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.

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.

Post-mortem computer tomography in ten cases of death while diving: a retrospective evaluation.

INTRODUCTION: Self-contained underwater breathing apparatus (SCUBA) diving deaths have always been a challenge for forensic pathologists. Post-mortem computer tomography (PMCT) allows intracorporeal gas visualization, contributing to identify the cases in which the cause of death is arterial gas embolism (AGE). However, in the literature, it is indicated to perform the radiological examination within 24 h after death. MATERIALS AND METHODS: In this retrospective study, 32 cases of death who had undergone PMCT 24-48 h after death/corpse finding between January 2011 and March 2021 were analyzed, including ten cases of SCUBA divers who died of AGE. All cases' radiological images were reviewed to localize the intracorporeal gas distribution alongside other findings that are usually related to SCUBA diving death. A semi-quantitative evaluation was also performed. RESULTS: Most of the divers showed gas within the left heart and the arteries. In addition, the semi-quantitative evaluation revealed that the divers presented a higher mean amount of intraarterial gas compared to the fresh corpses. On the other hand, the putrefied corpses presented gas within the portal system and generalized subcutaneous emphysema with higher frequency and quantity than the divers and fresh corpses. CONCLUSION: Our cases suggested that the PMCT, even when performed 24-48 h after death, remains a valuable tool to diagnose AGE in cases of SCUBA diving deaths. In addition, with the limit of the small sample size, our data showed that at least a medium quantity of intraarterial gas, when not associated with a high amount of gas within the portal system and subcutaneous emphysema, could be considered a diagnostic criterion of AGE.

Occult primary cardiac lymphomas causing unexpected/sudden death or acute heart failure.

Three cases of unexpected/sudden death (N = 2) or acute heart failure (N = 1) were investigated in our centre. The first patient died unexpectedly after surgery for cardiac tamponade and constrictive pericarditis; at autopsy, gross features mimicked a pericardial mesothelioma. The second patient died suddenly after recovering from a respiratory insufficiency episode; autopsy revealed an epicardial mass encircling the right coronary artery. The third patient presenting symptoms mimicked a fulminant myocarditis and she underwent endomyocardial biopsy. In all cases, histology disclosed a diffuse large B cell non-Hodgkin lymphoma, localized to the pericardium together with the right ventricle and the conduction system, to the epicardium and the right coronary artery or to the myocardium, respectively. Histology was crucial for the diagnosis, the atypical presentation favouring other diagnostic hypotheses. Although primary cardiac lymphoma is uncommon and usually shows a sub-acute onset, it may also cause unexpected/sudden death or acute heart failure.

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.

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.

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.

Fatal acute poisoning from massive inhalation of gasoline vapors: case report and comparison with similar cases.

We describe a case of an acute lethal poisoning with hydrocarbons resulting from massive accidental inhalation of gasoline vapors. The victim, a 50-year-old man was found unconscious inside a control room for the transport of unleaded fuel. Complete autopsy was performed and showed evidence of congestion and edema of the lungs. Toxicological investigation was therefore fundamental to confirm exposure to fumes of gasoline. Both venous and arterial blood showed high values of volatiles in particular for benzene (39.0 and 30.4 µg/mL, respectively), toluene (23.7 and 20.4 µg/mL), and xylene isomers (29.8 and 19.3 µg/mL). The relatively low values found in the lungs are consistent with the fact that the subject, during the rescue, underwent orotracheal intubation followed by resuscitation techniques, while the low concentrations for all substances found in urine and kidneys could point to a death that occurred in a very short time after first contact with the fumes of gasoline.

Unexpected double lethal oleander poisoning.

Nerium oleander is a very popular urban ornamental plant in Europe, but it is also extremely dangerous because it contains several types of glycosides, accidental ingestion of which can cause cardiac arrhythmias and even deaths. The rarity of such cases makes it difficult to think of oleander poisoning without evidences that suggest this possibility as the cause of the unexpected death. This report concerns the discovery of the bodies of 2 young people, a man and a woman, in a forest in conditions of extreme malnutrition. Medicolegal investigations showed neither pathologic nor traumatic causes of death, but the presence of vegetal remains in the stomach was noticed. A common toxicological analysis resulted negative, but the implementation of more detailed investigations showed the presence of digoxin in the blood of both cadavers, excluding the possibility of a pharmaceutical provenience of digoxin, this laboratory result was interpreted as evidence of ingestion of oleander, which contains oleandrine, the cross reaction of which with digoxin is widely described in the literature. Identification of the 2 subjects, which occurred after 4 years, strengthened the hypothesis of accidental poisoning by oleander because it was ascertained that the 2 young people were vegans--extreme vegetarians who reject the ingestion of foods of animal origin and live by eating only what they find in nature.