Mother, father, son and the Italian Law 40/2004. No 'delete' key

Assisted reproductive technology (ART) has emerged in recent years as a point of significant innovation in the medical field but is also controversial from a bioethical and legal standpoint. In the Italian context, this matter is regulated by Law 40/2004, which specifically requires that informed consent should be obtained from both members of a couple before proceeding with any ART procedure. This consent is deemed irrevocable at the moment of egg fertilization. Recently, a ruling by the Italian Constitutional Court on this matter elicited controversy. The decision permitted embryo transfer even in a case of parental separation, notwithstanding the father's explicit opposition. The Court emphasized the priority of the woman's psychophysical health over the man's, highlighting the traumatic consequences of interrupting the undertaken path. As a result, both the man's right to self-determination regarding the decision to become a father and the need for informed consent at every stage of medical procedures have been downplayed. Moreover, the extensive utilization of procedures like embryo cryopreservation, with associated parental implications, particularly concerning the time frame and the actuality of informed consent, is posing challenges to the initial application framework of Law 40/2004. The objective of this Commentary is to scrutinize and discuss the issues mentioned above.

Fourteen Deaths from Suspected Heparin Overdose in an Italian Primary-Level Hospital

Healthcare-related homicidal cases are not novel within the medical-legal landscape, but investigations are often made difficult with the scarcity of material evidence related to the crime. For this reason, it is necessary to carefully analyze the clinical documentation and employ ancillary forensic resources such as radiology, histopathology, and toxicology. In the presented scenario, the observation of 14 deaths from abnormal bleeding in a First-Level Italian Hospital revealed the administration of massive doses of heparin by a nurse. On behalf of the Judicial Authority, a multidisciplinary medical team investigated the case through the following steps: a thorough review of the clinical documentation, exhumation of the bodies belonging to the deceased patients, performing PMCT and autopsy, and collecting tissue samples for histopathological, immunohistochemical, and toxicological investigations. All the analyzed cases have been characterized by the observation of fatal hemorrhagic episodes not explained with the clinical conditions of the patients, confirmed using autopsy observations and the histological demonstration of the vitality of the lesions. However, due to the limited availability of biological material for the toxicological analysis, the indirect evidence from hematological analyses in hospitalized patients was crucial in demonstrating heparin overdose and its link to the recorded deaths. The present scenario demonstrates the fundamental importance of a multidisciplinary approach to cases of judicial interest related to the healthcare context. Therefore, the illustrated methodologies can be interpreted as an operational framework for similar future cases.

Development of associational fiber tracts in fetal human brain: a cadaveric laboratory investigation

The advent of diffusion tensor imaging (DTI) in addition to cadaveric brain dissection allowed a comprehensive description of an adult human brain. Nonetheless, the knowledge of the development of the internal architecture of the brain is mostly incomplete. Our study aimed to provide a description of the anatomical variations of the major associational bundles, among fetal and early post-natal periods. Seventeen formalin-fixed fetal human brains were enrolled for sulci analysis, and 13 specimens were dissected under the operating microscope, using Klingler's technique. Although fronto-temporal connections could be observed in all stages of development, a distinction between the uncinate fascicle, and the inferior fronto-occipital fascicle was clear starting from the early preterm period (25-35 post-conceptional week). Similarly, we were consistently able to isolate the periatrial white matter that forms the sagittal stratum (SS), with no clear distinction among SS layers. Arcuate fascicle and superior longitudinal fascicle were isolated only at the late stage of development without a reliable description of their entire course. The results of our study demonstrated that, although white matter is mostly unmyelinated among fetal human brains, cadaveric dissection can be performed with consistent results. Furthermore, the stepwise development of the associational fiber tracts strengthens the hypothesis that anatomy and function run in parallel, and higher is the cognitive functions subserved by an anatomical structure, later the development of the fascicle. Further histological-anatomical-DWI investigations are required to appraise and explore this topic.

The Dark Side of Energy Drinks: A Comprehensive Review of Their Impact on the Human Body

In recent years, the consumption of energy drinks by young adults and athletes has risen significantly, but concerns have been raised about the potential health risks associated with excessive consumption. These concerns include cardiovascular problems, nervous system disorders, and the potential for addiction. This review aims to examine the reported effects of acute or chronic abuse of energy drinks on human health. The analysis shows a significant prevalence of adverse effects, particularly on the cardiovascular and neurovegetative systems. In particular, the analysis identified nine cases of cardiac arrest, three of which were fatal. The aetiology of these adverse effects is attributed to the inherent neurostimulant properties of these beverages, of which caffeine is the predominant component. A comparison of documented effects in humans with experimental studies in animal models showed an overlap in results. This review highlights the need for greater rigour in the assessment of sudden cardiac death, particularly in young people, as legal substances such as energy drinks may be involved. We propose stricter limits on the consumption of these beverages than for caffeine, based on the evidence found and the data in the literature. This review also calls for the establishment of regulations governing the consumption of these products in view of their potential impact on human health.

Oxidative Stress Markers in Human Brain and Placenta May Reveal the Timing of Hypoxic-Ischemic Injury: Evidence from an Immunohistochemical Study

During pregnancy, reactive oxygen species (ROS) serve as crucial signaling molecules for fetoplacental circulatory physiology. Oxidative stress is thought to sustain the pathogenesis and progression of hypoxic-ischemic encephalopathy (HIE). A retrospective study was performed on the brains and placentas of fetuses and newborns between 36-42 weeks of gestation (Group_1: Fetal intrauterine deaths, Group_2: Intrapartum deaths, Group_3: Post-partum deaths, Control group sudden neonatal death); all groups were further divided into two subgroups (Subgroup_B [brain] and Subgroup_P [placenta]), and the study was conducted through the immunohistochemical investigations of markers of oxidative stress (NOX2, 8-OHdG, NT, iNOS), IL-6, and only on the brain samples, AQP4. The results for the brain samples suggest that NOX2, 8-OHdG, NT, iNOS, and IL-6 were statistically significantly expressed above the controls. iNOS was more expressed in the fetal intrauterine death (Group_1) and less expressed in post-partum death (Group_3), while in intrapartum death (Group_2), the immunoreactivity was very low. IL-6 showed the highest expression in the brain cortex of the fetal intrauterine death (Group_1), while intrapartum death (Group_2) and post-partum death (Group_3) showed weak immunoreactivity. Post-partum death (Group_3) placentas showed the highest immunoreactivity to NOX2, which was almost double that of the fetal intrauterine death (Group_1) and intrapartum death (Group_2) placentas. Placental tissues of fetal intrauterine death (Group_1) and intrapartum death (Group_2) showed higher expression of iNOS than post-partum death (Group_3), while the IL-6 expression was higher in the fetal intrauterine death (Group_1) than the post-partum death (Group_3). The AQP4 was discarded as a possible marker because the immunohistochemical reaction in the three groups of cases and the control group was negative. The goal of this study, from the point of view of forensic pathology, is to provide scientific evidence in cases of medical liability in the Obstetric field to support the clinical data of the timing of HIE.

