Abstracts

001

SARS-CoV-2 FULMINANT MYOCARDITIS: AN AUTOPSY AND HISTOPATHOLOGICAL CASE STUDY

Guillaume Gauchotte 1 , Véronique Venard 2 , Michaël Segondy 3 , Cyril Cadoz 4 , Aude Esposito-Fava 3 , Damien Barraud 4 , Guillaume Louis 4

1 Department of Biopathology, Legal Medicine, CHRU Nancy ; INSERM U1256, Université de Lorraine, Vandoeuvre-lès-Nancy, France

2 Department of Virology, CHRU Nancy, Vandoeuvre-lès-Nancy, France

3 Department of Legal Medicine, CHRU Nancy, Vandoeuvre-lès-Nancy, France

4 Department of Intensive Care Medicine, CHR Metz-Thionville, Ars-Laquenexy, France

Oral Presentation: Forensic pathology 1: special session on SARS-CoV-2, June 2, 2021, 9:00 AM - 10:30 AM

The coronavirus disease 2019 (COVID-19), due to SARS-CoV-2, is primarily a respiratory disease, causing in most severe cases life threatening acute respiratory distress syndrome (ARDS). Cardiovascular involvement can also occur, such as thrombosis or myocarditis, generally associated with pulmonary lesions. Little is known about SARS-CoV-2 induced myocarditis. We report the case of a 69-year-old man suffering from a refractory cardiogenic shock, without significant lung involvement. Prior to death, several nasopharyngeal swabs and a distal broncho-alveolar lavage were sampled in order to perform RT-PCR analyses for SARS-CoV-2-RNA, which all gave negative results. A medical autopsy was performed two days after death. The lungs were congestive, without significant hepatization. The heart weighted 403 g. Coronary arteries showed calcified atherosclerosis and contained two permeable stents, localized in the circumflex branch of the left coronary artery and in the right coronary artery. Microscopic examination of the heart revealed the existence of an intense multifocal inflammatory infiltration, in both ventricles and septum, composed in its majority of macrophages and CD8+ cytotoxic T lymphocytes (CD4/CD8 ratio: 0.11). Most of these T lymphocytes were positive for Tia-1 and granzyme B. Immunohistochemistry for anti-SARS nucleo-capsid protein antibody was strongly positive in myocardial cells, but not in lung tissue. In lung parenchyma, alveolar spaces were focally filled with a fibrine exudate, associated with a mild macrophagic alveolitis, without pneumocytes dystrophy. No fibrosis was seen. Liver parenchyma showed a moderate macro-vacuolated steatosis and an abundant peri-portal fibrosis associated with porto-portal septa. Multifocal centro-lobular necrosis was also observed, without significant inflammation. Acute tubular necrosis was observed in kidney, without inflammation. Pancreas showed a pluri-focal moderate lymphocytic and macrophagic inflammation and few phenomena of necrosis. RT-PCR was realized on formalin-fixed paraffin embedded lung and heart tissue blocks: only heart tissue was positive for SARS-CoV-2 RNA. In conclusion, this case study thus gives new insights in the pathogenesis of SARS-CoV-2 induced fulminant myocarditis and emphasizes on the importance and reliability of post-mortem analyses. In this pandemic context of COVID-19, the forensic pathologist should keep in mind the eventuality of a SARS-CoV-2 induced myocarditis and thus sudden death, even in the absence of lung injury and negative naso-pharyngeal swabs. Immunohistochemistry and FFPE tissue blocks-based SARS-CoV-2 RT-PCR can be useful to achieve this diagnosis.

002

EVIDENCE of SARS-CoV-2 ANTIBODIES AND RNA ON AUTOPSY CASES IN THE PRE-PANDEMIC PERIOD IN MILAN, ITALY

Gianguglielmo Zehender 1 , Alessia Lai 1 , Alessio Battistini 2 , Stefano Tambuzzi 2 , Giuseppe Lanza Attisano 2 , Paolo Bailo 2 , Andrea Piccinini 2 , Riccardo Zoja 2 , Cristina Cattaneo 2

1 Department of Biomedical and Clinical Sciences “Luigi Sacco”, University of Milan, Italy

2 LABANOF (Laboratorio di Antropologia e Odontologia Forense), Institute of Legal Medicine, University of Milan, Italy

Oral Presentation: Forensic pathology 1: special session on SARS-CoV-2, June 2, 2021, 9:00 AM - 10:30 AM

Introduction : At the end of December 2019, the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing serious pneumonia was identified in Wuhan, Hubei Province, China. The coronavirus disease 2019 (COVID-19) viral disease rapidly spread worldwide, and the first laboratory-confirmed Italian COVID-19 case was identified in Lombardy on February 20, 2020. However, some recently performed studies have confirmed the virus circulation also in the pre-pandemic period. To date, no studies on this item have been conducted on autopsy cases. We, therefore, wanted to address this specific topic by analyzing blood samples collected from cadavers subjected to autopsy at the Institute of Legal and Forensic Medicine in Milan, Italy.

Material and Methods: We selected all autopsy cases from 1st October 2019 to 27th March 2020 in which blood samples had been collected for judicial purpose. Three kind of test were carried out on each 3 ml sample: 1) PrimaLab rapid antigen serological test; 2) Elisa Wantai test; 3) Real-Time PCR test. The first two, albeit with different methodology, search for the presence in the blood of specific antibodies (IgM and IgG) produced by the immune system in response to the infection caused by SARS-CoV-2; the RT-PCR test, on the other hand, directly searches for the presence of SARS-CoV-2 viral RNA.

Results: We enrolled a total of 169 cases. Out of these, at least one positive result among the three applied methods was observed in 5 cases (2 suicide by hanging and 3 natural death). In 4 of them, the positivity was observed with the PrimaLab rapid antigen test; in detail, 3 cases tested positive for specific SARS-CoV-2 IgM antibodies and 1 case for specific SARS-CoV-2 IgG antibodies. In only 1 case, a concomitant positivity both to the Elisa test and the RT-PCR analysis was observed. By integrating such findings with the epidemiological-forensic data, it was observed that 2 of the aforementioned cases (both IgM positive) referred to subjects who died in the second half of October 2019, 2 others (one IgM positive and the other one positive both to the Elisa and to the RT-PCR analyses) to subjects who died in the first half of December 2019 and, finally, the last one (IgG positive) to an individual who died in mid-January 2020.

Discussion : Our study on samples collected before the first autochthonous case was detected in Italy confirms that SARS-COV-2 was already circulating since mid-October 2019. It also demonstrates that cadaveric blood samples may be a good substrate on which carry out tests for the searching of SARS-COV-2.

003

POST-MORTEM IMMUNE-RICH VERSUS IMMUNO-DESERT ORGAN PATTERNS FROM AUTOPSY WITH MEDICO-LEGAL IMPLICATIONS IN ANTEMORTEM COVID-19 POSITIVE AND NEGATIVE NASOPHARYNGEAL SWABS PATIENTS

Nicola Pigaiani 1 , Dario Raniero 1 , Vito Cirielli 2 , Elisa Vermiglio 1 , Giovanna Del Balzo 1 , Zeno De Battisti 3 , Davide Reganato 4 , Stefania Turrina 1 , Domenico De Leo 1 , Matteo Brunelli 5

1 Unit of Forensic Medicine, Department Of Diagnostics And Public Health, University Of Verona, Italy

2 Unit of Forensic Medicine, Hospital “San Bortolo”, Vicenza, Italy

3 Unit of Forensic Medicine, ASST Papa Giovanni XXIII, Bergamo, Italy

4 Bergamo, Italy

5 Unit of Pathology, Department of Diagnostics and Public Health, University of Verona, Italy

Oral Presentation: Forensic pathology 1: special session on SARS-CoV-2, June 2, 2021, 9:00 AM - 10:30 AM

Background : Documentation of macroscopic organ images, histopathological features and immunohistochemical analysis referred to autopsies after death caused by SARS-CoV-2 (COVID-19) is often incomplete due to scarce organ sampling, images from gross room, and/or lack of the immunoenviroment multi-target analysis. We aimed to provide cases with detailed gross, microscopic and immunohistochemical analysis.

Materials and Methods : 14 autopsies from deaths caused by COVID-19 (12 positives at nasal swab and 2 highly suspicious for COVID-19 infection by ante-mortem pathognomonic diffuse interstitial pneumonia) were performed. Gross images for all organs, multi-organ sampling, and detailed immunohistochemical and special analysis (CD3, CD8, CD20, CD1a, CD15, CD68-PGM1, CD68-KP1, CK8-18, CD61, PTAH, beta-tubulin and TWIST) were performed on tissue sections.

Results : Myofibroblastic regenerative foci were observed in 10/14 (71%), often visuable at 10x-all at 20X, with association of vasculitis in 5/10. Multigiants cells and giant morulae, positive for CD68, were observed. 4/14 (29%) showed DAD with huge amount of hemorrhagic pneumonitis. 4/14 (29%) did not evidence diffuse inflammatory foci (immuno-desert profile) in the pulmonary parenchyma, whereas vasculitis characterized such a case (PTAH+ along small vessels, CD61+ in the interstitium). Differently, 11/14 (79%) were characterized by diffuse inflammatory tissue in the interstitium and parenchyma, 3/14 (21%) with additional granulocytes and abscesses referred to bacterial additional infection. T,B-lymphocytes foci were patchy observed whereas macrophage-histiocytes lineage were constantly visuable in cases with immune-rich pathogenetic reactions (11/14). Beta-tubulin and TWIST resulted activated in the myofibroblastic regenerative morulae (four cases showed TWIST nuclear positive immunoexpression along ten cases characterized by regenerative foci and beta-tubulin in three out of fourteen). Kidneys showed inflammatory foci along pyramids with tubulitis in 4/14 (29%), the myocardium in 1/14 (7%) and brain in 1/14 (7%), mainly characterized by CD68-positive cells/CD3-T-cells, rarely granulocytes. The gastrointestinal tract showed inflammatory foci in 1/14 (7%) and liver in 4/14 (29%) but specificity of such inflammatory tissue need further investigation. Two deaths/14 (14%) without COVID-19 positive swab showed myofibroblastic reactions in the interstitium, hemorrhagic intralveolar homing and CD68-cells intermixed on T-cells.

Conclusion : 1) Although the immune-rich pathogenetic pattern is more frequently observed from lungs after death caused by SARS-CoV-2 (COVID-19), the immune-desert pattern may be observed (29%); 2) Myofibroblastic regenerative pathogenetic foci are observed in both deaths with anamnestic (ante-mortem) COVID-19 swab-pos and swab-neg; 3) Beta-tubulin and TWIST need further analysis to gain insights the pathogenetic myofibroblastic process, as a sensible marker of the COVID-19 pathobiology; 4) Data acquired from forensic autopsy, could be useful to elucidated this pathological process, also for judicial propose (death caused by COVID-19).

004

POST-MORTEM SARS-CoV-2 Detection, A Swiss Forensic Experience

Diego Aguiar 1 , Manuel Schibler 2 , Tony Fracasso 1 , Christelle Lardi 1

1 University Center of Legal Medicine, Geneva University Hospitals, Geneva, Switzerland

2 Laboratory of Virology, Geneva University Hospitals, Geneva, Switzerland

Oral Presentation: Forensic pathology 1: special session on SARS-CoV-2, June 2, 2021, 9:00 AM - 10:30 AM

Introduction : During recent COVID-19 pandemic, the ability to diagnose COVID-19 after death was crucial as a way to resolve undetermined death and also important for sanitary purposes. At the same time, the local increase of global mortality rates has brought more deceased to be admitted for forensic investigations. Clinical diagnosis of SARS-CoV-2 was widely performed by means of polymerase chain reaction (PCR) techniques from naso-pharyngeal swabs. The need for lower airway tract sampling to increase test sensitivity was early discussed, most of all in cases of severe infection. For postmortem population, we decided to select tracheobronchial swabs as an option for virus detection.

Material and Methods : During the first and second wave of the pandemic, systematic postmortem respiratory (tracheo-bronchial) swabs were routinely performed on demand of the local sanitary authorities during medico-legal autopsies. They were all analyzed for presence of SARS-CoV-2 by the laboratory of Virology, Geneva University Hospitals, with reverse transcriptase PCR (RT-PCR) technology. Unfortunately, we were limited by lack of swabs supply availability for postmortem services as well as by significant overload of laboratories. Therefore, we could not get the possibility of analyzing more than one swab per case.

Results: A total of 159 postmortem swabs were performed during 2020, with a global positivity rate of 12%. During the first wave, positivity rate raised up to 13% and up to 21% during the second wave.

Discussion: A positive test was considered of considerable value in the process of diagnosing COVID-19 related death, even if all data about the case always needs to be taken into consideration (evidence of hyperthermia, macroscopic and histopathological study, computed tomography (CT) pattern and microbiological results). In the post-mortem setting, the extent of validity of postmortem respiratory swabs results is still unknown, especially according to post-mortem interval. To this date few studies reported the analysis of postmortem respiratory swabs sampled during autopsies. Our experience with postmortem swabs will be shared and discussed in the light of comparative studies available in literature.

005

FORENSIC GUIDELINES DURING THE PANDEMIC: PERFORMING AUTOPSIES CAN BE SAFE

Giovanni Aulino 1 , Michele Rega 1 , Simone Grassi 1 , Marco Dell'Aquila 2 , Paola Cattani 3 , Vincenzo Arena 2 , Vincenzo Lorenzo Pascali 1 , Antonio Oliva 1

1 Deparment of Health Surveillance and Bioethics, Section of Legal Medicine, Università Cattolica del Sacro Cuore, Rome, Italy

2 Department of Woman and Child Health and Public Health, Section of Anatomical Pathology, Università Cattolica del Sacro Cuore, Rome, Italy

3 Department of Basic Biotechnological Sciences, Intensivological and Perioperative Clinics, Section of Microbiology, Università Cattolica del Sacro Cuore, Rome, Italy

Oral Presentation: Forensic pathology 1: special session on SARS-CoV-2, June 2, 2021, 9:00 AM - 10:30 AM

Description of the method : In this presentation we will discuss a protocol based on the guidelines proposed by Aquila et al, particularly focusing on the importance of risk assessment before performing forensic autopsies (REF). The protocol is composed by five steps: risk assessment, storage of the cadaver, virtopsy, autopsy and sample collection, sample preservation. In our institution, we give particular importance to the phase of risk assessment: in particular, in order to avoid false negatives, we perform multiple (four) post-mortem swabs (in the rhynopharynx, in the trachea and in the lungs) in all the cases in which forensic autopsy must be performed. A great importance is also given to virtopsy, both as a source of information complementary to the data obtained from the autopsy as an alternative technique for traumatic deaths in which forensic autopsy is not required by the public authorities.

Discussion : The Coronavirus pandemic has heavily affected Italy, with 2.683.403 positive cases and 92.720 deaths as of 12th of February. Several evidence on the persistence of SARS-CoV-2 on different kind of materials have been published, but how long the virus stays viable in cadavers is still a matter of debate. Autopsies, however, have always been fundamental to understand the causes of death and have always contributed to define diseases on a pathological basis. This explains why in the case of unknown infectious diseases, such as the pneumonia by Covid-19, autopsies play an even more crucial role. While the Italian Society of Pathologic Anatomy advised against the routinary performance of clinical autopsies during the pandemic, many other authors advocated that clinical and forensic autopsies are the only tool to distinguish the subjects died of COVID-19 from those died with COVID-19. A thorough knowledge of the eventual persistence of pathogen in deaths related to infectious diseases is fundamental in order to secure an approach to complete autopsy performance in which the operators can be fully aware of the eventual biological risks before exposition. Dell’Aquila et al. have proved that the swab can remain positive for up to 310 hours. In addition, it has been demonstrated that is possible that only one of the lung swabs may be positive with a negative swab in the rhynopharynx and in the trachea. Thanks to our protocol and guidelines was reduced the risk of detecting false-negative patients and for this reason no pathologist got infected during the performance of the swabs nor at the autopsies, which lasted 45 minute to 2 hours.

006

HOW THE COVID 19 PANDEMIC WILL CHANGE THE CRIME SCENE MANAGEMENT? AN OPERATIVE PROTOCOL FROM THE SCENE TO THE LABORATORY

Isabella Aquila 1 , Pietrantonio Ricci, Ludovico Abenavoli, Matteo Sacco, Roberto Raffaele, Natalia Malara, Vincenzo Arena, Simone Grassi, Mariarosaria Santangelo, Cristian D'Ovidio, Francesco Ausania, Santo Gratteri, Antonio Oliva

1 University Magna Graecia of Catanzaro, Italy

Oral Presentation: Forensic pathology 1: special session on SARS-CoV-2, June 2, 2021, 9:00 AM - 10:30 AM

The global pandemic COVID 19 is requiring to radically change the operative processes in every field. From the forensic point of view, to date few studies have assessed and described the biological risks during crime scene investigation. Unfortunately, at the present time this issue has to be discussed and, above all, immediate solutions have to be adopted to minimize infectious risk for forensic operators during operations that do present significant health and safety hazards. In this presentation we discuss these risks and then we propose an operating protocol that indicates in detail the infectious risk management in the forensic workflow starting in the crime scene and ending in the morgue/laboratory that in our opinion could be valid especially during the COVID-19 pandemic.

007

AUTOPTIC EXAM of A SARS-COV-2 POSITIVE SUBJECT REMAINS A HIGHLY DANGEROUS PROCEDURE AFTER ONE DAY OF DEATH

Silvestro Mauriello 1 , Filippo Milano 1 , Fabio Guidato 1 , Bartolo Caggiano 1 , Gian Luca Marella 1 , Marco Mezzelani 1 , Luigi Tonino Marsella 1

1 Forensic Medicine, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy

2 Department of Surgical Sciences, University of Rome Tor Vergata, Rome, Italy

Oral Presentation: Forensic pathology 1: special session on SARS-CoV-2, June 2, 2021, 9:00 AM - 10:30 AM

Introduction : study aim is to examine the capability of SARS-CoV-2 virus particles to persist in deceased persons, in order to investigate if pathological process such as viral infections, could continue after death. This could find out if patients who died with the infection still could be potentially carriers of the virus, a great issue for the public health in terms of both, virus spread control and safety of healthcare professionals.

Materials and methods : in this study we included 15 patients (8 males and 6 females; 46–92 years-old), suffering from SARS-CoV-2 interstitial pneumonia (from 1 to 108 days of hospitalization), with comorbidities (8 had heart failure, arrhythmia or ischemic heart disease, 6 hypertension, 6 dementia, 3 chronic renal failure, 2 neoplasms, 2 diabetes, 2 obesity, 1 recent kidney transplantation, 1 stroke), and who died from this infection. We studied the persistence of SARS-CoV-2 by real time-PCR in 24 h post-mortem nasopharyngeal swabs of subjects who died from SARS-CoV-2 infection. Real-time- Polymerase Chain Reaction (RT-PCR) analysis targeted the common envelope (E) gene, the specific nucleocapsid (N) and RNA-dependent-RNA-polymerase (RdRp) genes, within an hour (T0) and after 24 hours (T1) from death. The results of RT-PCR test are showed as cycle-threshold (Ct) values. Ct-values less than 35 were considered as positive tests.

Results : in our study RT-PCR investigations showed that, after 24 h, SARS-CoV-2 viral RNA was still detectable in 60% of subjects, with an increase of the viral load in more of 50% of cases. Furthermore, more of 20% of cases were positive for all evaluated genes (E, N and RdRp). Patients mean age was 73,1 ± 11.

Conclusions : the study allows us to consider the autoptic exam of a SARS-CoV-2 positive subject a highly dangerous procedure also after 24 h. The peculiar results emerged from our investigation suggest the importance of obtaining more than one post mortem swab, before a patient can be considered SARS-CoV-2-negative with a reasonable degree of certainty. This could justify the need to adopt appropriate protective measures by both the medico-legal team in the surveys on the investigative scenes and the staff of the morgue and even in a hospital setting when a diagnostic autopsy is required.

008

RANDOM DISCOVERY OF A HERPES SIMPLEX VIRUS ENCEPHALITIS BY MRI

Pia Genet 1 , Doron Merkler 2 , Jean-Baptiste Zerlauth 3 , Tony Fracasso 1

1 University Center of Legal Medicine Lausanne-Geneva (CURML), University of Lausanne and University of Geneva, Switzerland

2 Department of Pathology and Immunology, University of Geneva, Switzerland; 3 Diagnostic Imaging Center, Lausanne, Switzerland

Oral Presentation: Forensic imaging 1, June 2, 2021, 9:00 AM - 10:30 AM

Case description : We describe a case of a 61-year-old man who was found dead at home. He was not known for any illness and no symptoms were described before death. At autopsy, signs of pneumonia were detected. The macroscopically examination of the brain revealed no pathological findings. The microscopically evaluation of the brain showed small groups of inflammatory cells in the brainstem. The detailed analyze of MR images of the brain, which have been performed before the autopsy, showed a hypo-intensity on T1-weighted images and a hyper-intensity on T2-weighted images of the frontal and temporal lobes with damage of the cingulate cortex bilaterally, the limbic lobe and the insular cortex on the left side. These images raised the suspicion of a herpes simplex virus encephalitis. Neuropathological and immunohistochemical investigations, which thus were carried out, showed various infiltrates of CD3+ T-cells in the brainstem. Multiple of these CD3+ T-cells were actually corresponding to cytotoxic CD8+ T-cells. Additionally, to these infiltrations, we found CD68+ macrophages and activated microglia. Furthermore, we could, immunohistochemically, show an HSV-1 positivity of the hippocampi.

Discussion : An herpex simplex virus encephalitis is an inflammation of the brain which can be caused by herpex simplex virus (HSV-1 and HSV-2). It belongs to the rare virus encephalitides and can be often fatal. It can be difficult to diagnose this encephalitis in postmortem, especially if the person doesn’t show any symptoms before death. In order to detect this kind of encephalitis several examinations have to be performed; but for initiating these examinations the clinical history has to be known and the suspicion of an encephalitis has to be evocated before autopsy. It has to be highlighted that the macroscopically examination of the brain and the CT- scan images, if available, can report any pathological finding. This case shows how easily the right diagnose can be missed and how significant interdisciplinary work is. Moreover, it underlines the importance of MRI for the correct evaluation if the brain. In this case the diagnose wouldn’t have been possible without this imaging technique.

009

DETECTION AND INTERPRETATION OF SHARP FORCE SKELETAL TRAUMA USING RADIOLOGICAL IMAGING

Amy Spies 1 , Maryna Steyn 1 , Daniel Prince 2 , Desiré Brits 1

1 Human Variation and Identification Research Unit (HVIRU), School of Anatomical Sciences, Faculty of Health Sciences, University of The Witwatersrand, Johannesburg, South Africa

2 Department of Diagnostic Radiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Oral Presentation: Forensic imaging 1, June 2, 2021, 9:00 AM - 10:30 AM

Sharp force trauma (SFT) is a common occurrence in victims of violent crime, and the detection, analysis, and interpretation thereof is critical for the accurate investigation of these cases. Computed tomography (CT), conventional X-ray and low-dose full-body X-ray (Lodox) scans were assessed with regards to their sensitivities for detecting SFT to the skeleton, including the number of skeletal defects, the minimum number of blows inflicted, the type of SFT and, as a result, the class of weapon used. For this purpose, a pig model was used. A non-serrated, single-edged kitchen knife was used to stab ten pigs, post-mortem, on one side of the body, while a panga was used to chop the other side. The side to of the body on which each weapon was used was alternated for each pig and therefore not kept consistent, reducing bias. The pigs then underwent CT, X-ray and Lodox scanning followed by maceration, allowing both the radiological images as well as the dry bones to be examined. The number of skeletal defects and the minimum number of impacts identified both radiologically and osteologically were noted. The type of SFT was also determined based on several macroscopic characteristics of the trauma. The sensitivity and specificity of each imaging modality for detecting skeletal SFT was calculated. CTs had the highest sensitivities, detecting 70.4% of all skeletal defects and 82.8% of the minimum number of impacts. Lodox scans were slightly more sensitive than X-rays, identifying 47.0% of all skeletal defects and 58.4% of impacts, while X-rays identified 35.4% and 43.5% respectively. All imaging tools were more sensitive for identifying defects as a result of chopping trauma (CT: 78.3 %; X-ray: 46.5%; Lodox: 59.3%) compared to defects resulting from stabbing trauma (CT: 56.7%; X-ray: 17.2%; Lodox: 26.8%). Overall specificities for detecting SFT defects were high for all methods, ranging between 92.9% and 97.5%. All radiological methods were highly sensitive in correctly classifying the type of SFT (i.e., stabbing vs chopping), while only Lodox scans had a sensitivity lower than 70.0% for classifying stab wounds. Results indicate that CT scans should be the radiological method of choice for examining SFT to bone, but when this is not possible or feasible, Lodox scans can be used. X-rays, however, are not recommended for skeletal SFT analyses. However, none of the radiological methods are as accurate as dry bone for detecting SFT, and an osteological analysis is therefore still considered the gold standard. Broadly determining the class of sharp instrument used, based on the type of SFT and certain macroscopic characteristics of the trauma, is possible using CT, X-ray and Lodox scans.

010

MICRO-CT ANALYSIS OF EXPERIMENTALLY PRODUCED BONE FRACTURES OF THE LIMBS

Andrea Gabbin 1 , Silvia Agusson 1 , Paolo Fais 2 , Guido Pelletti 2 , Caterina Politi 2 , Massimo Montisci 1 , Giovanni Cecchetto 1 , Guido Viel 1 , Chiara Giraudo 3

1 Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Italy

2 Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Italy; 3 Institute of Radiology, Department of Medicine (DIMED), University-Hospital Padova, Italy

Oral Presentation: Forensic imaging 1, June 2, 2021, 9:00 AM - 10:30 AM

Background : the interpretation of patterns of lower limb fractures is of great interest in forensic traumatology, allowing to define the direction and speed of the applied force, the site of the impact and the characteristics of the vehicle responsible for the injury. Aim of the study: a standardized experimental model for the production of human tibia and fibula fractures, simulating the outcomes of road traumas, was created in order to test, through macroscopic and micro-radiological analyses, a potential correlation between the direction of the injurious force and the pattern of fractures produced.

Materials and methods : four pairs of articulated human tibia and fibula were used, on the midpoint of which a 6 kg grave was dropped from a height of 1 meter, using a standardized machinery. The fracture stumps thus obtained were macroscopically analysed, through photographs and videos taken with a Google Pixel 3 smartphone and a Nikon D90 camera, and subsequently subjected to micro-CT scans. The results obtained were statistically compared.

Results : This study describes the analysis of experimentally produced fracture patterns by fractography and micro-TC. In fractography only a longitudinal or oblique black line was observed in the impact area. In micro-CT a better characterization of the fracture pattern was observed, with chip fragments and multiple fracture lines in the area of impact.

Conclusions : This study demonstrates that micro-CT is superior to fractography for reconstructing bone impact direction. Micro-CT is able to locate fracture lines, reconstruct bone segments in 3D images and calculate bone mineral density in the trabecular and cortical bone without any need for optical transparency.

011

CASE REPORT OF A SKELETON FIND IN FOREST - EXPLOSION TRAUMA VERSUS BLUNT FORCE TRAUMA OF THE SKULL

Wolf Schweitzer 1 , Sebastian Eggert 1 , Michael Thali 1 , Stephan Bolliger 1 , Magda Roidou 1

1 Zurich Institute of Forensic Medicine, Zurich, Switzerland

Oral Presentation: Forensic imaging 1, June 2, 2021, 9:00 AM - 10:30 AM

Partly skeletonized human remains which constituted an almost complete skeleton were found in a forest. The identity was confirmed as being that of an approximately 45-year-old man. What appeared to us as an outstanding feature was the fracture pattern of the skull, which seemed to present a strong contrast with the remaining skeleton, which was almost completely unharmed. The skull fracture pattern, particularly as seen in post-mortem CT (PMCT) was then compared to skull data from other cases in our database. There, we looked at cases of blunt trauma and various firearm injuries. Based on this data comparison, we deemed an explosion trauma to be the best explanation for the findings in the case at hand. Further investigation then found that the deceased, who had a history of depression, had indeed been a trained pyrotechnician. Based on this and further results of the examination, suicide was considered a plausible manner of death. Details of the skull fractures, and comparison with other cases, will be presented and discussed.

012

INTEGRATION OF COMPUTED TOMOGRAPHY WITHIN A MEDICOLEGAL INSTITUTE: IMPACT AND EVOLUTION OF POST MORTEM IMAGING PRACTISES

Noémie Bergot 1 , Joseph Benzakoun 3,4 , Ghazi Hmeydia 3,4 , Lilia Hamza 1 , Tania Delabarde 2 , Jean François Meder 3,4 , Bertrand Ludes 1,2

1 Medicolegal Institute of Paris, France

2 UMR 8045 CNRS BABEL University of Paris, France

3 GHU Paris Psychiatry and Neuroscience, Paris, France

4 Équipe IMA-BRAIN, Center of psychiatry and neuroscience, inserm UMR 1266, Paris, France

Oral Presentation: Forensic imaging 1, June 2, 2021, 9:00 AM - 10:30 AM

Introduction : The installation of computed tomography (CT) units within medicolegal institutes increases the feasibility of post mortem CT (PMCT) by simplifying corpses transport and allowing access to CT at any time. The objective of our study is to evaluate the impact of integrated PMCT (iPMCT) on volume and type of PMCT activity.

Material and methods : All CT reports of decedents who underwent a scanner for the Medico-Legal Institute of Paris (IML-P) on an in-hospital PMCT (hPMCT) at Sainte Anne Hospital (between May 2014 and January 2018) and on iPMCT (between February 2018 and December 2020) were analysed. The following elements were compared between the two periods: context and number of examinations, age, sex, identification, retained cause of death, as well as the total of bodies admitted to the IML-P during these periods.

Results : 1212 scans were performed on iPMCT among 8775 bodies (13%) admitted in IML-P after February 2018, as compared to 118 among 10587 (1%) on hPMCT before January 2018, which corresponds to an average of 34 scans per month on iPMCT compared to 3 per month on hPMCT. Subjects scanned on iPMCT were older (median age 54, IQR 37-69 vs. 31, IQR 17-37, p<0.001) and less frequently identified (767/1212 = 63% vs. 102/118 = 86%, p<0.001) than on hPMCT. The sex ratio was not significantly different between the two periods (822/1212 = 68% men on iPMCT vs. 78/118 = 66% on hPMCT, p=0.9). The most frequent causes of death were medical causes (20%) or undetermined causes (37%) on iPMCT whereas it was ballistic trauma (64%) or other traumatic injuries (16%) on hPMCT.

Discussion: The integration of a CT scanner within a medicolegal institute allows a strong increase in the rate of exploration of admitted corpses, especially elderly, unidentified deceased who died in non-traumatic conditions. This switch towards a new population type should allow further developments for subject identification and non-invasive management of bodies in non-traumatic situations.

013

THE ROLE OF POST-MORTEM RADIOGRAPHERS IN A UNIVERSITY CENTRE OF ANATOMY

André Guerra 1 , Sami Schranz 1 , Michel Kielar 1 , Hughes Cadas 1,2 , Sara Sabatasso 1,2 , Silke Grabherr 1

1 University Center of Legal Medicine Lausanne-Geneva (CURML), University of Lausanne and University of Geneva, Switzerland

2 Faculty of Biology and Medicine, University of Lausanne, Switzerland

Oral Presentation: Forensic imaging 1, June 2, 2021, 9:00 AM - 10:30 AM

The University Center of Legal Medicine Lausanne-Geneva (CURML) has the particularity that it is also in charge of teaching Anatomy in the University of Lausanne. This is done via a specific unit, called “Faculty Unit of Anatomy and Morphology” (UFAM). This unit works with donated bodies, which are employed mainly for teaching (pre- and postgraduated, medical students, surgical training for specialists, continued education, health professionals) and for research. As the CURML has also a forensic imaging unit that has own equipment allowing MDCT (Multidetector Computed Tomography), Magnetic Resonance Imaging (MRI), 3D-Surface Scanning (3DSS) and Digital Radiography, the aim was to develop post-mortem imaging for the purposes of the UFAM. Therefore, experienced forensic radiographers from the forensic imaging unit integrated the UFAM, creating thereby a new sub-specialty for radiographers: The post-mortem radiographer (PMR). This professional profile helps for the future developments of anatomy teaching and medical research (including forensic), with the integration of various imaging techniques. The role of the PMR is to assist the anatomy teaching using donated bodies. He or she has therefore the role of a mortuary technician taking care of bodies from their arrival in the center until their use for different research projects or teaching and finally to their cremation. Additionally, the PMR starts to implement post-mortem imaging to the different steps. As a first step, a native Post Mortem Multidetector Computed Tomography (PMCT)-scans of all the cadavers is added to the standard procedure, allowing to perform an accurate selection of bodies according to specific needs (dissection courses, specific training for specialists, research). Indeed, the identification of anatomical variations, specific pathological traits, old/recent surgery or prostheses is possible thanks to this radiological screening. Also the adequate fixation (frozen, formalin fixation etc.) can be chosen for each body based on the obtained information. Regarding research in particular, this radiological screening also allows the selection of bodies for the inclusion into research protocols. Additionally, the systematic execution of PMCT-scans of anatomical bodies allows to create an exhaustive database for research. The main interest of incorporating PMRs into an Anatomy unit is to improve and further develop the role of imaging in anatomy teaching and in medical research, including forensic research. The skills of the PMRs are also highly demanded in clinical research or training, especially when studies are performed on human corpses that need interventional radiology. Thanks to the professional experience and activity of the PMR, this professional represents an effective interface between Anatomy and Forensic Pathology. The creation of a digital radiological database will allow refining educational approaches as well as research projects.

014

"SEEING FOR REAL"? SOCIO-ANTHROPOLOGICAL ANALYSIS OF THE POST-MORTEM IMAGING INTEGRATION IN FORENSIC MEDICINE

Céline Schnegg 1 , Séverine Rey 1 , Alejandro Dominguez 1,2 , Silke Grabherr 2

1 School of Health Sciences (HESAV), University of Applied Sciences and Arts Western Switzerland (HES-SO), Lausanne, Switzerland

2 University Center of Legal Medicine Lausanne-Geneva (CURML), University of Lausanne and University of Geneva, Switzerland

Oral Presentation: Forensic imaging 1, June 2, 2021, 9:00 AM - 10:30 AM

Introduction : Modern post-mortem imaging techniques – post-mortem computed tomography (PMCT), post-mortem magnetic resonance imaging (PMMR), post-mortem computed tomographic angiography (PMCTA) and 3D Surface Scanning (3DSS) or photogrammetry – are increasingly used as a complementary tool to autopsy in death investigations. In particular, they allow to describe the whole skeleton, to determine precisely a ballistic trajectory or to visualize the vascular system. The aim of our socio-anthropological study is to analyze the integration of post-mortem imaging into the daily work of a medico-legal institute and the adjustments it implies between forensic doctors, radiologists and radiographers.

Material and Methods : Designed with a qualitative approach, our study is based on ethnographical observations (100 days) of investigation practices in a Swiss forensic medicine department using and developing postmortem imaging, interviews with the professionals (22) of the forensic medicine and imaging section, and analysis of forensic reports. It is funded by the Swiss National Science Foundation (10001A_176428).

Results : As an innovation which is often considered revolutionary, post-mortem imaging is used as a complement to conventional autopsy. As such complement, its integration into the forensic procedures has consequences on the organisation of bodies investigations. According to the hypotheses about the causes of death, forensic doctors, radiologists and radiographers debate in order to organize the priorities and the use of each imaging technique. The added value of radiological examinations (visualization power) is weighed against their duration, which delays the autopsy. Also, side effects and eventual technical artefacts have to be considered, such as the effects of PMCTA on the texture and the consistency of the organs and post-mortem lividities. Most importantly, discussion and debate arise about the “ways of seeing” and the respective probative value of both, autopsy and post-mortem imaging. One of the main discussions concerns the proximity degree and relationship between “virtual” and “real” bodies. Here a difference can be observed that distinguishes between the forensic pathologists, who touch and cut, and the members of the imaging unit who “reduce bodies to images”. We also identified discrepancies around the probative value of post-mortem imaging, especially in cases of discordance between radiological and autopsy results. The outcome of the debates always seems to be the same: the results of radiological exams must be confirmed through autopsy and the examination of the “real bodies”. This reduces forensic imaging to a “guide for autopsy”.

Discussion : Direct observation, senses of the forensic expert during autopsy, toxicological and histological analysis remain the gold standard to find the cause of death, decreasing the strength and the legitimacy of post-mortem imaging. The integration of post-mortem imaging into the forensic investigations implies debates and even resistances as it questions the practices and the professional vision of forensic pathologists.

015

THE MEDICO-LEGAL ASSISTANCE OF THE DOMESTIC VIOLENCE VICTIMS

Beatrice Gabriela Ioan 1 , Bianca Hanganu 1 , Ionescu Carmen Simona 2

1 Grigore T. Popa University Of Medicine And Pharmacy, Iasi, Romania

2 Institute of Legal Medicine, Iasi, Romania

Oral Presentation: Bioethics and medical law, June 2, 2021, 11:00 AM - 12:18 PM

The Istanbul Convention states that domestic violence means all acts of physical, sexual, psychological or economic violence, which occur in the family or in the household, between current or ex-spouses or partners, regardless of whether the aggressor shares or shared the same home with the victim. Statistics show that women are more frequently victimized and suffer more serious injuries, which is why domestic violence is often equated with male abuse of women. The increased prevalence and individual, family and social impact make domestic violence one of the most pressing social problems in the contemporary world. The phenomenon of domestic violence takes place in a dynamic social context, which has become increasingly complex due to the addition of new forms, such as domestic violence in emigrant communities or domestic violence in homosexual couples. Domestic violence is a particular form of violence, often underreported, which means violating a relationship based on trust. To these are added the ample long-term impact and the complex causality in which individual factors are intertwined with the social and family ones. In turn, victims of domestic violence outline a particular pattern of victimhood due on the one hand to the permanent risk of repeating acts of violence and on the other hand due to special treatment needs. In this paper, the authors analyze the medico-legal assistance of the domestic violence victims, emphasizing the complexity of the cases and that the victims must be placed at the center of this activity. The particularities of the the medico-legal assistance of the domestic violence victims are analyzed in terms of aspects such as: biases that may occur during the examination, the need to respect privacy and confidentiality, creating opportunities for access to forensic services, correct information and guidance for victims to benefit from appropriate multidisciplinary assistance.

Keywords : domestic violence, victims, legal medicine, assistance

016

WHAT MAKES DOCTORS TO BE COMPLAINED AGAINST? STUDY REGARDING THE PROFILE OF THE ROMANIAN DOCTORS INVOLVED IN COMPLAINTS FROM PATIENTS

Bianca Hanganu 1 , Magdalena Iorga 1 , Beatrice Gabriela Ioan 1

1 Grigore T Popa University of Medicine And Pharmacy Of Iasi, Romania

Oral Presentation: Bioethics and medical law, June 2, 2021, 11:00 AM - 12:18 PM

Introduction: Based or not on a real mistake of the doctor, patients' complaints about the care provided by doctors are a universal reality of medical practice. The factors that contribute to the patients' decision to complain are multiple, being related both to the person and the professionalism of the doctor, as well as to the medical practice in general, to different cultural aspects, or to an interpenetration of them. The objective of the study was to evaluate the characteristics of doctors in Romania involved in complaints from patients, in order to achieve a profile of the doctor prone to be complained about. This study is part of an extensive doctoral research aimed at identifying methods to prevent patients' complaints about medical responsibility and to reduce their impact on physicians.

Material and method : The study was quantitative prospective; data collection was done using a questionnaire applied online through the GoogleDocs platform. The target population was represented by practicing doctors in Romania, and the completion of the questionnaire was voluntary and anonymous. The questions concerned both socio-demographic aspects and aspects related to current medical practice, including the history of complaints from patients, and allowed different forms of answer: two or more variants, type Yes / No, with the Likert scale of 5 points and open answers. The collected data were analyzed using SPSS software, version 20. Results. The study group consisted of 1684 doctors, of which 271 (16.1%) were complained by patients at least once. The profile of the doctor prone to be reported by patients, resulting from the statistical analysis of the data by binary logistic regression: male, senior physician, from surgical specialties, with older age and seniority, who works in regional hospitals and who performs a greater number of on-call shifts per month.

Discussion : Both our study and studies in the literature place male doctors at higher risk of being complained about, the reasons being related both to the specialties in which they practice and to the way they relate to patients. The large number of on-call shifts and the practice in regional hospitals imply for doctors a large number of patients in a short time, physical and mental exhaustion, congestion of hospital spaces and higher expectations from patients. Older age and seniority in work are associated with a higher risk for the doctor to be complained about in terms of a larger number of patients consulted and the increased complexity of cases.

Conclusion: Complaints made by patients against physicians have multiple causality and, implicitly, require multidimensional prevention measures. Thus, the identification of a profile of the doctor prone to be reported by patients contributes to the creation of targeted interventions to prevent complaints.

017

HOW DO ANESTHESIOLOGISTS PRACTICE THE DUTY OF INFORMATION IN COTONOU HOSPITALS? PATIENT CANDIDATE TO ELECTIVE SURGERY POINT OF VIEW

Ernest Ahounou 2 , Cedric Bigot 1 , Esther Hounvenou 2 , Eugène Zoumenou 2

1 Unit of Legal Medicine – FSS, University of Abomey-Calavi, Cotonou, Benin

2 Unit of Anesthesia and Reanimation- FSS, University of Abomey-Calavi, Cotonou, Bénin

Oral Presentation: Bioethics and medical law, June 2, 2021, 11:00 AM - 12:18 PM

Introduction : Medical ethics and law recommend that the medical team obtain the consent of patients before the medical act. In Benin, the doctor has to inform the patient to obtain his freely given consent. This duty is essential in surgery and anesthesiology. This study's objective was to write down the perceived quality of the information delivered to patients during pre-anaesthetic consultations.

Material and Methods : We conducted a descriptive and analytical cross-sectional study in 2 of the two largest hospitals in the city of Cotonou (CNHU and CHU-MEL). We conduct the study from June to October 2020. It focused on adult patients (more than 18 years old) who had a pre-anaesthetic consultation for elective surgery.

Results : We include 224 patients in this study. The mean age in the sample was 38.8+/-1.8 years. There were 66.5% of women. 57% of patients had already undergone surgery with anaesthesia. All the information given to the patients were verbal. Of the 224 patients, 90 % received information about the surgery process, and 80% received at least one information about the anaesthesia technique planned for the operation. Doctors discussed preoperative youngster with the patient in 87% of cases. On the other hand, the most significant part of the interviewed was not receiving information about potential surgery complications (80%) and postoperative pain management (60%). Patients felt that they correctly understood the information given to them by the doctor in 38% of cases. Patients wished to have more explanations in 73% of cases. We also found that patient with affiliation with medical practitioner were the most satisfied patients with the information communicated in the consultation room (p = 0.001). Satisfaction was significantly associated with the experience of the doctor who gives information to the patient.

Discussion : The pre-anaesthetic consultation is a privileged opportunity to inform the patient and to obtain his informed consent. The ethical and deontological provisions regarding information due to candidates for surgery are not always well respected. Practitioners very often omit information that could generate concerns for patients. Our study also shows that 1 in 3 patients leave this consultation dissatisfied. Guides and leaflets related to anaesthesia could be offered to patients.

018

ELECTIVE ABORTION (COMPETING INTERESTS - INDIVIDUAL BODILY AUTONOMY OF THE WOMAN VS UNBORN CHILD’S INTEREST TO LIVE)

Ecem Kirkit 1 , Şebnem Akipek Öcal 2

1 Cukurova University, Adana, Turkey, ( https://orcid.org/0000-0001-5826-4170 )

2 TED University (https://orcid.org/0000-0002-4216-405X), Ankara, Turkey

Oral Presentation: Bioethics and medical law, June 2, 2021, 11:00 AM - 12:18 PM

According to classic definition, abortion is the removal of pregnancy tissue, products of conception or the foetus and placenta from the uterus. Abortion has basically two different types: therapeutic abortion and elective abortion. Therapeutic abortion is vital for mother’s health, so it is mostly acceptable for each doctrinal views. On the other hand, elective abortion has always been a controversial issue around the world. In some countries abortion is legal but in some others it is illegal. Even in countries where it is legal, there is a doctrinal view that states the best interests of the child and the interest to live should be protected. This doctrinal view conflicts with the doctrinal view that considers elective abortion as part of the individual bodily autonomy of the woman and underpins elective abortion being legal. Abortion is related to not only unborn child’s interest to live but also individual bodily autonomy of the woman. It should be emphasized that unborn child does not have a personality, therefore does not have right to live, has just an interest to live. European Court of Human Rights considers that it is neither desirable, nor even possible to answer whether the unborn child does not have a personality for the purposes of Article 2 of the Convention. This is due to the fact that the definition of the embryo is yet to be reached consensus and the discussion of common rules on embryo is still being researched. Essentially, the law systems and doctrinal views have to make a choice between these two competing interests. Individual autonomy and relational autonomy is different forms of autonomy. Individual autonomy forms the basis of the continental European legal system’s perspective. Per contra, Asian countries law systems accepts relational autonomy. Differences in legal systems’ view of autonomy differentiate in their approach to elective abortion, the concepts discussed and justification. Relational autonomy can also require father’s consent in elective abortion. In contrast to relational autonomy, individual autonomy considers abortion to be associated with the bodily autonomy of the woman. For this reason, it gives the right to decide only to the mother individually. In this study, elective abortion will be evaluated in the scope of different doctrinal views by considering the concepts of the foetus’ interest to live, the best interests of the child, individual autonomy and relational autonomy. The evaluation will be based on the grounds of that de lege data Swiss-Turkish Law’s legal provisions of elective abortion and de lege feranda doctrinal views.

019

PSYCHIATRY AND FITNESS-TO-DRIVE ASSESSMENT: THE INFLUENCE OF PSYCHIATRIC DISEASE AND ITS PHARMACOLOGICAL TREATMENT

Cristian Palmiere 1 , Tony Godet 1 , Gérard Niveau 1

1 University Center of Legal Medicine Lausanne-Geneva (CURML), University of Lausanne and University of Geneva, Switzerland

Oral Presentation: Bioethics and medical law, June 2, 2021, 11:00 AM - 12:18 PM

According to the current specialistic literature, both psychiatric disorders and psychiatric drug treatments may produce changes of psychomotor performance which can significantly affect the ability to drive safely. Driving is considered a complex task requiring a range of skills, including adequate information processing and integration, vigilance, attention maintenance, concentration, and good memory. Drivers with psychiatric disorders or those using psychotropic medications often experience functional deficits, compromised cognitive functioning, and impaired psychomotor aptitudes, which might affect their driving performance and therefore increase risk of traffic accidents. Drivers with schizophrenia, for instance, are reported to have a risk of car accidents approximately two times greater than that of age-matched controls. In these individuals, driving capacity appears to be affected by clinical symptoms, including psychomotor impairment, cognitive deficits, and the side effects of prescribed medication. The fluctuating nature of mental illnesses would further complicate their prognosis as well as their fitness-to-drive. For people suffering from major depressive disorder, even when not on anti-depression medication, it has been observed that they can experience higher levels of sleepiness when driving and a significantly slower reaction time. On the other hand, having mental illness is not necessarily equal to absolute inability to drive, though fitness-to-drive assessment of individuals with mental illness should be focused on the unique characteristics of mental illnesses. As far as psychiatric medication is concerned, relatively few studies have exhaustively investigated the consequences of a specific drug treatment on driving. Residual daytime sleepiness and impairment of psychomotor and cognitive functioning the day after bedtime administration has been traditionally considered the main problems associated with the use of hypnotics. It is therefore evident that the evaluation of the fitness-to-drive in subjects suffering from psychiatric diseases, and in particular of subjects receiving psychopharmacological treatment, requires a solid knowledge of the clinical characteristics of psychopathological disorders, on the one hand, and of the undesirable effects of prescribed psychopharmacological treatments on the other hand, in particular taking into account the fact that such subjects are often prescribed complex psychopharmacological treatments characterized by two or more psychotropic drugs. The aim of this presentation is to describe the legislative situation in force in Switzerland regarding medical and psychiatric fitness-to-drive assessment, especially with reference to the psychiatric situation of the persons who undergo medical and psychiatric fitness-to-drive assessment, and any psychotropic pharmacological treatment that may be prescribed.

020

CADAVER LAB, A SAFETY METHOD TO REFINE TECHNICAL AND NON-TECHNICAL SKILLS IN ENDOCRINE SURGERY

Massimo Zedda 1 , Domenico Spagnolo 1 , Simone Grassi 1 , Antonio Gioacchino Spagnolo 1 , Vincenzo Lorenzo Pascali 1 , Rocco Domenico Alfonso Bellantone 2 , Marco Raffaelli 2 , Antonio Oliva 1

1 Department of Health Surveillance and Bioethics, Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy

2 U.O.C. Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy

Oral Presentation: Bioethics and medical law, June 2, 2021, 11:00 AM - 12:18 PM

Case report : Surgical specialties are exposed to a significant medico-legal risk. As the surgical procedures are progressively more technically complex, their learning curves become longer. However, most of the surgical errors are related to a failure in non-technical skills like intraoperative communication, situational awareness, leadership, teamwork and decision-making. According to current evidence, both technical and non-technical skills can be improved through cadaver lab. This kind of learning has been experimented in neurosurgery for the treatment of subdural hematomas, in thoracic robotic surgery for the esophagectomy, and in general surgery for laparoscopic hepatic segmentectomy. Cadaver lab was also used in the training of military doctors to insert intraosseous vascular accesses in non-routine sites such as the humeral head. In the light of this evidence, at the Fondazione Policlinico Universitario A. Gemelli IRCCS (Rome, Italy) a cadaver lab has been instituted for the endocrine surgery. This presentation will concern the medico-legal/ethical issues and the experience of learning on cadavers through a complex and innovative approach (TOETVA - Trans Oral Endoscopic Thyroidectomy Vestiboular Approach) on 6 cases (4 males and 2 females, aged between 55 and 80 years) who died in non-traumatic circumstances. All interventions have been videotaped.

Discussion : If compared with the gold standard for thyroidectomy (open thyroidectomy), TOETVA is a complex procedure, mainly indicated because of a better aesthetic outcome. TOETVA involves additional risks such as mental nerve paralysis or injury (Fig. 1), and it currently is not listed in national or international guidelines for the treatment of benign or malignant thyroid diseases. Moreover, this technique is burdened by an increased operation time and hospital stay after surgery and is feasible only in selected cases such as small tumor and without extrathyroidal extension. Lira et al reported that the surgeon has acquired the skills to perform it only after at least 15 TOETVA. Therefore, in this work, we had repeated every step of the surgical procedure for six times (Fig. 2). Moreover, this case has shown that cadaver lab represents a procedure that can successfully refine the technical skills and the non-technical skills, does improving the quality of the surgical treatment, allowing the surgeon to practice in a safety context. Learning TOETVA on cadavers does not imply ethical issues, since it uses a natural orifice for surgical access. Furthermore, the cadaver lab allows to refine surgical practice on a safety contest and reducing the after-surgery complications with a consequently decrease of the medico-legal risk.

022

RHABDOMYOLYSIS IN A STAPHYLOCOCCUS DURING THE PANDEMIC OF COVID-19: A DIFFERENTIAL DIAGNOSIS

George Cristian Curca 1 , Larisa Udristioiu 1 , Ioana Ruxandra Turlea 2

1 University of Medicine and Pharmacy Carol Davila, Bucharest, Romania

2 National Institute of Legal Medicine Mina Minovici Bucuresti, Bucharest, Romania

Oral Presentation: Forensic pathology 2: special session on SARS-CoV-2, June 2, 2021, 2:00 PM - 3:30 PM

Background : Rhabdomyolysis is a syndrome determined by skeletal muscle damage followed by leakage of myoglobine and cytosolic enzymes into plasma and endotoxemia. Rhabdomyolysis by Staphylococcus aureus infection is rare and during the pandemic of COVID-19 in a differential diagnosis even rare. We present a case report of severe rhabdomyolysis in a patient with STAPHYLOCOCCAL SEPSIS in COVID-19 context and review of relevant literature.

Case description : A 31-year-old male without any known comorbidities presented to the emergency department with a nasal folliculitis, followed by transient hemifacial allergic reaction and low back pain, then thoracic pain and dyspnea. The body temperature was normal with high leukocytosis (24.000/mm3). Because of the dyspnea, the doctors suspected a novel coronavirus infection. During the pandemic of COVID-19, most cases of shortness of breath are due to lung conditions. The pacient was tested for COVID-19, but the PCR result was negative. Intense and diffuse thoracic pain and thighs pain became prominent. The clinical evolution was fulminant with 3.000 white cell counts. In 72 hours a multiple organ dysfunction syndrome (MODS) and death occured. Autopsy revealed bronchopneumonia, disseminated abscesses (spleen, pulmonary, important mediastinal lymph nodes hypertrophy). Blood tests and muscular biopsy were positive for Staphylococcus aureus, with reactive lymph nodes histiocytosis. A medular biopsy was requested.

Discussion : Differential diagnosis in a COVID-19 context is sometime difficult: time is urging, symptoms are confusing and nonspecific, epidemiological guidelines are rigid and may determine a pressure on medical system. Rare and severe pathology could be misdiagnosed.

023

IMPACT OF THE SARS-COV-2 PANDEMIC ON MEDICO-LEGAL CASES IN THE CONTEXT OF CRIMINAL LAW

Ricardo Mendonça 1 , Barbara Smyk 1 , Cristina Cordeiro 1,2 , Carla Carreira 1,2

1 Central Branch of the National Institute of Legal Medicine and Forensic Sciences, Coimbra, Portugal

2 Faculty of Medicine of the University of Coimbra, Portugal

Oral Presentation: Forensic pathology 2: special session on SARS-CoV-2, June 2, 2021, 2:00 PM - 3:30 PM

Introduction : The current new Coronavirus pandemic (COVID19) has undoubtedly, and drastically, changed the everyday life of our populations. Portugal was no exception. Between March 19th and May 2nd of 2020, the government issued a State of Emergency, introducing general mandatory confinement. The effects of such were felt in numerous areas, including in medico-legal clinical practice. This study aims to determine the effects of confinement on cases within the scope of criminal law, namely offenses against physical integrity committed during and after the State of Emergency.

Material and Methods : This study was quantitative, retrospective, and descriptive, based on the analysis of the medical reports elaborated. We included all the cases regarding criminal law that were evaluated at the Central Branch of The National Institute of Legal Medicine and Forensic Sciences (Portugal), between March 19th and July 3rd of 2020, covering both the period of confinement and 2 months directly after. For comparison, we used the cases from the same period of 2019, having excluded in both groups, the cases concerning events that occurred outside of the criteria period. Furthermore, we intend to continue to broaden the comparison using the same periods in the previous 4 years (2015-2018). Once collected all the data we conducted, firstly, the descriptive statistics using measures of central tendency and dispersion and secondly the chi-square test, searching for associations among variables, considering the level of significance to be p<0.05.

Results : Preliminary results have shown that, in the specified period, there was a significant decline in the number of offenses against physical integrity committed during the pandemic. However, within the lower overall number of cases, there was a significant increase in domestic violence, with the majority of the subjects being female. There was also a spike in the number of offenses that emerged directly after the confinement. No statistically significant differences were observed in the number of sexual assaults, regarding the subject’s age or profession and the period between the event and the consolidation of the sequelae.

Discussion : To conclude, although the number of offenses against physical integrity committed during the determined period in 2020 was inferior to the number of cases from the corresponding period of 2019, the confinement seems to have sparked a peak in domestic violence. However, there was also a spike in the number of cases once the State of Emergency was over, probably in relation to the opening of establishments and greater circulation of people. Being a novel subject, this presentation will impact the forensic community by serving as an opportunity for interdisciplinary communication and collaboration necessary for the recognition of important risk factors and the implementation of appropriate prevention measures.

024

POST-MORTEM CT FEATURES OF LUNGS OF COVID-19 CASES

Coraline Egger 1 , Pia Genet 1 , Virginie Magnin 1 , Tony Fracasso 1 , Johannes Alexander Lobrinus 3

1 University Center of Legal Medicine Lausanne-Geneva (CURML), University of Lausanne and University of Geneva, Switzerland

3 Department of Pathology, Geneva University Hospital, Switzerland

Oral Presentation: Forensic pathology 2: special session on SARS-CoV-2, June 2, 2021, 2:00 PM - 3:30 PM

Introduction : Being aware of the clinical imaging features of the new coronavirus disease (COVID-19), we were curious to analyze post-mortem CT features of SARS-CoV-2 pneumonia cases and compare them with those encountered on living patients.

Material and Methods : In our study we analyzed ante- and post-mortem CT-images of SARS-CoV-2 pneumonia cases in a medico-legal (N=15) and clinical pathology collective (N=5). It was a retrospective interpretation of prospectively acquired data between March and October 2020, still in progress when submitting abstract.

Results : As observed in living cases, ground-glass opacities and consolidations are the most frequent observations on post-mortem MDCT, with air bronchogram. But the detection of ground-glass opacities is not rare in postmortem imaging and this is mainly related to the presence of hypostasis (livor mortis).

Discussion : Post-mortem MDCT is useful to screen SARS-CoV-2 pneumonia cases, prepare the autopsy and guide samples. But caution is required since one of the major signs, namely ground-glass opacities, are frequently encountered in post-mortem imaging as the manifestation of livor mortis. However, one of the discriminating criteria seems to be the frank and declive distribution.

025

CT GUIDED LUNG PUNCTURE IN SARS-COV-2 CONFIRMED POSITIVE DECEASED PATIENTS

Alexandra Ron 1 , Antonia Fitzek 1 , Armin Hoffmann 2 , Klaus Püschel 1 , Benjamin Ondruschka 1 , Axel Heinemann 1

1 Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

2 Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

Oral Presentation: Forensic pathology 2: special session on SARS-CoV-2, June 2, 2021, 2:00 PM - 3:30 PM

Since the SARS-CoV-2-associated pandemic broke out worldwide, there have been controversial opinions on whether decedents of Covid-19 should undergo an autopsy. The main reason for that was the unknown contagiousness and missing recommendations for personal protective equipment. This discussion has placed further emphasis on development and research on modalities with minimally invasive access (“minimal invasive autopsy”) as a safer alternative to conventional autopsy. Different approaches have been made at the Institute of Legal Medicine in Hamburg, Germany, to understand the pathogenesis of SARS-CoV-2 and its role in the chain of fatal causality. Depending on the consent of the relatives, autopsies as well as minimally invasive tissue sampling, including postmortem ultrasound (pmUS)- and postmortem computertomography (pmCT) – guided punctures were carried out. In our study, we used targeted pmCT-guided lung biopsies to obtain samples in four deceased – three of them were tested positively for SARS-CoV-2 for the first time by post mortem nasopharyngeal swab. The selected cases showed no radiological signs of global severe lung damage, so that definable suspicious lesions as well as inapparent control segments were identified through pmCT which enabled targeted lung biopsies by manual navigation. Interestingly, a relevant virus load was detected by targeted sampling but we failed to demonstrate a significant spatial correlation between radiological signs and virus load which could be due to the limited sample. Further results of the study will be presented.

026

SUITABILITY OF EXHUMATION TO ANSWER THE QUESTION “DID THEY DIE «BY » COVID-19?”

Maria Pieri 1 , Pascale Basilicata 1 , Mariagrazia Marisei 1 , Serena Dei Medici 1 , Massimo Niola 1 , Claudio Buccelli 1

1 University of Naples "Federico II", Dep. of Advanced Biomedical Science, Naples, Italy

Oral Presentation: Forensic pathology 2: special session on SARS-CoV-2, June 2, 2021, 2:00 PM - 3:30 PM

Objectives : Indications to reduce the number of autopsies to the minimum adopted by several countries during the first phases of pandemic now poses problems related to the need to ascertain deaths caused «by» COVID-19. An Italian Court ruling is presented and commented with respect to the opportunity to proceed with exhumations and autopsies in 18 deceased, residents in the same nursing home.

Design: Anamnestic data were checked to outline any possible correlation with SARS-CoV-2 infections and/or COVID-19 disease at the time of death. Indications of a medico-legal assessment asked by the Judge to highlight eventual inadequate sanitary management, and eventual professional liabilities, were also considered, together with available literature.

Results : Detailed medical records and the exact cause of death were not available for any of the 18 deceased; only in 3 patients an ab ingestis inhalation pneumonia was hypothesized. Data from care records evidenced the recurrence of typical symptoms of a respiratory tract infection referred to the last weeks before death.

Pathophysiology of COVID-19 is still not fully elucidated, and a diagnostic protocol allowing an irrefutably diagnosis of “death «by»” is still not available. Data on virus survival after death are limited to few weeks (at controlled conditions) and no data on exhumed bodies are available.

Conclusions : The Judge’s decision not to proceed with exhumations can be fully explained on the uncertainty and usefulness -in terms of legal evidence and imputability- of data obtainable from exhumations. The decision is entirely acceptable also considering risks for all subjects involved in bodies exhumation/transport to and from the morgue/reburial, as well as on pietas and due process.

027

HUMANITARIAN FORENSIC ACTION OF THE ICRC FOR COVID-19: A GLOBAL PERSPECTIVE

Indu Nepal 1 , Pierre Guyomarc'h 1 , Kristy Winter 1 , Oran Finegan 1

1 International Committee of the Red Cross - ICRC, Geneva, Switzerland

Oral Presentation: Forensic pathology 2: special session on SARS-CoV-2, June 2, 2021, 2:00 PM - 3:30 PM

The COVID-19 pandemic has severely impacted health and medico-legal systems worldwide. As the International Committee of the Red Cross (ICRC) ensures humanitarian protection and assistance for victims of war and armed violence, they can take additional action in response to emergencies. This allows the ICRC to assist in responding to an outbreak for both countries with functioning medico-legal systems and those in hard to reach war-torn areas. The stress of increased deaths from the pandemic adds the threat of overwhelming or collapsing medico-legal systems. Additional stress can arise when the cultural, religious and spiritual needs of the communities are disregarded unnecessarily over fear of increased infectious risk from the deceased. Harmful rumours, pseudoscientific advice and misconceptions around handling of the deceased can have dual consequences; such as an increased mortality from minimising the severity of SARS-CoV-2 or to the other extent, affecting final mourning ceremonies, and the right of families to follow their customs and traditions. In collaboration with community engagement colleagues, the ICRC Forensic Unit formed a Forensic Task Force to adapt to the needs of death-care workers globally to effectively and safely respond and to address the growing needs concerning the dead and their families. Working with the World Health Organisation and the International Federation of Red Cross and Red Crescent societies, further recommendations and guidance were aligned and published. To ensure the recommended measures are adopted and respected by community members and stakeholders, the ICRC took an evidence-based approach through a series of steps:

Media monitoring and social listening to understand community concerns, fears and information needs

Rapid assessment with staff and volunteers to track rumours and concerns

Community-based workshops to understand challenges and coping mechanisms in handling the remains of the deceased

Adaptation of guidance to consider relevant religious practices in Islam, Hinduism and Buddhism

Engagement with religious and local authorities to validate and share relevant information

Development of a series of communication materials (posters, video, social media content) with easy to follow guidance and to correct rumours and false information

Translation of communication materials in relevant languages suited to the context

Support to death-care workers and authorities through easy-to-follow guidance, as well as technical assistance ensuring availability of PPE

Adaptation of programs and support to communities to suit their specific needs and context

There are challenges in conducting prevention activities to ensure dignity of the dead is respected and ensured. In certain context, there is fear that “talking about the dead” could create panic and fear in the community choosing dialogue format to share necessary information which can be resource intensive over other approaches such as public awareness campaigns.

028

COMBINATION BETWEEN PROTOCOLS WITH THE RELIGIONS, CULTURALS, AND TRADITIONS OF THE DECEASED REGARDING FORENSIC HUMANITARIAN ACTION IN PANDEMIC OF COVID-19 IN INDONESIA

Evi Untoro 1

1 University Of Trisakti, INPALMS, Jakarta, Indonesia

Oral Presentation: Forensic pathology 2: special session on SARS-CoV-2, June 2, 2021, 2:00 PM - 3:30 PM

COVID-19 Pandemic as the WHO announced in March 2020, has made the Protocols in Global way on preparing the deceased to the burial and cremation as something that cannot be accepted by family of the late. The Protocols is very strict and contradictive with the way they used to be, the family cannot touch and have a proper way on funeral ceremonial like it used to be. In Indonesia, there are many Religions (5 that the government accepted to be the majority are Islam, Catholic, Christian, Buddhism, Hinduism), Culturals and Traditions that could be cut off by the WHO International Protocols in handling the Deceased of Pandemic Covid-19. Some of the families forced to retrieve the deceased to their home for proper ceremony and burial that will spread the contagious of SARsCOV-2 to the surroundings, some of them have been detained on the breach of the Quarantine Law. This case report will show the Forensic Humanitarian Actions and the revision on adopted International Protocols in the Hospital Mortuary, Funeral Home and Cremation also the burial system in Indonesia that can be accepted by the family with the different backgrounds in mourning the love one of covid-19 deceased funeral ceremony in the new normal system.

Keywords : Indonesia, Covid-9 Pandemic, WHO Protocols, Forensic Humanitarian Actions

029

A NEW TECHNIQUE TO REHYDRATE MUMMIFIED TISSUE USING MOISTURIZERS

Chiara Rossetti 1 , Stefano Vanin 2 , Rosa Boano 3 , Giacomo Belli 4 , Ezio Fulcheri 5

1 Department of Medicine and Surgery, University of Insubria, Varese, Italy

2 Department of Earth, Environmental and Life Sciences (DISTAV), University of Genoa, Italy

3 Department of Life Sciences and Biology of Burial Systems, University of Turin, Italy

4 Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Italy

5 Department of Integrated Surgical and Diagnostic Sciences (DISC), Section of Pathological Anatomy, University of Genoa, Italy

Oral Presentation: Forensic anthropology 1, June 2, 2021, 2:00 PM - 3:30 PM

Introduction : In histological examination of mummified tissues, a critical aspect is the rehydration of the samples before the paraffin inclusion. A preventive tissues’ rehydration is particularly important before their dehydration obtained by an increasing of concentrations of alcoholic solutions, up to absolute ethyl-alcohol. The mummified tissues, properly rehydrated, preserve histological and morphological features as in fresh tissues samples, even if there is a great variability among cases. Over the years, several rehydrating hydro-alcoholic solutions have been reported in the scientific literature, including formaldehyde, human serum and fabric softener. In this study a new rehydration technique based on the use of common commercial moisturizers is described.

Material and Methods : During a survey performed in 2019, on the remains of the Cistercian nun Angela Veronica Bava (1591-1637 AC), in the Church of the Benedictine nuns in Fossano, (Northern Italy), tiny fragments of blackish material, adhered to the bones, were collected. The tissues’ sample of a 5 mm3 volume containing also some insect fragments, was rehydrated by immersion in commercial moisturizers for 3 days. Later, routinely, the sample was treated with an 80% alcoholic solution for 3 days and finally it was paraffin embedded. The Sample slices were stained with Haematoxylin-eosin, Masson’s trichromic and Van Gieson’s stain.

Results : Histological investigation shows poorly preserved but still recognizable fibres bundles and fragments of muscular tissue. Other fragments detected were irregular shaped and partially destroyed bones spicules, due to skeletonization process. In some sections, fragments of the insects’ cuticle were recognizable.

Discussion : This study showed the partial preservation of the tissues and demonstrated that the natural mummification process occurred before the skeletonization of the body due to the unfaithfully environmental conditions of the second burial place, which led to a rehydration and pulverization of muscles, with the exception of fragments of tissue, that strongly adhere to the surface of the bones. Also entomological investigation confirmed the change of the conservation condition of the corpse during the time, with periods of low humidity (dry) as documented by the presence of beetles in the family Dermestidae and spider and periods of high humidity with the formation of mold, documented by the presence of fungi feeder in the order of Coleoptera. This innovative technique, using moisturizes, allowed the histological investigations of a tiny fragments of material still present to the bones, otherwise hardly to identify with common procedures of rehydration

030

ANTHROPOMETRIC STUDY FOR STATURE ESTIMATION ON ROMANIAN ADULT POPULATION

Madalina Maria Diac 1 , Andreea-Alexandra Hleșcu 1 , Elena F. Kranioti 2 , Diana Bulgaru Iliescu 1

1 University Of Medicine And Pharmacy "Grigore T Popa" Iasi, Romania

2 Forensic Medicine Unit, Department of Forensic Sciences, University of Crete, Rethymnon, Heraklion, Greece

Oral Presentation: Forensic anthropology 1, June 2, 2021, 2:00 PM - 3:30 PM

Introduction : The estimation of stature from bones plays an important role in identifying unknown bodies, body parts or skeletal remains. At the same time, the stature it is an important component of the biological profile in forensic identification, being one of four demographic characteristics of it. The present study aims to provide standards for stature estimation for contemporary Romanians using tibial length and to set the basis for acquisition of biological profile for this population that can lead to new methods for estimating other aspects of biological profile, such as age, sex and ethnicity.

Material and methods : The study group included 137 cases represented by deceased adults, who were subjected to forensic autopsies performed in a limited territory in Romania. The study was a prospective one, being approved by the Ethic Committee of “Grigore T. Popa” Medicine and Pharmacy University. As a working methodology, the study was carried out on cadaveric material, with deceased persons whose full autopsy is mandatory. The working material was represented by the length of tibia measured during the forensic autopsy. Before the autopsy, at all cases was taken the stature of the deceased people.

Results : The resulting database was analysed using SPSS 23.0. Statistical analysis was carried out in three stages to check the normality of the study, to carry out the correlational analysis and mathematical analysis for the development of regression formulas. Tibia length showed high correlation with stature for males, females and the total samples. Four regression formula were created for stature estimation of Romanian males, females with known age and unknown sex and age.

Discussion and conclusions : The cadaveric material included in the study is an important source of research in forensic anthropology, as it allows researchers to work on known parameters. The mathematical method which was used in this paper is highly applicable in future research in the field of forensic anthropology. The results of the analysis are impressive and gave a good applicability in a forensic anthropological context, the regression analysis showed us a high prediction of stature for all four-regression formula (R2≥0.770) of the variance of height. The data used in this paper provides reliable results with a large applicability in the future for estimating the stature from tibia length for Romanian adult population. This paper is a good start in development of the forensic anthropology studies for Romanian adult populations.

Keywords : stature estimation, forensic anthropology, tibia length

031

FEEDING AND TAPHONOMIC VARIABILITY OF THE CADAVER IN A HUMAN SURROGATE IN ABIDJAN (ALIMENTATION ET VARIABILITÉ TAPHONOMIQUE DU CADAVRE CHEZ UN SUBSTITUT HUMAIN À ABIDJAN)

Kobenan Kouadio 1 , Kouakou Firmin Kouassi 1 , Alexandre Flanklin Koffi 1 , Hassane Dao 1 , Louis Roi Nondenot Aboua 1 , Jean-Bertin Beugre 1

1 University Félix Houphouet-Boigny, Abidjan, Ivory Coast

Oral Presentation: Forensic anthropology 1, June 2, 2021, 2:00 PM - 3:30 PM

Introduction : The degradation of an individual's corpse seems to be attributable to the biophysiological equipment of the individual. The effect of the biological energy provided by the resources brought to the organism, in this case food, on the taphonomic variability of the corpse is far from being sufficiently studied. The present study aims to examine the influence of the type of diet on the taphonomic variability of the human cadaver.

Material and Methods : A sample of four (04) carcasses of juvenile male human surrogates (pigs) of the species sus scrofa domesticus, three (03) of which were experimental and one (1) control aged three (3) months and having a mass between 19 and 24 kg. The three (03) experimental pigs are respectively subjected to energy, construction and functional feed. The control was fed a general diet. The different carcasses were exposed to the open air at four similar sites. The experiment was repeated according to the same protocol on sites comparable to the first ones. Feeding was measured by means of a questionnaire. The duration of decomposition was measured by means of an observation sheet.

Results : The results show that the duration in days of the different phases of disintegration of the carcass, i.e. swelling, active decomposition and advanced decomposition of pigs having been fed a general feed differs from that of pigs having ingested a more energetic, constructive or functional feed. The initial and skeletal phases of the carcass do not vary with any type of feed.

Discussion : The type of feed would mainly influence the phases of the taphonomic process of the cadaver.

Keywords : Cadaveric taphonomy - Feeding - Human substitute - Juvenility - Ivory Coast

032

TRABECULAR INNER MORPHOLOGY OF POST-CRANIAL BONE FRACTURES OF KNOWN POST-TRAUMATIC AGES: CAN 3D MEASUREMENTS THROUGH MICRO-CT BE USEFUL FOR DATING?

Alessia Viero 1 , Lucie Biehler-Gomez 2 , Carmelo Messina 3,4 , Annalisa Cappella 5 , Massimo Montisci 1 , Guido Viel 1 , Giovanni Cecchetto 1 , Franco Tagliaro 6 , Cristina Cattaneo 2

1 Legal Medicine And Toxicology Unit, Department of Cardio-thoraco-vascular Sciences And Public Health, Padua, Italy

2 LABANOF (Laboratorio di Antropologia e Odontologia Forense), Sezione di Medicina Legale, Department of Biomedical Sciences for Health, University of Milan, Italy

3 IRCCS Istituto Ortopedico Galeazzi, Milan, Italy

4 Department of Biomedical Sciences for Health, University of Milan, Italy

5 Laboratorio di Morfologia Umana Applicata, IRCCS Policlinico San Donato, San Donato Milanese, Italy

6 Section of Legal and Occupational Medicine, Dept. of Diagnostics and Public Health, University of Verona, Italy

Oral Presentation: Forensic anthropology 1, June 2, 2021, 2:00 PM - 3:30 PM

The accurate dating of bone fractures in forensic casework is crucial since it can assist in testing witness statements and contribute to understanding the chronology of events prior to death in cases of violent death, abuse, maltreatment and torture. The estimation of the post-traumatic survival time (PTST) is based on the tissue healing response after traumatic tissue damage and to date, in case of bone injuries, it remains a tricky issue in the forensic field, especially when dealing with dry bones. New high-resolution imaging, and in particular microcomputed tomography (micro-CT), has the potential to significantly improve our abilities to interpret antemortem and perimortem lesions in a less destructive analysis. The present experimental pilot study is aimed at evaluating the applicability of micro-CT on dry bones to find useful parameters able to describe the trabecular microarchitecture for objective fracture dating. With this intent, four regions of interest (two located in the callus and two in areas more distant to it – referred to as healthy bone) were selected by visual inspection from each of the nine costal fractures of known post-traumatic ages constituting the study sample. The 3D measurements of the trabecular inner morphology of the bone samples were performed on the four selected areas of interest using the five histomorphometric parameters most commonly used for the study of the 3D bone trabecular microarchitecture with micro-CT, including anisotropy, connectivity, BV/TV fraction [%] (bone volume fraction), trabecular thickness [mm] (TbTh) and trabecular separation [mm] (TbSp). As a result, the quantitative preliminary micro-CT measurements of the 3D trabecular microstructure of bone calluses obtained from this study demonstrate the existence of trends for some parameters of the trabecular microstructure relative to the age of the callus, including the degree of anisotropy, connectivity and trabecular spacing. The results obtained are consistent with the healing process of bone and in line with the current literature and could represent useful features for the construction of objective and quantitative models for fracture dating.

033

WHEN SKULL TRAUMATIC INJURIES ARE HARD TO RETRIEVE: CONTRIBUTIONS OF FORENSIC ANTHROPOLOGY AND IMAGING TO THE RECONSTRUCTION OF PERIMORTEM EVENTS

Eugénia Cunha 1,2 , Sandra Sousa 1 , Catarina Gomes 1 , Diana Logrado 1 , Zoi Argyropoulou 1 , Ana Rita Inácio 1 , Carlos Santos 1 , Miguel Costa Lopes 1 , Henrique Rodrigues 1 , Sofia Frazão 1

1 National Institute of Legal Medicine and Forensic Sciences, South Delegation, Lisboa, Portugal

2 University of Coimbra, Centre for Functional Ecology, Department of Life Sciences, Lab. of Forensic Anthropology, Coimbra, Portugal

Oral Presentation: Forensic anthropology 1, June 2, 2021, 2:00 PM - 3:30 PM

Some violent deaths, with strong suspicions of aggressions to the skull, reveal to be complex cases where fractures are hard to find. Only a thorough, holistic analysis of the complete skull can reveal the needed traces to document what happened to the victim at the time of death. We here discuss forensic cases where the detailed Forensic anthropology analysis of the skull, mostly the inner part, as well as the CT scan were paramount to the clarification of the case. It has to be bear in mind that in either case, the skull was completely skeletonized. We highlight the importance of diastases, the finding of hair trapped in the sutures, and the need for a very careful process of cleaning and maceration. The scrupulous observation of teeth can also unveil traumatic events. Moreover, the basis of the skull, to where most of the fractures are directed, is also a key anatomical area to the interpretation, in particular when asphyxiation might be involved. While some details are revealed by anthropology, others can only be perceptible through imaging. Altogether, a significant step forward can be given in the interpretation. Practical procedures to be taken into account in similar cases are provided. More and more, interdisciplinarity is the key to successful forensic expertise. We strongly argue that good complicity between Forensic anthropology and Forensic imaging is indispensable and highly recommended.

034

DETECTION OF HAEMORRHAGE IN DRY BONE FRACTURES: A NEW APPROACH WITH HISTOLOGY COMBINE WITH RAMAN SPECTROSCOPY

Tania Delabarde 1,2 , Daniel Chappard 3 , Bertrand Ludes 1,2

1 Medicolegal Institute, Paris, France 2 UMR 8045 CNRS BABEL University of Paris, France

3 GEROM IRIS-IBS, Institute of Health Biology, Angers, France

Oral Presentation: Forensic anthropology 1, June 2, 2021, 2:00 PM - 3:30 PM

When bodies are found highly putrefied or in fully skeletonized state, the assessment of vitality on dry bone fracture is often consider impossible. Very few studies have studied the possibility to detect fibrin or red blood cell clots in dry bone fracture with histochemical and immunohistochemical techniques. Raman spectroscopy is a non-destructive analytical technique that uses the inelastic scattering of light to provide information on chemical composition. Raman spectrum of every molecule is unique and Raman spectroscopic probing of blood components has been used since four decades in numerous clinical research. Since 2010, this technique is used in forensic investigation of crime scenes to distinguish between different body fluids and analyze the composition of blood trace to differentiate human blood from other species. Our presentation aims to discuss the possibility to determine the presence of blood cells on fracture margin from four forensic cases based on new technique using Raman spectroscopy combine with undecalcified bone histology.

Description of the method : The decomposed (ranging from highly putrefied to skeletonized) remains of four adults sustaining a total of seven peri mortem craniofacial fractures consistent with blunt force trauma were examined macroscopically and bone samples were then processed for undecalcified histological analysis. A Raman spectroscopy analysis was performed on the embedded poly methylmethacrylate blocks with an InVia Qontor confocal fitted Raman microscope fitted with the WIRE 5.0 software. A video image of the block surface was taken before analysis to localize the areas of interest. The final spectra were obtained by aver-aging 15 scans acquired on the different areas of interest for each spectrum from 700-1700 cm-¹.

Discussion : Decomposed blood clots were detected histologically in all the cases, but Raman spectroscopy was performed to confirm these findings. The classical Raman spectrum of calcified bone was evidenced at distance from the fracture margin with characteristic peaks of hydroxyapatite (phosphate and carbonate) together with peaks of the amide 1 and 3 from the bone collagen. Characteristics peaks of heme were evidenced at the location of blood clot for three cases, in one case Raman spectra were not enough specific to conclude. Though the detection of signs of haemorrhage remains very difficult in dry bone samples, our results are encouraging, even if further research is needed. Histology remains the gold standard to determine vital fracture based on haemorrhage marker, however when decomposition has altered tissues and cells, the potential of undecalcified bone histology combine with Raman spectroscopy may be developed to become a new recognized method to confirm the presence of blood clot at fracture margins.

035

ANALYSIS OF ULTRASTRUCTURAL AUTOLYTIC CHANGES IN THE OSTEOCYTE OF HUMAN REMAINS, BY TRANSMISSION ELECTRON MICROSCOPY, IN ORDER TO ESTIMATE PMI IN FORENSIC ANTHROPOLOGY

Chiara Rossetti 1 , Cesare Garberi 2 , Jutta Maria Birkhoff 2 , Paola Braga 3 , Marcella Reguzzoni 1

1 Department of Medicine and Surgery of Insubria University, Varese, Italy

2 Department of Biotechnology and Life Science of Insubria University, Varese, Italy

3 Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Italy

Oral Presentation: Forensic anthropology 1, June 2, 2021, 2:00 PM - 3:30 PM

Introduction : The estimation of the post-mortem interval (PMI) of human skeletal remains is one of the most important issues in forensic anthropology. Further analyses are usually performed on human remains, in particular in those of forensic interest. Although, the PMI estimate could be very changeable and difficult especially in decomposed or skeletonised remains. Therefore, it is important to investigate the progress of bone diagenesis. This is possible through the ultrastructural study of the autolytic modifications of the osteocyte, by techniques not widely used in forensic pathology, such as TEM.

Materials and Methods: Fragments of I rib were taken from eight subjects, males, aged between 25 and 50 years, without metabolic pathologies, subjected to autopsy. Each fragment was placed in an empty container, with a semi-closed cap, placed in a laboratory with steady temperature and humidity. From each sample, at certain time intervals (PMI: 24 h, PMI: 1 month, PMI: 2 months; PMI: 3 months; PMI: 4 months; PMI; 6 months; PMI; 10 months; PMI: 20 months) small fragments of cortical bone were taken. After specific preparation, inclusion in epoxy resin, and microtome cutting with a diamond blade (90 -120 nm), the samples were observed at TEM, focusing on the ultrastructure of the osteocyte, detecting the progressive degeneration of nuclear and cytoplasmic components.

Results : At PMI 0 it was possible to observe well-preserved osteocytes, with walls well attached to the osteocyte lacuna, the presence of a nucleus with normal chromatin, the evidence of preserved mitochondria and extensions containing cytoplasm; however, the first signs of cellular autolysis were evident: the dilation of the perinuclear cistern, the fragmentation of the endoplasmic reticulum, the presence of ribosomes clusters, the precipitation of the glycocalyx, the swelling of the mitochondria; at PMI 1 the core begins to detach itself from the gap; in some osteocytes the chromatin was thickened, typical of a pycnotic nucleus, in other osteocytes cariorexes and caryolysis had already occurred; residues of endoplasmic reticulum and ribosomes were evident; at PMI 2 some osteocyte lacunae showed large masses of cytoplasmic debris; from PMI 3 to PMI 20 the lacunae appeared almost empty with peripheral cytoplasmic residues in the canaliculi.

Discussion: The ultrastructural study of the post mortem modifications of the osteocyte, using TEM, seems to provide useful results for the estimation of the PMI. In particular, appreciable differences were noted between PMI 0, PMI 1 and PMI 2, while from the third month after death, lacunae appeared almost empty. This result makes it possible to use the bone matrix also for the estimation of PMI very close to the time of death, in case of great forensic interest.

