Malpratice claims in cardiology and cardiac surgery: A medico-legal issue.

Medical liability has become a challenge in every physician's modern practice with the consequent loss of the physician's autonomy and an increase in "defensive medicine". From this perspective, the role of Legal Medicine in assessing medical liability has become increasingly specific and a homogenization of the methods of ascertainment is increasingly necessary, since such a process can contribute to strengthening the guarantees in professional liability procedures. Focusing on malpractice claims in the field of cardiology, the complexity of the management of cardiac pathologies and the frequency of severe adverse events implies the importance of a multi-disciplinary approach, together with the application of a shared ascertainment methodology. In particular, it is essential for the forensic pathologist to collaborate with experts in cardio-pathology, cardiology and/or cardiac surgery in cases of alleged medical liability in the cardiologic field and to follow the guidelines which have been produced to assist the expert dealing with deaths reflecting cardiac disease, in order to prevent criticism of case analysis in medico-legal environments and to promote the standardization of the structure of the juridical-legislative medical malpractice lawsuits.

Road traffic deaths: A retrospective analysis (2009-2019) in the north of the Italian region Emilia Romagna.

OBJECTIVE: International literature and several national studies demonstrate that alcohol and illicit drugs impair driving abilities, diminishing the level of attention, and cause traffic accidents. In Italy, driving under the influence of alcohol or drugs is regulated by Articles 186 and 187 of the National Street Code, which defines penalties and fines for the convicted. The aim of this study was the collection of all available data from 2009 to 2019 focusing on deaths related to road accidents in the Unit of Legal Medicine of Department of Medicine and Surgery at the University of Parma, in order to assess any consumption of alcohol, illicit drugs, and medicinal drugs among drivers. METHODS: Data were retrieved from autopsy reports found at the Unit of Legal Medicine of Parma University related to 327 subjects who died following road accidents in the Italian areas of Parma, Reggio-Emilia, and Piacenza. The population was divided into subgroups according to age, gender, crash time, and drug positivity. RESULTS: Those in the age group 46 to 65 years old were involved in the most accidents, whereas the category with fewest members included subjects under 26 years old. The majority of road accidents occurred during the daytime and on weekends. Among the toxicological investigations carried out (only for drivers), the highest prevalence was found for alcohol (43.1%), followed by illicit drugs (14.4%) and medicinal drugs (7.8%). The prevalence of alcohol and illicit drugs in combination was 11.8%. Regarding subjects positive for alcohol and illicit drugs in combination, 44.4% had a blood alcohol concentration (BAC) > 1.5 g/L and overall, in 61.1% of the total cases a BAC > 0.81 g/L was detected. CONCLUSIONS: Our results are in line with national and international studies highlighting the prevalence of high BAC levels in most of the cases. Confirmation analyses on blood collected from people who died following road accidents showed levels of BAC above 0.8 g/L (threshold for penal sanctions) in the majority of the subjects who tested positive for alcohol. They also revealed cocaine, cannabis, and benzodiazepines as the most common illicit drugs and medicinal drugs used, respectively, as demonstrated in several international studies.

Markers of mechanical asphyxia: immunohistochemical study on autoptic lung tissues.

Forensic pathologists are often asked to provide evidence of asphyxia death in the trial and a histological marker of asphyxiation would be of great help. Data from the literature indicate that the reaction of lung tissue cells to asphyxia may be of more interest for forensic purposes than migrating cells. The lungs of 62 medico-legal autopsy cases, 34 acute mechanical asphyxia (AMA), and 28 control cases (CC), were immunostained with anti-P-selectin, anti-E-selectin, anti-SP-A, and anti-HIF1-α antibodies, in order to verify if some of them may be used as markers of asphyxia death. Results show that P- and E-selectins expression in lung vessels, being activated by several types of trigger stimuli not specific to hypoxia, cannot be used as indicator of asphyxia. Intra-alveolar granular deposits of SP-A seem to be related to an intense hypoxic stimulus, and when massively present, they can suggest, together with other elements, a severe hypoxia as the mechanism of death. HIF1-α was expressed in small-, medium-, and large-caliber lung vessels of the vast majority of mechanical asphyxia deaths and CO intoxications, with the number and intensity of positive-stained vessels increasing with the duration of the hypoxia. Although further confirmation studies are required, these preliminary data indicate an interesting potential utility of HIF1-α as a screening test for asphyxia deaths.

Primary cutaneous cribriform carcinoma of the neck: a case report.

Primary cutaneous cribriform carcinoma is an unusual apocrine tumour that mainly occurs on the limbs of middle-aged females. We herein report a case of a 32-year-old woman who underwent surgical excision of a nodular lesion on her neck that had been present for 10 months. Histopathology showed a dermal tumour composed of interconnected aggregations of neoplastic cells and round spaces of various size and shape, resulting in a cribriform pattern. A diagnosis of cutaneous cribriform carcinoma was made. No peripheral lymphadenopathy was evident, and investigations for internal malignancies gave negative results. The patient was tumour-free 2 years after surgery. Although primary cutaneous cribriform carcinomas have up to now shown an indolent course, the number of reported cases is too limited for definitive prognostic conclusions. Therefore, surgical excision with clear margins and adequate follow-up are recommended.

Pulmonary embolisation of bone fragments from penetrating cranial gunshot wounds.

