Petechial bleedings in sudden infant death.

The autopsy reports of 484 cases of deceased infants (201 females, 283 males) were analysed retrospectively for the existence of external and internal petechial bleedings (PET). The cases were divided into five groups on the basis of the cause of death (sudden infant death syndrome, sepsis, airway infections, asphyxia and trauma). Internal PET (pleural, pericardial, epicardial, thymic and peritoneal) were observed in each group with a lower prevalence in cases of trauma. The highest prevalence of external (cutaneous and conjunctival) PET was detected in cases of asphyxia (38% and 31%, respectively). However, even if with low prevalence, such bleedings were detected in every group. Factors like sex, age, cardiopulmonary resuscitation and its duration did not influence the presence of PET. The detection of external PET at autopsy is a suspicious finding that suggests asphyxia. Because of the possible natural origin of these bleedings, the medicolegal investigation has to be as complete as possible and has to include histology as mandatory.

Fatal lipid embolism following intraarterial angiography at an early stage of arteriosclerosis.

Intraarterial angiography was performed on a patient with peripheral arterial occlusive disease (Fontaine IIb). No relevant risk factors were known, and a previous angiography had been undertaken without incident. After administration of contrast medium, the patient complained of acute pain in the lower abdomen and both legs, and a sudden rise in blood pressure was observed. The patient subsequently lost consciousness and died within 1.5 h. Postmortem examination showed that death was due to peripheral atheromatous microembolism of lipids, and not cholesterol as is usual in these cases. The differential diagnosis is discussed and a review of the literature is presented.

How and why does the platelet count in postmortem blood change during the early postmortem interval?

We examined the changes in the early postmortem platelet count in postmortem blood and the reasons for these changes by counting the platelets, by performing in vitro hypostatic tests, by estimating the percentage of erythrocytes by volume in postmortem blood samples, by immunohistochemistry (anti-CD61, anti-fibrinogen), and by immunoelectron microscopy (anti-CD62, anti-CD63, anti-thrombospondin). The apparent initial increase in the platelet count in postmortem blood was found to be caused by hypostatic phenomena. The subsequent discontinuous decrease in the platelet count despite continuing hypostasis in the corpse can be explained in part by postmortem thrombolysis and the development of reversible platelet-platelet aggregates. The main point is, that changes in the postmortem blood environment cause potentially reversible adhesion of platelets to pre-adsorbed fibrinogen on erythrocytes. Thus the decrease in the number of platelets in postmortem blood is not attributable to postmortem clotting but to a decrease in the number of countable platelets in postmortem blood.

[Visual evoked potentials in low blood alcohol concentrations]. / Visuell evozierte Potentiale bei niedrigen Blutalkoholkonzentrationen.

BACKGROUND: Both the acute toxic effects of ethanol on the central nervous system and the effects of chronic alcohol consumption on the optic nerve (tobacco-alcohol amblyopia) are well known. We investigated the acute effect of low blood alcohol concentrations on visual evoked potentials. MATERIALS AND METHODS: A pattern VEP (stimulation by TV monitor, alternating chequerboard patterns, 45', 2 Hz, contrast 90%) was performed in ten healthy volunteers in sober condition and 0, 30, 60, 90 and 120 min following ingestion of 1 g/kg body weight ethanol (resulting in a blood alcohol concentration of 0.8-1.1%). Blood samples were drawn from the cubital vein simultaneously with each recording to determine blood alcohol concentration. RESULTS: Neither peak latencies nor amplitudes showed significant changes related to blood alcohol concentration. CONCLUSION: No acute impairment of the optic nerve caused by ingestion of low doses of alcohol could be found using pattern VEP.

[Impairment of safety in navigation caused by alcohol: impact on visual function]. / Beeinträchtigung der Sicherheit im Schiffsverkehr durch Alkohol. Einfluss auf das Visuelle System.

