Marta Rorat

Liver steatosis in Polish children assessed by medicolegal autopsies

BackgroundCases of non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are increasing in the pediatric population. Their growing prevalence coincides with the obesity epidemic. Assessment of the incidence requires liver biopsies on a representative population sample, which are hampered by the absence of indications for invasive examination on children without clinical symptoms. The aim of the current study was to assess the incidence of liver steatosis in the population of children up to 18 years old from Lower Silesia.MethodsWe retrospectively reviewed 342 medico-legal autopsy reports from 2000 to 2009. We separated a group of 256 children whose death was caused by trauma. Liver steatosis was diagnosed according to the results of histopathological examinations and typical macroscopic imaging.ResultsIn the 265 children who died from trauma, liver steatosis was reported in 11 (4.2%) children (6 boys) aged between 6 months and 18 years old. Six of the 11 children (54.5%) were found to be overweight. In all 342 children, steatosis was found in 18 (5.3%) children (13 boys), while NASH was diagnosed in 1 (0.3%). Excess body weight was observed in 55.6% (10/18) of children with steatosis.ConclusionsLiver steatosis can occur at any age, even in infancy. Being overweight is a very important risk factor. Gross examination of the liver is insufficient for the diagnosis of steatosis because of its lower sensitivity and specificity. Verification of liver steatosis requires reference histopathological examination.

Analysis of injuries and causes of death in fatal farm-related incidents in Lower Silesia, Poland

INTRODUCTION Workers in the agriculture sector are among the groups at the highest risk of fatal occupational injuries. The aim of study is to show the most common causes of farm-related deaths in Poland, with the circumstances, injuries sustained and mechanisms of death. MATERIALS AND METHODS There were 109 (90.8%) males aged 19-81 and 11 females aged 19-73. 18.3% were over 60 years of age. There were 6 children (boys) aged between 2-6. A retrospective review was undertaken of 16,140 medico-legal autopsy reports by the Department of Forensic Medicine in Wroclaw between 1991-2011, which included 120 fatal farm-related incidents. The study protocol included gender, age, date and cause of death, all injuries found, circumstances and mechanism of death, place of death and blood alcohol concentration. RESULTS The most common (33/120; 27.5%) causes of death, both in men and women, were traffic accidents, the second being hit, crushed or buried by materials and falling objects. The most common injury was multi-organ damage (27/120; 22.5%), less common were cranio-cerebral injury (17/120; 14.2%) and thoracic blunt trauma (11/120; 9.2%). In multi-organ and thoracic traumas the mechanism of death was almost always exsanguinations. 85.3% of victims died at the place found. 37.2% of victims were drunk. CONCLUSION In Poland, fatal injuries occurring in agriculture are mostly related to the misuse of transport and machinery. The main efforts to prevent accidents are engineering improvements, use of personal protective equipment, alcohol intake prevention and appropriate education of the workforce. Special prevention programmes should take gender and age differences into account.

Fatal cisplatin overdose in the treatment of mediastinal lymphoma with the ESHAP regimen - analysis of the causes of the adverse drug event.

Background: Cisplatin is a chemotherapeutic agent that may cause acute (or chronic) organ toxicity. As there is no antidote, prevention of adverse drug events is essential for patients’ safety. Case Report: The authors present the case of a 33-year-old woman treated for lymphoma with the ESHAP regimen, who died of an overdose of cisplatin. The drug was administered at a rate 4 times greater than the recommended maximum dose. The first symptom of overdose – partial hearing loss – appeared after administration of the last dose of the drug on day 4 of the chemotherapy course. The initiation of intensive treatment with plasmapheresis and dialyses was ineffective. The patient died 18 days after receiving the last dose of cisplatin. The medication schedule had been prepared by an inexperienced physician. The information on cisplatin dosage had been sourced from a vague instruction in a clinical oncology manual: ‘100 mg/m2 continuous i.v. infusion d.1–4’. The instruction was misinterpreted. The patient was given 100 mg/m2 on each of the 4 days of the treatment. Conclusion: Special care must be taken when preparing a medication schedule; the treatment must be checked by an experienced physician and verified by the nursing staff. The patient should be monitored for symptoms of cisplatin intoxication.

The clinical course of late diagnosed fatal cases of A (H1N1) influenza in Poland.

INTRODUCTION The most frequent complication of A (H1N1) influenza and the leading cause of death was pneumonia with a primary viral or mixed viral and bacterial etiology. 182 patients had died because of a pandemic influenza in Poland by 31st July 2010. MATERIAL AND METHODS A retrospective study of 6 fatal cases of pandemic influenza, aged 23-41, including 3 women, hospitalised between November 2009 and February 2011 in different Polish medical centres. RESULTS We present the clinical course of 6 late diagnosed cases of A (H1N1) influenza. All patients presented typical flu-like symptoms in the beginning. 4/6 patients had severe disease risk factors: pregnancy, arthritis, Wegener granulomatosis and obesity. All patients were seen by doctors, no one had received antiviral therapy, 4/5 were treated with antibiotics before they were hospitalized. One patient had nosocomial infection. Patients were admitted to the hospital on the 3rd to 8th day of the disease. They received oseltamivir treatment on the 4th to 9th day. All patients developed pneumonia complicated by acute respiratory distress syndrome. Death appeared between the 4th and 27th day after the onset of symptoms. Autopsies were performed in 5 cases and revealed haemorrhagic pneumonia in 2 patients. CONCLUSION Delayed diagnosis and antiviral treatment initiation has a significant impact on mortality in A (H1N1) influenza. During the influenza epidemic, patients presenting typical symptoms should always be suspected of having influenza. Antiviral treatment has to be initiated immediately, especially if there are risk factors of severe disease.

