Vehicular homicide or cardiovascular event? The importance of the autopsy findings.

We present the case of a 61 years old woman who was hit by a car, resulting in fractures of the pubic bone, left ischium-pubis ramus and right femur, with need of hip replacement surgery. In the next days she was affected by two episodes of acute coronary syndrome, treated with coronary angioplasty surgery. After undergoing total hip replacement surgery an episode of asystole caused her death. A full autopsy showed coronary stenosis and chronic ischemic heart disease associated with a recent myocardial infarction. The pre-existing condition of T.L. could not be ignored but the initial traumatic event and the subsequent fractures played a further co-occurrent causal role. The initial trauma represented the first step of the phenomenological chain that led to a series of adverse cardiological events and to an irreversible asystole, so that the car driver should be partly considered accountable for the death of the woman.

Medico-Legal Issues in Cremation: Comparative Analysis of International Legislation.

Cremation has seen a constant increase in popularity all around the world. Because of its extensively destructive nature, however, a series of medico-legal issues arise concerning identification, forensic autopsy, external examination, histological, toxicological and genetic exams to be performed not in the immediacy of death. The aim of this study is to compare the international legislation on cremation, seeking the response of various countries to their medico-legal issues. Several affinities but also some differences were found. Similarities include the need for a certificate by a medical examiner excluding any medico-legal issues and non-natural causes of death and the expression of consent to cremation given by the deceased when still alive otherwise by relatives. Significant differences were found in German law, which provides for a second medical examination prior to cremation and in Italian law providing for the medical examiner to collect biological samples from the body and store them for a minimum of ten years for any future purpose of justice. The Italian approach could give a plausible solution to the medico-legal issues raised by cremation with the imperative premise, however, we need to look deeply into its privacy and consent implications, cost-benefits rate, sample collection and storage protocol.

Autoptic findings of sudden cardiac death (SCD) in patients with arrhythmogenic ventricular cardiomiopathy (AVC) from left ventricle and biventricular involvement.

OBJECTIVES: To evaluate autoptic histopathological findings of arrhythmogenic ventricular cardiomyopathy (AVC) as major cause of sudden cardiac death (SCD) in young adults. BACKGROUND: According to Heart Rhythm Society (HRS)'s international consensus, histological criteria for AVC diagnosis include a progressive myocardial atrophy of the right ventricle characterized by a transmural fatty or fibrofatty replacement in a segmental or diffuse pattern (residual myocytes <60 % vs 60-75 % by morphometric analysis) explaining the electrical instability with increased risk of SCD. However, there is increasing evidence for atypical patterns of localizations and percentage of fibrofatty replacement suggesting the need to update histopathological features of AVC. METHODS: Histology examination of ventricles, atria, and septum was performed on 10 autopsy of SCD due to AVC. Staining with hematoxylin-eosin and PicroSirius Red/Fast Green were performed on the heart samples to identify specific fibrofatty patterns. RESULTS: Our analysis showed that: 1) myocardial replacement by a diffuse segmental fatty or fibro-fatty tissue characterized right and left ventricles as well as atrial walls; 2) the degree of fibrofatty tissue replacement was less than 40 % both in left ventricle (n = 4, 40 %) and biventricular (n = 6, 60 %) localization; 3) perivascular fibrosis, inflammatory infiltrate, areas of hypertrophy and/or areas of coagulative necrosis as signs of hypoxic damage in the first stage. CONCLUSIONS: We confirmed prior evidence for fibrofatty replacement both in biventricular and septal localizations. Importantly, we observed a less degree (<40 %) of fibrofatty replacement as compared to current guidelines. This supports the need to further explore the histological patterns of fibrofatty infiltration in a larger study population to improve the histological diagnostic criteria of AVC.

The Central Importance of Information in Cosmetic Surgery and Treatments.

The increase in the number of people who choose to have medical procedures done to improve their appearance may be due to changed social and cultural factors in modern society, as well to the ease of access and affordable costs of these cosmetic treatments. Today, two elements legitimate recourse to this type of treatment: the broad definition of health accepted by the law and the scientific community, and the provision of meticulous information to the entitled party previous to obtaining his or her consent. In Italy, while current case-law views treatments exclusively for cosmetic purposes as unnecessary, if not even superfluous, it nonetheless demands that providers inform clients about the actual improvement that can be expected, as well as the risks of worsening their current esthetic conditions.

