-71 years. In 25 of these subjects, pre-existing pathological conditions of a cardiovascular nature, not recognised at the time of death, were reported. Out of the total deaths studied, 9 subjects died following a diving accident related to free diving, while 43 subjects died from scuba or rebreather diving. Among the latter subjects, the cause of death was attributed to drowning in 17 cases, arterial gas embolism (AGE) from pulmonary over-distension in 11 cases, cardio-circulatory arrest (CA) favoured by pre-existing and non-existing heart disease known prior to the death in 10 cases, decompression sickness (DCS) in 2 cases, a combination of DCS and AGE in 2 cases and oxygen intoxication in 1 case. Twelve of the fatal accidents occurred in the marine area near the village of Arenzano, where the shipwreck of the oil tanker, the "Haven", sank in 1991 and is today the largest shipwreck explored by divers in the Mediterranean Sea. In all cases of diving deaths, a multi-disciplinary approach is important: in particular, the role of the forensic pathologist is essential in order to accurately reconstruct the dynamics of the accident, thus identifying the predisposing or triggering factors that led to death, and defining the cause of it.

Effect of Polymer Composition on the Optical Properties of a New Aggregation-Induced Emission Fluorophore: A Combined Experimental and Computational Approach

Nowadays, fluorophores with a tetraphenylethylene (TPE) core are considered interesting due to the aggregation-induced emission (AIE) behavior that enables their effective use in polymer films. We propose a novel TPE fluorophore (TPE-BPAN) bearing two dimethylamino push and a 4-biphenylacetonitrile pull moieties with the typical AIE characteristics in solution and in the solid state, as rationalized by DFT calculations. Five different host polymer matrices with different polarity have been selected: two homopolymers of poly(methylmethacrylate) (PMMA) and poly(cyclohexyl methacrylate) (PCHMA) and three copolymers at different compositions (P(MMA-co-CHMA) 75:25, 50:50, and 25:75 mol%). The less polar comonomer of CHMA appeared to enhance TPE-BPAN emission with the highest quantum yield (QY) of about 40% measured in P(MMA-co-CHMA) 75:25. Further reduction in polymer polarity lowered QY and decreased the film stability and adhesion to the glass surface. LSC performances were not significantly affected by the matrix's polarity and resulted in around one-third of the state-of-the-art due to the reduced QY of TPE-BPAN. The theoretical investigation based on density functional theory (DFT) calculations clarified the origin of the observed AIE and the role played by the environment in modulating the photophysical behavior.

Synthesis of Functionalized Triblock Copolyesters Derived from Lactic Acid and Macrolactones for Bone Tissue Regeneration

Synthetic and functional grafts are a great alternative to conventional grafts. They can provide a physical support and the precise signaling for cells to heal damaged tissues. In this study, a novel RGD peptide end-functionalized poly(ethylene glycol)-b-poly(lactic acid)-b-poly(globalide)-b-poly(lactic acid)-b-poly(ethylene glycol) (RGD-PEG-PLA-PGl-PLA-PEG-RGD) is synthetized and used to prepare functional scaffolds. The PGl inner block is obtained by enzymatic ring-opening polymerization of globalide. The outer PLA blocks are obtained by ring-opening polymerization of both, l-lactide or a racemic mixture, initiated by the α-ω-telechelic polymacrolactone. The presence of PGl inner block enhances the toughness of PLA-based scaffolds, with an increase of the elongation at break up to 300% when the longer block of PGl is used. PLA-PGl-PLA copolymer is coupled with α-ω-telechelic PEG diacids by esterification reaction. PEGylation provides hydrophilic scaffolds as the contact angle is reduced from 114° to 74.8°. That difference improves the contact between the scaffolds and the culture media. Moreover, the scaffolds are functionalized with RGD peptides at the surface significantly enhancing the adhesion and proliferation of bone marrow-derived primary mesenchymal stem cells and MC3T3-E1 cell lines in vitro. These results place this multifunctional polymer as a great candidate for the preparation of temporary grafts.

Immunohistochemical detection of Fibronectin, P-Selectin, FVIII, HSP-70 and MRP-8 in the skin of ligature marks of suicidal hangings

The determination of vitality of skin injuries is one of the most central research areas in forensic pathology for it is often necessary to discern antemortem from postmortem damage. Typical is the case of a hanging, which should be distinguished from the postmortem suspension of a body. In this study, 15 human skin samples from ligature marks (study group) of victims of suicidal hanging and 15 uninjured skin samples (negative control group) were analyzed. In addition, 15 skin samples from ecchymoses in homicide victims with short survival intervals were investigated as a positive control group. Sections were processed for immunohistochemistry in order to detect the expression of Fibronectin, P-Selectin, FVIII, HSP-70, and MRP8. Immunohistochemical reactions were classified semiquantitatively (mild - score 1, moderate - score 2, and intense - score 3). In the ligature marks, Fibronectin was significantly less expressed compared to ecchymoses. The expression was similar to hanging marks and uninjured skin. In both ligature marks and ecchymoses, the expression of P-Selectin was significantly increased compared to uninjured skin. In both ligature marks and ecchymoses, expression of HSP-70 was significantly decreased in the epidermis compared to uninjured skin. In both ligature marks and ecchymoses, the expression of FVIII and MRP8 was significantly increased in the dermis and hypodermis compared to uninjured skin. The results of this study show that the immunohistochemical study of early inflammatory and coagulation factors could help determine the vitality of ligature marks. The combined analysis of P-Selectin, FVIII, HSP-70, and MRP-8 can be considered for this purpose.