036

ICRC RECOMMENDATIONS FOR THE MANAGEMENT AND RESOLUTION OF LONG-TERM UNIDENTIFIED HUMAN REMAINS: OUTCOMES OF THE 2020 INTERNATIONAL CONFERENCE

Jane Taylor 1 , Maria Mikellide 1

1 International Committee Of The Red Cross - ICRC, Geneva, Switzerland

Oral Presentation: Forensic humanitarian action 1, June 2, 2021, 4:00 PM - 5:45 PM

Problem Analysis : Each year large numbers of people go missing around the world as a result of armed conflict, violence, migration and disasters. Regardless of the circumstances under which people disappear, absence and uncertainty have devastating, long-lasting consequences for families, communities and entire societies. Unable to mourn and to achieve closure, many families search for news of their loved ones for years, even for decades. Despite the concerted efforts by governments, Non-Governmental Organizations and International Organizations to identify the remains of missing persons, many cases of human remains continue to be unidentified in mortuaries for years, often decades.

Objectives : After attending this presentation, attendees will be familiar with the phenomenon of long-term cases of unidentified human remains and the environments that are most affected by it. Attendees will gain a deeper understanding of the contributing factors behind this phenomenon, which if studied and addressed can help minimize incidence in the future. Most importantly, attendees will gain an appreciation of the negative consequences of this phenomenon for families of the missing. This presentation will impact the forensic community by making a case for the use of as many lines of evidence to help maximize the chances of identification using a multi-dimensional and iterative approach. Most importantly, this presentation will demonstrate the importance of family involvement in forensic investigations on the missing and shed light on their wishes when it comes to long term unidentified cases.

Methodology : After observing the challenges linked to this phenomenon in many of its operating contexts, the ICRC convened an international meeting of experts in Tbilisi, Georgia in February 2020 to discuss the reasons behind the unidentified cases, identify parallels and patterns amongst contexts, highlight multi-disciplinary and innovative methodologies to increase case resolution, and to develop recommendations for long term dignified management of these cases in keeping with the wishes of families of the missing. International experts from over 16 operational contexts across South, North and Central America, Europe and the Middle East shared experiences and lessons-learned across a number of parameters which are known to influence the identification of missing persons, including domestic and international legal frameworks, interagency cooperation, and forensic practices and procedures. The conference also brought together families of the missing who provided guidance on their wishes about the long-term management of the missing who remain unidentified.

A set of ICRC Recommendations, which can be considered best practice for the prevention and management of the long-term unidentified, were developed and will be the focus of this presentation.

037

FITTING FORENSIC SCIENCES TO HUMANITARIAN ACTION ON UNACCOMPANIED MINORS: THE EXAMPLE OF THE ZENDRINI SERVICE CENTRE IN MILANO

Marco Cummaudo 1,2 , Vera Gloria Merelli 1,2 , Danilo De Angelis 1,2 , Francesca Magli 1,2 , Lidia Maggioni 1,2 , Stefano Tambuzzi 1,2 , Giuseppe Lanza Attisano 1,2 , Cosimo Palazzo 2 , Antonella Colombo 2 , Barbara Lucchesi 2 , Paola Montedoro 2 , Immacolata Agostinelli 2 , Michela Marognoli 2 , Laura Marando 2 , Azzurra Senatore 2 , Rossana Mazzoni 2 , Sofia Trezzi 2 , Chiara Fornoni 2 , Cristina Cattaneo 1,2

1 LABANOF, Istituto Di Medicina Legale, Dipartimento Di Scienze Biomediche Per La Salute, Università Degli Studi Di Milano, Italy

2 Centro Servizi Zendrini, Comune di Milano, Italy

Oral Presentation: Forensic humanitarian action 1, June 2, 2021, 4:00 PM - 5:45 PM

At the end of May 2019, the multifunctional centre “Centro Servizi Zendrini” was inaugurated in Milan, Italy. This facility aims to improve the processes of hosting and integrating unaccompanied foreign minors and it is open 24 hours a day, seven days a week. It acts simultaneously as a first level reception centre and a hub for the fulfilment of all the bureaucratic and legal procedures provided for by the new Italian legislation on unaccompanied foreign minors. With the so-called “Zampa law” (law 47/2017), in fact, minors are no longer identified in the classic identification hotspots, but in structures dedicated to the first reception where they remain for a maximum of 30 days. Afterwards, they are transferred to second level reception centres belonging to the Reception and Integration System (SAI). Since its opening to date (February 2021), two hundred and ninety-five minors aged between 12 and 18 years (mean age 16,9) have been hosted. Over 60% came from north Africa, 17% from Asia and 15% from eastern European countries. The Service Centre Zendrini has twelve beds to accommodate minors while waiting for the assignment of a place in the second reception communities. A multidisciplinary team works in the facility and it includes social workers, educators, psychologists, intercultural mediators, volunteers from an internal Italian school, forensic physicians and anthropologists. The team is responsible for several activities ranging from residential reception with care interventions, to the assessment of the social condition of the minor and the implementation of initiatives for psycho-physical development. At the same time Italian classes are given and legal assistance is provided to guide the minor during all his judicial and administrative proceedings, ensuring the fulfilment of his protection needs (e.g. application for international protection). Moreover, in the absence of valid documents, and if there is a doubt about the age declared during the initial interview, the biological age is ascertained by a team composed of a forensic physician, an odontologist and an anthropologist. Furthermore, if the minor reports to have been a victim of violence, the forensic physician and the anthropologist are responsible for the identification and documentation of any injuries present on his body, and for drawing up the final report. During all these activities, the minor is supported by an intercultural mediator who, together with the social worker and the psychologist, represents a fundamental reference figure for these children and adolescents who find themselves thrown into a socio-cultural reality that is often profoundly different from the one they come from. All in all, the Service Centre Zendrini could represent a complete model of multidisciplinary assistance to unaccompanied minors in which forensic medicine is appropriately integrated.

038

THE COIMBRA UNIVERSITY CENTRE FOR HUMANITARIAN AND HUMAN RIGHTS FORENSIC RESEARCH AND TRAINING

Morris Tidball-binz 1 , Duarte Nuno Vieira 2 , Michael Pollanen 3 , Stephen Cordner 4 , Gabriella Citroni 5 , Cristina Cattaneo 6

1 International Committee of the Red Cross – ICRC, Geneva, Switzerland

2 Coimbra University Centre For Humanitarian And Human Rights Forensic Research And Training, Prévessin-Moëns, France

3 Department of Laboratory Medicine and Pathobiology, University of Toronto, Canada

4 Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia

5 University of Milano-Bicocca, Italy

6 LABANOF (Laboratorio di Antropologia e Odontologia Forense), Institute of Legal Medicine, University of Milan, Italy

Oral Presentation: Forensic humanitarian action 1, June 2, 2021, 4:00 PM - 5:45 PM

In 2019 the Scientific Council of the Faculty of Medicine of the University of Coimbra, Portugal and its Rectorate approved the creation of The Coimbra University Centre for Humanitarian and Human Rights Forensic Research and Training, a novel platform for international academic cooperation aimed at the development and promotion of forensic science applied to human rights and humanitarian action. The Center was conceived in 2016 by its founding members in response to the growing need worldwide for stronger academic involvement and support for research and training in the novel field of humanitarian forensic action, including its complementarity with forensic science applied to the investigation and documentation of human rights violations. The Centre is also expected to become a platform for international academic cooperation in the fields of forensic science, human rights and humanitarian action, bringing together experts from different Universities renowned for their contribution to the development and practice of forensic science in support of humanitarian activities and human rights protection. The main objectives of the Centre include:

Offering an unprecedented platform of leading academic centers and practitioners offering research, training and advisory services on the scientific and legal basis of forensic sciences applied to human rights investigations, international criminal law and humanitarian action

Bringing together for academic purposes forensic scientists and jurists renowned for their experience and long-standing contribution to this field

Become a space for reflection on the relation, interface and interaction between the human rights and humanitarian objectives of applied forensic sciences, including to offer guidance and advice on this fundamental matter to planners and practitioners

Seek close collaboration and cooperation worldwide with organizations, institutions and academia interested or active in the application, research and training of academically sound forensic science in human rights and humanitarian activities

Offering opportunities for researchers from around the world for carrying out short-term residential projects based in Coimbra and benefitting as well from participating academic institutions in Europe, Canada and Australia

The Centre was presented at a side-event during the First International Symposium on Humanitarian Forensic Action for Preventing and Resolving the Missing, held at the end of November 2019 in Coimbra, Portugal and organized jointly by the University of Coimbra and the International Committee of the Red Cross. Since 2019 the Centre has provided training and advice to United Nations human rights special procedures, to NGOs and Governmental organizations; however, its full launch, planned for 2020, was postponed to the second half of 2021 due to restrictions imposed by the COVID-19 pandemic. -

039

LEGAL PERSPECTIVES ON UNIDENTIFIED BODIES FROM SHIPWRECKS IN THE MEDITERRANEAN SEA

Lorenzo Franceschetti 1,2 , Cecilia Siccardi 3 , Andrea Palamenghi 2,4 , Andrea Verzeletti 1 , Marilisa D'Amico 3 , Cristina Cattaneo 2

1 Forensic Medicine Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Italy

2 LABANOF (Laboratorio di Antropologia e Odontologia Forense), Institute of Legal Medicine, Department of Biomedical Sciences for Health, University of Milan, Italy

3 Department of Italian and Supranational Public Law, University of Milan, Italy

4 Cecilia Gilardi ONLUS Foundation, Turin, Italy

Oral Presentation: Forensic humanitarian action 1, June 2, 2021, 4:00 PM - 5:45 PM

Introduction : Every year, thousands of people die while crossing the Mediterranean Sea. The majority of these bodies has not been recovered yet and they are still lying under the sea. In Italy, the few cases of recovered bodies remain unidentified and end up buried in nameless headstones in cemeteries across Sicily. Behind these deaths, there is a family waiting for their beloved ones, both in Europe and in their home countries, risking never to know about their disappearance. Italian Institutions, the academic community and NGOs cooperate closely looking for solutions to such an important situation. The aim of this study was to analyze from a legal point of view the little debated topic of the national and international obligation to recovery and identify dead migrants.

Material and Methods : The Italian investigations opened after October 2013 and April 2015 shipwrecks in the Mediterranean Sea – in which more than 1000 persons lost their life – were presented and compared to review the national and international legislation and current scientific literature concerning the dignity of dead migrants and rights of the relatives of missing people.

Results : Missing migrants’ severe situation takes a juridical value on the basis of laws stated by the Italian Constitution, the international humanitarian law and the international human rights law. For example, the Geneva Conventions and additional protocols force Parties “to proceed with medical examination of the bodies, with a view to confirming death, establishing identity and enabling a report”. Also, the return of the remains of the deceased and of personal effects to the home country has to be facilitated.

Discussion : From the analysis, State’s obligation to protect “the right to know” of the relatives of missing migrants emerged, since specific rules are aimed to ensure the dignity of the dead and to preserve the right entitled to migrants’ relatives. However, even if these situations have been recognized, these obligations are actually not respected due to several reasons: uncertain jurisdiction of States, lack of standards and shared rules at European and international level, high cost of recovery and identification procedures. In conclusion, the existence of this “grey zone”, where fundamental rights are forsaken, is an urgent and current topic. In this perspective, practical measures are requested, especially since the inaction of European member states clearly collides with the international system of human rights. How long will it take to resolve this deadlock?

040

MIGRANTS AND HEALTH - CHALLENGES IN DATA RECORDING

Ana Corte-Real 1 , Tiago Nunes 1

1 Faculty of Medicine of the University of Coimbra, Portugal

Oral Presentation: Forensic humanitarian action 1, June 2, 2021, 4:00 PM - 5:45 PM

Migration is on a rising global trend, with international migrants comprising 3,5 percent of the global population, reaching an estimated 272 million international migrants in 2019, 51 million more than in 2010 (WHO report, 2019). As a result of global migration, countries have been transformed into multicultural societies (WHO report 2019). Meanwhile, they are often an ‘external/complementary part of society” rather integrated in its core. Ensuring identical rights of the host country in individual access to healthcare is a goal. To better understand the challenges and implications, it is important to note the different types of migrants. Although a refugee is a type of migrant, there are significant differences between refugees (asylum seekers, resettled and relocated refugees) and other types of migrants, such as international migrants, internal migrants, undocumented migrants and tourists. Two issues should be discussed: 1) Enhance capacity to tackle the social determinants of health and to accelerate progress towards achieving the Sustainable Development Goals, including universal health coverage; and 2) Strengthen health monitoring and health information systems.

Keywords : Migrants, Health, Clinical records

041

FORENSIC SCIENCE, HUMAN RIGHTS AND THE UNITED NATIONS

Morris Tidball-binz 1

1 University of Coimbra Centre for Humanitarian and Human Rights Forensic Research and Training, Prévessin-moëns, France

Oral Presentation: Forensic humanitarian action 1, June 2, 2021, 4:00 PM - 5:45 PM

Forensic science plays a growingly important role in supporting the United Nations (U.N.) efforts to protect and promote human rights worldwide. In particular, the Geneva-based United Nations human rights bodies, including the Human Rights Commission and its successor the Human Rights Council, as well as the Office of the High Commissioner for Human Rights and many U.N. human rights Special Procedures, have made growing use, since the early 1990’s, of forensic expertise in support of many of their activities; from the investigation and documentation of human rights violations, to technical cooperation and advice for Governments to help enhance their forensic capacity and improving compliance with human rights obligations. At the same time, the United Nations has been instrumental in developing, promoting and helping implement important standards of forensic best practice applied to human rights investigations. Some of these, such as the U.N. Manual on the Effective Prevention and Investigation of Extra-Legal, Arbitrary and Summary Executions (Minnesota Protocol), its revised new edition the Minnesota Protocol on the Investigation of Potentially Unlawful Death (2016) and the U.N. Manual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (Istanbul Protocol) are today considered as universal standards and have positively impacted forensic practice, research and training worldwide. It is also fair to say that the forensic profession has been enriched by its incorporation of human rights to the range of fields of forensic research and practice. An example of this is humanitarian forensic action, the development of which is rooted in the experience gained from forensic human rights investigations. This presentation will explore the past and present of the fruitful intersection between forensic science and United Nations human rights activities and identify areas for further and mutually beneficial development and cooperation between forensic practice, research and training, on one hand, and the United Nations efforts for ensuring universal respect for human rights, on the other.

042

AUTOPSIES ON MINORS: A TABOO? THE EXPERIENCE OF MILAN (2000-2020)

Stefano Tambuzzi 1 , Graziano Crudele 1 , Lidia Maggioni 1 , Cristina Cattaneo 1

1 LABANOF (Laboratorio di Antropologia e Odontologia Forense), Institute of Legal Medicine, University of Milan, Italy

Oral Presentation: Forensic pathology 3, June 2, 2021, 4:00 PM - 5:45 PM

Introduction : The performance of autopsies on minors (children and adolescents) is a practice that may not be performed routinely, or which tends to be discouraged. It is too often a procedure considered “inappropriate” as it maims the innocence of younger victims, according to certain cultures. Yet in the literature, the usefulness of performing autopsy on minors has been repeatedly affirmed. In this category of subjects, in fact, the autopsy allows to investigate the real incidence of disease or violence for epidemiological purposes, but also and above all, to look for signs of maltreatment and other medicolegal information. In Italy, the age of majority is reached at 18 and, and by consulting ISTAT (National Statistical Institute), it has emerged that in the period between 2001 and 2019 in Milan about 2000 underage subjects died. In this study, it was intended to investigate how many autopsies were carried out at the Institute of Forensic Medicine in the same period of time.

Material and Methods: From the autopsy archive of the Institute of Forensic Medicine, all cases of autopsies of minors in the selected period of time (01/01/2001 to 31/12/2020) were extrapolated. In particular, we focused on the following information: age, nationality, type of autopsy, manner of death, and dynamics of death. All the data collected were analyzed by descriptive statistics.

Results : Out of the total of more than 15000 autopsies, 345 autopsy cases of under-age subjects were extrapolated. In 2001, about 25% (n=22) of deceased children were autopsied; in 2019, 8.5% (n=6), thus with a decrease of 60% (Istat data for 2020 are not available yet). About 95% of them were ordered by the Judicial Authority (n=326). In 78% of all cases, the decedent was Italian (n=268), in 68% male (n=236), and in 26% under one year of age. In detail, 25% was between 1 and 9 years and 49% between 10 and 17 (n=89, n=86, n=170). Accidental events were the most represented manner of death (n=156, 45.2%), followed by natural death (n=103, 29.9%), suicides (n=37, 10.7%) and homicides (n=23, 6.7%). Blunt force trauma was the most observed (n=144, 41.7%), followed by asphyxia (n=35, 10.1%).

Discussions : Over the years there has been a relevant decrease in autopsies on minors. Autopsy and any laboratory analysis should be a routine practice in approaching a deceased minor if a natural cause is not certain. Whether it is prolonged illness and hospitalization or a sudden and unexpected event due to natural or exogenous cause, identifying the cause and manner of death is fundamental for child protection measures. However, our data shows that fewer and fewer autopsies are being performed over the last years, which indicates a dangerous lack of investigation of infant and adolescent deaths.

043

IDENTIFICATION OF NOVEL BIOMARKER-S OF SHAKEN BABY SYNDROME BY PROTEOMICS

Kim Wiskott 1 , Tatjana Sajic 1 , Federica Gilardi 1 , Aurélien Thomas 1 , Tony Fracasso 1

1 University Center of Legal Medicine Lausanne-Geneva (CURML), University of Lausanne and University of Geneva, Switzerland

Oral Presentation: Forensic pathology 3, June 2, 2021, 4:00 PM - 5:45 PM

Introduction : Abusive head trauma is a leading cause of mortality and morbidity in infants. Recent studies have shown an incidence of 38,8 cases for 100’000 births. Incidence of Shaken Baby Syndrome (SBS) could be higher than accidental head trauma. Diagnosis of SBS is hard in acute cases with atypical presentation, as well as in subacute and chronic presentation. At the present time, there is a lack of diagnosis tests for these clinical entities. This is why diagnosis of SBS often remains uncertain due to absence of confirming evidence. Recent studies showed early biomarkers of traumatic brain injury as a possible diagnostic and prognostic tool. Development of proteomics is bringing new insights into SBS biomarkers discovery and understanding of its pathophysiological processes.

Material and Methods : The aim of this project is to identify SBS biomarker-s via proteomics analysis of peripheral blood that would be applied to living patients to make SBS diagnosis easier and improve its prognosis through early and specific medical and family care. In this retrospective pilot study, we performed untargeted proteomics in peripheral postmortem blood to identify SBS biomarkers. Results of SBS group were compared to control group (infants who died of sudden infant death syndrome). Student t-test was used for statistical analysis.

Results : Postmortem blood revealed to be an excellent matrix for postmortem proteomic investigations with more than 800 proteins detected. Twenty-five proteins were significantly increased in the blood of SBS cases. Interestingly, these biomarkers were brain membrane protein or proteins from complement or coagulation cascade.

Discussion : This pilot study has shown promising results in the identification of biomarker-s characteristic of SBS. These results will be discussed.

044

FORENSIC AUTOPSY IN INFANT AORTIC ANOMALIES – OUR EXPERIENCE DURING THE PAST 7 YEARS

Filip Perde 1,2 , Arthur Keresztesi 3 , Larisa Udristioiu 1,2 , George Cristian Curca 1,2

1 National Institute of Legal Medicine “Mina Minovici", Bucharest, Romania

2 University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania

3 Insitution of forensic medicine Ialomita, Romania

Oral Presentation: Forensic pathology 3, June 2, 2021, 4:00 PM - 5:45 PM

Introduction : Coarctation of the aorta is a congenital anomaly where the aorta narrows adjacent to the ductus arteriosus. This anomaly causes an important morbidity and mortality to children and young adults.

Methods : We present here four cases of infant aortic anomalies in which the malformation was detected only after birth, during the early neonatal period, due to systemic complications. In all cases a malpractice was claimed, this being the main reason for performing a forensic autopsy. Prior to the autopsy, three cases received surgical intervention and in one case the patient died during investigations.

Results : We highlighted the principal steps taken for the forensic autopsy:

A thorough enquiry of the medical records, which usually was not available before the autopsy

A detailed dissection of small structures, even if those are modified by surgery

An investigation of comorbidities which can aggravate or hide the manifestations of the main disease

Establishing a correct pathophysiology of the malformation and the possible involvement of the medical misconduct

We compared the results with the literature, the similar adult autopsy and the antemortem investigations.

Conclusion : This malformation alone is very easy to miss during the standard paediatric autopsy given the fact that the continuity of the luminal diameter of the aortic arch is not usually measured and the finding of another malformation or complication divert from further dissection. We found that the forensic autopsy was an essential tool for drawing a certain conclusion and identify the litigation issues, only if an adapted dissection technique is performed and the results are correlated with the available medical data.

045

SEVERE PULMONARY FAT EMBOLISM AFTER RESUSCITATION IN A CHILD

Alessia Carminati 1 , Claudia Castiglioni 1 , Tony Fracasso 1

1 University Center of Legal Medicine Lausanne-Geneva (CURML), University of Lausanne and University of Geneva, Switzerland

Oral Presentation: Forensic pathology 3, June 2, 2021, 4:00 PM - 5:45 PM

.Fat embolism is a well-known phenomenon in orthopedic surgery and in forensic medicine, essentially in cases of blunt trauma with bone fractures. If the trauma led to the death, fat pulmonary embolism is considered as a vital sign. Some studies showed that fat pulmonary embolism can be found without fracture, for example in cases with fatty liver or diabetes, or in cases with diffuse soft tissue contusions. We present the case of a child that was discovered floating in water. Cardio-pulmonary resuscitation was performed for one hour, by external cardiac massage, airway intubation and application of two intra-osseous catheters in the tibial region bilaterally. Eye-witnesses described the presence of abundant foam in the mouth. At autopsy we could not find any typical sign of drowning, nor any natural disease that could explain the death. No traumatic lesions were observed after imaging investigations (full body CT and MRI) and standard autopsy. The standard histological examination of lung tissue showed many optically empty vacuoles in the capillaries and little arteries. The Oil Red O staining showed severe pulmonary fat embolism (stage II according to the Falzi classification). The absence of major preexisting pathologies and skeletal fractures makes it difficult to understand the origin of pulmonary fat embolism. It is interesting to note that in the literature fat embolism is reported following intra-osseous injections in animals. To the best of our knowledge this phenomenon has never been reported in humans. In this case, intra-osseous catheters seem to be the only possible explanation for pulmonary fat embolism, but more studies are necessary to clarify this.

046

NATURAL OR ACCIDENTAL DEATH? THE ROLE OF PRE AND POST-AUTOPSY INVESTIGATIONS FOR A DIFFERENTIAL DIAGNOSIS BETWEEN SUDDEN INFANT DEATH SYNDROME (SIDS) AND ASPHYXIA

Matteo Sacco , Luigi De Aloe 1 , Angelica Zibetti 1 , Carlo Filippo Bonetta 1 , Carmen Scalise 1 , Francesco Sicilia 1 , Fabrizio Cordasco 1 , Santo Gratteri 1 , Pietrantonio Ricci 1 , Isabella Aquila 1

1 University Magna Graecia Of Catanzaro, Italia

Oral Presentation: Forensic pathology 3, June 2, 2021, 4:00 PM - 5:45 PM

Sudden infant death syndrome (SIDS) is defined as the unexpected death of an infant. There are various risk factors such as the prone position, the use of heavy blankets and co-sleeping with parents. The differential diagnosis between SIDS and asphyxia is often difficult at autopsy because the macroscopic findings may overlap. In these dubious cases, it is essential to know the child’s position during sleep with respect to other objects or surrounding people on the scene. In most cases, this cannot be done directly because the scene has already been altered by the medical staff due to the need for first aid with transfer of the child to another location. We present three cases of suspected SIDS in which the child had been transported to the emergency room and the scene was contaminated by medical intervention. In each case, before the autopsy, the parents were subjected to a questionnaire that evaluated the child's placement in a cot or sharing the bed with parents; the supine or prone position; the type of mattress (soft or hard); the placement of pillows, puppets or other surrounding objects. All the risk factors for SIDS were evaluated, i.e. smoking, alcohol or drug use during pregnancy, prematurity, any previous pathologies. Information was collected about the times of previous feedings and the time elapsed between feeding and sleeping. The assessment of risk factors was integrated with a simulation of the baby's position in the crib through an experimental model with doll reenactment. The scene was reproduced by separately questioning the parents and the intervening doctors. In all cases, an autopsy was performed. After the autopsy, toxicological and histological analysis were performed. In all three cases the autopsy showed data suggestive of asphyxia, such as subpleural petechiae, cyanosis, fluid blood, in the absence of other significant findings. Toxicological investigations excluded acute intoxication. In the first case, histological examination identified starch granules in the lungs with coagulative necrosis of the tracheal epithelium. The collection of the circumstantial data revealed that the child had had a fever in the previous days and that he had eaten fruit before sleeping. In the second and third cases, pulmonary edema, marked blood congestion with intraalveolar erythrocyte extravasation and exfoliation of the bronchial epithelium as from caustic acid were found. In these two cases, the baby breastfed before sleeping. In all three cases, the time between eating and sleeping was at regular distance. The questionnaires did not reveal intrinsic or extrinsic risk factors for SIDS. Furthermore, the reconstruction of the scene with doll reenactement showed a correspondence of the versions of physicians and parents and did not evidence puppets, pillows, soft surfaces or co-sleeping in any case.

047

CAN AN EXPLOSION BE A PERFECT CRIME?

Jarosław Berent 1 , Anna Smędra 1

1 Medical University of Łódź, Poland

Oral Presentation: Forensic pathology 3, June 2, 2021, 4:00 PM - 5:45 PM

We assume perfect crime to be a situation where an event occurs and its real causes are unknown to anyone, that is, it would not even occur to anyone that the actual cause could be different from the seemingly obvious one. In this presentation we will attempt to answer the question: can an explosion be a perfect crime? At first glance, no. Our imagination almost automatically considers an explosion to be so spectacular that its signs should be easily visible at a distance, by everyone and at first sight. And especially by someone as experienced as a forensic pathologist. But is this really the case? Let’s analyze an instance where there may have been an explosion, followed by a traffic accident. Could such an event become a perfect crime? Descriptions of blast-related injuries have been long established in the textbooks. However, the occurrence of certain types of injuries, their number, nature, size and severity is very variable since it is strongly related to the distance from the location of the explosion, the type, size and location of the explosive load, the presence of obstacles between the load and the body as well as the position of the victim and their clothing. Available publications conclude that sometimes no lesions whatsoever are observed, but now and again they are more common to occur. Moreover, the complete image of the situation may be masked by other circumstances, which seem obvious in a given situation. For instance, in the analyzed case the circumstances of the traffic accident can conceal the signs of the blast. Consequently, it might transpire that an explosion can become a perfect crime indeed. If we do not consider such possibility and look for appropriate traces, we may completely overlook the blast and focus on the accident instead. Thus, when analyzing a case of a possible explosion overshadowed by the circumstances of a traffic accident, in order not to let the perpetrator get away with a perfect crime, we must first of all look for injuries that could have only been caused by an explosion and, at the same time, could not have been caused by the traffic accident alone. While lesions that could have been due the accident but are less likely to occur are less relevant, all the other lesions, which could have been brought about by the blast as well as the accident, are not very important and their description will merely be an inventory of lesions. We must not forget about the dangers of describing numerous typical lesions – which, due to tiredness, stress and lack of experience – might lead to an oversight of atypical markers of blast.

048

“A FATAL NAIL IN THE COFFIN” WITH AN IMPROVED EXPLOSIVE DEVICE: ABOUT ONE CASE

Fabrice Dedouit 1,2,3 , Céline Guilbeau Frugier 1 , Fatima Zohra Mokrane 2,3 , Nihel Feki 4 , David Gainza 1 , Hervé Rousseau 2 , Norbert Telmon 1,3

1 Department of Forensic Medicine, CHU Toulouse, France

2 Department of Radiology, CHU Toulouse, France

3 Center for Anthropobiology and Genomics of Toulouse(CAGT, UMR 5288), France

4 Forensic Medicine Department, Hospital of Sfax, Tunisie

Oral Presentation: Forensic pathology 3, June 2, 2021, 4:00 PM - 5:45 PM

Introduction : A 77 years old single man, retired teacher in sciences and technology, was found dead at home. The body was severely decomposed. Based on police investigations, a natural death was suspected. Due to putrefactive changes, the general attorney asked for a medico-legal autopsy.

Material and methods : Radiographies and autopsy showed a severe head trauma with two potential gunshot trajectories. New police investigations found an intact homemade nail bomb in the house. Neighbors revealed that the victim had psychiatric disorders with memory loss. A re-examination of the radiographies and clothes revealed presence of two nails in the right shoulder of the jacket worn by the victim. Consequently, new macroscopical examinations of the skull were performed, followed by complementary explorations (Post Mortem Computed Tomography; scanning electron microscopy with energy dispersive X-ray spectroscopy (SEM-EDX) to identify and characterize potential metallic deposits on the bone defects; analyses of the nails and the intact nail bomb).

Results : Bone entry and exit wounds, lesional trajectories were determined. A gunshot trauma was excluded. The projectiles were consistent with the nails and the explosion with fireworks components use. According to the death scene, autopsy findings, technical analysis, and outcome of the police investigations, death was attributed to detonation of a homemade explosive device, charged with nails, in close proximity to the decedent’s head. The mode of death was supposed to be suicidal or accidental.

Discussion and Conclusion : The authors will discuss the originality of this case, and include it in the literature focused on improved explosive devices, imaging, SEM-EDX, and post explosion residues. This case was remarkable for an unusual destruction of the head caused by a nail bomb, and illustrates the necessity to have a multidisciplinary forensic approach. The diagnosis was possible by the results of crime scene investigation, autopsy and complementary explorations. Explosive-related deaths typically involve either accidental detonation at the workplace, or homicidal discharge during wartime and terrorist activities. Nonterrorrist suicidal deaths caused by explosives are infrequent. This case illustrates the necessity to have a multidisciplinary forensic approach. The authors will discuss this unusual case, which illustrates the necessity to have a multidisciplinary forensic approach, and include relevant literature.

049

AN UNUSUAL HOMICIDE-SUICIDE: HOW TO RECOGNISE THE USE OF GRENADES AT A CRIME SCENE

Joris Vranken 1 , Wim Van de Voorde 1

1 Department Of Forensic Medicine, University Hospitals, Leuven, Belgium

Oral Presentation: Forensic pathology 3, June 2, 2021, 4:00 PM - 5:45 PM

Background : In Western-European countries suicides using hand grenades are very rare. This case report would like to focus on quickly recognizing blast injuries and environmental damages, so potentially dangerous situations can be avoided.

Case : A 47 year old ex-soldier and his 49 year old wife were found dead in their chalet after that they have not been seen for two month. Policemen reported two bodies in advanged stage of decomposition without signs of ballistic of blast trauma. After starting the forensic examination at the crime scene we founded several clues that an explosion had occurred. All examinations were stopped immediately, the place was evacuated and DOVO (the Belgium federal service for explosive clearance and destruction) was asked to search for other explosives. After examining some suspicious objects with X-rays the place was called safe. We found two grenade explosion craters (one in the doorway and one in the middle of the bed between the two decomposed bodies), 3 safety levers (of an M72 grenade) and 1 empty grenade box (for storage of 4 grenades). Behind and under the bed were also found a loaded handgun, two empty cartridge cases and 1 deformed bullet (7.65 mm). In the wooden walls and in the ESP insulation panels on the ceilings were small millimetric impacts. It was impossible to have a total injury assessment based on the external examination of the two bodies alone, necessitating autopsy and postmortem imaging. Post mortem examination of the 49 year old woman revealed three ballistic entry wounds at the back of the head and one exit wound anterior of the left ear. Two bullets were found inside the skull. The skin at the back of thorax was strongly decomposed and deformed with underlying multiple rib and vertebrae fractures. CT-scan showed a massive amount of small metal fragments (shrapnel) inside of the thorax. Autopsy of the 47 year old man showed only a massive blast injury with traumatic amputations of the both legs. CT-scan showed a massive amount of small metal fragments at the legs and less in the thorax. Based on the forensic investigation, it was believed that the man first killed his wife with three shots at the back of the head and then committed suicide by detonating at least one grenade in his lap while laying on bed next to his deceased wife.

Discussion : Suicide attempts by using hand grenades are very rare in Western European Countries. This could be an explanation why grenade impacts are not always recognized immediately, however there is always a possibility that there are some explosives left. Therefore, it is of the greatest importance for the safety of all services that potentially dangerous situations are detected as quickly as possible.

050

VIOLENCE IN INTIMATE RELATIONSHIPS: FORENSIC PATHOLOGY AND CLINICAL FORENSIC MEDICINE

Diana Logrado 1 , Mário Sardinha 1 , Inês Gouveia Abundância 1 , Zoi Argyropoulou 1 , Miguel Costa Lopes 1

1 National Institute of Legal Medicine and Forensic Sciences, Lisbon, Portugal

Oral Presentation: Forensic pathology 3, June 2, 2021, 4:00 PM - 5:45 PM

Case description : The cases to be presented concern victims of violence in intimate relationships (VIR). All victims were submitted to a Forensic Pathology examination and had been previously observed in a Clinical Forensic examination (between 2013 and 2019), both in a possible VIR context. These examinations took place in the Southern Branch of the National Institute of Legal Medicine and Forensic Sciences (Lisbon, Portugal) and in the Medical-Legal and Forensic Offices dependent on this Branch (South of the country). There were different kinds of relationship between victim and offender. The interval between the Clinical observation and the victim’s death was, in some cases, of years. The Clinical Forensic examinations revealed the presence of sequelae in some victims. In some of the Clinical reports was stated that precautionary measures should be instated in order to ensure the victim’s safety. The medico-legal autopsy revealed signs of trauma in some cases. It was not possible to determine the manner of death in all cases, some having been classified as suicides.

Discussion : Violence in intimate relationships (VIR) constitutes a worldwide serious public health and human rights challenge. Official data concerning VIR is lacking. It is widely known that VIR sometimes ends with the victim's death, either directly (homicide) or indirectly (considered as a risk factor for suicide). According to the Annual Internal Security Report (Portugal), 26 homicides occurred in the context of an intimate relationship in the country in 2019. With this presentation, we try to humanize some VIR death numbers, by describing specific cases, some of which may even have been overlooked in official statistics, especially the ones that ended with the victim’s suicide. Furthermore, all these cases had had a prior Clinical Forensic examination, which means that the victim, while still alive, had been known to the system and the Public Prosecutor’s Office had been notified of the situation.

051

DEADLY STAYS: A 10-YEAR AUTOPSY STUDY OF DEATHS IN HOTELS

Mehmet Atılgan 1 , Cemyiğit Deveci 1 , Sema Demirçin 1 , Refik Akman 2

1 Department Of Forensic Medicine, Akdeniz University, Antalya, Turkey

2 Turkish Council of Forensic Medicine, Antalya Group Administration, Antalya, Turkey

Oral Presentation: Forensic pathology 4, June 3, 2021, 9:00 AM - 10:30 AM

Introduction : The hotel industry is an essential part of the service industry and provides a safe place to accommodate to both travelers and locals. The industry is especially important in touristic destinations and tourist turnover rate triggers growth and evolution of this industry in these destinations. However, deaths in hotel rooms make them lose value and may cause serious problems for hotel and tourism industry. Thus, the aim in this study is to determine and evaluate the causes of deaths in hotels in Antalya within the last decade, observe the seasonal changes in trends, and find out preventable causes to discuss appropriate precautions.

Material and Methods : We evaluated 8137 autopsy cases, performed in Antalya Group Administration of Council of Forensic Medicine, between January 1st 2010 and December 31st 2019. All deaths occurred during a hotel accommodation and within hotel borders, including their respective beach areas, and those who collapsed during their hotel stay and died shortly in a hospital or on their way to a hospital were included. A total of 900 hotel deaths, on which autopsies were performed, were identified.

Results : The total number of autopsies performed in Antalya within the last decade was 8137 and 900 (11%) of them were related to hotel deaths. A mean age of 54.3±18.55 (ranging from 2 to 94 years-old) was found for the decedents died during their stays. Forty-two different countries of origin were detected during evaluation of autopsy reports. Decedents were most commonly from Russia (n=251, 27.9%), followed by Germany (n=229, 25.4%) and Turkey (n=150, 16.7%). Existing cardiovascular diseases (n=379, 42.1%) were the most common cause, followed by drowning in sea (n=116, 12.9%) or in a pool (n=58, 6.4%), and diseases of respiratory system (n=47, 5.2%).

Discussion : Apart from vacations and conferences, hotels are used for various reasons, such as during pest maintenance or remodeling, to have weddings, for quick getaways, as well as to do drugs, for prostitution, to commit suicide or even to die. Thus, it is inevitable for medical examiners to encounter all manners of deaths originating from hotels. The variety of causes of deaths in present study demonstrates this fact. This study especially points out the unnecessary deaths because of preventable and intervenable causes every year in hotel rooms. The authors believe that ensuring pretravel health assessment to every traveler, providing hotel medical staff with necessary medical information about the hotel customers and legislative action taken by the state for hotels to take appropriate measures may help decreasing the preventable deaths, improve international travel, and further improve the cities economically heavily depended on touristic activities.

052

THYROID GLAND ALTERATIONS FOR THE POST-MORTEM INTERVAL DEFINITION: A PRELIMINARY STUDY

Enrica Rosato 1 , Martina Bonelli 1 , Marcello Locatelli 2 , Angela Tartaglia 2 , Domenico Angelucci 3 , Cristian D'Ovidio 1

1 Department of Medicine and Aging Science, Section of Legal Medicine, Center for Advanced Studies and Technology (CAST), University ''G. d’Annunzio'' of Chieti-Pescara, Chieti, Italy

2 Department of Pharmacy, University "G. d’Annunzio" of Chieti-Pescara, Chieti, Italy; 3 Division of Pathology, SS. Annunziata Hospital, Chieti, Italy

Oral Presentation: Forensic pathology 4, June 3, 2021, 9:00 AM - 10:30 AM

Introduction: The observation of cadaveric phenomena represents the method for estimating the time of death but not always they define the precise time of death. The post-mortem immunohistochemical metods represents a valid tool in the evaluation of post-mortem interval (PMI). The morfological post-mortem changes of the thyroid gland have been previously studied for the definition of the late PMI, in our experimental study we tried to analyze the immunohistochemical changes of the thyroid gland in the early PMI.

Material and Methods: We selected healthy male rats, aged three months, weight of 350-400 g. The sacrifice of the rats was made by reproducing asphyxia/hypoxia by simulating a carbon dioxide (CO2) intoxication respecting the ethical protocols of our country. The samples were taken at time 0, 8, 16 and 24 hours after death, keeping the rats in contact with ice and in the refrigerator (Temperature 5-8 C°). The entire thyroid gland was taken for each rat and fixed in formalin. The histological sections were stained with hematoxylin-eosin (EE) and immunohistochemical stains (TTF1, thyroglobulin, calcitonin and chromogranin A).

Results: We observed the first reaction of follicular cells at 8 hours after death with cellular cleavage as a sign of necrobiosis, at 16 and 24 hours the cleavage is greater with pale colloid (with EE). Similarly, immunohistochemical stains at 8 hours after death showed the initial loss of affinity for the nuclei of follicular cells (TTF1) which intensified at 16 and 24 hours, while cell affinity for calcitonin and chromogranin A disappeared after 8 hours.

Discussion: The preliminary results obtained from our study shows time-dependent colorability intensities of thyroid markers. Previously, this relationship was observed on late PMI with colorable thyroglobulin up to 5 days after death while after 13 days the reaction was negative, calcitonin was always colorable for at least 4 days after death while it was no longer colorable after 12 days. In our study we observed time-dependent morphological changes in the rats’ thyroid gland at 8 hours after death which may be useful for estimating the early PMI. The results must be considered preliminary because, in order to improve the accuracy in estimating the PMI, we are introducing additional parameters such as the different type of death and the correlation with serum thyroid hormone levels.

053

EVALUATION OF PERIPHERAL BLOOD CELLS DEGRADATION AND EXTRACELLULAR VESICLES FOR PMI ESTIMATION

Enrica Rosato 1 , Martina Bonelli 1 , Cristian D'Ovidio 1 , Marcello Locatelli 2 , Angela Tartaglia 2 , Pasquale Simeone 3 , Paola Lanuti 3

1 Department of Medicine and Aging Science, Section of Legal Medicine, Center for Advanced Studies and Technology (CAST), University ''G. d’Annunzio'' of Chieti-Pescara, Chieti, Italy

2 Department of Pharmacy, University of Chieti-Pescara "G. d’Annunzio", Chieti, Italy

3 Center for Advanced Studies and Technology (C.A.S.T.), University "G. d'Annunzio" Chieti-Pescara, Chieti, Italy

Oral Presentation: Forensic pathology 4, June 3, 2021, 9:00 AM - 10:30 AM

Introduction : Determination of post-mortem interval (PMI) has always been based on empirical analysis of macro-data not always endowed with the sufficient reliability. A reliable PMI estimation is a critical issue in forensic investigations, as it can have important implications for the course of judicial investigations. Due to the need to identify new elements with greater specificity and reproducibility in determining the time of death, in recent years research has been concentrated in the field of thanatochronology. Several methodological approaches have been proposed but, to the best of our knowledge, none of these have yet involved the study of the absolute number and viability of platelets, red blood cells and the main leukocyte populations (granulocytes, monocytes, T-lymphocytes - CD4, CD8 - B lymphocytes and natural killer cells), contextually to the evaluation of the extracellular vesicles.

Material and methods : We have evaluated the main lymphocyte subpopulations at different PMI correlating this data with study of platelets, red blood cells and extracellular vesicles. The analysis of vital (7ADD-) T lymphocytes (CD3 + / CD4 + or CD3 + / CD8 +) and natural killer cells (CD56 +), were performed through the no-lyse no-wash protocols commonly used in multiparametric flow cytometry (PMID: 31633216). The membrane integrity (Falloidin-) of platelets (CD31 + / CD41a +) and red blood cells (CD235a +) was also evaluated. Furthermore, we have analysed phenotype and number of intact extracellular vesicles (Falloidin-) of leukocyte (CD45 +), platelet (CD31 + / CD41a +) and endothelial (CD31 +) origin. The samples were acquired by means of a flow cytometer equipped with the volumetric counting module (FACSVerse, BD Biosciences). Cases analyzed were divided in homogeneous groups, considering cause of death.

Results : We have optimized methods in multiparametric flow cytometry for the evaluation of the viability of the figured elements of the blood and for the evaluation of circulating extracellular vesicles, in order to estimate the PMI.

Discussion : Among the studies for PMI estimation, the evaluation of morphological changes detectable in leukocytes has also been proposed. From these studies it emerged that the cellular changes can be useful to evaluate PMI in a time interval between 6 and 120 h after death. Based on the results obtained from these studies we have considered the study of the absolute number and viability of platelets, red blood cells and the main leukocyte populations, contextually to the evaluation of the extracellular vesicles in order to identify new methods for PMI estimation.

054

TIME DEPENDENT POST-MORTEM PROTEOME CHANGE: PMI EFFECT ON MOUSE BRAIN TISSUE TO IDENTIFY EARLY TIME SENSITIVE POST-MORTEM BIOMARKERS

Martina Bonelli 1 , Cristian D'Ovidio 1 , Enrica Rosato 1 , Marcello Locatelli 2 , Angela Tartaglia 2 , Eleonora Bossi 3 , Fabrizio Di Giuseppe 3 , Stefania Angelucci 3

1 Section of Legal Medicine, Center for Advanced Studies and Technology (CAST), University ''G. d’Annunzio'' of Chieti-Pescara, Chieti, Italy

2 Department of Pharmacy, University of Chieti-Pescara "G. d’Annunzio", Chieti, Italy

3 Center for Advanced Studies and Technology (CAST), Stem TeCh Group, 'G. d'Annunzio' University of Chieti-Pescara, Chieti, Italy

Oral Presentation: Forensic pathology 4, June 3, 2021, 9:00 AM - 10:30 AM

Introduction : Assessing PMI is one of the most difficult task and continuous challenge in forensic pathology. In fact, although PMI estimation is of fundamental importance in medico-legal issues, its reliable estimation could be difficult. The importance of PMI estimation in forensic caseworks requires an implementation of studies aimed at identifying new methods or new biomarkers capable to evaluate this item. For this purpose, various strategies are now considered; one on this is the proteomics, an emerging tool of great potential in forensic science. The use of proteomics in fact permits efficient and reproducible analysis through identification and characterisation of peptides and proteins from different biological and non-biological matrices.

Material and methods : Brain tissues harvested from 6-week old female SAMR1 mice were processed and comparative analysis were carried out in order to identify post-mortem-induced changes in mouse brain proteome at different time points: 0, 4, 8, 12, 24, 32 hours post mortem. Total protein content in each brain sample was determined; values were reported as the average of protein concentrations obtained at each time point. For each sample we carried out 2D electrophoretic run (with a technical triplicate) for each time point resolving 150 μg of total proteins on a 4-7pH gradient. Significantly expressed proteins have been selected, at each time point, for mass spectrometry analysis.

Results : Several proteins differentially expressed over the post mortem time course (p<0,01) were identified by mass spectrometry; proteins identified in the early post mortem stage (<24 hours) were involved in the binding molecular function while in the late post mortem stage (>24 hours) proteins identified were involved in the control of cell replication, genome stability and protein biosinthesis.

Discussion : Proteomics begins to be considered as an important tool for estimating PMI. As emerged from literature analysis, several studies were performed in order to identify a protein degradation pattern onto solid matrices, especially on skeletal muscle tissue from animal, promoting a correlation between the qualitative and quantitative change of proteins and properties of meat, mainly for food purposes. On the contrary, few studies having as main objective the correlation between proteomic data and PMI estimation in the forensic field, were carried out. In our study, we aimed to profile postmortem changes in the cortical proteome of animal models applying a gel based approach (two-dimensional gel electrophoresis (2-DE) combined with MALDI-MS analysis), identifying thus potential novel biomarkers.

055

MORPHOMETRIC ANALYSIS OF RUN-OVER INJURIES IN FATAL PEDESTRIAN-MOTOR VEHICLE CRASHES

Giorgia Franchetti 1 , Arianna Giorgetti 2 , Alessia Viero 1 , Barbara Bonvicini 1 , Alessandro Sartori 1 , Paolo Fais 2 , Guido Viel 1 , Giovanni Cecchetto 1

1 Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Italy

2 Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Italy

Oral Presentation: Forensic pathology 4, June 3, 2021, 9:00 AM - 10:30 AM

Background : the interpretation of patterns of lower limb fractures is of great interest in forensic traumatology, allowing to define the direction and speed of the applied force, the site of the impact and the characteristics of the vehicle responsible for the injury. Aim of the study: a standardized experimental model for the production of human tibia and fibula fractures, simulating the outcomes of road traumas, was created in order to test, through macroscopic and micro-radiological analyses, a potential correlation between the direction of the injurious force and the pattern of fractures produced.

Material and methods : four pairs of articulated human tibia and fibula were used, on the midpoint of which a 6 kg grave was dropped from a height of 1 meter, using a standardized machinery. The fracture stumps thus obtained were macroscopically analysed, through photographs and videos taken with a Google Pixel 3 smartphone and a Nikon D90 camera, and subsequently subjected to micro-CT scans. The results obtained were statistically compared.

Results : this study describes the analysis of experimentally produced fracture patterns by fractography and micro-TC. In fractography only a longitudinal or oblique black line was observed in the impact area. In micro-CT a better characterization of the fracture pattern was observed, with chip fragments and multiple fracture lines in the area of impact.

Conclusions : this study demonstrates that micro-CT is superior to fractography for reconstructing bone impact direction. Micro-CT is able to locate fracture lines, reconstruct bone segments in 3D images and calculate bone mineral density in the trabecular and cortical bone without any need for optical transparency.

056

AN AUTOPSY-BASED ANALYSIS OF FATAL ROAD TRAFFIC COLLISIONS: HOW THE INJURY PATTERN DIFFERS WITH THE TYPE OF VEHICLE

Stefano Tambuzzi 1 , Federica Collini 1 , Wendelin Rittberg 1 , Cristina Cattaneo 1

1 LABANOF (Laboratorio di Antropologia e Odontologia Forense), Institute of Legal Medicine, University of Milan, Italy

Oral Presentation: Forensic pathology 4, June 3, 2021, 9:00 AM - 10:30 AM

Introduction : Nowadays road traffic collisions (RTC) are still a major cause of death, even in developed countries. In 2018 there were around 23.400 people killed in Europe. In Italy, 3.310 people died due to RTCs, which is the highest number of road traffic fatalities among all European countries. Looking at the distribution among vehicles, in 2016 nearly all of the victims of fatal RTCs were driver or passenger in a car, motorbike, bicycle, truck, or pedestrian. In particular, cars (46%), pedestrians (21%), and motorbikes (17%) make up for 84% of all fatal RTCs.

Material and Methods : A retrospective post-mortem study was carried out, by selecting all the victims of RTCs that were autopsied at the Institute of Legal Medicine from 2007 to 2019. It was divided into two parts: the former was the analysis of a database by general epidemiological information; the latter was the detailed analysis of 180 autopsy reports of RTC victims and it focused on the causes of death and the sustained injuries. Five different categories of victims were selected: pedestrians and occupants of cars, motorbikes, bicycles, and trucks. For each of such categories, 40 autopsy reports were analyzed, except for truck occupants (20 autopsy reports) due to their rarity.

Results : From the analysis of the 1022 fatal RTCs, it emerged that 776 were males (76%) and 240 females (24%). Most of the females were pedestrians (58%), followed by drivers (25%) and passengers (18%). Of the male sample, 67% were drivers, 26% pedestrians, and 7% passengers. In 53% of all cases, the victim was found dead when the rescue team arrived. By the analysis of the autopsy reports, the highest proportion of multiple injuries was found in truck occupants (90%), followed by motorcyclists (80%), car occupants (78%), cyclists (72%), and pedestrians (65%). The highest proportion of traumatic head injuries was sustained by pedestrians (35%), and cyclists (28%).

Discussion : Most of the victims of RTCs were male drivers and the age group most affected was the twenties to forties. From the autopsy reports, car and truck occupants, as well as motorcyclists, had a higher proportion of multiple injuries than pedestrians and cyclists. Pedestrians and cyclists instead died more often because of traumatic head injury. The finding that more than half of all victims died immediately after the accident may arise some reflections about the factual safety of vehicles and on the attention of drivers when driving. Furthermore, in such cases, the information concerning the type of reported injuries would have been lost if the autopsy had not been performed. Therefore, forensic medicine is confirmed as a pivotal discipline for the protection of Public Health, allowing the collection of relevant information on which to base prevention strategies.

057

DIFFUSE AXONAL INJURY IN ROAD TRAFFIC ACCIDENTS: A CROSS-SECTIONAL STUDY

Biplab Rath 1 , Sudipta Ranjan Singh 1 , Manoj Kumar Mohanty 1 , Suvendu Purkait 1 , Chinmaya Dash 1

1 All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India

Oral Presentation: Forensic pathology 4, June 3, 2021, 9:00 AM - 10:30 AM

Introduction : Road traffic accidents are a common occurrence in developing countries like India. India is now ranked 1st in the accident fatalities. Head injury is the major cause of morbidity and mortality in these cases. Studies mostly have concentrated on the gross findings of the brain about the mortality pattern. Acceleration or deceleration happening over a span of time results in injury to axons diffusely, termed as Diffuse Axonal Injury. It manifests as axonal swellings in the light microscopy. This study was done to know about the diffuse axonal injury sustained as a result of the Road Traffic Accident and its association with various injuries.

Material and Methods : All Road Traffic Fatalities coming to the mortuary for autopsy were taken into account in the study period (July 2018 - December 2019). The brain fixed in formalin, processed, and stained with H&E stain. The slides were observed under the microscope.

Results : Diffuse axonal Injury was most commonly seen in motorcyclists followed by pedestrians. It was evident in cases that had a survival period of more than 6 hours with the highest if the survival period is 10 hours. It was most commonly associated with Microscopic Intracranial Haemorrhage. Grossly it was found to be mostly associated with Sub-Arachnoid hemorrhage and Skull Base Fractures.

Discussion : Most of the stress goes for the gross findings and their treatment in cases of Road Traffic Accident victims, ignoring the microscopic injuries. This leads to long term morbidities in patients. There lies the need for research to know about the diagnostic techniques, associative factors, and their possible treatment to decrease human suffering at large.

058

X RAY MICRO-CT TO ASSESS THE INNER AND OUTER MORPHOLOGY OF HUMAN COCHLEA AND TO PREPARE THE ISOLATION FROM THE PETROUS BONE

George Cristian Curca 1 , Iuliana Diac 1 , Catalin Dogaroiu 1 , Larisa Udristioiu 1 , Codrut Sarafoleanu 1 , Ion Tiseanu 2 , Ioana Porosnicu 2 , Mihai Lungu 2 , Mariana Rosu 3

1 University of Medicine and Pharmacy Carol Davila, Bucharest, Romania

2 National Institute for Lasers, Plasma and Radiation Physics, Magurele, Romania

3 National Institute of Legal Medicine Mina Minovici, Bucharest, Romania

Oral Presentation: Forensic anthropology 2, June 3, 2021, 9:00 AM - 10:30 AM

Introduction : Burning activities of the human body after death or during death may cause extensive damage to the human proteins including DNA. The chances to find useful DNA in order to have a positive identification is dependent of the burning temperature, exposure time, burning scene, etc. Cochlea cortical bone is many fold more useful to find ancient DNA or degraded DNA after a fire exposure than teeth samples or postcranial bones (14-16 to 183 fold, Gamba. C. et al, 2014).

Methods : In one case with severely burnt human remains in which no nuclear DNA was found for a positive identification we tried to prepare the petrous bone for further DNA analyze. Anthropological methods to identify and clear debris from the petrous bone were applied, an extensive micro-CT analyze using micro X ray tomography equipment with a nanofocus source with W target, maximum power 30W, 2400 projections/measurement and a X Ray beam filter of Al (1mm), with detector flat panel 2k x 2k pixels was performed (Fig. 1, Fig. 2). Using micro-CT scans and digital reconstruction software the inside of the cochlea was video recreated (as a virtual video tour) in astonishing details. The cochlea may be then liberated from the petrous bone using a drilling method or a sandblaster method (Pinhasi, R. 2019).

Results : Micro CT enabled a high definition 3D of the cochlea and morphological guiding marks which enabled the drilling procedure. The cochlea was transformed into bone powder in a more detailed method than processing the entire petrous bone and an extensive search for DNA was performed.

Conclusion : In our opinion harvesting cochlea from within the petrous bone need not to be very specific and thorough in order to be taken out either by drilling or by sandblasting. However, the DNA methods and techniques are the one that may require a specific quantity of bone powder in order to increase the chances for a DNA protein to be found. Micro-CT reconstruction may offer possibilities to determine petrous bone and cortical cochlea composition, forensically useful if however non-organic particles (i.e. metals) are to be found especially if their elemental composition needs to be determined (XR powder Diffraction).

Keywords : forensic anthropology, human burnt remains, cochlea preparation, microCT, DNA analyze preparation

059

AGE ESTIMATION: CAMERIERE'S OPEN APICES METHODOLOGY ACCURACY ON A PORTUGUESE SAMPLE

Inês Caldas 1,2,3 , Maria Lurdes Pereira 1,4 , Áurea Madureira-Carvalho 3,5

1 Faculty Of Dental Medicine Of The University Of Porto, Portugal

2 Institute of Research and Advanced Training in Health Sciences and Technologies, Department of Sciences, University Institute of Health Sciences (IUCS), CESPU, CRL, Gandra, Portugal

3 Centre for Functional Ecology, Department of Life Sciences, University of Coimbra, Portugal

4 Instituto de Saúde Pública, Universidade do Porto, Portugal

5 REQUIMTE/LAQV, Laboratory of Pharmacognosy, Department of Chemistry, Faculty of Pharmacy, University of Porto, Portugal

Oral Presentation: Forensic anthropology 2, June 3, 2021, 9:00 AM - 10:30 AM

Introduction : Age estimation is of the utmost importance in the forensic field. Several techniques have been described concerning age estimation in children and youngsters using dental techniques. One of those techniques is the Cameriere's 2007 open apices method, which relies on the measurement of open apices and tooth length. Moreover, it has been stated that population specific values enhance this method performance. Therefore, the aim of this work is to assess the accuracy of the Cameriere’s 2007 method in a Portuguese population

Material and methods : A sample of 533 digital panoramic orthopantomographs from Portuguese sub-adult individuals of known age and sex was studied. The sample was composed of 268 males and 265 females’ individuals aged between 6.08 and 16.96 years (mean age 10.97 years; standard deviation=2.90), who had undertaken radiographs for clinical purposes. An open code computer-aided drafting software (ImageJ) was used to measure the variables according to the author's published guidelines. Age was estimated using the European Cameriere’s formula (2007); afterwards, a linear regression analysis for this population, using the same variables (sex, X5, N0, S and SxN0) was performed, and applied to a subsample of 200 orthopantograms. Paired T- tests were performed to compare predictions to participants’ real age. The significance threshold was set at 5%.

Results : Using the European formula, subjects' age was underestimated both in boys and in girls (mean=0.39 years ±1.18, and mean=0.82 years ±1.15, respectively). Paired T- tests performed to compare predictions to participants real age showed statistically significant differences in both sexes (p<0.001). Additionally, the linear regression analysis modeled for this specific population was able to explain 84.8 % of the chronological age variation with a standard error of 1.132 years. In this Model, all predictors, except for sex (p=0.162) were significant to the fit (p<0.05), being the Model formula expressed as: age=10.337-(2.370*X5)+(0.700*N0)-(0.427*S)–( 0.327*(S*N0)). Lastly, paired t-tests performed to compare predictions with the new model to participants real age showed no statistically significant differences (p=0.162).

Conclusion : In conclusion, the present results support the Cameriere’s method for age estimation in Portuguese subadults as a reliable practice, although correlations may vary between specific population groups and, therefore, specific formulae may be useful for a more accurate prediction.

060

MANAGEMENT OF FRAGMENTED HUMAN REMAINS. IMPROVING THE PROTOCOLS FOR DISASTER VICTIM IDENTIFICATION AND COUNTER-TERRORISM MISSIONS

Lise Malfroy Camine 1 , Lorenzo Campana 1 , Vincent Varlet 1 , Virginie Magnin 1 , Ruben Soto 1 , Negahnaz Moghaddam 1 , Silke Grabherr 1

1 University Center of Legal Medicine Lausanne-Geneva (CURML), University of Lausanne and University of Geneva, Switzerland

Oral Presentation: Forensic anthropology 2, June 3, 2021, 9:00 AM - 10:30 AM

Introduction : Disaster Victim Identification (DVI) missions are an ethical mandatory task in mass disasters and international guidelines (e.g. of INTERPOL, ICRC) provide effective protocols. Nevertheless, explosions and air crashes may result in multiple fragmented human remains (FHRs), which need to be identified with respect to the dead and bereaved families. Currently, individually packed fragments are gathered into bodybags, thus losing the geolocation data, and possibly damaging them during transportation. Their collection and examination represent a major but difficult task for the forensic anthropologists, and their identification relies on expensive and time-consuming genetic analysis. The aim of our research is to develop a new and specific management protocol for FHRs, combining forensic archaeology innovative devices and virtual re-association, in order to record the geolocation of FHRs to enhance the identification process, and to allow further virtual scene reconstructions.

Material and Methods : Development of a recovery protocol: in a preliminary approach, two intact porcine femurs were first scanned, using a Multi-Detector Computed Tomography (MDCT). After fragmentation they were scattered onto a delimited area, where a one-meter square deployable grid was set up and documented. Each fragment was individually packed, labelled with the reference of its grid square, and placed into the corresponding box of a prototyped sectorized stretcher, that is fold into a standard bodybag and scanned through MDCT. Virtual re-association of fragmented bones: we scanned six porcine femurs using a MDCT before and after fragmentation. Once segmented using Mimics® (Materialise®), fragment models were virtually re-associated with CloudCompare®: High roughness features were manually selected on complementary fragments, then used for alignment of the bone surfaces, which were automatically registered by the Iterative Closest Point (ICP) algorithm. Fragments were merged and virtually reconstructed.

Results and Discussion : Preliminary results show that our recovery protocol allowed for simple and quick fragments collection, and helps to preserve the geolocation data. Moreover, the sectorized stretchers improved the MDCT imaging. This protocol will be evaluated on a larger outdoor area, with the help of unmanned aerial vehicles support and aerial photogrammetry. The virtual reconstruction of the fragmented remains was satisfactory and limitations regarding segmentation process and time needed for the analyses have been listed and identified. This could be improved through automatization processes of various steps in the future, which is currently evaluated. The management protocol developed herein will be helpful for future DVI operations and also for counter-terrorism investigations in case of bombing terrorist attack. Through scene reconstructions, the link between the fragmentation/dispersion degree of a body and its relative position to the explosive engine could be investigated.

061

BONES IN THE BOX: A PRACTICE MANUAL FOR QUALITY MDCT VOLUME RENDERING 3D RECONSTRUCTION OF ANTHROPOLOGICAL SAMPLES

André Guerra 1 , Pia Genet 1,2 , Virginie Magnin 1 , Negahnaz Moghaddam 1

1 University Center of Legal Medicine Lausanne-Geneva (CURML), University of Lausanne and University of Geneva, Switzerland

Oral Presentation: Forensic anthropology 2, June 3, 2021, 9:00 AM - 10:30 AM

Introduction : Research in Virtual Anthropology (VA) has become an important part within the field of forensic anthropology. Anthropologists and forensic radiographers often collaborate in forensic casework to perform Multidetector Computed Tomography (MDCT)-scans of anthropological samples. A MDCT-scan performs a “virtual copy” of the examined bones and permits to preserve the original aspect of the bones for posterity. These images might later be used to create a Tridimensional (3D) Volume rendering (VR) of the bones. However, MDCT procedures used for corpses need to be adapted to anthropological samples. The main aim of our study was to develop an optimal procedure to perform MDCT’s of dry bones and bone samples, which were extracted during an autopsy.

Material and methods : Samples of not macerated clavicles issued for the purpose of forensic casework have been scanned inside containers made by different types of packaging material: cardboard, glass, plastic, plasticized expanded polystyrene, and compressed expanded polystyrene. Additionally, we re-scanned all containers by wrapping the anatomical sample in a plastic bubble sheet. Then, each MDCT was segmented to obtain a 3D VR and the different MDCT-scans were compared.

Results : The various MDCT-scans carried out on the different containers and the bones showed that the cardboard, plastic and glass containers didn’t permit to analyze specific areas of the samples, which were directly attached to the containers. However, by adding the plastic bubble wrap around the anatomical piece a detailed evaluation was possible and thus improved the previous procedure significantly. Furthermore, we noticed that by using material with an aerial density Hounsfield Unit (HU) close to -1000, such as the plasticized expanded polystyrene and the compressed expanded polystyrene, better 3D VR segmentation of the anatomical piece could be obtained.

Discussion : We have set up a best practice manual in order to create a complete digital 3D VR of different anthropological samples with the aim of allowing the best anthropological evaluation. With our technique we like to highlight the importance of a good differentiation of all structures of the sample. This is possible if the HU densities of the containers, which are used, are close to an aerial density, like for example with a compressed expanded polystyrene.

062

Half-tooth maturation stages in two-rooted lower third molars for forensic age estimation

Inês Caldas 1,2,3 , Áurea Madureira-Carvalho 3,4 , Maria Lurdes Pereira 1,5

1 Faculty Of Dental Medicine Of The University Of Porto, Portugal

2 Centre for Functional Ecology (CFE), Department of Life Sciences, University of Coimbra, Portugal

3 Institute of Research and Advanced Training in Health Sciences and Technologies, Department of Sciences, University Institute of Health Sciences (IUCS), CESPU, CRL, Gandra, Portugal

4 REQUIMTE/LAQV, Laboratory of Pharmacognosy, Department of Chemistry, Faculty of Pharmacy, University of Porto, Portugal

5 Epidemiology Research Unit, Institute of Public Health, University of Porto, Portugal

Oral Presentation: Forensic anthropology 2, June 3, 2021, 9:00 AM - 10:30 AM

Age estimation using third molar mineralisation status is commonly used in the forensic field. When doubts arise concerning the age estimation, the selected age is usually the lowest. Yet, this procedure is adopted in order to protect the individual’s rights, and not necessarily to estimate the most accurate age. Thus, the aim of this work is to determine if two-rooted lower left third molars display different maturation stages, considering the mesial and distal halves, and if this has any impact in age estimation. A sample of 502 orthopantomograms (OPT) belonging to 326 male and 176 female individuals (chronological mean age of 14.87±3.28), attending the Dental Clinic of the Faculty of Dental Medicine of the University of Porto was assessed. Estimated age was determined using Demirjian stages1 applied to the mesial and distal staging tooth halves of the lower left third molars and the models of regression formulae for age estimation described by Duango et al2. Afterwards, a linear regression analysis for this population, using the variables sex, mesial tooth stage development (MTS) and distal tooth stage (DTS) development was performed and applied to a subsample of 200 orthopantograms. Paired T- tests were carried out to compare predictions to participants’ real age. The significance threshold was set at 5%. The majority of males (n=197, 60.4%) and females (n=107, 60.8%) displayed the same maturation stage in both halves of the lower left third molar. Additionally, in both sexes, there were statistically significant differences between age estimation using different tooth halves (p<0.005) and also between chronological and estimated age, regardless of the tooth half used (p<0.005). Both halves underestimate age (p<0.05), being these differences more evident using the distal dental stage maturation. Additionally, the linear regression analysis modeled for this specific population was able to explain 83.3 % of the chronological age variation with a standard error of 1.134 years. In this Model, all predictors, except for sex (p=0.940) were significant to the fit (p<0.05), being the model formula expressed as: age=8.194+(0.689*MTS)+(0.736*DTS). Lastly, paired t-tests performed to compare predictions with the new model to participants real age showed an underestimation of age (mean=0.94±1.29) without statistically significant differences (p=0.301). Accordingly, our results suggest that using tooth half root maturation stages population models may improve chronological age estimation accuracy.

063

Ancestry estimation: Skull versus Genetic analysis

Catarina Coelho 1 , Sofia Botelho 2 , Rui Pereira 3,4 , Armando Serra 5 , Sofia Wasterlain 6 , Eugénia Cunha 1,5

1 Universidade de Coimbra, Laboratório de Antropologia Forense, Centre for Functional Ecology, Departamento de Ciências da Vida, Calçada Martim de Freitas, Coimbra, Portugal

2 Faculdade de Ciências da Universidade do Porto, Portugal

3 Institute of Molecular Pathology and Immunology of the University of Porto, Portugal

4 Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Portugal

5 Instituto Nacional de Medicina Legal e Ciências Forenses, IP, Coimbra, Portugal

6 Centro de Investigação em Antropologia e Saúde, Department of Life Sciences, University of Coimbra, Portugal

Oral Presentation: Forensic anthropology 2, June 3, 2021, 9:00 AM - 10:30 AM

Ancestry estimation can be achieved by different disciplines. In Forensic Anthropology, ancestry estimation is one of the four parameters of an individual's biological profile, an essential step of the identification process. The evaluation of this parameter is possible through the application of metrical and morphological methods to the skull and post-cranial skeleton. Ancestry can also be estimated through Genetics. Ancestry Informative Markers (AIMs), with high divergence in the allele frequencies between major human population groups, can be employed, thus collectively allowing inferring the probable biogeographical origin of a given sample. This investigation aims to compare the results of the Anthropological and Genetic approaches on inferring ancestry of identified skeletonized human remains. Fifty individuals were selected from the 21st Century Identified Skeletal Collection. This collection is composed of 302 individuals housed in the Laboratory of Forensic Anthropology, at the University of Coimbra, Portugal. Ancestry estimation in Anthropological analysis was achieved using the program AncesTrees to the metric analysis (http://osteomics.com/AncesTrees/). The morphological evaluation was also fulfilled, using the Hefner and Linde (2018) descriptions and the analysis were carried on hefneR ( http://osteomics.com/hefneR/ ). The genetic analysis was accomplished by genotyping 46 AIM-Indels in a single PCR multiplex following Pereira et al. (2012). Cluster membership proportions were estimated using STRUCTURE V2.3.4 (Pritchard et al., 2000), and Snipper App Suite V2.5 was used to assess likelihood ratios between continental ancestral origins and obtain Principal Component Analysis plots. Regarding the Anthropological analysis, five (10%) individuals revealed different classifications in metric and morphological evaluations. Of these five, it was observed that in three individuals the morphological analysis was in agreement with the genetic analysis. In only one case there were different results in the three types of assessment. According to the genetic analysis, it was possible to identify 39 individuals with only one main ancestral origin, and eleven individuals with probable admixed ancestry. The admixture patterns are in accordance with the Portuguese history, being promptly detected through the ancestry membership proportions calculated and the low likelihood ratios obtained for these individuals. In an overall perspective, only five individuals exhibited non-matching results between the two sciences. The results presented here are very encouraging not only because they demonstrate that different disciplines can corroborate and complement each other, but also because they can help improve methods by confronting and understanding different results.

064

WILLEMS METHOD OF DENTAL AGE ESTIMATION IN CHILDREN – META-ANALYSIS

Cosmin-Daniel Tirdea 2, 1 , Teodora Petcu 2 , Razvan Marian Siminiuc 1 , Sorin Hostiuc 1,2

1 "Prof. Dr. Mina Minovici" National Institute Of Legal Medicine, Bucharest, Romania

2 University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania

Oral Presentation: Forensic anthropology 2, June 3, 2021, 9:00 AM - 10:30 AM

Introduction : Estimating a chronological age based on dental measurements is a highly debated topic due to its importance in many fields such as pedodontics, orthodontics, legal medicine, as well as in the field of anthropology. The use of dental age as a mean of estimating chronological age provides better accuracy compared to other methods. The aim of this study is to check the accuracy, as well as the applicability and reliability of this method of estimating the dental age at the level of population groups of various origins.

Material and methods : A systematic search of online databases (Pubmed, Embase, Medline and Web of Science) was performed for identifying the articles utilizing Willems’s dental maturity scaling method for age estimation in children. All the research articles were published in English language. All retrieved data was entered into specially designed data sheets in an Excel database were the following types of data have been included: name of the first author, year of publication, country in which the study was conducted, age, division of participants by age groups and also DA (dental age) + SD (standard deviation) CA (chronological age) + SD for each age group analyzed. Meta-analysis was then conducted using Jamovi v1.2.27 software.

Results : Out of the total 973 selected articles; 392 studies were recruited for qualitative analysis and out of them, 50 studies were selected for meta-analysis, with 31326 individuals whose age ranged from 3.0 to 18.9. The general polled data indicated that Willems method overestimated CA by 0.04 years for males and underestimated CA by 0.06 years for females. For males in the 9-15 age groups, the overestimation of the CA by the Willems method was minimal, between 0.06 and 0.09, while for women in the same age group the accuracy was also very high, with an average underestimation ranging from 0.01 - 0.04 years.

Discussion : By integrating the data from all the selected studies, the method proved to be the most effective in the age groups from 8.0-14.99 and becomes more and more inefficient with ageing. Overall, Willems’s method of dental age estimation gives a minimum overestimation in males and a minimal underestimation in females and is thus, accurate and reliable enough to be utilized for forensic purposes.

065

DEATH IN CUSTODY IN LISBON: NUMBERS IN THE PORTUGUESE CONTEXT

Mário Sardinha 1 , Ana Rita Inácio 1 , Ana Abreu 1

1 National Institute of Legal Medicine and Forensic Sciences, Portugal

Oral Presentation: Forensic pathology 5, June 3, 2021, 11:00 AM - 12:30 PM

Death in custody can be described as the one occurring between the deprivation of a person’s liberty by agents of a State, or of entities operating within the jurisdiction of that State, and the moment the person is free from their effective control. In Portugal, it is not mandatory to perform a medico-legal autopsy in all such cases, although the law was being reviewed to include that requirement. According to the Directorate-General of Reintegration and Prison Services (DGRSP), there were 393 deaths in custody in Portugal between 2013 and 2018 (78.9% natural, 20.6% suicides, and 0.5% homicides). With a few exceptions, medicolegal autopsies are performed by the National Institute of Legal Medicine and Forensic Sciences (INMLCF). Since there is no backwards feedback to the DGRSP and it is not mandatory to perform a medico-legal autopsy, the authors aimed to assess the existing data regarding such cases in the INMLCF. We searched the INMLCF’s Pathology databases for keywords (in Portuguese) such as “prison”, “arrest”, “police”, or “inmate”, in cases of cadavers admitted to the Southern Branch (Lisbon) between 01-01-2013 and 31-12-2018. We found 49 cases and excluded five (false positives – the database showed one or more keywords, but the case was not a death in custody). All 44 had been submitted to autopsy (not all cadavers admitted are autopsied). None had died during the arrest procedure nor in police stations. Half were non-natural deaths (39% suicide, 2% homicide, 2% accidental, 7% undetermined), 48% natural deaths, and 2% undetermined. The majority were male (95%) and Portuguese nationals (82%); of the 18% non-nationals, half were from member States of the Community of Portuguese-speaking Countries. The average and median ages were 49 years (21-82). This data is in line with the knowledge that some deaths in custody, specifically when they are presumed natural deaths, do not include a medico-legal autopsy during the investigation process, since the percentage of non-natural deaths in our sample was higher than in the DGRSP’s data (50% versus 21.1%). A relevant bias is the absence of backwards feedback to the DGRSP’s data once the investigation ends. Another bias is the regional versus national data. Regarding the former, the institutions should assess the existence of legal mechanisms for cooperation and data sharing (or work to create such mechanisms). Regarding the latter, it is relevant to mention that these are preliminary results (only including data from the INMLCF’s Southern Branch) of an ongoing nation-wide project.

066

PRACTICAL APPLICATION OF SYNTHETIC HEAD MODELS IN REAL BALLISTIC CASES

Fabiano Riva 1,2 , Tony Fracasso 1 , André Guerra 1 , Pia Genet 1

1 University Center of Legal Medicine Lausanne-Geneva (CURML), University of Lausanne and University of Geneva, Switzerland

2 Ecole des sciences criminelles – Université de Lausanne, Switzerland

Oral Presentation: Forensic pathology 5, June 3, 2021, 11:00 AM - 12:30 PM

Introduction : with the purpose of solving shooting crimes, shooting tests are often recommended in order to reproduce the wound characteristics. For the shooting tests several “simulants” can be used: ballistic gelatine 10%, polyurethane plates and leather have already been approved and are used in ballistic trauma to simulate respectively soft tissues, bones and skin. Despite the efforts in the research of “surrogates” in the field of forensic ballistic, the development of synthetic models needs still to be improved through a validation process based on specific real caseworks.

Material and Methods : this study has been triggered by the findings observed during the autopsy performed on two victims killed in the same shooting incident, with the same semi-automatic pistol calibre 6.35mmBrowning, same FMJ ammunition and with similar wounding characteristics; namely two retained head shots with ricochet against the interior wall of the skull. In both cases, a partially deformed projectile had been recovered during the autopsy. Both trajectories have been described by the mean of antemortem and postmortem computed tomography (CT) images. The thickness of the different tissues and structures along the bullets trajectories as well as the incident angles between the bullets paths and the skull walls have been measured and reproduced during the assemblage of the synthetic head models. Two different types of models (“open shape” model (OSM) and “spherical” model (SM)), have been assembled using leather, polyurethane and gelatine to simulate respectively skin, bone and soft tissues. Six shots have been performed in total. After shooting, the results on the models have been recorded photographically and by the mean of the CT. The results of the models have been compared to the findings of PMCT and the autopsy findings.

Results : out of the six shots, two perforated the models and four were retained. When the projectile was retained, the use of both models allowed reproducing the wounds characteristics observed on both victims in terms of penetration and ricochet behaviour. However, the projectiles recovered from the models showed less deformation than the bullets collected during the autopsies.

Discussion : both models reproduced the expected wounds characteristics during shooting; however, the OSM allowed a better controlling on the shooting parameters than the SM. Until to date, the OSM has been tested only with low energy projectiles; the SM should be more suitable to simulate the damages caused by the effect of a bigger temporary cavity, because the spheres enclose the gelatine more than an open model does. Finally, the difference in bullet deformation could be caused by the choice of the bone simulant, which might under-represent either the strength, or density of human bone. More effort should be put to develop a more representative material for ballistic impact simulations against bones.

067

FORENSIC SIGNIFICANCE OF CTNI SERUM FOR THE DETECTION OF TERMINAL MYOCARDIAL DAMAGE IN RATS CAUSED BY HYPERTHERMIA

Emina Dervišević 1 , Sabaheta Hasić 2 , Muhamed Katica 3 , Nermin Sarajlić 1 , Adis Salihbegović 1

1 Department of Forensic Medicine, Faculty of Medicine, University of Sarajevo, Bosnia and Herzegovina

2 Department of Medical Biochemistry, Faculty of Medicine, University of Sarajevo, Bosnia and Herzegovina; 3 Department of Pathological Physiology of Domestic Animals, Veterinary Faculty, University of Sarajevo, Bosnia and Herzegovina

Oral Presentation: Forensic pathology 5, June 3, 2021, 11:00 AM - 12:30 PM

Introduction : An increasing number of deaths are caused by hyperthermia in the world and often require forensic examination.

Objectives : To determine whether the biochemical marker cTnI with circulating value has forensic significance in the detection of myocardial damage in rats in experimental conditions of hyperthermia by exposure to water temperatures of 41 °C.

Material and methods : The study was conducted on 24 adult Wistar rats that were methodologically divided into two experimental groups, depending on water temperature exposure of 37 °C (KG, n = 8) and 41 °C (G41, n = 16). Depending on the length of time of exposure to water temperatures of 41 °C are further divided into G41-AM (20 minutes of exposure), G41-PM (exposure until death). Blood for analysis of the concentration of cardiac troponin I (cTnI) was taken before the experiment and after the expiration of the given duration of the experiment of 20 minutes or death. The concentration of cTnI was determined in serum by ELISA method. The level of statistical significance was, p< 0.05.

Results : Eight rats (53.3%) of the G41 group achieved a core temperature that is the threshold for heat stroke. The median survival time for group G41 was 175.5 minutes. The median cTnI was 358.64 (273.41-490.34) for group KG 37, G41 560.31 (431.78-838.36). The control group of rats had significantly lower serum cTnI values compared to G41, p = 0.023. The increase in cTnI concentration in KG37 was at the level of p = 0.028, in the G41p group = 0.001, and in the G44 group, p = 0.001. Examination of the length of exposure to appropriate temperatures led to significant increases in cTnI in the serum; A significant difference was found in the values of cTnI KG37 and G41-PM (p= 0.005). CTnI values differed significantly in the G41-AM and G41-PM groups (p = 0.009). The concentration for cTnI for G41 was ≥625.45 pg / ml (sensitivity 71.0%, specificity 87.5%, PPV 83.3% and NPV 77.7%, p = 0.011). In G41 ° C, a positive correlation was found between serum cTnI values and body temperature measured in fatal outcome (rho = 0.58;

Conclusions : cTnI with their changes in serum concentration indicate exposure to high water temperature. From the forensic aspect, the significance of cTnI in serum for the detection of terminal myocardial damage was determined on a model of rat hyperthermia. This finding requires further validation on human material in order for cTnI to be included as a biochemical marker of terminal myocardial damage caused by hyperthermia.

Keywords : hyperthermia, cardiac protein I, myocardium, forensic significance

068

VICTIMS AND PERPETRATORS: 20 YEARS OF FEMINICIDE IN MILAN

Lidia Maggioni 1 , Stefano Tambuzzi 1 , Lucie Biehler-Gomez 1 , Giussy Barbara 2 , Alessandra Kustermann 2 , Cristina Cattaneo 1,2

1 LABANOF, Istituto Di Medicina Legale, Dipartimento Di Scienze Biomediche Per La Salute, Università Degli Studi Di Milano, Italy

2 Service for Sexual and Domestic Violence (SVSeD), Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy

Oral Presentation: Forensic pathology 5, June 3, 2021, 11:00 AM - 12:30 PM

Introduction : In the 1970s the term "Feminicide" was issued by the feminist movement to mean the intentional murder of a woman based on her gender to raise awareness in the struggle to protect women. Today, however, its meaning has been broadened. In 2017, 87,000 women were intentionally killed worldwide, of whom 50,000 were killed by intimate partners or family members. Globally, 137 women die every day at the hands of their close ties. In Europe, where the risk of being killed by a family member or intimate partner is lower, in countries such as the UK, France, Germany, and Italy, on average, a woman is killed by a man every three days. In Italy, women victims of voluntary murder were 111 in 2019, and 133 in 2018. To deepen the extent of this sad phenomenon, a retrospective study was conducted on the autopsy cases of the Institute of Forensic Medicine, from 1999 to 2019; we have excluded 2020 because of the particular living conditions imposed by the SARS-CoV-2 pandemic.

Material and Methods : From the archives of the Institute of Forensic Medicine in Milan, all cases concerning female victims of murder were extrapolated. In particular, the study focused on some characteristics, such as age and nationality of the victim, place of murder, victim/perpetrator relationship, and detrimental modality involved. All the data collected were analyzed using frequency and percentage calculus.

Results : Out of the total of more than 15,000 autopsies (murders n =535, 3.6%), from 1999 to 2019, 200 cases of female victims of murder were extrapolated (mean 9.5 cases per year). The most represented are between the ages of 18 and 49; victims were Italian in 74% (n=148). The murder was perpetrated in 76.5% of the cases (n=153) in a domestic setting, committed for 73.5% by subjects related to the victim (ongoing or terminated romantic relationship, family). Murderers were male in 85% of cases. The most represented type of trauma is sharp force injuries (32%, n=64), followed by blunt force, gunshot and asphyxia (n=43, 21.5%; n=37, 18.5%; n=33, 16.5%). Victims under the age of 49 were mostly killed by sharp force injuries and asphyxia, women over the age of 50 by blunt force trauma.

Discussion : Feminicide has reached pandemic proportions, its prevalence is increasing worldwide and often goes unpunished, calling for global efforts to develop measures and strategies to prevent and respond to this phenomenon. It is necessary to strengthen the monitoring and screening of feminicide and violence by the partner – and not only - around the world to better understand, reduce and finally end feminicide globally.

069

TYMPANAL BONE FRACTURE IN FORENSIC PRACTICE

France Evain 1 , Karl-Olof Lovblad 2 , Tony Fracasso 1

1 University Center of Legal Medicine Lausanne-Geneva (CURML), University of Lausanne and University of Geneva, Switzerland

2 Universtiy Hospital of Geneva, Switzerland

Oral Presentation: Forensic pathology 5, June 3, 2021, 11:00 AM - 12:30 PM

Tympanal bone fracture is an uncommon complication of head trauma, mostly associated with mandibular or petrous bone fracture. By reviewing the medico-legal literature we could not find any publication on this topic, whereas tympanal bone fracture may lead to chronic complications (including external auditory canal stenosis and conductive hear loss) with an important impact in both clinical and judiciary field (chronic disabilities with loss of income for example). We decided to investigate the prevalence and mechanisms of tympanal bone fracture, by means of a retrospective observational study on victims who underwent head CT after trauma and clinical forensic investigation in our Center. We selected 159 cases of victims of blunt head trauma (following assault, traffic accident or work accident), between January 2016 and December 2020. Re-examination of head CT revealed 12 cases of tympanal bone fracture among the victims. Seven individuals showed cranial fractures involving the petrous part of the temporal bone (at the same side of de tympanal bone fracture). Three presented temporomandibular fracture after a fall with chin impact. Only two victims exhibited isolated tympanal bone fracture. The mechanisms of such fracture are mandibular head kickback in the articular fossa following high energy impact on the chin (usually associated with temporomandibular fracture) and extension of a petrous bone fracture. These aspects will be discussed.

