Fat overload syndrome following intravenous lipid emulsion administration as antidote in suspected anesthetic intoxication: insights from a clinical and forensic case experience.

Abstract: Medication errors pose significant risks to patients' health, representing a relevant social and economic issue for the healthcare system. This study focuses on the life-threatening consequences of an overdose of intravenous lipid emulsion (ILE), used as an antidote for suspected bupivacaine intoxication in a young woman undergoing hip surgery. Shortly after administration of the local anesthetic, the woman experienced cardiac arrest and was admitted to the intensive care unit with severe respiratory failure, metabolic acidosis and deep coma. Despite medical intervention, her condition worsened, leading the medical team to administer ILE for suspected bupivacaine intoxication. The patient's condition did not improve and ultimately resulted in death. The autopsy highlighted a widespread presence of oily material in the vascular system, compatible with an overdose of ILE. At a checking, medical records reported a dose of ILE that was 4-fold higher than the recommended dose in this off-label indication. This case report highlights the important need for healthcare professionals to understand the risks of using ILE as an antidote. Adequate monitoring of these "sentinel events" and their critical evaluation can lead to the implementation of specific clinical risk management protocols to reduce the risk for the patient and contain healthcare costs.

Sudden death after fatal percussion of the cervical neurovascular bundle.

Background: Atypical compression of the neck may be classified as asphyxia in which the external compression on the cervical anatomical structures occurs in a peculiar manner. In such cases, death occurs due to the combination of several pathophysiological phenomena, such as respiratory, vascular, and nervous. When the mechanical action on the neck is violent and rapid, it is more correct to use the word percussion rather than compression. Usually there are no skin lesions of special significance in this type of neck percussion, unlike the cases of choking, strangulation, and hanging, and the diagnosis is challenging. It is important to carefully evaluate the body during the autopsy to identify which pathophysiological mechanism caused the death. Case report: A young woman died immediately after being struck by a concrete beam at the level of her neck. The woman was on vacation with her boyfriend and decided to hang from a concrete beam suspended between two columns to take a souvenir photo when the beam suddenly broke and fell on her. The autopsy revealed multiple abrasions, swelling, and lacerations to the face, neck, and chest. Internal examination revealed primarily the presence of hemorrhagic infiltration in the anterior cervical compartments and lacerations of various organs, including the trachea. Conclusion: Based on all the obtained data, including toxicological and histological, the cause of death was atypical ab extrinsic percussion of the neck, directed particularly at the right cervical neurovascular bundle.

Death by artery injury: two peculiar cases of sharp force fatality.

Background: As sharp force injury accounts for 10-20% of clinical forensic examinations, forensic pathologists are often asked to investigate deceased victims of stab wounds. Moreover, homicide by sharp force (stabbing) is one of the most common in European countries, involving generally domestic or interpersonal conflict. Stabbing as a suicide method constitutes a low percentage of all suicides, 2% to 3%. Accidental death due to sharp force is even rarer (0-3%) and usu-ally caused by an impact or a fall into different type of glass surface. Death due to stabbing is usually caused by exsanguinating incisions to organs or large blood vessels (such as arteries), leading to haemor-rhagic shock. Penetrating artery injuries are well known in clinical settings, and extremities are the most common sites of such injuries. Indeed, 50% to 60% of injuries occur in femoral or popliteal arteries, 30% in brachial artery. Aims: The aim of this paper is to present two rare cases of sharp force fatality, showing how a thorough forensic pathology methodology, including death scene investigation, autopsy examination, and toxicological analyses, are pivotal to detect the manner of death. Case Reports: This paper presents two peculiar cases of sharp force fatalities: the first, a single and accidental stab injury on the right armpit which caused a complete transection of the axillary artery; the second, a single homicidal stab wound on the lower leg causing a full-thickness lesion of the anterior tibial artery.

3D printing and 3D bioprinting technology in medicine: ethical and legal issues.

Abstract: There has been a surge of interest in new technologies in medicine because of their promising clinical applications. Extensive research on additive manufacturing and its applications in the medical field has been carried out with good results and very high expectations. Due to their disruptive nature and potential, 3D printing and even more 3D bioprinting raise many ethical and safety concerns that need to be adequately addressed to provide good regulation before entering clinical practice. This article aims to highlight the general ethical concerns associated with the use of additive manufacturing in medicine and the lack of current international regulatory directives to guide these experiments. Transparency about how these new medical devices are regulated and approved is a fundamental requirement to promote and improve public trust, efficiency, safety and quality.

Death occurred due to undiagnosed systemic amyloidosis: a case report.