Explaining deep convolutional models by measuring the influence of interpretable features in image classification

The accuracy and flexibility of Deep Convolutional Neural Networks (DCNNs) have been highly validated over the past years. However, their intrinsic opaqueness is still affecting their reliability and limiting their application in critical production systems, where the black-box behavior is difficult to be accepted. This work proposes EBAnO, an innovative explanation framework able to analyze the decision-making process of DCNNs in image classification by providing prediction-local and class-based model-wise explanations through the unsupervised mining of knowledge contained in multiple convolutional layers. EBAnO provides detailed visual and numerical explanations thanks to two specific indexes that measure the features’ influence and their influence precision in the decision-making process. The framework has been experimentally evaluated, both quantitatively and qualitatively, by (i) analyzing its explanations with four state-of-the-art DCNN architectures, (ii) comparing its results with three state-of-the-art explanation strategies and (iii) assessing its effectiveness and easiness of understanding through human judgment, by means of an online survey. EBAnO has been released as open-source code and it is freely available online.

Local-scale impacts of extreme events drive demographic asynchrony in neighbouring top predator populations

Extreme weather events are among the most critical aspects of climate change, but our understanding of their impacts on biological populations remains limited. Here, we exploit the rare opportunity provided by the availability of concurrent longitudinal demographic data on two neighbouring marine top predator populations (the black-browed albatross, Thalassarche melanophris, breeding in two nearby colonies) hit by an exceptionally violent storm during one study year. The aim of this study is to quantify the demographic impacts of extreme events on albatrosses and test the hypothesis that extreme events would synchronously decrease survival rates of neighbouring populations. Using demographic modelling we found that, contrary to our expectation, the storm affected the survival of albatrosses from only one of the two colonies, more than doubling the annual mortality rate compared to the study average. Furthermore, the effects of storms on adult survival would lead to substantial population declines (up to 2% per year) under simulated scenarios of increased storm frequencies. We, therefore, conclude that extreme events can result in very different local-scale impacts on sympatric populations. Crucially, by driving demographic asynchrony, extreme events can hamper our understanding of the demographic responses of wild populations to mean, long-term shifts in climate.

An economic and environmental analysis of wine packaging systems in Italy: A life cycle (LC) approach

The main aim of this study was to perform a combined life cycle assessment and life cycle costing of the most used wine packaging systems in Italy. Packaging plays a key role in food and beverage production and supply chain, but the increasing volume of packaging used causes many environmental concerns. The wine sector is no exception, especially in Italy that is the largest producer in the world. Eight packaging alternatives were compared in environmental and economic terms assuming a functional unit of three litres and a cradle to grave approach: one aseptic carton system, two bag-in-box systems, two PET bottle systems, and three glass bottle systems. The results were analysed with an eco-efficiency portfolio approach. There was consistency between the LCA and LCC results for most of the packaging systems. From both the environmental and economical point of views, aseptic cartons and bag-in-box systems were the most sustainable alternatives, while the glass systems had the worst global performances due to the high weight and consequent huge energy consumption during bottle production. The size of the containers was the key factor that most affected the results both in environmental and economic terms.

Management of the Medico-Legal Dispute of Healthcare-Related SARS-CoV-2 Infections: Evaluation Criteria and Case Study in a Large University Hospital in Northwest Italy from 2020 to 2021

Healthcare-related SARS-CoV-2 infection is an issue of particular concern during the pandemic. It has important repercussions on the National Health System, which represents a source of medical-legal health disputes. In the healthcare context, there are reports of negative screening at hospital admission (via nasopharyngeal swabs) and subsequent diagnosis of SARS-CoV-2 infection during hospitalization. Such cases cannot be considered a priori of healthcare-related infections but require extensive in-depth evaluation. In this study, we propose an empirical classification to frame cases of SARS-CoV-2 infection diagnosed in the hospital (first negative admission swab, with subsequent positive test during hospitalization). The classification is based on five categories: nosocomial, probably nosocomial, indeterminate, probably community, and community cases. We analyzed patients who died after testing positive for SARS-CoV-2 during hospitalization (with initial negative screening) in the largest hospital in Northwest Italy from February 2020 to 31 December 2021. A total of 383 cases were tracked and are listed as follows: 41 cases (11%) were classified as nosocomial (i.e., 3.2% of COVID-19 deaths). In contrast, 71 cases (19%) were classified as probably nosocomial, 69 (18%) were indeterminate (i.e., the clinical, radiological, and laboratory characteristics did not provide information on the genesis of the infection), 166 (43%) were classified as probably community cases, and 36 (9%) were defined as community cases. Deceased patients with nosocomial SARS-CoV-2 infection constituted the following: 3.23% (41/1266) with respect to the total number of COVID-19 deaths, 1.1% (41/3789) with respect to those who entered the hospital with a negative swab and 0.82% (41/4672) with respect to the total of deaths from any cause of death. In this paper we discuss the topic and issues of nosocomial COVID-19 in hospitalized patients and address the medicolegal implications.

A Survey on Undergraduate Medical Students' Perception of COVID-19 Vaccination

The objectives of this study were to obtain information on medical students’ attitudes toward COVID-19 vaccination and to identify the main barriers to its acceptance. We conducted an anonymous online survey on a sample of undergraduate medical students from one main Italian University. The questions were aimed at exploring their attitudes toward vaccination to prevent COVID-19, their perceptions of the risk/threat of COVID-19 and the factors associated with their attitudes toward COVID-19 vaccination. A high percentage of students in our sample stated that they had been vaccinated or that they intended to be vaccinated against the COVID-19 coronavirus. A total of 239 questionnaires were analyzed. Age, social, geographic and demographic characteristics, health conditions and interest in vaccination were recorded; 93% of the students declared that they encouraged vaccination and 83% stated that the reason was “Moral responsibility towards the community”. Four students had not yet been vaccinated, mainly because of “Contradictory information on efficacy and safety”. The Likert-type questions revealed high agreement on the importance of vaccination and whether it should be made mandatory (“indispensable tool” and “ethical duty” were cited to explain this position). The results show a high level of acceptance of COVID-19 vaccination among these medical undergraduates who, being halfway through their training and involved in clinical practice, are already in possession of specific scientific knowledge and, to a small extent, come from different areas of Italy.