070

LOOKING FOR ABUSIVE HEAD TRAUMA IN THE EYES OF THE TODDLERS

Francesca Cazzato 1 , Vincenzo Fattoruso 1 , Simone Grassi 1 , Domenico Lepore 2 , Vincenzo Lorenzo Pascali 1 , Antonio Oliva 1

1 Department of Health Surveillance and Bioethics, Section of Legal Medicine, Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Italy

2 Department of Head-Neck, Section of Ophthalmology, Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Italy

Oral Presentation: Forensic pathology 5, June 3, 2021, 11:00 AM - 12:30 PM

Introduction : Abusive Head Trauma (AHT), also called shaken baby syndrome, is a form of child abuse in which the abuser inflicts a blunt trauma or vigorously shakes the infant or the toddler. AHT can be evaluated through six features (with a sensitivity of 72.3% and a specificity of 85.7%): retinal hemorrhages, rib and long-bone fractures, apnea, seizures and head or neck bruising. An ophthalmologic consultation is crucial when AHT is suspected. Since January 2015, at Fondazione Policlinico Universitario A. Gemelli IRCCS a protocol was set to evaluate severe brain injury and/or physical injuries suggestive of abuse by a cross-functional team composed by a pediatrician, a forensic pathologist and an ophthalmologist. Therefore, this presentation will focus on the importance of retinal imaging in AHT cases.

Material and methods : We performed a retrospective analysis of a case series regarding 10 eyes of 5 infants (aged 0.6-10 months) with AHT who were admitted to our institution with severe intracranial hemorrhages. The clinical presentation and findings of dilated fundus examination (DFE), optical coherence tomography (OCT) images and digital wide-field fundus photography were reported.

Results : The mean age of the 5 infants with AHT at presentation was 5.73 months. Two of the infants were males and three were females. All cases with intracranial hemorrhage had preretinal and intraretinal hemorrhages. DFE, OCT and digital wide-field fundus photography acquired good quality retinal images in all infants.

Discussion : RetCam (Pleasanton, CA, USA) represents the gold standard for the acquisition of retinal images in suspected AHT infants. However, hand-held OCT is extremely valuable in forensic evaluation since it can detect even small macular hemorrhage through the identification of preretinal blood accumulation, vitreous detachment or retraction and vitreal attachment to the internal limiting membrane. Also, the vitreoretinal membrane may be seen in OCT supporting the mechanism of direct mechanical effect. Therefore, as showed by our cases, the combination of RetCam and OCT imaging can give relevant hints for the diagnosis of AHT, allowing to evaluate, the extent, spread and morphology of the hemorrhages.

071

FINDINGS IN HEAT-RELATED DEATH: 3 CASE REPORTS

Ioana Diaconescu 1 , George Cristian Curca 1 , Lăcrămioara Luca 2 , Maria Bosa 2 , Sorin Hostiuc 1

1 Carol Davila University of Medicine and Pharmacy, Dept. of Legal Medicine and Bioethics, Bucharest, Romania

2 Pathology Dept, National Institute of Legal Medicine Mina Minovici, Bucharest, Romania

Oral Presentation: Forensic pathology 5, June 3, 2021, 11:00 AM - 12:30 PM

Introduction : Heat stroke is caused by elevated environmental temperature, with an increased body temperature of over 40.6 degrees Celsius, leading to severe dehydration, systemic inflammatory response and finally multiple organ failure. Post mortem diagnosis in heat-related cases pose a challenge for the forensic pathologist. While typical macroscopic findings are absent, investigational elements with evidence of exposure to high ambient temperature are therefore important for heat-related diagnosis.

Methods : We present three case reports of autopsies from heat-related deaths caused by sun burns. An autopsy for all 3 cases was performed, with seric and histopathological analysis.

Discussion : Case one is represented by a 62 years old man with a history of ethanol intake, cardiac, hepatic and renal pathologies, who was hospitalised for less than a week with coma and severe dehydration. The autopsy revealed sun burns, cerebral edema, bronhopneumonia and pulmonary thrombosis. Case two is a 94 year old man who was found unconscious outside his house with severe dehydration and extensive sun burns, hospitalized for one month who died from septic shock. Case 3 is a 65 year old man, with a history of ethanol intake, who was admitted to the hospital for sun stroke with severe sun burns, who died from septic shock.

Conclusion : We will emphasize the key autopsy findings in heat-related death and discuss the main elements for a post-mortem diagnosis. Sun burns and severe dehydration were central elements for the heat-related death

072

DIAGNOSTIC CHALLENGES IN SUDDEN DEATH – A DIABETIC KETOACIDOSIS CASE REPORT

Luis Cardoso 1 , Nair Rosas-Pinto 2

1 National Institute of Legal Medicine and Forensic Sciences, Aveiro, Portugal

2 National Institute of Legal Medicine and Forensic Sciences, Porto, Portugal

Oral Presentation: Forensic pathology 6, June 3, 2021, 2:00 PM - 3:30 PM

The authors present a case of a 20 year old female, found dead at her apartment. She had been diagnosed with type I diabetes at the age of 10 and had multiple recorded episodes of diabetes decompensation. There was no history of any signs or symptoms prior to death, nor of any abuse of substances. At the external examination, we found purplish bruises in the abdomen and anterior aspect of both thighs, compatible with subcutaneous insulin administration. Internal examination showed signs of intracardiac thrombosis, hepatomegaly with multiple yellowish parenchymal patches and striation of kidney cortex. Histologic analysis of tissue samples from all major organs, including the pancreas, revealed recent organizing intracardiac thrombus, pancreatic fibrosis with reduction in Langerhans islets, glycogenic liver disease and Armanni-Ebstein kidney lesions. Toxicology and biochemical analysis of peripheral blood and vitreous humour samples revealed a blood ketone concentration of 0.37 g/L and vitreous glucose concentration of 750 mg/dL. Death was due to diabetic ketoacidosis. Knowing the prior medical history was of utmost importance concerning the ancillary exams in the investigation of the cause of death. However, the forensic pathologist must keep in mind that fatal diabetic ketoacidosis can be the first presentation of the disease. Routine ketone monitoring in our toxicology laboratory plays a central role concerning that diagnosis. Even so, in sudden death of unknown causes, non ketonic diabetes complications such as hypoglycaemia and hyperglycaemic hyperosmolar state must also be investigated. Recent studies suggest that diabetes complications, as well as other hiperketonemic or abnormal glycaemic states (such as alcoholic ketoacidosis) can be easily and rapidly investigated in the autopsy room even before laboratory standard methods, using urine dip tests or commercially available portable glucose and ketone monitoring devices. The authors consider that these methods of early screening of metabolic causes of death at the time of the autopsy could therefore be of significant interest for the optimal diagnosis in sudden deaths.

073

ASSESSMENT OF HYPERGLYCEMIA ON VITREOUS SAMPLES

Razvan Marian Siminiuc 1 , Cosmin-Daniel Tirdea 1 , Elena Niculescu 1 , Sorin Hostiuc 1

1 "Prof. Dr. Mina Minovici" Institute of Legal Medicine, Bucharest, Romania

Oral Presentation: Forensic pathology 6, June 3, 2021, 2:00 PM - 3:30 PM

Introduction : The use of vitreous humor for estimating the post-mortem interval and for post-mortem diagnosis of metabolic disorders is well established in forensic practice. Due to the better postmortem preservation of glucose in the vitreous humor compared to blood, it is the preferred choice for the post-mortem diagnosis of diabetes mellitus and ketoacidosis. The aim of the current study is to assess the values of glucose, lactate and ketones in the vitreous humor, in relation with an ante-mortem diagnosis of diabetes mellitus, the manner of death and the post-mortem interval.

Material and methods : We conducted a retrospective study on 396 autopsy cases, 124 females and 272 males, with a mean age of 53.3 years (SD ±18.7) from the National Institute of Legal Medicine “Prof. Dr. Mina Minovici” Bucharest, between 2011-2020. The samples of vitreous humor were analysed by the Thanatochemistry Laboratory, using a Semiautomated Analyser Rx Monza with a colorimetric enzymatic assay method. The glucose, lactate and ketones levels were measured. The data regarding the ante-mortem diagnosis of diabetes mellitus, the manner of death and the estimation of the post-mortem interval was obtained from the case’s archive. Statistical analysis was performed using Jamovi 1.6.14.

Results : The mean glucose level was 84 mg% (SD ±143; 0.360-1161 mg%) for the entire study, with a mean of 81.2 mg% (SD ±135; 1.36-924 mg%) in the female group and 85.3 mg% (SD ±147; 0.360-1161 mg%) in the male group, p=0.793. Lactate levels had a mean of 202 mg% (SD ±127; 13.3-1119 mg%), 220mg% (SD ±136; 39.1-989 mg%)-female group and 193 mg% (SD ±122; 13.3-1119 mg%)-male group, p=0.047. Ketones levels were analysed in 90 samples, 88.9% (n=80) were negative, 11,1% (n=10) were positive with a mean of 32 mg% (SD ±31.6; 5-92 mg%).

Discussion : Glucose levels in the vitreous may be used for the postmortem evaluation of an antemortem hyperglycemia. Extremely high values and/or the presence of ketone levels may be indicative for diabetic ketoacidosis

074

ANATOMICAL VARIATION OF THE LARYNGO-HYOID REGION AND IMPLICATIONS IN THE INTERPRETATION OF NECK TRAUMA – A PROSPECTIVE STUDY OF 72 CONSECUTIVE CASES

Peter Vanezis 1 , Humaira Pathan 1

1 Queen Mary University of London, United Kingdom

Oral Presentation: Forensic pathology 6, June 3, 2021, 2:00 PM - 3:30 PM

Objective : The larynx and hyoid bone (laryngo-hyoid complex) is the central focus of pathologists when determining whether neck trauma from compression or other forms of blunt impact trauma has occurred. Anatomical variations in this region can lead to wrongly concluding the cause and manner of death in some individuals. This paper aims to identify the prevalence of anatomical variants present within an adult population.

Method : In this prospective study, 72 cadavers (47 males and 25 females), all non-trauma cases, were examined during autopsy examination, to assess the presence of certain features within the laryngo-hyoid complex, including: fusion of the greater horns with the body of the hyoid bone; the presence of unilateral, bilateral or absent triticeous cartilages; absence of one or both superior cornua (horns) of the thyroid cartilage. In addition, age and sex were examined as a variable for these anatomical features. Any rare or unusual findings were also noted.

Results : 87% (61/72) of the sample had fusion of the hyoid bone. With regard to the triticeous cartilages, 51% (37/72) of cases showed bilateral absence; 22% (16/72) were present on one side only; 27% (19/72) were present on both sides. Bilateral superior thyroid cornua were found in 96% (69/72) of the thyroid cartilage and only 3 cadavers (4%) displayed other abnormal thyroid cartilage anatomy. There was no evidence of association of age or sex with the three anatomical structures.

Conclusion : A significant proportion of individuals showed fusion of the hyoid bone, absence of the triticeous cartilages and bilateral presence of the superior cornua of the thyroid cartilage. Awareness of the prevalence of variations in the anatomy of the laryngo-hyoid complex will aid pathologists in assessing trauma to this region and avoiding any pitfalls.

075

ΒAPP IMMUNOHISTOCHEMISTRY IN BRAIN TRAUMA: SHOULD IT BE OR NOT BE PERFORMED?

Michela Colombari 1 , Stefania Turrina 1 , Domenico De Leo 1

1 Department Of Diagnostics And Public Health, Section Of Forensic Medicine, University Of Verona, Italy

Oral Presentation: Forensic pathology 6, June 3, 2021, 2:00 PM - 3:30 PM

Objectives : Beta-amyloid precursor protein (βAPP) is mainly known as the precursor of the fibrillogenic Aβ peptide which forms the amyloid deposits in the Alzheimer’s disease. βAPP has also been demonstrated to be the most reliable marker of axonal damage in the Neuropathological diagnostic practice. Nevertheless, βAPP immunohistochemistry is not widely adopt in the Forensic setting.

Material and methods : We carried on a literature review of the scientific works published until January 2020 on PubMed. Keywords of the research were “βAPP” and “axonal injury”, “βAPP” and “head trauma”, “βAPP” and “traumatic brain injury”. Then we focused on the positive and negative aspects concerning the βAPP immunohistochemistry in forensic settings.

Results : The nowadays scientific literature, comprehensive of approximately 40 articles, refers to the βAPP immunohistochemistry as the most reliable indicator for axonal injury. Because βAPP accumulates at the level of the break points of damaged axons, it has been described as a highly specific marker for axonal injury. However, the specificity of βAPP immunohistochemistry for axonal injury has never been precisely estimated as well as its sensitivity. Interestingly, the last has been proved by several studied to increase along with the survival time after the head injury: in cases of survival time after trauma shorter than 30 minutes βAPP sensitivity is null, while it starts to turn positive after 35-60 minutes, increasingly stains over the first 3-4 days and then lasts for approximately 30 days. Furthermore, the precise estimation of βAPP sensibility and specificity appears to be related to the variability of the laboratory immunohistochemistry methodology adopted according with the different types of βAPP antibodies used or the variable number of analyzed brain areas. Indeed, very few scientific works performed a proper brain tissue sampling (fully comprehensive of the different brain areas) and the methodology appears difficult to be properly reproduced. Since its introduction in 1990s, βAPP has usually been detected in non-traumatic cases such as ischemic brain damage, showing low specificity for trauma. Nevertheless, some studies revealed the morphological pattern of βAPP distribution is a reliable indicator to differentiate traumatic from non-traumatic damage in up to 80% of the cases.

Discussion : There is evidence that βAPP immunohistochemistry on brain tissue can be useful to answer some of the most common questions that forensic pathologists are usually asked, such as the survival time after the head trauma. Standardized protocols are needed to make the methodology easily reproducible in the different forensic laboratories.

076

STUDY CASE OF FATAL JUVENILE DELINQUENCY IN A SCHOOL

Yudha Nurhantari 1 , Adji Suwandono 1 , Mardhatillah Marsa 1 , Indra Faisal 1 , Dewanto Yusuf Priyambodo 1 , Novianto Adi Nugroho 1 , Ida Bagus Gede Surya Putra Pidada 1 , Lipur Riyantiningtyas Budi Setyowati 1

1 Universitas Gadjah Mada, Yogyakarta, Indonesia

Oral Presentation: Forensic pathology 6, June 3, 2021, 2:00 PM - 3:30 PM

Background : In Indonesia, Yogyakarta is known as a student city, where many students from around the country stay for their study. Recently, juvenile delinquency in Yogyakarta has increased. There was a violence during school extracurricular activity resulted several injured and the death of three students. This paper aimed to report fatal cases of juvenile delinquency victims, during the basic training course of a student hiking association in a private school.

Material and methods : This study was done using the data taken from the autopsy report in Forensic Medicine Installation of Dr. Sardjito Hospital, Yogyakarta.

Results : Three dead victims were sent to our institution for forensic examination. The first victim was never examined, since the family wanted the body immediately sent back home. The second victim died due to cranial blunt injury, and the third victim’s death caused by abdominal blunt injury, however, both victims had multiple blunt injuries on their body. Alcohol and drugs were negatives.

Conclusion : The victims died due to severe blunt trauma to the head (the first victim) and abdominal (second victim), and the manner of death was estimated to be homicide. It needs attention from the school teacher to prevent any violence in the school.

Keywords : juvenile delinquency; blunt trauma; head; abdominal

077

DRIFT BODIES DISCOVERED ON OR CLOSE TO THE COASTLINE OF SHIMANE PREFECTURE: A 10-YEAR AUTOPSY STUDY

Kaori Kimura-Kataoka 1 , Junko Fujihara 1 , Akari Kusaka 1 , Takamitsu Sasaki 1 , Sultana Jannatul Ferdoush Jerin 1 , Rahman Mamunur 1 , Gong Ao 1 , Haruo Takeshita 1

1 Department of Legal Medicine, Shimane University School of Medicine, Izumo, Japan

Oral Presentation: Forensic pathology 6, June 3, 2021, 2:00 PM - 3:30 PM

Background : Japan is surrounded by the Sea of Okhotsk on the north, the East China Sea on the south, the Pacific Ocean on the east, and the Sea of Japan on the west. Shimane Prefecture is located on the Sea of Japan side near the western end of the Honshu Island, and consists of the mainland and Oki Islands. Shimane Prefecture contains a coastline of about 1027 km (562 km on the mainland and 465 km on Oki Islands). Because of this long coastline, we often experience drift bodies recovered on or near the coastline. In this study, we have evaluated autopsy cases of these drift bodies recovered on or near the coastline of Shimane Prefecture in the 10-year period.

Material and Methods : Necessary data of bodies recovered on or near the coastline of Shimane Prefecture was extracted from our autopsy data in the Department of Legal Medicine, from January 2010 to December 2020. Any cases discovered inside the vehicle near the coastline were excluded. We analyzed sex, age (approximate age), locations of the bodies discovered, nationality, time after death, and cause of death.

Results : Among 1134 autopsies performed in the above 10-year period, 57 cases were drift bodies recovered on or near the coastline (50 and 7 discovered from the mainland and Oki Islands’ coastline, respectively). There were 41 males and 16 females, with approximate ages from teens to 80’s. Identifications were confirmed in 10 individuals (29 Japanese and 4 Koreans) from dentistry and/or DNA typing. In particular, DNA typing was beneficial in the identifications of Korean individuals. Possible nationalities were speculated from the personal belongings in 13 individuals (1 Japanese, 9 Koreans, 4 North Koreans and 2 Chinese) while 1 individual was suspected of East Asian origin. Unfortunately, 7 individuals remain as unidentified, even the nationalities were undetermined. The range of time after death was 1.5 days to 2 years whereas the cause of death was either drowning or unidentifiable because of severe decomposition.

Discussion and Conclusion : Because Japan is surrounded by sea, in addition to the geographic locations of the neighboring countries and the oceanic current, we often encounter drifted bodies on the coastline of Shimane Prefecture. Identifications have been confirmed by dentistry and /or DNA typing with information provided by the dentist’s office or from relatives in Japanese individuals while DNA typing has been useful in Korean individuals with the cooperation of Korean Consulate General. In the regions where drift bodies from foreign countries are likely to be discovered, it is important to exchange information about missing persons between Prefectural Police but one must never forget to inform the necessary foreign authorities when there is a possibility of individuals from foreign countries.

078

PRELIMINARY TAPHONOMIC STUDY ON DROWNED VICTIMS IN A NON-SEQUESTERED AQUATIC ENVIRONMENT IN THE MEDITERRANEAN SEA

Lorenzo Franceschetti 1,2 , Andrea Palamenghi 2,3 , Debora Mazzarelli 2 , Daniele Maria Gibelli 4 , Andrea Verzeletti 1 , Cristina Cattaneo 2

1 Forensic Medicine Unit, Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Italy

2 LABANOF (Laboratorio di Antropologia e Odontologia Forense), Institute of Legal Medicine, Department of Biomedical Sciences for Health, University of Milan, Italy

3 Cecilia Gilardi ONLUS Foundation, Turin, Italy

4 LAFAS (Laboratorio di Anatomia Funzionale dell’Apparato Stomatognatico), Department of Biomedical Sciences for Health, University of Milan, Italy

Oral Presentation: Forensic pathology 6, June 3, 2021, 2:00 PM - 3:30 PM

Introduction : Drowning deaths have recently drawn the public attention because of the several mass disasters that repeatedly occurred in the last 10 years, causing the death of thousands of migrants crossing the Mediterranean Sea. Human decomposition in water environments poses several challenges to forensic pathologists and anthropologists tasked with the identification of submerged bodies. Postmortem modifications in water are similar to those of terrestrial decomposition: several factors interplay in the postmortem changes, e.g., depth of submersion, animal activity, currents and clothing. The fate of bodies found in water has not been extensively investigated, especially as for taphonomic changes in the marine environment. Few cases reported the postmortem changes in sea water but are often based on bodies retrieved from shallow waters or on limited samples. The present study aims at investigating postmortem changes on drowned victims in a non-sequestered marine environment in the Mediterranean Sea.

Material and method : On 18th April 2015, a fishboat carrying approximately 1000 migrants capsized off the Libyan coast and sank in the Mediterranean Sea 400 m deep. Seven missions were carried out to recover the bodies from the surroundings and from the chambers of the wreck within an eighteen-month time span. A retrospective study was performed on the data collected during the autopsy on the bodies of the victims. In particular, postmortem changes in the series of non-sequestered bodies which have been retrieved from the open sea were described. Of 217 bodies, 171 met the inclusion criteria, i.e., available detailed pictures showing all body parts in anterior, posterior and lateral views and decomposition changes were studied. The total aquatic decomposition score (TADS) was assessed separately by two observers on the autopsy photographic records, using the Decomposition Scoring System by De Donno et al. (2014) (modified from Heaton et al., 2009) and an inter-observer agreement was calculated by Krippendorff’s alpha coefficient.

Results : The results showed a strong agreement between the observers (□=0.90). The degree of decay within the study sample varied from a moderate appearance to extensive decomposition with disarticulation and dispersion of several body parts. Moreover, according to the sequence of the recovery missions, increasing TADS were observed.

Discussion : Our findings confirm that prolonged submersion leads to increasing decomposition rates and, eventually, to full disarticulation of the remains. This research represents a descriptive unicum which follows the decomposition progression of a large sample in a non-sequestered marine environment of the Mediterranean Sea. In addition, a deeper knowledge on taphonomic events that occur in a specific marine environment could provide useful elements for the postmortem interval estimation and subsequent identification. Nevertheless, some critical issues emerged and new elements that may help forensic practitioners evaluating the decay status of submerged bodies were discussed and suggested.

079

PEDIATRIC CASE OF A BUTTON BATTERY INGESTION: ABOUT ONE FATAL CASE

Fabrice Dedouit 1 , Céline Guilbeau Frugier 1 , Fatima Zohra Mokrane 2,3 , Frédéric Savall 1,3 , Hervé Rousseau 2 , Norbert Telmon 1,3

1 Department of Forensic Medicine, CHU Toulouse, France

2 Department of Radiology, CHU Toulouse, France

3 Center for Anthropobiology and Genomics of Toulouse (CAGT, UMR 5288), France

Oral Presentation: Forensic imaging 2, June 3, 2021, 4:00 PM - 5:45 PM

Introduction : An 8-year-old boy, died at home in a context of massive hematemesis. His parents explained he complained for abdominal pains since one month. Ten days before death, a general practitioner diagnosed of gastro-intestinal infection and gave antispasmodic-antalgic drugs. The day before the death, he always complained for epigastric pain. The attempt of resuscitation by the emergency medical service was unsuccessful. An external examination of the body, performed by a forensic pathologist, confirmed that the blood came from the oral cavity, but origin of the bleeding was undetermined. No obvious traumatic lesions was visible on the body. The general attorney asked for a medico-legal autopsy.

Material and methods : A Post Mortem Computed Tomography (PMCT) was performed, but not checked, and followed by the autopsy. Complementary samples for histology and toxicology were performed. Radiological interpretation of the PMCT was secondary conducted.

Results : The autopsy revealed a complete large erosion of the wall of the thoracic oesophagus, in continuity with the aorta, creating an aorto-oesophageal fistula. Trachea, bronchi, and stomach contained blood with clots. The histology confirmed the fistula, without any other pathology of the oesophagus. The PMCT revealed a rounded foreign body in the distal ileum, hyperdense, with metallic artefacts, measuring 20*6 mm, consistent with a button battery. Death was attributed to a massive external haemorrhage due to an aorto-oesophageal fistula, induced by ingestion of a battery.

Discussion/Conclusion : The authors will discuss this unusual case, which illustrates the necessity to have a multidisciplinary forensic approach, and include relevant literature.

080

3D PRINTED SPLINT DESIGNED BY 3D SURFACE SCANNER FOR PATIENTS WITH HAND ALLODYNIA: A FORTUITOUS COLLABORATION BETWEEN CLINIC AND FORENSICS

Lorenzo Campana 1 , Sami Schranz 1 , Martine Giroud 2 , Stephane Hertig 3 , Coraline Egger 1

1 University Center of Legal Medicine Lausanne-Geneva (CURML), University of Lausanne and University of Geneva, Switzerland

2 Clinical Neuroscience Department, Geneva University Hospitals, Switzerland

3 Surgery Department, Geneva University Hospitals, Switzerland

Oral Presentation: Forensic imaging 2, June 3, 2021, 4:00 PM - 5:45 PM

Introduction : Allodynia is a pain of neuropathic origin, triggered by a stimulus that is normally painless. For example, a slight touch of the skin or a slight sensation of hot or cold is extremely painful. Rehabilitation of allodynia is long and uncertain. Protecting the pain area from stimuli is a priority of care. The pain caused when manufacturing a classic molded orthosis is unbearable for the patient. The orthosis has a life time, and experience shows that it is not possible to reproduce an identical splint.

Material and Methods : The present work consisted in the creation of protective splints by 3D print. The size, shape and texture of the limb were first digitalised painless and contactless by our forensic 3D surface scanner team (a fortuitous collaboration). The data was then used to digitally design the splint, in a specific 3D printer format.

Discussion : The pros and cons of 3D orthosis versus standard molded orthosis from the point of view of the patient and the practitioner and time/cost comparison are discussed. We conclude with the evaluation of a larger scale application and related indications of this technology.

081

SUITABILITY OF FORAMEN MAGNUM MEASUREMENTS IN SEX DETERMINATION IN FORENSIC CONTEXT: A PRELIMINARY STUDY IN BENIN POPULATION

Cedric Bigot 1,2 , Sonia Adjadohoun 2 , Kofi-Mensa Savi de Tove 3 , Jean Louis Savi de Tove 1 , Boris Adjovi 2 , Olivier Biaou 2 , Vicentia Boco 2

1 Unit of Legal Medicine – FSS, University of Abomey-Calavi, Cotonou, Benin

2 Unit of Forensic Imaging – FSS, University of Abomey-Calavi, Cotonou, Benin

3 Unit of Forensic Imaging, UPAR, Parakou, Benin

Oral Presentation: Forensic imaging 2, June 3, 2021, 4:00 PM - 5:45 PM

Introduction : Previous studies concluded that studying the foramen magnum (FM) measurements could enable sex determination with good reliability for forensic identification issue. The reliability of identification methods based on foramen magnum measurements is related to natives populations. In Benin, access to the dry skull is challenging because of the population's particular relation to death. This study's objective was to collect data of various morphometric dimensions of FM by using computed tomography (CT) images and assess the value of this measurements' in the estimation of the sex with a view to exploitation in forensic identification.

Material and Methods : We conduct a descriptive and analytical preliminary study with a sample of 200 (114 men and 84 women) cranial CT scans. The CT scans were collected in Hospital CNHU-HKM from Benin subject who had cranial bones CT for several medical reasons. This sample does not include subjects with congenital or acquired diseases or injury, causing probable cranial deformities. Antero-posterior and transverse diameters of the foramen magnum were measured. Radinsky's and Teixeria's formulae were used to calculate the area of the foramen magnum. The distribution of measurements was compared by sex. The collected data were subjected to binary logistic regression analysis.

Results : The age range of the sample was 18 to 90 years (mean (SD)=51.4 (16.6 years)). The values of the men's FM measurements are significantly higher than those of the women. Equations for predicting sex from diameters and areas were obtained by logical regression. The male correct prediction rate is higher than 75% for each of the four models. Binary logistic regression performed from anteroposterior diameter or areas correctly predicted gender in 64% to 66% of cases. Regression-based on the transverse diameter provides a useful sex classification in 56.8% of cases.

Discussion : FM measurements observed in our sample are very close to those of other studies carried out in black Africa. In our study, the binary logistic regressions used to predict sex from each of the foramen magnum's diameters or area confirms the thesis of sexual dimorphism. Whatever the model, the performance obtained with the foramen magnum remains inferior to that obtained with a complete skull. Measurements of the foramen magnum can be used to identify sex in a forensic context in Benin. However, its use should preferably be done as a confirmatory test or in situations where the occipital bone is the only structure of the skull that is complete.

082

STAB WOUND RECONSTITUTION USING DIFFERENT RADIOLOGICAL TECHNIQUES: A CASE REPORT

Virginie Magnin 1 , Diego Aguiar 1 , Silke Grabherr 1 , Coraline Egger 1

1 University Center of Legal Medicine Lausanne-Geneva (CURML), University of Lausanne and University of Geneva, Switzerland

Oral Presentation: Forensic imaging 2, June 3, 2021, 4:00 PM - 5:45 PM

Case description : A 22-year-old man was stabbed in the back and immediately fell down after a sensation of paralysis. A knife of 20 cm was found at the crime scene. After being transferred to the hospital, a forensic clinical examination revealed a cutaneous wound of 1.8 cm long in the back at the level of the first lumbar vertebra (L1). A few days later, the patient presented with signs of cauda equine syndrome. A non-enhanced multi-detector computed tomography (MDCT) of the spine was performed and revealed a hypodense horizontal trajectory within the subcutaneous adipose tissue and paravertebral musculature between the wound and the vertebral canal as well as a horizontal fracture of the posterior part of L1. A following myelography (myelo-CT) indicated an extravasation of contrast agent from the vertebral canal through a posterior dural tear. A magnetic resonance imaging (MRI) of the spine was then performed and highlighted a horizontal hyposignal on T2 sequence within the posterior body of L1 with a sharp end. It also showed a horizontal hypersignal on T2 sequence with a restriction of diffusion of the spinal cord at the same level. Reconstruction of the trajectory was performed with different measurements. Radiologically, a wound depth of 6.6 cm was measured on the MRI between the cutaneous surface and the end of the vertebral fracture. After comparing this measure to the knife, discovered at the crime scene, the width of the blade was of 1.6 cm at this level. This measurement fitted the length of the cutaneous wound of the back of 1.8 cm. We concluded that a stab wound was inflicted in the back of the victim, which resulted in a partial section of spinal cord, and that the knife found at the crime scene could be at the origin of that wound.

Discussion : This case shows the usefulness of medico-legal reinterpretation of clinical radiological images in cases of sharp trauma. It is particularly interesting because the different imaging modalities were perfectly able to reproduce the trajectory. Thanks to the specific anatomical region of the stab wound it was even possible to correlate the length of the trajectory to the suspected crime weapon, which is not always the case. These investigations were particularly useful for the police investigation.

083

CHANGES IN TISSUES AND ORGANS THROUGH PMCTA CARRIER SUBSTANCES

Gina Maria Bruch 1 , Pia Genet 2 , Florian Tobias Fischer 3 , Tony Fracasso 2 , Silke Grabherr 2

1 University of Geneva, Switzerland

2 University Center of Legal Medicine Lausanne-Geneva (CURML), University of Lausanne and University of Geneva, Switzerland

3 Institute of Legal Medicine, Munich, Germany

Oral Presentation: Forensic imaging 2, June 3, 2021, 4:00 PM - 5:45 PM

Introduction : Contrast media (cm) in combination with carrier substances (cs) are used in forensic medicine to perform postmortem (pm) angiographies by computed tomography (PMCTA). Studies have already shown the advantages and disadvantages of lipophilic contrast agents mixed with paraffin oil. Iodine-based hydrophilic contrast agents in combination with a water-soluble carrier substance, e.g. polyethylene glycol (PEG), are also used in PMCTA, but their effects on the body and further exams have been described in less detail until now. The aim of this work is to describe macroscopic and microscopic organ and tissue changes due to the above mentioned carrier substances by an in vitro experiment.

Material and Methods : To demonstrate and compare changes in the corpse caused by the cm carrier substances PEG 200 and Paraffinum subliquidum, all samples were collected during one autopsy (without angiography) according our standard procedure and stored in the two liquids at room temperature. Samples of liquid femoral vein blood, cardiac muscle, lung, liver, fat tissue, inferior vena cava, abdominal and coronary arteries were gathered. The samples were documented photographically during autopsy and 24h as well as 72h after preservation. Histological slices were obtained from the autopsy samples and after storage in the liquids for 72h.

Results : Samples preserved in PEG 200 showed solidification (for the blood) or hardening of almost all structures. Most noticeable was a hardening of the vessel’s walls. All PEG 200 associated specimens appeared as if they were fixed after 24h and 72h. In addition, friable blood agglomerates had formed in the previously liquid blood. In the microscopic examination of the PEG samples, all tissue sections were structurally very well preserved. The evaluation of the structure of each organ and tissue was easily possible. The quality of the immunohistochemical investigations after storing in PEG was excellent. In contrast, the samples placed in paraffin oil had a soft, tissue-like consistency. However, these samples showed the first signs of decay in the form of a green discoloration after only 24h and an advanced decomposition after 72h. At histology, all organs showed gas bubbles as a sign of decay in the hematoxylin-eosin stain. Histological investigation was clearly limited due to decomposition.

Discussion : This study allowed us to analyze in detail the different impact of cs on several tissues and organs: Paraffinum subliquidum preserved organs and tissue in their original condition. However, in the course of time, decomposition of the samples has been observed. Polyethyleneglycol, on the other hand, seemed to dehydrate and fix the tissues and organs without affecting the microscopic assessability. In addition, blood agglomerates developed after immersion in PEG which may not be readily classified in an autopsy (vital thrombus vs. postmortem clot) and could affect the autopsy result in certain cases.

084

MULTIMODAL IMAGING PLATFORM FOR FORENSIC RESEARCH, APPLICATION, AND EDUCATION

Ion Tiseanu 1 , George Cristian Curca 2 , Ioana Porosnicu 1 , Daniel Avram 1 , Mihail Lungu 1 , Carmen Tiseanu 1

1 National Institute for Lasers, Plasma And Radiation Physics, Magurele, Romania

2 University of Medicine and Pharmacy Carol Davila, Bucharest, Romania

Oral Presentation: Forensic imaging 2, June 3, 2021, 4:00 PM - 5:45 PM

Introduction : Our multimodal imaging system, Tomo-Analytic, is currently systematically upgraded and extended up to the capabilities of a platform for various applications, such as bioimaging and forensic research as well as education. Such a system can represent an accessible and complementary alternative to the synchrotron tomography/XRF methods. The potential for specialist training in forensic radiology is outlined.

Methods and devices : Center for Advanced X-ray Imaging (http://tomography.inflpr.ro) of the National Institute for Lasers, Plasma and Radiation Physics (INFLPR) (http://www.inflpr.ro) has a unique infrastructure of several in-house built instruments: a fully 3D microtomograph (microCT) component is configured to take several hundred highly resolved radiographic views of the object in order to build a 3-D model of its internal structure. It includes a microfocus X-ray source and high-resolution CMOS flat-panel detectors. The investigated sample is placed on a four-axis motorized manipulator, to ensure a high degree of freedom in sample positioning. The microbeam X-ray fluorescence (microXRF) – the key element of this component consists of a policapillary lens which provides a focal spot size of 20-30 μm and a significant increase of the X-ray intensity reaching the sample (up to 3.5 orders of magnitudes). 2D composition mapping with spatial resolution down to 25 μm is determined by the accurate XY scanning of the sample. Co-registration of the morphology images provided by microCT and 2D composition maps is simplified by a common manipulator. The X-ray (XEOL)/Optical Excited Optical Luminescence components – were recently added aiming at bioimaging applications. The excitation sources include X-ray generators, UV excitation lamps and various lasers operating in the near-infrared spectral region.

Results : Results include combined microCT and microXRF on burnt bone fragments to ascertain the degree of alteration and the incineration environment or gunshot digital radiography and XRF to assess the distribution and elemental composition of existing metal particles. The wall thickness of the cells is directly correlated with the degree of bone alteration by fire. Finally, we present preliminary data on lanthanide-based luminescent nanomaterials used as effective luminescent labels in developing the latent fingerprints on various substrates. The targeted parameters for the forensic applications are high sensitivity, high contrast, low background, and autofluorescence interference.

085

INVERSION TIME OPTIMIZATION FOR POSTMORTEM FLAIR MRI: A PILOT STUDY

Christine Bruguier 1,2 , Virginie Magnin 2 , Jean-François Knebel 1 , Pia Genet 2 , Vincent Dunet 1

1 Service of Diagnostic and Interventional Radiology, Lausanne University Hospital, Switzerland

2 University Center of Legal Medicine Lausanne-Geneva (CURML), University of Lausanne and University of Geneva, Switzerland

Oral Presentation: Forensic imaging 2, June 3, 2021, 4:00 PM - 5:45 PM

Introduction : Since January 2016 we are evaluating in our institute forensic cases by Magnetic Resonance Imaging (MRI). Our protocols have been created based on sequences most used in clinical practice. The images obtained are of good quality except for the FLAIR (Fluid Attenuated Inversion Recovery) sequence for which we obtain a wide range of contrast, different from that encountered in living patients. We noted by changing the inversion time of the sequence that we could again obtain a living patient-like contrast. By means of this pilot study we aimed at evaluating the impact of two variables (i.e. temperature and the delay between the time of death and the postmortem MRI), that we think to have an influence on the optimal inversion time (TI) value, which allows obtaining the living patient-like image contrast.

Material and Methods : Before the acquisition of a FLAIR sequence, a quick FLAIR sequence was added by varying the TI from 1660 ms to 900 ms each 110 ms, in order to find the corresponding contrast. For 24 postmortem cases, two radiologists independently evaluated the images and were asked to choose which TI corresponded to the image of a standard patient-like FLAIR contrast. Rectal temperature and delay between the time of death and MRI were recorded. Pearson ‘s correlation tests (rho) between the mean TI value, temperature and delay were performed, as well as the evaluation of the interobserver reliability with the Prevalence-Adjusted and Bias-Adjusted Kappa (PABAK).

Results : Temperature ranged from 5.7° to 29.0° while the delay between the death and the MRI ranged from 13.05 hours to 768 hours. Optimal TI value ranged from 1330 ms to 1100 ms, with moderate interobserver reliability (PABAK=0.56, 95%CI [0.28-0.84]). Optimal TI value was significantly correlated with the temperature (Pearson’s rho=0.70; p=0.0014) and the delay from death (Pearson’s rho=-0.67; p=0.00027). Rectal temperature and the delay from death were collinear (Pearson’s rho=-0.79; p<0.00001).

Discussion : Postmortem brain FLAIR imaging contrast is significantly related to body temperature and the postmortem delay. TI value should be adapted to obtain living patient-like image contrast. A larger study cohort is needed to confirm these preliminary results and to evaluate whether a mathematical formula could be used, thus avoiding additional acquisitions, and allowing us to correct the TI.

086

FORENSIC ANTHROPOLOGY ON THE IDENTIFICATION OF DENTAL MEDICAL DEVICES – CASES FROM THE COLECÇÃO DE ESQUELETOS IDENTIFICADOS SÉCULO XXI

Catarina Coelho 1 , Inês Oliveira Santos 1 , Eugénia Cunha 1 , Isabel Poiares Baptista 1 , Maria Teresa Ferreira 1

1 Universidade de Coimbra, Portugal

Oral Presentation: Forensic anthropology 3, June 4, 2021, 9:00 AM - 10:30 AM

Tooth loss is a common and global occurrence, and oral rehabilitation is common consequence. The presence of dental prostheses fixed and removable, which are of common use by the European population, are an example of this. If it has unique characteristics, this type of dental devices may be useful for identification. In forensic analysis, a positive identification is achieved through the reconciliation of antemortem and postmortem data. Thus, the presence of individualizing characteristics or devices on skeletonized human remains, as for example dental prostheses, may allow an identification without more time-consuming and expensive methods. However, the lack of brands or serial numbers in these devices, as well lack of systematic register on databases may difficult its use for human identification. The aim of this work is to present and describe the cases of an identified skeletal collection, the Colecção de Esqueletos Identificados Século XXI (Laboratory of Forensic Anthropology, University of Coimbra) with dental medical devices and illustrate its relevance for the identification process in Forensic Anthropology. The individuals in the collection were macroscopically observed and all cases presenting dental prostheses registered. Thirty individuals (20 females and 10 males), aged between 38 and 91 years, had removable and fixes prosthesis, in acrylic or other materials. In total, 48 dental devices were found. The most common were removable acrylic prostheses (n=42), and also there were also present non acrylic, fixed and removable (n=6). No identifying marks or production labels were found in the prosthesis. This work demonstrates the importance of an accurate report of medical devices on skeletal remains, and of correctly labelling and marking these devices. Also, it is shown the research potential of a recent collection of identified skeletons in forensic research stressing the importance of a multidisciplinary approach.

087

CHALLENGES FROM THE WW2 ABYSS: THE EXCAVATION OF MORE THAN 800 HIGHLY COMMINGLED SKELETONIZED HUMAN REMAINS FROM THE KARST PIT JAZOVKA, CROATIA

Ana Mikulka 1,2 , Ivona Paltrinieri 1 , Amir Obhođaš 3

1 Ministry for Croatian Veterans, Department for Detainees and Missing Persons, Zagreb, Croatia

2 Faculty of Humanities and Social Sciences, University of Zagreb, Croatia

3 Croatian State Archives, Zagreb, Croatia

Oral Presentation: Forensic anthropology 3, June 4, 2021, 9:00 AM - 10:30 AM

In July 2020, Ministry for Croatian Veterans and its Department for Detained and Missing Persons, organized and carried out challenging task of exhuming more than 800 victims from a 40 meters’ deep karst pit Jazovka in 5 days’ time. Victims were executed and thrown down the shaft in two rounds of executions; first in 1943, and second time in 1945. Majority of victims were patients from the hospital, who were transported 70 km into the wooded mountains at the end of the WW2 when partisan forces liberated capital city of Zagreb. Ministry has a legal mandate to gather all the facts and circumstances surrounding the potential mass grave, following the organization and management of the exhumations from the WW2 and post-war period. All activities are lead with the intent that every person has a right to the dignified resting place. In this note, we would like to present technical challenges of this massive endeavour that took 75 years to be resolved. Jazovka pit is one of the most notorious examples of the extrajudicial crimes committed in this part of the region. It also takes prominent role in public narrative, emphasised by 50 years of mandatory silence by the former state. Croatian society needs to resolve the past crimes and surrounding events in order to heal. Principles of humanitarian approach are embedded in the working framework of the Croatian Model of Searching for Missing Persons, especially part that is oriented towards the surviving families and relatives. After the discovery of the large number of mortal remains in 1989, it took another 10 years for the officials to examine the find. In 1999, examination took place, but exhumation did not. Minimal number of individuals at the time was estimated to be 447. It took another 11 years for the proper exhumation to take place. Despite its narrow entrance of 1 meter in diameter, bell-shaped pit can be reached with relative ease, so it is not surprising that curious visitors disturbed the burial pit over the years. Challenges in the filed were many, but with the implementation of the Model and its experienced and well-trained work force with technical capacities that follow; we successfully excavated more than 800 highly commingled skeletonized human remains and transported them to the examination facility. Other challenges await; Croatia was hit with strong earthquakes that rendered some of our facilities useless so the next step within the Model, planned anthropological examination, is scheduled after new facilities are operational, hopefully soon and in the post-pandemic time.

088

The human in humanitarian forensic action: from tragic deaths to the return to the families

Luísa Marinho 1

1 Simon Fraser University, Department of Archaeology & Centre for Forensic Research, Portugal

Oral Presentation: Forensic anthropology 3, June 4, 2021, 9:00 AM - 10:30 AM

Forensic anthropology has a primary role in the assistance to humanitarian crisis where identification of human remains is required. Not only that but forensic anthropologists, in collaboration with an array of other experts, can contribute to the clarification of when, how and what happened to a missing person who turned an unidentified dead person. Ultimately, every missing and/or dead person has someone who misses them and this is - or should be - the starting and ending point of the forensic humanitarian assistance, as it is not possible to talk about humanitarianism without the focus being on the people. This is especially true for the discipline of forensic anthropology, assuming that before the forensic expert comes an anthropologist with an interest for all aspects of humans in past and present societies. As such, our work is about, for and with the people. The emphasis might often be “about” the missing to be found or the dead to be identified. However, this cannot be claimed as humanitarian action if we do not bear in mind at all instances that it is being done “for and with the people”, in this case the families, friends and anyone suffering for the lost loved one. Too often, not only have people lived the trauma of having a loved one die, but they might also suffer in the obliviousness of the whereabouts of their dead loved one. This is the reality in many corners of the world, where entire or fringes of society have endured through conflicts, natural disasters, or migration. One such contexts is lived in Spain where people have been for over 80 years searching for the victims of enforced disappearance during the civil war and pot-war periods. It is estimated that nearly 200,000 men and women were executed or murdered extra-judicially during those years, and Spain remains today the second country in the world in number of enforced disappearances whose remains in mass graves have not been recovered or identified. Spain offers a prime example of why the families have to be at the centre of a very much needed humanitarian response. As forensic anthropologists, after accomplishing the important steps of searching, recovering and identifying, it is the returning of the deceased that gives meaning and purpose to all previous steps. A number of lessons can thus be drawn when forensic experts work up-close with the civil society. These include lessons of multi and transdiciplinarity, collaborative work, the need for the discussion to happen in the social space, lessons of empathy and dignity, among others. Serious reflection on these lessons should bring out the human in humanitarian forensic action wherever and whenever claimed necessary.

089

MACROSCOPIC OBSERVATION VERSUS 3D SURFACE SCANS AND CT SCANS IN VIRTUAL ANTHROPOLOGY: TESTING THE LIMITS

Claudine Abegg 1 , Ilaria Balbo 2 , Alejandro Dominguez 1,3 , Silke Grabherr 1 , Lorenzo Campana 1 , Negahnaz Moghaddam 1

1 University Center of Legal Medicine Lausanne-Geneva (CURML), University of Lausanne and University of Geneva, Switzerland

2 Università di Bologna, Italy

3 School of Health Sciences (HESAV), University of Applied Sciences and Arts Western Switzerland (HES-SO), Lausanne, Switzerland

Oral Presentation: Forensic anthropology 3, June 4, 2021, 9:00 AM - 10:30 AM

Introduction : Virtual Anthropology rests upon the assumption that virtual bone models created through techniques such as 3D surface scanning or CT scanning are reliable, and that the “traditional” methods employed by anthropologists are readily applicable to 3D models. This assumption should however be tested and anthropological methodologies potentially adapted to a virtual anthropology setting. In this research, we tested the appearance of cranial sutures under macroscopic observations versus 3D surface scans and CT scans. In this research, we tested the appearance of cranial sutures under macroscopic observations versus 3D surface scans and CT scans.

Material and Methods : Ten skulls of known sex and age were analysed. All human bone specimen used were issued from cases in which they were macerated and scanned for the purpose of forensic examination at the CURML. Further examination for this research’s purpose was entirely non-invasive. 3D surface scans and CT scans were performed on all craniums. Eight cranial suture points were considered on every skull, according to the method established by Meindl and Lovejoy in 1985 to evaluate the age of an individual based on cranial suture closing. Two observers independently graded the cranial suture points macroscopically, then on the 3D surface scan models, and finally on the CT scans volume-rendering model. The process was repeated two weeks later, so that both intra and inter-observer error could be evaluated. The data was statistically evaluated.

Results : Interobserver error was high in this research, in all observation mediums considered, raising the idea that anthropological methods based on qualitative assessment of bone features will be unreliable when assessing virtual models. Furthermore, the results also suggest that macroscopic observations differed significantly from 3D surface scan observations. Observations made on 3D surface scans versus CT models also differed significantly. Observations made on reconstructions from CT scans, however, yielded results comparable to those obtained through macroscopic observations on real bones.

Discussion : This research shows that methods developed based on qualitative assessment of bone features can yield very different results when applied to digital 3D models. Here, we focused on a complex anatomical landmark (cranial sutures) which the software needed to depict correctly in order to interpret if the sutures were open or closed. These results show that as the use of digital models become commonplace in anthropology; it is crucial that each method routinely used in anthropological research is tested for its reliability when transposed to the digital environment.

090

COLD CASE: SEARCHING FOR TWO RESISTANCE MEN MISSING SINCE 1944

Jean-loup Gassend 1

1 University Center of Legal Medicine Lausanne-Geneva (CURML), University of Lausanne and University of Geneva, Switzerland

Oral Presentation: Forensic anthropology 3, June 4, 2021, 9:00 AM - 10:30 AM

On August 23rd 1944, American troops, accompanied by local members of the French Resistance, reached the outskirts of Cannes. A sharp encounter occurred with German troops near the St Cassien Bridge, in which 10 Americans and three Frenchmen were killed, mostly by artillery fire. After the battle, the ten Americans and one of the Frenchmen were recovered and identified with little difficulty. However, resistance members Francis Tonner and Henry Bergia were nowhere to be found. At the site of the encounter, the families were eventually able to recover a left hand wearing Bergia’s wedding ring and Tonner’s wallet as well as a leg wearing his shoe. Both men were considered to have been vaporized by shellfire. A search of archival documentation has however revealed that both men may in fact have been recovered and been buried as unknown bodies, one in the American Military Cemetery in Draguignan, the other in the French National Cemetery in Boulouris. Unknown “American” body X-77 from Draguignan had been found badly maimed by artillery fire on August 23rd 1944 near the St Cassien bridge. The body was wearing civilian clothes and was missing its left forearm as well as its head. It was shown to Francis Tonner’s brother, who declared at the time that the body was not that of Tonner. The French seem to then have considered the body as American, and buried it as such in the local cemetery. When the US graves registrations exhumed the body a year later, they were not able to link it to any missing American soldier, but nonetheless buried it as unknown body X-77. The circumstances of death, the missing left hand and the fact that the body was not recognized by Tonner’s brother, indicate that the body is in all likelihood that of Bergia. In order to determine what may have happened to Tonner, we studied the cases of two other resistance members killed in Cannes on August 23rd 1944. Both men had apparently been transported to Draguignan by the American army, where their deaths were registered by the local town hall. If Tonner’s body was also brought to Draguignan, he would probably not have been identified as his wallet was recovered in Cannes. The death registry of the Draguignan town hall was therefore searched for declarations of death of unknown bodies, without success. However, the Draguignan civilian cemetery registry revealed that an unknown French body had been buried in the military section on August 25th 1944. This body was later displaced to the French Military Cemetery in Boulouris. Unfortunately, no file exists with any details regarding the condition of this body. However, it could very well be that of Tonner.

092

XRAY MICRO-CT, XRAY MICRO FLUORESCENCE AND FOURIER-TRANSFORM INFRARED SPECTROSCOPY (FTIR) TO ANALYZE SEVERELY BURNT HUMAN REMAINS

George Cristian Curca 1 , Iuliana Diac 1 , Larisa Udristioiu 1 , Ion Tiseanu 2 , Ioana Porosnicu 2 , Mihai Lungu 2 , Dan Mihailescu 3 , Maria Mernea 3 , Mariana Rosu 4

1 University of Medicine and Pharmacy Carol Davila, Bucharest, Romania

2 National Institute for Lasers, Plasma and Radiation Physics, Magurele, Romania

3 Dept. of Anatomy, Animal physiology and Biophysics, University of Biology, University of Bucharest, Romania

4 National Institute of Legal Medicine Mina Minovici, Bucharest, Romania

Oral Presentation: Forensic anthropology 3, June 4, 2021, 9:00 AM - 10:30 AM

Introduction : Fire may be used to damage human body, to destroy physical evidences and jeopardise justice to prevail. Forensic anthropology is frequently call in last years to find solid answers to questions such as identification, manner, circumstances or criminal behaviour activities.

Methods : In one case with severely burnt human remains we tried to substantiate evidence with the help of a 3D platform combining micro CT and micro XRF capabilities. Micro XRF enabled to assess elemental substances on the surface and within the outer surface of the burnt bones remains. The burning temperature and the chemical nature of substances found on the burnt bones was in interest and thus we performed FTIR.

Results : A signature of chemical elements was ascertaining, being able to identify further cases using a similar setup and criminal activities. Micro CT enabled a high definition 3D view of the skeletal remains assessing organic structure, human species characteristics, non-organic particles trapped inside the bone structure or melted substances trapping gas in the gas formation of the burning processes. FTIR results added detailed data regarding the burning temperature found to be inconstant from near 300-400 Celsius degrees to over 800 celsius degrees as to a better understanding of the burning scenario. Different substances which might be used as burning accelerators were determined spectroscopically.

Conclusions : Terrorist acts and subsequent cases, criminal cases or natural disasters impose team formation with forensic anthropologists, forensic odontologists, forensic pathologists or such multidisciplinary knowledge and skills in the formation of such professionals as forensic pathologists. Physical and Chemical analyses such as microXRF and micro CT, stable isotopes determination and finally DNA analysis with a positive identification are not just methods but also extensions of a forensic anthropological laboratory and a team work endeavour toward professionals and institutions.

Keywords : microXRF, microCT, FTIR, human burnt remains, forensic anthropology

093

SUBSTANCE ABUSE DISORDERS IN PERPETRATORS IMPRISONED FOR DOMESTIC VIOLENCE

Oana-Maria Isailă 1,2 , Sorin Hostiuc 1,2 , Mihai Teodor 1 , George Cristian Curca 1,2

1 National Institute of Legal Medicine "Mina Minovici", Bucharest, Romania

2 University of Medicine and Pharmacy, “Carol Davila”, Bucharest, Romania

Oral Presentation: Forensic toxicology, June 4, 2021, 11:00 AM - 12:30 PM

Introduction : There is a close connection between the desire for control, substance abuse, and domestic violence. At the national level, previous studies in domestic violence focused their attention on the victims, without trying to analyze the underlying causes for this phenomenon from the aggressor’s perspective, if he/she is imprisoned for domestic violence. The aim of this study was to identify the characteristics of drug abusers and substance use disorders in a correctional system.

Material and Methods : We performed a retrospective study using forensic psychiatry reports of 234 detainees, imprisoned for all types of interpersonal violence, that were divided in two groups: domestic violence perpetrators (DVP), and perpetrators in the context of other types of violence (OVP). They were examined at the National Institute of Legal Medicine from Bucharest between 2016-2020. We included subjects for which the report had to establish criminal competence. We used Jamovi for statistical analysis; association tests were done using the Chi square test. A p value below .05 was considered statistically significant.

Results : We found 132 DVP subjects (56%) and 102 OVP subjects (44%). One hundred sixty-one subjects (66.8%) were chronic substance abuse users, of which 83 (63 %) DVPs and 78 (76 %) OVPs. The difference was statistically significant (p = .026). Most subjects were chronic ethanol abusers, of which 72 (55%) from the DVP group and 71 (70%) from the OVP group, the difference being statistically significant (p = .019). Only subjects in the OVP group were chronic alcohol users combined with drugs: 9 (9%), statistically significant difference chi square, p <.001. Other types of drugs of abuse encountered in our study included: legal highs - 6 (5%) DVP, 3 (3%) OVP; cannabis: 4 (3%) DVP, 7 (7%) OVP; volatile substances: 0 DVP, 4 (4%) OVP; cocaine: 2 (2%) DVP, 3 (3%) OVP; methadone: 1 (1%) in both groups; heroin: 3 (2%) DVP, 2 (2%) OVP; LSD: 1 (1%) DVP, 2 (2%) OVP. The only statistically significant difference was found for volatile substances (p = .022). At the moment of the aggressive behavior leading to imprisonment 26 (20%) DVP and 22 (22%) OVP had behavioral disorders due to alcohol consumption; 4 (3%) DVP and 5 (5%) OVP showed behavioral disorders due to drugs consumption; 19 (14%) DVP and 16 (16%) OVP had addiction syndrome. The differences were not statistically significant.

Conclusions : Most perpetrators imprisoned for domestic violence were diagnosed with substance abuse disorders, usually represented by chronic ethanol abuse. However, as a general remark, the usage profile is not very different from perpetrators imprisoned for other violent crimes. Even when the statistical analysis yielded statistically significant differences between these two groups, the magnitude of the effect was too small to be clinically relevant.

094

COMPARISON OF BLOOD ALCOHOL LEVELS DETECTED IN DRIVERS, BEFORE AND DURING THE COVID-19 PANDEMIC

Cosmin-Daniel Tirdea 1 , George Cristian Curca 1 , Doina Radu 1 , Lidia Seretean 1 , Razvan Marian Siminiuc 1

1 "Prof. Dr. Mina Minovici" National Institute of Legal Medicine, Bucharest, Romania

Oral Presentation: Forensic toxicology, June 4, 2021, 11:00 AM - 12:30 PM

Introduction : Alcohol, whether used recreationally or used in sanitation products, has become more and more common in our lives lately. With the onset of the COVID-19 pandemic, people began to use alcohol-based products in almost any space, even in their own cars; this, associated with quarantine or other proactive measures to limit the spread of the disease, were considered to be able to change the pattern of blood alcohol test results in drivers. The purpose of this study is to see if this has in any way influenced the levels of alcohol registered in the National Institute of Legal Medicine in 2020 compared to 2019.

Material and methods : The database (made using Excel 2019) was extracted from the archive of the toxicology laboratory of the “Prof. Dr. Mina Minovici” National Institute of Legal Medicine Bucharest. In 2019, 3060 samples were registered at the request of the police, 18 at the request of individuals and 1571 retroactive calculations. In 2020, 2393 samples were registered at the request of the police, four at the request of individuals and 1313 retroactive calculations. Among the exclusion criteria we list: the refusal to take biological samples and the refusal of testing with the ethyl test by the police. The analyzed data was divided for each month of the year studied and then the results were compared.

Results : After applying the above-mentioned exclusion criteria we found a majority of males with positive blood alcohol tests both in 2019 (95% males, 5% females with averages of men in 2019 – 0.52 mg/L vs. women 0.34 mg/L) and in 2020 (93% males, 7% females with averages of men – 0.54 mg/L vs. women 0.28 mg/L) In 2019, the average alcohol level identified by the police through a breath analyzer test was 0.52 mg/L. The averages of the alcohol in the blood samples collected at the institute were 1.25 g‰ respectively 1.35 g‰ in the samples collected one hour after arrival. For 2020, however, the average alcohol level identified by the police was 0.55 mg/L and in the blood samples collected at the institute averages were 1.29 g‰ respectively 1.54 g‰.

Discussion : After analysis and comparison of the data, we saw a decreased testing in 2020 compared to 2019, associated with higher overall values for the blood alcohol tests. This may be due to either an increase in consumption under lockdown and lack of occupation or the fact that police raids were limited during the pandemic. Consumption has also seen an increase among men especially in 2020 compared to 2019. The increased values at the second sampling were caused by the fact that only selected cases (usually with increased values in the first sample) were sampled one hour later.

095

SEXUAL AND DOMESTIC VIOLENCE: TOXICOLOGICAL ANALYSES PERFORMED ON VICTIMS OF THE SVS E D CENTRE IN MILANO OVER A 3-YEAR PERIOD (2018-2020)

Gaia Giordano 1 , Vera Gloria Merelli 1 , Giuseppe Lanza Attisano 1 , Michele Boracchi 1 , Domenico Di Candia 1 , Giussy Barbara 2 , Alessandra Kustermann 2 , Cristina Cattaneo 1

1 Section of Legal Medicine, Department of Biomedical Sciences for Health, University of Milan

2 Department of Obstetrics and Gynecology, Service for Sexual and Domestic Violence (SVSeD), Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan

Oral Presentation: Forensic toxicology, June 4, 2021, 11:00 AM - 12:30 PM

At the Institute of Legal Medicine of the University of Milan, an epidemiologic study was conducted on victims of the SVSeD (Sexual and Domestic Violence Service) of IRCCS Ca’ Granda to establish the prevalence of DFSA (Drug Facilitated Sexual Assault) and the trends of toxicological substances occurring in victims of sexual assaults from 2018 to the 2020. A total number of 2470 individuals were admitted to SVSeD in a 3-year period: 1075 of them were examined for sexual violence, 1310 for domestic violence and 85 for both of them. The population admitted to SVSeD was mainly female (precisely 93% of total individuals). Moreover, minor individuals (i.e., people of less than 18 years old for the European Law) were the 20% of the total. The majority of the assisted people went to SVSeD for the first time, while 8% had been examined by similar services for a previous sexual violence and/or domestic violence event. From the total number of victims, 139 individuals suffered from alcoholism and 16 had already been followed by NOA (Nucleo Operativo Alcologia), 159 were admitted drug abusers and 43 were followed by SerT (Servizio Tossicodipendenze); moreover, 221 victims had a diagnosed psychiatric disease and 199 had already been followed by CPS (Centro Psico-Sociale). From the examinations, 211 victims, according to description of the event, were considered eligible for toxicological analyses of blood and urine: a total of 377 blood and urine specimens were collected and analyzed using High Performance Liquid Chromatography – Mass Spectrometry (HPLC-MS) and Gas Chromatography – Mass Spectrometry (GC-MS). Positive results were detected in 106 samples belonging to 89 patients; the most common molecules detected were nicotine and its metabolite (cotinine), identified in 3.7% and 15.6% of the samples respectively, followed by cocaine (5.3%) and its metabolites (benzoylecgonine, 9.2%, and ecgonine methyl ester 0.8%); moreover, coca ethylene was detected in 0.3% of the samples. Furthermore, antidepressants were detected in 3.7% of the specimens, benzodiazepines in the 2.9%, amphetamines in the 2.4%, methadone in 1.1%. From the toxicological analyses, psychostimulants appear to be the most common drugs found in victims of sexual violence, as antidepressants and sedative-hypnotic drugs; otherwise, no evidence of GHB nor Flunitrazepam could be reported in the population even if they are common “date rape drugs”.

096

STUDY OF CORRELATION BETWEEN THE TOXICS QUANTIFIED IN BLOOD AND BONE (RIBS). PRACTICAL IMPLICATIONS

Lucia Fernandez 1 , Maria Falcon, Simona Picchini, Aurelio Luna 1

1 University Of Murcia, Spain

Oral Presentation: Forensic toxicology, June 4, 2021, 11:00 AM - 12:30 PM

The main aims of postmortem toxicological analysis are to determine the presence of possible substances in the corpses and for that, conventional matrices typically used are blood, vitreous humor, urine, among others. However, in the field of forensic toxicology, there are many cases in which these biological samples are not available for the analysis (advanced state of decomposition, carbonized, mummified, embalmed or skeletonized). In these cases different alternative tissues have been studied such as the bones. However, interpreting post-mortem toxicological results in bone is very complex since there is no standardized data about therapeutic, toxic or lethal concentrations of drugs in bone. In this way, quantitative data about drugs in bone would not give more information than qualitative data, so the development of a correlation between postmortem toxic values in blood and bone would be of great interest. We analyzed bone samples (ribs) from 28 corpses which were positive to one or more substances in blood. Analyzed substances were: methadone, morphine, 6-MAM, tramadol, BEG, amitriptyline, venlafaxine, duloxetine, carbamazepine, pregabaline, quetiapine, atenolol, bisoprolol, oxazepam, nordiazepam, lorazepam, bromazepam, alprazolam, clonazepam and lormetazepam. Drugs were detected in blood in 48 occasions and they were found in the corresponding bone sample in 38 cases (77%). We studied the possible existence of a correlation between concentrations in blood and bone, obtaining the following results from linear regression study: for opiates R = 0.921, R2 = 0,848; for antidrepressives R = 0.995, R2 0.989; for benzodiazepines R = 0.725, R2 = 0.525. These results are preliminary; we must continue studying this correlation as this would be a great advance for postmortem toxicological studies.

097

EVALUATION OF HYDROGEN CYANIDE AND CARBOXYHEMOGLOBIN FOR THREE FIRE-RELATED DEATHS IN DIFFERENT FIRE SCENARIOS

Daniel Tabian 1 , Gabi Drochioiu 3 , Madalina Maria Diac 1 , Valentin Petre-Ciudin 4 , Mihaela Badea 2 , Diana Bulgaru Iliescu 1

1 “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania

2 Faculty of Medicine, Transilvania University of Brasov, Romania

3 Faculty of Chemistry, “Alexandru Ioan Cuza” University of Iasi, Romania

4 “Sfantul Ioan cel Nou” Emergency Hospital Suceava, Romania

Oral Presentation: Forensic toxicology, June 4, 2021, 11:00 AM - 12:30 PM

Fires produce a complex toxic environment consisting of flame, heat, lack of oxygen and smoke. The composition of the smoke depends on the burned materials, such as mattresses, upholstery, or plastic bottles, which release a large amount of hydrogen cyanide (HCN). We present three cases of fire victims, of which one in open space fire of vegetation debris and household waste (case 1), another one being a room fire (case 2) and the third, a burning train (case 3). We measured the concentration of HCN and carboxyhemoglobin (COHb) by spectrophotometry and evaluated their contribution to the mechanism of death and advanced the hypothesis that HCN concentration can be interpreted as vital sign. HCN was determined kinetically spectrophotometrically with a recent procedure using a ninhydrin reagent, published by Tabian et al. (2020, 2021). The COHb blood concentration of the first victim was 73.7%, whereas it decreased to 5.15% for second victim and more than 40% for the third. Femoral blood HCN concentrations were 1.3 μg ml-1 (case 1) and 1.043 μg ml-1 (case 2), whereas the total cyanide, which includes thiocyanates, was 1.904 μg ml-1 (case 2). Total cyanides concentration in the third case was 5.682 μg ml-1. We can assume that HCN could have played a role in the death mechanism in all cases. The first case was atypical, because HCN intoxication usually occurs in room fires. The toxic concentration of HCN in the second case was a sign that the victim must have been still alive when the fire started. The lethal concentration obtained in the third case agrees with other reported studies, as the burning of mattresses and upholstery releases appreciable amounts of HCN. Our findings indicate that the concentration of HCN in the blood should be determined for victims exposed to smoke inhalation.

099

MORTALITY IN CASES OF ACUTE ALCOHOL INTOXICATION IN CHILDREN: A 10-YEAR RETROSPECTIVE STUDY OF THE MOSCOW REGION, RUSSIA

Semyon Plis 1 , Olesya Veselkina 1 , Vladimir Klevno 1 , Vasiliy Vlassov 2

1 Department of Forensic Medicine, Moscow Regional Research and Clinical Institute ("MONIKI"), Moscow, Russia;

2 Department of Health Care Management and Economics, National Research University Higher School of Economics, Moscow, Russia

Oral Presentation: Forensic toxicology, June 4, 2021, 11:00 AM - 12:30 PM

Introduction : In Russia, most forensic autopsies include blood alcohol tests, but nobody tried to analyze this data in cases of children deaths.

Material and Methods : We undertake analysis of the juvenile mortality using autopsy reports (included toxicology study) from Moscow Region Bureau of Forensic Medical Examination (not including Moscow city) from January 1, 2009 to December 31, 2018. We excluded the stillborn babies (n = 35), cases when it was impossible to identify the sex of the child (n = 2), cases when the correct blood sampling procedure for the toxicology study was not followed (n = 1), and cases when the corpse was partially destroyed (burned, dismembered, putrefied) (n = 43); giving a dataset of n= 3,321. In all cases, blood alcohol concentration (BAC) was measured by gas chromatography. BAC higher than 0,2 g/l was classified as intoxication.

Results : Of 3,321 cases, in 2,250 (67.7%) death was caused by external factors (unnatural death). Alcohol intoxication was more often diagnosed in cases of unnatural deaths, which was more common in teenage groups and decreased with years. The mean age of children who died while intoxicated was 13.7 (95% CI: 13.2-14.3). The youngest child was a 39-day-old male with BAC 0.29 g/L. Another lethal case was registered in a 7-month-old child with BAC 1.8 g/L and 0.19 g/L in the urine. The age groups 1–4 and 5–9 are small. Children from age group (1-4) died an average BAC of 0.31 g/L (95% CI: 0.09 – 0.53, BACmax = 4.8 g/L. In the age group 5–9 years, except for the case of poisoning with ethanol (BAC = 5.2 g/L) death occurred at a BAC of 0.47 g/L (95% CI: 0.35 – 0.59, BACmax = 1.1 g/L). In 10–14 age group, the proportion of deaths associated with intoxication in males and females was equal. The average BAC in this age group was 1.06 g/L (95% CI: 0.82 – 1.3, BACmax = 4.7 g/L). In 15–17 age group, the proportion of deaths associated with intoxication is the highest (75%, n = 152). Except for the cases of ethanol poisoning in the 15–17 age group, the BAC was 1.48 g/L (95% CI: 1.34 – 1.62, BACmax = 6 g/L). The postmortem BAC in group 15-17 was higher than in group 10-14 (MD = 0.41, 95% CIMD: 0.12 – 0.71).

Discussion : Forensic alcohol "screening" shows that number of children who dies with alcohol intoxication is high, even in age group which are not able to use it by themselves. Alcohol could be not only the cause of death in children, but the main predictor of accident.

100

ANALYSIS OF THE CAUSAL CONNECTION IN FATAL ACCIDENTS INVOLVING MORE THAN A CAR: CASE REPORT

Çağdaş Savaş 1 , Mert Onur Özdemir 1 , Çağlar Özdemir 2 , İsmail Özgür Can 1

1 Dokuz Eylül University Faculty of Medicine, Department of Forensic Medicine, Izmir, Turkey

2 Erciyes University Faculty of Medicine, Department of Forensic Medicine, Kayseri, Turkey

Oral Presentation: Forensic pathology 7, June 4, 2021, 2:00 PM - 3:30 PM

Case Description : The police report states that a 4-year-old Syrian girl suddenly ran across the pedestrian crossing with no glancing round. The report indicates as the first car involved in the accident ran into the girl with its left front rearview mirror and left fender. Subsequently, the child was thrown to the left due to the impact and got hit by an another car coming from behind. The child was taken to emergency immediately but she died at the hospital. The cause of death was reported as general body and neck trauma in the postmortem examination however forensic autopsy was not performed. In the medicolegal evaluation made by our department regarding the event; not performing autopsy and whether there are traumatic findings in the possible contact areas of the first car and not being evaluated for its potential to cause death was seen as a deficiency. It has been found that the child was not thrown to the left of the car with the alleged impact, continued to move and covered a distance as a result of detailed analysis of photographs and images of the crime scene. Also, no traumatic findings were observed on the right side of the head-face and the right shoulder-arm region, which may be a impact region and in parts of the car that allegedly hit the child no signs of impact were found. For all these reasons, the opinion was expressed that there is no evidence that the first car strike the child.

Discussion : Traffic accidents are an important socioeconomic, medical and legal problem. It is the first reason of the injuries-related deaths all over the world. Pedestrian injuries have high mortality and morbidity in childhood. Especially in deaths due to accidents involving more than one car, the contribution of each driver's actions to the death should be considered separately. 80-85% of pedestrian injuries are caused by striking the front and front corners of the car for this reason, the tampon is the first region of impact and primary wounds are seen at this level. Pedestrians can be thrown even if cars crash at low speeds. This study emphasizes the importance of analyzing the causal connection between the actions of each driver and the damage caused in the considerations of fatal cases that occur after a traffic accident involving more than one car. We are of the opinion that performing an autopsy procedure and the causal connection between the actions of each driver and the resulting damage should be analysed within the information in the literature and specific to each case especially in fatal accidents involving more than one car.

101

MINIMALLY INVASIVE AUTOPSY WITH POST MORTEM ULTRASOUND GUIDED- BIOPSIES VERSUS CONVENTIONAL AUTOPSY: COMPARISON OF DIAGNOSTIC PERFORMANCE

Antonia Fitzek 1 , Axel Heinemann 1 , Inga Kniep 1 , Dustin Möbius 1 , Benjamin Ondruschka 1 , Alexandra Ron 1 , Julia Schädler 1

1 Institute of Legal Medicine, Hamburg-Eppendorf, Germany

Oral Presentation: Forensic pathology 7, June 4, 2021, 2:00 PM - 3:30 PM

The aim of this study was to determine the diagnostic performance diagnostic performance of minimally invasive autopsy using ultrasound-guided biopsies and computed tomography (CT) for detecting causes of death and to investigate the feasibility of MIA as an alternative to conventional autopsy (CA), particularly in the setting of emerging infections. For this prospective, single-center, cross-sectional study in an academic hospital, 41 deceased patients associated with SARS-CoV-2 underwent usMIA only, or both usMIA followed by CA from June 2020 to December 2020. Family consent was obtained for all autopsy types. usMIA initially started with ultrasonography of the lungs and was then extended to the heart, kidneys, spleen, liver and prostate or uterus (except brain) including biopsy collection. Six patients underwent both types of autopsy with extended biopsy sampling. Those involved in the usMIA and CA procedures were blinded to each other's findings. The usMIA approach combined diagnostic post mortem CT- screening followed by ultrasound-guided biopsy of major organs and pathologic lesions. The primary outcome measure was the performance of usMIA and CA in determining the immediate cause of death. The secondary outcome measures were diagnostic yield of usMIA and CA for all, major, and grouped principal diagnoses, frequency of clinically unsuspicious findings, and quality assurance in further microbiologic diagnosis. The results will be presented. In conclusion, usMIA is an easily accessible, cost-effective, and feasible procedure with high diagnostic performance in detecting pulmonary pathologies during the COVID-19 pandemic, but also giving clues in many cases to alternative causes of death if a CA is rejected by next of kin.

102

SUICIDE AND SOCIO-CLIMATE CHANGES

Calin Scripcaru 1 , Diana Bulgaru Iliescu, Andreea Birlescu, Veronica Scripcaru 2

1 Institute of Legal Medicine, Iasi, Romania

2 Emergency Hospital "Sf. Spiridon", Iasi, Romania

Oral Presentation: Forensic pathology 7, June 4, 2021, 2:00 PM - 3:30 PM

Suicide is any situation in which death occurs as a result of a deliberate act committed by the victim. Currently, the notion of suicide tends to be replaced by that of suicidal behavior. The latter includes: successful suicide, suicide attempt and suicide ideas. Suicide is a disease associated, in turn, with mental disorders such as depression, schizophrenia, bipolar disorder, alcohol dependence and other substances. Our study is a retrospective one, through which we followed epidemiological data on suicide over three generations, between 1982 and 2017, the case being taken from the region of Moldova (period 1982-1993) and later from Iasi County (1994-2017).

103

ARTIFICIAL INTELLIGENCE (AI) AND EARLY PREDICTION OF POST-TRAUMATIC STRESS DISORDER (PTSD). AI FOR CLINICAL PRACTICE AND PRACTITIONERS

Victor Trousset 1 , Thomas Lefèvre 1

1 Forensic medicine unit at Jean Verdier Hospital (Bondy, France) - APHP, Paris, France

Oral Presentation: Forensic pathology 7, June 4, 2021, 2:00 PM - 3:30 PM

Introduction : Identifying subjects at risk of developing PTSD after a traumatic event is still a challenge for standard determinant approaches. Among traumatic events, sexual assault is most strongly associated with PTSD. Forensic expert is confronted daily with sexual violence to collect forensic evidence but also provide the necessary care. Early prediction of PTSD by AI on initial data alone and before the disorder is diagnosed conclusively (one month later) would enable more rapid intervention and hopefully avoid the emergence of chronic, invasive, and disabling symptoms, particularly common in sexual assault survivors.

Material and Methods : An overview of the literature was conducted with MEDLINE to identify any studies that are interested in early prediction of PTSD after a traumatic event.

Results : Few studies have used AI for early prediction of PTSD, the majority having been conducted in hospital, more specifically, in emergency departments, and have used various types of clinical, biological and psychological data. Prediction using only data collected in the emergency department showed a prediction capacity ranging from accurate to good (AUC=75 to 85%) regardless of the type of data used in the prediction model. The best predictive performance was obtained by combining both clinical and biological data. Data from retrospective studies based on the WHO WMH Surveys has been used to predict PTSD, with one study focusing on a large number of traumas and another on trauma caused by sexual violence. Based on these initial data alone, the results were variable, with excellent predictive performance in the study on all types of trauma (AUC=98% in Kessler 2014) and poor for the sexual violence study (AUC=64% in Scott 2018).

Discussion : PTSD is not often studied in relation to a specific trauma, but rather to "trauma in general". This can lead to bias when interpreting and comparing studies. The majority of studies to date have been secondary, retrospective analyses of cohort epidemiological data or cohorts reconstituted from hospital data. The challenge is to transpose these results to prospective data for external validation on just one type of trauma. The majority of studies conducted to date focus on the use of AI in replacing current tools or scales that are difficult for practitioners to use, or whose initial design, validation and use are the result of research. They do, however, offer reasonable hope for more affordable, perhaps more effective and more operational means for health professionals, including forensic expert, to be able to diagnose PTSD. Most of the studies are related to laying the groundwork and providing prototypes that will enable the future conception of algorithms for general use. We are therefore only at the very beginning of the process of rigorous development of predictive or decision-support algorithms in this field.

104

ACETAMINOPHEN OVERDOSE IN A SUICIDE CASE - CASE REPORT

Cosmin-Daniel Tirdea 1 , Razvan Marian Siminiuc 1 , Luminita Luca 1 , Sorin Hostiuc 1

1 "Prof. Dr. Mina Minovici" National Institute Of Legal Medicine Bucharest, Romania

Oral Presentation: Forensic pathology 7, June 4, 2021, 2:00 PM - 3:30 PM

Introduction : Acetaminophen (Paracetamol) is one of the most commonly used analgesics worldwide. It has an excellent safety profile in therapeutic doses. However, acetaminophen overdose is a major health problem worldwide. Hepatic injury and, less commonly, acute kidney injury are the major suggested consequences of acetaminophen overdose. Indeed, acetaminophen overdose is the leading cause of fulminant hepatic failure. Acetaminophen poisoning is frequently implicated in self-harm. The purpose of this article is to highlight the effects of paracetamol in an overdose case.

Case description : We present the case of a 25-year-old female hospitalized for acute drug intoxication by self-administration of 20 acetaminophen tablets. The patient came to the emergency unit 24 hours after ingestion with mild drowsiness, abdominal pain, vomiting, nausea and mild hepatic cytolysis. The patient promptly received n-acetylcysteine (NAC). Over time, despite aggressive treatment, hepatic cytolysis syndrome worsened and she eventually died after ten days of hospitalization. Post-mortem and histopathological examinations revealed cerebral edema, encephalopathy, pulmonary atelectasis, diffuse cardiac ischemia, acute liver failure, hepatocyte necrosis and renal tubular necrosis.

Discussion : Acetaminophen is a centrally acting COX-2 inhibitor possessing both antipyretic and analgesic properties. NAC is considered the gold-standard antidote for acetaminophen poisoning. It aids in the detoxification within the hepatocyte. Cases of acetaminophen-related death or liver failure despite NAC use, however, have been reported. Toxic amount of paracetamol ingestion can lead not only to liver complications but also cerebral, cardiac, renal and hematological complications despite the right treatment.

105

THE HUMAN THANATHOTRANSCRIPTOME: DEAD BUT NOT ENTIRELY

Bram Bekaert 1,3 , Laura Antiga 2 , Lode Sibbens 1 , Yasmina Abakkouy 1 , Ronny Decorte 1,3 , Wouter Van Den Bogaert 3 , Wim Van de Voorde 1,3

1 KU Leuven, Forensic Biomedical Sciences, Department of Imaging & Pathology, Leuven, Belgium

2 University Pompeu Fabra (UPF), Department of Experimental and Health Sciences (CEXS), Barcelona, Spain

3 UZ Leuven, Laboratory of Forensic Genetics, Leuven, Belgium

Oral Presentation: Forensic pathology 7, June 4, 2021, 2:00 PM - 3:30 PM

RNA analysis of post-mortem tissues, or thanatotranscriptomics, has become a topic of interest in forensic science due to the essential information it can provide in forensic case investigations. Several studies have previously investigated the effect of death on gene transcription, but it has never been conducted with samples of the same individual. For the first time, a longitudinal mRNA expression analysis study was performed with post-mortem human blood samples from individuals with a known time of death. The results reveal that, after death, two clearly differentiated groups of up- and down-regulated genes can be detected. Pathway analysis suggests active processes, rather than passive degradation, are the source of early post-mortem changes of gene expression in blood. In addition, a generalised linear model with an elastic net restriction predicted post-mortem interval with an RMSE of 4.88 hours. Although promising, the forensic relevance of the model is currently limited and should be further improved in more extended studies.

106

FORENSIC MEDICINE AND THE CHALLENGE OF IMPUNITY OF POLITICAL ASSASSINATIONS IN AFRICA

Henry Ognan Dogo 1

1 Ministere Justice Togo

Oral Presentation: Forensic pathology 7, June 4, 2021, 2:00 PM - 3:30 PM

Politically motivated or government-instigated killings exist in all regions of the world, and Africa cannot escape this obvious reality. Committed either in isolation (elimination of one or more individuals outside of any conflict) or in the context of a generalized political conflict (mass elimination), these physical eliminations whose authors are the secret agents, forces of the order or militias in the service of state powers, target individuals or persons whose activities, opinions or ideologies constitute a certain embarrassment for political powers. Thus, the targets which belong to different spheres are journalists, trade unionists, political opponents, magistrates etc. The cases of Norbert ZONGO in Burkina Faso, Floribert CHEBEYA in the DRC or even Medhi Ben BARKA in Morocco are examples, among many others. In the event of their death being ascertained under special or unclear conditions, the quality of these personalities should constitute a reason for medico-legal obstacle with a view to in-depth investigations to determine the circumstances and real causes of their death. The false official authorities on the real causes of these deaths make it very difficult to establish the truth and the responsibility. These cover-up mechanisms and other institutional factors give perpetrators a degree of impunity as it now becomes very difficult to prove the facts. In this context, forensic medicine becomes one of the best bulwarks fighting against such a scourge of impunity. Because it allows, in the presence of human remains (whole or fragmented fresh bodies, skeletal bodies ...), to make the deceased speak and reveal the causes and the real circumstances of the death. This is the case of the assassinations of Thomas SANKARA, Norbert ZONGO and Floribert CHEBAYA, despite multiple attempts at concealment, revealed their criminal characteristics when they were scrutinized by forensic medicine. In addition, of course, medicine has proven its capacity in terms of judicial investigation and the fight against the impunity of political assassinations; it seems in many respects to have certain limits, especially in the face of modern methods of physical elimination of the twenty-first century. Invasive, and that hardly leaves the slightest trace of a crime. Therefore, it becomes urgent to find suitable solutions to overcome these new methods of assassination, which risk allowing criminals to slip through the cracks, thus endangering all of humanity.

107

FATAL AXILLARY ARTERY THROMBOSIS AFTER A DISLOCATION OF THE GLENOHUMERAL JOINT; A CASE REPORT

Razvan Marian Siminiuc 1 , Cosmin-Daniel Tirdea 1 , Lăcrămioara Luca 1 , Sorin Hostiuc 1

1 "Prof. Dr. Mina Minovici" Institute of Legal Medicine, Bucharest, Romania

Oral Presentation: Forensic pathology 8, June 4, 2021, 4:00 PM - 5:45 PM

Abstract : Arterial occlusion caused by thrombus can have a wide variety of causes, ranging from metabolic diseases to traumatic events. Prolonged ischemia caused by arterial obstruction, leads tissue necrosis and the release of metabolic products that can cause multiple organ dysfunction syndrome and cardiac arrest after restoring the blood flow in the ischemic area.

Case description : We present the case of a 77-year-old male who arrived in an emergency unit, following a fall on ice. He was diagnosed and treated for a dislocation of the right glenohumeral joint. Later that day, he came to another emergency unit, due to his worsening state, with the suspicion of a stroke, not confirmed by the CT scan. The next day, he was referred to a third hospital with the diagnosis of right superior limb ischemia. Angiography confirmed a 3 cm occlusion of the right axillary artery, due to an intimal lesion. He received successful surgery for the replacement of the occluded artery with saphenous vein graft. However, shortly after surgery, he developed severe bradycardia and cardiorespiratory arrest, unresponsive to resuscitation.

Discussion : This case highlights the importance of early diagnosis and treatment of acute limb ischemia following traumatic events. Even if a dislocated joint is not usually a life-threatening condition, the assessment of possible associated injuries must be done, in order to avoid a delayed treatment and fatal complications.

108

CREATION OF A FORENSIC PATHOLOGY BIOBANK IN SWITZERLAND. WHICH ISSUES AND RESEARCH OPPORTUNITIES?

