'The healthcare system is not designed around my needs': How healthcare consumers self-integrate conventional and complementary healthcare services.

OBJECTIVE: To explore healthcare consumers' experiences of healthcare service integration. METHODS: This phenomenological study comprised three focus groups of 13 participants who were purposively invited to span three broad generations: young adults, middle-aged adults and seniors. Transcripts of focus group recordings were analysed thematically. RESULTS: Key themes were that: (i) healthcare consumers manage their own healthcare, (ii) healthcare consumers value open, non-judgmental communication with healthcare providers, and (iii) healthcare consumers want flexibility in healthcare services. CONCLUSIONS: Healthcare consumers integrated their own healthcare, including complementary and alternative medicine (CAM) and conventional medicine, by researching practitioners and services and by engaging in service and product rating strategies. They moulded available health services around their needs. Without the support of healthcare providers, healthcare integration, knowledge exchange and risk management are limited. A system of healthcare integration that omits CAM fails to meet community needs, policy aims for greater efficiency, and duty of care to healthcare consumers.

Multiple interchanging of tissue samples in cases of breast cancer.

Due to the suspicion of a gynaecologist, a pathologist was suspected of incorrect diagnoses in cases of breast cancer and the interchanging of tissue samples. Many women applied to the attorney's bureau to clarify the reproaches. The privately owned laboratory for pathology was searched and 926 histological slides, roughly the same number of paraffin blocks and about 20 formalin fixed tissue samples were confiscated. Together with other confiscated material, at least 1236 histological slides and additional 249 paraffin blocks had to be sorted. Histological slides and paraffin blocks were matched with patients as far as possible following the laboratory book. Many of the warranted samples which were diagnosed as containing the carcinoma by the pathologist were missing. A total of 160 samples were chosen and rediagnosed by two independent pathologists. The formalin fixed tissue was negative for DNA most likely due to storage in formalin for years. Most of the histological slides were positive for DNA. On the whole, 18 expertises about histological findings and the DNA results were given. In some cases only DNA results could be presented, as previous experts had only performed DNA examinations without controlling the histological diagnosis. In six cases a carcinoma could be confirmed and the DNA profile matched with patient's DNA; in seven cases a carcinoma was confirmed without match with the patient; in two cases the carcinoma could not be confirmed in the presented samples. A jurisdictional solution was impossible because the accused pathologist died during the investigation. In conclusion, it must be stated that a DNA examination of histological slides should never be performed without a rediagnosis of an independent pathologist and photographic documentation of the findings. Whenever possible, material should be left on the slide.

Fatal intoxication due to excessive dichloromethane inhalation.

A 22-year-old white male was found dead at his working place in a car lacquering company. He had removed lacquer residues by using a solvent containing dicloromethane (DCM) without using a gas mask. Pathology revealed signs of asphyxiation with obvious petechial bleedings and expressed microthrombosis of the pulmonary arteries. Toxicological analysis showed excessive concentrations of DCM which are inhaled due to exposure of extreme air concentrations.

[Detection and documentation of masked blood stains with infrared technique]. / Auffindung und Dokumentation maskierter Blutspuren mit Infrarottechnik.

On dark textiles the visualization of blood stains with the naked eye is either difficult or impossible. In experimental stains and in case work stains we have applied an infrared (IR) video camera in combination with a video printer. As an alternative, an IR goggle was used which could also be connected with a video printer. The results obtained on a variety of different stains and stain carriers are encouraging. Stains showing poor contrast usually become more contrasted. Stains which are partly masked can become complete. Masked stains can become visible. The system is not effective in all combinations of stains and carriers. But it solves a great proportion of formerly problematic cases. Documentation of results is quite easy if a videoprinter is used.

[Possibilities for using bedside cards as secondary comparison in trace element studies with the PCR technique]. / Einsatzmöglichkeiten von bedside-Karten als sekundäres Vergleichsmaterial bei Spurenuntersuchungen mit der PCR-Technik.

When fresh blood is not available as a control in stain investigations extracted teeth, hair, preserved tissue samples, histological slides, cigarette butts or used stamps can also be used. This paper reports on a stain investigation performed 7 months after the death of the victim, where a bedside card from the medical records was successfully employed as a control blood sample. In a series of 10 bedside cards up to 9 years old, the investigation with the PCR method showed recognizable patterns in the STR systems SE 33 and TC 11. Matching patterns could be found from the 4 sections of each card (anti A, anti B, anti AB and anti D). A comparison of the oldest card with a fresh blood sample of the patient also showed matching patterns. AMPFLPs were successful with more recent cards. Using the PCR method typing of bedside cards from medical records up to 10 years old can be used in stain investigations.

