Extrema Ratio Research Articles

527. A RIGHT CERVICOTOMIC APPROACH TO RETRIEVE A DENTAL PROSTHESIS FROM THE ESOPHAGUS

Abstract Foreign body (FB) ingestion in the upper gastrointestinal (GI) tract is a relatively common emergency presenting numerous diagnostic and therapeutic challenges. Adults most frequently ingest FBs accidentally while eating solid food. The esophagus accounts for 57% to 75% of all FBs impactions in GI tract. More than 80% FB pass spontaneously, around 10-20% require an endoscopic removal, and less than 1% have to be treated surgically, depending on the nature and location of the FB. A 68 years old man presented to the Emergency Department complaining of a mild dysphagia since two days before. A laryngeal endoscopy showed edema of the right aryepiglottic fold; salivary stagnation hiding the pyriform sinus; edema of the right vocal cord; the airway caliber was adequate. A chest radiograph showed a dental prosthesis, probably ingested during a seizure, in the upper esophageal tract. The patient developed dyspnea and phonation difficulty due to neck swelling. An urgent CT scan showed signs of esophageal perforation and diffuse edema. A multidisciplinary equipe was assembled to properly treat the patient. In the operating room, two attempts of retrieval with a flexible and a rigid endoscope failed because the dental prosthesis was stuck in the right pyriform sinus. After a careful evaluation of the FB location, the surgeon performed a right cervicotomy, uncommon when compared with the traditional left side approach to the neck, and retrieved it through an esophagotomy. A nasogastric tube was inserted and a paraesophageal 19 Ch drain in aspiration was placed in situ. Over time, no signs of esophageal leakages were detected post-operatively and eventually the patient was able to feed with solid foods without complications. Any esophageal FB may cause potentially fatal injuries, therefore it must be retrieved within 12 to 24 hours. An endoscopic approach should be attempted first, with surgery being the extrema ratio. The surgical approach depends on the nature and location of the FB. A left cervical approach should not be regarded as dogmatic, and a right-sided approach, being equally safe and effective from a surgical point of view, could be appropriately chosen when clinically indicated.

The Motion of the Italian National Bioethics Committee on Aggressive Treatment towards Children with Limited Life Expectancy.

The motion of the Italian National Bioethics Committee entitled “Aggressive treatment or therapeutic obstinacy on young children with limited life expectancy” comprises a premise that rejects therapeutic obstinacy and makes 12 recommendations. Recommendation no. 1 states the general rules: it ascribes a cardinal role to a shared care plan, it supports pain management therapy and pain relief, it opposes ineffective and disproportionate clinical treatment and defensive medicine. The other recommendations are correlated to the enacting of a national law establishing clinical ethics committees in paediatric hospitals; participation of parents and their fiduciaries in the decision-making processes; recourse to courts only as extrema ratio in the event of irremediable disagreement between the medical team and the family members; accompaniment at the end of life also through continuous deep sedation combined with pain therapy; access to palliative care; the need to reinforce research on pain and suffering in children; clinical trials and research studies conducted in children; the training of doctors, healthcare personnel and psychologists, to support parents in emotional and practical terms; the facilitation of the closeness of parents to children in extremely precarious clinical conditions; the relevant role of the associations of parents of sick children. Comments are made, in particular, about the innovative recommendations respectively relating to the adoption of care planning, the establishment, by law, of clinical ethics committees in paediatric hospitals and the limitation of recourse to courts—only as extrema ratio—in the event of irremediable disagreement between the medical team and the family members.

Theories of whistleblowing

Abstract“Whistleblowing” has entered the scholarly and the public debate as a way of describing the exposure by the member of an organization of episodes of corruption, fraud, or general abuses of power within the organization. We offer a critical survey of the main normative theories of whistleblowing in the current debate in political philosophy, with the illustrative aid of one of the epitomic figures of a whistleblower of our time: Edward Snowden. After conceptually separating whistleblowing from other forms of wrongdoing disclosures, we introduce and discuss two families of normative views of this practice: the “Extrema Ratio” and the “Deontic” views. We show how the two views can be usefully considered in tandem to offer an all‐round assessment of the moral justification of whistleblowing either as an extraordinary individual conscientious act of indictment or as an ordinary dutiful organizational practice of answerability that enables the capacity of self‐correction of an organization.

Love in extrema ratio

The tidal deformability of a self-gravitating object leaves an imprint on the gravitational-wave signal of an inspiral which is paramount to measure the internal structure of the binary components. We unveil here a surprisingly unnoticed effect: in the extreme mass-ratio limit the tidal Love number of the central object (i.e. the quadrupole moment induced by the tidal field of its companion) affects the gravitational waveform at the leading order in the mass ratio. This effect acts as a magnifying glass for the tidal deformability of supermassive objects but was so far neglected, probably because the tidal Love numbers of a black hole (the most natural candidate for a compact supermassive object) are identically zero. We argue that extreme mass-ratio inspirals detectable by the future laser interferometric space antenna (LISA) mission might place constraints on the tidal Love numbers of the central object which are roughly eight orders of magnitude more stringent than current ones on neutron stars, potentially probing all models of black hole mimickers proposed so far.

Sialendoscopy for salivary stones: principles, technical skills and therapeutic experience.

