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Commuting road traffic collisions (RTCs) are one of the main causes of occupational death worldwide, including Italy. Among the prominent yet relatively understudied personal risk factors in the subpopulation of workers, there is the use of psychoactive substances. Since the phenomenon of driving under alcohol and drugs effects in the commuter sub-population has so far been poorly studied, we carried out a study by comparing results obtained from the analysis of commuters and non-commuters. The percentage of commuting RTCs victims was 10.4% out of all the RTCs. Commuter victims were mostly men, 51–60 years-old, motorcyclists (32.1%) or car drivers (28.6%), employees, deceased during Fridays and Saturdays, in the afternoon (35.7%) and in the evening (32.1%). It was possible to perform toxicological analyses in 60.7% of commuter cases: approximately 40% tested positive, always and only for ethanol (median Blood Alcohol Concentration, BAC, of about 1.03 g/L). Values above the legal limit were observed in 23.5% of the toxicological samples analyzed from commuter accidents. Our findings contribute to bridging the gap in knowledge in the area of RTCs and commuting and emphasize the importance of carrying out toxicological investigations, with possible repercussions on both insurance issues and public health strategies, which are relevant for analyzing the phenomenon structurally.

Purpose Explosion-related deaths are uncommon events which require expertise and confidence so that an appropriate death investigation can be performed. The present study aims to provide a detailed forensic analysis of the issues and implications arising in the event of an explosion. Methods A retrospective review of casualty data was conducted on electronic literature databases. Cases concerning deadly explosions registered at the Milan Institute of Legal Medicine were examined and analyzed altogether. Results Explosions may involve closed or open systems. A security assessment of the site is always necessary. Alterations of the site due to rescue procedures can occur; thus, on-site forensic investigation should be adapted to the environment. Then, a study protocol based on autopsy procedures is presented. Application of the postmortem radiology enforces forensic procedures both for the analysis of blast injuries and skeleton fractures, and for identification purposes. Blast injuries typically cause lacerations of the lungs, intestine and major vessels; moreover, hyoid fractures can be documented. Histopathology may help to define blast injuries effectively. Forensic chemistry, toxicology and ballistics provide useful investigative evidence as well as anthropology and genetics. Different forensic topics regarding explosions are discussed through five possible scenarios that forensic pathologists may come across. Scenarios include self-inflicted explosion deaths, domestic explosions, work-related explosions, terrorist events, and explosions caused by accidents involving heavy vehicles. Conclusion The scenarios presented offer a useful instrument to avoid misinterpretations and evaluation errors. Procedural notes and technical aspects are provided to the readers, with an insight on collaboration with other forensic experts.

The article provides a comparative analysis of the regulatory and legal regulation for the processing of a special category of personal health data in the European Union and in the Russian Federation in regard to the digitalization of national health systems. Special attention is paid to the legal framework for the transmission of health information at the cross-border level. It is established that within the framework of European and Russian legislation at this stage, in the context of the formation of digital medicine, there is a comparability in the definition of legal mechanisms for the protection of medical data. It is also noted that in the issue of the transfer of personal health data to third countries, both the Russian Federation and the European Union choose the path of strict restrictive regulation and the introduction of a closed list of grounds for overcoming the ban on cross-border transfer. The reasons for this approach to issues of supranational interaction in healthcare are analyzed, as well as the potential risks of inertia of national legislators in this issue. Based on the analysis, the authors propose a number of amendments and additions to the national legislation on personal data, aimed at simplifying the interaction between jurisdictions on the transfer of confidential medical information. The authors suggest an international agreement on the exchange of medical data in digital format, which potentially should include not only the Russian Federation and the EU states, but also other countries, including Eurasian Economic Union member states, China, and countries of the American continent. The proposed concept is intended to create an opportunity for the formation of a supranational information system in the field of healthcare, which allows for the effective exchange of medical data, taking into account the sovereign interests of the countries participating in the agreement.

