The hunger strike in prison: bioethical and medico-legal insights arising from a recent opinion of the Italian national bioethics committee.

This contribution addresses some bioethical and medico-legal issues of the opinion formulated by the Italian National Bioethics Committee (CNB) in response to the dilemma between the State's duty to protect the life and health of the prisoner entrusted to its care and the prisoner's right to exercise his freedom of expression. The prisoner hunger strike is a form of protest frequently encountered in prison and it is a form of communication but also a language used by the prisoner in order to provoke changes in the prison condition. There are no rules in the prison regulations, nor in the laws governing the legal status of prisoners, that allow the conscious will of the capable and informed subject to be opposed and forced nutrition to be carried out. However, this can in no manner make therapeutic abandonment legitimate: the medical doctor should promote every action to support the patient. In the recent opinion formulated by the CNB it was remarked how self-determination is a central concept in human rights and refers to an individual's ability to make autonomous and free decisions about his or her life and body.

Detection of Three Opioids (Morphine, Codeine and Methadone) and Their Metabolites (6-Monoacetylmorphine and 2-Ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine) in Larvae of Lucilia sericata Species by UHPLC-TF-MS and Validation.

Insects on corpses could be a useful tool for the detection of exogenous substances such as drugs of abuse. The identification of exogenous substances in carrion insects is critical for proper estimation of the postmortem interval. It also provides information about the deceased person that may prove useful for forensic purposes. High-performance liquid chromatography coupled with Fourier transform mass spectrometry is a highly sensitive analytical technique that can identify substances even at very low concentrations, such as in the case of searching for exogenous substances in larvae. In this paper, a method is proposed for the identification of morphine, codeine, methadone, 6-monoacetylmorphine (6-MAM) and 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP) in the larvae of Lucilia sericata, a common carrion fly widely distributed in temperate areas of the world. The larvae, which were reared on a pig meat substrate, were killed once they reached their third stage by immersion in hot water at 80 °C and aliquoted into 400 mg samples. The samples were fortified with 5 ng of morphine, methadone and codeine. After solid-phase extraction, the samples were processed with a liquid chromatograph coupled to a Fourier transform mass spectrometer. This qualitative method has been validated and tested on larvae from a real case. The results lead to the correct identification of morphine, codeine, methadone and their metabolites. This method could prove useful in cases where toxicological analysis must be conducted on highly decomposed human remains, where biological matrices are very limited. Furthermore, it could help the forensic pathologist to better estimate the time of death, as the growth cycle of carrion insects can undergo changes if exogenous substances are taken.

Cytokine storm and histopathological findings in 60 cases of COVID-19-related death: from viral load research to immunohistochemical quantification of major players IL-1ß, IL-6, IL-15 and TNF-α.

This study involves the histological analysis of samples taken during autopsies in cases of COVID-19 related death to evaluate the inflammatory cytokine response and the tissue localization of the virus in various organs. In all the selected cases, SARS-CoV-2 RT-PCR on swabs collected from the upper (nasopharynx and oropharynx) and/or the lower respiratory (trachea and primary bronchi) tracts were positive. Tissue localization of SARS-CoV-2 was detected using antibodies against the nucleoprotein and the spike protein. Overall, we tested the hypothesis that the overexpression of proinflammatory cytokines plays an important role in the development of COVID-19-associated pneumonia by estimating the expression of multiple cytokines (IL-1ß, IL-6, IL-10, IL-15, TNF-α, and MCP-1), inflammatory cells (CD4, CD8, CD20, and CD45), and fibrinogen. Immunohistochemical staining showed that endothelial cells expressed IL-1ß in lung samples obtained from the COVID-19 group (p < 0.001). Similarly, alveolar capillary endothelial cells showed strong and diffuse immunoreactivity for IL-6 and IL-15 in the COVID-19 group (p < 0.001). TNF-α showed a higher immunoreactivity in the COVID-19 group than in the control group (p < 0.001). CD8 + T cells where more numerous in the lung samples obtained from the COVID-19 group (p < 0.001). Current evidence suggests that a cytokine storm is the major cause of acute respiratory distress syndrome (ARDS) and multiple organ failure and is consistently linked with fatal outcomes.

Media-Based Research on Selfie-Related Deaths in Italy.

