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.

Parameters for estimating the time of death at perinatal autopsy of stillborn fetuses: a systematic review.

BACKGROUND: Stillbirth is defined by the WHO as birth of a fetus with no vital signs, at or over 28 weeks of pregnancy age. The estimation of time of death in stillbirth appears crucial in forensic pathology. However, there are no validated methods for this purpose. OBJECTIVE: To perform a systematic review of the available literature regarding the estimation of the time of death in stillborn fetuses, in terms of hours or days. METHODS: Electronic databases were searched from their inception to August 2018 for relevant articles. Macroscopic, histologic, and radiologic parameters were evaluated. RESULTS: Nine studies with 664 stillborns were included. The evaluation of extent and location of fetal maceration signs showed good accuracy in estimating the time of death; by contrast, a dichotomous assessment of maceration (present vs absent) was found to be unreliable in a subsequent study. Histologic assessment of the loss of nuclear basophilia in fetal and placental tissues showed excellent accuracy; an "autolysis equation" was proposed to achieve an even higher accuracy in fetuses who had been dead for < 24 h. Magnetic resonance imaging of the lung parenchyma, pleural fluids, and brain parenchyma could estimate the death-to-autopsy time, but the results appeared weak and conflicting. CONCLUSION: Pathologic examination, based on the assessment of maceration, and even more of the loss of nuclear basophilia, may be a reliable method to estimate the time of death in stillborn fetuses. Further studies should be encouraged to validate these results. Imaging techniques have not yet found application in this field.

To kill or be killed: the coup de grâce for a warrior after multiple sword wounds.

Finding traumatic lesions on ancient skeletal remains offers a unique opportunity to investigate the circumstances surrounding the time of death. Here we present the unique find of a late 17th, early 18th century young male from Southern Italy with eight traumatic skull lesions. A detailed anthropological examination using X-ray and 3D CT scanning techniques was conducted in order to evaluate traumatic extent, direction and degree of severity of each skull injury. The nature, number and timing of repair of the traumata suggest that they were intentional blows inflicted in battle. Gross and radiographic evidence shows that the individual survived long after one of these traumata, most likely suffered in a previous battle. Shape, size and location, as well as different orientation and implied trajectory of the multiple wounds, suggest that they were produced by a heavy, sharp cutting weapon. The perimortem aspect of most of the traumata revealed them to be contemporary injuries, suffered in a final assault by a heavy sword during a face-to-face combat. The largest and deepest fracture penetrating the skull cavity possibly resulting in traumatic brain injury was here suggested as the fatal one, even if the victim may have survived for several days prior to death.

A hypothesis of sudden body fluid vaporization in the 79 AD victims of Vesuvius.

In AD 79 the town of Herculaneum was suddenly hit and overwhelmed by volcanic ash-avalanches that killed all its remaining residents, as also occurred in Pompeii and other settlements as far as 20 kilometers from Vesuvius. New investigations on the victims' skeletons unearthed from the ash deposit filling 12 waterfront chambers have now revealed widespread preservation of atypical red and black mineral residues encrusting the bones, which also impregnate the ash filling the intracranial cavity and the ash-bed encasing the skeletons. Here we show the unique detection of large amounts of iron and iron oxides from such residues, as revealed by inductively coupled plasma mass spectrometry and Raman microspectroscopy, thought to be the final products of heme iron upon thermal decomposition. The extraordinarily rare preservation of significant putative evidence of hemoprotein thermal degradation from the eruption victims strongly suggests the rapid vaporization of body fluids and soft tissues of people at death due to exposure to extreme heat.

Joint consensus on abdominal robotic surgery and anesthesia from a task force of the SIAARTI and SIC.

Minimally invasive surgical procedures have revolutionized the world of surgery in the past decades. While laparoscopy, the first minimally invasive surgical technique to be developed, is widely used and has been addressed by several guidelines and recommendations, the implementation of robotic-assisted surgery is still hindered by the lack of consensus documents that support healthcare professionals in the management of this novel surgical procedure. Here we summarize the available evidence and provide expert opinion aimed at improving the implementation and resolution of issues derived from robotic abdominal surgery procedures. A joint task force of Italian surgeons, anesthesiologists and clinical epidemiologists reviewed the available evidence on robotic abdominal surgery. Recommendations were graded according to the strength of evidence. Statements and recommendations are provided for general issues regarding robotic abdominal surgery, operating theatre organization, preoperative patient assessment and preparation, intraoperative management, and postoperative procedures and discharge. The consensus document provides evidence-based recommendations and expert statements aimed at improving the implementation and management of robotic abdominal surgery.

Some inconsistencies in Demirjian's method.

Nowadays, given the massive migration movements toward and across EU countries, age assessment can be highly useful for estimating the real age of asylum seekers or in medico-legal assessments of age-disputed children charged with criminal acts. Demirjian et al.'s dental maturity score is currently a dental scoring system universally adopted for age assessment of unidentified children. Here we explore the biological compatibility of Demirjian's scores with respect to the estimation of certain chronological ages of forensic interest through an algorithm based on the theory of constrained graphs integrated with combinatory analysis. Rather than simply respect Demirjian's indications (direct method) on a sample of children, we followed a reverse procedure (indirect method) as follows: i. chronological age selection and identification of the corresponding maturity score (MS); ii. determination of all the possible combinations of dental maturity stages whose sum of the scores is equal to the MS under consideration; iii. checking for all such possible combinations the biological congruity of the state of maturity of each tooth compared to the chronological age initially chosen. By evidencing dental development inconsistencies, our mathematical approach explains why Demirjian's method typically overestimates age. Therefore, even if the method in question remains the recommended way to assess individual dental maturity, it should definitely be considered unsuitable for application in certain forensic scenarios, particularly as regards the most disputed age range 14-16 years.

