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Professor Angelo Moretto

Department of Biomedical Sciences and Clinics

University of Mio

and

International Centre for Pesticides and Health Risk Prevention (ICPS)

Luigi Sacco Hospital, my

(Angelo.moretto @ unimi.it)



 

Court of Appeal of Brescia

Section Labor and Pensions



 

Case 72/2012

Actors:

Defendant main: CSL Onlus Foundation

Defendant (other): Company Reale Mutua Assicurazioni SPA



 

On November 22, 2012, the writer was instructed dall'Ill. Judge mo Dr. Antonella New technical expertise to perform medico-legal acts related to the pathology of which is affected Ms, asking the following question:

" Upon reading the pleadings, visited the woman, made ​​any finding, even instrumental, indicating the CTU, given a value of 3.7 COHb after about 2 hours of normobaric oxygen therapy, which was the probable value COHb before such therapy;

Say if the aftermath of the worker complained after the event, to have been caused by the COHb value so determined;

in case of a positive answer to that question, describing the permanent consequences derived from the event to the worker in question, reporting every useful element to specify the harmful consequences occurring in practice, including in relation to social life and habits of life;

determine the periods of temporary disability resulting from the accident;

established, determining the degree percentage, damage to health derived the worker as a result of the after effects of a permanent nature;

ascertain to what extent the aftermath derivatives have impacted the ability of specific occupational and whether, and to what extent, persists or residue on the applicant's ability to wait for other jobs suited to their personal skills and environmental factors. "



 

 

The beginning of the appraisals was fixed the day 13/12/2013 at 17:30 in Via Grassi 74 Mio were present prof. Angelo Moretto (CTU), dr. U. Bread for the plaintiff, prof. A. Zoia and Dr. A. Ferrami for the defendants. At this meeting, the CTU illustrated the anticipated operating conditions and reported in the minutes of the meeting (Annex 1), with which the consultants agreed to part. In particular, during these operations, the CTU was aware of the existence of health records are not present in the file. Given the opposition of a part, Ill. Mr. mo. Judge, dated 17.1.2013 incorporated the question authorizing the acquisition of any useful documentation for the answer to the question itself.

Given the organizational and logistical difficulties, and the complexity of the case, the CTU required extensions of the deadlines that were granted.

The day was held 05.16.2013 at 12.00 in Via Grassi 74, my second meeting of experts which, in addition to the CTU, participated prof. A. Zoia, while the dr. U. Pani is linked via computer video conference. Dr. A. Lucchini Ferrami had announced he would not attend, believing his presence is not necessary. At this meeting, the CTU illustrated the progress of the work and some thoughts on the case. The prof. Zoia agreed, while the dr. Pani expressed his disagreement (see report in Annex 2). The dr. Pani agreed that he would send the references to correct some discrepancies with the information given by the CTU, but these references are not received. In any case, the CTU, as reported in the minutes, saw again the records on file and experience, and confirmed his remarks.

On 24/06/2013 the writer sent a draft of this report, the consultants part for comments and additions. On XXXX dr.



 

Key elements of the clinical history of Ms f (b.) derived from health records in acts or acquired

Health record (CS): from 26/02/1997 16/05/2006

  • In therapy with Sotalex

  • EO: extrasystoles

  • Controls on annual: anything relevant for our purposes



 

Visit Dr. M. Neurological Camerlingo, 27/09/2004

  • "... has had a number of episodes of lipotimico recall, none of which suggests an origin primitive neurological "

Various documentation relating to gynecological pathology, not relevant for our purposes, in the years 2004-2006.

07/02/2007. Minutes of the Hospital SB PS C (BG) and subsequent hospitalization

  • 13:07 hours access, code yellow

  • In history: From 3 hours O 2 therapy 3 liters / minute

  • In history: .... at 9 this morning ... loss of consciousness, vomiting ...... related hypertensive crisis and tachycardia, dizziness refers ...

  • EO: Pupils were cooperative and oriented .... and isocicliche, and reactive to light stimulus

  • "It Pharaohs toxicology contact Dr. BG: only asphyxiating gas undetectable, rapidly cleared from the pc, unburnt fumes containing low amounts of CO, dosage carbossiHB to 3 hours essentially normal in Smoke ...... pcs Net O 2 therapy at 6 - 8 l / min for 3 hours and then discharge "

  • Vital signs: (now not shown) FC 76/min, PA 158/98 mm Hg, Sat O 2 100% (not shown now, but later) FC 63/min, PA 145/70 mm Hg, Sat O 2 100 %

  • Arterial blood gas analysis of 13:08 (and compared with that of 08/02/2007 hours 12:42):

Parameter

07/02/2007

(In ambient air)

13:08 hours

08/02/2007

(O2 therapy, based on the medical record)

Hours 12:42

pH

7,437

7,423

pCO 2

32.1 mm Hg

35.4

pO 2

88.6 mmHg

95.7

ElB

-2.1 Mmol / l

-0.9

BEecf

-3.0 Mmol / l

-1.3

BB

45.3 mmol / l


 

CHCO 3

21.2 mmol / l

22.6

SO 2

97.6%, (c) 97.1%

97.8%

CTO 2

18 vol%

16.9%

O 2 Hb

93.5%

95.7%

COHb

3.7%

1.6%

HHb

2.3%

2.2%

metHb

0.5%

0.5%

sulfHb

0.0%

0.0%

  • ECG: normal

  • CT head: normal

At 20.00 on 7/2/2007 Ms was hospitalized at the Department of General Medicine of the same hospital.

From the documentation of admission

  • Family history and physiological: not completed

  • Next medical history: nothing new to history of PS

  • EO: apparently nothing to report (handwriting difficult to interpret, Ed)

  • Clinical Diary:

    • At the entrance: ".... dubious likely fainting from CO poisoning"

    • 8/2, 12:10 h: objectivity neurological negative, complaining headache ...

    • 8/2, 16 h ... severe headache in the frontal region. Not strictly speaking, no nystagmus, photophobia not

    • 9/2, h9: PAO 110/60, ... headache ..... (during menstruation)

    • 10/2, 10 h: PAO 140/75, not detectable focal neurological deficits. The march instability (no nystagmus). Reduced headache.

    • 12/25, 9.30 am PA 100/70 (supine) 110/80 (ortho) FC 80R .... keeps upright with his eyes closed with some uncertainty. Mild frontal headache ..

    • 13/2 (illegible)

    • 14/2-17/2: no changes of note

Graphics (from 7/2):

  • O2 therapy from 7/2 a 9/2

  • Glucose 5%, 500 ml x 3 from 7/2 a 9/2

  • Sotalex, Tavor and Acetamol, and occasionally Contramal or Toradol.

Nursing data collection (from 7/2/2007). The following are the relevant data

  • Mr. Smoke 5-6 / day

  • 7/2: PA 130/80

  • 7/2: Saturation 98% in Air Environment

  • 7/2: Negative rest

  • 7/2 O2 therapy 2 l / min from the entrance up to 14/2 (see discrepancy with graphics)

  • 8/2: night rested a little disturbed because .... (inaudible) O 2 T

  • 10/2: complains of dizziness thrilling .....

  • 11/2: refers thrilling that spontaneously regresses

  • On other days nothing significant to report

Routine blood tests, nothing significant to report

Findings:

  • neurological examination (13/2): General weakness and uncertainty in the march

  • Rx sinuses (14/2): .. deviation of the septum with right-convex turbinate hypertrophy

  • Abdominal ultrasound (15/2): nothing to report

  • Echocardiogram (15/2): ... prolapse of the anterior mitral regurgitation insignificant ..... .....

  • MRI brain (16/2): normal; no lesions in the posterior fossa, and supratentorial, in particular in correspondence of the globes Pale and white matter of semioval centers.

  • clinical course: persistence of instability in the march with headache (persistent discharge)

Discharged on 17.2.2007 with a diagnosis of "headache".

Health record (CS: 15/05/2007

  • CO poisoning flaw to exhaust dryer and boiler with an outcome of headache and occasional dizziness. Net impairment of neurological tests. Sending Jobs to BG Med for Fitness

Visit to the Poison Control Center, OO. RR. Bergamo, 02/03/2010, dr. E. Georgi

  • Conclusion: " Framework ...... and .... as a cause or contributing cause attributable to previous exposure to CO ".

MRI brain at Humanitas Gavazzeni, 27/04/2010

  • No alterations, especially the basal nuclei and the brainstem

  • When supratentorial, circumscribed island of nonspecific gliosis at the back of the crown to the right corona radiata.

(...)

Relationship counseling technique psychiatric and neuropsychological, dr. M. Garbarini and Dr. E. Zugno of 06/19/2013

In order to clarify the clinical picture of Ms francs CTU asked to be assisted by Drs. Garbarini and Zugno, such as auxiliary CTU. The full report is in Annex 3, while the following are the relevant data.

According to dr. Garbarini and Zugno, this framework can be considered compatible as a result of CO poisoning. Segnao obiettivabili also that there is no evidence of the pre-existence of a premorbid personality disorder, or a personal or family history positive for the presence of mood disorders. The biological damage was then quantified by 16-18%.

Description of event 07/02/2007
 

The reconstruction of the event is mostly based on the report of the UPG 05/02/2009 Omar Rota, Department of Medical Prevention, ASL Province of Bergamo, and the SIT made the 10-11-12/11/2009 to Lieutenant PF Labour, Public Prosecutor at the Court of Bergamo.

