TGF-β blockade drives a transitional effector phenotype in T cells reversing SIV latency and decreasing SIV reservoirs in vivo

HIV-1 persistence during ART is due to the establishment of long-lived viral reservoirs in resting immune cells. Using an NHP model of barcoded SIVmac239 intravenous infection and therapeutic dosing of the anti-TGFBR1 inhibitor galunisertib (LY2157299), we confirmed the latency reversal properties of in vivo TGF-β blockade, decreased viral reservoirs and stimulated immune responses. Eight SIV-infected macaques on suppressive ART were treated with 4 2-week cycles of galunisertib. ART was discontinued 3 weeks after the last dose, and macaques euthanized 6 weeks after ART-interruption(ATI). One macaque did not rebound, while the remaining rebounded between week 2 and 6 post-ATI. Galunisertib led to viral reactivation as indicated by plasma viral load and immunoPET/CT with the 64Cu-DOTA-F(ab')2-p7D3-probe. Half to 1 Log decrease in cell-associated (CA-)SIV DNA was detected in lymph nodes, gut and PBMC, while intact pro-virus in PBMC decreased by 3-fold. No systemic increase in inflammatory cytokines was observed. High-dimensions cytometry, bulk and single-cell RNAseq revealed a shift toward an effector phenotype in T and NK cells. In summary, we demonstrated that galunisertib, a clinical stage TGFβ inhibitor, reverses SIV latency and decreases SIV reservoirs by driving T cells toward an effector phenotype, enhancing immune responses in vivo in absence of toxicity.

Gait analysis advancements: rehabilitation value and new perspectives from forensic application

The clinical and rehabilitation value of gait analysis is remarkable and indisputable and poised to grow as technological advancements unfold. This article aims to shed light on the advances in how gait is assessed, enabling those who have suffered an injury impairing their motor skills to be diagnosed more accurately and efficiently as well as to compare the hallmarks of rehabilitative and forensic gait analysis. The authors have conducted an analysis of relevant papers (published between 1967 and 2020) from a medicolegal perspective, cited in PubMed, MEDLINE, Cochrane Library, EMBASE, and available recommendations for the legal application of such techniques. Moreover, considering the use of gait analysis as a forensic tool, this study broadens the scope of research by including search engines, legal databases, and court filings (DeJure, Lexis Nexis, Justia) between 2000 and 2022. The instrumental assessment of movement (Gait Analysis) has come to constitute an essential analytical tool for the biomedical sector to objectively and accurately assess human movement and posture. The article is also aimed at elaborating differences and similarities between clinical and forensic gait analysis. When it comes to the forensic applicability of gait analysis and its evidentiary value, however, there is a pressing need for a review of its scientific basis. Therefore, it is necessary to conduct a thorough evaluation of its use in legal practice, as stressed in scientific literature and surveys. It is of utmost importance to highlight the procedural and assessment standards currently applied to forensic gait analysis, to evaluate its strengths and weaknesses, and to achieve standardized guidelines based on broad scientific consensus.

Genotoxicity of Particles From Grinded Plastic Items in Caco-2 and HepG2 Cells

Large plastic litters degrade in the environment to micro- and nanoplastics, which may then enter the food chain and lead to human exposure by ingestion. The present study explored ways to obtain nanoplastic particles from real-life food containers. The first set of experiments gave rise to polypropylene nanoplastic suspensions with a hydrodynamic particle size range between 100 and 600 nm, whereas the same grinding process of polyethylene terephthalate (PET) produced suspensions of particles with a primary size between 100 and 300 nm. The exposure did not cause cytotoxicity measured by the lactate dehydrogenase (LDH) and water soluble tetrazolium 1 (WST-1) assays in Caco-2 and HepG2 cells. Nanoplastics of transparent PET food containers produced a modest concentration-dependent increase in DNA strand breaks, measured by the alkaline comet assay [net induction of 0.28 lesions/10⁶ bp at the highest concentration (95% CI: 0.04; 0.51 lesions/10⁶ base pair)]. The exposure to nanoplastics from transparent polypropylene food containers was also positively associated with DNA strand breaks [i.e., net induction of 0.10 lesions/10⁶ base pair (95% CI: −0.04; 0.23 lesions/10⁶ base pair)] at the highest concentration. Nanoplastics from grinding of black colored PET food containers demonstrated no effect on HepG2 and Caco-2 cells in terms of cytotoxicity, reactive oxygen species production or changes in cell cycle distribution. The net induction of DNA strand breaks was 0.43 lesions/10⁶ bp (95% CI: 0.09; 0.78 lesions/10⁶ bp) at the highest concentration of nanoplastics from black PET food containers. Collectively, the results indicate that exposure to nanoplastics from real-life consumer products can cause genotoxicity in cell cultures.