BACKGROUND: The incidence of taking selfies and sharing them on social media as well as selfie-related dangerous behaviors is increasing, particularly among young people, also leading to selfie-related trauma and death. This study was performed to obtain epidemiological characteristics of selfie-related mortality in Italy. METHODS: Scientific literature and Italian media were reviewed. RESULTS: Twelve victims from 11 events, from 2014 to 2018, were analyzed (sex, age, accident types, the nationality, the Italian region where the incident took place, if the person involved was indigenous or a tourist, the dynamics and the causa mortis, if other people have been involved in the selfie, and if other people were deceased). The majority of selfie victims were male teenagers, the average age was 23.6 years, the most preferred site of taking selfies was the natural environment followed by the railway one, the most frequently reported event or accident type was falling from a height, and the most frequent causes of selfie-related deaths were multitrauma and drowning. CONCLUSIONS: Selfie-related deaths in Italy appear to be an issue and appear to be increasing. Particularly, male teenagers and young adults are at high risk for selfie-related deaths. Measures should be taken to reduce their incidence.

Fatal Acute Intracranial Subdural Hematoma After Spinal Anesthesia for Cesarean Delivery: Case Report and Review of the Literature.

The authors report on the autopsy case of a 40-year-old primigravida without either coagulation disorders or anticoagulant/antiplatelet therapy, who developed a fatal intracranial subdural hematoma after spinal anesthesia (SA) for elective cesarean delivery for tocophobia.Intracranial subdural hematoma is the most dreaded complication of SA and is often misdiagnosed with postdural puncture headache.In this article, the authors discuss pathophysiological mechanisms and risk factors for the development of an intracranial subdural hematoma after SA and review the pertinent literature.

Retroperitoneal Hemorrhage Caused by Trephine Biopsy.

The bone marrow biopsy is usually a safe procedure; however, it can occasionally present important complications. These complications are not always immediately evident or quickly diagnosed and may include pain at the biopsy site, trauma to neighboring structures, vascular injuries, infection, transient pressure neuropathies, pneumoretroperitoneum, and hemorrhage. Several risk factors are recognized, including thrombocytopenia, concurrent use of anticoagulants, and the presence of an underlying myeloproliferative disorder. While several reports of adverse events have been published, only 2 deaths attributable to this procedure have been reported. We present 2 cases of fatal hemorrhage after bone marrow biopsy.

Accuracy of scoring of the epiphyses at the knee joint (SKJ) for assessing legal adult age of 18 years.

Important aspects of forensic practice are age estimation and discrimination of individuals of unknown age as adults and minors. The developing knee joint was recognized as a potential site for age examination in late adolescence. We analyzed a sample of anteroposterior x-rays of the knee joints from 446 living individuals from Umbria, Italy (234 males and 212 females), aged between 12 and 26 years. We evaluated the ossification of the distal femoral (DF), proximal tibial (PT), and proximal fibular (PF) epiphyses. We took into account possible persistence of the epiphyseal scars in the ossified epiphyses by the adopted stages of those previously introduced by Cameriere et al. (2012). We also used measurements from all three epiphyses to calculate the total score of maturation for the knee joint (SKJ). Cohen Kappa coefficients of intrarater agreement for staging the DF, PT, and PF epiphyses were 0.839, 0.894, and 0.907, while interrater agreement was 0.919, 0.791, and 0.907, respectively. The resulting receiver operating characteristic (ROC) curves of SKJ show better discriminatory power than those for DF, PT, and PF epiphyses in predicting that the participant, either male or female, was an adult or a minor. The areas under the curves for SKJ were 0.991 and 0.968 vs. 0.944, 0.962, 0.974 and 0.891, 0.910, 0.918 for males and females, respectively. The results of the 2 by 2 contingency tables showed that SKJ score of 4 in males and SKJ score of 5 in females were the most suitable cut-off value in discriminating between adults and minors. Principally, the sensitivity test for males was 0.94, with 95 % confidence interval (95 % CI) 0.90 to 0.97 and specificity was 0.96 (95 % CI 0.91 to 0.98). The proportion of correctly classified individuals was 0.95 (95 % CI 0.91 to 0.97). For females, the sensitivity test was 0.89 (95 % CI 0.84 to 0.92) and specificity was 0.92 (95 % CI 0.87 to 0.96), the proportion of correctly classified individuals was 0.90 (95 % CI 0.85 to 0.94). These results indicate that the SKJ method may give valuable supporting information in forensic procedures for discriminating individuals of legal adult age of 18 years. Further studies should address the usefulness of the SKJ method in different populations.

