Postmortem computed tomography (PMCT) and autopsy in deadly gunshot wounds--a comparative study.

INTRODUCTION: Postmortem computed tomography (PMCT) data in gunshot-related death were evaluated by two reader groups and compared to the gold standard autopsy for the determination of forensic pathology criteria. MATERIALS AND METHODS: Reader group I consisted of two board-certified radiologists whereas one board-certified radiologist and one board-certified forensic pathologist formed group II. PMCT data of 51 gunshot-related deaths were evaluated for the forensic pathology criteria number of gun shots, localization of gunshot injury, caliber, and direction of the gunshot differentiating between entry and exit wound as well as associated injury to surrounding tissue. The results of both reader groups were compared to the each other and to autopsy findings considered as gold standard. RESULTS: Reader groups I and II and as gold standard the autopsy evaluation showed in general a good correlation between all results. The overall discrepancy rate was 12/51 (23.4%) cases for group I and 8/51 (15.6%) for group II. DISCUSSION: Ultimately, the designated reader is able to draw the following conclusion from the presented data. At first, physical autopsy is better than PMCT regarding the localization of most gunshot injuries. Second, PMCT presents with better results than physical autopsy in locating fragmented bullets/fragment clouds, and finally, PMCT results of two radiologists were equivalent to the results of one evaluating radiologist and one pathologist with the exception of caliber assessment. However, referring to the pure numbers, the slight but not significant difference in the overall discrepancy rate of both reader groups might indicate the advantage of combining expertise in evaluating imaging in cases of gunshot-related death.

[What are the effects of different places of death of old people?] / Welche Auswirkungen zeigen unterschiedliche Sterbeorte betagter Menschen?: Eine Analyse Münchner Todesbescheinigungen.

Background: Inadequate quality of medical postmortem examinations has been discussed in the forensic medical literature for many years. It is known that older deceased persons are less likely to have a non-natural cause of death certified and autopsies are performed less frequently compared to younger deceased persons. Methods: Death certificates of all deaths that occurred in Munich with an age of ≥ 75 years during the death period 01/01/2013-31/12/2014 were analyzed. Standardized, anonymized data entry was performed. The collected data were analyzed descriptively. Results: A total of 26,303 persons died during the study period. Of these deaths, 16,146 (60.7%) were ≥ 75 years. Most common places of death for the aged were hospital (56.1%), private address (21.8%), and nursing home (20.0%). A natural mode of death was reported in 88.5%, unexplained in 8.8%, and non-natural in 2.7%. Most common immediate causes of death were diseases of the circulatory system (23.5%), inaccurately designated or unknown causes of death (20.0%), and diseases of the respiratory system (16.3%). Autopsies were performed on 4.9%, largely judicial. The parameters studied showed large differences in the analyses depending on the place of death. Discussion: This study again shows considerable quality deficiencies in the issuance of death certificates. Despite the dual approach of the Munich health authority (control, training), the quality of death certificates could not be sustainably improved in recent years. Types and causes of death showed partly considerable differences depending on the place of death and the doctor who issued the certificate. The deficits identified in the information provided under the heading "Causes of death" are also likely to have a negative impact on the cause of death statistics.

Advances in multiscale image processing and its effects on image quality in skeletal radiography.

Multi-frequency processing (MFP) leads to enhanced image quality (IQ) of radiographs. This study is to determine the effect of third generation MFP (M3) on IQ in comparison to standard second-generation MFP (M2). 20 cadavers were examined and post-processing of radiographs was performed with both M2 and M3. Three readers blinded to the MFP used for each image independently compared corresponding image pairs according to overall IQ and depiction of bony structures and soft tissue (+ 2: notably better > 0: equal > - 2: notably worse). A significant deviation of the median grade from grade 0 (equal) (p < 0.01) for each evaluator A, B and C speaks against an equal image quality of M2- and M3-images. M3-images were categorized with better grades (+ 1, + 2) in 87.7% for overall image quality, in 90.4% for soft tissue and 81.8% for bony structures. M3 images showed significant higher averaged SNR and CNR for all investigated lower extremities than that of M2 images (0.031 < p < 0.049). The newest generation of MFP leads to significantly better depiction of anatomical structures and overall image quality than in images processed with the preceding generation of MFP. This provides increased diagnostic accuracy and further decreased radiation exposure.

Blood stain pattern analysis.

