Commentary to the paper: A child of two mothers: what about the father? Italian overview.

Assisted reproductive techniques have made it possible for same-sex couples to become "parents", and for children to have two mothers, or even two fathers. Such parents have applied for the legal registration of the birth certificates issued abroad for children born through assisted procreation procedures that would not have been legally possible in Italy. The Italian Constitutional Court and the Supreme Court of Cassation have however ruled against such recognition, pointing out that the children's best interest can be pursued through adoption "in extraordinary circumstances", as regulated by law n. 184, enacted in 1983. The article's Author has stressed the need for  new piece of legislation, specifically aimed at more effectively regulating such scenarios. We share that sentiment, and wholeheartedly hope that Italian lawmakers will soon draw up and enact a new law, based on adoption in exceptional circumstances, so that children born abroad through assisted reproduction may be allowed to live in a loving family settings, raised by the parents who made their births possible in the first place. Such new norms will have to ensure that the children's well-being and fundamental rights are upheld, including the right to know their biological origins.

The Application of Photogrammetry in the Autopsy Room: A Basic, Practical Workflow.

Photogrammetry is a technique that uses two-dimensional photographs taken from different angles and positions to determine three-dimensional coordinates and distances. Becoming familiar with the photography technique for photogrammetry purposes is the first step to obtaining high-quality results. Ten human cadavers were studied to develop this protocol. Appropriate equipment settings, measurements, and suitable ambient conditions were determined. Finally, the protocol was tested on one cadaver wherein a full postmortem examination was conducted, allowing accurate 3D modeling and measurements of the human body. This straightforward, step-by-step workflow will help users become familiar with this technique. A thorough description of the necessary steps is reported, including equipment, environment requirements, body placement, how to take photographs, and the minimum suggested number of photographs. Numerous graphics show the protocol's main steps to help users understand and reproduce the entire process. Photogrammetry allows the permanent recording and storage of photographic evidence of conditions that existed at the time of autopsy and accurate measurements of the body. The 3D model can have a powerful effect in court, where the findings can be accurately depicted without elicitation of strong emotion that may influence the judge or jurors. The primary disadvantage of photogrammetry for forensic pathology is its time-consuming nature. However, the widespread use of the photogrammetry technique in postmortem rooms would allow in-depth testing to detect and fix potential pitfalls, making this technique more reproducible and verifiable, increasing its admissibility in courts.

Recent Medico-Legal Developments on the Issue of Epilepsy and Driver's License Requirements in the Italian and European Legislation.

Epilepsy is a condition that comprises a group of neurological disorders characterized by seizures. Forms of epilepsy that produce abrupt bouts that cause lapses in consciousness may pose a major road safety problem for drivers who, while going through a seizure, could seriously harm themselves as well as others. A fundamental strategy for the purpose of reducing the risk of car accidents caused by epileptic drivers is constituted by prevention, in addition to adequate pharmacological therapies. In that respect, forensic medicine plays a pivotal role, since it deals with the set of requirements that must be met by those who have been diagnosed with epilepsy in order to get a driver's license, and with the obligation to signal such individuals to the national Driver and Vehicle Licensing Agency (in Italian: Motorizzazione Civile). In that regard, the Italian legislative framework is partly hazy in some respects, which the authors have set out to analyze herein, taking into account recently issued European norms. The aim of this paper was to better understand the current Italian legislation in the matter of epilepsy and driver's license requirements, especially regarding the medical criteria that must be met in order to obtain the driving license. The importance of those criteria is underlined by the fact that they directly influence (and are influenced by) the safety for the drivers and for the persons involved in car accidents. Thus, we can consider the issue not only strictly of medico-legal relevance but also from the standpoint of primary prevention. The analysis was conducted by reviewing the most recent documents of medico-legal relevance, in the light of European Union legislation. The authors have ultimately stressed the need for clearer and straightforward regulations, given that professional liability may arise whenever a driver's license is issued, in disregard of legal norms, to an individual who then causes a road accident.

Perspectives on Patient Safety and Medical Malpractice: A Comparison of Medical and Legal Systems in Italy and the United States.

OBJECTIVES: Italy is experiencing a crisis of malpractice litigation with important repercussions on the insurance industry (e.g., lower profits), physicians (e.g., defensive medicine), and the courts (e.g., work backlog, lengthy proceedings). We searched for common ground between legal systems in Italy and the United States and considered the implications for international collaborations in patient safety. METHODS: We examined the judicial frameworks of medical malpractice litigation in two countries with different legal foundations: the United States (a public-private system governed by common law) and Italy (a publicly financed healthcare system governed by civil law). RESULTS: We found important differences and similarities across the two systems that suggest a high compatibility for future comparisons and collaborations. Although many Italian hospitals maintain risk management programs, the U.S. emphasis on patient safety and quality has not yet been integrated into Italian healthcare systems. CONCLUSIONS: Based on our findings, we propose that the Italian system might benefit from assertively adopting some concepts from the U.S. system. In particular, we consider the role of the law and Italian medicolegal experts as key facilitators for the integration of patient safety and risk management units within Italian healthcare facilities.