COVID-19 pandemic, substance use disorders and body image issues, a worrisome correlation

The SARS-CoV-2 pandemic has profoundly affected the social fabric and the economic and health care viability and functioning of most countries. Aside from its deeply destructive impact on health care systems and national economies, the pandemic has jeopardized people's emotional and psychological well-being as well. The authors aimed to shed a light on how the pandemic has been affecting patients with addiction issues and body dysmorphic disorder (BDD), which is characterized by negative thoughts about appearance and body misperceptions. People with body dysmorphic disorder are in fact at increased risk of developing substance use disorders, and such a destructive association has only been made more severe by pandemic-related restrictions, emotional distress and anxiety, as well as longer exposure to social media and online interactions. This is a major cause for concern, because substance use worsens symptoms of BDD and contributes to unfavorable treatment outcomes.

The COVID-19 pandemic and contact tracing technologies, between upholding the right to health and personal data protection

Countries responded to the COVID-19 pandemic with various levels of restrictions and lockdown in an effort to save lives and prevent the saturation and collapse of national health systems. Unfortunately, the blockades have entailed hefty socioeconomic costs. In order to contrast the spread of the virus, states have used contact tracing technology, in the form of mobile phone applications designed to track close contacts of those infected with COVID-19. Recent research has shown the effectiveness of this solution, particularly when used in conjunction with manual tracking. Nonetheless, the contact tracing app raises concerns due to the potential privacy implications. The authors have delved into the European legislation that protects privacy through the principles of proportionality and minimization, arguing that in order to quickly resolve the pandemic caused by COVID-19, one cannot blindly trust the exclusive help of technology. Instead, we need the involvement of health personnel, scientists, and no less importantly, the citizenry's sense of solidarity and the duty to abide by the rules of social distancing, the use of protective devices and hygiene rules to protect public health.

Commentary - CRISPR-based techniques: Cas9, Cas13 and their applications in the era of COVID-19

The CRISPR (Clustered Regularly Interspaced Short Palindromic Repeats)/Cas9 (CRISPR-associated protein 9) system enables scientists to edit diverse genome types with relative ease, with the aim - in the near future - to prevent future human beings from developing genetic diseases. The new opportunities arising from the system are broad-ranging and revolutionary, but such prospects have also been the cause for alarm throughout the international scientific community. The authors have laid out a review of the trials carried out so far in terms of genome editing, for the ultimate purpose of weighing implications and criticisms. We feel that possible valuable alternatives, such as induced pluripotent stem cells should not be overlooked.

Paediatric nursing management of renal replacement therapy: Intensive care nursing or dialysis nursing?

BACKGROUND

Children who develop Acute Kidney Injury may start renal replacement therapy (RRT) in Paediatric or Neonatal Intensive Care Units (hereafter PICU or NICU); RRT can be delivered either by paediatric dialysis nurses or by critical care nurses. In both case, nurses devoted to this task must have a high level of competence in providing care to children receiving haemodialytic treatment in a specific technological environment.

AIM

The objective of this research was to investigate which models have been adopted to organize nursing care in RRT management in different Italian PICU and NICU, and to explore the training of ICU nurses on the management of RRT.

METHODS

A multi-centre survey was conducted through an online questionnaire directed to the Italian PICU and NICU nurse coordinators.

RESULTS

A total of 15 Intensive Care Units (12 PICU and 3 NICU) in 12 hospitals were involved. The mean nurse/patient ratio in these units is 1:3. In 72.7% of critical care units, dialysis treatment is delivered by critical care nurses belonging to the unit itself, while in 27.3% of units paediatric dialysis nurses are in charge of dialysis treatment in collaboration with critical care nurses. In 25% of surveyed units there is some structured form of collaboration between Paediatric Dialysis nurses and critical care nurses. However, 75% of units did not respond to this specific question. The different units adopt various forms of RRT training for nursing staff.

CONCLUSION

The scenario resulting from this analysis showed how in our sample of Italian hospitals there is no standard practice for RRT nursing management. In addition, although various forms of training for nursing staff exist, a proper educational programme and/or a standardized specific training about RRT management for nursing staff is not in place in the surveyed hospitals.

RELEVANCE TO CLINICAL PRACTICE

The lack of standardized protocols or guidelines for RRT delivery to critically ill children can compromise their safety. The structuring of these protocols and the production of best clinical practice guidelines would allow standardization of the nursing management of the RRT and of the corresponding training. This may help to provide the proper care and to guarantee the patients' safety.

Intrapartum sonography of fetal head in second stage of labor with neuraxial analgesia: a literature review and possible medicolegal aftermath

OBJECTIVE

Intrapartum ultrasound (IU) is a valid support to obstetric management of fetal head progression in the second stage of labor in nulliparous with neuraxial labor analgesia (NLA). Nulliparous with NLA may have a prolonged the second stage of labor. The aim of this literature review was to evaluate the mode of delivery, as well as maternal and fetal morbidities associated with missed progression of fetal head detected with IU in the second stage of labor in nulliparous women with NLA.