The Day 07/02/2007 6:00 am come into the service sigg.re ie MP M. Bergamini and work until about 7:30 am in the ward Ironing adjacent to the laundry room. Thus, sigg.re moving into laundry room where the service takes to 8.00 Ms MT Pezzoli. At the turn of the 8 hours, Ms Bergamini runs for 10-20 minutes. Shortly after Ms francs relates to Ms Pezzoli not feeling well. When he returns, Ms Bergamini calls rescue the RSPP (Mr. P. Bosio) and the Medical Director (Dr. S. Schiattareggia). Upon their arrival, Ms is conscious, accused as the cause of his discomfort dryers in the environment, and refuses to be accompanied to the emergency room. It is then accompanied in the other room (probably after 10, various SIT) and the dr. Schiattareggia shows blood pressure limits, modest tachycardia (90/min) not arrhythmic, no neck stiffness, tendon reflexes bright, normal pupillary light reflexes. For precautionary reasons (according to him) began oxygen therapy (probably between 9.30 and 10, Mr. SIT. L.) at low volume (1.8-2 liters / min for 1.5-2 hours, statement on CTU Dr. P. Ostir of 19/10/2011), administered by nasal cannula (so-called "goggles", Ed) that Ms stand fatigue (SIT Bergamini, Pezzoli SIT). The dr. Schiattareggia refers saturation O 2 of 97-98%, constant in repeated measurements. Note that, presumably, dr. Schiattareggia used a pulse oximeter (or oximeter polsiossimetro) that is not able to differentiate oxyhemoglobin from COHb, and then the data of normality reported by dr. Schiattareggia, and has successfully led to the exclusion of methane gas poisoning, tells us nothing about the presence of CO and COHb.

Ms never lost consciousness, responded in kind to the questions (various SIT), and continued to have vomiting, apparently without throwing up (various SIT). In place are also involved Mr. L., P. Bosio, A. Zilioli, reporting on the state of the pipes of the plant. All meal correct positioning of the gas pipe, and slight deviation of the connection of the exhaust pipe of the combustion gases of one of the dryers.

None of the participants, in addition to Ms refers smell relates to a gas leak, or symptoms similar to that alleged by Ms despite being left in the room where the windows and doors were not opened (various SIT). The Bergamini sigg.re Pezzoli and resumed work in the laundry room (respective SIT). The Bergamini sigg.re Pezzoli and deny symptoms even in the earlier days (respective SIT).

From the report of the UPG 05/02/2009 Omar Rota, shows that the local dimension was large and airy due to the presence of a system of " forced ventilation where there is an almost continuous recirculation of air . "
 

At about 12 o'clock Mrs. receded accompanied by Mr. Spinelli, friend of the same, and went to the emergency room of the Hospital of C (BG).

At the Hospital Emergency Department with access code yellow was recorded at 13.07. It was reported that Mrs folder was 3 hours in the O 2 therapy 3 liters / minute. Ms EO is cooperative and oriented .... Pupils were and isocicliche, and reactive to light stimulus. Vital signs: (now not shown) FC 76/min, PA 158/98 mm Hg, Sat O 2 100% (not shown now, but later) FC 63/min, PA 145/70 mm Hg, Sat O 2 100 %

Performs blood gases at 13:08, then repeated the following day at 12:42 (see table above).

The doctor of the PS contact Dr. Pharaohs toxicology of Bergamo which excludes poisoning from natural gas, and considers the levels of carbossiHB (COHb) measured at 13:08 substantially in accordance with the case of the patient smoke; however, suggests O 2 therapy at 6-8 l / min for 3 hours, and then discharge. However, it is admitted at 20:00. During hospitalization performs O2 therapy (2-3 l / min) until at least day 9/2. During hospitalization also performs brain MRI results were normal. At neurological examination should be noted asthenia and general uncertainty in the march. It is discharged with a diagnosis of the day 08/02/2007: "Headache".

Work sull'intossicazione CO

According to the authors' consent (for all see Hampson et al., 2012) the diagnosis of CO poisoning is essentially clinical and based on

  • Evidence of recent exposure to CO

  • The presence of symptoms consistent with poisoning

  • High levels of COHb (more than 3-4% in non-smokers, higher than 10% in smokers). Note that it has been estimated that every pack of cigarettes smoked per day increases by 5% from the base level of non-smokers (1-3%) (Piantadosi, 2002). The COHb that is found in non-smokers derives mainly from endogenous metabolic processes.

With regard to symptoms, it is worth noting that there is no symptom that is sensitive or specific intoxication. The most common symptoms, which may occur singly or in various combinations in relation to the subject that the extent and mode of exposure, headache, dizziness, nausea / vomiting, confusion, weakness, chest pain, dyspnea, loss of consciousness . No combination of these symptoms allows you to exclude or confirm the diagnosis of CO poisoning. Although headache is the most common symptom, this does not occur with peculiar characteristics in the case of CO intoxication.

Regarding the COHb levels of 3-4% may be indicative of exposure to CO occurred for non-smokers, while these same levels are quite compatible in smokers not exposed to excess CO environmental.

The treatment of intoxication by CO is the administration of oxygen which accelerates the elimination of COHb and relieves tissue hypoxia. Administration should be made with high-flow mask or endotracheal intubation, or hyperbaric oxygen if available (see, for all the recommendations of the American Thoracic Society in the U.S. Hampson et al., 2012). The administration of oxygen by nasal cannula (the "goggles" applied to Ms francs) is not considered sufficiently effective therapeutic point of view. This consideration is of course also affects calculations that can be done to estimate the values ​​of COHb in the hours before, on the basis of measurements made in the hours following exposure, in our case the measurement made on 07/02/2007 at 13.08. In fact, the elimination half-life of COHb is estimated at 300-360 minutes if the subject remains in ambient air, and in 70-80 minutes if the subject is administered normobaric 100% oxygen with a mask or endotracheal intubation (Locatelli, 2009; Hampson et al., 2012).

Less clear is the picture of chronic CO, both for its clinical features for its long-term consequences (see, eg, Kao and Nanagas, 2005), especially because the cases that are reported in the literature have numerous factors limited information on exposure and confounding.

Delayed consequences of intoxication by CO

In relation to the type of patients studied and follow-ups, the percentage of subjects cha undergo neurological sequelae / neuropsychiatric after CO poisoning can reach 40%, and even beyond (Weaver at al., 2007; Crystal and Ginsberg, 22000).

No criteria is totally predictive of the onset of neurological sequelae / neuropsychiatric in poisoned by CO. It is seen that the risk factors for sequelae include age (greater than 36 years), the exposure for at least 24 hours, loss of consciousness, and at least 25% COHb (Weaver et al., 2007; Hampson et al. , 2012). By multivariate analysis, only age greater than 36 years and exposure for at least 24 hours were significant risk factors (Weaver et al., 2007) Moreover, even in the absence of these factors are sometimes observed late sequelae.

The clinical picture of delayed effects (also known in Italy under the generic name of "post-interval syndrome") is not pathognomonic, and presents changes in variables between different patients: memory impairment, depression, visual motor skills, deficits in executive functioning ( Devine et al. 2002). Other paintings include less frequent deficiency of capacity for abstraction, control of fine movements and attention, and behavioral and psychiatric symptoms (Devine et al., 2002). The lagged effects appear after a symptom-free interval ranging from 3 to 40 days, although there are reports, however, not very clear, with a delay of a few months (Locatelli, 2009)

Devine et al. (2002), and Prockop and Chichkova (2007), among others, report that the brain changes radiologically detectable (CT and MRI) are highly variable. In general, these are indicative of damage to the globus pallidus and white matter (demyelination). However, there may also be cortical and subcortical lesions in the temporal lobe, occipital and parietal. In general, the imaging findings were correlated with the appearance of clinically detectable damage, whereas in subjects without clinical sequelae of neurological / neuropsychiatric the radiological picture was normal. However, it was pointed out that, in any case, the radiological changes are not pathognomonic of previous CO poisoning, but can also occur in other pathological conditions (Prockop and Naidu, 1999; Chichkova and Prockop, 2007; Weaver 2009; Crystal and Ginsberg, 22000).

Some authors reported an improvement of the clinical picture in most of the intoxicated over the years (Choi 1983; Crystal and Ginsberg, 22000; Hampson et al., 2012). For example in the large statistical Weaver et al. (2007) went from 42% of intoxicated at 6 weeks, 30% at 6 months, 18% at 12 months after the event. Nanagas and Kao (2005) and Porter et al. (2002) reported that 75% and 50% of patients, respectively, with syndrome "post-interval" had returned to normal after 1 year and Pavese et al. (1999) reported improvement in all their patients, including one patient with chronic intoxication, after a year.

Regarding the mechanism of induction of injury, it is believed that, in addition to hypoxia related to the presence of COHb, intervene phenomena of oxidative stress associated with reduced mitochondrial function and interaction with platelets. They have been called into question inflammation, independent of hypoxia (Weaver 2009; Crystal and Ginsberg, 22000; Hampson et al., 2012).

Considerations on the work environment

A combustion control of the laundry drying on the run 21/02/2007 showed 2-11 ppm CO in the flue gas leaving the dryer that had the tube partially disconnected the day 07/02/20007. It should be noted that abnormal levels of CO in ambient air are considered to be those greater than 35 ppm (Locatelli, 2009). For comparison, in cigarette smoke inhaled by a smoker the CO content is 2000-45000 ppm (Scherer, 2006).

Controls carried out by specialist firm (Dr. Ing Sergio Castelli) 27/2/2007 showed the ventilation openings on the premises laundry, normal.

Considerations in relation to the question posed by Mr. Judge

The question put by Mr. Judge, consists, in effect, of various questions which must be answered in a sequential manner, because the answer to each question depends, at least in part, by the response to the previous. Therefore the question, and its response shall be divided as follows:

indicating the CTU, given a value of 3.7 (%, Ed) COHb after about 2 hours of normobaric oxygen therapy, which was the probable value COHb before such therapy;

The answer to this part of the question is not simple nor direct, and you will have to arrive at the answer, as we shall see, use accessory items.

Recall that the first measurement of COHb was performed at 13:08 of 7/2/2007, approximately 6 hours after the start of their employment, and thus potential exposure, and about 3 hours after they move to another room and start of oxygen therapy with nasal cannula that is likely to be proceeded for about 2 hours, until the expulsion of Ms, and its subsequent access to the ER occurred about one hour after removal from the workplace.

