J. Preuß

Heroin-associated nephropathy

Since the first reports in the late 1960s and early 1970s there have been numerous studies describing the clinical and pathological features of renal diseases associated with chronic parenteral abuse of heroin, cocaine, morphine, amphetamine, and other narcotic and hallucinogenic drugs, including several adulterants. The past 35years have witnessed an explosive growth in illicit drug use in many parts of the world. Meanwhile, drug addict nephropathy constitutes an important cause of end-stage renal disease. The term ´heroin-associated nephropathy’ includes different morphological findings following chronic drug abuse. Up to now it still remains ambiguous as to whether or not heroin/morphine itself, adulterants, other diseases like hepatitis B and C infection, or HIV, lead to a spectrum of morphologically described ´heroin-associated’ findings in the kidneys. As a measure of prevention it appears that the purity of heroin plays an important role.

Medical malpractice as reflected by the forensic evaluation of 4450 autopsies

A multicentre retrospective analysis of 4450 autopsies carried out due to suspicion of medical malpractice in 17 German institutes of forensic medicine from 1990 to 2000 was performed for the German Federal Ministry of Health. During the time period analysed an increase of cases could be mentioned. The main results of the study are: in the cooperating institutes the total number of autopsies due to suspected medical malpractice ranged from 1.4 to 20%. In more than 40% of the cases preliminary proceedings were started because the manner of death was certified as non-natural or not clarified. Hospital doctors were more affected by medical malpractice claims than doctors in private practice. However, the number of confirmed cases of medical malpractice was higher for doctors in private practice than for hospital doctors. Although surgery is still at the top of the disciplines involved in medical malpractice claims the number of confirmed surgical cases was below the average. Mistakes in care were confirmed to be above the average. Medico-legal autopsies are still a very sufficient method to evaluate cases of medical malpractice: 2863 cases could already be clarified by autopsy. Up to now there is no systematic registration of medical malpractice charges in Germany. A systematic registration should be initiated to build up and/or improve error reporting systems and, thus, to improve patient safety. Compared to other sources of medical malpractice claims (arbitration committees of the medical chambers, reference material of health and insurance companies, files of civil courts) the data of the present multicentre study are in so far unique as only lethal cases were evaluated and a complete autopsy report was available as basis of an expert opinion in alleged medical malpractice cases.

Death Due to Hypothermia Morphological Findings, their Pathogenesis and Diagnostic Value

Morphological findings in fatalities due to hypothermia are variable and unspecific. If body cooling is rapid and the duration of the cooling process until death is short, autopsy findings can be scarce or even completely missing. Typical morphological findings in hypothermia are frost erythema, hemorrhagic gastric erosions, lipid accumulation in epithelial cells of renal proximal tubules and other organs. Although being unspecific as exclusive findings, they are of high diagnostic value regarding the circumstances of the case. The main pathogenetic mechanisms of morphological alterations due to hypothermia are disturbances of microcirculation, changes of rheology, cold stress, and hypoxidosis. Typical morphological findings can be found in two thirds of all cases.

Behandlungsfehlervorwürfe in der Notfall- und Rettungsmedizin sowie der Notaufnahme

ZusammenfassungBasierend auf einer multizentrischen Obduktionsstudie zu strafrechtlichen Behandlungsfehlervorwürfen gegen Ärzte werden Fälle dargestellt, die Notärzte, Rettungsassistenten und Notaufnahmepersonal betreffen. Notärzte sind deutlich seltener von Fehlervorwürfen betroffen als Notdienstärzte. Häufigste Vorwürfe waren unzureichende Diagnostik/Behandlung, das Stellen einer Fehldiagnose bzw. unterlassene Krankenhauseinweisung. Häufig wurden Myokardinfarkte übersehen. Bei der Quote bejahter Behandlungsfehler liegen Notärzte mit 10,2% deutlich hinter anderen Berufsgruppen. Klassischer Vorwurf gegenüber Rettungsassistenten ist die unterlassene Verbringung in ein Krankenhaus bzw. die fehlende Hinzuziehung eines Notarztes. Behandlungsfehlervorwürfe mit nachweisbarer Kausalität für den Todeseintritt stellen eher die Ausnahme dar. Die Obduktionsbefunde exkulpieren in der Regel den beschuldigten Arzt, sodass in entsprechenden Fällen eine behördliche Todesursachenklärung veranlasst werden sollte.AbstractBased on a retrospective multicenter autopsy study on medical malpractice claims cases concerning emergency physicians and ambulance officers will be addressed. Malpractice claims against emergency physicians are not as frequent as against emergency service doctors. Claims are mainly due to wrong diagnosis and treatment, missed diagnosis or missing hospital admission. Especially myocardial infarctions are misdiagnosed not seldom. The rate of confirmed cases of medical malpractice is for emergency physicians with 10.2% behind other medical disciplines. Ambulance officers are mainly confronted with claims of omitted admission to hospitals or information of an emergency physician. Malpractice claims with approved causality for death are very rare. Autopsy findings are in most cases in favor of doctors. Therefore in suspicious cases a medico-legal autopsy should be strived for by qualifying the manner of death as unnatural.

Non-diagnosed pulmonary hyalinizing granuloma (PHG) as a cause of sudden unexpected death

Pulmonary hyalinizing granuloma (PHG), a very rare benign tumour of the lungs, was first reported in 1977. We present a PHG of a 32-year-old woman from Yemen who collapsed 1 day after her arrival in Germany. Tuberculosis was suspected and the health authorities nearly closed part of one of the major international airports in Europe. However, this drastic measure was avoided by autopsy and a correct interpretation of the solid-elastic and well-circumscribed lung tumour as not characteristic for tuberculosis. Although the final diagnosis of PHG was only achieved after histology, this case strongly illustrates the necessity of a profound morphological training of forensic physicians.