[Wrong statement of manner of death after insufficient post-mortem examination]. / Fehlerhafte Angabe der Todesart nach insuffizienter Leichenschau.

When death certificates already completed are submitted during forensic post-mortem examinations or autopsies, blatant errors are often found, especially with regard to the classification of the manner of death. This is partly attributable to insufficient knowledge of the classification criteria, but also to the fact that the post-mortem examination was not properly performed and even clear signs of unnatural death (e.g. a strangulation mark or sharp force injuries) are overlooked. To avoid such misinterpretations, a thorough reformation of the post-mortem examination system and a regular continuing specialized training of the physicians performing post-mortems seem necessary.

[Conventional radiology versus the increasing importance of post-mortem computed tomography]. / Konventionelle Radiologie im Zeitalter (zunehmender Bedeutung) der postmortalen Computertomographie.

Radiological imaging can provide valuable additional information, facilitate and improve the quality of subsequent autopsy. Although the use of cross-sectional imaging methods is increasing, they are not always available in medico-legal practice. In many cases it is advisable to perform conventional X-rays before autopsy, especially in cases of gunshot injuries, as illustrated by a case in which the victim suffered several gunshot wounds with one projectile lodged in a vertebral body. The radiological findings essentially contributed to the rapid location of the projectiles and the reconstruction of the bullet paths.

[Post-mortem examination prior to cremation--an instrument to verify the quality of medical post-mortems and uncover non-natural deaths?]. / Die Krematoriumsleichenschau--Instrument zur Qualitätskontrolle der ärztlichen Leichenschau und Aufdeckung nichtnatürlicher Todesfälle?

The external post-mortem examination, its deficient quality and possible causes have been the subject of numerous political and professional discussions. The external post-mortem examination is the basis for the decision whether further criminal investigations are required to clarify the cause of death. It is thus an essential instrument to ensure legal certainty. Before cremation, a second external post-mortem examination is performed by a public medical officer to make sure that errors of the first post-mortem are corrected. In the present study, cases were retrospectively analyzed in which a forensic autopsy had been ordered on the basis of the results of the post-mortem examination performed before cremation. The entries on the death certificate regarding the manner and cause of death were compared with the autopsy results. Between 1998 and 2007, 387 autopsies were ordered after external examination before cremation. In 55 cases (14.2%), the autopsy revealed a non-natural death, although a natural death had been attested on the death certificate. In descending order, a wrong manner of death was attested by clinicians, general practitioners and emergency physicians. With regard to the place where the first external post-mortem had been performed the lowest error rate was seen in nursing homes. Concerning the cause of death, discrepancies between the first post-mortem and autopsy were found in 59.4% of the cases. In this respect, general practitioners and clinicians were ranking first, whereas in nursing homes the cause of death was wrongly assessed in over 70% of cases. At present, the medical post-mortem does not meet the required quality standards, especially with regard to legal certainty. Determination of the cause of death on the basis of the external post-mortem examination is a challenging task even for the experienced medical examiner. As to the categorization of the manner of death it has to be stated that non-natural deaths are often not recognized or that the possibility to certify a death as unclear is not sufficiently used. As a result, it seems important to demand intensive, qualified, additional training in external post-mortem examinations for physicians.

Human obesity reduces the number of hepatic leptin receptor (ob-R) expressing NK cells.

OBJECTIVE: In the industrialized world, obesity is an increasing socioeconomic health problem. Obese subjects have a higher risk of developing several types of cancer. NK cells are an integral component of the innate immune system, able to destruct tumor cells. The adipokine leptin plays a crucial role in the development of obesity and its related diseases. Peripheral leptin signaling is modulated by the liver. METHODS: The aim of this study was to evaluate the number of hepatic NK cells (CD56+) and the number of leptin-receptor positive (Ob-R+) cells in the livers of five normal-weight and five obese humans. Livers were removed during autopsy and accurately defined sections were stained immunohistochemically and CD56+, Ob-R+, and double-positive cells were quantified. RESULTS: Results revealed a dramatic reduction of NK cells and Ob-R-expressing NK cells in the livers of obese individuals. CONCLUSIONS: The present study demonstrates, for the first time, body-weight-dependent numbers of hepatic NK cells. This supports the hypothesis of obesity-associated alterations of immune cell numbers in different human organs.