The emogasanalitico examination was performed in ambient air, and this is stated: Saturation of hemoglobin and normal pO2, pCO2 reduced 3.7% COHb. The figure of the pCO2 and the first detection of PAO and FC high, may reflect a state of agitation with moderate hyperventilation. The value of COHb found is compatible with the condition of Ms Smoke, and is slightly higher than the values ​​that are found in non-smokers. Moreover, we do not know when, prior to the examination emogasanalitico, the lady smoked the last cigarette. The next review, about 24 hours later, during which he has certainly done O2 therapy, the level was 1.6%, within the levels that are observed in non-smokers. The question then to be asked is whether this observed reduction in the levels of COHb represents only the elimination of the excess of COHb in a smoker who abstained from smoking for about 24 hours during which apparently was subjected to a continuous oxygen therapy 2 ( or 3) lt / min, which is indicative of a downward trend of the concentration, following excessive exposure to environmental type, and which therefore would allow an extrapolation to higher values ​​around 9 am (likely the end of the hypothesized exposure) compared to 13 hours of 7/2/2007.

A first simple answer might be that being Ms Smoke, 3.7% COHb is within the basic values ​​of smokers. The lowest value (1.6%) found 24 hours after it is compatible with the fact that Ms has not smoked for over 24 hours. In fact, 24 hours represent at least 4 half-lives of elimination of COHb in the absence of oxygen. Note that four half-lives correspond to a removal of 94%, and therefore it is reasonable to believe in these conditions the percentage of COHb has dropped to essentially basal levels. These data, although suggestive, are not entirely convincing that the COHb Ms francs were within the range that smoking even on the morning of 7/2/2007, at 9 o'clock.

Suppose now that 1.6% is the value of the base so that Mrs ie 2.1% (3.7-1.6 = 2.1) and the value in excess of 7/2/2007 13:08 pm. This excess value may be used to calculate backwards a possible concentration 4 hours before, or at 9 o'clock when is ceased the hypothesized exposure. During this period, Ms has been subjected to oxygen by nasal cannula for 1.5-2.5 hours, please note that it is nasal cannula, in various SIT referred to as unwelcome, and therefore poorly executed, by Mrs. It is not therefore of oxygen with 100% oxygen with normobaric mask or endotracheal intubation according to the literature that reduces from 300-360 to 70-80 minutes the half life of COHb. Therefore, it may be postulated intermediate half-life of 200 minutes (2 hours without O2 therapy, 2 hours with O2 therapy is not optimal). On the basis of this hypothesis could be an estimated value of COHb of 5-6% at 9 o'clock yet compatible with the status of a smoker, if Ms had smoked that morning; on this we do not have reliable information.

The set of symptoms complained of by Ms, while remaining compatible with CO poisoning, however, is not specific, so it is not possible on a clinical basis for the successful completion of intoxication occurred. In particular, Ms f also complained earlier episodes of unconsciousness. Also noteworthy is that Ms was in the menstrual phase, which can justify the headache.

As you can see, the available clinical data are not conclusive in affirming or exclude an excessive exposure to CO occurred. Moreover, this exposure, if confirmed, would be modest in any case, on the basis of the calculations shown above.

There are, however, additional information that may be taken into consideration.

  1. A first clinical consideration, refers to the fact that the results of CO poisoning are related to injuries of the brain tissue that result in square radiologically detectable. These paintings, although not pathognomonic of sequelae of CO poisoning, are always associated with clinical symptoms of the syndrome known as post-interval, with features ranging from subject to subject. In the case of Ms, the MRI of the brain was normal on 16/02/2007, and in particular the radiologist underlines the normality of the areas most often affected in the syndrome interval (globus pallidus and white matter of the semi-oval centers). The repetition of the examination on 27/04/2010, reported only limited island of nonspecific gliosis at the rear crown of the corona radiata to the right, and always normal to the basal ganglia and brainstem. Note that it is circumscribed lesion and agenesis. These characteristics, in particular the monolateralità, are scarcely compatible with a poisoning seen that the lesions toxic type tend to be diffuse and symmetrical.

  2. From the reconstruction of the event, on the basis of the various GIS, it is possible to deduce that many people were present at the place where the alleged intoxication should have happened and no one has complained about any problems, and neither that day nor in the earlier days.

  3. Moreover, the technological findings described above, although subsequently executed episode (14 and 20 days after) showed adequate ventilation and air in the room, and proper operation of the combustion of the dryers seen that the emission of CO, which possibly would be exit from the tube connected wrong, it was at most 11 ppm, well below the levels that are necessary to get a picture of poisoning in the exposed.

In conclusion, although we can not conclude with absolute certainty, the available data are consistent with the exclusion of an event of acute or chronic poisoning by CO of Ms.

Say if the aftermath of the worker complained after the event, to have been caused by the COHb value so determined;

On the basis of the considerations set out above it is not considered as alleged by the patient may be attributable to CO poisoning, which probably did not happen. In any case, even assuming that there has been an excessive exposure, the extrapolated values ​​are not so high as to configure a picture of intoxication such as to lead to the symptoms complained, after the episode and currently, by Ms. In fact, the extrapolated value of 5-6% is consistent with levels observed in smokers, and therefore may have been experienced previously by Mrs.

Regarding the hypothesis of chronic intoxication lasted for days or weeks, as suggested by CT of the plaintiff, the biological data available do not provide any support and the absence of symptoms of work colleagues contrasts with that hypothesis.

in case of a positive answer to that question, describing the permanent consequences derived from the event to the worker in question, reporting every useful element to specify the harmful consequences occurring in practice, including in relation to social life and habits of life;

determine the periods of temporary disability resulting from the accident;

established, determining the degree percentage, damage to health derived the worker as a result of the after effects of a permanent nature;

ascertain to what extent the aftermath derivatives have impacted the ability of specific occupational and whether, and to what extent, persists or residue on the applicant's ability to wait for other jobs suited to their personal skills and environmental factors. "

In this part of the question you do not believe you need to respond by excluding it took an acute or chronic CO poisoning.



 

Bibliography

Choi IS. Delayed neurologic sequelae in carbon monoxide intoxication, Arch Neurol 1983 40 :433-435

Crystal AH, Ginsberg MD. Carbon Monoxide. In Experimental and Clinical Neurotoxicology (Spencer and Schumburg eds), Oxford University Press, New York, 2000, p. 318-329

Devine SA, Kirkley SM, Palumbo CL, White RF. MRI and neuropsychological correlates of carbon monoxide exposure: A case report, Environmental Health Perspectives 2002, 110 :1051-1055

Hampson NB, Piantadosi CA., Thom SR, Weaver LK., Practice recommendations for the diagnosis, management, and prevention of carbon monoxide poisoning, Am J Respir Crit Care Med 2012, 186 :1095-1101

Kao LW, Nanagas Ka. Carbon monoxide poisoning. Med Clin N Am 2005 89:1161-1194.

Locatelli C. Acute poisoning from carbon monoxide: The point of view of the toxicologist, Underwater and Hyperbaric Medicine 2009, 2 : 19-23

Pavese N, Napolitano A, De Iaco G, R Canapicchi, Collavoli PL, Lucetti C, G Gambaccini, Bonucelli U. Clinical outcome and magnetic resonance imaging of carbon monoxide intoxication. A long-term follow-up study. Ital J Neurol Sci 1999, 20:171-178.

Porter SS, Hopkins RO, Weaver LK, Bigler ED, Blatter DD. Carpus callosum atrophy and neuropsychological outcome Following carbon monoxide poisoning. Arch Clin Neuropsy, 2002, 17: 195-204.

Prockop LD, Chichkova RI. Carbon monoxide intoxication: An updated review, Journal of the Neurological Sciences 2007, 262 :122-130

Prockop LD, Naidu KA. Brain CT and MRI findings after carbon monoxide toxicity, Journal of Neuroimaging 1999 9 : 175-181

Scherer G. Carboxyhemoglobin and thiocyanate as biomarkers of exposure to carbon monoxide and hydrogen cyanide in tobacco smoke, Experimental and Toxicologic Pathology 2006, 58 :101-124

Weaver LK, Valentine JK, and Hopkins RO. Carbon monoxide poisoning. Risk factors for cognitive sequelae and the role of hyperbaric oxygen, Am J Respir Crit Care Med 2007 176 : 491-497

Weaver LK. Carbon monoxide poisoning, N Engl J Med 2009, 360 :1217-27

Weaver LK. Carbon Monoxide Poisoning, The New EngD Journal of Medicine 2002 347 : 1054-1056

 

The CTU would be denounced. The science proves it. But trust the judges?

 

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The CTU should be sued for false expertise, abuse of office and fraudulent misrepresentation and defamation

to art.372/373cp, abuse of office art.479cp, false ideological art. 480cp and defamation art.596 of the Criminal Code.

appointed technical consultant causa72/2012 the 22novembre 2012 in the Court of Appeal of Brescia Section Labor and Pensions

Given that:

1 - What is now under appeal to the Supreme Court.

2 - That the crimes of which they are not yet lapsed.

3 - That in no case shall the advice could serve to exempt from providing the proof that she was entitled to provide in accordance with the principles that govern the relative burden.

 

WHEREAS IN FACT

 

On 07 \ 02 \ 2007 I suffered an injury on the job for carbon monoxide poisoning and gas POS registered office as Case No. BG. 506 579 680.   (POS Annex 1)

 

The POS, after receiving the following documents (attachment.) By CS :: certifying that "a ring of the manifold leading to the exhaust gas dryer laundry was found, immediately after the completion of signaling ' accident, removed from its seat and then just before the dryer was running definitely has poured an unknown amount of exhaust fumes in the environment ", he enclosed the proof of the smoke (CS Documents POS Annex 2 ) recognize the ' injury monoxide poisoning and quantified the damage to 4%. (POS Annex 1)

 Reconfirmed with the judgment given by Judge Monica Bertoncini in a labor dispute.

