Axel Heinemann

Decubitus Ulcers: Pathophysiology and Primary Prevention

BACKGROUND Pressure sores are a serious complication of multimorbidity and lack of mobility. Decubitus ulcers have become rarer among bed-ridden patients because of the conscientious use of pressure-reducing measures and increased mobilization. Nonetheless, not all decubitus ulcers can be considered preventable or potentially curable, because poor circulation makes some patients more susceptible to them, and because cognitive impairment can make prophylactic measures difficult to apply. METHODS A systematic literature search was performed in 2004 and 2005 in the setting of a health technology assessment, and a selective literature search was performed in 2009 for papers on the prevention of decubitus ulcers. RESULTS Elderly, multimorbid patients with the immobility syndrome are at high risk for the development of decubitus ulcers, as are paraplegic patients. The most beneficial way to prevent decubitus ulcers, and to treat them once they are present, is to avoid excessive pressure by encouraging movement. At the same time, the risk factors that promote the development of decubitus ulcers should be minimized as far as possible. CONCLUSIONS Malnutrition, poor circulation (hypoperfusion), and underlying diseases that impair mobility should be recognized if present and then treated, and accompanying manifestations, such as pain, should be treated symptomatically. Over the patients further course, the feasibility, implementation, and efficacy of ulcer-preventing measures should be repeatedly re-assessed and documented, so that any necessary changes can be made. Risk factors for the development of decubitus ulcers should be assessed at the time of the physicians first contact with an immobile patient, or as soon as the patients condition deteriorates; this is a prerequisite for timely prevention. Once the risks have been assessed, therapeutic measures should be undertaken on the basis of the patients individual risk profile, with an emphasis on active encouragement of movement and passive relief of pressure through frequent changes of position.

Pressure sores: epidemiology, medico-legal implications and forensic argumentation concerning causality.

Abstract The aim of the present investigation was to identify the frequency and grading of pressure sores in a large series of unselected consecutive deceased subjects before cremation and to discuss aspects of the forensic argumentation concerning causality. A total of 10222 corpses were examined prospectively over a 1-year-period (1998) for the occurrence, localization and grading of pressure sores. Epidemiological aspects (e.g. age, sex, underlying and contributing causes of death, place of death etc.) were taken from the death certificate. The mean prevalence of pressure sores was 11.2% (87.1% isolated sores; predominant localization of advanced grades on the sacrum in 69.6%). There was a positive correlation between the prevalence of sores and advanced age resulting in a clear female predominance in the age group of 80 years and over because of differences in life expectancy. A significant correlation was found between the prevalence of pressure sores and certain underlying diseases, e.g. trauma, senile dementia, neurological diseases, apoplexy and marasmus. Pressure sores of all grades were more frequently found in the deceased when a senior citizen’s or nursing home was given on the death certificate as the domicile in the last period of life. The forensic argumentation for the causal relationship of a pressure sore as the focus of fatal infectious complications or septicemia has to be based on the results of clinical expertises and forensic investigations (evaluation of the institutional documentation of the patient’s course, autopsy findings, histology, immunohistochemistry). The vast majority of physicians seem to pay only little attention to the potentially fatal outcome of pressure sores and fatalities associated with this condition are clearly underreported. From the point of view of social medicine, the prevalence of pressure sores in a defined population can be seen as a parameter for the quality of nursing and medical care. In bringing these fatalities to light, the field of legal medicine contributes to a general quality control of standards of nursing and medical care.

Rauschgifttodesfälle mit Methadonbeteiligung (Hamburg 1990–1996)

