Medico-Legal issues in a neurosurgical case series of Rathke Cleft Cysts. Informed consent, complications and medical liability / Implicaciones médico-legales en una serie de casos de neurocirugía de quistes de hendidura de Rathke. Consentimiento informado, complicaciones y responsabilidad médica

Rathke cleft cysts (RCCs) are asymptomatic benign sellar cysts. Their surgical treatment may lead to a series of well known complications, many of which can be interpreted as failed surgical interventions. We present a retrospective study on patients with treated RCCs that filed a claim for compensation for medical professional liability, with the aim of reporting the medico-legal issues related to the surgical resection of RCC. A retrospective analysis was performed between 1999 and 2016 on patients diagnosed with RCCs and who underwent surgical resection. The clinical experience of the patients alleging medical liability was analysed by an interdisciplinary group following the European Guidelines proposed by the European Academy of Legal Medicine. Eight patients developed late complications and made a claim for compensation. Only in one case a prognostic error was detected. The pre- and postoperative conditions, as well as the onset of early and late complications are reported and discussed in the paper, as well as the differentiation between "error-free" vs "error-related" complications. Understanding the underlying causes of the increase in compensation claims, as in the specific case, can help not only in the reduction of errors, but also in the prevention of compensation claims, which result in an increase in public and private spending. One of the main causes of the disproportion between the request for compensation and actual compensation is the expectation regarding surgery and the onset of complications, which could be solved through the appropriateness of consent submitted before the intervention

Los quistes de hendidura de Rathke (Rathke cleft cysts [RCC]) son quistes sellares benignos asintomáticos. Su tratamiento quirúrgico puede llevar a una serie de complicaciones bien conocidas, muchas de las cuales pueden interpretarse como intervenciones quirúrgicas fallidas. Presentamos un estudio retrospectivo sobre pacientes tratados con RCC que presentaron una reclamación de compensación por responsabilidad profesional médica, con el objetivo de informar los problemas médico-legales relacionados con la resección quirúrgica del RCC. Se realizó un análisis retrospectivo entre 1999 y 2016 en pacientes diagnosticados con RCC y resecados quirúrgicamente. La experiencia clínica de los pacientes que alegaban responsabilidad médica fue analizada por un grupo interdisciplinario siguiendo las pautas europeas propuestas por la Academia Europea de Medicina Legal. Ocho pacientes mostraron complicaciones tardías e hicieron una reclamación de compensación. Solo en un caso se detectó un error pronóstico. Las condiciones pre y postoperatorias, así como el inicio de las complicaciones tempranas y tardías, se analizarán en el documento, así como la diferenciación entre las complicaciones «sin errores» y las complicaciones que fueron consecuencia de un error médico. Comprender las causas subyacentes del aumento de las reclamaciones de indemnización, como en el caso específico, puede ser de ayuda no solo en la reducción de errores, sino también en la prevención de reclamaciones de indemnización, que dan como resultado un aumento del gasto público y privado. Una de las principales causas de la desproporción entre la solicitud de compensación y la compensación real es la expectativa con respecto a la cirugía y la aparición de complicaciones, que podrían resolverse mediante la adecuación del consentimiento presentado antes de la intervención

Hair analysis to discriminate voluntary doping vs inadvertent ingestion of the aromatase inhibitor letrozole.

Letrozole is an aromatase inhibitor, used to treat postmenopausal women with hormone receptor-positive or unknown advanced breast cancer. It is prohibited in sport because it is used together with androgen anabolizing steroids to avoid their adverse effects. In the case of an adverse analytical finding, it may be important to distinguish between repetitive use due to voluntary administration and occasional use, possibly due to involuntary intake. With the objective to identify the dose capable of producing a positive hair test, and to apply these results to the scenarios of inadvertent letrozole ingestion by an athlete, this study investigates the urinary excretion and incorporation into hair of single doses of letrozole. Seven subjects were recruited for an excretion study of letrozole and its metabolite bis(4-cyanophenyl) methanol (M1) in urine, after the consumption of 0.62 mg, 1.25 mg, and 2.5 mg of letrozole, and to investigate the incorporation in hair after ingestion of 0.62 mg and 2.5 mg of letrozole. Urine and hair samples were also obtained from two women in chronic therapy. Urinary concentrations of letrozole and its metabolite M1 were lower in subjects administered once with 0.62 mg, 1.25 mg, or 2.5 mg letrozole than in women in regular therapy with 2.5 mg/day. In hair collected after a single dosage, concentrations of 16-60 pg/mg were detected while in women in chronic therapy concentrations were higher than 160 pg/mg all along the hair shaft. Hair analysis turned to be a promising possibility for the discrimination of letrozole repetitive use vs occasional/inadvertent administration.

