Is the team leading surgeon criminally liable for his collaborators’ errors? judges confirm responsibility and condemn an otorhinolaryngologist

In current healthcare, delivery of medical and surgical treatment takes place in a multidisciplinary manner. This raises the problem of distinguishing the conditions under which the person who has properly carried out his duties, respecting the related leges artis, can be held responsible for damages materially caused by another member of the medical team. Jurisprudence has developed the so-called “principle of trust” for which every member of the team can rely on the fact that other members are acting in compliance with the leges artis of their specialisation. The Supreme Court has limited the application of this principle. The authors examine the jurisprudence on responsibility of the team in otolaryngology and conclude that individual liability should be limited to the specific expertise of the individual specialist

An atypical case of trigeminal trophic syndrome: a legal medicine perspective in medical responsibility

BACKGROUND: Trigeminal trophic syndrome is a rare complication of peripheral or central damage to the trigeminal nerve characterized by anesthesia, paresthesia and a secondary persistent facial ulceration. METHODS: We describe the case of a 40-year-old woman with previous history of Le Fort I osteotomy for a class III malocclusion who developed trigeminal trophic syndrome. Atypically, the cutaneous symptoms appeared bilaterally and 8 years after surgery. RESULTS: Differential diagnosis was based on clinical history, tissue biopsy and serologic evaluation. Atypical findings could be linked to the surgical burdens of Le Fort I osteotomy, a procedure characterized by a bilateral incision on the maxillofacial bones with a reasonable probability of causing a bilateral injury of the peripheral branches of the trigeminal nerve. CONCLUSION: Although the long delay between trigeminal trophic syndrome onset and surgery and the absence of adequate medical evidence cannot confirm a link with previous surgery in this case, the increasing number of maxillofacial surgery cases suggests that this complication may be more frequent in the next decades, and thus, involved specialists should be aware of this condition as a possible complication of maxillofacial surgery procedures

Ethics and/or aesthetics? reflections on cosmetic surgery for adolescents

Cosmetic surgery entails various ethical issues, even more so in cases involving adolescent patients. Cosmetic surgeons need to take into account how modern societies consider physical appearance an essential component of everyday life, as well as the vulnerability of youths and adolescents. For that reason, it is imperative to thoroughly assess the psychological and emotional states, in addition to the motivations, of minor patients. That goal can be achieved through the use of the DAS-59, (the Derriford Appearance Scale)1 , an effective and dependable tool devised to evaluate the psychological difficulties and distress experienced by people living with problems of appearance. Prior to undergoing cosmetic surgery procedures, adolescents should be required to go through adequate counseling, over multiple sessions and extended to their family members as well, on account of the complex issues inherent in evaluating the risk-benefit ratio and a prospective patient's decision-making capability. A concerted effort on the part of surgeons, psychiatrists or psychologists is key in determining the real motivations behind a minor's decision to opt for cosmetic surgery in the first place. Possible psychiatric conditions may in fact prevent a minor from making a free, informed decision. From an ethical standpoint, cosmetic surgery procedures should be geared to serve the best interest of the minor patient, who may experience distress over his or her body image, from a health and psychological balance perspective and improve his or her social, affective and working life. Besides, cosmetic surgery should not be overly invasive compared to its potential benefits. Those procedures aimed at achieving ″ideal beauty″ are not desirable and ought to be banned. By virtue of such criteria, the authors have set out to evaluate the ethical admissibility of some aesthetic treatments. Thus, doctors should not consent to any request coming from their patients, but rather, intervene only in presence of an objective physical flaw or deformity, e.g. protruding ears, which have a potential to negatively affect social life and interactions

The transposition of council directive 2013/59 into italian law

By the European Directive no. 2013/59 Euratom, the European Union has aimed to provide Member States with updated instructions in order to prevent damages possibly arising from radiations in health care, work and social settings. Among the most relevant amendments, the authors have found: a) the introductions of new defining criteria; b) the updating of some dosage related standards, such as the one about the threshold absorbed by the crystalline lens; c) a new set of rules for the measurement of emissions from devices and data management; d) a greater degree of clarity in ascribing liability to anyone involved in utilizing ionizing radiation-emitting devices. The paper outlines the Italian legislative state of affairs by delving into all relevant aspects of the current legislation, what has been put in place in the process of enacting the European Directive and the measures that could be suitable for future improvement

war pensions schemes at the root of a set of medico legal criteria as current as ever

