B cells orchestrate tolerance to the neuromyelitis optica autoantigen AQP4.

Neuromyelitis optica is a paradigmatic autoimmune disease of the central nervous system, in which the water-channel protein AQP4 is the target antigen1. The immunopathology in neuromyelitis optica is largely driven by autoantibodies to AQP42. However, the T cell response that is required for the generation of these anti-AQP4 antibodies is not well understood. Here we show that B cells endogenously express AQP4 in response to activation with anti-CD40 and IL-21 and are able to present their endogenous AQP4 to T cells with an AQP4-specific T cell receptor (TCR). A population of thymic B cells emulates a CD40-stimulated B cell transcriptome, including AQP4 (in mice and humans), and efficiently purges the thymic TCR repertoire of AQP4-reactive clones. Genetic ablation of Aqp4 in B cells rescues AQP4-specific TCRs despite sufficient expression of AQP4 in medullary thymic epithelial cells, and B-cell-conditional AQP4-deficient mice are fully competent to raise AQP4-specific antibodies in productive germinal-centre responses. Thus, the negative selection of AQP4-specific thymocytes is dependent on the expression and presentation of AQP4 by thymic B cells. As AQP4 is expressed in B cells in a CD40-dependent (but not AIRE-dependent) manner, we propose that thymic B cells might tolerize against a group of germinal-centre-associated antigens, including disease-relevant autoantigens such as AQP4.

A 15-year review of lightning deaths in Germany-with a focus on pathognomonic findings.

Lethal accidents caused by lightning are divided into observed and unobserved events. Pathognomonic or characteristic findings are often overlooked during external postmortem examination. Classical mistakes may be made which may often lead to an incorrect diagnosis. An analysis of 270 fatalities was performed on a historical collection of the Committee for Lightning Conductor Construction for the United Economic Area e. V. (ABBW) on lethal accidents due to lightning that occurred in Germany for the period 1951-1965. Furthermore, a selective literature research was carried out. The aim of the study was to analyze the death scene, the clothing, and the victim. The authors focused on chief findings which were relevant to the correct diagnosis of "death by lightning." Both Lichtenberg figures and singed body hair were considered pathognomonic for a lightning strike. The question arose as to whether Lichtenberg figures, for example, represented the finding that most often led to the correct diagnosis. Of the 270 lightning-struck victims from the case collection, 129 (47.8%) had singed body hair and 25 (9.3%) had Lichtenberg figures. A comparison of the frequency of the two reported findings, singed body hair versus Lichtenberg figures, has only been performed in the literature for case numbers below 40. This study is the first evaluation of a relatively large number of lethal accidents due to lightning. Singed body hair was reported more frequently in lightning-struck victims than Lichtenberg figures. This study showed that singed body hair is probably more diagnostically important than Lichtenberg figures.

Insights in ChAdOx1 nCoV-19 vaccine-induced immune thrombotic thrombocytopenia.

SARS-CoV-2 vaccine ChAdOx1 nCoV-19 (AstraZeneca) causes a thromboembolic complication termed vaccine-induced immune thrombotic thrombocytopenia (VITT). Using biophysical techniques, mouse models, and analysis of VITT patient samples, we identified determinants of this vaccine-induced adverse reaction. Super-resolution microscopy visualized vaccine components forming antigenic complexes with platelet factor 4 (PF4) on platelet surfaces to which anti-PF4 antibodies obtained from VITT patients bound. PF4/vaccine complex formation was charge-driven and increased by addition of DNA. Proteomics identified substantial amounts of virus production-derived T-REx HEK293 proteins in the ethylenediaminetetraacetic acid (EDTA)-containing vaccine. Injected vaccine increased vascular leakage in mice, leading to systemic dissemination of vaccine components known to stimulate immune responses. Together, PF4/vaccine complex formation and the vaccine-stimulated proinflammatory milieu trigger a pronounced B-cell response that results in the formation of high-avidity anti-PF4 antibodies in VITT patients. The resulting high-titer anti-PF4 antibodies potently activated platelets in the presence of PF4 or DNA and polyphosphate polyanions. Anti-PF4 VITT patient antibodies also stimulated neutrophils to release neutrophil extracellular traps (NETs) in a platelet PF4-dependent manner. Biomarkers of procoagulant NETs were elevated in VITT patient serum, and NETs were visualized in abundance by immunohistochemistry in cerebral vein thrombi obtained from VITT patients. Together, vaccine-induced PF4/adenovirus aggregates and proinflammatory reactions stimulate pathologic anti-PF4 antibody production that drives thrombosis in VITT. The data support a 2-step mechanism underlying VITT that resembles the pathogenesis of (autoimmune) heparin-induced thrombocytopenia.

