Medicolegal assessment of blood transfusion errors--an interdisciplinary challenge

Given a current total incidence of erroneously administered blood transfusions of 1:12,000-1:36,000 (AB0 incompatible 1:38,000), the percentage of lethal outcomes ranges between 2 and 5%; i.e. the sole fact of an erroneous transfusion does not mandatorily result in a causal connection with lethal outcome, which can give rise to problems in the medicolegal assessment. We report on the conception and results of a novel interdisciplinary approach to assess the lethal significance of blood transfusion errors. Besides autopsy, histological investigation and immunohistochemical detection of AB0 incompatible foreign red blood cells in autopsy specimens, transfusion medicine investigations offer the opportunity to assess several immunohaematologic features. We assessed the immunohaematologic gel card ("microcolumn") technique for suitability in the forensic assessment of an AB0 incompatible transfusion incident in a septic patient, who had had no history of previous blood transfusions, with lethal outcome. After such an erroneous transfusion had been simulated in vitro, pre-transfusion and cadaver patient blood samples (p.m. interval: 3 days) were analysed. Amongst other things, IgG-loaded erythrocytes were detected in pre- and post-transfusion samples; the presence of irregular antibodies directed against blood group antigens and anti-A or anti-B isoagglutinins, respectively, especially in the pre-transfusion sample was ruled out. Besides the demonstration of AB0 incompatible red blood cells in the cadaver blood sample, blood group incompatibilities other than AB0 were excluded. With regard to the cause of death, in synopsis with autopsy findings and clinical symptoms, the results did not allow for a final discrimination between the impact of the pre-existing septic inflammatory response syndrome and sepsis, respectively, and potential lethal effects of a (haemolytic) transfusion reaction. Besides pre- and post-transfusion compatibility testing in clinical transfusion medicine as required by German National Guidelines, the reported immunohaematologic investigations offer an important supportive tool for the forensic assessment of lethal erroneous transfusions and investigation of blood samples of survivors of transfusion incidents as well. Besides established morphological techniques, they allow for a certain evaluation of the pathophysiological impact of transfusion incidents as well as a diversified assessment of immunohaematologic features beyond the AB0 system.     

Distributions of genetic markers in a Nebraska population

Seven genetic marker systems were analyzed from liquid blood and dried bloodstain specimens submitted to the Nebraska State Patrol Crime Laboratory from various law enforcement agencies throughout Nebraska. The phenotypic and genotypic frequencies for the ABO, Lewis, esterase D (ESD), phosphoglucomutase (PGM), adenylate kinase (AK), adenosine deaminase (ADA), and haptoglobin (HP) systems were calculated. The results indicate that the phenotypic frequencies are generally in agreement with frequencies reported in other populations in the United States.     

Validation studies of an immunochromatographic 1-step test for the forensic identification of human blood.

An immunochromatographic 1-step test for the detection of fecal occult blood was evaluated for applicability for the forensic identification of human blood in stained material. The following experiments were conducted: 1) determination of the sensitivity and specificity of the assay; 2) evaluation of different extraction media for bloodstains (sterile water, Tris buffer pH 7.5 provided in the test kit, 5% ammonia); 3) analysis of biological samples subjected to a variety of environmental insults; and 4) evaluation of casework samples. This immunochromatographic 1-step occult blood test is specific for human (primate) hemoglobin and is at least an order of magnitude more sensitive than previous methods for detecting human hemoglobin in bloodstains. The antigen is insensitive to a variety of environmental insults, except for exposure to certain detergents and household bleaches and prolonged exposure to certain preparations of luminol. The entire assay can be conducted in field testing conditions within minutes. When in the laboratory the supernatant from a DNA extraction is used for the assay, there is essentially no consumption of DNA for determining the presence of human hemoglobin in a forensic sample. The data demonstrate that this test is robust and suitable for forensic analyses.     

