Can a causal relationship be established between acoustic neuroma and occupational exposure to non-ionizing radiations from mobile devices? Comparison between scientific literature data and medico-legal methodology.

BACKGROUND: Over the process of establishing the causal relation-ship, medical and legal methodologies may be at variance over the definitional standards and terminologies applied, which can hinder the activities of expert witnesses. OBJECTIVES: The article's authors have set out to assess whether, and under what conditions, a causal relationship can be established between acoustic neuroma and exposure to non-ionizing radiation from mobile communication devices. METHODS: The study design is a Systematic Review. The authors have drawn upon a 2020 Turin Court of Appeals ruling which found such a causal relationship in a somewhat peculiar case: rare tumor and exposure to non-ionizing radiation of unusually long and regular dura-tion. The case presents several peculiarities, herein analyzed in light of a) scientific evidence relative to the etiopathogenesis of the neuroma; b) available medico-legal literature defining causality evaluation criteria, and lastly c) court filings in regard to the probability standards applied to prove causal relationship. RESULTS: A direct tie cannot be proven, not even in cases of sub-stantially intense and lengthy exposure, if the medico-legal standards applied are not consistent enough to prove that nexus is more likely than not. DISCUSSION: Several elements suggest a causal relationship is unlikely: a) a dearth of evidence on humans; b) rats exposed to such radiation have developed cardiac tumors, not in their ears; c) exposure has caused no tumors in mice; d) the length of exposure is incompat-ible with tumor size and type. That fourth point only concerns the case herein explored, whereas the first three have a general scope of validity. The main limitation of the present study design is the heterogeneity among the included studies. Retrospective and prospective studies have been included, which may be a source of bias.

Commentary - Heroin purity and adulteration: an updated snapshot from the Italian Early Warning System.

Not Available.

Drug-facilitated sexual assaults (DFSA): a serious underestimated issue.

OBJECTIVE: Drug-facilitated sexual assault (DFSA) is a nonconsensual sexual act in which the victim is incapacitated or unconscious due to the effects of alcohol, a drug and/or other intoxicating substances. Dozens of drugs (including ethanol) can potentially be used to commit sexual assaults, but γ-Hydroxybutyric acid (GHB) and flunitrazepam are the most common "date rape drugs". MATERIALS AND METHODS: Multidisciplinary databases were browsed using the following search terms: "drug-facilitated sexual assault", "chemical submission", "date rape", "rape drugs", and "drink-spiking". Moreover, a search for reports was conducted on Institutional websites to identify documentation published by international agencies or institutions. Articles and reports were independently evaluated by each author. RESULTS: There are no accurate estimates of the number of DFSA occurring each year, although assaults are increasingly reported. Many DFSA, however, are still not reported. Victims are reluctant to report incidents because of embarrassment, guilt or perceived responsibility, or because they do not clearly remember the assault. Moreover, most of the drugs typically used in sexual assaults are rapidly metabolized, making them undetectable in routine drug screenings. CONCLUSIONS: Most of the substances involved in DFSA, with the exception of alcohol, are under international control and scheduled under the United Nations Single Convention on Narcotic Drugs of 1961 and the Convention on Psychotropic Substances of 1971. However, several psychotropic substances and antihistamines used in sexual assaults are still not under international control, allowing for trafficking, often via the Internet and courier. The absence of international control makes it difficult to obtain accurate data on the nature and the extent of the problem.

Fighting obesity in children from European World Health Organization member states. Epidemiological data, medical-social aspects, and prevention programs.

