Amniotic fluid embolism-apropos two consecutive cases

Amniotic fluid embolism (AFE) is a sporadic, unpredictable, and usual fatal obstetric complication. The paper deals with two cases of maternal deaths because of AFE verified by medicolegal autopsy. In both the cases, several known risk factors associated with AFE, such as increased maternal age (41 and 35 years), diabetes, augmented labor, and cesarean delivery, were identified. Clinical features were typical, including sudden onset of cardiovascular and respiratory symptoms. In the patient who survived longer, both clinical and autopsy signs of disseminated intravascular coagulopathy were present, while they were absent in the case where death occurred rapidly. This paper describes briefly the particular features to look for at autopsy and stresses the importance of histology examination and staining techniques.     

羊水栓塞死亡医疗纠纷案件的法医学分析

目的分析引发医疗纠纷的羊水栓塞死亡病例的相关因素,以帮助提高对羊水栓塞诊治能力,减少医疗纠纷。方法对我中心2006～2009年间鉴定的8例医疗纠纷相关羊水栓塞死亡病例的临床资料及过失认定进行回顾性分析。结果（1）医疗因素分析：7例具有使用催产素史;3例发生于产前破膜后,5例发生于产后;具有典型临床症状5例,不典型临床症状3例;早期诊断7例;3例实施子宫次全切除术;发生在二级医院以下6例。（2）法医学鉴定分析：催产素使用不当及观察记录缺陷占87.5%（7/8）;7例早期诊断羊水栓塞,但在供氧、解痉和子宫切除方面存在治疗缺陷。结论提高对产前、产后羊水栓塞症状特点的认识和处置能力,强化病历记录规范、完整及充分告知说明,是减少医疗纠纷案件的关键,也是法医学鉴定判断的重要依据。     

羊水栓塞诊断的方法学研究进展及法医学意义

羊水栓塞(amniotic fluid embolism,AFE)是指分娩过程中羊水进入母血循环,引起肺栓塞、休克甚至死亡等一系列严重症状的综合征。目前对于AFE的诊断为排除性诊断,方法缺乏灵敏性和特异性。因此随着以AFE为死因的孕产妇病死率的升高,寻找更精确的AFE诊断方法成为了法医学研究的重点。本文结合相关文献概述了AFE诊断方法的研究进展,希望能为法医学鉴定提供方法学参考。     

实验性兔羊水栓塞血浆NO和ET的含量变化

目的观察兔羊水栓塞(AFE)后血浆一氧化氮(NO)、内皮素(ET)含量的动态变化。方法采用怀孕家兔制作羊水栓塞动物模型,将不同性质的自身羊水注入兔血循环,分别在羊水注入前、注入后5min、45min从兔心脏取血,用镉还原法、放射免疫分析(RIA)法分别检测血浆中NO和ET的动态变化。结果注入羊水后ET含量显著增加,NO含量则显著降低,对照组无显著变化。NO与ET含量变化呈显著负相关。结论NO、ET的动态变化在羊水栓塞早期的一过性肺动脉高压及随后发生的DIC等过程中起重要作用。     

APM染色法在羊水栓塞诊断中的应用价值

目的　探讨APM染色法在羊水栓塞 (AFE)病理学诊断中的应用价值。方法　采用APM染色法对 1988年至 2 0 0 1年确诊为AFE的 19例病例 (AFE组 )和羊水吸入性肺炎的胎儿 3例 (阳性对照组 )、其它死因的 10例产妇 (阴性对照组 )重新进行染色和组织学检查 ,对其检验结果进行比较分析。结果　阳性组全部检出羊水成分 ,阴性组部分病例检出羊水成分 ,发现漏诊、误诊各 1例。与HE染色相比较 ,APM染色能提高角化上皮和粘液的检出率。结论　APM染色能提高羊水成分的检出率 ,有助于提高AFE诊断的准确性 ,可用于AFE病理学诊断。     