[Homicides without clues in children]. / Spurenarme Tötungsdelikte an Kindern.

From 1990 to 1995, 274 deaths of infants (age range 7 days-6 years) were investigated in Münster, where there were no indications of suspicious circumstances. In 167 cases a legal autopsy was carried out and revealed 5 homicides. In 107 cases where an autopsy was not ordered by the prosecutor 3 homicides were discovered. A similar frequency of homicides in both groups indicates that the criteria used to form the basis of a decision by the prosecutor to release the body are insufficient. On average one out of 30 cases was found to be a homicide as the result of the autopsy where the initial assumption was death from natural causes.

[Stain examination with DNA technology--a retrospective analysis]. / Spurenuntersuchungen mit DNA-Technologie--eine Retrospektivanalyse.

The extended possibilities of forensic stain analyses during recent years have mainly resulted from the application of DNA technology. Among the VNTR polymorphisms, one can differentiate between five consecutive generations of systems, i.e. multi locus systems (MLS), single locus systems (SLS), so-called AMPFLP's (amplificable fragment length polymorphisms), short tandem repeats (STR's), micro satellite systems. The routine application in our laboratory lets us distinguish 3 phases: (I) RFLP phase (MLS+SLS); (II) combined application of RFLP-SLS and AMPFLP's; (III) PCR phase (combined application of AMPFLP's and STR's.--Investigations applying conventional blood group systems and RFLP analysis have been cancelled in phase III. Since 1989 328 cases have been investigated. The number of cases per year was doubled in phase III compared to phase I, but the proportion of DNA determination has been increased by app. 800%. Although in phase III the stain material was on average more degraded and quantitatively smaller the application of STR systems was successful in 90% of all cases and therefore much more effective than other systems. Compared to phase I, the probabilities of inclusion were smaller in phase III. Problematic stains were more often investigated. Also, a strategic change has occurred. New standards had to be elaborated, i.e. to the avoidance of contamination, to the critical evaluation of stain composition and to the validation of systems.

[Prostaglandin E in vaginal smears--a possibility for sperm detection in azoospermia]. / Prostaglandin E in Vaginalabstrichen--eine Möglichkeit des Spermanachweises bei Azoospermie.

The identification of seminal traces is exceptionally difficult, if the semen of the assailant is azoospermic. The evident value of prostatic acid phosphatase (PAP) activity must be evaluated in such cases with caution. In a murder investigation of a 13 year old girl a positive PAP reaction was found in vaginal swabs and in her underpants. Spermatozoa could not be found. Using the gas-chromatographic method, described by Douse (1985) the presence of prostaglandin E could be demonstrated in the swabs as well as in the crotch of the underpants. The offender was found to be a man with azoospermia, who admitted intercourse but with the consent of the victim. The E prostaglandins are mainly synthesized in the vesiculae seminal and seen to be specific for semen. Swabs taken from mouth and rectum showed negative reactions for prostaglandins in this case. Prostaglandins could never be detected in vaginal swabs taken at least 7 days after intercourse. Conversely Douse could detect prostaglandins in swabs up to 58 hours after intercourse. Apparently the prostaglandin detection by Douse provides a suitable alternative besides to the quantitative and immunological PAP detection or the immunological detection of the protein p 30.

An unusual case of homicidal near drowning followed by electrocution.

A young woman was found dead in a bath-tub with her facial orifices under water and current burn marks at the right big toe and at the neck near the hairline. Initial police investigations assumed an accidental electric shock due to a radio falling into the water. The forensic autopsy was followed by extensive histology and immunohistochemistry of the internal organs and skin marks. Intensive vital reactions of a near-drowning were detected that suggested a survival period of at least 20 min. Furthermore, an energy dispersive x-ray spectroscopy analysis on the current burn marks and on possible current applicators was performed, as well as reconstruction experiments with a cadaver of a pig that had been slaughtered shortly before. The results of all investigations revealed a two-step procedure with a primary near-drowning and a final current application with consecutive cardiac arrest.

Does the transferrin C2 frequency depend on age?

In a previous study Beckman and Beckman [Hum Hered 1986;36:254-255] reported a decrease in the Tf C2 frequency with age, from 0.173 in newborns to 0.099 in 70-year-old healthy individuals. The authors suggested a selective disadvantage for Tf C2. In a population from Leipzig (FRG) older people have the highest C2 gene frequency (0.1701 vs. 0.1629 in children < 5 years). The differences are not significant. A dependency of C2 frequency on age seems to remain in question.