Driving under the influence of alcohol has been shown to increase the risk of involvement in road traffic collisions (RTCs) however, less is known about the effects of illicit drugs, and a clear correlation between drug concentrations and RTC risk is still debated. The goal of this narrative review is to assess the current literature regarding the most detected psychoactive drugs in RTC (ethanol, amphetamines, cannabis, opioids and cocaine), in relation to driving performance. Evidence on impaired driving due to psychoactive substances, forensic issues relating to the assessment of the impact of drugs, blood cut-off values proposed to date as well as scientific basis for proposed legislative limits are discussed. At present there is no unequivocal evidence demonstrating a clear dose/concentration dependent impairment in many substances. Per se and zero tolerance approaches seem to have negative effect on drugged driving fatalities. However, the weight of these approaches needs further investigation.

Explosion-related deaths are a disregarded topic of forensic sciences, despite the pivotal role of the forensic pathologist in such investigations. In fact, very few scientific articles have been published up to now, even if there is a considerable increase of terrorist attacks worldwide due to the use of improvised explosive devices (IEDs). In this paper, the authors show a retrospective autopsy-based study on the two major civilian terrorist events which occurred in Milan (Italy). The first one took place in a closed system, where a gelignite bomb was set inside the National Agriculture Bank in December 1969. 17 people were killed, and all of them underwent forensic autopsies, which were performed at the Milan Institute of Legal Medicine. The second event took place in an open system, where a car bomb exploded in Palestro Street in July 1993. 5 people were killed, forensic autopsies were performed as well. A total of 22 explosion-related deaths were assessed in this study. For each victim, the analysis of clothes, external and internal examinations were reported; furthermore, a statistical analysis using Fisher’s exact test was carried out in order to show differences among blast injuries that occurred in a closed system versus an open system. The analysis of the autopsy reports, which included the descriptions of clothes, and the injury patterns allowed a possible reconstruction of the bodily exposure side of the victims in relation to the origin site of the explosive devices.

This article deals with legal and ethical aspects of sterilization of capable women of reproductive age. The authors point to the ethical and legal contradiction of establishing a high age criterium. Also, the authors consider the most common reasons for litigation during voluntary sterilization.

This research focuses on the application of Artificial Intelligence (AI) methodologies to the problem of classifying vehicles involved in lethal pedestrian collisions. Specifically, the vehicle type is predicted on the basis of traumatic injury suffered by casualties, exploiting machine learning algorithms. In the present study, AI-assisted diagnosis was shown to have correct prediction about 70% of the time. In pedestrians struck by trucks, more severe injuries were appreciated in the facial skeleton, lungs, major airways, liver, and spleen as well as in the sternum/clavicle/rib complex, whereas the lower extremities were more affected by fractures in pedestrians struck by cars. Although the distinction of the striking vehicle should develop beyond autopsy evidence alone, the presented approach which is novel in the realm of forensic science, is shown to be effective in building automated decision support systems. Outcomes from this system can provide valuable information after the execution of autoptic examinations supporting the forensic investigation. Preliminary results from the application of machine learning algorithms with real-world datasets seem to highlight the efficacy of the proposed approach, which could be used for further studies concerning this topic.

In Europe, the modern legal systems, as a rule, provide for the right of citizens to a free and informed choice in matter of family planning and procreation, and therefore the right of women to resort to abortion in case of medical and social indications, or even in case of the mother’s request to terminate an unwanted pregnancy. However, being abortion not only a legal issue, but also a social and moral one, different legal systems adopt a wide range of normative models, which take into account, among other things, the existing cultural traditions and the influence of Church on society. Many states recognize the mother and other relatives’ right to compensation arising from the birth of an unwanted child. Much more controversial is the recognition of the rights of a child with a congenital pathology to indemnity from unwanted birth as a result of medical error. In the present article it is examined the experience of Italy, a country where family traditionally represents a considerable cultural and symbolic value. The paper reviews the main normative acts governing the performance of abortion. The research investigates the issues concerning the legal regulation of the compensation for damages arising in connection with the birth of an unwanted child. The present study examines the trend, emerging in the judicial practice, towards the recognition of the physically challenged child’s rights to compensation for the damage deriving from the birth as a result of medical errors.