European "Federalism" and its Encroachments on National Institutions

The European Union is a supranational governance organizationthat is more federal than unitary but which, instead of a constitutionallyestablished balance of powers, exhibits a dynamic confusionof powers. This institutional structure has not only servedto subordinate member-states' institutional structures, whetherfederal or unitary, and to alter their traditional balance ofpowers, it has also served to reduce national governmental autonomyin the name of a shared supranational authority, diminish nationalcontrol over subnational units, and undermine democratic legitimacyat both the national and EU levels. It has had a differentialeffect on member states, with a greater disruptive impact onunitary states, such as France and Britain, than on federalstates, such as Germany.     

Local level political and institutional changes in Japan: An end to political alienation?

Background  In Japan, a steady increase of non-voters is evident on the national and local levels over the past few decades. However, since the mid-1990s, a new wave of political participation at the local level has attracted politicians as well as social scientists. Citizen participation is increasing in terms of the number of non-profit organizations, participatory procedures, and engagement in new political networks. Citizens growing involvement in local politics coincides with institutional changes that offer new autonomy in respect of local policy-making.Objectives  In this paper, we will argue that these local trends might have an impact on national politics through the repolitization of citizens. However, preconditions are, ceteris paribus, the restoration of political trust through participation and institutional changes that support citizen involvement in politics.The authors have been engaged in a project on “Civil Society in Japan: Partnership as a New Item of Japan’s Local Politics” since 1 March 2006. The project is located at the Department for Japanese Studies at the Martin Luther University of Halle-Wittenberg (Germany) and financed by the German Research Foundation (Deutsche Forschungsgemeinschaft, DFG).

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Form variants of globular hyaline microthrombi. Light microscopy, immunohistochemical and scanning and transmission electron microscopy observations

Globular hyaline microthrombi are characterized by their diameter (2-30 micron), globular form, and positive PAS and PTAH reaction. They are a morphologic indicator of disturbed microcirculation and hemostasis, such as that occurring in shock. In two of our cases, we observed large globular hyaline microthrombi, some with central webbed degradation progressing to the formation of closed or open hollow globules. The electron microscopic findings were similar to those observed by other investigators in typical shock bodies. On the basis of the morphologic findings, the authors conclude that degradation phenomena start at the center of globular hyaline microthrombi and can progress to the surface where accelerated fibrinolysis is possible. The cellular elements that other investigators have described as a possible condensation center for fibrin precipitate proved to be structurally intact cells that are apparently located in niches of open hollow globules or in the center of circular hyaline microthrombi. The diagnostic relevance, vitality, and temporal classification are discussed.     

Legal incompetents' need for guardians in Florida

This study assesses the alleged need for guardians in Florida. A survey of the state's 74 public receiving facilities, community mental health centers, and clinics; 30 private receiving facilities; 11 Aging and Adult district offices; Developmental Services institutional and residential placements; and six state mental hospitals revealed that 11,147 persons in Florida reportedly need a legal guardian. The limitations, implications, and possible policy responses to this alleged need are discussed.     

Sharp force injuries in clinical forensic medicine--findings in victims and perpetrators

The injury findings in 58 perpetrators and 158 victims surviving bodily injuries due to sharp force are presented here. Defence injuries were found in 45.9% of the victims without any significant differences between males and females. There was no clear predominance of defence injuries on the left forearm and hand, as is known from autopsy studies; the right and the left hands were affected with an almost identical frequency. Regarding other parts of the victims' bodies, the topographic distribution of injuries showed a marked concentration on the left side (63.7%). The thorax, head and neck were frequently affected (45.9%, 15.3% and 15.3%, respectively), and less often the abdomen (11.1%), the lumbar and gluteal region (6.3%) and the lower extremities (6.1%). In surviving victims with only one singular stab apart from the upper limbs, the incidence of additional defence injuries on the hands and/or forearms was significantly higher (28.3%) than in fatalities. When the perpetrators had unintentionally cut their own hands, the frequency of these injuries on the right and left hands was almost equal.