Skin simulants for wound ballistic investigation - an experimental study.

Gunshot wound analysis is an important part of medicolegal practice, in both autopsies and examinations of living persons. Well-established and studied simulants exist that exhibit both physical and biomechanical properties of soft-tissues and bones. Current research literature on ballistic wounds focuses on the biomechanical properties of skin simulants. In our extensive experimental study, we tested numerous synthetic and natural materials, regarding their macromorphological bullet impact characteristics, and compared these data with those from real bullet injuries gathered from medicolegal practice. Over thirty varieties of potential skin simulants were shot perpendicularly, and at 45°, at a distance of 10 m and 0.3 m, using full metal jacket (FMJ) projectiles (9 × 19 mm Luger). Simulants included ballistic gelatine at various concentrations, dental silicones with several degrees of hardness, alginates, latex, chamois leather, suture trainers for medical training purposes and various material compound models. In addition to complying to the general requirements for a synthetic simulant, results obtained from dental silicones shore hardness 70 (backed with 20 % by mass gelatine), were especially highly comparable to gunshot entry wounds in skin from real cases. Based on these results, particularly focusing on the macroscopically detectable criteria, we can strongly recommend dental silicone shore hardness 70 as a skin simulant for wound ballistics examinations.

Variant interpretation in molecular autopsy: a useful dilemma.

Sudden cardiac death (SCD) in adolescents and young adults may be the first manifestation of an inherited arrhythmic syndrome. Thus identification of a genetic origin in sudden death cases deemed inconclusive after a comprehensive autopsy and may help to reduce the risk of lethal episodes in the remaining family. Using next-generation sequencing (NGS), a large number of variants of unknown significance (VUS) are detected. In the majority of cases, there is insufficient evidence of pathogenicity, representing a huge dilemma in current genetic investigations. Misinterpretation of such variants may lead to inaccurate genetic diagnoses and/or the adoption of unnecessary and/or inappropriate therapeutic approaches. In our study, we applied current (ACMG) recommendations for variant classification in post-mortem genetic screening of a cohort of 56 SCD victims. We identified a total 53 rare protein-altering variants (MAF < 0.2%) classified as VUS or worse. Twelve percent of the cases exhibited a clinically actionable variant (pathogenic, likely pathogenic or VUS - potentially pathogenic) that would warrant cascade genetic screening in relatives. Most of the variants detected by means of the post-mortem genetic investigations were VUS. Thus, genetic testing by itself might be fairly meaningless without supporting background data. This data reinforces the need for an experienced multidisciplinary team for obtaining reliable and accountable interpretations of variant significance for elucidating potential causes for SCDs in the young. This enables the early identification of relatives at risk or excludes family members as genetic carriers. Also, development of adequate forensic guidelines to enable appropriate interpretation of rare genetic variants is fundamental.

Insights to enhance the examination of tool marks in human cartilage.

This work deals with the examination of tool marks in human cartilage. We compared the effectiveness of several cleaning methods on cut marks in porcine cartilage. The method cleaning by multiple casts achieved the significantly highest scores (P = 0.02). Furthermore, we examined the grain-like elevations (dots) located on casts of cut cartilage. The results of this study suggest that the casting material forms these dots when penetrating cartilage cavities, which are areas where the strong collagen fibres leave space for the chondrocytes. We performed fixation experiments to avoid this, without success. In addition, 31 casting materials were compared regarding contrast under light-microscope and 3D tool marks scanner. Under the light-microscope, brown materials achieved significantly higher values than grey (P = 0.02) or black (P = 0.00) whereas under the 3D scanner, black materials reached higher contrast values than grey (P = 0.04) or brown (P = 0.047). To compare the accuracy and reproducibility of 6 test materials for cartilage, we used 10 knives to create cut marks that were subsequently scanned. During the alignment of the individual signals of each mark, the cross-correlation coefficients (Xmax) and lags (LXmax) were calculated. The signals of the marks in agarose were aligned with significantly fewer lags and achieved significantly higher cross-correlation coefficients compared to all tested materials (both P = 0.00). Moreover, we determined the cross-correlation coefficients (XC) for known-matches (KM) per material. Agarose achieved significantly higher values than AccuTrans®, Clear Ballistics™, and gelatine (all P = 0.00). The results of this work provide valuable insights for the forensic investigation of marks in human costal cartilage.