Correction: Aquaro et al. Post-Mortem Cardiac Magnetic Resonance in Explanted Heart of Patients with Sudden Death. Int. J. Environ. Res. Public Health 2022, 19, 13395

The authors wish to make the following corrections to this paper [...].

Early Saphenous Vein Graft Aneurysm Rupture: A Not So-Late Complication. Case Report and Comprehensive Literature Review

BACKGROUND AND OBJECTIVES

Saphenous vein graft (SVG) is a cardiac surgical practice used to create a cardiac bypass in cases of coronary artery obstruction. It consists of a surgical procedure that involves the creation of an aorto-coronary communication by a venous conduit (saphenous vein) to bypass coronary stenosis and allow cardiac revascularization. This practice can be affected by early and late complications. The most feared complication is graft aneurysm or pseudoaneurysm degeneration and rupture which are considered late complications. This paper presents a rare case of SVG aneurysmal rupture that occurred 24 h after surgery and a review of the literature to provide a general look at the state of knowledge.

MATERIALS AND METHODS

The systematic review was carried out using the guidelines according to the PRISMA method.

RESULTS

Cases of aneurysmal rupture have never been described prior to one month after surgery. The male sex and subjects under 45 are the most affected by this complication. Death occurs in less than half of the cases, being more frequent in young people. Performing a CT or angio-CT examination led to the diagnosis.

CONCLUSIONS

It is impossible to estimate the implanted vessel's quality, so postoperative follow-up is fundamental. Transesophageal ultrasound can be useful, and hematochemical tests are valuable early diagnostic tools, whrease CT and angio-CT can be useful even months after surgery. Forensic analysis should always perform an autopsy and graft histological examination.

FOXO3 Depletion as a Marker of Compression-Induced Apoptosis in the Ligature Mark: An Immunohistochemical Study

One of the most challenging issues in forensic pathology is lesion vitality demonstration, particularly in cases of hanging. Over the past few years, immunohistochemistry has been applied to this field with promising results. In particular, protein and transcription factors involved in the apoptotic process have been studied as vitality markers for the ligature mark. This study represents an implementation of our previous studies on ligature mark vitality demonstration. In this study, we evaluated the FOXO3 expression in post-mortem cervical skin samples through an immunohistochemical analysis. To evaluate FOXO3 expression, anti-FOXO3 antibodies (GTX100277) were used. The study group comprised 21 cases, 8 women and 13 men, whereas the control group consisted of 13 cases of subjects who died due to other causes. Decomposition and no clear circumstantial data were exclusion criteria. We found that FOXO3 is decreased in hanging cases compared with normal skin in other causes of death (p-value < 0.05). No differences were seen concerning the type of hanging material (hard or soft), type of hanging (complete or incomplete), and position of the knot. Our results suggest that FOXO3 depletion could be a valid immunohistochemical marker of ligature mark vitality.

Insulin and Oral Hypoglycemic Drug Overdose in Post-Mortem Investigations: A Literature Review

Background and Objectives: Insulin and oral hypoglycemic agents are drugs widely used in the world population due to their therapeutic effects on diabetes mellitus. Despite these benefits, they can also cause accidental or voluntary drug overdose. This review aims to evaluate post-mortem investigations in cases of suspected hypoglycemic drug overdose. Materials and Methods: We performed a comprehensive search using the Preferred Reporting Items for Systematic Review (PRISMA) standards; we systematically searched the PubMed, Science Direct Scopus, Google Scholar, and Excerpta Medica Database (EM-BASE) databases from the point of database inception until August 2022. The following inclusion criteria were used: (1) original research articles, (2) reviews and mini-reviews, (3) case reports/series, (4) and only papers written in English. Results: Thirty-three scientific papers, including original research articles, case reports, and case series, fulfilled the inclusion criteria. A total of 109 cases of insulin or hypoglycemic drug overdose were found. There were 71 cases of suicide (65%), 25 cases of accidental poisoning (23%), and 13 cases of homicide (12%). The most commonly used drug was insulin (95.4%). Autopsy and post-mortem examinations were performed in 84 cases, while toxicological investigations were performed in 79 cases. The most common gross findings in the autopsy were pulmonary edema (55.7%) and congestion (41.8%), while the most common histological finding was neuronal depletion or necrosis (29.1%). Conclusions: In the suspicion of death from insulin or overdose from oral hypoglycemic agents, autopsy findings may be nonspecific, and the search for injection marks can be positive at the external examination. Significant post-mortal alterations can interest biological samples and an early autopsy investigation is recommended.

Post-Mortem Cardiac Magnetic Resonance in Explanted Heart of Patients with Sudden Death

BACKGROUND

We sought to evaluate the diagnostic accuracy of post-mortem cardiac magnetic resonance (PMCMR) of explanted hearts to detect the cardiac causes of sudden death.

METHODS

PMCMR was performed in formalin-fixed explanted hearts of 115 cases of sudden death. Histological sampling of myocardium was performed using two different approaches: (1) guideline-based sampling; (2) guideline-based plus PMCMR-driven sampling.

RESULTS

Forensic diagnosis of cardiac cause of death was ascertained in 72 (63%) patients. When the guideline-driven histological sampling was used, the PMCMR interpretation matched with final forensic diagnosis in 93 out of 115 cases (81%) with sensitivity of 88% (79-95%), specificity of 65% (47-80%), PPV of 84% (78-90%), NPV of 73% (58-84%), accuracy of 81% (72-88%), and AUC of 0.77 (0.68-0.84). When a PMCMR-driven approach was added to the guideline-based one, the matching increased to 102 (89%) cases with a PMCMR sensitivity of 89% (80-94%), a specificity of 86% (67-96%), PPV of 95% (89-98%), NPV of 73% (59-83%), accuracy of 89% (81-93%), and AUC of 0.88 (0.80-0.93).

CONCLUSIONS

PMCMR has high accuracy to identify the cardiac cause of sudden death and may be considered a valid auxilium for forensic diagnosis. PMCMR could improve histological diagnosis in conditions with focal myocardial involvement or demonstrating signs of myocardial ischemia.

Is Healthcare Responsibility in Patients' Suicide Provable Beyond all Reasonable Doubt? An Analysis of Preventing Strategies and Medical Liability Through a Case Series

As a result of the duty of care, the healthcare professional has an obligation of surveillance towards the patients that are under their treatment. According to that principle, the Italian Criminal Supreme Court declared a guilty sentence in many cases of psychiatric patients' suicide, recognizing the criminal liability of the healthcare personnel. This is true not only for suicides occurred inside the hospital, but also for the suicide of psychiatric outpatients. Only in a few cases, the Italian Supreme Court acquitted the healthcare personnel. This happened when it was recognized that the suicide event was unavoidable. Despite the fact that suicide risk is often unpredictable, this does not exclude medical liability. In this work we examine the judicial aspects of five cases of suicide of psychiatric patients, considering whether different preventive strategies could have been effective in preventing the suicide event. This work aims to understand whether the suicide of psychiatric patient is effectively preventable and - referring to healthcare responsibility under penal judgment - if that could be proven beyond all reasonable doubt.