Reliability of frontal sinus by cone beam-computed tomography (CBCT) for individual identification.

Analysis of the frontal sinus is an important tool in personal identification. Cone beam-computed tomography (CBCT) is also progressively replacing conventional radiography and multi-slice computed tomography (MSCT) in human identification. The aim of this study is to develop a reproducible technique and measurements from 3D reconstructions obtained with CBCT, for use in human identification. CBCT from 150 patients (91 female, 59 male), aged between 15 and 78 years, was analysed with the specific software program MIMICS 11.11 (Materialise N.V., Leuven, Belgium). Corresponding 3D volumes were generated and maximal dimensions along 3 directions (x, y, z), X M, Y M, Z M (in mm), total volume area (in mm(3)), V t, and total surface (in mm(2)), S t, were calculated. Correlation analysis showed that sinus surfaces were strongly correlated with their volume (r = 0.976). Frontal sinuses were separate in 21 subjects (14 %), fused in 67 (44.6 %) and found on only one side (unilateral) in 9 (6 %). A Prominent Middle of Fused Sinus (PMS) was found in 53 subjects (35.3 %). The intra- (0.963-0.999) and inter-observer variability (0.973-0.999) showed a great agreement and a substantial homogeneity of evaluation.

[Medical overuse, defensive medicine and new reform of professional mistake].

Reflecting on the inappropriateness (medical overuse) and on defensive medicine, the Authors wonder whether the new Italian reform of professional guilt, desired at all institutional levels, will actually contain the high economic costs produced by these large and widespread phenomena. After having characterized the medical overuse and the defensive medicine indicating the common traits and main differences, the reflection is conducted by exploring the many scientific evidence that does not document any causal link between the decriminalization of professional conduct and the containment of the costs produced by the prescriptive inappropriateness. They conclude by stating that, for their containment, a third reform of professional liability will not be helpful. Instead, it must focus on other issues, mainly addressing the excessive reliance on judicial recourse. It should provide for mandatory out-of-court conciliatory mechanisms and clarifying the protective umbrella of the doctor's non-criminality.

Sexually Transmitted Infections in Adolescents and Young Adults: A Cross Section of Public Health.

INTRODUCTION: Sexually transmitted infections (STIs) can be caused by a number of microorganisms that vary greatly in size, life cycle, clinical manifestations, and sensitivity to available treatments. Transmission of STIs can occur during unprotected (or condomless) sexual contact and through the exchange of body fluids during any type of activity. The prevalence of sexually transmitted diseases remains high in the world, despite diagnostic and therapeutic improvements for these infectious diseases that rapidly eliminate the contagiousness of patients. Our study determines the prevalence of STI pathogens in adolescents and young adults in the population of the Province of Macerata (Italy). We will analyze data in correspondence to age and gender, and we will compare our results to international studies. MATERIALS AND METHOD: We analyzed STI test results from the entire database of a Provincial Health Authority for the period 2021-2022. The samples came from the following age groups: 0-12, 13-18, 19-25, and 26-35 from 2021 to 2022. The results came from vaginal and cervical swabs (for females); urethral, rectal, and pharyngeal swabs (for males and females); and seminal fluid (for males) for the following infections: HPV, Chlamydia trachomatis, Mycoplasma genitalium, Ureaplasmas, Gardnerella, Trichomonas vaginalis, Neisseria gonorrhoeae, and Treponema pallidum. The results also came from blood tests for HIV, hepatitis C, hepatitis B, and Treponema pallidum (TPHA, VDRL). In addition, we examined results from urine tests for chlamydia, Neisseria gonorrhoeae, trichomonas, and Treponema pallidum. CONCLUSIONS: The literature for other countries reports the need for comprehensive, culturally and developmentally sensitive care to address sexuality-related issues in adolescents and young adults, a need that also applies to Italy. These data will be of great importance in adopting evidence-based STI control programs in Marche Region. This study could, indeed, represent a landmark for public health officials and professionals, with the aim of promoting adolescents' access to sexual health services to receive useful information, strengthening preventive measures in younger age groups, and designing sexual education programs.