Kim Wiskott 1 , Federica Gilardi 1 , Katarzyna Michaud 1, Aurélien Thomas 1 , Tony Fracasso 1

1 University Center of Legal Medicine Lausanne-Geneva (CURML), University of Lausanne and University of Geneva, Switzerland

Oral Presentation: Forensic pathology 8, June 4, 2021, 4:00 PM - 5:45 PM

Background : A biobank is a collection of biological material associated with health database. The field of biobanking has significantly developed over the past thirty years and is currently implemented from the academic laboratories to institutional government supported repositories such as population wide biobanks. Research based on biobank material gives access to data of a large number of people and can often significantly accelerate the understanding of disease and improve the quality of the care. Each year, 500 autopsies are performed in our center. A big part of collected samples is used for forensic investigations in the medicolegal context and is destroyed after three years at the end of the medicolegal procedure (according to our internal procedure). The legal and ethical framework to use these samples for research is often complex and confused, which is unfortunate given the potential of these biospecimens. Indeed, all samples collected during medico-legal autopsies are valuable for researchers because they originate mostly from young and healthy people who are poorly represented in worldwide institutional biobanks. In this context at the beginning of the year 2019, the Forensic Pathology Biobank was created in our center. For forensic centers, creation of a biobank is a great way to standardize conservation model and index specimens.

Ethical and legal considerations : Ethical standards and national laws regulate biobanking operations. Ethical principles are promulgated by two declarations of the World Medical Association. The declaration of Helsinki (1964) lays down ethical norms for medical research involving human subjects, guided by the three principles of dignity, autonomy and privacy. In 2016, declaration of Taipei described ethical considerations regarding health databases and biobanks. Concerning legal aspects of research on human being, swiss legislation is based on the Human Research Act and two specific articles refer more specifically to deceased persons. Swiss legislation is relatively supportive for human research and is designed to ensure quality and transparency of research.

Perspectives : FPB opens up a whole new range of possibilities in both clinical and basic research. We are now performing a series of investigations by different methods (mostly omics-related) to determine whether these samples are good matrices also in cases of long postmortem delay; preliminary results are promising.

Conclusion : Creation of FPB is the best way to standardize local conservation practices and improve personal data management. Its development gives rise to many questions about technical standards, ethical and legal issues but also many research opportunities that will be discussed in our presentation.

109

ARTIFICIAL INTELLIGENCE IN FORENSIC MEDICINE FOR THE PRACTISING DOCTOR

Bertrand Ludes 1,5 , Laurent Tournois 1,2 , Thomas Lefèvre 3,4

1 CNRS UMR 8045 BABEL, Paris, France

2 BioSilicium, Riom, France

3 IRIS Institut de Recherche Interdisciplinaire sur les enjeux Sociaux, UMR8156 CNRS - U997 Inserm - EHESS – Université Sorbonne Paris Nord, Paris, France

4 AP-HP, Jean Verdier hospital, Department of forensic and social medicine, Bondy, France

5 Medicolegal Institute of Paris, France

Oral Presentation: Forensic pathology 8, June 4, 2021, 4:00 PM - 5:45 PM

Objectives : Since the last decade, applications based on artificial intelligence (AI) have emerged in order to help forensic medical doctors in their daily practice. This review aims at describing such applications and the potential impacts of AI in the practices of current and future forensic medicine.

Material and Methods : PubMed, SpringerLink, Science Direct, Wiley Online Library, ACS publications and IEEE Xplore databases as well as ResearchGate, Google Scholar and Google Search were explored to extract articles and studies of interest for selection. The inclusion criteria for article selection were the description of applications intended to be used by forensic medical doctors and developed for the main expertise fields of thanatological and clinical forensic sciences, such as post-mortem identification, the estimation of the post-mortem interval, the determination of the causes of death and the estimation of the age of adolescent migrants. Each selected article was then rated by assessing the maturity level of the described AI application within. A special attention was paid to the applications with the highest or closest maturity level for a routine use by forensic medical doctors.

Results : Few applications based on AI approaches were reported to be used by forensic medical doctors to date. In practice, the applications used by medical doctors were mostly developed for identification purposes. However, hundreds of research projects involving AI have been conducted in forensic science and research studies have appeared to be still in progress. The performance of AI models in forensic medicine ranged from approximately 30% for the less accurate model to approximately 99%, on small sample sizes, for the best one depending on the application and the forensic expertise field. Both performance range limits were related to the determination of the causes of death.

Discussion : The implementation of AI in forensic medicine is not a trivial process. Although most of current AI applications are more than 75% accurate, many AI models are trained on too little data, so that such models are not able to generalize on new data. Further validation studies are required to allow the implementation of those models in real and operational environments. Moreover, forensic medical doctors may be reluctant to use AI in daily practice due to ethical, professional and AI-inherent issues, such as the presence of biases and the lack of elements of AI interpretability in specific kinds of application. Finally, the use of AI in forensic medicine requires its acceptance and appropriation from all the involved actors, that is to say forensic medical doctors as well as lawyers and magistrates.

110

SUDDEN DEATH OF A YOUNG MAN: THERE ARE THE CLUES, BUT THERE IS NOT THE KILLER

Simone Grassi 1 , Giovanni Aulino 1 , Francesca Cazzato 1 , Massimo Zedda 1 , Alessandro Alfonsetti 1 , Vincenzo Arena 2 , Mònica Coll 3 , Oscar Campuzano 3 , Vincenzo Lorenzo Pascali 1 , Ramon Brugada 3 , Antonio Oliva 1

1 Section of Legal Medicine, Department of Health Surveillance and Bioethics, Università Cattolica del Sacro Cuore, Rome, Italy

2 Section of Anatomical Pathology, Department for Woman and Child Health and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy

3 Institut d'Investigació Biomèdica de Girona Dr. Josep Trueta, Girona, Spain

Oral Presentation: Forensic pathology 8, June 4, 2021, 4:00 PM - 5:45 PM

Case presentation : A 22-year-old young man in good health suddenly died when he was in a shop after having reportedly smoked cannabis. The prosecutor requested an autopsy to find the cause of the death. At external examination of the body no relevant sign was found. At the autopsy, performed five days after the death, the heart (500 g) presented no anomaly. Left anterior descending coronary artery had, at 2 cm from its beginning, a 0,3 cm-thick 5,5 cm-long myocardial bridging. Histopathological examination of the myocardium found fibrosis and disarray in the left ventricle myocardial area above the MB, fibrosis in sinoatrial node area and some areas in which fatty tissue separated the myocardium in the antero-lateral region of right ventricle free wall. No signs of myocarditis were found. At toxicologic testing traces of THC and a THC-COOH concentration of 3 ng/mL were found in blood, while a THC concentration of 9 ng/mL and a THC-COOH concentration of 1800 ng/mL were found in the bile. At post-mortem NGS we identified a rare variant of SLMPA (c.599C>T).

Discussion : The described case of SD in the young is extremely challenging since all its main features (myocardial bridging as the only macroscopic anomaly in the context of microscopic features suggestive of hypertrophic cardiomyopathy, fatty infiltration of the myocardium, fibrosis in sino-atrail node, a rare variant with no definite role in a gene associated to BrS, and cannabis consumption before the SD) are difficult to be interpreted. The MB we found can be considered particularly long and thick but, according to current evidence, its clinical significance must be considered uncertain. Fibrosis and disarray have already been associated with MB in young cases of SD and could be related to the myocardial ischemia and/or to early signs of hypertrophic cardiomyopathy. The fibrosis of the sino-atrial node is physiological, because it acts as a “modulator of structural and functional integrity”, but it is rare in young age. Toxicologic testing was positive for cannabis use. However, THC concentration in peripheral blood was low. This evidence is compatible with the report of the witness (recent cannabis smoking) because of the possible post-mortem redistribution of the substance (the autopsy was performed five days after the death). A cannabis acute assumption could have played a role in the cause of the death because of the potential pro-arrhythmic effect. Finally, the variant found at molecular autopsy concerned SLMPA, a gene that has been associated to Brugada Syndrome, but, according to current guidelines, must be classified as of unknown significance. Therefore, in this case we can state that there are several possible cause of the death, but none of them is certain.

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IS ACUTE PULMONARY EMPHYSEMA DETECTABLE BY POST-MORTEM CT-SCAN?

Claudia Castiglioni 1 , Eugénie Chevalme 2 , Virginie Magnin 1 , Tony Fracasso 1

1 University Center of Legal Medicine Lausanne-Geneva (CURML), University of Lausanne and University of Geneva, Switzerland

2 Service of Legal Medicine of CHRU, Nancy, France

Oral Presentation: Forensic pathology 8, June 4, 2021, 4:00 PM - 5:45 PM

Acute pulmonary emphysema (APE) is described as a sign of vitality in some death by mechanical asphyxia such as drowning and strangulation. The diagnosis of APE is based on macroscopic and especially microscopic examination of lung tissue. Our study aimed to verify if signs of APE are also detectable by post-mortem CT-Scan. For this purpose, we retrospectively selected 10 cases of drowning with APE and 10 cases of complete hanging without APE. The presence of APE was preliminary confirmed by digital morphometric analysis of lung tissues. The following exclusion criteria were used to avoid any interference: age >60y, chronic respiratory or cardiac diseases, inhalation of gastric content, cardiopulmonary resuscitation, post-mortem interval at autopsy >72h. In all cases a post-mortem CT-Scan of the body was performed before the autopsy. For each case, an evaluation of the following radiological pulmonary findings was made: presence of ground glass opacities, thickening of the bronchial wall and distance of lung anterior edges on the middle line. Histological standard examination of lung tissue was also performed for each case. At post-mortem CT-Scan, ground glass opacities were present in all cases in both group, especially in the anterior areas in the drowning group and in the posterior areas in the complete hanging group. The presence of ground glass opacities is related to alveolar edema and in our study it did not show any correlation with APE. An increase in the thickness of the bronchial wall was observed only in few cases of drowning. In 9 cases of drowning, the edges of the lungs were very close or overlapped, as confirmed at chest opening during the autopsy. Actually this finding is often detected at autopsy in drowning as consequence of APE. Surprisingly in our study an overlapping of pulmonary edges was observed at post-mortem CT-Scan also in a few cases of complete hanging in which APE was absent and the anterior edges of the lungs were far from each other at the chest opening. All the bodies presenting this overlapping were young and very tall and thin, suggesting a correlation between the radiological pulmonary overlapping and body structure. We concluded that at post-mortem CT-Scan there are no signs to detect APE before the autopsy, and we recommend great caution in the interpretation of some radiological sign, such the overlapping of pulmonary edges.

113

AUTOPSY PRACTICE IN SLOVAKIA FROM A FORENSIC MEDICINE POINT OF VIEW

Jozef Sidlo 1,2 , Peter Očko 1,2 , Ľubomír Mikuláš 1,2 , Ján Šikuta 1,2

1 Comenius University in Bratislava, Faculty of Medicine, Institute of Forensic Medicine, Bratislava, Slovakia

2 Health Care Surveillance Authority, Department of Forensic Medicine, Bratislava, Slovakia

Oral Presentation: Forensic pathology 8, June 4, 2021, 4:00 PM - 5:45 PM

Introduction : Role of the autopsy in the system of quality assessment in health care and in establishing the cause of death in so called non treated population and in the cases of violent deaths is irreplaceable. Over the last decades of the 20th century and the first two decades of the 21st century we have been witnesses of a decreasing autopsy rate at global, European and national levels. A new institution - Health Care Surveillance Authority (HCSA) - for the management, and new network of workplaces for performance of pathological-anatomical and medico-legal autopsies in Slovakia was established in 2004. The objective of this paper is to explain a recent development and current situation of autopsy practice in Slovak republic from a forensic medicine point of view.

Material and Methods : There was made an analysis of the development of autopsy rate in the years 1995 – 2020 and development of absolute numbers of performed autopsies according the “type” of autopsy in the years 2005 - 2020. The statistics data for the purpose of this analysis were acquired from the Statistical Office and the Health Care Surveillance Authority.

Results : Autopsy rate decreased in the years 1995 – 2004 from 18.3% to 12.5%. In the years 2005 – 2020 according to the data from the HCSA autopsy rate in the above mentioned period ranged from 18.1% to 12,8%. The total number of autopsies in the years 2005 – 2020 in absolute numbers decreased from 9,677 to 7,595. The number of medico-legal autopsies decreased from 4,438 to 3,697. The number of pathological-anatomical autopsies decreased from 3,724 to 3,167. The number of autopsies ordered by police and connected with expert opinions decreased from 1515 to 731. There was relative increase of the rate of medico-legal autopsies in comparison with the total number of all performed autopsies from 46% to 49% due to considerable decrease of number of pathological-anatomical autopsies.

Discussion : In spite of the fact that a new institution centrally managing performance of autopsies was established, a current development in this field shows that a tendency of autopsy rate decrease is progressive and permanent also in Slovak republic.

112

ARE WE LOSING FORENSIC AUTOPSIES? A GLIMPSE FROM ITALY

Stefano Tambuzzi 1 , Lidia Maggioni 1 , Donna Gherardi 1 , Riccardo Zoja 1 , Cristina Cattaneo 1

1 Institute of Legal Medicine, University of Milan, Italy

Oral Presentation: Forensic pathology 8, June 4, 2021, 4:00 PM - 5:45 PM

Introduction : In the field of forensic pathology, the term "suspicious death" refers to any death where there is uncertainty about the circumstances. There are numerous reports in literature in which impression at the scene of crime have deceived investigators and only the autopsy allowed for the identification of the manner of death. Yet in this historical period, forensic pathology does not seem to have an adequate connection with justice. In fact, in many countries, it seems to be losing importance, and countries, such as France have proceeded to reform the medicolegal system. In this study, the experience of the Institute of Milano, Italy, is presented. The findings have made it possible to reflect on the current state of forensic medicine and on the behavior of the Public Prosecutor's Office in investigating cause and manner of death.

Material and methods : A retrospective study was carried out examining all autopsies performed at the Institute of Forensic Medicine during 2019. After the analysis of the main epidemiological data, it was assessed in how many cases the forensic pathologist in charge carried out a medical-legal inspection at the scene of death, as well as sample collection during the autopsy, and, finally, for how many of such cases the Prosecutor authorized lab analyses.

Results : A total of 699 autopsies were performed. The forensic pathologist was asked to intervene on-site in only 92 (17.8%) cases. In 26.6% (n=186) of these suspicious deaths cases, the deceased was entrusted to the Health Authority and the remaining to the Judicial one. In such cases, the Prosecutor authorized lab analysis (e.g. toxicology, histology, anthropology, genetics, etc.) in 106 cases (20.7%). All steps of medicolegal investigation of death from scene of crime to judicial autopsy and to lab analysis, were performed in only 27 cases (5.2%).

Discussions : Based on the observed forensic reality, it is necessary to emphasize that a medical-legal on-site inspection of the scene of death should always be carried out, with the collection of forensic evidence, as well as it should be mandatory to always perform a complete autopsy and not just external examinations, along with at least toxicology and histology analyses. Indeed, the autopsy is a fundamental tool of health surveillance and protection of Public Health. Our study of one year of activity has shown a preoccupying trend in medicolegal investigations requested by justice.

114

THE SILENCE OF THE VICTIM. CASE REPORT

Ângela Santos 1 , Joana Araújo 1,2 , Catarina Ribeiro 1,3 , Patrícia Jardim 1,2,4

1 National Institute of Legal Medicine, Porto, Portugal

2 Faculty of Medicine Porto University, Porto, Portugal

3 Catholic Portuguese University Porto, Portugal

4 Abel Salazar Biomedical Institute of Porto University, Porto, Portugal

Oral Presentation: Clinical forensic medicine 1, June 4, 2021, 4:00 PM - 5:45 PM

Intimate partner violence is a concept that includes a wide range of abuse types. Often, the victim, due to her own condition of vulnerability, fear and/or dependence towards the aggressor, doesn’t express or even has any awareness of being suffering some kind of abuse, consistently denying any confrontation to this fact. These are the situations that require a careful and diligent analysis, from health professionals, authorities and/or any other person who gets in contact with the victim. On the other side, one should always take into account the autonomy and free will of the victim. The authors present the following case: after an anonymous complaint regarding domestic violence, the victim was submitted a forensic exam within the scope of Criminal Law and Forensic Psychology. The victim was a 61-year-old medical doctor and she reported multiple incidental traumatic events, which resulted, on temporary lesions, during the three years of relationship with her actual boyfriend – a 63-year-old medical doctor. She denied any episode of physical or psychological abuse from her boyfriend and repeatedly noted the stability and complicity in their relationship. After confronting the medical and judicial information provided, many factual and clinical (mainly ophthalmologic) incongruences to the victim’s report came up. Those incongruences led to the compatibility between the initial complaint and the actual occurrence of a perpetrated physical and psychological abuse. It was possible to identify multiple abuse risk indicators, for instance, the unsuitability between the explication of a certain traumatic event and the observed or documented lesion, the lack of explication regarding the injuries, the multiple incongruences during the report from the victim, the delay on seeking for health care, or on the other hand, the repeated admission on different medical services due to unspecific symptoms, the job absence, and, at last, the highly emotional dependence towards the aggressor. Thus, with this work, it is intended to deepen and systematize the approach and alert signs on an alleged case of intimate partner violence, as well as, provide a practical analysis of one specific case of this kind of violence denied by the victim.

115

EVALUATION OF GENERAL FORENSIC REPORTS ISSUED IN THE PEDIATRIC EMERGENCY DEPARTMENT

Ilknur Arslan 1 , Mete Korkut Gülmen 2 , Sıla Aslan 3

1 Adana City and Training Research Hospital, Department of Pediatric intensive care, Turkey

2 Çukurova University Department of Forensic Medicine, Turkey

3 Hatay State Hospital Department of Forensic Medicine, Turkey.

Oral Presentation: Clinical forensic medicine 1, June 4, 2021, 4:00 PM - 5:45 PM

Introduction : Considering the difficulty of obtaining sufficient history, emergency service personnel should be careful and knowledgeable in forensic cases. However, studies have shown that physicians do not have enough information about forensic case reporting and preparing forensic reports. In this study, the general forensic examination reports prepared in the pediatric emergency service will be evaluated in terms of the circular.

Material and method : For this retrospective study; general forensic reports examined belong to forensic cases aged between 1 month and 18 years who applied to the pediatric emergency service of Adana City Training and Research Hospital between 01.01.2018-31.12.2019.

Results : In this study 6577 cases included, 39.9% were girls and 60.1% were boys, the mean age was 126.4 ± 70 (2-216) months; 42.9% of the cases applied in 2018 and 57.1% in 2019. The most common reason was traffic accidents (35.1%). Laboratory examination was not required in 82.7% of the cases, radiological examination was not performed in 65.9% of the cases. The percentage of the cases that were treated on an outpatient basis were 77.5%, 12.4% were hospitalized, and 4% were observed in the emergency department. In 57.4% of the cases, there was no information in the reports about how the events occurred. In 54.9% of the reports no information about the complaint of the person applying to the hospital was found. In 58.1% of the cases, there was information about the lesion detected as a result of the physical examination, while in 41.9% of the cases, any lesion was not detected or stated. In 41% of the reports, there was no information about systemic examination. Life-critical conditions were present in 8.1% of the cases, there was no life-critical situation in 86.4% of the cases. While the percentage of the cases that can be solved with simple medical intervention was 49.8, the situations that cannot be solved with simple medical intervention were detected in 26.9% of the cases and in 23.3% of the cases there was no information about simple medical intervention. A final forensic report was prepared for 4.4% of the cases, while it was stated that 54.6% of the cases had a temporary forensic report, in 40.9% of the cases no information was given about the temporary or final forensic report.

Conclusion : The Ministry of Health General Directorate of Health Services, stated how the forensic reports should be prepared with the circular dated 22.05.2005 and numbered 13292, which regulates the principles to be followed in the execution of forensic medicine services. However, we have observed that physicians take an incomplete approach in preparing forensic reports. In order to eliminate this deficiency, activities such as training and symposiums for physicians and emergency service personnel should be organized more frequently.

116

Diagnosis violence: a pilot study indicating the inadequacy of emergency wards in detecting and preventing physical abuse.

Lidia Maggioni 1 , Stefano Tambuzzi 1 , Stefano De Vecchi 1 , Alessandra Kustermann 2 , Giorgio Massimiliano Costantino 3 , Cristina Cattaneo 1,2

1 LABANOF, Istituto Di Medicina Legale, Dipartimento Di Scienze Biomediche Per La Salute, Università Degli Studi Di Milano, Italy

2 Service for Sexual and Domestic Violence (SVSeD), Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy

3 Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy

Oral Presentation: Clinical forensic medicine 1, June 4, 2021, 4:00 PM - 5:45 PM

Introduction : "Violence" is commonly considered to be any behavior of abuse of power and control, exercised by one subject over another. Victims of any kind of violence, especially those who suffer injuries, both physical and psychological, can access the health service and interface with the figures who work in it. The purpose of this paper is to analyze the "performance" of first aid doctors in the management of victims of violence (in the absence of clinical forensic doctors), examining the plethora of symptoms found by doctors during the examination, the concrete activities carried out by health professionals and, finally, the data reported in the related medical records.

Material and methods : The medical records of all patients obtained in 2017 at the Emergency Department of the Policlinico Hospital of Milan were examined, classified by health professionals as victims of violence perpetrated by a third party (about 1.22% of patients, n=991). For each medical record 53 parameters were analyzed including epidemiological data, relating to the characteristics of the incident, the clinical modus operandi, especially with reference to diagnosis of type, manner and age of trauma.

Results : Of the 991 medical records examined, 52.4% refer to male patients and the age groups most represented are those between 19-39 (55% of subjects). Victims arrive in the emergency room within 2 hours of the incident in 34% of cases. In 80.5% of cases the doctor diagnosed a blunt force injury, most represented to the head and face (32.8% and 53.5%). In the medical record an exhaustive description of the lesions (including at least 4 parameters: location, size, color, shape, etc.) was present only in 4.1% of cases. In 99.3% of cases no clothing belonging to the victim or attacker was kept and photographs of the injuries were taken in only 2.8% of cases.

Discussion : The correct fulfillment of a medical-legal protocol during the medical examination in the Emergency Room is essential not only for a proper administration of justice with respect to perpetrators but also and especially as a preventive measure: identifying any victim of abuse in time may prevent the worse scenario and save lives; in particular this process frequently must start from the emergency room. The study revealed the lack of attention paid by doctors to the description of facts and lesions, the lack of a photographic record and of thorough sampling of any biological and inorganic trace, probably due to a poor preparation in clinical forensic medicine and to the lack of acknowledgment that identification of manner, cause and time of trauma is indeed a medical act which has the goal of preventing harm and therefore the disease of violence. Measures must be taken in order to correct this dangerous trend.

117

EVALUATION OF TRAUMATIC COGNITIVE IMPAIRMENTS

Emin Biçen 1 , Halil Ilhan Aydogdu 1 , Sibel Caglar Atacan 1 , Afrodit Falihi 1

1 The Ministry of Justice Council Of Forensic Medicine, Turkey

Oral Presentation: Clinical forensic medicine 1, June 4, 2021, 4:00 PM - 5:45 PM

Introduction : Head injuries and traumatic brain injury are a serious public health problem impacting 1.6 million people each year in the USA. It is also considerably prevalent across the world and it is even called the "silent epidemic". It is well-known that each year, 55 million people are exposed to traumatic brain injury.

Material - methods : The files of the patients who were referred to our center for disability assessment between January 01, 2019 and December 31, 2019, and who were found to have suffered head trauma at the time of the incident, were retrospectively reviewed. Age, sex, type of incident, location and nature of the lesion with the date of the incident, examination findings, cranial CT and MR imaging results, and neurocognitive test results were analyzed comparatively.

Results : The age of the patients ranged between 14 and 78 years. The mean age was 39.8 ± 14.43, and the median age was 39. 109 (81.3%) of them were male and 25 (18.7) were female. Of the patients who were referred to determine their degree of disability, 43 (32.1%) had a work accident, 83 (61.9%) had a traffic accident, 6 (4.5%) had a physical assault, 2 (1.5%) had a history of firearm injuries. As a result of the examination, imaging tests and neurocognitive test results for the disability assessment of the patients, 87 (64.9%) of them had organic brain damage causing significant cognitive damage. Post-traumatic stress disorder in 5 (3.7%) patients and other trauma-related sequelae (craniectomy defect, epilepsy, hearing or vision loss, etc.) were detected in 8 (6%) patients. In 34 (25.4%) patients, no sequela due to head trauma was detected. WMS-I and WMS-II scores of the patients were found to be significantly lower in the organic brain injury group (P=0.001). Moreover, the test results were determined to be significantly lower among patients with organic brain damage in WMS-IV tests (P=0.001).

Conclusion : The diagnosis of organic brain damage can be made through multidisciplinary clinical examination, radiological imaging, and neurocognitive tests. In traumatic injuries, remarkably severe loss of personal actual information and orientation, as well as serious loss of verbal and logical memory are noted.

118

THE COLOUR PERCEPTION OF EYE WITNESSES WITH NORMAL CLINICAL COLOUR VISION OF THE COLORS OF OBJECTS ILLUMINATED BY ARTIFICIAL LIGHT SOURCES WITH DIFFERENT COLOR CHARACTERISTICS

Kazim Hilmi Or 1

1 Private Office of Ophthalmology, Istanbul, Turkey

Oral Presentation: Clinical forensic medicine 1, June 4, 2021, 4:00 PM - 5:45 PM

Introduction : In forensic science – especially in criminal cases – when there is a crime, the color information in the eyewitness testimonies is important for the court judgement. In recent years, many lamps with different color renderin index have been used for lighting purposes. Individuals with a visual acuity 1.0 and normal clinical color vision can name false colors in artificial lighting conditions without lying.

Material and Methods : 32 subjects were exposed to 12 different color plates on a background gray with human body reflection ratio under different artificial lighting conditions (red LED 50 lux, sodium vapor lamp 50 lux, compact fluorescent 50 lux, white LED 50 lux, room lighting 6500 K 50 lux and room lighting 6500 K 300 lux) according to their personal vocabulary on color. After measuring at 300 lux with high color rendering index (> 90), they evaluated the color plates in terms of type-value-saturation according to the Munsell scale in the same lighting conditions as before. With light sources, certain and similar illuminances are created on the surfaces. A total of 32 subjects, 22 females and 10 males, participated in the study. Subjects used verbal adjectives for the colours they perceived for a total of 60 different conditions and their responses were recorded. The findings of the experiment were tested statistically by Student t test and SPSS.

Results : In all lighting conditions and on all color plates, subjects have shown false statements without lying. The correct spoken ratios were different in only a few of the 72 different combinations of lighting and color plates. Similar results were seen both when grouping close color representations that are used commonly in society and when the colors were scientifically arranged and classified according to Munsell, although in these conditions some colors might be said truely. According to the sex, different color representations for the same color could not be shown except for only two of the 72 different combinations of illumination and color plates. The fact that the colors of the color plates, which were seen in the illumination with a color rendering index > 90, were not correctly described in the Munsell type, generally suggests that the conditions under which the color consistency happens has to be questioned.

Discussion : As result; the findings should be valid not only for the eye witnesses but also for the color perception of judges, prosecutors, lawyers, forensic medical professionals and other members of the society who examined the evidence on similar conditions. Different perceptions of the same color under different lighting conditions (even without mixed light) shows that color perception of eye witnesses can be false without lying.

119

CRITICAL DIAGNOSIS GOES UNNOTICED UNTIL EXPERT OPINION CONCERNING CRIMINAL CAPACITY OF A JUVENILE: CASE REPORT

Nazlican Aras 1 , Burak Baykara 2 , Erdem Özkara 1

1 Department of Forensic Medicine, Dokuz Eylül University Faculty of Medicine, Izmir, Turkey

2 Department of Child and Adolescent Psychiatry, Dokuz Eylül University Faculty Of Medicine, Izmir, Turkey

Oral Presentation: Clinical forensic medicine 1, June 4, 2021, 4:00 PM - 5:45 PM

Description : In Turkish legal system, criminal courts rely on forensic medicine and psychiatry practitioners to conclude whether a person has criminal capacity or not. Because there is no specific guideline or list of diagnoses, evaluations are made on a case-by-case basis. These reports carry great importance as they can help justice system to reach a fair verdict, even further unravel diagnoses that may have been missed by previous physicians. A 16-year-old male was accused of sexual abuse of a 14-year-old girl. The defense claimed that the boy lacked criminal capacity to commit a crime. When asked for their opinion by the court, Institute of Forensic Medicine stated that no mental retardation or childhood psychopathology was found to affect the child's perception of the legal meaning and consequences of the act or his ability to direct his behavior. Therefore, the court found the boy guilty of attempted sexual abuse and sentenced him to six years in prison. The family appealed the court decision and requested that an expert opinion from the departments of forensic medicine and child psychiatry should be taken into consideration.

Discussion : Child’s first psychiatric admission was at the age of 6, with complaints of opposition and enuresis. Over time, many complaints such as attention deficit and hyperactivity, anger and impulse control problems, bizarre obsessive-compulsive behavior, grandiosity observed consequently. He didn’t respond to psychosocial therapies and psychotropic medications, instead his symptoms worsened with certain drugs. It’s concluded from medical reports that these complaints were present while he was on trial, including psychotic-based OCD. Occasionally, ADHD and OCD are transitional diagnoses that show a neurodevelopmental problem which occurs before the diagnosis of schizophrenia. Impulse and behavioral control difficulties, attention deficit and hyperactivity, difficulties in family, social malfunctioning and delinquent behaviors in school are observed, which is called the pre psychotic stage (prodrome psychosis) where functionality deteriorates significantly and the need for treatment becomes evident. In our expert opinion, the delinquent should’ve been diagnosed with early onset schizophrenia, according to DSM-5, impairing his criminal capacity. The delay in the diagnosis of psychotic disorders may result in a forensic case and create multiple victims, including the delinquent. For this reason, it is of great importance that children with certain symptoms should also be evaluated for psychotic diseases and treated in a timely manner for the sake of both the patient and the whole society.

Keywords : juvenile delinquency, expert witness, medico-legal assessment, forensic psychiatry

120

A TURNING POINT IN THE EUROPEAN TABLE GUIDE – TEMPOROMANDIBULAR JOINT APPROACH

Cristina Figueiredo 1 , Américo Afonso 1 , Ana Corte-Real 2

1 Faculty of Dental Medicine, University of Porto, Portugal

2 Faculty of Medicine, University of Coimbra, Portugal

Oral Presentation: Clinical forensic medicine 1, June 4, 2021, 4:00 PM - 5:45 PM

Introduction : Table guides intend to be an equitable tool for medico-legal expertise in disability assessment of the victims. Temporomandibular joint(TMJ) is one of the most complex joints in the human body. TMJ trauma assessment in the medico-legal context is a challenge due to the complexity of TMD. Evidence-based knowledge in the field of TMJ trauma and in temporomandibular joint disorders diagnosis and treatment, provides the necessary data for medico-legal assessment. Aim: The aim of this study was to present a medico-legal approach of TMJ disability, within orofacial trauma. It also aims to present a new perspective within Civil law disability assessment based in TMD diagnosis tool.

Material and Methods : An observational, cross-sectional study was performed within the database of the National Institute of Legal Medicine and Forensic Sciences, Portugal, between 2000-2017. Descriptive and statistical analysis was made.

Results : Post-traumatic orofacial reports (n=2622) included 234 TMJ trauma reports distributed by the civil, labour and criminal law. The majority encompassed criminal law and related to male individuals, followed by civil law that presented similarities between genders. Discussion: TMD are chronic musculoskeletal diseases, with a complex etiopathogenesis, which may be a sequelae from the traumatic event. The categorization of these clinical data is not consensual in the scientific field and, consequently, the comparison issues are hampered by the lack of methodological standardization. The lack of systematic analysis following protocols as Research Diagnostic Criteria for TMD(RDC/TMD) can be highlighted concerning the information on this diagnosis and corresponding disability. On the other hand, the reference value for TMD impairment in European tables provide an indicative value to be assigned by the expert. However, the sequela designation in the table-guides lack padronization according to the standardised protocols and present a wide range of values, difficulting the fixation of impairment values.

Conclusion : A turning point was highlighted regarding medico-legal table guides within Civil law and TMJ disability contexts, in line with the EU strategic program action.

Keywords : Forensic Medicine, Traumatology, Disability evaluation, Temporomandibular joint, Temporomandibular disorders

121

LIMITS OF PROFESSIONAL LIABILITY IN DENTAL PRACTICE

Beatriz Hipólito 1 , Ana Corte-Real 1

1 Faculty of Medicine of the University of Coimbra, Portugal

Oral Presentation: Clinical forensic medicine 1, June 4, 2021, 4:00 PM - 5:45 PM

Introduction : Dental practice is of particular interest because it encompasses both aesthetic and functional components. This study aimed to present Portuguese medicolegal data on corporal damage evaluation related to iatrogenic sequelae during dental practice.

Material and methods : A retrospective study was performed by analysing data from the database of the Laboratory of Forensic Dentistry of the Faculty of Medicine, University of Coimbra, Portugal, from 2017 to 2020.

Results : The medicolegal files (n=31) were selected according to the inclusion and exclusion criteria. Iatrogenic sequelae were categorised as risk: periodontal and neurological injuries, maxillary sinus perforation, hemorrhage, loss of prosthetic rehabilitation, periimplantitis, mandible fracture, temporomandibular disorders (TMD), tooth loss, instrument swallowing and aspiration, accidents with NaOCl, retained tooth, dry alveolitis, oro antral communication and tuberosity fracture. In general sequela was associated mostly with TMD and orthodontic treatment, followed by neurological deficit (37%) and periodontal affection, namely recession (11%).

Discussion and conclusion : Greater attention to these data by professionals was emphasised, especially when considering patient safety and health care quality. This study presents the Portuguese data on professional liability in the field of dental practice, categorising iatrogenic sequelae into the rehabilitation type, as well as the oral rehabilitation procedure and timeline.

Keywords : Professional liability; Injuries and Wounds; Health

Posters

122

TWO AUTOPSY CASES OF TRANSTHYRETIN CARDIAC AMYLOIDOSIS

Masayuki Kashiwagi 1 , Mio Takayama 2 , Mikiko Aoki 3 , Seiya Kato 4 , Kenji Hara 1 , Aya Matsusue 1 , Brian Waters 1 , Ryoko Ohwaki 1 , Kazuki Nabeshima 3 , Shin-ichi Kubo 1

1 Department of Forensic Medicine, Fukuoka University, Japan

2 Tokyo Medical Examiner’s Office, Tokyo, Japan

3 Department of Pathology, Fukuoka University, Japan

4 Division of Pathology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : Amyloid cardiomyopathy is emerging as an important and under-recognized cause of heart failure and cardiac arrhythmias, especially in older adults. This disorder is characterized by extracellular deposition of amyloid fibrils formed from misfolding of secreted light chains (AL) or transthyretin protein (ATTR). In ATTR, amyloid aggregates typically result from excessive accumulation of wild-type transthyretin (ATTRwt) or from protein structural defects caused by TTR gene variants. In ATTRwt amyloidosis, the misfolding of TTR is associated with age (formerly called senile systemic amyloidosis, SSA), mainly affecting the heart, although it has a systemic distribution. We report two forensic autopsy cases of transthyretin cardiac amyloidosis. Case 1: A stopped minivan, driven by a male in his seventies, was bumped from behind by a compact car. The minivan moved forward slightly due to the collision, but started again suddenly, crashed through a guardrail and onto a train track about 10 m below. The car was found severely damaged, several minutes after a collision with a passing train. The driver suffered numerous fractures, and died at the scene of the accident. Case 2: A male in his seventies was found dead in the driver’s seat of his car parked beside his house. The driver's door was open and his right lower leg was outside the car. He had blood on his right lower leg, including his pants and boots. There was a 0.5 cm diameter bruise on the medial right lower leg, leading to a cutaneous vein. There was a pool of blood on the ground next to his right foot. He had a stroke 15 years ago and had been taking the antiplatelet drug cilostazol since then.

Results and discussion : We determined that the cause of death in case 1 was suffocation based on blood aspiration caused by a skull fracture, and the cause of death in case 2 was hypovolemic shock due to the wound on his right leg. The heart weights were 383 g (case 1) and 431g (case 2). Hematoxylin and eosin staining showed patchy and transmural amyloid deposition in the atria and ventricles in both cases. The deposition showed the characteristic apple-green birefringence of the Congo red stain under polarized light. The amyloid was positive for TTR. Therefore, we diagnosed both cases as transthyretin cardiac amyloidosis. These cases may be ATTRwt cardiac amyloidosis. ATTR cardiac amyloidosis is a less severe prognosis than AL cardiac amyloidosis.

123

INTRAUTERINE BLUNT HEAD TRAUMA DUE TO MOTHER FALLING FROM HEIGHT: A CASE REPORT

Gulislam Agacan 1 , Birol Demirel 1

1 Department of Forensic Medicine, Gazi University Faculty Of Medicine, Ankara, Turkey

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

A 33 weeks pregnant woman, whose age was not revealed, falls from the third floor of her own residence. A witness calls the ambulance. The patient was conscious when she was brought to the emergency room and said that she does not have any recollection of the event. Her father claimed that he was not aware of his daughter’s pregnancy, and assumed the swelling in her feet and abdomen was due to some kind of kidney disease. Examination of the patient revealed that she had a right humerus fracture and vaginal bleeding. After the decision of fetal intrauterine death, the dead baby was delivered, and a systemic medico-legal autopsy was performed on the newborn to determine the cause of death and to complete other essential assessments. No visible traumatic findings were identified on the external examination at the autopsy of the male newborn. There was also no sign of maceration. Internal examination revealed diffuse subcutaneous hemorrhage, a compression fracture in the vertex, and a linear fracture from the vertex to the right temporal bone. Subarachnoid hemorrhage was detected in the left temporal lobe and the right parietal lobe. The histopathological analysis confirmed the subarachnoid hemorrhage in the brain, 4 mm atrial septal defect in the heart, and meconium aspiration in the lungs. Findings from the biochemical examinations revealed that there were no chemical substances in the baby's body, including quinine, ergotamine, and misoprostol which are commonly used for forced abortion. The cause of death was determined as skull fractures and subarachnoid hemorrhage due to blunt traumatic head injury.

Discussion : Falling is the second most common cause of trauma during pregnancy. It is also known that the risk of falling is higher in the third trimester. When blunt trauma occurs, it is expected that factors like maternal soft tissue and amnion fluid absorb the impact of the trauma and prevent direct fetal injury. We present a rare case where the mother did not get a lethal injury, but the fetus has died as a result of blunt head trauma despite it is widely accepted that serious maternal injuries are predictive factors for stillbirth and fetal injuries. In this case, it can be thought that the baby protected the mother from a fatal injury by absorbing the trauma on the contrary to the usual situation. Treatment and clinical management of pregnant women with traumatic injuries is a complex process. It is important that healthcare professionals cooperate and report to judicial authorities when necessary. Forensic medicine professionals should remember that in autopsies of stillbirth cases, it is essential to examine the body both for traumatic patterns and for the findings to determine whether there is a desire for an illegal abortion.

124

AN AUTOPSY CASE OF TRAUMATIC CEREBRAL INFARCTION DUE TO VASCULAR INJURY AND THROMBOEMBOLISM

Akira Hayakawa 1 , Rie Sano 1 , Yoichiro Takahashi 1 , Haruki Fukuda 1 , Takafumi Okawa 1 , Rieko Kubo 1 , Yoshihiko Kominato 1

1 Department of Legal Medicine, Gunma University, Graduate School of Medicine, Maebashi, Japan

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Case description : An 84-year-old woman was found unconscious after being hit by a car while crossing the road. CT scan demonstrated slight acute left subdural hematoma, traumatic subarachnoid hemorrhage accompanied by intraventricular puncture, vertebral fracture, multiple rib fractures, pelvic fractures, and ulnar fracture. The patient was comatose and treated symptomatically. Subsequent CT scans conducted on the day after admission showed improvement of the arachnoid hemorrhage and subdural hematoma, and no indication of cerebral hernia. Contrast-enhanced CT scans showed no sign of contrast agent extravasation in the pelvis. Because spontaneous breathing returned two days after the accident, the ventilator was withdrawn. After a while, however, bradycardia and bradypnea appeared gradually, subsequently leading to cardiac arrest and death. Postmortem CT (PMCT) and forensic autopsy were performed 22 h after death. Other than the findings of previous CT at the hospital, PMCT showed low density and swelling in the territory of the right middle cerebral artery. External examination at autopsy demonstrated multiple abrasions and subcutaneous hemorrhages throughout the body. Internal examination demonstrated acute subdural hematoma, traumatic subarachnoid hemorrhage, cerebral contusion, intraventricular hemorrhage, cerebral hernia, and cerebral infarction corresponding to the area perfused by the right middle cerebral artery. Vertebral fracture, multiple rib fractures, pelvic fractures, radial fractures, and anemia in various organs were also observed. Histopathological examination revealed a lumen-obstructing thromboembolism just before the right anterior choroid plexus bifurcation of the right middle cerebral artery. The thrombus was coated with fibrin, and showed little reaction with the vascular endothelium, indicating that the interval from thrombus formation to death had been approximately 1-2 days. Cracking of the atheroma and thrombus formation were observed at the origin of the right middle cerebral artery.

Discussion : Traumatic cerebral infarction is one of the most severe complications of traumatic brain injury, and its prognosis is poor unless appropriate medical intervention is performed early. In this case, the patient had been hit by a car, resulting in damage to the intima of the origin of the right middle cerebral artery. The resulting thrombus had obstructed the right middle cerebral artery peripheral to the vascular injury, causing extensive cerebral infarction in the area supplied by this artery. Based on the temporal changes in CT findings and the time elapsed after thrombus formation inferred from the pathological changes in the thrombus, it was estimated that the traumatic cerebral infarction had resulted from the vascular injury sustained at the time of the accident. Findings of successive CT scans performed from the antemortem to postmortem periods suggested progressive thromboembolism followed by cerebral infarction, as well as pathological examination verified the timing of the vascular injury based on the findings of the vascular intima and thrombus.

125

A CASE REPORT ON COMPLEX SUICIDE BY SELF-STABBING AND JUMP FROM A CLIFF

Zoi Argyropoulou 1 , Catarina Gomes 1 , Oleksandr Shaychuk 1

1 National Institute of Legal Medicine and Forensic Sciences of Portugal, Lisbon, Portugal

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Complex suicides are defined as suicides in which more than one method is applied. Complex suicides account for 1.5 – 5 % of all suicides and can be divided into further sub-categories such as planned and unplanned. In planned complex suicides, two or more methods are employed simultaneously in order to ensure that the outcome will be fatal (even if one fails). On the contrary, unplanned complex suicides, include a succession of suicide methods after the first method has failed, caused too much pain or has not led to death quickly enough. The methods used for committing a planned complex suicide reflect the spectrum of the classical methods of suicide. Here we report a case of a planned complex suicide by self-stabbing in the neck and jumping from a cliff. The victim was a 22-year-old man, suffering from depression, found at the bottom of the cliff in Cabo da Roca, in Sintra, Portugal. At first inspection, besides the multiple blunt force trauma injuries, the victim presented a stab wound on the right side of neck. Testimonies on site reported the victim stabbed himself on the neck with a knife before jumping from the cliff. The autopsy findings where consistent with blunt force injuries on the skin (bruises, abrasions and lacerations), multiple cranial fractures and lacerations of the meninges and brain tissue, contusion of the heart and lungs, parenchymal lacerations of the liver and right kidney, and a comminuted fractured of the right scapula. The neck injury presented a fusiform shape, clean-cut edges and breached through the subcutaneous tissue and muscle, between the right carotid artery and jugular vein, leaving the vessels intact and reaching the C5/C6 discus and dura mater. Police investigation found the victim’s car in a nearby area with a suicide note inside. The knife was nowhere to be found. The cause of death was attributed to the traumatic lesions of the head, thorax and abdomen and the manner of death concluded to be suicide. In this case, we focus on a planned complex suicide using an uncommon combination of methods of death. We conclude that a meticulous examination of both the surroundings and the victim’s medical history, plus a full medico-legal autopsy are necessary to clarify such unusual cases and exclude a third-party intervention.

126

FORENSIC MULTIDISCIPLINARY APPROACH TO A CASE REPORT OF HUMAN REMAINS: GENETIC, ANTHROPOLOGICAL AND TOXICOLOGICAL FINDINGS

Camilla Tettamanti 1 , Rosario Barranco 1 , Simonetta Verdiani 1 , Francesca Frigiolini 1 , Alessandro Bonsignore 1 , Francesco Ventura 1

1 University of Genova, Department of Legal and Forensic Medicine, Genova, Italy

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Case Description : A case of skeletal remains, found wrapped in a blanket in a forest in the Liguria region (Italy) during the summer, is herein presented. It emerged shortly after, that three months before the skeleton was found, two people had reported the disappearance of their brother, a 50 years-old man with a history of drugs addiction. Therefore, a complete autopsy was performed with the scope of personal identification and determining the cause of death. The process followed a number of steps: first the forensic pathologist performed an anatomical reconstruction of the skeletal remains, presented in five separated plastic bags. Traumatic and pathological lesions were excluded. Then, an anthropological evaluation was carried out, based on the analysis of the skull and the pelvis to determinate the gender, an evaluation of the skull, pelvis and IV rib to estimate the age and the measurement of the size of femoral and humeral bones to estimate the height. Afterwards, a collection of the following samples was carried out: the sole small part of decomposed soft tissue (in the right arm) and some hairs for the toxicological analysis, the head of the femur and two molar teeth for the genetic identification. The only relatives available for the comparison of genetic tests were the brother and the sister of the missing person, as both parents were dead and cremated. In order to overcome such a critical issue, both STRs and Y polymorphisms analysis were carried out to compare profiles obtained by dental samples and stubs: the results obtained using a dedicated software to calculate the likelihood ratio for parentage showed a compatibility between the skeletal remains and the relatives. Moreover, the interpretation of the anthropological data - obtained using Meindl’s, Lovejoy’s, Brooks’ and Suchey’s, Maillart’s, and Iscan’s methods, Eliakis’ Formula and skull and hip key-points, according to the Literature for gender estimation - suggested that the remains belonged to a man, aged between 54 and 64 years, with an height of approximately 180 cm; these features matched with the description of the alleged relatives.

Discussion : The interpretation of the combination of genetic and anthropological results allowed a highly accurate personal identification of the skeletal remains. The toxicological analysis of muscles sample (Gas Chromatography-Mass Spectrometry) reveled a concentration of 37.8 μg/g of morphine. Hair samples confirmed morphine positivity in proximal 2 cm: the related Literature suggests that, in this case, the cause of death is to be attributed to an opioid overdose. It can be concluded, therefore, that only a careful and complete forensic approach, consisting of autoptic, genetic, anthropological and toxicological analysis, allows to obtain, in a case of human remains, an accurate personal identification and a precise determination of the cause of death.

127

CHALLENGING DIFFERENTIAL DIAGNOSIS IN DEATH: GIANT CELL MYOCARDITIS, CARDIAC SARCOIDOSIS AND IDIOPATHIC GRANULOMATOUS MYOCARDITIS

Carlos Pontinha 1,2 , Mário Sardinha 1 , Diana Logrado 1

1 National Institute of Legal Medicine and Forensic Sciences, Lisbon, Portugal; 2 Central Lisbon University Hospital Centre, Lisbon, Portugal

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Case description : The authors present the case of a 45-year-old man who was in a train station when sudden dyspnoea installed, evolving into cardiorespiratory arrest, with subsequent fall to the railway line. No information on personal history was available. At the autopsy, we saw traumatic injuries not suitable to produce death, which were compatible with the reported fall, as well as signs of therapeutic intervention. We also observed the presence of a pacemaker; the myocardium was pinkish-brown with a purple area in the interventricular septum and an extensive whitish area in the proximal two-thirds of the septum and entire left ventricle. Toxicology exams revealed no substances in the tested samples. The histopathological study revealed an extensive non-necrotizing granulomatous inflammatory process with giant cells. Special stains did not identify microorganisms. These histological findings were compatible with cardiac sarcoidosis, idiopathic giant cell myocarditis and granulomatous myocarditis. In order to help with the differential diagnosis, further samples from different organs were analysed: lungs, liver, and kidneys. None showed granulomatous inflammatory processes. We made efforts to gather personal history data, to no avail.

Discussion : Cardiac sarcoidosis, giant cell myocarditis and idiopathic granulomatous myocarditis are granulomatous diseases that share both clinical and histological characteristics. They are rare entities, which distinction is not clear in the literature. Additionally, some studies point to giant cell myocarditis being part of the cardiac sarcoidosis spectrum. The sarcoidosis diagnosis is facilitated by the recognition of non-necrotizing granulomas involving other organs, but in situations where the only organ affected is the heart, it is especially difficult to distinguish. Epidemiologically, giant cell myocarditis has a higher incidence in young and middle-aged adults, coursing with fulminant myocarditis, while sarcoidosis affects mainly young adults, having a more indolent course. The case presented illustrates the various diagnostic difficulties, since histologically no evidence of extra-cardiac sarcoidosis was observed, and epidemiologically the deceased’s age fitted both pathologies. In addition, there was a lack of information on the personal history and, strictly speaking, on the period prior to death. This case aims to draw attention to rare and potentially fatal clinical entities, which are difficult to diagnose either post mortem or, especially, ante mortem, and that require different treatment.

128

RECENT ADVANCE OF MYCOLOGY TO APPLICATION IN FORENSIC CASEWORK

Hideaki Kato 1 , Sanae Kanno 1 , Mamiko Fukuta 1 , Yoshimi Nakamura 1 , Jun Ohtaki 1 , Yasuhiro Aoki 1 , Takashi Yaguchi 2

1 Department of Forensic Medicine, Nagoya City University Graduate School Of Medical Sciences, Nagoya, Japan

2 Chiba University Research Center for Pathogenic Fungi and Microbial Toxicoses, Chiba, Japan

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : the value of fungi to forensic investigation had been confined mainly to cases involving poisoning or the illicit use of psychotropic species to date. Recently, the usefulness of fungi in the setting of providing trace evidence, estimating the postmortem interval had been reported. Case 1:In April, a 81-year-old female was found with mummification in her house. She was suffered from mental disease and sometimes alluded to suicide to her friends. Whitish colony was noted in her neck and nose. Penicillium corylophilum was identified in her nose and neck, and Rodotolura mucilaginosa was identified in her neck by isolation culture and biochemical investigation. Postmortem interval was speculated from 1 to 2 months. Case 2:In July, a nearly skeletonized adult corpse was found from inside the house. No obvious injury was observed in his body. Autopsy was carried out but cause of his death was not identified. Whitish colonies were attached to the bottom of his right foot. Penicillium citrinum, Aspergillus sydowii, and Yarrowia lipolytica were identified from the colony in his foot by isolation culture and biochemical investigation. Approximately 1 month was considered to be passed since death. Case 3: In October, a nearly skeletonized adult corpse was found in the bedroom in his house. Autopsy was carried out and no significant finding was identified. Whitish colonies were observed in the right side of his face. Aspergillus sydowii was identified in his face by isolation culture and biochemical investigation.

Discussion and Conclusion : Fungi were occasionally observed on the cadavers at the forensic casework. Analyzing fungi might provide the useful information such as, trace evidence and estimating time since death, investigating cause of death and so on. Accumulation of data is required to establish fungi as a forensic tool.

129

ESTIMATING GESTATIONAL AGE OF A TUBAL ECTOPIC PREGNANCY. A CASE OF MATERNAL DEATH

Emmanouil Sakelliadis 1 , Konstantinos Katsos 1 , Michael Sofopoulos 1 , Dimitrios Vlachodimitropoulos 1 , Chara Spiliopoulou 1

1 Department of Forensic Medicine and Toxicology, Medical Faculty, National And Kapodistrian University Of Athens, Greece

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Despite biomedical engineering progress and the opportunity for early prompt diagnosis, ectopic pregnancies still represent a remarkable cause of maternal death. Such cases may have legal implications for some medical practitioners, especially gynecologists. In our case, a young woman died after complaining about abdominal pain. Autopsy revealed hemoperitoneum due to left fallopian tube rupture. A small villiform tissue was observed in the ruptured tube. Microscopic examination of this tissue sample revealed findings compatible to first semester pregnancy. A few years later, we have been informed that in the context of litigation, gestational age was more precisely determined from 9th to 12th week, based on the absence of nucleated red blood cells. A second expert opinion about estimating gestational age was requested to be performed in our Department, resulting to an extended review of the literature. According to the literature, clinical experience has indicated that tubal pregnancies present different growth rates than intrauterine. Moreover, ectopic pregnancy embryos may present null development. A few studies have suggested various approaches to the histopathological estimation of gestational age, such as tubal diameter, ki-67 expression, and morphological characteristics of tertiary chorionic villi. Nowadays, gestational age is estimated via ultrasonographic approach. The last menstrual period, reported by the pregnant woman, is used as an aid for early-timed estimations. A more precise gestational age estimation requires many factors to be taken under consideration, in order to draw scientifically correct, and evidence-based conclusions. In the forensic context, gestational and embryonic age is estimated mainly by morphological characteristics of the fetus. In everyday medical practice, it is common knowledge that a positive finding is establishing the diagnosis, as a negative one cannot simply confirm it.

130

ANTIPSYCHOTIC-RELATED FATAL PULMONARY EMBOLISM: MEDICO-LEGAL IMPLICATIONS THROUGH CASE-SERIES

Syrine Azza Manoubi 1 , Marwa Boussaid 1 , Mohamed Amine Mesrati 1 , Yosra Mahjoub 1 , Meriem Boughattas 1 , Abir Aissaoui 1

1 Legal Medicine Departement Of Taher Sfar Teaching Hospital, Mahdia, Tunisia

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Case description : We describe four cases of fatal pulmonary embolism occurring in patients put on antipsychotics. They received between two and three different antipsychotics on average. For three patients, a past medical history of psychosis beyond ten years have been noted, unlike the fourth patient who had just been diagnosed with a Brief psychotic disorder. None of them had a common risk factor for venous thromboembolism excepting heavy smoking in two cases and obesity in the two others. For all of them, blood levels of different antipsychotics taken were within the norms. Prophylactic measures against thromboembolic events haven't been performed in any case. For the four situations and based on the necropsy findings associated with the histopathological examination, death was attributed to massive thrombotic pulmonary embolism.

Discussion : Thromboembolic events are one of the side effects of antipsychotics treatments. This side effect had been associated with both first and second-generation antipsychotics independently from the duration of the therapy, the medication compliance, and the dose of the prescribed drug. The cases of fatal pulmonary embolism following antipsychotics intake diagnosed after an autopsy have been reported. Even if no complaint has been filed following the death of these patients, it is important to raise the awareness of psychiatrists for this complication to avoid the engagement of their criminal and civil liabilities. These cases provide additional evidence on the role of antipsychotics in the occurrence of thromboembolic complications. Psychiatrists have to prescribe these treatments with high caution. We encourage them to make clear screening guidelines for anticoagulant prophylaxis to optimally manage this life-threatening side effect.

131

SUDDEN DEATH RELATED TO CARDIAC HYDATID CYST OF THE RIGHT VENTRICLE IN CHILDREN: CASE REPORT

Oumaima Brahim 1 , Elyes Turki 1 , Bilel Gammoudi 1 , Firas Hagui 1 , Elaa Chebbi 1 , Sara Ben Abderrahim 1 , Raja Ghzel 2

1 Department of forensic medicine, Ibn El Jazzar University Hospital, Kairouan, Tunisia

2 Department of medicine emergency, Ibn El Jazzar University Hospital, Kairouan, Tunisia

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Case description : A 9-year-old boy with no medical history who died suddenly after a sudden onset of acute chest pain. The deceased had grown up surrounded by animals in a rural area of the city of Kairouan in the center of Tunisia. At autopsy, there was multi-visceral congestion and epiglottis edema. Cardiac dissection revealed a cystic formation protruding into the right ventricle. The cyst was enveloped by a thickfibrous tissue, and it featured germinative membranes, which infiltrated the myocardium. It was reptured and contained a floating membrane and several small vesicles. Toxicological analyses were negative. A hydatid serology using the Elisa method turned out to be positive. Microscopic examination ascertained the diagnosis of a reptured cardiac hydatid cyst. The death was related to a fulminant anaphylactic shock caused by the sudden and spontaneous rupture of an isolated cardiac hydatid cyst.

Discussion : Secluded cardiac involvement by E. granulosus is very uncommonespecially in children. Its incidence isestimated to be at about 0.5-2% of hydatidcyst cases. The coronary circulation is the main pathway by which the parasitic larvaer each the heart. The interventricular septum and the free wall of the left ventricular are the most common cardiac sites involved with hydatid cyst (55-60%). However, identification of an isolated right ventricle located hydatid cyst, like in our case, is atypical and quite rare. Unless it’s in a critical anatomic site, cardiac hydatid disease is usually diagnosed late, as patients can manifest non-specific symptoms such as cough, palpitations and chest pain. The cyst may affect cardiac function leading to conduction and rhythmic disturbances, angina, acute myocardial infarction or valvular dysfunction. Cystic rupture is the most frequent complication (24-60%) and generally results in anaphylactic reaction with circulatory collapse. Other complications may occur leading to death, such as pericarditis, embolus, cardiac tamponade and cardiac arrhythmias. This case highlights the value of the autopsie in the diagnosis of unexpected cases of cardiac hydatid cyst when death occurs before medical intrvention.

132

DEATH IN THE PSYCHIATRIC SETTING: ACTIVITY OF FORENSIC DEPARTMENT OF SFAX TUNSIA

Houssein Lebkem 1 , Wiem Ben Amar 1 , Narjes Karray 1 , Elaa Chebbi 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 CHU, Sfax, Tunisie

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : The excess of mortality rates of patients in psychiatric hospitals is a universal clinical finding. In fact, this mortality is reported to be two to three times as high as in the general population. However, in Tunisia, this mortality rates and the causes of death remain little known. Here, we aim to assess the peculiarities of death among psychiatric patients hospitalized in the region of Sfax in Tunisia and to suggest preventive measures.

Material and methods : This is a retrospective descriptive study of all cases of patients in psychiatric hospitals death collated in the forensic department of Habib Bourguiba university hospital in sfax-Tunisia during a 3-year period (1 st January 2017 to 31 st December 2019).

Results : During this period, 66 deaths were collected. The average age was 43.7 years with a standard deviation of 15.03 years. The majority of victims were males (74.2%). They were mostly without profession (51.5%), low educated (50%) and from urban origin (56.1%). The deaths were violent in 53% of cases. The natural deaths were noted only in 12 victims. The suicide with intoxication was the majority mean used by the victims (8 cases of suicide by intoxication among 22 cases of all types of suicide). The death was accidental in 9 cases.

Conclusion : Our study allows us to conclude that a large proportion of patients in psychiatric hospitals deaths are preventable. This prevention can be by more training the staff on the identification of the suicidal crises and improving the psychiatric setting health coverage like making unit of intensive care in this service.

133

DEADLY INTOXICATION WITH PARAPHENYLENE DIAMINE: 14-YEAR STUDY

Houssein Lebkem 1 , Wiem Ben Amar 1 , Malek Zribi 1 , Narjes Karray 1 , Moulaye Ahmed Dhehby Ahmedou 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 CHU, Sfax, Tunisie

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : Paraphenylene diamine (PPD) is a toxic aromatic amine that has long been used by women for hair dye. In Tunisia, this product is known as "Dabghet El Maghreb". PPD poisoning has become increasingly common in our country. The objective of our work is to determine the circumstances of this toxic death in order to propose a preventive strategy.

Patient and methods : This is a retrospective descriptive study of all cases of death that have undergone a forensic autopsy for PPD intoxication at the Forensic Medicine Service of Sfax-Tunisia for a period of 14 years (2006-2019).

Results : We collected 11 cases during this period. The average age was 28.9 years [19-66] with female predominance. Most of the victims were unemployed (64%), of rural origin (91%) and single (73%). Intoxication was probably suicidal in most cases. The concept of family conflict was noted in 64% of cases. Intoxication occurred at home in 91% of cases. Death was in hospital in 64% of cases. At autopsy, pulmonary, cerebral and laryngeal edema were found in 91% of cases. The toxin was present in the urine in 27%, in the blood 46%, and in the stomach 36% of cases.

Conclusion : The high frequency and seriousness of PPD poisoning justifies the establishment of a preventive strategy and strict regulation of the use of this product to combat this phenomenon.

Keywords: Paraphenylenediamine, poisoning, death, diagnosis, prevention

134

IMPLICATIONS OF THE COVID-19 PANDEMIC IN THE MANAGEMENT OF THE BODIES OF DECEASED PATIENTS IN HOSPITALS IN TUNISIA

Jaweher Kammoun 1 , Malek Zribi 1 , Wiem Ben Amar 1 , Narjes Karray 1 , Houssein Lebkem 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic departement Habib Bourguiba Hospital- Sfax, Tunisia

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

SARS-CoV-2, the virus that causes COVID-19, is a pathogen classified in GR3 (risk group 3) which can cause polymorphic clinical symptoms and complications which can be fatal. It should be considered, in principle, that the risk of contamination is the same in a deceased patient as in the living patient. Therefore, care should be taken when handling the body of the deceased. In the current state of the SARS-CoV-2 pandemic, it is necessary to be familiar with the situations requiring a systematic virological sample as well as those which require the immediate immediate brewing of the body of the deceased. In addition, the declaration of death from a communicable disease must never be omitted when the disease is confirmed by a positive test. The Covid-19 disease pandemic was capable of creating radical changes all over the world and prompted us to urgently set up treatment guides and resuscitation services in order to provide timely care for people infected with the coronavirus. In this work, we propose to set out the rules recommended by the National Authority for Health Accreditation and Assessment in the management of the bodies of patients who died in hospitals in the era of the Covid-19 pandemic. We detail the procedures to follow in the event of a patient infected with the SARS-CoV-2 virus dies in a Covid-19 unit, a patient who died in a hospital service other than the Covid-19 unit, and whether or not posing an obstacle forensic at burial.

135

IMMUNOHISTOCHEMICAL DETECTION OF HEME OXYGENASE-1 IN ACUTE MYOCARDIAL INFARCTION

Yuko Ishida 1 , Yumi Kuninaka 1 , Mizuho Nosaka 1 , Emi Shimada 1 , Akiko Ishigami 1 , Akihiko Kimura 1 , Hiroki Yamamoto 1 , Fukumi Furukawa 1 , Mariko Kawaguchi 1 , Toshikazu Kondo 1

1 Wakayama Medical University, Wakayama, Japan

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Heme oxygenase-1 (HO-1) is an inducible stress-response protein that imparts anti-oxidant and anti-apoptotic effects. However, its significance in forensic diagnosis of myocardial infarction (MI) is unknown. We immunohistochemically examined the expression of HO-1 in MI heart samples to discuss their forensic applicability to determination of the MI. The heart samples were obtained from 23 MI cases and 33 non-MI cases as controls. HO-1 positive signals in cardiocyte nuclear were detected in 78.2% MI cases, however, that were detected in only 24.2% control cases with statistical difference between MI and control groups. In contrast to HO-1 protein expression, there was no significant difference in the appearance of myoglobin pallor regions and leukocyte infiltration in the hearts between MI and control cases. From the viewpoints of forensic pathology, immunohistochemical detection of HO-1 in hearts can be considered a valuable marker to diagnose MI.

136

FORENSIC PATHOLOGICAL STUDY ON TEMPORAL APPEARANCE OF DENDRITIC CELLS IN SKIN WOUNDS

Yumi Kuninaka 1 , Yuko Ishida 1 , Mizuho Nosaka 1 , Emi Shimada 1 , Akihiko Kimura 1 , Hiroki Yamamoto 1 , Fukumi Furukawa 1 , Mariko Kawaguchi 1 , Wolfgang Eisenmenger 2 , Toshikazu Kondo 1

1 Wakayama Medical University, Wakayama, Japan

2 University of Munich, Germany

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Dendritic cells (DCs) can essentially contribute to innate and adaptive immune system in various organs. A double-color immunofluorescence analysis was carried out with anti-CD11c and -HLA-DRα antibodies to detect DCs in 53 skin wounds (their postinfliction intervals: Group I, 0-3 days; Group II, 4-7 days; Group III, 9-14 days; and Group IV, 17-21 days). CD11c+HLA-DRα+ DCs were first observed in skin wounds with postinfliction intervals of 3 days, and the DC numbers were found to be elevated in skin wounds with the subsequent increase in postinfliction intervals. Semi-quantitative morphometric analyses showed that the DC number was the highest in the 12-days-old wound. More than 50 DCs were present in 8 of 10 samples (80%) in Group II and 14 of 16 samples (87.5%) in Group III, and there was no difference between the two groups. Thus, the presence of DCs in a skin wound was possibly estimated as a postinfliction intervals of at least 3 days. Furthermore, when a skin wound contained >50 DCs, its age would be judged as 4-14 days. Collectively, the appearance of DCs in human skin wounds may provide useful information in determining the age of a wound.

137

FIBRINOLYTIC ROLE OF CX3CR1 AND ITS APPLICATION TO THROMBUS AGE ESTIMATION IN DEEP VEIN THROMBOSIS MODEL MICE

Mizuho Nosaka 1 , Yuko Ishida 1 , Akiko Ishigami 1 , Yumi Kuninaka 1 , Hiroki Yamamoto 1 , Emi Shimada 1 , Yumiko Hashizume 1 , Mariko Kawaguchi 1 , Akihiko Kimura 1 , Toshikazu Kondo 1

1 Department of Forensic Medicine, Wakayama Medical University, Wakayama, Japan

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : In the processes of formation and resolution of venous thrombi, several biological events such as the intrathrombotic leukocyte accumulation and the remodeling of extracellular matrices, are often found. We previously demonstrated the pathophysiological roles of inflammatory cytokines in the processes of thrombus resolution using genetically engineered mice. In this study, the pathophysiological roles of CX3CR1 in the resolution of DVT on wild-type (WT) mice and Cx3cr1-deficient (Cx3cr1 KO) mice were examined.

Methods : In anesthetized mice, the inferior vena cava (IVC) was exposed via an abdominal laparotomy, and ligated with silk suture. At 1 to 21 days after the ligation, the thrombosed IVCs were harvested. Immunohistochemical staining of thrombosed IVCs were performed. In each section, five microscopic fields were randomly selected (magnification ×1,000), and the number of positive cells within the thrombi were counted and summed.

Results : Immunohistochemically, in WT mice intrathrombotic CX3CR1-positive cells could be found 3 days after IVC ligation in all mice. At 3 and 5 days, the positive cell numbers were smaller than 15. At 7, 10 and 14 days, the positive cell numbers were over 15. Concomitantly, the gene expression of Cx3cr1 was detected in the thrombi. When Cx3cr1 KO mice were treated in the same manner, thrombus size was much larger than WT mice. Moreover, the blood flow of the IVC was more recovered in WT than in Cx3cr1 KO mice. Intrathrombotic Mmp2, Plat, Plau and Vegf mRNA expressions were significantly reduced in Cx3cr1 KO mice than in WT ones. These observations indicated that the absence of CX3CR1 impaired fibrinolytic activity.

Conclusion : Collectively, the temporal changes of intrathrombotic CX3CR1-positive cells in thrombus formation and resolution can be an useful index for thrombus age determination. Moreover, CX3CR1 can have benefit roles for the thrombus resolution by inducing MMP2, uPA, tPA and VEGF expression. CX3CR1 can be a good molecular target for the DVT treatment.

138

ASSOCIATION BETWEEN STIMULANT-CONTROLLED CLOCK GENE REGULATION AND THE EXPRESSION OF DRUG-METABOLIZING ENZYMES

Naoto Tani 1,2 , Tomoya Ikeda 1,2 , Tatsuya Hirokawa 1,2 , Shigeki Oritani 1 , Takaki Ishikawa 1,2

1 Department of Legal Medicine, Osaka City University Medical School, Osaka, Japan

2 Forensic Autopsy Section, Medico-legal Consultation and Postmortem Investigation Support Center, Osaka, Japan

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : Circadian clock genes regulate the expression of the drug-metabolizing cytochrome P450 enzymes, thereby contributing to the time-of-day-dependent processing of drugs. In fact, the pharmacokinetic characteristics of a drug are known to vary greatly depending on the dosing time. How stimulants affect the expression of drug-metabolizing enzymes through the regulation of circadian clock genes was investigated.

Materials and Methods : The expression of the clock genes BMAL1 and PER2 was analyzed by real-time polymerase chain reaction in human hepatoma-derived HepG2 cells exposed to methamphetamine (MA). The same conditions were used to examine the transcriptional regulation of genes encoding the drug-metabolizing enzymes CYP3A4 and CYP2D6. The expression of these two genes was also assessed in an experiment in which BMAL1 levels in HepG2 cells were reduced by siRNA knockdown. Furthermore, the regulation of BMAL1, PER2, CYP3A4, and CYP2D6 was evaluated by gene expression and immunohistochemical analyses in 54 autopsy cases involving the intake of a stimulant, using liver tissue samples collected within 48 hours after death.

Results : Following the addition of MA to HepG2 cells, the expression of BMAL1 and CYP2D6 decreased as the stimulant exposure time elapsed. In contrast, PER2 mRNA levels increased in a time-dependent manner, and the magnitude of this increase was proportional to the concentration of MA. When MA concentrations were high, CYP2D6 mRNA levels increased one hour after stimulant addition, but decreased at three hours. The expression of CYP3A4 and CYP2D6 was elevated when BMAL1 levels were decreased by siRNA. Under the same knockdown conditions, MA treatment enhanced the transcription of CYP3A4 in a time-dependent manner, while it lowered the expression of CYP2D6. In autopsy cases of stimulant intake, the expression of PER2 and CYP3A4 was elevated as blood stimulant concentrations increased. In contrast, CYP2D6 expression was enhanced when blood stimulant levels were moderate, and was reduced at higher stimulant concentrations.

Discussion : These results demonstrate that the reduction of BMAL1 levels leads to the induction of both CYP3A4 and CYP2D6. They also indicate that stimulant intake affects the expression of genes encoding circadian clock components, as well as drug-metabolizing enzymes.

139

A COMPARATIVE STUDY OF PLEURAL EFFUSION IN WATER AREA, WATER TEMPERATURE AND POSTMORTEM INTERVAL IN FORENSIC AUTOPSY CASES OF DROWNING

Akiko Ishigami 1 , Masayuki Kashiwagi 2 , Yuko Ishida 1 , Kenji Hara 2 , Mizuho Nosaka 1 , Aya Matsusue 2 , Hiroki Yamamoto 1 , Brian Waters 2 , Shin-ichi Kubo 2 , Toshikazu Kondo 1

1 Wakayama Medical University, Wakayama, Japan

2 Fukuoka University, Fukuoka, Japan

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Japan is surrounded by the sea and has many rivers, and drowning as the cause of death is the second most frequent in the world. Storage of pleural effusion is one of major findings and found in about 80 per cent of drowning death cases and the time for disappearing is relatively long. We measured the weight of lungs, that of pleural effusion (PE), and their sum as the intrathoracic (IT) weight (total weight of lungs + pleural effusion), and calculated the ratio of pleural effusion [(PE weight/IT weight)x100]. A total of 131 drowning death cases diagnosed through forensic autopsy were investigated in this study. The diagnosis was based on macroscopic findings, microscopic findings and diatom test. The cases of open pleural cavity, pleural adhesion and infants were excluded. The cases were classified as the water area (fresh water, brackish water and sea water), the water temperature (under 18°C, more than 18°C) and postmortem interval (less than 1 day, 1-3 days, more than 3days). Each examined parameter showed no significant difference between injuries, drug, chemicals, ethanol-positive and -negative groups. The preset study demonstrated that the ratio of pleural effusion would be more effective for diagnosis of drowning. However, the accumulation of pleural effusion would be affected by water area, water temperature and postmortem intervals. Collectively, it is important to assess the ratio of pleural effusion under consideration of these factors in an autopsy cases of victim found in the water.

140

INFLAMMATORY CYTOKINE-INHIBITING MECHANISMS ATTRIBUTABLE TO CENTRAL NERVOUS SYSTEM DISORDERS

Tomoya Ikeda 1,2 , Naoto Tani 1,2 , Miho Watanabe 1 , Tatsuya Hirokawa 1 , Kei Ikeda 1 , Fumiya Morioka 1 , Takaki Ishikawa 1,2

1 Osaka City University Medical School, Osaka, Japan

2 Forensic Autopsy Section, Medico-legal Consultation and Postmortem Investigation Support Center, c/o Department of Legal Medicine, Osaka City University Medical School, Osaka, Japan

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Inflammatory pathology and its inhibiting mechanisms in central nervous system disorders, mainly the cerebral edema that is seen in stimulant drug and heatstroke autopsy cases, were investigated using biochemical and histopathological tests and experiments with cultured nerve cells. (Specimens and Methods) Using right heart blood and cerebrospinal fluid from 87 autopsy cases, mainly involving stimulant drugs and heatstroke, biochemical tests and immunohistochemical tests of the cerebral parietal lobe were conducted for interleukin (IL)-6, IL-8, nerve-specific enolase (NSE), and myelin basic protein (MBP). Changes in markers under various environments in cultured nerve cells were also investigated. (Results and Discussion) In both blood and cerebrospinal fluid, IL-6 showed significantly higher values in stimulant drug cases, and IL-8 showed significantly higher values in stimulant drug and heatstroke cases, compared with other causes of death. Excluding heatstroke, there were no obvious differences in NSE and MBP in blood and cerebrospinal fluid between causes of death. The results of immunostaining showed high staining of NSE and MBP in heatstroke. In cultured nerve cells, NSE and IL-8 showed high levels in a heatstroke model in which the culture temperature was raised. In groups administered 4-aminopyridine and ephedrine as a stimulant drug model, the rates of increase in IL-6, IL-8, NSE, and MBP were not higher than in the heatstroke model. When IL-8 was administered to counter the increase in IL-6 in culture solution under each condition, there was an inhibitory effect on IL-6. These results showed that heatstroke cases have mainly nerve cell structural damage, whereas stimulant drug cases have central nervous system damage centered on inflammatory changes. It was also shown in culture experiments that IL-6, which is seen at the start of these inflammatory changes, is inhibited by IL-8, suggesting that IL-8 may act as an inflammation inhibitor when inflammation starts in the body.

141

BIOCHEMICAL AND HISTOPATHOLOGICAL STUDY OF IMMUNOGLOBULIN A EXPRESSION IN MUCOSAL TISSUE IN CASES OF CENTRAL NERVOUS SYSTEM DYSFUNCTION

Yayoi Aoki 1 , Tomoya Ikeda 1,2 , Naoto Tani 1,2 , Tatsuya Hirokawa 1,2 , Fumiya Morioka 1 , Kei Ikeda 1 , Alissa Shida 1 , Kazunori Miyamoto 2 , Takaki Ishikawa 1,2

1 Department of Legal Medicine, Osaka City University Medical School, Osaka City, Japan

2 Forensic autopsy section, Medico-legal Consultation and Postmortem Investigation Support Center (MLCPI-SC), Osaka City, Japan

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : Immunoglobulin A (IgA) plays a central role in immune mechanisms on the mucosal surface. However, the immune mechanisms involved in central nervous system (CNS) dysfunction associated with hypoxic-ischemic encephalopathy or hyperthermia are unknown. In this study, biochemical and pathological changes in IgA were investigated in autopsy patients with various forms of CNS dysfunction.

Materials and Methods : Sixty autopsy patients (causes of death including sharp instrument injury, blunt injury, asphyxia, drowning, methamphetamine intoxication, hyperthermia, hypothermia, and sudden cardiac death) were investigated. IgA levels were measured in right heart blood by turbidimetric immunoassay, and hematoxylin and eosin-stained and IgA-immunostained paraffin-embedded samples from the gastrointestinal tract and lung were scored. The immunostaining of gastrointestinal tract tissue was scored on a five-grade scale (1: none, 2: slight, 3: moderate, 4: high, and 5: maximum). The staining patterns of lung tissue were categorized as granular/membranous staining or mild, moderate, or high-level staining.

Results : The IgA level in blood was high in patients who had died by asphyxia and low in those who had died by hyperthermia or methamphetamine intoxication. Immunohistochemical testing showed that the lungs of patients who had died from hypothermia, methamphetamine intoxication, or sudden cardiac death exhibited mainly membranous staining, whereas those who had died from asphyxia exhibited a mixture of granular and membranous staining. Although gastrointestinal tissue tended to be somewhat strongly stained in patients who had died from hypothermia, there were no significant differences among the various causes of death.

Discussion : A comparison of IgA levels in the right heart blood by cause of death showed that IgA levels were elevated in individuals who had died from asphyxia and whose brain was in an acute hypoxic-ischemic state. However, they were decreased in cases of methamphetamine intoxication or hyperthermia, in which death was caused by CNS dysfunction as a result of drug use or high ambient temperature. This result suggested that IgA secretion is maintained in hypoxic states, and that in CNS dysfunction, immune function itself may be impaired and IgA secretion suppressed. Immunohistological tests of the mucosal surface, which is key to the immune mechanism of IgA, showed that, in the lungs of individuals who had died from asphyxia, IgA formed granules detached from the mucosal surface in some patients. However, IgA detachment and loss from the mucosal surface were not seen in any case of death from methamphetamine intoxication or hyperthermia. These findings suggest that a hypoxic state in the CNS may have a strong effect on IgA secretory function.

142

THE CLINICAL AND FORENSIC KARONTE DATABASE IN VICENZA-ITALY: USEFULNESS OF INFORMATION FROM 2308 AUTOPSIES FOR HEALTH FOR ALL/WHO

Vito Cirielli 1 , Chiara Dalle Carbonare 2 , Andrea Galassi 1 , Alessandra De Salvia 3 , Michela Colombari 2 , Umberto Nardi 1 , Gianmaria Fanchin 1 , Roberta Tamiozzo 1 , Stefania Turrina 2 , Domenico De Leo 2 , Matteo Brunelli 4

1 Unit of Forensic Medicine, Department of Prevention, U.L.S.S. 8 BERICA, Vicenza, Italy

2 Unit of Forensic Medicine, Department of Diagnostic and Public Health, University of Verona, Italy

3 Unit of Forensic Medicine, Department of Prevention, U.L.S.S. 2 MARCA TREVIGIANA, Treviso, Italy

4 Unit of Pathology, Department of Diagnostic and Public Health, University of Verona, Italy

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Aim and scope : The database of indicators on the health system and health in Italy should be structured in such a way that it can be queried by the HFA (Health for All) software provided by the World Health Organization adapted to national needs. The WHO categorization have been recently updated and encounters 10 sections, among which the first (Group-1), named socio-demographic context, accounts the overall mortality as subcategory and the second section (Group-2) lists the cause of death as main category. International (Eurostat) and national (Istat) database do need spoke-data at any level, in order to recruit ongoing information. We detailed our clinical and forensic regional database built in Unit of Forensic Medicine, Vicenza Hospital, Veneto Region, Italy.

Materials and methods : Clinical and forensic autopsies registered in a database named KARONTE at Vicenza Hospital, were reviewed, during the period between March 2009 and February 2018. Both clinical and forensic data were registered. Date of autopsy, sex, age, primary cause of death, secondary morbidity, further diseases and additional notes were audited along columns of excel.

Results : 2308 autopsies were recorded, mean 59 years old, 1548 males; 760 females. 1606 (69%) cases were clinical autopsies and 702 (31%) were forensic cases. The majority of deaths occurred among the 60 to 79 years age group (Group-1 WHO). The leading primary cause of death (Group-2 WHO) observed was cardiac arrest associated with acute myocardial infarction, cardiomyopathies, coronary atherosclerosis or cardiovascular abnormalities, followed by sepsis and respiratory conditions. 206 cases (9%) involved intrauterine fetal death. The majority of deaths in forensics cases is related to accident (34, 5%), overdose (35, 5%) and gunshot trauma (20, 3%). Deaths for work-related injuries were 5 (0.7%). Homicides and suicides involved gunshot fatal injuries were 23 cases (3%). Hanging and drowning were the most common manner in suicides cases, respectively 54 (8%) and 14 (2%) cases of 702. Software analysis poned the big data into graph and tabular forms for critical evaluation.

Conclusion : 1) worldwide international/national or regional database, such as KARONTE database, are useful to recruit information for Group-1 and 2 Health for all/WHO categories; 2) both clinical and forensic information available in database are needed to promote strategy for public health; 3) again, crude number analysis, percentages, tables, graphs and/or maps may be obtained and simple software allows to represent the statistical data in graphical and tabular form; 4) at light of COVID-19 pandemia, it is therefore possible to view the historical series of the indicators, make forecasts and compare several indicators in different years for all available territorial units and compare cause of death along pre-COVID-19 era and the actual era.

143

ACCIDENTAL DEATHS IN THE ELDERLY: A RETROSPECTIVE STUDY OF FORENSIC AUTOPSIES IN CENTRAL TUNISIA

Bilel Gammoudi 1 , Elyes Turki 1 , Oumaima Brahim 1 , Firas Haggui 1 , Elaa Chebbi 1 , Maroua Naouar 1 , Wael Majdoub 1

1 Forensic Medecine Service Ibn El Jazzar Kairouan Tunisia, Tunisia

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : Accidental mortality is a major public health problem worldwide. Despite the improvement in life expectancy in recent years, it seems that many accidental deaths in the elderly could still be avoided with suitable prevention. The objectives of our study were to determine the epidemiological, socio-demographic and thanatological characteristics of accidental deaths in the elderly in the region of Kairouan, center of Tunisia, and to assess the priorities for action in terms of prevention.

Material and Methods : It is a retrospective descriptive study of the cases of accidental deaths in the elderly autopsied in the Department of Forensic Medicine of Ibn El Jazzar University Hospital of Kairouan, Tunisia, during 07 years between 2009 and 2015.

Results : From 2009 to 2015, a total of 1938 forensic autopsies were carried out. Among them 367 (18.93%) were aged over 65 years. 72 cases (19.61%) were accidental deaths in the elderly. The mean age was 75.84 years. The majority of the victims were male (81.9% vs 18.1%). Most of the deceased were from rural regions (79.2%). Traffic accidents were the most frequent circumstance of death (73.6%) followed by domestic accidents (19.4%) and accidents in the workplace (5.6%). 47% of the victims of traffic accidents were pedestrians and 23% were motorcycle drivers. The types of domestic accidents were as follows: fall 11.11%, animal bites 2.77 %, drowning 1.38 %, accidental gunshot injury 1.38 %, thermal burns 1.38% and carbon monoxide poisoning 1.38%. Multiple injuries were the cause of death in 66% of the cases of traffic accidents and in 20% of falls. Isolated head injuries were the cause of death in 60% of traffic accidents and in 20% of falls.

Discussion : The majority of the victims (81.9%) were male in our study. In France, in 2006, there were 18549 deaths from domestic accidents. Male excess mortality was observed: 32.2 / 100,000 in men vs 19.4 / 100,000 in women. In our study, traffic accidents were the most frequent circumstance of death accounting for 73.6% of the cases. In Australia, the death rate has risen among drivers aged over 65 years since 2010. Fall prevention programs have proven their efficiency in terms of reducing the risk of falls, the number of hospitalizations and limitation of loss of functional autonomy. Those programs consist on reconditioning balance and walking, by implementing specific exercises. It is essential to support retirees in the preservation of elderly‘s health, promote their autonomy at home, maintain their quality of life.