MATERIALS AND METHODS

The literature review was performed using PubMed, Cochrane, Medline, EMBASE, Scopus, Google Scholar and book chapters searches to identify relevant articles from 2001 to 2019, evaluating the mode of delivery and morbidities of the second stage of labor. Search terms used were "Intrapartum ultrasound", "dystocia", "prolonged labor", "neuraxial analgesia", "persistent occiput posterior position", "asynclitism", "second stage of labor", "medico-legal aftermath". Prolonged second stage was defined as three hours and more. Retrospective case series of women with prolonged second stage of labor with NLA were identified. The primary outcome was the incidence of operative vaginal delivery (OVD) and cesarean delivery (CS).

RESULTS

The use of NLA may determine a prolonged second stage of labor (PSSL). IU when compared to the traditional vaginal digital examination (VDE) demonstrated the highest degree of diagnostic accuracy.

CONCLUSIONS

The use of IU during NLA can aid in the diagnosis of fetal head progression, station or malposition and malrotation, alerts obstetrician on the possibility of dystocic labor, indicating to stop the drug administration in NLA and shift to OVD or CS. Extending the second stage of labor beyond current American College of Obstetricians and Gynecologists (ACOG) recommendations is beneficial. The ISUOG guidelines recommended the clinical application of IU to diagnose the persistent occiput posterior position (POPP) and asynclitism (A) in dystocic labor and produce photographic evidence of the case. Maternal and neonatal complications, medicolegal consequences and litigation can decrease if the IU device is used as good practice.

Advancements in uterus transplant: new scenarios and future implications

Women suffering from Uterine Factor Infertility (UFI) arising from congenital conditions (e.g., Rokitansky-Kuster-Hauser syndrome) or hysterectomy can fulfill their wish to achieve motherhood only by resorting to surrogacy, which is, however, banned in most countries. Medical research has long been looking into uterus transplant (UTx), which may constitute a valuable alternative for such patients. Following decades of animal testing and clinical trials, several successful pregnancies have been carried to term. Yet UTx is still to be considered as an experimental procedure. The report's authors believe UTx has the potential to become a mainstream surgical practice, but for the time being, several ethical issues need to be weighed in before it does.

Transition of care in pediatric oncohematology: a systematic literature review

BACKGROUND

The transition of medical care from a pediatric to an adult environment is a psychological change, a new orientation that requires a self-redefinition of the individual, to understand that changes are taking place in his life. Up to 60 percent of pediatric patients who transition to adult services will experience one or more disease or treatment-related complication as they become adults. A nurse who knows how to recognize potential barriers at an early stage can play a pivotal role in the educational plan for the transition process.

MATERIALS AND METHODS

A literature search was undertaken of PUBMED, CINAHL and The Cochrane Library, with specific inclusion and exclusion criteria, including articles published in the lasts ten years.This literature review has been performed according to the PRISMA statement.

RESULTS

Using the keywords in different combination 38 articles were found in The Cochrane Library, 5877 in PUBMED, 274 in CINAHL. 88 articles were selected after the abstract screening. 31 after removing the duplicates and reading the full text.

DISCUSSION

The main themes surrounding transition of care that emerged from the synthesis are the organization of care within common models of transition, innovative clinical approaches to transition, and the experience of patients and caregivers. The transition from pediatric to adult care of cancer or SCD survivors is an emerging topic in pediatric nursing. The organization of care is affected by the lack of clear and well-structured organizational models. Further research is needed to deepen the understanding of some aspects of the transition.

Nootropics use in the workplace: psychiatric and ethical aftermath towards the new frontier of bioengineering

OBJECTIVE

The authors have sought to expound upon and shed a light on the rise of nootropics, which have gradually taken on a more and more relevant role in workplaces and academic settings.

MATERIALS AND METHODS

Multidisciplinary databases have been delved into by entering the following keys: "nootropics", "cognitive enhancement", "workplace", "productivity", "ethics", "bioengineering". In addition, a broad-ranging search has been undertaken on institutional websites in order to identify relevant analysis and recommendations issued by international institutions and agencies. Papers and reports have been independently pored over by each author. This search strategy has led to the identification of 988 sources but only 64 were considered appropriate for the purposes of the paper after being selected by at least 3 of the authors, independently.

RESULTS

The notion of an artificially enhanced work performance - carried out by the 'superworker' - is particularly noteworthy and resonates with the conception of contemporary work on so many different levels: the rising need and demands for higher degrees of flexibility and productivity on the job, the implications of a '24/7' society, where more and more services are available at any time, the ever greater emphasis on entrepreneurial spirit, individual self-reliance and self-improvement, and last but not least, the impact of an ageing society on economic standards and performance.