Bloodstain pattern analysis (BPA) refers to the collection, categorization and interpretation of the shape and distribution of bloodstains connected with a crime. These kinds of stains occur in a considerable proportion of homicide cases. They offer extensive information and are an important part of a functional, medically and scientifically based reconstruction of a crime. The following groups of patterns can essentially be distinguished: dripped and splashed blood, projected blood, impact patterns, cast-off stains, expirated and transferred bloodstains. A highly qualified analysis can help to estimate facts concerning the location, quality and intensity of an external force. A sequence of events may be recognized, and detailed questions connected with the reconstruction of the crime might be answered. In some cases, BPA helps to distinguish between accident, homicide and suicide or to identify bloodstains originating from a perpetrator. BPA is based on systematic training, a visit to the crime scene or alternatively good photographic documentation, and an understanding and knowledge of autopsy findings or statements made by the perpetrator and/or victim. A BPA working group has been established within the German Society of Legal Medicine aiming to put the knowledge and practical applications of this subdiscipline of forensic science on a wider basis.

Image quality is resilient against tube voltage variations in post-mortem skeletal radiography with a digital flat-panel detector.

In recent phantom studies low-contrast detectability was shown to be independent from variations in tube voltage in digital radiography (DR) systems. To investigate the transferability to a clinical setting, the lower extremities of human cadavers were exposed at constant detector doses with different tube voltages in a certain range, as proposed in the phantom studies. Three radiologists independently graded different aspects of image quality (IQ) in a comparative analysis. The grades show no correlation between IQ and kV, which means that the readers were not able to recognize a significant IQ difference at different kV. Signal-to-noise and contrast-to-noise ratios showed no significant differences in IQ despite the kV-setting variations. These findings were observed from a limited kV range setting. Higher kV-settings resulted in lowest patient exposure at constant IQ. These results confirm the potential of DR-systems to contribute to standardization of examination protocols comparable to computed tomography. This may prevent the trend to overexpose. Further investigations in other body regions and other DR-systems are encouraged to determine transferability.

Detection of blood aspiration in deadly head gunshots comparing postmortem computed tomography (PMCT) and autopsy.

BACKGROUND: The aim of our study was to analyze the reliability of postmortem computed tomography (PMCT) versus autopsy in detecting signs of blood aspiration in a distinct group of patients following deadly head, mouth or floor of mouth gunshot injuries. METHODS: In this study, in 41 cases PMCT was compared to autopsy reports, the gold standard of postmortem exams, regarding detection of blood aspiration. PMCT was evaluated for the presence and level of typical signs of blood aspiration in the major airways and lung using a semi-quantitative scale ranging from level 0 (no aspiration) to 3 (significant aspiration) also taking density values of the described potential aspiratory changes into account. RESULTS: Overall, in 29 (70.7%) of 41 enrolled cases PMCT and autopsy revealed the same level of aspiration. A difference of one level between PMCT and autopsy resulted for 5 (12.2%) of the remaining 12 cases. More than one level difference between both methods resulted for 7 cases (17.2%). Autopsy described no signs of aspiration in 10 cases, compared to 31 cases with reported blood aspiration. In contrast, PMCT revealed no signs of blood aspiration in 15 cases whereas 26 cases were rated as positive for signs of aspiration in the major airways. In 18 of these 26 cases considered positive for blood aspiration by autopsy and PMCT, clear signs of aspiration signs were also described bilaterally by both methods. CONCLUSIONS: The presented study provides evidence for the assumption that PMCT seems to be helpful in the detection of blood aspiration in cases of deadly head gunshots. In conclusion, it seems reasonable to suggest performing PMCT additionally to traditional postmortem exams in cases of suspected aspiration to rule out false-negative cases and to possibly allow for a more detailed and rather evidence based examination reconnoitering the cause of death. However, the adequate use of PMCT in this context needs further evaluation and the definition of an objective scale for aspiration detection on PMCT needs to be established in future studies.

[Inspection of a corpse by the family physician (general practitioner) in practice and nursing home]. / "Atemstillstand" oder "Herzversagen" gehören nicht auf den Totenschein. Was der Hausarzt bei der Leichenschau beachten muss.

Inspection of a corpse by the physician is a responsible last service he can offer his patient. Apart from reliably establishing death and the time of its occurrence, the physician must thoroughly inspect the corpse to clarify the cause of death. Regrettably, the results of an autopsy are often at odds with the cause of death as entered in the death certificate. Poor nursing care and homicides can be detected only on the basis of correct information about the cause of death. Only then do statistics on causes of death in the population make sense and can provide useful data. If an unnatural cause of death is suspected, or if it is not possible to ascertain the cause, the police or public prosecutor (coroner) must be notified.