Motives for khat use and abstinence in Yemen--a gender perspective.

BACKGROUND: Khat consumption is widespread in Yemeni society and causes problems both in economic development and public health. Preventive measures have been largely unsuccessful and the cultivation continues to proliferate. The gender-specific motives for khat use and abstinence were studied to create a toe-hold for more specific interventions. METHODS: In a quota sample with equal numbers of males, females, abstainers and consumers, 320 subjects were interviewed on their specific opinions about khat and its impact on subjective and public health, and on social and community functioning. Strata were compared in their acceptance and denial of opinions. Notions that could predict abstinence status or gender were identified with multivariate logistic regression analysis. RESULTS: Male khat users had a strong identification with khat use, while females were more ambivalent. The notion that khat consumption is a bad habit (odds ratio (OR) 3.4; p < 0.001) and consumers are malnuorished (OR 2.2; p = 0.046) were associated with female gender among khat users. Among the females worries about health impact (OR 3.2; p = 0.040) and loss of esteem in the family (OR 3.1; p = 0.048) when using khat predicted abstinence. Male abstainers opposed khat users in the belief that khat is the cause of social problems (OR 5.1, p < 0.001). Logistic regression reached an accuracy of 75 and 73% for the prediction of abstinence and 71% for gender among consumers. (All models p < 0.001.) CONCLUSIONS: Distinct beliefs allow a differentiation between males, females, khat users and abstainers when targeting preventive measures. In accordance to their specific values female khat users are most ambivalent towards their habit. Positive opinions scored lower than expected in the consumers. This finding creates a strong toe-hold for gender-specific public health interventions.

[Aquatic fatalities--a systematic retrospective analysis]. / Ertrinkungstod--eine systematische retrospektive Untersuchung.

In a retrospective analysis of the autopsy material (n = 5,767) of the Institute of Legal Medicine of the Hanover Medical School covering the period of 1998-2007, all aquatic fatalities were evaluated, categorized and systematically compared under epidemiological and forensic criteria. The total of 156 cases of death by drowning (2.7 % of all autopsies) included 38 bathtub drownings and 28 deaths in the water for which no pathological anatomical cause of death could be reliably demonstrated. A control group (n = 221) was investigated for the presence of aqueous liquid in the sphenoid sinuses and compared with the findings of the drowning cases without signs of putrefaction. About 16 % of the control cases had fluid in the sphenoid sinuses compared with 57.6 % in the drowning group. Most of the drowning victims were men (60.9 %), whereas in the group of bathtub drownings the majority were women. More than half of the drowning cases (n = 89) could be classified as accidents. The individual groups showed a different incidence of findings associated with drowning.

[Causes of death among pilots: "acute myocardial infarction"--are the present examination methods for airworthiness sufficient?]. / Todesfälle bei Piloten: "Der akute Myokardinfarkt"--Sind die derzeitigen Flugtauglichkeitsuntersuchungen ausreichend?

The European Union plans to harmonize the aviation requirements, in particular the flight crew licensing requirements. On 23 May 2007, the German Federal Ministry of Transport, Building and Urban Affairs published the Flight Crew Licensing Requirements, which are based on the Joint Aviation Requirements, Flight Crew Licensing 3, Amendment 5. These guidelines also list the examination methods to be used for testing the medical fitness of pilots. In this Amendment some examinations which were part of the routine tests before JAR-FCL3 became effective have been deleted, e.g. the exercise ECG. This article presents two cases from the autopsy material of the Institute of Legal Medicine in Hanover and discusses the problems associated with the new examination guidelines.

Renal transplantation normalized hydrogen peroxide production of neutrophils within the first day.