Abstract The ca. 1000 drug-related fatalities that were examined in Hamburg from 1990–1996 by the Institute of Legal Medicine were analysed with respect to consumption of substitute drugs such as methadone. The incidence of methadone-related fatalities has increased in the last two years. The highest incidence was found in 1995 when methadone was detected in the blood of about 20% of all drug-related fatalities. Lethal monointoxications or combined intoxications with a dominant role of methadone were experienced rarely (about 1% of all drug-related fatalities). Of the persons who were enroled since 1990 in a methadone maintenance programme 2% have been registered as drug- related fatalities. The mortality of street addicts without comparable medical help was about 10% in the same period. There is further need for improved methods of registration, documentation and forensic/sociological analysis of all drug-related fatalities for reliable conclusions concerning mortality rates of drug users who are enroled in methadone maintenance programmes.Zusammenfassung Unter dem Aspekt des Konsums von Ersatzdrogen (insbesondere Methadon) wurden die ca. 1000 Hamburger Rauschgifttodesfälle im Zeitraum 1990– 1996 retrospektiv analysiert. Die Anzahl der Drogentodesfälle mit chemisch-toxikologischem Nachweis eines Methadon- (Begleit-) Konsums zeigt eine stark ansteigende Tendenz. Die bislang höchste Inzidenz des Methadonnachweises zeigte sich im Jahr 1995 mit ca. 20% aller Drogentoten. Tödliche Monointoxikationen bzw. Mischintoxikationen, bei denen Methadon relevant an der Gesamttoxizität der nachgewiesenen Drogen beteiligt war, wurden nur höchst vereinzelt beobachtet (bisher ca. 1% aller Drogentodesfälle). Von den bei der Hamburger Ärztekammer registrierten Methadon-Substituierten sind bisher ca. 2% verstorben; die Letalität der Drogenkonsumenten ohne Substitution sowie entsprechende institutionelle Anbindung und Hilfe liegt dagegen bei ca. 10% im Untersuchungszeitraum. Für weitergehende Schlußfolgerungen und Verallgemeinerungen zum Sterberisiko Methadonsubstituierter bedarf es einer exakten Erfassung, Dokumentation sowie einer rechtsmedizinischen und sozialwissenschaftlichen Analyse aller Drogentodesfälle bzw. gezielter Kohortenstudien.In Deutschland wird zunehmend über Rauschgifttodesfälle mit Methadonnachweis berichtet [12, 14]. Die Letalität ist ein vergleichsweise hartes Kriterium der Qualitätskontrolle, das auch mit geringerer Latenz Therapieeffekte sichtbar machen kann. Sie sagt zweifellos wenig über Lebensqualitätsaspekte aus, doch spiegelt sie den grundlegensten Anspruch der therapeutischen Seite wider: Zunächst das Überleben der Drogenabhängigen zu sichern, um darauf aufbauend eine langfristige psychosoziale Rehabilitation zu verwirklichen. Die Einschätzung der Letalität in einem unbehandelten Vergleichskollektiv ist jedoch nicht unproblematisch, wenn es – wie bei den i.v. Drogenabhängigen – nicht einmal einheitliche Schätzungen der Grundgesamtheit gibt. Hamburg hat eine seit Jahren anhaltend hohe Rauschgiftletalität zu verzeichnen, die in den Jahren bis 1992 stark anstieg, um sich dann auf erhöhtem Niveau zu stabilisieren (Abb. 1). Hier war seit 1990 eine vergleichsweise intensiv betriebene Ausweitung der Methadonsubstitution zu beobachten, bis die Kostenträger Anfang 1996 ihre weitere Unterstützung einschränkten. Da der Stadtstaat Hamburg räumlich und administrativ gut überschaubar ist, ist davon auszugehen, daß sich die Effekte dieses Therapieangebotes gut abbilden lassen und auch im Bereich der Letalität widerspiegeln lassen.

Investigation of medical intervention with fatal outcome: the impact of post-mortem CT and CT angiography

Post-mortem computed tomography (PMCT) has been proven for its appropriateness to become an integral part of routine pre-autoptic forensic investigations either in the field of forensic investigation of fatal medical error or in hospital quality management. The autoptic investigation of unexpected and peri-interventional deaths can be usefully guided by post-mortem imaging which offers significant added value in the documentation of misplacement of medical devices before dissection with the risk of artificial relocation and the detection of iatrogenic air embolism. Post-mortem CT angiography (PMCTA) augments PMCT in the search for sources of hemorrhages and for the documentation of vascular patency and unimpaired perfusion after general and cardiovascular surgery or transvascular catheter-assisted interventions. Limitations of PMCT and PMCTA in medical error cases are method-related or time-dependent including artifacts by early post-mortem tissue change. Thromboembolic complications including pulmonary embolism, the differentiation of ante- and post-mortem coagulation and the detection of myocardial infarction remain areas with compromised diagnostic efficiency as compared to autopsy. Furthermore, extended survival periods after a complication in question impedes visualization of contrast agent extravasation at vascular leakage sites. PMCT and PMCTA contribute substantially for proving a correct interventional approach and guide forensic or clinical autopsy in the reconstruction of adverse medical events with fatal outcome. Post-mortem imaging could also assume a new role as an alternative in a clinicopathological setting if autopsy is not achievable when the probability in the individual case is acceptable to answer specific questions.