CONCLUSIONS

Moreover, it is worth mentioning that human enhancement technologies will predictably and increasingly go hand in hand with gene editing, bioengineering, cybernetics and nanotechnology. Applications are virtually boundless, and may ultimately affect all human traits (physical strength, endurance, vision, intelligence and even personality and mood).

Transition of care in pediatric oncohematology: a systematic literature review

BACKGROUND

The transition of medical care from a pediatric to an adult environment is a psychological change, a new orientation that requires a self-redefinition of the individual, to understand that changes are taking place in his life. Up to 60 percent of pediatric patients who transition to adult services will experience one or more disease or treatment-related complication as they become adults. A nurse who knows how to recognize potential barriers at an early stage can play a pivotal role in the educational plan for the transition process.

MATERIALS AND METHODS

A literature search was undertaken of PUBMED, CINAHL and The Cochrane Library, with specific inclusion and exclusion criteria, including articles published in the lasts ten years.This literature review has been performed according to the PRISMA statement.

RESULTS

Using the keywords in different combination 38 articles were found in The Cochrane Library, 5877 in PUBMED, 274 in CINAHL. 88 articles were selected after the abstract screening. 31 after removing the duplicates and reading the full text.

DISCUSSION

The main themes surrounding transition of care that emerged from the synthesis are the organization of care within common models of transition, innovative clinical approaches to transition, and the experience of patients and caregivers. The transition from pediatric to adult care of cancer or SCD survivors is an emerging topic in pediatric nursing. The organization of care is affected by the lack of clear and well-structured organizational models. Further research is needed to deepen the understanding of some aspects of the transition.

Synthetic cathinones related fatalities: an update

OBJECTIVE

Synthetic cathinones, more commonly known as "bath salts", are synthetic drugs chemically related to cathinone, a psychostimulant found in the khat plant. They are the first most consumed products among new psychoactive substances, which cause psychostimulant and hallucinogenic effects determining a number of fatalities worldwide.  In this paper, we have systematically reviewed cases of synthetic cathinones-related fatalities analytically confirmed, which have occurred in the last few years.

MATERIALS AND METHODS

Relevant scientific articles were identified in Medline, Cochrane Central, Scopus, Web of Science and Institutional/government websites up to November 2017 using the following keywords: synthetic cathinones, mephedrone, methylenedioxypyrovalerone, MDPV, methylone, ethylone, buthylone, fatal intoxication, fatalities and death.

RESULTS

In total, 20 citations met the criteria for inclusion, representing several fatal cases with analytically confirmed synthetic cathinones in biological sample/s of the deceased. The death was attributed to hyperthermia, hypertension, cardiac arrest and more in general to the classic serotonin syndrome. Only rarely did the concentration of the parent drug causing fatality overcome the value of 1 mg/L in post-mortem biological fluids.

CONCLUSIONS

Abuse of synthetic cathinones still represents a serious public health issue. Systematic clinical studies on both the animal and human model are lacking; therefore, the only available data are from the users who experience the possible hazardous consequences. Analytical methodologies for the identification of parent compounds and eventual metabolites both in ante-mortem and post-mortem cases need to be developed and validated. Analytical data should be shared through different communication platforms with the aim of stopping this serious health threat for drug users.

The case of Patient Safety Indicator 12 (PSI12): use of administrative data to estimate the incidence of "Postoperative Pulmonary Embolism or Deep Vein Thrombosis". A pilot study in a General Hospital

INTRODUCTION

The AHRQ Quality Indicators (QIs) were created in order to both identify the performance and to track the improvement of patient safety. Patient Safety Indicator 12 (PSI12) is relative to the risk of Post Operatory Pulmonary Embolism or Deep Venous Thrombosis (PO DVT/PE). This pilot study has three main objectives. Firstly, to perform an analysis of the performance of different hospital wards by using administrative data; secondly, to analyze defects in the process that led to the occurrence of the adverse event; thirdly, reviewing the single PO DVT/PE.

METHODS

Data were extracted from a Hospital Information data flow (SIO) and compared to Clinical Discharge Record. PSI12 estimates were computed before and after the screening. Control Charts allowed the static analysis of performance between different hospital wards in 2014. The Ishikawa diagram was drawn for the analysis of the underlying causal process.

RESULTS

The number of PSI12 cases provided by DRGs through SIO data flow decreased from 45 to six after the comparison with the correspondent clinical records. Four clinical records provided full information allowing the analysis of process. The Ishikawa Diagram identified the defects in the process of prophylaxis that resulted into a PO DVT/PE.

DISCUSSIONS

The clinical records screening revealed a lower incidence of PO DVT/PE with respect to the DRGs statistics. Overall the PO DVT/PE occurrence in 2014 fell into the control limits, although the result could be undermined by the low quality of clinical records compilation. The failure in the prophylaxis procedure was imputable to pitfalls in the health care management and to the individual attitude towards patient safety procedures. In conclusion, the reliability and validity of administrative data in monitoring quality and safety are worthy to be explored in the context of further validation studies.

