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.

[Sudden death from hypoglycemia]. / La morte improvvisa da ipoglicemia.

The sudden death by hypoglycemia is an aspect of the forensic pathology frequently neglected. Authors initially described the pathogenesis of different hypoglycemia forms, distinguishing the primary ones due to hyperinsulinism and the secondary ones due to functional insufficiency of other organs (hypophysis, thyroid, adrenal gland, liver); after that Authors described three cases of sudden death induced hypoglycemia by hyperinsulinism: two were unweaned with nesidioblastosis and one adolescent. In any form of hypoglycemia the central nervous system damage is present with evident neuronal degenerative-necrotic phenomena, widespread edema with microhemorrhage, swollen and dissociation of myelin sheath, glial cells hyperplasia. Death caused by primary hypoglycemia is histopathologically different from the secondary one because of the maintenance of hepatic glycogen content in the former, that increase in striated muscles, including the heart, in spite of the constant secretion of catecholamine from the adrenal medulla. Glycogen is depleted in secondary hypoglycemia. In the primary form, behind the adrenal medulla hyperfunction, the increased functional activity of the adrenal cortex is moderate, contrasting with the seriousness of the syndrome, due prevalently to inhibit the gluconeogenesis response conditioned by the persistence of stored glycogen in the liver, heart and striated muscles. The rare anoxic processes coming with resynthesis of hepatic glycogen have to be considered in the differential diagnosis. The primary hypoglycemic death, especially in unweaned, is frequently promoted by other processes inducing hypoxia (fetal asphyxia outcome, pneumonia, etc.) or worsening the hypoglycemia (hypothyroidism, etc.). The secondary hypoglycemias are characterized by the normality of exocrine pancreas and by organic alterations that cause glycogen depletion from the liver.

[2 fatal cases of acute myeloid leukemia (M3, M4) during pregnancy]. / Su due casi mortali di leucemia mieloide acuta in gravidanza (M3, M4).

Two cases of unexpected post-partum death of women with acute leukemia are described. In the first case (1st pregnancy) the diagnosis (acute promyelocytic leukemia: M3) was performed one week before delivery and death occurred 3 days later, because of hemorrhagic and renal DIC complication. Since one month before hospitalization, laboratory exams indicated a serious hematological pathology and no further exams were carried out by the physicians, elements of professional fault were recognized in them, considering that because of the diagnostic omission it was impossible to make an early diagnosis and thus perform to specific therapy, adopted only in the terminal phase. This specific therapy is able to determine remission from most cases of acute promyelocytic leukemia. In the second case (2nd pregnancy) the diagnosis (acute myelomonocytic leukemia: M4) was performed only postmortem because, during the whole pregnancy, no signs of disease were evident. After a few hours from the spontaneous delivery, death occurred as a result of an intractable + hemorrhagic syndrome caused by primary hyperfibrinolysis and repeated episodes of cardiac arrest, without possibility of recognizing it. The medical procedures for this case, both throughout pregnancy and terminal phases, appeared free of censure.