Giant heart tumors in infants leading to sudden, unexpected death: Description of two cases

Primary cardiac tumors (PCT) are extremely rare in the pediatric population, with an incidence of 0.0017–0.027%. 1 More than half are diagnosed within the first year of life. 1,2 The vast majority of these tumors are benign, however some of them manifest the potential for malignant arrhythmias, which can lead to sudden cardiac death. 1 The types of heart tumors encountered in infants and children are different from those seen in adults. The most common intracardiac tumor (PCT) in pediatrics is rhabdomyoma (45%) and in adults it is myxoma. 1,3 The clinical signs and symptoms depend especially on the size and location, rather than the tumor type. 2,3 The clinical manifestations of PCT vary from asymptomatic presentations (despite enormous size) to lifethreatening cardiac events. 3 Unfortunately, they are often missed until autopsy. We report two cases of sudden infant death, both caused by a primary cardiac tumor and both diagnosed postmortem. Case report 1 A 12-month-old, previously healthy male infant died suddenly and unexpectedly, collapsing on the floor during play. His mother noticed convulsions, evidence of cyanosis, and breathing difficulties. The child quickly lost consciousness and suffered a cardiac arrest. The attempted resuscitation carried out by the mother, and then by an ambulance team, failed. The doctor observed significant anisocoria but could not determine the cause of death. Apart from sporadic infections of the upper respiratory tract, the child had not been ill. The parents had not observed anything worrying in his development or behavior. The complete medical documentation, including prenatal history, and somatic and psychomotor development, shows that the proband was the first child of the 22-year-old mother, from her first pregnancy, which developed normally and ended in the 39th week in spontaneous delivery. At birth the child weighed 4100 g, measured 57 cm, and was in good general condition, with an Apgar score of 10 in the first and subsequent minutes. After birth, apart from jaundice between the 3rd and 5th days with the maximum bilirubin concentration of 248 mmol/L, no abnormalities were observed. At that time, the infant underwent abdominal ultrasonography, which did not detect any abnormalities. Auscultation demonstrated normal heart sounds without any pathological murmurs. In subsequent months of the infant’s life only typical preventive physical examinations were conducted, which did not demonstrate any irregularities.

Pharma News / PharmaTicker

Mit Aflibercept wurde eine innovative antiangiogene Substanz entwickelt, die sich vor allem durch ihren 3-fachen Wirkansatz von bisherigen Angiogenesehemmern unterscheidet. Im Unterschied zu Anti-VEGFR-Antikörpern oder sogenannten Small-MoleculesVEGFR-Tyrosinkinase-Inhibitoren agiert das aus löslichen VEGF-R1 und VEGF-R2 zusammengesetzte Fusionsprotein wie eine Falle. Es fängt zirkulierende VEGF-A, VEGF-B und zudem PlGF, verhindert so die Kompensation der untereinander interagierenden Wachstumsfaktoren und blockiert die Tumorangiogenese nicht nur umfassender, sondern zudem vergleichsweise rasch und teilweise 1000fach stärker als z.B. Bevacizumab [1–3]. Signifikant verbesserte Ansprechrate und Überlebenszeit Dass Aflibercept bei Patienten mit metastasiertem kolorektalen Karzinom hochwirksam ist – unabhängig davon, ob sie bereits antiangiogen vorbehandelt sind oder nicht –, zeigen die Ergebnisse der VELOUR-Studie auf [4]. In dieser großen multinationalen randomisierten Phase-III-Studie waren 1226 Patienten nach Versagen einer Oxaliplatin-basierten Therapie mit Aflibercept versus Placebo in Kombination mit FOLFIRI behandelt worden – ein Drittel nach Vorbehandlung mit Bevacizumab. Die zusätzliche Behandlung mit Aflibercept zur Chemotherapie erbrachte einen signifikanten Überlebensvorteil bzw. senkte das Sterberisiko um knapp 20% (HR 0,817; p = 0,0032) [4]. Die effektive antiangiogene Wirkung des Fusionsproteins bilde sich insbesondere in der vergleichsweise hohen und gegenüber dem Kontrollarm signifikant erhöhten Ansprechrate (19,8 vs. 11,1%; p = 0,0001) ab. Mit der therapieinduzierten Reduktion des Tumorvolumens gingen tumorbedingte Beschwerden zurück. Auch im Hinblick auf die Verträglichkeit schnitt Aflibercept gut ab [4].