Childhood obesity is one of the most serious public health chal-lenges of this century. Overweight and obese children are likely to stay obese into adulthood and more likely to develop non-communicable diseases like diabetes and cardiovascular diseases at a younger age. In the WHO European Region one child out of 3, is overweight or obese. Over 60% of children who are overweight before puberty will be overweight in early adulthood. Children and adolescents, aged 5-19 have shown rising obesity rates in almost all nations, including where the situation was far from alarming 40 years ago. Several nations have seen the prevalence almost double: Israel has gone from 5.8% in 1975 to 11.9% in 2016, Andorra from 6.2% to 12.8%, and Malta from 7.4% to 13.4%. Analyzing overweight and obesity, we can see that they follow similar trends and patterns. In 1975 the majority of European countries had a prevalence less than 10% and obesity less than 5%, while no European country had overweight prevalence higher than 30% and obe-sity higher than 10%. In 2016 the trend reversed, showing a worrying increase in the number of European countries with a high prevalence of overweight (over 30%) and obesity (over 10%) (Fig. 1)(29). Starting from the analysis of epidemiological data on obesity in the WHO European Region, the paper analyzes the adopted prevention programs in order to assess their effectiveness and figure out the best strategies to reduce the prevalence of overweight and obesity. The WHO European Childhood Obesity Surveillance Initiative reported that children tend to overeat and not to do enough physical exercise. Different preventive programs have identified different areas of action and corresponding measures: consumption of healthy foods, physical exercise, care before conception and during pregnancy, early childhood, school age children, weight management, monitoring and evaluation. Primary prevention is essential to reduce obesity incidence: it is easier to act on the adoption of healthy eating habits than intervene with diets on children who already have weight issues. Working on pre-vention programs represents an investment for the future of children's health. By simply acting on prevention, particularly on body weight reduction, it could be possible to tackle the spreading of correlated di-seases. Therefore, prevention programs ought to be prioritized priority at a national and international level.

Guidelines, good practices and best clinical health practices: valuable guidance for physicians and judges?

Enactment of law n. 24, 8th March 2017, (so-called "Gelli-Bianco" law), has given rise to substantial innovations in the realm of medical liability: on the one hand, an attempt has been made towards redefining the boundaries of professional liability, for the purpose of curbing the use of "defensive medicine"; on the other hand, there is the effort to delineate good medical conduct by means of "institutionalization" and a greater degree of consistency of guidelines and good clinical health care practices. There are, however, thought-provoking cues concerning the relationship between the two concepts, which can be sensibly developed, even in light of international scientific literature. This paper has been designed to critically analyze both principles and their relation within the framework of the newly enacted piece of legislation denominated "Gelli-Bianco", in light of the Italian jurisprudence while at the same time, searching for common ground in international law, particularly Anglo-Saxon countries, aiming to clarify the lawmakers' ultimate goal as well as the law's practical scope of application.

Medico-legal aspects of tort law patient safeguards within the Gelli-Bianco piece of legislation.

The authors aim to put into context the recently passed piece of Italian legislation known as "Gelli-Bianco", in an effort to highlight the root causes and the underlying motives that led to its enactment. The new law's innovative aspects are elaborated on, in terms of treatment safety and civil liability of health care professional and providers. The report's main purpose is to shed light on the alleged benefits, against the backdrop of the worrisome data from recent years, gathered from case-based analysis of adverse events and related costs, without overlooking the likely challenges associated with innovations that are meant to affect complex systems with conflicting interests at play.

Is the team leading surgeon criminally liable for his collaborators' errors? Judges confirm responsibility and condemn an otorhinolaryngologist.

SUMMARY: In current healthcare, delivery of medical and surgical treatment takes place in a multidisciplinary manner. This raises the problem of distinguishing the conditions under which the person who has properly carried out his duties, respecting the related leges artis, can be held responsible for damages materially caused by another member of the medical team. Jurisprudence has developed the so-called "principle of trust" for which every member of the team can rely on the fact that other members are acting in compliance with the leges artis of their specialisation. The Supreme Court has limited the application of this principle. The authors examine the jurisprudence on responsibility of the team in otolaryngology and conclude that individual liability should be limited to the specific expertise of the individual specialist.

The credibility of testimony from minors allegedly victims of abuse within the Italian legislative framework.

The authors aim to analyze the key aspects related to the testimony of children who might have been victims of sexual harassment and abuse. The issue of medico-legal psychiatric assessment of minors who claim to have been sexually abused is extremely contentious and widely-debated, not only due to the growing spread of such claims, but also on account of the technical challenges it raises. For these reasons, national as well as European lawmakers have intervened by enacting new legislation, and scientific communities have established new sets of guidelines aimed at improving the overall conditions under which a child is called to testify as well as the process through which depositions are collected and evaluated, so as to ensure that any assessment of the reliability of the testimony is scientifically grounded. The authors also highlight the importance of regulatory measures meant to minimize the risk that the questioning of a child might negatively affect his or her emotional balance by limiting and lessening stressful conditions and anxiety, which may traumatize and irretrievably scar the child. Moreover, they stress the importance of dealing with the social issue of child abuse by strengthening a preventive set of measures.

