Publications

  • Cristian Palmiere, Alessandro Bonsignore, Marc Augsburger
    Clinical chemistry and laboratory medicine : CCLM / FESCC. 09/2014;
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    ABSTRACT: Low-molecular-weight heparins have become the predominant choice for deep venous thrombosis prophylaxis and treatment. However, their use may cause bleeding complications. Intrahepatic bleeding is exceptional and only very few cases have been described. The authors present a unique case of fatal intrahepatic hematoma complicating nadroparin use in a 65-year-old woman with a hepatic cyst who was admitted to hospital for unilateral total hip arthroplasty. At autopsy, hemoperitoneum (2,000 ml of blood and clots) was evident. A ruptured sub-capsular hematoma involving the right lobe of the liver was observed. The hemorrhage within the cyst induced by the nadroparin use was likely responsible for the subsequent hepatic hematoma, liver rupture, and death. This case highlights the need for pathologists and surgeons to be aware of the possibility of intrahepatic hematoma in patients who have received low-molecular-weight heparins, undergone major surgery and present postoperative hemodynamic instability, especially in those with preoperative diagnosis of hepatic cyst.
    Forensic Science Medicine and Pathology 08/2014; · 2.44 Impact Factor
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    ABSTRACT: Intentional or unintentional caffeine abuse due to excessive intake of beverages or energy drinks containing caffeine is relatively frequent. However, death due to caffeine intoxication is rare and case reports of fatalities from caffeine toxicity are relatively infrequent. In this report, we describe an autopsy case involving a 31 year-old man who intentionally took a large amount of caffeine tablets in the form of a weight loss supplement as part of a suicide plan. Caffeine femoral blood concentration (170 mg/l) was within the toxic and potentially lethal ranges reported in the literature in similar cases. Postmortem biochemistry results suggested depressed glomerular filtration rate and pre-renal failure at the time of death but failed to reveal myoglobinuria, glycosuria, ketonuria or ketonemia. Based on the absence of pathological findings at autopsy and the high blood caffeine level, death was attributed to acute caffeine toxicity. The case emphasizes the usefulness of performing exhaustive toxicology and searching for all potentially relevant information in order to formulate appropriate hypotheses concerning the cause and manner of death.
    Forensic Science Medicine and Pathology 04/2014; · 2.44 Impact Factor
  • Rivista Italiana di Medicina Legale. 01/2014;
  • Rivista Italiana di Medicina Legale. 01/2014;
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    ABSTRACT: Introduction. In spite of the benefits of autopsies, there has been in recent years a drastic decline in the number of autopsies performed, mainly due to an apparent unattractive cost-benefit ratio and fears of the medico-legal consequences. Material and Methods. A retrospective study was conducted on the reports of all the 879 consecutive autopsies performed at "Policlinico of Bari" from 1990 to 2009. Results. All clinical diagnoses were compared with autopsy findings showing 558 concordant diagnoses (most of all neoplasms); 123 certain discordant diagnoses (69 of them with potential impact on survival, such as acute myocardial infarctions, pulmonary thromboembolisms, internal haemorrhages, surgery complications, aortic aneurism ruptures, and so on); 116 uncertain discrepant diagnoses; 82 unclear diagnoses. Conclusions. The rate of discrepancy allows the authors to hypothesize that a better diagnostic assessment could lead to a different outcome. In terms of risk-management this negative performance needs to be carefully analysed and requires a comprehensive audit of all services provided. In this sense, the authors underline the crucial importance of autopsy as an essential tool to address unresolved clinical questions and highlight previously undiagnosed medical conditions.
