Investigation on physical restraint use in hospital: health responsibility, ethical and medical legal considerations.

Background: The issue of restraint has long been considered a difficult political and social situation, affecting both healthcare wor-kers and facilities. The practice of restraint is still widespread in many public and private care settings, but there is a lack of systemic studies capable of monitoring the phenomenon. The framing of the question essentially concerns the right to personal freedom, guaranteed by the Italian Constitution. Materials and Methods: An anonymous questionnaire was developed containing questions on knowledge of the regulations on restraints, how, ways, and when they are implemented, and general information such as age, gender, educational qualification, qualification, O.Us. to which they belong. The collected data were statistically processed (Chi-square test) with the Epi Info 7.1.5 program (CDC-Atlanta- USA). A total of 1002 questionnaires were completed. The stratification of the sample by structure shows that 73.9% were public facilities. The indicative figure is represented by the 23.8% of respondents who say that "the restraint is not noted in the medical record". Conclusions: Restraint could be a real risk for the healthcare worker, encroaching on the issue of health liability. It is therefore important to raise awareness among healthcare professionals and top management of the need to structure, at company level, procedures that comply with the "Recommendations on physical restraint" to overcome the use of restraint through the improvement of care pathways in compliance with organizational and risk management standards.

A case of suicide of psychiatric patient in the Sicilian hospital: accidental or professional liability of "top management"?

Background: In the hospital environment, any liability for organizational inadequacy and/or inefficiency, or again for defects in the facilities, or inadequacy of health equipment may be found in the work of the apex professional figures: Medical Director, the General Manager, and/or others. The responsibility for the internal organization of the department falls on the figure of the Director of the Complex Structure where the deficiencies have not been promptly and adequately reported to the top figures. Case Report: A woman 61-year-old, was admitted on a voluntary basis to the Department of Psychiatry. On the third day, in the early morning hours, the patient was found on the ground floor, lying on the floor near the entrance door of the ward with a lacerated contusion wound to the head. The woman underwent total body CT examination with findings of fractured polytrauma as well as subarachnoid hemorrhage and complete fracture of the spleen, which was surgically removed. Three days later, despite the care given, death occurred. The injuries ascertained were consistent with voluntary precipitation from the second-floor stairwell window. The investigations conducted by the police and the checks carried out by the head of the Internal Prevention and Protection Service and the company's Risk Manager, highlighted multiple critical issues. Conclusion: The case allows for numerous considerations relating to liability profiles in the determinism of the patient's death, the hospital's company failure to implement measures to prevent the patient's suicide in the hospital was influential.

The Role of Bloodstain Pattern Analysis (BPA) in Reconstructing the Dynamics of Forensic Cases.

Background: Bloodstain Pattern Analysis (BPA) is a forensic scientific discipline used to resolve criminal events. By studying the size, shape, and distribution of the bloodstains that constitute one or more bloodstain patterns, it is possible to determine the physical events responsible for their creation, as well as the positions and movements of the victim and, in cases of homicide, the perpetrator during the act. Materials and Methods: BPA analysis was applied as a support in the reconstruction of the event dynamics in four forensic cases, in addition to the data collected during on-site inspections and instrumental investigations including PMCT, autopsies, histological, and toxicological analyses. Particularly laborious was its application in a case involving a decomposed body. In all cases, a thorough photographic analysis of the bloodstains found on the clothing worn as well as in the areas surrounding the location of the corpse was conducted. Conclusions: The combination of investigations, together with the data derived from the application of BPA, allowed events to be attributed to: homicide by blunt force trauma; homicide-suicide using a bladed weapon; homicide using firearms; unplanned complex suicide. The analysis of the cases presented highlights the importance of a multidisciplinary approach through the use of additional instrumental and specialist investigations such as the study of bloodstains present at the crime scene for the reconstruction of criminal events.

Use of morcellation in laparoscopic myomectomy. Medical malpractice and medicolegal considerations.