Evidence for the transfer of methadone and EDDP by sweat to children's hair.

In cases where there is a question as to whether children have come into contact with drugs, examinations of their scalp hair are frequently carried out. Positive test results are often discussed in the forensic community due to the various possible modes via which drugs and their metabolites can be incorporated into the hair. These include drug uptake by the child (e.g. oral ingestion or inhalation), but also contamination of hair via contact with the sweat from drug users. In this study, the possibility of methadone and its metabolite EDDP being incorporated into children's hair by contact with sweat from persons undergoing opiate maintenance therapy (methadone) was examined. The transfer of methadone and EDDP via sweat from methadone patients (n = 15) to children's hair was simulated by close skin contact of drug-free children's hair, encased in mesh-pouches, for 5 days. Sweat-collecting patches (hereafter referred to as 'sweat patches') were applied to the test persons' skin. One strand of hair and one sweat patch were collected daily from each patient. Analyses were performed using GC-MS/MS (hair) and LC-MS/MS (serum, sweat patches). After 4 days of skin contact, methadone was detectable in the formerly drug-free hair strands in all 15 study participants. EDDP was detectable in 34 of 75 hair strands, with the maximum number of positive results (11 EDDP-positive hair strands) being detected after 5 days. These results show that transfer of methadone and EDDP to drug-free hair is possible through close skin contact with individuals taking part in methadone substitution programmes. A correlation between serum concentration, sweat concentration and substance concentration in hair strands could not be demonstrated, but a tendency towards higher concentrations due to longer contact time is clearly evident.

Anatomical In Vitro Investigations of the Pediatric Larynx: A Call for Manufacturer Redesign of Tracheal Tube Cuff Location and Perhaps a Call to Reconsider the Use of Uncuffed Tracheal Tubes.

BACKGROUND: Some in vivo studies question the traditional "funnel-shaped" infant larynx; further anatomic examinations were warranted. Examination of fixative free fresh autopsy laryngeal and upper tracheal specimens and multiple measurements was needed to determine consistency between current tracheal tube designs and anatomic observations. METHODS: Larynges from 19 males and 11 females (Caucasian term newborn to 126 months) were examined by the same forensic pathologist. Measurements included anterior/posterior (A/P) and transverse (T) diameters of the cricoid outlet (CO), interarytenoid diameter (IAD), cricothyroid membrane (CTM), distance from the vocal cords (VC) to CO (VC-CO), and calibration of the larynx lumen with uncuffed tracheal tubes as measuring rods. Assessment of "safe tracheal tube placement" was assessed using manufacturer recommended cuffed Microcuff (Kimberly-Clark, Koblenz, Germany) tubes. RESULTS: In 77% (95% confidence interval [CI], 58-90) of specimens, the proximal end of the cuff was within the CO and in 23% even with or close to the CO. The VC-CO varied from 9.1 to 13.17 mm in infants, 11.55 to 15.17 mm in toddlers, and 13.19 to 18.34 mm in children. The A-P/T ratio of the CO was nearly 0.99 in most larynges; the IAD was greater than CO in all specimens. The CTM could be minimally distended in all specimens. CONCLUSIONS: First, despite being marketed as a safer tracheal tube design, the proximal end of the Microcuff cuff rested within or close to the cricoid cartilage theoretically increasing potential cuff-induced injury when using the VC markings for positioning. Our data suggest that the optimal cuff free distance (VC-CO) would be ~13.5 mm for a Microcuff internal diameter (ID) size 3.0, ~15 mm for size 3.5, and ~16 to 19 mm for greater sizes.Second, the CO was virtually circular in all specimens, suggesting that appropriately sized uncuffed tubes should provide an adequate seal in most neonates and toddlers, thus avoiding the potential for cuff-related necrosis injury.Third, the IAD was always greater than CO confirming that the narrowest point of the infant larynx is the nondistensible cricoid cartilage and not the easily distended glottis.Fourth, appropriately sized Microcuff tubes with the cuff deflated completely filled the lumen of the CO and proximal trachea in all specimens. Our data suggest the need for all manufacturers to further evaluate tracheal tube cuff locations and lengths in relation to the VC safe insertion markings, particularly for neonates and toddlers.Fifth, the CTM is minimally distensible, thus having important implications for emergency surgical airway access with most currently available emergency airway devices.

