Serial Killings and Attempted Serial Killings in Hospitals, Nursing Homes, and Nursing Care.

BACKGROUND: Serial killing by doctors or nurses is rare. When it occurs, it is generally only detected after multiple homicides by the same perpetrator have escaped detection in the past. The persons at greatest risk are multimorbid elderly patients whose sudden death for natural reasons would not come as a surprise. However, patients' risk of falling victim to homicide is increased only if such vulnerable patients are exposed to perpetrators with certain personality traits. In this situation, homicides can be committed in which little or no evidence of the crime is left behind. In this review, we address the frequency, nature, and circumstances of serial killings and attempted serial killings in hospitals, nursing homes, and nursing care. METHODS: This review is based on publications retrieved by a selective review of the literature in monographs, medical databases, specialty journals, general-interest media, and the Internet. RESULTS: An evaluation of searchable, published case descriptions of serial killings and attempted serial killings in hospitals, nursing homes, and nursing care, mainly from Europe and the English-speaking countries, enables identification of the type of patients at risk, the modes of homicide, and the personality traits of the perpetrators. Multimorbid, care-dependent and nursing-dependent persons are the main victims. The perpetrators (men and women) generally act alone and have often been working in patient care for many years. The most common method of homicide is by drug injection; violent physical homicide is rarer. In many cases, irregularities in drug stocks, erratic behavior of a staff member, and/or a cluster of sudden deaths are indeed noticed, but are too slowly acted upon. CONCLUSION: Irregularities in drug stocks, inexplicably empty drug packages and used syringes, erratic behavior of a staff member before and after a patient's death, or a cluster of unexpected deaths mainly involving elderly, multimorbid patients (detectable from internal mortality statistics) should always lead to further questioning and investigation.

Extremely Preterm Babies-Legal Aspects and Palliative Care at the Border of Viability.

There are various legal considerations and rare decisions of courts in western countries concerning palliative care and the border of viability in cases of extremely preterm babies. Nevertheless, on the one hand, regulations and decisions of courts describe the conditions physicians have to accept. On the other hand, courts are also able to accept that every case can be special, and needs a unique answer. Therefore, the framework can be described as well as the medical disciplines, which should be involved in a particular case.

Organ manifestations of COVID-19: what have we learned so far (not only) from autopsies?

The use of autopsies in medicine has been declining. The COVID-19 pandemic has documented and rejuvenated the importance of autopsies as a tool of modern medicine. In this review, we discuss the various autopsy techniques, the applicability of modern analytical methods to understand the pathophysiology of COVID-19, the major pathological organ findings, limitations or current studies, and open questions. This article summarizes published literature and the consented experience of the nationwide network of clinical, neuro-, and forensic pathologists from 27 German autopsy centers with more than 1200 COVID-19 autopsies. The autopsy tissues revealed that SARS-CoV-2 can be found in virtually all human organs and tissues, and the majority of cells. Autopsies have revealed the organ and tissue tropism of SARS-CoV-2, and the morphological features of COVID-19. This is characterized by diffuse alveolar damage, combined with angiocentric disease, which in turn is characterized by endothelial dysfunction, vascular inflammation, (micro-) thrombosis, vasoconstriction, and intussusceptive angiogenesis. These findings explained the increased pulmonary resistance in COVID-19 and supported the recommendations for antithrombotic treatment in COVID-19. In contrast, in extra-respiratory organs, pathological changes are often nonspecific and unclear to which extent these changes are due to direct infection vs. indirect/secondary mechanisms of organ injury, or a combination thereof. Ongoing research using autopsies aims at answering questions on disease mechanisms, e.g., focusing on variants of concern, and future challenges, such as post-COVID conditions. Autopsies are an invaluable tool in medicine and national and international interdisciplinary collaborative autopsy-based research initiatives are essential.

Liquid silicone embolism syndrome (SES) in lungs and liver - A case report.

Silicone embolism syndrome (SES) is a well known complication after injection of silicone gel as well as liquid silicone. Rarely, men use physiologic salt solution or liquid silicone injected into the subcutaneous tissue of the scrotum, the penis, the upper genital or the inguinal region. Those men, who call themselves "siliconers", want to get a larger penis and scrotum, also visible when wearing clothes. Injections of liquid silicone in the mentioned regions can lead to liquid silicone embolism in the lungs and also the liver, sometimes eventually leading to death via right heart failure as in the present case. Autopsy revealed "frog spawn"-like vacuoles in the subcutaneous tissue of the genital region and liquid silicone embolism in lungs and liver. Additionally, toxicological analyses revealed different liquid silicones. Smaller oligomers were transported into lung and liver, larger ones showed local enrichment at the injection site. The seized Polydimethylsiloxane (PDMS) could not be detected in abdominal fat, blood or urine, potentially due to low perfusion of fat tissue, the aqueous character of blood and urine or the time span between last injection and death.

