[Relation of external biometric parameters to health risk and mortality--analysis and evaluation of different measurement methods and study results]. / Das Verhältnis ausserer Körpermasse zum Erkrankungsrisiko und zur Todesursache--Analyse und Bewertung unterschiedlicher Messmethoden und Studienergebnisse (I).

In clinical practice diagnoses can be found which are partially based on body measurements. By measuring body height and body weight the patient is categorised, for example by Body-Mass Index (BMI), in different adipose grades. Different diseases are associated with specific biometric parameters. Abdominal adiposity measured by waist circumference correlates with the risk of colon carcinoma and is one diagnostic criteria of the metabolic syndrome. An unhealthy waist-hip ratio (WHR) can cause a higher risk of a cardiovascular disease and dementia. By combining body measurement with cause of death found during the medicolegal autopsy, clinical relevant correlations can be uncovered. Research in medical databases (e.g. PubMed) was carried out to find studies showing possible associations between body measurements, their indices and morbidity or causes of death. This article is a selective survey of these published studies, current guidelines and the German Institute for Standardisation - Norm (DIN-Norm). We give a wide thematic overview and select relevant parameters, which should be taken during medico-legal autopsies in future. The ascertainment of those parameters and their adjustment with the findings of the medico-legal autopsies can be a key to finding predictors of history of disease and relevant morbidity risks in the institutes of forensic medicine. Such findings are very important in the assessment of risk for living patients and necessary preventive actions. Beside the measurement of waist and hip circumference mentioned in specific clinical guidelines in Germany, we suggest, after analysing the parameters, to measure the thickness of the subcutaneous fat on the anterior chest and the thigh circumference as well.

Medico-legal autopsy in postoperative hemodynamic collapse following coronary artery bypass surgery.

Sudden unexpected postoperative hemodynamic collapse with a high mortality develops in 1-3% of patients undergoing coronary artery bypass surgery (CABG). The contribution of surgical graft complications to this serious condition is poorly known and their demonstration at autopsy is a challenging task. Isolated CABG was performed in 8,807 patients during 1988-1999. Of the patients, 76 (0.9%) developed sudden postoperative hemodynamic collapse resulting in subsequent emergency reopening of the median sternotomy and open cardiac massage. Further emergency reoperation could be performed in 62 (82%) whereas 14 patients died prior to reoperation and a further 21 did not survive the reoperation or died a few days later. All 35 (46%) patients who did not survive were subjected to medico-legal autopsy combined with postmortem cast angiography. By combining clinical data with autopsy and angiography data, various types of graft complications were observed in 27 (36%, 1.3 per patient) of the 76 patients with hemodynamic collapse. There were no significant differences in the frequency (33 vs. 40%) or number of complicated grafts per patient (1.2 vs. 1.4) between those who survived reoperation and who did not. Autopsy detected 25 major and minor findings not diagnosed clinically. Postmortem cast angiography visualized 2 graft twists not possible to detect by autopsy dissection only. Surgical graft complications were the most frequent single cause for sudden postoperative hemodynamic collapse in CABG patients leading to a fatal outcome in almost half of the cases. Postmortem angiography improved the accuracy of autopsy diagnostics of graft complications.

[Medicolegal experiences in external post-mortem examinations before cremation--a retrospective analysis of the years 1998-2008]. / Rechtsmedizinische Erfahrungen bei der Kremationsleichenschau--eine retrospektive Analyse der Jahre 1998-2008.

The paper presents a retrospective analysis of 16,541 external post-mortem examinations carried out before cremation by the Institute of Forensic Medicine of the University of Bonn between 1998 and 2008 with regard to different variables (age, sex, place of death, cause of death etc.). In more than 50 % of cases, the individuals had died in a hospital followed by their apartment or a nursing home. The first post-mortem examination was mainly performed by hospital doctors followed by emergency doctors and office practitioners. As to the age distribution, the 6th to 8th decade of life was prevalent. In 99.8 %, a natural death was certified in the first external post-mortem and only in 0.2 % the manner of death was determined to be non-natural or unclear. In more than half of the cases, the non-natural deaths were determined by emergency doctors. Deaths wrongly classified in the first external post-mortem were mostly accidents and deaths associated with medical procedures. Although the second external examination before cremation is very useful in detecting previously overlooked signs of homicide, it is only of limited value in homicides with few external traces or for detecting underlying diseases and causes of death. In this respect, the second external examination before cremation can only check the plausibility of the cause of death given by the attending physician. The gold standard for a reliable certification of the manner and cause of death remains the autopsy.

[Lethal atraumatic splenic rupture due to infectious mononucleosis]. / Letale atraumatische Milzruptur infolge infektiöser Mononukleose.

The authors report on the sudden and unexpected death of a 20-year-old man from atraumatic rupture of the enlarged spleen due to infectious mononucleosis. The case exemplifies the forensic relevance of infectious mononucleosis, atraumatic splenic rupture and post-mortem serological tests.

[Clinical autopsies. Practical approach, legal foundations and ethical considerations]. / Klinische Obduktionen. Praktisches Vorgehen, rechtliche Grundlagen und ethische Uberlegungen.