Law on advance health care directives: a medical perspective.

The paper's authors aim to elaborate on law 22 dicembre 2017, n. 219 , designed to regulate informed consent practices and advance health care directives", which has sparked a passionate debate centered on the substantial innovation achieved over the past decades in bio-medical science and at the same time, the noteworthy accomplishments made in enforcing human and personal rights. Within the paper, article three is delved into, which covers the creation of the so-called DAT ("Disposizioni anticipate di trattamento", advance health care directives), by which patients, in light of possible future incapacity to choose, can express their convictions and decisions on how to be treated and their consent or dissent to undergo treatments and procedures, including artificial nutrition and hydration. The authors peruse the new law's provisions through a medical perspective, and observe how they are heavily tilted towards patient choice, thus making doctors little more than mere tools of such decisions.

Medical use of cannabis: Italian and European legislation.

This review illustrates some brief considerations of the medical use of cannabis recently issued in Italy. History and uses of cannabis throughout centuries and different countries are illustrated together with a description of botany and active phytocannabinoids. Then, medical use of cannabis anti-pain treatment for patients resistant to conventional therapies is described in case of chronic neuropathic pain, spasticity, for anticinetosic and antiemetic effect in nausea and vomiting caused by chemotherapy, for appetite stimulating effect in cachexia, anorexia, loss of appetite in cancer patients or patients with AIDS and in anorexia nervosa, hypotensive effect in glaucoma resistant to conventional therapies and for reduction of involuntary body and facial movements in Gilles de la Tourette syndrome. Italian most recent legislation on medical cannabis is detailed with some law proposals, also showing the inconsistent legislation within European Union. Some final considerations of future studies are also reported.

Medical advancements: emergency contraception (EC). Medico-legal implications of EC on adolescents.

The article's main focus is documenting what the best options are in order to make sure that minors are allowed to play a key role in the management of issues arising from the use of emergency contraception. In that regard, there is a lack of clean-cut legislative measures and, although there are several legal and ethical norms designed to get parents or legal guardians involved in such decisions, there seems to be an increasingly widespread tendency to give weight to the minor's will, thus acknowledging her decision-making capacity. Lastly, the paper's authors undertake a thorough examination as to what the duties of doctors are, and the measures that need to be put in place in order to safeguard the minor patients' conditions. They arrive at the conclusion that emergency contraception is suitable for minors even in absence of the stated consent from their parents or guardians, but it is of utmost importance to implement adequate measures aimed at the provision of proper care, prevention and education.

Cosmetic surgery for children and adolescents. Deontological and bioethical remarks.

The only interventions deemed ethically acceptable are those that serve the "objective interest" of the minors involved from the standpoint of and conducive to sound mental health and balance in a patient's teenage years; by the same token, disproportionate interventions (e.g. overly invasive or pointlessly risky), or all those deemed unsuitable with regards to a poor cost-benefit ratio are viewed as unacceptable. In the process of considering the best interest of the minors involved, a wide array of factors come into play, such as: age, maturity, psychological and emotional conditions, motivations put forth by the underage patient, the opportunity to procrastinate the operation: parents, who are naturally entitled to give consent to the surgical procedures, and physicians are primarily liable to safeguard and act in the minor's best interest. The authors attempt to lay out how medical science has evolved over the past century, and aim to set forth an array of considerations centered on cosmetic surgery for adolescents.

Ethical and medico-legal remarks on uterus transplantation: may it solve uterine factor infertility?

Uterus transplantation was firstly tested with animal trials sixty-five years ago. Despite several successful attempts in human subjects, the different procedures still lay at the experimental stage, in need of further studies and investigations before they can be considered as standard clinical practices. Uterus transplant cannot be regarded as a life-saving procedure, but rather a method to restore woman ability to procreate, when lost, thus improving her quality of life. Uterus transplant is a complex surgical procedure and presents significant health threats. Medical staff should therefore always obtain informed consent from patients, emphasizing such risks. Before that, women undergoing uterine transplants should be thoroughly informed about the hazards inherent to the procedure and especially about the dangers of immunosuppressant drugs, administered after the surgery which may injure the fetus, eventually formed in the restored organ and even lead to its death, thus nullifying the purpose of the transplant itself. Therefore, the risk-benefit ratio of uterus transplantation needs to be carefully assessed and described.

