Malpratice claims in cardiology and cardiac surgery: A medico-legal issue

Medical liability has become a challenge in every physician's modern practice with the consequent loss of the physician's autonomy and an increase in "defensive medicine". From this perspective, the role of Legal Medicine in assessing medical liability has become increasingly specific and a homogenization of the methods of ascertainment is increasingly necessary, since such a process can contribute to strengthening the guarantees in professional liability procedures. Focusing on malpractice claims in the field of cardiology, the complexity of the management of cardiac pathologies and the frequency of severe adverse events implies the importance of a multi-disciplinary approach, together with the application of a shared ascertainment methodology. In particular, it is essential for the forensic pathologist to collaborate with experts in cardio-pathology, cardiology and/or cardiac surgery in cases of alleged medical liability in the cardiologic field and to follow the guidelines which have been produced to assist the expert dealing with deaths reflecting cardiac disease, in order to prevent criticism of case analysis in medico-legal environments and to promote the standardization of the structure of the juridical-legislative medical malpractice lawsuits.

Hair determination of per- and polyfluoroalkyl substances (PFAS) in the Italian population

Per- and polyfluoroalkyl substances (PFAS) are anthropogenic chemicals present in the environment and defined as persistent organic pollutants (POPs). The interest in these forms of contaminants is related to the toxic consequences for health derived from exposures and bioaccumulation processes. The present research aims at assessing differences in the exposure of PFAS in the Italian population by hair analyses. To this aim, 20 compounds of the PFAS family were investigated in hair of 86 Italian subjects distributed across the regions of Veneto, Emilia-Romagna, Lombardy and Marche. The applied method was ad hoc developed in a previous research and included SPE extraction and LC-QTOF analysis. In the analyzed population, 66.4 % had quantifiable amounts of one or more PFAS molecules (up to 4 compounds); mean PFAS content, expressed as sum of PFAS, was 0.1457 ng/g, ranging from "not detected" to 0.85 ng/g (SD 0.1867). PFOA and PFOS were the chemicals most frequently detected, with mean concentrations of 0.1402 ng/g and 0.1155 ng/g, respectively. PFBA was detected in 9.3 % of subjects with a mean concentration of 0.3760 ng/g; PFNA in 3.5 % of subjects with mean concentration 0.12 ng/g; PFDA was found in one subject at the concentration of 0.541 ng/g. PFUnA and PFHxS were detected below the limit of quantification. The overall results displayed differences in the presence and prevalence of PFAS in hair of the Italian population on a geographical base. On the contrary, no significatively differences in the amount of PFAS were observed when considering gender or age classes. On this base, hair can be considered a good diagnostic tool to assess PFAS exposure on a regional-scaled base. Of course, more studies are required to infer PFAS internal dose from hair results due to its peculiar detection window and to interpretative issues derived from external contamination.

FDG-PET/CT in the Radiotherapy Treatment Planning of Locally Advanced Anal Cancer: A Monoinstitutional Experience

Aims

Radiotherapy with concurrent 5-fluorouracil/mitomycin-C based chemotherapy has been established as definitive standard therapy approach for anal cancer. Intensity Modulated Radiotherapy (IMRT) leads to a precise treatment of the tumor, allowing dose escalation on Gross Tumor Volume (GTV), with a surrounding healthy tissues sparing. Our study assessed the impact of 18-Fluorodeoxyglucose positron emission tomography (18FDG-PET/CT) on the radiotherapy contouring process and its contribution to lymphatic spread detection, resulting to a personalization of Clinical Target Volume (CTV) and dose prescription.

Methods

Thirty-seven patients, with histologically proven squamous cell carcinoma of the anal canal (SCCAC) were analyzed. All patients were evaluated with history and physical examination, trans-anal endoscopic ultrasound, pelvis magnetic resonance imaging (MRI), computed tomography (CT) scans of the chest, abdomen and pelvis and planning 18FDG-PET/CT. The GTV and CTV were drawn on CT, MRI and 18FDG-PET/CT fused images.