BACKGROUND: So far in Germany, no legally binding standards for blood alcohol concentration exist that prove an impairment of navigability. The aim of our interdisciplinary project was to obtain data in order to identify critical blood alcohol limits. In this context the visual system seems to be of decisive importance. MATERIALS AND METHODS: 21 professional skippers underwent realistic navigational demands soberly and alcoholized in a sea traffic simulator. The following parameters were considered: visual acuity, stereopsis, color vision, and accommodation. RESULTS: Under the influence of alcohol (average blood alcohol concentration: 1.08 per thousand ) each skipper considered himself to be completely capable of navigating. While simulations were running, all of the skippers made nautical mistakes or underestimated dangerous situations. Severe impairment in visual acuity or binocular function were not observed. Accommodation decreased by an average of 18% ( p=0.0001). In the test of color vision skippers made more mistakes ( p=0.017) and the time needed for this test was prolonged ( p=0.004). CONCLUSIONS: Changes in visual function as well as vegetative and psychological reactions could be the cause of mistakes and alcohol should therefore be regarded as a severe risk factor for security in sea navigation.

[Impairment of safety in navigation caused by alcohol: pupillography and measurement of pupil movements]. / Beeinträchtigung der Sicherheit im Schiffsverkehr durch Alkohol. Pupillographie und Augenbewegungsmessungen.

OBJECTIVE: To evaluate data in an interdisciplinary project (ophthalmology, forensic medicine, internal medicine, psychology,and nautical science) in order to identify critical blood alcohol limits in sea navigation. METHODS: A sea traffic simulator was employed for realistic nautical demands on 21 professional experienced skippers under sober and alcoholized conditions (target blood alcohol concentration: 1.0 per thousand ). After simulated navigation, pupil light reflex, spontaneous pupil movements,nystagmus,and saccades were evaluated by pupillography. Modification of the pupillograph enabled us also to measure optokinetic nystagmus. RESULTS: Evaluation of the pupil light reflex revealed obvious changes in the extent of relative contraction and in redilatation time under the influence of alcohol. Diminished vigilance could be observed in all of the skippers when optokinetic nystagmus was tested. CONCLUSION: The pupillograph represents a suitable device for measuring functions of the visual and vegetative systems. Thus, the impact of these functions on nautical capability can be demonstrated. If further investigations such as ophthalmological, medical, psychological, and nautical evaluations are taken into account, it could be determined that blood alcohol levels of 1.0 per thousand may exclude safe navigation.

Magnetic resonance imaging of the brain during alcohol absorption and elimination--a study of the "rising tide phenomenon".

The absorption phase of alcohol is typically accompanied by more marked behavioral effects than the elimination phase. The mechanism behind this so-called "rising tide phenomenon" has not been fully elucidated. We hypothesized that the rising tide of alcohol during the absorption phase increases the permeability of the blood-brain barrier (BBB), thus elevating the free water content with consequent edema. The resulting increase in intracranial pressure, combined with alcohol's direct toxic effects, results in a synergetic reinforcement of the symptoms of intoxication. To test this hypothesis we performed proton magnetic resonance imaging (MRI) on the human brain during the alcohol absorption and elimination phases. Our results indicate that the alcohol-induced transient opening of the BBB is a possible factor behind the rising tide phenomenon.

[Duration of absorption in alcohol intake of 0.3, 0.5 and 0.8 g of alcohol per kg of body weight in 30 minutes]. / Zur Dauer der Resorptionszeit bei einer Ethanolbelastung von 0,3, 0,5 und 0,8 g Alkohol pro kg Körpergewicht in 30 Minuten.

In expert opinion the time of absorption after ethanol consumption often must be estimated, because back calculation is not permitted during this period of possible ethanol absorption. HEIFER called this time "waiting times" in back calculation. He undertook an investigation of these "waiting times" in drinking experiments with different dosages and a drinking period of 60 minutes. The presented investigation dealt with the maximum "waiting times" after a shorter time of drinking. Within 30 minutes three groups, each amounting to 10 persons, were given 0,8, 0,5 and 0,3 g of ethanol per kg body weight. The results of these experiments showed that the maximum "waiting times" in back calculation after a drinking period of 30 minutes sometimes are longer than the "waiting times", calculated by HEIFER after a drinking period of 60 minutes.

[Species differentiation by placental morphology with human and animal tissue. A contribution to species determination in relation to embryo findings]. / Speziesdifferenzierung durch Plazentamorphologie an menschlichem und tierischem Gewebe. Ein Beitrag zur Artdiagnose bei einem Embryofund.