    Annali dell'Istituto superiore di sanita 01/2014; 50(1):44-8. · 0.76 Impact Factor
  • Rivista Italiana di Medicina Legale. 01/2014;
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    ABSTRACT: Metformin is an oral antihyperglycemic agent used in the management of type 2 diabetes mellitus. Lactic acidosis from metformin overdose is a rare complication of metformin therapy and occurs infrequently with therapeutic use. Fatal cases, both accidental and intentional, are extremely rare in clinical practice. Metformin is eliminated by the kidneys, and impaired renal function can result in an increased plasma concentration of the drug. In this report, we describe an autopsy case involving a 70-year-old woman suffering from diabetes mellitus and impaired renal function who received metformin treatment. Metformin concentrations in the peripheral blood collected during hospitalization and femoral blood collected during autopsy were 42 and 47.3 µg/ml, respectively. Lactic acidosis (29.10 mmol/l) was objectified during hospitalization. Furthermore, postmortem biochemistry allowed ketoacidosis to be diagnosed (blood β-hydroxybutyrate, 10,500 µmol/l). Death was attributed to lactic acidosis due to metformin intoxication. Increased plasma concentrations of the drug were attributed to severely impaired renal function. The case emphasizes the usefulness of performing exhaustive toxicology and postmortem biochemistry towards the more complete understanding of the pathophysiological mechanisms that may be involved in the death process.
    Deutsche Zeitschrift für die Gesamte Gerichtliche Medizin 11/2013; · 2.69 Impact Factor
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    ABSTRACT: The focus of healthcare debate has in recent years shifted from doctors and healthcare professionals in general to patients and the principle of patient self-determination. Patient competence therefore plays an increasingly central role in the legal framework of many Europeans countries. Consequently, healthcare policy has to address the possible repercussions of a non-systematic approach to cases of patient incapacity. The diverse nature of the experiences of the mentally or physically disadvantaged clearly raises problems for the healthcare professional. In this setting, we examine Italy's Law no. 6/2004 from a comparative perspective, in particular analysing legislation in the same area from Spain, France, Great Britain and the Netherlands.
    Health Policy 08/2013; · 1.51 Impact Factor
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    ABSTRACT: We report a fatal case of streptococcal and meningococcal meningitis in a previously healthy 2-year-old child, a simultaneous co-infection of both pathogens that is poorly reported in the reviewed literature. The lack of a clinical diagnosis in addition to the medico-legal aspects arising from possible professional liability for the emergency service doctor who had failed to recognize the child's symptoms led to a forensic autopsy within 48 h after the death. After external and internal examination, Waterhouse-Friderichsen Syndrome (WFS) was suspected. Consequently, cerebrospinal fluid, whole blood, nasal and pharyngeal swab and pleural liquid samples were selected and collected for microbiological studies. All tested samples resulted Neisseria meningitidis DNA and Streptococcus pneumoniae DNA positive. The NM genotyping Real-Time PCR resulted positive for NM serotype C. Microscopic histological study confirmed these findings. We underline that when a patient presents fever and petechiae (50-60% of patients), WFS must be considered, even when the patient has a non-toxic appearance. Due to its rapid progression and often devastating consequences, therapy should be started as soon as WFS is suspected. Emphasis should also be placed on the importance of public education programs and on broadening protection against meningitis through new vaccines. In such cases, from a forensic point of view, there is a strong need for a robust, multidisciplinary approach in order to reach the correct post-mortem diagnosis.
    Journal of forensic and legal medicine 08/2013; 20(6):678-82.
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    ABSTRACT: In this article, the authors present a case of intrauterine foetal death (IUFD). The post-mortem histologic examination revealed placental mesenchymal dysplasia (PMD), a rare human placental disorder. Moreover, cases of PMD are often misdiagnosed as partial mole. The mother was a 26-year-old Italian, whose pregnancy, her first, had been uneventful until week 34⁺⁴ of gestation when IUFD suddenly occurred. The 2350 g male foetus showed no external abnormalities and the karyotype was 46, XY. The placenta weighed 450 g, the chorionic disk was round shaped, measuring 19.5-20.5 cm in diameter and had many enlarged villous structures. Histologically, the parenchyma showed abnormally enlarged and focally hydropic stem villi. Many of them were also surrounded by a fibrinoid material. Neither abnormal trophoblastic proliferation nor inclusion was observed in the examined sections. Causes and pathogenesis of PMD are still unclear and it is difficult to make a diagnosis solely on prenatal ultrasound during pregnancy. Generally, the correct diagnosis is reached only after the histological analysis of the placenta. However, obstetricians and gynaecologists should consider PMD also when a normal looking foetus is accompanied by a molar placenta (index factor for placentomegaly). The authors stress the importance of cooperation and information exchange among clinical and forensic pathologists, neonatologists, obstetricians and gynaecologists to avoid medical malpractice court proceedings in cases of IUFD.