[Fatal complications by air embolism in legal interruption of pregnancy]. / Tödliche Komplikationen durch Luftembolie bei legaler Interruptio

PIP: Fatal air embolism as a complication of legal abortion in a 29-year-old woman is reported. After anesthesia had been induced and dilatation accomplished (Hegar 14), the suction tube was introduced into the uterus. The surgeon felt unusually heavy pressure when the pump was started, and heavy bleeding was observed. Aspiration was discontinued, and the abortion was completed by curettage. Irregular breathing and cardiovascular collapse occurred 4 minutes after the start of the operation, and resuscitation attempts were unsuccessful. Autopsy revealed pulmonary edema, pulmonary emphysema, and air bubbles in many areas of the vascular system, which confirmed the clinical diagnosis of air embolism. The hose of the suction cannula was found to have been attached to the exhaust outlet of the suction pump. It is suggested that the exhaust should be clearly differentiated from the intake valve in order to avoid similar accidents in the future.^ieng

Post-mortem orthopantomography--an aid in screening for identification purposes.

Ante-mortem orthopantomograms may be of great value in the identification of human remains. This x-ray technique provides an overall view of the teeth and jaws and thus of numerous individual structural characteristics within a short time. Standardised post-mortem orthopantomography has previously not been feasible in the forensic practice. The present study shows how orthopantomography can be applied to identification procedures. The reproduction of ante-mortem x-ray conditions is implemented here in the production of post-mortem x-rays, using a purpose-designed radiographic tripod. For the first time, account is taken not only of the size and structure but also of the nature of the soft tissue covering of exhibits. For post-mortem preparation of these radiographs, appropriate positioning aids, a spinal column substitute and a soft tissue filter were constructed. Individual macerated jaws as well as the complete cranium can now be positioned correctly in the upright orthopantomograph (OPG). The method presented expands the spectrum of forensic radiology for the individual case and in our opinion also offers a reliable aid for victim identification in the wake of mass disasters, aircraft crashes and terrorist attacks, where a large number of bodies have to be identified under great pressure.

[Recent data for frequency of autopsy in Germany]. / Aktuelle Daten zur Obduktionsfrequenz in Deutschland.

BACKGROUND AND OBJECTIVE: : Today clinico-pathological autopsies serve as a measure of quality assurance in clinical medicine. Furthermore reliable information on the distribution of different causes of death can only be gained by a significant autopsy rate. Medicolegal autopsies are essential for the discovery of non-natural or violent deaths. This study provides information on changes in clinico-pathological and medicolegal autopsy rates between 1994 and 1999. METHODS: : A survey of autopsy rates in 1994 and 1999 was undertaken covering all German pathological and medicolegal institutes. The autopsy figures of the different states were analysed separately. Most autopsies performed in pathological institutes were clinico-pathological autopsies and almost all autopsies performed in Institutes of Legal Medicine were medicolegal autopsies. RESULTS: Between 1994 and 1999 the frequency of clinico-pathological autopsies decreased from about 4 % to 3 % of all deaths. The medicolegal autopsy rate remained stable on a low level at about 2 %. The differences between various states are up to 4-fold for clinico-pathological autopsies and up to 5-fold for medicolegal autopsies. CONCLUSIONS: : The autopsy rates in Germany are frighteningly low compared to other European countries. Considering the dramatic decline of clinico-pathological autopsy rates the role of the post-mortem examination as a control of clinical medicine and death statistics cannot be fulfilled properly. The low medicolegal autopsy rate is responsible for the high number of undetected non-natural or violent deaths.

Medico-legal aspects of postmortem pink teeth.

While the phenomenon of pink teeth has been known since 1829, when it was first described by Bell, its application in forensic medicine has been limited. Recently, however, attention was again focused on pink teeth in legal cases. The medico-legal implication was the use of pink teeth as a possible means of evaluating the cause of death. Pink teeth can occur during life and postmortem. Except for very few and poorly documented exceptions, they develop earliest after 1 to 2 weeks postmortem. Their chemical analogy is seepage of hemoglobin or it's derivates into the dentinal tubules. Prerequisites are hyperemia/congestion and erythrocyte extravasation of the pulp capillaries, furthermore autolysis and a humid milieu. Therefore, they are most often associated with water immersion. The intensity of characteristics varies between different cases and also between different teeth in an individual case. Since the ante-mortem prerequisites are non-specific and can be replaced by certain postmortem conditions, there exist until now no specific correlation to the cause of death. The phenomenon is very often seen in victims of drowning where the head usually lies in a head-down position. From this it can be assumed that pink teeth even if not identical to postmortem lividity can, at least to some extent, be considered as analogous. Since, there is no obvious connection between the occurrence of pink teeth and the cause of death, it may be concluded that pink teeth are not pathognomonic for a specific cause of death and this is therefore an unspecific phenomenon.