Relationship between anatomical sites and severity of the lesions and use of alcohol and psychotropic substances in traumatized drivers admitted to the Emergency Department of Padua, Italy.

INTRODUCTION: Driving under the influence of alcohol and/or psychoactive substances increases the risk of road accidents, but it is controversial whether this affects site and severity of injuries. MATERIAL AND METHODS: We search for alcohol, cannabinoids, cocaine, benzodiazepines, opioids, methadone, amphetamines and barbiturates in biological fluids of 1764 traumatized drivers admitted to the Emergency Department (ED) of Padua between 2010 and 2014. RESULTS: We note correlation between alcohol and benzodiazepines and admission in ICU and between all the intoxications and the reserved prognosis. The sites of injuries were: head (37.13%), maxillofacial (8.33%), spinal column (44.67%), thoracic (15.31%), abdominal (5%), pelvic (2.55%) and limb traumas (23.58%). We observed a correlation between head trauma (p < 0.0001), maxillofacial trauma (p = 0.0418), thoracic trauma (p = 0.0215), pelvic trauma (p = 0.0008), spinal column trauma (p < 0.0001) and the totality of the intoxication and an association between benzodiazepines and thoracic and pelvic trauma. CONCLUSIONS: Alcohol and benzodiazepines intoxication increases the risk of reserved prognosis and admission in ICU; benzodiazepines intoxication correlates with thoracic and pelvic trauma.

The Dangerous Pattern of Concurrent Use of Alcohol and Cocaine Among Drunk-Drivers of Northeast Italy.

AIM: To estimate the prevalence of drug and polydrug use among drunk-drivers during the driving license regranting program, in order to assess the inclusion of toxicological tests on hair and urine samples in the systematic methodology in this category of subjects. SHORT SUMMARY: A total of 2160 drunk-drivers were tested for alcohol and drugs during driving license regranting. Thirty-one subjects showed alcohol use, 212 illicit drug use and, among these, 131 were polydrug users. Nineteen different patterns of drug and polydrug use were found. Cocaine was detected in 165 subjects. METHODS: The study was performed on 2160 drunk-drivers examined at Legal Medicine and Toxicology Unit of the University of Padova, in a 3-year-period (2014-2017). The positivity for one or more illicit drugs in hair or urine samples was confirmed by LC/MS and GC/MS methods. Chi-square test, Fischer's exact test and Cochran-Armitage Trend test were used to study the correlation between general characteristics of the examined sample and the presence of drug/polydrug use. RESULTS: Thirty-one subjects showed alcohol use, 212 illicit drug use and, among these, 131 were polydrug users. Nineteen different patterns of drug and polydrug use were found. Cocaine was detected in 165 subjects in whom 122 showed a concurrent use of alcohol and cocaine, identified through the detection of cocaethylene in hair samples. No significant association and/or trends between drug/polydrug use and the general characteristics of the sample were detected. CONCLUSIONS: The results show that drug and polydrug use among drunk-drivers should be subjected to toxicological as well as alcohological monitoring, especially in the regranting procedure. The implementation of this procedure could improve the knowledge of dimensions of the issue, providing a powerful means for the reduction of phenomenon of driving under the influence of alcohol and drugs.

Non-fatal Overdose with U-47700: Identification in Biological Matrices.