Background: In recent years, due to the increase in medical mal-practice complaints, the Sicilian Regional Health System has adopted procedures for the direct management of claims by each health facility with the aim of reducing the costs of insurance premiums and related taxes. Mandatory sentinel event monitoring is a crucial part of this strategy to improve patient safety and quality of care. The reported case relates to a laparoscopic myomectomy surgery performed by means of morcellation, a controversial technique. After the FDA's intervention in 2014, it is believed that morcellation may worsen the staging of the disease by spreading malignancies such as leiomyosarcoma into the abdomen. Case report: A 28-year-old woman, underwent laparoscopic surgery for uterine fibroids and an ovarian cyst removal in August 2018. Post-surgery, she was diagnosed with Leiomyoma. She returned to the hospital due to metrorrhagia and was discharged after a week. Persistent symptoms led to her readmission and subsequent exploratory laparoscopic surgery at another hospital. This resulted in a total hysterectomy and the discovery of uterine leiomyosarcoma, with FIGO STAGE IIIB staging. Despite chemotherapy, she passed away six months later. Discussion and Conclusions: This case highlights medical-legal issues. Informed consent for morcellation and its risks was not obtained. The morcellation technique was used, increasing cancer spread risk. The histopathological process was inadequate, with three biopsies leading to misdiagnosis. This could be medical malpractice, making providers legally responsible for the patient's deteriorating condition and the anticipation of possible death.

Homicide-Suicide and multidisciplinary approach: case series and a review of the literature.

Introduction: Despite being relatively rare in our country, murder-suicide phenomena have garnered increasing media attention over the years. However, actual data on their prevalence and characteristics remain limited. This study aims to describe and characterize all murder/suicide events reported at the Institute of Forensic Medicine in the Province of Messina, with a particular focus on distinguishing between cases of filicide/suicide and dyadic deaths. Materials and Methods: A retrospective observational analysis of judicial cases from 2018 to 2023 was conducted. Injuries were primarily localized to the head, neck, and chest for women, and to the head for men. In the case of filicides, death occurred through an asphyxiation mechanism, followed by the mother's suicide by hanging or falling. Conclusion: Within the scope of the medical examiner's activities, it is clear that acquiring more information through a standardized technical investigation and adopting a uniform approach could enhance the quality of the forensic service provided daily. This improvement, which would be in the interest of institutions and civil society, could be achieved through the sharing of procedures at both national and international levels.

Multiple suicidal gunshot wounds. Case reports and mini-review of literature.

Background: To determine the manner of death (MOD) and, there-fore, to classify the event as natural, suicidal, homicidal, or accidental is an essential and routine task in forensic medicine. The evaluation of MOD presents numerous difficulties due to unusual anamnestic and circumstantial data, in addition to autopsy findings and postmortem findings. Materials and Methods: A mini review of the literature on the topic was performed. Here we report two cases of uncommon self-inflicted multiple GWs (SMGWs) to the head and thorax, suspected of killing. The presence of more than one gunshot wound is suggestive of homi-cide, especially when they involve the head. A review of the literature on the topic was performed on PubMed's database, showing, although considered infrequent, cases documenting SMGWs are not rare. Conclusion: In the cases reported, the initial suspicion of involvement of third persons was excluded through the examination of the death scene, post-mortem (CT and autopsy) findings and clinical-circumstantial data. The analysis derived from the review of the related literature allowed us to highlight the presence of common findings which should be considered in the evaluation of such cases.

Homicidal or suicidal death? Evidence-based approach to assessing cause of death in a peculiar forensic case.

Background: In recent years, the improvement of common standards of forensic practice has received attention to promote an unambiguous and better-quality forensic investigation method. Although most hanging deaths are attributed to suicides, cases occasionally occur due to accidents or homicides. From an investigative point of view, hanging deaths are usually straightforward, but unusual circumstances may raise suspicions of crime. This includes complex suicides, which are rare events pursued by victims with two or more different fatal methods and can be classified as planned or unplanned, depends on whether the methods are applied simultaneously or sequentially. The multiplicity of injuries detected can often lead to misinterpretations, thus making a multidisciplinary approach extremely important. Case Report: A 44-year-old man, after requesting law enforcement, has been instead found inside a garden of an uninhabited property located a few kilometers away from his own property, suspended from a beam with wire; the wire created a noose at the back of his head, his hands were placed at his neck, and stab wounds were found. Conclusions: The crime scene investigation, interview of relatives, autopsy, histological and toxicological examinations, and GAP led to the determination that the death was suicide. This comprehensive approach emphasizes the importance of meticulous investigation and analysis to reach accurate conclusions in forensic cases.