BACKGROUND: Hemodialysis patients are in a state of oxidant stress. In renal transplantation reactive oxygen species (ROS) are considered to be important factors of ischemia-reperfusion injury. Neutrophils produce ROS as part of the host defense against invading bacteria. This study was designed to investigate whether neutrophil function in hemodialysis patients is immediately affected by renal transplantation. METHODS: We evaluated the neutrophil respiratory burst and phagocytic activity in renal transplant patients with living-related donor (LRD) and cadaveric donor (CAD) grafts using flow cytometry techniques. Twenty patients (LRD = 6, CAD = 14) and 20 healthy volunteers were included in the study. Venous blood samples were drawn before anesthesia, 5 min before reperfusion, 1 h and 1, 3 and 7 days after reperfusion. RESULTS: Before surgery, a significant increase in hydrogen peroxide production in neutrophils was seen for both renal transplantation groups compared to healthy subjects. Within 24 h after reperfusion hydrogen peroxide production almost decreased to normal values. The phagocytic capacity of neutrophils was continuously depressed. There were no differences between the CAD and LRD groups. CONCLUSIONS: We found that the enhanced respiratory burst activity of patients with chronic renal failure decreased to normal values within 1 day following renal transplantation. Our results suggest that reduced respiratory burst activity resulting in a diminished risk of tissue damage by the uncontrolled production of ROS.

Ethanol-induced malfunction of neutrophils respiratory burst on patients suffering from alcohol dependence.

BACKGROUND: Polymorphonuclear, neutrophil granulocytes (PMN) play a major role in the control of infections, and people who abuse alcohol are susceptible to infections. Resistance against infections ensues intracellularly following initial phagocytosis of microorganisms with the oxygen-dependent respiratory burst, the key enzyme of which is the respiratory burst oxidase, whereby oxygen radicals are produced for microbial destruction. To date there is insufficient information available in connection with the process of impaired defence against infection in patients suffering from alcohol dependence. Therefore, our investigation was carried out to determine the influence of alcohol exposition on the formation of oxygen radicals and the respiratory burst. METHODS: 4.5 ml of whole blood was taken from 10 healthy adults and 10 patients suffering from alcohol dependence. An additional 3.5 ml of whole blood was taken from the alcoholic patients for determination of the blood alcohol concentration. The respiratory burst of PMN was tested using the Four-Colour-Continuous Flow Cytometer. Each experimental procedure consisted of 4 test samples [negative controls, Escherichia coli, FMLP-supplement (N-formyl-l-methionyl-l-leucyl-l-phenylalanin), PMA-supplement (phorbol-12-myristate-13-acetate)]. Differing concentrations of ethanol were also introduced to each of the tests performed (0.20 to 4.00 g/l). RESULTS: Ethanol revealed a marked decrease of burst activity in those patients suffering from alcoholism with increased alcohol concentration. A dependence between the burst activity and the ethanol concentration was seen to be statistically significant. This effect was only evident after stimulation with E. coli and FMLP in those patients with alcohol dependence. CONCLUSION: The results presented in this study show an impairment in the function of PMN in those patients addicted to alcohol due to the decrease in burst activity. In view of the results of the different stimuli, the second-messenger effects were not evident. A clarification of this phenomenon could well be assumed as an allosteric receptor effect on the burst oxidase, namely, a direct effect on the phagocytosis interaction between circulating granulocytes and causative organisms.

[Practicability of the mobile one-finger scanner Cross Match MV5 in fingerprinting of corpses: are mobile fingerprinting scanners suitable for use in mass disasters?]. / Praktikabilität des mobilen Einzelfingerscanners Cross Match MV5 in der Leichendaktyloskopie: Sind die mobilen Einzelfingerscanner für den Einsatz bei Massenkatastrophen geeignet?

Dactyloscopy is a special field in the police records department and a suitable means for identifying unknown dead persons as well as solving crimes by taking fingerprints from living persons. Apart from the conventional methods of dactyloscopy, mobile and more compact instruments are to facilitate taking prints of fingertips and palms also at the scene of mass disasters. In the presented study, living persons and corpses were examined to find out the possible uses and limits of mobile one-finger scanners. The concrete issue of the investigation was whether the mobile one-finger scanner Cross Match MV5 is suitable for application in mass disasters. The device was used in 12 corpses aged 5 weeks to 76 years (mean postmortem interval 5.5 days) and in 28 living persons aged 6 weeks to 87 years. In summary, the scanner produced qualitatively good prints in all age groups of the living individuals. In the corpses, the prints were only partly evaluable. In particular, fingers and fingertips with soot blackening and livid discoloration were difficult to analyse. Postmortem rigidity also complicated the handling of the scanner. In fresh corpses, the scanner can be recommended without reservation. Even if the epidermis was detached, the scanner was able to produce evaluable prints of the dermis of the hypothenar.