An Exceptional Case of Acute Respiratory Failure Caused by Intra-Thoracic Gastric Perforation Secondary to Overeating.

An 18-year-old female patient arrived at the emergency department complaining of abdominal pain and fullness after a heavy meal. Physical examination revealed she was filthy and cover in feces, and she experienced severe abdominal distension. She died in ED and a diagnostic autopsy examination was requested. At external examination, the pathologist observed a significant dilation of the anal sphincter and suspected sexual assault, thus alerting the Judicial Authority who assigned the case to our department for a forensic autopsy. During the autopsy, we observed anal orifice expansion without signs of violence; food was found in the pleural cavity. The stomach was hyper-distended and perforated at three different points as well as the diaphragm. The patient was suffering from anorexia nervosa with episodes of overeating followed by manual voiding of her feces from the anal cavity (thus explaining the anal dilatation). The forensic pathologists closed the case as an accidental death.

Limitation of professional medical liability in case of emergency medical treatment according to the joint criminal divisions of the Supreme Court of Cassazione.

Judgement no. 8770 released on February 22, 2018 by the joint criminal divisions of the Supreme Court of Cassazione innovatively established that emergency medical conditions represent "problem of special complexity" and, therefore, it is mandatory to apply art. 2236 of the Italian Civil Code. This article provides that health care professional may be convicted only in case of willful misconduct or gross negligence. The authors analyze the jurisprudential evolution of all those elements that are fundamental to assess health care professional liability: a) special complexity of the performance b) relation between imprudence and carelessness c) conditions that may make the healthcare liability gross. The principles approved by the joint criminal division within the above mentioned judgment significantly expand special complexity cases' range and, therefore, the corresponding liability's limitation range is extended. Due to the solidity of the reasons on which it is based, this sentence could permanently influence the orientation of the Courts and, therefore, dramatically diminish the risk of professional liability for healthcare staff. There is, however, a lack of clarity in the practical applications of the distinction between unskillfulness, on the one hand, and imprudence and negligence on the other. This event risks to nullify the usefulness of the joint criminal divisions' intervention. In fact, if the Court considers the health care professional behavior to be imprudent or negligent (rather than unskilled), no limitation of liability can be applied. KEY WORDS: Carelessness, Criminal and civil medical liability limitation, Emergency medical treatments, Gross negligence, Problems of special complexity, Unskillfulness, imprudence.

An atypical case of trigeminal trophic syndrome: A legal medicine perspective in medical responsibility.

BACKGROUND: Trigeminal trophic syndrome is a rare complication of peripheral or central damage to the trigeminal nerve characterized by anesthesia, paresthesia and a secondary persistent facial ulceration. METHODS: We describe the case of a 40-year-old woman with previous history of Le Fort I osteotomy for a class III malocclusion who developed trigeminal trophic syndrome. Atypically, the cutaneous symptoms appeared bilaterally and 8 years after surgery. RESULTS: Differential diagnosis was based on clinical history, tissue biopsy and serologic evaluation. Atypical findings could be linked to the surgical burdens of Le Fort I osteotomy, a procedure characterized by a bilateral incision on the maxillofacial bones with a reasonable probability of causing a bilateral injury of the peripheral branches of the trigeminal nerve. CONCLUSION: Although the long delay between trigeminal trophic syndrome onset and surgery and the absence of adequate medical evidence cannot confirm a link with previous surgery in this case, the increasing number of maxillofacial surgery cases suggests that this complication may be more frequent in the next decades, and thus, involved specialists should be aware of this condition as a possible complication of maxillofacial surgery procedures.

Neurotoxicity Induced by Mephedrone: An up-to-date Review.

BACKGROUND: Mephedrone is a ß-ketoamphetamine belonging to the family of synthetic cathinones, an emerging class of designer drugs known for their hallucinogenic and psychostimulant properties as well as for their abuse potential. OBJECTIVE: The aim of this review was to examine the emerging scientific literature on the possible mephedrone-induced neurotoxicity, yet not well defined due to the limited number of experimental studies, mainly carried on animal models. MATERIALS AND METHODS: Relevant scientific articles were identified from international literature databases (Medline, Scopus, etc.) using the keywords: "Mephedrone", "4-MMC," "neurotoxicity," "neuropharmacology", "patents", "monoamine transporters" and "neurochemical effects". RESULTS: Of the 498 sources initially found, only 36 papers were suitable for the review. Neurotoxic effect of mephedrone on 5-hydroxytryptamine (5-HT) and dopamine (DA) systems remains controversial. Although some studies in animal models reported no damage to DA nerve endings in the striatum and no significant changes in brain monoamine levels, some others suggested a rapid reduction in 5-HT and DA transporter function. Persistent serotonergic deficits were observed after binge like treatment in a warm environment and in both serotonergic and dopaminergic nerve endings at high ambient temperature. Oxidative stress cytotoxicity and an increase in frontal cortex lipid peroxidation were also reported. In vitro cytotoxic properties were also observed, suggesting that mephedrone may act as a reductant agent and can also determine changes in mitochondrial respiration. However, due to the differences in the design of the experiments, including temperature and animal model used, the results are difficult to compare. CONCLUSIONS: Further studies on toxicology and pharmacology of mephedrone are therefore necessary to establish an appropriate treatment for substance abuse and eventual consequences for public health.

