[Caution: aggressive! Dog bite injuries in clinical forensic medicine]. / Vorsicht: bissig! Hundebissverletzungen in der klinischen Rechtsmedizin.

Younger children in particular are at risk of becoming victims of dog attacks due to their small size. Such a biting incident can fulfil various criminal offences. In order to be able to satisfy possible legal claims, the injuries should be documented by forensic medicine and thus be legally binding. Therefore, close cooperation between the treating surgeons and forensic experts is recommended. A retrospective analysis of the cases of dog bite injuries in children and adults treated by clinical forensic medicine at the University Medical Center Rostock was carried out under various aspects. Adult casualties were predominantly injured on the lower extremities. The children examined were predominantly bitten on the head, neck and face region as well as the upper extremities. Injury severity ranged from skin redness to severe substance defects with loss of body structures. The biting dog was known in about half of the cases. In order to avoid dog bites in children, parents as well as children should be trained in dealing with dogs.

Biomechanical comparisons of three minimally invasive Achilles tendon percutaneous repair suture techniques.

BACKGROUND: While no gold standard exists for the management of Achilles tendon ruptures, surgical repair is common in healthy and active patients. Minimally invasive repair methods have become increasingly popular, while biomechanical equivalency hasn't been proven yet. METHODS: A mid-substance Achilles tendon rupture was created 6 cm proximal to the calcaneal insertion in 27 fresh-frozen cadaveric ankles. Specimens were randomly allocated to 1 of 3 repair techniques: Huttunen et al. (2014) (1) PARS Achilles Jig System, Nyyssönen et al. (2008) (2) Achilles Midsubstance SpeedBridge™, Schipper and Cohen (2017) (3) Dresdner Instrument and subsequently subjected to cyclic loading with 250 cycles each at 1 Hz with 4 different loading ranges (20-100 N, 20-200 N, 20-300 N, and 20-400 N). FINDINGS: After 250 cycles no significant differences in elongation were observed between PARS and Dresdner Instrument(p = 1.0). Furthermore, SpeedBridge™ repairs elongated less than either Dresdner Instrument (p = 0.0006) or PARS (p = 0.102). Main elongation (85%) occurred within the first 10 cycles with a comparable elongation in between 10 and 100 and 100-250 cycles. While all repairs withstood the first 250 cycles of cyclic loading from 20 to 100 N, only the PARS (468 ± 175) and Midsubstance SpeedBridge™ (538 ± 208) survived more cycles. Within all 3 groups suture cut out was seen to be the most common failure mechanism. INTERPRETATION: Within all groups early repair elongation was seen. While this was least obvious within the SpeedBridge™ technique, ultimate strengths of repairs (cycles to failure) were comparable across PARS and SpeedBridge™ with a decline in the Dresdner Instrument group.

Mongolian Spots - A challenging clinical sign.

Mongolian Spots (MS) are the most common birthmarks in newborn children. The condition presents as greenish-bluish to greyish macules, particularly in the lumbosacral area. The incidents of MS can vary in different ethnic groups and normally fade in early childhood. MS can be misinterpreted as hematomas because of the color and the predilection site. This paper discusses the case of a two-month old female admitted to hospital under suspicion of child abuse. The clinical forensic examination of the infant and her two older sisters found the children were in good health and did not show signs of abuse, despite the infant presenting with multiple and extensive greyish-blue macules. Thirteen months later, a welfare officer requested another forensic examination on the now 15-month-old child after noticing greyish-blue macules. Following a second examination, no evidence of abuse was found. This case illustrates the issue of MS as a differential diagnosis of hematomas.

The adulterated XANAX pill: a fatal intoxication with etizolam and caffeine.

A 49-year old man was found dead at home next to a glass containing a dried, white, crystalline substance and near a bag containing pills with the imprint XANAX, the trade name of alprazolam. A comprehensive screening of material collected during the autopsy revealed the presence of etizolam and caffeine in lethal concentrations (0.77 µg/mL and 190 µg/mL) but no trace of alprazolam. Benzodiazepine analogue etizolam is rarely prescribed in Germany, and as a result there are not many reports about fatal cases. It has anxiolytic, hypnotic, sedative and muscle-relaxant properties and is used for the short-term treatment of anxiety and panic attacks. The purine alkaloid caffeine, conversely, is the most widely used central nervous system stimulant. The following report outlines potentially the first reported case of a lethal combination of the downer etizolam and the upper caffeine in medical literature.