144

SUICIDE IN CHILDREN AND ADOLESCENTS: A TUNISIAN PERSPECTIVE FROM 2009 TO 2015

Bilel Gammoudi 1 , Elyes Turki 1 , Oumaima Brahim 1 , Firas Haggui 1 , Elaa Chebbi 1 , Maroua Naouar 1 , Wael Majdoub 1

1 Forensic Medecine Service Ibn El Jazzar Kairouan Tunisia, Tunisia

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : Suicide is defined as “all cases of death resulting directly or indirectly from a positive or negative act of the victim himself, which he knows will produce death”. In Tunisia, little data are available about the epidemiology and the characteristics of suicide, mainly because of the absence of official statistics. The aim of this study was to analyze the epidemiologic, social, and forensic aspects of children and adolescents who ended their lives by committing suicide and were living in Kairouan, (Tunisia).

Material and Methods : It is a retrospective descriptive study of the cases of child and adolescent those were autopsied in the Department of Forensic Medicine of Ibn El Jazzar University Hospital of Kairouan, Tunisia between 2009 and 2015.

Results : A total of 49 cases, with a female predominance (61.2%) and a mean age of 15.4 ± 2.1, were registered. Most of the victims were from rural areas (93.1%). In most cases, suicide occurred in the victim’s home or the surrounding area (73.4%). The identified precipitating factors were family problems in 55.1%, and school issues in 12.2%. The most common suicide method was hanging (69.38%) for both genders, followed by self immolation for males and poisoning for females, the majority using pesticides

Discussion : The governorate of Kairouan followed by Bizerte, Nabeul, Kasserine and Gafsa recorded the highest number of child suicide cases. Our data showed that child and adolescent suicide increased after the revolution. In a study on the impact of 2008’s economic crisis in 54 countries, there were about 4900 excess suicides in the year 2009 compared with the expected number based on previous trends. In our study, suicide occurred more commonly among females with a female to male ratio of 1.6:1. In contrast, a higher suicide rate among teenage females was recorded in China, India, and some Middle Eastern countries. In our study, factors that were found to be most common precipitating suicide were family problems, school issues, and the break-up of romantic relationships. A study carried out in Turkey in 2009 by Uzun et al. showed that 15% of the victims had miscellaneous family problems while 8% of them had school problems. In our study, the majority of the suicide victims hanged themselves. Firearm suicides and jumping from a high place are the most common modes of suicide in the USA and Hong Kong, respectively. In our study, we had only one case of firearm suicide because of the stringent regulatory framework on firearms in Tunisia.

145

MEDICO-LEGAL AND HISTOPATHOLOGICAL ASPECTS IN DEATHS CAUSED BY HYPOTHERMIA

Andreea-Alexandra Hleșcu 1 , Laura Rîșcanu 1,2 , Adriana Grigoraș 1,2 , Cornelia Amălinei 1,2

1 University of Medicine and Pharmacy ”Grigore T.Popa”, Iasi, Romania

2 Institute of Legal Medicine, Iași, Romania

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : Thermal aggression through exposure to low temperatures has profound implications in forensic practice, representing an area of interest for research due to the complex issues it raises, both in terms of diagnosis of death and the mechanisms involved in death determinism. The aim of the study is to highlight the lesions caused by hypothermia in the heart and kidneys tissues.

Material and method : The study group included 71 cases diagnosed with hypothermia at the Institute of Legal Medicine Iasi, selected from our files. In order to select the study group, the circumstance of death and the quality of the archived biological material have been evaluated. As a consequence, inadequate material due to autolysis and putrefaction or cases in which another diagnosis of death was established after the initial histopathological analysis were excluded, despite of favourable circumstances of death. Haematoxylin-eosin (H&E) staining was performed for each heart and kidney fragment and Periodic acid (PAS) staining was added for kidney specimens.

Results : The average age was 57.80 years, with age range between 91 and 56 years old, with a predominance of males (78.9%). The necropsy examination of the corpse showed the frostbite described by Keferstein in 72% of cases, Wischnewski petechial in 26 cases (36.6%), stomach retraction or Puharevici sign in 34 cases (47.9%), scrotal retraction or Puparev's sign in 34 cases (60.7%). Microscopic examination of heart tissue in the investigated cases revealed the presence of foci of myocardial degeneration, the accumulation of lipid inclusions in the cytoplasm of cardiac striated muscle cells, and the presence of contraction bands. Tubular cellular vacuolization due to the deposits of cytoplasmic lipids and glycogen have been identified in kidneys.

Discussion : Our results are consistent with literature, supporting the value of circumstances of death, environmental characteristics, and exposure to cold which indicates the hypothermia involved in the mechanism of death. The macroscopic examination of the suggestive signs, along with microscopic examination demonstrating degenerative lesions in both organs (heart and kidneys) may support the diagnosis of hypothermia.

Conclusion : The macroscopic study correlated with the microscopic examination of the heart and kidneys tissue fragments obtained during necropsy provide valuable clues for the diagnosis of death caused by hypothermia.

146

AN AUTOPSY CASE OF A SOLVENT ABUSER

Hiroshi Kinoshita 1 , Naoko Tanaka 1 , Mitsuru Kumihashi 1 , Mostofa Jamal 1 , Tadayoshi Yamashita 1 , Shoji Kimura 1

1 Kagawa University, Kagawa, Japan

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

We present a fatal case of solvent abuser. A male in his forties was found dead in his house, with numerous empty vinyl bags and the bottles containing mixture of toluene and methanol were nearby. Autopsy showed no evidence of external injury, and comorbid diseases were also excluded. Concentrations of toluene, methanol and formic acid in a femoral venous blood sample were 20.1 μg/mL, 0.21 mg/mL and 25.2 μg/mL, respectively. No ethanol was detected in blood sample, and drug screening using a TriageTM test panel (Biosite Diagnostic Inc, San Diego, CA) yielded negative results. Toluene concentration in femoral blood was at a lethal level, and methanol concentration was within a toxic range. Heavy and relatively long-term exposure to toluene was suggested from the high concentration of hippuric acid in urine (12.91 g/L). From the autopsy findings, results of the toxicological examination and investigation by the authorities, we concluded that the cause of his death was due to poisoning of toluene and methanol. Since in some kinds of solvent contain methanol or methanol ester in itself, methanol is sometimes detected in case of solvent abuse. We should also take into consideration about the toxicity of methanol.

147

ROLE OF THE INTERNET IN THE EMERGENCE OF NEW FATAL METHODS OF SUICIDE: AN AUTOPSY CASE

Wiem Ben Amar 1 , Nihel Feki 1 , Hela Siala 1 , Malek Zribi 1 , Hassen Ennouri 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Habib Bourguiba Hospital, Sfax, Tunisie

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

The choice of the method of suicide varies considerably according to the gender, the environmental and intrinsic factors specific to the person. Recently, it has been established that the availability of information about suicide, particularly on Internet search engines, has an important influence on the choice of the suicide method. Thus, the availability of factual and detailed information increases the number of suicides, in particular by poisoning by an odorless and painless gas. This method has become the most preferred method of suicide especially among women due to the facility, accessibility and efficiency of this method. In this work, we report an original case of suicidal asphyxiation by using helium gas. In this case, a young woman researched suicide on the Internet and found an advocated method of suicide using helium. The forensic investigation showed a body discovered at the home, lying on the ground and no signs of violence were noticed. On the other hand, a plastic bag tightened by a ribbon around the head with the presence of a plastic tubing inside the bag connected to a Helium bottle were objectified by the investigators. Autopsy findings were suggestive of asphyxia, but were otherwise negative. This case is reported for its originality due to the unusual method of suicide employed, but also duo to the difficulties to confirm the diagnosis. From this case, we will discuss the interpretation of the autopsy examination, toxicological analyses and the role of the Internet in the rapid dissemination of information on highly fatal suicide methods.

148

SUICIDE WITH NITRITE: ANALYTICAL AND FORENSIC PATHOLOGICAL ISSUES

Nicola Pigaiani 1 , Francesco Taus 1 , Federica Bortolotti 1 , Guido Mazzoleni 2 , Michele Brevi 1 , Franco Tagliaro 1,3 , Rossella Gottardo 1

1 Unit of Forensic Medicine, Department of Diagnostics and Public Health, University of Verona, Italy

2 Pathology Service, South Tyrol Local Health Authority, Bolzano, Italy

3 Laboratory of Pharmacokinetics and Metabolomic Analysis, Institute of Translational Medicine and Biotechnology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

In recent years, a significant increase of reports about suicidal cases due to intentional sodium nitrite intake has been described. In the medicolegal context, the investigation of intoxication cases by sodium nitrite, without any suspicion, is not straightforward. Indeed, in some cases, the lack of crime scene data or pathological signs could make difficult the detection of nitrite poisoning. Moreover, the determination of nitrite in whole blood is challenging, due to its instability being rapidly oxidized to nitrate by hemoglobin. Although several methods have been proposed for the clinical determination of nitrate and/or nitrite in biological samples, none of these is specifically focused on the determination of these ions in cadaveric samples, and the diagnosis of nitrite fatal intoxication in forensic context is generally based on methemoglobin quantification. The present paper reports the optimization and validation of analytical method based on capillary zone electrophoresis (CZE) with UV detection, for the determination of nitrite and nitrate in biological fluids and its application to two authentic cases of nitrite intoxication. The analyses were carried out on a bare fused-silica capillary (75 mm inner diameter) using 100 mM tetraborate (pH 9.24) as background electrolyte and applying a voltage of - 15 kV. The detection was obtained by direct UV absorption recorded at 214 nm wavelength. Bromide was used as internal standard. Linearity was established in the range of 250-5000 μmol/L). Reproducibility (intraday and day-to-day) was good with relative standard deviations (RSDs) < 14.7 % for peak areas. The method was applied to the determination of nitrite/nitrate in two real forensic cases and in both high concentrations of nitrate (6500 and 4400 μmol/L) were found in blood samples. Nitrite was found only in not quantifiable traces due to the instability of this ion in cadaveric blood, being converted to nitrate. The present method represents a new tool for the determination of nitrite in post-mortem samples including nitrite overdoses and therapeutic nitrate intoxications, without the need of methemoglobin determination.

149

MEDICO-LEGAL ASPECTS OF THE TRADITHERAPY BY THE OIL OF CADE

Jaweher Kammoun 1 , Malek Zribi 1 , Wiem Ben Amar 1 , Hela Siala 1 , Hassen Ennouri 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic department Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : Traditherapy or traditional medicine has been a daily practice in Tunisia. The traditherapy with oil of cade can be used by healers to treat children. This practice can sometimes lead to death. Many charlatans in our country still use this substance despite the illegality of its use. We propose to study the medico-legal and legal aspect of the tradithérapie by cade oil through 3 cases of death in children who have undergone this practice.

Cases reports : We collected 3 cases of intoxication with cade oil. The socioeconomic level was low for all children. The arguments of the use of these behaviors were the parental convictions of the effectiveness of these means against the failure of the modern means. The average age was 14 months 8 days. The sex ratio was 2. The mean interval of onset of digestive symptoms was 14 hours on average. Autopsy was performed in only one case. Legislation has affected all victims with a statement to the Child Protection Officer. Toxicological analysis was performed on all victims for diagnostic and forensic purposes. It was positive for organophosphates. We noted a decrease of the cholinesterase activity.

Conclusion : The intoxication of the child as part of unconventional care is a voluntary attack on his physical integrity. Toxicological investigations have their place in the diagnostic orientation and must be carried out quickly. The signs of intoxication are often ephemeral hence the interest of the medical file which must be perfectly realized. Prevention is important based on the sensitization of both parents and health staff to prevent death.

150

PRIMARY FORENSIC EVALUATION OF FATAL POISONING IN SFAX, TUNISIA

Wiem Ben Amar 1 , Hela Siala 1 , Malek Zribi 1 , Moulaye Ahmed Dhehby Ahmedou 1 , Houssein Lebkem 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Habib Bourguiba Hospital, Sfax, Tunisie

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : Fatal poisoning remains a frequent cause of death in the world and also in Tunisia. The incriminated products are of different natures. Our objective is to draw up the epidemiological profile of the victims of fatal intoxications in the region of Sfax (Tunisia) in order to develop adequate preventive measures.

Material and Methods : We performed a retrospective and descriptive study of all cases of toxic related death occurring and examined in the forensic medicine department of Habib bourguiba hospital in sfax Tunisia, between January 1st 2006 to December 31st 2019.

Results : We collected 106 cases of death secondary to a toxic cause. The average age of the victims was 30 years and 2 months [7 months-85 years]. A male victim predominance was observed (sex ratio: 1.05). The intoxications occurred during the winter season (30.76%) and at the victim's home (94.33%). It was mostly accidental form (54.71%) followed by the suicidal form (45.28%). The suicidal motive was family conflict, followed by emotional shock and financial problems. Carbon monoxide was the most common incriminated product (40.38%), followed by organophosphates and drug intoxication. Depending on the incriminated toxin, external examination showed the presence of miosis (20%) and a carmine red coloration of the lividities (37.5%). At autopsy, cerebral and pulmonary edema and the presence of a product in the stomach were the most common findings. As for the toxicological examination, it was positive in 68% of cases.

Conclusion: Toxic death is a frequent cause of death in Tunisia. This study could be a key element to implement specific preventive measures.

151

FORENSIC EVALUATION OF FATAL CARBON MONOXIDE POISONING

Malek Zribi 1 , Hela Siala 1 , Wiem Ben Amar 1 , Jaweher Kammoun 1 , Hanen Dhouib 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Habib Bourguiba Hospital, Sfax, Tunisie

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : Carbon monoxide (CO) poisoning remains the leading cause of death from toxic origin in the world and also in Tunisia. Our aim is to describe the trends of Carbon monoxide death in Sfax (Tunisia), the victim's profile in order to establish preventive measures.

Materials and Methods : We conducted a retrospective and descriptive study of all carbon monoxide death collected and examined in the forensic medicine department of Sfax, Tunisia between January 1st, 2011 and December 31, 2019.

Results : We collected 41 cases of deaths related to carbon monoxide poisoning. The average age of the victims was 32 years and 2 months and a male predominance was identified. Deaths occurred in winter (61%), at home (97.65%) and at work (2.43%). As for medico-legal form, it was accidental in all cases. The poisoning was collective in 44% of the cases. The source of CO was mainly the faulty water heater often placed in poorly ventilated areas (56%) followed by the braséros (22%). The classic aspect of carmine red lividities was found in the majority of cases. The average level of HbCO in the blood was 51.59% [15.30% -76%].

Conclusion : Fatal carbon monoxide poisoning persists as a public health problem in Tunisia. Currently, there are no national statistics available on the incidence of this type of poisoning in Tunisia. The creation of a national registry and reportable diseases of all cases of poisoning may prove useful for preventing it in future generations.

152

LEGAL AND ETHICAL ISSUES RELATED TO TELE-MEDICAL ASSISTANCE

A Wiem Ben Amar 1 , Hanen Dhouib 1 , A Malek Zribi 1 , Narjes Karray 1 , Moulaye Ahmed Dhehby Ahmedou 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic Department Habib Bourguiba University Hospital, Sfax, Tunisia

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Telemedicine has revolutionized the field of health. One of the most interesting fields of telemedicine is tele-medical assistance. It appears more and more as a relevant solution to meet the challenges facing health systems. However, despite all these advances and considerable progress, it can be a source of many ethical and legal conflicts. In this paper, we propose to analyze the legal and ethical issues related to the practice of tele-medical assistance. We conducted a survey of surgeons practicing at three university hospitals in Tunisia concerning tele-medical assistance. We designed a questionnaire comprising 16 items with simple choice questions:

A first part collecting information on participants’ characteristics (sex, age, specialty, grade).

A second part inviting them to describe their experience in videoconferencing.

A third part concerning their opinion concerning the benefits of medical tele-assistance, as well as its ethical and legal issues.

We shared the questionnaire using google Forms. A total of 39 surgeons responded to the questionnaire. Among the participants, only 14 (35.9%) had an idea about the concept of remote support. The participants found that videoconferencing surgical tele-assistance fully respects patient privacy and the confidentiality of their data in 38% and 30.8% of cases, respectively. 77% of participants felt that informing the patient about the course of the procedure and its video recording is mandatory. In addition, for 31 participants (79%), the collection of consent must be carried out in writing. In addition, 43.6% of the participants thought that teleassistance does not really expose the surgeon to an additional medico-legal risk that could involve 'advantage its medical liability over conventional surgery. The emergence of telemedicine undoubtedly constitutes a fundamental advance in the practice of medicine. However, it is not devoid of medico-legal risks. On the other hand, telemedicine also poses important ethical questions. Although the various acts of telemedicine are intended to respond as well as possible to the various demands of patients, mainly based on improving their quality of life, equity of care for all individuals, promoting their autonomy, concerns relating to privacy protection, patient confidentiality arise.

153

CRIMINAL MEDICAL LIABILITY IN THE CONTEXT OF COVID-19 PANDEMIC

Wiem Ben Amar 1 , Narjes Karray 1 , Malek Zribi 1 , Hela Siala 1 , Jaweher Kammoun 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Habib Bourguiba Hospital, Sfax, Tunisie

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

The COVID-19 infection causes to medical community many difficulties worldwide. In addition to its therapeutic problems, it can generate situations with high medico-legal risk to doctor who can see his criminal medical liability engaged. In fact, in Tunisia, this new infection imposes many specific legal obligations. Some of these obligations have recently been introduced, therefore still little or not known by doctors, despite the need for them to comply with. In this paper, we propose to analyse the circumstances of medical practice in Covid-19 pandemic period, which risk to engage the doctor's criminal medical liability, and to set out the sanctions incurred, in order to protect health professionals against the specific legal risk of this emerging disease.

154

ETHICAL ISSUES OF MEDICAL CONFIDENTIALITY IN THE CONTEXT OF HIV INFECTION

Wiem Ben Amar 1 , Hela Siala 1 , Malek Zribi 1 , Moulaye Ahmed Dhehby Ahmedou 1 , Houssein Lebkem 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Habib Bourguiba Hospital, Sfax, Tunisie

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

AIDS is a growing epidemic around the world. Despite the low prevalence of this epidemic in Tunisia, it continues to raise many questions relating to the rights of patients with HIV infection during treatment. Among these rights, one of the most problematic is the right of the respect of the medical confidentiality. On the one hand, the loss of autonomy at the advanced stage of AIDS leads to discussing the possibility of announcing the diagnosis to the family, especially at the end of life, if the patient refuse the treatments, or to ensure the continuity of medical care. On the other hand, the risk of transmissibility of the disease to others may raise the question of the choice between respecting the confidentiality of patient data and protecting the public health. Thus, through five cases of patients infected with HIV collected in the infectious diseases department of the Hedi Chaker CHU in Sfax, we propose to analyze the problems raised by the application of the medical confidentiality right in the context of HIV infection from a legal, deontological and ethical point of view.

155

HOMICIDE IN THE SETTINGS OF DOMESTIC VIOLENCE WITH A RARE CASE OF ISOLATED MESENTERIC RUPTURE

Svetlozar Spasov, Pavel Timonov, Antoaneta Fasova, Stela Yancheva , Ivan Tsranchev

1 Medical University of Plovdiv, Plovdiv, Bulgaria

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : According to WHO 35% of women worldwide have experienced either physical and/or sexual violence in their lifetime. While blunt abdominal trauma is quite often, an isolated rupture of the mesentery is observed in about 4 to 11% of the cases of blunt abdominal trauma.

Case description : We present a case of 39-years- old woman, who is a victim of a fatal domestic violence committed by her intimate partner with the cause of death being the rare isolated tear of the mesentery of the small intestine. During the crime scene investigation, the clear signs of attempted alteration and concealment of the evidence was noticed. The children of the couple gave false testimonies, claiming that the deceased had fallen down a flight of stairs earlier the same day. During the forensic autopsy multiple traumatic injuries, mainly consisting of contusions and abrasions on the head, neck, chest, abdomen, lower and upper extremities were found. Some of them were fresh and some of them old at a different stage of healing. Besides 6 fractured ribs, no other trauma to the internal organs of the cranial and thoracic cavity was found. In the abdominal cavity a substantial amount of blood, measuring to 2000ml was found. The source of the internal bleeding turned out to be a 10 cm long tear in the mesentery of the small intestine. The soft tissues at the radix of the mesentery of the small intestine, more specifically over the lumbar lordosis were visibly contused. Besides the tear of the mesentery of the small bowel no trauma to other abdominal organs was found. Upon the additional incisions on the back and extremities performed during the autopsy, a contusion of the hypodermis was found in the lumbar area. Along the forearms contusions in the hypodermis and muscles were present.

Discussion : In the case presented, the cause of death was ruled to be acute internal hemorrhage due to a mesentery rupture of the small intestine. While the small intestine is the most commonly involved organ, followed by spleen and liver, only in around 4% to 11% of all cases mesentery is involved as an isolated abdominal injury. Mesenteric tears usually occur during rapid deceleration and very rarely from a direct strike from a blunt object to the abdomen. The isolated mesenteric tear, along with the presence of bruises and abrasions of different ages, located on different regions of the body, which are not prominent and not accessible to be traumatized by accidental falling, points towards the causative object to be blunt with a relatively small surface, such as the human fist or a foot. In the case presented, the isolated rupture to the mesentery became a medico-legal proof of the committed crime.

156

GRIEVOUS INJURIES CAUSED DURING ROAD RAGE INCIDENTS: A CASE SERIES FROM THE BROADER REGION OF ATTICA, GREECE.

Dimitrios Kouzos 1 , Christoforos Kolentinits 1 , Ioanna Anastopoulou 1 , Konstantina Galani 1 , Konstantinos Katsos 1 , Emmanouil Sakelliadis 1 , Chara Spiliopoulou 1

1 Department of Forensic Medicine and Toxicology, Medical Faculty, National and Kapodistrian University Of Athens, Athens, Greece

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Road rage presents an increasing frequency during the last years, a fact that has allowed for adoption of various definitions, possibly in an effort to better describe this phenomenon. Many aggressive behaviors varying from relatively simple (eg. shouting, screaming, and yelling at another driver) to more complex (eg. use of weapon, even the vehicle itself, to incite damage), or even sometimes with attempts to kill, injure or intimidate a pedestrian/another driver/passenger or to damage their vehicle in a traffic incident, may provide adequate description of the actual extent this phenomenon has today. In Greece, a forensic clinical examination is requested by the Authorities when allegations are made by a victim who has sustained injuries after a violent incident. In the Department of Forensic Medicine and Toxicology of the National and Kapodistrian University of Athens, road rage constitutes the fourth most common cause of injuries inflicted during community violence incidents. In most of these cases, victims sustain injuries that are considered as actual bodily harms, whilst grievous injuries are presented in a small but significant proportion. Some of the most severe injuries recorded during road rage incidents include an ankle fracture after a run-over, rib fractures along with spleen rupture after an assault, eye socket fractures, a frontal bone fracture after a blank shot with a firearm, an assault towards a father and his son which led to a nasal bones fracture of the father, a severe lower limb injury after dragging a person along the road through the driver’s window, a blunt force injury to a woman’s face and multiple face injuries caused by multiple blows with a metal object held by the offender. In these cases, a variety of mechanisms had caused the injuries such as weapons, blunt instruments, limbs and even vehicles. In all the aforementioned cases, the offenders were unknown to the victims. As in many countries, so in Greece, road rage is an existing phenomenon. During these incidents, both actual and grievous bodily harms can be observed. Therefore, it is of great importance to inform and educate drivers about the possible consequences of such incidents in order to deter such acts.

157

ELDER ABUSE IN CONTEXT OF CRIMINAL LAW - CASE REPORT

Barbara Smyk 1 , Ricardo Mendonça 1 , Cristina Cordeiro 1,2 , Carla Carreira 1,2

1 Central Branch of the National Institute of Legal Medicine and Forensic Sciences, Coimbra, Portugal

2 Faculty of Medicine of the University of Coimbra, Portugal

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Case description : The case at hand reports an 89-year-old female victim, a retired primary school teacher, brought to the Emergency Room after her neighbours called the authorities due to screaming coming from her house. During the medicolegal examination, she initially stated to have fallen down a staircase at home. However, confronted with the inconsistencies in her story, she admitted that her lesions were inflicted by her son. He would frequently be physically and psychologically violent, punishing her, refusing to provide food and water, and prohibiting her to watch TV. He also controlled her finances. The victim was a widow, living with this son, having three other children who lived in different districts. Physical examination uncovered numerous hematomas, abrasions, and ecchymosis in at least three stages of evolution, dispersed throughout the body surface, namely on the face, thorax, abdomen, and limbs. Apart from the medicolegal evaluation, she was also assessed by social services. Given the characteristics of the lesions (number, bilateral locations, different development stages, and in locations rarely viewed in events of accidental aetiology) we judged the case to be a repeated physical abuse, inflicted by a third party. The circumstances surrounding the case, lead to the assumption that we were facing a life-threatening situation for the victim, and as such, psychosocial care measures were adopted to ensure her treatment and protection.

Discussion : Elder abuse is a kind of abuse with multiple peculiarities. In many cases, the victims are heavily dependent on third parties, which prevents them from defending themselves. Furthermore, frequently the victims do not report the abuse because of shame or the proximity of the perpetrator (frequently being close family members). In these cases, we are also compelled to seek other forms of abuse, such as psychological and economical abuse, or negligence. Considering all the aspects of elder abuse, medicolegal evaluation should be more holistic and complemented with social services intervention applying necessary safety and protection measures. This presentation constitutes an excellent opportunity for literature review as well as it serves as an acknowledgment of the vital importance of interdisciplinary communication and collaboration necessary for the correct evaluation and orientation of these victims.

158

FORENSIC AGE ESTIMATION OF UNACCOMPANIED POTENTIAL MINORS IN PORTUGAL – A CASE REPORT

Sofia Monteiro Cunha 1 , Bárbara Mendes 1 , Ana Rita Marques 1 , Patrícia Jardim 1,2

1 National Institute of Legal Medicine and Forensic Sciences - North Branch, Porto, Portugal

2 Faculty of Medicine of University of Porto, Porto, Portugal

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Forensic Age Estimation is an expertise in Forensic Medicine, which aims to define the chronological age of a person involved in judicial proceedings in the most accurate way. Justice Courts request this evaluation to Legal Medicine Institutes and their Forensic Physicians. For the age assessment methodology, the German Age Study Group recommends taking medical history (including illnesses and medications that could have influenced growth), physical examination (anthropometric data and sexual maturity characteristics), an X-ray of the hand and a dental examination with a panoramic radiograph of the jaw region. If hand skeletal development is complete, an additional CT scan of the clavicles should be requested. The Justice Family Court required a forensic age estimation evaluation in order to seek the probable age of an undocumented male, who 20 days earlier had illegally entered in Portugal through a ship from Casablanca. During the forensic evaluation, he denied any relevant medical background, chronic medication, tobacco smoking or other drugs misuse. He claimed to be 16 years and 9 months of age and to live with both parents and four siblings in Casablanca. He also claimed to enter the ship in Casablanca for fun and did not pretend to leave his country. On physical examination: height 163cm and weight 47.5Kg and Tanner stage 4; we did not find any physical lesions or malformations. We had required the following imagiological exams: an x-ray examination of the hand and an orthopantomography. The age estimation was between 13.7 - 16.1 years old for bone maturation and 13.9 - 20.3 for dental maturation (we used a study of Turkish population because of the absence of studies in Moroccan population). Using the minimum age concept by Schmeling et al, the minimal ages are 13.7 and 13.9 years old. The highest minimum age was 13.9 years old. The most probable age was determined to be 16.8 years old. Depending on the reasons stated by the Justice Court for requesting a forensic age assessment, the expert report made by the Forensic Physician should indicate the most likely age and/or the minimum possible age of the person examined and comment on the plausibility of the stated age. The minimum-age concept ensures that the age estimation is never overestimated but instead usually less that the actual age. If the determined minimum age lies over the stated age, we can rule out the given age; but, if the determined minimum age is under the stated age, the given age is compatible with the reported findings. In this case, as the minimum age diagnosed falls below the age given by the person, the forensic age assessment is compatible with the stated age. The probable age was determined to be 16.8 years old.

159

FREIBERG’S DISEASE AS A WORKPLACE ACCIDENT: ASSESSMENT OF ITS MEDICOLEGAL CAUSATION

Maria Isabel Lemos 1 , Bárbara Santa Rosa 1,2 , Renato Pinho 1

1 National Institute Of Legal Medicine And Forensic Sciences, Portugal

2 Faculty of Medicine of Coimbra University, Portugal

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Causation assessment is not always straightforward. High energy impacts at long bones anatomic segments with associated bruises and linear fractures, usually, do not raise any doubts. However, this may not be true when facing conditions associated with minor traumas. We present a case of a 53-year-old female who injured herself during labour time, as she was barefoot and hit her left toes on a step, falling right after. There’s no relevant past medical history as well as no use of chronic medication. She received medical assistance from the insurance company two days later. On physical examination, there was pain and swelling localized to the second metatarsal head region of the forefoot. A left foot radiograph was performed and showed no fractures. Almost four weeks after the traumatic event, a computed tomography (CT) scan of the same foot revealed no appreciable changes. Two months later, a magnetic resonance imaging (MRI) revealed a subchondral insufficiency fracture in the second metatarsal head, accompanied by bone marrow edema of the same metatarsal head and neck, with inflammatory / edematous changes of the surrounding soft tissues. Initial conservative measures included shoe wear modifications and corticosteroid infiltrations. Afterwards, platelet-rich plasma injections, physical therapy and protected weight-bearing (Barouk shoe). Almost one and a half years after initial trauma, she underwent a Weil osteotomy with bone grafting of the defect and fixation with a screw. A few months after surgery, she developed local swelling on the plantar surface of the foot. An ultrasound study was performed and revealed imaging findings compatible with plantar fibromatosis. When analysing the outlined case, we concluded that the acute injury consisted of a second metatarsophalangeal joint sprain with an associated contusion of the second metatarsus’s head. This initial injury evolved to avascular necrosis, with an established subchondral insufficiency fracture accompanied by bone marrow edema - Freiberg’s disease. As for the discussion of medicolegal causation, although Freiberg’s disease is an uncommon disease which affects females predominantly in the second decade of life, there are some reports on older patients. It is commonly associated with vascular compromise and considered by some as a multifactorial disease. However, it can also be secondary to traumas, as the one stated by the victim. Regarding temporality, the sequence of the injury and the event is appropriate. Although the fracture was only detected two months after the event, this does not represent an objection on causation, when keeping in mind that radiographs and CT scans can be normal on early stages of the disease. Thus, the lack of previous medical history converges to the conclusion that the traumatic mechanism provided and the stated evolution course represent the most likely cause for her condition.

160

CLINICAL FORENSIC EVALUATION OF THE FUNCTIONAL AND AESTHETIC OUTCOMES OF STAB WOUNDS TO THE ABDOMEN AND CHEST IN AN ASSAULT CASE

Eduarda Duarte 1 , Maria Isabel Lemos 1 , Ricardo Dias 1,2

1 National Institute of Legal Medicine and Forensic Sciences, Portugal

2 Institute of Biomedical Sciences Abel Salazar - Porto University, Portugal

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

We present a case of a 27-year-old caucasian man who claims to have been attacked with a knife by an acquaintance. He was transported to the hospital emergency service, where he presented with two incised wounds, one located in the upper region of the left hemithorax (3cm), and the other located in the left iliac fossa (2cm). At physical examination he presentedabdominal guarding. An abdominal ultrasound was performed, with no relevant alterations; a chest X-ray showed a large volume pneumothorax on the left side, for which a chest tube was placed. An exploratory laparotomy was performed, revealing laceration of the mesentery, mesocolon, small intestine and colon, with associated enteric/fecal peritonitis. Thus, he underwent surgical hemostasis of the mesocolon and mesentery, segmental enterectomy of the small intestine and segmental colectomy of the sigmoid colon. He developed post-operative sepsis, with colic anastomosis dehiscence, which led to a second surgical intervention 8 days later - resection of dehiscent colonic anastomosis and terminal colostomy with stoma placement. He was discharged from the hospital 23 days later, clinically and analytically improved, with a functioning colostomy, and controlled pain, maintaining General Surgery follow-up consultations. Subsequently, he underwent clinical forensic evaluation in the context of the reported assault. The most preeminent findings on the physical examination were located on the abdomen, which showed extensive surgical scarring, with atrophic and parched areas and irregular margins, and a stoma in the lower left quadrant of the abdomen, with a collecting pouch. Penetrating thoracic/abdominal or combined injuries are some of the most common injuries caused by assault. In our clinical practice as forensic experts we often evaluate stabbing injuries, which usually result from assault. The portuguese Penal Code criminally penalizes offenses to another person’s body or health, and considers some aggravating factors, such as the assault to the victim’s physical integrity resulting in permanent and severe physical disfigurement, depriving them from an important organ or member, resulting in particularly painful or permanent disease, taking away or seriously affecting their ability to work, procreate or engage in sexual activity, their intellectual abilities, or their use of the body, senses or language; or if it endangers their life. It is up to the forensic expert to establish if there exists a causal link between the reported trauma and the observed damage, and to document in a clear and detailed way all the consequences that resulted from it, allowing a smoother and more diligent progress of criminal proceedings.

161

BRUISING IN THE ELDERLY AND ANTICOAGULANT/ANTIPLATELET THERAPIES – CHALLENGES ASSESSING ELDER ABUSE

Maria Isabel Lemos 1 , Eduarda Duarte 1 , Sofia Frazão 1,2,3 , Ricardo Dias 1,2

1 National Institute Of Legal Medicine And Forensic Sciences, Portugal

2 Institute of Biomedical Sciences Abel Salazar – Porto University, Portugal; 3 Faculty of Medicine of Porto University, Portugal

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

We present three cases of bruising on elders with chronic use of anticoagulant/antiaggregant therapies – all of them are females, aged between 86 and 91. The first case refers to an elder, with chronic use of clopidogrel, who reported an episode of assault, consisting of scratching and pushing, after which she fell. She also referred that water was thrown at her head, her diaper was ripped off and her mouth was covered by the perpetrator’s hand. This happened at her home, where she lives along with her daughter and son-in-law (the alleged perpetrator). On physical examination, we found several senile purpura lesions on both dorsal forearms and hands. At the center of one of these lesions, there was a bleeding abrasion. We also found multiple bruises located on both anterior arms and anterior right forearm. The second case concerns an elder who allegedly fell during a homestay at her daughter’s house. Because of her functional impairment, she spends every other week at both her daughter’s and son’s houses, and bruises are frequently seen whenever she returns from her daughter’s house. Amongst other medications, she takes Aspirin®. Throughout observation, we found a 15 cm long bruise on the left breast’s upper quadrants. Several other bruises were found, in different evolution stages, located on the left lateral chest wall and on the upper and lower limbs. The third case depicts an institutionalized elder, with compromised mobility, medicated with warfarin. When examining her legs, we noticed signs of aged skin and chronic venous insufficiency, with heterogeneous hyperpigmentation. She presented multiple diffuse yellow bruises on both anterior legs, overlapping the anterior surface of the tibia. We considered the presence of abuse signs on the first two outlined cases, and an accidental etiology on the third. By presenting these cases, our aim is to focus on the effect of the referred medications on bruising patterns and its correlation with elder abuse detection, considering that bruising is frequently used as a marker of abuse. However, since geriatric population’s skin is extremely fragile, highly influenced by the effects of sun damage or vascular disease, bruising is common in this population, regardless of the presence/absence of abusive situations. We then rely on some indicators such as the number of observed bruises, as well as their size, location and evolution stages. Nevertheless, chronic use of medications that interfere with normal blood clotting is also common in this population – which makes them prone not only to present more bruises, but also larger and more pronounced ones. Even when abuse is self-reported and there is compatibility with the observed lesions, these therapies may represent a challenge when assessing elder abuse, as they may mask or mimic markers of abuse.

162

COMMINUTED HUMERAL HEAD AND DIAPHYSIS FRACTURE FOLLOWING ELECTRIC SHOCK - CASE REPORT

Eduarda Duarte 1 , Carlos Oliveira 1,2 , Joana Azevedo 1

1 National Institute of Legal Medicine and Forensic Sciences, Portugal

2 Grouping of Health Centres Entre Douro e Vouga I - Feira/Arouca, Portugal

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Work-related injuries in adults account for most electrical injuries, especially among construction and electrical workers. Electrical injuries may result from direct effect of electrical current on body tissues, from its conversion to thermal energy, or from blunt mechanical injury due to either musculoskeletal tetanic contractions or to a fall after electrocution. A 62-year-old male electrical worker presented in emergency care after a workplace accident. He suffered an electric shock while repairing an electric distribution panel, denying any falls resulting from this event. Physical examination showed only a small abrasion on the first finger of his left hand, with no burn wounds present on the rest of his body surface. The patient also complained of left shoulder pain. After excluding any cardiac complications, both radiographs and a CT scan of his left shoulder were performed, which diagnosed an extensively comminuted humeral fracture of the head (involving the tuberosities and both surgical and anatomical necks) and diaphysis, with largely displaced bone fragments. Five days later he was submitted to proximal humeral plate osteosynthesis. After the surgery, the patient began rehabilitation treatment, focusing on pain control, restoration of range of motion and improvement of function, aiming to return to his professional activity. Approximately a year after the accident the osteosynthesis material was removed, and about two months following this procedure the patient was allowed to resume his professional activity. This workplace accident resulted in unfavourable orthopaedic sequelae, with globally limited left shoulder range of movement and inability to reach the back of his head, the lumbar region or the opposite shoulder with his left hand. Bone has the highest resistance of any body tissue, generating the greatest amount of heat when exposed to an electrical current. In addition to burn-related injuries, bones can fracture from falls resulting from the electric shock, blast injuries, or under the stress of repetitive tetanic muscle contractions. These fractures are rare. When present, they are frequently located on structures surrounded by significant and strong muscular bodies, such as the spinal processes of the vertebrae, the femoral neck, the head and neck of the humerus and the ulna. This particular case described a severely comminuted and displaced fracture involving the head and diaphysis of the left humerus, a lesion that invariably evolves to significant functional impairment. It is important to perform a detailed and complete physical examination and imagiological study of the musculoskeletal system in order to correctly identify and manage these fractures, thus maximizing the patient’s functional outcome.

163

DEPRESSED SKULL FRACTURE IN A 4-MONTH-OLD INFANT: CONSIDERATIONS ON ACCIDENTAL TRAUMA VS CHILD ABUSE

Maria Isabel Lemos 1 , Salomé Dias Afonso 1 , José Moura Fernandes 1,2

1 National Institute Of Legal Medicine And Forensic Sciences, Portugal

2 School of Health Sciences – Polytechnic of Porto, Portugal

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Child abuse is a challenging diagnosis. As forensic experts, dilemmas concerning differential diagnosis between accidental and non-accidental traumas are not uncommon. We present a case of a 4-month-old male infant who was allegedly lying on his crib over a rolled blanket, and then rolled and hit his head on one of the railing’s balls. He cried immediately but calmed down shortly after and never lost consciousness. One hour later, his mother noticed a skull depression and took him to the Emergency Room. This is an infant with an irrelevant past medical history, whose household consists of an extended family, with a low socioeconomic status. On physical examination, a skull depression was found in the left parietal region - it was stiff, painless and had no associated bruise. A cranioencephalic computed tomography scan was performed and showed a focal sinking of the left parietal scale, maintaining the integrity of both internal and external boards (ping-pong fracture); there were no associated injuries, including intra- or extra-axial hemorrhages. Ophthalmoscopy showed no bleeding, as well as a normal macula and optic disc. The skeletal X-ray showed no evident fractures. During his hospitalization, his mother was inconsistent regarding the history of the event, giving new/different information to different health care workers. Ping-pong fractures, a type of depressed skull fractures (DSFs), can be congenital or acquired. Acquired DSFs are related to obstetric traumas or can occur as the result of a direct trauma - this can happen both accidentally or be inflicted, with the latter raising suspicions about child abuse, especially in infants. Some clinical findings might be in favour of abuse: multiple or complex fractures, non-parietal fractures, and associated intracranial injury. Considering the reported case, the fracture’s characteristics and the absence of other clinical manifestations led us to conclude that the ping-pong fracture could be secondary to an accidental trauma, such as the one stated by his mother. Also, the history’s incongruencies could support the diagnosis of abuse, as it may be considered in the presence of unease about the circumstances of the injury. However, on every report given by his mother, the exact traumatic mechanism was always the same – and it was compatible with producing this type of DSF. Although some findings might be frequently associated with inflicted trauma, they cannot be taken as certain evidence of abuse, but should encourage a careful assessment. Children suffering from abuse usually have a poor social network, and therefore they might rely exclusively on health care and educational professionals’ awareness on identifying signs of abuse. Nonetheless, this diagnosis carries out an important legal impact, resulting in children being removed from their homes. Child abuse must not be missed out but should also not be considered lightly.

164

CHILD PHYSICAL MALTREATMENT IN SOUTH OF TUNISIA

Malek Zribi 1 , Hela Siala 1 , Wiem Ben Amar 1 , Narjes Karray 1 , Moulaye Ahmed Dhehby Ahmedou 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Habib Bourguiba Hospital, Sfax, Tunisie

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : Child maltreatment is recognized as a major public health and social problem, with potentially devastating effects on children and families, as well as serious economic and social costs. The aim of this study was to emerge the problem of child physical abuse in Sfax (Tunisia) and to highlight the characteristics of the children that are in danger, as few relevant studies have been conducted in that area so far.

Material and methods : This is a retrospective study designed based on data that derived from the assault and battery consultation of the forensic department of Sfax, through the period of two months (January 2019-February 2019).

Results : Physical maltreatment by any perpetrator before the age of 18 years was reported by 126 cases (11%). 54,4% of these cases were boys and 45,6% were girls. The mean age for boys was 15,1 years and for girls 14,03 years. Overall, 29.8% of the children reported physical maltreatment by peers and casual aquaintances and 11.7% by relatives. The physical examination found traumatic injuries in 21% of cases, consisting in bruises in 52%, scratches in 46.4%, dermabrasion, contusion in 39%, contuse wounds in 9.2%, simple wound in 3.5%, fracture in 7.8%. Thirty-one percent of the children physically abused had evidence of injury to the head and neck region, while 28% had injuries in thelimbs. The physical abuse was associated with sexual abuse 30% of cases.

Conclusion : The small number of the allegations attributed to the fact that most cases of physical abuse goes unreported. Research in large study population is recommended, in order to define the characteristics of the children that are in danger in Tunisia. Actions are required at all levels of prevention, emphasizing to the early detection of the problem and the effective management.

165

VIOLENCE AGAINST ADOLESCENT IN SFAX, TUNISIA

Wiem Ben Amar 1 , Hela Siala 1 , Malek Zribi 1 , Narjes Karray 1 , Elaa Chebbi 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Habib Bourguiba Hospital, Sfax, Tunisie

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : Violence is one of the leading causes of morbidity and mortality in young people. It causes physical injuries, post-traumatic stress disorder, depression, and school performance disruption. The aim of this study is to describe the patterns of adolescent abuse in Sfax (Tunisia).

Methods : We conducted a retrospective and descriptive study of all adolescent victims of violence who consulted in the forensic medicine department of Sfax, Tunisia on January and February 2019. The current definition of adolescent adopted by the world health organization was used (between 10 and 19 years old).

Results : We collected 102 cases of adolescents victims of physical and sexual abuse over the study period. Among them, 53% were boys. The median age was 14 years with a minimum of 10 and a maximum of 19. Overall, 63.7% were victims of physical assault and 36.6% were victims of sexual assault. 81.4% of the victims had an urban origin. Males were mostly students (79.1%) or day laborers (18.7%) and were assaulted by strangers or acquaintances or family members. Females victims were mostly students (64.8%) or housewives (27.7%), likely to be assaulted by intimate partners (20.3%). About half of the victims presented a simple bruise without serious injury and 7.7% of the patients presented a fracture. 52.3% of the adolescent physically abused had injuries in the head, while 13.8% had injuries in the upper and lower limbs. The mean temporary partial disability was estimated at 5.21 days. 9 cases had a permanent partial disability to pretend. As for sexual assault, the gynecological examination found an intact hymen in 44.4% of the cases. The anal examination objectified in most cases (80.5%) a normal anal orifice without fissures with a good anal-sphincter tone.

Conclusion : The profile of adolescent victim of violence is now established. This study could be a key element to implement specific preventive measures.

166

CHARACTERISTICS ELDERLY INJURIES IN SFAX, TUNISIA

Wiem Ben Amar 1 , Hela Siala 1 , Malek Zribi 1 , Fatma Daoud 1 , Houssein Lebkem 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Habib Bourguiba Hospital, Sfax, Tunisie

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : Factors associated with elderly injuries are understudied and its prevalence in Tunisia has not been reported. The aim of this study was to identify the prevalence and factors associated with elderly injuries in Sfax(Tunisia).

Patients and Methods : We conducted a retrospective and descriptive study of all elderly victims aged over 60 years who consulted on January and February 2019 in the forensic medicine department of sfax, Tunisia. The data were collected from the victim's interview, medical examination and investigations as well as expert conclusions.

Results : Elderly trauma cases accounted for 64 of the total 1146 trauma victims consulting over 2 months. 43 victims were men and 21 were women. The mean age was 66.51 years, with an age range of 60-81 years. 81.25% of the victims had an urban origin. More than half of the victims (56.25%) presented a simple bruise without serious injury, 20.31% presented contused wounds. 23.43% of the patients presented a fracture among them 7 cases required surgical treatment. 32.81% of the cases were related to voluntary violence. The aggressor was the intimate partner in 5 cases, acquaintances in 4 cases and a robber in one case. We had no information about the aggressor in 11 cases. As for the road traffic accident, elderly victims were walkers in 25.58% of the cases and motorbike driver in 23.25% of the cases. The average temporary total incapacity period was 26.35 days with a minimum of 0 days and a maximum of 90 days. Concerning the road traffic accident victims, 93% of patients had a partial permanent incapacity to predict after consolidation (IPP), as for voluntary violence victims only 14.28% have an IPP to predict.

Conclusion : An enhanced understanding of the injuries of an elderly trauma can expedite diagnosis, treatment and management of these trauma.

167

OCCUPATIONAL ACCIDENT SERIES FROM THE DEPARTMENT OF FORENSIC MEDICINE OF DOKUZ EYLUL UNIVERSITY MEDICAL FACULTY: A FIVE YEARS RETROSPECTIVE STUDY (2016-2020)

Elif Demet Karanfil 1 , Erdem Özkara 1

1 Dokuz Eylul University Faculty of Medicine, Department of Forensic Medicine, Izmir, Turkey

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction and Objectives : Occupational accidents, a preventable public health problem that causes many deaths or injuries every year, have severe individual and social consequences. Our study aims to obtain up-to-date data on occupational accidents on a regional basis, reveal the effects of accidents on people's health, identify risky working areas, and guide them for preventive measures.

Material and Methods : The cases for which a medicolegal evaluation report prepared by our department was issued due to occupational accidents between 01.01.2016- 31.12.2020 were analyzed. The cases' socio-demographic characteristics, the sector they worked in, the types of trauma they experienced, the characteristics of the lesions, how the injury was evaluated within the scope of the Turkish Criminal Code, and the conditions causing incapacity were recorded in the data recording form. Statistical analysis was done using SPSS 24.0 program. Descriptive statistics are expressed in numbers and percentages; Chi-Square and Fisher's Exact Test were used to evaluate the relationship between variables, and p <0.05 was considered significant.

Results : One hundred eighty-six cases were evaluated. 91.93% of the cases were male, and the mean age was 36.18 ± 12.34 years. When the occupations and the sectors they work in are examined, construction workers (29%) suffered the most injuries. The most frequent accidents occurred in the building-construction sector (33.3%). The injury was most frequently caused by cutting/ piercing / crushing tools (32.3%). 19.9% of the cases were injured due to falling from a height. Most frequent injuries of the upper extremity (n: 100) occurred in the cases. The frequency of injury to the thoracic region (p = 0.017), vertebra (p = 0.005), and abdominal region (p = 0.039) were found to be significantly higher in construction workers compared to other occupational groups. The conclusion sections of medicolegal reports prepared by our department by evaluating the cases within the Turkish Penal Code scope were examined. It was observed that a simple medical intervention could not eliminate the injuries that occurred in 76.3% of the cases, and in 28.4% of them, it was life-threatening. One hundred fourteen patients had bone fractures, and when grouped according to the effects of bone fractures on life functions, the most frequent involvement was 'severe' (32.8%).

Discussion : Our study has once again been demonstrated that the building-construction industry is a dangerous and risky area. It has been concluded that it is necessary to evaluate the regional and periodic characteristics of occupational accidents and consider that the COVID-19 pandemic may increase the occupational accident exposure of some occupational groups. It is considered essential to determine the measures to be taken by putting forward the environmental, social, economic, and political factors that cause work accidents.

168

NEURO-BIO-CHEMICAL BALANCE WITHIN DEVIANT DELINQUENT BEHAVIORS IN ADOLESCENTS

Simona Irina Damian 1 , Cristina Schiopu 2 , Cristinel Stefanescu 1

1 University of Medicine and Pharmacy “Grigore T.Popa” Iasi, Romania

2 Institute of Psychiatry”Socola”, Iași, Romania

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Juvenile delinquency is often viewed as a social phenomenon. Behavior disorders, especially in teenagers and outside true psychiatric pathologies, are analyzed as innerneuro-hormonal imbalances with outter familial and social influences based on intellectual and emotional stimulation levels. All outer stimuli trigger powerful and abrupt responses in these individuals due to their physiological transformations, that affect the neurological bio-chemistry and the central nervous mechanisms. Some of the cerebral areas are hyperactive, affecting impulse control, volition, emotional balance and the tendency to aggressiveness. Beyond hormonal impregnation, it seems that some of the dopaminergic activity is increased, similar to addictive behaviors, triggering satisfaction and rewarding systems and conducting to gratification and short term satisfaction seeking, beyond the limitations imposed by cognitive functions. Prolactin hyper-secretion even in males, could explain some of the behavioral deviance, as new studies suggest. Further research on neuro-bio-chemical activity in teenagers might reveal patho-physiological justifications for deviant behavior, even in non-psychiatric patients, which could change the forensic psychiatric evaluation on adolescents by individualizing clinical and biological aspects of each case.

Keywords : behaviour, forensic, deviance, juvenile, socio-psychology, delinquency

169

CISTERCIAN NUN ANGELA VERONICA BAVA’S DEATH: EVIDENCE OF AN ACCIDENTAL TRAUMA

Alessandro Bonsignore 1,2 , Giuseppe Minetti 2 , Maria Pigati 1 , Francesca Buffelli 3 , Rosa Boano 4 , Ezio Fulcheri 1,3

1 University of Genova, Genova, Italy

2 IRCCS San Martino Teaching Hospital, Genova, Italy

3 IRCCS - Istituto Giannina Gaslini, Genova, Italy

4 University of Torino, Italy

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : In 2019 a conservative canonic reconnaissance on the remains of the Cistercian nun Angela Veronica Bava (1591-1637 AC) was performed in the Benedictine nuns Monastery in Fossano (Northern Italy).

Anthropological methods : the biological identification of the skeleton was carried out with the main macroscopic methods accredited in anthropological literature (White and Folkens, 2005). The criteria for the morphological diagnosis of sex were based on the analysis of the skull morphology; estimation of age-at-death took into consideration the cranial sutures, dental wear, intra-vitam tooth loss and articular alterations of the post-cranial skeleton.

Anthropological results : female, 30-50 years old, 158 cm tall. State of preservation and anthropological observations: the skeleton was not complete and partially altered due to post-depositional processes. Nevertheless, it was possible to identify some unique anatomical characters such as the supernumerary bones of the skull, a morphological variant of the foramen magnum, a severe dental wear and alterations in muscle activities on the metacarpal bones. CT examination was performed with a first scan of the vertebrae C1 to C3 - individually examined - and a second scan of the vertebrae aligned as in vivo. The examination was integrated with multi-planar three-dimensional reconstructions with Volume Rendering Tecnique.

Radiological Report : a comminuted fracture of the left facet joint of the atlas, with slight disconnection of a lateral bone fragment, was observed; the fracture gap was extended from the lateral margin up to the medial margin of the atlas-occipital facet. Such a fracture, with a longitudinal course, also reached the left lateral mass of the atlas. No radiological signs of callus formation were visible. Although the state of conservation of the skeleton was not optimal, no sharp fractures have been observed in adjacent vertebrae.

Discussion : the CT pattern resulted suggestive for type D Jefferson's fracture, according to the AO classification: an unstable vertebral fracture, which typically occurs due to a traumatic mechanism of compression with vector of force vertically directed. The limitations of our study are related to the lack of soft tissues; therefore, it was not possible to establish whether the transversus ligament was intact. An infraction of the soma of C2 - with a longitudinal course - not involving the odontoid process was also observed; no bone lesions affected C3. In all the above-described fractures, the bone remodelling process was not evident; accordingly, it was possible to hypothesize that skeletal fractures occurred in life, pre- or peri-mortem. In the absence of historic documentation, the doubt still persists. An accidental trauma is now introduced as a possible cause of cistercian nun Angela Veronica Bava's death.

170

THE USEFULNESS OF CHEILOSCOPY IN SEX IDENTIFICATION

Oana-Maria Isailă 1,2 , Caba Iulia-Maria 2 , Sorin Hostiuc 1,2

1 National Institute of Legal Medicine "Mina Minovici", Bucharest, Romania

2 University of Medicine and Pharmacy „Carol Davila”, Bucharest, Romania

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : Lip prints have individual characteristics that can be used for human identification in cheiloscopy. The aim of this study is to determine the usefulness of cheiloscopy in sex identification.

Material and Methods : We performed an analytical study based on 50 subjects, of which 25 (50%) were males and 25 were (50%) females, appertaining to the age group 18-59-years-old. The materials used to collect the lip prints were: non-transfer-proof lipsticks, white paper sheets and lip print photographs. Subjects who presented scars, active lesions, trauma of any nature (chemical, thermal, mechanical) or malformation of the lips, were excluded from the study. The lip prints were divided into four quadrants (Y, Y’, X, X’), each quadrant being further subdivided into four sections, denoted by indices ranging from 1 to 4, and analyzed using the classification of Suzuki and Tsuchihashi.We used SPSS for statistical analyses. The level of statistical significance for Pearson's correlation coefficient was considered a p value below.05.

Results : We found no identical lip prints. After analyzing all of the 16 section, we found that type grooves was the most encountered type in females (being predominant in 10 of 16 sections: Y1, Y’3, Y’4, X1, X2, X4, X’1, X’2, X’3, X’4), followed by type III (in 5 of 16 sections: Y2, Y3, Y’1, Y’2, X3). In males, the results were similar: type II was predominant in 10 of the 16 sections (Y1, Y2, Y’2, Y’3, Y’4, X1, X2, X3, X’3, X’4) followed by the type III, found to be predominant in 3 sections (Y3, X4, X’2).

Conclusions : Even though every subject had an individual pattern of lip prints, most of them, irrespective of gender, presented predominance of type II of grooves. This result does not support the reliability of cheiloscopy for sex identification.

171

HOLISTIC FACIAL RECOGNITION VS. FEATURES FACIAL IDENTIFICATION: A STUDY ON WHOLE FACES AND SEGMENTED FACES

Elena Ruiz Mediavilla 1 , Sergio Castro Martínez 1 , Miriam Santana Almeida 2

1 General Commissariat of Scientific Police, Madrid, Spain

2 Universidad Alcalá de Henares, Alcalá de Henares, Spain

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

The facial identification performed by experts is based on a feature by feature morphological comparison. Generally features are studied within the entire face but this is not always possible due to partial face concealment or deficiencies in image quality, which can make this task difficult. To verify whether the experts are capable of obtaining good results when they cannot carry out the morphological comparison considering the entire face, and to verify the differences between experts and non-experts, two tests have been designed. Both tests are made up of the same 20 pairs of images; one test shows the faces complete and the other one the faces segmented. The complete faces test was answered by 73 non-experts and 30 experts, and the segmented faces test by 79 non-experts and 35 experts. In both cases national and international participants took part. For each test and for each image the minimum, maximum and median values of grade responses (from -3 to +3) are shown. Also the medium level of difficulty of the image is indicated and the error percentages calculated (results are shown by males and females). The overall results are shown by each test, analyzing the answers by grade, the errors made and the percentages of false + and false -, in addition to calculating the error rates according to whether the image was of male or female. Also the medium level of difficulty and the errors made according to the level of difficulty are shown. The overall results show that experts make fewer errors in both complete-face and segmented-face tests, making the feature by feature comparison methodology performed by the expert more effective than the holistic recognition method performed by non-experts. The segmented faces test accumulates more errors than the complete faces test; even so the experts have obtained a high percentage of correct answers. It is concluded that experts are able to carry out this task successfully despite not having been able to study the face as a whole.

Keywords : Facial recognition, identification, face, features, non-experts, experts

172

SEX DETERMINATION OF TUNISIAN POPULATION BY CT SCAN ANALYSIS OF THE MASTOID PROCESS

Syrine Azza Manoubi 1 , Marwa Boussaid 1 , Mohamed Amine Mesrati 1 , Meriem Boughattas 1 , Saida Jerbi 2 , Abir Aissaoui 1

1 Legal Medicine Departement Of Taher Sfar Teaching Hospital, Mahdia, Tunisia

2 Radiology Departement Of Taher Sfar Teaching Hospital, Mahdia, Tunisia

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : In certain forensic cases, the identification of human remains is mandatory. The mastoid process is a favorable bone for anthropological analysis due to the compact structure of the petrous portion and its protected location at the base of the skull. Thus, it is considered a good indicator of sex determination based on several metric methods. Nevertheless, these methods remain population-specific. Our work aimed to analyze the sexual dysmorphism of the mastoid process in a Tunisian population sample and to establish formulas for sex determination.

Materials and Methods : A prospective study was conducted at the imaging department of Tahar Sfar University Hospital of Mahdia. We assessed 316 anonymous cranial computed tomography (CT) scans performed between ** and** corresponding to Tunisian adults of known age and sex (166 males and 155 females), without any malformation or traumatic injury or pathology at the mastoid processes. Nine measurement parameters were used: the Asterion-Porion distance (AP), the Porion-Mastoidal distance (PM), the Asterion-Mastoidal distance (AM), the Conventional Mastoid Height (CMH), the Mastoid area (MV), the Maximal oblique sagittal diameter (OSDMAX), the maximal oblique coronal diameter (OCDMAX), and the anterior inclination angle (AIA). Statistical analysis was performed with the Statistical Package for the Social Sciences (SPSS) version 21.0. The significance level (p) was set at 0.05.

Results : The current study showed a significant difference in mean values between the sex groups for all the assessed mastoid-process parameters. Men had higher average values (p <0.05) except for the AIA. Our results showed that the best discriminatory parameters for sex determination were AP and CMH with an accuracy of 74.5%. We used these variables to establish an unstandardized canonical discriminant function equation: “D” (mm)= 3232 + (AP X 0.899) + (CMH x 0.890). It has been concluded that if "D” is greater than 3298.5887 mm, it would be a male, otherwise, it would be a female. The sensitivity and specificity of this method in the sex determination were 70.5 % and 64.0%, respectively.

Discussion : The results of the current study suggest that measurements of the mastoid process can be used for sex determination in a contemporary Tunisian population, especially when only the mastoid process is found intact. These conclusions can be relevant for countries of the Mediterranean region to identify shipwrecked' corps after illegal immigration. However, this analysis has some limitations that need to be pointed out, to improve it. The current study, performed on a sample of the Tunisian population, should be carried out on other population samples to validate it worldwide.

173

SOLVING COMMINGLING ISSUES USING BONE ELEMENTS OF THE HIP JOINT: A GEOMETRIC MORPHOMETRIC APPROACH

Ioanna Anastopoulou 1 , Fotios Alexandros Karakostis 2 , Konstantinos Moraitis 1

1 Department of Forensic Medicine and Toxicology, School of Medicine, National and Kapodistrian University of Athens, Greece

2 Senckenberg Center for Human Evolution and Palaeoenvironments, Eberhard Karls University at Tübingen, Germany

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : The term “commingling” is utilized to describe a skeletal assemblage belonging to more than one individual. This phenomenon typically accompanies various medico-legal contexts: natural phenomena, man-made incidents, warfare or terroristic acts. Given than that the forensic anthropological examination requires a human skeleton as complete as possible, an efficient re-association of the commingled elements is crucial, especially in cases of multiple deaths. In the present study, a new sorting method based on the evaluation of the skeletal elements’ shape is developed. In order to explore this, we utilized the skeletal elements of the hip joint, the larger and the most important joint of the human skeleton, as the anthropological examination of the femur and the innominate can provide an individual’s full biological profile.

Material and Methods : A number of 97 adult individuals from three different skeletal collections were selected. Each individual’s right femur and innominate were scanned with a 3D scanner. The same number of eleven landmarks were placed on the acetabulum and the femoral head, on points which geometrically correspond to the two adjoining articular surfaces. The landmarks’ raw coordinates were transformed into Procrustes coordinates in order to remove the factor of size. The femur that presented the smallest Procrustes distance with the acetabulum examined was consider to be its match and belong to the same individual based on their shape resemblance.

Results : In more than half of the cases (53.6%), the methodology presented no error, as for each acetabulum examined the matching femur was the method’s first indication (the closest Procrustes distance). In 27.8% of the cases, the correct match was the second closest indication, while in 15.5% of the cases, it was included among the first 3 to 6. Finally, the rate of individuals for which the correct match was among the first 7 to 12 indications was less than 3.1%. Even in the latter cases, the methodology succeeded in rejecting an approximate 90% of the possible matches. Consecutive blind tests of ten individuals confirmed the applicability of this methodology in small-scale commingled contexts, as well.

Discussion : Until now, the re-association of human remains is performed based on optical resemblances, which is prone to the researcher’s subjectivity and by metric methods which are unable to sort individuals of similar size. Therefore, this new landmark-based method takes into consideration the articular surfaces’ shape resemblance. We recommend that this would be used as a means to safely reject the 90% of the matches based on the shape incompatibility and the remaining 10% would be supplementary examined. Future research should expand this methodology to the other joints of the human skeleton.

174

OSTEOMETRIC DETERMINATION OF SEX USING 3D MODELS OF THE STERNAL RIB END

Ioanna Karagiorgou 1 , Ioanna Anastopoulou 1 , Fotios Alexandros Karakostis 2 , Elena Kranioti 3 , Konstantinos Moraitis 1

1 Department of Forensic Medicine and Toxicology, School of Medicine, National and Kapodistrian University of Athens, Greece

2 Senckenberg Center for Human Evolution and Palaeoenvironments, Eberhard Karls University at Tübingen, Germany

3 Forensic Medicine Unit, Department of Forensic Sciences, University of Crete, Heraklion, Greece

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : Anthropological examination of 3D bone models derived from high-resolution scanners has now become a common practice in many institutes and forensic laboratories around the world. Alongside, many universities digitize their skeletal collections in an effort to protect the remains from further wear due to handling, and for ethical reasons. All these create an ever-growing digital database of virtual remains. The anthropological practices need to get updated accordingly, and be adopted on the new settings, while anthropologists should get trained on using the virtual bones. When unidentified skeletal remains surface, sex is the first biological attribute to be assessed. Sexual dimorphism is evident on the majority of anatomical features, regardless of their size. The sternal rib end is considered by many researchers as a reliable estimator of age and sex. Osteometric sex estimation studies utilizing the sternal rib end, where firstly developed in the mid 1980’s and since then many researchers have developed population-specific equations. The aim of this study is to assess sexual dimorphism on the digitized sternal end of the third to fifth rib from both anatomical sides.

Material and Methods : The skeletal elements utilized derive from two contemporary Greek skeletal populations (68 males and 43 females, aged 19-101 years old) from Athens and Heraklion, Greece respectively. The models were created with the use of a structured-light 3D scanner, while a set of two measurements were taken from each rib specimen: superior-inferior height (SIH) and anterior-posterior breadth (APB). Univariate equations for sex determination were created with the use of discriminant function analysis.

Results : The results of the analysis demonstrated that the SIH measurement is more sexually dimorphic than the APB (alpha value of .05) while the Pearson correlation test revealed no significant correlation to the age-at-death for both of the measurements. Finally, the cross-validated discriminant function equations produced correct classification results ranging between 74.0–82.9%.

Discussion : These findings are in accordance with the results of previous studies, indicating that the use of 3D models in anthropological analysis can produce accurate results. This method can be a useful addition to the existing sex determination methods, when 3D bone models are available. Future studies should focus on updating the traditional anthropological methods, given that virtual bone models are becoming increasingly popular.

175

AGE AND SEX RELATED ANTHROPOMETRIC AND ANTHROPOSCOPIC CHANGES IN THE HUMAN MANDIBLE, USEFUL IN FORENSIC IDENTIFICATION, QUANTIFIABLE ON PANORAMIC RADIOGRAPHY ON A ROMANIAN POPULATION

Razvan Marian Siminiuc 2, 1 , Andreea Rosu 2 , Cosmin-Daniel Tirdea 1 , Sorin Hostiuc 1

1 "Prof. Dr. Mina Minovici" Institute Of Legal Medicine, Bucharest, Romania

2 "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : Forensic identification of human remains is still of great significance in a large number of deaths, either natural or unnatural. Improvements in this field can be made using new available technologies. The aim of this study is to evaluate the anthropometric and anthroposcopic changes in human mandible, using panoramic radiographs, and to compare these changes between age and sex, with the purpose of identifying the sexual dysmorphism and age-induced differences.

Materials and methods : We designed a retrospective study based on 89 eligible panoramic radiographs of 47 females and 42 males (age 16-88 years) made between 2013-2020. We made 15 measurements: bigonial width, interforaminal distance, distance between the left mental foramen and the alveolar ridge, distance between the left mental foramen and the base of the mandible, distance between the right mental foramen and the alveolar ridge, distance between the right mental foramen and the base of the mandible, left and right ramus height, left and right ramus width (both measured at the subcondylar level), left and right ramus width (both measured at the middle of the ramus height), left and right ramus width (both measured in the gonial area) and the mental height; and we observed 3 anthroposcopic changes: the presence or the absence of prominent mental tubercles, the mental shape (rounded/rectangular) and the thickening of the mandibular angle at the site of masseter insertion (absent/present). The measurements were made using Adobe Photoshop CS5 and IBM SPSS Statistics 26 was used for statistical analysis.

Results : The most significant differences between sexes were observed in the bigonial width (p<0,001), mental height (p<0,001), left ramus height (p=0,001), right ramus height p<0,001, left ramus width measured at the subcondylar level (p<0,001), right ramus width measured at the subcondylar level (p<0,001). Regarding the anthroposcopic changes, a rectangular mental shape was more common in males and a rounded one in females, the prominent mental tubercles were more frequent in males, and also a thickening of the mandibular angle at the site of masseter insertion was found to be more common in males.

Discussions : The human mandible can be considered an anatomical element that has a significant sexual dysmorphism. This study shows that the sex related changes in the human mandible such as: bigonial width, mental height, mental shape etc. can be used in the forensic identification, strongly supported by other available studies. Regarding age-related changes, we did not find any statistical significant differences.

176

CAN WE ESTIMATE AGE BY CT SCAN ANALYSIS OF THE MASTOID PROCESS?

Oumaima Brahim 1 , Marwa Boussaid 1 , Mohamed Amine Mesrati 1 , Habiba Sandid 1 , Saida Jerbi 2 , Abir Aissaoui 1

1 Department of Legal Medicine, Taher Sfar Teaching Hospital, Mahdia, Tunisia

2 Department of Radiology, Taher Sfar Teaching Hospital, Mahdia, Tunisia

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction : The mastoid region has attracted attention from multiple researchers for anthropological analysis, in particular sex determination. However, in the literature, few authors have focused on the estimation of age through the analysis of the growth and development of the mastoid process. Most of these studies were interested in the growth of the mastoid air cell system and mastoid pneumatization. The current study aimed at analyzing the relationship between age and metric parameters of mastoid process in a Tunisian population using CT-scan analysis in order to establish an age estimation equation.

Material and methods : For this a cross-sectional study was conducted. We collected 316 cranial CT scans corresponding to 166 males and 150 females of known age and sex. The used measurement parameters were Asterion-Porion distance (AP), Porion-Mastoidale distance(CMH), Asterion-Mastoidale distance(AM), Conventional mastoid height (CMH), True mastoid height (TMH), Maximal oblique sagittal diameter (OSDmax), Maximal oblique coronal diameter (OCDmax), Mastoid area (MA) and Anterior inclination angle(AIA). We used multiple linear regression analysis.

Results : We were able to establish a formula for estimating age. After applying the statistical analyzes, this formula was able to predict the real age of individuals aged 30 years or less in 62% (r²=0.62).

Discussion : As anthropology evidence, it should be noted that age estimation after 25 years with fair amount of accuracy is often crucial. This can be explained by the fact that human growth is a continuous process which goes through, first a developmental stage and second, the maintenance of status or maturation arrest seen on third decade. The results of the current study suggest that measurements of the mastoid process can be helpful for age estimation in the Tunisian population for samples aged 30 years or less. Thus, the validation of the equations established need to be performed on other population samples by further studies. Although, these shortcomings will be taken into account in the continuation of this work.

177

ACCURACY ASSESSMENT OF DENTAL AGE ESTIMATION WITH THE NOLLA METHOD IN ROMANIAN SUBADULTS: A CROSS-SECTIONAL STUDY

Ioana Diaconescu 1 , Alina-Cristina Condesteanu 2 , George Cristian Curca 3 , Sorin Hostiuc 2

1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania

2 Carol Davila University of Medicine and Pharmacy, Faculty of Dental Medicine, Dept. of Legal Medicine and Bioethics, Bucharest, Romania

3 Carol Davila University of Medicine and Pharmacy, Faculty of Medicine, Dept. of Legal Medicine and Bioethics, Bucharest, Romania,

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

Introduction and Objectives : Age estimation plays a key role in forensic science, especially in anthropology, being used for identification of deceased persons or in immigration matters. Regarding the usefulness of dental age assessment in forensic medicine, we aimed to evaluate the accuracy of the Nolla method in predicting chronological age in Romanian subadults.

Methods : Digital Orthopantomogram of 130 subjects (49 males, 61 females), aged from 47 and 197 months were enrolled. The Pearson’s Correlation Coefficient test for paired data was applied by age groups and sex to compare the chronological age and dental age. Statistical tests were performed at a p<0.01.

Results : The use of the Pearson test revealed a strong correlation between the chronological age and that estimated by the Nolla method for the entire population group (0.957). The correlation was slightly higher for the female subgroup (0.962) than for the male subgroup (0.958). Regarding the validity of the Nolla method, the dental age was underestimated compared to the chronological age by an average of about 15 months for the common group, 17 for the female and 12 for the male subgroup.

Conclusion : Using the Nolla method, age is underestimated; the method has a greater precision in the female compared to the male subgroup. The data from this study showed that the Nolla method can be used to estimate the age of the Romanian subadults.

178

INSECT COLONISATIONS ON BURIED BODIES IN EARLY STAGES OF DECOMPOSITION

Ersin Karapazarlioglu , Erol Bayhan, Selime Olmez Bayhan, Murat Mert

1 Ruhr University Bochum, Germany

Poster Presentation 1, June 2, 2021, 1:15 PM - 2:00 PM

The estimation of the time since death is one of the fundamental questions to be addressed at the forensic investigations. There are several methods to determine the time since death, however forensic entomological analysis is the one of the most important methods. The main objective of this study is to explore and to observe the decomposition process of carcasses and determining the insect species on buried bodies in early decompositional stages bodies to assist forensic investigation by providing information on when a crime was committed, or a person died. This study was carried out in the province of Sirnak in Turkey in winter. A total of 8 domestic sheep (Ovis Aries) carcasses were used in the study. Due to the fact that the corpses were buried shallowly in forensic cases, deep burials were not performed like normal burial. Sheep carcasses were buried at a depth of 20 and 50 cm. and they exhumed on the 10th, 30th, 60th and 90th days after burial. During this process, insect species and decay processes were examined. In the study, nine species belonging to six families were identified. These species are Chrysomya albiceps (Diptera: Calliphoridae), Metopina sp. (Diptera: Phoridae), Melanotus sp. (Coleoptera: Elateridae), Aphodius erraticus, Aphodius fimetarius (Coleoptera: Scarabaeidae) Aleochara lanuginosa, Aleochara rutilipennis, Philonthus splendens (Diptera: Staphilinidae) and Tetramorium caespitum (Hymenoptera: Formicidae). Metopina sp. and Melanotus sp. were found in all exhumations. Chrysomya albiceps was found on the tenth and thirtieth days, Aphodius erraticus on the thirtieth and sixtieth days, Aphodius fimetarius and Aleochara rutilipennis on the sixtieth and ninetieth days, and Aleochara lanuginosa on the ninetieth day only. The exhumed carcasses on the tenth day were in fresh decay stage, whereas unearthed carcasses on the thirtieth, sixtieth and ninetieth days were in bloat stage. The burial site, depth, soil type, moisture, air content, temperature etc. affect the decay process, insect access and its successional pattern. Therefore, different studies should be carried out in different geographical regions, climates and conditions.

179

ETHICS OF BIOMEDICAL RESEARCH IN GERIATRICS IN TUNISIA

Oumaima Brahim 1 , Wael Majdoub 1 , Elaa Chebbi 1 , Firas Haggui 1 , Bilel Gammoudi 1 , Souhaiel Mlayeh 1

1 Department of Forensic Medicine, Ibn El Jazzar University Hospital, Kairouan, Tunisie

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Introduction : Elderly people are often excluded from clinical research and treated with drugs that have only been tested in young adults. This is partly related to the difficulty of conducting geriatric clinical studies as well as the practical problems encountered at all stages of a clinical trial. From an ethical standpoint, the ability at taking a decision, the free-will, and the informed consent of an elderly person require special attention in this case.

Objective : We aim in this work to study the practical problems encountered in clinical trials in geriatrics and the main ethical dilemmas that arise from them. We also discuss the legal and deontological framework.

Discussion : All phases of a geriatric clinical study must meet ethical principles, particularly autonomy, equity, beneficence, and non-maleficence. Biomedical researches in geriatrics are likely to raise ethical issues in practice: from writing the protocol to collecting data, each step is to be prepared and conducted with care. In fact, on the one hand, the recruitment of the elderly in a clinical study comes up against the patient's entourage. On the other hand, the elderly person is considered to be a fragile person, most likely to develop side effects that could hinder the continuity of research. Besides, the information of an elderly person who is suitable for experimentation may not be well understood and rather taken as an obstacle to free and informed consent. It should also be remembered that the ethical character of a study is based first on its scientific validity. When this first requirement is met, the problem that arises, and even more amplified in the geriatric population, is to determine the ability of the subject to make a decision and the collection of free and informed consent. It is difficult to judge whether the patient freely consents or not. The way to determine an elderly subject's ability to understand has also been widely debated but remains difficult in practice. According to Tunisian law, there is no specific legislative text concerning research on an elderly person. Doctors must refer to the conditions cited by the Tunisian code of medical deontology and the decrees of the Ministry of Public Health, dated 13 January 2015, relating to the protection of people who lend themselves to experimentation by respecting some rules. One of these rules is informed consent.

Conclusion : Depriving older people of access to the most recent treatments is a translation of the non-respect of a fundamental ethical principle that is equity. However, it is essential and imperative that the team conducting biomedical research in geriatrics to be more cautious in order to protect the rights of the patient.

180

COVID-19: THE INVISIBLE MASSACRE OF THE ELDERLY AND THE POSSIBLE PROFESSIONAL LIABILITIES

Andrea Cioffi 1

1 Sapienza University Of Rome, Italy

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

The elderlies are probably the most affected by the COVID-19 Pandemic. Despite this, the measures aimed at preventing the serious consequences that this health emergency may have on the elderly are still inadequate. This study analyses the effects of the current pandemic on elderlies and debilitated patients. In addition, the study focuses on the legal implications of the damages that the elderlies are suffering in this worldwide emergency in consideration of the predictability and yhe avoidability of the numerous deaths in the elderly homes.

181

MEDICAL LIABILITY FOR CULPABLE ABSTENTION IN THE CONTEXT OF THE COVID-19 PANDEMIC

Wiem Ben Amar 1 , Narjes Karray 1 , Malek Zribi 1 , Hela Siala 1 , Fatma Daoud 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Habib Bourguiba Hospital, Sfax, Tunisie

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

The COVID-19 infection is a serious disease, which causes to medical community many difficulties worldwide. This pandemic has generated many situations in the medical exercise for which the urgent saving intervention of the doctor is essential. This urgent intervention to rescue a person in danger is above all a moral obligation but, also an ethical, deontological and legal one. Indeed, the non-assistance to a person in danger is considered like a criminal offense, which is punishable by serious sanctions. However, in the context of the COVID-19 pandemic, this complex offense still vaguein the assessment of the danger and in the appreciation of the risk for oneself or for others. Here, we propose to decipher the particularities of the offense of failure to assist to a person in danger in the context of the COVID-19 pandemic, and to detail the legal, ethical and disciplinary issues that arise from this offense.

182

ETHICAL ISSUES RAISED BY ALZHEIMER'S DISEASE IN THE TUNISIAN CONTEXT

Jaweher Kammoun 1 , Wiem Ben Amar 1 , Malek Zribi 1 , Narjes Karray 1 , Hela Siala 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic department, Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Alzheimer's disease is a neurodegenerative disease that affects most frequently older adults. The symptoms of this disease are mainly represented by the gradual decline of cognitive abilities, resulting in a progressive loss of autonomy. Alzheimer's patient is therefore a vulnerable person, dependent, and on a high risk of abuse and exploitation. The legislator provided special measures for the protection of these persons, who are considered, at the stage of dementia, as major incapacitated persons, including civil, penal and social field. But these measures remain insufficient. Ethical principles based on respect for the patient's dignity, choices, will, and rights, including information and access to quality care, are not always easy to respect in our context.

In this paper, we propose to discuss the ethical problems raised by the medical and social care of this pathology.

183

ASSESSMENT OF THE KNOWLEDGE OF A SAMPLE OF TUNISIAN DOCTORS IN THE FIELD OF PATIENT RIGHTS TO INFORMATION

Oumaima Brahim 1 , Wael Majdoub 1 , Firas Haggui 1 , Bilel Gammoudi 1 , Souhaiel Mlayeh 1

1 Department of Forensic Medicine, Ibn El Jazzar University Hospital, Kairouan, Tunisie

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Introduction : Informed consent is a matter of respect for the patient as a human being ensuring active participation regarding health care. However, patients are not always aware of this right, doctors may be unreceptive to it and the resources for satisfying it are often not available. The knowledge of doctors of scalable legal concepts is variable. This work aims to evaluate the knowledge of a sample of Tunisian physicians in the topic of the patient’s right to informed consent and to discuss the regulatory and deontological framework.

Material and methods : This is a retrospective and cross-sectional study, conducted on a sample of 160 Tunisian doctors from the teaching Hospital of Kairouan in Tunisia. The data were collected through a preestablished survey with questions in the field of patient right to information between Janvier 2018 and Janvier 2021. From this database, we analyze the physicians’ behavior towards the patient's right to be informed about his health condition and to give consent.

Results : Only 32% of physicians ensure that each patient is informed. Complete and exhaustive information was elaborated to patients by the doctors in 22%. The results indicated that oral consent was obtained in 54 % from a total of 93% of patient’s consent. In the case of minor children and unable patients, consent was obtained from the guardianship in 76%. Moreover, the present study showed that around 40% of the physicians don’t have an idea about the legal and deontological framework. This study revealed manifest deficiencies in the declarative, procedural or conditional knowledge of Tunisian physicians in the topic of patient rights of informed consent. It confirms the data in the literature.

Discussion : According to Tunisian law, there is no specific legislative text concerning patient’s right to information and consent on subjects related to health. It is important to mention that it is Regulation and not Law that governs these rights. They are regulated by a regulation, namely, decree n° 81-1634 dated 30 November 1981, relating to the general internal regulations of hospitals and specialized institutes and centers depending on the Ministry of Public Health. According to the 33rd article of this Decree, “ doctors must inform the patient on their state of health under the conditions cited by the code of medical deontology. Other sources provide the patient’s right to information and to give consent before a medical act, such as the charter of patients and jurisprudence. To avoid legal action, according to the doctrine of informed consent, physicians must disclose enough information for the patient to make an “informed” decision. The medical responsibility may be engaged in case of a proven lack of information. Further training in this area should be undertaken to face any shortcomings.

184

FALLING FROM HEIGHT OR VIOLENCE: THE IMPORTANCE OF THE CRIME SCENE INVESTIGATION

İsmail Özgür Can 1 , Mert Onur Özdemir 1 , Elif Demet Karanfil 1 , Mustafa Tepe 2 , Mehmet Tokdemir 3

1 Department Of Forensic Medicine Of Dokuz Eylul University Medical Faculty, Turkey

2 Department of Physics of Ege University Science Faculty, Turkey

3 Department Of Forensic Medicine Of Izmir Katip Celebi University Medical Faculty, Turkey

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Case description : In the crime scene investigation of the dead body found next to seven-story construction; the corpse was lying on his back, partly on the soil and partly on the concrete floor. The phone belonging to the corpse was found on the balcony on the seventh floor. No fingerprints were found on the phone, and the contents of the deceased's phone could not be accessed. The distance from the projection of the balcony on the 7th floor to the corpse was 6.35 m. There was no footage in the construction area's security cameras showing that the person went to the roof. Construction officials reported that they did not see a foreigner entered the construction area. In the information obtained from the corpse's relatives, it was stated that he did not have suicidal feelings, did not have a psychiatric illness, and just returned from his friend's funeral. In the autopsy, there were no fractures in the head, upper and lower extremities. Multiple abrasions in the lumbar region, multiple paravertebral rib fractures, lung, spleen, liver injuries, and internal bleeding were determined. No substance was detected in the toxicological examination.

Discussion : In deaths after falling from height; It is stated that the height of fall, the body part hitting the ground, and the floor structure are adequate. In our case, it was observed that the lesions detected in the body's external examination were consistent with the structure of the ground. The characteristics of paravertebral rib fractures, liver, spleen, and lung injuries were consistent with the body's position on the ground and the fall height. However, no bone fracture was detected in the head and extremities. The distance from the place where the body was found to the building was evaluated. It was understood that the person gained a certain speed as he moved away from the building. However, the origin of death was not determined precisely. In our case report, the importance of careful and comprehensive crime scene investigation in the evaluation of falls from a height will be discussed.

185

ASSESSING A PRACTICAL CASE REGARDING A POSSIBLE HIV INFECTION THROUGH THE EYE AND ORAL MUCOSA: A BRIEF COMMENT UNDER THE PORTUGUESE CRIMINAL AND LABOUR LAW

Cristina Catanho 1 , Maria Paula Ferrão 1

1 Instituto Nacional De Medicina Legal e Ciências Forenses, I.P. - Delegação Sul, Lisboa, Portugal

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

The Instituto Nacional de Medicina Legal e Ciências Forenses (INMLCF, IP) is the reference institution in Portugal for the Forensic Sciences. Among the competencies of the INMLCF, IP, we would like to highlight the personal injury assessment which can be evaluated in different areas, namely: Labour Law, Criminal Law and Civil Law. This assessment is performed under clinical forensic. In the Scope of Criminal law one of the purposes is to understand if there was an injury caused to the body or health, physical or mental, of the person being examined. This can be legally evaluated under the Portuguese Penal Code (CPP). While conducting forensic examinations under the scope of criminal law, we came across a case of assault by a homeless individual against a Police Officer. The case has a certain peculiarity: the possibility of HIV infection, through the ocular membrane and oral mucosa. During the detention of the homeless individual, the detainee's blood was projected under a "spray effect", against the Police Officer‘s face, reaching the eyeball and oral mucosa. After this situation, the homeless individual said that was HIV positive. Afterwards, the Police Officer went to the Emergency Service of the Army Hospital, where he was observed and submitted to post-exposure prophylaxis (PPE). He was referred to follow-up consultations in Infectious Diseases Service of that Hospital. The HIV virus is considered a biological infection agent. At the time of the event, the detainee’s viral load and adherence to a possible antiretroviral therapy was unknown. During this forensic examination it was found that the Police Officer had already been examined at the Infectious Diseases consultation, and that the serologies performed 1.5 months and 3 months after exposure remained negative. Under the Portuguese Law, infection by a biological agent is considered a form of aggression. Additionally, aggressions against Police Officers during their work shift are considered work accidents. The aim of this study is to comment on how this case could be analysed under labour and criminal law in Portugal. We also intended to study the accuracy of the follow-up actions on these cases, in accordance with current Portuguese standards, as well as international guidelines.