How Long Can a Dead Body Remain Infectious?: Postmortem Nasopharyngeal Swabs and SARS-CoV-2 Culture in a Corpse Over an 87-Day Period

ABSTRACT

The SARS-CoV-2 pandemic involved several changes and difficulties in the work of forensic pathologists. Postmortem nasopharyngeal swabs for the diagnosis of the SARS-CoV-2 infection are recommended before an autopsy examination by the Centers for Disease Control and Prevention.Autopsy examinations must not be performed for SARS-CoV-2 infection cases when airborne infection isolation rooms or other suitable spaces are unavailable. However, it has not yet been reported whether the presence of SARS-CoV-2 at a low viral load may be enough to infect and disseminate the contagion.Here, we report the case of a 67-year-old man found dead at home on November 9, 2020, and transferred immediately after to the Genova District Mortuary. As the first postmortem molecular nasopharyngeal swab resulted positive, a weekly sampling was carried until February 4, 2021. All the molecular tests were positive for SARS-CoV-2, including the last swab performed 87 days after the arrival of the corpse at the morgue. Virus isolation conducted on VERO E6 cells revealed no cytopathic effect indicating no viral replication as early as 18 days after the corpse's arrival at the morgue and until January 2021.Our findings suggest that the presence of the genome of SARS-CoV-2 at low viral load should not be considered a sign of an active infection but a trace of a remaining viral genome from a previous infection. Then, if the virus shows no replication activity, its molecular detection should not constitute a threat to public health. Further studies are required to establish the infection's potential and its correlation with viral load.

A Rare Case of Fatal Thyroid Hemorrhage After Fine-Needle Aspiration: Case Report and Review of the Literature

ABSTRACT

Sudden death due to massive hemorrhage after a mini-invasive ambulatory diagnostic procedure is extremely rare. Fine-needle aspiration (FNA) of thyroid nodules is very safe, displaying a low rate of complications, all of which mild and often self-limiting. In few cases do these complications necessitate surgical decompression, and rarely does FNA of a thyroid nodule lead to the death of the patient.We report a case of sudden death caused by respiratory insufficiency after compression of the vascular and nervous structures of the neck and obstruction of the upper airways by hemorrhages dissecting the thyroidal and perithyroidal tissues in a 78-year-old woman. These hemorrhages were the result of vascular lacerations caused during diagnostic FNA of a nodule suspected of malignancy. In such cases, it is important to conduct a complete autopsy and histological analysis to ascertain the origin of massive hemorrhage involving the structures of the neck and to attribute the cause of death to the aforementioned procedure. The forensic pathologist must bear in mind that even extremely small damage, such as that produced by a fine needle, may cause a fatal hemorrhage in subjects with a subverted anatomo-pathological picture (such as, for example, the massive fibrosis of an organ).

A central place foraging seabird flies at right angles to the wind to jointly optimize locomotor and olfactory search efficiency

To increase the probability of detecting odour plumes, and so increase prey capture success, when winds are stable central place foraging seabirds should fly crosswind to maximize the round-trip distance covered. At present, however, there is no empirical evidence of this theoretical prediction. Here, using an extensive GPS tracking dataset, we investigate, for the first time, the foraging movements of Bulwer's petrels (Bulweria bulwerii) in the persistent North Atlantic trade winds. To test the hypotheses that, in stable winds, petrels use crosswind to maximize both the distance covered and the probability of detecting olfactory cues, we combine state-space models, generalized additive models and Gaussian plume models. Bulwer's petrels had the highest degree of selectivity for crosswinds documented to date, often leading to systematic zig-zag flights. Crosswinds maximized both the distance travelled and the probability of detecting odour plumes integrated across the round-trip (rather than at any given point along the route, which would result in energetically costly return flight). This evidence suggests that petrels plan round-trip flights at departure, integrating expected costs of homeward journeys. Our findings, which are probably true for other seabirds in similar settings, further highlight the critical role of wind in seabird foraging ecology.

Eating problems in ADHD: self-regulatory or inattentive/impulsive

Introduction

ADHD is a risk factor for impulsive/compulsive eating problems (EP). In, bulimia nervosa and compulsive eating disorder, EP are frequently preceded by negative affect and experienced as loss of control. Clarifying the underlying causes (eg., ADHD symptoms and/or psychological distress) of EP in ADHD would allow the development of targeted interventions.

Objectives

To a) compare levels of EP between ADHD patients and a community sample, and b) test if ADHD symptoms and psychological distress predict EP, in ADHD patients.

Methods

Adults with ADHD (n=32; age=23.78+/-6.12; 69% males) from the Neurodevelopmental Outpatient Unit of Coimbra and healthy participants (n=30; age=36.90+/-13.23; 57% males) answered an online survey including the Portuguese versions of the Adult ADHD Self-Report Scale Symptom Checklist, the Parkinson’s Disease Impulsive-Compulsive Disorders Questionnaire-Current Short and the Depression, Anxiety and Stress Scale.