Due to the onset of the syndrome intersperse post I made a complaint to both criminal and civil.

The criminal proceedings (Case numero370 \ 2009 RG Not. Offense mod. 21) was dismissed because, the judge wrote dr. Masia: "(...) DETAIL OF HONOR PROVES THE CONSIDERATIONS SET OUT IN ITS WRITTEN BY DEFENSE DELL'INDAGATA HIGHLIGHTING SUSPECTED DELAYED PRESENTATION OF COMPLAINT COMPLAINT , "flying over the fact that the complaint for escape of methane gas and carbon monoxide poisoning was d ' office and only then that I was aware. (Criminal Annex 3)

The judgment of the Court of First Instance of Bergamo with ruling no. 983 \ 11 dismissed the appeal of the motivating myself:  The only fact that the broad investigation tried to suggest is that this morning the exhaust pipe of the dryer fumes were a bit 'disconnected (see dep. SGIA, Hair) ( ...) Among other things, none of the other operators, despite the request of help of Lani and the fact that she claimed to have breathed methane, had the hint of the smell of gas. (See deposits. Peli, Heritage and Scggia ). "(attachment. 4 Judgment Bertoncini)

 

The Appeals Court Brescia Work section 72 \ 12 RG granted the request for appeal on the following grounds:

"The Board, taking into account that the CTU, which is required to reply to the criticisms of the consultant's part of the worker, 
that the low value of 3.7 COHb 
should be assessed in the light of oxygen carried by dr. Scgia, had merely observed not to share,
considered it necessary to have a new technical consultancy, aimed, in particular:
to determine, given a value of 3.7 COHb after about two hours of normobaric oxygen therapy, 
which may have been the likely value of COHb before this therapy, " 
 
but in turn rejects my application based on the elaborate expert CTU Angelo Moretto, for the following reasons: 
 " With reference to the work environment, the CTU has clarified that abnormal levels of CO in ambient air
are to be considered those exceeding 35 ppm 
and that in cigarette smoke inhaled by a smoker the content of CO
is 2000-45000 ppm. He added that a combustion control executed 21.2.2007 s
ui exhaust fumes from the drying of the fact that the day had the tube partially disconnected, 
demonstrated the presence of CO in the flue gas output of 2 - 11 ppm. " 
(Attachment. 5 judgment call)
 
Using the same words CTU Angelo Moretto here that carry:
A combustion control of the laundry drying on the run 21/02/2007 
showed 2-11 ppm CO in the flue gas output from the dryer 
which presented the pipe partially disconnected the day 07/02/20007. 
It should be noted that abnormal levels of CO in ambient air are to be considered 
those above 35 ppm (Locatelli, 2009). 
For comparison, in cigarette smoke inhaled by a smoker the CO content is 2000-45000 ppm (Scherer, 2006).
(Annex 4 moretto expertise. No. 7)
 
THE ACTS
 

Writes prof. Angelo Moretto: (Annex 7 of expertise Moretto)

 "On November 22, 2012, the writer was instructed dall'Ill. Judge Dr. Antonella New mo

perform technical advice medico-legal acts related to the pathology of which is affected Ms,

asking the following question:

"Upon reading the pleadings, visited the woman, made any finding, even instrumental, indicating the CTU,

considered a value of 3.7 COHb after about 2 hours of normobaric oxygen therapy, which has been

the probable value of COHb before such therapy; Say if the after-effects alleged by the worker

after the event, to have been caused by the COHb value so determined;

in case of a positive answer to that question, describing the permanent consequences derived the worker

the event in question, reporting every useful element to specify the consequences

harmful in practice occurred, including in relation to social life and habits of life;

determine the periods of temporary disability resulting from the accident; established,

determining the percentage grade, the damage to the health derived the worker

 as a result of the after effects of a permanent nature; ascertains the extent to which the after-effects

derivatives have impacted the ability of specific occupational

 and whether, and to what extent, persists or residues in the applicant

the ability to wait for other jobs suited to their personal skills and environmental factors. "

 

The CTU prof. Angelo Moretto filed, July 9, 2013, his expert's report,

that is, ictu oculi, is patently false the scientific and ideological

as well as insulting and defaming me.

 

It is well established that a trial has deliberately altered, as evident as important,

which is proof of the smoke, for the formation of judgment

and provided a description of deliberately false and omission of the places

and facts in such a way as to mislead the judgment by the courts of appeal,

stating ,

 

without the support of an environmental detection, even when the CTU Ostir Dr. Patrizia (coroner POS) 

 at first instance concluded: (Annex 8 ctu Ostir first degree)

 "It is actually documented a disconnection of the manifold

leading the exhaust gas from the drying of the laundry on the outside of the structure,

but was not able to understand how

and in what quantity the exhaust fumes may have been discharged into the surrounding

(Before turning off the device)

and the actual degree of ventilation of the environment at the time of verification of "failure," and when this failure actually occurred. "

this as follows: (Annex 7)

 

"A combustion control of the laundry drying on the run 21/02/2007

showed 2-11 ppm CO in the flue gas output from the dryer

which presented the pipe partially disconnected the day 07/02/20007.

It should be noted that abnormal levels of CO in ambient air are to be considered

those above 35 ppm (Locatelli, 2009).

For comparison, in cigarette smoke inhaled by a smoker the CO content is 2000-45000 ppm (Scherer, 2006).

 

Of the cigarette as the sole source of production of nitric certified by prof. Angelo Moretto,

( CTU discussed, and excluded the possibility that there was an active source of pathological concentrations of CO )

a much more important source was certified by the same C Sat: pipe smoke emissions of a natural gas boiler disconnected.  

(Annex 2)

 

and the loss of natural gas, as evidenced by Sndrea (attachment. testimony Selli 9) and the CD from Pli My Tera and Beini;

certified by the testimony of the legal representative of CS to judge Dr Monica (Annex 10)

Bertoncini stating that: "the tube of methane (...) was correctly inserted, only the band was a bit 'loose."

And the certification of CS INAIL about replacing the gasket oven. (Appendix 2 )

And, while ignoring the quality and duration of oxygen therapy, which have been submitted without information

and consent from the dr. Schigia, subtly induced to suspect that I had been smoking before the examination blood gas analysis, stating:

 "The CTU has discussed at length the possible significance of the level of 3.7% COHb, and does not have any fate

attempt to consider Ms Lan a chain smoker.

The levels of COHb, as I said, depends on the time since the last cigarette smoked,

and we know nothing of when this occurred. "  (Attachment 7)

 

A demonstration of the crimes, it is sufficient to note that, despite evidence of smoke attached

 

 CTU says:  

"Considerations on the work environment: (ANNEX No. 7)

A combustion control of the laundry drying on the run 21/02/2007

showed 2-11 ppm CO in the flue gas output from the dryer

which presented the pipe partially disconnected the day 07/02/20007.

It should be noted that abnormal levels of CO in ambient air are considered to be those greater than 35 ppm (Locatelli, 2009).

For comparison, in cigarette smoke inhaled by a smoker the CO content is 2000-45000 ppm (Scherer, 2006). "

The test of the smoke lays for well over 218 300 ppm 25 ppm allowed by law (April 28, 2002 DM 60 \ 02)

  and to 10mg of cigarette permitted by law.

Moreover, the same Scherer G. quoted him, said: "the actual amount of CO inhaled by the smoker

varies according to the mode of smoking: the number of puffs, the depth, the duration of apnea ... "" 

Varies according to the porosity of the paper, the greater or lesser efficiency of the filter and the degree of humidity of the tobacco.

These rates measured with smoking machines, (in compliance with ISO) range from 0.5 to 13 mg per cigarette. "

 In fact, the variable dose cigarette smoke to calculate the absorbed CO are varied and depend on:

 

-          From the number cigarettes smoked per day,

-          The type of tobacco

-          From the number puffs per cigarette

-          from the range of smoke ventilation

-          From the suction flow

-          From the shape of the mouth

-          From deep inhalation

-          By the time inhalation

-          From lung capacity (ventilation, diffusion, pressure of CO, absorption

and elimination of carbon monoxide. (Coburn et al 1965)

-          From the efficiency of the filter paper porosity, moisture contained in the cigarette. (Robinson and Forbes, 1975; Benowitz, 1983).

-          From the content of CO in cigarette smoke.

 

And, all of it, nothing can be said or connect to Ms Lan.

It 'also testified that he did not smoke at 7.40 and that he was quitting smoking.

Moreover, " the COHb concentrations do not correlate with the severity of symptoms "(Ernst and Zibrak, 1998).

"The acute symptoms are unlikely to occur in cigarette smokers." (U.S. Department of Health and Human Services, 1983.)

 

It should be noted that, with equilibrium concentration of COHb in the ambient air of 20ppm,

 the concentration of COHb in blood is 3.7%.

With a concentration of 30ppm (35mg \ Nm3) is 5.3 COHb in blood.

Faculty of Engineering - University of Siena Degree in "Management Engineering"

CO limit value for air quality

Maximum daily 8 hours: 10 mg / m 3  ( DM 60/2002 )

The statistical effect detected by prolonged exposure to levels of 10-15 ppm of CO

(COHb in the blood of the order of 2.5%),

 is a decrease in the ability to recognize the time intervals.

The exposure for 8 hours at CO levels of 30 ppm (35 mg/Nm3)

corresponds to about 5% COHb in blood,

 and due to the inability to respond to typical test of psychomotor activity.

Higher values ​​lead to states of anxiety or other psychological disorders.

Values ​​of 750 ppm are responsible for his death. "

Values: 

A base level of 0.4% COHb resulting from the production of CO in the human body;

 Smoking is a normal level of COHb in blood higher than 5% (6% to 20 cigarettes / day ;

Approximately 8% to 40 cigarettes / day).

Industrial or urban areas, even the non-smoking residents often show levels between 1.5 and 2%.