Delay in diagnosis affects the clinical outcome in a cohort of cvid patients with marked reduction of iga serum levels.

Common variable immunodeficiency disorders (CVID) represent a collection of diseases leading to an absent or strongly impaired antibody production. CVID presents a wide range of immunological abnormalities and clinical manifestations, including infections, inflammatory and autoimmune diseases, and malignancies. The aim of this observational study was to analyze the epidemiological and clinical features of a cohort of 75 Italian CVID patients, and evaluate the correlation with comorbidity and mortality. Clinical data were retrospectively collected: the cohort was followed-up for a maximum of 30years (mean time of 10.24years, median of 9years). An higher age at the diagnosis of CVID and an higher age at onset of symptoms were significantly associated with a reduction of patients survival if stratified per median of IgA (less than or >8.00mg/dl). Thus IgA levels at diagnosis are correlated with patients survival contributing to identify a subset with a worse prognostic outcome.

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.

Electroconvulsive Therapy in Italy: Will Public Controversies Ever Stop?

BACKGROUND: The use of electroconvulsive therapy (ECT) is still very limited in Italy for ideological rather than scientific reasons. OBJECTIVES: To describe the public controversies surrounding ECT in Italy and to propose a plan of action to resolve the dispute. METHODS: We describe the historical background and the current public controversies about ECT by reviewing the official documents issued by the entities involved in the debate and by reporting our personal experiences of ECT practice. RESULTS: According to the highest legal and health authorities, there are no ethical reasons for doubting the licit nature of ECT. However, because of politically and ideologically based conflicts, public ECT centers are still lacking. The situation could further deteriorate because local initiatives are endeavoring to criminalize and ban the treatment. CONCLUSIONS: The enactment of specific regulations and guidelines concerning the use of ECT by the Italian government is highly warranted to increase the availability of the treatment. Education and information campaigns must strive to increase the knowledge of health professionals and the lay public regarding the safe and beneficial use of ECT.

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.

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.

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.

Suggestions on how to make suboptimal kidney transplantation an ethically viable option.

To overcome kidney donation, the pool of potentially eligible donors has been widened by using suboptimal organs harvested from living donors or cadavers. These organs may engender health complications as age, risk factors, and pathologies of donors fail to meet the standard donor criteria. After examining a wide array of literature on suboptimal kidney transplants, we evidenced two major issues: the lack of standardized terminology and the lack of longterm data on the health outcomes of both suboptimal living donors and recipients. Consequently, surgeons are still unable to provide patients with thorough information to obtain a well-informed consent. Suboptimal kidney transplantation still remains in its experimental stage, thereby raising many ethical and medico-legal concerns. We suggest that one possible solution to overcome some of the ethical shortcomings of suboptimal kidney donations is to provide living donors and recipients honest, accurate, and thorough information about its health risks. To this aim, we advocate adopting a widely standardized terminology that would embrace the whole concept of suboptimal kidney transplantation, increasing the number of future publications on the health outcomes of living donors and recipients, spurring ethical reflection to improve the experience of suboptimal kidney transplantation and reduce the waiting-list for kidney transplantation.

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.

Plastination: ethical and medico-legal considerations.

The international plastination phenomenon has proved to be immensely popular with audiences world-wide. Never before has the human body been exposed to public gaze in such an accessible manner. The exhibitions have perplexed many, included anatomists, some of whom find the display of human bodies unethical. The objective of this study is to review the attention on the use of plastination and exhibition of entire human bodies for non-educational or commercial purposes. The nature of these exhibitions and the uneasy balance between entertainment and education has caused heated debate. The possible legitimacy of the expression of one's will as far as exhibition purposes isn't considered sufficient for the indiscriminate use of a corpse despite the ethical necessity of respecting the wishes of individuals based on respect for the deceased. The informed consent of an individual represents only the most basic and minimal prerequisite for the use of the deceased's body for exhibition purposes, and is absolutely not enough on its own to justify its use in entertainment exhibitions or for the commercialization of the death.

Prevalence and Severity of Myocardial Perfusion Imaging Abnormalities in Inmate Subjects.

AIM: We evaluated the prevalence and severity of myocardial perfusion abnormalities among inmates undergoing cardiac single-photon emission computed tomography. We also compared the results with those obtained in a cohort of non-inmates. METHODS: Between January 2009 and December 2013, 2420 consecutive subjects (258 inmates and 2162 non-inmates) with suspected or known coronary artery disease underwent stress myocardial perfusion single-photon emission computed tomography (MPS) to our institution. The decision to submit inmates to MPS was taken by the physicians of the penal institutions or ordered by the court based on the survey of part. To account for differences in clinical characteristics between inmates and non-inmates, we created a propensity score-matched cohort considering clinical variables and stress type. RESULTS: Before matching, inmates were younger and had higher prevalence of male gender, smoking, chest pain, and previous myocardial infarction or revascularization (all p < 0.001). After matching, all characteristics were comparable in 258 inmates and 258 non-inmates. The total amount of abnormal myocardium was similar in inmates and non-inmates before and after matching. Infarct size and severity were larger in inmates before (p < 0.001) and after (p < 0.01) matching and left ventricular ejection fraction was lower in inmates compared to non-inmates (p < 0.01). CONCLUSIONS: Detention is associated with larger infarct size compared to a general population of subjects referred to stress MPS also after matching for clinical variables and stress type. The similar prevalence of normal MPS in the matched cohort suggests that this imaging technique might be appropriate in inmates.

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.