Injection of toxic agents: an unusual cause of death.

Self-injection of toxic substances is a rare method of suicide. Since only case reports exist in the forensic literature, an evaluation of the autopsy reports of the Munich Department of Legal Medicine in the period 1976-1994 was performed including 36 suicides and seven homicides due to injection of toxic agents. The majority of the decreased were physicians nurses or, in cases of homicidal intoxication relatives. The commonly used substances were anaesthetic drugs.

Frequency of blood spatters on the shooting hand and of conjunctival petechiae following suicidal gunshots wounds to the head.

A total of 103 suicidal and 29 homicidal gunshot fatalities were evaluated. In 42% of the suicides, characteristic findings like blood spatters and/or powder soilings, could be found on the shooting hand by naked-eye inspection indicating the importance of an accurate examination of the deceased's hands at autopsy for a preliminary diagnosis. Petechial hemorrhages of the conjunctivae due to the gas pressure after discharge of the weapon were observed in 22% of those cases with contact shot wounds to the head/neck, but not in cases of distant shot injuries following the use of non-high velocity ammunition. Therefore, conjunctival petechiae can be regarded as an additional but optional sign of contact head shots in cases without alterations possibly influencing the development of conjunctival pin-point bleedings. The evidence of such findings can be of practical importance if the entrance shot wound cannot be examined for whatever reason.

Determination of fetal age by immunohistochemical estimation of surfactant-producing alveolar type II cells.

We monitored the immunohistochemically determined amount of surfactant-producing alveolar type II cells in human fetal lung using polyclonal antibodies against apoprotein B and C of human pulmonary surfactant. Lungs of 30 dead-born fetuses without lung affection aged between 15 and 38 weeks of gestation were evaluated and the surface density of surfactant-producing alveolar type II cells was determined by morphometry. In lungs of fetuses with a gestational age less than 22 weeks no relevant number of positively reacting cells could be found. Between the 22nd and 29th week a progressive increase with considerable inter-individual variability was observed. From the 30th week on the number of the type II pneumocytes appeared rather constant without further significant increase. We provide evidence that the immunohistochemical detection of surfactant-producing alveolar type II cells is useful for the determination of the age of unknown and especially fragmented fetuses: The lack of surfactant-producing alveolar type II cells in fetal lungs before the 22nd week allows a rather safe distinction between fetal lungs of higher age from those of lesser age. Between the 22nd and 29th week an age-dependent increase in the number of these cells occurs with wide inter-individual variability allowing only an approximate age determination. In particular, this may be an important piece of information in fragmented fetal corpses. Furthermore, the number of surfactant-producing alveolar type II cells provides additional information on pulmonary maturation and may thus be helpful in the estimation of a theoretical survival chance.

Self-mutilation with needles.

Two cases of self-mutilation with needles are reported. One of the deceased suffered from chronic schizophrenia and committed suicide by plastic bag suffocation. At autopsy several needles were detected grown into the connective tissue of chest or abdominal organs. In the other case a knitting needle was used for repeated manipulations at the forehead leading to a defect of the skin and the skull. At least one vessel was injured leading to an extensive haemorrhage in the left hemisphere of the brain. The forensic and etiologic aspects of the cases are discussed.

[Change in congener analysis caused by percutaneous absorption of propanol-containing antiseptics]. / Veränderung von Begleitstoffanalysen durch percutane Resorption propanolhaltiger Antiseptika.

According to the forensic literature, an alteration of blood alcohol concentration through alcohol disinfection before venepuncture is unlikely, however, percutaneous resorption of alcohol containing antiseptics is well documented. There are no investigations available, elucidating to what extent this is also correct for congener alcohols, particularly propanol-1/-2, which have serum levels in range of mg/l. In experiments with surgical hand and local skin disinfection, carried out with and without oral alcohol, relevant levels of propanol-1/-2 between 0.2 and 2 mg/l were measured. We conclude, that the routine clinical use of antiseptics is able to alterate and to falsify congener levels and can lead to incorrect interpretation of congener analysis.

[Isopropanol and acetone level in serum after preoperative surface disinfection with antiseptics containing isopropanol]. / Isopropanol- und Acetonspiegel im Serum nach präoperativer Flächendesinfektion mit isopropanolhaltigen Antiseptika.