Deactivation of cardiovascular implantable electronic devices in patients nearing end of life : Reality or only recommendation?

BACKGROUND: Current guidelines recommend considering deactivation of cardiac implantable electronic devices (CIEDs) in patients nearing death. We evaluated the implementation of this recommendation in unselected deceased individuals with CIEDs. METHODS: Over a 7-month period in 2016, all deceased persons taken to the Rostock crematorium were prospectively screened for CIEDs and these were interrogated in situ. Pacing rate, pacing mode, and lead output were documented as well as patient data including location and time of death. In implantable cardioverter-defibrillators (ICDs), tachycardia therapy adjustment and occurrence of shocks 24 h prior to death were also recorded. RESULTS: We examined 2297 subjects, of whom 154 (6.7%) had CIEDs. Of these subjects, 125 (100%) pacemakers (PMs) and 27 (96.4%) ICDs were eligible for analysis. Death in persons with ICDs occurred most frequently in hospital (55.6%), while this was less frequently the case for individuals with PMs (43.2%). Furthermore, 33.3% of subjects with ICDs and 18.5% with PMs died in palliative care units (PCU). Shock therapies were switched off in three (60%) individuals with ICDs who died in the PCU, whereas antibradycardia therapy was not withdrawn in any PM patient in the PCU. Therapy withdrawal occurred in two patients with PMs (1.3%) who died in hospital. Patients with PMs had high ventricular pacing rates at the last interrogation (69 ± 36.0%) and often suffered atrioventricular block (39.2%). Six (25%) of the 24 active ICDs presented shocks near the time of death. CONCLUSION: Many CIED patients died in hospital; nonetheless, in practice, CIED deactivation near death is rarely performed and might be less feasible in subjects with PMs. However, there is still a need to consider deactivation, especially in individuals with ICDs, as one fourth of them received at least one shock within 24 h prior to death.

Individual programming of current multiprogrammable pacemakers : Still unsatisfactory?

BACKGROUND: Pacemaker (PM) technology has developed tremendously in recent decades. We evaluated the extent of individual programming in current PMs. METHODS: Over a 7-month period in 2016, all deceased persons taken to the Rostock crematorium were prospectively screened for cardiac implantable electronic devices (CIEDs) and these were interrogated in situ. Programming of patient data, leads, and study parameters including mode, lower rate, upper tracking or sensor rate (UTSR), ventricular refractory time, sleeping function, hysteresis, and PM-mediated tachycardia intervention were analyzed and compared with delivery settings. Alterations in atrial/ventricular capture management and atrial/ventricular sensing assurance as well as changes in sensitivity and lead output were evaluated. RESULTS: We examined 2297 subjects, of whom 154 (6.7%) had CIEDs, with 125 (81.2%) being PMs. Finally, 72 (57.6%) PMs were eligible for analysis with an operation time of 31.0 ± 27.0 months. We excluded 28 (18.2%) implantable cardioverter defibrillators (ICDs), 51 (41%) PMs presenting elective replacement indicator (ERI), two (1.6%) PMs with programming to insufficient function prior to death, and the left ventricle parameter of one (1.4%) cardiac resynchronization therapy pacemaker (CRT-P); further one CIED (0.6%) was not contactable. PMs offered in mean 75.2% of study parameters thereof 88.0% were to adjust manually, whereof 49.3% stayed unchanged to delivery mode. Lead output, UTSR, lower rate, and mode were the most frequently changed parameters (>85.7%, 65.3%, 54.2%, and 52.8%, respectively) compared with unmodified ventricular refractory time and hysteresis (91.7% and. 85.4%, respectively); 2.8% of PMs had out-of-the-box settings. The most frequent personalized data were last (88.9%) and first name (73.6%), while atrial and ventricular serial lead numbers were rarely entered (18.2% and 23.4%, respectively). CONCLUSION: The programming possibilities of PMs have advanced greatly. Nonetheless, improvements in individual PM programming are still needed as demonstrated by the findings in this study, e.g., PMs with manufacturer settings and lack of individual data.

Unusual head injury by a forklift vehicle.

A case of an unusual head injury by a forklift vehicle is presented.

[Unexpected Complications in the Withdrawal Treatment of the Research Chemical AH-7921]. / Unerwartete Komplikationen während des Entzugs vom Research Chemical AH-7921.