On the occasion of an embryo being found with attached placenta, species differentiation of the fetus was to be carried out within the framework of a preliminary proceeding. Consulted gynecologists diagnosed a human embryo. From the macroscopic and histologic structure of the placenta, our investigations resulted a species diagnosis of an embryo belonging to the order Carnivora (cat). The diversity of external placental shapes as well as of different histologic structures permit species differentiation. The delimitation of the human embryo from nonhuman tissue should always be possible, even on formalin-fixed material.

[Forensic aspects of spatially and temporally related multiple corpses]. / Forensische Aspekte bei räumlich und zeitlich zusammenhängenden Mehrfach-Leichenfunden.

The authors analysed 171 cases of two or more corpses, found in a spatial and temporal coherence. The investigation revealed cases of manifold-homicides, homicides with suicide of the perpetrator, manifold-suicides, affects of cryptic, non human dangers from the outside, joint exposition to potential dangerous situations and casual deaths of two people at one place due to natural, internal diseases. The necessity of an autopsy in each case is pointed out.

Criteria for age estimation in living individuals.

This paper presents updated recommendations of the Study Group on Forensic Age Diagnostics for age estimations in living individuals in criminal proceedings. In order to increase the diagnostic accuracy and to improve the identification of age-relevant developmental disorders, a physical examination, an X-ray examination of the left hand, as well as a dental examination including the determination of the dental status and an X-ray of the dentition should be performed in each case. If the skeletal development of the hand is completed, an additional radiological examination of the clavicles should be carried out. Minimum requirements for reference studies are defined and recommendable studies are listed. Instructions for the examination and the preparation of expert reports are presented. The committee of the study group organizes annual proficiency tests for quality assurance.

[Current issues in medical liability]. / Aktuelle Fragen der strafrechtlichen Arzthaftung.

Currently, liability discussions are being dominated by AIDS and the legal problems associated with birth and death. The introduction of routine AIDS tests without the knowledge of those concerned is disputed heatedly and, in fact, may well constitute bodily assault and render those responsible liable to prosecution. In AIDS cases, the apparent breach of the Hippocratic oath of secrecy by Physicians can be justified on the grounds of both the extraordinary circumstances prevailing and conflicting duties. The transmission of AIDS could give rise to prosecution for causing bodily injury or manslaughter. The drawing up of a law to protect embryos is designed to establish legal constraints in the fields of reproduction and gene technology. In reframing section 168 StGB, which provides protection to the dead embryo, legislators assume that the head of a medical clinic is the lawful custodian of the corpse of a person who has died in his institution. This should help to resolve many of the problems arising from post-mortem examinations. The questions of euthanasia and medical assistance in cases of suicide were raised at the 1986 Conference of German Lawyers. Whereas medical treatment that could be considered as interference with the natural process of dying may be withdrawn in the case of irreversible terminal suffering, active euthanasia, i.e. the deliberate killing of a terminal patient, was rejected. With regard to noninterference in a suicide attempt by a third party, the free decision of the person wishing to commit suicide should be respected. In general, however, the maxim in dubio pro vita should be respected and where any doubt exists, an attempt should be made to save the person's life.

[Legal aspects of treatment and care of elderly patients]. / Rechtliche Aspekte bei der Behandlung und Pflege alter Menschen.

Legal aspects in criminal and civil law of treatment of senior patients are discussed: Problems of euthanasia, physician's duty to save and protect life, patient's right of freedom and the problems of unlawful personal injuries. If the senior patient is unable to give consent, then the consent of the patient's legal representative (legal guardian) must be obtained, in certain cases also the consent of the District Court.

[Interpretation of postmortem digoxin levels: evaluating a "corrective factor" for postmortem blood digoxin concentration]. / Zur Interpretation von postmortalen Digoxinspiegeln: Uberprüfung eines "Korrekturfaktors" für postmortal gemessene Digoxinkonzentrationen im Blut.