Abstract: Amyloidosis is a disorder related to errors in protein folding. We present a clinical case of systemic amyloidosis manifesting as hypotension, tachycardia, pain, weight loss, asthenia, anorexia, dysphagia, and mood deflection in a 49-year-old-year-old woman with a previous clinical history of articular and muscular pain, correlated to suspected seronegative arthritis. The blood test revealed kidney insufficiency, an electrocardiogram identified low voltages of the peripheral leads and T waves anomalies. A serum protein electrophoresis revealed the presence of high levels of monoclonal kappa free chains. The woman started to have a sense of suffocation, and after one week she was found dead in her bed. After the autopsy, the results of Congo red staining of the myocardium were characteristic of amyloid. According to the autoptic and the histological examination, death occurred due to acute cardiac and respiratory arrest secondary to amyloid cardiomyopathy in a patient with undiagnosed systemic amyloidosis.

Vitamin D status of inmates: the experience of penitentiaries prisons in the province of Salerno in Southern Italy.

Introduction: Prisoners are at risk of developing vitamin D deficiency due to their lacking exposure to sunlight. So far, there are no published studies evaluating blood levels of vitamin D in relation to the health status of inmates and the quality of the Italian prison system. Aim: To investigate vitamin D status and its determinants in a cohort of prisoners. Subject and Methods: One hundred and seventy-two (172) pri-son inmates (males, n=159, age 47± 11.3 years; females, n=13, age 43.91±12.18 years) of three penitentiaries in the province of Salerno. Vitamin D deficiency, insufficiency and sufficiency were respectively defined as a 25(OH)D level <20 ng/mL; from 20 to 30 ng/mL, >30 ng/mL. Results: In our group, Vitamin D deficiency occurs in 77.32% of the prisoners with 32.55% of the cases having severe insufficiency. Prisoners with higher BMI show lower circulating vitamin D levels (p<0.001). No significant relationship was found with the duration of detention (Pearson R: 0.01). Conclusion: In this cohort of inmates the vitamin D status is determined by BMI, but not by the duration of the detention.

Abuse and misuse of prescription opioids: is it only an Ameri- can problem? An observational study on an Italian casuistry.

ABSTRACT: Medical use of prescription opioids has steadily increased since the 1990s, particularly in the U.S.A. and Canada, along with abuse of these substances and significant increases in rates of addiction and death related to prescription opioids. The American authorities speak of an "addiction epidemic" and are launching a series of countermeasures to better address the problem. In Europe, there is an increasing use of prescription opioids and related problems, but the European context is much less dramatic than the American and Canadian ones. Never-theless, based on the data, it cannot be ruled out that a similar crisis will occur on the Old Continent. The aim of this study is to analyze the Italian context to better understand whether there is a possibility of an addiction epidemic. Twenty-four cases of death of people under treatment with pre-scription opioids have been retrospectively analyzed. Toxicological samples were collected with routine methods during the autopsy, followed by systematic screening for substances by diverse methods. Volatile compounds were identified using gas chromatography-flame ionization detection (GC-FID). Medical drugs and drugs of abuse were identified via the use of gas chromatography-mass spectrome-try (GC-MS) and liquid chromatography-tandem mass spectrometry (LC-MS-MS). Of a total of 24 subjects, 14 died due to an overdose of Tramadol, while 7 died due to an overdose of Buprenorphine and 3 dues to a Fentanyl overdose. The most used drug was Tramadol. Histological examination was performed with hematoxylin/eosin staining, though no significant findings emerged apart from widespread edema and focal sclerosis of the myocardium, and interstitial and alveolar edema of the lungs. Our data show that attention must be paid to prescription opioids. European institutions, as soon as possible, must implement preventive measures that avoid the recurrence of the North American situation.

Bleeding varicose veins' ulcer as a cause of death: a case report and review of the current literature.

ABSTRACT: Chronic venous insufficiency (CVI) and varicose veins (VVs) of the lower limbs are very frequent vascular diseases in Western countri-es. One possible complication of these conditions is skin ulceration and its consequent rupture, which can be spontaneous or due to mild or trivial trauma. In some cases, the resulting hemorrhage is fatal. When the victim is found dead, a large amount of blood around the body might lead to the hypothesis of violent death. The Forensic Pa-thologist needs to be very careful in the corpse's examination, in order to exclude any alternative cause of death. Herein, an illustrative case is reported, as well as a literature review of the literature concerning sudden hemorrhages from VVs. We found 27 scientific papers, the total reported cases of VVs rupture with profuse hemorrhages were 36, 32 of which were fatal. The main characteristics of such forensic scenario have been collected. Corpse examination of the victims showed pallor of the skin and mucous membranes, as well as marked pallor of organs as a sign of hemorrhagic shock, but these pathological findings are unspecific. Usually, the skin near the ulcer presented color alteration (discoloration and atrophy or pigmentation and hyperemia). Besides, the histological examination of the skin could be a valid instrument to demonstrate the presence of the ulcer, even if it could be very difficult to sample, because of its small size. An important limit of our study is the small number of collected cases. More studies in this field are needed to improve evidence concerning death due to VVs rupture.