DWI of the brain: Postmortal DWI of the brain in comparison with in vivo data

PURPOSE Changes in water diffusion can be quantified by diffusion-weighted MR imaging. However, there are only few reports about changes in post mortem brain. The aim of this study was to investigate the temporal pattern of the apparent diffusion coefficient (ADC) in the brain after death, to compare the values to in vivo brain and to assess the value of ex vivo DWI as a forensic tool. MATERIAL AND METHODS The study was approved by the local Ethics Committee, and informed consent was obtained from all relatives and the control subjects. Twenty-one corpses, died of natural cause, were examined (13 males, 8 females; age: 70.5±8.7 y, weight 74±18 kg). Diffusion-Weighted Imaging (DWI) was performed with b-values of 0 and 1000 s/mm(2) at 1.5 T. Scans were repeated in intervals of 1 h. ADC-maps were calculated in thalamus, cerebrum and cerebellum. The obtained values were statistically compared to healthy volunteers (n=3) and to literature data. RESULTS The ADC in the three regions decreased characteristically during the examination time. In the cerebrum there was a significant difference between ex vivo and in vivo ADC (p<0.001) as well as in the other regions (thalamus: p<0.001, cerebellum: p=0.045). CONCLUSION DWI of the postmortal brain can be added to the MRI methods for a post mortem imaging.

Post-mortem computed tomography and post-mortem computed tomography angiography following transcatheter aortic valve implantation

OBJECTIVES At present, transcatheter aortic valve implantation (TAVI) is widely used. As with any interventional treatment, however, TAVI may also be accompanied by complications and may result in periprocedural mortality. This study aims to evaluate such complications and causes of death after TAVI. METHODS The study included 32 deceased (59.4% female, n = 19, median age: 82 years) patients with TAVI, since 2008, in whom post-mortem computed tomography (PMCT) and PMCT angiography were performed with the intention of identifying complications. RESULTS Altogether, we registered bleeding (28.1%, 9/32), perforation and rupture (25%, 8/32), cerebral infarction (18.8%, 6/32), injury of the conduction system (3.1%, 1/32), insufficiency of the aortic (12.5%, 4/32) and the mitral valve (9.4%, 3/32) and of valve-in-valve procedures (9.4%, 3/32). Furthermore, there were findings due to cardiopulmonary resuscitation and intensive care. PMCT and PMCT angiography has advantages over autopsy. The demonstration of bleeding vessels, ruptures, the position of the implanted aortic valve and its effects on the mitral valve and its suspensions were more easily accessible by computed tomography-imaging display than by customary autopsy photo-documentation. CONCLUSIONS After TAVI, PMCT and PMCT angiography successfully demonstrated the complications leading to death. PMCT and PMCT angiography contribute to the post-mortem analysis of causes of periprocedural death.

A formula to calculate the standard liver volume in children and its application in pediatric liver transplantation.

Due to a lack of available size‐matched liver grafts from children, most pediatric recipients are transplanted with technical variant grafts from adult donors. Size requirements for these grafts are not well defined, and consequences of mismatched graft sizes in pediatric liver transplantation are not known. Existing formulas for calculation of a standard liver volume are mostly derived from adults disregarding the age‐related percentual liver weight changes in children. In this study, we aimed to establish a formula for general use in children to calculate the standard liver volume. In a second step, the formula was applied in pediatric patients undergoing liver transplantation at our institution between 2000 and 2010 (n = 377). Analysis of a large number (n = 388) of autopsy data from children by regression analysis revealed a best fit for two formulas: “Formula 1,” children 0 to ≤1 year (n = 246): standard liver volume [ml] = −143.062973 +4.274603051 * body length [cm] + 14.78817631 * body weight [kg]; “Formula 2,” children >1 to <16 years (n = 142): standard liver volume [ml] = −20.2472281 + 3.339056437 * body length [cm] + 13.11312561 * body weight [kg]. In comparison with children receiving size‐matched organs, we found an elevated risk of liver graft failure in children transplanted with a small‐for‐size graft, whereas large‐for‐size organs seem to have no negative impact.