Results

The ADHD group reported experiencing more EP than healthy individuals (18/32 vs. 4/30; χ2=12.458, p<.001). ADHD patients with EP suffered from severer ADHD inattentive, hyperactive, and global symptoms and higher levels of psychological distress (p<.001 to p=.027). Logistic regression model testing if ADHD and psychological distress symptoms predicted EP, in ADHD, explained 38.8% of the variance and showed that the only significant predictor was ADHD symptoms (B=.121, SE=.051, p=.017).

Conclusions

Our results indicate that EP are associated with severer ADHD clinical pictures. EP arose secondarily to ADHD symptoms, instead of serving as means to alleviate psychological distress. Clinicians should be mindful that, in ADHD patients, EP follow specific motivations, i.e., impulsivity and inattention, and may respond to combined cognitive-behavioural/executive training strategy.

Disclosure

No significant relationships.

Blunt head trauma in a peculiar case of partial mummification. Murder or accidental event?

The finding of a partially mummified body presenting signs of trauma requires the forensic pathologist to conduct a careful and complex examination; multidisciplinary analysis is often necessary.We report a case where the partially mummified corpse of an elderly man was found in his own home more than seven years after death. Complete post-mortem investigation revealed a cranial fracture and an acute subdural haematoma.An in-depth multidisciplinary analysis provided important information on the modality and cause of death but it was not possible to establish whether the trauma and death resulted from an accidental event or from an assault.

Fatal work-related injuries in the Genoa district (North-Western Italy): Forensic analysis of the 10-year period between 2011 and 2020

According to the ILO (International Labor Organization), an occupational accident is that which occurs in the course of work and results in either a fatal or non-fatal injury. Occupational-related deaths are increasingly a concerning issue, also worldwide, with severe social repercussions: it is clear that when a person loses their life, it has a permanent impact on all their family, as well as incurring direct and indirect costs for employers, workers and the community at large. The aim of the present retrospective-observational study is to investigate, from an autoptic and forensic point of view, the characteristics of occupational-related deaths of victims received between the 10-year period of 2011-2020 by the Municipal Morgue of Genoa, which forms part of the Institute of Forensic and Legal Medicine, for the purpose of providing a Forensic and Coroner's overview of this important phenomenon. The study comprises of a list of 47 people who died as a result of an occupational injury: 46 males and 1 female. It was observed that workers in the construction and steel manufacturing industries were in the category most at risk of fatal accidents (40.5%). In 41 cases (87.2%), death was related to major mechanical trauma, from falling from a height (42.5%) objects falling directly onto the victim (38.3%) and lastly, from pedestrian road accidents (6.4%). Fatal head traumas with endocranial haemorrhage accounted for deaths in 23 of all the cases studied (63.4%). As shown in our study, death in the workplace is still today having to be considered as an important social issue and it is still necessary to improve the workers' knowledge of the related hazards and risks involved at work, together with preventative procedures. An in-depth analysis of such risks in the workplace, as well as the monitoring and training of workers is fundamental if we are to achieve an overall improvement in working conditions.

Environmental variability directly affects the prevalence of divorce in monogamous albatrosses

In many socially monogamous species, divorce is a strategy used to correct for sub-optimal partnerships and is informed by measures of previous breeding performance. The environment affects the productivity and survival of populations, thus indirectly affecting divorce via changes in demographic rates. However, whether environmental fluctuations directly modulate the prevalence of divorce in a population remains poorly understood. Here, using a longitudinal dataset on the long-lived black-browed albatross (Thalassarche melanophris) as a model organism, we test the hypothesis that environmental variability directly affects divorce. We found that divorce rate varied across years (1% to 8%). Individuals were more likely to divorce after breeding failures. However, regardless of previous breeding performance, the probability of divorce was directly affected by the environment, increasing in years with warm sea surface temperature anomalies (SSTA). Furthermore, our state-space models show that warm SSTA increased the probability of switching mates in females in successful relationships. For the first time, to our knowledge, we document the disruptive effects of challenging environmental conditions on the breeding processes of a monogamous population, potentially mediated by higher reproductive costs, changes in phenology and physiological stress. Environmentally driven divorce may therefore represent an overlooked consequence of global change.

Synthesis and Spectroscopic Characterization of Thienopyrazine-Based Fluorophores for Application in Luminescent Solar Concentrators (LSCs)

Organic fluorophores have found broad application as emitters in luminescent solar concentrators (LSCs) for silicon photovoltaics. In particular, the preparation of organic conjugated systems with intense light-harvesting ability, emissions in the deep-red and NIR regions, and large Stokes shift values represent a very challenging undertaking. Here, we report a simple and easy way to prepare three symmetrical donor–acceptor–donor (DAD) organic-emitting materials based on a thienopyrazine core. The central core in the three dyes was modified with the introduction of aromatic substituents, aiming to affect their optical properties. The fluorophores were characterized by spectroscopic studies. In all cases, visible-NIR emissions with large Stokes shifts were found, highlighting these molecules as promising materials for the application in LSCs.

Controversies and Challenges of Mass Vaccination against SARS-CoV-2 in Italy: Medico-Legal Perspectives and Considerations

The worldwide spread of SARS-CoV-2 and the pandemic has resulted in a serious global crisis in the health, social and economic spheres. After an initial period of enthusiasm related to the efficacy of vaccines, in many European countries, a growing distrust in the population has matured, due to the reporting of severe adverse effects. Throughout the world, some cases of adverse events after the administration of the vaccine have been reported. In this communication, we want to discuss all the medico-legal aspects related to the global vaccination companion in terms of medical professional responsibility, informed consent and vaccination obligation, with particular attention to the Italian situation. Health professionals are tasked with promoting confidence in vaccination for the general population. Complete and detailed information and reliance on scientific research is essential to understand the great importance of the vaccination campaign. From a criminal point of view, we must avoid blaming health professionals in the case of side effects. At the same time, we must protect the population, ensuring compliance with the indications, guidelines, and an adequate method of administration. On the other hand, from a civil law perspective, it is correct to ensure full protection of those rare cases in which the administration of the vaccine is related to adverse events. Without a broad and global vaccination campaign, it will be impossible to overcome COVID-19.