186

MANAGEMENT OF CORPSES IN HOSPITALS IN THE CONTEXT OF THE COVID-19 PANDEMIC

Jaweher Kammoun 1 , Malek Zribi 1 , Wiem Ben Amar 1 , Hassen Ennouri 1 , Elaa Chebbi 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic departement Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Coronavirus disease 2019 (COVID-19) has rapidly affected mortality worldwide. There is unprecedented urgency to understand who is most at risk of severe outcomes, and this requires new approaches for the timely analysis of large datasets. It should be considered, in principle, that the risk of contamination is the same in a deceased patient as in the living patient. Therefore, care should be taken when handling the dead body. In the current state of the SARS-CoV-2 pandemic, it is necessary to be well aware of the situations requiring a systematic virological sample as well as those, which require the immediate brewing of the body of the deceased. Furthermore, we should never forget to declare the death from a transmitted disease to the health authorities when the disease is confirmed by a positive test. The objective of our work is to discuss the particularities of management and handling of the bodies of patients who died in hospital in the context of the COVID-19 pandemic, and this by exposing the different situations that may be encountered. We detail the procedures to follow in the event of a patient infected with the SARS-CoV-2 virus who dies in a COVID-19 unit, of a patient suspected of being infected with the SARS-CoV-2 virus who dies in another department of the hospital, and finally in the event of a deceased arrival in the emergency room of the health establishment.

187

DEATH CERTIFICATION

Hadjazi Omar 1

1 University Hospital of Sidi bel abbes Algeria, Algeria

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Background : The death certification continues to be debated within the medical profession and the judiciary one, as well. To sign such a document is not a trivial procedure and it can result in serious consequences, such as administrative and judicial hassle, medico-social concerns, epidemiological complications etc. The aim of this work is to elaborate improvement proposals of the death certification.

Methods : The investigation was documented from death certificates signed by GP that led to a Forensic autopsy at the Forensic unit of the University Hospital of Sidi Bel Abbes. We have analyzed a total of 50 death certificates between.

Conclusion : Based on the results of this study we emphasize on the contact of GP with forensic pathologist and on the continuous medical training for GP. Finally, it is important and advisable to give more power to the forensic pathologist.

188

NON-FATAL HUMAN BITE MARKS. A FORENSIC STUDY FROM GREECE

Emmanouil Sakelliadis 1 , Konstantinos Katsos 1 , Christoforos Kolentinits 1 , Konstantinos Moraitis 1 , Chara Spiliopoulou 1

1 Department of Forensic Medicine and Toxicology, Medical Faculty, National and Kapodistrian University Of Athens, Greece

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Introduction : Human bite marks may be inflicted during interpersonal violent incidents, such as sexual crimes, child abuse and physical quarrels. Clinical forensic assessment of human bite injuries requires detailed description of the injury, proper photography and possibly collections of swabs for DNA identification. A few studies have described anatomical distribution of human bite injuries, but their results have showed various differences, especially based on victim’s sex.

Methods : For this retrospective study, we used the cases of forensic clinical examinations that were conducted during 2013-2019 at the Department of Forensic Medicine and Toxicology of National and Kapodistrian University of Athens, Greece by three Senior Forensic Pathologists. Anatomical distribution of human bite marks, demographic characteristics of victims and perpetrators, and other variables of the alleged incidents were collected anonymously for every case of alleged community violence.

Results : 26 cases were identified in which at least a human bite was inflicted to the victim (14 males and 12 females). In most of these cases (76.9%, 20 cases) only one perpetrator had assaulted and had bitten the victim, with a slight male predominance (53.8%, 14 cases). The perpetrators were known to the victims in 20 cases (76.9%). Most incidents concerned victimization in the community context (69.2%, 18 cases), and interpersonal violence between neighbors was the most frequent reason (5 cases). Allegations for 8 cases were subjected to the Greek Law about Domestic Violence, mainly concerning intimate partners (6 cases). 21 victims (80.8%) had sustained a single human bite mark, and only in 5 cases this was the sole injury ascertained. The predominant site of human bite marks were the upper limbs (80.8%, 21 cases), followed by the torso (15.4%, 4 cases) and the head (7.7%, 2 cases). Human bite marks to the neck and the lower limbs were not observed in any of these cases. Only in one case, human bite marks involved a sexual-related crime.

Conclusion : Our study demonstrates both similarities and differences to the existing literature. Human bite injuries represent an intriguing injury during everyday forensic practice, which may require collaboration of forensic practitioners, in order to extract the best scientific conclusion.

189

EPIDEMIOLOGICAL FEATURES OF DOMESTIC VIOLENCE IN CENTRAL EAST TUNISIA: A CLINICAL-BASED STUDY OVER FIVE YEARS (2015-2020)

Syrine Azza Manoubi 1 , Marwa Boussaid 1 , Mohamed Amine Mesrati 1 , Hiba Limem 1 , Meriem Boughattas 1 , Abir Aissaoui 1

1 Legal Medicine Departement of Taher Sfar Teaching Hospital, Mahdia, Tunisia

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Introduction : Domestic violence represents a substantial phenomenon worldwide. However, data regarding domestic violence in most of the Middle East and North Africa countries are scarce. This study aims to analyze the epidemiological features of domestic violence in one of the provinces of Central East Tunisia.

Material and Methods : We conducted a retrospective, descriptive and cross-sectional study relating to victims of domestic violence who consulted the Legal Medicine department of the Taher Sfar hospital in Mahdia (a province located in Central East Tunisia) between September 2015 and October 2020.

Results : In total, 480 cases of domestic violence out of 2200 were collected. Most of the victims were women (93.80%) complaining of intimate partner violence (77.7%). The mean age of the victim was 35.85 ± 0.6 years. Most of them were married (87.2%), unemployed (64.4%), and living in an urban area. Most of the aggressors were men (95.8%), with a mean age of 41.49± 0.46 years with past history of alcoholism in 35% of cases. Domestic violence occurred frequently at home (91.9%), in front of witnesses (62.9%), motivated by economic issues (34.6%). The assault has been reported at least once a week in 32% of cases. The prevalent type of violence was verbal and physical (94.2%) by the use of blunt weapons on uncovered areas inducing mostly bruises (78%). Marital rape has been reported in almost 8% of cases. Urgent medical care was provided in 23% of cases, while hospitalization was required in 3% of cases. During the study, six cases of uxoricide have been reported. The Temporary Total Disability was on average of 4 days and the average of the Permanent Partial Disability accorded was 3% without ever having exceeded 20%.

Discussion : Fight domestic violence is based on some measures that ensure better protection against all kinds of assaults. These measures can be either a ratified convention like The Convention of Istanbul or the enactment of specific laws such as the Tunisian law 2017-58 of August 11, 2017, on the elimination of violence against women. In our study, identified epidemiological features related to domestic violence were similar to reported data in Western countries. However, data in Arabic World still insufficient to compare them with our findings.

190

IMPACT OF THE PORTUGUESE FOREST WILDFIRES ON MEDICO-LEGAL CRIMINAL LAW CASES

Ricardo Mendonça 1 , Barbara Smyk 1 , Diogo Calçada 1 , Susana Tavares 1 , Carla Carreira 1,2

1 Central Branch of the National Institute of Legal Medicine and Forensic Sciences, Coimbra, Portugal

2 Faculty of Medicine of the University of Coimbra, Portugal

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Introduction : On the 17th of June and the 15th-16th of October of 2017, Portugal suffered from great forest wildfires, which led to the death or serious bodily injury of hundreds of people. Fire-provoked lesions, namely burns and carbon monoxide intoxications, can, depending on their gravity, lead to prolonged hospitalization, need of assisted ventilation, surgical treatments, or even death. This study tried to analyse the impact of these wildfires on the survivors examined within the scope of criminal law evaluation in the Central Branch of The National Institute of Legal Medicine and Forensic Sciences (Portugal).

Material and Methods : This study was quantitative, retrospective, and descriptive, based on the analysis of the elaborated medical reports. We included all the cases regarding criminal law that were evaluated at the Central Branch of The National Institute of Legal Medicine and Forensic Sciences (Portugal), after the victims of the wildfires pressed charges. Once collected all the data we conducted, firstly, the descriptive statistics using measures of central tendency and dispersion and secondly the chi-square test, searching for associations among variables, considering the level of significance to be p<0.05.

Results : The results depict that within 35 examined victims the majority were men, age 45 or superior, affected by flames or heat, mainly on the limbs and face. Many of the victims required mechanical ventilation and surgical treatment, having prolonged period between the event and the consolidation of the sequelae. As many as 34,3% of the examined victims had injuries corresponding to serious offense on their physical integrity (article 144º of the Portuguese Criminal Code), the majority concerning serious disfiguration or direct life endangerment.

Discussion : To conclude, any victim of a wildfire is a very particular case, requiring a meticulous and detailed medico-legal examination to determine any potential legal consequences. What emphasizes this type of victim in particular is the prolonged periods required for lesions resolution, often need of hospitalization, including Intensive Care Units, physical and psychological repercussions, and a grand potential of the lesions corresponding to serious offense of the physical integrity. Being rare cases and infrequent settings, this presentation constitutes an excellent opportunity for literature review as well as it serves as an acknowledgement of the vital contribution of Forensic Medicine for the correct evaluation of these victims.

191

POST ERUPTIVE DENTAL CHANGES UTILIZED IN AGE ESTIMATION: COMPARATIVE ANALYSIS OF OLZE’S AND DRUSINI’S METHODS

Cosmin-Daniel Tirdea 2, 1 , Alexandru-Daniel Popescu-Bercescu 2 , Razvan Marian Siminiuc 1 , Sorin Hostiuc 1,2

1 "Prof. Dr. Mina Minovici" National Institute Of Legal Medicine, Bucharest, Romania

2 University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Introduction: Forensic dentistry has proven to be indispensable in identifying and achieving the profile of the person. Age estimation using dental data is often used due to the strength of the teeth and limited taphonomic changes. Dental radiography is a common tool used in dentistry for diagnosis and treatment evaluation, and its use in forensic medicine is increasing, especially in forensic anthropology/odontostomatology.

Materials and methods : The panoramic radiographs of 114 people aged 16 to 88 were analyzed. We used the following exclusion criteria: unknown age, absence of all lower premolars, premolars with dental treatments. We used the Olze and Drusini methods to assess post eruptive dental changes for age estimation. The following data was included in an Excel database: for the Olze’s method we used four variable, namely: cementum apposition, secondary dentin formation, periodontal recession, attrition; for the Drusini’s method we used three variables, namely: crown height, coronal pulp chamber height and tooth coronal index (TCI). The measurements for Drusini’s method were made using Adobe Photoshop CS5, and for statistical analysis we used SPSS Statistics 26.

Results : After applying the above-mentioned exclusion criteria, a total number of 78 subjects were included in the final analysis. The average real age was 42.26 with a standard deviation of 13.319, the average age for Olze’s method was 35.578 with a standard deviation of 7.716 and the average age for Drusini’s method was 42.812 with a standard deviation of 11.765.

Discussion : There is a high correlation between the real age and estimated age especially using the Drusini’s method. No significant differences were observed between males and females. The use of both methods for estimating age is easy, non-invasive and reproductible.

192

MEDICO LEGAL ASPECTS OF SPOUSAL SEXUAL ABUSES IN KAIROUAN, TUNISIA

Firas Haggui 1 , Elyes Turki 1 , Elaa Chebbi 1 , Oumaima Brahim 1 , Bilel Gammoudi 1

1 Department of Forensic Medicine, Ibn El Jazzar University Hospital, Kairouan, Tunisie

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Introduction : Spousal sexual abuse may be physical, psychological and sexual. Although frequent but underreported, spousal sexual are newly recognized in Tunisian law in 2017. Through this study, we will analyze the epidemiological characteristics of spousal sexual abuse victims in Kairouan, Tunisia and precise its’ medico-legal implications.

Material and methods : It is a descriptive retrospective analysis about female victims of sexual abuse performed over a period of 08 years (2009-2016). We collected data from departments of Forensic medicine and Gynecology/obstetrics of The Ibn Jazzar University Hospital.

Results : 216 cases of sexual abuse victims were collected. Age of the victims ranged from 20 to 40 years old. The place where the abuse happened was the house of the victims in all cases. The perpetrator was the partner of the victim in only 06 cases (2.7%). Most of the cases were young, from rural areas, with a low socio-economic and educational level. The abuse consisted in vaginal penetration in two cases and anal penetration in 04 cases.

Discussion : In our study, the husband was the aggressor in only 06 cases of all 216 cases of sexual abuse. This rate appears lower than in literature. This low rate can be explained by many reasons such as rural areas of victims who are rarely aware of their rights. Furthermore, lack of sexual education is a main reason for underreported intimate partner sexual violence, as society believes that women should not refuse intercourse to their husbands. Moreover, low socio-economic levels, makes jobless women feel that they are dependent to their partners, and that reporting sexual violence may lead to divorce and thus to worse conditions. As about the sexual violence itself, we noticed that anal penetration was more reported than vaginal penetration. Culture and Islamic prohibition of this act explain this difference. Sexual violence in our country in married couples had only been recognized in 2017 with the new law 2017-58. However, despite the legal framework protecting women victims of violence, our society considers that women cannot refuse sexual intercourse to their husbands even without consent.

193

WOMEN SEXUAL ABUSES IN THE REGION OF KAIROUAN, TUNISIA: EPIDEMIOLOGIC PROFILE AND MEDICO-LEGAL ASPECTS

Elaa Chebbi 1 , Elyes Turki 1 , Firas Haggui 1 , Oumaima Brahim 1 , Bilel Gammoudi 1 , Oumayma Fersi 1

1 Department of Forensic Medicine, Ibn El Jazzar University Hospital, Kairouan, Tunisia

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Introduction : Sexual abuses are a major public health problem in Tunisia and the world. It is a frequent reason of consult including infractions and crimes with a sexual aspect. Sexual assault victims are susceptible to suffer from physical and psychological complications. Our study aims to analyze epidemiological characteristics of victims of sexual abuses in Kairouan.

Material and methods : It is a descriptive retrospective analysis about female victims of SA performed over a period of 08 years (2009-2016). We collected data from departments of Forensic medicine and Gynecology/obstetrics of The Ibn Jazzar University Hospital.

Results : Our study was about 216 victims who consulted for a sexual abuse. The age range was between 3 to 82 years with an average age of 20.4 years. Children (under 18 years old) represented more than half of the cases with 58.8 %. Most of the victims were single (84.3%). As about the perpetrators, they were all male, with a mean age of 25.7. The assailant was unique in almost all the cases (94.7%) and he was known to the victim in 73.2% of cases. Physical examination showed signs of violence in 43.8% of cases such as bruises and skin grazes. Genital examination showed that 87% of victims had a hymen tear that was recent in 17.6% of cases. Only 36% of victims had vaginal swabs to look for sperm, and sperm was found in 28.2% of cases. A pregnancy was found in 6% of cases by beta HCG dosage and in 7.2% of cases by an ultrasound.

Discussion : In our study, similarly to data literature, as most of the victims were women, female gender is considered a high risk of sexual abuses. Young age, low socio-economic and educational levels are also risk factors. The presence of vulnerability factors such as old age, mental or physical disabilities exposes victims to a higher risk of sexual assaults. As about the assailant, he was unique in more than half of the cases and the assault happened in his house, like in other studies. Physical signs of violence was found in almost half of the cases however, their absence does not mean the consent of the victim as the assailant can use different methods to threaten the victim (firearm, arm …). Genital examination of the victims showed recent hymen tear in 17.6% of the cases but the hymen examination utility can be limited if the victim is previously used to sexual intercourse. Sexual abuses are a medico legal emergency concerning mostly female victims. However, they are frequently underreported especially when the assailant is the partner or a member of the family and when the victim is young or vulnerable.

194

PATTERNS OF INTIMATE PARTNER HOMICIDE IN SFAX (TUNISIA)

Wiem Ben Amar 1 , Hela Siala 1 , Malek Zribi 1 , Moulaye Ahmed Dhehby Ahmedou 1 , Elaa Chebbi 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Habib Bourguiba Hospital, Sfax, Tunisie

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Introduction : Intimate partner homicide (IPH) is a major threat to women’s safety and well-being worldwide. It is associated with negative physical and mental health outcomes. Our aim is to describe the trends of intimate partner homicide in Sfax (Tunisia), the victim profile and to report the forensic data related to these case.

Methods : We conducted a retrospective and descriptive study of all cases of IPH collected between January 14, 2011 and December 31, 2019and examined in the forensic medicine department of sfax, Tunisia. We use the terms of intimate partner homicide to mean homicides occurring between current or former dating, cohabiting and married heterosexual couples.

Results : Among 5901 postmortem examinations during the 9-year period, 109 (1.84%) were homicides. 15 cases of IPH were collected (13.7% of all homicides). The distribution of IPH by year varied. On average, 1.45 cases of homicide victims a year were reported and a maximum in 2019 (5 cases were reported). All the victims were female. The mean age of the victims was 34 +/-10.51. Over all, 66.66% of the victims were married. Half of the victims were unemployed. Homicides mainly took place in the urban areas (8). Crime scene information was reported in only 8 cases. Mostly, homicides took place in private residence (7) followed by deserted areas (1). Mechanical asphyxia (9) and blunt trauma (3) were the most methods used by perpetrators, followed by sharp forces (2) and falling from height (1). The partner homicide was followed by aggressor suicide in three cases.

Discussion and conclusion : Ensuring that all women can live violence-free will require multi-disciplinary support.

195

EPIDEMIOLOGICAL AND FORENSIC ANALYSIS OF SEXUAL HOMICIDE IN SFAX

Wiem Ben Amar 1 , Hanen Dhouib 1 , Malek Zribi 1 , Hela Siala 1 , Moulaye Ahmed Dhehby Ahmedou 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Habib Bourguiba Hospital, Sfax, Tunisie

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Introduction : Sexual homicide is a rare event that represents only a very small proportion of violent crimes. Therefore, research addressing sexual homicide in our country is lacking. Our aim is to report sexual homicide's cases in Sfax (Tunisia), the victim profile and the forensic data related to these case in order to establish preventive measures.

Methods : We conducted a retrospective and descriptive study of all cases of sexual homicides collected and examined in the forensic medicine department of sfax, Tunisia between January 14, 2011 and December 31, 2019. Sexual homicide is defined as homicide committed where there has been sexual behavior and/or arousal before, during, or after killing the victim.

Results : 7 cases were related to sexual homicide accounting for 6.3% of all the homicides. There were five cases of rape and two cases of pederasty. Homicides which represents 6.3% of all homicides. There were five cases of rape and two cases of pederasty. The victim was a female in 5 cases (71.4%). The median age was 50 with extremes ranging from 26 to 77 years. Concerning matrimonial status, three victims were single, three were married and one was divorced. Most victims didn’t have pathological history. However, two women suffered from schizophrenia. Most homicides took place in private indoor settings, and only one case was committed in a rural area. Orofacial suffocation was the predominant mechanism of death in 71.4%. Ligature strangulation coupled with blunt trauma were found in 14.2% of cases. Ligature strangulation associated with sharp force injuries were described in 14.2% of cases. The two male victims had homosexual habits. In both cases, perpetrator was a prostitution client. Genital lesions such as vulvar lacerations, swelling or bruising were found in two victims. Anal lacerations were objectified in a male and a female. The final case had a testis bruise. Cytological specimens for semen were positive in all cases. As for the perpetrators, they were all males. Two victims were assaulted by the same perpetrator which had also a history of incest with his sister at a younger age. He was arrested after the second sexual homicide, thanks to genetic fingerprints found on the two victims (case 1 and 3). Victims knew their perpetrators in 85.7%.the aggressor was part of the family, intimate, friendly or leisure sphere.

Conclusion : To prevent sexual homicide, Tunisian legislation in the Law No. 58 of August 11, 2017 relating to the elimination of violence against women, reduced punishment of rape to 20 years instead of death penalty, in order to reduce the incidence of sexual homicide.

196

SEXUAL VIOLENCE AGAINST MINORS AND PSYCHOLOGICAL IMPACT: A STUDY OF 8 YEARS

Wiem Ben Amar 1 , Narjes Karray 1 , Malek Zribi 1 , Hela Siala 1 , Moulaye Ahmed Dhehby Ahmedou 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Habib Bourguiba Hospital, Sfax, Tunisie

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Introduction : Sexual violence against minors is an important issue worldwide and can have long-lasting and devastating psychological and social consequences. Health professionals, including the forensic expert, through the quality of their medical care, can participate in limiting its consequences. In this work, we aim to evaluate the socio-familial profile of the victims of sexual violence, the psychological impact of these violences and to deduct the contribution of the forensic expert in the victims medical care.

Material and methods : This is a retrospective descriptive study of all cases of suspected sexual violence against minors collected in the Forensic Department in the Habib Bourguiba University Hospital of Sfax- Tunisia during the period from January 01st, 2011 to October 31th, 2018.

Results : During this period of study, 30 cases of suspected sexual violence against minors were examined at the forensic department under requisition and received a psychiatric interview. We found that sexual violence against minors occuratny age, with a female predominance. The perpetrator of the sexual violence is almost always a man, often a foreign person (46.7%). The abuse was mainly of sexual touching in 73.3% of cases. The gynecological examination performed in most female victims showed an intact hymen in 70.6% of the cases. The proctological examination carried out on 28 victims revealed the presence of recent anal fissures in 2 cases. The psycho-traumatic impact of the sesexual violences was marked by a polymorphic expression of suffering (instinctual, cognitive and behavioral disorders).

Conclusion : This study allowed us to conclude that multidisciplinary work, research, continuous training of personnel and improvement of resources today seem to be a priority in the care of child victims of sexual violence.

198

MORPHOMETRIC TRAITS OF MANDIBULAR CANINES FOR SEX ESTIMATION OF INDIVIDUALS IN ROMANIAN ADULT POPULATION

Madalina Maria Diac 1 , Andreea-Alexandra Hleșcu 1 , Diana Bulgaru Iliescu 1

1 University Of Medicine And Pharmacy "Grigore T Popa", Iasi, Romania

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Introduction : Dental identification is the study of forensic odontology and represents a superior method of identification due to the increased resistance of teeth to the action of physical, mechanical, chemical and thanatological factors. The main concern of the authors is the development of the forensic odontological identification process for Romanian population. In this vein, the objective of the present paper was to create discriminant function regarding the sex estimation base on the morphometric traits of the mandibular canines.

Material and methods : The research included a retrospective study of 73 cases that were represented by radiographic images of the mandibular dental arch. As a working methodology, the authors analysed orthopantomographic images taken on living people between the ages of 21 and 70, of which 33 were women and 40 men. The images were analysed using the RadiAnt DICOM Viewer program, through which the appropriate dental measurements were carried out involving the calculation of the maximum distance between the medial (lingual) and the oral (external) face of the analysed tooth (mesio-distal diameter of the right canine and of the left one).

Results and discussions : The results show important dates regarding the dental identification for Romanian legal medicine validate the relation between the mesio-distal measurements of the teeth and the sex of unknown individuals. In order to develop methods of estimating the sex of cases according to the predictors MDD C3.3 and MDD C4.3 respectively, the discriminating analysis was carried out which allowed the obtaining of three discriminatory functions. The objective pursued in this paper, to develop discriminatory formulas helping to estimate sex with the highest accuracy, has been achieved. The results of the analysis of the study group indicated a normal distribution of the variables included in the study, namely: the age of the participants, the mesio-distal diameter of the right mandibular canine (MDD C4.3) and the mesio-distal diameter of the left jaw canine (MDD C3.3), which concluded that the study group is statistically significant. Predicting sex from tooth measurements is an important element in forensic anthropology for Romanian population. The mesio-distal diameters of the right and left mandibular canines are important predictable factors in the estimation of sex. Based on the analyses carried out, it is objectified that the best predictability is provided by the mesio-distal diameter of the left mandibular canine. The results of the present study also validated for the Romanian population the fact that the mesio-distal diameters of the teeth are greater in males than in females.

Keywords : forensic odontology, sex estimation, forensic identification

199

CASE STUDY: CURRENT CHALLENGES IN THE IDENTIFICATION OF MISSING PERSONS IN ROMANIA

Ionescu Carmen Simona 1 , Ligia Elena Barbarii, Bianca Hanganu, Beatrice Gabriela Ioan

1 Institutul Medico-legal, IASI, Romania

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

To what extent are we prepared to face, at European standards, the challenges met in cases of missing persons? What about catastrophes? The current challenges are due to the increase of migration in the European space, the multiple and diverse possibilities of manifesting aggression and the existence of numerous methods and procedures for human identification worldwide. The Symposium organized by the authors in 2019 highlighted the existence of several problems related to the identification of missing persons, especially unidentified human remains that reached a large number at the end of 2019 in our country, of approximatively 2000. Romanian specialists, as well as three foreign professionals in the field of human identification, examined the current situation and used their experience to complete the models of standard operational procedures and inter-institutional protocols. At the Humanitarian Forensic Action International Symposium in Coimbra in 2019, new models were presented that addressed the problem of human unknown remains. We considered it beneficial to follow the French model, established after the Paris attack in 2015. It consists in the adoption of the international standards proposed by Interpol in cases of mass disasters for the daily cases of forensic identification. The implementation of this model in France has shown the importance of creating forensic identification centers to ensure the optimal collection of ante and postmortem data and efficient identifications. The forensic team should coordinate the collection of pre-mortem medical data by the police (taking into account that the police is currently focusing on non-medical data, namely fingerprints and photographs), to establish the procedures for collaboration between forensic institutions and investigators and to create a database for ante and post mortem medical data. The current study aims to find viable solutions in order to adopt the French model, by adapting it to the specific conditions of our country. We are convinced that our concern for the rapid and reliable identification of unknown human remains will put the basis of feasible intra- and inter-institutional collaboration in mass disasters too.

201

CASEWORK IMPLEMENTATION OF A TRI-ALLELIC MPS PANEL IN A DISTANT KINSHIP TEST

Jorge Ruiz-Ramírez 1 , María De La Puente 1 , Lorena Girón-Santamaría 1 , Ana Freire-Aradas 1 , María Fondevila 1 , Adrián Ambroa-Conde 1 , Ana Mosquera-Miguel 1 , Ángel Carracedo 1,2 , Christopher Phillips 1 , María Victoria Lareu 1

1 Forensic Genetics Unit, Institute of Forensic Sciences, University of Santiago de Compostela, Spain; 2 Fundación Pública Galega de Medicina Xenómica (FPGMX), Santiago de Compostela, Spain

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Case description : A distant kinship test was conducted in our laboratory, applying standard forensic markers to the analysis. The pedigree of this case consisted of: a female proband, her mother and two alleged half-sisters. Although several STR kits were used, these markers were not able to provide enough discrimination power to verify any of the two kinship hypotheses, and the results of STR test were inconclusive. Thus, in order to enhance the likelihood ratio (LR), the samples were analyzed on an Ion S5™ (Thermo Fisher Scientific) with the Qiagen-ICMP MPSplex large-scale SNP and microhaplotype panel, using Massively Parallel Sequencing (MPS) to genotype more than 1400 markers and applying compiled European allele frequencies.

Discussion : Despite the loss of several markers in each sample resulting in incomplete profiles, the genetic information provided by the MPSplex panel itself was more than sufficient to increase the likelihoods associated with each kinship hypothesis, and no further data was required in the case. Pedigree simulations we have performed for the MPSplex panel indicate no overlap of the LR value distributions between each hypothesis. Therefore, results are a good illustration of how the emerging use of MPS applied to real casework provides a key breakthrough in some scenarios, such as the ability to resolve a complex pedigree or distant kinship when STR data cannot resolve the hypotheses.

202

BIO-GEOGRAPHICAL ANCESTRY INFERENCE FROM DECONVOLUTED MICROHAPLOTYPE PROFILES

María De La Puente 1 , Jorge Ruiz-Ramírez 1 , Ana Mosquera-Miguel 1 , María Pérez-Infantes 1 , Nerea Veira-Varela 1 , Lorena Girón-Santamaría 1 , Adrián Ambroa-Conde 1 , Ana Freire-Aradas 1 , Professor Ángel Carracedo Álvarez 1,2 , Christopher Phillips 1 , María Victoria Lareu 1

1 Forensic Genetics Unit, Institute of Forensic Sciences, University of Santiago de Compostela, Spain

2 Fundación Pública Galega de Medicina Xenómica (FPGMX), Santiago de Compostela, Spain

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Introduction: With the adoption of massively parallel sequencing (MPS) technologies, microhaplotypes (MHs) are being explored as forensic genetic markers. Previously, we designed and validated a multipurpose panel of MHs in two different MPS platforms: the Ion S5 and MiSeq. The developed MH-panel showed advantages for individual identification, especially in cases that have highly degraded DNA; complex or distant kinship testing; mixed DNA analysis; and the inference of the bio-geographical ancestry of a trace donor. Here, we test the ability of the panel to predict ancestry from deconvoluted profiles from simple mixtures.

Material and Methods : Volume mixtures of two components at ~1ng/μl were prepared in different ratios. Mixture component DNAs were selected from the HGDP-CEPH population panel, ensuring both haplotypes and ancestry had been previously characterized. Mixture samples were analysed as described in [de la Puente M, et al. Forensic Sci Int Genet (2020) 45:102213]. The bioinformatic pipeline described in [de la Puente M, et al. Forensic Sci Int Genet (2020) 45:102213] was used to call the haplotypes, but the minimum allele frequency threshold was modified in order to allow efficient detection of the minor component. Deconvolution of mixed profiles was performed by several analysts with a varying experience in mixture interpretation. Bio-geographical ancestry analysis was performed at a continental level, and included deconvoluted profiles of the major and minor components, as well as the reference profiles of the component samples.

Results : Differences in mixtures deconvolution were minimal and all the haplotypes were assigned correctly to the major or minor components. All the interpretations were considered in order to construct consensus minor and major profiles by applying the most conservative approach for each marker. Full reference profiles of the mixture component DNAs and partial deconvoluted profiles from minor and major components obtained similar ancestry inference results. However, profile completeness can affect these inferences, especially for minor components.

Discussion: These results demonstrate that, to a certain level, ancestry inference from simple two-donor mixed MHs profiles is feasible and can provide investigative leads when applied to cold cases. The use of MH markers simplifies mixture deconvolution in comparison to STRs, as stutter artefacts do not need to be taken into account. At the same time, and in contrast to the use of SNP-based ancestry panels, the same MHs used for ancestry inference can be used for individual identification of the mixture components by applying probabilistic genotyping software.

203

PATTERNS AND IMPACTS OF SEXUAL HARASSMENT AMONG FEMALE STUDENTS IN AN EGYPTIAN UNIVERSITY

Sanaa Aly 1 , Sara Fathy Ibrahim 1 , Enas Ameen Mostafa 1 , Abeer Mohamed Hagras 1

1 Forensic Medicine & Clinical Toxicology department, Faculty of Medicine, Suez Canal University, Ismailia, Egypt

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Background : Sexual harassment (SH) is an uprising problem worldwide especially in Egypt. Young girls are at greater risk. Aim of the study: To curb violence against women in the form of SH by determining the magnitude, patterns and circumstances of SH among female students in Suez Canal University (SCU).

Methods : A cross-sectional study was conducted on a representative sample (644 female students) from all the faculties in SCU using a self-administered anonymous questionnaire. The used questionnaire is a modified version of United Nations Entity for Gender Equality and Empowerment of Women (2013). The psychological impact of SH was assessed based on the WHO Self Reporting Questionnaire (SRQ). Results: All students experienced SH mainly in the physical form. Nearly 97% and 70% of students experienced verbal and visual SH respectively. It mostly happened at all times (58.5%), in the streets (80%) and least on campus (15%). Most of the harassers were younger than 20 years old (85%) and strangers (99.5%). 60.7% of harassed students didn't do anything as a reaction at time of SH as they thought the situation won't go any better. More than one third of harassed students (33.5%) are psychologically affected. The most common social impacts of SH were feeling a lack of trust of others (88.7%) and feeling humiliated (77.5%). Both psychological and social impacts are significantly experienced by harassed females. Negative responses of the victim and surrounding people were mainly observed with low awareness of Egyptian law against SH.

Conclusion : SH among SCU students is prevalent. Therefore, we need to encourage researchers and policymakers to collaborate in order to help and support the effective existence of an integrated strategy to solve this problem in terms of laws, government policies, and participation of civil society and the media.

204

USE OF CONE BEAM CT TO ANALYZE SAW MARKS IN BONE – AN ORIGINAL COLLABORATION WITH DENTAL IMAGING SERVICE. CASE REPORT

Rufino Felizardo 1,2 , Tania Delabarde 2,3 , Bertrand Ludes 2

1 Department of Odontology Rothschild hospital Paris APHP - UFR Odontology University of Paris, France

2 Medico-legal Institute of Paris, France

3 UMR 8045 BABEL CNRS Université de Paris, France

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Case description : A carbonized and dismembered body was found in a dump located in Paris suburbs. We examined this body to determine biological profil and to perform an analysis of bone injuries. A total of 16 grooves or complete section planes were found at the level of the proximal and distal femoral and tibial articular surfaces indicating the use of a sharp injuring instrument for dismemberment. This wounding agent cuts by removing material causing a loss of substance that does not allow the edges to reassociate. In addition to the direct optical stereomicroscope (Zeiss200-C) examination of bone sections underwent a conventional CT scan imaging examination (GE LightSpeed VCT©) with a voxel resolution of 365microns. An original collaboration with the dental imaging unit of the Rothschild hospital made available a Planmeca ProMax Mid© Cone Beam CT of same pieces. CBCT allows volume acquisition with finer resolutions than the CT scan using an isometric voxel not deformed from 100 to 150microns. For this we used the object holder plate used for scanning impressions and radiological guides. The volumes obtained are then analyzed on the Romexis ©version 6 viewer which allows multiplanar reconstructions, volume rendering and scale measurements.

Discussion : This non-destructive analysis permits to measure in 3D the depths, lengths and sizes of the various grooves. Five notch measurements, repeated at three depth levels determined the edges spacing who appeared regular, with an average size of 1.2mm (+/-0,13). The end of these grooves has a square profile compatible with a manual saw-type instrument. The use of CBCT made it possible to obtain fine, high resolution (3 times more accurate than CT scan) non-destructive measurements of saw marks. These volumes, easy to handle, can be analyzed a posteriori in comparison with optical images and allow dynamic illustrations during trials.

205

THE LIMITATIONS OF RADIOLOGICAL INVESTIGATIONS IN GUNSHOT INJURIES

Matteo Sacco 1 , Carmen Scalise 1 , Angelica Zibetti 1 , Carlo Filippo Bonetta 1 , Luigi De Aloe 1 , Francesco Sicilia 1 , Fabrizio Cordasco 1 , Saverio Gualtieri 1 , Fiorella Caputo 1 , Santo Gratteri 1 , Pietrantonio Ricci 1 , Isabella Aquila 1

1 University Magna Graecia of Catanzaro, Italy

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

In this work, in order to carry out an objective analysis of the applicability and limits of the diagnostic investigation, a case of a 52-year-old man who died from gunshot wounds was analyzed. Total body CT was performed on the corpse, followed by external examination, autopsy examination and histo-pathological examination. On the external examination of the body, an oval-shaped ecchymotic entry hole was found at the distal phalanx of the fourth finger of the right hand (GS1); a hole in the interphalangeal region between the fourth and fifth fingers, corresponding to an exit hole of a shoot at the thorax (GS2); gunshot wound at the proximal third of the lateral surface of the left arm (GS3); gunshot wound in the left subclavicular region, oval with eccentric excoriated ecchymotic border (GS4); hole in the left pectoral region (GS5). Massive hemothorax with massive cardiac tamponade was detected. The analysis of the lungs revealed multiple lacerations compatible with gunshot wounds. The heart muscle was lacerated on the anterior and posterior surface with solutions of continuity compatible with gunshot wounds. With 3D multi-slice CT it was possible to determine the entry and exit of the bullet through the analysis of specific bone fracture characteristics, respectively, with the inverted or everted edges of the injured bone tissue. In particular, a bullet entered at the distal phalanx of the fourth finger of the right hand and exited in GS 2 causing fracture of the proximal and distal phalanges of the right hand; GS 3 entered the anterolateral surface of the left arm and passed through the underlying tissues, tearing the left lung and forming a terminal niche at the spinal column in the medullary canal; GS 4 entered the left sub-clavicular region, tearing the underlying tissues, tearing the root of the aorta in the emergency with the heart and forming a terminal niche in the muscles of the left neck; finally, GS 5 entered the left pectoral region, tore the underlying tissues, the right lung parenchyma and stopped at the subcutis of the right paravertebral dorsal region. These holes therefore presented incomplete passages with the formation of three terminal niches. Despite the usefulness of the method in evaluating lesions, CT in this case has shown some limitations. First, there was evidence of poor accuracy in evaluating blood vessels. Other important limitations were the overestimation of intracavitary haemorrhages, the underestimation of soft tissue infiltrations (especially in lean subjects with little visceral fat) and the presence of artifacts created by the passage of air when faced with continuously transversal solutions, as in gunshot wounds.

206

COMBINATION OF MAXIMUM INTENSITY PROJECTION MODE AND COLOR LOOKUP TABLE TO ENHANCE DENTAL MATERIALS IN PMCTS IN FORENSIC ODONTOLOGY AT THE INSTITUT MEDICO-LEGAL OF PARIS

Rufino Felizardo 1,2,3 , Joseph Benzakoun 4 , Aida Ben Cheikh 2 , Steve Toupenay 1,2 , Tania Delabarde 2,3 , Bertrand Ludes 2,3

1 Department of Odontology Rothschild hospital Paris APHP - UFR Odontology University of Paris, France

2 Medico-legal Institute of Paris, France

3 UMR 8045 CNRS BABEL University of Paris, France

4 Department of Neuroradiology GHU ST Anne Hospital, Paris, France

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Since 2019, at the Institut Medico Legal of Paris, we have been integrating Dentascan© or dento-maxillo-facial acquisitions during PMCT examinations of unidentified bodies. In order to make these images more relevant, we have developed a rapid sequence of image post-processing, in a few minutes, applicable on unidentified current bodies but also in situations of numerous victims (fires, accidents…). Description: the acquisition of a dentascan volume is carried out with a GE CT scan Lightspeed VCT© type with the following parameters: Helical Mode; 140Kv, 200mAs, slice thickness: 0.625mm repeated every 0.312mm; pitch: 0.53; FOV143mm (512x512)- medium filter BonePlus; HU windows: WC600 WW3200. Dicom data was exported to a MacBookPro Apple© with GPU Intel Iris Plus Graphic 650© processor and reformatted with Horos V3.3.6 from Horoproject.com. First step: panoramic reconstruction (manual procedure) in one or two sequences with Dental3DPlugin 4.1.2© of maxillar and mandibular dental archs depending in body position (fig1). Second step: we apply an Maximum Intensity Projection (MIP) mode with thick slab between 8 to 11. Third step: application of a color lookup table (UCLA type) and variation of HU window level (WL range 3700 to 4300) and window width (WW range 1390 to 2500) for isolating dental materials. The resulting image is exported and superimposed (with 50% transparency) on the initial panoramic MIP image to enhance in color the dental exogenous materials. This type of Dentomaxillo-facial volume allows classic MPR views but above all curved reconstructions of the jaw and / or mandibular panoramic like type (in one or two reconstructions depending on the condition of the body). These images are obtained with non-destructive methods, avoiding maxillo-mandibular sampling and allowa broader analysis than conventional intraoral images and easier comparison with antemortem data. These snapshots with dental exogenous materials (amalgams, inlays, onlays, endodontic filings, implants, fixed and removal prostheses…) can be widely disseminated to practitioners looking for antemortem data via the “identification alert” e-mail procedures issued by the Dental Identification Unit (UIO) from French National Dental Council.

207

SUDDEN DEATH AFTER PHYSICAL ACTIVITIES

A Wiem Ben Amar 1 , Hanen Dhouib 1 , A Malek Zribi 1 , Houssein Lebkem 1 , Fatma Daoud 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic departement Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Several studies have studied sudden death during sports. However, few studies have examined sudden death during physical activities in general, whether in the context of sport practicing or in everyday life activities.

We aim to study the demographic characteristics of the victims who died after a physical effort, whether sporting or otherwise, and to identify the risk factors contributing to death. It’s about a retrospective descriptive study concerning all cases of death occurring shortly after a physical effort, examined in the forensic department of Habib Bourguiba Hospital in Sfax between January 2011 and December 2016. During the six year study period, 45 cases of death following an effort were collected. 63% of victims died in the course of physical activity (n = 28) and 35% died in the course of daily activity (n = 16). Only one file does not contain information on the exact nature of the effort. A clear male predominance was noted (sex ratio = 10). Only 5 victims were under the age of 30. Medical and surgical histories were recorded for only 34 victims, dominated by hypertension (11%). Cardiac failure was the most common cause of death among the various age groups. Ischemic heart disease predominated in patients over the age of 30 (70%), while hypertrophic heart disease was the common cause of death in the youngest victims (29%). Extracardiac causes mainly related to subarachnoid hemorrhages (4%). Sudden death during physical effort is an underestimated phenomenon. Death often occurs after moderate physical efforts. The early diagnosis of cardiac risk factors may help to reduce these deaths.

208

CONTRIBUTION OF ANATOMOPATHOLOGICAL EXAMINATION IN PULMONARY EMBOLISM DIAGNOSIS

A Wiem Ben Amar 1 , Hanen Dhouib 1 , A Malek Zribi 1 , Houssein Lebkem 1 , Jaweher Kammoun 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic departement Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Pulmonary embolism is the third leading cause of cardiac death after stroke and coronary artery disease. However, it is unfortunately under diagnosed especially when it’s not obvious during the forensic autopsy. Hence the interest in requesting an anatomopathological examination in case of doubt. In this paper, we aim to highlight the contribution of the anatomopathological examination in the confirmation of doubtful cases of pulmonary embolism. We carried out a retrospective study, extended over a period of five years (January 2013-December 2017) including all the forensic autopsies performed in Habib Bourguiba hospital’s Forensic department in Sfax Tunisia. During the five years of study, 3,215 autopsies were performed in the forensic department of Sfax. 212 autopsies required an anatomopathological study. Eight cases of pulmonary embolism were discovered at the end of the histological examination of the pulmonary samples. 6 cases of fibrinocuroric embolism were collected including 2 in the week following the trauma and one case in postpartum. We have identified 2 cases of fatty embolism with delays of 7 days till 3 months post-traumatic. The average age of the victims was 55. We noted a male predominance (sex ratio 5/3). Pulmonary embolism that can be fatal. The medical examiner must consider it as a potential cause of death, especially in a traumatic context. If there is any doubt, anatomopathological examination must be carried so as not to miss the diagnosis.

209

DEATH BY MECHANICAL ASPHYXIA: A 4-YEAR RETROSPECTIVE STUDY IN SFAX-TUNISIA

Jaweher Kammoun 1 , Malek Zribi 1 , Wiem Ben Amar 1 , Moulaye Ahmed Dhehby Ahmedou 1 , Houssein Lebkem 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic departement Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Introduction : Mechanical asphyxia represents a set of phenomena that prevent air from entering to the lungs and thus causing oxygen deprivation in tissues. It’s a frequent cause of death which can have suicidal, criminal or accidental origin and presents a violent death requiring a forensic autopsy which allows to remove the doubt and to specify the exact cause of death. The aim of our work is to present a victimology profile through the epidemiological characteristics of deaths from mechanical asphyxia and to identify the main lesions found at the autopsy of victims.

Materials and methods : It’s a retrospective study over a period of 4 years between January 1, 2016 and December 31, 2019. This study is carried out in the forensic departement in Sfax-Tunisia and including all victims of death by mechanical asphyxia. The data were recruited from forensic autopsy reports, interrogatory of kinfolk and the report of the relevant fact.

Results : We collected 361 cases of death from mechanical asphyxia during our study period, that present 14.87% of all autopsy activity in our department. Regarding the medico-legal form, 64.26% of mechanical asphyxias had probably an accidental origin, 32.4% a suicidal origin and 1.1% criminal origin. The place of death was seawater for the shipwrecks of illegal immigrants in the majority of cases (42.38%) and domestic in 39.88% of the cases. Submersion was the most common cause of mechanical asphyxiation (62.6%) followed by hanging (31.3%) followed by suffocation (4.98%) and strangulation in 1.1%. The average age is 31.74 years with a sex ratio of 1.04. Young adult male were more affected by hanging and submersion. The majority of victims didn’t have a profession (34.1%) and were coming from a rural area in 68.97% of the cases. More than the one third had a pathological history, in particular psychiatric, in 25.5% of the cases. On the external examination of the corpses, most of the victims were in fresh condition and showed no traumatic lesions. Asphyxial syndrome was present in the majority of cases with cervico-facial cyanosis in 45.42%. At autopsy, acute edema and pulmonary congestion were noted in 88.36% of cases.

Discussion and conclusion : Violent deaths from mechanical asphyxiation are frequent. All the medico-legal forms can be observed moreover the possibility of simulation or camouflage remains possible from where the capital role of the forensic doctor to establish the medico-legal diagnosis based on the data of the investigation, the autopsy and in some cases the results of additional examinations.

210

DEATH BY HANGING IN SOUTH TUNISIA

Jaweher Kammoun 1 , Malek Zribi 1 , Wiem Ben Amar 1 , Elaa Chebbi 1 , Moulaye Ahmed Dhehby Ahmedou 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic department Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Introduction : Hanging is almost always self-inflicted, intentionally or accidentally. Several mechanisms can be responsible of death during. Accessible and radical character of death by hanging makes it one of the popular methods used in suicide. The accidental form of hanging occurs mostly in children. The aim of our work is to draw up the socio-epidemiological profile of the victims who died from hanging and to describe the circumstances of death and the forensic autopsy data.

Material and methods : This is a retrospective study carried out in the forensic service in Sfax, Tunisia over a period of 4 years (2016-2019) including all the victims who died by hanging. The data were recruited from forensic autopsy reports, interrogatory of kinfolk and the report of the relevant fact.

Results : We collected 113 cases of hanging that present 31.3% of mechanical asphyxia during this period. Most of the hangings had probably of suicidal origin. The probably accidental origin of hanging was noted in 5 children. The place of death was the home in the majority of cases. Hanging were complete in 73.5%. It occurred during the second half of the night in half of cases. The average age of the victims is 34.12 years with a sex ratio of 2.22. The majority of the victims were day laborer (46.9%) and from a rural area (74.13%). 43.4% had a pathological history, notably psychiatric in 35.4% of the cases with poor adherence to their treatment in almost all of the cases. In the case of suicide, the victims left a farewell letter in 13.3% of the cases with the notion of social or economic conflict in 50.4%. The hanging link was a rope in the majority of cases (62.8%). On external examination of the corpses, most of the victims were in a fresh state and showed no traumatic lesions. Asphyxial syndrome was present in the majority of cases with head and neck cyanosis in 90.3%. The furrow was incomplete in the majority of cases. At autopsy, acute edema and pulmonary congestion were noted in 68.1% of cases. Lesions of the hyoid bone were observed in 37.2%, of the thyroid cartilage in 31.9% and in the muscles of the neck in 38.9%. Two victims presented a lesion of the cervical spine.

Discussion and conclusion : The private nature of hanging means that there are rarely opportunities to prevent it in the period immediately before the fatal event. Earlier interventions will have to be considered. To prevent hanging as a means of suicide, we need more information about the cultural problems experienced by indigenous youths in their teenage years. Young people in the justice system may need personal support. There is a pressing need to determine if young people, especially in rural areas, have adequate access to the professional expertise needed to diagnose and treat mental disorders.

211

DEATH BY HANGING IN CHILD IN SFAX- TUNISIA

Jaweher Kammoun 1 , Malek Zribi 1 , Wiem Ben Amar 1 , Fatma Daoud 1 , Hela Siala 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic department Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Introduction : Hanging is almost always self-inflicted, intentionally or accidentally. The radical and easy nature of death by hanging makes it one of the popular methods used in suicide. The accidental form of hanging occurs mostly in children. The aim of our work is to draw up the socio-epidemiological profile of the victims who died from hanging and to describe the circumstances of death and the forensic autopsy data.

Material and methods : This is a retrospective study carried out in the forensic service in Sfax-Tunisia over a period of 4 years (2016-2019) including all the children who died by hanging. The data were recruited from forensic autopsy cards, interrogatory of kinfolk and the report of the relevant fact.

Results : We collected 25 cases of hanging that present the quarter of mechanical asphyxia during this period. Most of the hangings had probably of suicidal origin (76%). The probably accidental origin of hanging was noted in 5 children. Hanging were complete in 76%. It occurred during the second half of the night in the majority of cases (40%). The average age of the victims is 12 years with a sex ratio of 0.78. The average age of child victims of accidental hanging is 4.8 years. The majority of the victims were students (64%) and from a rural area in 84% of the cases. In the case of suicide, the victims left a farewell letter in 32% of the cases with the notion of social or economic conflict in 44%. The hanging link was a rope in the majority of cases (52%). On external examination of the corpses, most of the victims were in a fresh state and showed no traumatic lesions. Asphyxial syndrome was present in the majority of cases with head and neck cyanosis in 92%. The furrow was incomplete in the majority of cases. At autopsy, acute edema and pulmonary congestion were noted in 84% of cases. Lesions of the hyoid bone were observed in 36%, of the thyroid cartilage in 12% and in the muscles of the neck in 32%. No victims presented lesions of the cervical spine.

Discussion and conclusion : The study of the epidemiological characteristics of child victims of hanging is of great help for the understanding and the prevention of a suicidal act especially in child with a social or economic conflict and of an accidental hanging especially in very young children.

212

EVALUATION AND FORENSIC SIGNIFICANCE OF MESSAGE SUBSTANCES IN FAT AND MUSCLE—A PRELIMINARY INVESTIGATION

Yayoi Aoki 1 , Tomoya Ikeda 1,2 , Naoto Tani 1,2 , Tatsuya Hirokawa 1,2 , Fumiya Morioka 1 , Kei Ikeda 1 , Alissa Shida 1 , Kazunori Miyamoto 2 , Takaki Ishikawa 1,2

1 Department of Legal Medicine, Osaka City University Medical School, Osaka City, Japan

2 Forensic autopsy section, Medico-legal Consultation and Postmortem Investigation Support Center (MLCPI-SC), Osaka City, Japan

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Introduction : Leptin is secreted from adipocytes and acts in the hypothalamus, serving to stimulate sympathetic nerves and decrease fat mass from energy consumption. Myostatin is synthesized from muscle, and exerts a major negative effect on the increase and function of muscle mass. The purpose of this study was to forensically investigate changes in leptin and myostatin levels in blood and cerebrospinal fluid (CSF) that result from central dysfunction associated with head trauma in autopsy cases.

Material and Methods : The study was conducted with 88 autopsy cases (blunt head injury, blunt non-head injury, asphyxia, drowning, acute cardiac death, and others). Leptin and myostatin in left heart blood and CSF were measured using ELISA, and investigated for each cause of death. Using postmortem computed tomography, the relationships of leptin and myostatin to subcutaneous fat mass, visceral fat mass, and muscle mass were investigated in autopsy cases. Immunohistochemical tests were also performed for each marker using hypothalamic tissue, subcutaneous fat tissue, and chest skeletal muscle tissue.

Results : Leptin and myostatin levels were measured in blood and CSF. The results showed higher leptin levels in women in both blood and CSF, but no significant difference between men and women in myostatin. In terms of the correlation between blood leptin and total fat mass, visceral fat mass, and subcutaneous fat mass, a moderate correlation coefficient was seen in men. In women, although a correlation existed between blood leptin and visceral fat mass, no correlations were seen between leptin and total fat mass or subcutaneous fat mass. No correlation was identified between muscle mass and myostatin level. The results of a comparison by cause of death showed higher levels of leptin in both blood and CSF with blunt head injury than with other causes of death. Myostatin, on the other hand, showed no significant differences. The results of immunohistochemical tests showed no significant differences.

Discussion : Although women showed higher levels of leptin in blood and CSF, no difference in myostatin was seen between men and women. This would seem to be partially attributable to the effects of fat accumulation in postmenopausal women. Both blood and CSF levels of leptin were shown to be high for blunt head injury. This was conjectured to be from either the breakdown of the leptin-regulating mechanism associated with central dysfunction, or the action of the blood pressure-elevating mechanism in fatal conditions. Since those changes do not occur in myostatin in muscle, the type of adipose tissue is conjectured to strongly affect leptin production at times of central dysfunction. The results of this study demonstrate that when central function is inhibited, leptin in fat is more strongly affected than the level of myostatin secreted from muscle.

213

HOMICIDE BY STABBING IN THE REGION OF KAIROUAN, TUNISIA: A RETROSPECTIVESTUDY OF 48 AUTOPSY CASES

Oumaima Brahim 1 , Elyes Turki 1 , Arwa Haddaji 1 , Firas Haggui 1 , Elaa Chebbi 1 , Bilel Gammoudi 1 , Raja Ghzel 2

1 Department of forensic medicine, Ibn El Jazzar University Hospital, Kairouan, Tunisia

2 Department of emergency medicine, Ibn El JazzarUniversity Hospital, Kairouan, Tunisia

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Introduction : A sharp weapon is a weapon with a blade that has piercing and/or cutting properties depending on the force applied. These sharp objects are the most commonly used weapon in criminal deaths.

Material and Methods : We conducted a retrospective study of stab-wounds autopsy cases collected in the Departmentof Forensic Medicine of Ibn El Jazzar University Hospital of Kairouan (Tunisia) over eleven years (2008-2018).

Results : Forty-eight cases of homicide by stabbing were collected, representing 68% of all homicidal cases and 1.4% of all autopsy cases during the same period with a sex ratio of 23. The mean age of the victims was 31.96±10.98 with ages ranging from 12 to 63 years. Thirty-eight cases (79.2%) were of rural origin, 30 victimswere singles (62.7%), and 42 weredaily-laborers (87.5%). The months that recorded the highest numbers of homicides were November and August. The most common reason for the assault was a settling-score on the street. The perpetrator was known by the victim in 89.6% of cases, having used a knife as a weapon in 89.6% of cases. The thorax was the most frequently affected area, resulting in fatal heart wounds.

Discussion : As noted in our result, similar studies carried out in Europe have shown that stabbing constitutes the most widely used homicide method. This is probably due to the easy availability of these weapons. However, in the United States of America, where firearms are readily available, homicides are the most frequently secondary to wounds by projectiles. Numerous studies confirm that homicides are more frequently committed by men as noted in our study (95.8%). Our study has also shown that the assailants were mostly 20-40 years of age, which is consistent with other reports. As reported in the littérature, the actual study has shown that there is a relationship between a homicide and a low socioeconomic status of both the assailant and the victim and most of them were workers or farmers. As noted in our study, other others have shown that the thorax area was the most frequently affected region resulting in fatal wounds.

214

DEATH DUE TO ELECTROCUTION IN KAIROUAN, TUNISIA: A 10-YEAR RETROSPECTIVE DESCRIPTIVE STUDY

Oumaima Brahim 1 , Elyes Turki 1 , Jemli Ines 1 , Elaa Chebbi 1 , Firas Haggui 1 , Bilel Gammoudi 1 , Raja Ghzel 2

1 Department of forensic medicine, Ibn El Jazzar University Hospital, Kairouan, Tunisia

2 Department of emergency Medicine, Ibn El Jazzar University Hospital, Kairouan, Tunisia

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Introduction : Electrical trauma seems to beone of the common causes of morbidity and mortality which are usually preventable with simple safety measures. Diagnosis of death by electrocution can present a challenge for bothphysicians and forensic pathologists especially with lack of elecrical marking. The aim of the presentstudyis to describe the epidemiological and pathological findings seen in lethal cases due to electrocution over 10 years.

Material and Methods : An observational retrospective study of death by elctrocution was conductedin the forensic and emergency medecine departements of Ibn El JazzarUniversity Hospital of Kairouan in Tunisia, during the 10-year period (2009-2018). Demographic features and clinical and pathological findings were obtained from medical and medicolegal autopsy records.

Results : During the study period, a total of 54 cases were included representing 1.7% of all autopsy cases during the same period. The main findings of the study showed that the majority of cases involved young men at work, with a hight-voltage current affecting mostly upper extrimities. Most of victims (74%) died in the scene of accident. Electric mark was evident in 43 cases (79.6%). Of the 54 deaths, 50 were accidental and 4 were suicidal. No cases of homicide were encountered. The most common findings in autopsy were bleeding and pulmonary congestion.

Discussion : As noted in our study, similar studies have shown that tmost cases of electrocution are seen among workers (ironsmiths, welding and electrical industries) followed by those who were unemployed. As noted in our study, some authors have proven that 50 percent of the victims were single and not educated. Contrary to our results, most of cases electrocution were reported to be caused by low voltage sources, and in 14.6% of cases a high voltage source was involved. Deaths were due to accidental exposure to electrical current in the majority of cases, followed by the suicidal and homicidal form. Death due to electrocution concerned mostly youngworkers men. A combination of education and proper usage and functioning of electrical appliances as well as using proper clothing in hazardous locations to prevent electrocution are some of the most essential points that may decrease the incidence of these events.

215

FATAL DONKEY BITE IN CHILDREN: A CASE REPORT

Oumaima Brahim 1 , Elyes Turki 1 , Bilel Gammoudi 1 , Firas Haggui 1 , Wael Majdoub 1 , Amel Mosbahi 1

1 Department of Forensic Medicine, Ibn El Jazzar University Hospital, Kairouan, Tunisie

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Case presentation : A healthy 21-month-old girl was found dead at a farmyard in front of her home next to a donkey that belonged to the family. External examination showed the child to be normally dressed, but the upper right portion of her T-shirt was torn. The body presented a bluish and oval bruise on the right arm measuring 10 x 2 cm. Areas characteristic of donkey bites were present on the right side of the neck and the upper part of the shoulder. Moreover, the examination revealed a semi-circular abrasion measuring 12 cm × 5.5 cm and presenting an internal concavity. It stretched from the middle left side of the occiput to the interscapular region. The concave margins of some of these previously outlined abrasions faced each other and thus together made a characteristic bite mark impression. The autopsy showeda hemorrhagic infiltration in the right lateral cervical region. The right sternocleidomastoid musclewas crushed and torn and the right internal jugular vein was cut. A vertebral fracture was found associated to a complete spinal cord transection. Toxicological testing was negative. The bite mark analysis revealed a partial match between the donkey’s dental formula and the anterior cervical bite mark on the victim. Death was attributed to cervical trauma and spine injuries from a donkey attack.

Discussion : Donkeys are widely used throughout Africa. Even if they are usually regarded as a docile and non aggressive animals, their behavior pattern can change, mainly before and during the mating season. Donkeys generally cause human injuries by trampling or kicking, but the possibility of biting should not be underestimated. Donkey bites, in contrast to dog and cat bites, result in loss of tissue and crush injuries. This can be explained by the fact that the force of a donkey bite is sufficiently strong. According to the literature, the most frequent causes of death associated with animal bites are exsanguination and infection. In our case, death was attributed to cervical spine injuries. The bite marks have to be interpreted and analyzed with appropriate photos. An odontological assessment is needed to confirm the animal perpetrating the attack. Although animal-inflicted injuries are a worldwide major public health problem, lethal donkey bites have very rarely been reported. A combination of education and proper humane handling of these domestic animals may decrease the incidence of these injuries.

216

SUDDEN DEATH DURING PHYSICAL RESTRAINT BY THE TUNISIAN POLICE: A CASE REPORT

Oumaima Brahim 1 , Wael Majdoub 1 , Firas Haggui 1 , Bilel Gammoudi 1 , Souhaiel Mlayeh 1

1 Department of Forensic Medicine, Ibn El Jazzar University Hospital, Kairouan, Tunisia

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Case presentation : A 58-year-old male, with a past medical history of dilated cardiomyopathy, reduction in left ventricular ejection fraction, and cardiac pacing. He had been arrested by police in connection with a robbery and have been punched in the face. A few seconds later, he lost consciousness and arrived deceased in the hospital. A forensic autopsy was demanded to identify the cause of death and its relation to the assault. On external examination, we found dermabrasion of the left cheek and two centimetric wounds of the internal face of two lips. The autopsy showed congestion of the viscera, a brain and lung edema were noted with an implanted pacemaker in the subclavian area. The heart weighed 700g and cross-sections revealed hypertrophic cardiomyopathy with left ventricular dilatation, confirmed with histological examination. Death was attributed to rhythmic decompensation of previous heart disease. This previous condition was precipitated and aggravated by emotional stress due to the minor trauma.

Discussion : The Police is sometimes confronted with the death of a subject during physical restraint. In most of these cases, a clear Cause of Death cannot be determined by the Pathologist. The cause of death in these cases seems to be multifactorial and is comprised of both personal factors and factors during and after the struggle. The different factors are comingled and augment each other. The end effect is that the subjects end up in a fatal spiral. In literature, four main causes of death are mentioned: a neck hold, positional asphyxiation, Excited Delirium Syndrome (EDS) and hyperthermia, and stress. The cause of death often remains unknown after extensive investigation, autopsy, and toxicology. When a death during or immediately after apprehension occurs, the forensic expert is required to determine with certitude the manner of death being natural or unnatural. In this case, the cause of death was cardiac decompensation from a stressful state which was induced during the arrest. During stress, cortisol levels elevate, and as a result of this adrenaline and noradrenaline raise (fight or flight response). During the post-exercise phase, malignant ventricular fibrillation can occur. In persons with a heart condition, severe stress can lead to sudden death. when death occurs during severe stress, no structural or anatomical abnormalities are seen during the autopsy. Further systematic research of this issue, including detailed analyses and investigations of such cases, is necessary to develop general and specific preventative measures to reduce the risk of death in the custody population.

217

WHEN ALTERNATIVE MEDICINE BECOMES DEADLY

Oumaima Brahim 1 , Wael Majdoub 1 , Firas Haggui 1 , Bilel Gammoudi 1 , Elyes Turki 1 , Souhaiel Mlayeh 1

1 Department of Forensic Medicine, Ibn El Jazzar University Hospital, Kairouan, Tunisie

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Case presentation : A 42-year-old man with a past medical history of cavum tumor was discovered dead at the home of a "healer". The preliminary investigations reported that the victim visited the healer for "cupping therapy" (Hijama) and that he also ingested some of the Peganum harmala seeds to reduce the pain secondary to anticancer drugs. A medico-legal autopsy was conducted to determine the cause of death. External examination showed the presence of Hijama marks on the face and the abdomen which are reddish, rounded, and well-defined bruises centered by multiple superficial scarification wounds). A moderate subarachnoid hemorrhage was found. The lungs were edematous and heavy. Gastric contents showed the presence of multiple blackish seeds (Nigella). The toxicological analysis showed the presence of an alkaloid substance in the urine. On the microscopic examination, tumor cells were found in the cavum. Death was related to neurological and respiratory complications of acute intoxication by the Harmal.

Discussion : "Alternative" medicine includes a wide variety of treatment methods that are not conventional. However, the use of these methods is widely widespread nowadays in the Middle East and North Africa in particular to alleviate the side effects of anti-cancer treatments. Approximately 40 percent of adults in the United States admit to using some type of alternative medicine on a regular basis. Such alternative practices can sometimes have serious consequences, leading to believe, wrongly, that there is another path that is faster and more efficient to achieve a cure. Popular forms of alternative medicine include Chiropractic Medicine, acupuncture and Herbal Medicine – By using plant parts like roots, leaves, berries, and flowers. Peganum Harmala is a plant commonly used in traditional medicine as a sedative and analgesic but exposes users to the risk of overdose and poisoning. The pharmacologically active compounds of this plant (훽-carboline and quinazoline alkaloids) stimulate the central nervous system by inhibiting the metabolism of amine neurotransmitters, or by direct interaction with specific receptors. They are reported to cause a pronounced depression of cholinesterase activity. Lethal doses bring about convulsions, which are followed by motor paralysis due to the marked depressive action upon the central nervous system. Respiration is paralyzed and a decrease in body temperature occurs. The perfused heart is arrested in the diastolic phase and the contractions of smooth muscle are diminished. The course of the nervous syndrome is usually short and death follows within 30-36 hours after the onset of signs of central nervous system intoxication. Given that alternative medicine is widely widespread we should be vigilant because some malicious people take advantage of the vulnerability of these cancer patients.

218

INTRA-THORACIC ACRYLIC-GLASS BALLS IN A HANGING VICTIM: AN UNEXPECTED FINDING

Eduardo Coutinho 1 , Rosa De Gouveia 1,2 , João Pinheiro 1,3

1 National Institute of Legal Medicine and Forensic Sciences, Coimbra, Portugal

2 Faculty of Medicine, University of Coimbra, Portugal; 3 School of Health Technology of Coimbra - Polytechnic Institute of Coimbra, Portugal

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Hanging is one of the most commonly used lethal methods of suicide worldwide. Deaths occur rapidly after suspension in more than 70% of the cases. In Portugal, mechanical asphyxia by hanging is the first cause of death in suicides. We present the case of a 76-year-old man autopsied at the National Institute of Legal Medicine and Forensic Sciences in Coimbra, who was found at home by his caregiver, after having committed suicide by hanging with a rope. External examination of the body showed the typical yellowish-brown dry incomplete ligature mark, oblique upward and located on front and both sides of the neck, with skin abrasion and situated above the thyroid cartilage. Internal examination showed fractures of both the right great hyoid and the superior thyroid horns. Cervical vertebra and the intima of the carotid arteries were intact. However, during the autopsy and, when opening the chest wall, a conglomerate of synthetic translucent balls was unexpectedly found. These balls were observed in the costal arches replacing some ribs and occupying practically the entire upper half of the left pleural cavity. Toxicological blood studies were negative for drugs or alcohol. Histopathological examination did not reveal signs of infection. The authors studied the nature and origin of these balls and discussed their influence to the cause of death. They concluded that it was an incidental finding related to previous treatment for tuberculosis, confirmed by an epidemiologic inquiry to the victim´s family. This case aims to draw the attention of young medical generations to the possibility of getting in contact with these incidental findings, diagnosed ante-mortem by image techniques or postmortem at autopsy, and mainly highlights the importance necropsy examination in identifying possible complications of such therapeutic interventions, that can ultimately cause death.

219

SUDDEN CARDIAC DEATH DUE TO VENTRICULAR MYOCARDIAL NON-COMPACTION

Oumaima Brahim 1 , Mohamed Amine Mesrati 1 , Syrine Azza Manoubi 1 , Marwa Boussaid 1 , Yosra Mahjoub 1 , Abir Aissaoui 1

1 Taher Sfar Hospital, Mahdia, Tunisia

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Case presentation : A 20-year-old male patient with no particular past medical history who was followed up at the cardiology department for dyspnea. Echocardiography showed reduced ejection fraction of the left ventricle with potential hypertrabeculation in the right ventricle, confirmed by cardiac MRI. The patient was not put under medication and was later lost to follow-up. He died few months later without a clear cause explaining death. A forensic autopsy was performed and revealed a heart weighing 325g. The axial dissection of the heart found left ventricle hypertrabeculation with parietal thinning measured at 0.5cm and some intra-cavitary adhering thrombi. Left ventricle examination found wall thickening at 1.2cm. The lungs were the site of profuse oedema. The rest of the organs were congestive without any abnormality. Toxicology was negative. Based on clinical history and the necropsy findings, death was attributed to acute ventricle arrhythmia secondary to a myocardium non-compaction.

Discussion : Ventricular non-compaction (VNC) is a rare myocardium disorder, which can be both genetic and sporadic. The usual site of invovment is the myocardium of the left ventricle. VNC can be detected in all age groups, ranging from the fetal period to adulthood. It is characterized by prominent myocardial trabeculations and deep inter-trabecular spaces creating a perfect environment for thrombi formation due to stasis of blood flow in the inter-trabecular recesses of non-compacted myocardium. The clinical manifestation is highly variable which can lead to mistaken diagnoses. It is often complicated by ventricular dysfunction, arrhythmias and cardiac embolism. No consensus exists about diagnostic criteria of VNC. Ventricular hypertrabeculation cardiomyopathy has become recognized as a distinct entity on the basis of clinical imaging classifications. Cardiac Magnetic Resonance Imaging (CMRI)-based criteria (Petersen criteria) is considered as the gold standard. However, no specific well-defined anatomic criteria have been proposed for the diagnosis of VNC to date. The imaging criteria are not anatomically controlled, and it is unclear how they relate to the postmortem heart. Collaboration between forensic medicine and cardiology should be taken into consideration with the aim to standardize diagnostic criteria and to avoid over diagnosis in healthy people with a benign prognosis.

220

HOMICIDAL VIOLENCE: MEDICO-LEGAL IMPLICATION OF A RUPTURE OF A HEPATIC HYDATID CYST

Oumaima Brahim 1 , Marwa Boussaid 1 , Mohamed Amine Mesrati 1 , Hiba Limem 1 , Meriem Boughattas 1 , Abir Aissaoui 1

1 Taher Sfar Hospital, Mahdia, Tunisia

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Case description : A 24-year-old male, without any past medical history, was a victim of a physical assault. He had been punshed in the abdomen. Few seconds later, he lost consciousness and arrived deceased in the hospital. A forensic autopsy was demanded in order to identify the cause of death and its relation with the assault. On external examination, no skin rash nor traumatic lesions were detected on the body. Autopsy showed a brain and lung edema and congestion of the viscera. However, no glottis edema was found. Cross sections of the liver revealed a cystic structure measuring 10*7 cm in diameter. The cyst was reptured to an hepatic vein. The content of the cystic structure was haemorrhagic and containing one daughter vesical. Toxicological analysis was negative. Histological examination confirmed the presence of communication between the cystic cavity and the hepatic vein and the presence of scolices. Death was attributed to anaphylactic shock due to a rupture of the hydatid cyst into pericystic hepatic vein. This rupture was precipitated and aggravated by the blunt trauma. The liability of the violence in the occurrence of the death was qualified as partial by the justice.

Discussion : Postmortem diagnosis of anaphylaxis is difficult, but it becomes easily evoked when cyst appear macroscopically ruptured. Haemorrhagic cyst content as seen in the present case is a significant sign of intravascular spread of antigenic hydatid fluid and anaphylaxis. Rupture of hydatid cyst of the liver may happen spontaneously from intracystic hyperpressure or erosion of the cystic wall by inflammatory phenomena. However, it can be precipitated by trauma. Causality nexus between the trauma and the rupture of the cyst is not always that obvious, especially when rupture occurs after minor trauma perpetrated by another person. The forensic expert is required to determine with certitude the manner of death by studying the criteria of medico-legal imputability. Risk factors of spontaneous rupture of the cyst must be taken into consideration such increased diameter, superficial location and young hydatid cyst (I, II, III). The discussion would be developped regarding three hypothesis: rupture of the cyst is directly, partially or not imputable to the trauma.

221

THE “SLEEP TIGHT” DRUG – FATAL METHADONE POISONING IN TWO CHILDREN

Helena do Côrro 1 , Ana Sofia Coelho 1 , Susana Tavares 1 , António Padilha 1

1 National Institute of Legal Medicine and Forensic Sciences, Leiria, Portugal

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

According to the World Health Organization (WHO) in 2019, an estimated 5.2 million children under 5 years died mostly from preventable and treatable causes. Poisoning accounts for about 7% of all accidents in children under 5 years worldwide and is implicated in about 2% of all childhood deaths in the developed world, and over 5% in developing countries. In Portugal, the most common cause of death among children is motor vehicle crash and poisoning is in 8th place. According to intent, accidental injuries are the most common cause of injury-related death. The pattern of poisoning in children is constantly changing and every day we face new, unknown and dangerous compounds. With the illegal drug abuse, many people who intend to quit drugs undergo methadone treatment to abandon their substance abuse. This has resulted in easy access to this synthetic opioid and consequently, the number of ingestions has increased over time. Cases reports of pediatric methadone ingestion have been published since the late 1960s and the pediatric morbidity and mortality related to methadone toxicity has risen over time. Children, especially the ones aged between 0 to 4 years, are vulnerable to the effects of methadone as small doses may cause dramatic symptomatology and death. Like other opioids, methadone will depress respiration, particularly in higher doses or in people who are not tolerant to opioids. The authors report 2 interesting cases: The first one, a 12 weeks female victim, not breast-fed, whose parents have a past history of drug addiction and revealed that it was an unwanted pregnancy. The second one, a 9-year old male child, Belgian, that came on vacations to Portugal with his mother and stepfather, medicated usually with an antihistamine and melatonin. The deceased had a severe traumatic brain injury 4 years before, put into a medically induced coma, from which he recovered. In both cases, the victims were found dead in their beds (the female infant always slept in the same bed with the parents) during their sleep, both without any previous symptomatology. In the autopsy, the external and internal evaluations were very meticulous, without any signs or findings of acute traumatic lesions. A detailed histopathologic study and wide toxicologic screening lead to the conclusion that both children's cause of death was fatal poisoning with methadone. In the case of the female victim the manner of death was a homicide and in the male boy wasn’t possible to assure if it was an accidental or homicidal event.

These 2 revealing pediatric cases related to methadone are excellent to be acknowledged, not only because it shows the silent toxicity of this drug, as it informs to the possible under-recognized form of child maltreatment associated with this synthetic opioid. All the reported cases were studied and analysed in the National Institute of Legal Medicine and Forensic Sciences, Portugal.

222

HOW FAR DOES THE AUTONOMY OF THE SUICIDAL PATIENT GO? – A REFLECTION ABOUT A CASE

Helena do Côrro 1 , Bianca Rino 1 , Ana Sofia Coelho 1

1 National Institute of Legal Medicine and Forensic Sciences, Leiria, Portugal

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

The development of healthcare, together with the growth of an ideological plural society, has led to the emergence of a vision of the patient considering his aspirations, giving him the right to self-determination regarding his health. The fulfillment of the respect for the patient's autonomy regarding health obliges professionals to ensure the patient's wishes, personal values, and preferences. The authors aim to present a borderline case of what are the rights of the patient/victim and the duties of healthcare providers. A victim decided to commit suicide and consciously refused physically to receive any medical help or treatment from the medical emergency team, preventing any therapeutic action while conscious. For that reason, he was restrained to proceed with the appropriate treatment. He died on the scene due to the seriousness of the injuries he had sustained before the medical emergency services were called. The victim had a psychiatric history of 20 years, diagnosed with depressive pathology. He had been hospitalized 13 years before "undergoing psychiatric recovery", was followed by Psychiatry and Psychology, and had "severe migraines" for 10 years. He was found at home, by his mother, verbalizing "Mom, I'm going in peace". The suicide was executed with a knife (21.5cm), causing injuries in the neck and upper limbs, and lethal injuries to the chest.

In the present case, it was not described in the documentation of the event that there was oral verbalization by the deceased about his will to not to be assisted. However, it was found that the victim was conscious, having spoken to those who were present. Added to this fact is the description of his reluctance to be assisted and the irrefutable intention of suicide, both through the modus operandi and through the location and number of injuries. Thus, the question is: how far should the performance of health professionals go? Can we use our daily training in saving lives, indiscriminately and without a reflection on each specific situation? In suicide attempts, will the conscious patient be able to take the full and considered decision of not wanting to be assisted? This paper aims to reflect on the concept of patient/victim autonomy and the multiplicity of conflicts that emerge on the threshold of what is the patient's will and the health professional's obligation to fight for life. All the reported cases were studied and analysed in the National Institute of Legal Medicine and Forensic Sciences, Portugal.

223

24 HUNGRY CRABS AND A CORPSE - A POSITIVE IDENTIFICATION CASE

Helena do Côrro 1,2 , Gonçalo Carnim 1 , João Pinheiro 1,2

1 National Institute of Legal Medicine and Forensic Sciences, Coimbra, Portugal

2 School of Health Technology of Coimbra - Polytechnic Institute of Coimbra, Portugal

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Identification of a human being is imperative not only because of humanitarian and emotional reasons but also for legal and administrative purposes. Forensic science and forensic medicine are crucial tools to this process. Sometimes, identification is extremely difficult, particularly in mass disasters or genocides, when the bodies are often reduced to fragments and/or severely decomposed. The methodologies developed over the years in this type of situation are now used in daily routine practice. When the bodies are recovered from the water, extra challenges arise to the forensic pathologist, either to diagnose the cause and manner of death or to identify the victim. The authors describe a case of an unidentified individual found next to the Mondego river in Figueira da Foz, central Portugal, severely decomposed, without any identification documents. A multidisciplinary team composed by 2 forensic pathologists, a forensic anthropologist, and an autopsy technician performed the autopsy. A radiograph executed before the autopsy showed osteosynthesis material in the left forearm, right leg, and lumbar spine. The body was partially skeletonized (face, right thigh, and leg) and saponified on the limbs. As it was recovered from the water, many aquatic artifacts were found such as 24 crabs. Clothing and teeth were carefully described, as well as the cranial, pubic, and leg hair; height and gender determined; a small protruding skin mark was observed at the prepuce, and old self-inflicted injuries were found in the left forearm. Despite the limitations imposed by the decomposition, the authors could confirm and detail the osteosynthesis material previously seen. A thoracic spine fracture was also detected. After the autopsy, the Criminal Police took care of the investigation and found out that, a man living in Figueira da Foz had been seen throwing himself off the bridge over the same river, 3 weeks before the corpse appeared. This man was missing since that. Antemortem information was requested from the victim's suspected mother. The reconciliation of the antemortem and postmortem data, namely particular signs provided by the mother, the osteosynthesis material observed both in x-ray and in the body, and the results of the forensic anthropology examination, lead the authors to a positive identification: a 22-yr. old male, drug addict, suffering from a psychiatric disorder with previous suicide attempts. The detailed description of the general characteristics of a body and other unique traits is indispensable and proved to be invaluable by ruling out potential candidates and find the right one, as verified in this case. This paper argues that investigating unknown victim’s cases in the daily practice of a forensic institute helps forensic professionals to improve and train their skills for the study of missing people in mass disasters, genocides, torture, and related contexts. All the reported cases were studied and analysed in the National Institute of Legal Medicine and Forensic Sciences, Portugal.

225

CHILDHOOD SEXUAL ASSAULT IN CENTRE – EAST OF TUNISIA: AN EPIDEMIOLOGICAL STUDY

Habiba Sandid 1 , Mohamed Amine Mesrati 1 , Hiba Limem 1 , Marwa Boussaid 1 , Meriem Boughattas 1 , Abir Aissaoui 1

1 Taher sfar hospital, Mahdia, Tunisia

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Introduction : Despite recent legislative changes through the enactment of the 2017-58 law on the elimination of violence against children, sexual violence remains fairly frequent and is often underestimated. The precocity of the forensic examination as well as the quality of the care of the victim by the doctor often condition the judicial consequences.

Objectives : We aimed in this work to describe the epidemiological peculiarities of victims of sexuel assault in the region of Mahdia. Study population: this retrospective study of 85 cases of victims of sexual assault examined at the legal medicine department of the Taher Sfar university hospital in mahdia. The objective of the current study was to use data from January 2016 to January 2021 to construct an epidemiological profile of childhood sexuel assault.

Results : The victims were organized into three lists: 0-10 years (9%), 10-15 years (41%), 15 -18 years (50%). The majority were female (75%). The perpetrator was generally unique (94%), known to his victim (88%), or even a member of family circle (18%). Sexual assault by penetration was mostly reported (80%) and was almost exlusively penile (98% of cases). The medical examination was usually done away with the facts after 72h. The gynecological examination revealed a torn hymen 16 cases of which 2 (4%) had a recent tear and 14 (24%) had old defloration. It also revealed a compliant hymen without traumatic lesions in 4 victims (5%). Anal penetration was diagnosed in 50 victims (55%) with masculin predominance (60 %). Complications of the most reported sexual assaults were pregnancy 2% of cases. No infectious complications have been identified. In total, 70% of the certificates issued made it possible to conclude that the injuries.

Conclusions : Minor Sexual violence remains underreported. The current statistical data do not allow to know the phenomenon as a whole, because the majority of the acts remain unknown, because of the absence of complaint or medical consultation. The care of victims of sexual abuse requires a multi-disciplinary approach: medical, psychiatric, social and legal.

226

CASE REPORT: VIOLENCE OR DILATED CARDIOMYOPATHY: WHICH IS THE MECHANISM OF DEATH

Habiba Sandid 1 , Mohamed Amine Mesrati 1 , Hiba Limem 1 , Marwa Boussaid 1 , Meriem Boughattas 1 , Abir Aissaoui 1

1 Taher sfar hospital, Mahdia, Tunisia

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Case presentation : A 64-year-old man without any relevant past medical history was found died at home. A forensic autopsy was ordered by the judicial authorities. On external examination, we found traumatic injuries in the head, trunk and limbs. At autopsy, the heart weighing 390 g with dilated ventricular chamber without coronory, valvular or pericardial disease. A troponin dosage <0.1 mmol / l. Histologically, the myocardium shows interstitial fibrosis of the left ventricle. The death was attributed to a cardiac arrythmias due to an intense physical and mental stress.

Conclusion : An intense physical or mental stress stimulates the sympathetic nervous system and hormonal secretions with several consequences including an acceleration of the heart frequence a high blood pressure and a spasm of the coronary arteries. All this phenomenon can contribuate to a cardiac rythme disorder. So establishing imputabily between the traumatic event and death in dilated cardiomyopathy is crutial because it will depend on the legal consequences.

227

AMUSSAT’S SIGN IN A DROWNING CASE: A PITFALL TO KEEP IN MIND

Hiba Limem 1 , Marwa Boussaid 1 , Mohamed Amine Mesrati 1 , Habiba Sandid 1 , Meriem Boughattas 1 , Abir Aissaoui 1

1 Taher Sfar Hospital, Mahdia, Tunisia

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Presentation of the case : A 41-year-old man was found dead face down in 10 metres deep well with a 4 metres water level. He has medical history of psychiatric illness and he stopped his medication in the last period. The autopsy revealed Amussat’s sign at the level of the two carotid arteries. Based on the testimony, the clinical history, the necropsy and the histopathological findings, death was attributed to drowning.

Conclusion : Amussat’s sign can be attributed to hyperextension or hyperflexion of the neck during the convulsive phase due to mechanical asphyxia and during the fall in the water causing overstretching of cervical structures, including carotid arteries. This sign is strongly suggestive of hanging. However, in case of drowning, this sign should be interpreted with high caution and can be misleading. That’s why a careful examination of the whole body and especially the neck is needed.

228

CAUSAL LINK BETWEEN PEGANUM HARMALA AND HEMORRHAGIC STROKE: ABOUT AN AUTOPSIC CASE

Firas Haggui 1 , Elyes Turki 1 , Elaa Chebbi 1 , Oumaima Brahim 1 , Bilel Gammoudi 1

1 Department of Forensic Medicine, Ibn El Jazzar University Hospital, Kairouan, Tunisia

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Case presentation : It is about a young adult, 38 years old, who was hospitalized in an intensive care unit for a neurological distress following an ingestion of a 100g of Peganum Harmala seeds mixed with honey prepared by a charlatan. Clinical examination showed a Glasgow score of 06 above 15, a bilateral myosis and a hypertensive peak with a blood pressure: 23/11 cm Hg. CT-scan showed a hemorrhagic stroke in the brainstem and an intraventricular hemorrhage. The patient deceased after four days of hospitalization due to multivisceral failure. The body examination and the autopsy showed a hemorrhagic infiltration of the brainstem, pulmonary edema and multivisceral congestion. Toxicology analysesconfirmed the presence of alkaloids of Peganum Harmala. All these elements confirm the diagnosis of death by a hemorrhagic stroke due to a Peganum Harmala intoxication.