Quantitative analysis of victim demographics and injury characteristics at a metropolitan Medico-Legal Center.

For the timeframe of February 1st, 2003 until December 31st, 2005, all forensic medical experts at the Medico-Legal Center of the Institute of Legal Medicine in Hamburg, Germany, completed a standardized questionnaire for every consenting surviving violence victim (n=2733) age 14 and older. Central to the quantitative analysis of the data collected was the extraction of specific injury characteristics from the sample population. A correlation was demonstrated between injury typologies and four possible perpetrator-victim constellations, each of which was subcategorized into sexual and non-sexual assaults.

Modellprojekt zur Implementierung eines medizinischen Kompetenzzentrums für Gewaltopfer in Hamburg

ZusammenfassungIn Hamburg erfolgt die klinisch-rechtsmedizinische Untersuchung von verletzten Gewaltopfern seit 1998 als niedrigschwelliges Angebot. Alle Opfer von Gewalt werden auf eigenen Wunsch, unabhängig von einer Anzeige bei der Polizei, im Institut für Rechtsmedizin kostenlos untersucht. Verletzungen werden dokumentiert, Spuren gesichert und rechtsmedizinische, gerichtsverwertbare Gutachten erstellt. Es werden dabei im interdisziplinären Verbund mit anderen Abteilungen der Universitätsklinik Konzepte für spezifische Opfergruppen entwickelt. Der Aspekt der Psychotraumatisierung kann durch ein im Institut für Rechtsmedizin bestehendes Angebot psychologischer Krisenintervention berücksichtigt werden. Im ersten Jahr der auf dieser Basis seit 2003 als Modellprojekt weitergeführten Ambulanz wurden 1.071 Patienten (62% Frauen, 38% Männer, ca. 21% ausländische Nationalität) untersucht, 40% von ihnen außerhalb des Institutes. Die berichtete Sachlage deutete in 26,5% der Fälle auf einen Partnerschaftskonflikt, in 17,7% auf ein Vergehen gegen die sexuelle Selbstbestimmung hin. Raubtaten wurden in 6,1%, andere Aggressionskonflikte in 30,5% der Fälle dargestellt (15% Sachlage unklar). Der Fremdtäteranteil betrug insgesamt 30%. Die als Modellprojekt konzipierte Hamburger Initiative hat das Ziel, den Versorgungsbedarf bei Gewaltopfern zu erkennen, das Angebot des rechtlichen Opferschutzes zu optimieren und Rechtsmedizin als integrierendes und vernetzendes Element im existierenden regionalen Hilfesystem zu etablieren.AbstractA medico-legal competence centre for victims of violence was established in Hamburg in 1998 where a low threshold of intervention is provided. Victims who come to the Competence Centre to have their injuries documented are not required to report the offence to the police. A forensic documentation of injuries as well as the securing of biological evidence is available for free. The service is expanded to provide victims not just with the possibility of further examination by the appropriate departments of the University Hospital Hamburg-Eppendorf, but also with in- house psychological support. In 2003, 1071 victims of violence were examined (62% females, 38% males, about 21% with foreign nationality). The underlying history was violence in intimate partnerships in 26.5% of the cases, sexual violence in 17.7%, robbery in 6.1%, and other categories of non-intimate violence in 30.5% (history unknown in 15%). The project analyses the provision of care and legal aid for acute cases and thereby contributes to an improvement in the situation of victims of violent crime by connecting existing services in the public health system in Hamburg.

Medico-legal aspects of pressure sores.

Forensic pathologists are increasingly confronted with the need of expertises, which refer to neglected prevention of pressure sores in cases of suspected malpractice. In Hamburg, Germany, a monitoring system for advanced grade decubitus was established by use of routine post mortem examinations before cremation. The trend of decubitus prevalence turned out to be correlated with a local nursery-related quality improvement programme demonstrating the impact of care factors. However, forensic expertise in individual cases must balance very carefully if a fatal decubitus disease was predominantly care-related. A study on nine fatalities with advanced grade decubitus failed to show an increase of Procalcitonin (PCT) as a marker for septicemia. A suppurative osteomyelitis was found in only nine of 20 cases with grade IV decubitus. Even if there is proof for septicemia, the causality must be ensured to be truly decubitus-related.