Delirium in ICU patients following cardiac surgery: An observational study.

AIMS AND OBJECTIVES: To observe the clinical and structural factors that can be associated with the post-operative onset of delirium in patients who have undergone heart surgery. BACKGROUND: Several risk factors could contribute to the development of delirium, such as the use of some sedative drugs and a patient's history with certain types of acute chronic disease. However, in the literature, there is little knowledge about the association between delirium in patients who have undergone cardiac surgical intervention and their clinical and environmental predictors. DESIGN: We used an observational design. METHODS: We enrolled 89 hospitalised patients in the ICU. Patients were first evaluated using the Richmond Agitation Sedation Scale and subsequently using the Confusion Assessment Method for the ICU. A linear model of regression was used to identify the predictors of delirium in patients. RESULTS: The patients had an average age of 89 years (SD = 6.9), were predominantly male (84.3%) and were mostly married (79.8%). The majority of patients had been subjected to bypass (80.9%), while 19.1% had undergone the intervention of endoprosthesis. The logistic regression model showed that patient age, the duration of mechanically assisted ventilation, continuous exposure to artificial light and the presence of sleep disorders were predictors of the onset of delirium. CONCLUSION: This study further confirms that clinical aspects such as insomnia and one's circadian rhythm as well as structural elements such as exposure to artificial light are variables that should be monitored in order to prevent and treat the onset of severe post-operative delirium. RELEVANCE TO CLINICAL PRACTICE: Identifying the possible factors that predispose a patient to the onset of delirium during intensive therapy following cardiac surgery, it is fundamental to implement interventions to prevent this syndrome.

Unreasonable obstinacy: Ethical, deontological and forensic medical problems.

Especially in oncology and in critical care, the provision of medical care can require therapeutic choices that could go beyond the patient's will or intentions of the protection of his health, with the possible adoption of medical behaviors interpreted as unreasonable obstinacy or, at the opposite extreme, as euthanasia. In some cases, the demand for obstinate therapeutic services could come from the patient or from his relatives, in which case the dilemma arises for the health professional between rejecting such a request, in respect of their professional autonomy, or abiding by it for fear of a professional care responsibility for therapeutic abandonment. We analyzed and commented on emblematic clinical cases brought to court for alleged wrong medical conduct due to breach of the prohibition of unreasonable obstinacy. In healthcare it is impossible to fix a general rule defining any therapeutic act as appropriate, because on one hand there are technical assessments of medical competence, and on the other the perception of the patient and of his family members of the usefulness of the health care provided, which may be in contrast. The medical act cannot make treatments that are inappropriate for the needs of care or even be unreasonable; conversely, before the request by the patient or by his family members for disproportionate health services in relation to the results they may give in practice, in compliance with the legislative and deontological provisions, the doctor can refuse them, thus safeguarding both his decision-making autonomy and, therefore, his professional dignity.

Pulmonary Eosinophilic Inflammatory Infiltration Post-Intensive Care in a Nearly Drowned Young Man with Papillary Fibroelastoma: A Rare Complication Discovered by Forensic Autopsy.

Papillary fibroelastoma is a rare benign lesion of heart (1). It is the second most common primary cardiac neoplasm, accounting for 4.4-8% of all tumors of the heart (2). We described a forensic autopsy of a nearly drowned young man with cardiac papillary fibroelastoma who died because of a pulmonary inflammatory infiltration rich in granulocytes after intensive care. This occurrence is rare but possible and should be kept in mind because a lung inflammatory infiltrate rich in eosinophilic granulocytes can be present in different pathological conditions and differential diagnoses are often difficult to do.

Contralateral risk reducing mastectomy in Non-BRCA-Mutated patients.

The use of contralateral risk reducing mastectomy (CRRM) is indicated in women affected by breast cancer, who are at high risk of developing a contralateral breast cancer, particularly women with genetic mutation of BRCA1, BRCA2 and P53. However we should consider that the genes described above account for only 20-30% of the excess familiar risk. What is contralaterally indicated when genetic assessment results negative for mutation in a young patient with unilateral breast cancer? Is it ethically correct to remove a contralateral "healthy" breast? CRRM rates continue to rise all over the world although CRRM seems not to improve overall survival in women with unilateral sporadic breast cancer. The decision to pursue CRRM as part of treatment in women who have a low-to-moderate risk of developing a secondary cancer in the contralateral breast should consider both breast cancer individual-features and patients preferences, but should be not supported by the surgeon and avoided as first approach with the exception of women highly worried about cancer. Prospective studies are needed to identify cohorts of patients most likely to benefit from CRRM.