We describe the case of a young male patient who had consumed the morphine-like substance AH-7921 which is available via the internet. He was initially admitted to hospital because of obstipation and presented within a day of inpatient treatment for the first time with a generalized tonic-clonic epileptic seizure with subsequent urinary retention. Within a few hours, the patient then also developed bradycardia, while at the same time describing symptoms of physical opioid withdrawal which gradually deteriorated within the following hours. We initiated a treatment with buprenorphine which resulted in a considerable reduction of withdrawal symptoms, so the patient could be discharged from hospital.

Distinction between forensic evidence and dermatological findings.

The external examination after death requires knowledge in forensics/pathology, dermatology, as well as associated diseases and age-related alterations of the skin. This article highlights some findings with forensic evidence versus dermatological findings. The lectures in forensic medicine should be structured interdisciplinarily, especially to dermatology, internal medicine, surgery, pathology, and toxicology in order to train the overlapping skills required for external and internal postmortem examinations.

[Cardiovascular alterations associated with doping]. / Kardiovaskuläre Schäden durch Doping.

Doping -the abuse of anabolic-androgenic steroids in particular- is widespread in amateur and recreational sports and does not solely represent a problem of professional sports. Excessive overdose of anabolic steroids is well documented in bodybuilding or powerlifting leading to significant side effects. Cardiovascular damages are most relevant next to adverse endocrine effects.Clinical cases as well as forensic investigations of fatalities or steroid consumption in connection with trafficking of doping agents provide only anecdotal evidence of correlations between side effects and substance abuse. Analytical verification and self-declarations of steroid users have repeatedly confirmed the presumption of weekly dosages between 300 and 2000 mg, extra to the fact that co-administration of therapeutics to treat side-effects represent a routine procedure. Beside the most frequent use of medications used to treat erectile dysfunction or estrogenic side-effects, a substantial number of antihypertensive drugs of various classes, i.e. beta-blockers, diuretics, angiotensin II receptor antagonists, calcium channel blockers, as well as ACE inhibitors were recently confiscated in relevant doping cases. The presumptive correlation between misuse of anabolic steroids and self-treatment of cardiovascular side effects was explicitly confirmed by detailed user statements.Two representative fatalities of bodybuilders were introduced to outline characteristic, often lethal side effects of excessive steroid abuse. Moreover, illustrative autopsy findings of steroid acne, thrombotic occlusion of Ramus interventricularis anterior and signs of cardiac infarctions are presented.A potential steroid abuse should be carefully considered in cases of medical consultations of patients exhibiting apparent constitutional modifications and corresponding adverse effects. Moreover, common self-medications -as frequently applied by steroid consumers- should be taken into therapeutic considerations.

[Autopsies for anatomical teaching and training in clinical forensic medicine]. / Autopsien mit Situs-Lehre in der klinischen Rechtsmedizin.

BACKGROUND: Clinical forensic medicine does not only entail examination of patients after physical violence but also the option of clinical autopsies, e.g. after non-notifiable complications of medical interventions, after fatalities closely following medical interventions or fatalities as a result of injuries when the public prosecutor decides not to order a medicolegal autopsy. Based on this routine the Institute of Forensic Medicine at the University of Rostock offers a training course in topographical anatomy to physicians for further training in interventional and surgical disciplines. METHODS: At the beginning of autopsies the participants can explore the approaches of interventional puncture techniques as well as surgical techniques and the basic topographical anatomy in small groups of 2-4 persons under the supervision of forensic examiners. The format is essentially oriented to the early further training period but fulfils the requirements for the exploration of complex operative techniques. The course was adapted for physicians and offered separately to students. The explorations are performed manually or by support with autopsy instruments. RESULTS: The courses offer an ideal room for individual, discipline-specific topics and result in a great benefit for all participants. A statistical assessment can only be achieved with a larger number of participants. CONCLUSION: Making autopsy rooms available for teaching and further training represents an additional feature to the profile of clinical forensic medicine. Lessons in topographical anatomy provide a great benefit for patient safety. It seems to be important to offer the opportunity to address individual interests in a closed meeting to consolidate skills and abilities in a non-judgemental environment. The post-mortem examiners have to ensure that the autopsy is carried out lege artis. Basic ethical principles and all regulations from an accredited scope have to be adhered to.

