How to prove neglect in the context of the post-mortem examination.

Understanding the causes, extent, and period of neglect is not only a medical but also a forensic task when it comes to legal investigations. In this study, we evaluated 46 autopsied cases where there was clear evidence of physical neglect during the last period of the deceased's life. The age of the deceased ranged from 21 to 96 years; most of them were female (71.7%). The majority of cases (89.9%) took place in a domestic environment, with partners or relatives providing care. The most frequent post-mortem findings were pressure sores, followed by inflammatory skin changes, and signs of malnutrition and dehydration. Neglect was the cause or co-cause of death in 23% of the cases. More than half of the deceased showed severe contamination of the skin surface by excrement, and in almost 40% of the cases, fly infestation was found. The majority of insects belonged to the group of house flies (Diptera: Muscidae), mainly the common house fly, Musca domestica. By analyzing the entomological evidence, it was possible to prove an insect infestation period of at least several days ante-mortem. Since the period of neglect may be relevant in terms of legal proceedings, the present work demonstrates the particular importance of insect traces in providing this evidence. While prosecution and conviction of caregivers remain challenging, it is all the more essential that entomology and legal medicine collaborate on the analysis of findings of neglect.

Bone finds and their medicolegal examination: a study from Hesse, Germany.

Bones found by chance can be of great criminal or historical interest. The nature of their appraisal depends on the individual case, the locally effective legislation and the available resources. To assess whether a find is relevant with respect to criminal investigation, the circumstances of the find and the results of the forensic examination carried out by trained personnel must be considered. The aim of this study was to obtain an overview of the circumstances and nature of the finds as well as the results of the subsequent expert opinions by evaluating bone finds from the federal state of Hesse, Germany. For this purpose, over a 10-year period from 2011 to 2020, all bone finds examined at the Institutes of Legal Medicine in Gießen and Frankfurt am Main, Germany, were evaluated retrospectively with regard to the locations and circumstances of the finds, their nature (human or non-human), the postmortem interval, possible traces of violent impact and the results of further examinations. Of the 288 bone finds evaluated, 38.2% were found in forests, meadows and parks. In 50.7%, the finds contained human bones, of which 37.0% had a forensically relevant postmortem interval of 50 years or less. Evidence of trauma was described in 77.4% of the human bone cases: postmortem damage in 78.8%, peri-mortem injury in 9.7% and ante-mortem injury in 11.5%. DNA examinations were performed in 40.4% of the human bone finds. They yielded STR profiles in 81.3%, leading to a definite identification in 35.4%. Among the non-human bones sent in, the most common were bones from pigs (23.4%), deer (18.1%), cattle (16.4%), roe deer (11.7%) and sheep (11.7%). The macroscopic examination is the first step of the forensic-osteological evaluation and sets the course for further examinations or investigations. DNA examinations are of great importance for the reliable identification of human bones. They were responsible for 70.8% of successful identifications.

Comparison of all completed suicides in Frankfurt am Main (Hessen) before and during the early COVID-19 pandemic.

To research the effect of the COVID-19 pandemic on mental health, the prevalence and characteristics of all completed suicides in the city of Frankfurt am Main were compared for a 10-month period before the pandemic (March 2019-December 2019) with one during the early pandemic (March 2020-December 2020). Medicolegal data collected in the context of the FraPPE suicide prevention project were evaluated using descriptive statistical methods. In total, there were 81 suicides during the early pandemic period, as opposed to 86 in the pre-pandemic period. Though statistically not significant, the proportion of male suicides (73%) was higher during the early pandemic period than before (63%). The age-at-death was comparable in the pre-pandemic and pandemic periods (average, 54.8 vs. 53.1 years). Between these two periods, there was no difference in respect to the three most commonly used suicide methods by men: fall from a height (26% vs. 22%), intoxication, and strangulation (each 24% vs. 19%). For women, there was, however, a shift in methods from strangulation (38%), intoxication (28%), and fall from a height (19%) to fall from a height (50%), strangulation (18%), intoxication, and collision with a rail vehicle (14% each). There was a trend towards more suicides among non-German nationals during the early pandemic (suicide rate/100,000 inhabitants: German, 14.3 vs. 11.5; non-German, 4.4 vs. 8.8). Before the pandemic, 54% of the suicides were known to have a mental illness in contrast to 44% during the early pandemic. Overall, no increase in completed suicides could be observed in Frankfurt am Main during the early pandemic.