Fatalities associated with NPS stimulants in the Greater Cologne area.

This study centres on the prevalence of new psychoactive substances (NPS) stimulant use, and its relevance as a cause of death amongst individuals between the ages of 12 and 35 in the greater Cologne area. An automated solid-phase extraction-liquid chromatography-tandem mass spectrometry method was developed for the determination of 97 stimulants in urine (including conventional stimulants, e.g. amphetamine and MDMA), of which 68 analytes were fully validated for quantification. Samples of urine or kidney tissue (in cases where urine was unavailable) of 268 deceased were collected, during autopsy, between January 2011 and May 2017 and analyzed. Blood (if available) was also investigated in cases where urine/kidney samples were tested positive for NPS. An intake of stimulants (including NPS stimulants) was proven in 50 cases. In 33 cases, only conventional stimulants were detected. A total of 17 cases were tested positive for NPS. Of the 17 NPS-positive cases, 13 were also tested positive for other conventional drugs of abuse (mostly amphetamine and MDMA). In six NPS-positive cases, at least three different NPS were proven to be ingested. Due to the determined blood concentrations, NPS was assigned as the leading cause of death, or of toxicological relevance, in the cause of death in only 5 cases. In two of the cases, NPS was judged to be a component of a multidrug poisoning, but of minor relevance.

Sudden death of a young adult with coronary artery vasculitis, coronary aneurysms, parvovirus B19 infection and Kawasaki disease.

We present a case of a 20-year-old man who suffered from Kawasaki disease (KD) associated with a florid parvovirus infection, and who died suddenly from thrombotic occlusion of the coronary arteries. The autopsy revealed several aneurysms of the coronary arteries, a chronic vasculitis and a myofibroblast proliferation leading to focal luminal narrowing. The inflammatory response as well as the detection of the viral particles by PCR in blood and in the lesional tissue demonstrated a possible cause by Parvovirus infection. The expression of endoglin on endothelial cells of neoangiogenesis indicates the involvement of the TGF-beta pathway, necessary for maintaining chronic inflammation. In addition, a possible connection between the intake of methylphenidate, arteritis and a possible pre-existing heart disease must be discussed. Furthermore, KD must also be considered as a cause of sudden death in the adult population.

Correction to: Post-mortem distribution of the synthetic cannabinoid MDMB-CHMICA and its metabolites in a case of combined drug intoxication.

The following clarification to the content of Table 3 (MDMB-CHMICA data from previously published cases of acute (non-fatal) and fatal drug intoxications) of the named manuscript needs to be brought to the readership's attention.

Umbilical cord entanglement's frequency and its impact on the newborn.

Neonaticide is a serious allegation that needs a complete chain of criminal investigations. In this context, a nuchal cord is considered to be responsible for an infant's death, but there is a clear lack of evidence. The purpose of our study is to reveal if a nuchal cord can be responsible for stillbirth, poor perinatal outcome, or neonatal death in the forensic aspect. We conducted a prospective study in collaboration with the Augustinian Sisters' Hospital in Cologne, Germany in the period from February 2014 to May 2016. Four-hundred eighty-six children were enrolled. All births were assessed regarding the occurrence of an umbilical cord entanglement, and perinatal outcome was measured by arterial blood gas analysis, Apgar after 1, 5, and 10 min after birth as well as the general vitality. The prevalence of a nuchal cord was 16.87%. Apgar decrease and acidosis were significantly associated with a nuchal cord. No adverse perinatal outcome was recorded in this constellation. There was no child death regarding the first 24 h, and no mother experienced a syncope while giving birth. We can conclude that a nuchal cord is not associated with adverse perinatal outcome.

SDH and EDH in children up to 18 years of age-a clinical collective in the view of forensic considerations.

