Abgrenzung Diagnosefehler zu Befunderhebungsfehler

In medical malpractice allegations the burden of proof is often crucial to the outcome of the proceedings. In principle, the burden of proof is assigned to the complainant (patient) and only in exceptional cases, especially in the presence of a gross error in treatment, is the burden of proof reversed so that the defendant (physician) has to prove that the treatment did not cause injury to the patient. To supply this proof is of course very difficult. In this context a judgment of the Federal Court of Justice (BGH) from December 2010 achieves a special significance which, in conjunction with an earlier BGH ruling in April 2004, provides that this reversed burden of proof applies even for a slight error in assessment of findings but in contrast only for a very serious diagnostic error. The failure to recognize assessment of findings as medically necessary thus represents the considerably more medicolegally serious offence of medical misdemeanour. On the other hand, a much larger scale diagnostic error is classified as an ultimately not always avoidable medical error that can occur without negligence. From the perspective of practitioners it is recommended that a diagnosis (at least a tentative diagnosis) should be derived on the basis of the findings obtained or if this does not appear possible to initiate other necessary diagnostic measures. From the perspective of the medical expert, the expert recommendation is to always very carefully differentiate between these two medical errors in medical liability cases.     

Liposomes for Topical Use: A Physico-Chemical Comparison of Vesicles Prepared from Egg or Soy Lecithin

Developments in nanotechnology and in the formulation of liposomal systems provide the opportunity for cosmetic dermatology to design novel delivery systems. Determination of their physico-chemical parameters has importance when developing a nano-delivery system. The present study highlights some technological aspects/characteristics of liposomes formulated from egg or soy lecithins for topical use. Alterations in the pH, viscosity, surface tension, and microscopic/macroscopic appearance of these vesicular systems were investigated. The chemical composition of the two types of lecithin was checked by mass spectrometry. Caffeine, as a model molecule, was encapsulated into multilamellar vesicles prepared from the two types of lecithin: then zeta potential, membrane fluidity, and encapsulation efficiency were compared. According to our observations, samples prepared from the two lecithins altered the pH in opposite directions: egg lecithin increased it while soy lecithin decreased it with increased lipid concentration. Our EPR spectroscopic results showed that the binding of caffeine did not change the membrane fluidity in the temperature range of possible topical use (measured between 2 and 50 °C). Combining our results on encapsulation efficiency for caffeine (about 30% for both lecithins) with those on membrane fluidity data, we concluded that the interaction of caffeine with the liposomal membrane does not change the rotational motion of the lipid molecules close to the head group region. In conclusion, topical use of egg lecithin for liposomal formulations can be preferred if there are no differences in the physico-chemical properties due to the encapsulated drugs, because the physiological effects of egg lecithin vesicles on skin are significantly better than that of soy lecithin liposomes.     

When is injury potentially reversible in a lung ischemia–reperfusion model?

ObjectiveTo verify the impact of ischemic time on lung cell viability in an experimental model of lung ischemia–reperfusion (IR) injury and its repercussion on lung performance after reperfusion.MethodsTwenty-four animals were subjected to selective clamping of the left pulmonary artery and divided into four groups (n = 6) according to ischemic time: 15 (IR15), 30 (IR30), 45 (IR45), and 60 min (IR60). All animals were observed for 120 min after reperfusion. The hemodynamics, arterial blood gases measurements, and histologic changes were analyzed. Immunofluorescence assays for caspase 3 and annexin V were performed. Lipid peroxidation was assessed by thiobarbituric acid–reactive substances, and caspase 3 activity was assessed by colorimetric extract.ResultsThe partial pressure of arterial oxygen significantly decreased at the end of the observation period in the IR30, IR45, and IR60 groups (P < 0.05). The final mean arterial pressure significantly decreased in the IR60 group (P < 0.05). We observed a significant increase in caspase 3 activity and caspase 3–positive cells by immunofluorescence in the IR45 group compared with the other groups (P < 0.05). Additionally, there was an increase in necrotic cells assessed by annexin V in the IR60 group. The histologic score did not show differences among the different groups.ConclusionsThe degree of cell damage had a negative impact on lung performance. Sixty minutes of lung ischemia and posterior reperfusion resulted in an increased number of necrotic cells, suggesting that these cells may not be able to reverse the effects of the IR injury because of the lack of viable cells.     