A guide to classify tattoo motives in Mexico as a tool to identify unknown bodies.

JUSTIFICATION: In Mexico, the number of unidentified bodies has been steadily rising for years. By now, more than 50,000 bodies are considered unidentified. Forensic laboratories that could perform comparative molecular genetic investigation are often overburdened and examinations can take months. Therefore, pragmatic approaches that can help to identify more unknown bodies must be sought. The increased use of distinctive physical features might be one, and the high rate of tattooed people in Mexico points towards a great potential of tattoos as a tool for identification. The prerequisite for a comparison of antemortem (missing persons) and postmortem (unknown bodies) data is an objective description of the particularities, e.g., of the tattoos. The aim of this study was to establish an objective classification for tattoo motives, taking into consideration local preferences. METHODS: In the database of the medicolegal services of the Instituto Jaliscience de Ciencias Forenses (IJCF) in Guadalajara, postmortem data of 1000 tattooed bodies from 2019 were evaluated. According to sex and age, the tattooed body localization and the tattoo motives were categorized. RESULTS: The 1000 tattooed deceased showed tattoos on 2342 body localizations. The motives were grouped and linked to the following 11 keywords (with decreasing frequency): letters/numbers, human, symbol (other), plant, symbol (religious), animal, object, fantasy/demon/comic, tribal/ornament/geometry, other, unrecognizable. CONCLUSION: Using the proposed classification, tattoo motives can be described objectively and classified in a practical way. If used for antemortem (missing persons) and postmortem (unknown bodies) documentation, motives can be searched and compared efficiently-helping to identify unknown bodies.

Clinico-pathological correlation of lacrimal caruncle tumors: a retrospective analysis over 22 years at the University Eye Hospital Bonn.

PURPOSE: The lacrimal caruncle is composed of numerous structures including different glands as well as hair follicles. Accordingly, the spectrum of benign and malignant lesions is broad, and the clinical diagnosis is often challenging. Here we systematically analyzed excised caruncular tumors over the past 22 years with special emphasis on the clinico-pathological correlation to provide a guidance for clinicians. METHODS: Retrospective evaluation with clinico-pathologic correlation of surgically removed caruncular tumors between 1998 and 2020 at a tertiary referral center. RESULTS: Eighty-two caruncular tumors were identified in the respective period. The patients were between 11 and 85 years of age (mean, 46.8 years; median, 49 years). Nevi (n = 35), cystic lesions (n = 14), oncocytoma (n = 9), papilloma (n = 8), sebaceous gland hyperplasia (n = 8), and reactive lymphoid hyperplasia (n = 4) were observed most frequently. Besides, we are the first reporting herniated orbital fat accompanied by a pyogenic granuloma. 2.4% (n = 2) were malignant tumors (sebaceous gland carcinoma, conjunctival intraepithelial neoplasia with pyogenic granuloma). CONCLUSION: Caruncular tumors show a broad spectrum of mostly benign tumors. They can occur in patients of any age. However, 8/9 oncocytomas and both malignant lesions were detected in patients older than 60 years. Although the clinical diagnosis was confirmed in only 68.3% by the histopathological analysis, the two malignant lesions were identified as such already clinically. Caruncular lesions with a history of growth or other signs of malignancy should be excised followed by detailed histopathological examination to allow a final diagnosis and exclude rare malignant tumors with lethal potential.

A randomized, open-label, multicenter study of switching to brolucizumab with or without a loading dose for patients with suboptimal anatomically controlled neovascular age-related macular degeneration-the FALCON study.