Interpretation of postmortem serum digoxin levels is made difficult above all by a possible prefinal or postmortem rise in digoxin concentrations in the blood. To compensate for this postmortem increase, Eriksson et al. (1984) divided the level of postmortem digoxin in femoral venous blood by a factor of 1.5; in the opinion of these authors, postmortem digoxin levels still exceeding "therapeutic levels" after division by 1.5 are an index of digoxin overdose. The diagnostic value of this "correction factor" was investigated. In 56 cases with documented digoxin medication, samples of postmortem femoral venous blood were taken and the level of digoxin determined. In none of the cases had there been a clinical diagnosis of digoxin intoxication. Fifty percent of the measured values were above "therapeutic levels" (0.7 ng/ml to 2.2 ng/ml). Following division by 1.5, 20% of the cases still showed levels exceeding 2.2 ng/ml; the highest "corrected" value was 4.44 ng/ml. Taking into account the length of time between final dosage and death, individual differences in sensitivity to digitalis glycoside, and the complexity of ante- and postmortem dispersion processes, we concluded for the cases we studied that an (undetected) digoxin overdose was not even likely in those cases whose postmortem values after division by 1.5 lie above "therapeutic levels". The "correction factor" proposed by Eriksson et al. (1984) is only of limited diagnostic value; at best the "corrected" values can give an approximate indication of the corresponding antemortem serum digoxin concentrations. In particular, "corrected" values only a little above "therapeutic levels" could not confirm suspicion of an overdose with sufficient certainty.

Improved DNA typing of human urine by adding EDTA.

The effect of different EDTA concentrations on the DNA content of urine samples was examined and compared to untreated urine at various storage temperatures and times. The results indicate that adding EDTA increases the DNA stability for long time storage especially at low temperatures.

Photometric measurement of pressure-induced blanching of livor mortis as an aid to estimating time of death. Application of a new system for quantifying pressure-induced blanching in lividity.

A newly developed digital system employs photometric measurement of pressure-induced blanching of livor mortis to estimate time of death. The conventional method of applying pressure with thumb or forceps relies largely on subjective interpretation. Our system improves on this method by photometric quantification of color changes produced by defined magnitudes of pressure. We tested the new system by applying increasing levels of pressure to lividity in 50 cadavers with known time of death. Characteristics courses for pressure-induced changes were found for the brightness component of livor mortis, revealing distinct differences between the respective postmortem intervals. The surface areas under these curves were then calculated and distributed into 10-hour postmortem time categories. Variance analysis of these surface values revealed clear differences between the time categories, especially in the medians. Distinct differences between the various postmortem time categories were also evident for the chroma component of livor mortis. The new system offers a further method--in addition to body temperature, rigor mortis, and the electrical responsiveness of skeletal muscles--for estimating time of death, especially after long postmortem intervals.

Photometric measurement of color changes in livor mortis as a function of pressure and time. Development of a computer-aided system for measuring pressure-induced blanching of livor mortis to estimate time of death.

Until now, blanching of livor mortis in estimating time of death has generally been assessed based on subjective impressions, i.e. on whether blanching is visible after the application of pressure. We have developed a measuring system that uses digital processing to objectify the relationship between the pressure applied and blanching of postmortem lividity. The pressure is electronically registered by a strain gauge. At predefined levels (10, 20, 30, up to 100 N) the software triggers a color measurement by a commercially available tristimulus colorimeter. All parameters are measured in a single procedure and routed to the computer through a data interface. The pressure-induced color changes in the livor mortis are evaluated according to the L*, a*, b* system (CIE-LAB according to DIN 5033, DIN 6174), which closely approximates the physiology of sight. An additional color spacing formula (delta E) allows analysis of color changes irrespective of the basic skin tone. Initial measurements on cadavers showed that application of increasing pressure produced regular courses of color changes in livor mortis.

Determination of paracetamol (acetaminophen) in different body fluids and organ samples after solid-phase extraction using HPLC and an immunological method.

A solid-phase extraction method routinely used for serum samples was improved and applied to the qualitative and quantitative determination of paracetamol in different body fluids, e.g. blood, urine, cerebrospinal fluid, synovial fluid, vitreous humor, and in tissue samples. A very simple method showed best results: Body fluids were mixed with phenacetine as internal standard and phosphate buffer (pH 6.8). Then protein was precipitated using acetonitrile. After strong centrifugation the supematant was transferred to a preconditioned Bakerbond C18-SPE-column. Elution with methanol without a prior washing step showed best recovery rates. The extracts were investigated using high-performance liquid chromatography with ultraviolet detection, a photometrical and an immunochemical method.