[Orthopaedic implants. Application outside of patient care?]. / Orthopädisch-Unfallchirurgische Implantate. Verwendungsmöglichkeiten außerhalb der Patientenversorgung?

Internal fracture fixation represents a widespread concept for the treatment of fractures. As the number of implants increases, person tracking may be possible. In spring 2010 near Rostock (Germany), human remains including a stainless steel nail were found. Forensic analysis considered the parts of skeleton to belong to a man of medium height, exposed to outdoor conditions for several years to a few decades. The tibial nail was analysed and according to the product identification number possible hospitals of implant placement and transportation paths were determined and screened. Furthermore a match analysis of the database of missing individuals of the last 15 years was undertaken and a DNA match analysis identified a local individual who had been missing since winter 2003. Equipped with the actual patient's identity, out of academic interest a survey of clinical documents such as discharge letters and operative reports was performed, but was inconclusive. Although technically feasible, tracking the patient in this case based on the implant product number itself was unsuccessful. In this case report, the feasibility, validity and efficiency of this option are presented and discussed.

[The surgically treated gunshot injury. Securing evidence in hospitals without primary participation of police or legal medicine]. / Die operierte Schussverletzung. Schussspurensicherung im klinischen Bereich ohne primäre Beteiligung der Polizei oder der Rechtsmedizin.

Against the background of a problematic reconstruction of a hunting accident, the question arises how such cases can be handled in hospitals and how exhibits can be adequately dealt with. After evaluating a questionnaire on current conditions of securing evidence in cases of surgically treated gunshot wounds from 26 surgical institutions in Mecklenburg-Western Pomerania and in consideration of the certified advanced training in the field of legal medicine, recommendations are given regarding the securing of evidence within the clinical setting without primary involvement of police or legal medicine.

Changes in length of the plantar aponeurosis during the stance phase of gait--an in vivo dynamic fluoroscopic study.

In locomotion, ligaments and muscles have been recognized to support the arch of the foot. However, it remains unclear to what extent the passive and active structures of the lower extremity support the longitudinal arch of the foot during walking. In this study, the mechanical function of the plantar aponeurosis (PA) is investigated by elongation measurements in vivo during the stance phase of gait, in combination with measurements of the mechanical properties of the PA in vitro. Fluoroscopy was used to measure the dynamic changes in PA length and the angular motion of the metatarsophalangeal joint of the first ray, measured during the stance phase (StPh) in 11 feet. Simultaneously, ground forces were measured. Additionally, four cadaver feet delivered topographic information relating to the PA, and three autopsy specimens of PA served to determine the in vitro mechanical properties of PA. The present study revealed a non-significant peak average PA shortening of 0.48% at about 32.5% StPh, followed by a significant average peak elongation of 3.6% at 77.5% StPh. This average peak elongation of 3.6% corresponds to a force of 292N, as estimated by mechanical testing of the autopsy PA specimens. Considering the maximum peak elongation measured in one volunteer of 4.8% at 76% StPh, a peak PA load of 488N might be expected. Hence, with an average body weight of 751N, as allocated to the 11 investigated feet, this maximum peak force would correspond to about 0.65×body weight. As far as we are aware, this is the first report on a dynamic fluoroscopic study of the PA in gait with an appreciable number of feet (11 feet). In conclusion, muscles contribute to support of the longitudinal arch of the foot and can possibly relax the PA during gait. The 'windlass effect' for support of the arch in this context is therefore questionable.

Neuropathological alterations in cocaine abuse.

Cocaine abuse represents a significant health issue worldwide. Besides cardiovascular complications, psychiatric and neurologic symptoms are the most common manifestations of cocaine toxicity. In cocaine abusers brain abnormalities have been shown with computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), or single photon emission computed tomography (SPECT). The spectrum of neuropathologic alterations seen in cocaine abusers is broad. The major findings consist of vascular complications such as stroke, subarachnoid and intracerebral hemorrhages and cerebral ischemia. Persons with underlying arteriovenous malformation or aneurysm are especially prone for such events. Except for a few incidents of vasculitis, the etiology of cocaine- related cerebrovascular events is still unclear. Cocaine-induced vasospasm, impaired hemostasis and platelet function, as well as decreased cerebral blood flow, have been proposed as possible mechanisms. On the molecular level, alterations in the expression of transcription factors and changes of brain neurotransmitter systems have been reported.

c-Myc and EBV-LMP1: two opposing regulators of the HLA class I antigen presentation machinery in epithelial cells.