Biosimilar is defined by The European Medical Agency as a biological medicinal product, which is similar but not identical to the biological drug already authorized. The biosimilar and its reference product are expected to display the same safety and efficacy profile and are generally used to treat the same conditions. The Italian Medicines Agency considers biosimilars as a valid therapeutic option with an economic advantage, especially in primary naïve patients with no previous exposure to the originator or with a sufficiently long wash-out period ("secondary naïve"). The identification of "secondary naïve" is not well defined and can be subjected to different variables, mainly the drug biologic effect and its immunogenicity. The first one depends on the type of biologics and on their mechanism of action. The second one is related to the fact that biologicals may be immunogenic and can trigger an anti-drug antibody response (ADA). ADA may behave as neutralizing antibodies blocking the active site of the biological but can also recognize other epitopes favoring the formation of immune-complexes that eventually affect the pharmacodynamics. Moreover, the concomitant immune-suppressive treatment can affect the immunogenicity, even if the exact mechanism remains unknown. In conclusion, the development and use of biosimilars represent a tool for increasing health system sustainability. However it is of paramount importance to distinguish between the pharmacodynamics of a given drug and its immunogenicity being the two aspects unrelated. Thus a detailed definition of "secondary naïve" patients is challenging, and may be related to both the two parameters.

The present study analysed the asbestos lung burden in necroscopic samples from 55 subjects free from asbestos-related diseases, collected between 2009 and 2011 in Milan, Italy. Multiple lung samples were analysed by light microscopy (asbestos bodies, AB) and EDXA-scanning electron microscopy (asbestos fibres and other inorganic fibres). Asbestos fibres were detected in 35 (63.6%) subjects, with a higher frequency for amphiboles than for chrysotile. Commercial (CA) and non-commercial amphiboles (NCA) were found in roughly similar frequencies. The estimated median value was 0.11 million fibres per gram of dry lung tissue (mf g(-1)) for all asbestos, 0.09 mf g(-1) for amphiboles. In 44 (80.0%) subjects no chrysotile fibres were detected. A negative relationship between asbestos mass-weighted fibre count and year of birth (and a corresponding positive increase with age) was observed for amphiboles [-4.15%, 95% confidence interval (CI) = -5.89 to -2.37], talc (-2.12%, 95% CI = -3.94 to -0.28), and Ti-rich fibres (-3.10%, 95% CI = -5.54 to -0.60), but not for chrysotile (-2.84%, 95% CI = -7.69 to 2.27). Residential district, birthplace, and smoking habit did not affect the lung burden of asbestos or inorganic fibres. Females showed higher burden only for amphiboles (0.12 versus 0.03 mf g(-1) in males, P = 0.07) and talc fibres (0.14 versus 0 mf g(-1) in males, P = 0.03). Chrysotile fibres were shorter and thinner than amphibole fibres and NCA fibres were thicker than CA ones. The AB prevalence was 16.4% (nine subjects) with concentrations ranging from 10 to 110 AB g(-1) dry, well below the 1000 AB g(-1) threshold for establishing occupational exposure. No AB were found in subjects younger than 30 years. Our study demonstrated detectable levels of asbestos fibres in a sample taken from the general population. The significant increase with age confirmed that amphibole fibres are the most representative of cumulative exposure.

Background Medical malpractice is an important topic worldwide, and orthopedics is a clinical branch that is considered to be at a high risk for claims. The analysis of a series of medmal insurance claims allows forensic pathologists, clinicians, and insurance companies to probe the risk of a specific clinical branch for medical malpractice claims and highlights areas where care may be improved. We investigated the main features of a major Italian insurance broker’s archive in order to identify recurrent pitfalls in this field. Materials and methods A retrospective study was carried out on orthopedics claims. The archive covered claims from 2002 to 2013 that targeted 1980 orthopedists. Results 635 claims were found and analyzed with a focus on the clinical activity invocked in the claim, the presence of alleged team malpractice, the clinical outcome of the case, and the final forensic decision regarding the claim. 299 orthopedists had at least one malpractice claim made against them during the available period; 146 orthopedists were subject to more than one malpractice claim. Most of the claims regarded perioperative and operative cases, usually originating from civil litigation. The anatomical sites most commonly involved were the hip or knees, and sciatic nerve lesions were the main contributor. Conclusions Orthopedics is a medical specialty with a high risk for malpractice claims. In our study, medical malpractice was observed in nearly 50% of the cases—typically in surgery-linked cases resulting in permanent impairment of the patient. Death from orthopedics malpractice seemed to be rare. Level of Evidence IV.