Industrial environments with CO concentrations above 100 ppm are considered at risk

Values ​​between 5 and 20 ppm were detected in daily averages of many urban centers.

Cigarette smoke contains typically 400-500 ppm of carbon monoxide.

An MCI is not catalyzed in good condition emits 2000-3000 ppm of carbon monoxide.

 

And Lani, as is clear from the nursing record of hospitalization, declared,

referring to quit smoking before, about 6 \ 7 cigarettes per day.

Also forget, that the CO dissolved in the plasma, not bound to hemoglobin,

is calculated as COHb and not included in the calculation made by him, and that is what caused the damage.

And despite the independent appraiser, CENED (attachment.) And the following:

The expert Professor Angelo Moretto

- Without having done any environmental detection,        

- - stated (Annex 7) The CTU has not ignored the chronology;        

CTU discussed, and excluded the possibility that there was an active source of pathological concentrations of carbon monoxide.

- ignoring the testimony UPG Dr. Arrigoni, deeds, that on page 2 of n.1305 \ RG 09 (ANNEX Ranked # 15)        

"I checked out later that it was a dryer that runs on natural gas, so it has an outlet pipe of smoke similar to that of the boilers. From this tube exits the smoke of combustion of methane. The smoke of the boilers are all toxic gases contain various types. (...) The products of combustion of a gas boiler, in which the dryer can be treated as such, must be brought out because it also contains CO2 and CO, however, does not come out pure methane as such. It should be out CO2 and a low percentage of carbon monoxide, I could not tell how much. ". The percentage of carbon monoxide generally increases when the boiler is located in a poorly ventilated area or the combustion does not work well for problems of maintenance of the machine. "The products of combustion of a gas boiler, in which the dryer can be treated as such, must be brought out because it also contains CO2 and CO, however, does not come out pure methane as such. The rest home had put a tape to prevent detachment, I thought I more correct from a technical point of view in a metal band, given that, as I reported, it was impossible to secure it to the ground. (From the booklet of installation shows the opposite) The tape was adopted only after the event. Was not there before. There was suction hood. I did not deliver the booklets maintenance of the boiler. "

 

-          Ignoring these booklets, as documented, are non-existent. (Annex 16)

-          Ignoring the simultaneous escape of methane,

-          Ignoring the testimony of Sli Anea, (ANNEX Ranked # 17)

-          ignoring the evidence of smoke that lays the operation of the boiler to 50.2% with an emission of carbon monoxide in the 218.300ppm,   (Annex 18)

-          ignoring the testimony of the UPG dr. Arrigoni (attachment.) Which states that in the absence of maintenance increases the production of carbon monoxide; (Annex 15)

-          ignoring the fact that the emission tubes are not in their home in the project of building facilities,

- Ignoring the fact that no doctor, especially after noting several times the O2 saturation with a pulse oximeter, O2 therapy maintained for 2 hours, as a precaution, as stated by dr. Schiattareggia which Prof. Moretto da blindly credit for convenience.

- Ignoring that were violated any regulations for the management of injury and poisoning by carbon monoxide and methane gas leak.

certifying the courts

-in        that in the working environment there was a source of carbon monoxide

and that the environmental ppm did not exceed 35ppm.

b-      induced And to think that Lan had been intoxicated the last cigarette smoked. (Annex 7) .

c-       That the headache was due to menstruation, ignoring that had begun well in advance

two days after admission, compared to its rules.

d-      That loss of consciousness could be possible, but not caused by intoxication by CO,

seen the previous fainting, ignoring the fact that he no longer had

after starting beta-blocker therapy as documented by medical records kept by the competent physician.

e-        It reiterated what was stated,

 

despite

the observation of the CTP dr. Breads, which carry here in full, highlighting in yellow the parties of interest "

Answers to counter dr. Breads, CT of the applicant (Annex 7)

Note: For ease of reading, the full text of the counter CT dr. Pani is shown in italics,

and the answers or comments CTU in character and bold plan,

immediately following the passages to which they refer.

Preliminarily we want to reiterate some of the concepts:

1) it would be appropriate to abandon / divert attention from the concomitant intoxication of methane,

because misleading. And 'documented the disconnection of the PIPE exhaust of a dryer

and it has certainly given the environmental pollution of enclosed with the OC.

The issue was quickly dealt with in CTU, because the problem of the smell of gas was raised by both Mrs and Mr Lan. Yes, but denied by the other participants. It should be noted that Mr. It also refers to the doctor of the hospital emergency room where he accompanied Ms Ce lanf would have said that the blood of Ms Lan emit odor.

2) as well as must be properly weighed the statements of Lan and if you want also the Si, similarly must be properly assessed the statements of other witnesses, as they still employees of the nursing home, or dr. Wake, Medical Director ( who visited for the first pc face and apply the O2, doing lead by an attendant cylinders) whose position is objectively conflicted with the search for the truth of the facts, and which can not fail to be censored behaviors: non-certification of care to the diagnosis and Lan, POS failure to report; resistance to the demands of "voluntary resignation" of the pc, to return home or to be able to go into PS to be cured. It was the conduct of the first attending physician dr. Sch greatly complicate the ability to make a posteriori diagnosis of what happened at the local laundry. If he promptly turned 118, we would have the clinical data related to 9am that morning, rather than at 13 h (time of arrival to the ED Ce), but prevailed action of "screening" of suspected poisoning holding the Lan perhaps even against the will , however without making the obligatory certification and complaints promptly mandatory. His description of any valid clinical decision had to be drawn up at the same event ie 07:02:07

CTU does not deny that the administration of oxygen therapy has made the whole recognition of a possible CO poisoning; has not been expressed about the behavior of the participants because not required, nor useful in the reconstruction of the facts.

 

Regardless of the discrepancies and different opinions raised during the collegial expert, described by CTU:

"....... The dr. Pani believed to disagree on some points, for which undertook to provide detailed directions. On the same points CTU undertook to review the documentation to verify the discrepancies highlighted by dr. Pani. The discrepancies are as follows (opinion dr. Breads / opinion CTU):

· 1) is true / not true that even work colleagues Ms Lan we complained about noise attributable to CO poisoning the day 07/02/2007, nor in the days before

· 2) is true / not true that Ms Lan fainted and lost consciousness falling on the table of Ironing

· 3) oxygen was administered by mask / oxygen was administered with "glasses" nasal

· 4) is not true / is true that Mr. Lan resented "goggles" for the administration of oxygen

· 5) the lady came to the 12.30/la lady came around 12.00

· 6) is feasible / not feasible for a chronic poisoning exposure duration for at least a few days. ....... "

1) The Lan was the only one to remain on the premises polluted continuously since the beginning of the work shift, 06 h, as the Bini who had started work at the same time, in fact immediately abandoned the premises of the laundry for the ride of delivery clean sheets to departments, then was absent from the premises polluted. The other connects the EP started work at 08. So it was only the LAN to be exposed longer to the CO, and then only to suffer acute intoxication. With regard to possible chronic intoxication of days previous declaration of assets that exist in the days preceding illness stated in testimony given by the SIT Yes

The CTU has been mainly reported the findings of fact of the UPG Omar Rota (Report of 05/02/2009) and available on the SIT. Has decided not to use statements that reported the statements of others, not consistent with them.

2) The Lan says he lost consciousness, the same SGIA testifies "that it would pay in semideliquio" regardless of the lack of fairness of the term declared by a graduate in medicine and surgery, and enabled "medical director" and with many interests to minimize the severity of symptoms of the injured, it is very likely that Lan had at least a brief loss of consciousness or at least an altered state of consciousness.

The expert did not find any evidence that Ms. Lan had fainted, though, having similar episodes previously accused Ms Lan, this could have happened. Certainly, none of the witnesses reported seeing Ms Lan fainted while everyone agrees on the presence of vomiting and a general malaise.

3 ) Assuming that the dr. Schia to minimize (but in the first instance even denied the administration of O2) states conduct of O2 therapy with glasses, Lan says that he could not bear to wake up the goggles and the mask was applied to the O2. He testified that he found it at 12 with O2 mask, there is also a similar assertion of Hair .

The CTU has not been able to find records on file in the statement of Ms Hair on the application of the mask to administer oxygen therapy. Mr. It is the only witness who speaks of mask and not "goggles"

4) See point 3

5) being the time from hospital Ce L of half an hour, and having been immediately accompanied in PS just free to exit the CS, it is likely to be out at 12.30

This is an assumption made ​​by CT, which assumes that after the release she went directly to the emergency room , and inconsistent with various statements.

6) Seizures and euphoria in the days before the Feb. 7 that would be reported by both the Pubic Goods from third parties related to the claims but documented and witnessed by Yes

The CTU has decided not to use statements that reported the statements of others, not consistent with them.

In the report Prof Moretto on page 10 is not true that Lan refused to be accompanied to the PS, if on the other hand having a state of altered consciousness, and if the dr Schggia director of the first "rescue" immediate place he had the indication, said orientation welfare should have dominance, but unfortunately it is likely for the interests of C If and to prevent investigations POS, etc. ASL., as was done in the past to minimize the incident and conspiratorial attitude / omission to provide hold and administer O2 hide / minimize CO poisoning occurred. How Schgia says he found on his arrival in the laundry Lan semideliquio, vomiting and headache, and the exhaust pipe deconnesso or as he says "bias" and regardless of the presence or absence of the so-called controversy of "ties containment" of the tube applied attended by chefs factotum -> exist for common sense all the elements to affirm the existence of a set of symptoms correlated with CO poisoning, or at least suspect CO poisoning, a source of CO in operation (the dryer on) in a closed room, and his "failure / discrepancy functional: the disconnection of the exhaust pipe.

The CT does not bring evidence to the contrary affirmation on the refusal to be taken to hospital. The rest of the paragraph contains assumptions and considerations on the "common sense" is not supported by data, so it is not considered to comment.