Quantitative evidence of suppressed TMEM119 microglial immunohistochemistry in fatal morphine intoxications.

The aim of this pilot study was to investigate the diagnostic potential of TMEM119 as a useful microglia-specific marker in combination with immunostainings for phagocytic function and infiltrating capacity of monocytes in cases of lethal monosubstance intoxications by morphine (MOR), methamphetamine (METH), and of ethanol-associated death (ETH) respectively. Human brain tissue samples were obtained from forensic autopsies of cases with single substance abuse (MOR, n = 8; ETH, n = 10; METH, n = 9) and then compared to a cohort of cardiovascular fatalities as controls (n = 9). Brain tissue samples of cortex, white matter, and hippocampus were collected and stained immunohistochemically with antibodies against TMEM119, CD68KiM1P, and CCR2. We could document the lowest density of TMEM119-positive cells in MOR deaths with highly significant differences to the control densities in all three regions investigated. In ETH and METH deaths, the expression of TMEM119 was comparable to cell densities in controls. The results indicate that the immunoreaction in brain tissue is different in these groups depending on the drug type used for abuse.

Primary stability of the Activ L® intervertebral disc prosthesis in cadaver bone and comparison of the keel and spike anchoring concept.

BACKGROUND: High primary stability is the key prerequisite for safe osseointegration of cementless intervertebral disc prostheses. The aim of our study was to determine the primary stability of intervertebral disc prostheses with two different anchoring concepts - keel and spike anchoring. METHODS: Ten ActivL intervertebral disc prostheses (5 x keel anchoring, 5 x spike anchoring) implanted in human cadaver lumbar spine specimens were tested in a spine movement simulator. Axial load flexion, extension, left and right bending and axial rotation motions were applied on the lumbar spine specimens through a defined three-dimensional movement program following ISO 2631 and ISO/CD 18192-1.3 standards. Tri-dimensional micromotions of the implants were measured for both anchor types and compared using Student's T-test for significance after calculating 95 % confidence intervals. RESULTS: In the transverse axis, the keel anchoring concept showed statistically significant (p < 0.05) lower mean values of micromotions compared to the spike anchoring concept. The highest micromotion values for both types were observed in the longitudinal axis. In no case the threshold of 200 micrometers was exceeded. CONCLUSIONS: Both fixation systems fulfill the required criteria of primary stability. Independent of the selected anchorage type an immediate postoperative active mobilization doesn't compromise the stability of the prostheses.

Semi-Automated Determination of Heavy Metals in Autopsy Tissue Using Robot-Assisted Sample Preparation and ICP-MS.

The endoprosthetic care of hip and knee joints introduces multiple materials into the human body. Metal containing implant surfaces release degradation products such as particulate wear and corrosion debris, metal-protein complexes, free metallic ions, inorganic metal salts or oxides. Depending on the material composition of the prostheses, a systemic exposure occurs and may result in increasing metal concentrations in body fluids and tissues especially in the case of malfunctions of the arthroplasty components. High concentrations of Cr, Co, Ni, Ti and Al affect multiple organs such as thyroid, heart, lung and cranial nerves and may lead to metallosis, intoxications, poly-neuropathy, retinopathy, cardiomyopathy and the formation of localized pseudo tumors. The determination of the concentration of metals in body fluids and tissues can be used for predicting failure of hip or knee replacements to prevent subsequent severe intoxications. A semi-automated robot-assisted measurement system is presented for the determination of heavy metals in human tissue samples using inductively coupled plasma mass spectrometry (ICP-MS). The manual and automated measurement processes were similarly validated using certified reference material and the results are compared and discussed. The automation system was successfully applied in the determination of heavy metals in human tissue; the first results are presented.

Lesions and characteristic injury patterns caused by high-voltage fault arcs.