S Riva,1 S Del Sordo,2,3 U Genovese,1,3 G Pravettoni1 1Department of Oncology and Hemato-oncology, University of Milan, Italy; 2FOLSATEC (Foundations & Ethics of the Life Sciences) PhD School, University of Milan, Milan, Italy; 3Healthcare Accountability Lab, University of Milan, Milan, Italy Aims: The overall goal of this article is to make a scientific comment about the psycho-social consequences of hemophilia patients affected by human immunodeficiency virus (HIV) and/or hepatitis C virus (HCV) and to point out the related medicolegal issues. Methods: This commentary takes into account some published evidences about the current scenario of hemophilia patients infected by HIV and/or HCV who received contaminated blood products in the late 1970s through 1985. Results: Several psychological and medicolegal consequences are related with HIV and HCV contamination of blood products. A multidisciplinary approach is needed to treat all the difficulties experienced by these patients and to ensure good clinical decisions in medical practice. Conclusion: The literature on the psychosocial functioning of hemophilia patients with human HIV and HCV infection offers a number of implications, including medicolegal issues, that can be discussed for guaranteeing a good level of care and safeguard of this group of patients. Keywords: hemophilia, viral contaminated blood products, monetary compensation, medico-legal issues, medical decision making

The medical malpractice is a rising and central topic for the forensic pathologist and forensic autopsies are a mandatory step in the judicial evaluation of the suspected medical malpractice. Reliable national and international registers about the medical malpractice are still missing and nowadays the necroscopic archives are therefore one of the best sources of data about such a complex phenomenon. We analyzed the archive of the Institute of Forensic Medicine of the Milan University from 1996 to 2009 and selected 317 lethal cases of suspected medical malpractice. The mean age of our cases was 60±18 years for males and 58±19 years for the females. In 70% of such cases the patient death occurred in a hospital setting. The first 24h of hospitalization turned out to be the hottest period for deaths followed by malpractice claims. The surgical branches were obviously the most involved, with abdominal surgery, orthopedics, neurosurgery and gynecology as the main contributors. Just 12% of the total amount of cases came from all the internistic branches put together. Non-hospital malpractice was typically caused by misdiagnosed myocardial infarctions and aortic ruptures. A full forensic report was present in 71 cases (all belonging to the 2007-2009 period): in 69% of cases the judicial autopsy revealed as a sufficient tool for diagnosing the cause of death; medical malpractice was confirmed in only 17% of the whole cases and a causal link between the ascertained malpractice and the patient death was recognized in only 12.7% cases.

The authors analyzed the injury pattern of 385 victims of fall from a height which underwent a complete autopsy, with the objective to investigate whether it was possible to construct a mathematical model to be used for height of the fall diagnosis. The cases were selected and enrolled according to a balanced stratification of the heights of the fall, allowing a subdivision into seven classes consisting of 55 subjects each: 6 m or less, 9 m, 12 m, 15 m, 18 m, 21 m, 24 m or more (maximum 36 m). For each case anthropologic and necroscopic data was collected and analyzed to obtain a standardized description of the injury pattern was obtained, dividing the body into 4 major anatomical areas (Head, Thorax, Abdomen, Skeleton), each of them further divided in 5 major organs. Every organ was finally divided into 5 objective degrees of injury. Statistical analysis was performed on all the available data using IBM SPSS Statistics 20, to test the performance of the “injury pattern assessment table” in the diagnosis of the height of the fall and to develop a related mathematical model. Our findings confirm that the height of the fall is significantly associated with age, weight of the body and the injury pattern. An Injury Pattern Assessment Table and two mathematical models which correlates the height of the fall with analyzed variables are presented.