Fatal accidents at work in agriculture associated with alcohol intoxication in Lower Silesia in Poland

BACKGROUND Determining the prevalence of alcohol intoxication and the level of intoxication in victims of fatal occupational accidents is necessary to improve work safety. The circumstances of the accident and the time between alcohol consumption and death are important factors. MATERIAL AND METHODS A retrospective review of 18 935 medico-legal autopsy reports and toxicological reports performed in the Department of Forensic Medicine at the Wroclaw Medical University, Poland, in the years 1991-2014. The study protocol included circumstances, time and cause of death, injuries, quantitative testing for the presence of ethyl alcohol, gender and age. RESULTS There were 98 farm-related fatalities. There were 41.8% (N = 41) of victims who had been intoxicated - 95.1% (N = 39) of them were males aged 19-70 years old, 4,9% (N = 2) were females aged 37-65 years old. In 8 cases the blood alcohol concentration (BAC) was 50-150 mg/dl; in 15 cases it was 150-250 mg/dl and in 18 cases it was > 250 mg/dl. In 21 cases, the BAC was determined using alternative material and 76% (N = 16) victims were in the alcohol elimination phase with 19% (N = 4) victims in the alcohol absorption phase. The most common causes of death were traffic accidents, drowning and deaths resulting from being caught in or hit by moving parts of machinery or equipment. CONCLUSIONS Alcohol consumption is a crucial risk factor in fatal agricultural accidents. In order to establish the time of alcohol consumption, all victims of agricultural accidents should be tested for alcohol concentration in their blood and urine or vitreous. Improving safety at work requires that the sobriety of employees should be monitored before and during work. Med Pr 2017;68(1):23-30.

Sepsis: Medical errors in Poland

Health, safety and medical errors are currently the subject of worldwide discussion. The authors analysed medico-legal opinions trying to determine types of medical errors and their impact on the course of sepsis. The authors carried out a retrospective analysis of 66 medico-legal opinions issued by the Wroclaw Department of Forensic Medicine between 2004 and 2013 (at the request of the prosecutor or court) in cases examined for medical errors. Medical errors were confirmed in 55 of the 66 medico-legal opinions. The age of victims varied from 2 weeks to 68 years; 49 patients died. The analysis revealed medical errors committed by 113 health-care workers: 98 physicians, 8 nurses and 8 emergency medical dispatchers. In 33 cases, an error was made before hospitalisation. Hospital errors occurred in 35 victims. Diagnostic errors were discovered in 50 patients, including 46 cases of sepsis being incorrectly recognised and insufficient diagnoses in 37 cases. Therapeutic errors occurred in 37 victims, organisational errors in 9 and technical errors in 2. In addition to sepsis, 8 patients also had a severe concomitant disease and 8 had a chronic disease. In 45 cases, the authors observed glaring errors, which could incur criminal liability. There is an urgent need to introduce a system for reporting and analysing medical errors in Poland. The development and popularisation of standards for identifying and treating sepsis across basic medical professions is essential to improve patient safety and survival rates. Procedures should be introduced to prevent health-care workers from administering incorrect treatment in cases.

Sepsis in Poland: why do we die?

Objective: To investigate the adverse events and potential risk factors in patients who develop sepsis. Subjects and Methods: Fifty-five medico-legal opinion forms relating to sepsis cases issued by the Department of Forensic Medicine, Wroclaw, Poland, between 2004 and 2013 were analyzed for medical errors and risk factors for adverse events. Results: The most common causes of medical errors were a lack of knowledge in recognition, diagnosis and therapy as well as ignorance of risk. The common risk factors for adverse events were deferral of a diagnostic or therapeutic decision, high-level anxiety of patients or their families about the patients health and actively seeking for help. The most significant risk factors were communication errors, not enough medical staff, stereotype-based thinking about diseases and providing easy explanations for serious symptoms. Conclusion: The most common cause of adverse events related to sepsis in the Polish health-care system was a lack of knowledge about the symptoms, diagnosis and treatment as well as the ignoring of danger. A possible means of improving safety might be through spreading knowledge and creating medical management algorithms for all health-care workers, especially physicians.

Etiology and Complications of Central Nervous System Infections in Children Treated in a Pediatric Intensive Care Unit in Poland

Central nervous system infections are significant causes of mortality and long-term neurologic complications in children. Survivors often require an extended period of rehabilitation. The authors carried out a retrospective analysis of 1158 children (aged 1 month to 16 years; 31 boys) treated in one pediatric intensive care unit in Warsaw between 2002 and 2010. Forty-three of 1158 (3.7%) children presented with neuroinfections. Nearly two-thirds of the children were younger than age 5 years. The majority of cases (62.8%) were vaccine-preventable bacterial infections. The most frequent complications were brain edema (30.2%), brain hemorrhage (27.9%), and secondary nosocomial pneumonia (25.6%). One-fifth of children developed late, long-term neurologic complications. The mortality rate was 20.9%. The study showed that central nervous system infections are significant causes of hospitalization in the pediatric intensive care unit and often result in death or long-term complications. These infections mainly affect children younger than age 5 years. The majority could be prevented with immunizations.