2014-2017. How medically assisted reproduction changed in Italy. A short comparative synthesis with European countries.

More than ten years after law n. 40 of February 19, 2004 became effective, regulation on medically assisted reproduction has dramatically changed outlook. The authors report on the steps that led to these changes through Courts' rulings, the Supreme Court's verdicts and the European Court of Human Rights' decisions, as well as ministerial regulations and guidelines concerning medically assisted reproduction. The aforementioned jurisprudential evolution was set to reach a new balance between the embryo's right to its own dignity and the woman's right to health and freedom of self-determination in reproduction. No court ruling denies that embryos have also to be safeguarded. In fact, there are still numerous prohibitions, including using embryos for experimental purposes. Judges aim primarily at avoiding that embryos' rights overcome the right to parenthood. The authors review the legislation of the various European countries: some have adopted a legislation to regulate medically assisted reproduction, while others have developed in this field some recommendations or guidelines. This is why they call for enactment of a European law governing the implementation/operational methods of medically assisted reproduction in order to avoid the scourge of procreative tourism to countries that have a more permissive law.

Italian law on the vehicular homicide: medical legal issues and comparative analysis.

Law no. 41/2016, enacted after a parliamentary debate characterized by a strong media pressure, intends to give a strong response to the growing social alarm caused by road accidents causing deaths. In this perspective, it introduced the categories of road homicide and road injuries within the Penal Code and the new hypotheses of mandatory and facultative arrest in flagrante delicto. This paper aims at comparing the rules by which the United Kingdom, France, Spain, Germany and Italy protect people's lives and safety of vehicular traffic in order to highlight strengths and weaknesses with a view to future reforms. A survey on the European legislature highlights that, while other countries tend to criminally sanction several dangerous driving conducts, Italy has preferred, on the one hand, to punish only with administrative sanctions some violations related to reckless driving (with the exception of driving under the influence of alcohol and drugs) and, on the other, to provide for particularly harsh prison sentences in the case of vehicular homicide. The authors criticize this approach and other aspects of the new law. Moreover, it seems that the legislator's aim has not been achieved because traffic accidents have not decreased. They also believe that better results could be obtained by increasing controls on the roads and developing a policy of economical investments which improves road safety.

Hepatotoxicity of paracetamol and related fatalities.

Paracetamol, also known as acetaminophen, is the most commonly used antipyretic and pain reliever and since 1955 it is available over-the-counter as a single formulation or in combination with other substances and, as indicated by the World Health Organization, it can be used in all the three steps of pain intensity. Paracetamol toxicity is one of the most common causes of poisoning worldwide. While paracetamol is described as relatively nontoxic when administered in therapeutic doses, it is known to cause toxicity when taken in a single or repeated high dose, or after chronic ingestion. Repeated supratherapeutic misuse, non-intentional misuse, and intentional ingestion may all result in hepatic toxicity, the main cause of acute liver failure (ALF) in the United States and Europe. Since paracetamol is responsible for nearly half of the cases in the US of acute liver failure and remains the leading cause of liver transplantation, continued awareness promotion, education and research should be constantly undertaken. We herein review the literature on paracetamol toxicity with particular attention to aspects of liver damage and related fatalities.

Hepatotoxicity induced by greater celandine (Chelidonium majus L.): a review of the literature.