The ghost dead: ethical and medico legal analysis on the Mediterranean tragedies.

Background: Cadaveric identification represents a legal, moral and medico-legal obligation and also fulfills the ethical function to allow the living to offer their dead a merciful burial. In the Mediterranean basin we have been witnessing for years a struggle for life where hundreds of migrants die in an attempt to reach Europe. For these people right to be recognized is not easy because of ante-death biological data are not always available for comparison, and DNA analysis is not always feasible cause for the absence of data with which to compare. In Italy a multidisciplinary protocol has been adopted that involves the acquisition of data provided by family members present in the countries of origin. Materials and Methods: Between August 2015 and December 2021, bodies of 879 migrants of various nationalities washed up on the shores of Sicily and Calabria. These men, women, and children, in various states of preservation, were examined. Each body underwent a multidisciplinary approach. External examination and autopsy aimed to determine the cause of death for judicial purposes and to facilitate individual identification. Whenever possible bodies underwent total body post-mortem computed tomography examination to identify fractures and prosthetic implants. including inspection of the third molar to provide an estimate of the age. Conclusions: The activity carried out in cooperation with Prefecture, Scientific Police, and National and International Red Cross highlighted the importance of employing multiple scientific skills to compensate for the lack of biological information. The importance of appropriate behaviors to avoid contamination and ensure proper preservation underlines the importance of the establishment of a dedicated database.

The role of PMCT in firearm injuries. Case study.

Background: The use of radiological approaches in forensic investigations is rapidly emerging as an alternative to traditional autopsies. Here, we present the experience of the Sicilian and Calabrian forensic medical departments over the past five years, highlighting the application of PMCT to support autopsies in cases involving gunshot wound victims. Materials and Methods: From January 2020 to March 2024, thirty cadavers who died from gunshot wounds underwent total body PMCT examinations followed by autopsies. The examinations included multi-planar and 3D reconstructions. Data collected for each subject included gender, age, mode of death, type of weapon, number of shots, body sites affected, and presence of retained bullets. A team of two radiologists and two forensic physicians evaluated the images and compared them with the autopsy findings. Conclusion: PMCT and 3D reconstruction enabled evaluation of entry wounds, fracture margins, injury sites, fragments, and anatomical trajectories. The results from PMCT were compared with autopsy findings in terms of entry wounds, wound channels, foreign bodies, organ and skeletal injuries, and causes of death. PMCT showed concordance with autopsy findings in determining the cause of death in all cases. The speed, non-invasiveness, and ability to manipulate and reconstruct data make PMCT an ideal technique for supporting forensic investigations and autopsies. PMCT is highly reliable for accurately identifying lethal wounds and determining the cause of death. It excels at tracking wound paths, distinguishing entrance and exit wounds, locating retained bullets, and detecting fragmentation and dispersion of ballistic components.

Sudden Unexpected Death in Epilepsy (SUDEP). Full forensic approach in two cases and review of literature.

Background: The SUDEP is defined as a sudden unexpected death in patients affected by epilepsy, with or without evidence of a seizure, excluding documented status epilepticus, in which postmortem examination does not reveal a toxicologic or anatomic cause of death. Materials and Method: Here we report two cases observed at the Institute of Forensic Medicine of Messina, regarding the phenomenon, that were analyzed by a multidisciplinary approach. Meantime a systematic review of literature was performed using PubMed and Scopus databases. Conclusion: Although the mechanisms of SUDEP are not fully understood, several studies have allowed the identification of different brain areas whose anomalous stimulation, during epileptic seizures, could interfere with the correct control of cardiovascular and respiratory activities. The study highlights the importance of a complete multidisciplinary forensic approach analyzing different aspects in people affected by epilepsy, with no other cause of death. Furthermore, reinforce the definition of SUDEP for uniform cause-of death certification in these cases.