Gastrointestinal Symptoms in Children With Life-Limiting Conditions Receiving Palliative Home Care.

Context: Children with life-limiting diseases suffer from gastrointestinal (GI) symptoms. Since the introduction of specialized palliative home care (SPHC) in Germany, it is possible to care for these children at home. In phase 1 of care the aim is to stabilize the patient. In phase 2, terminal support is provided. Objectives: Analysis were performed of the differences between these phases. The causes and modalities/outcome of treatment were evaluated. Methods: A retrospective study was performed from 2014 to 2020. All home visits were analyzed with regard to the abovementioned symptoms, their causes, treatment and results. Results: In total, 149 children were included (45.9% female, mean age 8.17 ± 7.67 years), and 126 patients were evaluated. GI symptoms were common in both phases. Vomiting was more common in phase 2 (59.3 vs. 27.1%; p < 0.001). After therapy, the proportion of asymptomatic children in phase 1 increased from 40.1 to 75.7%; (p < 0.001). Constipation was present in 52.3% (phase 1) and 54.1% (phase 2). After treatment, the proportion of asymptomatic patients increased from 47.3 to 75.7% in phase 1 (p < 0.001), and grade 3 constipation was reduced from 33.9 to 15% in phase 2 (p < 0.05). Conclusion: Painful GI symptoms occur in both palliative care phases but are more common in phase 2. The severity and frequency can usually be controlled at home. The study limitations were the retrospective design and small number of patients, but the study had a representative population, good data quality and a unique perspective on the reality of outpatient pediatric palliative care in Germany.

Single Nuclei Sequencing Reveals Novel Insights Into the Regulation of Cellular Signatures in Children With Dilated Cardiomyopathy.

BACKGROUND: Dilated cardiomyopathy (DCM) is a leading cause of death in children with heart failure. The outcome of pediatric heart failure treatment is inconsistent, and large cohort studies are lacking. Progress may be achieved through personalized therapy that takes age- and disease-related pathophysiology, pathology, and molecular fingerprints into account. We present single nuclei RNA sequencing from pediatric patients with DCM as the next step in identifying cellular signatures. METHODS: We performed single nuclei RNA sequencing with heart tissues from 6 children with DCM with an age of 0.5, 0.75, 5, 6, 12, and 13 years. Unsupervised clustering of 18 211 nuclei led to the identification of 14 distinct clusters with 6 major cell types. RESULTS: The number of nuclei in fibroblast clusters increased with age in patients with DCM, a finding that was confirmed by histological analysis and was consistent with an age-related increase in cardiac fibrosis quantified by cardiac magnetic resonance imaging. Fibroblasts of patients with DCM >6 years of age showed a profoundly altered gene expression pattern with enrichment of genes encoding fibrillary collagens, modulation of proteoglycans, switch in thrombospondin isoforms, and signatures of fibroblast activation. In addition, a population of cardiomyocytes with a high proregenerative profile was identified in infant patients with DCM but was absent in children >6 years of age. This cluster showed high expression of cell cycle activators such as cyclin D family members, increased glycolytic metabolism and antioxidative genes, and alterations in ß-adrenergic signaling genes. CONCLUSIONS: Novel insights into the cellular transcriptomes of hearts from pediatric patients with DCM provide remarkable age-dependent changes in the expression patterns of fibroblast and cardiomyocyte genes with less fibrotic but enriched proregenerative signatures in infants.

A Fatal Case of Cardiac Contusion After Blunt Chest Injury.

ABSTRACT: In this article, we report the autopsy findings of a 48-year-old man who sustained blunt trauma to the thorax. A medical record review revealed no history of cardiac disease. He presented to the hospital with a computed tomography-verified fracture of the left fourth and fifth ribs, and pulmonary and cardiac contusion. He was released from the hospital in stable condition at his own request 7 days later. Because of sudden deterioration, he was readmitted to the hospital the next day. Electrocardiogram detected cardiac arrhythmia on the 15th day after chest trauma. Electrocardiography detected pericardial effusion and severe mitral insufficiency resulting in left ventricular failure. Death was attributed to diffuse alveolar damage-complicating pneumonia due to cardiac contusion with mitral insufficiency occurring 25 days after hospital admission. Internal examination revealed diffuse fibrinous pericarditis, left atrial tear right above the anterior mitral valve leaflet with intrapericardial granulation tissue, and no sign of myocardial damage. Immunohistochemistry showed significantly more CD68-positive macrophages within tissue taken from the heart, a finding indicative of previous atrial and ventricular myocardial contusion. This case report demonstrates that routine hematoxylin and eosin staining may not always reveal significant myocardial damage.