Providing concise proof of child abuse relies heavily on clinical findings, such as certain patterns of injury or otherwise not plausibly explainable trauma. Subdural hemorrhaging has been identified as a common occurrence in abused children whereas epidural hemorrhaging is related to accidents. In order to explore this correlation, we retrospectively analyzed clinical data of children under 19 years of age diagnosed with either injury. Reviewing 56 cases of epidural and 38 cases of subdural bleeding, it was shown that subdural bleeding is more common in young children and extremely often a result of suspected abuse in children under 2 years of age. Epidural hemorrhaging however never was found in the context of suspected abuse, was unrelated to other injuries typical for abuse, and did not see a statistically significant increase in any age group. In conformity with currently theorized mechanisms of injury for both types of bleeding, we found that subdural hemorrhaging in young children is closely associated with abuse whereas epidural bleeding is not.

Post-mortem distribution of the synthetic cannabinoid MDMB-CHMICA and its metabolites in a case of combined drug intoxication.

This case report centres on the post-mortem distribution of the synthetic cannabinoid MDMB-CHMICA and its metabolites in the case of a 27-year-old man found dead after falling from the 24th floor of a high-rise building. Toxicological analysis of post-mortem samples confirmed, besides consumption of the synthetic cannabinoids MDMB-CHMICA (1.7 ng/mL femoral blood) and EG-018, the abuse of THC (9.3 ng/mL femoral blood), amphetamine (1050 ng/mL femoral blood), MDMA (275 ng/mL femoral blood), and cocaine. Regarding EG-018 and cocaine, only traces were detected in heart blood as well as in the brain (EG-018) and urine (cocaine), respectively, which is why no quantification was conducted in the femoral blood sample. It was concluded from femoral blood analysis that, at the time of death, the man was under the influence of the synthetic cannabinoid MDMB-CHMICA, THC, amphetamine and MDMA. Comprehensive screenings of all post-mortem specimens were conducted to elucidate the post-mortem distribution of MDMB-CHMICA and its metabolites. The MDMB-CHMICA concentrations ranged between 0.01 ng/mL (urine) and 5.5 ng/g (brain). Comparably low concentrations were detected in cardiac and femoral blood (2.1 ng/mL and 1.7 ng/mL, respectively) as well as in the psoas major muscle (1.2 ng/g). Higher concentrations were found in the lung (2.6 ng/g), liver (2.6 ng/g), and kidney (3.8 ng/g). Gastric content yielded a MDMB-CHMICA concentration of 2.4 ng/g (1.1 µg absolute). Screening for MDMB-CHMICA metabolites resulted in the detection of mainly monohydroxylated metabolites in the blood, kidney, and liver specimens. Results indicated that monohydroxylated metabolites of MDMB-CHMICA are appropriate target analytes for detecting MDMB-CHMICA intake.

Relevance of medical reports in criminal investigations of cases of suspected child abuse.

If a case of physical child abuse is suspected in Germany, the general feeling is often that "it does not matter whether you make a report or not" because, generally, no conviction is made anyway. This study investigates the juridical analysis of complaint cases of physical child abuse [criminal complaint parag. 225 StGB (German penal code) with filial victim]. It focuses on the doctor's role and the impact of their practice in relation to a later conviction. It is based on the analysis of 302 files of the enquiry from 2004-2009 from the department of public prosecution in Cologne, Germany. Besides general epidemiological data on the reporting person, the affected child and the presumed offender, the documents were reassessed for the relevance of medical reports for successful convictions. Only 7% (n = 21) of 302 complaints led to a conviction. In 38.1% (n = 8) of those cases, a medical report was mentioned as a piece of evidence, and just in two cases a (legal) medical report was quoted and mentioned as relevant for the conviction. 50% of the complaint cases with legal medical expertise led to a trial. In contrast, only 30.2% with a common medical report and 7.3% without a report led to a trial. The results show how a medical report existed in only a few cases. In those cases, the rate of performed trials was higher than for those without a medical report, but the report played a minor part when reasoning a verdict.

Comparative proteome analysis for identification of differentially abundant proteins in SIDS.

Sudden infant death syndrome (SIDS) remains one of the most common causes of post-neonatal infant mortality in developed countries. Its pathogenesis is still poorly understood. The goal of the present study was to characterize changes in the proteome of SIDS compared to age-matched controls in heart and medulla tissues as well as in blood samples using two complementary quantitative proteomic techniques: 2D-DIGE and iTRAQ aiming to provide new insights into the mechanism of SIDS and to find diagnostic protein patterns. Our results revealed collectively 122 modulated proteins in SIDS of which 83 proteins were up-regulated. They are involved in metabolic processes, cellular processes, and localization. Gene expression patterns of selected proteins were further validated by reverse transcription quantitative real-time PCR (RT-qPCR). The role of hypoxia, inflammation, and apoptosis in SIDS was demonstrated by exploring some candidate proteins especially APOA1, GAPDH, S100B, zyxin, and complement component C4A. According to the results of this study, these proteins might be used as diagnostic biomarkers for SIDS. All of them were up-regulated in SIDS except for C4A that was down-regulated.