Does episiotomy always equate violence in obstetrics? Routine and selective episiotomy in obstetric practice and legal questions

OBJECTIVE

The study's main goal is to figure out whether episiotomy, a widely applied invasive procedure, may constitute a determining factor of liability for practitioners according to the standards of obstetric violence.

MATERIALS AND METHODS

The authors have aimed to analyze laws and documentation issued on the matter by sovereign states, statements and remarks from International health organizations, in addition to scientific article available on the main search engines (PubMed, Scopus, Google Scholar) and legal databases (Lexis, Justia).

RESULTS

The body of research has highlighted the existence of a wide-ranging agreement as to routine episiotomy, deemed to be a scientifically unfounded procedure, and which should, therefore, be avoided. By virtue of that, routine episiotomy might easily give rise to charges and liability for doctors and midwives alike; likewise to claims may stem from a failure to perform an episiotomy when it was actually needed.

CONCLUSIONS

Unlike routine episiotomy, selective episiotomy is far more unlikely to cause charges of obstetric violence against operators. Unfortunately, the criteria in order to establish when a selective episiotomy is indicated are far from consistent and would require an additional effort on the part of scientific societies towards a more clearly defined and shared description.

Rights of the Dying Child: The Nurses' Perception

AIM

The Charter of the Rights of the Dying Child was formulated as a professional guide for caring the child in the final stages. The study examines the nurses' degree of agreement with the Charter's principles and their perception of the implementation of those principles in hospital.

MATERIALS AND METHODS

A multicenter, cross-sectional study to observe the nurses' positions about the 10 rights outlined in the Charter, using an online questionnaire in 5 pediatric hospitals in northern Italy.

RESULTS

A total of 119 nurses (44.9%) completed the questionnaire. The majority (range: 86.6-100%) expressed their agreement with the Charter's principles (Likert ≥4). Lower ratings were reported in Charter's principles implementation items (range: 42.9-89.1%). Being older and working in a smaller hospital lead the nurses to overlook the child's right to be informed and to be given the opportunity to make decisions about his/her own life and death (p = 0.02, p < 0.01). Postgraduate training induced greater awareness of the dying child (p = 0.01).

CONCLUSIONS

This study highlights the value of the Charter of the Rights of the Dying Child as a reference guideline for nurses working in pediatric hospitals. Better training is important to improve the nurse's communication skills and the pediatric palliative care should be offered to all families that have a child with incurable disease mostly in the end of life.

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.

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.

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.

Assessing malpractice lawsuits for death or injuries due to amniotic fluid embolism

Amniotic fluid embolism (AFE) is a pregnancy complication known to be extremely hard to diagnose, since it manifests itself abruptly and with no warning signs, presenting an incidence rate of about 1 in 40000 deliveries, and maternal morbidity and mortality ranging from 20% to 60%. Although almost a century has gone by since it was first identified (1926) and despite medical research having been conducted on such a syndrome, diagnostic procedures and treatment methods have not yet been clarified enough. Specific biochemical markers have been produced in research laboratories, but their clinical value results to be limited, given how rapid the pathological process moves forward. At the time being, no diagnosis is feasible which may effectively prevent the disease from occurring. Certainly, a multidisciplinary approach might contribute to saving the lives of mother and infant, as well as ensuring better life standards. The paper's authors aim to highlight the medico-legal issues, in light of several rulings from the Italian Constitutional Court as well as lower courts. The authors also advocate for the creation of a nation-wide registry meant to collect all signaled AFE instances so that research on this as yet devastating syndrome can be conducted based on hard data.

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.

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.

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.

Sildenafil-associated hepatoxicity: a review of the literature

Sildenafil citrate (Viagra®) is a vasoactive agent available worldwide since 1998 for the treatment of male erectile dysfunction. It is a selective phosphodiesterase type 5-enzyme inhibitor able to potentiate the downstream effects of nitric oxide on smooth muscle relaxation and vasodilation through its effects on the cyclic guanosine monophosphate (c-GMP) pathway in the erectile tissue of the penis. When sildenafil is orally administered, it is rapidly absorbed with a maximum plasma concentration achieved within 1 h and has a terminal half-life of between 3 to 6 h. The drug is extensively and rapidly metabolized by the liver, primarily by the CYP3A4 enzyme. Although the drug is well tolerated, specific adverse events have been observed, like flushing, headaches, dyspepsia, and visual disturbances. Liver toxicity related to sildenafil consumption has been considered a very rare event. However, in the last decade, some cases of sildenafil-associated hepatotoxicity have been reported. Furthermore, some hepatic intoxications have been reported after the intake of "natural" or "herbal" aphrodisiac supplements sold through Internet, sex shops, social media, and by word-of-mouth found to contain sildenafil and other phosphodiesterase type 5 (PDE-5) inhibitors. Studies investigating a possible link between sildenafil use and liver damage are limited, and the underlying mechanism responsible for hepatotoxicity is still missing. Studies in animals evidence that the hematopoietic function of the liver may have severely been affected as a result of a probable toxic effect of sildenafil. Here, the studies reporting liver toxicity by sildenafil in humans and in animals are reported and discussed.