The following report has been devised in an attempt to address and elaborate on the medico-legal assessment criteria applicable to warrelated damages, in light of the Presidential Decree n. 915, 23rd, December 1978, by drawing comparisons among workplace-injury legislation, welfare systems, and the conventional standards within medico-legal doctrine. Among the elements herein analyzed: a) analytical criteria, expecting an overhaul and thorough implementation of injury case records; b) quality and quantity-related adjectivization such as «grave» and «remarkable»; c) the irrelevance of residual functional capabilities that do not provably affect one's capacity to successfully engage in any given type of work; d) the assessment of multiple, permanent impairment instances, whether they be homogeneous, heterogeneous, monocrone (i.e. arising from a single event), policrone (resulting from multiple events), concurrent or coexisting; e) the definition of organ; f) the concept of paired organs; g) partial loss of the left-over organ. The paper's authors ultimately highlight the enduring quality of the medico-legal criteria inherent to the legislation at hand, which, however, ought to be overhauled and updated in order to better reflect the conceptual developments that have occurred with regards to damage compensation in tort law and workplace injuries and occupational disease, which have given rise to the concept of biological damage as a basic one, worthy of redress in itself, regardless of further workrelated consequences. ---------- Il presente contributo analizza i criteri medico-legali di valutazione del danno patito a causa della guerra alla luce del decreto del Presidente della Repubblica n. 915 del 23 dicembre 1978, operando un raffronto sia con i criteri previsti dalle leggi in materia di infortuni sul lavoro e di previdenza sociale sia con le tradizionali acquisizioni della dottrina medico-legale. In particolare, vengono analizzati: a) il criterio analogico, auspicando la revisione e l'adeguata implementazione della casistica delle menomazioni; b) le aggettivazioni qualiquantitative, come «grave» e «notevole»; c) l'irrilevanza di quelle residue capacità funzionali che non presentino alcuna utilità agli effetti della capacità a proficuo lavoro; d) la valutazione delle menomazioni plurime a carattere permanente, a seconda che siano omogenee, eterogenee, monocrone, policrone, concorrenti o coesistenti; e) il concetto di organo; f) la nozione di organo pari; g) la perdita parziale dell'organo superstite. Gli autori concludono evidenziando la perdurante qualità dei criteri medico-legali previsti dalla normativa in esame, la quale, tuttavia, dovrebbe essere aggiornata per tenere conto dell'evoluzione concettuale intervenuta in sede sia di risarcimento del danno in responsabilità civile sia di infortuni sul lavoro e di malattie professionali, che ha introdotto la nozione di danno biologico quale danno di base, già di per sé meritevole di tutela indipendentemente da ulteriori conseguenze di carattere lavorativo e lucrativo. ---------- Este trabajo analiza los criterios médico-legales para evaluar el daño sufrido como resultado de la guerra a la luz del Decreto Presidencial n. 915 del 23 de diciembre de 1978, haciendo una comparación tanto con los criterios establecidos por las leyes sobre accidentes de trabajo y seguridad social como con las adquisiciones tradicionales de doctrina médico-legal. En particular, se analizan: a) el criterio analógico, esperando la revisión y la implementación adecuada de la casuística de impedimentos; b) adjetivos cualitativo-cuantitativos, tales como "serio" y "notable"; c) la irrelevancia de las capacidades funcionales residuales que no presentan ninguna utilidad para los efectos de la capacidad de trabajo rentable; d) la evaluación de impedimentos permanentes múltiples, según sean homogéneos, heterogéneos, monocromados, policromados, concurrentes o coexistentes; e) el concepto de un órgano; f) la noción de un órgano igual; g) pérdida parcial del órgano superviviente. Los autores concluyen destacando la calidad continua de los criterios médico legales establecidos por la legislación en cuestión, que, sin embargo, deberían actualizarse teniendo en cuenta la evolución conceptual que se produce tanto en la indemnización por daños en la responsabilidad civil como en los accidentes de trabajo y enfermedades profesionales, que introdujo la noción de daño biológico como un daño básico, que ya en sí mismo merece protección, independientemente de otras consecuencias lucrativas y relacionadas con el trabajo

Hepatotoxicity induced by greater celandine (Chelidonium majus L.): a review of the literature

The available literature assessing Chelidonium majus L. (CM) hepatotoxicity potential, and its risk to benefit assessment has been reviewed in this paper. Identification of significant scientific literature was performed via the following research databases: Cochrane Central, Google Scholar, EMBASE, Medline, Science Direct, Scopus, Web of Science, using the following keywords: "Chelidonium majus", "greater celandine", "Hepatotoxicity", "Liver" "Injury", "Toxicity" individually investigated and then again in association. CM named also greater celandine, swallow-wort, or bai-qu-cai (Chinese), has been used for a long time in traditional Chinese medicine and phytotherapy. Its extracts have been claimed to display a wide variety of biological activities: antimicrobial, anti-inflammatory, spasmolytic, antineoplastic, hepatoprotective, and analgesic. Moreover, herbal medicine suggests this plant have numerous additional effects which have not yet been scientifically evaluated, such as antitussive, diuretic, and eye-regenerative. However, despite its claimed hepatoprotective effects, several hepatotoxicity cases have been reported to be probably or highly probably connected with CM exposure, after their evaluation through liver-targeted causality assessment methods. CM hepatotoxicity has been defined as a distinct form of herb-induced liver injury (HILI), due to an idiosyncratic reaction of the metabolic type. This evidence has to be considered in relationship with the absence of considerable benefits of CM therapy. Therefore, the risk to benefit ratio of the use of herbal products containing greater celandine can actually be considered as negative