Medical malpractice is currently a crucial topic and anesthesia is a key specialty for the improvement of patient safety. However, death and permanent impairment due to anesthesia still occur and studies of insurance analysis data are increasing. We investigated the main features of a major Italian insurance broker's archive in order to identify possible recurrent pitfalls in this critical field of medicine.Three hundred seventeen Italian claims were analyzed, filling out a standardized form that recorded information on patient and physician's characteristics, procedures, sequence and location of events and outcomes. The operative setting, the type of anesthesia performed the origin of the multidisciplinary team malpractice hypothesis, the final clinical outcome and the malpractice investigation results were also analyzed.In 225 malpractice claims, the adverse event was surgery-linked, either intraoperatively (114 cases) or postoperatively (111 cases): abdominal surgery (26%), orthopedics (22%), gynecology (20%), heart surgery (11%) and neurosurgery (9.5%) were the most frequently involved surgical specialties. In 92 cases, the claim was unlinked to a surgeon's activity, with dental damage in oral intubation procedures as the greatest contributor (42.3%). Anesthetists' malpractice was technically ascertained in 39% of cases, 74.8% resulting in permanent impairment.Malpractice was mainly suspected in surgery-linked procedures. Most of the claims were settled for procedural error in performing locoregional anesthesia and oral intubation procedures. 60% of all closed claims resulted in no malpractice ascertained. Confirmed malpractice typically deals with non surgery-linked and non multidisciplinary team cases, causing permanent impairment.

Defensive medicine is a significant force driving the high costs of healthcare systems and has a substantial influence on physicians' behavior because they primarily concern about malpractice liability and not patient's health protection. This attitude disagrees with deontological duties and could impair physicians' ability of judgment and clinical reasoning. Reducing defensive medicine also could mean improving the quality in healthcare systems and eliminating unnecessary costs.

The use of innovative technologies in the health sector can be a key element in clinical risk management. In order to reduce errors in medical recording and to provide medico-legal evidence, Digital PenPaper technology has been adopted by medical staff of a hospital in Milan. The Authors introduce the first results of this trial: notable advantages have been reported in compilation, transmission and storage of medical records. Furthermore, this technology could provide evidence in evaluating medical malpractice claims.

Acute respiratory distress syndrome (ARDS) is a heterogeneous syndrome that lacks definitive treatment. The cornerstone of management is sound intensive care treatment and early anticipatory ventilation support. A mechanical ventilation strategy aiming at optimal alveolar recruitment, judicious use of positive end-respiratory pressure (PEEP) and low tidal volumes (VT) remains the mainstay for managing this lung disease. Several treatments have been proposed in rescue settings, but confirmation is needed from large controlled clinical trials before they be recommended for routine care. Non-invasive ventilation (NIV) is suggested with a cautious approach and a strict selection of candidates for treatment. Mild and moderate cases can be efficiently treated by NIV, but this is contra-indicated with severe ARDS. The extra-corporeal carbon dioxide removal (ECCO2 R), used as an integrated tool with conventional ventilation, is playing a new role in adjusting respiratory acidosis and CO2. The proposed benefits of ECCO2 R over extra-corporeal membrane oxygenation (ECMO) consist in a reduction of artificial surface contact, avoidance of pump-related side effects and technical complications, as well as lower costs. The advantages and disadvantages of inhaled nitric oxide (iNO) are better recognized today and iNO is not recommended for ARDS and acute lung injury (ALI) in children and adults because iNO results in a transient improvement in oxygenation but does not reduce mortality, and may be harmful. Several trials have found no clinical benefit from various surfactant supplementation methods in adult patients with ARDS. However, studies which are still controversial have shown that surfactant supplementation can improve oxygenation and decrease mortality in pediatric and adolescent patients in specific conditions and, when applied in different modes and doses, also in neonatal respiratory distress syndrome (RDS) of preemies. Management of ARDS remains supportive, aimed at improving gas exchange and preventing complications. Progress in the treatment of ARDS must be addressed toward the new paradigm of the disease pathobiology to be applied to the disease definition and to predict the treatment outcome, also with the perspective to develop predictive and personalized medicine that highlights new and challenging opportunities in terms of benefit for patient's safety and doctor's responsibility, with further medico-legal implication.