Identification of N-piperidinyl etonitazene in alternative keratinous matrices from a decomposing cadaver.

This short report describes research on N-piperidinyl etonitazene, also known as etonitazepipne, in keratinous matrices (hair and nails) after death related to a suspected opioid overdose. Etonitazepipne belongs to the family of benzimidazole opioids, a class of new synthetic opioids that has penetrated the illicit drug market. Analysis in the case under study showed the presence of etonitazepipne in both hair and nails, confirming that the substance accumulates in the body with repeated intake.

New Insights on Molecular Autopsy in Sudden Death: A Systematic Review.

Sudden unexpected deaths often remain unresolved despite forensic examination, posing challenges for pathologists. Molecular autopsy, through genetic testing, can reveal hidden causes undetectable by standard methods. This review assesses the role of molecular autopsy in clarifying SUD cases, examining its methodology, utility, and effectiveness in autopsy practice. This systematic review followed PRISMA guidelines and was registered with PROSPERO (registration number: CRD42024499832). Searches on PubMed, Scopus, and Web of Science identified English studies (2018-2023) on molecular autopsy in sudden death cases. Data from selected studies were recorded and filtered based on inclusion/exclusion criteria. Descriptive statistics analyzed the study scope, tissue usage, publication countries, and journals. A total of 1759 publications from the past 5 years were found, with 30 duplicates excluded. After detailed consideration, 1645 publications were also excluded, leaving 84 full-text articles for selection. Out of these, 37 full-text articles were chosen for analysis. Different study types were analyzed. Mutations were identified in 17 studies, totaling 47 mutations. Molecular investigations are essential when standard exams fall short in determining sudden death causes. Expertise in molecular biology is crucial due to diverse genetic conditions. Discrepancies in post-mortem protocols affect the validity of results, making standardization necessary. Multidisciplinary approaches and the analysis of different tissue types are vital.

A study into the nature and extent of polydrug use in driving recidivism behavior.

OBJECTIVE: Polydrug use has become a frequent pattern of drug consumption in Europe, and this is considered a particularly dangerous risk factor for impaired driving. In Italy, persons whose license has been revoked or suspended due to the use of psychoactive drugs can reapply for a new driving license, depending on the judgment of the relevant local medical committee (CML). To regain a revoked license, offenders must remain drug free throughout an observation period. An important problem with enforcement of impaired driving is recidivism. The aim of the present study is to analyze the influence of polydrug use on driving recidivism. METHOD: We report the findings of several years' experience at the forensic toxicology laboratory of the University of Macerata. Hair samples collected over a 7-year period by the CML from drug users were analyzed for cocaine, opiates, and cannabis using gas chromatography-mass spectrometry. RESULTS: Three hundred thirty-five of the tested subjects were recidivists. Recidivism was more frequent among monodrug users (81%) compared with polydrug users (19%), but logistic regression showed that polydrug use is certainly a risk factor for recidivism compared to monodrug use (odds ratio [OR] = 1.99). The sex and age distribution of recidivist subjects showed a strong predominance of males in both groups, but there were no sex differences. There were more recidivist polydrug users than recidivist monodrug users in the younger age groups (OR = 2.012). Cocaine use was most prevalent in the recidivist monodrug group. All drugs analyzed were demonstrated to be a risk factor for recidivism among monodrug users, whereas only the cocaine and cannabis combination was shown to be a risk factor for recidivism among polydrug users (OR = 1.65 versus cocaine; OR = 1.30 versus Δ9-tetrahydrocannabinol). Almost all polydrug users became monodrug users, and cocaine was the most frequently detected drug in the subsequent test during the monitoring phase. CONCLUSIONS: Our results show that polydrug use increases the risk of impaired driving recidivism and represents a considerable threat to road safety.

Comparative analysis between CDT in serum and Ethyl glucuronide in hair to define the best reliable tool for the diagnosis of alcohol abuse.