BACKGROUND: Epstein-Barr virus (EBV)-encoded latent membrane protein 1 (LMP1) up-regulates the human leukocyte antigen (HLA) class I antigen presentation machinery (APM). This appears counterintuitive with immune evasion in EBV-associated tumours like nasopharyngeal carcinoma (NPC). METHODS: Latent membrane protein 1-transfected epithelial cell lines were used as a model system to study the impact of LMP1 and c-Myc on HLA class I components. The expression of components of the HLA class I APM, c-Myc and Ki-67 was analysed in LMP1+ and LMP1- NPC by immunohistochemistry. RESULTS: In epithelial cells, LMP1 up-regulated HLA class I APM. This effect could be counteracted by c-Myc, which itself was up-regulated by LMP1 apparently through IL6 induction and Jak3/STAT3 activation. Studies of NPC biopsies revealed down-regulation of HLA class I APM expression. No difference was observed between LMP1+ and LMP1- NPC. However, expression of Ki-67 and c-Myc were up-regulated in LMP1+ tumours. CONCLUSION: These findings raise the possibility that c-Myc activation in NPC might antagonise the effect of LMP1 on HLA class I expression thus contributing to immune escape of tumour cells.

Review: The neuropathology of drug abuse.

Drug abuse represents a significant health issue. The major substances abused include cannabis, opiates, cocaine, amphetamine, methamphetamine and 'ecstasy'. Alterations of intracellular messenger pathways, transcription factors and immediate early genes within the brain reward system seem to be fundamentally important for the development of addiction and chronic drug abuse. Genetic risk factors and changes in gene expression associated with drug abuse are still poorly understood. Besides cardiovascular complications, psychiatric and neurologic symptoms are the most common manifestations of drug toxicity. A broad spectrum of changes affecting the central nervous system is seen in drug abusers. The major findings result from the consequences of ischaemia and cerebrovascular diseases. Except for a few observations of vasculitis, the aetiology of these cerebrovascular accidents is not fully understood. The abuse of amphetamine, methamphetamine and MDMA has been related to neurotoxicity in human long-term abusers and to the risk of developing Parkinson's disease. However, whether such neurotoxicity occurs remain to be established. Systematic histological, immunohistochemical and morphometric investigations have shown profound morphological alterations in the brains of polydrug abusers. The major findings comprise neuronal loss, neurodegenerative alterations, a reduction of glial fibrillary acidic protein-immunopositive astrocytes, widespread axonal damage with concomitant microglial activation as well as reactive and degenerative changes of the cerebral microvasculature. These observations demonstrate that drugs of abuse initiate a cascade of interacting toxic, vascular and hypoxic factors, which finally result in widespread disturbances within the complex network of central nervous system cell-to-cell interactions.

Postmortem proteomic analysis in human amygdala of drug addicts: possible impact of tubulin on drug-abusing behavior.

Besides the ventral tegmental area and the nucleus accumbens as the most investigated brain reward structures, several reports about the relation between volume and activity of the amygdala and drug-seeking behavior have emphasized the central role of the amygdala in the etiology of addiction. Considering its proposed important role and the limited number of human protein expression studies with amygdala in drug addiction, we performed a human postmortem proteomic analysis of amygdala tissue obtained from 8 opiate addicts and 7 control individuals. Results were validated by Western blot in an independent postmortem replication sample from 12 opiate addicts compared to 12 controls and 12 suicide victims, as a second "control sample". Applying 2D-electrophoresis and MALDI-TOF-MS analysis, we detected alterations of beta-tubulin expression and decreased levels of the heat-shock protein HSP60 in drug addicts. Western blot analysis in the additional sample demonstrated significantly increased alpha- and beta-tubulin concentrations in the amygdala of drug abusers versus controls (P = 0.021, 0.029) and to suicide victims (P = 0.006, 0.002). Our results suggest that cytoskeletal alterations in the amygdala determined by tubulin seem to be involved in the pathophysiology of drug addiction, probably via a relation to neurotransmission and cellular signaling. Moreover, the loss of neuroprotection against stressors by chaperons as HSP60 might also contribute to structural alteration in the brain of drug addicts. Although further studies have to confirm our results, this might be a possible pathway that may increase our understanding of drug addiction.