上海地区非法行医致孕妇死亡案例回顾性研究

目的研究上海地区非法行医致孕妇死亡案例并分析其特点,探究其形成原因及预防机制。方法收集本研究所2001～2005年接受上海市公安机关委托非法行医致孕妇死亡案例11例,按照孕妇情况、死亡原因及非法行医者的诊疗措施等进行分类整理分析。结果非法行医致孕妇死亡的原因多为产后大出血、羊水栓塞,多伴软产道裂伤。孕妇多未进行正规产前检查,到缺乏必要医疗条件的个体非法行医者处或者家中分娩,非法行医者往往存在不正当应用催产素,强行分娩,未采取及时有效抢救措施。     

Retrograde venous cerebral air embolism from disconnected central venous catheter: an experimental model

There are few reported cases of death attributed to retrograde cerebral air embolism from central venous catheter. The pathophysiological mechanism and the necessary conditions are not fully understood, also because of missing experimental data. We performed experimental simulation while working on a possible case of retrograde cerebral air embolism. A hermetic system consisting of two containers connected to each other and to an electric pump by means of rubber hoses was built. In this system, a fluid (water and blood) could continuously flow under conditions similar to those of the common jugular vein. The part of the system representing the jugular vein could be freely positioned at angles between 0 and 90°. A central venous catheter was inserted into this part. After disconnection, the behavior of the air bubbles entering the hose through the tip of the catheter was evaluated at different positions. At angles between 0 and 45°, the air bubbles followed the fluid flow. At angles >45°, the air bubbles showed the tendency to flow upstream; this phenomenon was more evident the more vertically the hose was located. We were able to demonstrate that a retrograde air embolism can be caused by a disconnected catheter and is even more likely if the neck is in a vertical position.     

实验性兔羊水栓塞肥大细胞类胰蛋白酶的含量变化

目的观察家兔羊水栓塞 (AFE)后肺组织中肥大细胞类胰蛋白酶 (MCT)含量的变化。方法分别于健康怀孕家兔耳缘静脉注入羊水、制造羊水栓塞的动物模型 ;取肺组织进行HE染色和免疫组织化学MCT染色 ,镜下观察AFE兔肺组织中MCT的变化。结果对照组兔肺组织MCT呈弱阳性反应 (平均阳性细胞计数 11 2 5个 ) ,注入羊水组和注入胎盘提取液与羊水混合液组肺组织中MCT呈强阳性反应 (平均阳性细胞计数分别为 3 2 98和 45 5 3个 )。结论在羊水栓塞时兔肺组织MCT含量增加     

实验性兔羊水栓塞血浆凝血指标的含量变化

目的观察兔羊水栓塞(AFE)后血浆凝血指标的动态变化。方法采用怀孕家兔制作羊水栓塞动物模型,将不同性质的自身羊水注入兔血循环,分别在羊水注入前、注入后,5min、45min从兔心脏取血,用血凝仪检测血浆中各项凝血指标包括纤维蛋白原定量(FIB)、血浆凝血酶原时间(PT)、凝血酶凝固时间(TT)、活化部分凝血活酶时间(APTT)的动态变化。结果注入羊水后PT、TT、APTT时间显著延长(P<0.01),FIB则显著降低(P<0.01),而对照组无显著变化(P>0.05)。结论凝血指标的动态变化表明羊水栓塞早期有发生DIC的趋势,胎盘提取液中的某些成分可能加重了DIC的严重程度。     

完善我国医疗损害鉴定制度的思考

医疗鉴定意见在医疗纠纷案件的定性和裁判中具有十分重要的地位.我国现行的医疗鉴定制度由医学会组织的医疗事故技术鉴定和司法鉴定机构组织的医疗过错司法鉴定两者并存,形成了医疗鉴定制度“二元化”的现象.《中华人民共和国侵权责任法》的施行虽然消除了医疗损害赔偿案件适用法律的“二元化”问题,但医疗鉴定制度的“二元化”现象并没有被打破.探讨建立“一元化”的医疗鉴定制度,并引入专家辅助人制度对“一元化”医疗鉴定制度进行监督和辅助,希望在寻求司法公正与效率的基础上建立更加科学、完善、合理的医疗鉴定体制.     

