Natale Mario di Luca

Ethical and Legal Implications of Elective Ventilation and Organ Transplantation: “Medicalization” of Dying versus Medical Mission

A critical controversy surrounds the type of allowable interventions to be carried out in patients who are potential organ donors, in an attempt to improve organ perfusion and successful transplantation. The main goal is to transplant an organ in conditions as close as possible to its physiological live state. “Elective ventilation” (EV), that is, the use of ventilation for the sole purpose of retrieving the organs of patients close to death, is an option which offsets the shortage of organ donation. We have analyzed the legal context of the dying process of the organ donor and the feasibility of EV in the Italian context. There is no legal framework regulating the practice of EV, neither is any real information given to the general public. A public debate has yet to be initiated. In the Italian cultural and legislative scenario, we believe that, under some circumstances (i.e., the expressed wishes of the patient, even in the form of advance directives), the use of EV does not violate the principle of beneficence. We believe that the crux of the matter lies in the need to explore the real determination and will of the patient and his/her orientation towards the specific aim of organ donation.

Not Only a Clinical Nightmare: Amniotic Fluid Embolism in Court

Amniotic fluid embolism (AFE) is an uncommon obstetric condition involving usually women in labour or in the early post-partum period. Clinical consequences of this unpredictable and unpreventable pathology may be extremely serious with high morbidity and mortality rates. Data obtained from the US Amniotic Fluid Embolism Registry show that the process is more similar to anaphylaxis than to embolism, and the term anaphylactoid syndrome of pregnancy has been suggested because foetal tissue or amniotic fluid components are not universally found in women who present signs and symptoms related to AFE. The first aim of this paper has been to focus on the medico-legal aspects concerning the misdiagnosis and the treatment of the AFE and the Authors, with this purpose in mind, reviewed the main national law cases on medical malpractice claims involving both physicians and hospitals. The second aim has been to highlight the need to introduce a National register as a useful tool to raise the awareness of this disease among physicians and to improve the quality of care, which can be achieved through a proper identification and reporting of AFE cases. The application of a national register may limit the number of medico-legal litigations, which according to the national and foreign Jurisprudence are not currently based in favour of the predictability of AFE, but they focus their discussion on the importance of a prompt medical assistance when the effects of this disorder occur.

Hydraulic Resistance of Vitreous Cutters: The Impact of Blade Design and Cut Rate

Purpose To measure the hydraulic resistance (HR) of vitreous cutters equipped with a Regular guillotine Blade (RB) or double edge blade (DEB) at cut rates comprised between 0 and 12,000 cuts per minute (CPM) and compare it with vitreous fragment size. This was an in vitro experimental study; in vivo HR measure and vitreous sampling. Methods HR, defined as aspiration pressure/flow rate, was measured in balanced salt solution (BSS; Alcon, Fort Worth, TX) (in vitro) and during pars plana vitrectomy of 20 consecutive patients aged 18 to 65, undergoing macular surgery. HR was recorded at increasing cut rates (500–6000 CPM for the RB and 500–12,000 CPM for the DEB; 5 mL/min flow). Vitreous samples were withdrawn and analyzed with Western and collagen type II and IX immunostaining to evaluate protein size. The main outcome measures were hydraulic resistance (mm Hg/ml/min [±SD]) and optic density for Western blot and immunostaining. Results RB and DEB showed identical HR in BSS between 0 and 3000 CPM. Above 3000 CPM, RB HR steadily increased, and was significantly higher than DEB HR. Vitreous HR was also similar for the two blades between 0 and 1500 CPM. Above 1500 CPM, RB offered a significantly higher resistance. Western blot and immunostaining of vitreous samples did not yield a significant difference in size, regardless of blade type and cut rate. Conclusions DEB is more efficient, offering a lower HR than RB over 1500 CPM in human vitreous. There is no viscosity reduction as a function of cut-rate between 1500 and 12,000 CPM, as HR does not vary. Translational Relevance Future vitreous cutters will benefit of a DEB; optimal cut rate needs to be defined, and the simple increase of cut rate does not provide benefits after a certain limit to be assessed.

Variability in findings of anogenital injury in consensual and non- consensual fisting intercourse: A systematic review

Fisting is an uncommon and potentially dangerous sexual practice. This is usually a homosexual activity, but can also be a heterosexual or an autoerotic practice. A systematic review of the forensic literature yielded 14 published studies from 8 countries between 1968 and 2016 that met the inclusion/exclusion criteria, illustrating that external anogenital (anal and/or genital) trauma due to fisting is observed in 22.2% and 88.8% (reported consensual and non-consensual intercourse, respectively) of the subjects, while internal injuries are observed in the totality of the patients. Establishing the reliability of the conclusions of these studies is difficult due to a lack of uniformity in methodology used to detect and define injuries. Taking this limit into account, the aim of this article is to give a description of the external and internal injuries subsequent to reported consensual and non-consensual fisting practice, and try to find a relation between this sexual practice, the morphology of the injuries, the correlation with the use of drugs, and the relationship with assailant, where possible. The findings reported in this paper could be useful, especially when concerns of sexual assault arise.