[Postmortem dismemberment/mutilation--medicolegal and criminalistic evaluation of the autopsies performed by the Institute of Legal Medicine at the Hanover Medical School]. / Leichenzerstückelungen/-verstümmelungen --differenzierte rechtsmedizinische und kriminalistische Aufarbeitung des Sektionsgutes des Institutes für Rechtsmedizin der Medizinischen Hochschule Hannover.

Among all the autopsies performed by the Institute of Legal Medicine at the Hanover Medical School between 1978 and 1998. 16 cases of postmortem dismemberment/mutilation were evaluable under criminalistic and medicolegal aspects. In the present study, particular attention was paid to the psychosocial circumstances of the perpetrator's and victim's lives and also to the classification of the different types of postmortem dismemberment/mutilation illustrated by case reports. Apart from an unfavourable personal life situation at the time of the offence, essential predisposing factors were: poor integration in society and family, occupational problems, drug abuse and mental diseases. As the interactions between these factors differ in every single case and may be combined with other factors, the analysis of such homicides should always be based on the assessment of the individual case.

[Examination of live victims of violent crimes at the Institutes of Legal Medicine of Hanover, Cologne and Leipzig]. / Untersuchung von Gewaltopfern Lebendbegutachtungen in den rechtsmedizinischen Instituten von Hannover, Köln und Leipzig.

During the last few years the importance of clinical forensic medicine has increased within the field itself, but also in interdisciplinary cooperation. Although examinations of live victims play a substantial role in the every-day work of most German forensic scientists, the number of data published on their frequency and the type of offence for which they were performed is small. For this reason a comparison of the data from the Institutes of Legal Medicine in Hanover, Cologne and Leipzig was carried out. Most of the examinations performed by all the three institutes were ordered by courts, the prosecution or the police. Only in a few cases did private persons or hospitals ask for a forensic expert opinion on injuries. During the study period the total number of examined violence victims per annum increased noticeably from 252 in 1999 to 507 in 2003. The total number of examinations during the five-year study period amounted to 1181 in Hanover, 393 in Leipzig and 198 in Cologne, which all have a similar number of inhabitants in the respective catchment area of the institutes. Most of the examinations were carried out in victims of bodily harm, sexual assault and child abuse, but also in traffic offences, for age determination, in self-inflicted injuries and in suspects of homicide. On the one hand the remarkable rise of the number of physical examinations shows that the importance of forensic expert opinions is increasingly recognized. On the other hand the considerable regional differences demonstrate that the competence offered by the Institutes of Legal Medicine in the documentation and interpretation of violence is by far not yet sufficiently used.

[An unusual case of double death]. / Ein ungewöhnlicher Doppeltodesfall.

The report presents the case of an alleged double homicide or a homicide followed by suicide of a couple, in which the court-ordered autopsy of both victims revealed that the homicide had been committed by the husband immediately before he died himself from cardiac failure. The article gives a short summary of the pathophysiological relations between emotional tension (stress) and physical strain and the effects on the cardiovascular system. The case report describes a homicide by strangulation immediately followed by the perpetuator's death from a natural cause.

[Fatalities after injuries by wild animals]. / Todesfälle nach Verletzungen durch Wildtiere.

The article summarises three fatalities after attacks by wild animals. The first case describes a 90-year-old woman who died as a result of pneumonia after a bear fell on her and caused multiple chest fractures. The second case deals with a 76-year-old woman who was hit in the middle face by the hoof of a camel and, thereafter, died of myocardial infarction. The third case describes a 27-year-old biologist who died from severe blunt trauma after an attack of a wild living elephant. The article gives a summary of typical injury patterns of selected wild animals and outlines potential reasons of death as a result of the injuries.

The greater trochanter-head contact method: a cadaveric study with a new technique for the intraoperative control of rotation of femoral fractures.