Bone embolism is a very rare event that usually occurs in trauma-induced septic bone lesions, after bone surgery or after bone marrow transplantation, and normally remains silent. To our knowledge, there are no previous reports of bone embolism after a gunshot to the head. We describe a case of pulmonary embolism associated with bone fragments after a gunshot to the head in which bone fragments surrounded by leukocytes, interstitial and intra-alveolar oedema and haemorrhage around the embolised vessels, leukostasis and fat and bone marrow embolism suggest that the survival time from the gunshot was sufficiently long to allow changes in lung microcirculation and lung tissue.

Surgical margin marking for high-risk basal cell carcinomas of the cephalic region: a single-centre experience.

AIM: Mohs micrographic surgery is the treatment of choice for basal cell carcinomas (BCCs) at high risk for local recurrence. This procedure is scarcely employed in Italy, even when it appears necessary, for different causes, including high costs, organization problems, or low professional experience with the technique. Aim of this study is to report our experience with the "surgical margin marking", as alternative to standard Mohs micrographic surgery in the management of high-risk BCCs of the head and neck region. METHODS: A retrospective analysis on 102 (64 males and 38 females; mean age: 66.8 years; median: 68 years; range: 53-87 years) of 208 patients with high-risk basal cell carcinomas of the head and neck region, submitted to surgical margin marking has been made. All cases had completed a 3-year follow-up. Primary tumours were 52 (51%), recurrent tumours were 50 (49%). RESULTS: The mean number of micrographic surgery stages for a complete tumour clearance was 1.65 (range: 1-4 stages). In 47% (N.=49) of cases the tumours were removed by a single stage, while in 42.1% (N.=43) of patients two stages were required. Only 2 patients (2%) showed recurrences during a mean follow-up of 61.2 months (median: 62 months; range: 37-84 months). CONCLUSION: Our experience supports the effectiveness of the surgical margin marking technique in the treatment of high-risk basal cell carcinomas of the cephalic region. It may represent an alternative approach to Mohs micrographic surgery in dermatologic departments of many hospitals, where standard Mohs micrographic surgery is more difficult to perform.

Sentinel lymph node biopsy in patients with thick (= 4 mm) melanoma: a single-centre experience.

BACKGROUND AND OBJECTIVE: Lymphatic mapping/sentinel lymph node biopsy (LM/SLNB) have become routine techniques for staging the regional lymph nodes in early stage melanoma, yet their role in the management of thick (= 4 mm) melanoma is debated. The aim of the present study is to review our experience with LM/SLNB in a series of patients with thick primary melanoma, to evaluate its utility in this melanoma subset. PATIENTS AND METHODS: Thirty patients (18 men and 12 women; mean age 70.6 years; median 75 years) with thick primary melanoma underwent LM/SLNB, using both radioisotope and blue dye. The statistical tests were performed by using SAS software for Windows, version 8.2. RESULTS: The primary tumour sites were head/neck (n = 5; 16.6%), trunk (n = 10; 33.3%), and extremities (n = 15; 50%). Tumour thickness ranged from 4 to 17 mm (mean 5.14 mm; median 4.5 mm). Ulceration was observed in 23 (76.6%) tumours. Eleven patients (36.6%) had at least a positive sentinel lymph node (SLN). The mean follow-up was 27.3 months (median 26 months; range 5-63 months). Patients without SLN metastases had a 5-year disease-free survival rate of 78.9%, vs. 18.2% for patients with SLN metastases (P = 0.0121 by log rank test). The 5-year overall survival rate for patients without SLN metastases was 89.5%, whereas patients with SLN metastases had a 5-year overall survival rate of 36.4% (P = 0.0272 by log rank test). CONCLUSION: Our retrospective analysis indicates that the SLN status is predictive of recurrence and survival in patients with thick melanoma, and LM/SLNB should be routinely performed in this subset of melanoma patients.

Demonstration of Ollulanus tricuspis in the stomach of domestic cats by biopsy.

Ollulanus tricuspis is a small nematode of the family Ollulanidae, found in the stomach of domestic cats and other felids. Of 131 gastric biopsy samples collected at endoscopic examination, four were shown to contain the parasite. Vomiting was the main presenting sign in three cats and weight loss in the fourth. The stomachs were grossly normal on endoscopic examination. Chronic gastritis was observed histologically in two cases, while the remaining cases were microscopically normal. The significance of the parasite remained undetermined. To our knowledge, this is the first report of O. tricuspis infection in domestic cats in which the diagnosis was made by examining routine endoscopic biopsy samples.

Detection and significance of adenoviruses in cases of sudden infant death.

Respiratory tract infections have been thought to act as a trigger mechanism in sudden infant death. In 118 autopsy cases of infant death, paraffin-embedded or frozen lung tissues were investigated by means of a nested polymerase chain reaction (PCR) to detect adenovirus (AV) DNA. The primers used are general primers and allow the detection of most pathogenic adenoviruses with high specificity and sensitivity and independently of devitalization of viruses or degradation of viral DNA. For the investigation three groups were established: there were 13 cases of unnatural death, 78 cases of natural death without histological signs of interstitial pneumonia, and 27 cases with interstitial pneumonia. The first group was AV negative. In the group without interstitial pneumonia AV was detected in 10.2% of the cases. In the group with interstitial pneumonia the frequency of AV detection was almost 26%. The results obtained demonstrate an association between interstitial pneumonia and detection of AV DNA, indicating that AV may play an important part in pulmonary infection in infants. Histological evidence of interstitial pneumonia was not observed in all AV-positive cases, perhaps because nonspecific virus-related changes occurred only in early stages of viral infection. Comparison of the AV frequency in SIDS (25%) and non-SIDS cases (4%) indicates an association between pulmonary AV infections and sudden death. These results support the working hypothesis of respiratory infections acting as a trigger mechanism in sudden infant death.