医疗损害鉴定主体改革刍议

医疗损害鉴定主体,包括鉴定机构及鉴定人,是医疗损害鉴定制度改革的起点。医疗事故鉴定模式中的专家组并不是鉴定主体．但其合议制的实质对鉴定结论的科学性具有重要作用,应予保留。应改革鉴定结论形成机制,允许出具多样化的鉴定结论。医疗损害鉴定制度的改革应采取司法行政部门主管、司法鉴定机构组织鉴定工作、医学会推荐鉴定人的模式。由于医学的专业性极强,鉴定人应当来自于现任专职医务人员。在保证鉴定人中立性、公正性的同时,要重视保证医务人员参与鉴定工作的积极性。     

Iatrogenic Burns of the Neckline in a Patient with Tetraparesis During Tracheotomy

The paper presents a case of an atypical iatrogenic complication after tracheotomy analyzed on the basis of the case dossier materials submitted to the authors by the court of justice to prepare a forensic medical opinion concerning the correctness of the medical procedure. A 37‐year‐old woman was brought by the ambulance service to the hospital with acute respiratory failure due to post‐tracheostomy tracheal stenosis. Tracheotomy was performed on an emergency basis. The patient suffered severe burns of the chest and neck. The experts concluded that the most probable cause of the incident was electrocautery‐induced ignition of the disinfectant used for cleaning the skin before the surgery. It was established that with correct handling of the procedure, the aforementioned incident should not have taken place. Therefore, it cannot be regarded as a normal complication inherent in the risk associated with the procedure, but as a consequence of a medical error.     

医疗损害鉴定主体改革刍议

医疗损害鉴定主体,包括鉴定机构及鉴定人,是医疗损害鉴定制度改革的起点。医疗事故鉴定模式中的专家组并不是鉴定主体,但其合议制的实质对鉴定结论的科学性具有重要作用,应予保留。应改革鉴定结论形成机制,允许出具多样化的鉴定结论。医疗损害鉴定制度的改革应采取司法行政部门主管、司法鉴定机构组织鉴定工作、医学会推荐鉴定人的模式。由于医学的专业性极强,鉴定人应当来自于现任专职医务人员。在保证鉴定人中立性、公正性的同时,要重视保证医务人员参与鉴定工作的积极性。     

Analysis of Dental Case Reports in the Context of Court Decisions: Causal Nexus and Aspects of Fault

The purpose of expert reports is to support the judge in his decisions, by providing technical information. However, it remains uncertain as to what extent the content of these reports is used, and if they are effectively associated with judicial decisions. The aim of this study was to perform a qualitative analysis of case reports in relation to the judicial decisions rendered in association with these reports, by determining the connection between causal nexus and aspects of fault. The case reports included lawsuits against dentists, issued by the Medical Justice Department of the State Court of Appeals of Rio Grande do Sul, Brazil, between 2010 and 2013. Comparing the percentage of agreement between case report and judicial decision, causal nexus was 79.9% and fault was 86.7%. The high percentages of agreement found in relation to fault and causal nexus highlight the relevance of expert reports in weighing the judge's decision.     

从法医角度看医疗纠纷及其产生的原因与防范

从医疗纠纷鉴定人角度研究医疗纠纷,为相关机构防范医疗纠纷提供思路。医疗纠纷是多种原因引起的,一般采用诉讼方式解决。法医在医疗纠纷的解决中扮演重要角色。在医疗纠纷鉴定中要判定诊疗行为对患者造成的损害后果,判定诊疗行为是否存在医疗过失,判定医疗过失与损害后果之间的因果关系．正确地进行死因分析和证据的取舍认定。在引起医疗纠纷的原因中,以技术性、责任心、医患交流不足等方面的原因居多。医护人员应提高自身的业务水平、责任心及服务质量;加强医患交流,建立畅通的医患沟通渠道;增强自我法律防护意识,建立健全的医疗规章管理制度。     

