[Information on Death Certificates: Comparison Between Inpatient and Outpatient Sectors]. / Angaben auf Todesbescheinigungen ­ Vergleich des hospitalen und ambulanten Bereichs.

The death of a person and the circumstances of death are documented on the death certificate in Germany. The path of the corpse to burial as well as the quality of the cause of death statistics are significantly influenced by the information in the official death certificate. The quality of the information in the death certificates has been repeatedly criticized. The aim of the present study was to identify typical sources of error in death certificates and to obtain information on whether qualitative differences exist between death certificates completed in the outpatient and inpatient sectors. A retrospective evaluation was performed of 218 death certificates of deaths examined by the Institute of Legal Medicine as part of a second postmortem examination prior to cremation. Of these, 118 death certificates were issued in the hospital and 100 death certificates were issued on an outpatient basis by the family physician or a physician on duty in the outpatient sector. All but one of the death certificates issued on an outpatient basis were legible. The information on the underlying disease was plausible. More than one-third of the epicrises had no significant findings or were not completed at all. The entry on the immediate causes of death in the designated field on the death certificate (Ia in the causal chain) were inadequate in one third of the cases. The error rate in the entries was higher in outpatient than in inpatient deaths. In the future, therefore, it will be necessary to prepare for the special situation of a post-mortem examination by means of further and advanced training events and to convey the importance of the diagnoses determined in the process, in order to eliminate these avoidable sources of error.

Fatal outcome of SARS-CoV-2 infection (B1.1.7) in a 4-year-old child.

This case report highlights details of a case of critical acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) with B1.1.7 variant in a 4-year-old girl who died due to pneumonia and pulmonary hemorrhage. The girl was referred to our University ECMO Center from another University hospital for veno-arterial extracorporeal membrane oxygenation (VA-ECMO). In the clinical course, superinfection with Pseudomonas aeruginosa was detected. Virological evidence of herpes simplex sepsis was also obtained in blood samples on her day of death. Transcription polymerase chain reaction (PCR) confirmed SARS-CoV-2 infection in lung tissue. Postmortem computed tomography showed pulmonary hemorrhage with inhomogeneous density values in both lungs. Lung tissue showed no ventilated areas. Autopsy revealed a massively congested lung with evidence of acute respiratory distress syndrome (ARDS) and pneumonia with multiple abscesses. Histopathology showed a mixture of diffuse alveolar injury with hyaline membranes, massive hemorrhage, and bronchopneumonia with multiple granulocytic abscesses. Cardiac examination revealed pericarditis. Suspicion of myocarditis or myocardial infarction could not be confirmed microscopically. To our knowledge, this is the first autopsy-based case report of the death of a previously healthy child due to the new variant B 1.1.7 in Germany.

Hepatic Vasculopathy and Regenerative Responses of the Liver in Fatal Cases of COVID-19.

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infects the nasopharynx and lungs and causes coronavirus disease-2019 (COVID-19). It may impact the heart, brain, kidney, and liver.1 Although functional impairment of the liver has been correlated with worse clinical outcomes, little is known about the pathophysiology of hepatic injury and repair in COVID-19.2,3 Histologic evaluation has been limited to small numbers of COVID-19 cases with no control subjects2,4 and demonstrated largely heterogeneous patterns of pathology.2,3.

Autopsy Findings and Venous Thromboembolism in Patients With COVID-19: A Prospective Cohort Study.

BACKGROUND: The new coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused more than 210 000 deaths worldwide. However, little is known about the causes of death and the virus's pathologic features. OBJECTIVE: To validate and compare clinical findings with data from medical autopsy, virtual autopsy, and virologic tests. DESIGN: Prospective cohort study. SETTING: Autopsies performed at a single academic medical center, as mandated by the German federal state of Hamburg for patients dying with a polymerase chain reaction-confirmed diagnosis of COVID-19. PATIENTS: The first 12 consecutive COVID-19-positive deaths. MEASUREMENTS: Complete autopsy, including postmortem computed tomography and histopathologic and virologic analysis, was performed. Clinical data and medical course were evaluated. RESULTS: Median patient age was 73 years (range, 52 to 87 years), 75% of patients were male, and death occurred in the hospital (n = 10) or outpatient sector (n = 2). Coronary heart disease and asthma or chronic obstructive pulmonary disease were the most common comorbid conditions (50% and 25%, respectively). Autopsy revealed deep venous thrombosis in 7 of 12 patients (58%) in whom venous thromboembolism was not suspected before death; pulmonary embolism was the direct cause of death in 4 patients. Postmortem computed tomography revealed reticular infiltration of the lungs with severe bilateral, dense consolidation, whereas histomorphologically diffuse alveolar damage was seen in 8 patients. In all patients, SARS-CoV-2 RNA was detected in the lung at high concentrations; viremia in 6 of 10 and 5 of 12 patients demonstrated high viral RNA titers in the liver, kidney, or heart. LIMITATION: Limited sample size. CONCLUSION: The high incidence of thromboembolic events suggests an important role of COVID-19-induced coagulopathy. Further studies are needed to investigate the molecular mechanism and overall clinical incidence of COVID-19-related death, as well as possible therapeutic interventions to reduce it. PRIMARY FUNDING SOURCE: University Medical Center Hamburg-Eppendorf.