SUMMARYObstructive sialadenitis is the most common non-neoplastic disease of the salivary glands, and sialendoscopy is increasingly used in both diagnosis and treatment, associated in selected cases with endoscopic laser lithotripsy. Sialendoscopy is also used for combined minimally invasive external and endoscopic approaches in patients with larger and proximal stones that would require excessively long laser procedures. The present paper reports on the technical experience from the Ear, Nose and Throat Unit of the Sant'Orsola-Malpighi Hospital of Bologna, and from the Department of Otorhinolaryngology of the University Hospital of Cagliari, Italy, including the retrospective analysis of the endoscopic and endoscopic assisted procedures performed on 48 patients (26 females and 22 males; median age 45.3; range 8-83 years) treated for chronic obstructive sialadenitis at the University Hospital of Cagliari from November 2010 to April 2016. The results from the Sant'Orsola-Malpighi Hospital of Bologna have been previously published. The technical aspects of sialendoscopy are carefully described. The retrospective analysis of the University Hospital of Cagliari shows that the disease was unilateral in 40 patients and bilateral in 8; a total of 56 major salivary glands were treated (22 submandibular glands and 34 parotids). Five patients underwent bilateral sialendoscopy for juvenile recurrent parotitis. 10 patients were treated for non-lithiasic obstructive disease. In 33 patients (68.75%) the obstruction was caused by salivary stones (bilateral parotid lithiasis in 1 case). Only 8 patients needed a sialectomy (5 submandibular glands and 3 parotids). The conservative approach to obstructive sialadenitis is feasible and can be performed either purely endoscopically or in a combined modality, with a high percentage of success. The procedure must be performed with dedicated instrumentation by a skilled surgeon after proper training since minor to major complications can be encountered. Sialectomy should be the "extrema ratio" after failure of a conservative approach.

The 100-plus-Year-Old Case for a Minimalist Criminal Law (Sketch of a General Theory of Substantive Criminal Law)

Criminal law defines the system of government of which it is the political expression; thus having a normative theory of substantive criminal law is paramount. U.S. criminal law has developed in the absence of such overarching theory, and is now plagued by overcriminalization. This Article advances a model of a minimalist criminal law grounded on strong normative principles that are presented and defended not from the perspective of metaphysics or moral philosophy, but rather in a historical and comparative perspective, as a matter of political choice. Core among those principles is the idea that in a liberal democracy the criminal law should be seen as the extrema ratio, or option of the last resort. After laying out and defending the model, the Article deals with issues related to its implementation, advancing an argument for the constitutionalization of substantive criminal law. The Article argues that, on the basis of existing yet overlooked constitutional doctrine, criminal laws should be subject to at least strict scrutiny.

La sicurezza tra necessità e limitazione dei diritti: una riflessione penalistica

The author deals with the thorny connection between security, more and more debated as a fundamental right, and other rights - equally fundamental - that often suffer of a huge limitation in order to preserve public safety and pacific cohabitation. He perfectly gets the political importance of security as a pretext for tightening up the Criminal Law, used as a criterion to regulate the everyday life, instead of being used as an extrema ratio.

Some metallic spherules in calcareous-marly sediments of the Romanoro Flysch, Sestola-Vidiciatico tectonic unit (Modena district, Northern Apennines, Italy)

Some metallic microspherules were found in a calcareous-marly sample from the Romanoro Flysch (Modena district, Northern Apennines, Italy). The outcrop is a tectonic scale, part of the Sestola-Vidiciatico Unit, without stratigraphic contacts with other formations. The age of the setting stratum was attributed at the middle Miocene, but this datum contradicts the previous authors, who dated the outcrop at the Eocene (Zanotti, 1988), or Cretaceous (Reutter, 1969; Rentz, 1971; Daniele et al. 1996). Morphological, mineralogical and chemical studies were carried out on the microspherules and on some grains. The crust of microspherules is essentially made of iron (from 66% to 48%, like FeO), with other minor elements (Al, Ti, Mn, Ni). The core is made of an FeNi alloy. There are other grains of: quartz, calcite, pyrite, mica and black minerals, with edges. The black ones are polymetallic aggregates of: Fe, Mn, Ti, Al, Cu. About the origin of these microspherules four hypotheses: cosmic origin (exceptional extraterrestrial event), volcanic origin, diagenetic origin, wartime origin (Extrema Ratio). The first one has been confirmed.

The Shape of Modulation-Broadened, Unsaturated, Lorentzian Magnetic Resonance Transitions

The effect of modulation broadening on the shape of unsaturated, Lorentzian absorption lines is examined. The closed, analytic expressions for the Fourier coefficients anL due to Wahlquist are employed to derive exact formulas relating the location and amplitude of the extrema, the location and amplitude of the slope extrema, the slope extrema ratio, and the location of the zeros of the observed a2L to the true half-width for arbitrary modulation amplitude [normalized modulation amplitude (1/β)]. Wahlquist's results for a1L are extended to include the location and amplitude of the slope extrema. It is shown that simultaneous measurement of a1L and a2L, when the normalized modulation amplitude is near unity, can be employed to determine if the lineshape is Lorentzian. For a Lorentzian lineshape, these measurements can be used to determine the linewidth and the number of paramagnetic spins under conditions of near-maximum sensitivity. Graphs and tables of the various results of experimental interest in making these determinations and calculations are included.