Physician-Patient Relationship, Assisted Suicide and the Italian Constitutional Court.

In 2017, Italy passed a law that provides for a systematic discipline on informed consent, advance directives, and advance care planning. It ranges from decisions contextual to clinical necessity through the tool of consent/refusal to decisions anticipating future events through the tools of shared care planning and advance directives. Nothing is said in the law regarding the issue of physician assisted suicide. Following the DJ Fabo case, the Italian Constitutional Court declared the constitutional illegitimacy of article 580 of the criminal code in the part in which it does not exclude the punishment of those who facilitate the suicide when the decision has been freely and autonomously made by a person kept alive by life-support treatments and suffering from an irreversible pathology, the source of physical or psychological suffering that he/she considers intolerable, but fully capable of making free and conscious decisions. Such conditions and methods of execution must be verified by a public structure of the national health service, after consulting the territorially competent ethics committee. This statement admits, within strict and regulated bounds, physician assisted suicide, so widening the range of end-of-life decisions for Italian patients. Future application and critical topics will be called into question by the Italian legislator.

Uninformed consent: Who knows what Ivan Ilyich would have thought?

ABSTRACT: In the modern era, when prolonging life is not an option, the end-of-life discussions are unavoidably influenced by Neuroethics. Despite this, it is interestingly evident how the sentiments of a terminal patient of 1885 and a physician of 2020, are still comparable. This paper pre-sents the arguments behind the so-called "Therapeutic Misconception" and the aim of palliative care to provide dying patients support. It is essential to address priorities of informed consent, signed before any remedy is provided. A key component of the newest Neuroscience research is the analysis of motivation and free will. So, it is necessary to comprehend if the patient struggles to feel at peace with these aspects of his "right to die": Is he free to choose or is he influenced by the doctors? Is this confusion an example of "Therapeutic Misconception"? Is his Informed Consent totally "Informed"? In order to broaden our understanding, we account for many critical situations, such as the mentally impaired Psychiatric patients or the famous Italian case of Eluana Englaro. In addition, we suggested some current approaches such as Artificial Intelligence, useful in preserving some cognitive functions the patient may have lost. Furthermore, research in this field is very critical and in some Catholic countries like Italy, people faced difficulties accepting the idea of the "Anticipated directives". In general, whatever the mental status and whatever the terminal state, the patients seem still far from handling their own auto-determination and their Consent, even if the ultimate goal is to die with dignity.

Crossbow injuries: A case report with experimental reconstruction study and a systematic review of literature.

In modern times crossbow - a ranged weapon diffused during Middle Ages - is increasing its popularity in recreational hunting and sports; crossbow bolts have a great penetration capacity, despite their low initial velocity. Great concerns emerge when considering that notwithstanding crossbow is a potentially lethal distance weapon, it is easy to obtain without having to undertake any tests on the buyer's mental or physical health. Although rare, crossbow injuries can be challenging for the forensic pathologist due to great similarities with other wounds pattern (gunshots wounds or injury due to sharp force). Especially when the arrow is removed from its original position or the body is decomposed, identification of the weapon can be difficult. According to forensic literature, suicides, homicides and non-lethal injuries by crossbow have been reported up to the present day. We followed the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) indications in the identification and selection of studies and reviewed a series of cases of both fatal and non-fatal crossbow injuries, according to the manner of death (homicide, suicide, accidental). The casuistic part of this paper deals with an attempted murder of a 21-year old man: a case of non-lethal crossbow injury of the thorax in which an interdisciplinary approach, involving forensic inspection, ballistic and radiology tests, led to solve the case.

Role of post mortem CT (PMCT) in high energy traumatic deaths.

BACKGROUND: Post Mortem Computed Tomography (PMCT) is being increasingly implemented in forensic field and could be an adjuvant to classic autopsies. In this study we evaluated the feasibility of complementation of conventional autopsy in trauma victims with PMCT. MATERIALS AND METHODS: A total of 21 subjects, who had sustained various types of blunt high-energy trauma, were selected from the casuistry of the Section of Legal Medicine at University of Pisa: before autopsy, a PMCT examination (Toshiba Aquilion 16 CT scanner) was performed, and after the acquisition of the raw images, MPR and VR reconstructions were performed with dedicated software. RESULTS: PMCT is more sensitive than conventional autopsy in detecting skeletal injuries, whilst autopsy constitutes the method of choice for the detection of thoracic and abdominal visceral injuries. CONCLUSIONS: PMCT should be considered a useful tool in addition to conventional autopsy in evaluating trauma victims: it detects further bone fractures in body parts difficult to investigate during autopsy (i.e. posterior regions), facilitating the pathologist in the reconstruction of events and in determining the cause of death.