Results

Thirty-four (91%) out of 37 patients presented lymph nodes involvement, in one or more areas, detected on 18FDG-PET/CT and/or MRI. The 18FDG-PET/CT showed positive lymph nodes not detected on MRI imaging (PET+, MRI−) in 14/37 patients (38%). In 14 cases, 18FDG-PET/CT allowed to a dose escalation in the involved nodes. The 18FDG-PET/CT fused images led to change the stage in 5/37(14%) cases: four cases from N0 to N1 (inguinal lymph nodes) and in one case from M0 to M1 (common iliac lymph nodes).

Conclusions

The 18FDG-PET/CT has a potentially relevant impact in staging and target volume delineation/definition in patients affected by anal cancer. In our experience, clinical stage variation occurred in 14% of cases. More investigations are needed to define the role of 18FDG-PET/CT in the target volume delineation of anal cancer.

Driving under the influence of drugs: Prevalence in road traffic accidents in Italy and considerations on per se limits legislation

OBJECTIVE

The objective of this study was to present the prevalence and concentrations of drugs in blood samples of drivers involved in road traffic accidents (RTAs) and to discuss the effects of adopting different concentration cutoff values proposed or applied in other European countries on the number of driving under the influence of drugs (DUID) offenses.

METHODS

Blood samples from drivers involved in RTAs in Padova province from 2014 to 2017 were analyzed for the presence of alcohol and drugs. The prevalence of positive subjects was reported for each substance adopting the limits of quantification (LOQs) of our laboratory and the concentration cutoff values proposed and/or used in other European countries. The reduction of cases of driving under the influence of illicit drugs in applying different cutoffs was calculated.

RESULTS

Four thousand four hundred forty-three blood samples were analyzed: 23.7% were positive for alcohol and 19.9% for psychoactive drugs, with prevalences of polydrug and alcohol-drug abuse of 4.5 and 6%, respectively. The most frequently detected drugs were cannabinoids (9.7%) and cocaine (7.2%), followed by benzodiazepines (4.1%), opiates (1.9%), and other opioids (1.7%). Barbiturates, amphetamines, and ketamine were identified in a much smaller number of cases. The overall decrease in DUID cases when adopting different cutoffs with respect to cases above the LOQs was between 8 and 84%. The adoption of high LOQs such as those used in the European Union's research project on Driving Under the Influence of Drugs, Alcohol and Medicines (DRUID) decreases the hypothetical number of DUID offenses by a quarter, and per se limits proposed as broadly equivalent to a blood alcohol concentration (BAC) between 0.2 and 0.8 g/L dramatically reduce the cases of DUID (cocaine -81%, cannabis -79%, opioids -97%, opiates -96%, and amphetamines -77%); no ketamine-positive samples were above the cutoff.

CONCLUSIONS

The implementation of high analytical limits or per se limits based on impairing concentrations in the Italian legislation could result in the prosecution of a much lower number of drugged drivers involved in RTAs, with a decrease from 25% to more than 80% depending on the limits.

Crime scene and body alterations caused by arthropods: implications in death investigation

The activity of arthropods on corpses has been largely investigated, since they can produce information to reconstruct the peri-mortem events. However, the feeding/movement activity of insects around the crime scene, among the clothes and on the body, can also cause some alterations that can lead to wrong reconstruction and misinterpretations. This article summarises all the post-mortem arthropods artefacts related to the scene (i.e. fly artefacts and floor stripes) and the body (i.e. skin and other soft tissue alterations, bone alterations and hair alterations) that can mislead the forensic pathologist, discussing macroscopic and microscopic findings derived from forensic casework and from experimental laboratory studies, in order to provide a useful instrument to avoid misinterpretations and evaluation errors. Finally, some procedural notes for the documentation and the interpretation of findings are proposed.

Down-Staging after Two Different Preoperative Chemoradiation Schedules in Rectal Cancer

Aims

To compare preoperative downstaging, toxicity and sphincter-saving procedures obtained with preoperative radiotherapy and two different concomitant chemotherapy schedules.

Methods

From February 1997 to August 2001, 68 consecutive patients were treated with external radiotherapy (5040 cGy in 28 fractions) and concomitant chemotherapy: group a) 36 patients (10T2, 19T3, 7T4, 25 adenocarcinoma and 11 mucinous histology) were treated with cis-diamminedichloroplatinum bolus + 5-fluorouracil continuous infusion; group b) 32 patients (14 T2, 18 T3, 27 adenocarcinoma and 5 mucinous histology) were treated with 5-fluorouracil bolus ± mitomycin C. The interval between the end of radiotherapy and surgery ranged from 4 to 9 weeks.