The handling of SARS-CoV-2 associated deaths - infectivity of the body.

The body of a deceased with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection is considered infectious. In this study, we present the results of infectivity testing of the body and testing of mortuary staff for SARS-CoV-2. We performed real-time quantitative polymerase chain reaction (RT-qPCR) for SARS-CoV-2 on 33 decedents with ante mortem confirmed SARS-CoV-2 infection. Swabs of the body surface from five different body regions and from the body bag or coffin were examined. A subset of the swabs was brought into cell culture. In addition, screening of 25 Institute of Legal Medicine (ILM) personnel for ongoing or past SARS-CoV-2 infection was performed at two different time points during the pandemic. Swabs from all locations of the body surface and the body environment were negative in cases of negative post mortem nasopharyngeal testing (n=9). When the post mortem nasopharyngeal swab tested positive (n=24), between 0 and 5 of the body surface swabs were also positive, primarily the perioral region. In six of the cases, the body bag also yielded a positive result. The longest postmortem interval with positive SARS-CoV-2 RT-qPCR at the body surface was nine days. In no case viable SARS-CoV-2 was found on the skin of the bodies or the body bags. One employee (autopsy technician) had possible occupational infection with SARS-CoV-2; all other employees were tested negative for SARS-CoV-2 RNA or antibody twice. Our data indicate that with adequate management of general safety precautions, transmission of SARS-CoV-2 through autopsies and handling of bodies is unlikely.

Cerebellar heterotopia of infancy in sudden infant death syndrome: an observational neuropathological study of four cases.

Sudden infant death syndrome (SIDS) is the sudden unexpected death of an infant < 1 year of age that remains unexplained after comprehensive workup including complete autopsy and investigation of the circumstances of death. The triple risk hypothesis posits that SIDS results as a combination of both intrinsic and extrinsic factors on the background of a predisposing vulnerability. Neuropathological examination in the past has focussed mainly on the brainstem as the major player in respiratory control, where subtle findings have been linked to the chain of events leading to death in SIDS. The cerebellum has received less attention, probably due to an assumed negligible role in central cardiorespiratory control. We report four cases of SIDS in which neuropathological investigation revealed cerebellar heterotopia of infancy, a distinct malformation of the cerebellum, and discuss the potential impact of this condition on the aetiology and pathogenesis of SIDS.

Cases of asphyxia in children and adolescents: a retrospective analysis of fatal accidents, suicides, and homicides from 1998 to 2017 in Hamburg, Germany.

PURPOSE: Injury-related asphyxia is one of the most common causes of death in children in Germany. However, only a few systematic studies have analyzed the causes and circumstances of asphyxia in children and adolescents. METHODS: All cases of asphyxia in children and adolescents (0-21 years of age) among the Hamburg Legal Medical Department's autopsy cases from 1998 to 2017 were retrospectively analyzed with special focus on how often external findings were completely absent. RESULTS: Among 249 cases of fatal asphyxia, 68% were accidents, 14% were suicides, and 13% were homicides. Most of the cases involved boys. Adolescents and young adults aged 15-21 years represented the main age group. Drowning was the leading mechanism of asphyxia. Younger age was associated with less frequent detection of external signs of asphyxia in the postmortem external examination. Petechial hemorrhages were the most common visible external indication of asphyxia. No external findings indicative of asphyxia were present in 14% of the cases. CONCLUSION: Asphyxia in children and adolescents often involves accidents. However, postmortem external examination alone is insufficient to identify asphyxia and the manner of death.

Dying with SARS-CoV-2 infection-an autopsy study of the first consecutive 80 cases in Hamburg, Germany.