BACKGROUND/OBJECTIVE: We report on a case of severe intoxication after insufflation of U-47700, a synthetic opioid that acts as a selective agonist of the µ-opioid receptor, and is several times more potent than morphine. A man in his 30s was found irresponsive in his apartment and was brought to the emergency department of a local hospital. A comatose state and severe respiratory depression were present. Hetero anamnesis revealed that the patient could have taken the substance named "U-47700", bought on the Internet. After supportive care, the patient fully recovered. METHOD: Urine, blood and a white powder found at his home were collected during his hospital stay and sent for testing using liquid chromatography-high resolution mass spectrometry (LC-HRMS) on an Orbitrap instrument. Later, his pubic hair was also collected. A standard comprehensive toxicology screening was performed. RESULTS: U-47700 was identified in all biological samples and in the seized white powder. Using liquid chromatography-high resolution mass spectrometry (LC-HRMS) the presence of U-47700 and its phase I and phase II metabolites in blood, urine and pubic hair was confirmed. U-47700 was determined at 94 ng/mL and 5.2 ng/mL in blood at the admission and the day after, respectively, and 3.02 ng/mg in pubic hair, together with its metabolites. No other opioid nor designer drug could be detected in blood and urine, while in pubic hair Cocaine, Benzoylecgonine, Norcocaine, Mephedrone, Ketamine, Norketamine, 3,4-Methylenedioxymethamphetamine, Tetrahydrocannabinol and Cannabinol were also detected. CONCLUSION: The toxicological findings confirmed the use of U-47700 in the intoxicated patient and also revealed a history of a poly-drug use. The use of LC-HRMS allowed the easy identification of the NPS and its metabolites in fluids and hair.

A Social Media-Based Acute Alcohol Consumption Behavior (NekNomination): Case Series in Italian Emergency Departments.

BACKGROUND: NekNomination, also known as NekNominate, Neck and Nominate, or Neck Nomination, is a social network-based drinking game which is thought to have originated in Australia and spread all over the world between 2013 and 2014. Individuals record videos of themselves while rapidly drinking excessive quantities of alcoholic drinks (necking) and then nominate friends to outdo them within 24 hours; the videos are then posted on social media such as Facebook or YouTube. The consequences of this drinking game have been very dangerous; at least 5 people under age 30 years have died after drinking deadly cocktails, and many others have suffered from alcohol intoxication. OBJECTIVE: The goal of the research is to evaluate data about clinically important acute alcohol intoxication among teenagers and young adults and inform and educate the general public, especially parents, teachers, and health workers, about the spreading craze of dangerous Internet-related behavior among today's teenagers and young people up to the age of 23 years. METHODS: Patients aged 15 to 23 years with acute alcohol intoxication who came to the emergency department (ED) of 2 major hospitals in Italy from January 1, 2011, to June 30, 2014, were included in this study. Data were retrieved from prehospital and intrahospital medical records and included personal information, methods of intoxication, triage color code, date and time of access to the ED, any relevant signs and symptoms, blood alcohol concentration, and diagnosis at discharge. RESULTS: A total of 450 young patients (male 277/450, 61.5%, female 173/450, 38.5%; age 15 to 16 years 15/450, 3.3%, age 17 to 18 years 184/450, 40.9%, age 19 to 23 years 251/450, 55.8%) were recruited. The causes of intoxication were happy hour, binge drinking, NekNominate, eyeballing, other alcoholic games, or a mix of them. Happy hour was found to be more common among the older patients, whereas NekNominate accounted for almost half of the youngest group of hospitalizations. Eyeballing occurred in 1.6% (7/450) of cases; binge drinking and other alcoholic games caused 23.3% (105/450) and 23.8% (107/450) of hospitalizations, respectively. On admission, 44.2% (199/450) of patients were assigned a red or yellow color code requiring immediate medical attention; about 14% of them required additional medical assistance (after being in the ED) or hospitalization, some in semi-intensive care units. CONCLUSIONS: Our study shows that the increased numbers of hospitalizations due to alcohol intoxication in the adolescent age group, as a consequence of NekNominate or other drinking games, is alarming and represents a serious public health issue. The potential markers of improper use of social networks must be clearly identified, including categories at risk of alcohol abuse, in order to develop intervention and prevention strategies in terms of education and awareness, which may help in averting potentially fatal episodes.

The Rise of New Alcoholic Games Among Adolescents and the Consequences in the Emergency Department: Observational Retrospective Study.