Exposure to high-voltage electric arcs as a result of an accident or by means to commit suicide can affect people's health and cause death. There are characteristic external findings that can be found on external examination. These include extensive skin burns, periorbital recesses or "crow's feet," vapor deposition of conductor material, known as metallization, and tightly spaced, roundish, crocodile skin like burns. The Institute of Legal Medicine of the Rostock University Medical Center recorded 16 deaths caused by exposure to electricity between 1990 and 2018. Six of these deaths were caused by exposure to high-voltage electric arcs and five of these deaths (83 %) showed crocodile skin like burns and one had periorbital recesses burns on the face as a result of a fault arc. To our knowledge, the present paper is the first report describing the frequent occurrence of crocodile skin like burns due to high-voltage fault arcs.

Acute Disseminated Encephalomyelitis with Seizures and Myocarditis: A Fatal Triad.

Autoimmune pathology of acute disseminated encephalomyelitis (ADEM) is generally restricted to the brain. Our objective is to expand the phenotype of ADEM. A four-year-old girl was admitted to the pediatric emergency room of a university medical center five days after a common upper respiratory tract infection. Acute symptoms were fever, leg pain, and headaches. She developed meningeal signs, and her level of consciousness dropped rapidly. Epileptic seizure activity started, and she became comatose, requiring intubation and mechanical ventilation. Serial brain magnetic resonance imaging (MRI) illustrated the fulminant development of ADEM. Treatment escalation with high-dose corticosteroids, immunoglobulins, and plasma exchange did not lead to clinical improvement. On day ten, the patient developed treatment-refractory cardiogenic shock and passed away. The postmortem assessment confirmed ADEM and revealed acute lymphocytic myocarditis, likely explaining the acute cardiac failure. Human metapneumovirus and picornavirus were detected in the tracheal secrete by PCR. Data sources-medical chart of the patient. This case is consistent with evidence from experimental findings of an association of ADEM with myocarditis as a postinfectious systemic autoimmune response, with life-threatening involvement of the brain and heart.

Secondary sclerosing cholangitis in critically ill patients after a traffic accident-a new entity that should be considered in death classification.

A 49-year-old female sustained a polytrauma after being hit by a vehicle in a traffic accident. Following the incident, the woman had various surgical interventions and underwent intensive care over a 6-week period. Eight months later, she died after developing secondary sclerosing cholangitis (SSC). Autopsy revealed liver failure and hepatic encephalopathy due to SSC caused by the polytrauma and the subsequent intensive care. Prior to the accident, there was no evidence of a pre-existing liver or biliary system disease. The death of the patient was classified as non-natural as a causal consequence of the traffic accident. SSC has been clinically described as a complication of intensive care. Since it has a high mortality rate, it is important that forensics and pathologists are aware of the condition.

Effect of electromagnetic fields on human osteoarthritic and non-osteoarthritic chondrocytes.

BACKGROUND: Studies of the effects of electromagnetic fields (EMFs) on cartilaginous cells show a broad range of outcomes. However EMFs are not yet clinically applied as standard treatment of osteoarthritis, as EMF effects are showing varying outcomes in the literature. The aim of this study was to examine effects of EMFs (5 mT or 8 mT) on osteoarthritic (OA) and non-OA chondrocytes in order to investigate whether EMF effects are related to chondrocyte and EMF quality. METHODS: Pellets of human OA and non-OA chondrocytes were exposed to a sinusoidal 15 Hz EMF produced by a solenoid. Control groups were cultivated without EMF under standard conditions for 7 days. Cultures were examined by staining, immunohistochemistry and quantitative real-time PCR for RNA corresponding to cartilage specific proteins (COL2A1, ACAN, SOX9). RESULTS: OA chondrocytes increased the expression of COL2A1 and ACAN under 5 mT EMF compared to control. In contrast no changes in gene expression were observed in non-OA chondrocytes. OA and non-OA chondrocytes showed no significant changes in gene expression under 8 mT EMF. CONCLUSION: A 5 mT EMF increased the expression of cartilage specific genes in OA chondrocytes whereas in non-OA chondrocytes no changes in gene expression were observed. An 8 mT EMF however showed no effect altogether. This suggests that EMF effects are related to EMF but also to chondrocyte quality. Further studies about the clinical relevance of this effect are necessary.

Histologic spectrum of the cardiac conducting tissue in non-natural deaths under 30 years of age: an analysis of 43 cases with special implications for sudden cardiac death.