Autopsies of deceased with a confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can provide important insights into the novel disease and its course. Furthermore, autopsies are essential for the correct statistical recording of the coronavirus disease 2019 (COVID-19) deaths. In the northern German Federal State of Hamburg, all deaths of Hamburg citizens with ante- or postmortem PCR-confirmed SARS-CoV-2 infection have been autopsied since the outbreak of the pandemic in Germany. Our evaluation provides a systematic overview of the first 80 consecutive full autopsies. A proposal for the categorisation of deaths with SARS-CoV-2 infection is presented (category 1: definite COVID-19 death; category 2: probable COVID-19 death; category 3: possible COVID-19 death with an equal alternative cause of death; category 4: SARS-CoV-2 detection with cause of death not associated to COVID-19). In six cases, SARS-CoV-2 infection was diagnosed postmortem by a positive PCR test in a nasopharyngeal or lung tissue swab. In the other 74 cases, SARS-CoV-2 infection had already been known antemortem. The deceased were aged between 52 and 96 years (average 79.2 years, median 82.4 years). In the study cohort, 34 deceased were female (38%) and 46 male (62%). Overall, 38% of the deceased were overweight or obese. All deceased, except for two women, in whom no significant pre-existing conditions were found autoptically, had relevant comorbidities (in descending order of frequency): (1) diseases of the cardiovascular system, (2) lung diseases, (3) central nervous system diseases, (4) kidney diseases, and (5) diabetes mellitus. A total of 76 cases (95%) were classified as COVID-19 deaths, corresponding to categories 1-3. Four deaths (5%) were defined as non-COVID-19 deaths with virus-independent causes of death. In eight cases, pneumonia was combined with a fulminant pulmonary artery embolism. Peripheral pulmonary artery embolisms were found in nine other cases. Overall, deep vein thrombosis has been found in 40% of the cases. This study provides the largest overview of autopsies of SARS-CoV-2-infected patients presented so far.

Correction to: Dying with SARS-CoV-2 infection-an autopsy study of the first consecutive 80 cases in Hamburg, Germany.

The affiliation of the author Martin Aepfelbacher was incorrectly assigned in the manuscript. Martin Aepfelbacher is affiliated to the Institute of Microbiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany, instead.

Pregnancy-related and maternal deaths in Hamburg, Germany: an autopsy study from 1984 - 2018.

Maternal deaths are rare events in industrial nations due to high quality medical services. These are often unexpected deaths occurring during pregnancy and labor, thus often requiring forensic autopsies. Our analysis will provide an overview of the expected range of causes of death. A retrospective analysis was carried out on all autopsies performed at the Department of Legal Medicine in Hamburg, Germany, over the last 34 years. Autopsies were carried out on 57 cases of maternal death over the 34- year period, i.e. 1 or 2 cases per year. The average age of women was 30 years. Approximately two thirds of deaths occurred during pregnancy. Cardiovascular events accounted for the leading causes of death from natural causes, suicides were the leading causes of non-natural death. Maternal deaths remained consistently rare over the examination period. There was a wide range of causes of death involving natural and non-natural causes.

The prone sleeping position and SIDS. Historical aspects and possible pathomechanisms.

The incidence of SIDS decreased during the previous 25 years significantly. This is mainly due to epidemiological research identifying important risk factors such as prone sleeping position and subsequent campaigns to reduce this risk factor.Originally, the prone sleeping position for babies had been strongly recommended in the sixties and seventies despite previous publications pointed to the associated risk. Worldwide, many infants died of SIDS whose deaths could have been avoided. Today, the recommendation that infants should sleep in supine position has been scientifically verified. In supine sleeping position, pathophysiological mechanisms can be avoided which may lead to hypoxia and death in prone position. Such mechanisms could be occlusion of airways (in particularly associated with face-down position), elevated diaphragm, positional cerebral hypoxia caused by constriction of arteries, rebreathing CO2, and overheating.Irrespective of the specific pathomechanism leading to death in individual cases, it has been established that the prone position is the most important risk factor for SIDS and therefore should be incorporated in the definition of the term SIDS.

Sudden death from acute epiglottitis in a toddler.