Context: Pulmonary thromboembolism (PTE) is the severe end stage of many different diseases producing prolonged patient immobilization or a hypercoagulative state. Lethal PTE is also one of the most frequent topics for suspected medical malpractice, especially when dealing with patients originally affected by non-critical illnesses and suddenly killed by a non-prevented embolic event. The crucial forensic question about a lethal PTE is the following one: was this lethal PTE an unpreventable complication or was it a consequence of real medical malpractice? Materials and methods: The authors analyzed the 1999–2009 autopsy archive of the Institute of Forensic Medicine of Milan University and selected all the cases where PTE was the cause of death. For every selected case, the authors also collected all the available demographic and clinical data. Statistical analysis was performed using SPSS V.16.00. Results: In the period 1999–2009, 129 (1.25%) cases out of a total of 10,288 autopsies were diagnosed as having suffered lethal PTE. The male to female ratio was 1:2 (34.1% versus 65.9%). The mean age at death was 67 ± 18 years. In 41% of cases the death occurred outside of the hospital and in the absence of any medical support; in 36.5% of cases it occurred during the territorial paramedical support or during the very first evaluation in the emergency; and in the remaining 22.5% of cases it occurred during a period of hospitalization. In 33.4% of the selected cases, a typical preliminary event was positively identified: a pure major trauma (18.6%); a trauma followed by a major surgery (7%); a major non post-traumatic surgery (7%); and a non-surgical delivery. Symptoms suggesting PTE were detected in 46 cases (35.7%). Nine cases underwent a judicial autopsy in the same original hypothesis of a medical malpractice for incorrect prophylaxis in acutely bed-restricted patients. Conclusions: Post-surgical PTE cannot be automatically labeled a consequence of medical malpractice. The combination of correct prophylaxis, careful diagnostic monitoring of the high-risk patient and the correct therapy surely reduces the occurrence of lethal PTE, but it does not completely erase such an insidious pathology. In the hypothesis of a causative medical malpractice, only careful analysis by an experienced forensic pathologist can make a reliable distinction between an unpreventable complication and real medical malpractice.

Si definiscono psicogeni i deficit che non possono essere attribuiti ad alterazioni strutturali o a malattie neurochimiche note, ma che possono essere provocati da malattie psichiatriche o da simulazione [1].

Il coma, sia definitivo sia transitorio, e caratterizzato dall’assenza completa di capacita di risveglio e dalla mancata coscienza di se e dell’ambiente circostante. Alcuni pazienti comatosi possono pero recuperare il ritmo sonno-veglia, riguadagnare la capacita di chiudere e aprire gli occhi a intervalli regolari per passare a quello che viene definito stato vegetativo. Comunque, i pazienti in stato vegetativo sono, per definizione, inconsci e non partecipi. In caso di ulteriore progressione verso un qualche grado di coscienza, si perviene allo stato di coscienza minima, espressione che definisce la possibilita di manifestare inconsistenti ma riproducibili evidenze di coscienza di se e dell’ambiente.

Come cavi elettrici, i nervi periferici raccolgono fasci di fibre, ciascuna composta da un assone e da una guaina di mielina; l’assone e l’elemento conduttore, la mielina e l’elemento isolante che impedisce la propagazione trasversale dell’impulso nervoso.

Il capitolo comprende una premessa generale dedicata al traumatismo cranico per poi trattare nel dettaglio le sole sequele soggettive del trauma cranico (TrCr). Si rimanda invece ad altre sezioni del presente manuale (epilessia, deficit dei nervi cranici) per una presentazione piu approfondita delle menomazioni post-traumatiche a riconosciuto fondamento lesionale oggettivo.

Le discipline RC, AP e IC prevedono espresse tabellazioni per la cosiddetta sindrome cerebellare, ne riconoscono implicitamente una considerevole variabilita clinica e dunque associano a tale dicitura sistematica ampi ventagli di valutazione percentuale. La valutazione medico-legale di un soggetto portatore di una sindrome cerebellare deve conseguire a un preciso grading del quadro clinico, poiche i determinanti di massima menomazione soggettiva si identificano nei disturbi della statica corporea e nei disturbi della cinetica deambulatoria, e invece riservandosi quantificazioni prossime ai limiti inferiori dei range previsti ai casi con anomalie — per esempio mono-artuali o mono-distrettuali — scarsamente incidenti sulla complessiva efficienza statica e motoria del soggetto. In accordo con quanto previsto recentemente da Rondinelli (Tabella 15.1) [1], la sindrome cerebellare grave (classi 3 e 4) e sostanzialmente caratterizzata dall’insieme di: difficolta di assumere e mantenere autonomamente una stabile postura eretta; necessita di pratico ausilio da parte di terze persone al fine di una deambulazione efficace e sicura in piano.