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.

The role of fillers in aesthetic medicine: medico-legal aspects

In recent years there has been an exponential increase of fillers use in aesthetic medicine. The popularity of this anti-wrinkle product is based on their capacity to offer significant improvement in the aesthetic field, particularly to skin rejuvenating processes with non-invasive and less expensive techniques, if compared to the surgical methods (i.e. surgical lifting). The great number of fillers on the market is composed of a large heterogenic number of biomaterials. The aim of this review was to provide an overview and a classification of the filling materials that are most commonly used. A synthesis of the literature concerning fillers and related side effects was also reported. The law decree no. 23 of 1998, converted in the law no. 94 of 1998 and the principal judgments of the Italian Court of Cassation have been examined with the medico-legal issues related to fillers use in medicine. With respect to their degradation, filler materials may be classified as temporary (degradable), semi-permanent and permanent (not degradable). The temporary fillers such as hyaluronic acid and collagen are completely degraded by the surrounding tissue in a few months. The permanent fillers, such as the ones derived from silicon oil and minerals are not biodegradable and may cause serious and irreversible side effects. Their use requires a physician with a high level of specialization to perform the treatment, a deep knowledge of face anatomy and a great degree of experience.

"Vehicular homicide", a new Italian offence: law provisions and comparison with some other European countries

According to the most recent World Health Organization report, road accidents represent a very serious public health issue, claiming each year more than 1.2 million lives worldwide and being the leading cause of death among young people aged between 15 and 29 years. Up to now, the policies to reduce this issue are different, unbalanced and often inadequate not only in Italy, but also in the other European Countries. Specifically, the Italian Parliament has recently introduced a new law (n. 41 of March 23rd, 2016), making vehicular homicide together with road traffic injuries a criminal offense, both to be punished as a result of negligence. The measure came into force on March 25th, 2016. In this paper, the provisions of the above-reported law have been assessed, taking into account the modifications introduced in the Penal Code by this law and the impact it is having and will have on drivers on a day-to-day basis. Similarities and differences with legislative framework of some other European countries were also examined. Finally, some open questions to be solved are named as an open eye for future considerations.

The static evolution of the new Italian code of medical ethics

Eight years since the last revision, in May 2014 the Italian code of medical ethics has been updated. Here, the Authors examine the reform in the light of the increasing difficulties of the medical profession arising from the severity of the Italian law Courts. The most significant aspects of this new code are firstly, the patient's freedom of self-determination and secondly, risk prevention through the disclosure of errors and adverse events. However, in both areas the reform seems to be less effective if we compare the ethical codes of France, the United Kingdom and the United States. In particular, the non-taking into consideration of the said code quality standards and scientific evidence which should guide doctors in their clinical practice is to say the least questionable. Since these are the most significant changes in the new code, it seems inevitable to conclude that the 2014 edition is essentially in line with previous versions. Now more than ever it is necessary that medical ethics acknowledges that medicine, society and medical jurisprudence have changed and doctors must be given new rules in order to protect both patients' rights and dignity of the profession. The physician's right to refuse to perform treatment at odds with his own clinical beliefs cannot be the only mean to safeguard the dignity of the profession. A clear boundary must also be established between medicine and professionalism as well as the criteria in determining the scientific evidences that physicians must follow. This has not been done in the Italian code of ethics, despite all the controversy caused by the Stamina case.

Clinical applications of sodium oxybate (GHB): from narcolepsy to alcohol withdrawal syndrome

Gamma-hydroxybutyrate (GHB) is a short chain fatty acid endogenously produced within the central nervous system (CNS) and acts as a precursor and metabolite of the inhibitory neurotransmitter γ-aminobutyric acid (GABA). Although, it is an illegal recreational drug of abuse, its sodium salt (sodium oxybate) has been utilized as a medication for a number of medical conditions. The first aim of this review was to focus on current applications of sodium oxybate for the treatment of narcolepsy, with a particular emphasis on the key symptoms of this disorder: cataplexy and excessive daytime sleepiness (EDS). Secondly, the effectiveness of sodium oxybate therapy for the treatment of alcohol withdrawal syndrome (AWS) and the maintenance of alcohol abstinence has been assessed. Nowadays, sodium oxybate is the first-line treatment for narcolepsy and it is highly effective in meliorating sleep architecture, decreasing EDS and the frequency of cataplexy attacks in narcoleptic patients. Sodium oxybate currently finds also application in the treatment of AWS and the maintenance of alcohol abstinence in alcoholics. Most of the studies evaluating the efficacy of GHB in the treatment of AWS use a dosage of 50 mg/kg divided in three or four administrations per day. Human studies showed that GHB (dose of 50 mg/kg, divided in three administrations per day) is capable to increase the number of abstinent days, reduce alcohol craving and decrease the number of drinks per day. However, there is limited randomized evidence and, thus, GHB cannot be reliably compared to clomethiazole or benzodiazepines. Some randomized data suggest that GHB is better than naltrexone and disulfiram regarding abstinence maintenance and prevention of craving in the medium term i.e. 3-12 months. It is recommended that GHB should be used only under strict medical supervision, since concerns about the abuse/misuse of the drug and the addiction potential have been arisen.