The available literature assessing Chelidonium majus L. (CM) hepatotoxicity potential, and its risk to benefit assessment has been reviewed in this paper. Identification of significant scientific literature was performed via the following research databases: Cochrane Central, Google Scholar, EMBASE, Medline, Science Direct, Scopus, Web of Science, using the following keywords: "Chelidonium majus", "greater celandine", "Hepatotoxicity", "Liver" "Injury", "Toxicity" individually investigated and then again in association. CM named also greater celandine, swallow-wort, or bai-qu-cai (Chinese), has been used for a long time in traditional Chinese medicine and phytotherapy. Its extracts have been claimed to display a wide variety of biological activities: antimicrobial, anti-inflammatory, spasmolytic, antineoplastic, hepatoprotective, and analgesic. Moreover, herbal medicine suggests this plant have numerous additional effects which have not yet been scientifically evaluated, such as antitussive, diuretic, and eye-regenerative. However, despite its claimed hepatoprotective effects, several hepatotoxicity cases have been reported to be probably or highly probably connected with CM exposure, after their evaluation through liver-targeted causality assessment methods. CM hepatotoxicity has been defined as a distinct form of herb-induced liver injury (HILI), due to an idiosyncratic reaction of the metabolic type. This evidence has to be considered in relationship with the absence of considerable benefits of CM therapy. Therefore, the risk to benefit ratio of the use of herbal products containing greater celandine can actually be considered as negative.

Hepatotoxicity associated to synthetic cannabinoids use.

Synthetic cannabinoids (SCs) are psychotropic compounds, chemically created in laboratory to mimic cannabinergic brain activity of delta-9 tetrahydrocannabinol. The consumption of these compounds for recreational purposes can lead to a variety of adverse effects on health including overdose and deaths. Increasingly popular as substances of abuse since the 2000s, SCs were produced initially to bind and study cannabinoid receptors (they also can be called synthetic cannabimimetics) failing in eliminating the psychoactive effects. Currently, SCs are misused by students and young adults as "natural products" because of their herbal aspect. Actually, these apparently innocuous recreational substances hide toxic effects to health. Reported side effects are cardiovascular, gastrointestinal, neurological, renal, metabolic, ophthalmologic, pulmonary and psychoactive including dependence and withdrawal. A few cases of SCs ingestion have also been associated with liver failure. We herein review the recent literature on the SCs toxicity with particular attention to liver damage aspects.

Use of corneas for transplant after self-inflicted eyeballs enucleation in the Italian law.

The authors analyze from an ethical and legal point of view the case of a 37 year old man, hospitalized for four days because of a 'dissociative syndrome', who had introduced in both his orbits a portable radio antenna. Most likely, he completed the self-enuclation using his own hands. He was brought to the Ophtalmic Hospital by nurses who handed the two eyeballs to the physicians who ascertained that the corneas were intact. Then, they performed the conservative extraction. In the following days those corneas were transplanted (keratoplasty) on two subjects on the waiting list at that hospital. The case raises the question of whether it is lawful and ethically acceptable to take, for transplant use, the corneas of a mentally incapable patient who has excised his own eyeballs. The authors analyze the case from the angle of the Italian law and Oviedo Convention. Neither of them has a specific regulation on this topic. It is therefore necessary to apply general principles that holdvalidfor Italy and a variety of countries worldwide. Particularly, the choice to use the corneas for transplant did not prejudice the physical integrity of the patient, who could no longer utilize his own eyeballs. His self-determination has not been affected; in fact, he was not in the position to make a conscious decision. Additionally, the so-called "implied consent" could be applied. Therefore, the principle of human solidarity, which is the moral duty to benefit others, seems to prevail in the case at hand.

The conscientious objection: debate on emergency contraception.

The authors discuss the emergency contraception (EC) topic, assessing scientific and ethical aspects. The almost totality of the studies carried out tends to report on the use of drugs as an emergency measure to prevent pregnancy. However, it is not yet completely excluded that emergency contraceptives can induce medical abortion. The debate on side effects of EC continues to be a highly emotional and controversial issue both for advocates who believe they will lower considerably the number of unintended pregnancies and abortions, and for opponents who believe that using emergency contraception amounts to an abortion. This latter hypothesis highlights the conflicting aspect of the conscientious objection to abortion of physicians and pharmacists. This research work is aimed at investigating the emergency contraception issue, paying particular attention to the medico-legal and regulatory aspects of this subject. Particularly, the authors focus on the conscientious objection in order to assess, if any, legal protection for physicians and pharmacists who claim a right to conscientious objection. Inappropriate use of EC could be resolved through a registry of user. This registry, of course, would not have the intention of persecution, but would only serve to detect possible cases of subjugation, exploitation and harassment.