Cause of Death in Charred Bodies: Reflections and Operational Insights Based on a Large Cases Study

Our study aims to demonstrate the experience of analyzing fully or partially charred corpses to offer a proper implementation protocol for determining the cause of death. In this study, we present a total of 103 cases obtained from the University of Rome La Sapienza and the University of Pisa archives. All cases were classified based on the extent and severity of burns using a visual method. We divided all cases into two groups. The first group included grade I-II burns (21 cases) without the need for identification. The second group (82 cases) included injuries worse than grade burns II, so all cases were analyzed using an analytical method. For each case, we have documented which of the following analyses have been used and the corresponding findings: inspection, autopsy examination, imaging examination, genetic and toxicological examinations, and histological examination. The results describe the main diagnostic findings and show that only the application of all the above systematic analyses can provide greater accuracy and reliability in describing the causes of death or solving problems, such as identification. In conclusion, we propose an available protocol that defines the main steps of a complete diagnostic pathway that pathologists should follow daily in studying charred bodies.

Traumatic Internal Carotid Artery Injuries: Do We Need a Screening Strategy? Literature Review, Case Report, and Forensic Evaluation

Internal carotid artery dissection (ICAD) represents the cause of ictus cerebri in about 20% of all cases of cerebral infarction among the young adult population. ICAD could involve the extracranial and intracranial internal carotid artery (ICA). It could be spontaneous (SICAD) or traumatic (TICAD). It has been estimated that carotid injuries could complicate the 0,32% of cases of general blunt trauma and the percentage seems to be higher in cases of severe multiple traumas. TICAD is diagnosed when neurological symptoms have already occurred, and it could have devastating consequences, from permanent neurological impairment to death. Thus, even if it is a rare condition, a prompt diagnosis is essential. There are no specific guidelines regarding TICAD screening. Nevertheless, TICAD should be taken into consideration when a young adult or middle-aged patient presents after severe blunt trauma. Understanding which kind of traumatic event is most associated with TICAD could help clinicians to direct their diagnostic process. Herein, a review of the literature concerning TICAD has been carried out to highlight its correlation with specific traumatic events. TICAD is mostly correlated to motor vehicle accidents (94/227), specifically to car accidents (39/94), and to direct or indirect head and cervical trauma (76/227). As well, a case report is presented to discuss TICAD forensic implications.

State-of-the-Art on Wound Vitality Evaluation: A Systematic Review

The vitality demonstration refers to determining if an injury has been caused ante- or post-mortem, while wound age means to evaluate how long a subject has survived after the infliction of an injury. Histology alone is not enough to prove the vitality of a lesion. Recently, immunohistochemistry, biochemistry, and molecular biology have been introduced in the field of lesions vitality and age demonstration. The study was conducted according to the preferred reporting items for systematic review (PRISMA) protocol. The search terms were "wound", "lesion", "vitality", "evaluation", "immunohistochemistry", "proteins", "electrolytes", "mRNAs", and "miRNAs" in the title, abstract, and keywords. This evaluation left 137 scientific papers. This review aimed to collect all the knowledge on vital wound demonstration and provide a temporal distribution of the methods currently available, in order to determine the age of lesions, thus helping forensic pathologists in finding a way through the tangled jungle of wound vitality evaluation.

Death after the Administration of COVID-19 Vaccines Approved by EMA: Has a Causal Relationship Been Demonstrated?

More than eight billion doses of COVID-19 vaccines have been administered globally so far and 44.29% of people are fully vaccinated. Pre-authorization clinical trials were carried out and the safety of vaccines is still continuously monitored through post-commercialization surveillance. However, some people are afraid of vaccine side effects, claiming they could lead to death, and hesitate to get vaccinated. Herein, a literature review of COVID-19-vaccine-related deaths has been carried out according to the PRISMA standards to understand if there is a causal relationship between vaccination and death and to highlight the real extent of such events. There have been 55 cases of death after COVID-19 vaccination reported and a causal relationship has been excluded in 17 cases. In the remaining cases, the causal link between the vaccine and the death was not specified (8) or considered possible (15), probable (1), or very probable/demonstrated (14). The causes of deaths among these cases were: vaccine-induced immune thrombotic thrombocytopenia (VITT) (32), myocarditis (3), ADEM (1), myocardial infarction (1), and rhabdomyolysis (1). In such cases, the demonstration of a causal relationship is not obvious, and more studies, especially with post-mortem investigations, are needed to deepen understanding of the possible pathophysiological mechanisms of fatal vaccine side effects. In any event, given the scarcity of fatal cases, the benefits of vaccination outweigh the risks and the scientific community needs to be cohesive in asserting that vaccination is fundamental to containing the spread of SARS-CoV-2.

Physician-Patient Relationship, Assisted Suicide and the Italian Constitutional Court

In 2017, Italy passed a law that provides for a systematic discipline on informed consent, advance directives, and advance care planning. It ranges from decisions contextual to clinical necessity through the tool of consent/refusal to decisions anticipating future events through the tools of shared care planning and advance directives. Nothing is said in the law regarding the issue of physician assisted suicide. Following the DJ Fabo case, the Italian Constitutional Court declared the constitutional illegitimacy of article 580 of the criminal code in the part in which it does not exclude the punishment of those who facilitate the suicide when the decision has been freely and autonomously made by a person kept alive by life-support treatments and suffering from an irreversible pathology, the source of physical or psychological suffering that he/she considers intolerable, but fully capable of making free and conscious decisions. Such conditions and methods of execution must be verified by a public structure of the national health service, after consulting the territorially competent ethics committee. This statement admits, within strict and regulated bounds, physician assisted suicide, so widening the range of end-of-life decisions for Italian patients. Future application and critical topics will be called into question by the Italian legislator.

MiRNAs as New Tools in Lesion Vitality Evaluation: A Systematic Review and Their Forensic Applications

Wound vitality demonstration is one of the most challenging fields in forensic pathology. In recent years, researchers focused on the application of histological and immunohistochemical staining in this sphere of study. It is based on the detection of inflammation, red cell infiltration, and tissue alterations at the histological examination, all of which are supposedly present in antemortem rather than post-mortem wounds. Nevertheless, some doubts about the reliability of those markers have arisen. Furthermore, the lack of a standardized protocol and the operator dependency of this approach make the proper interpretation of its results difficult. Moreover, a differential miRNAs expression has been demonstrated in antemortem and post-mortem wounds. Herein, a systematic review concerning the current knowledge about the use of miRNAs in lesion vitality evaluation is carried out, to encourage researchers to deepen this peculiar study area. A compendium about the potential miRNAs that may be further investigated as vitality markers is also provided. The aim is to collect all available data about this topic to direct further studies on this field and highlight the future applications of miRNAs in forensic pathology. We found 20 articles and a total of 51 miRNAs that are involved in inflammation and wound healing. Further studies are certainly needed to deepen the role of miRNAs in inflammatory processes in lesioned skin and to evaluate their reliability in distinguishing between antemortem and post-mortem lesions.