In the past, histological findings of the cardiac conduction system or its adjacent structures, such as filiform fibers at the transition from bundle of His to bundle branches, connective tissue at the apex of the ventricular septum, or fibromuscular alterations of the arteries has been considered as a cause of death. However, the prevalence of such findings in a healthy population has been rarely analyzed systematically. In the present study, the morphology of the cardiac conduction system of 43 heart-healthy individuals who died of non-natural causes (ages 0 to 30 years) was investigated. In a high percentage of cases, connective tissue at the apex of the ventricular septum (97.7%), filiform fibers at the transition from bundle of His to the bundle branches (27.9%), and fibromuscular proliferations of the sinoatrial node artery (41.9%), and the AV-node artery (39.5%) could be detected. Based on our observations, these alterations should not be considered as a pathologic entity or as a cause of death.

Death within 44 days of 2,4-dinitrophenol intake.

We report the case of a 50-year-old obese man (115 kg body mass at 1.77 m height), who started taking 2,4-dinitrophenol (DNP) for weight reduction 44 days before his death. After 43 days of taking DNP, the man showed signs of intoxication with nausea, vomiting, and attacks of sweating. After admission to a hospital where the man concealed his DNP intake, sinus tachycardia, tachypnea, and general unrest were noted. The patient died 9 h after the onset of those symptoms. Upon autopsy, a yellowing of palms and soles was striking. The initially uncertain cause of death could only be clarified by the forensic toxicological examinations and subsequent police investigations. Finally, the man had a total intake of 12.3 g of DNP in 44 days which is relatively high compared to other lethal DNP intoxications.

Make-up and love bites: two reports about exceptional cases of self-inflicted "injuries".

Self-inflicted injuries and their differentiation from inflicted injuries may have severe legal implications. The detection of these injuries is an important task in clinical forensic medicine. We present two cases of skin discolorations caused by using make-up and suction of the skin which have only rarely been reported. In the first case a 19-year-old woman asserted she was punched against her left clavicle and her right eye by a perpetrator, and that during the following forced sexual intercourse she had been bitten on the neck. On medicolegal examination 3 days later dark blue, shimmering discolorations at her right eyebrow, the left side of the neck and the left clavicle were seen. At first sight these discolorations appeared as bruises; however, they could easily be removed by a simple wipe with a finger. In the second reported case a 23-year-old woman reported she had been assaulted by two men who forcefully pressed her against a wall, partially undressed her and forced her to touch and rub one man's penis. Medicolegal examination 32 h after the incident revealed several round to oval shaped, reddish to brown discolorations on both of her upper arms resembling so-called love bites created by suction. In both cases the preliminary investigation by the public prosecutor were closed. However, case 1 is still subject to legal investigations due to false incrimination. Self-infliction of injuries should always be considered in forensic examinations, even if they do not follow the classical pattern.

Encephalopathy and death in infants with abusive head trauma is due to hypoxic-ischemic injury following local brain trauma to vital brainstem centers.

BACKGROUND: Infants with abusive head trauma (AHT) have diffuse brain damage with potentially fatal brain swelling. The pathogenesis of the brain damage remains unclear. We hypothesize that brain damage in AHT is due to hypoxic-ischemic injury with hypoxic-ischemic encephalopathy (HIE) rather than primary traumatic brain injury (TBI) with traumatic diffuse axonal injury (tDAI). METHODS: We studied brain tissue of AHT victims. Primary outcome measure was the presence of primary traumatic versus hypoxic-ischemic brain injury. The diagnosis of tDAI followed a standardized semiquantitative diagnostic approach yielding a 4-tiered grading scheme (definite, possible, improbable, and none). In addition, results of quantitative immunohistochemical analysis in a subgroup of AHT victims with instant death were compared with matched SIDS controls. RESULTS: In our cohort of 50 AHT victims, none had definite tDAI (no tDAI in 30, tDAI possible in 2, and tDAI improbable in 18). Instead, all AHT victims showed morphological findings indicative of HIE. Furthermore, the subgroup with instant death showed significantly higher counts of damaged axons with accumulation of amyloid precursor protein (APP) in the brainstem adjacent to the central pattern generator of respiratory activity (CPG) (odds ratio adjusted for age, sex, brain weight, and APP-count in other regions = 3.1; 95 % confidence interval = 1.2 to 7.7; p = 0.015). CONCLUSIONS: AHT victims in our cohort do not have diffuse TBI or tDAI. Instead, our findings indicate that the encephalopathy in AHT is the due to hypoxic-ischemic injury probably as the result of respiratory arrest due to local damage to parts of the CPG in the brainstem.