BACKGROUND: Treatment initiation with brolucizumab, a new potent anti-vascular endothelial growth factor (VEGF) agent, is typically performed with three monthly injections (loading dose) and has been well studied in treatment-naïve patients. However, no clinical data are available yet on whether or not anti-VEGF pretreated patients also benefit from a loading dose. In the clinical setting, different heterogeneous treatment patterns are used as no clinical trial has addressed this so far in a head-to-head comparison. Therefore, the FALCON study is investigating whether patients with unsatisfactory response to previous anti-VEGF treatments benefit from a loading dose at the switch to brolucizumab treatment. METHODS: FALCON is a 52-week, two-arm, randomized, open-label, multicenter, multinational study in patients with residually active neovascular age-related macular degeneration (nAMD) who will be randomized 1:1 and started with brolucizumab 6 mg loading (three monthly loading doses) or brolucizumab 6 mg non-loading (one initial injection) and consecutive treatment every 12 weeks, respectively. The primary objective is to demonstrate non-inferiority of the non-loading vs. loading arm in mean change of best-corrected visual acuity (BCVA) from baseline to the mean value at week 40 to week 52. Secondary objectives include the assessment of anatomical outcomes, treatment intervals, safety and tolerability. RESULTS: FALCON will be the first study to assess treatment initiation with an anti-VEGF agent in a switch situation with or without loading dose in patients with nAMD. CONCLUSIONS: The results will support the optimization of treatment of patients with previous unsatisfactory anti-VEGF response. Therefore, we expect to see an impact on current clinical practice which has been established for more than a decade. TRIAL REGISTRATION: Clinicaltrials.gov: NCT04679935, date of registration-22-Dec 2020; EUDRACT number: 2019-004763-53, date of registration-03 Dec 2019.

Detection and infectivity of SARS-CoV-2 in exhumated corpses.

Postmortem detection of severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) after the exhumation of a corpse can become important, e.g. in the case of subsequent medical malpractice allegations. To date, data on possible detection periods [e.g. by reverse transcription polymerase chain reaction (RT-PCR)] or on the potential infectivity of the virus after an exhumation are rare. In the present study, these parameters were examined in two cases with a time span of approximately 4 months between day of death and exhumation. Using SARS-CoV-2 RT-PCR on swabs of both lungs and the oropharynx detection was possible with cycle threshold (Ct) values of about 30 despite signs of beginning decay. RT-PCR testing of perioral and perinasal swabs and swabs collected from the inside of the body bag, taken to estimate the risk of infection of those involved in the exhumation, was negative. Cell culture-based infectivity testing was negative for both, lung and oropharyngeal swabs. In one case, RT-PCR testing at the day of death of an oropharyngeal swab showed almost identical Ct values as postmortem testing of an oropharyngeal swab, impressively demonstrating the stability of viral RNA in the intact corpse. However, favorable climatic conditions in the grave have to be taken into account, as it was wintertime with constant low temperatures. Nevertheless, it was possible to demonstrate successful postmortem detection of SARS-CoV-2 infection following exhumation even after months in an earth grave.

Infectivity of deceased COVID-19 patients.

The duration of infectivity of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) in living patients has been demarcated. In contrast, a possible SARS-CoV-2 infectivity of corpses and subsequently its duration under post mortem circumstances remain to be elucidated. The aim of this study was to investigate the infectivity and its duration of deceased COVID-19 (coronavirus disease) patients. Four SARS-CoV-2 infected deceased patients were subjected to medicolegal autopsy. Post mortem intervals (PMI) of 1, 4, 9 and 17 days, respectively, were documented. During autopsy, swabs and organ samples were taken and examined by RT-qPCR (real-time reverse transcription-polymerase chain reaction) for the detection of SARS-CoV-2 ribonucleic acid (RNA). Determination of infectivity was performed by means of virus isolation in cell culture. In two cases, virus isolation was successful for swabs and tissue samples of the respiratory tract (PMI 4 and 17 days). The two infectious cases showed a shorter duration of COVID-19 until death than the two non-infectious cases (2 and 11 days, respectively, compared to > 19 days), which correlates with studies of living patients, in which infectivity could be narrowed to about 6 days before to 12 days after symptom onset. Most notably, infectivity was still present in one of the COVID-19 corpses after a post-mortem interval of 17 days and despite already visible signs of decomposition. To prevent SARS-CoV-2 infections in all professional groups involved in the handling and examination of COVID-19 corpses, adequate personal safety standards (reducing or avoiding aerosol formation and wearing FFP3 [filtering face piece class 3] masks) have to be enforced for routine procedures.

Beneath cover-up tattoos: possibilities and limitations of various photographic techniques.