With regard to the efficiency of the machinery, the boiler is missing the vignette of compliance in the regional round of 21:02:07 was not declared in conformity, in view of the low energy yield of 50.2% and CO calculation referred to the dry fumes and no air equal to 218.3% then at least more than 21 times the normal tolerated.

To be precise, the document cited is not expressed on the energy performance of the machine. Furthermore, the fact that the boiler or not it had an energy efficiency according to the law, nothing says on CO in terms of health risk. As, however, demonstrate the certificates is that the concentration of CO in the flue gas was around 10 ppm, well below the levels that can cause toxic effects on exposed individuals.

Absolutely do not agree with the statement of Professor Moretto relative to the importance of the detection of HC PS HbCO of 3.7% of the blood gas quantized to 13,08 h after exposure in contaminated environment from about 06 to 08.30 (ONLY PERSON EXPOSED for at least 2h, 30) and after more than 3 h of O2 therapy, it is of critical importance. This value was 3.7% IMPORTANCE OF ACTIVE.

The CTU has discussed at length the meaning of the value of COHb of 3.7%, and did not simplistically dismissed as not relevant. The expert said, after many considerations, that the data does not allow any definitive conclusion.

Its quantitative assessment refers to the time of about 8.30 h slatentizzazione malaise of Lan is inductive function of time of half-life of CO in front of breathing air or O2. Of course it after 3 hours and 38 min of O2, the answer is complex (also in consideration of different concentazioni of O2 in the mixture and in ignorance of the inspiratory flow of O2 set). What is certain is that the whole is to be ascribed all'incongruo and conspiratorial and especially the negligent omission of description of the health activities conducted by Dr. Schia however, criticized as imperita and negligent. The analysis with a pulse oximeter / pulse oximeter peripheral was certainly inadequate to determine the severity of the clinical situation and confirmation of diagnostic hypotheses, treatment and management protocols to conduct inadequate even to suspect CO poisoning. The behavior, subjective aspects, the role of Chief Medical Facilities would configure behaviors that would go beyond the merely negligent. The quantitative aspect of the real extent of the degree of intoxication of the hemoglobin of the blood of Lan currently has only a relative significance, would have relevance at the time 07:02:07 to decide the best therapeutic treatment to reduce the risk of interval syndrome. Today, getting lost in the estimation of calculation may not be unique to the lack of certainty and the absence documented extent of% enrichment of the mixture administered to the respiratory Lan. The syndrome postintervallare is to recognize the Lan only with the documented existence of previous CO poisoning and with the absence of other pathology correlated clinically.

The expert agrees with the CT dr. Breads on the impossibility of reaching a conclusion on the quantitative levels of COHb. CT, however, poses diagnosis of "acute post-interval" in a symptomatic that can be compatible, but not pathognomonic, with such a diagnosis, since have no features uniquely attributable to a complication of CO intoxication. Even Auxiliaries CTU define "compatible" with acute post-interval the picture from their observed (see below), and do not pose such a diagnosis. The CT sets, and then uses this diagnosis, choice among many possible, to confirm the presence of the cause. Circular reasoning that obviously can not prove neither the cause nor the effect.

Prof. Moretto in relation to suspicion of smoking Lan, declared in 5 cigarettes / day, but that he was quitting smoking, it contradicts itself by reporting that the value of 3.7 found HbCO could be compatible in a smoker of 20 cigarettes / day, but it certainly can not be valid in the present case being the Lan possibly exposed to only a quarter (or less) of 20 Mr / day.

The CTU has played a much more detailed reasoning, and reference is made to the text of the report.

In any case, the Lan Hair that is evidenced by the "micro pause working at h 08 07:02:07" certainly not smoked, probably also because the malaise began, so the last cigarette was smoked maybe after dinner on the evening of 6, more than 12 hours before, so the late value of 3.7 is significant poisoning occurred .

The CT formula of the hypotheses that can not be confirmed by any objective information available.

Consequently, the statements of Professor Moretto are not correct, and it certainly can not deny the qualitative confirmation of CO poisoning occurred with the late detection of 3.7% over 3 and a half hours after the incident with performing breathing air and O2.

Please refer to the text of CTU for a discussion on poor usability of this data.

To confirm, however, the severity of the poisoning especially tissue and cellular / mitochondrial is the figure for the significant metabolic acidosis of the blood gases measured at 13,08 with evidence of a BEecf -3.0 mmol / l pathological persisted the next day to -1.3. (With hyperventilation of reward and relative hypocapnia) and especially with low partial pressure of O2 of only 88mmHg. The result of tissue damage / mitochondrial evidenced by these values ​​is significantly important severity of the poisoning. It is also only consistent predictor of the syndrome postintervallare which then triggered. And 'to remember that regardless of the values ​​of O2 bound to hemoglobin for CO-induced alterations of EME that move the saturation curve of O2 to hemoglobin, decreased O2 making available much more difficult transferable toward fabrics: then O2 transported less and especially less O2 available to the tissues because it is less transferable from Hb event which worsens the framework of the measured data to the blood gas. In addition to this must be added the direct damage of the CO in mitochondria with the block / slowing of cellular respiration, events really responsible for the extent of intoxication (related to metabolic acidosis / Tissue -> BE all'emogas) and the risk of development syndrome interval.

The argument made by CT is based on the assumption that there was CO poisoning. In any case the data relative to the deficit of bicarbonates is not particularly relevant, since even a calculated value and not measured. Furthermore, the framework of metabolic acidosis appears to paintings of CO poisoning with severe coma. For this reason, this data should not be overestimated, and can not be brought to support a diagnosis of CO poisoning.

CONCLUSIONS

Prof Moretto would seem to give more credence to the testimonies of those directly related to the position of the C If you still as employees (perhaps subject to pressures) minimizes and dismisses the complaints of the injured party, and especially by extreme importance to the statements of Dr. Schigia whose position in the story is at least in the great conflict of interest, which in the first witnesses denied making of O2 therapy, then ricorretta with O2 administered with "glasses ", but decided to ignore the conduct by dr. Schia pursued in assisting Lan. It is absolutely unexceptionable omission / conspiratorial aims to minimize or hide the injury and working on medical grounds: absolutely reckless inexperienced in contravention of the dictates and guidelines for suspected CO poisoning. spite of these "inconsistencies" would seem unbalanced the weight that is given to the claims of part (C Se) compared to the injured party (Lan) Prof Moretto IGNORE the set of symptoms in the acute phase of Lan (headache, malaise, nausea, vomiting, asthenia, transient loss of consciousness) rather strives to minimize the headache correlating with menstrual pain .. ignores the loss of consciousness as calling the ILLUSTRE Dr. Scegia "semideliquio" ...

Note that in the CTU symptom picture is not ignored, but it is described, and is not considered pathognomonic of CO poisoning. CTU does not appear to have ever embraced the description of " semideliquio "shown by dr. Splinter.

IGNORE the chronological coherence and clinic with acute CO poisoning outbreak in a closed place, with the exposure to the active source of CO, which would be sufficient to alert a clinician to determine diagnostic suspicion (avvallabile CO detector activation from the environment or from detection of HbCO ).

The CTU has not ignored the chronology; CTU discussed, and excluded the possibility that there was an active source of pathological concentrations of carbon monoxide.

IGNORE the evidence of abnormality of the CO source equipment that had documentatamente deconnesso the exhaust pipe.

The CTU has not ignored the disconnection of the exhaust pipe, but included it in the general framework of the emissions of the flue gas, which did not indicate emission of CO levels hazardous to health, whereas the concentration in the flue gas emission, and the resignation and features of the room.

IGNORE the document that states, however, does not comply by third party certifying the above equipment with testing 21:02:07 carried out after the poisoning.

The CTU has considered the above-mentioned document; the fact that the machine could be not in compliance from the point of view of energy efficiency, not port as a necessary consequence that emits CO concentrations hazardous to health, as confirmed by the analysis of the combustion fumes.

IGNORE the qualitative evidence of CO poisoning with the late detection of HbCO of 3.7 several hours after the poisoning occurred, consistent with the set of symptoms initially claimed by pcs. underestimating and minimizing the quantitative data with the attempt to assimilate to toxicosis dell'accanito chronic tobacco smoker 20 Mr. / d: data is not comparable to the present case

The CTU has discussed at length the possible significance of the level of 3.7% COHb, and has no fate no attempt to consider Ms Lan a chain smoker. The levels of COHb, as I said, depends on the time since the last cigarette smoked, and we know nothing of when this occurred.

IGNORE the chronological coherence of the emergence of post-interval syndrome in valid outcomes of acute poisoning by CO, with the typical picture of objectively documented neurasthenia, cognitive and attentional deficits, s. reactive depression.

The CTU has not ignored the symptom picture, that CT dr. Pani diagnostics as postintervallare syndrome. In agreement with the auxiliary dr. Garbarini and Dr. Zugno, CTU defines the set of symptoms as post-interval syndrome compatible with, but not diagnostic, being compatible with other pathological conditions. Is the set of available data that lead to the conclusion that the CTU, with high probability, it is not post-interval syndrome.

It would also seem that Prof Moretto want to skip the evaluation of its auxiliary Dr. Garbarini and Dr. Zugno that recognize possible and consistent with the syndrome Taking breaks disorder suffered by Lan and quantify the extent of damage to the person equal to 16-18% (which is not deviates from the evaluation of the undersigned quantized to 20%) provided of course recognize the valid preliminary CO poisoning of the 07:02:07 "

See above. Moreover, the auxiliary state in their report "the clinical examination may be compatible (not, note," can and coherent ", Ed) with the hypothesis of etiological poisoning from carbon monoxide."