Bleeding varicose veins' ulcer as a cause of death: a case report and review of the current literature

Abstract

Chronic venous insufficiency (CVI) and varicose veins (VVs) of the lower limbs are very frequent vascular diseases in Western countri-es. One possible complication of these conditions is skin ulceration and its consequent rupture, which can be spontaneous or due to mild or trivial trauma. In some cases, the resulting hemorrhage is fatal. When the victim is found dead, a large amount of blood around the body might lead to the hypothesis of violent death. The Forensic Pa-thologist needs to be very careful in the corpse's examination, in order to exclude any alternative cause of death. Herein, an illustrative case is reported, as well as a literature review of the literature concerning sudden hemorrhages from VVs. We found 27 scientific papers, the total reported cases of VVs rupture with profuse hemorrhages were 36, 32 of which were fatal. The main characteristics of such forensic scenario have been collected. Corpse examination of the victims showed pallor of the skin and mucous membranes, as well as marked pallor of organs as a sign of hemorrhagic shock, but these pathological findings are unspecific. Usually, the skin near the ulcer presented color alteration (discoloration and atrophy or pigmentation and hyperemia). Besides, the histological examination of the skin could be a valid instrument to demonstrate the presence of the ulcer, even if it could be very difficult to sample, because of its small size. An important limit of our study is the small number of collected cases. More studies in this field are needed to improve evidence concerning death due to VVs rupture.

MicroRNAs in Hypertrophic, Arrhythmogenic and Dilated Cardiomyopathy

MicroRNAs (miRNAs) are a class of non-coding RNAs of about 20 nucleotides in length, involved in the regulation of many biochemical pathways in the human body. The level of miRNAs in tissues and circulation can be deregulated because of altered pathophysiological mechanisms; thus, they can be employed as biomarkers for different pathological conditions, such as cardiac diseases. This review summarizes published findings of these molecular biomarkers in the three most common structural cardiomyopathies: human dilated, arrhythmogenic and hypertrophic cardiomyopathy.

Sudden unexpected death in infancy: Severe pulmonary anatomopathological findings in spite of inconsistent clinical features

Respiratory tract infections play a considerable pathogenetic role in many cases of sudden infant death (SID). Frequently, clinicians encounter difficulties in diagnosing the disease because of its often unspecific clinical and radiological presentation. We report three cases of sudden unexpected death in infancy (SUDI), involving two males and one female admitted to hospital due to mild respiratory distress. In all three cases, complete post-mortem investigations were successful in uncovering interstitial lung disease as the cause of death. These cases highlight the key role of infection-related interstitial lung diseases in the pathogenesis of some currently unexplained SUDI/SIDS and the diagnostic difficulties due to the variable clinical and histological pattern, thereby explaining the importance of performing complete post-mortem investigations whenever an infant dies suddenly and unexpectedly.

SARS-CoV-2 and the brain: A review of the current knowledge on neuropathology in COVID-19

SARS‐CoV‐2 (severe acute respiratory syndrome coronavirus 2), the new coronavirus responsible for the pandemic disease in the last year, is able to affect the central nervous system (CNS). Compared with its well‐known pulmonary tropism and respiratory complications, little has been studied about SARS‐CoV‐2 neurotropism and pathogenesis of its neurological manifestations, but also about postmortem histopathological findings in the CNS of patients who died from COVID‐19 (coronavirus disease 2019). We present a systematic review, carried out according to the Preferred Reporting Items for Systematic Review standards, of the neuropathological features of COVID‐19. We found 21 scientific papers, the majority of which refer to postmortem examinations; the total amount of cases is 197. Hypoxic changes are the most frequently reported alteration of brain tissue, followed by ischemic and hemorrhagic lesions and reactive astrogliosis and microgliosis. These findings do not seem to be specific to SARS‐CoV‐2 infection, they are more likely because of systemic inflammation and coagulopathy caused by COVID‐19. More studies are needed to confirm this hypothesis and to detect other possible alterations of neural tissue. Brain examination of patients dead from COVID‐19 should be included in a protocol of standardized criteria to perform autopsies on these subjects.

Autopsy findings in COVID-19-related deaths: a literature review

Although many clinical reports have been published, little is known about the pathological post-mortem findings from people who have died of the novel coronavirus disease. The need for postmortem information is urgent to improve patient management of mild and severe illness, and treatment strategies. The present systematic review was carried out according to the Preferred Reporting Items for Systematic Review (PRISMA) standards. A systematic literature search and a critical review of the collected studies were conducted. An electronic search of PubMed, Science Direct Scopus, Google Scholar, and Excerpta Medica Database (EMBASE) from database inception to June 2020 was performed. We found 28 scientific papers; the total amount of cases is 341. The major histological feature in the lung is diffuse alveolar damage with hyaline membrane formation, alongside microthrombi in small pulmonary vessels. It appears that there is a high incidence of deep vein thrombosis and pulmonary embolism among COVID-19 decedents, suggesting endothelial involvement, but more studies are needed. A uniform COVID-19 post-mortem diagnostic protocol has not yet been developed. In a time in which international collaboration is essential, standardized diagnostic criteria are fundamental requirements.

Post-mortem CMR in a model of sudden death due to myocardial ischemia: validation with connexin-43

OBJECTIVES

We sought to evaluate the effectiveness of post-mortem cardiac magnetic resonance (PM-CMR) for the identification of myocardial ischemia as cause of sudden cardiac death (SCD) when the time interval between the onset of ischemia and SCD is ≤ 90 min.

METHODS

PM-CMR was performed in 8 hearts explanted from pigs with spontaneous death caused by occlusion of the left anterior descending coronary artery: 4 with SCD after ≤ 40 min of coronary occlusion and 4 between 40 and 90 min. PM-CMR included conventional T1 and T2-weighted image and T1, T2, and T2* mapping techniques. Imaging data were compared and validated with immunohistochemical evaluation of the altered proportion and redistribution of phosphorylated versus non-phosphorylated connexin 43 (CX43 and npCX43, respectively), an established molecular marker of myocardial ischemia.

RESULTS

At T2-weighted images, the ischemic core was hypointense (core/remote ratio 0.67 ± 0.11) and surrounded by and hyperintense border zone. Compared to remote myocardium, the ischemic core had higher T1 (p = 0.0008), and lower T2 (p = 0.007) and T2* (p = 0.002). Cytoplasmatic npX43 and the npCX43/CX43 ratio were significantly higher in animals deceased > 40 min than in others.

CONCLUSION

PM-CMR can reliably detect early signs of myocardial damage induced by ischemia, based on conventional pulse sequences complemented by a novel ad hoc application of quantitative mapping techniques.

KEY POINTS

• Post-mortem MRI may help to understand cause of sudden cardiac death. • Post-mortem MRI allows detection of signs of myocardial ischemia as cause of sudden cardiac death within 90 and 40 min following coronary occlusion as demonstrated in a pig model of myocardial ischemia. • Signs of myocardial ischemia using conventional and mapping MRI technique are associated with the immunohistochemical changes of phosphorylated and dephosphorylated connexin-43 which is an established molecular marker of myocardial ischemia.