Results

Group a) Overall downstaging was 63.9%. Longitudinal shrinkage of the neoplasm allowed conservative surgery in 6 of 11 patients with a pre-chemoradiation tumor location ≤3 cm from the external anal ring. When patients with adenocarcinoma (25/36) were studied separately from patients with mucinous histology, 7/25 patients (28%) were found to have no microscopic evidence of residual tumor (pTO); 8/25 (32%) were found to have only rare isolated cancer cells (pTmic); only 7/25 patients (28%) were found to have no change. Overall, 72% patients had downstaging. In contrast, only 5/11 (45.5%) of mucinous tumors had partial downstaging and 6/11 (54.5%) no downstaging at all. Group b) Overall downstaging was 46.9%. When patients with adenocarcinoma (27/32) were studied separately, 7/27 (26%) were found to have pTO, 3/27 (11.1%) pTmic, and 13/27 (48.1%) no change. Only 1/5 (20%) of mucinous tumors had downstaging and 4/5 (80%) had no downstaging at all. Overall toxicity was comparable among groups a and b, except for lower hematologic and gastrointestinal G3-4 toxicity observed in group a.

Conclusions

The overall response allowed conservative surgery in 56 (82.3%) of the 68 patients. Continuous infusion of 5-fluorouracil and diamminedichloroplatinum as a radipsensitizer determined better results in group a than group b (63.9% downstaging vs 46.9% even with a higher incidence of mucinous histology). Mucinous histology, for a definitely lower response rate, could benefit from an even more aggressive approach.

Impairment and reorganization of the phosphoinositide-specific phospholipase C enzymes in suicide brains

A number of studies suggested that suicide may be associated with specific neurobiological abnormalities. Neurobiology studies focused upon abnormalities of signalling mechanisms with special regard to the serotonin system and the related Phosphoinositide (PI) signalling system. Previous data suggested the involvement of the PI-specific phospholipase C (PLC) family in neuropsychiatric disorders. By using PCR and morphological microscopy observation we examined the whole panel of expression of PLC isoforms in the brains of 28 individuals who committed suicide and in normal controls in order to evaluate the involvement of specific PLC isoforms. The overall PLC expression was reduced and a complex reorganization of the isoforms was observed. The knowledge of the complex network of neurobiological molecules and interconnected signal transduction pathways in the brain of suicide victims might be helpful to understand the natural history and the pathogenesis of the suicidal behavior. That might lead to obtain prognostic suggestions in order to prevent suicide and to new therapeutic agents targeting specific sites in this signalling cascade.

Impact of alcohol consumption on winter sports-related injuries

INTRODUCTION

This study was carried out to evaluate data about trauma-related winter sports, including risk factors such as high speed, gender, age, alcohol consumption, details about the accident and snow conditions.

METHODS

A retrospective review was conducted to determine the injury patterns and crash circumstances in holiday skiers and snowboarders. The data recorded were obtained from the database of the Pre-Hospital Emergency Registry of six skiing areas in the Dolomite mountains during the winter seasons November 2004-May 2009, injury data for major traumas from Ski Patrol Injury reports (helicopter, ambulance or ski slopes' patrol reports), and intrahospital Emergency Department data. Alcohol concentration in blood was detected in 200 individuals suffering from major trauma.

RESULTS

A total of 4550 injured patients, predominantly male (69%), mean age 22 years (range 16-72), were included in the observational analysis. Knee, wrist and shoulder injuries were frequently associated with major thoracic, abdominal or head traumas (64% of cases). Suboptimal technical level, high speed, low concentration, snow or weather conditions, faulty equipment and protective devices were among the various causes of accidents. The analysis revealed that high alcohol blood concentration was present in 43% of 200 patients.

CONCLUSIONS

Even though the major causes of accidents were excessive speed, excessive fatigue, technical errors and bad weather conditions, alcohol abuse was often discovered. Random sampling and a non-systematic detection of alcohol blood levels likely led to an underestimation of alcohol consumption-related injuries. It is recommended that investigations into alcoholic intoxication in injured skiers should be carried out on a large scale.