OBJECTIVE: To describe a new method for femoral rotational alignment during intramedullary nail insertion using the profile of the greater trochanter and its relation to the femoral head. METHODS: Radiologically, the line that represents the posterior border of the greater trochanter comes in contact with the femoral head contour during external rotation. The degree of rotation to achieve this contact was measured on both lower extremities of 15 whole fresh-frozen cadavers and seven dried human femora using a standard image intensifier. Computed tomography was used in the dried femora to assess the femoral anteversion angle, the length of the femoral neck, and the neck-shaft angle. RESULTS: The side difference of the greater trochanter-head contact angle was 6° or less in 14 of 15 whole fresh-frozen cadavers. Regarding the dried human femora, this angle had a strong positive correlation with femoral neck anteversion angle (r = 0.9), whereas no statistically significant correlation could be detected with the neck length or the neck-shaft angle. CONCLUSION: Our described method is simple to execute because it depends on a definite point of measurement. Furthermore, an angle is recorded for each extremity, which enables us to estimate the amount of the rotational difference. This method does not depend on special views, especially at the hip, but only a direct anteroposterior view with gradual internal rotation of the image intensifier.

The influence of blood alcohol concentrations of around 0.03% on neuropsychological functions--a double-blind, placebo-controlled investigation.

There is a general agreement that blood alcohol concentrations (BACs) of about 0.05% result in impairment of the ability to drive. This fact has been supported by means of experiments. In addition, there are only a few studies to date investigating low BACs. The present study aims to investigate the extent and quality of cognitive changes in low BACs of around 0.03%. Sixteen healthy male subjects were examined in a double-blind, placebo-controlled study. During the trials the BAC was regulated to about 0.03%. As part of the study a record was made of the general level of intelligence, subjective impairments, possible depressive symptoms, general ability to perform, vigilance, divided attention, response times and performance of memory. Statistical analysis took place using the two-period crossover design. Verbal intelligence, general performance, vigilance (optical stimuli), divided attention, vigilance towards acoustic stimuli and the general response time to acoustic and visual-acoustic sequential stimuli, and memory were not impaired significantly by a BAC of around 0.03%. The total response and motor response time to optical stimuli as well as decision time about sequential optical stimuli were, however, significantly changed for BACs of around 0.03%. In conclusion, the present results show that already in BACs of around 0.03%, particular cognitive functions which rely on perception and processing of visual information, are significantly impaired. This was evident in the more complex and urgent tasks.

The carina as a landmark for central venous catheter placement in small children.

Central venous devices are frequently used in children to monitor haemodynamic status, to administer fluids, medication, parenteral nutrition and for blood sampling. Life-threatening complications that may occur on insertion if the central venous catheter (CVC) is misplaced, are cardiac tamponade or a hydro-/haemopericardium. There is still controversy over the optimum catheter tip position in paediatric patients, whether to place the CVC tip in the superior vena cava, outside the pericardial boundaries or in the right atrium. However, the exact location of the pericardium cannot be seen on a normal chest x-ray. The carina is a radiographic marker for CVC placement, suggested on the basis of studies with conserved and fresh adult cadavers. In order to confirm this landmark for children, the present study was performed with 31 fresh cadavers of small children (mean age 12.5+/-3.4 months) that had been selected for autopsy in the Institute of Legal Medicine. Results clearly demonstrate that the carina was 0.5+/-0.04 cm above the pericardial duplication as it transversed the SVC. In no infant cadaver was the carina inferior to the pericardium. Thus, the results are analogous to those in adults and confirm that the carina is a simple anatomical-radiological landmark, superior to the pericardial reflection, that can be used to identify the placement of CVC even in newborn and small children.

The lingual tonsillar hyperplasia in relation to unanticipated difficult intubation: is there any relationship between lingual tonsillar hyperplasia and tonsillectomy?

The lingual tonsillar hyperplasia (LTH) is a rare and dangerous condition of the upper airway because it is one of several risks during intubation which can cause serious complications like cardiac arrest, cerebral anoxia, and death. The LTH is rarely detectable during a routine oropharyngeal examination. The lingual tonsil is of particular interest to forensic medicine to assess cases with malpractice in connection with intubation difficulties. Our study looked at how often autopsy specimens had enlarged lingual tonsils and whether any relationship existed between LTH and tonsillectomies. In total, 497 corpses were examined. Only in 16 cases (3.2%), an enlarged lingual tonsil was detected. Of the 16 cases, 10 (62.5%) had normal palatine tonsils; the other 6 cases (37.5%) had no palatine tonsils or were scarred, atrophied, or only remnants remained. Statistically, it was not possible to prove any relationship between enlarged lingual tonsils and tonsillectomies. From the forensic point of view, a description of the lingual tonsil should appear in special cases in autopsy reports. When reviewing malpractice cases, special anatomic features should be described.