Two fatal tiger attacks in zoos.

Two captive tiger attacks are presented that took place in Cologne and Münster zoos. Both attacks occurred when the handlers, intent on cleaning the enclosures, entered whilst the tigers accidently retained access to the location, and thus defended their territory against the perceived intruders. Both victims suffered fatal neck injuries from the bites. At Münster, colleagues managed to lure the tiger away from its victim to enable treatment, whilst the Cologne zoo tiger had to be shot in order to allow access to be gained. Whilst it was judged that human error led to the deaths of the experienced zookeepers, the investigation in Münster was closed as no third party was found to be at fault, whereas the Cologne zoo director was initially charged with being negligent. These charges were subsequently dismissed as safety regulations were found to be up to date.

Rate of deaths due to child abuse and neglect in children 0-3 years of age in Germany.

In recent years, increasing attention has been paid to the issue of (fatal) child abuse and neglect, largely due to the media attention garnered by some headline-grabbing cases. If media statements are to be believed, such cases may be an increasing phenomenon. With these published accounts in mind, publicly available statistics should be analysed with respect to the question of whether reliable statements can be formulated based on these figures. It is hypothesised that certain data, e.g., the Innocenti report published by UNICEF in 2003, may be based on unreliable data sources. For this reason, the generation of such data, and the reliability of the data itself, should also be discussed. Our focus was on publicly available German mortality and police crime statistics (Polizeiliche Kriminalstatistik). These data were classified with respect to child age, data origin, and cause of death (murder, culpable homicide, etc.). In our opinion, the available data could not be considered in formulating reliable scientific statements about fatal child abuse and neglect, given the lack of detail and the flawed nature of the basic data. Increasing the number of autopsies of children 0-3 years of age should be considered as a means to ensure the capture of valid, practical, and reliable data. This could bring about some enlightenment and assist in the development of preemptive strategies to decrease the incidence of (fatal) child abuse and neglect.

Not only smoking is deadly: fatal ingestion of e-juice-a case report.

A fatal case of nicotine intoxication by oral intake of a nicotine solution, sold via the Internet, is reported. The concentrated nicotine solution (72 mg/mL) is usually diluted with polypropylene, polyethylene glycol or glycerine, respectively, in order to allow the user to generate their own solution for vaporisation in electronic cigarettes (e-juice). A 34-year-old man was found lifeless by his parents, who reported that their son had been in good health and had shown no hints of suicidal behaviour. The medicolegal autopsy revealed unspecific findings. Toxicological analysis revealed nicotine concentrations of 5.5 mg/L in femoral venous blood, 136 mg/L in heart blood, 12.0 mg/kg in brain tissue, 42.6 mg/kg in kidney tissue, 89.5 mg/kg in lung tissue and a total amount of 3,950 mg in the gastric contents. Cotinine concentrations were 0.9 mg/L in femoral venous blood, 7.6 mg/L in heart blood, 0.4 mg/kg in brain tissue, 0.9 mg/kg in kidney tissue and 0.8 mg/kg in lung tissue. No cotinine was detected in the gastric contents. The nicotine level measured in the femoral blood was in good accordance with the levels reported in other fatal cases caused by oral or patch application of nicotine. Moreover, the high level of nicotine in lung and kidney tissue, compared to that within femoral blood, strikingly emphasises the strong effect of post-mortem redistribution, underlined by the comparably low concentration of nicotine in the brain. The extremely high level of nicotine in the heart blood is more likely due to the high concentration in the gastric contents, due to oral intake, and by accumulation of the basic substance in the acidic gastric contents. This further highlights the effect of post-mortem redistribution. The mother of the deceased later admitted that her son had been suffering from psychosis and that she found a package containing five nicotine solution vials of the brand "Titanium Ice" (of 50 mL each). Three of the vials were empty. The nicotine concentration in the e-juice Titanium Ice was confirmed by HPLC analysis.