Mucinous rectal adenocarcinoma can be associated to tumor downstaging after preoperative chemoradiotherapy

PURPOSE

The aim of this study was to evaluate downstaging as primary end point, and progression-free survival and overall survival as secondary end points, in rectal adenocarcinoma patients treated with preoperative chemoradiation.

METHODS

One hundred and thirty-six extraperitoneal adenocarcinoma patients (33 low rectum T2, 74 T3, 29 T4 [without sacral invasion], 25 with mucinous subtype) were treated with posterior pelvis preoperative radiotherapy (5040 cGy total dose, 180 cGy/fr, 5 fr/w, 10-15 MV linac X-rays) and concomitant 5-fluorouracil-based chemotherapy. After 6 to 8 weeks patients underwent surgery and prechemoradiation clinical stage was compared with pathologic stage to evaluate downstaging in each patient. Seventy-four patients received adjuvant chemotherapy. Median follow-up was 39 months (4-84).

RESULTS

Forty-four patients had macroscopic complete response, 52 patients had partial response, 37 patients showed no change and 3 patients had progression. At multivariate analysis only histotype showed correlation with downstaging (hazard ratio = 0.350 and 0.138 - 0.885 95 percent confidence interval) because of the evidence for poor downstaging in mucinous subtype. There were no significant differences in overall survival and progression-free survival between adenocarcinoma and mucinous subtype.

CONCLUSIONS

The main finding is that mucinous histology is associated with poor downstaging after preoperative chemoradiation but this poor response was not associated with worse outcome in this small study. The good outcome for mucinous histology is at odds with other reports in the literature and requires further study.

Non-invasive coronary flow reserve is correlated with microvascular integrity and myocardial viability after primary angioplasty in acute myocardial infarction

OBJECTIVE

To test whether preserved coronary flow reserve (CFR) two days after reperfused acute myocardial infarction (AMI) is associated with less microvascular dysfunction (" no-reflow" phenomenon) and is predictive of myocardial viability.

DESIGN

24 patients with anterior AMI underwent CFR assessment in the left anterior descending coronary artery (LAD) with transthoracic echocardiography and myocardial contrast echocardiography (MCE) 48 h after primary angioplasty in the LAD (mean 4 (SD 2) and 3 (1) days, respectively). Low-dose dobutamine echocardiography was performed 6 (3) days after AMI and follow-up echocardiography at three months.

RESULTS

No-reflow extent was greater in patients with impaired CFR (< 2.5) than in those with preserved CFR (> 2.5) (55 (35)% v 11 (25)%, p < 0.001). MCE reflow was more common in patients with preserved CFR (8/12) than in those with reduced CFR (1/12, p < 0.05). Wall motion score index in the LAD territory (A-WMSI) was similar at the first echocardiography (2.14 (0.39) v 2.32 (0.47), NS), although it was better in patients with preserved CFR at dobutamine (1.38 (0.45) v 1.97 (0.67), p < 0.05) and follow-up echocardiography (1.36 (0.40) v 1.97 (0.64), p < 0.05). An inverse correlation was found between CFR and A-WMSI at dobutamine and follow-up echocardiography (r = -0.49, p = 0.016 and r = -0.55, p = 0.005) and between MCE and A-WMSI at dobutamine and follow-up echocardiography (r = -0.75, p < 0.001 and r = -0.75, p < 0.001). By multivariate analysis MCE reflow remained the only predictor of recovery at both dobutamine and follow-up echocardiography (odds ratio 1.06, 95% CI 1 to 1.1, p = 0.009).

CONCLUSION

CFR is inversely correlated with the extent of microvascular dysfunction at MCE two days after reperfused AMI. CFR and MCE reflow early after AMI are correlated with myocardial viability at follow up.