Inflammation of the cardiac conduction system in a case of hyperthyroidism.

A 37-year-old female showed signs of hyperthyroidism 2 weeks before death after a partial thyroidectomy was carried out 15 years previously. An examination 3 days before death revealed a normal blood cell count, an increased level of thyroidal hormones, sinus tachycardia and a high blood pressure of 170/90 mm Hg. A hyperthyroidism was diagnosed and therapy with carbimazol (2 x 10 mg) was started but 2 days later fever and chill occurred and before death short phases of unconsciousness and dyspnoea. The autopsy findings showed an interstitial inflammation of the AV-node, the His-bundle and its branches which can correlate with typical ECG changes in hyperthyroidism.

Manipulated radiographic material--capability and risk for the forensic consultant?

As interest is being increasingly focused on the digital processing of radiographs for identification of the deceased, the benefits and risks of electronic image processing are presented. With digitization of all kinds of radiographic equipment being on the increase and image processing personal computers being readily accessible, increasing quantities of manipulated radiographic material are to be expected in the future. This potential risk is meanwhile highlighted from the legal aspect.

Death due to intravenous application of enteral feed.

A 6-month-old male infant was treated with intravenous infusions and enteral feed via a naso-gastric tube. Accidentally, enteral feed containing pureed carrots diluted with water was injected intravenously and the child died immediately. Carrot material could be found in the pulmonary blood vessels and in various organs of the systemic circulation.

[The practice of medical postmortem examination]. / Die Praxis der ärztlichen Leichenschau.

BACKGROUND AND OBJECTIVE: The quality of the external examination of corpses has repeatedly been criticized. This study provides information on the performance of the external examination of bodies in practice which is necessary for improving the quality of the examination. METHODS: 1000 randomly selected medical practitioners from the "Arztekammer Westfalen-Lippe" were sent a questionnaire concerning personal data, the performance of the external examination of bodies and possible influencing of the decision on the manner of death (i.e. natural, unnatural or uncertain) by a third person. In addition reports of four typical cases were presented and a classification of the manner of death was requested. RESULTS: The return rate of the questionnaires was almost 30%, 289 questionnaires were evaluated. Although most doctors stated that the external examination took them 20 to 30 minutes, only 25% undressed the body completely. Almost 50% of the doctors had been influenced by a third person in the decision on the manner of death at least once, most often by the police. The four short cases were incomprehensibly often classified as "natural death", especially by internists. CONCLUSIONS: Signs of an unnatural cause of death will only be detected by chance if the body is only briefly examined and not undressed completely. If such signs are absent the manner of death should be classified as "uncertain" in unclarified or doubtful cases, even against attempted influencing by third persons. In order to avoid conflicts of interests it would be desirable if only specialized medical practitioners would perform the external examination of corpses.

The distinction between lacerations and cuts in ligaments and tendons.

In contrast to skin wounds the characteristic forensic features of lesions of ligaments and tendons have rarely been investigated. However, in a suspected homicide the question became crucial whether an isolated discontinuity of the posterior atlanto-occipital membrane was caused by a rupture mechanism or by a cut. In order to reevaluate the associated criteria experimental lesions were made in ligaments and tendons and examined histologically. From these experiments the following criteria could be established: Lacerations exhibit complete destruction of the tissue texture with microruptures and splitting of fibres in the adjacent region. Such would edges have an irregular structure and fibres near the rupture site exhibit variable thicknesses due to traction. Incisions exhibit smooth wound edges with no disturbance of the tissue texture. The thickness of fibres near the rupture site is regular. These results were obtained by light microscopical examination and confirmed using electron microscopy. Under controlled experimental conditions the forces necessary to rupture tendons with a diameter of 1 mm varied between 50-70 Newton (N). In the suspected homicide, the lesion of the posterior atlanto-occipital membrane was examined visually and histologically and was compared with the experimentally established criteria. Based on these criteria the lesion could be identified as an incision which had probably been caused accidentally while severing the medulla during the first autopsy and was therefore not connected with the cause of death.