Discussion : Phytotherapy is taking a big place in healthcare systems in Tunisia due to the increasing number of herbalists and healers. In fact, Peganum harmala is one of the most used plants in traditional medicine due to its scientifically proved pharmacological effects whether therapeutic, abortifacient and even in some suicidal cases. The most common route of administration is ingestion. However, inhalation by fumigation is very common. This plant exposes to a high risk of overdose and intoxication. It’s active compounds are alkaloids such as Harmaline, Harmine, Harmalol and Harman. In human, Harmaline at the dose of 4 mg per kg has psychomimetic effects. Higher doses can cause seizures, paralysis of the central nervous system with a respiratory paralysis, hypothermia and heart failure. Patients can have different symptoms, most common are neurological in 34.4% (hallucinations, vertigo, seizures, coma), digestive in 31.9, and cardiovascular (arrhythmias, bradycardia, high or low blood pressure). In our case, the deceased man had a coma with a hypertensive peak, followed by a low blood pressure. CT-scan showed a hemorrhagic stroke in the brainstem. The hypertensive peak can cause complications such as aortic dissection, myocardial infraction, and hemorrhagic stroke like in our case. The association between a hemorrhagic brainstem stroke and Harmal ingestion poses a problem of imputability of a PeganumHarmala intoxication to the death. Confrontation of the autopsy findings, patient’s history, toxicology analysis and clinical data, is very important to confirm or deny the imputability link.

229

SELF-ADMINISTRATION OF ANESTHETIC DRUGS – A REPORT ON TWO CASES OF HEALTHCARE PROFESSIONAL SUICIDE

Sofia Monteiro Cunha 1 , Bárbara Mendes 1 , Dina Almeida 1,2

1 National Insitute of Legal Medicine and Forensic Sciences - North Branch, Porto, Portugal

2 Abel Salazar Biomedical Sciences Institute - University of Porto, Portugal

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Scientific studies have identified elevated suicide rates among healthcare professionals compared to the general population. The same suicide risk was found among the veterinary sector. Suicide by healthcare professionals has a distinctive feature: they are more likely to involve self-poisoning rather than methods used commonly in the general population (hanging or firearms). Easier access to controlled and potentially lethal medication and knowledge of its lethality are two factors that may explain this higher rate. A 37-year-old male nurse was found dead at home. There was an intravenous perfusion system inserted in his left antecubital fossa with a vial of Propofol attached. After a complete death scene investigation, multiple empty blisters of medication and a suicide note were found. During autopsy, there were no particular morphological changes except for pulmonary edema. The toxicology analysis performed on peripheral blood samples revealed toxic concentration of Propofol (>10.000 ng/mL) and therapeutic levels of fentanyl and benzodiazepines. A 31-year-old male veterinarian was found dead at work. There was an intravenous perfusion system inserted in his left antecubital fossa with a vial of Pentobarbital attached. An empty bottle of the same drug was found nearby. During autopsy, there were no particular morphological changes except for pulmonary edema. The toxicology analysis performed on peripheral blood samples revealed toxic levels of Pentobarbital (>150.000 ng/mL). Propofol is an anesthetic drug used in hospital settings for sedation and general anesthesia. By enhancing the inhibitory function of the neurotransmitter GABA, leads to central nervous system depression and respiratory drive reduction. [4-6] Death due to Propofol overdose is unlikely because of the low concentration commercially available, and its fast-acting effects which prevent self-administration of more than one ampoule. Pentobarbital is a short-acting barbiturate largely used as veterinary euthanasia agent, as it also leads to respiratory depression. In both cases, the cause of death was drug overdose and the manner of death was listed as suicide. In drug overdose investigation, death scene examination is paramount. There were empty bottles of drugs near the bodies and a suicide note in one case. This, combined with circumstantial information, helps the pathologist to establish the manner of death. Furthermore, toxicology studies are mandatory to confirm overdose as cause of death. In agreement with the literature, these cases support the hypothesis of increased risk of suicide in health professionals by self-poisoning using controlled medication, which itself is more readily accessible to them.

230

A POOL OF FINDINGS DUE TO A COCKTAIL OF DRUGS – A CASE REPORT

Deniz Maria Özgüler Passos 1 , Sofia Monteiro Cunha 1 , Ana Rita Marques 1 , Dina Almeida 1,2

1 National Institute Of Legal Medicine And Forensic Sciences - North Branch, Porto, Portugal, 2 Abel Salazar Biomedical Sciences Institute - University of Porto, Portugal

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Introduction : Illicit drug consumption is a public health concern and many consumers die at emergency departments. If drug intoxication is suspected, correlation between necropsy findings and postmortem toxicological results with circumstantial and clinical information is paramount. Clinical information is vital in forensic investigations as it directs the autopsy technique, the ancillary investigations and may support the cause and manner of death.

Case Report : A 27-year-old male, addict with a history of headaches for 1 month was taken to the emergency department for prostration after consuming gabapentin, methadone and cannabis. Urine drug screen in hospital revealed barbiturates, benzodiazepines, methadone and tetrahydrocannabinol. Cerebral computed tomography angiography revealed “left lenticular hemorrhage with tetraventricular flooding” and “acute hydrocephalus without vascular changes”. Despite neurosurgical treatment (cerebral shunt), patient was pronounced dead 2 days after admission. The forensic autopsy, performed 4 days after death, revealed cerebral edema, sinus venous thrombosis, tetraventricular hemorrhage, pons hemorrhage; thick secretions on the epicardium; softened myocardium with scattered punctate reddish lesions; and greenish secretions in the airways. Histologic study showed “extensive lesions of brain hemorrhage, recent venous sinus thrombosis, exudative pneumonia; extensive acute/subacute pericarditis and myocarditis”. Toxicological results from cardiac blood revealed THC-COOH (11 ng/mL).

Discussion/Conclusions : Necropsy findings in drug intoxication are nonspecific, making circumstantial and clinical information vital. Antemortem blood and urine analysis may outweigh postmortem toxicological studies, especially when facing a temporal gap between consumption and death. In this case, clinical information revealed methadone and tetrahydocannabinol in urine; while postmortem blood only showed the inactive metabolite of cannabis. Regarding both drugs presented in this case, cannabis causes vasodilation and reflex tachycardia, and negatively affects the coronary circulation, leading to myocardial ischemia and auricular fibrillation. Cannabis may also cause cerebral vascular changes, namely ischemic or, less commonly, hemorrhagic strokes. Studies show that cannabis may cause reversible cerebral vasoconstriction syndrome, whose main symptom is intense headaches for days or weeks. This syndrome is associated with ischemic cerebral stroke, non-aneurysmal subarachnoid hemorrhage, intracerebral hemorrhage, cerebral edema, etc. Another explanation for the cerebral hemorrhage is transitory arterial hypertension with impaired arterial autoregulation. Methadone, a synthetic opioid agonist, applied in illicit drug abstinence, oncologic and neuropathic pain treatment, can also be used abusively. Methadone abuse is linked to diffuse subcortical white matter injury and ischemic cerebral infarctions. Taking into account all data presented, the cause of death was attributed to cerebral hemorrhagic stroke associated with acute pneumonia and acute extensive perimiocarditis, in the context of drug abuse.

231

MULTIPLE INCISED WOUNDS TO THE NECK, ABDOMEN AND GENITALIA AS A UNIQUE MANNER OF SUICIDE – CASE REPORT

Deniz Maria Özgüler Passos 1 , Ana Rita Marques 1 , Filipe Fernandes 1 , Luis Cardoso 1 , José Moura Fernandes 1,2

1 National Institute Of Legal Medicine And Forensic Sciences - North Branch, Porto, Portugal

2 School of Health Sciences - Polytechnic of Porto, Portugal

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Case description : A 55-year-old male with a psychiatric medical background (schizophrenia and multiple previous suicide attempts) was found dead by his social supporters in his house, lying on the sofa. There were no signs of forced entry but there was blood in multiple rooms and a knife was found near the body. The autopsy revealed 7 incised wounds (2 on the face and 5 on the neck), 3 punctiform wounds on cervical region, multiple linear abrasions on the abdomen and multiple incised wounds on the genitalia. Two of the cervical wounds showed continuity with the muscular and superficial vascular planes, with transection of the left anterior jugular and inferior thyroid veins. The toxicology analysis was positive for two antipsychotic drugs in nontoxic levels. The cause of death was exsanguination due to the cervical lesions. Some of the previously described lesions were interpreted as hesitation wounds, which, in conjunction with the medical background and circumstantial information, leaded to the conclusion of a suicidal manner of death.

Discussion : Deaths associated with sharp-edged weapons are commonly associated with homicides, while suicides account for 1,6 to 3% of cases. Differentiation between self-inflicted and non-self-inflicted wounds is essential. This distinction requires analysis of autopsy findings together with the circumstantial information. Focus should be given to location, number and characteristics of wounds, presence of hesitation or defense wounds, examination of clothing, findings from death scene examination, such as paraphernalia or suicide notes and pre-existing psychiatric records. According to bibliography, male subjects with psychiatric disorders are more prone to choose this suicide method. In suicides, the anterior region of the neck and hemithorax, contralateral to the dominant hand, are most commonly affected due to their easy access. In contrast, in homicides, these sites are variable and depend on the dynamic positioning between the victim and the assailant. Despite multiple wounds being an argument for a homicidal manner of death, there are reports of suicides with a significant number of wounds. This case report enlightens an unusual suicide method, because of the location and high number of wounds. Attention should be given to hesitation wounds in the absence of defense wounds, one of the most useful findings for concluding a suicidal manner of death. These tend to be superficial, horizontal, parallel and clustered around a deeper incised wound, the latter usually fatal. The circumstantial information and death scene examination also stand out as essential for the manner of death diagnosis.

232

AN UNUSUAL CAUSE OF SUDDEN DEATH: CARDIAC MYXOMA

Hiba Limem 1 , Mohamed Amine Mesrati 1 , Marwa Boussaid 1 , Habiba Sandid 1 , Yosra Mahjoub 1 , Abir Aissaoui 1

1 Taher Sfar Hospital, Mahdia, Tunisia

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Case Presentation : A 55-year-old woman was found dead at home. Relatives stated that she had a history of hypertension under treatment. A judicial autopsy was ordered. External examination revealed the absence of external traumatic injuries. Internal necropsy revealed oedematous and congestive lungs. The heart weighted 450g with concentric myocardial hypertrophy. The coronary arteries revealed atherosclerotic changes without obstruction or any evidence of acute or chronic ischemia. In the left atrium, a brown tumor was identified, mesured 2x1.5 cm, ovoid, smooth-surfaced and attached to the left atrial septum. The brain weighed 1500 g with a brainstem reshuffle and marked cerebral oedema. The final report stated that this sudden death was attributed to an ischemic stroke secondary to myxoma of the left atrium.

Discussion and Conclusion : According to the literature, cardiac myxoma can be complicated, in half of the cases, by an intracardiac obstruction, peripheral or cerebral embolism causing a sudden death, as in the present case. This pathology can be familial in 10% of cases. Therfore, all first-degree relatives should be called and screened periodically with echocardiography in an attempt to identify asymptomatic cardiac myxomas.

233

FATAL ANAPHYLAXIS ASSOCIATED WITH ‘MURDER HORNET’– A CASE REPORT

Deniz Maria Özgüler Passos 1 , Joana Rita Batista 1

1 National Institute Of Legal Medicine And Forensic Sciences - North Branch, Porto, Portugal

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Case Report : A 71-year-old male with ‘unspecified’ respiratory disease, diabetes and obesity was found unconscious and cyanotic after an asian giant hornet sting. Orotracheal intubation was not possible to perform due to the supraglottic oedema and life support by the emergency response team was unsuccessful. The forensic autopsy, performed 2 days after death revealed moderate facial oedema, congestion and also tongue and laryngeal moderate oedema. The histological study report of the suspected insect sting location revealed no skin alterations as well as “morphologic alterations compatible with laryngeal, epiglottic, uvula and tracheal oedema and the presence of CD117 positive mast cells, in numbers above expected”, which were compatible with glottic oedema in the context of acute anaphylaxis. It was performed an immunological study one day after death, which revealed an increase in tryptase and total IgE concentration and the presence of the specific IgE type for asian hornet venom. The toxicological results were negative.

Discussion/Conclusions : The asian giant hornet has been reported in Portugal since 2011 and it is known to react more aggressively if threatened. Death in anaphylaxis is usually sudden and estimated to occur in around 1% of all anaphylaxis cases. Most necropsy findings are non-specific and the use of immunological markers facilitates the post-mortem diagnosis. Fatal anaphylaxis is a diagnosis of exclusion, making knowledge of the circumstances of death essential for the investigation, such as witnessed collapse following insect bite or known history of allergy. Risk factors for fatal venom anaphylaxis include middle age, male sex, white race, pre-existing cardio-vascular disease and specific immunological disorders such as mastocytosis. Necropsy findings are extremely variable, reflecting the speed and mode of death, which is often the result of shock rather than asphyxia, including signs of asthma (mucous plugging and/or hyperinflated lungs), petechial haemorrhages and pharyngeal/laryngeal oedema. In cases of rapid death the only finding might be visceral congestion and in more prolonged death there may be airway obstruction by oedema and mucous plugging. The histological study typically reveals respiratory mucosa oedema, inflammation associated with eosinophilia and epithelial desquamation and elevated count of mast cells in different organs and tissues. Elevated tryptase levels in blood suggests anaphylaxis, and in such cases it is always indicated to search for the specific IgE type for the suspected agent. Considering the circumstances of death, histologic and immunological studies, the cause of death was listed as fatal anaphylaxis due to wasp sting.

234

SHOTGUN WOUND TO THE CHEST – A CASE REPORT

Deniz Maria Özgüler Passos 1 , Sofia Monteiro Cunha 1 , Joana Azevedo 2 , Francisco Taveira 1

1 National Institute Of Legal Medicine And Forensic Sciences - North Branch, Porto, Portugal

2 Medico-Legal and Forensic Office of Entre Douro e Vouga, Santa Maria da Feira, Portugal

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Case Description : A 31-year-old female was found dead in the woods near her house with a gunshot wound to the chest. On scene, there was a shotgun with cartridges on it, an intact cartridge and two pieces of clothing of the upper body. Reported missing two days earlier, had psychiatric background, no previous suicide attempts or suicide note. Postmortem imaging revealed multiple small round opacities in the left hemithorax. She had a tank top with a hole in the anterior face of the left side; a contact gunshot wound in the anterior left hemithorax with an eccentric contusion ring (maximum length in the superior right quadrant); two apparent exit wounds in the distal third of the posterolateral side of the left hemithorax; several irregular abrasions in the sternal region, right side of the abdomen and posterior/lateral sides of the right arm. Internal examination revealed fractures of the anterior 5th left rib and posterior 8th-10th left ribs; pericardial, heart and left lung lacerations. Plastic wad recovered from the lower lobe tissue of the left lung. Toxicological analysis positive for antidepressants and anxiolytics; negative for alcohol and illicit drugs. The projectile trajectory defined as backwards, downwards right-to-left. The multiple abrasions described was attributed to the action of cadaveric fauna. The immediate cause of death was exsanguination.

Discussion/Conclusions : Suicides by shotguns occur so it is essential for forensic pathologists to be familiar with their wound characteristics. Determination of range of fire for a shotgun wound involves the inspection for soot and stippling, as well as inspection for the presence of wad injury and/or presence of wad within the body cavities. Determination of direction of shotgun fire is more problematic but, if discernible, it is important to document. Both range and direction of fire are important for the determination of manner of death. There are three possible directions for gunshot wounds within the chest: downward right-to-left; downward left-to-right and downward parallel. However, both direction (downward/upward) can occur as the trigger can be reached by both raising and lowering the stock of the weapon. Regarding garments defects produced by firearms, they cannot be used as a criterion for precluding suicide, as only a minority of victims expose the nude skin. According to Blessing & Lin (2016), the thoracic region is the 2nd most common site for suicide gunshot wounds, the predominant direction was backwards and downwards, the majority had psychiatric history but no suicide note and only 30% of cases had positive postmortem toxicology for alcohol/illicit drugs. We listed the manner of death as suicide considering autopsy findings (namely all wound characteristics); scene investigation; medical history and circumstantial information.

235

SUDDEN UNEXPECTED DEATH IN EPILEPSY? – A CASE REPORT

Deniz Maria Özgüler Passos 1 , Sofia Monteiro Cunha 1 , Marta Pinto 1 , Francisco Taveira 1

1 National Institute Of Legal Medicine And Forensic Sciences - North Branch, Porto, Portugal

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Case Description : A 21-year-old male found unconscious on the bathroom floor. Last seen alive 15 minutes earlier. First-responders documented cardiorespiratory arrest with pulseless electrical activity. Performed cardiorespiratory resuscitation until Hospital admission. He recovered 55 minutes later. Documented rhabdomyolysis, metabolic acidosis, aspiration pneumoniae and multiple organ dysfunction. Mechanically ventilated with intracranial pressure monitoring. Negative drug screen. Head CT revealed cerebral edema. EEG showed no epileptiform activity and signs of severe encephalopathy. Clinical and imagiological deterioration. Pronounced dead brain after six days. In Portugal, everyone is an organ donor (except if opposition made in life). Collected postmortem corneas, kidneys and heart. Background of idiopathic generalized epilepsy, diagnosed at age 16; antiepileptic drugs suspended the previous year; normal EEG since age 18. On external examination, iatrogenic alterations due to intracranial pressure monitoring and postmortem organ collection; and two ecchymosis (one on the middle third of the anterior face of the right leg and the other on upper third of the lateral face of the left thigh). On internal examination: cerebral edema, bilateral pleural effusion, pulmonary edema and congestion and heterogeneous coloration of lung parenchyma. Histological study revealed neuronal gliosis, neuronal pyknosis, cerebral edema and congestion, pulmonary congestion and edema, intra-alveolar hemorrhage and neutrophilic infiltrate in the bronchis. We did not perform toxicological analysis considering the 6-day Hospital stay and the therapeutic actions.

Discussion/Conclusion : Sudden Unexpected Death in Epilepsy (SUDEP) is a sudden, unexpected, witnessed or unwitnessed, nontraumatic and nondrowing death, occurring in benign circumstances, in an individual with epilepsy, with or without evidence for a seizure and excluding documented status epilepticus, in which postmortem examination does no reveal a toxicological or anatomic cause of death. If patient survives resuscitation for > 1h after a cardiorespiratory arrest and dies for its complications, it is a near-SUDEP. SUDEP is the predominant cause of premature death in young adults with epilepsy, with higher risk between ages 20 to 40. Pathological mechanisms remain unknown, possibly related to the effects on the autonomic nervous system. Postmortem brain findings are heterogeneous and pulmonary pathology includes edema, congestion and intra-alveolar hemorrhage. Minor degrees of aspiration is allowed. Gastric contents are frequently found in the upper airways at autopsy, displaced there during chest compressions or body manipulation, and its presence should not preclude SUDEP. Gastric contents in distal airway are more concerning for true aspiration (if there was no mechanical ventilation or chest compressions). The neutrophilic infiltration in the bronchia was attributed to the aspiration pneumoniae diagnosed at day one, assuming it followed the cardiorespiratory arrest. Hence, the cause of death was listed as near-SUDEP and not bronchopneumonia. We also highlighted that we could not exclude a cardiac cause of death in this case

236

LETHAL ACCIDENT OR SUICIDE? THE ROLE OF FORENSIC PATHOLOGY IN A CASE OF ORGANOPOSPHORUS DEATH

Fabrizio Cordasco 1 , Carmen Scalise 1 , Francesco Sicilia 1 , Matteo Sacco 1 , Angelica Zibetti 1 , Luigi De Aloe 1 , Carlo Filippo Bonetta 1 , Santo Gratteri 1 , Pietrantonio Ricci 1 , Isabella Aquila 1

1 University Magna Graecia of Catanzaro, Italy

Poster Presentation 2, June 3, 2021, 1:15 PM - 2:00 PM

Organophosphorus compounds (OPs) are insecticides frequently used in agriculture, especially in developing countries1. These substances can be used to cause death in a suicidal, homicidal or accidental way. Currently the suicidal mode is the most frequent. Accidental intoxication was instead very frequent among farmers until the 1980s2. The number of cases has drastically decreased in subsequent years, especially in developed countries, thanks to the use of safety devices and a better understanding of the action of insecticides. A recent study shows that only 8% of cases of OP poisoning are related to ingestion or accidental inhalation; the remaining cases are caused by voluntary ingestion3. Organophosphate pesticides induce an increase in acetylcholine in the pre-synaptic space which causes sympathetic overstimulation. The victim has an acute cholinergic crisis or a delayed intermediate neurotoxic syndrome. Respiratory collapse is the leading cause of death4. We report the case of a middle-aged man who died of accidental poisoning by organophosphates and subsequent autonomous road accident. The victim lost control of his car and crashed against a wall. He was transported to the hospital in a state of unconsciousness. The victim didn’t have severe traumatic injuries. The clinical picture was characterized by fever, metabolic acidosis, and high levels of cholinesterase, in addition to the presence of milky and foul-smelling liquid in the passenger compartment, on the clothing, and in the respiratory tract, making it possible to make a diagnosis of intoxication by organophosphorus compounds. A careful analysis of the clinical history and health documentation was carried out, and an autopsy was made. Diffuse skin redness of the anterior surface of the chest, abdomen, and limbs was observed. The trachea was hyperemic. The distal esophagus appeared congested and hyperemic. A psychological autopsy was carried out to complete the investigation. This was focused on a retrospective survey of the victim's life and psychological context, through interviews with family members, relatives and health professionals. The psychological autopsy showed that the victim, in addition to carrying out his work, in his free time cultivated farmland owned and at that time was using pesticides for sowing. On the basis of the data collected it was possible to conclude that the death was due to accidental OP poisoning. This case demonstrates how the forensic pathologist plays an important role in the post - mortem analysis into lethal intoxication cases. In these situations, it can be very difficult to recognize an accidental intoxication from a suicidal death. Forensic sciences, including psychological autopsy, are essential to understand dynamics of the events.

237

ALCOHOL, SOCIAL NETWORKS & ADOLESCENTS

Andrea Cioffi 1 , Fernanda Cioffi 2

1 Sapienza University Of Rome, Italy

2 Fertilitas Day Surgery Reproductive Medicine, Salerno, Italy

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

The problem of alcohol use among adolescents is very important and has often serious consequences. In recent years, with the widespread use of social networks, there seems to have been an increase in the prevalence of alcohol use among young people. This study aims to lay the foundations for a reflection on the relationship between alcohol, adolescents and social networks. To do this, the questionnaire method was used as it is believed to be the most direct means of understanding the views of adolescents on this subject.

238

PERCEPTION OF MEDICAL ETHICS IN THE PRACTICAL CONDUCT OF MEDICAL PERSONNEL IN HOSPITALS OF SFAX- TUNISIA

Jaweher Kammoun 1 , Malek Zribi 1 , Wiem Ben Amar 1 , Houssein Lebkem 1 , Moulaye Ahmed Dhehby Ahmedou 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic departement Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Medical ethics presents a reflection on the orientations in a particular clinical situation with a view to making the best possible decision. The doctor may be faced to ethical conflicts while caring for patients. Thus, ethical reflection attempts to resolve conflicts between competing values, rights and obligations in a complex medical situation. The main objective of our study is to analyze the place of ethics in the medical practice of doctors and future doctors as well as to know their ethical reflections for the resolution of some conflicts encountered during care.

Material and methods : This is a cross-sectional, descriptive and observational survey of doctors and future doctors in the university hospitals of Sfax. We have prepared a survey beforehand which has three parts: the socio-demographic data of the participants, the nature of the ethical conflicts encountered in medical practice and the perception of the importance of ethical help in resolving medical conflicts. The data collection was done over a one-week period from September 19, 2019 to September 25, 2019.

Results : We collected 150 participants in the proposed questionnaire from doctors and future doctors. They were women in 58% of the cases. They were medical graduates in 25% and future doctors not yet graduated (external, internal and residents) in 75% of the cases. Most participants were under the age of 35 (76%). Regarding the perception of the importance of medical ethics, 85% of the participants attached importance to medical ethics in their work. There is no link either with age or professional experience. There is a link with the specialty (p = 0.017). Most of the participants replied that they encounter ethical problems on a daily basis. The three most frequently encountered issues are about patient consent and autonomy, medical confidentiality and about situations of vulnerability. Regarding the perception of knowledge of ethics laws, 62% of participants felt they knew "little or not at all" these laws. There is no link with the profession or with age, but there is a significant link with professional experience (p = 0.03). For the role of the ethics committee, the majority of participants replied that it involves advising staff when they encounter ethical problems and providing training in medical ethics.

Discussion and conclusion : Doctors have a complex role in the care journey of their patients. Medical science is always in diagnostic and therapeutic evolution which lead practitioners to meet more and more ethical conflicts in their current practice.

239

NEW REGULATIONS RELATING TO MEDICAL OR SCIENTIFIC EXPERIMENTATION OF MEDICINES INTENDED FOR HUMAN MEDICINE IN TUNISIA AND RESPECT OF ETHICS

Narjes Karray 1 , Wiem Ben Amar 1 , Malek Zribi 1 , Jaweher Kammoun 1 , Hela Siala 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic department Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Biomedical research, although essential to the development of medical sciences, must be the subject of all legislative and regulatory attention to avoid abuses and guarantee respect for human rights. In this area, Tunisia made in October 2014, a substantial modification to the pre-existing legal framework with a general perspective of respect for patient rights and ethical principles. In this work, we propose to evaluate the knowledge concerning the ethics and the regulation of medical experimentation in Tunisia, to analyze the new legislative provisions in the matter and to study the degree of conformity of this new legal framework with international ethical standards.

Material and methods : A survey was carried out among all first year medical students enrolled in the optional unit "medical research" during the 2020-2021 academic year. A survey was developed and sent by email.

Results : All the learners answered were 46 students. They were predominantly female. Most of the learners had no ideas about bioethics and its standards. However, they were aware of the existence of a law that regulates medical research in Tunisia. According to the opinion of the students interviewed, the experimental subjects could only be adults for more than ¾ of the respondents. The learners believed that the experimental subjects had the right to receive money in return for their participation. 91.3% of them felt that they have the right to compensation for the constraints imposed by the experiment. Most learners saw information and consent as a requirement for all medical research. Most of them opted for consent on a form set by law (95.7%).

Discussion and conclusion : The new legislative provisions relating to experimentation in Tunisia have brought novelties concerning the subjects of research, the methods of collecting consent, information and compensation with the main objectives of protecting the rights of the participant experimentation, and the fundamental principles of research ethics. However, shortcomings persist in terms of vagueness, loopholes and questions requiring the enactment of a new law that would lay down principles, clarify definitions and provide for penalties.

240

ETHICAL ISSUES RELATED TO CANCER DIAGNOSIS ANNOUNCEMENT

Wiem Ben Amar 1 , Hassen Ennouri 1 , Malek Zribi 1 , Dr Hela Siala 1 , Fatma Daoud 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic Department, Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Cancer diagnosis announcement is a complex clinical task in physician practice. It is at the centre of a conflict between two basic ethical principles: autonomy and beneficence. On the one hand, the patient has the right to be fully informed of diagnosis and prognosis of his illness. On the other hand, disclosure of a fatal prognosis can cause profound psychological trauma to the patient. This work aims to report the experience of practitioners involved in the announcement of breast cancer diagnosis, and to identify ethical issues related to such an announcement.

Material and methods : We conducted a knowledge, attitudes and practices survey involving all practitioners called upon to announce the diagnosis of breast cancer in the two university hospitals of Sfax (Tunisia). A questionnaire was developed and presented directly to all these physicians.

Results : Among the 48 doctors who received the questionnaire, 34 agreed to participate in the study. All surveyed practitioners were confronted with the announcement of cancer diagnosis, but with varying frequency. Nearly half of them had one or more previous training sessions related to such an announcement, and therefore know its stages. The presence of a companion in the interview was considered desirable in 53% of cases. Before making the announcement, the vast majority of doctors (88.2%) took into account what the patient was wanting to know. During the announcement, 32.4% of practitioners rarely informed their patients of disease prognosis, and half of them frequently explained treatment possibilities. After the announcement, all surveyed practitioners took time to respond to the patient's questions.

Conclusion : In view of the shortcomings noted in doctors' knowledge and practice of cancer diagnosis announcement, a considerable effort should be devoted to training in order to improve doctor-patient communication skills. From an ethical point of view, the physician should allow the patient to remain an autonomous person able to take part in the decision-making process, while doing no harm to him.

241

PSORIATIC ARTHRITIS AND THE FORENSIC IMPLICATIONS OF ITS FUNCTIONAL LIMITATIONS REGARDING THE HANDS AND WRISTS IN A CASE OF ALLEGED ASSAULT

Eduarda Duarte 1 , Guido Duarte 1,2 , Patrícia Jardim 1,2,3,4

1 National Institute of Legal Medicine and Forensic Sciences, Portugal

2 Vila Nova de Gaia/Espinho Hospital Centre, Portugal

3 Institute of Biomedical Sciences Abel Salazar - Porto University, Portugal; 4 Faculty of Medicine of Porto University, Portugal

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Psoriatic arthritis is a chronic inflammatory disease often associated with psoriasis, usually seronegative for rheumatoid factor. It is characterized by a wide variety of musculoskeletal and extra-articular signs and symptoms involving the inflammation of synovial tissue, entheses and skin. These patients have heterogeneous clinical presentations, with diverse articular and dermatological features, and varied disease courses and outcomes, with about 40% to 60% of patients developing erosive and deforming joint complications. This condition culminates in deficient articular function, affecting patients’ ability to work, being significantly associated with high rates of absenteeism, and also affecting their social relationships and daily life activities. We present a case of a 42-year-old caucasian woman diagnosed with psoriatic arthritis since 2008, with predominantly peripheral articular involvement, more pronounced at the level of the wrists, hands and fingers, but also symptomatically involving the shoulders, the sacroiliac joints and the left tarsus and toes. Her medical treatment consisted on nonsteroidal anti-inflammatory drugs (NSAIDs), tramadol and golimumab. She retired in 2018 due to this condition, having previously worked as a caregiver for the elderly. She was able to perform her activities of daily living, albeit having some difficulties caused by articular joint stiffness, with inability to fully flex the joints of the fingers, culminating in weaker grip strength. The patient was submitted to a forensic clinical examination due to an assault in June 2019, reporting being pushed against a wall by her neighbour. She was, however, also accused of assault (hair pulling, pushing and scratching during the same event) by this neighbour. She contested this accusation, alleging that the osteoarticular pathology that she suffers from significantly affects her wrists, hands and fingers, rendering it impossible to perform actions that require the use of considerable physical force with her hands, namely the act of pulling the neighbour’s hair. Thus, an expert orthopaedic evaluation was requested in order to determine if the patient meets the conditions to use her hands in order to attack someone (namely pulling her neighbour’s hair) considering her diagnosis of psoriatic arthritis and the joint limitations that arise from it. After a thorough physical examination we observed that she maintained some level of residual pinch strength with the thumb and index fingers bilaterally (she was able to tear a paper sheet and to pull up her tights), despite the significant articular stiffness and deformity she presented at the level of both wrists, hands and fingers, being unable to actively make a full fist. These objective findings demonstrate that the subject could in fact have pulled her neighbour’s hair. Nevertheless, it would be very unlikely that any relevant injuries present on the neighbour’s scalp would have resulted from this action, considering the subject’s weak residual pinch strength.

242

SUBARACHNOID HEMORRHAGE THREE TIMES MISDIAGNOSED: CASE REPORT AND LITERATURE REVIEW

Alessandro Bonsignore 1 , Camilla Tettamanti 1 , Rosario Barranco 1 , Francesca Buffelli 2

1 University of Genova, Genova, Italy, 2 IRCCS - Istituto Giannina Gaslini, Genova, Italy

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : The incidence of acute subarachnoid hemorrhage (SAH) has been estimated at 6 cases per 100,000 persons per year. SAH is a serious disease, owing to its high mortality and morbidity; 10% of patients die before reaching hospital, and another 50% die within the first month. Patients who come to treatment (surgical or endovascular) in “Hunt and Hess" grade I-III conditions have good or excellent results in 90-96% of cases; in grade IV, the favorable outcome drops to less than 60%. The frequency of SAH non-recognition has led to the drafting of numerous protocols or recommendations of conduct.

Case report : A 47-year-old woman, with no history of noteworthy diseases, had an unprecedented sudden acute attack of intense pain in the right temporal region followed by a brief loss of consciousness (the so-called "warning leaks” or “sentinel bleeding”). Transported to the emergency room (ER), she had an episode of vomiting, but was discharged after a few hours with a diagnosis of "cervical distraction" and a prescription for analgesics. Six days later, she had a second acute episode with sudden loss of consciousness, and fell to the ground; in the ER, she was treated for facial wounds and was discharged again with NSAIDs prescription.

Five days later, another violent headache attack occurred during sleep (3rd episode) associated to photophobia. On this occasion, she underwent a cranial CT scan, which was considered by clinicians not revealing blood spillage. Once again, she was discharged with a diagnosis of "headache in cervical pain". After the third episode, she began to have symptoms attributable to a progressive deficiency of the third cranial nerve, configuring a fourth episode. Finally, she underwent MRA-cerebral angiography which revealed the presence of a saccular aneurysm associated to SAH. During the transfer to the Neurosurgery Unit, a fifth and very serious episode of bleeding occurred. From that moment on, the diagnostic and therapeutic measures were timely and appropriate to the case; the aneurysm was properly studied and treated leading to a residual left hemiplegia, loss of bowel control and impairment of cognitive functions.

Discussion : The presented case is an example of multiple failure to diagnose cerebral hemorrhage in the face of strong clinical and instrumental evidence and a history of previous warning leaks, which, if promptly diagnosed, would have resulted in complete recovery. As it was, the multiple medical mistakes led to serious disability of the patient. The Court therefore returned a guilty verdict, with repercussions for the physicians in both civil and criminal law.

Conclusion : Sudden intense headache should arouse suspicion and a SAH has to be excluded. However, a CT scan does not unequivocally prove the presence of intracranial blood; in such situations, a lumbar puncture is undoubtedly required.

243

ACCIDENTAL PENETRATING FACIAL INJURY

Biliana Mileva 1 , Metodi Goshev 1 , Ivan Tsranchev 2 , Pavel Timonov 2 , Alexandar Alexandrov 1

1 Department Of Forensic Medicine and Deontology, Medical University, Sofia, Bulgaria

2 Department of Forensic Medicine, Medical university, Plovdiv, Bulgaria

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Case description : We present a case of а woman aged 46 years with severe facial trauma after a penetrating injury from an elongated metal object. Two months after the surgical treatment, she was examined at the clinic of Forensic medicine and Deontology, Sofia, for a forensic medical assessment of the sustained injuries. The incident happened while she was shopping in a store. One of the shelves falls on top of her, knocking her down and pressing her against the ground. A metal part of it, approximately 30 cm long, stabbed her into the right temporal zone of her face, right in front of the upper part of her ear, and penetrated her oral cavity through the soft palate. While waiting to get the needed medical help, she felt how her mouth was filling with blood, making it difficult for her to breathe. The head movements were limited, and it was hard for her to evacuate the accumulating blood in her mouth. The same day she was sent for an operation, after thorough examinations, x-ray, and consultations with specialists. In the right temporal area, at a distance of 3,5 cm in front of the right ear, round hyperpigmented scar with a diameter of about 1.5 cm was noted during the forensic medical examination. According to the given medical documentation, there was a puncture wound in her right temporal area, with slightly uneven, discreetly abraded, contused, and swollen skin margins. Mouth opening was difficult due to the foreign body penetrating through the soft palate, with oral bleeding. The fragment was situated obliquely according to the midline of the head. The direction was right to left, from above to downwards, and back to forward. There are no fractures of the facial bones and no broken or erupted teeth in the oral cavity. The performed operation was under general venous anesthesia. Thorough antiseptic treatment was carried out, and the foreign body was removed, then hemostasis was achieved, and a suture was applied at the injured regions. There was no damage to great vessels or nerves in the affected anatomical areas. The postoperative period was uneventful, with no complications, and the patient's discharging was on the 4th day. Discussion: Penetrating facial injuries are rare and potentially dangerous conditions, and they require emergency management to maintain the normal anatomical and physiological appearance and functioning of the affected zone. The forensic medical assessment is hard in such types of injuries, because they may be life-threatening, they may have a multiplicity of complications during the recovery period, and they can be associated with disfiguration of the face.

244

FATAL IATROGENIC RUPTURE OF THE RIGHT AURICLE DURING CHEST TUBE PLACEMENT: WHAT MEDICAL ACCOUNTABILITY

Malek Zribi 1 , Moulaye Ahmed Dhehby Ahmedou 1 , Wiem Ben Amar 1 , Fatma Daoud 1 , Houssein Lebkem 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Habib Bourguiba Hospital, Sfax, Tunisie

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Object : Discussed a practitioner's responsibility for the death of a patient during a chest drainage procedure

Introduction : The insertion of a chest tube is a common procedure in Trauma care. Despite the many benefits, chest tube insertion is not always a harmless procedure, incorrect tube insertion amay have disastrous consequences like heart laceration this injury is rare but not impossible. Patient and observation: 17 years old patient operated in emergency for a strangulated diaphragmatic hernia, third day of postoperative hospitalization he developed dyspnea and respiratory distress a thoraco abdominal and pelvic CT scan showed a very abundant hydro pneumothorax requiring emergency drainage, during the installation of the drain a cardio respiratory arrest ensued the deceased was resuscitated for 30 minutes without recovery. His death required a forensic investigation, for which a forensic autopsy was performed. During the external investigation, we observed a wound opposite the 2nd left intercostals space and a left basithoracic wound. No traumatic lesions were found. At autopsy, the examination revealed a wound in the left second intercostals space with a laceration of the left upper lobe. In addition to these lesions, there was an area of bruising on the pericardium all around a perforated wound. The pericardial sac contained approximately 250 ml of blood fluid and clot; there was also a perforating wound in the right auricle, measuring 0.5 cm in diameter.

Discussion : Pneumothorax, hemothorax and purulent pleurisies are the main indications for thoracic drainage in intensive care. Thoracic drainage must be performed according to a well-defined technique, and is usually performed by an experienced practitioner. Precautions must be taken to avoid the appearance of serious or even fatal complications. In the reported case, chest drainage was justified and there were no contraindications. In the case studied, an atrial lesion with pericardial tamponade occurred during drainage. Previously, a cardiac injury with pericardial tamponade due to thoracic drainage has rarely been described in the literature. These cardiac lesions may be due to a technical error, a characteristic directly related to the patient or his illness, or a lack of experience of the doctor performing the drainage. In this situation, the operator may be prosecuted for unintentionally violating the bodily integrity of others and causing death in this case.

Conclusion : several complications can occur during the installation of a thoracic drainage, especially lesions of the underlying organs; these complications can be life-threatening if the organs affected are the large vessels and/or the heart. In the event of chest drainage followed by a serious and unexpected incident, the victim may hold the operator liable in court for involuntary bodily harm.

245

TAKO-TSUBO SYNDROM COMPLICATING PREGNANCY. A CASE REPORT

Bilel Gammoudi 1 , Elyes Turki 1 , Oumaima Brahim 1 , Firas Haggui 1 , Elaa Chebbi 1

1 Forensic Medecine Service Ibn El Jazzar Kairouan, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Case description : Mrs F.R, is second gesture and is 32 years old, with no cardiac pathological history. At 32 weeks of amenorrhea (WA) the parturient consulted our emergency room for a constrictive retro-sternal pain chest, wich irradiates to the whole of the upper left limp and associated to syncope and nausea. The anamnesis revealed the announcement of the death of her approach person by a traffic accident on hour before the beginning of the symptoms. The exam noticed a patient conscious, dyspnea, tachycardia at 90 bpm and hypotension at 80/50 mmHg. The obstetrical exam noticed a uterine height at 30 cm and a closed cervix. The electrocardiogram showed a minimal rising of the ST segment in the anterior territory with a q wave, a negative deep and not systematized T waves and a lengthening of the QT segment. A moderate rise of the troponin I and CPK MB were noticed. An ultrasound cardiac noticed a mid apical akinesia and a basal hyperkinesias suggesting characteristic shape of the “octopus trap Japanese”. A coronary angiography was performed without any abnormalities. The diagnosis of Tako-Tsubo Syndrom was retained. The clinical evolution was well. The rising of the ST segment disappeared after 24 hours and appearance of negative T waves at anterolateral leads associated with a lengthening of the QT segment. The patient took beta blockers prescribed at 48th hour of hospitalization. The clinical check up realized one month later, noticed a restitution ad integrum. At 37 WA, the parturient gave birth to a male baby weighing 3400 grams.

Discussion : Tako-Tsubo Syndrom (TTS) is rare myocardial pathology. Its incidence is estimated between 0.7 to 3 % of all coronaries syndroms. The etiopathogeniesis of TTS is misunderstanding. The hypothesis of a coronary spasm induced by emotional stress is widely accepted. Patients with TTS are without cardiovascular history such as in our case. The clinical symptomatology includes pain chest, rising of ST segment and myocardial enzymes. Other symptoms, such as nausea and syncope are associated. In our case the pain chest was associated to the signs of heart left failure and syncope. The cardiac ultrasound allows suspecting the diagnosis. In our case it showed a characteristic shape of the “octopus Japanese trap”. The treatment is based on beta blockers prescribed earlier. The clinical evolution is favorable but several complications can lead to death. In our case, the patient noticed a restitution ad integrum of all her parameters.

246

CONSEQUENCES OF INTIMATE PARTNER VIOLENCE ON MENTAL HEALTH AMONG TUNISIAN FEMALE VICTIMS

A Wiem Ben Amar 1 , Hanen Dhouib 1 , A Malek Zribi 1 , Elaa Chebbi 1 , Houssein Lebkem 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic Department Habib Bourguiba Hospital, Sfax, Tunisie

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Intimate partner violence (IPV) is a serious social problem. Violence can be psychological, physical, economic or even sexual. It could generate severe psychological repercussions. It represents a frequent and repeated reason in forensic department. In this paper we aim to describe the profile of female IPV victims, determine the prevalence of post-traumatic stress disorder (PTSD) and screen other psychiatric disorders among victims. We carried out a prospective study over a period of 03 months from June 1 to August 31, 2018. Data were collected from women who were viewed on judicial requisition, in the forensic department of Habib Bourguiba University hospital in Sfax, Tunisia. In addition to a questionnaire specifying the epidemiological characteristics relating to the victim, we used the Post-traumatic stress disorder Checlist scale version DSM-5 (PCL-5), the purpose of which is to establish a provisional diagnosis of PTSD, the Center for Epidemiological Studies-Depression Scale (CES-D) to identify depressive symptoms and assess their severity; and the Rosenberg scale to assess the victim's self-esteem. Among the 142 women victims of intimate partner violence, only 60 (22.3%) agreed to answer our questionnaire. The average age of the victims was 33.5 years (27-41.5). Most women were married at the age of 23 (20-26). The average duration of marriage was 7 years (3-14). The assaults concerned both rural and urban areas (52-48%). 50% of the victims had a regular professional activity and 25% had a low socio-economic level. Assaults were daily in 41.7% of the cases. The violence was physical in all cases. Bruises and abrasions were the most common lesions. The prevalence of PTSD was 58.3%. The mean PCL-5 score was 34.57 ± 11.64. Self-esteem was low or very low in 70% of victims. 88.3% of the women presented depressive symptoms. Regarding the association with other psychiatric consequences, PTSD was correlated with depressive symptoms (P: 0.001), suicidal ideation (P: 0.009), suicide attempts (P: 0.032), sleep disorders (P : 0.035) and the use of sleeping pills (P: 0.009). Female IPV victims do not seem to have a particular profile. The prevalence of PTSD revealed in our study calls for multidisciplinary social, medical and psychiatric management, especially since this symptomatology is often associated with other psychiatric comorbidities.

247

POST-CONCUSSION SYNDROME OF CRANIO-CEREBRAL TRAUMA SECONDARY TO ASSAULT

Jaweher Kammoun 1 , Malek Zribi 1 , Narjes Karray 1 , Wiem Ben Amar 1 , Fatma Daoud 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic department Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Post-concussion syndrome (PCS) most often occurs after mild or moderate cranio-cerebral trauma (CCT). It is usually manifested by symptoms which are not specific, making its diagnosis difficult to establish. The PCS constitutes a complaint frequently expressed by victims of CCT, during the forensic examination. In this context, the expert's role will be to establish the diagnosis of SPC, to verify its attribution to the cranio-cerebral trauma and to assess the rate of partial permanent disability in relation to this syndrome

Aims : Exhibit the various problems encountered in the compensation of the PCS and deduce the most efficient expert approach to guarantee a good repair.

Methods : We carried out a retrospective descriptive study on all cases of PCS caused by cranio-cerebral trauma following an assault at the time of the forensic examination realized in the Forensic department of the Habib Bourguiba Hospital (Sfax) during a period of 5 years. (2015-2019).

Results : We collected 12 patients. The mean age was 28 years with percentiles (25,75) of 23,5 years and 37 years. They were all male. The majority of patients had CCT perpetrated by an improvised blunt object. CCT was mild to moderate in most cases. A Temporary Total Disability (ITD) was assigned with an average of 30 days (percentiles (25,75) were 30 days and 45 days). At the time of the forensic examination, the most reported symptoms of PCS were headache and dizziness. To compensate the victims, we conducted a study of the PCS's attribution to the causative trauma. The consolidation date was set at an average of 02 months with extremes ranging from 03 weeks to 30 months. The average permanent partial disability was 15% with extremes ranging from 5% to 45%.

Discussion and conclusion : The compensation of PCS following a CCT is not always easy, especially in terms of the evaluation of the causal link between the PCS and the trauma. This causal link can only be established if the criteria of medico-legal accountability are present. The expert must keep vigilance and caution in his forensic examination, in order to guarantee adequate and fair compensation.

248

MEDICAL RESPONSIBILITY IN GYNECOLOGY-OBSTETRICS IN CASE OF POSTPARTUM HEMORRHAGES

Jaweher Kammoun 1 , Malek Zribi 1 , Wiem Ben Amar 1 , Houssein Lebkem 1 , Fatma Daoud 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic department Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Obstetric gynecology is one of the most complaint purveying specialties in medical responsibility. Childbirth, being a harmless physiological event, makes any accident inadmissible and thus may involve the medical responsibility of the practitioner in case of serious or even fatal complications such as postpartum hemorrhages. We proposed to analyse the circumstances of the obstetrician gynecologist’s medical responsibility in cases of postpartum hemorrhage, to expose the jurisprudence in the Tunisian case and in comparative laws, and to identify the primary prevention measures for medico-legal risks.

Methods : We carried out a retrospective study of expertise in medical responsibility oncerning postpartum hemorrhages, collected in the forensic unit of Sfax (Tunisia) over a period of fourteen years (from 1 January 2004 to 31 December 2019). We reported data from expert reports as well as the according judgment when available.

Results : The identified cases involved 08 complaint files in obstetrics and gynecology in case of postpartum hemorrhages. The fault of the practitioner could occur before the decision and indication of the act, during surgery, or during the follow up of the patient. The main high risk situations for patients and complaints for the doctor un case of postpartum hemorrhage were uterine rupture, uterine inertia, pregnancy-induced hypertension and its complications, and amniotic embolism. A nonsuit was pronounced in three cases

Conclusion : The prevention of medico-legal risk in obstetrics lays on the respect of recommended precautions during all stages of treatment. A rigorous maintenance of the medical records is essential. Sharing the information with the patient especially upon the occurrence of complications can reduce the number of complaints, especially penal proceedings which are very restrictive for the medical profession.

249

FACIAL TRAUMA IN THE CONTEXT OF VIOLENCE AGAINST WOMEN AND FORENSIC CONSIDERATIONS: ABOUT 414 CASES

Jaweher Kammoun 1 , Narjes Karray 1 , Malek Zribi 1 , Fatma Daoud 1 , Jaweher Kammoun 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic department Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Physical Violence against women is universal and can have many forms. When this violence affects the face, the aesthetic, functional and psychological repercussions on the victim can be serious. That justifies the particular attention paid by the Tunisian legislator to this type of violence. In this work, we aim to assess the scale of voluntary facial violence against women in our region, and to discuss the Tunisian legal provisions specific to this type of injury.

Material and methods : It is a retrospective descriptive study carried out at the forensic department of CHU Habib Bourguiba Sfax- Tunisia. We have compiled all cases of facial trauma in the context of violence against women, which were examined on judicial requisition during the period from March 1st, 2018 to August 31th, 2018.

Results : During this period, 1010 women victims of voluntary violence were received in the consultation of the forensic department, whose 414 (41%) had an isolated facial trauma or associated with other injuries in other localizations. The median age was 32 years with extremes ranging from 2 to 94 years. The victims were married in 82% of the cases and single in 16.1% of the cases. They were mostly low-educated, urban housewives. The perpetrator was the intimate- partner in 48.3% of the cases. The examination of the victim objectified multiple superficial traumatic lesions rarely serious lesions such as wounds (linear or contused) or fractures. The weapon used was a blunt object in most cases. In 1% of the cases, disfigurement by stab wound was noted (4 cases). The median duration of total temporary incapacity was 7 days with extremes ranging from 0 to 30 days. In 40% of cases, partial permanent incapacity was predictable.

Conclusion : Facial trauma in the context of violence against women can have serious functional and psychological repercussions. The Tunisian legislator targeted this type of violence by specific legal provisions, whether in article 228 of the Tunisian penal code or in his new organic law n° 2017-58 of August 11, 2017, relating to the elimination of violence against women. The main part of these provisions concerns the aggravation of the sanctions against the author of the disfiguring injuries.

250

ASSAULT AND BATTERY AMONG A TUNISIAN POPULATION: EVALUATION AND MEDICO-LEGAL CONSEQUENCES

Jaweher Kammoun 1 , Wiem Ben Amar 1 , Hassen Ennouri 1 , Hela Siala 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic department Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Violence is a universal scourge that tears at the fabric of communities and threatens the life, health and well being of us all. Eventhough, it is a poorly studied in Tunisia. Our objective is to improve knowledge of characteristic of physical violence and their medical and medico-legal consequences.

Material and methods : It’s a retrospective study over a period of two months January 1, 2019 and February 28, 2019. This study is carried out in the forensic service in Sfax-Tunisia and including all victims of of assault and battery during this period. The data were recruited from forensic reports of deliberate and the interrogatory of victims.

Results : We collected 637 forensic reports of deliberate assault and battery victims in the forensic department of Sfax that present 55.58% of all victims seen in the period of our study. The majority of victims were men (76%), aged between 18–40 years old (60%). Men were assaulted by a casual aquaintance in 57%, while women were mostly victims of marital violence (72% of cases). Assaulted children accounted for 18% of the case. The assault resulted in benign lesions like contusions in 50% of the cases, scratches in 48%, and in major trauma like fractures in 7% or severe head trauma in 3% of the cases. The traumatic injuries were observed in the head and neck regions in 59% of the cases, in the upper limbs in 32%, in lower limbs in 16% and in the thoracic region in 7% of the case. Natural arms were the most used weapons. The assault was associated to sexual abuse in 6% of the cases. Victims beneficiated of a medical care in most cases (94%), orthopedic treatment in 2% of cases and an operative treatment in 7 cases.Temporary partial disability was estimated less than 3 days in 46%.The severity of the assault is judged from the existence in the initial appraisal report of a permanent partial disability (PPD) expected after consolidation of the wounds which was the case in 19.5%.

Discussion and conclusion : Based on these results, physical violence affects both sexes and all age groups, resulting in benign lesions. Reporting the violence constitutes is one of the most important medical activities to combat this blight.

251

POST-TRAUMATIC STRESS DISORDER AFTER ROAD TRAFFIC ACCIDENTS: ABOUT 63 CASES

Wiem Ben Amar 1 , Hassen Ennouri 1 , Malek Zribi 1 , Dr Hela Siala 1 , Dr Jaweher Kammoun 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic Department, Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Road Traffic Accident (RTA) is one of the traumatic experiences which may result in Post-Traumatic Stress Disorder (PTSD). While the physical damage of such accidents is evident, the psychological consequences are often not apparent. The aim of this study is to determine the incidence level and identify factors associated with PTSD in RTA victims.

Materials and methods : We conducted a cross-sectional study of RTA survivors who were examined in forensic medicine department of the Habib Bourguiba Hospital in Sfax (Tunisia), on a three-month period between September and November 2018. "Post-Traumatic Stress Disorder Checklist Scale" (PCL-S) was used to detect PTSD. Severity of the trauma was assessed by the "Abbreviated Injury Scale" (AIS).

Results : We identified 63 victims with an average age of 39.66 years (extremes: 18-74). Most of the victims were male (sex-ratio=6), married (68.3%), and urban residents (66.7%), with a medium socio-economic level (77.8%). Three patients (4.8%) had psychiatric history. Twelve victims (19%) were pedestrians and 33 (52.4%) were driving a light vehicle during the RTA. The prevalence of PTSD among road accident victims was 44.4%. The typical profile of a patient with PTSD was that of an adult woman in a light vehicle, aged about 40, married, with a medium socio-economic level. Trauma was generally minor to moderate (AIS<3). Hospitalization was required in 57% of cases and disability was noted in eight patients (28.5%). Factors correlating with the occurrence of PTSD were: female gender, hospitalization after the accident and resulting disability.

Conclusion : The findings of this study revealed that nearly half of RTA survivors developed PTSD. Thus, there is urgent need to pay more attention to establishing consultation-liaison psychiatry services in trauma units of Tunisian hospitals, in order to prevent the appearance of PTSD.

252

DEATH BY ORGANOPHOSPHORUS POISONING: ABOUT 25 AUTOPSY CASES

Narjes Karray 1 , Wiem Ben Amar 1 , Malek Zribi 1 , Elaa Chebbi 1 , Jaweher Kammoun 1

1 Habib Bourguiba University Hospital, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Organophosphorus (OP) poisoning are responsible of a high rate of mortality. In Tunisia, despite the availability of an antidote and the easy access to health care structures, mortality rate due to OP poisoning is still high. In this paper, we will evaluate OP poisoning victims’ profile and conclude prevention means.

Material and methods : It is a descriptive retrospective analysis of all OP poisoning cases to whom we performed an autopsy in the Forensic Medicine Department of the University Hospital Habib Bourguiba Sfax- Tunisia over a period of 14 years (2006-2019).

Results : Over this period, we have collected 107 cases of death by poisoning, among which 25 are due to OP. Mean age of victims was 27.8 years ±14.3 years. We noted a feminine predominance (80%). Most of the victims were single, from rural areas, jobless and of low socio-economic level. Poisoning was suicidal in 92 % of the cases and criminal in only one case. The place where the poisoning happened was the house of the victim in most cases. We remarked a High summer peak pf deathly OP poisoning. Toxicological analyses were performed on blood, urine and gastric contents, which were positive in almost all cases.

Discussion : Poisoning is a public health problem in the world and in Tunisia. Deaths by toxic causes is becoming more frequent over the years especially suicidal deaths. In Tunisia, pesticides are the most used toxics in suicide by poisoning, and the most common is OP. In the world as well, according to many studies, Pesticides are the most common toxics responsible for deadly poisoning including OP and carbamates. This relatively high rate of suicide by OP poisoning might be explained by its frequent use as insecticide, its low cost, and the easy access to it. In fact, OP are very dangerous, prevention should be based on education, raising awareness, better communication with adolescents and early tracking of suicidal risk factors.

253

NON-INFECTIVE ENDOCARDITIS COMPLICATED BY CORONARY THROMBUS: ABOUT AN AUTOPSY CASE

Hiba Limem 1 , Mohamed Amine Mesrati 1 , Marwa Boussaid 1 , Habiba Sandid 1 , Meriem Boughattas 1 , Abir Aissaoui 1

1 Taher Sfar Hospital, Mahdia, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Case report : A 67-year-old man with a history of diabetes under treatment, died in a context of acute chest pain. A forensic autopsy was ordered. The necropsy revealed atheromatous and calcified coronary arteries with a reduction of their vascular lumen to approximately 80% and the presence of a recent thrombus in the anterior interventricular artery. Hyperchromic myocardial area with white scar of the free wall of the left ventricule was found. The aortic valvular apparatus showed vegetations. Anatomopathologic examination revealed lesions of fibrinous (abacterial) endocarditis of the aortic valve with multiple recent and old myocardial infarction scars on the left ventricular wall.

Conclusion : Non infective endocarditis can develop in a number of conditions, including autoimmune disease, malignancy and hypercoagulable states. The association of this pathology and coronary thrombus is an entity rarely reported in the literature and often diagnosed at autopsy.

254

ANIMAL PREDATION – A FORENSIC DIAGNOSTIC CHALLENGE

Filipe Fernandes 1 , Bárbara Mendes 1 , Ana Rita Marques 1 , José Moura Fernandes 1,2

1 National Institute of Legal Medicine and Forensic Sciences - North Branch, Porto, Portugal

2 School of Health Sciences - Polytechnic of Porto, Portugal

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Autopsy cases involving injuries resulting from animal predation are rare in the forensic practice and may be a diagnostic challenge for the pathologist. [1-3] First, discrimination needs to be done between postmortem injuries inflicted by animals from antemortem trauma and careful assessment of their contribution to the cause of death. Furthermore, postmortem animal predation can make the victims’ identification difficult, modify antemortem traumatic wounds and damage the internal organs, making the cause of death determination impossible.

Methods and Results - Case Report : A 47-year-old male victim, with a history of drug abuse and non-specified psychiatric disease, was found dead lying on his bed with signs of putrefaction, after not having been seen for a week. During death scene investigation, three animals (two dogs and one cat) were found alive inside the house, which was in bad hygiene/sanitary conditions. At autopsy, the body had an absence of soft tissues of the head, face, thorax and left arm with exposure of underlying bony structures and thoracic cavity exposure (without any of the thoracic organs present). Additionally, it was observed disarticulation of the mandible (without fracture), absence of part of the right clavicle and fragments of ribs and sternum. The available organs (brain and abdominal organs) showed only alterations compatible with putrefaction phenomena. No other traumatic or pathological lesions were identified in the undamaged structures. The victim was identified through lofoscopic procedures. Toxicology analysis (using fragments of liver and kidney and urine and gastric contents) was negative and the histological examination of skin edges of the lesions showed no signs of vitality (and therefore compatible with post-mortem animal predation) with no other cause of death identified histologically.

Conclusions : In this case, combining death scene investigation, circumstantial information, autopsy findings and results of the ancillary exams, it was possible to identify the body and to conclude that the traumatic injuries observed were caused by post-mortem action of animals (in this case the domestic animals found at the scene). However, due to the post-mortem traumatic injuries by animal predation and the putrefactive changes, it was not possible to identify the cause and manner of death, so the case was listed as undetermined. In autopsy cases with animal predation injuries, the circumstances at which the victim is found can lead to the initial suspicion of a crime, highlighting the importance of complete and adequate death scene examination for the correct interpretation of the facts.

255

COLLOID CYST, WHEN A CONSIDERED BENIGN CONDITION KILLS – CASE REPORT

Sara Costa 1 , José Moura Fernandes 1,2

1 National Institute of Legal Medicine and Forensic Sciences - North Branch, Porto, Portugal

2 Superior Heath School - Porto Polytechnic, Porto, Portugal

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Case Report : 27-year-old man, with no clinical background, presenting with headache 2 months prior to his death. The headache was increasing its intensity, becoming medication resistant, and associating with vomiting. During the transportation to the hospital the victim went into cardiac arrest and died. At autopsy the external examination revealed no significant findings. At the internal examination, no other changes were noticed besides brain oedema and the presence of a greenish elastic round shaped mass, inside the third ventricle of the brain. The mass was sent to histological examination, being classified as a colloid cyst. The toxicological study performed to the blood samples was negative.

Discussion and Conclusions : According to the literature, colloid cysts are rare benign congenital brain tumours that grow in the third ventricle, accounting for 0.5–2.0% of all intracranial tumours and 10–20% of all intraventricular tumors.1 Although they´re classified as benign, this tumours present a high level of neurological complications like headache, nausea, vomiting, behaviour changes and loss of consciousness.2,3 Sudden death was reported to occur in about 10% of patients and the symptomatic cases of colloid cyst of the third ventricle had a risk of acute deterioration in 34% with a mortality rate of 12%.4 In rare cases, the cyst can obstruct Monro’s foramen completely, resulting in sudden loss of consciousness, coma and death by cerebral herniation. In other situations, where there is no herniation, death can be due to cardiac arrest by neurogenic cardiac dysfunction (secondary to acute hydrocephalus). In this case, at the autopsy, there were no signs of herniation so, considering the autopsy findings and the result of the histological examination, it was considered that the victim died due to cardiac arrest in the subsequence of obstructive hydrocephalus due to the colloid cyst of the third ventricle.

256

HOMICIDAL OR SUICIDAL DEATH? A STABWOUND CASE REPORT

Sara Costa 1 , Sofia Monteiro Cunha 1 , Bárbara Mendes 1 , Dina Almeida 1,2

1 National Institute of Legal Medicine and Forensic Sciences - North Branch, Porto, Portugal

2 Abel Salazar Biomedical Sciences Institute - University of Porto, Portugal

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

A 75-year-old male was found dead on the kitchen floor with a knife inserted on the chest. Nine days prior, he was discharged from a psychiatric facility where he stayed due to a previous suicide attempt (drug overdose). In the external examination, the victim was undressed at the top, and presented six incised wounds on the left anterior chest and two incised wounds on the flexor side of the left forearm. Layer-by-layer dissection showed that two of the incised wounds penetrated until the pectoralis major muscle and the remaining four penetrated the chest wall, one of them reaching the pericardial sac and the other three the left lung. There was 1700ml of fluid blood and 240g of blood clots in the left pleural cavity. The mechanism of death was due to hemorrhagic shock due to thoracic injuries.

Discussion and Conclusions : Investigation of fatal stab wounds is extremely challenging, namely the determination of the differential diagnosis between self-inflicted and nonself-inflicted stab wounds. Fatalities from sharp force are mainly homicidal and only up to 3% of stabbing cases are listed as suicidal. There are some criteria for the differentiation of homicidal/suicidal stab wounds, such as: anatomical location, number of injuries, wound morphologic characteristics, presence of defense or hesitation wounds, clothing analysis, psychiatric history and death scene findings. According to literature, the thorax is the most common location in both situations. The total number of injuries does not allow per se the distinction between self-inflicted or nonself-inflicted injuries. Wound morphologic characteristics can help this diagnosis, namely its direction and axis. In suicides, injuries are usually unidirectional, parallel and horizontal and in homicidal, injuries are commonly multidirectional and vertical. Hesitation wounds are often seen in close proximity to the fatal wound and are believed to be the most useful parameter, especially in the absence of defense wounds. Defense wounds are typically located in the hands and extensor side of forearms. Self-inflicted injuries are usually on uncovered sites or regions that are uncovered after clothing has been pulled up. To determine the manner of death, it´s fundamental to verify the victim´s psychiatric history and previous suicidal attempts. The distinction requires a correlation between scene examination, autopsy findings, death’s circumstantial information and victim’s clinical data. In this particular case, despite of the number of lesions, the death was listed as a probable suicide.

257

ACCIDENTAL POSITIONAL ASPHYXIA – CASE REPORT

Sara Costa 1 , José Moura Fernandes 1,2

1 National Institute of Legal Medicine and Forensic Sciences - North Branch, Porto, Portugal

2 Superior Heath School - Porto Polytechnic, Porto, Portugal

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Case Report : 43-year-old man, with medical history of alcoholism and epilepsy, found death in his house, trapped in a narrow window, with his pants down to his ankles. The man had the left arm between his thorax and the window. Near the body, on the floor, there was a ladder, closed. The firefighters needed to break the wall, to take the victim out. At autopsy, at external examination, it´s important to highlight the presence of livor mortis in the anterior face of the neck (saving fold areas), in both inferior limbs, and at the left superior limb, distally to the inferior third of the arm; the presence of an abrasion in the inferior third of the lateral face of the right hemithorax and the presence of 3 linear abrasions in the inferior third of the lateral side of the left arm. The internal examination revealed: fracture of the 5th to 7th left anterior costal arches, and of the 6th and 7th right anterior costal arches; hiperinsuflation of the lungs and congestion in the majority of the organs. There weren´t other traumatic injuries and any pathological findings who might be attributed to a natural cause of death. The toxicological study was positive for alcohol (with the concentration of 2,65+/-0,34 g/L) and some medicines (in therapeutic concentrations).

Discussion and Conclusions : The lesions found at external examination, were compatible with the suspension of the body by the thorax, with the interposition of the left arm between the thorax and the window, as described by the police department. Positional asphyxia is a form of mechanical asphyxia that occurs when a person remains in a certain position for a long period, for variable reasons (trapped, drugged, drunken, or even by natural movement limitations), and the position adopted impairs the respiratory movements, resulting in a respiratory failure. This form of asphyxia is usually accidental, however, it has been also linked with torture and homicide. Considering the local description and photographs, it was considered that the victim was trying to enter the room, through the window, with the help of the ladder, which may have fallen, and consequently the victim stayed trapped in the window. The pants may have dropped due to the struggle to climb the wall and the body position may have restricted the thoracic movements, resulting in respiratory failure. This case was considered as a positional asphyxia type of death, which was compatible with an accidental manner of death.

258

SUICIDE DUE TO ACID INGESTION – TWO CASES REPORT

Sara Costa 1 , Sofia Monteiro Cunha 1 , Débora Lourenço 1,2 , Dina Almeida 1,3

1 North Branch of the National Institute of Legal Medicine and Forensic Sciences, Porto, Portugal

2 Medico-Legal and Forensic Office of Açores Oriental, Ponta Delgada, Portugal

3 Abel Salazar Biomedical Sciences Institute - University of Porto, Portugal

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Cases Description : A 53 year-old female ingested 500mL of hydrochloric acid and was admitted to the emergency department presenting greyish discoloration of the mouth and upper airway with deformed laryngeal anatomy. Thoracic-abdominal CT showed gastrointestinal oedema with oesophagus and gastric distention with wall thickness. Death occurred in the following day due to multiple organ failure. The victim had medical background of multiple myeloma with bone marrow auto-transplant the previous year, depression and a suicide attempt in the previous 6 months. In the day before the event her oncologist told her she had to perform another auto-transplant. At autopsy there were no signs of lesions on the external examination. Internal examination revealed brownish-blackish discoloration of the upper airway, gastrointestinal tract, diaphragm, peritoneum and some abdominal organs; stomach was discoloured and perforated and food fragments were found within the peritoneal cavity. Histological examination confirmed necrosis of oesophagus, diaphragm, stomach, mesentery, epiploon and peritoneum; acute tubular necrosis and thrombosis in the portal circulation. Toxicological blood analysis was positive for antidepressant and anxiolytic medicines. A 62-year-old male ingested 2L of sulphuric acid, and was admitted to the emergency department, presenting hematemesis, burn lesions in the oral cavity, and epiglottis disruption with reported difficulties in nasogastric intubation. Thoracic-abdominal CT showed oesophagus oedema and stomach wall thickness, suggesting imminent rupture. The victim developed stomach rupture and organ failure and died in the next day. Medical background of schizophrenia and previous suicide attempt 29 years ago was reported. At autopsy the external examination, revealed burn lesions on the nasolabial folds and lips. Internal examination revealed whitish ulcerations of the tongue, epiglottis and larynx; brownish discoloration of peritoneum and some abdominal organs; stomach was discoloured and perforated and brownish liquid with food fragments was found within the peritoneal cavity. Histological examination confirmed epiglottis/larynx inflammation and peritonitis. Toxicological blood analysis was positive for anxiolytic and anaesthetic medicines.

Discussion : Ingestion of caustic substances with the intention to commit suicide is uncommon but not rare. Ingestion in adults are often suicidal. Acids penetrate tissues rapidly, causing coagulation necrosis and potentially leading to important damage of the gastrointestinal tract wall, which ultimately can lead to gastric perforation anytime in the first 2 weeks after the ingestion. The conventional idea that acids spare the oesophagus wall has been recently questioned with observation of oesophageal damage and perforation after acid ingestion. Our first case, had discoloration of the oesophagus with histologically confirmed necrosis. Strongly corrosive substances usually result in extensive oesophageal and/or gastric transmural necrosis and may cause death due to shock secondary to gastrointestinal tract rupture. In both cases, the cause of death was chemical peritonitis due to stomach rupture after acid ingestion. The manner of death was listed as suicide.

259

VENOUS THROMBOEMBOLISM IN A PSYCHIATRIC INPATIENT – A CASE REPORT

Sara Costa 1 , Luis Cardoso 1

1 North Branch of the National Institute of Legal Medicine and Forensic Sciences, Porto, Portugal

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

This is a case of a 51-year-old woman, admitted to a psychiatric medical unit due to catatonia. A few days after the admission, she was subfebrile and hypotensive (interpreted as possibly related to risperidone). Some days after, she had an episode of loss of consciousness, followed by dyspnoea and tachycardia. The analytic study showed hiperlactacidemic metabolic acidosis, anemia, thrombocytopenia, and elevation of transaminases, alkaline phosphatase, gamma-GT and lactate dehydrogenase parameters, as well as coagulation dysfunction. Abdominal angio-TC showed cardiogenic liver disease and pulmonary signs of a Pulmonary thromboembolism (PTE). Cardiac echocardiogram revealed massive PTE, with thrombus in the right atrium and severe right ventricle dysfunction. The patient died despite the anticoagulant treatment, aminergic support and extracorporeal membrane oxygenation (ECMO). Besides the signs of therapeutic intervention, the autopsy, showed macroscopic and histological findings of pericarditis and acute myocarditis; macroscopic and histological findings of intra-cardiac thrombus (thus confirming the initial clinical diagnosis), as well as the presence of massive PTE in the pulmonary arterial circulation. In the abdominal cavity, we found 1400 cc of hemoperitoneum and 120 g of blood clots; the presence of hepatic subcapsular haematoma with evidence of rupture (capsular and parenchymal). There was also evidence of thrombosis at the inferior vena cava and in the deep veins of both inferior limbs.

Discussion and Conclusions: The cause of death was Myocarditis in association with massive PTE complicated with hepatic haematoma e hemoperitoneum, in a victim with deep vein thrombosis. Venous thromboembolism (VTE) is being recognized in recent years as a risk factor for sudden death in patients hospitalized in psychiatric departments. This case presented a forensic challenge to sort chronologically all the clinical information given and the autopsy findings. We considered that the catatonic state (and the inherent lack of mobility, which promotes venous stasis), in association with the myocarditis (which can promote a hypercoagulability state due to pro-inflammatory stress) were coadjuvant conditions for this fatal outcome. No traumatic injuries were found to be the cause of the hepatic haematoma, probably secondary to a complication of the portal hypertension due to passive congestion related to the right ventricle dysfunction. However, the reanimation manoeuvres may had contributed for the hepatic rupture and consequent hemoperitoneum.

260

STAB WOUND TO THE HEAD – A CASE REPORT

Sara Costa 1 , Sofia Monteiro Cunha 1 , Ana Rita Marques 1 , Rui Almeida 1

1 North Branch of the National Institute of Legal Medicine and Forensic Sciences, Porto, Portugal

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Case Description: A 58-year-old male Civil Parish employee with no known medical background, who missed two consecutive days at work, was found dead at home by local Police officers. The house’s back door was opened and the house sanitary conditions were poor. His work colleague told Police officers that the victim had an ongoing civil lawsuit and that victim’s brother took money from his bank account. He also told that drug addicts frequently attended his house. On external examination: knife inserted in the left temporal region, only observing its wooden handle; small reddish ecchymosis on the right side of the abdomen, on the left knee and on the upper lateral side of the right thigh; no traumatic lesions on the upper limbs. Cranial autopsy examination revealed cerebral edema, diffuse subarachnoid hemorrhage (more pronounced at left cerebral hemisphere and ventral surface of the brainstem); and hemorrhage with partially clotted blood within the lateral ventricles. The knife blade was inserted through the lateral aspect of the left temporal lobe and the blade tip ended at the middle aspect of the right frontal lobe. After cerebral evisceration, it was possible to observe a backwards, upwards left-to-right direction of the blade inside the cranial cavity. It had an 85-mm long and 17-mm wide blade. Afterwards, we observed a longitudinal slot fracture with 17-mm wide on the squamous portion of the left temporal bone; and a longitudinal stab wound with 21-mm wide in the left pre-auricular region, with a surrounding eccentric ecchymosis. Analysis of subungual region swabs of both hands and the blood on the knife handle only revealed presence of victim’s genetic profile. Toxicological study was negative for alcohol, illicit drugs and medications.

Discussion/Conclusion: Stab wounds to the head are uncommon. Injury to the brain occurs in the path of the penetrating instrument, but it may also cause intracranial hemorrhage or infarct. A stab wound to the temporal fossa is most likely to cause major neurologic injury because of short distance to the brainstem and blood vessels. Stab wound to the head could result from aggressions, accidents or self-inflicted events and the distinction is a major issue to the forensic pathologist. Suicidal head stab wounds are rare and are initially considered to be homicidal. The manner of death is established by the scene investigation, circumstantial information and autopsy findings. Forensic pathologist should also obtain information regarding victim’s psychiatric history. Although self-inflicted head stab wounds are unusual, they are more common among those who have psychotic illness. Considering the circumstantial information; scene investigation; absence medical background, suicide note, hesitation wounds or even defense wounds, the manner of death was listed as undetermined.

261

SUDDEN AND UNEXPECTED DEATH IN CHILDHOOD DUE TO AN UNDIAGNOSED HEPATOBLASTOMA: CASE REPORT AND REVIEW OF LITERATURE

Rosario Barranco 1 , Davide Bedocchi 1 , Alessandro Bonsignore 1 , Martina Drommi 1 , Francesca Buffelli 2 , Ezio Fulcheri 2 , Francesco Ventura 1

1 Department of Legal and Forensic Medicine, University of Genoa, , Italy

2 U.O.S.D. of Fetal and Perinatal Pathology, Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16148, Genoa, Italy

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Case description : The authors report the sudden and unexpected death of a 3-and-a-half-year-old infant due to an undiagnosed hepatoblastoma. The child suffered a major intra-abdominal bleeding (hematoperitoneum), leading to a fatal hemorrhage.

Discussion : In cases like these, it is of utmost importance to carry out both an autopsy as well as complete histological examination in order to determine if the hepatic tumor is the real cause of death. In the case of sudden and unexplained deaths in infancy and childhood, the forensic pathologist should always consider that complications related to hepatoblastoma could cause sudden death. This particular tumor is often scarcely symptomatic and can remain undiscovered for a long period of time.

Conclusion: The sudden and unexpected death of an infant or child due to cancer is a particularly rare event.

262

BINGE EATING EPISODE AS A DIRECT CAUSE OF DEATH IN A YOUNG INDIVIDUAL WITHOUT EATING DISORDER

Andrea Cioffi 1 , Benedetta Baldari 1 , Luifi Cipolloni 2

1 Sapienza University Of Rome, Rome, Italy

2 University of Foggia, Foggia, Italy

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Case description: We report the case of a young woman not suffering from mental illness diagnosed but only with a history of two binge eating episodes occurred a few years earlier. Subject died suddenly during a binge eating episode for stomach rupture. The overeating caused a single perforation of the stomach with leakage of food material within the abdominal cavity. There was no sign of gastric necrosis or peritonitis. Thus, it can be said that the subject died quickly.

Discussion : Binge eating is characterized by the ingestion of large quantities of food in a short time span. In the literature are reported exclusively cases of gastric perforation in subjects suffering from anorexia nervosa, binge eating disorder or bulimia nervosa. Our case, unique in the literature, shows that there is a risk of death even in subjects without diagnosis of eating disorders but only with history of isolated binge eating episodes. Therefore, physicians must carefully investigate the history of patients to assess any risks.

263

UNUSUAL CASE OF FAT EMBOLISM TWO MONTHS AFTER FOREARM FRACTURE

A Wiem Ben Amar 1 , Hanen Dhouib 1 , A Malek Zribi 1 , Hela Siala 1 , Elaa Chebbi 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Frensic Departement Habib Bourguiba University Hospital, Sfax, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Fat embolism syndrome in forensic practice is observed usually in cases of polytrauma related deaths. However, in rare cases, it can result from other non- traumatic causes. In order to link fat embolism to trauma, there are some considerations to take into account. Through reporting a litigious case of fat embolism syndrome occurred over two months after forearm bones fracture, we aim to discuss the accountability between the initial trauma and fat embolism syndrome in this case. A 35-year-old man was injured in a motorcycle accident. He sustained a head trauma with a frontal wound and subarachnoid haemorrhage and an open displaced fracture of the left forearm. After fracture’s surgical fixing, the patient was put outgoing. Two months later, he was admitted in the emergency department for respiratory distress. Shortly after that, he died. In the post-mortem examination, there was no evidence of pulmonary emboli but evidence of pulmonary oedema. Histological examination revealed gross and microscopic bilateral pulmonary congestion with bilateral diffuse fat micro emboli. The originality of this paper lies on the fact that there are no cases of fat embolism following isolated forearm fracture have been reported furtherer more after such a long delay.

264

DEATH FOLLOWING A TRAFFIC ACCIDENT: TRAUMA OR MECHANICAL ASPHYXIA?

A Malek Zribi 1 , Hanen Dhouib 1 , A Wiem Ben Amar 1 , Elaa Chebbi 1 , Moulaye Ahmed Dhehby Ahmedou 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic Department Habib Bourguiba University Hospital, Sfax, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Road trauma is a rich pathology with multiple lesion mechanisms. It represents an important part of daily forensic activities. However, sometimes, accident’s reconstruction may be difficult. The examiner could face forensic challenges in determining cause of death. In this paper, we report two cases of litigious fatal traffic accidents and discuss the mechanism leading to death. The first victim concerned a 29-year-old policeman who was accidentally hit by his colleague. he sustained a pelvis and both thighs trauma. Forensic examination revealed the presence of an asphyxia’s syndrome, crossing lesions such as tissue crushing without bone fracture or vascular wound. The second one was a 28-year-old man. He was deliberately struck by a car with a pelvic crossing. He sustained femur fracture with large thighs’ bruises. The forensic examination revealed frank asphyxia syndrome with sub conjunctival petechiae and hyperemia, thighs and bursae’s contused wounds without vascular rupture. Forensic pathologist should not only establish the cause of death but also the mechanism leading to death. In such cases, this task may be hard. Hence, we highlight the need of a rigorous forensic autopsy and a thoughtful responsible report.

265

RARE CAUSE OF UNEXPECTED DEATH IN INFANTS: ABOUT TWO CASES

Jaweher Kammoun 1 , Malek Zribi 1 , Wiem Ben Amar 1 , Hassen Ennouri 1 , Moulaye Ahmed Dhehby Ahmedou 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic departement Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Intestinal malrotation is an abnormality in the rotation of the primary intestinal loop during embryonic development. It is the most common congenital malformation of the small intestine. This anatomical abnormality is a serious pathology because it exposes patients to a high risk of duodenal obstruction due to the volvulus of the intestine. In the following report, we describe two rare cases of suspicious death in two children whose autopsy revealed a natural death from occlusion by volvulus due to mal intestinal rotation.

Clinical case : Two boys, 14 months and 2 years old, born at term and with no family history, with a personal history of multiple emergency room visits for abdominal pain and recurrent bloating since the first months of their lives. The symptoms were attributed to a simple abdominal colic and they were put on symptomatic treatments. One day before the death, they presented with refusal to eat, abdominal pain and abdominal bloating with greenish vomiting. Abdominal radiography was normal for both cases. They were put on symptomatic treatment and put out. The two infants were found dead the next morning. At autopsy, infants were slightly dehydrated. No traumatic injury was noted during the external examination. A hemoperitoneum was found with necrosis of the small intestine and the colon. In addition, a volvulus of the middle intestine in the upper right quadrant was observed with a total of four turns containing the duodeno-jejunal junction, the coecum and the appendix.

Conclusion : The intestinal malrotation is a serious abnormality because it exposes the patient to fatal complications. Consequently, in front of any chronic abdominal symptom, it is necessary to evoke the diagnosis of volvulus of the intestine in order to avoid a lethal evolution of the complications.

266

WATERHOUSE-FRIDERICHSEN SYNDROME: A FATAL CASE IN AN 18-MONTH-OLD INFANT

Jaweher Kammoun 1 , Wiem Ben Amar 1 , Malek Zribi 1 , Hanen Dhouib 1 , Elaa Chebbi 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic departement Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

The Waterhouse-Friderichsen (WFS) syndrome is an acute hemorrhagic necrosis of the adrenal glands. Meningococcal infection is the most common cause. It is manifested by a state of septic shock with a syndrome of multiorgan dysfunction up to death. It is more common in children than adults. At autopsy, diffuse and marked vascular lesion with haemorrhage and thrombosis is observed in many organs of the body. In this paper, we present a fatal rare case of a Waterhouse Friederichsen Syndrome associated with tonsillar hemorrhage in an 18-month-old child with meningitis symptoms leading to death. We report the case of an 18-month-old girl, without past medical history known, who was autopsied in the forensic department of sfax for unexplained death. The deceased was described a day before his death a fever that was blamed on an ear infection. In autopsy, the external examination has found purpuric lesions extending from the face to the roots of the lower limbs, red purple rash on the whole body and cyanosis. No traumatic lesions were found. The internal examination wasrevealed a cerebral edema, inflammation of the tonsils with pulmonary infection. There was also hemorrhage of the tonsils and adrenal glands with necrosis. A complete bacteriological study performed on blood and cerebrospinal fluid was positive. Indeed, leukocytes had high levels with many red blood cells. Gram-negative diplococcies were observed on Gram stain. The culture came back positive for Neisseria Meningitides. Genotyping PCR for Neisseria Meningitides was positive for serotype B. The pathological examination came back in favor of adrenal tonsillar hemorrhage caused by infection. The pathologist concluded that the cause of death was the result of a state of septic shock secondary to Meningococcal meningitis.

267

SELF-STRANGULATION BY VEHICLE-ASSISTED LIGATURE WITHOUT DECAPITATION

Wiem Ben Amar 1 , Hela Siala 1 , Malek Zribi 1 , Hanen Dhouib 1 , Zouheir Hammami 1 , Zouheir Khemekhem 1 , Samir Maatoug 1

1 Habib Bourguiba Hospital, Sfax, Tunisie

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Background : Self-strangulation with a vehicle-assisted ligature is reported to be very uncommon suicidal method. Related cases are rarely published, and many of them report massive injuries to neck organs, and even complete decapitation.

Case presentation : We report an unusual case of self-strangulation where a body was found dead inside a car with a rope around his neck and tied to an electric pole behind the car. The rope didn’t break while the car moved away, and no decapitation was associated. The manner of death was determined as suicide based on a complete criminal investigation supported by a detailed crime scene investigation and autopsy.

Conclusion: This case is reported for its originality due to the unusual method of suicide employed by the victim, and because it was not related to decapitation.