Feasibility of preoperative chemoradiation in rectal cancer patients aged 70 and older

In the present study, we report results of 28 rectal cancer patients, aged 70 years and older, treated with preoperative radiotherapy and 5FU concomitant chemotherapy. Twenty-eight out of 136 patients treated in our Department between 1997 and 2004 aged > or = 70 years, mean 73 (range 70-81); 3 T2, 18 T3, 7 T4; 15 N0, 5N1, 8 N2; Radiotherapy (5040 cGy, 28 fractions) was delivered combined with 5FU - based concomitant chemotherapy. Compliance to chemoradiotherapy was excellent. Major acute toxicity (> or = G3) evaluation showed haematological Grade 3 only in 2 patients. No severe acute Gastrointestinal toxicity was observed. All patients underwent surgery without severe perioperative complications. Complete pathological response pT0 was found in 3 patients (11%). Overall T downstaging occurred in 61% of the cases. Mean follow up was 34 months (range 4- 84). Kaplan Meier Overall Survival and Disease Free Survival at 5 years were 74% (95% CI 54 -95) and 65% (95% CI 38-93), respectively. Only 1 patient showed G3 diarrhea according to CTCAE that interfered with his Quality of Life and required hospitalization. In conclusion, concomitant radiochemotherapy 5FU based is safe in rectal cancer patients aged > or = 70 with a good tumour downstaging (61% of patients) and excellent feasibility. No treatment related death was observed.

[Medico-legal features of early discharge in acute myocardial infarction and chest pain]

The authors' aim is to outline some of the main medico-legal problems in cardiology, especially those regarding the premature hospital discharge of patients with undefined chest pain and/or with acute myocardial infarction. After a brief overview on the etiology and clinical definition of chest pain and myocardial infarction, premature hospital discharge is defined and the incidental medico-legal risks that physicians operating in such situations are exposed to are pointed out. Next, the profiles regarding both the positive and negative views of professional medical responsibility are described. In the negative frame, the authors outline the most frequent civil and penal aspects of the unpremeditated responsibility. Then the physician's error, in both qualitative (generic or specific guilt) and quantitative (degree) terms, is considered; particularly, negligence, imprudence and inexperience, as qualitatively accepted meanings of generic guilt, are dealt with by adopting illustrative cases settled in the light of the right legal interpretation. The phases of the diagnostic or prognostic error are evaluated, and clinical protocols, as a reference parameter for the identification of error, are considered. Lastly, the problem of causality, essential condition for the judgment about the professional responsibility, and the problem of the patient's consent, including an evaluation of the legal capability or incapability about the declaration of consent, are examined closely.

Solitary tract nuclei in acute heart failure

BACKGROUND AND PURPOSE

Symmetrical necrosis of the brain stem nuclei has been described as a consequence of severe transitory cerebral hypoxia mainly in neonates or young adults who experienced an episode of acute ischemia due to transitory acute heart failure. We report selective bilateral lesions of the solitary tract nuclei in 5 adults with short survival intervals after acute heart failure.

METHODS

In 5 patients who died due to cardiovascular pathology, histological examination was performed on multiple samples of cerebral hemispheres, on transverse sections of the midbrain and pons, and on transverse serial sections of the medulla stained with hematoxylin-eosin, Klüver-Barrera, and Luxol fast blue. The 3-dimensional reconstruction of the extension and topography of the medullary lesions was obtained with computed image analysis.

RESULTS

In 4 subjects who died soon after an episode of acute heart failure (range of survival 10 hours to 2 days), the dorsal portion of the solitary tract nuclei showed an eosinophilic roundish aspect bilaterally. In their context, the neurons showed changes characteristic of ischemic coagulation necrosis. In a fifth patient, a 32-year-old man who died 15 days after an episode of cardiac arrest, 2 circumscribed symmetrical infarcts with macrophagic and astrocytic reactions were found at the same level. The topography of the lesions and the inflammatory reaction and gliosis of patient 5 suggest that the findings in the other 4 patients correspond to initial features of selective lesions of the solitary tract nuclei after acute heart failure: the short interval of survival prevented the evolution of the reactive process. The nucleus is localized at the watershed zone between the terminal branches of the medullary collateral vessels of the vertebral arteries, thus representing the last meadow in the case of sudden fall of the systemic blood flow due to acute heart failure. The absence of lesions of other medullary and pontine nuclei accounts for a selective vulnerability of the neurons of the solitary tract nuclei, and the selective dendritic lesions suggest an excitotoxic component to ischemic cell death.

CONCLUSIONS

The commonly accepted resistance of the medullary centers to ischemic hypoxia in adults apparently could be due to the rapidity of death, which prevents the evolution of lesions that can be diagnosed. In addition, minor lesions in the medullary tegmentum after acute heart failure could play a role in the prevention of the resumption of autonomous cardiac and respiratory functions despite life-saving procedures.