Sudden unexpected non-cardiac death in the Genoa Medico-Legal District: A six year study (2014-2019) and literature review

Sudden death is described as a natural but unexpected death occurring within one hour from the onset of the patient's final symptoms. Despite cardiac disease being recognised as the cause of death in most people, sudden and unexpected death can also be non-cardiac related. Often a natural but sudden death is not subject to an autopsy, but only to an external examination, and this runs the risk of wrongly attributing the death to a cardiac cause. The present review is a retrospective-observational study which looks into the cases of sudden non-cardiac death recorded in the Genoa District (Italy) from 2014 to 2019 and investigated through complete autopsy examinations. Amongst these cases, 39 (31.5%) were attributable to gastrointestinal diseases, mostly due to the rupture of oesophageal varices; 39 (31.5%) to respiratory diseases, especially pulmonary infections; 31 (25%) to peripheral vascular disease, mostly attributable to pulmonary thromboembolisms or the acute dissection of aneurysms whilst the remaining 15 cases (12%) were attributable to intracranial haemorrhages.

Immunohistochemistry in postmortem diagnosis of acute cerebral hypoxia and ischemia: A systematic review

BACKGROUND

: Discovery of evidence of acute brain ischemia or hypoxia and its differentiation from agonal hypoxia represents a task of interest but extremely difficult in forensic neuropathology. Generally, more than 50% of forensic autopsies indicate evidence of brain induced functional arrest of the organ system, which can be the result of a hypoxic/ischemic brain event. Even if the brain is the target organ of hypoxic/ischemic damage, at present, there are no specific neuropathological (macroscopic and histological) findings of hypoxic damage (such as in drowning, hanging, intoxication with carbon monoxide) or acute ischemia. In fact, the first histological signs appear after at least 4 to 6 hours. Numerous authors have pointed out how an immunohistochemical analysis could help diagnose acute cerebral hypoxia/ischemia.Data sources: This review was based on articles published in PubMed and Scopus databases in the past 25 years, with the following keywords "immunohistochemical markers," "acute cerebral ischemia," "ischemic or hypoxic brain damage," and "acute cerebral hypoxia".

OBJECTIVES

: Original articles and reviews on this topic were selected. The purpose of this review is to analyze and summarize the markers studied so far and to consider the limits of immunohistochemistry that exist to date in this specific field of forensic pathology.

RESULTS

: We identified 13 markers that had been examined (in previous studies) for this purpose. In our opinion, it is difficult to identify reliable and confirmed biomarkers from multiple studies in order to support a postmortem diagnosis of acute cerebral hypoxia/ischemia. Microtubule-associated protein 2 (MAP2) is the most researched marker in the literature and the results obtained have proven to be quite useful.

CONCLUSION

Immunohistochemistry has provided interesting and promising results, but further studies are needed in order to confirm and apply them in standard forensic practice.

COVID-19-related deaths in residential care homes for elderly: The situation in Italy

The whole population is susceptible to infection but elderly people with previous diseases are at greater risk. All these epidemiological data show that older age represents an important risk factor for infection and especially for mortality. In recent weeks an increase in mortality among the elderly has been observed in many Italian residential care homes. In these accommodations a worrying spread of COVID-19 cases has been ascertained. According to the ISS report, 7.4% of the total deaths in care homes for elderly involved patients with SARS-CoV-2 infection and 33.8% involved patients with flu-like symptoms.

Herein, we discuss the dangerous spread of COVID-19 in residential care homes for elderly. In addition, we present a case of an elderly person admitted to a residential care home, whose COVID-19 diagnosis was performed only after death.

Taking care of life: the new Italian law on post-mortem donation for study purposes, training and scientific research

Anatomical dissection is considered a fundamental practice in the medical curriculum. Not only does it help students to familiarize themselves with the various bodily organs and to refine their surgical practice, it also fosters an attitude of awareness and respect towards death and the values of solidarity. On 10th February 2020, the Italian Parliament passed a new law entitled "Rules on the disposition of one's own body and post-mortem tissues for study purposes, training and scientific research". Here, we outline the main ethical and legal aspects of this law and suggest initiatives to encourage body donation. Through careful analysis of the law, we intend to open a discussion on the main ethical issues and to make comparisons with the international situation. The new legislation fills serious gaps in an area of great ethical relevance; not only does it endorse fundamental ethical principles, it also provides important guidelines for strengthening body donation, such as: ensuring respect for the dignity of the deceased, providing express consent, appointing a trustee, promoting information for both doctors and the community, and banning all forms of trade in bodies or body parts. This law is certainly an important milestone on the road to overcoming the scarcity of bodies for study and research. However, it is also essential to promote a favourable attitude to body donation and to strive to overcome obstacles to this practice by supporting continuous dialogue between anatomical institutes and the community. Further studies are necessary in order to assess the impact of the new law.

A rare iatrogenic mesenteric laceration and hemorrhagic shock after colonoscopy. Case report and literature review

AIM

We report a particular case study of the unexpected death of a 70-year-old caucasian man (affected by crohn's disease) due to the laceration of the ileocolic mesentery and its blood vessels following a colonoscopy procedure carried out only a few hours previously.

