'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.

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.

[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.

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.

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.

No stress--no whiplash? Prevalence of "whiplash" symptoms following exposure to a placebo rear-end collision.

Volunteer studies of experimental, low-velocity rear-end collisions have shown a percentage of subjects to report short-lived symptoms, but the cause of these symptoms remains unknown. It is unclear whether the symptoms arise from biomechanical stress causing injury or from psychological stress causing symptom expectation and anxiety. Similarly, the cause of symptoms remains obscure in virtually all "whiplash" patients because it is impossible to identify acute pathology in many cases. In this study subjects were exposed to placebo collisions that almost completely lacked biomechanical stress. It was highly probable that if the symptoms reported following low-velocity collisions were not due to injury but to other factors (including misattribution of symptoms from other sources), then the proportion of subjects reporting symptoms would be similiar to that reported for volunteers in true (experimental) low-velocity, rear-end collisions. A total of 51 volunteers (33 males and 18 females, mean age 32.4 years) were recruited through local newspaper advertisements. An experimental set-up for a placebo collision was constructed using two standard European cars. At time T0, prior to the placebo collision, a history and physical examination was performed, including a psychological analysis (Freiburger Personality Inventory). A symptom history and physical examination were also performed at time T1, immediately after the placebo collision, and the subjects completed symptom questionnaires 3 days (time T2) and 4 weeks (time T3) after the placebo collision. Data analysis included a determination of the predictive value of psychological data for the presence of symptoms following exposure to a placebo collision. At time T1, 9 out 51 participants (17.6%) indicated symptoms. Within 3 days (time T2) after the placebo collision, 10 (19.6%) of the subjects had symptoms, and within 4 weeks (time T3) 5 subjects (9.8%) had symptoms. Of the last group, two of the five did not relate these symptoms to the "collision". Subjects who endorsed symptoms at time T1 had significantly higher scores on the psychological scale of psychosomatic disorders (measured at time T0). Subjects endorsing symptoms at time T2 had significantly higher scores on emotional instability. There was also a tendency to higher scores on this sub-scale for subjects with whiplash-associated disorders (WAD) at time T3. A discriminant analysis using all four psychological scales from time T0 had a power of 87%, 83% and 92% for correct classification of subjects as asymptomatic times T1, T2 and T3, respectively. Approximately 20% of subjects exposed to placebo, low-velocity rear-end collisions will thus indicate WAD, even though no biochemical potential for injury exists. Certain psychological profiles place an individual at higher risk for phenomenon.

[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.

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.

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.

Film Formation and Redispersion of Waterborne Latex Coatings.

Poly(vinyl acetate-co-ethylene) latex dispersions are prepared and their films investigated with a focus on the effect of composition upon redispersion. Films of dispersions containing sufficient amounts of poly(vinyl alcohol) (PVA) can be redispersed in water. This property is lost in the presence of surfactant, a fact which suggests a procedure to control film formation. It is demonstrated that redispersion is due to a PVA-membrane which separates the particles. Loss of redispersibility in the presence of surfactant proceeds with the breakup of the membranes and a corresponding change of film properties. Experimental data is provided by light microscopy, mechanical testing, and TEM in conjunction with a staining method new to the field. The hypothesis is developed that interaction with surfactant leads to imperfect PVA-membranes that are no longer able to prevent latex polymer interdiffusion. Fluorescence correlation spectroscopy demonstrates the formation of surfactant micelles, as well as the simultaneous adsorption and aggregation of PVA onto the micelles. It is concluded that the competing surface of the surfactant micelles traps enough PVA to cause thinning and fragmentation of the membranes surrounding the particles, which enables interdiffusion of latex polymer. This effect can be used to convert the system from one forming a redispersible coating to one forming a nonredispersible (permanent) film. Copyright 2000 Academic Press.

Surfactant-encapsulated clusters (SECs): (DODA)20(NH4)[H3Mo57V6(NO)6O183(H2O)18], a case study.

We present a comprehensive study of the partially reduced polyoxomolybdate [H3-Mo57V6(NO)6O183(H2O)18]21-encapsulated in a shell of dimethyldioctadecylammonium (DODA) surfacmolecules. Treatment of an aqueous solution of (NH4)21[H3Mo57V6-(NO)6O183(H2O)18] . 65H2O (1a) with a trichloromethane solution of the surfactant leads to instant transfer of the encapsulated complex anion into the organic phase. Results from vibrational spectroscopy. analytical ultracentrifugation, small-angle X-ray scattering, transmission electron microscopy, elemental analysis, and Langmuir compression isotherms are consistent with a single polyoxometalate core encapsulated within a shell of 20 DODA molecules. The molar mass of the supramolecular assembly is 20249 gmol(-1) and the diameter is 3.5 nm. A material with the empirical formula (DODA)20(NH4)[H3-Mo57V6NO)6O183(H2O)18] (2) was isolated as a dark violet solid, which readily dissolves in organic solvents. Slow evaporation of solutions of 2 on solid substrates forces the hydrophobic particles to aggregate into a cubic lattice. Annealing these so-formed films at elevated temperature causes de-wetting with terrace formation similar to liquid crystals and block copolymers. Compound 2 forms a stable Langmuir monolayer at the air-water interface; Langmuir-Blodgett multilayers are readily prepared by repeated transfer of monolayers on solid substrates. The films were characterized by optical ellipsometry, Brewster angle microscopy, transmission electron microscopy, and X-ray reflectance.