Usefulness of SNPs as Supplementary Markers in a Paternity Case with 3 Genetic Incompatibilities at Autosomal and Y Chromosomal Loci.

BACKGROUND: In kinship testing, investigation of 15 short tandem repeats (STRs) usually provides decisive genetic information for resolving relationship cases. However, in complex deficiency cases, in cases with more than 2 mutations at different STR loci or when close (untested) relatives of the alleged father are suggested to be the biological father of the child, STR typing alone may not be sufficient. In these cases, the application of supplementary markers such as single nucleotide polymorphisms (SNPs) is recommended. METHODS: We describe a paternity case with 3 genetic incompatibilities (Penta D, VWA, and DYS385) between the alleged father and the child after analyzing 23 autosomal and 16 Y chromosomal STR loci. The question arose as to whether the alleged father could be excluded and a related person could be the biological father of the child, or whether the observed genetic incompatibilities were mutations. Interestingly, the 2 excluded full brothers of the alleged father possessed identical genetic incompatibilities at locus VWA and DYS385 as the alleged father. RESULTS AND CONCLUSIONS: Additional performance of a 50-plex SNP assay demonstrated that the observed mismatches were indeed mutations and the alleged father was the biological father of the child. The results show the usefulness of SNPs as supplementary markers in relationship testing when STR analyses show ambiguous results.

Neuroforensomics: metabolites as valuable biomarkers in cerebrospinal fluid of lethal traumatic brain injuries.

Traumatic brain injury (TBI) is a ubiquitous, common sequela of accidents with an annual prevalence of several million cases worldwide. In forensic pathology, structural proteins of the cellular compartments of the CNS in serum and cerebrospinal fluid (CSF) have been predominantly used so far as markers of an acute trauma reaction for the biochemical assessment of neuropathological changes after TBI. The analysis of endogenous metabolites offers an innovative approach that has not yet been considered widely in the assessment of causes and circumstances of death, for example after TBI. The present study, therefore, addresses the question whether the detection of metabolites by liquid-chromatography-mass spectrometry (LC/MS) analysis in post mortem CSF is suitable to identify TBI and to distinguish it from acute cardiovascular control fatalities (CVF). Metabolite analysis of 60 CSF samples collected during autopsies was performed using high resolution (HR)-LC/MS. Subsequent statistical and graphical evaluation as well as the calculation of a TBI/CVF quotient yielded promising results: numerous metabolites were identified that showed significant concentration differences in the post mortem CSF for lethal acute TBI (survival times up to 90 min) compared to CVF. For the first time, this forensic study provides an evaluation of a new generation of biomarkers for diagnosing TBI in the differentiation to other causes of death, here CVF, as surrogate markers for the post mortem assessment of complex neuropathological processes in the CNS ("neuroforensomics").

Fatal intoxication with 1,4-butanediol: Case report and comprehensive review of the literature.

A fatal case of 1,4-butanediol (1,4-BD) oral ingestion is reported here, in which a 51-year-old man was found dead in his bed. According to the police report, the deceased was a known drug user. A glass bottle labeled (and later confirmed to be) "Butandiol 1,4" (1,4-BD) was found in the kitchen. Furthermore, the deceased's friend stated that he consumed 1,4-BD on a regular basis. The autopsy and histological examination of postmortem parenchymatous organ specimens did not revealed a clear cause of death. Chemical-toxicological investigations revealed gammahydroxybutyrat (GHB) in body fluids and tissues in the following quantities: femoral blood 390 mg/L, heart blood 420 mg/L, cerebrospinal fluid 420 mg/L, vitreous humor 640 mg/L, urine 1600 mg/L, and head hair 26.7 ng/mg. In addition, 1,4-BD was qualitatively detected in the head hair, urine, stomach contents, and the bottle. No other substances, including alcohol, were detected at pharmacologically relevant concentrations. 1,4-BD is known as precursor substance that is converted in vivo into GHB. In the synoptic assessment of toxicological findings, the police investigations and having excluded other causes of death, a lethal GHB-intoxication following ingestion of 1,4-BD, can be assumed in this case. Fatal intoxications with 1,4-BD have seldom been reported due to a very rapid conversion to GHB and, among other things, non-specific symptoms after ingestion. This case report aims to give an overview to the published of fatal 1,4-BD-intoxications and to discuss the problems associated with detection of 1,4-BD in (postmortem) specimens.