MATERIAL OF THE STUDY

The autopsy showed that the lacerated blood vessels (i.e. the collateral and terminal branches of the superior mesenteric artery), which run along the section of the intestines between the end of the ileum and the ascending cecum, had led to a severe intra-abdominal hemorrhage and, consequently, fatal hemorrhagic shock.

RESULTS

In such cases, both an autopsy and complete histological analysis are essential in order to determine the exact point responsible for the intestinal hemorrhage and to better understand the pathological mechanism involved.

DISCUSSION

The unexpected death due to severe peritoneal hemorrhaging following a minimally invasive diagnostic clinical procedure, such as a colonoscopy, is particularly rare in Literature. In fact, amongst the several endoscopy procedures commonly used today, it is one of the safest procedures with the lowest recorded rate of complications. Furthermore, it is an even rarer event that a routine diagnostic colonoscopy can result in a fatality, with only two cases reported.

CONCLUSIONS

In the case of sudden death following such a routine diagnostic clinical procedure, the forensic scientist should not disregard the fact that also damage, which appears negligible (caused by the normal procedures used in carrying out a colonoscopy) can actually also result in severe and fatal hemorrhaging.

KEY WORDS

Colonoscopy, Fatal hemorrhage, Forensic pathology.

Forensic pathological study of methadone-related deaths in the Genoa (Italy) district: A six-year study

Methadone is a synthetic opioid, a pure agonist of the μ receptor. It is used for opioid maintenance therapy in heroin addiction. In recent years, Italian studies of incidence and prevalence have indicated an increase in the illegal sales of methadone and, consequently, an increase in deaths due to acute methadone intoxication as well. The present review is a prospective-observational study regarding epidemiological and toxicological analyses of methadone-related deaths recorded in the district of Genoa (Italy) from 2013 to 2018. The study includes a list of twenty-six people that have died from methadone toxicity: twenty-two males and four females. The concentration of methadone in the blood samples ranged from 181 to 4058.53 ng/mL, with an average of 964.29 ng/mL. Six subjects tested positive for methadone alone; twenty cases, however, presented drugs or substances in different concentrations in the blood samples. Illegal sales and consumption of methadone have a negative impact on the self-administration therapy of opioid addiction, inducing patients to increase their dosage or sell methadone in order to purchase illegal drugs. As shown in our study, this behaviour is associated with an increase in methadone-related deaths. Accordingly, careful monitoring of dosage administrated to patients is required in order to render the system safer.

Spastic quadriplegia following intradermal use of hydrogen peroxide in the tardive curettage procedure for the treatment of a giant congenital nevus

The possible transformation of a giant congenital melanocytic nevi (GCMN) in malignant melanoma estimated from 0.05% to 40% depend on the size of the lesions. Many are the surgical procedures proposed, including: full or partial-thickness excisions, dermabrasion, curettage in the first weeks of life and laser treatment. The curettage technique has been proposed in the literature for the treatment of GCMN in the first few weeks of life and defined as a relatively atraumatic surgery procedure without general complications. The authors report the first case in the literature of embolization due to use of subcutaneous peroxide infiltration before a tardive curettage procedure in a newborn case of GCMN resulting in spastic quadriplegia with dystonic reaction. Consequently, a lawsuit, due to this medical malpractice, has been opened.

Hospital-Acquired SARS-Cov-2 Infections in Patients: Inevitable Conditions or Medical Malpractice?

Despite numerous measures to contain the infection and limit its spread, cases of SARS-CoV-2 infections acquired in hospitals have been reported consistently. In this paper, we will address issues of hospital-acquired COVID-19 in hospitalized patients as well as medico-legal implications. After having conducted a literature search, we will report on papers on hospital-acquired SARS-CoV-2 infections. Ten scientific papers were selected and considered suitable for further analysis. According to several reports, the SARS-CoV-2 hospital-acquired infection rate is 12–15%. Hospital-acquired COVID-19 represents a serious public health issue, which is a problem that could create reluctance of patients to seek hospital treatment for fear of becoming infected. Healthcare personnel should do all that is necessary to address the problem and prevent further spreading, such as rigorous compliance with all procedures for containing the spread. From a medical-legal point of view, multiple aspects must be considered in order to understand whether the infection is a result of “malpractice” or an inevitable condition.

Philemon and Baucis deaths: A case of two siblings and state of the art

The simultaneous discovery of two corpses at the same scene obliges the forensic pathologist to consider many circumstances. First, the hypothesis of homicide/crime has to be investigated. However, when the circumstances, autopsy, histological data and toxicological and biochemical analyses suggest a natural cause of death, Philemon and Baucis syndrome should be considered. While a few cases of Philemon and Baucis deaths involving couples of spouses have been reported in the literature, only one paper describes the simultaneous deaths of two siblings. The case presented here concerns the death of two siblings who were found in an advanced stage of decomposition in their apartment, which had been allocated to them by social services. The victims were known to be living in conditions of social and economic deprivation and to be suffering from psychiatric disorders. The first suspected cause of death was malnutrition. However, this was excluded by complete autopsy, histological studies and, especially, biochemical investigations, which excluded starvation ketoacidosis. Moreover, no evidence of trauma or poisoning was found in either of the bodies. Despite the advanced stage of decomposition, one of the bodies presented with histological signs of myocardial sclerosis, left ventricular hypertrophy and contraction band necrosis, suggesting that the mechanism of death involved a fatal arrhythmia. The circumstances and the post-mortem findings were highly suggestive of Philemon and Baucis syndrome.

Medical Liability in Cancer Care During COVID-19 Pandemic: Heroes or Guilty?