The increase in alcohol consumption in society has not only led to a number of medical issues but has also become a matter of considerable legal importance. Thus, there is both scientific interest and the necessity to diagnose alcohol abuse in the application of the provisions of the law through laboratory tests that ensure maximum objectivity. The purpose of this work is to study and compare the diagnostic performance of two of the main markers of alcohol abuse, serum carbohydrate-deficient transferrin (CDT) and Ethyl glucuronide (EtG) in a group of 336 driving under the influence (DUI) of alcohol offenders. Thus, it is possible to establish the best marker of alcohol consumption in order to assess the fitness to drive of DUI subjects.EtG was detected in 55 hair samples, while CDT was detected in 5 blood samples. Of the EtG-positive subjects 96,4% had CDT values below the cut-off. While CDT refers to an alcohol consumption of approximately the previous 10 days, EtG allows to detect an excessive alcohol consumption of the last few months. Because of these two different time-windows, EtG proves to be more reliable, since it is more difficult for subjects to change their drinking practice to test negative to toxicological analysis. The determination of Ethyl glucuronide on hair matrix is a valuable tool for the diagnosis of alcohol abuse, with high sensitivity and specificity and certainly greater reliability than traditional markers such as CDT, being a direct marker of alcohol consumption.

What do we know about pathological mechanism and pattern of lung injury related to SARS-CoV-2 Omicron variant?

Pulmonary damage in SARS-CoV-2 is characterized pathologically by diffuse alveolar damage (DAD) and thrombosis. In addition, nosocomial bacterial superinfections and ventilator-induced lung injury (VILI) are likely to occur. The SARS-CoV-2 Omicron variant have manifested itself as a more diffusive virus which mainly affects the upper airways, such as the nose and pharynx. The mechanism leading to a lung injury with a complex clinical course for the Omicron SARS-CoV-2 variant remains unclear. A key question is whether the organ damage is due to direct organ targeting of the virus or downstream effects such as an altered immune response. An immune escape process of Omicron variant is being studied, which could lead to prolonged viral shedding and increase hospitalization times in patients with comorbidities, with an increased risk of pulmonary co-infections/superinfections and organ damage. This brief commentary reports the current knowledge on the Omicron variant and provides some useful suggestions to the scientific community.

The State of Play on COVID-19 Vaccination in Pregnant and Breastfeeding Women: Recommendations, Legal Protection, Ethical Issues and Controversies in Italy.

To date, extensive research has been conducted on vaccination against COVID-19 during pregnancy to verify the safety and efficacy of the vaccines, despite the fact that pregnant women were excluded from the initial clinical trials. The ever-increasing number of scientific publications has confirmed the absence of biological mechanisms associating mRNA vaccines with adverse effects in pregnancy and breastfeeding, although few studies have been carried out on their effect on fertility. While the Italian legal system provides for maternity protection measures and indemnity for vaccination damages pursuant to law no. 210/1992, it is not exempt from controversy. This contribution describes the state of play on COVID-19 vaccination in pregnant and lactating women, including: current recommendations for pregnant and lactating women; ethical issues related to vaccination hesitancy among pregnant women; the legislative paradox whereby sanctions may be imposed on women in certain professional categories who refuse vaccination because they are pregnant; and the possible legal consequences in the event of harm to the unborn child due to vaccination. All of this is considered in accordance with the principles of medical ethics, taking into account the national legislation.

Operational Health Pavilions in Mass Disasters: Lessons Learned from the 2023 Earthquake in Turkey and Syria.

The massive earthquake that hit Turkey and Syria in February 2023 killed tens of thousands of people, and most of the deceased have not yet been identified. Many victims were pulled from the rubble hours or days later, injured and in need of assistance, treatment, and food, and many have not yet been connected with their families. Armed forces, volunteers, technicians, and health workers must cooperate in synergy in these situations to ensure effective interventions and to improve resilience. Based on the lessons learned from the response efforts to this recent natural catastrophe, this brief report proposes, for the first time, an organisational model structured around five functional pavilions that can be safely set up at the edge of a disaster area. Each pavilion should run its own activities to make a vital contribution to the overall coordinated emergency response. Looking to the future, it is extremely important to apply a technical approach that leads to maximum operational synergy at a disaster site and during the first phase of a sudden-onset emergency.