    Forensic science international 06/2013; 229(1-3):e35-41. · 2.10 Impact Factor
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    ABSTRACT: In the literature, only a few cases of deaths related to the use of atypical firearms are present and even more rare are cases of suicide due to multiple lesions.In the present case, the authors report a rare occurrence of suicide due to 4 speargun shots, 3 to the chest and 1 to the head.A complete forensic approach led to attribute the death to acute cardiac failure due to hemopericardium after the injury of the left coronary artery.Scene investigation and autoptic findings allowed authors to hypothesize that injury to the head was a last attempt of suicide, elapsed during the progression of cardiac tamponade.With this report, the authors would like to share knowledge with the forensic community about speargun-related lesions distinguishing them from the very similar ones produced by cold steels.It also shows how it is possible to survive for some time after being shot by such a weapon.
    The American journal of forensic medicine and pathology: official publication of the National Association of Medical Examiners 04/2013; · 0.71 Impact Factor
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    ABSTRACT: Aderendo alla proposta del Gruppo Italiano dei Patologi Forensi in merito ad una collaborazione scientifica coordinata tra tutti i settorati italiani sulla valutazione dei dati tanato-cronologici del periodo consecutivo, il Dipartimento di Medicina Legale dell’Università di Genova ha concentrato il proprio studio sull’affidabilità dell’utilizzo di termometri ad infrarossi in comparazione con i termometri rettali. Sono stati selezionati per lo studio 41 cadaveri trasportati presso l’Obitorio Comunale di Genova annesso al nostro Dipartimento, di cui fosse nota con precisione l’ora del decesso. Lo studio ha avuto due tempi, uno sulla valutazione dello scarto tra il termometro a sonda rettale ed il termomento a infrarossi ed uno sulla valutazione dell’affidabilità della misurazione tramite il termometro ad infrarossi. Su alcuni casi è stato inoltre effettuata un’applicazione del nomogramma di Henssge per verificare se si risaliva ad un intervallo di tempo in cui si collocava l’ora nota della morte. Nonostante lo studio partisse da un presupposto certo (la conoscenza dell’ora della morte) il monitoraggio dei parametri tanatologici ed in particolare della temperatura cadaverica con vari strumenti è risultata nella maggior parte dei casi non omogena. Si è visto che vi era una netta differenza tra i rilevamenti con la sonda rettale e quelli effettuati sulla cute con il termometro ad infrarossi. Le differenze di temperatura variavano anche nell’ambito della sola misurazione ad infrarossi nei vari punti corporei prestabiliti. Era comunque possibile calcolare una deviazione standard della differenza tra le misurazioni con la rettale e le misurazioni con l’infrarosso. Tra quelli scelti, l’orecchio esterno risultava il punto corporeo meno deviante rispetto alla temperatura rettale. Era possibile anche calcolare un fattore correttivo tre i due termometri, che poteva essere utilizzato nell’applicazione pratica del termometro ad infrarossi. Tuttavia utilizzando il fattore correttivo nei casi scelti per l’applicazione del nomogramma di Henssge, si evidenziava come la temperatura maggiormente affidabile per la valutazione dell’epoca della morte era comunque quella rettale.