The Differential Diagnosis Between Natural Death and Homicide, an Everlasting Challenge for the Forensic Pathologist: An Exemplar Case Report.

Most of the work performed by the forensic expert is to find proof for different plausible hypotheses that may be used in a trial to serve justice purposes when the "identity" of a case is already unveiled. Yet the previous phase of the investigation is also of great importance, and sometimes (like in the presented case), it represents the core element of the entire investigation. The appropriate determination of the differential diagnosis between a natural death and a death of forensic interest (ie, homicide) is the first and crucial step in the classification of a case. This article analyzes the case of the body of a man found lying on the border of a country road with his wrists tied up with rope and the resulting investigation performed by the medicolegal forensic expert. In the end, as more specific examinations where performed aimed to find the truth, the final conclusions excluded a violent death and confirmed that the cause of the death was an acute myocardial infarction.

Bladder irrigation and urothelium disruption: a reminder apropos of a case of fatal fluid absorption.

BACKGROUND: Irrigation or washouts of the bladder are usually performed in various clinical settings. In the 1980s Elliot and colleagues argued that urothelial damage could occur after washouts and irrigations of the bladder. The exact mechanism underlying urothelial damage has not yet been discovered. To our knowledge, this is the first report of fatal fluid overload and pulmonary edema, due to urothelium disruption occurring during bladder irrigation, approached performing complete histological and immunohistochemical investigation on bladder specimens. The exposed case deserves attention since it demonstrates that, although very rarely, irrigation or washouts of the bladder may have unexpected serious clinical consequences. CASE PRESENTATION: An 85 year-old Caucasian man, unable to eat independently and whose fluid intake was controlled, underwent continuous bladder irrigation with a 3-way catheter due to a severe episode of macrohematuria. During the third day of hospitalization, while still undergoing bladder irrigation, he suddenly experienced extreme shortness of breath, breathing difficulties, and cough with frothy sputum. His attending nurse immediately noted that there was no return of the fluid (5 liters) introduced through bladder irrigation. He was treated urgently with hemodialysis. At the beginning of the dialysis treatment, the patient had gained 7.4 kg since the previous measurement (24 hours prior) without any clear explanation. Although a significant weight loss (from 81 to 76 kg) due to the dialysis procedure, the patient died shortly after the final treatment. The autopsy revealed that the brain and the lungs were heavily edematous. Microscopic examination of bladder specimens revealed interstitial and mucosal swelling, and loss of the superficial cell layer. Intermediate and basal urothelial cells were preserved. Altogether the above mentioned findings were suggestive of a diffuse disruption of the urothelium. In conclusion the death of the man was attributed to an acute severe pulmonary edema due to massive fluid absorption. CONCLUSION: Our case demonstrates that urothelium disruption may occur during irrigation and washouts of the bladder, also in the absence of other well-known predisposing conditions. Inappropriate use of bladder irrigation should be avoided and a close attention is required of the fluid balance is mandatory when irrigating the bladder.

Stem cell therapy: from evidence-based medicine to emotion-based medicine? The long Italian way for a scientific regulation.

On 23 May 2013, the Italian health minister decided to endorse a law regarding controversial stem cell-based therapies in 32 young terminally ill patients, shocking many scientists. According to the international scientific community, these therapies could be dangerous because they were not rigorously tested in humans. This decision was made after many days of media and judiciary pressure. Several lawsuits regarding stem cell-based therapies were brought before the judiciary districts of different Italian regions. We analyzed the Italian legal context regarding the field of pharmaceutical and medical devices, including the European Union trend. A national database - commonly used to manage legal materials for professional or educational purposes or both - was used to find relevant legal cases involving stem cell-based therapies. Stem cell-based therapies endorsed by the new Italian law have been the subject of an important discussion not only in the scientific community but also in various courts. We found several legal actions filed by parents in order to make stem cells available to their young children, who had serious neurodegenerative diseases. The majority of the analyzed legal disputes were settled in favor of the applicants, whereas only two decisions (Courts of Justice of Rome and Florence) rejected the complaint because of the absence of sufficient scientific data regarding stem cell-based therapies. The present Italian situation is influencing the destiny of future young patients and strongly impacting public and institutional opinion. It is a practical example of the complexity of the decision of not providing unapproved scientific stem cell-based therapies when medicine does not have any other alternative therapies.