Ventricular androgenic-anabolic steroid-related remodeling: an immunohistochemical study

Background: Several fatal cases of bodybuilders, following a myocardial infarction after long exposure to androgenicanabolic steroids (AAS), are reported. In recent years, evidence has emerged of cases of heart failure related to AAS consumption, with no signs of coronary or aorta atherosclerosis. This study aims to further investigate the pathogenesis of the ventricular AAS-related remodeling performing immunohistochemistry (IHC). Method: In order to examine innate immunity activity and myocytes and endothelial cell apoptosis, IHC analyses were performed on heart tissue of two cases of bodybuilders who died after years of supratherapeutic use of metelonone and nandrolone and where no atherosclerosis or thrombosis were found, using the following antibodies: anti-CD68, anti-iNOS, anti-CD163, anti-CD 15, anti-CD8, anti-CD4, anti-HIF1 α, and in situ TUNEL staining. Results: Results confirm the experimental findings of recent research that, in the absence of other pathological factors, if intensive training is combined with AAS abuse, myocytes and endothelial cells undergo apoptotic alterations. The absence of inflammatory reactions and the presence of an increased number of M2 macrophages in the areas of fibrotic remodeling confirm that the fibrotic changes in the heart are apoptosisrelated and not necrosis-related. Conclusions In conclusion, the study indicates that, in very young subjects with chronic hypoxia-related alterations of the heart, signs of a heart failure in the other organs and a history of AAS abuse, death can be ascribed to progressive heart failure due to the direct apoptotic cardiac and endothelial changes produced by AAS

Post vaccinal temporary sensorineural hearing loss

In our systematic research we identified four studies concerning the onset of neurological adverse events following vaccination and two excluding this association. A 33-year-old Italian man, belonging to the Italian Army was hospitalized because he suffered from vertigo, nausea and sudden right hearing loss not classified (NDD), that set in 24 h after the administration of tetanus-diphtheria and meningococcal vaccines. Some neurological events arising after vaccination are very difficult to treat. In our case, the functional recovery on low and medium frequencies was possible about 6 months after the morbid event

Comparison and combination of a hemodynamics/biomarkers-based model with simplified PESI score for prognostic stratification of acute pulmonary embolism: findings from a real world study

Background: Prognostic stratification is of utmost importance for management of acute Pulmonary Embolism (PE) in clinical practice. Many prognostic models have been proposed, but which is the best prognosticator in real life remains unclear. The aim of our study was to compare and combine the predictive values of the hemodynamics/biomarkers based prognostic model proposed by European Society of Cardiology (ESC) in 2008 and simplified PESI score (sPESI).Methods: Data records of 452 patients discharged for acute PE from Internal Medicine wards of Tuscany (Italy) were analysed. The ESC model and sPESI were retrospectively calculated and compared by using Areas under Receiver Operating Characteristics (ROC) Curves (AUCs) and finally the combination of the two models was tested in hemodinamically stable patients. All cause and PE-related in-hospital mortality and fatal or major bleedings were the analyzed endpointsResults: All cause in-hospital mortality was 25% (16.6% PE related) in high risk, 8.7% (4.7%) in intermediate risk and 3.8% (1.2%) in low risk patients according to ESC model. All cause in-hospital mortality was 10.95% (5.75% PE related) in patients with sPESI score ≥1 and 0% (0%) in sPESI score 0. Predictive performance of sPESI was not significantly different compared with 2008 ESC model both for all cause (AUC sPESI 0.711, 95% CI: 0.661-0.758 versus ESC 0.619, 95% CI: 0.567-0.670, difference between AUCs 0.0916, p=0.084) and for PE-related mortality (AUC sPESI 0.764, 95% CI: 0.717-0.808 versus ESC 0.650, 95% CI: 0.598-0.700, difference between AUCs 0.114, p=0.11). Fatal or major bleedings occurred in 4.30% of high risk, 1.60% of intermediate risk and 2.50% of low risk patients according to 2008 ESC model, whereas these occurred in 1.80% of high risk and 1.45% of low risk patients according to sPESI, respectively. Predictive performance for fatal or major bleeding between two models was not significantly different (AUC sPESI 0.658, 95% CI: 0.606-0.707 versus ESC 0.512, 95% CI: 0.459-0.565, difference between AUCs 0.145, p=0.34). In hemodynamically stable patients, the combined endpoint in-hospital PE-related mortality and/or fatal or major bleeding (adverse events) occurred in 0% of patients with low risk ESC model and sPESI score 0, whilst it occurred in 5.5% of patients with low-risk ESC model but sPESI ≥1. In intermediate risk patients according to ESC model, adverse events occurred in 3.6% of patients with sPESI score 0 and 6.65% of patients with sPESI score ≥1.Conclusions: In real world, predictive performance of sPESI and the hemodynamic/biomarkers-based ESC model as prognosticator of in-hospital mortality and bleedings is similar. Combination of sPESI 0 with low risk ESC model may identify patients with very low risk of adverse events and candidate for early hospital discharge or home treatment.