BACKGROUND: The links between the internet and teenager behavior are difficult situations to control and may lead to the development of new and excessive methods of drinking alcohol during alcoholic games. Findings indicate that reported cases are very useful sources for better understanding of alcoholic games, yielding successful measures promoting health among adolescents. Admittance of adolescents to hospital emergency departments (EDs) after consumption of excessive amounts of alcohol has become the norm in developed countries. The harmful effects of acute alcohol abuse are reported in this paper. OBJECTIVE: The aim of this work was to investigate the close connections between new drinking behaviors among adolescents and study the increase in new alcoholic games, together with the challenges that cause acute alcohol intoxication, the influence of the internet and social networks, and their consequences for public health services. METHODS: Data came from prehospital and intrahospital admissions attributable to alcohol consumption. From 2013 to 2015, 3742 patients were admitted to EDs due to acute alcohol intoxication: 830 of them were aged 15 to 30 years, and 225 were adolescents and young adults between 15 and 20 years who had been playing alcoholic games. Retrospectively, diagnostic data associated with extrahospital anamneses were selected by one of the hospital management information systems, Qlik. As a result of our previous experience, questionnaires and face-to-face interviews were performed at a later stage, when a clinical audit for intoxicated adolescent patients was described, with the overall goal of establishing a potential methodological workflow and adding important information to research carried out so far. RESULTS: Between 2013 and 2015, 830 young patients aged 15 to 30 years were admitted to EDs for acute alcohol intoxication. About 20% (166/830) of the sample confirmed that they had drunk more than 5 alcoholic units within 2 hours twice during the past 30 days as a result of binge drinking. Referring to new alcoholic games, 41% of the sample stated that they knew what neknomination is and also that at least one of their friends had accepted this challenge, describing symptoms such as vomiting, headache, altered behavior, increased talkativeness, and sociability. The median value of the weighted average cost of the diagnosis-related group relating to interventions provided by hospitals was the same for both genders, €46,091 (US $56,497; minimum €17,349 and maximum €46,091). CONCLUSIONS: Drinking games encourage young people to consume large quantities of alcohol within a short period of time putting them at risk of alcohol poisoning, which can potentially lead to accidental injuries, unsafe sex, suicide, sexual assault, and traffic accidents. The spread of these games through the internet and social networks is becoming a serious health problem facing physicians and medical professionals every day, especially in the ED; for this reason, it is necessary to be aware of the risks represented by such behaviors in order to recognize and identify preliminary symptoms and develop useful prevention programs. The strategic role of emergency services is to monitor and define the problem right from the start in order to control the epidemic, support planning, coordinate the delivery of assistance in the emergency phase, and provide medical education. Hospital-based interdisciplinary health care researchers collected specific data on hazardous drinking practices linked to evaluation of increased alcohol-related consequences and cases admitted to the ED.

Pedestrian Inattention Blindness While Playing Pokémon Go as an Emerging Health-Risk Behavior: A Case Report.

BACKGROUND: Cases of trauma resulting from the use of mobile phones while driving motor vehicles have become quite common in recent years. Road injuries incurred by people playing video games on mobile phones (or other media devices) while walking have also become a cause for concern. Pokémon Go has been the world's most popular game since it was launched in July 2016, with more than 15 million players trying to catch all Pokémon available in the game; however, the case detailed here is the first reported accident in the medical literature caused by a pedestrian distracted by the game while crossing a street. OBJECTIVE: We aim to provide additional information on the innovative nature of distractions that generate risks in road-users, and to explore the underreporting of pedestrian-motor vehicle collisions due to mobile device usage. METHODS: We included in this case report a 25-year-old male who suddenly crossed a road while playing Pokémon Go and was hit by a van, reporting several injuries and being assisted by the Emergency Medical Service of our hospital (Padova, Italy). The patient's history, the circumstances in which the collision happened, imaging data, and clinical course information were recorded per our hospital's privacy policy. RESULTS: The patient hit by the van was playing Pokémon Go on his mobile phone while crossing a street, despite red traffic lights, which he did not notice due to of the distraction induced by the game. CONCLUSIONS: Mobile videogames that imply movement (ie, walking, running, cycling) to play are an effective way to improve physical activity practice, especially in adolescents and young adults. Nevertheless, cases like the one presented here point out that these games could pose a significant risk to users who play while walking, cycling, or driving in unsafe areas such as city streets, because players become distracted and may ignore surrounding hazards. Comprehensive, multilevel interventions are needed to reduce accidents caused by distraction, and to stress findings on the positive and negative effects of video games, which are becoming a source of public health concern. Health care providers should be aware of their chief role in these possible prevention strategies, based on their direct interactions with road incident victims.