BACKGROUND: The goal of this study was to investigate the usefulness of various photographic techniques in visualizing previous tattoos under cover-up tattoos. MATERIAL AND METHODS: Ten volunteers with 11 known cover-up tattoos were examined using different photographic techniques: A Canon EOS 6D full-frame digital single-lens reflex camera used in conjunction with a SB600 off-camera flash system and an extension cord; and a Leica M8 digital imaging system camera in conjunction with two different infrared filters (715 nm and 850 nm) and a Metz CL-45 handle-mount flash. A Lumatec Superlite 400 forensic light source was used along with the Canon EOS 6D as a third system. RESULTS: The best results for black cover-up tattoos were achieved with the full-frame digital single-lens reflex camera in conjunction with the off-camera flash system and, for colored cover-up tattoos, with IR-photography at a wavelength of 850 nm. The Lumatec Superlite 400 light source did not provide better results for conventional photography than those obtained with flash lighting. DISCUSSION: In nine out of eleven cover-up tattoos, the previous tattoos could, at least, be partially visualized. The quality of the visualization depended on the color, pattern, density, and quality of the cover-up tattoo as well as on the photographic technique. None of the examined photographic techniques could satisfactorily image the previous tattoo if the cover-up tattoo was large and black, especially not if it was densely inked. CONCLUSION: Depending on the color of the cover-up tattoo, a full-frame digital single-lens reflex camera in conjunction with a SB600 off-camera flash system (for black cover-ups) or infrared photography with flash lighting and an 850 nm filter (for colored cover-ups) proved to be the best of the investigated techniques to visualize a previous tattoo under a cover-up tattoo.

Helium poisoning: new procedure for sampling and analysis.

An increasing number of suicidal asphyxiation with a plastic bag with inert gases, and in particular helium (He), have been reported from numerous countries over the last decade. These cases are differently managed and lead to different and variable interpretations. Based on the 12 last cases analysed in the laboratory and on the review of the most recent literature about this topic, updated autopsy guidelines for sampling have been proposed regarding to the samples choice and analytical challenges required by the gaseous state of this substance. Biological samples from airways (lungs lobe) followed by brain and cardiac blood are the best matrices to take during the autopsy to diagnose He exposure. Gaseous samples from trachea, pulmonary bronchi, gastric and cardiac areas are also recommended as alternative samples. The anatomical site of sampling must be carefully detailed, and to this end, forensic imaging constitutes a beneficial tool. Even if He detection is sufficient to conclude to He exposure, He concentrations in samples may be related to He exposure conditions (duration, breathing rate, etc.). A quantification in biological samples could be helpful to document more precisely the case. He concentrations in gaseous samples are reported up to 6.0 µmol/mL (tracheal gas), 2.4 µmol/mL (pulmonary gas), 0.64 µmol/mL (cardiac gas) and 12 µmol/mL (gastric gas). He concentrations in solid/liquid samples are reported up to 28 µmol/g (lungs) and 0.03 µmol/g (cardiac blood). The other matrices usually sampled during autopsy such as urine, peripheral blood, liver, fat matter and kidney appear as not relevant.

Genetic and epigenetic insights into uveal melanoma.

Uveal melanoma (UM) is the most frequent primary intraocular tumor in Caucasian adults and is potentially fatal if metastases develop. While several prognostic genetic changes have been identified in UM, epigenetic influences are now getting closer attention. Recent technological advances have allowed to exam the human genome to a greater extent and have improved our understanding of several diseases including malignant tumors. In this context, there has been tremendous progress in the field of UM pathogenesis. Herein, we review the literature with emphasis on genetic alterations, epigenetic modifications and signaling pathways as well as possible biomarkers in UM. In addition, different research models for UM are discussed. New insights and major challenges are outlined in order to evaluate the current status for this potentially devastating disease.

Estimating the postmortem interval of human skeletal remains by analyzing their fluorescence at 365 and 490 nm.