 

In the regret of the asymmetry evaluation of the real weight of the various testimonies (of people with different interests conscious and unconscious, involved in the events of 2007, 07.02), the present attempt, in retrospect, aimed at trying to rebuild THE FRAMEWORK OF TRUTH 'of the facts (and hidden complicated by the conspiratorial conduct at the time, and misdirection to today dr. Schigia-Medical Director of the CS), delegate to Prof. Moretto, unfortunately leaves the evidence of a result at least dull and deaf to the objectivity of a coherent set of evidence suggestive of CO poisoning occurred poorly managed, and evolved in Syndrome Taking breaks, which resulted in substantial harm to the person of Ms Lan.

 

Based on the above factors, the CTU does not consider to change its conclusions. "

COMPONENT FRAUDULENT

As for the intentional component, it is clear that the same should be recorded in the same professionalism as well as obtain it between the lines of his elaborate expert assessment.

You can also try to prove that the error was caused by false testimony before the Court, but it is noted that gave us a lot of her, while married to demonstrate the thesis that nothing has happened.

Because, ictu oculi, it was not super partes, seen that:

- Folded and evaluated the evidence one way

- Used the evidence of smoke in false and unscientific

- Certified in subtle ways that the environment was the norm and that the environment did not exceed 35 ppm allowed by law

- Did suspect that I had smoked before the exam and blood that I was intoxicated by the last cigarette smoked.

- It has penetrated into a sophisticated calculation, not devoid of conceptual errors, regarding the COHb

- Decreased the duration and quality of oxygen which are being referred and which was obtainable from the documents before the Court (CD).

- He has certified my exit from work at 12:30 pm, when he could obtain it from the transcripts contained in the CD or believe my testimony or that of He claimed that the output at 12.30.

- Has certificate, not considering the evidence, that it was I who did not want me to bring to the PS, which is absolutely not true as evidenced by You and how you can also get the transcript contained in the CD acts.

-         has altered, in his report, the statement of Dr. Pharaohs (poison control center of the 'Pope John XXIII Hospital of Bg.) in the medical record of the patient, as evidenced by the UPG Arrigoni before the judge d.ssa Bertoncini Monica "In Meanwhile I was also contacted by a doctor of Poisons Information Centre, which is also contacted by the PS, which, however, did not have sufficient information available to make a hypothesis and could not find any other explanation, other than that of the gas leak as a result of partial detachment of the tube. " (Annex 15)

 

Stating: " The doctor of the PS contact Dr. Pharaohs toxicology of Bergamo which excludes poisoning from natural gas, and considers the levels of carbossiHB (COHb) measured at 13.08 substantially in accordance with the case of the patient smoke ; however, suggests O 2 therapy at 6-8 l / min for 3 hours, and then discharge . "

 

 Altered, with this statement:

 

"The expert agrees with the CT dr. Breads on the impossibility of reaching a conclusion on the quantitative levels of COHb. The CT, however, poses diagnosis of "acute post-interval" in a symptomatic that can be compatible, but not pathognomonic, with such a diagnosis, since no features uniquely attributable to a complication of CO intoxication. Even Auxiliaries CTU define "compatible" with acute post-interval the picture from their observed (see below), and do not pose such a diagnosis. The CT sets, and then uses this diagnosis, choice among many possible, to confirm the presence of the cause. Circular reasoning that obviously can not prove neither the cause nor the effect of " (...)  "In accordance with the auxiliary dr. Garbarini and Dr. Zugno, CTU defines the set of symptoms as post-interval syndrome compatible with, but not diagnostic, being compatible with other pathological conditions. Is the set of available data that lead to the conclusion that the CTU, with high probability, it is not post-interval syndrome. "

as they have certified its auxiliaries: (Annex 16)

"  Such disorders appraised, the clinical examination may be compatible with the hypothesis of an etiological poisoning from carbon monoxide (...) The dynamics of events in fact shows the existence of a temporal link (in chronological order) between the supposed harmful event and the development of symptoms. (...) Ms Lan is not a person with a personal or family history positive for the presence of mood disorder, (...), supporting the hypothesis of a possible causal factor of an environmental nature. (...) The cognitive alterations observed, finally, appear to be greater in magnitude than those usually found in the paintings of alteration of affect and accumunabili are those most frequently found in the paintings of monoxide poisoning ... "

Denying the diagnosis and the cause and proposing other diagnosis other will cause. In fact, the CTU prof. Angelo Moretto, has been pursuing the aim of demonstrating his preconceived thesis and not the truth, causing damage certifying the truth and not concealing the truth.

 

ANALYSIS OF EXPERTISE filed by prof. ANGEL MORETTO (ANNEX 4)

 

Analyzing the expertise of Professor. Angelo Moretto, diagnosis of poisoning by carbon monoxide is given:

A - Positivity of COHb (carboxyhemoglobin) assessed by the elapsed time, dall'ossigenoterapia.

B - Because epistemological and that if other people were hurt.

C - From the presence of carbon monoxide emission sources and the environmental detection of carbon monoxide in ppm.

A- DATA CLINICAL SCIENCE

THE CTU Professor Angelo Moretto and CTP Dr. Pani agree that it is not possible to determine the amount of COHb because there are no reliable data, and in our opinion also based on false testimony. (Allegato7 CTU ) "The expert agrees with the CT dr. Breads on the impossibility of reaching a conclusion on the quantitative levels of COHb. ")

Writes prof. Moretto: Note that, presumably, dr. Schiattareggia used a pulse oximeter (or oximeter polsiossimetro) that is not able to differentiate oxyhemoglobin from COHb, and then the data of normality reported by dr. Schiattareggia, and has successfully led to the exclusion of methane gas poisoning, tells us nothing about the presence of CO and COHb "

If Dr Schiattareggia has really used a pulse oximeter, as hypothesized prof. Moretto? Why Schiattareggia continues with oxygen, despite repeated checks that gave a saturation normal? No doctor administering O2 for two hours in front of repeated controls that give O2 saturation in the standard. If not used for a co-oximeter?

Nevertheless, the CTU is cautious in the statement that there was no monoxide poisoning after a sophisticated calculation is not without conceptual errors, (p.15 CTU: "... the lowest value (1.6) observed after 24 hours (...) 24 hours, are at least four half-lives of elimination of COHb in the absence of oxygen. "3.7 The initial after four half-lives is 0.23 not 1.6 which he took as the basis of calculation.

Also you forget that even the baseline value is halved), concluding that "could be an estimated value of COHb of 5-6% at 9 o'clock."

He admits that that is a movement of COHb, but comparable to that of a smoker, admitting he does not know when the last cigarette was smoked.

this conclusion assumptions on assumptions not comforted by no sure data, ignoring both the duration of exposure to carbon monoxide, both the duration of oxygen, both the quantity, the mode of administration.

Forget also that the CO dissolved in the plasma, not bound to hemoglobin as COHb is not calculated and not included in the calculation made by him, and that is what caused the damage.

In the report ISTISAN 04 \ 23 National Institute of Health, citing the latest WHO monograph dedicated to the CO and epidemiological studies, is highlighted:  "that even at low ambient concentrations of CO of 1.2 ppm, suggesting the absence a threshold level in patients with previous diagnosis of arrhythmia and or heart disease, you have the inhibition of cytochrome a3 at the mitochondrial level that blocks the respiratory chain at the tissue level by generating the damage identified as post-interval syndrome. "

And Ms Lan is suffering from mitral valve prolapse treated with beta-blocker, and since then has not had lipotimiche crisis, the CTU Prof. Moretto creeps might have had the Mr. Lan. speaking of loss of consciousness.

However, it is now proven without any shadow of doubt, dr. Schgia continued, despite having checked the O2 saturation, oxygen therapy, which leads to say that at least Ms Lan was in hypoxia. The certainty is obtained from the tests performed at PS Cl. Bg.

(Annex 7) When it comes to the PS Cl. Bg, at 13.00 of the day 07 \ 02 \ 2007, after 3.30 hours of O2 therapy and 30 minutes of the ambient air is made ​​to the emo-gasanalisi blood which reveals that the oxygenated hemoglobin was 93.5 (values normal 95-99%, and the value of 93.5 would have required a finding urgent ...) was then still in tissue hypoxia after over three hours of oxygen and a 3.7 carboxyhemoglobin. (P.29 medical records) or the same examination performed the next day, the time of delivery of oxygen therapy, oxygenated hemoglobin from 97.8% and a carboxyhemoglobin of 1.7. (P. 28 medical records).

3.7 carboxyhemoglobin is considered a relatively low value, but considered the heart, the elapsed time and oxygen, especially hypoxia, it has been established that mechanism characterized by the detection of COHb is not very high, but with a greater risk of long-term sequelae.

As confirmed on page 5. REPORTS ISTISAN 04 \ 23: "... under hypoxic conditions the CO (carbon monoxide) moves mainly in the extravascular compartment with formation of carbossimioglobina (cellular hypoxia) . "

 (Annex 7) The CTP is noted that the data of metabolic acidosis alone supports the thesis monoxide poisoning severe. The expert Prof. A. Moretto, without framing it as a matter of clinical person with mitral valve prolapse, intoxicated, minimizes without explanation. Maybe that all smokers are in metabolic acidosis?

B- UP EPISTEMOLOGICAL

The expert Prof. Moretto then addresses the epistemological given, based on the SIT and the relationship of 'UPG Omar Rota. (Annex 7)  And in confirmation of his hypothesis of work for which there was no intoxication concludes on page 16 CTU "From the reconstruction of the event, on the basis of various SIT, it is possible to deduce that many people were present at the place where it should have occurred to the alleged poisoning and no one has complained about any problems, and neither that day nor in the earlier days."

In fact, a comparative analysis of the SIT shows that no one else, besides Ms. Lan., Could have been sick. The findings of fact, in the succession of events is aimed to show that the rescuers arrived on the scene of an accident and there remained until the Mr. Lani. has been moved to another room. Only then cooks would have placed the tubes, for which reason:

- Would value the testimonies of those who could bear witness to when you pull the hose or the presence of odor of methane, but only certify the clumsy repair, so much so that they were still sideways, keeping the non-existent ties. How to testify in a civil UPG Arrigoni.