Interstitial nephritis and autoimmune pancreatitis: a case report

Autoimmune pancreatitis is a rare form of pancreatitis characterized by responsiveness to steroid therapy and an often relapsing disease course. The mainstay of therapy is oral corticotherapy. Associations of interstitial nephritis with various autoimmune disorders have been described. We hereby report the case of a 69-year-old Caucasian man with a 2-year history of autoimmune pancreatitis, who presented with impairment of kidney function, proteinuria, and hypertension. Renal histopathology showed severe diffuse interstitial nephritis. With oral prednisone and ACE inhibitor therapy, complete recovery of kidney function was not achieved and proteinuria persisted. Therefore, mycophenolate mofetil was initiated. After 8 weeks, serum creatinine decreased, and a nearly complete and sustained resolution of proteinuria was seen, while tapering oral steroid doses. With autoreactive T cells playing a major role in the pathogenesis of both diseases, a common etiology of pancreatitis and interstitial nephritis can be assumed, and the beneficial effects of an inhibitor of lymphocyte proliferation, such as mycophenolate mofetil, can be explained. We infer from our case that mycophenolate mofetil can be effective in the control of simultaneous autoimmune pancreatitis and interstitial nephritis.     

Marine biodiversity,ecosystem functioning,and carbon cycles

Although recent studies suggest that climate change may substantially accelerate the rate of species loss in the biosphere, only a few studies have focused on the potential consequences of a spatial reorganization of biodiversity with global warming. Here, we show a pronounced latitudinal increase in phytoplanktonic and zooplanktonic biodiversity in the extratropical North Atlantic Ocean in recent decades. We also show that this rise in biodiversity paralleled a decrease in the mean size of zooplanktonic copepods and that the reorganization of the planktonic ecosystem toward dominance by smaller organisms may influence the networks in which carbon flows, with negative effects on the downward biological carbon pump and demersal Atlantic cod (Gadus morhua). Our study suggests that, contrary to the usual interpretation of increasing biodiversity being a positive emergent property promoting the stability/resilience of ecosystems, the parallel decrease in sizes of planktonic organisms could be viewed in the North Atlantic as reducing some of the services provided by marine ecosystems to humans.     

Aligning Funding and Need for Family Planning: A Diagnostic Methodology

With limited international resources for family planning, donors must decide how to allocate their funds to different countries. How can a donor for family planning decide whether countries are adequately prioritized for funding? This article proposes an ordinal ranking framework to identify under‐prioritized countries by rank‐ordering countries by their need for family planning and separately rank‐ordering them by their development assistance for family planning. Countries for which the rank of the need for family planning is lower than the rank of its funding are deemed under‐prioritized. We implement this diagnostic methodology to identify under‐prioritized countries that have a higher need but lower development assistance for family planning. This approach indicates whether a country is receiving less compared to other countries with similar levels of need.     

Differentiated thyroid carcinoma: the new UICC 6th edition TNM classification system in a retrospective analysis of 169 patients.

AIM: To compare the new, 6th edition, UICC TNM staging system with the former edition, we updated TNM staging in patients with differentiated thyroid carcinoma. METHODS: The new and old TNM classification systems for differentiated thyroid carcinoma were applied in a retrospective analysis of 169 patients who underwent therapy with radioiodine (131I) from 1975 through 2002 at the Department of Nuclear Medicine, Frankfurt. RESULTS: According to the new staging system, 83 patients (49%) were classified as T1 compared to 54 patients (32%) based on the former edition; 32 patients (19%) as T2 compared to 61 (36%) patients formerly. In 44 patients with minimal extrathyroid extension, formerly classified T4, the new TNM staging changed to T3, and no patient was classified T4. The one year relapse-free survival fraction under the former edition staging was 100% for T1 and 92.2% for T2, compared to 96.8% for new edition T1 and 93.3% for T2. CONCLUSION: The new TNM classification causes a significant change in staging. New T1 classified tumors had a slightly worse relapse-free survival fraction compared with the old T1 carcinomas. For patients treated at our department, the altered criteria for classifying extrathyroid extensions have had only a minor impact on disease management.