The study presented here is regarded as a continuation of the experiments of Sterzik et al., who developed a new practical method to distinguish between historical and recent human skeletal remains. Bone cross-sections were illuminated using light with wavelengths of 365 and 490 nm, causing fluorescence. The fluorescence was documented by photography and further analyzed to examine the areal extent of a certain fluorescent color. Contrary to the previous experiments of Sterzik et al., the present study focused on bones with postmortem intervals (PMIs) ≥ 50 years. Therefore, this study fills the gap created by the former study, pointing towards a correlation between the PMI and the areal extent of the fluorescent surface in both tests. The presence of blue and red fluorescent surfaces < 1% indicated a PMI ≥ 50 years. Furthermore, the presence of blue and red fluorescent surfaces > 1% can be regarded as a marker to exclude a PMI ≥ 50 years; in fact, these bones are likely to have a PMI < 30 years.

[Morphologic Corneal Changes after Crosslinking for Keratoconus]. / Morphologische Hornhautveränderungen nach Crosslinking bei Keratokonus.

Keratoconus is a relatively common (1 : 2000) bilateral disease leading to a change in biochemical and biomechanical corneal structure as well as thinning and ectasia. For more than 10 years, crosslinking has been a therapeutic option in cases of progression. Using riboflavin and UVA-radiation, the anterior corneal stroma (300 µm) gets stiffened by crosslinking of collagen fibers. When protocols and limitations are adhered, the procedure is described to be effective and of low-risk. This review gives an overview about physiologic and pathologic changes in keratoconic corneas before and after crosslinking. Based on histopathologic examination, the current knowledge in published literature is reviewed and is complemented by our own investigations.

Demographics of patients receiving Intravitreal anti-VEGF treatment in real-world practice: healthcare research data versus randomized controlled trials.

BACKGROUND: While randomized controlled trials (RCTs) are based on strict inclusion/exclusion criteria, non-interventional studies (NISs) might provide additional information to guide management in patients more representative to the real-world setting. The aim of this study was to compare baseline characteristics of patients receiving intravitreal treatment in the NIS OCEAN with those from published RCTs. METHODS: The ongoing OCEAN study enrolled patients treated with ranibizumab for neovascular age-related macular degeneration (nAMD), diabetic macular oedema (DME) or branch/central retinal vein occlusion (B/CRVO). Baseline patient characteristics were compared by indication within the OCEAN cohort. Furthermore, the characteristics were set in reference to those of published RCTs in the same indications. Confidence intervals (CIs) were calculated and assessed for statistically significant differences as indicated by non-overlapping CIs. RESULTS: Patient characteristics in the NIS OCEAN were evaluated for 3,614 patients with nAMD, 1,211 with DME, 204 with BRVO and 121 with CRVO. Between these groups, significant differences in mean age, gender distributions, and mean baseline VA were seen, reflecting known differences between the indications. Compared to the patient characteristics of published RCTs (trials selected by literature search: nAMD: 13 RCTs, DME: 9, RVO: 5), the OCEAN patients' mean age was significantly higher in every indication. The gender distributions across the trials were comparable, with only few differences between OCEAN and the RCTs. Regarding the mean baseline VA, notable differences were found in nAMD and in DME, with VA significantly higher in some RCTs and lower in others. CONCLUSIONS: The described differences underline the complementarity of NISs and RCTs. OCEAN covers a broader spectrum and more variability of patients than do RCTs. As baseline values may have impact on the treatment response (ceiling effect), there is an ongoing need for research in all patient subgroups. Country-specific assessments of patient populations can better reflect the real-world situation. NISs can deliver insights that RCTs may not, as NISs can include non-typical patients, patients with comorbidities, a broader age spectrum and patients of various disease stages. TRIAL REGISTRATION: The NIS OCEAN was registered on www.clinicaltrials.gov (identifier: NCT02194803 ).

[Subpectoral tenodesis of the long head of the biceps tendon with an interference screw and a cortical button : Clinical and cosmetic results after 1 year]. / Subpektorale Tenodese der langen Bizepssehne mittels Interferenzschraube und Cortical-Button : Klinische und kosmetische Ergebnisse nach einem Jahr.