Background: The COVID-19 outbreak rapidly became a public health emergency affecting particularly the frail category as cancer patients. This led oncologists to radical changes in patient management, facing the unprecedent issue whether treatments in oncology could be postponed without compromising their efficacy.

Purpose: To discuss legal implications in oncology practice during the COVID-19 pandemic.

Perspective: Treatment delay is not always feasible in oncology where the timing often plays a key role and may impact significantly in prognosis. During the COVID-19 pandemic, the oncologists were found between the anvil and the hammer, on the one hand the need to treat cancer patients aiming to improve clinical benefits, and on the other hand the goal to reduce the risk of COVID-19 infection avoiding or delaying immunosuppressive treatments and hospital exposure. Therefore, two rising scenarios with possible implications in both criminal and civil law are emerging. Firstly, oncologists may be “accused” of having delayed or omitted the diagnosis and/or treatments with consequent worsening of patients' outcome. Secondly, oncologists can be blamed for having exposed patients to hospital environment considered at risk for COVID-19 transmission.

Conclusions: During the COVID-19 pandemic, clinical decision making should be well-balanced through a careful examination between clinical performance status, age, comorbidities, aim of the treatment, and the potential risk of COVID-19 infection in order to avoid the risk of suboptimal cancer care with potential legal repercussion. Moreover, all cases should be discussed in the oncology team or in the tumor board in order to share the best strategy to adopt case by case.

An unusual case of coma related to glutamate receptor 3 (GluR3) auto-antibodies after a traumatic spinal cord injury: Clinical and pathological aspects

We report the case of a 28-year-old patient with a history of post-traumatic epilepsy who, following a spinal cord injury and the onset of nosocomial infection, went into a deep coma. A brain MRI revealed non-specific findings, anti-Glutamate Receptor 3 (GluR3) auto-antibodies were detected in the liquor, and the patient's serum and immunomodulatory therapy proved ineffective. Autopsy and histological investigations led to the diagnosis of autoimmune encephalitis. This case highlights the diagnostic difficulties of a rare and still poorly researched disease and the possible role that traumatic and infectious episodes may play in the progression or acceleration of an immune response. As for patients with unexplained encephalitis, tests for autoantibodies against GluR3 in cerebrospinal fluid and serum should be considered. Forensic pathologists should be aware of encephalitis and epilepsies and that complete post-mortem investigations are required in such cases.

Unusual suicide by a speargun shot: Case report

RATIONALE

Only a few cases of accidental deaths due to speargun injuries are reported in the literature. Murder or suicide cases are even rarer.

PATIENT CONCERNS

A 59-year-old male with a history of major depression and previous suicide attempts, was found, still alive and conscious, with a spear in his mouth and a fishing speargun a few meters away. The spear then penetrated the cranium and crossed the entire left cerebral hemisphere.

DIAGNOSES

The patient underwent a retrograde removal of the spear. During the surgery, there was a massive encephalic bleeding. After about 2 days of coma, brain death was confirmed. An autopsy was performed to determine the cause of death.

INTERVENTIONS

The scalp presented hemorrhagic infiltrates in the left parieto-temporal region. There were an acute subdural hematoma and subarachnoid hemorrhage. At the opening of the lateral ventricles a massive fronto-parieto-temporal hematoma was evident. The skull base had a massive hemorrhagic infiltration and a circular fracture of about 0.5 cm in diameter, due to the penetration of the spear. The hard palate showed a circular solution of continuity with net margins whose diameter was consistent with the size of the spear.

OUTCOMES

The cause of death was attributed to the traumatic cranial-encephalic lesions due to the speargun shot in the mouth.

LESSONS

The investigation into unusual cases of death constitutes a complex matter and requires a careful evaluation on the part of the forensic pathologist. A differential diagnosis may be necessary in order to rule out simulated suicide/homicide. In this particular case, the analysis of the scene of the self-suppression event and available circumstantial information, the evaluation of clinical data, the complete autopsy and the comparison between the injuries of the victim and the characteristics of the weapon used led to the confirmation of the suicidal nature of the death.

Unexpected death due to a biventricular thrombosis: Case report and review of literature

Cardiac thrombosis is an unusual condition characterised by the formation of a clot in the heart chambers. Biventricular thrombosis with obstruction of blood flow and fatal cardiogenic shock is anecdotal. This report describes a rare biventricular thrombosis in an elderly woman without known risk factors which was diagnosed at autopsy. A complete autopsy is essential to ascertain the cause of death, especially in complex cases with little medical history. We suggest a possible explanation for the pathophysiological mechanism.

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

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

Male circumcision: ritual, science and responsibility

INTRODUCTION AND OBJECTIVES

In Italy, four minors have died in the last year as a result of male circumcision (MC) procedures performed for cultural and religious reasons by unqualified persons in unhygienic conditions.

RESULTS AND DISCUSSION

After illustrating the historical and ethical outlines of the moral admissibility of MC within a comparative perspective, we examine the features of the Italian healthcare system with particular regard both to the heterogeneity of services available in the various Regions and to the risks engendered by excluding MC from the public health setting.

CONCLUSION

In order to adequately safeguard public health, particularly that of minors, there is a pressing need for thorough discussion of whether the National Health Service should perform MC on minors free of charge or, at least, for a reduced fee. The implementation of targeted campaigns may raise awareness of the importance of proper safety measures in MC.

Fatal hemorrhage from a periumbilical wound: Stabbing or hemorrhage from a caput medusae?