Validation of adequate endogenous reference genes for reverse transcription-qPCR studies in human post-mortem brain tissue of SIDS cases.

Sudden infant death syndrome (SIDS) is the main cause of post-neonatal infant death in most developed countries. It is still of ambiguous etiology. Gene expression studies of relevant target genes using reverse transcription quantitative real-time PCR (RT-qPCR) in SIDS cases, and comparing them with age-matched controls, could help in understanding the pathogenesis of SIDS. However, selecting inadequate reference genes used for normalization of the RT-qPCR gene expression data can give misleading results. The aim of the present study was to identify reference genes with the most stable expression in post-mortem brainstem samples of SIDS and control cases. Among the five candidate reference genes (GAPDH, GUSB, HMBS, SDHA, UBXN6) studied in both groups, SDHA and UBXN6 were identified as the most stable. To further demonstrate the importance of using validated genes for RT-qPCR data normalization, the expression of a potential gene of interest in SIDS, the RPS27A gene, was evaluated using validated versus non-validated reference genes for normalization. This gene encodes the ubiquitin protein that has been shown in other pathological studies to be induced in SIDS. Using the identified most stable genes for normalization of RPS27A gene expression data revealed, as expected, a statistically significant up-regulation in SIDS as compared to the controls. However, using a single unstable reference gene for normalization resulted in no significant differences in transcript abundance of RPS27A between SIDS and the controls. This emphasizes the need for validation of the suitability of reference genes used in a given tissue type under certain experimental conditions.

Assisted suicide by fentanyl intoxication due to excessive transdermal application.

Herein, we report a case of an assisted suicide committed by application of 34 matrix-based fentanyl-containing transdermal therapeutic systems (TTS) with different release rates. The TTS were supplied by the husband but administered by the deceased herself. Besides routine systematic toxicological analysis (STA), the concentrations of fentanyl and norfentanyl were determined in the blood (femoral and heart), urine, stomach content, brain, lung tissue, musculus iliopsoas, liver, kidney, bile and in some of the used TTS by LC-MS/MS. Blood levels of fentanyl were 60.6 µg/L in femoral blood and 94.1 µg/L in heart blood. These concentrations are in good concordance with levels described in cases with accidental or lethal suicidal fentanyl patch application. The organ distribution indicates an influence of post-mortem redistribution. The levels of residual fentanyl in the TTS were also determined. STA furthermore revealed supratherapeutic levels of bromazepam. Thus, the cause of death was a combination of fentanyl and bromazepam intoxication. However, considering the determined levels of fentanyl and norfentanyl in the entire set of specimens and the high toxicity in comparison to bromazepam, fentanyl was the leading toxic noxa.

Fatal postpartum air embolism due to uterine inversion and atonic hemorrhage.

We report a case of a 19-year-old woman who developed a persistent uterine hemorrhage after spontaneous delivery of a healthy child. Emergency laparotomy was indicated and then begun under stable circulatory conditions. Cardiac arrest occurred during the course of massive manual compression and packing of the uterus. After successful resuscitation, a supracervical hysterectomy was performed. During the suturing of the remaining cervix, a second cardiac arrest followed. The procedure was completed under constant external heart massage. Resuscitation was terminated due to the persistence of widened pupils. An autopsy was ordered by the public prosecutor as the manner of death was declared to be unascertained. An X-ray and a CT scan prior to the autopsy showed extensive gas embolism in both arterial and venous vessels extending from the pelvic region to the head. During the autopsy, gas was collected by aspirometer from the right ventricle of the heart. The autopsy showed no additional relevant findings, and gas analysis confirmed the suspicion of air embolism. The histological examination of the excised uterus especially in the corpus/fundus revealed an edema of the local smooth muscle cells and dilated vessels showing no sign of thrombogenesis. Upon evaluation of the clinical records, it became evident that, in addition to uterine atony, there had been a complete uterine inversion. This inversion was manually repositioned. After this maneuver, manual compression was performed. The air embolism, thus, was a complication of the manual repositioning of the uterine inversion. There is no evidence for other possible entries of the detected gas. In order to perform an effective exploration, the availability of all clinical records should be mandatory for medico-legal investigations of unexpected postpartum deaths.