Planking or the "Lying-Down Game:" Two Case Reports.

BACKGROUND: The monitoring and management of risks regarding children and young people admitted to the emergency department as a result of dangerous behaviors distributed via the Internet should be based on clinical reasoning and knowledge about these social media-related phenomena. Here we examine 2 cases of teenagers who reported severe injuries while performing the "planking" craze, a challenge that consists in lying face-down stiffly like a board on any kind of surface. OBJECTIVE: Our objective is to examine and describe the Internet craze called planking, also known as the "lying-down game," through 2 case reports from our experience, enriching this study with information gained through discussions with secondary school teenagers. METHODS: Details of the 2 case reports were taken from electronic medical records giving information on care support processes, care management, and the costs of traumatic episodes. Demographic data, hemoglobin and serum lactate values, and Injury Severity Scores were evaluated. The study took place in secondary schools of our city from 2013 to 2014 during medical education courses, with the aim of analyzing the influence of social media on teenagers' activities and behaviors. RESULTS: Both patients suffered multiple trauma injuries and needed high-level health assistance. The first patient underwent a splenectomy and the second one a nephrectomy; both of them required a long hospital stay (14 and 20 days, respectively), and the costs for their management have been estimated at US $27,000 and US $37,000, respectively. Their decision to perform the planking in dangerous locations was due to their ambition to gain peers' acclaim through shared videos and pictures. CONCLUSIONS: Reporting and understanding these cases may potentially help prevent future events occurring in similar circumstances: the scientific community cannot leave this problem unaddressed. There is also a role of education resources for health care professionals; for this, we must identify and follow up strange or misleading information found on websites. A key element of this research study was to report physicians' misperceptions concerning planking and, with these cases used for teaching purposes, improve knowledge of the clinical and forensic aspects of this emerging problem.

Fatal asthma; is it still an epidemic?

BACKGROUND: Asthma mortality has declined since the 1980s. Nevertheless the World Health Organization (WHO) identified asthma as responsible for 225.000 deaths worldwide in 2005, and 430.000 fatal cases are expected by 2030. Some unexpected and concentrated fatal asthma events all occurred between 2013 and 2015 in Veneto, a North Eastern region of Italy, which prompted a more in-depth investigation of characteristics and risk factors. METHODS: A web search including key words related to fatal asthma in Italy between 2013 and 2015 has been performed. Concerning the cases that occurred in Veneto, subjects' clinical records have been evaluated and details about concomitant weather conditions, pollutants and pollen count have been collected. RESULTS: Twenty-three cases of asthma deaths were found in Italy; 16 of them (69%) occurred in the Veneto Region. A prevalence of male and young age was observed. Most of patients were atopic, died in the night-time hours and during the weekends. The possible risk factors identified were the sensitization to alternaria, previous near fatal asthma attacks and the incorrect treatment of the disease. Weather condition did not appear to be related to the fatal exacerbations, whereas among the pollutants only ozone was detected over the accepted limits. Smoking habits, possible drug abuse and concomitant complementary therapies might be regarded as further risk factors. DISCUSSION: Although not free from potential biases, our web search and further investigations highlight an increasing asthma mortality trend, similarly to what other observatories report. The analysis of available clinical data suggests that the lack of treatment more than a severe asthma phenotype characterizes the fatal events. CONCLUSIONS: Asthma mortality still represents a critical issue in the management of the disease, particularly in youngsters. Once more the inadequate treatment and the lack of adherence seem to be not only related to the uncontrolled asthma but also to asthma mortality.

Sequential development of hepatocellular carcinoma and liver angiosarcoma in a vinyl chloride-exposed worker.