The Model of "Informed Refusal" for Vaccination: How to Fight against Anti-Vaccinationist Misinformation without Disregarding the Principle of Self-Determination

Vaccines are arguably a public health success story as well as an incredibly cost-effective medical resource. Despite this, worldwide concerns about their safety are growing, with the risk of increased morbidity and mortality in vaccine-preventable diseases because of vaccine refusal. The global political trend in developed countries is to increasingly reduce mandates and the compulsory nature of vaccination programs. This is due to strong opposition from anti-vaccination movements and groups. While these have existed since the beginnings of vaccinology, they have recently gained a strong foothold through massive exploitation of the media and especially the internet. This has led to widespread misinformation and greater difficulty for governments and health institutions in dealing with parents’ concerns and misconceptions. Common strategies in order to maintain a high degree of public acceptance of vaccines include the enhancement of adverse effect reporting systems, the enrichment of scientific literature, and the dissemination of targeted information to parents and health care providers. Vaccine risk perception, in fact, largely exceeds the evidence and is linked to well-known general population cognitive bias, which must be recognized and corrected. Although there is no doubt about the convenience of universal vaccination, a lively international debate is underway with regard to the legitimacy of mandatory vaccination programs. Most scientists agree that the individual’s right to self-determination should be preserved. The only way to simultaneously protect the right to health is to introduce an informed refusal model, which aims to guarantee the highest coverage rates for vaccination.

Role of post mortem CT (PMCT) in high energy traumatic deaths

BACKGROUND

Post Mortem Computed Tomography (PMCT) is being increasingly implemented in forensic field and could be an adjuvant to classic autopsies. In this study we evaluated the feasibility of complementation of conventional autopsy in trauma victims with PMCT.

MATERIALS AND METHODS

A total of 21 subjects, who had sustained various types of blunt high-energy trauma, were selected from the casuistry of the Section of Legal Medicine at University of Pisa: before autopsy, a PMCT examination (Toshiba Aquilion 16 CT scanner) was performed, and after the acquisition of the raw images, MPR and VR reconstructions were performed with dedicated software.

RESULTS

PMCT is more sensitive than conventional autopsy in detecting skeletal injuries, whilst autopsy constitutes the method of choice for the detection of thoracic and abdominal visceral injuries.

CONCLUSIONS

PMCT should be considered a useful tool in addition to conventional autopsy in evaluating trauma victims: it detects further bone fractures in body parts difficult to investigate during autopsy (i.e. posterior regions), facilitating the pathologist in the reconstruction of events and in determining the cause of death.

MicroRNAs and Sepsis-Induced Cardiac Dysfunction: A Systematic Review

Sepsis is a severe condition characterized by systemic inflammation. One of the most involved organs in sepsis is the heart. On the other hand, heart failure and dysfunction are some of the most leading causes of death in septic patients. miRNAs are short single-strand non-coding ribonucleic acids involved in the regulation of gene expression on a post-transcriptional phase, which means they are a part of the epigenetic process. Recently, researchers have found that miRNA expression in tissues and blood differs depending on different conditions. Because of this property, their use as serum sepsis biomarkers has also been explored. A narrative review is carried out to gather and summarize what is known about miRNAs' influence on cardiac dysfunction during sepsis. When reviewing the literature, we found at least 77 miRNAs involved in cardiac inflammation and dysfunction during sepsis. In the future, miRNAs may be used as early sepsis-induced cardiac dysfunction biomarkers or as new drug targets. This could help clinicians to early detect, prevent, and treat cardiac damage. The potential role of miRNAs as new diagnostic tools and therapeutic strategies worth deepening the complex network between non-coding RNA and biological pathways. Additional studies are needed to further investigate their role in sepsis-induced myocardium injury.

Hypo-Expression of Flice-Inhibitory Protein and Activation of the Caspase-8 Apoptotic Pathways in the Death-Inducing Signaling Complex Due to Ischemia Induced by the Compression of the Asphyxiogenic Tool on the Skin in Hanging Cases

The FLICE-inhibitory protein (c-FLIPL) (55 kDa) is expressed in numerous tissues and most abundantly in the kidney, skeletal muscles and heart. The c-FLIPL has a region of homology with caspase-8 at the carboxy-terminal end which allows the molecule to assume a tertiary structure similar to that of caspases-8 and -10. Consequently, c-FLIPL acts as a negative inhibitor of caspase-8, preventing the processing and subsequent release of the pro-apoptotic molecule active form. The c-FLIP plays as an inhibitor of apoptosis induced by a variety of agents, such as tumor necrosis factor (TNF), T cell receptor (TCR), TNF-related apoptosis inducing ligand (TRAIL), Fas and death receptor (DR). Increased expression of c-FLIP has been found in many human malignancies and shown to be involved in resistance to CD95/Fas and TRAIL receptor-induced apoptosis. We wanted to verify an investigative protocol using FLIP to make a differential diagnosis between skin sulcus with vitality or non-vital skin sulcus in hanged subjects and those undergoing simulated hanging (suspension of the victim after murder). The study group consisted of 21 cases who died from suicidal hanging. The control group consisted of traumatic or natural deaths, while a third group consisted of simulated hanging cases. The reactions to the Anti-FLIP Antibody (Abcam clone-8421) was scored for each section with a semi-quantitative method by means of microscopic observation carried out with confocal microscopy and three-dimensional reconstruction. The results obtained allow us to state that the skin reaction to the FLIP is extremely clear and precise, allowing a diagnosis of unequivocal vitality and a very objective differentiation with the post-mortal skin sulcus.

miRNAs as Novel Biomarkers of Chronic Kidney Injury in Anabolic-Androgenic Steroid Users: An Experimental Study

miRNAs are a family of 20–22 non-coding nucleotides that control gene expression by inhibiting the translation of their target messenger RNAs (mRNAs). Two models have been proposed to elucidate the mechanism of action: they act either hindering mRNA translation or enhancing mRNA degradation. Anabolic-Androgenic Steroids (AASs) represent a class of drugs used to treat several diseases. In the last few years, AASs have frequently been used for aesthetic purposes, indeed, they form part of the larger group called image- and performance-enhancing drugs (IPEDs). Long-term AAS use can lead to serious health consequences. In this regard, the present study aimed to analyze the role of several microRNAs (miRNAs) in renal damage after AAS use, to better understand the underlying mechanisms. For this purpose, two miRNAs (miR-21 and miR-205) were tested in two groups: AAS group (seven males, mean age 33.28 ± 4.68 years; mean body mass index (BMI) 27.04 ± 1.07), and chronic kidney disease (CKD) group (seven males, mean age 66.2 ± 5.4 years; mean BMI 24.75 ± 1.35). Finally, the same miRNAs were tested in the “Control” group (seven males, mean age 44.85 ± 5.75 years; mean BMI 26.5 ± 1.88). Kolmogorov-Smirnov Test was used to determine the normality of data distribution. All variables were normally distributed. Student’s t-test was used for comparisons between two groups. Analyzing the results of the present study, the two tested miRNAs (miR-21 and miR-205) were significantly higher in the CKD group compared to the AAS group, with mir-21 being much more expressed than miR-205. This study represents a pilot study to define if these expression patterns could be studied in other biological samples (plasma, urine) in subjects with different kidney injury linked to chronic kidney diseases and AAS use, to identify reliable biomarkers that could be applied in clinical and forensic diagnostics, as well as a target for toxicological investigations or therapeutic treatments.