The bacterium Haemophilus influenzae type b (Hib) can cause severe and life-threatening infections such as epiglottitis and meningitis. The course of the disease can be very rapid, resulting in sudden death. The incidence of Hib-induced epiglottitis in children has declined since the introduction of vaccinations in countries where such vaccinations are routinely administered. We herein present a case involving a 2.5-year-old boy who died suddenly at home. He had developed acute-onset throat and abdominal pain and a high fever. Despite an emergency cricothyrotomy due to a complicated intubation because of a massively swollen epiglottis, the efforts to resuscitate the child were unsuccessful. He was a previously healthy toddler, but he had not yet been vaccinated. Microbiologic analysis revealed the pathogenic bacterium Hib. The main autopsy finding was acute epiglottitis with swelling and cherry-red coloring of the epiglottis. Postmortem cultures of the cerebrospinal fluid and heart blood also revealed Hib as the pathogenic agent. Acute pneumonia was also diagnosed microscopically. The present report describes a rare case of Hib-induced acute epiglottitis and presents the key findings of forensic investigations in this type of disease.

The use of HIV post-exposure prophylaxis in forensic medicine following incidents of sexual violence in Hamburg, Germany: a retrospective study.

In Hamburg, Germany, the initiation of HIV post-exposure prophylaxis (HIV PEP) in cases of sexual violence is often carried out by forensic medical specialists (FMS) using the city's unique Hamburg Model. FMS-provided three-day HIV PEP starter packs include a combination of raltegravir and emtricitabine/tenofovir. This study aimed to investigate the practice of offering HIV PEP, reasons for discontinuing treatment, patient compliance, and whether or not potential perpetrators were tested for HIV. We conducted a retrospective study of forensic clinical examinations carried out by the Hamburg Department of Legal Medicine following incidents of sexual violence from 2009 to 2016. One thousand two hundred eighteen incidents of sexual violence were reviewed. In 18% of these cases, HIV PEP was initially prescribed by the FMS. HIV PEP indication depended on the examination occurring within 24 h after the incident, no/unknown condom use, the occurrence of ejaculation, the presence of any injury, and the perpetrator being from population at high risk for HIV. Half of the HIV PEP recipients returned for a reevaluation of the HIV PEP indication by an infectious disease specialist, and just 16% completed the full month of treatment. Only 131 potential perpetrators were tested for HIV, with one found to be HIV positive. No HIV seroconversion was registered among the study sample. Provision of HIV PEP by an FMS after sexual assault ensures appropriate and prompt care for victims. However, patient compliance and completion rates are low. HIV testing of perpetrators must be carried out much more rigorously.

Quality of death certificates in hospitals.

The cause-of-death-statistics and the release of the body for burial depend primarily on the information contained in the death certificate. How to handle the death certificate has been critically discussed in professional circles again and again. A retrospective review of 1,315 deaths from six acute care hospitals in Germany was carried out with regard to the quality of the death certificates, taking into account information contained in the medical records. The review covered the readability of the death certificate, the quality of the epicrisis, misclassifications relating to the manner of death and the degree of certainty regarding the cause of death. In 93 % of cases (n= 1,221), death certificates were clearly legible. In about half the cases (43.3 %, n=569), the quality of the entries in the "epicrisis" section was good. In 45 % of cases (n= 592), no details were provided in the "epicrisis " section. In 3.9 % (n = 42) of deaths classified as natural, information was given indicating a non-natural death. Most of these deaths occurred in connection with a fall or an injury (n = 27) or possible errors relating to treatment or care (n = 7). Overall, the review showed that clinicians handled the medical death certificate in a competent and careful manner. However, based on the content of the files, the review identified individual and avoidable misclassifications as to the manner of death and improbable causes of death; it also demonstrated that information on the epicrisis is often missing and needs significant improvement.

[Reconstructive investigations and identification measures in unknown soldiers of the Second World War]. / Rekonstruktive Untersuchungen und Identifikationsmassnahmen bei unbekannten Soldaten aus dem Zweiten Weltkrieg.

The article reports on the exhumation and identification of unknown soldiers from the Second World War. With the help of medicolegal investigation and reconstruction methods an American pilot presumably murdered by a shot to the head (lynch law) and an interned Italian soldier could be identified after about 70 years and brought back home.

[Obesity--comorbidities and causes of death]. / Adipositas: Folgekrankheiten und Todesursachen--eine rechtsmedizinische Betrachtung.

53% of the forensically autopsied decedents in Hamburg were overweight. The cause of death and any comorbidities, especially coronary heart disease, are often associated with the obese condition. This correlation is illustrated by two examples, viz. a 65- and a 56-year-old man with grade III obesity, which do not only show the medical but also the logistical problems that come along with it.