Varices are the main clinical manifestation of portal hypertension, and their bleeding is the predominant cause of mortality from this condition. Periumbilical varices are known as "caput medusae." Reports of their bleeding are rare, with only three fatal cases described in the literature. The antemortem diagnosis is relatively simple, while the postmortem diagnosis is more complex. This paper is the first report of fatal hemorrhage from a caput medusae for which the diagnosis was made postmortem, thanks to a complete diagnostic process including scene and circumstances, medical history, and autopsy with detailed histology. The circumstantial analysis showed the presence of a large amount of blood at the scene, blood which originated from a small abdominal wound; an analysis of the subject's clinical data reported that he was affected by portal hypertension. The autopsy revealed some dilated and convoluted veins in the subcutaneous tissue of the umbilical region; a fistula between these veins and the abdominal wound was detected. The histological study confirmed the presence of periumbilical varices, one of them ruptured and connected with the overlying skin. The cause of death was attributed to a massive hemorrhage generated by a periumbilical varix in a patient affected by portal hypertension.

Covid-19 and infection in health-care workers: An emerging problem

The 2019 coronavirus infection (called SARS-CoV-2) began in Wuhan, spread rapidly throughout the world. In many countries the exponential growth of Covid-19 cases is overwhelming health care systems with overcrowding of hospitals and overflowing Intensive Care Units. While people must stay at home to reduce the spread of this virus health-care workers do the exact opposite. In some countries doctors are working with insufficient protection and are constantly at risk of contracting Covid-19. Health-care workers should be constantly monitored because if they are infected they may spread the virus to colleagues, hospitalized patients and even family members. Increased rates of infection in health-care workers could cause the health-care system to collapse and a further worsening of the pandemic; if there are too few doctors it will be even more difficult to manage.

Elder abuse: a retrospective analysis of autopsy cases from the department of legal medicine in Genoa from 2006 to 2017

Elder abuse is a form of violence that is often misunderstood and still underestimated. This kind of abuse is classified in physical abuse, psychological abuse, financial abuse, sexual abuse, neglect and self-neglect. In this study, 784 cases of dead people over 65 years of age were retrospectively analyzed: in all cases, the cause of death was determined by the autopsy. Ten cases have been classified as victims of elder abuse: 7 females and 3 males aged between 67 and 91 (average age of 78.9 years). The types of abuse were as follows: neglect: 8 cases; physical abuse: 2 cases; psychological abuse: 2 cases; financial abuse: 2 cases; self neglect: 2 cases. In three cases, the victims had been subjected to two or more types of abuse. In 5 cases the victims had a neuro-psychic decay. In cases of neglect the cause of death was due to sepsis or dehydration. In a case of physical abuse, death was traumatic and related to physical violence. In cases of self neglect, death occurred due to cardiac causes. In cases of domestic abuse, the perpetrator was in most cases the elder's son and in one case the paid caregiver. In three cases, however, the abuses were committed against elderly guests in Nursing Homes. In three cases the perpetrator was affected by psychiatric disorders. Recognizing the elder abuse is often difficult and the understanding of the phenomenon in the case of death requires an integrated analysis of the autopsy data and the anamnesis of the victim.

Multidisciplinary study of sudden unexpected infant death in Liguria (Italy): a nine-year report

INTRODUCTION

We conducted a retrospective analysis of cases of sudden unexpected infant death (SUID) referred to the SIDS-ALTE Center of the Liguria Region (Italy) from 2010 to 2018. In all cases, the death scene was inspected, and a multidisciplinary post-mortem evaluation was conducted. Our aim was to analyze the epidemiological data and etiological distribution.

EVIDENCE ACQUISITION

We examined 15 cases initially classified as sudden infant death.

EVIDENCE SYNTHESIS

In all cases, the death was initially unexplained. Seven cases involved males and eight involved females. Their mean age was 67.47 days; the youngest victim was 2 days old, while the oldest was 8.5 months (253 days). In 7 cases, the post-mortem analysis showed an infection of lung. In 4 cases, the prone position of the infant during sleep was identified as a risk factor. Only in one case the cause of death remains unexplained, and it was classified as sudden infant death syndrome II according to San Diego Classification.

CONCLUSIONS

In the forensic approach to cases of SUID, it is always important to conduct a thorough multidisciplinary investigation. In order to avoid procedural errors that might compromise the post-mortem investigation, it is necessary to consider the medical and social history of both mother and child, in addition to the circumstances of the death. Moreover, a complete pediatric post-mortem examination and multidisciplinary discussion are required in order to identify potentially important causative or contributory factors.

Multidisciplinary study of sudden unexpected infant death in Liguria (Italy): an nine-year report

We conducted a retrospective analysis of cases of SUID referred to the SIDS-ALTE Center of the Liguria Region (Italy) from 2010 to 2018. In all cases, the death scene was inspected and a multidisciplinary post-mortem evaluation was conducted. Our aim was to analyze the epidemiological data and etiological distribution. We examined 15 cases initially classified as sudden infant death. In all cases, the death was initially unexplained. Seven cases involved males and eight involved females. Their mean age was 67,47 days; the youngest victim was 2 days old, while the oldest was 8.5 months (253 days). In 7 cases, the post-mortem analysis showed an infection of lung. In 4 cases, the prone position of the infant during sleep was identified as a risk factor. In only one case did the cause of death remain unexplained and it was classified as sudden infant death syndrome II according to San Diego classification. In the forensic approach to cases of SUID, it is always important to conduct a thorough multidisciplinary investigation. In order to avoid procedural errors that might compromise the post- mortem investigation, it is necessary to consider the medical and social history of both mother and child, in addition to the circumstances of the death. Moreover, a complete pediatric post-mortem examination and multidisciplinary discussion are required in order to identify potentially important causative or contributory factors.