Sono definiti disturbi del sonno e della veglia quelli correlati all’addormentamento o al mantenimento del sonno. Con l’ipotensione ortostatica neurogena ne accenniamo brevemente in questo capitolo, nonostante non siano previsti dalle tabelle di invalidita, per la possibilita che provochino improvvisa perdita della vigilanza con effetti simili a quelli delle crisi comiziali (Cap. 9).

Le lesioni di aree dei lobi temporali possono provocare sindromi a contenuto sensoriale (deficit visivi, uditivi, olfattivi e gustativi), disturbi nella percezione del tempo, anomalie della funzione mnesica o linguistica e, ancora, alterazioni dell’emotivita e del comportamento.

Salvo alcune eccezioni, le tabelle di invalidita in vigore in Italia non prevedono una specifica valutazione delle sindromi neurologiche caratterizzate da dolore cronico di origine non nota. Queste patologie si collocano pero tra quelle che piu frequentemente mettono in discussione la competenza diagnostica del medico-neurologo e rendono difficile la quantificazione di inabilita da parte del medico-legale. E quindi opportuno ricordare brevemente le piu importanti.

Il ritardo mentale (RiMent) e un’alterazione dello sviluppo che si manifesta prima dei 18 anni e impedisce il raggiungimento di un quoziente intellettivo (QI) superiore a 70, contro un normale di 100 [1]. Contrariamente a quanto avviene per la demenza, la diagnosi di ritardo mentale non richiede obbligatoriamente una compromissione della memoria.

Le malattie dei motoneuroni sono affezioni caratterizzate dalla degenerazione progressiva dei neuroni motori.

Alzarsi, andare incontro alla persona che si deve esaminare, salutarla con una stretta di mano non e solo frutto di normale educazione, ma e segno di interesse e puo offrire a utili indicazioni.

In dialysis patients, both central venous catheter (CVC) insertion and CVC use during the dialysis procedure pose important legal issues, because of potentially severe, even fatal, complications. The first issue is the decision of the kind of vascular access that should be proposed to patients: an arteriovenous (AV) fistula, a graft, or a CVC. The second issue, when choosing the CVC option, is the choice of CVC: nontunneled versus tunneled. Leaving a temporary nontunneled CVC for a prolonged time increases the risk of complications and could raise a liability issue. Even when choosing a long-term tunneled CVC, nephrologists should systematically explain its potential harms, presenting them as “unsafe for long-term use” unless there is a clear contraindication to an AV native or prosthetic access. Another critical issue is the preparation of a complete, informative, and easy-to-understand consent form. The CVC insertion procedure has many aspects of legal interest, including the choice of CVC, the use of ECG monitoring, the use of ultrasound guidance for cannulation, and the use of fluoroscopy for checking the position of the metal guidewire during the procedure as well as the CVC tip before the end of the procedure. Use of insertion devices and techniques that can prevent complications should obviously be encouraged. Complications of CVC use are mainly thrombosis and infection. These are theoretically expected as pure complications (and not as malpractice effects), but legal issues might relate to inappropriate catheter care (in both the inpatient and outpatient settings) rather than to the event per se. Thus, in the individual case it is indeed very difficult to establish malpractice and liability with a catheter-related infection or thrombosis. In conclusion, we cannot avoid complications completely when using CVCs, but reducing them to a minimum and adopting safe approaches to their insertion and use will reduce legal liability.

The first hand transplant meant — apart from the extraordinary surgical procedure and due to the particular therapeutic purpose — an opportunity for a multidisciplinary (medical, juridical, ethical) consideration to support or contradict such a therapeutic procedure’s legitimacy, which could be considered “the most hazardous and dangerous and greatest adventure on which man has ever embarked”.