268

NON-COMPACTION CARDIOMYOPATHY – A RARE CASE OF FATAL HEART FAILURE IN A YOUNG GIRL

Jacques Stoelben 1 , Natalie Stanislawski 1 , Holger Langreck 2 , Marlis Günther 3,4 , Christian Hirschmann 3,4 , Knut Albrecht 1,4

1 Brandenburgisches Landesinstitut für Rechtsmedizin, Potsdam, Germany

2 St. Josefs-Krankenhaus, Potsdam, Germany

3 Institut für Pathologie Klinikum Brandenburg, Brandenburg an der Havel, Germany

4 Medizinische Hochschule Brandenburg, Neuruppin, Germany

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

We are presenting the case of an 8-year-old girl, who died after an unsuccessful reanimation in the early morning hours. She had been suffering from dizziness and dry cough during the last four weeks prior to her death. 8 days before she died, she fell of a swing. The child was suffering from a Non-compaction Cardiomyopathy and had a history of ischemic infarcts of the brain, heart and kidneys as well as a pacemaker implantation. Non-compaction cardiomyopathy (NCCM/LVNC) is a rare disease of the left ventricle, representing 5-9 % of all cardiomyopathies in children with an incidence of 0,05-0,25 % per year. The cause is considered to lie in the embryogenesis of the heart. From today’s perspective an arrest occurs during the muscular compaction of the left ventricle and this causes a persistence of the intensive trabeculation mainly of the left ventricular apex wall with deep, staghorn-shaped recesses (non-compacted myocardium). Papillary muscles of the left ventricle are regularly poorly developed in this disease. The right ventricle is affected in about 22-40 % of the cases. During the course of the disease a dilatation of the ventricle can occur, and the patients suffer from heart failure, arrhythmia and thromboembolic events. Echocardiography and MRI are the primary methods for clinical diagnosis. The therapy is mainly restricted to symptomatic treatment and eventually heart transplantation. Until now, mutations in about 80 different genes have been detected to be associated with the disease. Autopsy findings: Normally developed child with signs of emergency treatment and a few unspecific haematomas. Heart: Dilated, round, relatively heavy (210 g). Left ventricle with endocardial fibrosis, pale and rough papillary muscles, mesh-like/spongy myocardial trabeculation, apical ballooning/aneurysm. Right ventricle with similar, but more discreet spongy trabeculation. Two pacemaker electrodes in the right atrium, one electrode in the left ventricular apex. Scull: no signs of recent fracture or intracranial bleeding. Brain: Oedema, no signs of recent trauma/bleeding, left hemisphere parieto-temporal with a ditch-like, 8 x 1,5 cm huge, grey defect zone. Kidneys: scarred, crater-like lesions of the renal cortex. Histology: Extensive scarring of the heart muscle around the pacemaker electrodes. Chronic pulmonary congestion. Old contusion lesion in the left hemisphere of the brain parieto-temporal with no correlation to the swing accident. Analysis of the Pacemaker recording: Ventricular fibrillation at the time of the emergency call. The cause of death was ventricular fibrillation due to Non-compaction Cardiomyopathy. The poster will present aetiology, clinic and pathomorphological findings of Non-compaction Cardiomyopathy.

269

FATAL METHAMPHETAMINE INTOXICATION OF A BODY PACKER: AN AUTOPSY CASE

Cemyiğit Deveci 1 , Sema Demirçin 1 , Derya Bulgur-Kırbaş 3 , Ceren Şibka 1 , Zülfikar Evren 2

1 Department Of Forensic Medicine, Akdeniz University, Antalya, Turkey

2 Turkish Council of Forensic Medicine, Antalya Group Administration, Antalya, Turkey

3 Şanlıurfa Training and Research Hospital, Şanlıurfa, Turkey

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

This presentation involves a case of a 53-year-old Middle Eastern man, with unknown medical history, found dead on a street in Antalya in the middle of the night. The man reportedly arrived in Antalya via plane 12 hours before his death, after crossing the southwest border of the country 20 days earlier. The external examination of the body and consequent postmortem investigation of cranial and thoracic cavity revealed no real cause of death, aside from an apparent hyperemia of the brain tissue suggesting a possible case of intoxication. Gastrointestinal system organs removed according to Virchow’s technique and the examination unveiled 106 intact and 18 ruptured drug packages wrapped in plastic foil, with a total weight of 295 grams, within the small intestine and colon. Subsequent toxicological analysis determined that the packages contained methamphetamine. The findings identified during the investigations made it possible to identify the cause of death as a methamphetamine overdose caused by a rupture of multiple intestinal methamphetamine packages. Body-packing is a term that describes illicit drug concealment and transportation in capsules, condoms, plastic wraps, and other forms of small packages within body. These drugs are either swallowed (i.e., body stuffing) or pushed into body cavities (i.e., body pushing), mostly into anus or vagina. Various types of illicit drugs (mainly cocaine, followed by heroin and methamphetamine) can be carried and smuggled by this method from one country to another, and can be pushed out of body by use of laxatives or enemas. Antemortem diagnosis of this syndrome in a potential carrier is possible by forensic medical, toxicological, and radiological methods. But sudden death of the carrier after their arrival to the city, and the lack of medical records and acquaintances make the diagnosis almost impossible without detailed and careful medicolegal autopsy. Anatolia is the shortest way to Europe for transportation of illicit drugs designed for European market from Southwest Asia. Although body packing is an important issue in the country, they are rarely identified. Body packers can show symptoms of gastrointestinal obstruction or perforation, and symptoms of intoxication hours after initial drug occultation, or even present no symptoms at all, depending on the integrity of the drug packages inside their body. The rarity and slow and occult clinical evolution of the condition, as well as the impossibility in many cases to recognize before death, constitute a challenge for the forensic practitioner. Conclusively, the reported case demonstrates the need of having a systematic approach to examine orifices externally and points out the importance of performing a through autoptic examination, including examination of complete gastrointestinal system contents, and toxicological analysis of both drug packages and biological samples, and their role in the difficult task of detecting body packers.

270

SPOUSAL HOMICIDE IN KAIROUAN, TUNISIA DURING COVID-19 PANDEMIC PERIOD

Elaa Chebbi 1 , Elyes Turki 1 , Firas Haggui 1 , Oumaima Brahim 1 , Bilel Gammoudi 1

1 Department of Forensic Medicine, Ibn El Jazzar University Hospital, Kairouan, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Homicide is the act of provoking death to another human being. Spousal homicide, the extreme type of spousal violence, includes homicides where the perpetrator is the partner whether they are in a relationship, married, separated or divorced. Our study is about two autopsic cases of spousal homicide that happened during the covid-19 pandemic period (March-Decembre 2020).

Cases study : Case 1: It is about a woman of 29 years old, divorced and a mother of 5 years old child. She was victim of an assault using a knife by her ex-husband. The assault happened in the street in the presence of many witnesses. Death happened immediately and judicial authorities required an autopsy. At the forensic examination, we found 04 penetrating wounds caused by a knife. Cause of death was an hemorrhagic shock due to a left pulmonary wound reaching the left auricle. Case 2: It is about a 44 years old woman, married, mother of three children. She was found dead in her bedroom. Her husband was as well found hanged near his wife’s dead body. Investigations revealed that the husband used to physically abuse his wife. Forensic examination found sings of strangulation and a stab wound in the neck. The man probably killed his wife then committed suicide. Woman’s cause of death was an hemorrhagic shock due to lacerations of left neck vessels.

Discussion : Spousal homicide victims are mostly women. There are several motives of these crimes, including the couple’s previous conflicts. Risk factors of spousal homicide are mainly previous physical and sexual spousal abuses. In our first case, the perpetrator was the ex-husband; the couple had problems concerning the child custody, in the second case, the husband used to physically harass his wife as witnesses said. Detecting these risk factors may help preventing extreme violence forms such homicide. As about the effect of the pandemic on homicide rates, the number of homicide cases during the pandemic period is similar to those of 2019 during the same period. However, lockdown, stress, concerns about health and joblessnessmight cause an increase in conjugal conflicts and thus and increase in cases of physical and sexual abuse.

271

REPARATION OF THE CRANIAL TRAUMA SEQUELAE FOLLOWING VOLUNTARY VIOLENCE: ABOUT 50 EXPERT REPORTS

Malek Zribi 1 , Houssein Lebkem 1 , Wiem Ben Amar 1 , Narjes Karray 1 , Hela Siala 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introdution : Cranial trauma is a major cause of death and disability. Repairing the cranial trauma patient is a source of complexity since the resulting sequelae can lead to different types of lesions that are difficult to assess. The judge's assessment is essential to avoid the nearly systematic but wrong diagnosis of pathological predispositions of the patient. This become more difficult when the forensic expert is faced with a victim of voluntary violence. In this work, we propose to study the sequelae of cranial trauma following voluntary violence in victims examined in the context of medical expertise in reparation for bodily injury and raise the various issues encountered during compensation.

Material and methods : It is a descriptive retrospective study of all cases of cranial trauma following voluntary violence evaluated in medical expertise in reparation for bodily injury in the forensic department of CHU Habib Bourguiba in Sfax- Tunisiain a period of 5 years from January 1st, 2015 to December 31th, 2019.

Results : In this study period, we collected 50 cases of cranio-facial trauma following voluntary violence. The average age was 32 years with a standard deviation of 12 years. We noted a male predominance (86%). In 46% of cases, the victims were daily employee of medium socio-economic level. The assault was in the majority of cases by a blunt object (82%). Initial unconsciousness was only seen in 19 victims. The initial lesions mentioned were contused wounds in 34 cases (68%), fractures in 10 cases, and depressed ones in 6 cases. This voluntary violence caused a subarachnoid hemorrhage to 4 victims, an extradural hematoma to 3 victims. The average temporary total incapacity was 21 days with extremes from 2 days to 03 months. On the day of expertise, the sequelae assessed on examination were polymorphic: a subjective syndrome of variable intensityin 28% of the cases, a wounds car without pain in 24% of the cases, a headache with scar and pain in 24% of cases and an isolated headache in 10% of cases. The average rate of partial permanent incapacity (PPI) assigned was 6% with extreme ranging from 0% to 65%. This significant rate of 65% was attributed to a victim who suffered from a major subjective syndrome with a sensory-motordeficit.

Conclusion : Our study allowed us to note a great polymorphism of the cranial trauma sequelae following an assault and to raise several problems of reparation. Indeed, we found a great variability in the attribution of a PPI rate for the same sequelae but of relatively variable intensity.

272

INFORMATION AND CONSENT IN THE TUNISIAN LAW: PARTICULARITY OF MINOR PATIENT

Houssein Lebkem 1 , Wiem Ben Amar 1 , Fatma Daoud 1 , Hanen Dhouib 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Chu, Sfax, Tunisie

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Every patient has the right to be informed of the care he will undergo and to give his consent before any care taken in order to ensure that the patient can participate in the decisions that concern him. They are legal and ethical requirements. In accordance with the doctrine of human rights that applies to medical law, this is part of respect for the person and his fundamental rights. Our aim is to remind the Tunisian law of consent and information of patient and to discuss the particularities of this right in children patient. The fact of informing and collecting informed consent from a patient is a daily and obligatory act in medical practice before any gesture of care. The Tunisian law bases this consent and obliges information in many texts of law. Inaccordance with the international conventions, consent is based on the best interests of the child and is the fundamental principle of any decision taken for the minor in the context of parental or family authority. The information of the minor must be adapted to his or her degree of maturity, and his or her consent must be sought if he or she is able to express his or her willand to participate in the decision concerning his or her state of health. However, the psychological development of the child does not allowitinsomecases (childunder12yearsofage). However, there are emergencies where the doctor must provide the necessary care. Any lack of information and/or consent may involve the medical responsibility of the practitioner and particularly in face of minor patient with acts of major.

Keywords : information, consent, law, minor, responsability

273

RABIES ENCEPHALITIS IN THE REGION OF KAIROUAN, TUNISIA: A RETROSPECTIVE STUDY OF 5 AUTOPSY CASES

Oumaima Brahim 1 , Wael Majdoub 1 , Bilel Gammoudi 1 , Amel Mosbahi 1 , Elyes Turki 1 , Firas Haggui 1

1 Department of Forensic Medicine, Ibn El Jazzar University Hospital, Kairouan, Tunisie

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Rabies remains a serious public health problem in many developing countries. Although Tunisia has implemented a national program against rabies since 1982, we are still recording one or two cases every year. We report five autopsy cases of a fatal rabies encephalitis and we discuss the physiopathology and the mechanism of death.

Material and methods : We conducted a retrospective study relating to Rabies cases, who were subjects to medico-legal autopsy at Legal Medicine department of the Aghlabites hospital in Kairouan in Tunisia between 1996 and 2020. Laboratory diagnosis of rabies was made on postmortem in The Pasteur Institute of Tunis.

Results : five cases of Rabies were retained. Victims were three females and two males with a mean age of 50 years. They were bitten by a stray dog on the face (2cases) and hand (3 cases). Clinical manifestations of rabies developped after an incubation period which lasts between 12 days and 90 days after an exposure. It was encephalitic (furious) rabies with hydrophobia in all cases. Among the victims only two had received doses of rabies vaccine. Death was attributed to respiratory and cardiac failure in all the cases. It occured at a mean of five days after onset of symptoms. On autopsy, biopsies of cerebral cortex, cerebellum, hippocampus and medulla were positive for rabies antigen on fluorescent antibody technique.

Discussion : Rabies is fatal encephalitis of viral origin in humans. Dogs are the main source of viral exposure.

There are two clinical forms of human rabies, the classical form is encephalitic and the other form is paralytic rabies. It shows variability and nonspecific signs of rabies encephalitis which are frequently not recognized by physicians. Hydrophobia is a characteristic manifestation of rabies. The rabies virus is a neurotropic agent. The precise pathophysiologic bases of the two forms of disease are not well understood. Paralytic rabies likely reflects neuronal injuries and dysfunctions. Whereas the injury in encephalitic rabies more prominently involves the brain parenchyma. In encephalitic rabies autonomic dysfunction is very common and includes cardiac arrhythmias, respiratory failure, hypersalivation and priapism. Death is usually due to respiratory failure, which occurs at a mean of five days after onset of symptoms. Given the fatal outcome of the disease, prevention should be implemented in endemic zones. It consists of vaccinating animals associated with a national program of rabies surveillance, providing post-exposure prophylaxis, increasing basic knowledge in rabies virus and especially spreading awareness among the targeted population.

274

MEDICO-LEGAL ASPECTS OF SUICIDE IN THE ELDERLY IN THE REGION OF KAIROUAN, TUNISIA

Firas Haggui 1 , Elyes Turki 1 , Elaa Chebbi 1 , Oumaima Brahim 1 , Bilel Gammoudi 1

1 Department of Forensic Medicine, Ibn El Jazzar University Hospital, Kairouan, Tunisie

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Death by suicide is a rare medico-legal form of death of the elderly. However, its frequency is increasing each year in Tunisia and in the world. Its’ happening raises questions about motives behind this act and its real magnitude in our society. Our aim is to study the epidemiological profile and medico legal characteristics of suicide of the elderly in Kairouan Tunisia.

Material and methods : Our study is a retrospective and descriptive study about cases of elderly suicide in people above 65 years seen in the department of Forensic Medicine Of the Teaching Hospital Ibn EL Jazzar of Kairouan over a period of 9 years (2009-2017).

Results : 40 cases of suicide of people above 65 years were collected which represents 1.2% of all autopsy cases. Age of victims was between 65 and 97 years old. The highest rate of suicide appears in women with a sex ratio = 0.6. Itwas more frequent in rural areas (72.5%). Review of medical and surgical history of the deceased people revealed that only 25% of cases had pathological history and no particular pathological factor dominated. As about psychiatric history, we found a mental state in 37.5% of cases. Almost half of the suicide acts happened in the houses of victims (47.5%). A motive of suicide was only found in 57.5% of cases. A decompensation of a psychiatric disease was only found in 11 cases. Hanging was the most common method of suicide (23 cases), followed by fall from height in 11 cases.

Discussion : Among the cases we have studied, there is a higher risk in old women to commit suicide by contrast to literature where some studies showed there is a higher risk in men. When we studied the medical history of victims, we found a mental state in 37.5% of the cases. Referring to literature, this rate appears lower, probably due to lack of diagnosis of psychiatric illnesses in old people. Depression in this age range is frequent and might be due to different circumstances that they live, especially joblessness, living alone and illnesses. As about the method, hanging was the most common method, similarly to literature. Many factors may affect the method of the suicide; availability and efficiency are the most important. Suicide of elderly is particular due to thefragility of this social category and its unexpectedness. Thus, we should implement efficient means of prevention. These means are mainly an early tracking of geriatric diseases particularly psychiatric and education of the families, in order to ensure a better care.

275

PATHOLOGY OF COVID-19: A POSTMORTEM HISTOPATHOLOGICAL AND IMMUNOHISTOCHEMICAL APPROACH

Giacomo Belli 1 , Giulia Rosi 1 , Clauda Carelli 1 , Elena Cavriani 1 , Emanuele Tino Poloni 2 , Valentina Medici 2 , Livio Tronconi 3 , Antonio Guaita 2 , Silvia Damiana Visonà 1 , Matteo Moretti 1

1 Unit Of Legal Medicine, Department Of Public Health, Experimental Medicine and Forensic Science, University Of Pavia, Italy

2 Abbiategrasso Brain Bank & Golgi-Cenci Foundation, Abbiategrasso (Milano), Italy

3 IRCCS Mondino Foundation, Pavia (Italy), Genomic and post-Genomic Center, IRCCS Mondino Foundation, Pavia, Italy

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Coronavirus disease 19 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and was first reported in late 2019. Since then, the virus rapidly spread all over the world. Due to the resultant serious public health crisis, the attention of the scientific community was turned towards COVID-19. Despite the importance of post-mortem studies in the understanding of pathophysiology, autopsies have been generally discouraged by government regulations due to the risk of further spreading the disease through the handling and dissection of corpses. This study aims to investigate the post-mortem histopathologic characteristics of the COVID-19 disease, using immunohistochemical techniques, coupled with morphology, we analysed samples of lung, heart and kidney obtained during autopsies of deceased COVID-19-positive subjects, performed at the Unit of Legal Medicine of Pavia.

Material and methods : The 15 cases of this study were selected based on the presence of pre-mortem SARS-CoV-2 infection, with some of them having already passed the acute phase of the infection. Immunohistochemistry (IHC) staining for SARS-CoV-2 coronavirus nucleocapsid, CD3, CD20, CD68, and CD42b was performed on histological samples of lungs, heart, and kidneys.

Results : The mean age of our study was 81 years old (range 29–94). Among the 15 subjects studied, 5 were male and 10 were female. Besides SARS-CoV-2 positivity, most patients also presented various comorbidities before death. We observed SARS-CoV-2 antibody positivity in a few cases in all three organs studied. Most cases showed the presence of inflammation in the lungs, predominantly characterized by T lymphocytes. B lymphocytes were also found in the lungs of three cases. Macrophages were ubiquitously present in the pulmonary alveoli, which normally contain a high quantity of these cells. Microthrombi were found in the majority of lung samples studied (8 cases). The heart samples showed variable results, with complete lack of T lymphocytes, while B lymphocytes were present in a small minority of cases (2 cases). Macrophages were the most frequent finding (6 cases), although not common. Microthrombi were found in the heart in a small subset of cases (4 cases). In the kidneys, inflammation was characterized by a strong presence of T lymphocytes (12 cases), with a small number of cases showing the presence of B lymphocytes (5 cases). The majority of renal tissue was found to have microthrombi (8 cases).

Discussion : The data obtained in this study could potentially offer a better understanding of how this recently identified pathology affects the human body and specific organs, with the goal of improving clinical management of affected patients and improving strategies for disease prevention. In conclusion, the present study outlines one of the many contributions that forensic pathology can make to medical knowledge, providing crucial data to better comprehend this new disease.

276

TOXIC DEATHS IN KAIROUAN, TUNISIA: ABOUT 90 AUTOPSY CASES

Elaa Chebbi 1 , Elyes Turki 1 , Firas Haggui 1 , Oumaima Brahim 1 , Bilel Gammoudi 1 , Oumayma Mellasi 1

1 Department of Forensic Medicine, Ibn El Jazzar University Hospital, Kairouan, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Toxic death is a major public health problem taking many medico-legal forms. The diagnosis is difficult to establish due to the multitude of toxic agents. This form of death raises many medico-legal problems and is a hard mission for the forensic expert. The aim of our study is to describe the epidemiological and medico legal profile of the toxic deaths in the region of Kairouan, Tunisia.

Material and methods : It is a descriptive retrospective study about all the cases of toxic deaths seen in the department of forensic medicine of the Ibn el Jazzar teaching hospital in Kairouan over a period of 10 years. (2010-2019). For each case, we performed an autopsy and realized toxicological analysis.

Results : Total number of toxic deaths was 90 cases, representing 2.7% of the total autopsies performed in our department. Age of victims was between 1 and 78 years of with a mean age of 33 years. Female victims were slightly more than male. Only ten victims had a mental state prior to the death. Two medico legal forms were seen: 44.4% were accidental and 55.6% suicidal. Pesticide intoxication was the most common toxic agent (52%), followed by carbon monoxide (CO) seen in 30% of cases.

Discussion : Toxic deaths are mostly accidental or suicidal, frequency of this type of death is very variable from a country to another, mainly due to different cultures and society’s perception of suicide or due to access to toxics. Our study showed that accidental toxic deaths are dominated by carbon monoxide intoxication. In fact, this gas is tasteless and odorless, frequently used in water heaters, but also in fumes produced by fireplaces. Its frequent use makes its intoxication common especially in bad aerated spaces and in winter. As about suicidal toxic death, pesticides are the most used, with higher frequency in women. The most used pesticide type is organophosphate, similarly to other studies. In our study, toxic deaths happen more often in winter, whereas, in other studies there were a winter predominance of some toxics and summer predominance of others. The diagnosis of toxic death is based on autopsy, toxicological analysis and the investigation data. Prevention is based on raising awareness and restrictions on sales of toxic agents.

277

THE FUNDAMENTAL ROLE OF FORENSIC SCIENCES IN DEATHS RELATED TO EXTREME WEATHER EVENTS

Fabrizio Cordasco 1 , Carmen Scalise 1 , Francesco Sicilia 1 , Matteo Sacco 1 , Angelica Zibetti 1 , Luigi De Aloe 1 , Carlo Filippo Bonetta 1 , Santo Gratteri 1 , Pietrantonio Ricci 1 , Francesco Galassi 1 , Elena Varotto, Isabella Aquila 1

1 University Magna Graecia of Catanzaro, Italy

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Climate change is today a global public health emergency. The overheating of our Planet, caused by air pollution due to human activities, generates increasingly frequent extreme atmospheric events (heavy rains, floods, hurricanes). In addition, the uncontrolled urbanization of areas with high hydrogeological risk must be considered. The destructive power of these events causes a high number of deaths, due to drowning or severe blunt injuries. In these cases forensic investigations allow to trace the causes of death and the time of death, reconstructing exactly dynamic of the events. Therefore, forensic elements have a fundamental role in collecting evidence for investigative purposes. Here we report a case in which the execution of a judicial inspection and autopsy, with the collection of forensic pathology and botany elements, allowed us to reconstruct the dynamics of the death of three people due to a flood. During a period of heavy rain, a young woman disappeared with her two children. At the time of disappearance, she was driving home. The road was surrounded by dense vegetation, which prevented the flow of water. For these reasons, the road had turned into a river that didn’t allow to continue further. Before disappearing, the woman had desperately called her husband, saying him that she would get out of the car to seek shelter nearby. After this phone call, the woman’s phone was unreachable. After several hours of searching, the car was found empty, with the doors open and the lights on. The following day the bodies of the woman and one of the children were found at about one kilometre away from the car, completely covered by mud and stones. The clothes were torn in several places, and the bodies had widespread bruising and abrasions. During the inspection of the places, botanical elements were collected in the site where the bodies were found to compare them with those present on the victims, using a taxonomic comparison method. An autopsy was carried out. Both bodies showed impact injuries to hard surfaces. The upper and lower airways were completely blocked by mud and earth. Foreign material was also evident in the lungs parenchyma. After a week, the body of the youngest child was found at a distance of about 500 meters from the others. The small body was located downstream of a river that flowed alongside the road travelled by their car. This body had widespread blunt injuries, while there were no signs of asphyxiation. In conclusion, we show that only combined use of forensic sciences makes known the exact dynamics of deaths due to extreme weather events. These elements can be used by the judicial authority to identify responsibilities in the poor prevention policies of natural disasters.

278

PATTERNS OF INTRAFAMILIAL HOMICIDE IN SFAX (TUNISIA)

Wiem Ben Amar 1 , Hela Siala 1 , Malek Zribi 1 , Jaweher Kammoun 1 , Elaa Chebbi 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Habib Bourguiba Hospital, Sfax, Tunisie

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Intrafamilial homicide is the most severe outcome of domestic violence. Our aim is to describe the trends of familial homicide in Sfax (Tunisia),the victim's profile and the relationship between the victim and the aggressor.

Methods : We conducted a retrospective and descriptive study of all cases of familial homicide collected and examined in the forensic medicine department of sfax, Tunisia between January 14, 2011 and December 31, 2019.

Results : 31 cases of intrafamilial homicide were collected (28.4% of all homicides). On average, 3.44 cases of homicide victims a year were reported with a maximum in 2019 (7 cases were reported). Homicide victims were mainly women (74.19) with a sex ratio of 2.87. The mean age of the victims were 9.52 +/-16.12. 43.75% of the victims were married and 20% were single. We had no information about the marital status in 11 cases. 32.22% of the victims were unemployed and 19.35% were day laborers. Concerning the death circumstances, 25.8% of homicides occurred between 18:00 and midnight while 12.9% of homicides happened between midnight and 06:00. Homicides mainly took place in the urban areas (38.7%), in a private residence (48.38%) followed by deserted areas (3.22%) and public place (3.22%). The aggressor was the intimate partner in 15 cases, the brother in 4 cases, parents in one case, both parents and brother in one case, the son in 4 cases, the stepfather in one case, stepson in three cases and the cousin in two cases. Mechanical asphyxia (12.9%), sharp forces (9.67%) and fire arm (9.67%) were the most methods used by the aggressor. Multiple and intricate criminal methods have also been observed in 16.12%.

Conclusion : An enhanced understanding of the dynamics of familial homicide may prove useful for preventing it in future generations.

279

GENDER DIFFERENCE IN HOMICIDE: COMPARING MALE AND FEMALE VICTIMS OF VIOLENT CRIME IN SFAX

Wiem Ben Amar 1 , Hela Siala 1 , Malek Zribi 1 , Houssein Lebkem 1 , Fatma Daoud 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Habib Bourguiba Hospital, Sfax, Tunisie

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Research addressing homicide across time and gender in our country is lacking. In the present study, gender specific trends of homicide rates and characteristics are examined.

Material and Methods : We conducted a retrospective, descriptive and analytic study of all cases of homicides collected and examined in the forensic medicine department of sfax, Tunisia between January 1, 2016 and December 31, 2019. Examination of gender specific characteristics was performed with Pearson’s χ2 test and Student’s t-test for both categorical variables and means comparisons. Significance was defined as p value <0.05.

Results : During the 4-year period, 48 homicides were collected. We observed gender-based differences regarding the victim's profession, the relationship between the victim and the offender as well as regarding the mean of death. Males were mostly day laborers and were assaulted by strangers or acquaintances or family members in public areas, whereas females were housewives, likely to be assaulted by intimate partners in private houses. Finally concerning the mean of death, it was fire arm homicides for men and mechanical asphyxiation for women.

Conclusion : The profile of the victim of homicide is now established with gender specific differences. This study could be a key element to implement specific preventive measures.

280

MATERNAL DEATH: ACTIVITY OF FORENSIC DEPARTMENT OF SFAX TUNISIA

A Malek Zribi 1 , Hanen Dhouib 1 , A Wiem Ben Amar 1 , Moulaye Ahmed Dhehby Ahmedou 1 , Jaweher Kammoun 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic Departement Habib Bourguiba University Hospital, Sfax, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Maternal death is a tragic event. Unfortunately, it represents a public health problem in the world and especially in the developing countries. Every minute a woman dies from complications of pregnancy and childbirth. 830 women per day which represents about half a million deaths each year. Tunisia is not spared. Faced with the scale and gravity of this problem, we propose in this paper to describe the epidemiological profile of maternal deaths in southern Tunisia, to determine the main etiologies of these maternal deaths and highlight the need of rigorous autopsy to identify future prospects for improving the maternal prognosis. It’s about a retrospective descriptive study including all cases of maternal death in southern Tunisia collected in the forensic department of Habib BOURGUIBA University hospital at Sfax Tunisia between June 2006 and June 2017. During the period of study, 9 cases were collected. Most of the women were from rural areas (6/9). The mean age was 35.4. Most pregnancies were attended by a doctor. Two pregnancies were followed by a midwife and one pregnancy was not followed. Most women were multiparous (7/9) Obstetric direct causes were found in 8 cases. Postpartum hemorrhage was responsible of two-thirds of death. Maternal mortality rate represents a global indicator of quality of care, influenced by socio-economic conditions, nutrition, hygiene, availability of health care equipment, including prenatal and obstetric care. Here lies the need to improve preventive strategies to overcome this issue.

281

FOREIGNERS’ DEATH IN SOUTH OF TUNISIA: CHARACTERISTICS OF VICTIMS AND AUTOPSY FINDINGS: ABOUT 80 CASES

A Malek Zribi 1 , Hanen Dhouib 1 , A Wiem Ben Amar 1 , Jaweher Kammoun 1 , Houssein Lebkem 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic Departement Habib Bourguiba University Hospital, Sfax, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

The aim of this study is to evaluate the epidemiological particularities of foreigners’ death in the region of Sfax, Tunisia and to identify certain prevention priorities. It’s about retrospective and descriptive study of foreign subjects autopsied at the department of forensic medicine of the university hospital Habib BOURGUIBA of Sfax, Tunisia during the period from January 2016 to June 2019. A total of 80 cases were collected, representing 3.79% of corpses autopsied at the department. The average age was of 47.1 years with a sex ratio of 3.33. The victims were from 13 different countries including 5 from Africa and 8 from Europe. The Libyan’s victims represented half of the autopsied victims. The majority of corpses of European origin were in Tunisia for tourist purposes, so the bodies were found in a hotel. There were 28 victims of the sinking of illegal immigrants. In 51.9% of the cases, the victims had no history, according to the interview with the families and those around them. Death was violent in 60.2% of the cases and natural in 27.5% once. The bodies were found in a state of putrefaction in 70% of the cases. Sfax remains a destination of medical tourism for foreigners. Autopsies performed on foreigners represented a no negligent part of the thanatological activity of our forensic department. The most worrying problem remains the death of illegal immigrants, such as identification, which requires prevention strategies.

282

SUICIDAL MECHANICAL ASPHYXIA DEATH: ACTIVITY OF FORENSIC DEPARTMENT OF SFAX-TUNISIA

Jaweher Kammoun 1 , Malek Zribi 1 , Wiem Ben Amar 1 , Hela Siala 1 , Fatma Daoud 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic departement Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Suicide is a common cause of violent death worldwide and in Tunisia. The causes and the suicidal modes are various. Suicide by mechanical asphyxia retains an important place among the different suicidal modes because of the ease of its realization and its almost radical character. The objective of our work is to present a victimology profile through the epidemiological characteristics of suicides by mechanical asphyxia and to identify the main lesions found at autopsy.

Material and methods : We conducted a retrospective study over a period of 4 years between January 1, 2016 and December 31, 2019. This study is carried out in the forensic departement of Sfax-Tunisia and including all those who committed suicide by mechanical asphyxia. The data were recruited from forensic autopsy cards, interrogatory of kinfolk and the report of the relevant fact.

Results : We collected 117 cases of suicides by mechanical asphyxia during our study period or 32.4% of all deaths by mechanical asphyxia in our department. The place of death was domestic in 80.3% of cases. We noted two modes of suicide by mechanical asphyxia: hanging in 91.5% of cases and submersion (8.5%). Hanging was more frequent in young adult male while submersion was more frequent in young adult female. Suicide occurred during Monday (38.5%) and especially during the second half of the night (57.3%). The average age is 36.08 years with a sex ratio of 2.07. The majority of victims were single (54.7%), daily workers (47.9%) and coming from a rural area in 76.1% of the cases. More than half had a pathological history, notably psychiatric in 41.9% of the cases. There was a notion of suicide attempt in 21.4% of cases.In case of hanging, the link was a cord in the majority of cases. In the event of submersion, drowning in fresh water was predominant mainly in a well of water at home. On the external examination of the corpses, most of the victims were in fresh condition and showed no traumatic lesions. An asphyxial syndrome was present in the majority of cases with cervico-facial cyanosis in 85.5%. At autopsy, acute edema and pulmonary congestion were noted in 70.9% of cases.

Discussion and conclusion : Strategies to reduce suicidal mechanical asphyxia should focus on the prevention of suicide in controlled environments, the emergency management and on the primary prevention of suicide in general. More research is required to better understand the recent rise in popularity of this method. The study of the epidemiological characteristics of suicide victims is of great help for the understanding and prevention of a suicidal act, especially among victims with psychiatric history. It’s desirable to create a national suicide register to reduce suicide cases in Tunisia.

283

SUICIDE IN SOUTHERN TUNISIA: A 14-YEAR STUDY

Jaweher Kammoun 1 , Wiem Ben Amar 1 , Malek Zribi 1 , Narjes Karray 1 , Hela Siala 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic departement Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Suicide is a huge public health problem, responsible for almost half of all violent deaths. In Tunisia, since the January 2011 revolution, there has been an exaggerated media coverage of suicide cases. The objective of our study is to report all the cases of suicide in south Tunisia, to establish their victimological profile and compare it over two equidistant periods in time compared to the revolution of January 14, 2011 in order to identify preventive measures.

Material and methods : We carried out a retrospective, descriptive and comparative study, relating to all the cases of suicide which were the subject of a forensic examination on judicial requisition at the service of Legal Medicine of Habib Bourguiba hospital in Sfax Tunisia over a period of 14 years (2004-2017). We carried out a comparative study compared to the date of the Revolution of January 14, 2011.

Results : We collected 581 suicide cases. The median age was 32 years [9 to 84 years] with a sex ratio of 2.2. Victims who were still single represented 53.7% of the cases. Their level of education was low in 16.2%. Personal psychiatric history was found in 34.6% of the cases collected. A personal history of attempted suicide was identified in 13.8% of suicides and 26.8% had addictive behaviors. Suicidal motives were dominated by family conflict and the decompensation of psychiatric pathology. The most common mode of suicide was hanging (47.2%), followed by self-immolation (17.7%). The number of suicides multiplied by 1.4 after the revolution, with 58.5% after against 41.5% before. Self-immolations doubled after 2011. Our work allowed us to identify a new profile of suicide after the revolutionary events of January 2011. After the revolution, suicide mainly affects a young subject under the age of 20 or an adult between 50 and 60 years, worker or day laborer, without psychiatric antecedents nor addictive behaviors, for economic problems most often.

Discussion and conclusion : Suicide is no longer specific to people with decompensated psychiatric pathologies or drug addicts, it has become the prerogative of the general population, and more specifically of people who can no longer cope to the growing economic problems that go beyond them.

284

CHILD DROWNING DEATH: A 4-YEAR STUDY

Jaweher Kammoun 1 , Malek Zribi 1 , Wiem Ben Amar 1 , Narjes Karray 1 , Fatma Daoud 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic departement Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Drowning is a common cause of death especially in Tunisia. Accidental origin in summer remains the most reported in several studies spoken about this phenomenon. We are interested in the study of child drowing death in order to draw up an epidemiological profile of these children and to describe the circumstances of their death.

Material and methods : This is a retrospective study carried out in the forensic department of Sfax-Tunisia over a period of 4 years (2016-2019) including all children who died by drowning under the age of 18 years. The data was recruited from the forensic autopsy cards and the interrogation of kinfolks.

Results : We have collected 34 cases of drowning, almost half of the cases of mechanical asphyxia in children during this period. All the cases are probably of accidental origin. Drowning occurred in the summer in the majority of cases (41.9%) and in the afternoon (64.5%). The average age of drowning victims was 6 years with a sex ratio of 1.8. The majority of victims died after drowning in sweet water (84%), in a water well in 58% of the cases. We noted 3 cases of drowing in seawater in the context of the shipwrecks of illegal immigrants. On the external examination of the corpses, most of the victims were in a fresh state and showed no traumatic lesions. An asphyxial syndrome was present in the majority of cases with facial cyanosis in 71%. At autopsy, an acute pulmonary edema was noted in all cases, with a wet appearance of the viscera in 64% of the cases and a stomach filled with water in 87% of the cases.

Discussion and conclusion : A substantial proportion of child deaths could be averted if parents and other close relatives paid more attention to the safety of children. The study of the epidemiological characteristics of child victims of drowning is of great help in understanding and preventing this accidental death, especially in young children.

285

SOCIODEMOGRAPHIC AND CLINICAL PROFILE IN ELDERLY SUICIDE VICTIMS IN SFAX-TUNISIA: A 14-YEAR STUDY

Jaweher Kammoun 1 , Wiem Ben Amar 1 , Narjes Karray 1 , Malek Zribi 1 , Houssein Lebkem 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic departement Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Elderly suicide is a major public health problem that is gaining more and more ground, given the aging population problem. This has rarely been the subject of forensic studies in Tunisia. The aim of our study was to identify the sociodemographic and clinical characteristics of elderly suicide victims over 60 years and determine what factors might increase suicide risk in this population.

Methods : We conducted a retrospective and descriptive study on suicide victims aged 60 and over, autopsied in forensic medicine department of the Habib Bourguiba hospital in Sfax, on a ten-year period between January 2006 and December 2019.

Results : We identified 46 cases with an average age of 66.4 years. The sex ratio was 2.28. Suicide victims were alone in 43.5% of cases. They were inactive professionally in 23.9% of cases. Almost half of suicide victims (54.3%) had a psychiatric history. A personal history of attempted suicide was listed in 19.6% of suicides. The notion of factors precipitating suicide was reported in 26.1% of suicides, in particular the notion of family conflicts in 9 suicides. Hanging was the most prevalent suicide mode in our study, affecting half of the cases (58.7%). In 65.2% of the cases, the suicide took place at home.

Discussion and conclusion : Elderly suicide seems a huge but largely preventable public health problem. Its prevention is essentially based on the identification of risk situations and the detection and treatment of depression: major suicide risk factor in this population.

286

TRENDS OF SUICIDE BY IMMOLATION IN SFAX (TUNISIA): A 14-YEAR STUDY

Wiem Ben Amar 1 , Hassen Ennouri 1 , Malek Zribi 1 , Jaweher Kammoun 1 , Hela Siala 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic Department, Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Suicide by self-immolation is a violent and spectacular way of suicide. In Tunisia, it gained interest after the self-burning of Mohamed Bouazizi, which was the starting point of the Tunisian revolution in 2011. The aim of this work is to establish the profile of self-immolation victims, and to describe the main circumstances and forensic findings.

Material and methods : We conducted a descriptive and retrospective study on all cases of self-immolation suicides collected and examined in forensic medicine department of Habib Bourguiba Hospital in Sfax (Tunisia), over a 14-year period, between January 2006 and December 2019.

Results : We collected 90 cases of self-immolation deaths, among which 73 occurred after the Tunisian revolution of 2011. The average age was 31,8 years. A male predominance was noted (sex-ratio=3,5). Most of the victims were single (65,2%), and jobless or day laborers (81%). Thirty victims had a psychiatric history (33,6%), most of them were suffering from schizophrenia. Fourteen victims had previously attempted suicide (15,7%). The main reasons for suicide were financial problems (25%) and decompensation of mental illness (24,3%). Most cases of suicide occurred in public places (43,3%). Seventy-seven victims were hospitalized (85,6%). The average body burned area was 67,7%.

Conclusion : Self-immolation frequently affects young men, jobless or day laborers, and mostly having financial or mental problems. Therefore, we need to establish urgent measures of prevention in individuals at risk in order to combat this phenomenon which is increasing significantly in Tunisia.

287

PATTERNS OF ELECTROCUTION IN SFAX (TUNISIA): A FOUR-YEAR-STUDY

Wiem Ben Amar 1 , Hassen Ennouri 1 , Malek Zribi 1 , Fatma Daoud 1 , Narjes Karray 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic Department, Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Nowadays, electrical injuries are increasingly becoming a significant health problem. Electrocutions are common in both industrial and domestic circumstances. The aim of this work is to study the epidemiological characteristics of electrocution victims, and to describe the main circumstances and forensic findings.

Material and methods : We conducted a retrospective study on all cases of electrocution collected and examined in forensic medicine department of the Habib Bourguiba hospital in Sfax, on a four-year period between January 2016 and December 2019.

Results : We identified 28 cases of fatal electrocution with an average of 7 cases per year. A clear male predominance was noted (sex-ratio=8,33). The average age was 34 years. Electrocution was accidental in 25 cases. Among them, 16 accidents occurred at work, and 9 at home. Suicidal electrocution was reported in 3 cases (10,7%), all these deaths were related to high-voltage current. Low voltage current was responsible for three-quarter of deaths. One case of lightning was observed. In low-voltage electrocutions, small electric burns at the point of entry were found in 18 cases (85,7%). Three high-voltage electrocutions were followed by polytrauma after fall from height. Three victims had no injuries on the body.

Conclusion : Electrocution deaths frequently affect young male victims, in contact with a low-voltage current. Considering the magnitude of this problem, it is imperative to design a prevention program to address mortality due to electrical injuries.

288

PRIMARY FORENSIC EVALUATION OF ROAD TRAFFIC RELATED INJURIES. THE ACTIVITY OF THE FORENSIC DEPARTMENT OF HABIB BOURGUIBA HOSPITAL IN SFAX (TUNISIA)

Wiem Ben Amar 1 , Hela Siala 1 , Malek Zribi 1 , Elaa Chebbi 1 , Moulaye Ahmed Dhehby Ahmedou 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Habib Bourguiba Hospital, Sfax, Tunisia

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : In developing countries and specially in Tunisia, road traffic accident is becoming one of the main causes of mortality and morbidity, whose road traffic accident is assuming primary responsibility. We propose to study road traffic accident circumstances and evaluate their forensic consequences.

Material and Methods : We conducted a retrospective and descriptive study of all victims of road accident injuries who consulted in the forensic medicine department of sfax, Tunisia on January and February 2019. The data were collected from the victim's interview, medical examination and investigations as well as expert conclusions.

Results : Among 1146 consultants examinations during the two months period, 498 (43.45%) were related to road traffic accident. Road traffic victims were mainly men with a sex ratio of 2.03. The typical profile of the victim was a young adult from 19 to 35 years (30%), a day laborer (56.62%) and from an urban origin (88.9%). About half of the victims presented a simple bruise without serious injury, 23% of the patients presented a fracture and 16.4% presented contused wounds. Walkers and motorbike were the more concerned by road traffic accident in the respective order 22.28% and 23.69%. The average duration of temporary total incapacity was 26.7 days with a minimum of 0 days and a maximum of 180 days. 88.55% of patients have a partial permanent incapacity to predict.

Conclusion : The present study findings provided an overview of road traffic injuries in Sfax,Tunisia. The incidence of road traffic accident is still very high in Tunisia, but the severity of injury was mild in most of the cases. There is an urgent need for an efficacious interventional programs to decline the burden of road traffic accident related morbidity and mortalities.

289

FORENSIC ANALYSIS OF FIRE ARM DEATH IN SFAX AFTER THE REVOLUTION OF JANUARY 14, 2011

Wiem Ben Amar 1 , Hela Siala 1 , Malek Zribi 1 , Houssein Lebkem 1 , Jaweher Kammoun 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Habib Bourguiba Hospital, Sfax, Tunisie

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Firearm wounds are serious and life-threatening injuries. The incidence of firearm deaths in Tunisia seems to have increased after the revolution of January 14, 2011. The aim of this study is to analyze the victim's profile, the general pattern and the forensic data concerning firearm related deaths.

Methods : We performed a retrospective and descriptive study of all cases of firearm related death occurring and examined in the forensic medicine department of Habib bourguiba hospital in sfax Tunisia, between January 14, 2011 and December 31, 2019.

Results : Over the 9 year study period, a total of 109 deaths were collected. Among them 17 cases were related to the use of firearms (15%). 82% of firearm deaths were male and 17% were female. More than half of the victims were young with a predominance of the age group between 20 and 39 years (53%). 41% of the victims were single. Homicides took place mostly in public place (10) followed by private residence (4). As for the medico-legal form, it was criminal in 16 cases and only one accidental case occurred during a marriage. The motive for the crime was dominated by interpersonal conflict (41%), we also notice intra-familial homicide, fights in marriages, a robbery homicide and political assassinations. 71% of the victims had only one entrance wound and 88% of the victims didn't have an exit wound. It was a long distance shot in 82% of the cases and a close-range shot in 18% of the cases. The bullet was located in the thorax in 30% of the cases, the skull in 18% of the cases, the neck in 18% of the cases and the abdomino-pelvic cavity in 12% of the cases. The cause of death was internal bleeding in 7cases, severe head trauma in 30% of the cases, abdominal-pelvic complication in 12% of the cases and complication of cervical trauma in 6% of the cases. 24% of the victims were hospitalized with an average length of stay in hospital was 8.75 days and extremes of 3 and 17 days.

Conclusion : Firearm homicide continues to threaten the health and well-being of Tunisian people. This can be attributed to the revolution and its impact on the security of the country's borders.

290

CHILD VIOLENT DEATH IN SFAX, TUNISIA: A 10 YEARS’ STUDY

Wiem Ben Amar 1 , Hela Siala 1 , Malek Zribi 1 , Narjes Karray 1 , Elaa Chebbi 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Habib Bourguiba Hospital, Sfax, Tunisie

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Violent death includes three mechanisms which are asphyxia, traumatic and toxic death. Mortality from violent injuries is more common among the young. The aim of this work is to specify the profile of children victims of violent death and to assess the preventive measures.

Materials : We conducted a retrospective and descriptive study of all cases of violent death in children collected between January 1st, 2008 and December 31, 2017 and autopsied in the forensic medicine department of Sfax, Tunisia.

Results : We collected 214 cases of violent death in children which represented 74.8% of all causes of death in children. Among them, 64% were boys. The average age was 9 years with percentiles [25,75] of [3, 14]. More than half of the victims had an organic or psychiatric family history (55.6%). They were mainly from an urban origin (44.9%). The majority of deaths occurred during the summer (35%). The most common place of death was the family home (76%).Among all victims, we observed that 87.8% of cases were accidental, 7.9% were suicidal and 2.8% were criminal. Deaths were mostly related to traumatic cause (62.1%), specially traffic road accidents.

Conclusion : Child Violent death in Tunisia need to be better understood. That's why research in large study population is recommended, in order to define the characteristics of children that are in danger and then, to establish preventive measures.

291

WITNESSED DEATH BY VIDEO RECORDS: NEVER TRUST APPEARANCES

Teresa Casalino 1 , Alessandro Copes 1 , Giuseppe Lanza Attisano 1 , Stefano Tambuzzi 1 , Lidia Maggioni 1 , Cristina Cattaneo 1

1 Institute Of Legal Medicine, Milan, Italy

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Introduction : Traffic accidents represent the first cause of death in people aged between 15 and 45. Today more and more often it happens to have video records that testify the dynamics of a fatal road accident and show what and how many injuries the victim has suffered. Such testimonies may be used outside forensic practice as a substitute for autopsy examination for the definition of the cause of death. However, are they really useful for forensic purposes? This study aims to assess whether it is possible to accurately predict the detrimental outcomes of a collision on human tissues and organs by watching videos of accidents, or to evaluate whether and how they may be misleading.

Materials and methods : Video records of five traffic accidents were analyzed: collisions between vehicles, pedestrian collisions, road, and rail accidents. The hypotheses formulated in terms of injuries by watching such video records were compared with the autopsy findings. The obtained results were divided into “correspondences” (hypothesized injuries that were confirmed by the autopsy), “underestimations” (lesions observed at the autopsy, but which were not hypothesized), “overestimations” (hypothesized injuries that were not found at the autopsy). The statistical test used was the two-sample T-Test with equal variance.

Results : The study showed that in most cases, there was an agreement between the hypotheses formulated by the observers of the videos and the lesions detected at the autopsy: a higher prevalence of correspondences emerged (on average 77%), if compared with the number of underestimations and overestimations (P-values: one-tailed P = 0.08; Two-tailed P = 0.16). However, the percentage of underestimations was on average 24% (with a maximum of 38%) compared to the total number of injuries detected for each case. A similar finding was observed for overestimations.

Discussion : It is possible to state that the approach based on video records observation can be useful, since the recorded events may reflect the traumatic injuries on the victim. Indeed, in our cases, several hypothesized injuries were later confirmed by the autopsy examination. A statistically significant difference between the two approaches was not observed. However, the only video records observation is not sufficient for correctly predicting mortal lesions. In conclusion, the analysis of video records cannot be a substitute for the assessment of injuries, which necessarily must require an autopsy to be confirmed and eventually in-depth investigations with more complex methods (such as the analysis of inorganic residues found on injuries).

292

SUDDEN DEATH AND SARS-COV2 INFECTION

A Wiem Ben Amar 1 , Hanen Dhouib 1 , A Malek Zribi 1 , Jaweher Kammoun 1 , Elaa Chebbi 1 , Zouheir Hammami 1 , Samir Maatoug 1

1 Forensic Departement Habib Bourguiba University Hospital, Sfax, Tunisie

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

In 2020, the world experienced the biggest health crisis: The Covid-19 pandemic. In Tunisia, first case of death related to Covid-19 infection was registered on March 18, 2020. In our forensic department, we registered the first case of sudden death in a victim who tested positive to the PCR test for this same virus. Unfortunately, few studies have focused on studying the circumstances and risk factors causing sudden death in asymptomatic carriers of Covid-19. In this paper, we aim to report doctor's actions to be taken in case of sudden death in the context of the Covid-19 pandemic and to explain risk factors that can cause sudden death in asymptomatic carriers of the virus. We carried out a retrospective descriptive study during the year 2020 (1st January to 31st December) including all cases of autopsies realized at the forensic department of Habib BOURGUIBA University Hospital. During this period, we realized 674 autopsies. We registered 21 cases of sudden death who tested positive in PCR test for Covid-19 virus. We found male predominance (sex ratio: 3.5). Age average was 64.24 ± 17.2 years. The most frequent risk factor found was hypertension in 7 victims. Diabetes and history of cardiac pathologies (coronary artery disease and arrhythmia) were reported in four victims in each one. Moreover, history of dyslipidemia was found in two other victims. In addition, one victim had asthma, another one had prostatic adenocarcinoma and only one victim was a smoker. Any victim of sudden death can be a Covid-19 virus’ carrier. Post-mortem sampling is compulsory. Age, male sex, high blood pressure and diabetes are important risk factors implicated in the severity and mortality of Covid-19 infections. Forensic autopsy is a key element in determining lethal mechanism and may reveal a cause of death other than Covid-19 virus infection such as decompensation of chronic pathology. However, any infected body is potentially contaminating. therefore, care should be taken when handling this body.

293

IMMUNOHISTOCHEMICAL INVESTIGATION OF CELL DEATH PROCESS AND CORRELATION WITH POST-MORTEM INTERVAL (PMI)

Vito Cirielli 1 , Nicola Pigaiani 2 , Dario Raniero 2 , Elisa Vermiglio 2 , Giovanna Del Balzo 2 , Enrico Ambrosi 2 , Stefania Turrina 2 , Domenico De Leo 2 , Matteo Brunelli 3

1 Unit of Forensic Medicine, Department of Prevention, U.L.S.S. 8 BERICA, Vicenza, Italy

2 Unit of Forensic Medicine, Department of Diagnostic and Public Health, University of Verona, Italy

3 Unit of Pathology, Department of Diagnostic and Public Health, University of Verona, Italy

Poster Presentation 3, June 4, 2021, 1:15 PM - 2:00 PM

Aim and scope : In recent years innovations in forensic pathology have brought new knowledge useful to improve the study of death. Nevertheless, noteworthy limitations are still observed in thanatochronology. The aim of this study is to analyze the death processes using immunohistochemical techniques, in order to identify a potential correlation between molecular cell expression and post-mortem interval (PMI).

Materials and methods : Tissue Micro Array (TMAs) were performed from parenchymatous organs of 1200 autopsies (2011-2018) with known PMI. The sections were stained with hematoxylin-eosin and immunophenotypic analysis of Caspase-8, Bcl-2, Annexin-1 and NF-κB was performed. The intensity of the chromogenic signal was divided into low-intensity (1+) and high-intensity (2+). The histopathological samples were digitized with the D-Sight / Fluo Menarini instrument and positive values were correlated with the PMI.

Results : Caspase-8 was constitutively expressed up to 8-10 days from death, regardless of the age of the deceased, the cause of death and the cadaveric tissue among those analyzed (heart, brain, liver); a high-intensity overexpression of Caspase-8 was detected in the brain within the first 3 days post-mortem; Caspase-8 presented a paranuclear distribution within 8-10 days post-mortem; after the 14th day, a decrease in expression and a change of distribution of Caspase-8 were observed in heart and liver, appearing as cytoplasmic “pulverulence”. Bcl-2 presented overexpression in the heart and liver within 3 days post-mortem, with high specificity and sensitivity near 25%. Annexin-1 was characterized by low- intensity expression in the brain from the first days after death to up to 8 days, simultaneously with the high-intensity overexpression of Caspase-8. No information could be extrapolated from the immunohistochemical analysis of Nf-kB.

Conclusions : Our results demonstrate that the immunohistochemical technique has great potential as a new tool to support the “classical” methods used in the forensic investigation of PMI.

Author Index

A Abakkouy, Yasmina 105 Ambroa-Conde, Adrián 201, 202 Abegg, Claudine 089 Ambrosi, Enrico 293 Abenavoli, Ludovico 006 Anastopoulou, Ioanna 156, 174 Aboua, Louis Roi Nondenot 031 Angelucci, Domenico 052 Abreu, Ana 065 Angelucci, Stefania 054 Adjadohoun, Sonia 081 Antiga, Laura 105 Adjovi, Boris 081 Ao, Gong 077 Afonso, Américo 120 Aoki, Mikiko 122 Agacan, Gulislam 123 Aoki, Yasuhiro 128 Agostinelli, Immacolata 037 Aoki, Yayoi 141, 212 Aguiar, Diego 004, 082 Aquila, Isabella 006, 042, 205, 236, 277 Agusson, Silvia 010 Aras, Nazlican 119 Ahmedou, Moulaye Ahmed Dhehby 133, 150, 152, 154, 164, 194, 195, 196, 209, 210, 238, 244, 264, 265, 280, 288 Araújo, Joana 114 Ahounou, Ernest 017 Arena, Vincenzo 005, 006, 110 Aissaoui, Abir 130, 172, 176, 189, 197, 219, 220, 224, 225, 226, 227, 232, 253 Argyropoulou, Zoi 033, 050, 125 Akipek Öcal, Şebnem 018 Arslan, Ilknur 115 Akman, Refik 051 Aslan, Sıla 115 Albrecht, Knut 268 Atılgan, Mehmet 051 Alexandrov, Alexandar 243 Augsburger, Marc Alfonsetti, Alessandro 110 Aulino, Giovanni 005, 110 Almeida, Dina 229, 230, 256, 258 Ausania, Francesco 006 Almeida, Rui 260 Avram, Daniel 084 Aly, Sanaa 203 Aydogdu, Halil Ilhan 117 Amălinei, Cornelia 145 Azevedo, Joana 162, 234

B Badea, Mihaela 97 Bigot, Cedric 017, 081 Bailo, Paolo 002 Birkhoff, Jutta Maria 035 Balbo, Ilaria 089 Birlescu, Andreea 102 Baldari, Benedetta 262 Boano, Rosa 029, 199 Banner, Jytte Boco, Vicentia 081 Barbara, Giussy 068, 095 Bolliger, Stephan 011 Barbarii, Ligia Elena 199 Bonelli, Martina 052, 053, 054 Barranco, Rosario 126, 242, 261 Bonetta, Carlo Filippo 046, 205, 236, 277 Barraud, Damien 001 Bonsignore, Alessandro 126, 169, 242, 261 Basilicata, Pascale 026 Bonvicini, Barbara 055 Basset, Patrick Boracchi, Michele 095 Basso, Cristina Bortolotti, Federica 148 Batista, Joana Rita 233 Bosa, Maria 071 Battistini, Alessio 002 Bossi, Eleonora 054 Bayhan, Erol 178 Botelho, Sofia 063 Baykara, Burak 119 Boudabbous, Sana Bedocchi, Davide 261 Boughattas, Meriem 130, 172, 189, 220, 224, 225, 226, 227, 253 Bekaert, Bram 105 Boussaid, Marwa 130, 172, 176, 189, 197, 219, 220, 224, 225, 226, 227, 232, 253 Bellantone, Rocco Domenico Alfonso 020 Braga, Paola 035 Belli, Giacomo 029, 265 Brahim, Oumaima 131, 143, 144, 176, 179, 183, 192, 193, 213, 214, 215, 216, 217, 219, 220, 228, 245, 270, 273, 274, 276 Ben Abderrahim, Sara 131 Brevi, Michele 148 Ben Amar, Wiem 132, 133, 134, 147, 149, 150, 151, 152, 153, 154, 164, 165, 166, 181, 182, 186, 194, 195, 196, 207, 208, 209, 210, 211, 238, 239, 240, 244, 246, 247, 248, 250, 251, 252, 263, 264, 265, 266, 267, 271, 272, 278, 279, 280, 281, 282, 283, 284, 285, 286, 287, 288, 289, 290, 292 Brits, Desiré 009 Ben Cheikh, Aida 206 Bruch, Gina Maria 083 Benzakoun, Joseph 012, 206 Brugada, Ramon 109 Berent, Jarosław 047 Bruguier, Christine 085 Bergot, Noémie 012 Brunelli, Matteo 003, 142, 293 Beugre, Jean-Bertin 031 Buccelli, Claudio 026 Biaou, Olivier 081 Budi Setyowati, Lipur Riyantiningtyas 076 Biçen, Emin 117 Buffelli, Francesca 169, 242, 261 Biehler-Gomez, Lucie 032, 068 Bulgaru Iliescu, Diana 030, 097, 102, 198 Bulgur-Kırbaş, Derya 269

C Cadas, Hughes 013 Chappard, Daniel 034 Cadoz, Cyril 001 Chebbi, Elaa 131, 132, 143, 144, 165, 179, 186, 192, 193, 194, 210, 213, 214, 228, 245, 246, 252, 263, 264, 266, 270, 274, 276, 278, 288, 290, 292 Caggiano, Bartolo 007 Chevalme, Eugénie 110 Caglar Atacan, Sibel 117 Chiba, Fumiko 200 Calçada, Diogo 190 Cioffi, Andrea 180, 237, 262 Caldas, Inês 059, 062 Cioffi, Fernanda 237 Campana, Lorenzo 060, 080, 089 Cipolloni, Luifi 262 Campuzano, Oscar 109 Cirielli, Vito 003, 142, 293 Can, İsmail Özgür 100, 184 Citroni, Gabriella 038 Cappella, Annalisa 032 Coelho, Ana Sofia 221, 222 Caputo, Fiorella 205 Coelho, Catarina 063, 086 Cardoso, Luis 072, 231, 259 Collini, Federica 056 Carelli, Clauda 275 Colombari, Michela 075, 142 Carmen Simona, Ionescu 015, 199 Colombo, Antonella 037 Carminati, Alessia 045 Condesteanu, Alina-Cristina 177 Carnim, Gonçalo 223 Copes, Alessandro 291 Carracedo, Ángel 201 Cordasco, Fabrizio 046, 205, 236, 277 Carracedo Álvarez, Ángel 202 Cordeiro, Cristina 023, 157 Carreira, Carla 023, 157, 190 Cordner, Stephen 038 Casalino, Teresa 291 Corte-Real, Ana 040, 120, 121 Castella, Vincent Costa, Sara 255, 256, 257, 258, 259, 260 Castiglioni, Claudia 045, 111 Costa Lopes, Miguel 033, 111 Castro Martínez, Sergio 171 Costantino, Giorgio Massimiliano 116 Catanho, Cristina 185 Coutinho, Eduardo 218 Cattaneo, Cristina 002, 032, 037, 038, 039, 042, 056, 068, 078, 095, 112, 116, 291 Crudele, Graziano 042 Cattani, Paola 005 Cummaudo, Marco 037 Cavriani, Elena 275 Cunha, Eugénia 033, 063, 086 Cazzato, Francesca 070, 110 Curca, George Cristian 022, 044, 058, 071, 084, 092, 093, 094, 177, Cecchetto, Giovanni 010, 032, 055

D Dalle Carbonare, Chiara 142 Demirel, Birol 123 Damian, Simona Irina 168 Dervišević, Emina 067 D'Amico, Marilisa 039 Deveci, Cemyiğit 051, 269 Dao, Hassane 031 Dhouib, Hanen 151, 152, 195, 207, 208, 246, 263, 264, 266, 267, 272, 280, 281, 292 Daoud, Fatma 166, 181, 207, 211, 240, 244, 247, 248, 249, 272, 279, 282, 284, 287 Di Candia, Domenico 095 Dash, Chinmaya 057 Di Giuseppe, Fabrizio 054 De Aloe, Luigi 046, 205, 236, 277 Diac, Iuliana 058, 092 De Angelis, Danilo 037 Diac, Madalina Maria 030, 097, 198 De Battisti, Zeno 003 Diaconescu, Ioana 071, 177 De Gouveia, Rosa 218 Dias, Ricardo 160, 161 De la Barde, Tanya Dias Afonso, Salomé 163 De La Puente, María 201, 202 Dogaroiu, Catalin 059 De Leo, Domenico 003, 075, 142, 293 Dogo, Henry Ognan 106 De Salvia, Alessandra 142 Dominguez, Alejandro 014, 089 De Vecchi, Stefano 116 Douillez, Caroline Decorte, Ronny 105 D'Ovidio, Cristian 006, 052, 053, 054 Dedouit, Fabrice 048, 079 Drochioiu, Gabi 097 Dei Medici, Serena 026 Drommi, Martina 261 Del Balzo, Giovanna 003, 293 Duarte, Eduarda 160, 161, 162, 241 Delabarde, Tania 012, 034, 214, 216 Duarte, Guido 241 Dell'Aquila, Marco 005 Dunet, Vincent 085 Demirçin, Sema 051, 269

d do Côrro, Helena 221, 222, 223

E Ebert, Lars Ennouri, Hassen 147, 149, 186, 240, 250, 251, 265, 286, 287 Egger, Coraline 024, 080, 080 Esposito-Fava, Aude 001 Eggert, Sebastian 011 Evain, France 069 Eisenmenger, Wolfgang 136 Evren, Zülfikar 269

F F. Kranioti, Elena 030 Fischer, Florian Tobias 083 Fais, Paolo 010, 055 Fitzek, Antonia 025, 101 Faisal, Indra 076 Flores Luque, Nicol Falcon, Maria 096 Fondevila, María 201 Falihi, Afrodit 117 Fonseca, Stephen Fanchin, Gianmaria 142 Fornoni, Chiara 037 Fasova, Antoaneta 155 Fracasso, Tony 004, 008, 024, 043, 045, 066, 069, 083, 108, 111 Fattoruso, Vincenzo 070 Franceschetti, Lorenzo 039, 078 Feki, Nihel 048, 147 Franchetti, Giorgia 055 Felizardo, Rufino 204, 206 Francois, Pierre Ferdoush Jerin, Sultana Jannatul 077 Frazão, Sofia 033, 161 Fernandes, Filipe 231, 254 Freire-Aradas, Ana 201, 202 Fernandez, Lucia 096 Frigiolini, Francesca 126 Ferrão, Maria Paula 185 Fujihara, Junko 077 Ferreira, Maria Teresa 086 Fukuda, Haruki 124 Fersi, Oumayma 193 Fukuta, Mamiko 128 Figueiredo, Cristina 130 Fulcheri, Ezio 029, 169, 261 Finegan, Oran 027, 041, 087 Furukawa, Fukumi 135, 136

G Gabbin, Andrea 010 Giroud, Martine 080 Gainza, David 048 Glardon, Matthieu Galani, Konstantina 156 Godet, Tony 019 Galassi, Andrea 142 Gomes, Catarina 033, 125 Galassi, Francesco 277 Goodwin, William Gammoudi, Bilel 131, 143, 144, 179, 183, 192, 193, 213, 214, 215, 216, 217, 228, 245, 270, 273, 274, 276 Goshev, Metodi 243 Garazdiuk, Marta 098 Gottardo, Rossella 148 Garberi, Cesare 035 Gouveia Abundância, Inês 111 Garibian, Sévane Grabherr, Silke 013, 014, 060, 082, 083, 089 Gassend, Jean-loup 090 Grassi, Simone 005, 006, 020, 070, 110 Gauchotte, Guillaume 001 Gratteri, Santo 006, 046, 205, 236, 277 Genet, Pia 008, 024, 061, 066, 083, 085 Grigoraș, Adriana 145 Gherardi, Donna 112 Guaita, Antonio 275 Ghzel, Raja 131, 213, 214 Gualtieri, Saverio 205 Gibelli, Daniele Maria 078 Guerra, André 013, 061, 066 Gilardi, Federica 040, 108 Guidato, Fabio 007 Giordano, Gaia 095 Guilbeau Frugier, Céline 048, 079 Giorgetti, Arianna 055 Gülmen, Mete Korkut 115 Giraudo, Chiara 010 Günther, Marlis 268 Girón-Santamaría, Lorena 201, 202 Guyomarc'h, Pierre 027,

H Haddaji, Arwa 213 Heinemann, Axel 025, 101 Haggui, Firas 143, 144, 179, 183, 192, 193, 213, 214, 215, 216, 217, 228, 245, 270, 273, 274, 276 Heinze, Sarah Hagras, Abeer Mohamed 203 Hertig, Stephane 080 Hagui, Firas 131 Hipólito, Beatriz 121 Hammami, Zouheir 132, 133, 134, 147, 149, 150, 151, 152, 153, 154, 164, 165, 166, 181, 182, 186, 194, 195, 196, 207, 208, 209, 210, 211, 238, 239, 240, 244, 246, 247, 248, 249, 250, 251, 263, 264, 265, 266, 267, 271, 272, 278, 279, 280, 281, 282, 283, 284, 285, 286, 287, 288, 289, 290, 292 Hirokawa, Tatsuya 138, 140, 141, 212 Hamza, Lilia 012 Hirschmann, Christian 268 Hanganu, Bianca 015, 016, 199 Hleșcu, Andreea-Alexandra 030, 145, 198 Hara, Kenji 122, 139 Hmeydia, Ghazi 012 Hashizume, Yumiko 137 Hoffmann, Armin 025 Hasić, Sabaheta 067 Hoshioka, Yumi 200 Hayakawa, Akira 124 Hostiuc, Sorin 064, 071, 073, 093, 104, 107, 170, 175, 177, 191 Hounvenou, Esther 017

I Ibrahim, Sara Fathy 203 Isailă, Oana-Maria 093, 170 Ikeda, Kei 140, 141, 212 Ishida, Yuko 135, 136, 137, 139 Ikeda, Tomoya 138, 140, 141, 212 Ishigami, Akiko 135, 137, 139 Inácio, Ana Rita 033, 065 Ishii, Namiko 200 Ines, Jemli 214 Ishikawa, Takaki 138, 140, 141, 212 Inokuchi, Go 200 Iulia-Maria, Caba 110 Ioan, Beatrice Gabriela 015, 016, 199 Ivaskevich, Ihor 098 Iorga, Magdalena 016 Iwase, Hirotaro 200

J Jacquot, Lise Jerbi, Saida 172, 176, 297 Jamal, Mostofa 146 Jimenez, Alejandra Jardim, Patrícia 114, 158, 241

K Kammoun, Jaweher 134, 149, 151, 153, 182, 186, 208, 209, 210, 211, 238, 239, 247, 248, 249, 250, 251, 252, 265, 266, 278, 280, 281, 282, 283, 284, 285, 286, 289, 292 Kinoshita, Hiroshi 146 Kanno, Sanae 128 Kirkit, Ecem 018 Karakostis, Fotios Alexandros 173, 174 Klevno, Vladimir 099 Karanfil, Elif Demet 167, 184 Knebel, Jean-François 085 Karapazarlioglu, Ersin 178 Kneubuehl, Beat Karray, Narjes 132, 133, 134, 152, 153, 164, 165, 181, 182, 196, 239, 247, 249, 252, 271, 283, 284, 285, 287, 290 Kniep, Inga 101 Kashiwagi, Masayuki 122, 139 Koffi, Alexandre Flanklin 031 Katica, Muhamed 067 Kolentinits, Christoforos 156, 188 Kato, Hideaki 128 Kominato, Yoshihiko 124 Kato, Seiya 122 Kondo, Toshikazu 135, 136, 137, 139 Katsos, Konstantinos 129, 156, 188 Kouadio, Kobenan 031 Kawaguchi, Mariko 135, 136, 137 Kouassi, Kouakou Firmin 031 Keresztesi, Arthur 044 Kouzos, Dimitrios 156 Khemekhem, Zouheir 267 Kranioti, Elena 174 Kiehl, Melissa Krenzer, Udo Kielar, Michel 013 Kubo, Rieko 124 Kimura, Akihiko 135, 136, 137 Kubo, Shin-ichi 122, 139 Kimura, Shoji 146 Kumihashi, Mitsuru 146 Kimura-Kataoka, Kaori 077 Kuninaka, Yumi 135, 136, 137 Kusaka, Akari 077 Kustermann, Alessandra 068, 095, 116

L Lai, Alessia 002 Locatelli, Marcello 052, 053, 054 Langreck, Holger 268 Logrado, Diana 033, 050, 127 Lanuti, Paola 053 Louis, Guillaume 001 Lanza Attisano, Giuseppe 002, 037, 095, 291 Lourenço, Débora 258 Lardi, Christelle 004 Lovblad, Karl-Olof 069 Lareu, María Victoria 201, 202 Loyola, Oscar Le Magueresse, Théo Luca, Lăcrămioara 071, 107 Lebkem, Houssein 132, 133, 134, 150, 154, 166, 207, 208, 209, 238, 244, 246, 248, 271, 272, 279, 281, 285, 289 Luca, Luminita 104 Lefèvre, Thomas 103, 109 Lucchesi, Barbara 037 Lemos, Maria Isabel 159, 160, 161, 163 Ludes, Bertrand 012, 034, 109, 204, 206 Lepore, Domenico 070 Luna, Aurelio 096 Limem, Hiba 189, 197, 220, 225, 226, 227, 232, 253 Lungu, Mihai 058, 092 Lobrinus, Johannes Alexander 024 Lungu, Mihail 084

M Maatoug, Samir 132, 133, 134, 147, 149, 150, 151, 152, 153, 154, 164, 165, 166, 181, 182, 186, 194, 195, 196, 207, 208, 209, 210, 211, 238, 239, 240, 244, 246, 247, 248, 249, 250, 251, 263, 264, 265, 266, 267, 271, 272, 278, 279, 280, 281, 282, 283, 284, 285, 286, 287, 288, 289,290, 292 Mernea, Maria 095 Madureira-Carvalho, Áurea 059, 062 Mert, Murat 178 Maggioni, Lidia 037, 042, 068, 112, 116, 291 Mesrati, Mohamad Amine 224 Magli, Francesca 037 Mesrati, Mohamed Amine 130, 172, 176, 189, 197, 219, 220, 225, 226, 227, 232, 253 Magnin, Virginie 024, 060, 061, 082, 085, 111 Messina, Carmelo 032 Mahjoub, Yosra 130, 219, 232 Mezzelani, Marco 007 Majdoub, Wael 143, 144, 179, 183, 215, 216, 217, 273 Michaud, Katarzyna Makino, Yohsuke 200 Mihailescu, Dan 092 Malara, Natalia 006 Mikellide, Maria 036 Malfroy Camine, Lise 060 Mikuláš, Ľubomír 113 Mamunur, Rahman 077 Mikulka, Ana 087 Manoubi, Syrine Azza 130, 172, 189, 219 Milano, Filippo 007 Marando, Laura 037 Mileva, Biliana 243 Marella, Gian Luca 007 Minetti, Giuseppe 169 Marinho, Luísa 088 Miyamoto, Kazunori 141, 212 Marisei, Mariagrazia 026 Mlayeh, Souhaiel 179, 183, 216, 217 Marognoli, Michela 037 Möbius, Dustin 101 Marques, Ana Rita 158, 230, 231, 254, 260 Moghaddam, Negahnaz 060, 061, 089 Marsa, Mardhatillah 076 Mohanty, Manoj Kumar 057 Marsella, Luigi Tonino 007 Mokrane, Fatima Zohra 048, 079 Matschke, Jakob Matsusue, Aya 122, 139 Montedoro, Paola 037 Mauriello, Silvestro 007 Monteiro Cunha, Sofia 158, 229, 230, 234, 235, 256, 258, 260 Mazzarelli, Debora 078 Montisci, Massimo 010, 032 Mazzoleni, Guido 148 Moraitis, Konstantinos 173, 174, 188 Mazzoni, Rossana 037 Moretti, Matteo 275 Meder, Jean Francois 012 Morioka, Fumiya 140, 141, 212 Medici, Valentina 275 Morris, Neil 082 Mellasi, Oumayma 276 Mosbahi, Amel 225, 283 Mendes, Bárbara 158, 229, 254, 256 Mosquera-Miguel, Ana 211, 212 Mendonça, Ricardo 023, 157, 190 Mostafa, Enas Ameen 213 Merelli, Vera Gloria 037, 095 Motomura, Ayumi 210 Merkler, Doron 008 Moura Fernandes, José 173, 241, 264, 265, 267

N Nabeshima, Kazuki 122 Niola, Massimo 026 Nakamura, Yoshimi 128 Niveau, Gérard 019 Naouar, Maroua 154 Nosaka, Mizuho 145, 146, 147, 149 Naouar, Maroua 153 Nugroho, Novianto Adi 077 Nardi, Umberto 152 Nunes, Tiago 040 Nepal, Indu 027 Nurhantari, Yudha 077 Niculescu, Elena 074

O Obertova, Zuzana Oliveira Santos, Inês 095 Obhođaš, Amir 096 Olmez Bayhan, Selime 188 Očko, Peter 123 Omar, Hadjazi 197 Ohtaki, Jun 138 Ondruschka, Benjamin 025, 110 Ohwaki, Ryoko 132 Onfray, Alexandre 042 Okawa, Takafumi 134 Or, Kazim Hilmi 128 Oliva, Antonio 005, 006, 020, 071, 119 Oritani, Shigeki 148 Oliveira, Carlos 172

Ö Özdemir, Çağlar 109 Özgüler Passos, Deniz Maria 240, 241, 243, 244, 245 Özdemir, Mert Onur 109, 194 Özkara, Erdem 129, 177

P Padilha, António 231 Pieri, Maria 026 Palamenghi, Andrea 039, 079 Pigaiani, Nicola 003, 158, 303 Palazzo, Cosimo 037 Pigati, Maria 179 Palmiere, Cristian 019 Pinheiro, João 228, 233 Paltrinieri, Ivona 096 Pinho, Renato 169 Páramo Peláez, Ricardo 041 Pinto, Marta 245 Pascali, Vincenzo Lorenzo 005, 020, 071, 119 Plis, Semyon 108 Pathan, Humaira 075 Poiares Baptista, Isabel 095 Pellaud, Nicole Pelletti, Guido 010 Politi, Caterina 010 Penados , Lourdes 083 Pollanen, Michael 038 Perde, Filip 046 Poloni, Emanuele Tino 285 Pereira, Maria Lurdes 060, 063 Pontinha, Carlos 137 Pereira, Rui 064 Popescu-Bercescu, Alexandru-Daniel 201 Pérez-Infantes, María 212 Porosnicu, Ioana 059, 093, 101 Petcu, Teodora 065 Prince, Daniel 009 Petre-Ciudin, Valentin 106 Priyambodo, Dewanto Yusuf 077 Phillips, Christopher 211, 212 Prouvost, Adele 042 Picchini, Simona 105 Purkait, Suvendu 058 Piccinini, Andrea 002 Püschel, Klaus 025 Pidada, Ida Bagus Gede Surya Putra 077

R Radu, Doina 103 Rodriguez Zorro, Andres 080, 083 Raffaele, Roberto 006 Roidou, Magda 011 Raffaelli, Marco 020 Ron, Alexandra 025, 110 Raniero, Dario 003, 303 Rosas-Pinto, Nair 073 Rath, Biplab 058 Rosato, Enrica 053, 054, 055 Raul, Jean-Sébastien Rega, Michele 005 Rosi, Giulia 285 Reganato, Davide 003 Rossetti, Chiara 029, 035 Reguzzoni, Marcella 035 Rosu, Andreea 185 Rey, Séverine 014 Rosu, Mariana 059, 101 Ribeiro, Catarina 124 Rouffaer, Christian 087 Ricci, Pietrantonio 006, 048, 215, 246, 287 Rousseau, Hervé 050, 088 Rino, Bianca 232 Roussel, Gaetan 042 Rîșcanu, Laura 155 Ruggiero, Mario 043 Rittberg, Wendelin 057 Ruiz Mediavilla, Elena 181 Riva, Fabiano 067 Ruiz-Ramírez, Jorge 211, 212 Rodrigues, Henrique 033

S Sabatasso, Sara 013 Scripcaru, Veronica 111 Sablouh, Bilal Segondy, Michaël 001 Sacco, Matteo 006, 048, 215, 246, 287 Senatore, Azzurra 037 Saint Martin, Pauline Seretean, Lidia 103 Saitoh, Hisako 210 Serra, Armando 064 Sajic, Tatjana 045 Shaychuk, Oleksandr 135 Sakelliadis, Emmanouil 139, 166, 198 Sheppard, Mary Salgado, Ariel 043 Shida, Alissa 151, 222 Salihbegović, Adis 068 Shimada, Emi 145, 146, 147 Samie-Foucart, Lydie Siala, Hela 157, 159, 160, 161, 163, 164, 174, 175, 176, 191, 192, 204, 205, 206, 221, 249, 250, 260, 261, 273, 277, 281, 288, 289, 292, 293, 296, 298, 299, 300 Sandid, Habiba 186, 234, 235, 236, 237, 242, 263 Sibbens, Lode 114 Sano, Rie 134 Siccardi, Cecilia 039 Santa Rosa, Bárbara 169 Sicilia, Francesco 048, 215, 246, 287 Santana Almeida, Miriam 181 Sidlo, Jozef 123 Santangelo, Mariarosaria 006 Sieberth, Till Santos, Ângela 124 Simeone, Pasquale 054 Santos, Carlos 033 Siminiuc, Razvan Marian 065, 074, 103, 113, 116, 185, 201 Sarafoleanu, Codrut 059 Singh, Sudipta Ranjan 058 Sarajlić, Nermin 068 Smędra, Anna 049 Sardinha, Mário 066, 121, 137 Smyk, Barbara 023, 167, 200 Sartori, Alessandro 056 Sofopoulos, Michael 139 Sasaki, Takamitsu 078 Soto, Ruben 061 Savall, Frédéric 088 Sousa, Sandra 033 Savaş, Çağdaş 109 Spagnolo, Domenico 020 Savi de Tove, Jean Louis 090 Spagnolo , Antonio Gioacchino 020 Savi de Tove, Kofi-Mensa 090 Spasov, Svetlozar 165 Scalise, Carmen 048, 215, 246, 287 Spies, Amy 009 Schädler, Julia 110 Spiliopoulou, Chara 139, 166, 198 Schibler, Manuel 004 Stanislawski, Natalie 278 Schiopu, Cristina 178 Steadman, Dawnie 041 Schnegg, Céline 014 Stefanescu, Cristinel 178 Schranz, Sami 013, 089 Steyn, Maryna 009 Schweitzer, Wolf 011 Stoelben, Jacques 278 Schyma, Christian Stojanovic, Mima 041 Scripcaru, Calin 111 Suwandono, Adji 077

Ş Şibka, Ceren 279

Š Šikuta, Ján 123

T Tabian, Daniel 106 Thomas, Aurélien 045, 117 Tagliaro, Franco 032, 158 Tidball-binz, Morris 038 Takahashi, Yoichiro 134 Timonov, Pavel 155, 243 Takayama, Mio 132 Tirdea, Cosmin-Daniel 064, 073, 094, 104, 107, 175, 191 Takeshita, Haruo 078 Tiseanu, Carmen 084 Tambuzzi, Stefano 002, 037, 044, 057, 069, 122, 126, 301 Tiseanu, Ion 058, 084, 092 Tamiozzo, Roberta 152 Tokdemir, Mehmet 184 Tanaka, Naoko 156 Tani, Naoto 148, 150, 151, 222 Toupenay, Steve 206 Tartaglia, Angela 053, 054, 055 Tournois, Laurent 109 Taus, Francesco 158 Trezzi, Sofia 037 Tavares, Susana 200, 231 Tronconi, Livio 275 Taveira, Francisco 244, 245 Trousset, Victor 103 Taylor, Jane 036 Tsranchev, Ivan 155, 243 Telmon, Norbert 050, 088 Turki, Elyes 131, 143, 144, 192, 193, 213, 214, 215, 217, 228, 245, 270, 273, 274, 276 Teodor, Mihai 102 Turlea, Ioana Ruxandra 022 Tepe, Mustafa 194 Turrina, Stefania 003, 075, 142, 293 Tettamanti, Camilla 136, 252 Thali, Michael 011

U Udristioiu, Larisa 022, 046, 059, 101 Urabe, Shumari 200 Untoro, Evi 028

V Van de Voorde, Wim 051, 114 Verdiani, Simonetta 126 Van Den Bogaert, Wouter 114 Vermiglio, Elisa 003, 293 Van der Wal, Allard Verzeletti, Andrea 039, 078 Van Rijn, Rick Vanezis, Peter 074 Veselkina, Olesya 099 Vanin, Stefano 029 Vidoli, Giovanna M Varlet, Vincent 060 Vieira, Duarte Nuno 038 Varotto, Elena 277 Viel, Guido 010, 032, 055 Veira-Varela, Nerea 202 Viero, Alessia 032, 055 Venard, Véronique 001 Visonà, Silvia Damiana 275 Vennemeyer, Matthew Vlachodimitropoulos, Dimitrios 129 Ventura, Francesco 126, 261 Vlassov, Vasiliy 099 Vranken, Joris 049

W Wasterlain, Sofia 063 Wei, Xuan Watanabe, Miho 140 Winter, Kristy 027 Waters, Brian 122, 139 Wiskott, Kim 043, 108

Y Yaguchi, Takashi 128 Yamashita, Tadayoshi 146 Yamaguchi, Rutsuko 200 Yancheva, Stela 155 Yamamoto, Hiroki 135, 136, 137, 139 Yates, Ryan

Z Zanollo, Florencia Zibetti, Angelica 046, 205, 236, 277 Zedda, Massimo 020, 110 Zoja, Riccardo 002, 112 Zehender, Gianguglielmo 002 Zoumenou, Eugène 017 Zeng, Chenyang Zribi, Malek 133, 134, 147, 149, 150, 151, 152, 153, 154, 164, 165, 166, 181, 182, 186, 194, 195, 196, 207, 208, 209, 210, 211, 238, 239, 240, 244, 246, 247, 248, 249, 241, 252, 263, 264, 265, 266, 267, 271, 278, 279, 280, 281, 282, 283, 284, 285, 286, 287, 288, 289, 290, 292 Zerlauth, Jean-Baptiste 008

The original online version of this article was revised: At Abstracts 173 and 174 the name of the first author was inadvertently left out.

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Change history

8/9/2021

A Correction to this paper has been published: 10.1007/s00414-021-02668-y