Professional dental and oral surgery liability in Italy: a comparative analysis of the insurance products offered to health workers.

INTRODUCTION: In Italy there has been an increase in claims for damages for alleged medical malpractice. A study was therefore conducted that aimed at assessing the content of the coverage of insurance policy contracts offered to oral health professionals by the insurance market. MATERIAL AND METHODS: The sample analysed composed of 11 insurance policy contracts for professional dental liability offered from 2010 to 2015 by leading insurance companies operating in the Italian market. RESULTS: The insurance products analysed are structured on the "claims made" clause. No policy contract examined covers the damage due to the failure to acquire consent for dental treatment and, in most cases, damage due to unsatisfactory outcomes of treatment of an aesthetic nature and the failure to respect regulatory obligations on privacy. DISCUSSION: On entering into a professional liability insurance policy contract, the dentist should pay particular attention to the period covered by the guarantee, the risks both covered and excluded, as well as the extent of the limit of liability and any possible fixed/percentage excess. CONCLUSIONS: When choosing a professional liability contract, a dentist should examine the risks in relation to the professional activity carried out before signing.

Informed consent in robotic surgery: quality of information and patient perception.

INTRODUCTION: Obtaining a valid informed consent in the medical and surgical field is a long debated issue in the literature. In robotic surgery we believe in the necessity to follow three arrangements to make the informed consent more complete. MATERIAL AND METHODS: This study presents correlations and descriptions based on forensic medicine concepts research, literature review, and the proposal of an integration in the classic concept of informed consent. CONCLUSION: In robotic surgery we believe in the necessity to follow three arrangements to make the IC more complete. Integrate the information already present in the informed consent with data on the surgeon's experience in RS, the number of procedures of the department and the regional map of expertises by procedure.

Malfunctions of robotic system in surgery: role and responsibility of surgeon in legal point of view.

Robotic surgery (RS) technology has undergone rapid growth in the surgical field since its approval. In clinical practice, failure of robotic procedures mainly results from a surgeon's inability or to a device malfunction. We reviewed the literature to estimate the impact of this second circumstance in RS and its consequent legal implications. According to data from the literature, device malfunction is rare. We believe it is necessary to complement surgical training with a technical understanding of RS devices.

Medicolegal implications of surgical errors and complications in neck surgery: A review based on the Italian current legislation.

Aim of the present paper is the review of the principal complications associated to endocrine neck surgery considering how expertise, full adoption of guidelines, appropriate technology and proper informed consent may limit the medicolegal claims at the light of the incoming new regulation of the medical professional legal responsibility. A literature search, using the Medline/PubMed database for full-length papers, was used. Postoperative recurrent laryngeal nerve (RLN) palsy and hypoparathy-roidism remain the principal causes of surgical malpractice claims . In the procedure of neck lymphadenctomy intra-operative haemorrhage, thoracic duct injury, injuries to loco-regional nerves can be observed and can be source of claims. After many years of increased medicolegal litigations, the Italian government is proposing a drastic change in the regulations of supposed medical malpractice in order to guarantee the patient's right to a safe treatment and in the meantime to defend clinicians from often unmotivated and prejudicial legal cases. Surgical errors and complications in neck surgery are a relevant clinical issue. Only the combination of surgical and clinical expertise, application of guidelines, appropriate technology and a routinely use of specific informed consent can contain potential medicolegal implications.

Iatrogenic splenic injury: review of the literature and medico-legal issues.

INTRODUCTION: Iatrogenic splenic injury is a recognized complication in abdominal surgery. The aim of this paper is to understand the medico-legal issues of iatrogenic splenic injuries. We performed a literature review on PubMed and Scopus using iatrogenic splenic or spleen injury and iatrogenic splenic rupture as keywords. Iatrogenic splenic injury cases were identified. Most cases were related to colonoscopy, but we also identified cases related to upper gastrointestinal procedures, colonic surgery, ERCP, left nephrectomy and/or adrenalectomy, percutaneous nephrolithotomy, vascular operations involving the abdominal aorta, gynecological operation, left lung biopsy, chest drain, very rarely spinal surgery and even cardiopulmonary resuscitation. There are several surgical procedures that can lead to a splenic injury. However, from a medico-legal point of view, it is important to assess whether the cause can be attributed to a technical error of the operator rather than being an unpredictable and unpreventable complication. It is important for the medico-legal expert to have great knowledge on iatrogenic splenic injuries because it is important to evaluate every step of the first procedure performed, how a splenic injury is produced, and whether the correct treatment for the splenic injury was administered in a judgment.