Strong experimental and clinical evidences have definitely linked occupational vinyl chloride exposure to development of angiosarcoma of the liver. In contrast, despite the International Agency for Research on Cancer having included vinyl chloride among the causes of hepatocellular carcinoma, the association between vinyl chloride exposure and hepatocellular carcinoma remains debated. This issue is relevant, because occupational exposure to high levels of vinyl chloride may still occur. We report a unique case of sequential occurrences of hepatocellular carcinoma and angiosarcoma of the liver, in a vinyl chloride-exposed worker without cirrhosis and any known risk factor for chronic liver disease. Both the hepatocellular carcinoma and the surrounding normal liver showed micronucleus formation, which reflects genotoxic effect of vinyl chloride. Angiosarcoma showed a KRAS G12D point mutation, which is considered to be characteristic of vinyl chloride-induced angiosarcoma. This case supports the pathogenic role of vinyl chloride in both hepatocellular carcinoma and angiosarcoma development.

Misinterpretation of Anogenital Findings and Misdiagnosis of Child Sexual Abuse: The Role of the Forensic Pathologist.

BACKGROUND: The interpretation of anogenital postmortem findings is an issue of main concern, because the nature and appearance of anogenital tissues during the postmortem interval is not widely known by health providers. CASE: An 8-year-old girl died in the hospital 48 hours after hospitalization. On the basis of the atypical anogenital findings, the health care professionals notified the fact to the Public Prosecutor as an alleged child abuse. The forensic pathologist ruled out this possibility, interpreting the anal findings due to physiological postmortem anal alterations and to the insertion of suppositories before death. SUMMARY AND CONCLUSION: Forensic pathological analysis should be included in routine postmortem evaluation in the case of suspected child sexual abuse, because normal postmortem findings could be misinterpreted by physicians, whose sole experience is on the basis of antemortem scenarios.

A case of chemical scalp burns after hair highlights: experimental evidence of oxidative injuries.

Hair highlights are quite common procedures carried out in hair salons by using a mixture of a lightening powder containing persulfates with a suspension containing hydrogen peroxide: a representative case of chemical scalp burns is described as a consequence of this treatment. The aim of the paper is to demonstrate the strict relationship between the scalp damage and the commercial products used in a case of hair highlighting. The results of some chemical analyses have been reported, showing, in particular, that the chemical reactivity of the mixture changes in the time, thus strongly suggesting that the procedure for the application of the mixture is critical for the occurrence of possible accidents. The presence in the powder of chemical compounds bearing aliphatic chains as surfactants explains the appearance of dramatic symptoms after days due to a slow dissolution of the oxidant compounds in the stratum corneum of skin with no effect in reducing injury of palliative treatments. Safety suggestions and recommendations for producers and workers are also included.

Underlying substance abuse problems in drunk drivers.

OBJECTIVES: The aim of this study was to investigate polydrug use in drunk drivers. METHODS: The experimental study was conducted on 2,072 drunk drivers undergoing a driving license reissue protocol at the Department of Legal Medicine of Padova University Hospital in the period between January 2011 and December 2012. The study protocol involved anamnesis, clinical examination, toxicological history, and toxicological analyses on multiple biological samples. RESULTS: One thousand eight hundred seventy-seven subjects (90.6%) were assessed as fit to drive, and 195 (9.5%) were declared unfit. Among those unfit, 32 subjects (1.6%) were declared unfit due to recent use of an illicit drug (time span < 6 months), 23 (1.1%) spontaneously interrupted the protocol before its end, and 140 (6.8%) completed the assessment. Ineligibility to drive after completeness of the protocol was established in 1.2% of cases for alcohol disorders and in 5.7% of cases for illicit drug abuse; only one subject was included in both subgroups. Cocaine was the most widely used substance, followed by cannabis, opiates, and psychotropic pharmaceutical drugs. CONCLUSIONS: The application of the protocol presented in this study allowed the identification of underlying polydrug use in drunk drivers. The study led to the identification of 6.8% unfit subjects on the basis of alcohol disorders and/or drug abuse, compared to 1.2% of identifiable unfitness if the protocol were limited to the mere assessment of alcohol consumption. The frequent association of alcohol and cocaine is different from other patterns of use in North Europe countries.

Iatrogenic perforation of a pulmonary angiomatoid lesion: histopathological study and review of the literature.

