The role of the autopsy in medical malpractice cases,II: controversy related to autopsy performance and reporting

CONTEXT: We studied 99 appellate court records in cases of alleged medical malpractice and found no relationship between discrepant clinical and autopsy findings and outcome of litigation. Standard-of-care issues and not diagnostic accuracy were at the heart of every case. OBJECTIVE: To characterize and discuss issues related to the autopsy and/or pathologist behavior that were raised in court records of medical malpractice litigation. DESIGN: In 18 appellate court records, issues were raised about quality of autopsy performance and reporting or about death certification. The details of these controversies are succinctly reported here in a manner intended to be instructive to pathologists who perform autopsies in a hospital setting or on a private fee-for-service basis. CONCLUSION: Autopsy reports are intended to provide objective medical information in a coherent format to the patient's medical record, to the attending physician and other concerned staff physicians, to other health care professionals, and to the families of the deceased. Inevitably, occasions arise that require legal counsel to be added to this list of parties with a legitimate interest. Our findings emphasize that incomplete, incoherent, obfuscated, or delayed reporting of autopsy findings do not meet professional standards, are unethical if intentional, and may be counterproductive.     

Acute retrograde aortic dissection during endovascular repair of a thoracic aortic aneurysm

Endovascular aneurysm exclusion represents a valuable alternative treatment for descending thoracic aortic aneurysms. Although the minimally invasive character of this procedure is obvious, major complications are possible. We report a 77-year-old male who developed acute retrograde dissection of the aortic arch and ascending aorta during endovascular stent-grafting of a descending aortic aneurysm. Emergent open surgical repair provided a successful outcome.     

Bilateral pulmonary artery banding for resuscitation in hypoplastic left heart syndrome

We report a case of a hypoplastic left heart syndrome with a nearly intact atrial septum and an obstructed anomalous pulmonary to systemic venous connection. Surgical atrial septectomy followed by bilateral pulmonary artery banding provided an optimal condition for the Norwood operation.     

Transrenal fixation of endovascular stent-grafts for infrarenal aortic aneurysm repair: mid-term results

PURPOSE: We evaluated mid-term results of a single-center consecutive series of endovascular stent-grafts implanted for aortic aneurysm repair with transrenal fixation, to determine clinical outcome, aneurysm anatomy, renal artery patency, and renal complications. METHODS: Modular stent-grafts were placed with transrenal fixation in 37 patients between November 1998 and July 2000. Follow-up evaluation included clinical examination, laboratory evaluation of serum creatine concentration, computed tomographic angiography, and renal duplex scanning. RESULTS: Thirty-seven patients underwent transrenal fixation of aortic stent-grafts as part of a Phase II US Food and Drug Administration study. Two patients subsequently underwent follow-up at institutions closer to their homes, and thus provided clinical information but no long-term renal or aneurysm morphologic data. There were no perioperative deaths. Five patients died during follow-up, at a mean of 9 months, because of myocardial infarction in 4 patients and respiratory failure in 1 patient. Thirty patients, ages 75 +/- 8 years, have been followed up for 28.5 +/- 7.2 months. Aneurysm diameter at follow-up was 5.0 +/- 0.8 cm, compared with 5.7 +/- 0.8 cm preoperatively. In 5 patients, endoleak developed during follow-up: 1 type I leak was treated with an aortic cuff, with temporary stabilization of the aneurysm and correction of the endoleak; 2 type II endoleaks were treated with translumbar coil embolization, and 1 resolved spontaneously; and 1 type III endoleak was treated with a combination of coil embolization and stent-graft extension to cover a graft defect. Preoperatively, serum creatinine concentration was normal in 23 patients, but increased persistently in 2 patients and was abnormal in 7 patients. Postoperatively, creatine concentration increased in 4 patients to greater than 20% of baseline level. Seventeen patients had no evidence of renal artery stenosis, compared with 13 patients with renal artery stenosis. Of 41 normal renal arteries, 90% remained unchanged, 1 became occluded, 3 demonstrated 60% stenosis. Nephrectomy was necessary in 1 patient because of cancer. Of 19 abnormal renal arteries, progression of disease was noted in 3 arteries. CONCLUSIONS: Transrenal fixation of aortic stent-grafts can be performed with acceptable mid-term outcome with respect to mortality, need for follow-up intervention, and aneurysm exclusion with protection from rupture. Postprocedural stenosis can develop in both normal and abnormal renal arteries. Rate of progression of disease was greater in patients with preprocedural renal dysfunction compared with patients with normal renal arteries. This is merely an observation, and may not be related to transrenal fixation. Long-term follow up is needed.     