Only an autopsy can demonstrate topographical and morphological circumstances in detail and correlate the clinical and autopsy findings based on the examination of all organs. The practical approach in a fatality is described based on the example of the Lüdenscheid Hospital. A uniform legal regulation for dealing with corpses does not exist in Germany. There are two approaches to the question under which circumstances a clinical autopsy is allowed: the extended permission solution and the objection solution. Whether a clinical autopsy can be carried out is decided by the medical specialist selected on application. Autopsies can be necessary from insurance or administrative legal grounds or in the case of an anatomical autopsy is decided by the persons themselves. In order to guarantee the quality of an autopsy it is necessary to use a standardized approach with evaluation and assessment of the results, for example using a quality assurance protocol and the production of an autopsy report. Using this approach important information can be gained not only on the accuracy of the main diagnosis and cause of death but also on additional diseases, response to therapy and the course of the disease and under circumstances can lead to modifications in the approach.

Bilateral calcified stylohyoid ligament: an incidental autopsy finding with medicolegal significance.

Eagle's syndrome occurs due to elongation of the styloid process or calcification of the stylohyoid ligament, which then may produce a pain sensation due to pressure exerted on various structures in the head and neck region. A case report of calcified stylohyoid ligament found incidentally at autopsy and further confirmed by computed tomography scan and histopathology is herein discussed with associated medicolegal significance.

[Opinionating errors in forensic medicine]. / Bledy opiniodawcze w medycynie sadowej.

The paper presents selected evident opinionating errors committed by experts in the field of forensic medicine who issued medico-legal opinions in criminal cases, aiming at determining causes of death. The authors analyze the causes of such errors and possibilities of avoiding them, as well as the impact of the said errors on the course of criminal proceedings and the legal position of the suspects or victims. The report emphasizes the potential effect of these opinions on the fate of individuals who have been found suspected or guilty based on such opinions should they be accepted by the court without verification by summoning another expert.

[Accreditation in pathology. Systematic presentation and documentation of activities in pathology]. / Akkreditierung in der Pathologie. Systematische Darstellung und Dokumentation der Tätigkeiten in der Pathologie.

In the last ten years, almost 60 departments of surgical pathology were accredited in Germany according to DIN EN ISO/IEC 17020. Accreditation in pathology was accompanied by the adoption of a highly dynamic process, which requires staff to be more aware of quality and to introduce a quality-oriented system. The accreditation body in turn needed to consider all the duties, responsibilities and processes in surgical pathology and was supported in this regard by the Sector Committee of Pathology and Neuropathology of the DGA German Association for Accreditation. In this review we illustrate the various problems associated with accreditation in surgical pathology by answering eight questions that have arisen over many years of activity. These include the registration and appropriate presentation of the scope of accreditation, the terminology, as well as the extent and depth of documentation. A department of pathology applying for accreditation is required to document the entire step-wise process leading to a surgical pathological diagnosis.

[Reconstruction of a fire homicide after pouring denatured alcohol on the victim]. / Rekonstruktion eines Brandmordes nach Ubergiessen mit Spiritus.

A 48-year-old man died from extensive burns suffered especially on the upper part of the body during a dispute with his ex-wife, who had poured spirit or a spirit-water mixture over him. For initially unknown reasons, the man's clothing caught fire. Whereas the public prosecutor assumed that the woman had intentionally poured a larger amount of spirit over her ex-husband before setting fire to him, the defendant first claimed to have poured the rest of a water-spirit mixture left over from cleaning the windows over the man and that his clothing caught fire on lighting a cigarette. To clarify the course of events, fire tests with spirit in various dilutions were conducted, which showed that even with undiluted spirit a direct contact with the flame of at least 1 second is necessary to start a fire. There is no deflagration, if spirit is used as a fire accelerant. In the trial, the defendant made a confession and admitted to have poured a mixture of 75% spirit and 25% water over her ex-husband and set fire to his right sleeve with the intention to kill him.

Virtopsy -- noninvasive detection of occult bone lesions in postmortem MRI: additional information for traffic accident reconstruction.

In traffic accidents with pedestrians, cyclists or motorcyclists, patterned impact injuries as well as marks on clothes can be matched to the injury-causing vehicle structure in order to reconstruct the accident and identify the vehicle which has hit the person. Therefore, the differentiation of the primary impact injuries from other injuries is of great importance. Impact injuries can be identified on the external injuries of the skin, the injured subcutaneous and fat tissue, as well as the fractured bones. Another sign of impact is a bone bruise. The bone bruise, or occult bone lesion, means a bleeding in the subcortical bone marrow, which is presumed to be the result of micro-fractures of the medullar trabeculae. The aim of this study was to prove that bleeding in the subcortical bone marrow of the deceased can be detected using the postmortem noninvasive magnetic resonance imaging. This is demonstrated in five accident cases, four involving pedestrians and one a cyclist, where bone bruises were detected in different bones as a sign of impact occurring in the same location as the external and soft tissue impact injuries.

[Sudden death in infancy]. / Der plötzliche Tod im Kindesalter.