Cosmetic surgery: medicolegal considerations.

Cosmetic surgery is one of the two branches of plastic surgery. The characteristic of non-necessity of this surgical speciality implies an increased severity in the evaluation of the risk-benefit balance. Therefore, great care must be taken in providing all the information necessary in order to obtain valid consent to the intervention. We analyzed judgments concerning cosmetic surgery found in national legal databases. A document of National Bioethics Committee (CNB) was also analyzed. CONCLUSION: The receipt of valid, informed consent is of absolute importance not only to legitimise the medical-surgical act, but it also represents the key element in the question concerning the existence of an obligation to achieve certain results/use of certain methods in the cosmetic surgery.

Excellence and safety in surgery require excellent and safe tutoring.

The surgical education in Italy has always been a very important issue. The aim of this article is to bring together the feedback of the definitions of the various components of the learning scheme and to evaluate the importance of the legal point. In March 2016 we performed a literature review. We have also examinated the internet pages of the Italian Department of Education, Health and Medical Order. In Italy the tutor had an unclear role from a legal point of view. He is the person who must be able to perform a specific procedure with expert technical and who must know how to stop the student if this is about to perform a dangerous maneuver. In Italy the ability to work for the trainee is limited in all reality, it depends on several factors including the increase of numbers of medical-legal disputes, the timing, the commitment it requires mentoring and a lack of mentors. CONCLUSION: In surgery, the problem is greater because of the increasingly of medico-legal implications that we are after surgical procedure. It would be necessary to define a role of the tutor in a regular protocol and a proper assessment of his performance.

Use of a simplified consent form to facilitate patient understanding of informed consent for laparoscopic cholecystectomy.

BACKGROUND: Surgical informed consent forms can be complicated for patients to read and understand. We created a consent form with key information presented in bulleted texts and diagrams combined in a graphical format to facilitate the understanding of information during the verbal consent discussion. METHODS: This prospective, randomized study involved 70 adult patients awaiting cholecystectomy for gallstones. Consent was obtained after standard verbal explanation using either a graphically formatted (study group, n=33) or a standard text document (control group, n=37). Comprehension was evaluated with a 9-item multiple-choice questionnaire administered before surgery and factors affecting comprehension were analyzed. RESULTS: Comparison of questionnaire scores showed no effect of age, sex, time between consent and surgery, or document format on understanding of informed consent. Educational level was the only predictor of comprehension. CONCLUSIONS: Simplified surgical consent documents meet the goals of health literacy and informed consent. Educational level appears to be a strong predictor of understanding.

Early medical skull surgery for treatment of post-traumatic osteomyelitis 5,000 years ago.

Here we describe the findings of a unique example of the early techniques adopted in neurosurgery around 5000 years ago, consisting in a double well healed skull trephination associated with a post-cranial traumatic event occurring intra vitam to a young male from the Early Chalcolithic cemetery of Pontecagnano (South Italy, ca. 4,900 - 4,500 cal BP). Morphological, X-ray and 3D-CT scan skull-cap evaluation revealed that the main orifice was produced by scraping, obtained by clockwise rotary motion of a right-handed surgeon facing the patient, while the partial trephination was carried out by using a stone point as a drilling tool. In both cases, bone regrowth is indicative of the individual's prolonged postoperative survival and his near-complete recovery. The right femur shows a poorly healed mid-shaft fracture presumably induced by a high energy injury, and a resulting chronic osteomyelitis, affecting both femurs by hematogenous spread of the infection. Our observations on the visual and radiological features of skull and femur lesions, along with evidence on the timing of experimental bone regrowth vs. healing of lower limb fractures associated to long-term bone infections now suggest that this young man underwent a double skull trephination in order to alleviate his extremely painful condition induced by chronic osteomyelitis, which is thought to have been the cause of death.