Analysis of the contentious relating to medical liability for healthcare-associated infections (HAI) in a Sicilian hospital.

Background: Since 2012, the Sicilian regional government, in view of the increase in malpractice claims, has adopted a "self-insurance system" The claims management activities have been delegated to the Claims Management Committees (CMCs), the importance of which was also emphasized by Law No. 24/2017. This study aims to describe the experience of Sicilian Hospital CMC and analyze the claims' features, especially for contentious HAIs. Healthcare-associated infections (HAIs) continue to be a major public health concern. The contraction of infection during hospitalization generally results in a significant worsening of the patient's quality of life and prolongation of his or her stay. Still, it is also responsible for an increase in costs that burden the hospital and the entire Health System. Material and Methods: The study investigates the analysis of claims received by a Messina Hospital Company between January 2015 and December 2023 even though for events that occurred in earlier years. From the database, cases in which the Company was sued for HAIs were extrapolated and analyzed, distinguishing them by year and by Department. The data collected were statistically processed with the Epi Info 7.1.5 program (CDC - Atlanta - USA). Conclusion: The CMC experience highlighted a statistically significant increase in complaints especially for those relating to HAI, without differences by Department. In most cases, the CMC admitted the hospital's liability, and an attempt at conciliation was promoted and moreover risk management initiatives were adopted. This is important when considering the recent ruling 6386/2023 of March 3, 2023.

Case of tracheal rupture after endotracheal intubation: clinical risk management and medico-legal considerations.

Background: Tracheal injury may be a rare complication of the endotracheal intubation procedure. Incidence and determinant factors are not well known, nevertheless a greater incidence have been recognized with a difficult maneuver or the use of nitrogen peroxide. The therapeutic approach can be conservative or surgical, depending on the characteristics of the lesion and of the patient and therefore the outcomes of medico-legal interest can be different. Case description: It is a case of alleged medical liability regarding a 70-year-old woman, that during the intubation procedure was pouncing on the right. Furthermore, nitrous oxide was used as an anaesthetic. A few hours after the operation the patient showed swelling on the right half of the face and on the right lateral region of the neck. The emergency chest CT scan highlighted subcutaneous emphysema and pneumomediastinum. In the operating room, fibrobronchoscopy was performed with a double-lumen bronchial tube which confirmed the hypotheses lesion; then, right posterolateral thoracotomy was perfor-med followed by suturing of the tracheal lesion. Subsequently, the patient was discharged in good clinical conditions but with a scar in the region of the right hemithorax. Conclusions: Iatrogenic tracheal injury is a rare and fearful complication of the orotracheal intubation procedure. Although risk factors that increase the probability of its onset have been recognized, in most cases it is not possible to identify the cause. From a medico-legal point of view, tracheal injury after intubation is unpredictable and inevitable, so in the case reported it was decided to proceed with a conciliatory solution.

Entrapment and rupture of the guide wire during PTCA: case report and medico-legal considerations.

Background: In recent years, due to the increase of complaints for medical malpractice, the Sicilian Regional Health System has adopted proceedings for the direct management of claims by each healthcare facility with the aim of reducing costs of insurance premiums and their relative taxes. Thus this management has led to increased awareness and management of clinical risk through the introduction of mandatory sentinel event monitoring. Case report: A 55-year-old man with acute ischemic heart disease, due to three-vasal coronary diasease, underwent angioplasty perfomed on the second diagonal branch of the anterior descending artery. Simultaneously following the discovery of a major middle tract stenosis, he underwent further angioplasty surgery during which guidewire entrapment occurred, precisely in the proximal section of the vessel, resulting in the rupture and persistence of some fragments despite attempts to extract them. Subsequent antiplatelet therapy was prescribed and no further procedures were indicated for the removal of the guide wire, meanwhile a persistent reactive anxious-depressive state was established. Conclusion: The medico-legal analysis of the case excluded liabilty since it was a fortuitous, unpredictable and inevitable event. However, the patient had not been adequately informed about the possibility of the complication presented, which resulted in prolonged hospitalization and compensation for the psychological disorder suffered as a result of the adverse event. The attempted economic agreement was unsuccessful. A civil lawsuit was subsequently filed by the patient and the Judge's report confirmed the corporate CMC assessment and ruled out that the side effects related to the guideline fragment.