Percutaneous tube thoracostomy (PTT) remains the most widely performed procedure to manage blunt or penetrating chest traumas. This life-saving manoeuvre can be frequently associated with complications. We present the case of a 76-year-old man, admitted to a peripheral hospital after a car accident and treated by PTT, who died shortly after the withdrawal of the chest tube. At autopsy, the victim was found to be affected by an extensive haemothorax resulting from the perforation of a subpleural angiomatoid lesion. The histopathological characteristics and the pathogenesis of the iatrogenic injury involving the vascular abnormality, along with its causal role in determining the fatal haemothorax, are critically discussed under both clinical and forensic points of view.

Alcohol drinking, mean corpuscular volume of erythrocytes, and alcohol metabolic genotypes in drunk drivers.

Regular and irregular abuse of alcohol are global health priorities associated with diseases at multiple sites, including cancer. Mechanisms of diseases induced by alcohol are closely related to its metabolism. Among conventional markers of alcohol abuse, the mean corpuscular volume (MCV) of erythrocytes is prognostic of alcohol-related cancer and its predictivity increases when combined with functional polymorphisms of alcohol dehydrogenase (ADH1B [rs1229984] and ADH1C [rs698]) and the mitochondrial aldehyde dehydrogenase (ALDH2 [rs671]). Whether these genetic variants can influence abuse in alcohol drinking and MCV has never been examined in drunk-driving traffic offenders. We examined 149 drunk drivers, diagnosed as alcohol abusers according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition Text Revision (DSM-IV-TR) and enrolled in a probation program, and 257 social drinkers (controls), all Caucasian males. Alcohol intake was assessed according to self-reported drink-units/d and MCV unadjusted and adjusted for age, smoking, and body mass index. Multivariable models were used to compute MCV adjusted means. Genotype analyses were performed by PCR on DNA from blood. The adjusted MCV mean was higher in drunk-driving abusers than in controls (92 vs. 91fL; P<.0001) and increased with the number of drink-units/d in both abusers and controls (P-trend=.0316 and .0089) already at intermediate quantities (0-1 vs. 2-4 drink-units/d: P=.054 and .024). Carriers of the common ADH1B*1/*1 (rs1229984) genotype were more likely to be drunk-driving abusers (P=.008), reported higher drink-units/d (P=.0126), and had larger MCV (P=.035). The rs698 ADH1C and rs671 ALDH2 polymorphisms were not associated with MCV. ADH1B*1/*1 polymorphism is significantly associated with being a drunk-driving abuser, higher alcohol drinking, and MCV enlargement. This suggests that drunk drivers with augmented MCV modulated by the alcohol metabolic ADH1B*1/*1 genotype may be at higher risk of driving incapability and of alcohol-related cancer.

Shortened telomeres in individuals with abuse in alcohol consumption.

Alcohol abuse leads to earlier onset of aging-related diseases, including cancer at multiple sites. Shorter telomere length (TL) in peripheral blood leucocytes (PBLs), a marker of biological aging, has been associated with alcohol-related cancer risks. Whether alcohol abusers exhibit accelerated biological aging, as reflected in PBL-TL, has never been examined. To investigated the effect of alcohol abuse on PBL-TL and its interaction with alcohol metabolic genotypes, we examined 200 drunk-driving traffic offenders diagnosed as alcohol abusers as per the Diagnostic and Statistical Manual of Mental Disorders [DSM-IV-TR] and enrolled in a probation program, and 257 social drinkers (controls). We assessed alcohol intake using self-reported drink-units/day and conventional alcohol abuse biomarkers (serum γ-glutamyltrasferase [GGT] and mean corpuscular volume of erythrocytes [MCV]). We used multivariable models to compute TL geometric means (GM) adjusted for age, smoking, BMI, diet, job at elevated risk of accident, genotoxic exposures. TL was nearly halved in alcohol abusers compared with controls (GMs 0.42 vs. 0.87 relative T/S ratio; p<0.0001) and decreased in relation with increasing drink-units/day (p-trend=0.003). Individuals drinking >4 drink-units/day had substantially shorter TL than those drinking ≤4 drink-units/day (GMs 0.48 vs. 0.61 T/S, p=0.002). Carriers of the common ADH1B*1/*1 (rs1229984) genotype were more likely to be abusers (p=0.008), reported higher drink-units/day (p=0.0003), and exhibited shorter TL (p<0.0001). The rs698 ADH1C and rs671 ALDH2 polymorphisms were not associated with TL. The decrease in PBL-TL modulated by the alcohol metabolic genotype ADH1B*1/*1 may represent a novel mechanism potentially related to alcohol carcinogenesis in alcohol abusers.