Massive β1-Adrenergic Receptor Reaction Explains Irreversible Acute Arrhythmia in a Fatal Case of Acute Pure Caffeine Intoxication

Caffeine, a naturally occurring purine-based alkaloid, is the most consumed psychostimulant worldwide. Since caffeine pharmacokinetics shows extreme interindividual variability, it is not easy to establish its toxic dose. Only a few cases of death due to acute caffeine intoxication have been described so far, the majority of which attributable to massive assumption of caffeine-based medications. We present a case of acute caffeine overdose due to ingestion of pure caffeine. The extremely high blood concentration of caffeine determined a strong cardiovascular response, leading to fatal arrhythmia, as supported by histological evidence of myocardial injury. Quantitation of catecholamines and their metabolites in urine samples was performed and showed level near the highest limit of normal ranges for norepinephrine and high level of epinephrine. Contraction band is a pathological modification of the myocell caused by the catecholaminergic action and can occur in conditions of alteration due to the interaction between calcium and catecholamines. We demonstrated the β1-adrenoceptor involvement in our fatal case by immunohistochemical analysis.

COVID-19 and kidney transplantation: an Italian Survey and Consensus

Italy was the first Western country to face the COVID-19 pandemic. Here we report the results of a national survey on kidney transplantation activity in February and March 2020, and the results of a three-round Delphi consensus promoted by four scientific societies: the Italian Society of Organ Transplantation, the Italian Society of Nephrology, the Italian Society of Anesthesia and Intensive Care, and the Italian Group on Antimicrobial Stewardship. All 41 Italian transplant centers were invited to express their opinion in the Delphi rounds along with a group of seven experts. The survey revealed that, starting from March 2020, there was a decline in kidney transplantation activity in Italy, especially for living-related transplants. Overall, 60 recipients tested positive for SARS-CoV2 infection, 57 required hospitalization, 17 were admitted to the ICU, and 11 died. The online consensus had high response rates at each round (95.8%, 95.8%, and 89.5%, respectively). Eventually, 27 of 31 proposed statements were approved (87.1%), 12 at the first or second round (38.7%), and 3 at the third (9.7%). Based on the Italian experience, we discuss the reasons for the changes in kidney transplantation activity during the COVID-19 pandemic in Western countries. We also provide working recommendations for the organization and management of kidney transplantation under these conditions.

Healthcare-Associated Infections: Not Only a Clinical Burden, But a Forensic Point of View

BACKGROUND

Healthcare-associated infections (HCAIs) occur when patients receiving treatment in a health care setting develop an infection. They represent a major public health problem, requiring the integration of clinical medicine, pathology, epidemiology, laboratory sciences, and, finally, forensic medicine.

METHODS

The determination of cause of death is fundamental not only in the cases of presumed malpractice to ascertain the causal link with any negligent behavior both of health facilities and of individual professionals, but also for epidemiological purposes since it may help to know the global burden of HCAIs, that remains undetermined because of the difficulty of gathering reliable diagnostic data. A complete methodological approach, integrating clinical data by means of autopsy and histological and laboratory findings aiming to identify and demonstrate the host response to infectious insult, is mandatory in HCAIs related deaths.

RESULTS

Important tasks for forensic specialists in hospitals and health services centers are the promotion of transparency and open communication by health-care workers on the risk of HCAIs, thus facilitating patients' engagement and the implementation of educational interventions for professionals aimed to improve their knowledge and adherence to prevention and control measures.

CONCLUSION

HCAIs are a major problem for patient safety in every health-care facility and system around the world and their control and prevention represent a challenging priority for healthcare institution and workers committed to making healthcare safer. Clinicians are at the forefront in the war against HCAIs, however, also forensic pathologists have a remarkable role.

New Rules on Patient's Safety and Professional Liability for the Italian Health Service

BACKGROUND

The phenomenon of clinical negligence claims has rapidly spread to United States, Canada and Europe assuming the dimensions and the severity of a pandemia. Consequently, the issues related to medical malpractice need to be studied from a transnational perspective since they raise similar problems in different legal systems.

METHODS

Over the last two decades, medical liability has become a prominent issue in healthcare policy and a major concern for healthcare economics in Italy. The failures of the liability system and the high cost of healthcare have led to considerable legislative activity concerning medical malpractice liability, and a law was enacted in 2012 (Law no. 189/2012), known as the "Balduzzi Law".

RESULTS

The law tackles the mounting concern over litigation related to medical malpractice and calls for Italian physicians to follow guidelines. Briefly, the law provided for the decriminalisation of simple negligence of a physician on condition that he/she followed the guidelines and "good medical practice" while carrying out his/her duties, whilst the obligation for compensation, as defined by the Italian Civil Code, remained. Judges had to consider that the physician followed the provisions of the guidelines but nevertheless caused injury to the patient.

CONCLUSION

However, since the emission of the law, thorny questions remain which have attracted renewed interest and criticism both in the Italian courts and legal literature. Since then, several bills have been presented on the topic and these have been merged into a single text entitled "Regulations for healthcare and patient safety and for the professional responsibility of healthcare providers".

Finding the Victim of Abuse: A New Frontier of Physicians' Liability? Data From a Local Italian Experience on Minor Maltreatment

Violence toward minors is a widespread phenomenon and effective programs are desperately needed to prevent it. Data from the literature showed that underreporting child/adolescents abuse has become a widespread phenomenon, exposing minors to additional harm from further potentially dangerous situations. It is proved that systematic screening and standardized procedures for minors presenting at emergency departments with the suspicion of abuse might increase the detection rate, reducing the risk of underreporting. In Italy a system of mandatory reporting is in place, and it is considered to be crucial in detecting abuse and preventing further harm to children. In this paper we report our experience with a regional (Tuscany) project named "Codice Rosa" (Pink code) introduced in 2014 with the aim to treat and protect the most vulnerable bracket of the population. We present data concerning the access of minors for suspected abuse at the emergency room of the local hospital, focusing on a case of omitted diagnosis leading to further violence episodes. According to our experience, since the introduction of the "Pink Code" there have been 43 cases of reported child abuse, with an increasing trend throughout these years (from 1 reported event in 2015 to 16 reported events in 2018). Despite the limited number of our population, the increasing trend in the reported events was particularly evident for bullying cases (n = 0 in 2015; n = 4 in 2018). Despite data are still limited, the procedure proved effective in preventing child abuse, though it could still be implemented. Minor abuse and maltreatment are important health issue globally which can lead to significant physical and psychological morbidity. Implementing knowledge of healthcare professionals on how to deal with child abuse and introducing educational programs on recognition, treatment and report of child abuse is mandatory not only to prevent missing diagnosis of child and minor maltreatment, but also to reduce the risk of professional liability on different bases.