A rare case of Spinal Epidural Abscess following mesotherapy: a challenging diagnosis and the importance of clinical risk management. Considerations concerning uncommon risk factor for development of Spinal Epidural Abscess and its prevention.

Spinal Epidural Abscess (SEA) is a rare pyogenic infection localized between dura mater and vertebral periostium. The development of SEA is associated with the presence of medical co-morbidities and risk factors that facilitate bacterial dissemination. It is possible distinguish two type of SEA: primary SEA due to pathogen hematogenous dissemination and secondary SEA resulting from direct inoculation of pathogen. This entity, very uncommon, shows a prevalence peak between the 5th and the 7th decade of life with predominance in males. The case is a 44 years old Caucasian man with chronic low back pain, treated with physiotherapy and anti-inflammatory drugs. Following an episode of acute severe exacerbation of pain, the patient underwent four session of dorsal and lumbo-sacral area mesotherapy. One month after the last session, the patient experienced acute sever lumbar pain, radiated to left lower limb and accompanied by fever and vomiting. During hospitalization, elevated levels of white blood cells and C Reactive Protein (CRP) were found. Moreover, a vertebral magnetic resonance imaging revealed the presence of intramedullary lesion. Furthermore, methicillin sensitive staphylococcus aureus was isolated from three blood cultures and antibiotic therapy was performed. In our case the patient had the typical SEA onset, without any specific risk factors excepting the execution of four session of mesotherapy. Aim of this study is to explain risk factors for the SEA development and to clarify how act as preventive measure, because also acupuncture can promote bacterial infection.

Is it time for international guidelines on physical restraint in psychiatric patients?

The freedom-restraining measures used during Involuntary Health Treatment (IHT) are highly criticized in the medical community. Physical restraint techniques are currently largely used worldwide in Psychiatry. The use of restraints against the patient's will can be considered a serious intrusion of basic human rights and even an act of violence against the patient. In all cases, the restraint should not lead to injuries or damage to the patient's health and should be implemented with a respect of the human rights and dignity. Generally, the use of restraint should be considered as a last resource, when all the other methods have failed. Since it represents the principal freedom-limitation measure, it should be constantly monitored by physicians who apply these methods. The case of a 58 years-old white male, affected by chronic schizoaffective disorder and cannabinoid dependence, was under involuntary medical treatment as a consequence of antisocial behavior. During the IHT he suffered firstly a pharmacological restraint and then a physical restraint in order to suppress a slight state of agitation. The patient was completely blocked to the bed for more than 80 hours and died after three days of hospitalization. The aim of this study is to evaluate the suitability of restrictive methods for psychiatric patients in order to establish specific rules to prevent abuse of restraint techniques and even to help physicians to treat psychiatric patients.

An immunohistochemical study of the diagnostic value of TREM-1 as marker for fatal sepsis cases.

Triggering receptor expressed on myeloid cells-1 (TREM-1) is produced and up-regulated by exposure of myeloid cells to lipopolysaccharides or other components of either bacterial or fungal origin, which causes it to be strongly expressed on phagocytes that accumulate in inflamed areas. Because TREM-1 participates in septic shock and in amplifying the inflammatory response to bacterial and fungal infections, we believe it could be an immunohistochemical marker for postmortem diagnosis of sepsis. We tested the anti-TREM-1 antibody in 28 cases of death by septic shock and divided them into two groups. The diagnosis was made according to the criteria of the Surviving Sepsis Campaign. In all cases, blood cultures were positive. The first group was comprised subjects that presented high ante-mortem serum procalcitonin and the soluble form of TREM-1 (s-TREM-1) values. The second group comprised subjects in which s-TREM-1 was not measured ante-mortem. We used samples of brain, heart, lung, liver and kidney for each case to test the anti-TREM-1 antibody. A semiquantitative evaluation of the immunohistochemical findings was made. In lung samples, we found immunostaining in the cells of the monocyte line in 24 of 28 cases, which suggests that TREM-1 is produced principally by cells of the monocyte line. In liver tissue, we found low TREM-staining in the hepatocyte cytoplasm, duct epithelium, the portal-biliary space and blood vessel. In kidney tissue samples, we found the TREM-1 antibody immunostaining in glomeruli and renal tubules. We also found TREM-1 staining in the lumen of blood vessels. Immunohistochemical staining using the anti-TREM-1 antibody can be useful for postmortem diagnosis of sepsis.