    Zacchia 01/2013;
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    ABSTRACT: Gli autori prendono spunto dal ritrovamento di resti scheletrici per descrivere una buona prassi metodologica capace di dirimere dubbi in tema di diagnosi differenziale tra lesività vitale o post-mortale. L’esame necroscopico di uno scheletro quasi completo appartenente ad una donna di 72 anni, affetta da morbo di Alzheimer in stadio avanzato ed allontanatasi dalla propria abitazione 14 mesi prima del ritrovamento, metteva in evidenza alcuni segmenti scheletrici con perdite di sostanza chiaramente correlate all’azione di macrofauna. Alcune perplessità erano destate da un’area di perdita di sostanza ossea, di forma grossolanamente ovalare (0,6 x 0,5 cm) repertata all’estremità distale dell’omero sinistro a livello della fossa olecranica. Sebbene tale lesione macroscopicamente non presentasse le caratteristiche tipiche di un foro d’arma da fuoco a munizionamento singolo, veniva formulato, dal Sostituto Procuratore, quesito specifico al fine di dirimere tale dubbio. Si procedeva così ad un’analisi approfondita al microscopio ottico, previa colorazione con ematossilina-eosina e reazione con Na-rodizonato per la ricerca di eventuali residui di particelle di polvere da sparo, ed al microscopio confocale con lettura laser dei margini della lesione ossea individuata. La lettura dei preparati istologici consentiva di escludere la presenza di residui e/o di polveri da sparo, riconducendo l’area di perdita di sostanza ossea presente in corrispondenza della fossa olecranica dell’omero sinistro all’azione traumatica post-mortale di un grosso dente aguzzo di animale e alla concomitante patologia osteoporotica da cui la donna era affetta, nonché allo spessore (minimo) della regione anatomica attinta. In conclusione, l’esame necroscopico in uno alle indagini istologiche ed istochimiche consentiva di escludere che la causa mortis fosse da attribuire a causa violenta correlata all’impiego da arma da fuoco, attribuendo, invero, le lesioni ossee riscontrate in corrispondenza di alcuni segmenti scheletrici all’azione post-mortale di morsi di animali.
    Zacchia 01/2013;
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    ABSTRACT: Background: To limit the chimerism typical of transplanted organs, which constantly reveals mixed profiles, laser microdissection (LCM) has been hypothesized as a valid tool in comparison with manual dissection. Case Report: A 42-year-old man with end-stage HBV/HDV liver cirrhosis and single hepatocellular carcinoma (HCC) underwent liver transplantation. Four months later hepatic nodules were diagnosed. The histological investigation showed an HCC. Despite therapy, the man died as a result of metastatic carcinoma 9 months later. On behalf of the public prosecutor, we performed short tandem repeat analysis on the hepatic nodules to determine whether the carcinoma had originated from the transplanted liver. Conclusions: The manually dissected samples revealed a high degree of chimerism that did not allow a clear diagnosis. Instead, the detected chimerism was very low in the microdissected samples, where the tumor origin was clearly diagnosable as a recurrence of the recipient's primitive HCC. Accordingly, the application of LCM improved the quality of the results leading to an exclusion of medical liability profiles, confirming the high quality safety procedure of the Italian system in solid organ transplantation, and showing at the same time how useful this technique may be in selected forensic cases.
    Annals of transplantation : quarterly of the Polish Transplantation Society. 01/2013; 18:408-13.
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    ABSTRACT: The authors present the case of a 59-year old woman who has been treated with a dual beauty procedure. Firstly, she underwent to an infrared therapy for cellulite at thighs, hips, abdomen and buttocks. Subsequently, the same day, she went through a depilatory treatment performed using hot wax stripping on her thighs and legs. In the evening, the woman felt intense pain in the legs and for that reason, the day after, she went to the emergency room, where I and II degree burns to her thighs and knees were bilaterally diagnoses.The woman leaned lawsuit against the beautician who was investigated for personal injuries. The forensic pathologist chosen as the Public Prosecutor Consultant was asked to evaluate if the alleged injuries were due to the infrared therapy, the hot wax stripping or both, and arising from a negligent, reckless or incompetent operator.On the basis of clinical and circumstantial data, a slight personal injury arising solely from the depilatory treatment was diagnosed.However, according to the legislation in force at the time of events, the beautician was not sentenced from a penal point of view. The burns, indeed, were considered as a possible side effect of hair removal through hot wax stripping.
    Italian Journal of Legal Medicine. 12/2012; 1(1):56.