Regulation of miRNAs as new tool for cutaneous vitality lesions demonstration in ligature marks in deaths by hanging

This study aims to demonstrate that the application of miRNA expression in forensic pathology, in cases of hanging, applying the method on skin samples. The proposed investigative protocol allowed us to highlight a different miRNA expression in the skin ligature marks of subjects who died by hanging compared to healthy skin control samples. The results obtained showed an increase in the expression of miRNAs recognized as regulators of the inflammatory response in skin lesions such as miR125a-5p and miR125b-5p. Furthermore, overexpression of additional miRNAs - miR214a-3p, miR128-3p, miR130a-3p, and miR92a-3p - with anti-inflammatory activity was highlighted. It was possible to document a statistical significance to control skin samples only for miR103a-3p (p < 0.05), miR214-3p and miR92a-3p (p < 0.01) The upregulation of miR222-3p and miR150-5p, respectively related to mast-cell activation and neutrophils after the application of traumatic stimuli supports the immunohistochemical data showed in literature. The diagnostic accuracy of miRNAs could expand the range of diagnostic tools available in the assessment of the vitality of a lesion.

Natural Products in Neurodegenerative Diseases: A Great Promise but an Ethical Challenge

Neurodegenerative diseases (NDs) represent one of the most important public health problems and concerns, as they are a growing cause of mortality and morbidity worldwide, particularly in the elderly. Despite remarkable breakthroughs in our understanding of NDs, there has been little success in developing effective therapies. The use of natural products may offer great potential opportunities in the prevention and therapy of NDs; however, many clinical concerns have arisen regarding their use, mainly focusing on the lack of scientific support or evidence for their efficacy and patient safety. These clinical uncertainties raise critical questions from a bioethical and legal point of view, as considerations relating to patient decisional autonomy, patient safety, and beneficial or non-beneficial care may need to be addressed. This paper does not intend to advocate for or against the use of natural products, but to analyze the ethical framework of their use, with particular attention paid to the principles of biomedical ethics. In conclusion, the notable message that emerges is that natural products may represent a great promise for the treatment of many NDs, even if many unknown issues regarding the efficacy and safety of many natural products still remain.

Bioethical approach to robot-assisted surgery

Challenges the current model of consent

Touch DNA: impact of handling time on touch deposit and evaluation of different recovery techniques: An experimental study

"Touch DNA" is DNA obtained from biological material transferred from a donor to an object or a person during physical contact. This particular kind of evidence could play an essential role in forensic laboratory work and is considered an important tool for investigators. Even though the principal aspects of "Touch DNA" have been extensively studied, to date, there are few reports in the research field of DNA retrieval from garments that have been worn. This study aimed to investigate the "handling time", analyzing particularly the minimum contact time required to deposit a sufficient amount of DNA on a garment to produce an interpretable profile of the "handler". Moreover, three different sampling techniques were compared ("dry swab", "cutting out", and "adhesive tape") with the aim of defining the technique that guarantees the best recovery of the three methods tested. Analyzing the data of this experimental model, a "handling time" of two seconds is enough to release sufficient DNA on to a garment to obtain a complete profile. Moreover, this study demonstrated that when targeting for foreign DNA, the sample area should be narrowed down as much as possible to the smallest area possible to maximize target DNA recovery.

miR-1, miR-499 and miR-208 are sensitive markers to diagnose sudden death due to early acute myocardial infarction

MicroRNAs (miRNAs) are strongly up-regulated under pathological stress and in a wide range of diseases. In recent years, miRNAs are under investigation for their potential use as biomarkers in cardiovascular diseases. We investigate whether specific cardio-miRNAs are overexpressed in heart samples from subjects deceased for acute myocardial infarction (AMI) or sudden cardiac death (SCD), and whether miRNA could help differentiate between them. Forty four cases of death due to cardiovascular disease were selected, respectively, 19 cases categorized as AMI and 25 as SCD. Eighteen cases of traumatic death without pathological cardiac involvement were selected as control. Immunohistochemical investigation was performed for CD15, IL-15, Cx43, MCP-1, tryptase, troponin C and troponin I. Reverse transcription and quantitative real-time PCR were performed for miR-1, miR-133, miR-208 and miR-499. In AMI group, stronger immunoreaction for the CD15, IL-15 and MCP-1 antibodies was detectable compared with SCD and control. Cx43 showed a negative reaction with respect to the other groups. Real-time PCR results showed a down-regulation of all miRNAs in the AMI group compared with SCD and control. The selected miRNAs presented high accuracy in discriminating SCD from AMI (miR-1 and miR-499) and AMI from control (miR-208) representing a potential aid for both clinicians and pathologists for differential diagnosis.

Increased iNOS and Nitrosative Stress in Dopaminergic Neurons of MDMA-Exposed Rats

Several mechanisms underlying 3,4-Methylenedioxy-N-methylamphetamine (MDMA) neurotoxicity have been proposed, including neurochemical alterations and excitotoxicity mediated by reactive oxygen species (ROS), nitric oxide (NO), and reactive nitrogen species (RNS). However, ROS, NO, and RNS sources in the brain are not fully known. We aimed to investigate possible alterations in the expression of the ROS producer NOX enzymes (NOX2, NOX1, and NOX4), NO generators (iNOS, eNOS, and nNOS), markers of oxidative (8-hydroxy-2′-deoxyguanosine, 8OHdG), and nitrosative (3-nitrotyrosine, NT) stress, as well as the colocalization between cells positive for the dopamine transporter (DT1) and cells expressing the neuronal nuclei (NeuN) marker, in the frontal cortex of rats receiving saline or MDMA, sacrificed 6 h, 16 h, or 24 h after its administration. MDMA did not affect NOX2, NOX1, and NOX4 immunoreactivity, whereas iNOS expression was enhanced. The number of NT-positive cells was increased in MDMA-exposed animals, whereas no differences were detected in 8OHdG expression among experimental groups. MDMA and NT markers colocalized with DT1 positive cells. DT1 immunostaining was found in NeuN-positive stained cells. Virtually no colocalization was observed with microglia and astrocytes. Moreover, MDMA immunostaining was not found in NOX2-positive cells. Our results suggest that iNOS-derived nitrosative stress, but not NOX enzymes, may have a crucial role in the pathogenesis of MDMA-induced neurotoxicity, highlighting the specificity of different enzymatic systems in the development of neuropathological alterations induced by the abuse of this psychoactive compound.

A review and analysis of new Italian law 219/2017: 'provisions for informed consent and advance directives treatment'

Background

In December 2017, Law 219/2017, ‘Provisions for informed consent and advance directives’, was approved in Italy. The law is the culmination of a year-long process and the subject of heated debate throughout Italian society. Contentious issues (advance directives, the possibility to refuse medical treatment, the withdrawal of medical treatment, nutrition and hydration) are addressed in the law.