Histomorphometric analysis of osteocyte density and trabecular structure of 92 vertebral bodies of different ages and genders.

BACKGROUND: Knowledge of the histomorphometric structure of the vertebral body and factors influencing the structure is essential for a fundamental understanding of osteoporosis and osteoporotic fractures. The present study is focused on osteocyte density - a parameter seldom investigated so far - and trabecular width as well as bone area over tissue area in human vertebral bodies. METHODS: Ninety-two vertebral body specimens (C5, C6, Th8, Th12, L1, L2) from 12 males and seven females were studied (Ethics Application Number A 2017-0072). The prepared vertebral specimens were extracted from the ventral aspect with a Jamshidi needle®. The punches were decalcified and subsequently H&E stained. Using the Fiji/Image J program (version 1.53 f, Wayne Resband, National Institute of Mental Health, USA), osteocyte numbers were counted per calcified bone surface, and the trabecular width and bone area of trabecular bone were measured. The collected data were analyzed using the statistical software package SPSS, version 23.0 (SPSS Inc., Chicago, USA). Pearson's correlation coefficient was used for correlation analyses. Multiple linear regression analyses were also performed. RESULTS: Osteocyte density did not differ significantly in comparisons based on gender and age (≤65 years; ≥66 years). Men had wider trabeculae (p < 0.001) and a higher bone area over tissue area (BA/TA, %) (p = 0.025) than women. Individuals over 65 years of age had thinner trabeculae (p < 0.001) and a smaller BA/TA (%) (p < 0.001) than younger individuals. Multiple linear regression analyses were performed to determine the influence of 'gender' and 'age' on trabecular width and bone area over tissue area. The R² was 0.388 for trabecular width and 0.227 for BA/TA (%). Per year of life, trabecular width decreases by 0.368 µm (ß < 0.001) and BA/TA (%) by 0.001% (ß = 0.001). Men have on average 8.2 µm wider trabeculae than women (ß = 0.035). A negative correlation (r = -0.275) was observed between trabecular width and osteocyte density. The wider the trabeculae, the fewer osteocytes per mm² (p = 0.008). CONCLUSIONS: Surprisingly, we found no difference in osteocyte density with reference to age or gender. However, we did register significant age- and gender-related differences in bone area over tissue area and trabecular thickness. The age-related differences were more pronounced, implying that age-dependent loss of bone structure may be more important than differences between genders.

Heat distribution of polymerisation temperature of bone cement on the spinal canal during vertebroplasty.

PURPOSE: In the last 15 years, vertebroplasty and kyphoplasty have become established operative procedures for treating osteoporotic vertebral-body fractures and vertebral bodies afflicted with metastases. These procedures are quickly performed with few personnel and material resources and have a low rate of complications. However, cases of neurological impairment are reported in the scientific literature. We analysed whether potentially harmful heat is radiated/conducted by the polymerisation temperature of polymethylmethacrylate (PMMA) bone cement in the spinal canal. METHODS: We performed vertebroplasty on 25 vertebral bodies and measured the temperature distribution during polymerisation of bone cement within the spinal canal using heat probes placed in the respective areas. The vertebral bodies were located in a circulating water bath at 37°C. RESULTS: During polymerisation of the bone cement, a temperature rise was measured. The peak temperature was reached after few minutes. Temperature curves differed; a maximum temperature of up to 43.16°C was detected for a few seconds only. CONCLUSION: When vertebroplasty is performed correctly, there is no temperature development that could eventually damage the spinal cord or spinal nerves.

Disaster victim identification-experiences of the "Autobahn A19" disaster.

The chain reaction pile-up on the multilane highway ("Autobahn") A 19 in April 2011 was regarded as the most severe traffic accident within the last 20 years in Germany. The situation worsened when 34 of the 83 involved vehicles caught fire. As a result of this crash, 8 high-grade heat-damaged victims were found. The victim identification algorithm of the IDKO (Identification Commission of the German Federal Office of Criminal Investigation) was applied as the standard tool for forensic mass disaster evaluation. This approach included inspection of the body at the scene, post-mortem CT-scan with 3-D reconstruction, and full autopsy with toxicological examinations and DNA-analyses. As a result of the investigations we were able to identify all 8 victims. Independent of successful victim identification according to IDKO standards, the exact sequence of events and cause of death remained unclear in some of the victims.