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.

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.

[Examining patients with facial skull fractures from an etiological and legal perspective]. / Untersuchung von Patienten mit Gesichtsschädelfrakturen unter ätiologischen und rechtsrelevanten Gesichtspunkten.

Maxillofacial traumas are common and often associated with other injuries. From a forensic point of view, it is often necessary to relate the traumatic event to the subsequent injuries. The aim of this study was to explore the etiology of maxillofacial injuries due to objective signs and the anamnestic history of patients. In a prospective study over a 1-year period, all patients presenting with mandibular and midface fractures seeking treatment at the University Medical Center in Münster. Germany, were investigated. Demographic data, patient history, and pattern and etiology of injury were recorded, along with evaluations of the patients' descriptions. Thorough clinical and radiological investigation was performed and photographic records were taken. In our study, 122 patients, with a male to female ratio of 2:1 were included. The mean age was 30.7 +/- 13.4 years. Assault was the most common etiology (40%), followed by traffic accidents (29%) and falls (17%). Alcohol was reported to play a role in 40% of all injuries. There was no difference in the number of patients with mandibular or midface fractures. In 75%, maxillofacial fractures were associated with other injuries. The patients' descriptions of the orofacial traumas seemed to be highly. For age, anatomical location, concomitant injuries, and other signs of trauma, we found no statistical association with the underlying etiology.

Organically modified aluminosilicate mesostructures from block copolymer phases

Organically modified aluminosilicate mesostructures were synthesized from two metal alkoxides with the use of poly(isoprene-b-ethyleneoxide) block copolymers (PI-b-PEO) as the structure-directing molecules. By increasing the fraction of the inorganic precursors with respect to the polymer, morphologies expected from the phase diagrams of diblock copolymers were obtained. The length scale of the microstructures and the state of alignment were varied using concepts known from the study of block copolymers. These results suggest that the use of higher molecular weight block copolymer mesophases instead of conventional low-molecular weight surfactants may provide a simple, easily controlled pathway for the preparation of various silica-type mesostructures that extends the accessible length scale of these structures by about an order of magnitude.

[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.

[Pulmonary artery catheters: are deadly complications avoidable?]. / Pulmonalarterienkatheter: Sind tödliche Komplikationen vermeidbar?

UNLABELLED: Three cases are presented dealing with rare lethal complications during the insertion of pulmonary artery catheters (PAC). Complications resulting from catheter insertion have been reported on numerous occasions; we report further examples of inadequate insertion techniques. CASE REPORTS: Deviating from the recommended guidelines was presumably a significant factor in the development of fatal pulmonary bleeding. In the first case PAC-related perforation of the right ventricle resulting in cardiac tamponade was found at autopsy. Clinically, this perforation had not been noticed. A guidewire was allegedly employed during insertion. The diameter of the perforation (3 mm) suggests that either the balloon was deflated or the guidewire was used incautiously. In the second case during insertion the balloon was described as being inflated "after" reaching a wedge position. Considering this fact, catheter migration with perforation of a distal small artery was evident. Distal migration is more frequently associated with rupture of the pulmonary artery. In the third case we found a sequence of intimal lesions in the right main pulmonary artery and a segmental artery of the right lung. This high number of PAC-induced lesions is unusual and suggests inappropriate inflation technique. CONCLUSIONS: Based on our observations, we believe the low complication rate associated with PAC insertion has led to deviations from the normal guidelines by some physicians. Despite adequate precautions and insertion technique, iatrogenic lesions cannot be avoided in all cases because of pre-existing risk factors. For the evaluation of catheter-induced complications and the development of a risk profile, more autopsies as well as more detailed clinical documentation would be necessary.

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.

Macrophage subtype patterns in protracted asphyxiation.

The question was examined whether protracted asphyxiation is associated with a distinct macrophage subtype pattern in lung tissue. Immunohistochemical preparations of lung specimens were tested with the antibodies MRP8, MRP14, 27E10 and 25F9 in cases of protracted asphyxiation (n = 8) and in "control" groups (hanging: n = 6; peracute deaths: n = 9). MRP8 and MRP14 interstitial cell counts showed a doubling in protracted asphyxiation. Furthermore, clear increases of 27E10 and 25F9 cells (intravascular and interstitial) were found in protracted asphyxiation, both in the intravascular and interstitial compartments. At present the results look promising as to an additional diagnostic criterion for the differential diagnosis between acute and protracted asphyxiation.