Assessment of the stability of exogenous gamma hydroxybutyric acid (GHB) in stored blood and urine specimens

OBJECTIVE

The aim of this work is to test the stability of exogenous GHB in whole blood and urine samples collected from living and deceased GHB free-users, spiked with known concentrations of GHB and stored at different temperatures (-20°C, 4°C and 20°C) up to 4 weeks.

MATERIALS AND METHODS

GHB was added to GHB-free ante-mortem blood and urine samples at the concentration of 5 and 10 mg/L, respectively whereas in post-mortem blood and urine specimens at 50 and 10 mg/L respectively. All samples were stored at three different temperatures: -20°C, 4°C and 20°C and extracted and analyzed at three days, 1 week, 2 weeks, 3 and 4 weeks in duplicate. No preservatives were added. GHB was quantified by GC-MS after LLE according to a previously published method.

RESULTS

Post-mortem blood specimens showed a reduction of GHB levels higher than 10% only after a period of 4 weeks of storage for samples kept at +4°C and +20°C, whereas samples stored at -20°C showed a mean reduction of 8.7%. In post-mortem urine samples, there was a mean reduction of GHB levels higher than 20% at all storage temperatures, after 4 weeks of storage. Ante-mortem blood samples showed a reduction of GHB levels lower than 10% only after 3 days of storage at -20°C and at +4°C (samples stored at +20°C showed a mean reduction of 10.4%). After 4 weeks of storage, there was a mean reduction of GHB concentrations higher than 20% at all storage temperatures. Ante-mortem urine samples showed a reduction of GHB levels higher than 10% after just 3 days of storage for samples kept at all tested temperatures. After 4 weeks of storage, there was a mean reduction of GHB concentrations higher than 25% at all storage temperatures.

CONCLUSIONS

According to our findings, it would be useful to perform GHB analysis both in blood and urine specimens within 3 days of sampling and the specimens should be stored at -20°C or 4°C in order to avoid instability issues.

Mephedrone related fatalities: a review

OBJECTIVE

Synthetic cathinones are an emerging class of designer drugs abused of due to their psychostimulant and hallucinogenic effects, similar to those of cocaine, methylenedioxymethamphetamine (MDMA), amphetamines and methamphetamines. Mephedrone is a cathinone analogue (4-methyl aromatic analogue of methcathinone) that was reported to be implicated in several fatalities in the media across Europe, but only a few have actually resulted in mephedrone cited as the cause of death. In this paper, we aim to systematically review analytically confirmed cases of mephedrone-related fatalities.

MATERIALS AND METHODS

Relevant scientific articles were identified from Medline, Cochrane Central, Scopus, Web of Science, Science Direct, EMBASE and Google Scholar, through May 2015 using the following keywords: "Mephedrone", "fatal intoxication," "fatalities", "acute intoxication" and "death".

RESULTS

In total, 10 citations met the criteria for inclusion, representing 18 fatal cases with analytically confirmed mephedrone in biological sample/s of the deceased. The death was attributed to mephedrone intoxication in 9 cases (range of post-mortem blood mephedrone concentration: 1.33-22 mg/L), whereas multiple drug toxicity, involving mephedrone was cited as cause of death in 6 cases (range of post-mortem blood mephedrone concentration: 0.04-1.3 mg/L).

CONCLUSIONS

Data suggest that the abuse of mephedrone remains to be a public health issue. Mephedrone appears to have a rather narrow therapeutic window that makes its use dangerous. Dosages which supposedly fall within recreational use limits could also lead to death when combined with other drugs in certain circumstances. Forensic Toxicology laboratories must assess their testing procedures to ensure they can achieve both an appropriate screening regime and targeted quantitative analysis for the detection of mephedrone in various biological matrices.

NBOMe: new potent hallucinogens--pharmacology, analytical methods, toxicities, fatalities: a review

OBJECTIVE

NBOMe is a class of emerging new psychoactive substances that has recently gained prominence in the drug abuse market. NBOMes are N-2-methoxy-benzyl substituted 2C class of hallucinogens, currently being marked online as "research chemicals" under various names: N-bomb, Smiles, Solaris, and Cimbi. This article reviews available literature on the pharmacology; the analytical methods currently used for the detection and quantification of NBOMe in biological matrices and blotters, together with intoxication cases and NBOMe-related fatalities.