Estimates of Non-Alcoholic Food-Derived Ethanol and Methanol Exposure in Human.

Food-derived alcohol is almost not in question due to its low concentration. Nevertheless, could it pose a problem for some risk groups and forensic cases? To answer this, we aimed to simultaneously evaluate ethanol and methanol ingredients of a variety of non-alcoholic foods in two different countries and estimate their possible health and forensic consequences. Alcohols in foods were analysed by headspace gas chromatography (HS-GC). Human average acute daily food consumptions and food-derived blood alcohol concentrations (BAC) were determined by using the data of the EFSA Nutrition Survey. Methanol and ethanol ingredients of similar foods varied between the two cities. Most foods produce higher methanol concentrations than the Maximum Allowable Dose Level (23 mg). Especially fruit juices lead to the critical level of ethanol for children (6.0 mg/kg bw). Based on the results, adult daily intake of selected food groups does not bear ethanol that exceeds the legal limit of BAC or the limit not allowed by the religious and does not lead to acute alcohol toxicity. But these low levels of ethanol and methanol consumed via non-alcoholic foods for life can raise the vulnerability to chronic health problems (cancer, liver cirrhosis, Alzheimer's disease, autism, ocular toxicity, alterations in fetal development), and may lead to positive ethanol metabolite results (e. g. Ethyl glucuronide) when a low cut-off level is used. Therefore, studies on the alcohol contents of various natural and processed non-alcoholic foods along with their effects on humans, and new regulations on labeling the food products and conscious food consumption are in particular importance. It would also be important to consider unintentional alcohol consumption via non-alcoholic foods in the evaluation of clinical and forensic cases.

Unilateral and bilateral agenesis of the upper thyroid horns - A morphometric analysis of the larynx.

The agenesis of one or both upper thyroid horns (UTH) cannot be considered rare with an incidence ranging between 0.8-9.4%. Studies so far have mostly described frequencies, yet surveys on its morphology and traumatology are missing. It is unknown to what extent this anatomical variant impacts the overall symmetry of the larynx. For the trauma reconstruction after cervical trauma this knowledge is required as an asymmetric larynx can show a different fracture pattern. In this investigation, larynxes with unilateral (n=21)/bilateral (n=5) agenesis of the upper thyroid horn(s) and a control group with regular larynxes (n=23) were juxtaposed. Various measurements were taken after µ-CT scanning. In total 10 distances/angles for the thyroid cartilage and 8 for the cricoid cartilage were compared. Using intra-individual and matched pair comparisons the symmetry was assessed. The results of this investigation showed significant differences in the intra-individual and pairwise comparison for the opening angle and the length of the thyroid alae although the lateral inclination of the thyroid alae showed no significant difference. Combining these three parameters into one symmetry score, the comparison was not significant. This research demonstrates that neither unilateral nor bilateral agenesis of the UTH is related to a structural disbalance of the larynx. Thus, different fracture patterns or vulnerabilities are not to be expected.

Arrhythmogenic Ventricular Cardiomyopathy Associated With Fibromuscular Dysplasia of Ostial Right Main Coronary Artery.

In this article, we report the autopsy findings of a 23-year-old woman, who was found unconscious at home by her relatives. During the transportation to the hospital, the woman was handed over to the ambulance personnel, who were the first to provide cardiopulmonary resuscitation. In the hospital, after an hour-lasting asystole, the heart activity was restored. Prolonged cardiac arrest led to hypoxic brain injury, which resulted in a persistent coma. Examinations carried out during hospitalization detected hypokinetic interventricular septum, frequent ventricular extrasystoles and ventricular fibrillation. The patient died within 35 hours of admission to the hospital. Gross findings of the heart included a noticeable increase of the adipose tissue in the right ventricular wall, where histologically focal myocardial atrophy with focal transmural lipomatosis reaching endocardium were detected. Death was attributed to arrhythmogenic ventricular cardiomyopathy. Pathogenic variants in JUP gene and KCNH2 gene confirmed the diagnosis. Other finding of note was fibromuscular dysplasia of ostial right main coronary artery causing a significant luminal narrowing.

Pregnancy-associated Death - Clarifying the Cause of Death and Medico-legal Assessments in Accusations of Malpractice.