BACKGROUND: Pathologies of the long head of biceps tendon (LHB) can cause anterior shoulder pain. Surgical treatment includes tenotomy and tenodesis (TD), however TD causes fewer cosmetic deformities and less cramping of the biceps muscle. To date, numerous techniques for TD have been described but the "gold standard" has not yet been established. OBJECTIVES: The purpose of this study is to evaluate the functional and cosmetic outcome following subpectoral biceps TD with an interference screw and a cortical-button (STLHB-IC) after 1 year. MATERIALS AND METHODS: 35 patients (10 female, 25 male) with an average age of 57.4 ± 7 years were examined after STLHB-IC with a follow up of 12.8 ± 1.2 months. The constant score (CS), the long head of biceps score (LHBS) and the subjective shoulder value (SSV) were assessed. Furthermore, the cosmetic result was evaluated by the patient and the examiner, and the elbow flexion strength (EFS) was measured. RESULTS: The CS (82.5 ± 17.2), LHBS (90.1 ± 11.5) and SSV (83.2 ± 17.7) showed good and excellent results. The SSV increased significantly pre vs. postoperatively (40.6 ± 19.7 vs. 83.2 ± 17.7). The CS (82.5 ± 17.2) and the LHBS (90.1 ± 11.5), as well as the EFS (17.5 ± 4.8 kg) of the affected shoulder revealed no significant differences compared with the non-affected shoulder (CS: 91.8 ± 11.3, LHBS: 99.1 ± 11.5; EFS: 19.7 ± 4.8). Severe Popeye deformities (measured by LHBS) were found in 6% of the cases, however if they occurred patients (13.4 ± 3.8) evaluated them as significantly less disadvantageous than the examiners (11.9 ± 4.7). There were no neurovascular injuries, infections or fractures. CONCLUSION: STLHB-IC is a safe, reproducible technique with convincing functional and cosmetic results that provides high patient satisfaction.

[Potential of Adaptive Optics for the Diagnostic Evaluation of Hereditary Retinal Diseases]. / Adaptive Optiken ­ Möglichkeiten für die Diagnostik hereditärer Netzhauterkrankungen.

The use of adaptive optics in ophthalmoscopy is a breakthrough technological achievement. With AO ophthalmoscopes, the microscopic retinal structure can be visualised non-invasively and on a cellular level, allowing for cellular scale imaging of the retinal nerve fibre layer, the smallest retinal capillaries, rod and cone photoreceptors, and the retinal pigment epithelium mosaic in the living subject. Regarding the diagnostic evaluation of retinal diseases, the current research focuses on monogenetic retinal diseases, which - when better understood - may allow for conclusions to be drawn about other multifactorial diseases and their underlying mechanisms (model disease). For disease monitoring and current and future pharmacological intervention (e.g. gene therapy), they will help to better establish novel and reliable clinical endpoints. New AO imaging devices have just become commercially available, and the number of retinal pathologies visualised with AO is increasing. Recently, an AO-based microstimulation technique has been introduced, which offers the possibility to directly correlate retinal structure with visual function on a cellular level.

[Retinal optical coherence tomography biomarkers in dementia]. / Retinale optische Kohärenztomographie-Biomarker bei demenziellen Erkrankungen.

BACKGROUND: Due to the general aging of society, the prevalence and incidence of dementia are expected to increase considerably. In order to timely identify patients and assess their need for treatment and/or supportive measures, comprehensive and easy access screening methods are required, which, however, are yet to be developed. To date, several biomarkers for the presence of dementia on high-resolution spectral domain optical coherence tomography (OCT) and OCT angiography (OCT-A) images were identified. AIM: To summarize previously identified OCT biomarkers in dementia and to assess their suitability for comprehensive screening examinations. MATERIAL AND METHODS: A literature search was conducted on PubMed until March 2023 for the keywords "dementia", "mild cognitive impairment", "OCT", "OCT angiography" and "retinal biomarkers". Relevant publications were identified and summarized. RESULTS: Numerous unspecific alterations on OCT imaging and OCT­A were identified in patients with (predementia) dementia according to many population and clinical studies. These include a reduced thickness of the peripapillary retinal nerve fiber layer, the ganglion cell complex and the central retinal region. Additionally, a reduced vascular density and an enlarged foveal avascular zone (FAZ) were identified on OCT­A imaging. CONCLUSION: The currently known OCT biomarkers are too unspecific, and there is to date no OCT or OCT-A-based signature distinguishing between different types of dementia. Further longitudinal studies with larger sample sizes are warranted to develop and evaluate such distinct OCT signatures for different types of dementia and their respective early disease stages and to assess their prognostic value. Only then is the inclusion in comprehensive screening investigations feasible.