MATERIALS AND METHODS

Relevant scientific articles were identified from Medline, Cochrane Central, Scopus, Web of Science, Science Direct, EMBASE and Google Scholar, through June 2015 using the following keywords: "NBOMe", "Nbomb", "Smiles", "intoxication", "toxicity" "fatalities", "death", "pharmacology", "5-HT2A receptor", "analysis" and "analytical methods". The main key word "NBOMe" was individually searched in association to each of the others.

RESULTS

The review of the literature allowed us to identify 43 citations on pharmacology, analytical methods and NBOMe-related toxicities and fatalities.

CONCLUSIONS

The high potency of NBOMes (potent agonists of 5-HT2A receptor) has led to several severe intoxications, overdose and traumatic fatalities; thus, their increase raises significant public health concerns. Moreover, due to the high potency and ease of synthesis, it is likely that their recreational use will become more widespread in the future. The publication of new data, case reports and evaluation of the NBOMes metabolites is necessary in order to improve knowledge and awareness within the forensic community.

Cost analysis of brachial plexus injuries: variability of compensation by insurance companies before and after surgery

Traumatic paralysis of the brachial plexus is an extremely disabling pathology. The type of trauma most frequently suffered by this group of patients is due to motorcycle injuries. It therefore affects a population of young patients. In the majority of cases, these patients receive compensation for permanent damage from insurance companies. Surgery of the brachial plexus enables various forms of functional recovery, depending on the number of roots of the brachial plexus involved in the injury. The aim of this study is to compare the functional deficit and the extent of the related compensation before and after surgical intervention, and to evaluate the saving in economic terms (understood as the cost of compensation paid by insurance companies) obtainable through surgical intervention. The authors analysed the functional recovery obtained through surgery in 134 patients divided into 4 groups on the basis of the number of injured roots. The levels of compensation payable to the patient before surgical intervention, and 3 years after, were then compared. The results showed that the saving obtainable through surgical treatment of brachial plexus injuries may exceed 65% of the economic value of the compensation that would have been attributable to the same patients if they had not undergone surgical treatment.

Sensitivity of autopsy and radiological examination in detecting bone fractures in an animal model: Implications for the assessment of fatal child physical abuse

Skeletal injuries are often strong indicators of child abuse and their detection is therefore crucial. The aim of this study was to compare the sensitivity of three diagnostic approaches, namely autopsy, traditional (conventional) radiology, and computed tomography on "battered" piglets, in order to verify the sensitivity of each method, with respect to the true number of bone fractures assessed once the piglet was skeletonised (osteological control). Four newborn cadaver piglets who had died from natural causes were severely beaten post-mortem in every district of the body. Traditional radiography, computed tomography (CT) and autopsy were performed. The piglet was then macerated until skeletonised and the number of all fractures present recorded (osteological control). On the cranium, traditional radiology revealed only 35% circa of actual fractures, autopsy detected only 31% (P<0.01 for both comparisons versus osteological control), whereas CT imaging detected all fractures actually present. For ribs, radiology detected only 47% of all fractures present, and autopsy 65% circa (P>0.05 for both comparisons versus osteological control), while CT scans detected 34% (P<0.01). In suspected cases of fatal child abuse, we suggest that the bones of specific districts be directly analysed either at autopsy or by collecting specific diagnostic sites, such as parts of the rib cage, and subjecting them to maceration. The removed areas could be replaced with artificial material for cosmetic purposes. The authors stress the importance of combined radiological, CT scan, autopsy and osteological survey in the detection of perimortem bone fractures.

A distinct strategy to generate high-affinity peptide binders to receptor tyrosine kinases

We describe a novel and general way of generating high affinity peptide (HAP) binders to receptor tyrosine kinases (RTKs), using a multi-step process comprising phage-display selection, identification of peptide pairs suitable for hetero-dimerization (non-competitive and synergistic) and chemical synthesis of heterodimers. Using this strategy, we generated HAPs with K(D)s below 1 nM for VEGF receptor-2 (VEGFR-2) and c-Met. VEGFR-2 HAPs bound significantly better (6- to 500-fold) than either of the individual peptides that were used for heterodimer synthesis. Most significantly, HAPs were much better (150- to 800-fold) competitors than monomers of the natural ligand (VEGF) in various competitive binding and functional assays. In addition, we also found the binding of HAPs to be less sensitive to serum than their component peptides. We believe that this method may be applied to any protein for generating high affinity peptide (HAP) binders.

[2 cases of Beckwith-Wiedemann syndrome. Morphogenetic characteristics, cardiac involvement and current diagnostic possibilities]

This report describes two new cases of BWS. This diagnosis of BWS may be missed because of variable or incomplete clinical expression. Recognition of such patients is important, however, because they have the potential for development of neoplasias. There also appears to be an increased risk of malignancies associated with hemihypertrophy and BWS.