BACKGROUND: Pregnancy-associated deaths are extremely rare in Germany. Most deaths are from natural causes, and a range of causes are possible. METHOD: The deaths of 22 women who died of pregnancy-associated causes and who were autopsied in the Institute of Forensic Medicine of Justus-Liebig University Gießen between 1992 and 2016 were analyzed. RESULTS: The autopsy results and histological examinations for the majority of women who died of pregnancy-associated causes between 1992 and 2016 showed that they had died of natural causes, although complications of pregnancy were a leading cause of death. CONCLUSION: The death of a pregnant woman should not automatically raise the suspicion of malpractice, although the question does arise in cases of bleeding complications only detected at very late stages. Experts must prove that a real mistake was made during treatment and provide evidence of the causality between malpractice and patient death. Particularly when well-known complications of pregnancy were present, this is only the case if poor monitoring resulted in the complication being detected too late or if treatment was not in accordance with accepted standards of care. The majority of pregnancy-associated deaths are from natural causes and the death of a pregnant woman does not mean that medical malpractice was involved, although this accusation is often levelled in cases where rupture was not immediately diagnosed or in cases of fatal postpartum hemorrhage.

Senior driving under the influence: A five-year retrospective study of alcoholized road-users aged 70 and over.

The demographic development in Germany shows a steady increase to senior citizens. The driving suitability of older road-users is of large social and political concern, because awareness and reactivity can be influenced by age-related diseases and potential medication, particularly in combination with the consumption of alcohol. This study provides an overview of senior road-users under the influence of alcohol. Therefore, 404 cases of drunken-driving by road-users aged 70 and over within the purview of the Institute of Legal Medicine at Justus-Liebig-University, Giessen, from the years 2009-2013 were evaluated in retrospect. The vast majority of the drivers were male (88.4% of the cases). Distribution of the blood alcohol concentrations were almost equally in male and female drivers with 62.8% of all cases showing a blood alcohol concentration (BAC) of more than 1.1‰ and 10.9% a BAC of more than 2.0‰. In 48.5% of the cases, drunk driving was associated with an accident. 54.5% of the drivers stated suffering from at least one disease and 60% admitted a regular medication or an intake prior to the incident. Moreover, the collected data includes aspects such as the kind of traffic participation as well as neurological and physiological deficits of the road-users. If accidents were caused by drunk driving, the external circumstances and consequences of these accidents were analyzed, too. The evaluation revealed, that the standard medical examination protocol proved to be improbable to cover polypharmacy and multimorbidity of older alcoholized drivers. So, an evaluation and adaptation of the common medical examination protocol must be considered.

Termination of Pregnancy for Medical Indications under Sec. 218a Para. 2 of the German Criminal Code - Real-life Data from the "Gießen Model".

Background Following the legal provisions on the termination of pregnancies in Art. 13 of the SFHG (Law on the Assistance for Pregnant Women and Families, passed on 27.07.1992, BGBl. I, p. 1398) the so-called embryopathic indication for termination was abandoned. Since then, sec. 218a para. 2 of the German Criminal Code (StGB) states that for late terminations, i.e., terminations after the 12th week of gestation post conception, the pregnant woman must be in exceptional distress "according to medical opinion". Method Between 01.05.2012 and 25.07.2016, a total of 160 pregnancy terminations were carried out in Gießen University Hospital under sec. 218a para. 2 StGB. The following data were obtained from the patients' files: age of the pregnant woman, number of pregnancies, type of fetal disease or malformation, time of diagnosis, medical and psychosocial counseling given to the pregnant woman, time of termination or delivery, type of termination, fetal gender. Results 160 pregnant women (mean age: 31.6 years) underwent termination of pregnancy between the 13th - 37th week of gestation. Chromosomal anomalies were diagnosed prenatally in 60 cases, and anomalies were diagnosed on ultrasonography in 100 cases, with the preponderance of cases presenting with developmental disorders of the central nervous system and cardiovascular system. Conclusion In addition to recording intrauterine fetal disorders, when pregnancies are terminated under sec. 218a para. 2 StGB, treating physicians are expected to give plausible reasons why "according to medical opinion" the pregnancy represents a danger to the life of the pregnant woman or of grave injury to her physical or mental health and enter these reasons in the patient's medical records.

[National and international aspects of the medico-legal examination of injured witnesses and defendants in criminal proceedings].