MicroRNAs expression in pituitary tumors: differences related to functional status, pathological features, and clinical behavior.

BACKGROUND: MicroRNAs (miRNAs) are small non-coding RNA molecules that regulate gene expression at post-transcriptional level, having a role in many biological processes, such as control of cell proliferation, cell cycle, and cell death. Altered miRNA expression has been reported in many neoplasms, including pituitary adenomas (PAs). PURPOSE: In this study, we aimed to evaluate the expression of 20 miRNAs involved in pathways relevant to pituitary pathophysiology, in PAs and normal pituitary tissue and to correlate their expression profile with clinical and pathological features. METHODS: Pituitary tumor samples were obtained during transphenoidal surgery from patients with non-functioning (NFPA, n = 12) and functioning (n = 11, 5 GH-, 3 ACTH-, 3 PRL-omas) PAs. The expression of selected miRNAs in PAs and in normal pituitary was analyzed by RT-qPCR. miRNAs expression was correlated with demographic, clinical, and neuroradiological data and with histopathological features including pituitary hormones immunostaining, Ki-67 proliferation index, and p53 immunohistochemistry evaluation. RESULTS: All evaluated miRNAs except miR-711 were expressed in both normal and tumor pituitary tissue. Seventeen miRNAs were significantly down-regulated in pituitary tumors compared to normal pituitary. miRNAs were differentially expressed in functioning PAs or in NFPAs, as in the latter group miR-149-3p (p = 0.036), miR-130a-3p (p = 0.014), and miR-370-3p (p = 0.026) were significantly under expressed as compared to functioning tumors. Point-biserial correlation analysis demonstrated a negative correlation between miR-26b-5p and Ki-67 (p = 0.031) and between miR-30a-5p and 'atypical' morphological features (p = 0.038) or cavernous sinus invasion (p = 0.049), while 508-5p was inversely correlated with clinical aggressiveness (p = 0.043). CONCLUSIONS: In this study, we found a significant down-regulation of 17 miRNAs in PAs vs normal pituitary, with differential expression profile related to functional status and tumor aggressiveness.

Association between genetic polymorphisms of glutathione S-transferase M1/T1 and psoriasis in a population from the area of the strict of messina (Southern Italy).

Glutathione S-transferases (GST) are antioxidant enzymes with frequent genetic polymorphisms. Homozygosis for gene deletion ("null" genotype) of GSTM1 and GSTT1, causing decrease of the antioxidant potential of the organism, is frequent, with variable frequency in different ethnic contexts. Although oxidative stress notoriously plays a role in the pathogenesis of psoriasis, few studies exist on the association between GSTM1/GSTT1 genotype and psoriasis, with different results. We aimed to assess the frequency of GSTM1/GSTT1 polymorphisms in Southern Italian psoriatic patients and controls and investigate the association of the GSTM1/GSTT1 genotype with individual and disease parameters. To this aim, the GSTM1/GSTT1 genotype of 148 psoriatic patients and 148 age- and sex-matched controls was defined by PCR on oral mucosa cells. GSTT1 null was associated with psoriasis (55.4% of patients vs. 25% of controls, p = 9.58 × 10-8, odds ratio 3.73), while GSTM1 null was not. The GSTM1/GSTT1 "double null" genotype conferred an even higher odds ratio for psoriasis (5.94). The association between psoriasis and GSTT1 null was stronger in women (54.1% of patients vs. 19.7% of controls, p = 8.13 × 10-5) than in men (56.3% of patients vs. 28.7% of controls, p = 0.0002). No association was found between GSTM1/GSTT1 genotype and psoriasis severity, age of onset or comorbidities (psoriatic arthritis, metabolic syndrome). The remarkable differences among the few available data on the association between GSTM1/GSTT1 polymorphisms and psoriasis suggest the need for further studies, on different and larger populations, to improve knowledge on the pathogenesis of psoriasis and possibly provide more precise and personalised prevention and treatment in the future.