Food choices among newly married couples: convergence,conflict, individualism,and projects

Individuals entering marriage merge their personal food systems to create a joint spousal food system. This investigation examined newly married couples' food choices. Qualitative interviews conducted with 20 couples as they entered marriage and again 1 year later revealed that some reported initial food homogamy, while others had varying degrees of compatibility in food preferences and tolerances. All couples reported some dietary convergence. Convergence was initially symmetrical (similar merging for both partners) or asymmetrical (one partner changed more), and sometimes convergence patterns evolved further. Unresolved food choice negotiations led to food conflicts. Prior food broadening experiences, initial dietary congruity, health/weight philosophies, foodwork, and commensal patterns were conditions shaping couples' food choice negotiations and dietary convergence patterns. Some food individualism persisted for most partners, helping to alleviate food choice conflicts. Food projects occurred when one partner was committed to molding the other's food choices. Overall, food choice negotiations involving both convergence and conflict were important components of marital adjustments that may have later health consequences.     

Outcome of pediatric patients treated with extracorporeal life support after cardiac surgery

Background

Extracorporeal life support (ECLS) has been used for over two decades in select patients after cardiac surgery. We previously described factors associated with death in this population. We now review our recent experience to reassess factors related to mortality.

Methods

All pediatric patients who received ECLS support within 7 days after surgery between July 1995 and June 2001 were examined to describe clinical features associated with survival. We compared the results with our prior report to assess changes in practice and outcome.

Results

Seventy-four patients were followed. Fifty percent survived to discharge. Hospital survival was not significantly related to patient age, cannulation site, or indication. Thirty-five percent of patients required hemofiltration while on ECLS and were significantly less likely to survive (23% vs 65%). A multivariate analysis combining all children from our prior report with the present cohort revealed that patients who received hemofiltration were five times more likely to die (odds ratio 5.01, 95% confidence interval 2.11-11.88). Children with an adequate two-ventricular repair had lower risk of death (odds ratio 0.42, 95% confidence interval 0.19-0.91) after adjusting for patient age, study period, and hours elapsed before initiation of ECLS after surgery.

Conclusions

Patients with an adequate two-ventricle repair have significantly higher hospital survival, whereas those with single ventricle physiology or need for dialysis have decreased survival.     

Black stain and dental caries in schoolchildren in Potenza, Italy

This study examined the correlation between dark pigmented dental plaque (black stain) and caries. Black stain was observed in 67 of 1086 schoolchildren (from 6-12 years old). The mean DMF-T was 0.49 = 1.05 for children with black stain and 0.97 = 1.40 for children with black without black stain (p<0.05). The results suggest an association between black stain and a decreased caries experience at least in the permanent dentition. Further studies are necessary to examine the etiology and whether or not black stain can protect against caries.     

Computer-assisted education for critical care nurses

Technology is changing rapidly and health care is just beinnng to see the wave of technological advances. Computer-assisted educational software is available for many topics and in many media. Educators and learners need to explore these media and determine how they can best fit into a total learning experience. Computers should be used to enhance education and training, rather than replace the human instructor. The latest software and hardware are interesting to learners, but technology needs to be weighed along with outcomes of education. Over the next 10 years, many of the materials we use today for critical care education will be replaced with more advanced technologies. Subject matter experts should work with computer experts to design and improve computer-assisted technology. In addition, all educators should assess the return on investment of these newer technologies before embracing them.     

Liver disease caused by failure to racemize trihydroxycholestanoic acid: gene mutation and effect of bile acid therapy

BACKGROUND & AIMS: Inborn errors of bile acid metabolism may present as neonatal cholestasis and fat-soluble vitamin malabsorption or as late onset chronic liver disease. Our aim was to fully characterize a defect in bile acid synthesis in a 2-week-old African-American girl presenting with coagulopathy, vitamin D and E deficiencies, and mild cholestasis and in her sibling, whose liver had been used for orthotopic liver transplantation (OLT). METHODS: Bile acids were measured by mass spectrometry in urine, bile, serum, and feces of the patient and in urine from the unrelated recipient. RESULTS: Liver biopsy specimens showed neonatal hepatitis with giant cell transformation and hepatocyte necrosis; peroxisomes were reduced in number. High concentrations of (25R)3alpha,7alpha,12alpha-trihydroxy-5beta-cholestanoic acid in the urine, bile, and serum established a pattern similar to that of Zellweger syndrome and identical to the Alligator mississippiensis. Serum phytanic acid was normal, whereas pristanic acid was markedly elevated. Biochemical, MRI, and neurologic findings were inconsistent with a generalized defect of peroxisomal function and were unique. Analysis of the urine from the recipient of the deceased sibling's liver confirmed the same bile acid synthetic defect. A deficiency in 2-methylacyl-CoA racemase, which is essential for conversion of (25R)THCA to its 25S-isomer, the substrate to initiate peroxisomal beta-oxidation to primary bile acids, was confirmed by DNA analysis revealing a missense mutation (S52P) in the gene encoding this enzyme. Long-term treatment with cholic acid normalized liver enzymes and prevented progression of symptoms. CONCLUSIONS: This genetic defect further highlights bile acid synthetic defects as a cause of neonatal cholestasis.