- They would value the testimonies of those having stayed in the same room polluted by gas, long to provide relief to the LAN, it would not be bad.

A more careful examination of the evidence leads, in fact, to exclude with certainty that these may be witnesses of the tube is removed, and the possibility of getting sick "

Annex 17 report summary information assets. Mary : " When I came back in the laundry Hair M. Teresa Lan told me that he was sick because 'he breathed methane. I got to call the RSPP P Bo; together we went down to the laundry with Dr. Schiia. I saw that Zii Ao, the cook, then added a kind of clamp to the exhaust pipe of the dryer number two. "

Annex no. 18 summary information Pli But Tsa: - "... I immediately directed to the nearby local cuisine when I found the chef Mr. Zli and another guy I can not remember the name and I told him what had happened and asked them if they were to put the pipe that had broken off and was out of the office. They came right away and have placed the pipe in no time ... the Bini went away, and I remained close to Lan for about 5 minutes until they arrived Beini accompanied by Dr. Splinter, the Sister Superior and the head Po Bo. "

Goods and rightly Schigia said they had not smelled gas, nor to have seen the tube removed because it arrived after everything had been arranged by the chefs.

The only witnesses who had "the smell of natural gas" and the tube can be removed only Zli, Si, Bi, and the same lanf.

 

No, over the Lan, found himself in the situation and in a position to feel bad.

 

The argument ignored the odor of natural gas and the existence of the bands was important to demonstrate the falsity of the various witnesses who deny even the detachment of the tube, oxygen administration, the impediment to travel to the PS. It is, however, testified dall'UPG Arrigoni, in front of the judge Monica Bertoncini, that such ties do not exist, even proving the falsity of the evidence upon which this report is based CTU. 

Professor Angelo Moretto, and beyond the question of the judge wrote in his report: (Annex 7)

"" Upon reading the pleadings, visited the woman, made any finding, even instrumental, indicating the CTU, given a value of 3.7 COHb after about 2 hours of normobaric oxygen therapy, which was the probable value COHb before such therapy; Say if the aftermath of the worker complained after the event, to have been caused by the value of COHb determined as (...)

 

it would have been easier to conclude: (Annex 7)

"The expert agrees with the CT dr. Breads on the impossibility of reaching a conclusion on the quantitative levels of COHb ";

but substituting the judges in the evaluation of the evidence, not considering the evidence in the first instance, not requiring in turn an environmental expert witness, wanting to support his preconceived thesis is committed to falsehood knowingly engineering issues, hiding the true and inducing errors of judgment in the courts . Forcing me to appeal to the Supreme Court.

He wrote prof. Angelo Moretto in his report: Description of the event 07/02/2007 (Annex 7)

"The reconstruction of what is largely based on the report of the UPG 05/02/2009 Omar Rota, Department of Medical Prevention, ASL Province of Bergamo, and the SIT made the 10-11-12/11/2009 to Lieutenant PF Labour, Public Prosecutor at the Court of Bergamo.

The Day 07/02/2007 6:00 am come into the service sigg.re ie MP M. Bi and work until about 7:30 am in the ward Ironing adjacent to the laundry room. Thus, sigg.re moving into laundry room where the service takes to 8.00 Ms MT Pli. At the turn of the 8 hours, Ms Beri runs for 10-20 minutes. Shortly after Ms Lan refers to Mrs. Hair was not feeling well. When he returns, Ms Heritage called the RSPP to the rescue. "

The reconstruction of what happened , derived from the testimony of these witnesses before the judge Dr. Monica Bertoncini and have more value than those collected by the Judicial Police and the UPG in the preliminary investigation , on the other hand is completely different:

(Annex 19) Ms. Beni testifies: "I arrived at 5:30 and had to be loaded dryers both machines. I did not detect any anomalies it smelled of gas. "

At 6 o'clock service takes Ms. Lan.

Continue Ms. Beni: "About 8 o'clock when I got to bring the stuff to wash your hair told me that the applicant had felt bad and told me that he had breathed methane."

(ANNEX Ranked # 20) The Hair testifies: "(...) I arrived at 7.40 am and asked the applicant if kept me company while I smoked a cigarette. She made ​​me company, but not smoked because he was quitting. After 20 \ 30 minutes (...) told me that he was sick and could smell methane (...) made ​​me see that the large pipe the dryer was a little 'off, precisely what does not come out from them and I have not had methane smell the scent of methane (...) I immediately called the cook Limb and he fixed the pipe, then came back even the Beni (...).

According to this reconstruction, Ms Heritage at 6 o'clock, when the service takes Lan it is no longer in the laundry room. At 7.40 service takes Mrs. Pell. At eight, eight and ten Lan feels bad. The Hair called cooks who settle the flue gas duct. At eight o'clock, the lady returns Goods, which, however, denies being present.

This suggests that the only one left in the workplace for a long time was Ms. Lan, denying the motivations of judges and the same Moretto given about the epistemological .  (Annex 7)

Also in the first degree is, from the evidence of the legal representative of CS   (Annex 18) that the smoke emission tube was removed, the methane gas fitting was loose. (ANNEX Ranked # 15) And the witness dr. Arrigoni who lacked the hose clamp. It is present in the acts of appeal, the testimony of A Selli which states: "There was a strong smell of natural gas ..." (Annex 17)

This would be enough to make it unusable all the expertise prof. Angelo Moretto having it based solely on the criminal case filed, ignoring acts as the court of first instance.

C- UP OF ENVIRONMENTAL

 (ANNEX No. 7) The expert Prof. Moretto went on to analyze the environmental data. Performs a CTU virtual environment. He writes:

Page 14 consideration of the working environment:

 

" A combustion control on the drying of laundry performed on 21 \ 02 \ 2007 showed 11 ppm in the flue gas ...

 

In step 3 on page 16 :

In addition to the findings technological (...) showed (...) CO emissions, which would eventually exit from the tube badly connected, to a maximum of 11 ppm, well below the levels that are necessary to get a picture of poisoning in the exposed .

 

Worsens his incompetence on page 4 Annex 4:

"To be precise, the document cited is not expressed on the energy performance of the machine. Furthermore, the fact that the boiler or not it had an energy efficiency according to the law, nothing says on CO in terms of health risk. How much, however certificates is shown that the concentration of CO in the flue gas was around 10 ppm, far from the levels that can cause toxic effects on exposed individuals. "

 

The above document shows the absolute inability of Professor Moretto read the test of the smoke acts. This document confirms that the machine operates at 50.2% and produces no 11 ppm established by the CTU, but 218,000 ppm (218%) when the law does not permit more than 1,000 ppm.

Prof Moretto proves quite incompetent both in the reading of the test of the fumes, both as regards the determination of the environmental ppm CO. For him the only source of carbon monoxide production this was a hypothetical cigarette.

With regard to environmental ppm is quite necessary to know the local volume, volume replacement air, flue draft, and consumption of methane.

CONCLUSION

The CTU Moretto Annex 7 accusation CT Pani:

"The argument made by CT is based on the assumption that there has been an intoxication ..."

 

The same can be said of him: he reasoned on the basis that there was no intoxication.

 

But while the CT Pani makes a diagnosis CTU Prof. Moretto not wearing a differential diagnosis that justifies the clinical situation of the Lan. It merely deny.

But do not just deny it is also necessary to put a differential diagnosis. And in front of a symptom common to other diseases it proceeds to exclusion. It was not affected by flu syndrome, had not been intoxicated by fungi or other food, he had gastroenteritis syndrome in the course was not due to heart problems as to when Ms Lan. when treated with sotalex had not had it tachi-arrhythmias fainting it was not intoxicated by alcohol and was not in delirium tremens, had not been tossicata solvent, had cerebral ischemia, cerebral hemorrhages it (excluding both the Tac that the MRI) brain tumors it was not seizures. He had psychiatric disorders (hysteria, confusion, anxiety, depression) excluded from the same auxiliary CTU.

 

And also the Medical Officer of CS certified health card (CS: 15/05/2007 (ANNEX Ranked # 19)

 " CO poisoning by default exhaust dryer and boiler with an outcome of headache and occasional dizziness. Net impairment of neurological tests. Send to BG Med Jobs for fitness. "

 

(ANNEX Ranked # 20) The control of CTU Professor Moretto exclude neuro psychiatric disorders complained that the counterparty to the Lan. certifying the following:

"Such disorders appraised, the clinical examination may be compatible with the hypothesis of an etiological poisoning from carbon monoxide (...)

The dynamics of the events it shows the existence of a temporal link (in chronological order) between the alleged harmful event and the development of symptoms. (...)

Ms. Lan is not a person with a personal or family history positive for the presence of mood disorder, (...), supporting the hypothesis of a possible causal factor of type environment. (...) The cognitive alterations observed, finally, appear of greater magnitude than those usually found in the paintings of alteration of affect and accumunabili are those most frequently found in the paintings of monoxide poisoning ... "

 

While it is not necessary to indicate preliminary investigations, different from the examination of his own expertise, of which just over

And ask

1)        a declaration that the expert appraisal Angelo Moretto is manifestly false.

2)        the indictment of the denounced.

In the alternative, you ask the following preliminary investigation is carried out:

1) What is willing to appoint an expert witness in order to ascertain the same circumstances with judicial experiment.     

2) What is a ctu face trial on the fumes from an industry expert.     

3) That it is found the loss of methane gas     

4) Whether you face a CTU environmental or at least it is found that the coupling of the tubes that lead outside the combustion fumes are in the housing on the project of construction of the facilities and that there is the usability.     

5) What you face a psychological evaluation on the testimonies of Zili Ao, Beni and Mary Hair Maa Tersa aimed at establishing whether true or false     

6) What is called to witness to the competent physician G. Gatti     

7) What is called to testify at Sli     

8) What is called to testify UPG Arrigoni     

9) What is called to testify Dr. Pani.     

10) And at the end of the trial have reported. 

 

But trust the judges?