In industrial countries, sudden infant death syndrome (SIDS) poses the most common mode of deaths occurring in the postneonatal period. During the last years the incidence has decreased and is currently less than 0.5 per 1000 live births. The cause of SIDS is still unknown. One theory claims that SIDS is due to suffocation caused by failure of central respiratory control, CO(2) rebreathing or airways obstruction. Further pathological factors including hyperthermia as well as impairment of the sleeping- and waking centre are in discussion. The most important risk factors include lying prone, heat exposure of the child, premature delivery, maternal age less than 18 years, smoking and drug abuse during pregnancy and the absence of breast feeding. SIDS is not an entity but a descriptive term for sudden and unexpected deaths in infancy without adequate cause of death being established by methods currently used. SIDS in forensic medicine is not only important because of its relative frequency, but also because of the differential diagnoses which have to be considered in each case. Therefore other natural and unnatural causes of death have to be explored by autopsy and careful postmortal examination (histological, toxicological, microbiological and virological analysis), taking into account circumstances at the death scene and medical history of the infant.

[Autoptically confirmed malpractice cases]. / Autoptisch bestätigte Behandlungsfehler.

Claims of lethal medical malpractice cases in penal law are mostly dealt with by experts in forensic medicine since in lethal cases the autopsy is crucial for determining the cause of death. Knowledge of the cause of death, in turn, is the necessary basis of an expert opinion on negligence and the causality between negligence and cause of death. Compared to civil lawsuits filed for malpractice and cases dealt with at the arbitration committees of the medical councils penal lawsuits with 1500 to 2000 cases per year are of minor importance. Our own retrospective multicentre study on lawsuits filed for lethal cases of medical malpractice (based on autopsy findings of 4450 cases) revealed an annual increase in autopsies due to medical negligence from 3 to 6 hundred. Hospital doctors are more frequently affected by medical malpractice claims than private-practice physicians. However, the rate of confirmed medical malpractice cases is much higher for doctors in private practice. Although surgeons are most frequently charged with medical malpractice the rate of confirmed medical malpractice cases is comparatively low in surgery. Medico-legal autopsies in cases of alleged medical malpractice are often ordered by the public prosecutor because the manner of death was classified as unnatural or undetermined. Therefore the often-heard reproach that doctors frequently make mistakes and do their very best to hide them is not true. Thus, it has to be recommended that in a case of unexpected death associated with medical treatment the doctor in his own interest should classify the manner of death as undetermined.

[Sudden death in the presence of systemic mastocytosis and urticaria pigmentosa]. / Plötzlicher Tod bei systemischer Mastozytose mit Urticaria pigmentosa.

Systemic mastocytosis is an extremely rare disease characterised by abnormal mast cell production and accumulation of mast cells in the bone marrow or organs, and to some extent also in the skin (urticaria pigmentosa). To date there have been no descriptions of death caused by systemic mastocytosis. The present first description of such a fatality is based upon a case of anaphylactic histamine shock, probably caused by the consumption of peanuts. The affected person suffered from urticaria pigmentosa and developed a fairly typical pruritus prior to death. In the serum sample taken post-mortem the tryptase concentration was markedly elevated. The diagnosis of systemic mastocytosis was established on the basis of two primary and three secondary criteria according to the WHO classification, which underlines the importance of histological investigations in cases where the cause of death is unclear.

Clinical, educational, and epidemiological value of autopsy.

The autopsy is now often regarded as of marginal use in modern clinical practice. In this Review we contend that the autopsy remains an important procedure with substantial, if largely underused, potential to advance medical knowledge and improve clinical practice. Many doctors lack familiarity with autopsy practices, and are insufficiently aware of the benefits for not only bereaved families but also present and future patients. In this Review, which has an international perspective, we consider the ascent and decline of the autopsy, the legal frameworks that govern its use, the value and potential pitfalls of alternatives to the conventional method, and the autopsy's role in undergraduate medical education. We also draw attention to the continuing ability of autopsies to improve the completeness and reliability of death certification, which is important for public-health strategies and for some bereaved families.

[Unusual findings in a death caused by a car fire]. / Ungewöhnliche Befunde bei einem Todesfall durch Fahrzeugbrand.

Witnesses detected a burning car in the parking lot next to a discotheque in the early morning hours. After the fire had been extinguished, the charred body of the 23-year-old car owner was found in the driver's seat. The young man had been a guest of the discotheque the previous night and consumed plenty of alcoholic drinks. The traces left by the fire on the car suggested that the fire had started in the passenger compartment. At autopsy, greyish-brown discoloration and induration of the mucosa of the respiratory tract were found in addition to massive aspiration of soot and signs of soot swallowing. The macroscopic and histological findings pointed to a chemical burn of the airways probably caused by chlorine gases developing when the covering of the passenger compartment was burning. Chemical burns due to inhalation, aspiration and swallowing of soot are all signs of vitality, so that a smoldering fire must have gone on for a while inside the car with the windows closed. The most probable cause of the fire is that clothing or textile material in the car was set on fire by a burning cigarette.