After preoperative skin disinfection in pediatric surgery, serum levels of isopropanol up to 12.2 mg/l (MW 5.0 mg/l +/- 3.37, n = 26) were found. They result from a rapid and prolonged but uncharacteristic percutaneous resorption of the isopropanol-containing disinfectant. In about 50% of the cases, serum levels of acetone showed an increase up to 82 mg/l already before skin disinfection, presumably caused by preoperative starvation. After skin disinfection, raised acetone levels were found in 19 of 26 cases. As increased isopropanol and acetone levels are discussed as alcoholism markers, a falsification of congener analysis after skin disinfection, e.g. in cases of adult victims of accidents, has to be taken into consideration. Endogenous serum levels of methanol (0.87 mg/l +/- 0.49), ethanol (0.32 mg/l +/- 0.09), acetaldehyde (0.31 mg/l +/- 0.10) and others remained unaffected. Some uncharacteristic elevations of propanol-1 levels are caused by contaminated rubber caps.

[Suicidal gunshot wounds--site and characteristics]. / Suizidale Schussbeibringung--Lokalisation und Besonderheiten.

117 gunshot suicides (111 male and 6 females) were investigated. The head was the most favorite site of the entrance wounds and some extraordinary cases were observed. 7 cases showed more than one gunshot wounds and in two of these suicides the second shot was placed directly in the first wound. Unusual sites of the gunshot wounds were the dorsal part of the neck, the right nostril and the right ear. In one case a gun powder muzzle-loader was loaded with two projectiles and in another suicide the lethal brain damage was caused by the gas pressure due to shot from a blank gun tightly pressed to the right temporal head.

[When parents decide against therapy for the children. The case of Emil M.: a conflict between parents and medicine]. / Wenn Eltern für ihre Kinder gegen eine Therapie entscheiden. Der Fall Emil M.: ein Konflikt zwischen Eltern und Medizin.

If parents refuse to allow an accepted, scientifically well-founded treatment for their child, and if this results in obvious negative consequences for the child's welfare, the physician can appeal to the family court. Before doing so, however, a detailed explanation of the situation and counseling of the parents is imperative. In an emergency that brooks no delay, however, the physician can carried out the treatment he considers absolutely necessary even against the wishes of the child's parents. If, as a result of unacceptable parental decisions--e.g. withdrawal of treatment from the child--harm to the child ensues, the parents can hardly be pursued by the law, since, according to the principles of criminal law, this would only be possible if it can be proved without a shadow of doubt that the treatment would definitely have prolonged the child's life, or with certainty protected it from some other prejudice.

Postmortem 3-D reconstruction of skull gunshot injuries.

BACKGROUND: In cases of severe decomposition or skeletonization of a corpse after cerebral gun shot injury it is difficult to exactly reconstruct the bullet path in the brain. However, in case of murder or homicide this might become necessary to answer forensic questions such as the ability to move or other actions of the victim. MATERIALS AND METHODS: Therefore a method in terms of three dimensional reconstruction technique was developed by fusing computed tomography scans (CT) of the original skull and magnetic resonance images (MRI) of a normal brain of adequate size. Hereby five cases were investigated. RESULTS: In three cases an excellent concordance between the reconstructed bullet trajectory and the autopsy reports was achieved. In one case the original brain was not available for CT-scanning due to previous autopsy. However, the findings were in line with the pathology report. In one case there was a difference of about 1-2 cm between the original autopsy description and the reconstructed bullet path. This was due to only a part of the skull being available for image reconstruction. CONCLUSION: The findings suggest that this method can successfully be applied to adequately reconstruct bullet paths in cases of completely skeletonized skulls, but should carefully be used in cases of incomplete skulls.

Accidental head explosion: an unusual blast wave injury as a result of self-made fireworks.

A 33-year old hobby pyrotechnician sustained a lethal craniofacial trauma secondary to a salute fireworks blast. He was examining a misfire of a self-constructed salute gun, when it detonated, causing an explosively rupture of his forehead, which led to his immediate death. An autopsy was performed to achieve knowledge of the injury and to be able to reconstruct the events that lead to it. The pressure effect of the explosion caused a shredded rupture of the forehead with a regional spread of brain tissue and small polygonal skull fragments up to 30m from the detonation site. Furthermore multiple cinderlike fragments of black powder were embedded in the skin of the face and the anterior aspect of the neck (s.c. blast tattoo). The complete destruction of the forehead in combination with the multiple blast tattooing suggested that the explosion detonated while he was leaning over the device.