Depending on the type of offence, the medico-legal examination of victims of violence for the purpose of collecting evidence in criminal proceedings requires prompt physical examination of the victim, the exact description and, wherever possible, photographic documentation of the injuries and their forensically correct interpretation. Examination, documentation and assessment have to meet minimum standards. In addition it must be ensured that the examiner or expert has an independent organisational, administrative and financial status. An independent expert must not be an organisational part of the police force, the public prosecution and the court. Legal regulations have to make sure that the expert cannot be influenced "through official channels". His or her financial independence must make attempted bribery at least improbable. The independence of the expert is particularly important, if persons become victims of violence while they are under the custody of the state, especially the police, in prisons and after compulsory commitment to a psychiatric hospital.

Forensic Age Estimation.

BACKGROUND: Forensic age estimation is requested by courts and other government authorities so that immigrants whose real age is unknown should not suffer unfair disadvantages because of their supposed age, and so that all legal procedures to which an individual's age is relevant can be properly followed. 157 age estimations were requested in Berlin in 2014, more than twice as many as in 2004. METHODS: This review is based on pertinent articles retrieved by a selective search in the PubMed and MEDPILOT databases, supplemented by relevant recommendations and by the findings of the authors' own research. RESULTS: The essential components of age estimation are the history, physical examination, X-rays of the hands, panorama films of the jaws, and, if indicated, a thin-slice CT of the medial clavicular epiphyses, provided that there is a legal basis for X-ray examinations without a medical indication. Multiple methods are always used in combination, for optimal accuracy. Depending on the legal issues at hand, the examiner may be asked to estimate the individual's minimum age and/or his or her most probable age. The minimum-age concept can be used in determinations whether an individual has reached the age of legal majority. It is designed to ensure that practically all persons classified as adults have, in fact, attained legal majority, even though some other persons will be incorrectly classified as minors. CONCLUSION: Forensic age estimation lets courts and other government authorities determine the official age of persons whose actual age is unknown-in most cases, unaccompanied refugees who may be minors. The goal is to carry out age-dependent legal procedures appropriately in accordance with the rule of law. The minimum-age concept is designed to prevent the erroneous classification of minors as legal adults.

[Alleged suicide by insulin]. / Vermeintlicher Suizid durch Insulin.

A 26-year-old man, who was on probation, was found dead in his home by his mother. Insulin vials and 2 insulin pens, which the man's stepfather (an insulin-dependent diabetic) had been missing for over a week, were found next to the deceased. The circumstances suggested suicide by an injected insulin overdose. At the time of the autopsy, the corpse showed already marked signs of autolysis. Clinical chemical tests confirmed the injection of insulin, but indicated hyperglycemia at the time of death. Toxicological analyses revealed that the man had consumed amphetamine, cannabinoids, and tramadol in the recent past. Histological examination finally revealed extensive bronchopneumonia as the cause of death. The most plausible explanation for the results of the autopsy and the additional examinations was an injection of insulin as a failed attempt of self-treatment. It is conceivable that the man had discovered by a rapid test that he was a diabetic, but had decided not to go to a doctor to avoid disclosure of parole violation due to continued drug abuse. He may have misinterpreted the symptoms caused by his worsening bronchitis and the developing bronchopneumonia as symptoms of a diabetic metabolic status and may have felt compelled to treat himself with insulin.

Articular Joint Lubricants during Osteoarthritis and Rheumatoid Arthritis Display Altered Levels and Molecular Species.

BACKGROUND: Hyaluronic acid (HA), lubricin, and phospholipid species (PLs) contribute independently or together to the boundary lubrication of articular joints that is provided by synovial fluid (SF). Our study is the first reporting quantitative data about the molecular weight (MW) forms of HA, lubricin, and PLs in SF from cohorts of healthy donors, patients with early (eOA)- or late (lOA)-stage osteoarthritis (OA), and patients with active rheumatoid arthritis (RA). METHODS: We used human SF from unaffected controls, eOA, lOA, and RA. HA and lubricin levels were measured by enzyme-linked immunosorbent assay. PLs was quantified by electrospray ionization tandem mass spectrometry. Fatty acids (FAs) were analyzed by gas chromatography, coupled with mass spectrometry. The MW distribution of HA was determined by agarose gel electrophoresis. RESULTS: Compared with control SF, the concentrations of HA and lubricin were lower in OA and RA SF, whereas those of PLs were higher in OA and RA SF. Moreover, the MW distribution of HA shifted toward the lower ranges in OA and RA SF. We noted distinct alterations between cohorts in the relative distribution of PLs and the degree of FA saturation and chain lengths of FAs. CONCLUSIONS: The levels, composition, and MW distribution of all currently known lubricants in SF--HA, lubricin, PLs--vary with joint disease and stage of OA. Our study is the first delivering a comprehensive view about all joint lubricants during health and widespread joint diseases. Thus, we provide the framework to develop new optimal compounded lubricants to reduce joint destruction.