Medical Terminology Coding Systems and Medicolegal Death Investigation Data: Searching for a Standardized Method of Electronic Coding at a Statewide Medical Examiner’s Office*

Abstract: Medical examiner and coroner reports are a rich source of data for epidemiologic research. To maximize the utility of this information, medicolegal death investigation data need to be electronically coded. In order to determine the best option for coding, we evaluated four different options (Current Procedural Terminology [CPT], International Classification of Disease [ICD] coding, Systematized Nomenclature of Medicine Clinical Terms [SNOMED CT], and an in‐house system), then conducted internal and external needs assessments to determine which system best met the needs of a centralized, statewide medical examiner’s office. Although all four systems offer distinct advantages and disadvantages, SNOMED CT is the most accurate for coding pathologic diagnoses, with ICD‐10 the best option for classifying the cause of death. For New Mexico’s Office of the Medical Investigator, the most feasible coding option is an upgrade of an in‐house coding system, followed by linkage to ICD codes for cause of death from the New Mexico Bureau of Vital Records and Health Statistics, and ideally, SNOMED classification of pathologic diagnoses.     

Educating Jurors about Forensic Evidence: Using an Expert Witness and Judicial Instructions to Mitigate the Impact of Invalid Forensic Science Testimony

Invalid expert witness testimony that overstated the precision and accuracy of forensic science procedures has been highlighted as a common factor in many wrongful conviction cases. This study assessed the ability of an opposing expert witness and judicial instructions to mitigate the impact of invalid forensic science testimony. Participants (N = 155) acted as mock jurors in a sexual assault trial that contained both invalid forensic testimony regarding hair comparison evidence, and countering testimony from either a defense expert witness or judicial instructions. Results showed that the defense expert witness was successful in educating jurors regarding limitations in the initial expert's conclusions, leading to a greater number of not-guilty verdicts. The judicial instructions were shown to have no impact on verdict decisions. These findings suggest that providing opposing expert witnesses may be an effective safeguard against invalid forensic testimony in criminal trials.     

HPLC-DAD determination of mepivacaine in cerebrospinal fluid from a fatal case

A fatal case involving mepivacaine-induced epidural anesthesia is described. The pathological findings were typical of cardiac shock from ischemic origin. Cerebrospinal fluid (CSF) was obtained several hours after death and mepivacaine was identified by gas chromatography-mass spectrometry (GC-MS). Its concentration was determined by high performance liquid chromatography with diode array detection (HPLC-DAD). Extraction from CSF was performed by deproteinization with acetonitrile. The mepivacaine concentration in the sample was 264 microg/mL. Concentrations of mepivacaine in CSF following epidural anesthesia are not reported in literature to our knowledge. This is the first reported case of death in which the mepivacaine concentration in CSF has been determined.     

A Case of Lethal Idiopathic Plasmacytic Lymphadenopathy with Polyclonal Hypergammaglobulinemia: A Medical Challenge for the Forensic Pathologist

A rare case of lethal idiopathic plasmacytic lymphadenopathy (IPL) with polyclonal hyperimmunoglobulinemia with chronic renal failure is described. A 40‐year‐old woman who had suffered from upper airways disease was admitted to the Emergency Room with acute renal failure and hypergammaglobulinemia. She developed pericardial effusion, a pruritic rash, splenomegaly and fell into a coma after 6 days. Multiple myeloma, infection, collagenopathy, and coagulopathy were ruled out. Finally, a form of malignant hypergammapathy was suspected. At autopsy, lymph nodes were infiltrated by polyclonal plasma cells and lymphocytes, with erythrophagocytosis features; immunohistochemistry confirmed the plasma cells (CD138+), with a prevalence of kappa‐positive cells, B (CD20+) and T (CD3+) cells. Kidneys showed advanced glomerulosclerosis containing similar infiltrates. The cause of death was IPL with polyclonal hypergammaglobulinemia and advanced renal failure. Similar cases are unusual, and possible medical liability associated with failure to diagnose and treat idiopathic plasmacytic lymphadenopathy deserves discussion and further studies.