Death after liposuction: case report and review of the literature.

We report the case of a 41-year-old woman who died after surgical intervention for liposuction. The case was studied by a methodological approach including examination of clinical records and documentation, analysis of anatomo-histopathological findings and evaluation of physicians' behaviour. Autopsy excluded the lethal complications most frequently associated with liposuction (pulmonary embolism, sepsis, necrotizing fasciitis, perforation of abdominal organs) and identified the cause of death as 'massive necrosis of brain-stem and cerebellum, due to spontaneous thrombosis of the basilar and cerebellar district'. Analysis of the physicians' behaviour, together with a review of the literature, excluded medical errors or malpractice. The Court of Law ruled the death as a fatal unforeseeable complication of the operation. The medico-legal interest of the case lies in the singular anatomo-pathological cause of death, discussed in relation to the hypothesis of professional responsibility after surgical intervention for liposuction.

Bio-medicolegal guidelines and protocols: survey and future perspectives in Europe.

The preservation of uniqueness and the enhancement of the value of evidence in legal medicine is based on the implementation and development of a "quality management system," which includes a continuous education of specialists, the introduction and application of guidelines and protocols, as well as mechanisms of internal quality control. This ongoing process shows differences with regard to various fields of knowledge such as forensic genetics, toxicology, forensic pathology or forensic psychiatry, especially if different European countries are compared. To get an overview on the development of legal medicine in different European countries, a questionnaire was developed and sent to representatives of 42 European countries to verify the existence of bio-medicolegal guidelines and protocols. A National Society of Legal Medicine is established in 27 out of 32 countries (84%) which could be included in the final analyses. In 25 countries (78%), a specialisation is necessary as a prerequisite of inclusion in a national register, and 30 of the countries (94%) have guidelines in at least one field of legal medicine. The most common guidelines concern forensic pathology (in the fields of professional qualification and sudden death), forensic toxicology (driving under the influence of drugs and substance testing) and forensic genetics (paternity testing and personal identification). The findings of this study show that comparison is possible and can be a basis for further consensus in the European medicolegal community. The process of harmonisation of the medicolegal autopsy rules in Europe initiated in 1990 was a first step on this way. Further consensus is necessary and might be gained by developing European guidelines for each field within the subdisciplines, based on a standard European Guideline Format.

Early myocardial dysfunction after chronic use of anabolic androgenic steroids: combined pulsed-wave tissue Doppler imaging and ultrasonic integrated backscatter cyclic variations analysis.

BACKGROUND: The chronic consumption of androgenic anabolic steroids (AAS) has shown to cause subclinical impairment of myocardial function. Pulsed-wave Doppler tissue imaging (PWDTI) detects early regional alterations of ventricular function, whereas integrated backscatter cyclic variations (IBScv) are tightly related to the contractile efficiency of the left ventricular wall. The aim of this study was to identify the effects of chronic AAS misuse on myocardial function using both PWDTI and IBScv. METHODS: Twenty-eight male bodybuilders (11 AAS users, 17 AAS nonusers) and 20 healthy sedentary subjects (controls), matched according to age, were studied. To assess left ventricular function, each subject underwent standard Doppler echocardiography, PWDTI, and IBScv analyses. RESULTS: Left ventricular mass was significantly higher in AAS users than in AAS nonusers and controls. Global systolic function (assessed by determining the ejection fraction) was similar in all subjects, but isovolumetric relaxation time was significantly higher in AAS users than in controls. On PWDTI analysis, AAS users showed regional systolic and diastolic dysfunction (evaluated by measuring s', e', and a') not detectable in the other two groups. IBScv identified regional systolic impairment only in AAS users at the level of the left ventricular inferior wall. CONCLUSIONS: The present study confirms that in AAS users, PWDTI and IBScv are effective and reliable noninvasive diagnostic tools for detecting early abnormalities of the systolic and diastolic longitudinal myocardial function, probably related to an increase in myocardial collagen content, interpretable as a repair process against the direct cellular injury produced by AAS.