Main text

What emerges clearly are concepts such as quality of life, autonomy, and the right to accept or refuse any medical treatment – concepts that should be part of an optimal relationship between the patient and healthcare professionals. The law maximizes the value of the patient’s time to decide. Every patient is allowed to make choices for the present (consenting to or refusing current treatment) as well as for the future, conceived as a continuation of the present, and to decide what comes next, based on what he/she already knows. The law identifies three distinct but converging paths towards the affirmation of a care relationship based on reciprocal trust and respect: the possibility to consent to or refuse treatment, the shared care planning, and advance directives.

Conclusions

The fundamental point to emerge from the new Italian law is that consensus is an essential connotation of the treatment relationship. Consensus is not limited to the acceptance/rejection of medical treatment but is ongoing. It is projected into the future through shared care planning and advance directives which act as tools for self-determination and the manifestation of the beliefs and preferences of persons unable to express their will. These principles are in line with the idea of appropriate care as evaluated from two different perspectives, one of scientific adequacy and the other commensurate with the individual’s resources, fragility, values, and beliefs. Surely, however, the new law is not the end of the matter on issues such as conscientious objection, which is deeply rooted within the Italian cultural and political debate. In this regard, healthcare institutions and policymakers will be called upon to develop and implement organizational policies aimed at the management of foreseeable conscientious objection in this field.

Emergency contraception in adolescents. A grey area in Italian legislation

OBJECTIVE

To explore Italian legislation and the social climate regarding the issue of emergency contraception (EC) in adolescents.

RESULTS

In recent years, in Italy, we have seen changes in the law and in attitudes towards EC. Since 2016, EC has been approved for sale as a non-prescription drug to women over the age of 18. However, the requirement for a prescription is still in force for women under 18. This raises questions such as the minor's ability to consent to family planning services to prevent pregnancy, and whether physicians require parental consent before providing an EC prescription to minors. This article explores these issues within the social and legislative context of adolescent reproductive health care, demonstrating a need for EC among Italian adolescents.

CONCLUSION

Making EC difficult for minors to access seems to respond to a political stance that clashes with existing social needs and with medical evidence that shows that EC is safe and reliable for use in adolescents, and that the increased use of EC has no negative effects on regular, ongoing contraceptive use or encourages risky sexual behaviour. Future interventions by Italian policy-makers should target these themes in order to make EC easily available to adolescents throughout the country.

Septic cardiomyopathy: The value of lactoferrin and CD15 as specific markers to corroborate a definitive diagnosis

Current scientific consensus about the physiopathology in the progression from severe sepsis to septic shock and death focuses on myocardial contractile dysfunction. Nevertheless, objective parameters to establish a pathological correlate of a fatal outcome are lacking; then a cause of death due to sepsis can remain an unsolved problem. We first reviewed all death cases recorded at our institutions during the period from 2007 until 2015. Then, we conducted a retrospective study of a selected autopsy series of people who had received “sepsis” as cause of death. Two pathologists re-examined the heart sections while the most suitable myocardial sample for each case was stained for immunohistochemistry with antibodies targeted for specific inflammatory-related molecules. We used specific antibodies for the following markers: alpha-smooth muscle actin (alpha-SMA); fibronectin; matrix metallopeptidase 9 (MMP-9); intercellular adhesion molecule 1 (ICAM-1); caspase-3; lactoferrin (LF); cluster differentiation 15 (CD15). The statistical significance of differences was assessed using student’s t-test for unpaired data or non-parametric Mann–Whitney or Wilcoxon tests for skewed variables or one-way analysis of variance and post hoc Scheffe’s test for continuous variables and Pearson’s χ²-test for discrete variables. Linear regression analysis was used to determine the presence of a correlation between continuous variables. At our institutions, 2220 deaths have been recorded during the period study. Sepsis accounted as a cause of death for the 20% of total. We finally enrolled 56 cases; of these, only 20 were positive for microbiological analysis. At histological examination, clear inflammation was detectable in the 32% of cases; otherwise, immunohistochemical reaction showed a positive reaction for LF and CD15 in more than a half cases (56%). We still ignore all the underlying mechanisms of sepsis and all its pathophysiological connections with cardiac metabolism; in this sense, we aim to corroborate the diagnostic value of anti-LF and anti-CD15 staining for the post-mortem detection of myocardial inflammation.

Preimplantation and prenatal diagnosis, wrongful birth and wrongful life: a global view of bioethical and legal controversies

BACKGROUND

Prenatal diagnosis based on different technologies is increasingly used in developed countries and has become a common strategy in obstetric practice. The tests are crucial in enabling mothers to make informed decisions about the possibility of terminating pregnancy. They have generated numerous bioethical and legal controversies in the field of 'wrongful life' claims (action brought by or on behalf of a child against the mother or other people, claiming that he or she has to endure a not-worth-living existence) and 'wrongful birth' claims (action brought by the mother or parents against the physician for being burdened with an unwanted, often disabled child, which could have been avoided).

OBJECTIVE AND RATIONALE

The possibility which exists nowadays to intervene actively by programming and deciding the phases linked to procreation and birth has raised several questions worldwide. The mother's right to self-determination could be an end but whether or not this right is absolute is debatable. Freedom could, with time, act as a barrier that obstructs intrusion into other people's lives and their personal choices. Therapeutic choices may be manageable in a liberal sense, and the sanctity of life can be inflected in a secular sense. These sensitive issues and the various points of view to be considered have motivated this review.

SEARCH METHODS

Literature searches were conducted on relevant demographic, social science and medical science databases (SocINDEX, Econlit, PopLine, Medline, Embase and Current Contents) and via other sources. Searches focused on subjects related to bioethical and legal controversies in the field of preimplantation and prenatal diagnosis, wrongful birth and wrongful life. A review of the international state of law was carried out, focusing attention on the peculiar issue of wrongful life and investigating the different jurisdictional solutions of wrongful life claims in a comparative survey.

OUTCOMES

Courts around the world are generally reluctant to acknowledge wrongful life claims due to their ethical and legal implications, such as existence as an injury, the right not to be born, the nature of the harm suffered and non-existence as an alternative to a disabled life. Most countries have rejected such actions while at the same time approving those for wrongful birth. Some countries, such as France with a law passed in March 2002, have definitively excluded Wrongful Life action. Only in the Netherlands and in three states of the USA (California, Washington and New Jersey) Wrongful Life actions are allowed. In other countries, such as Belgium, legislation is unclear because, despite a first decision of the Court allowing Wrongful Life action, the case is still in progress. There is a complete lack of case law regarding wrongful conception, wrongful birth and wrongful life in a few countries, such as Estonia.

WIDER IMPLICATIONS

The themes of 'wrongful birth' and 'wrongful life' are charged with perplexing ethical dilemmas and raise delicate legal questions. These have met, in various countries and on certain occasions, with different solutions and have triggered ethical and juridical debate. The damage case scenarios result from a lack of information or diagnosis prior to the birth, which deprives the mother of the chance to terminate the pregnancy.