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    ABSTRACT: In the literature, there are few studies on atherosclerosis in the pulmonary artery in human beings and no cases similar to the one presented has been reported until now. The aim of the study is to describe a particularly unusual case of primary severe pulmonary atherosclerosis, in a 40-year old man, reporting its pathological aspects associated with interstitial lung disease as a cause of a mild pulmonary fibrosis. Case presentation: The patient had marked atherosclerosis in the pulmonary trunk and its branches, probably caused by a series of hemodynamic and endothelial changes, subsequent to the pulmonary hypertension. An autopsy was performed a few days after death in order to explain the reasons of the sudden death. Despite the typical pattern of pulmonary atherosclerosis is generally associated with many co-morbidities, we have found only a significant right ventricular hypertrophy. A complete forensic approach led to attribute the cause of death to cardiorespiratory failure due to severe pulmonary atherosclerosis. Conclusion: in the light of the limited number of reports in the literature, this paper seeks to widen knowledge in the area of atherosclerosis in the pulmonary artery.
    Romanian Journal of Legal Medicine 11/2012; 20(3):177-80. · 0.21 Impact Factor
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    ABSTRACT: In this report, two cases of death in patients diagnosed with multi-systemic AA amyloidosis at autopsy were investigated for any medical errors that may have contributed to their deaths. The patients developed nephrotic syndrome post-operatively and following trauma. The second patient had been on hemodialysis for idiopathic kidney disease prior to the trauma she sustained. Complete autopsies with immunohistochemistry and electron microscopy were used to show the extracellular deposits of amyloid in the kidneys and also in other organs, including the heart. Cardiac involvement for this type of amyloidosis has never been reported in the literature. Post-mortem analysis showed multi-systemic AA amyloidosis as the cause of nephrotic syndrome, and ultimately the cause of worsening clinical outcomes, for the two patients. A comprehensive histopathological study led to a peculiar organ-specific observation of AA amyloidosis, which requires more thorough investigations by clinicians and must be considered in the evaluation by forensic pathologists in cases of professional liability.
    Australian Journal of Forensic Sciences 11/2012; In press. · 0.53 Impact Factor
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    ABSTRACT: Since the approval of Law N° 40/2004, Italian specialists have been applying assisted reproductive techniques in compliance with a number of restrictions. Several attempts were made to find a solution to the practical and ethical issues brought about by this restrictive legislation. Finally, in May 2009, the Italian Constitutional Court banned most of the limitations. In the last year the authors worked together to study the impact of the Italian Constitutional Court modifications on assisted reproduction from both a gynecological and medico-legal point of view. Despite the clinically positive impact of the ruling, a lot of technical and legal unsolved issues still exist. Analyzing these problems, the authors stress the importance of a multidisciplinary approach to achieve adequate legislation in order to improve patients' outcome and avoid "reproductive migration" from Italy to other European Countries. New regulation could also be important for practitioners by keeping the risk of legal troubles to the minimum.
    European journal of obstetrics, gynecology, and reproductive biology 04/2012; 163(1):1-4. · 1.97 Impact Factor
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    ABSTRACT: Anaesthesia-related death is one of the most complex events to be studied in forensic pathology because of its rarity and its doubtful presentation. Particularly, the difficulties in assessing the cause of deaths in such circumstances are underlined. A scale must be considered in order to determine the causal role of anaesthesia in the process leading to death. Indeed, beyond deaths exclusively explained by anaesthetic care, there are deaths that are not anaesthesia-related and deaths explained by surgery and co-morbidities in which the role of anaesthetic care has to be carefully investigated. A retrospective analysis of 3138 autopsies is presented with the aim of better understanding the patho-physiological process of anaesthesia-related mortality and to determine the causal role of anaesthesiological care in the process leading to death, thus assessing the real incidence of deaths due to anaesthesia (0.16%). In the present study, the number of deaths generically anaesthesia-related (33 cases) accounts for 2.06% of autopsies due to medical malpractice claims and 1.05% of all autopsies. The number of deaths totally related to anaesthesic care is rather low with 0.32% of autopsies due to medical malpractice claims and 0.16% of all autopsies. Anaesthesia-related deaths were due to lack of or delay in intubation (2 cases), acute cardio-respiratory failure (2 cases) and anaesthetic-induced hepatotoxicity (1 case). The importance of a careful forensic investigation (clinical and familial history, medical records, complete autopsy and toxicology), which can lead to a clear understanding of anaesthesia-related deaths, is also stressed.
    Medicine, science, and the law 04/2012; 52(2):112-5. · 0.48 Impact Factor

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