Neurocognitive correlates in driving under the influence of Cannabis

BACKGROUND & OBJECTIVE Delta (9)-tetrahydrocannabinol (THC) is the main psychoactive compound in cannabis and is frequently identified in blood samples from apprehended drivers suspected for driving under the influence of drugs. Changing social norms towards cannabis and higher acceptability towards the drug emphasize the need for in-depth understanding of the acute neurocognitive and psychomotor effects caused by cannabis and how these effects are correlated to driving skills and performance. METHOD In this review, PubMed, Cochrane Central, Scopus, Web of Science, Science Direct, EMBASE and Google Scholar databases were used to identify and select publications up to January 2017 dealing with acute and chronic neurocognitive effects induced by cannabis and ability to drive. Thirty-six publications were selected for this review. The studies conducted were experimental, using simulators or on-road studies and brain imaging (structural and functional) to better understand the acute and chronic effects on cognitive functions comprised in the short and long-term fitness to drive after cannabis consumption. CONCLUSION In a case-crossover self-report study a significant odds ratio increase was found for driving- related injury after combined exposure to cannabis and alcohol compared to cannabis alone (OR of 10.9 and 5.8 respectively). Both, experimental and epidemiological studies have revealed that THC affects negatively both, psychomotor skills and cognitive functions. Studies of the acute effects of cannabis on driving have shown that drivers under the influence of this substance are impaired. Indeed, driving under the influence of cannabis doubles or triples the risk of a crash. Specifically, cannabis use impairs critical-tracking tasks, increases lane weaving, decreases reaction time, and divided attention.

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 peoples 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 legislators 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.

Informed consent to research trials on Alzheimer’s disease: how to foster research without infringing upon the patient’s right to self-determination

Informed consent procedures are sometimes viewed by doctors as little more than bureaucratic formalities to be fulfilled, because information can only minimally bridge the gap in knowledge and expertise which exists in every doctor-patient relationship. That is even more so in the case of diseases for which a decision (about hospitalization, for instance, or pharmacotherapies) is expected from patients who need treatment because they suffer from a cognitive deficit. Yet, the ethical value of informed consent rests on its ultimate goal of allowing the patients to gain awareness so that they can make decisions about their health in a rational fashion, even though such a goal is at times unattainable. This is particularly true in the case of Alzheimer’s disease (AD) a severely disabling condition, affecting approximately 25 millions individuals worldwide with tremendous impact on the affected individuals, caregivers, and the national health systems. In this editorial the authors aim to bring attention to the very peculiarities of AD research and set forth proposals for prospective legislative amendments designed to enhance research opportunities without impinging on patient self-determination.

Gamete Donation: Are Children Entitled to Know Their Genetic Origins? A Comparison of Opposing Views. The Italian State of Affairs

Medically assisted fertilization techniques give rise to a wide array of issues, such as the rights to secrecy, partial anonymity or to the full disclosure of information about the donors’ identities. The authors espouse the right of donor-conceived children to know their biological origins, and delve into opposing views, either in favour of the gamete donors’ right to anonymity or against it. Be that as it may, the right to know one’s biological origins has been gaining a foothold as part of the broader right to personal identity. The latter is in fact codified and upheld in numerous international treaties and conventions as a fundamental human right. The authors expound upon the Italian legislation, which is designed to enforce total donor anonymity. Against that backdrop, the authors weigh the suitability of further regulating access to sensitive, identifying information about the procreation methods involved in each case.

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.

Ventricular androgenic-anabolic steroid-related remodeling: an immunohistochemical study

BackgroundSeveral fatal cases of bodybuilders, following a myocardial infarction after long exposure to androgenic-anabolic steroids (AAS), are reported. In recent years, evidence has emerged of cases of heart failure related to AAS consumption, with no signs of coronary or aorta atherosclerosis. This study aims to further investigate the pathogenesis of the ventricular AAS-related remodeling performing immunohistochemistry (IHC).MethodIn order to examine innate immunity activity and myocytes and endothelial cell apoptosis, IHC analyses were performed on heart tissue of two cases of bodybuilders who died after years of supratherapeutic use of metelonone and nandrolone and where no atherosclerosis or thrombosis were found, using the following antibodies: anti-CD68, anti-iNOS, anti-CD163, anti-CD 15, anti-CD8, anti-CD4, anti-HIF1 α, and in situ TUNEL staining.ResultsResults confirm the experimental findings of recent research that, in the absence of other pathological factors, if intensive training is combined with AAS abuse, myocytes and endothelial cells undergo apoptotic alterations. The absence of inflammatory reactions and the presence of an increased number of M2 macrophages in the areas of fibrotic remodeling confirm that the fibrotic changes in the heart are apoptosis-related and not necrosis-related.ConclusionsIn conclusion, the study indicates that, in very young subjects with chronic hypoxia-related alterations of the heart, signs of a heart failure in the other organs and a history of AAS abuse, death can be ascribed to progressive heart failure due to the direct apoptotic cardiac and endothelial changes produced by AAS.