Polymorphism of glutathione S-transferases M1 and T1: susceptibility to solar keratoses in an Italian population.

BACKGROUND: Polymorphisms of glutathione S-transferases (GSTs) are linked to skin cancer, but data on their association with solar keratosis (SK) are few and conflicting. AIM: To verify the possible association between the development of SK and the 'null' GSTM1 and/or T1 genotype. METHODS: Analysis of the GSTM1 and T1 genotype of 33 subjects with ≥3 solar keratoses and of 150 controls, before and after stratification based on smoking habits, sun exposure and immunosuppression. RESULTS: The GST T1 null allele is significantly (P < 0.03) associated with increased prevalence of SK in our population. CONCLUSIONS: Our study, the first on a Mediterranean population, shows the existence of a correlation between SK and the GST T1 null genotype. This result points out significant differences between subjects of different ethnic and geographical origin and warrants further investigation on a larger population, and ethnically different populations.

[Genetic polymorphisms (GSTT1 e GSTM1) and urinary excretion of t,t-muconic acid among refinery workers]. / Polimorfismi genetici (GSTT1 e GSTM1) ed escrezione urinaria di acido t,t-muconico in lavoratori di una raffineria.

Many xenobiotics agents are metabolized by enzymes mechanisms through Phase I, activating substances procancerogene through oxidative reactions, and / or through mechanisms Phase II, acting on metabolic intermediate products of oxidative processes with conjugation reactions with endogenous mediators, in order to generate hydrophilic products that can be easily excreted by the body. Among the enzymes Phase II is a heterogeneous group represented by glutathione S-transferase. Genetic polymorphisms encoding for these enzymes (GSTs) are responsible phenotypic expression of enzymes specifically involved in the detoxification and elimination of different genotoxic agents (IPA, toluene, benzene). Accordingly, the authors have investigated a population of subjects professionally exposed to benzene (used in active refining and storage of crude oil) in order to assess the genetic profile in relation to possible null genotype (responsible for the failure phenotypic expression of protein) of polymorphism GSTT1 and GSTM1 and correlate the impact that the genotype effect of normal metabolic pathway t, t-muconico.

Y-chromosome haplotypes in Italy: the GEFI collaborative database.

A sample of 1176 males from 10 Italian regions have been typed for DYS19, DYS389-I, DYS389-II, DYS390, DYS391, DYS392, DYS393, and DYS385. Individual haplotype data are available on line. A low degree of variation is present among regions. Use of this database is specifically recommended for forensic applications in Italy.

[Aorto-esophageal fistula caused by foreign body]. / La fistola aorto-esofagea da corpo estraneo.

Aortoesophageal fistula is a rare but fatal cause of upper gastrointestinal bleeding. AEF develop progressively from the esophageal perforation caused by foreign body. Clinically, there is a medial chest pain, followed by hematemesis and finally terminal exsanguination. Diagnosis must be achieved during the free intervals in this triad of often rapidly succeeding signs.

Population study of the short tandem repeat polymorphisms HumTH01, HumvWA31, HumFESFPS and HumF13A01 in Sicily (Southern Italy).

Population genetic studies were carried out on randomly selected and unrelated healthy individuals from Sicily (n = 140-150 individuals) using the short tandem repeat (STR) systems HumTH01, HumvWA31, HumFESFPS and HumF13A01. After vertical electrophoresis on polyacrylamide denaturing gels 6 alleles could be identified for TH01, 9 for vWA31, 7 for FESFPS and 11 for F13A01. No significant deviations from Hardy-Weinberg were observed.