Injury potential of one-litre beer steins.

Injuries resulting from blows with beer steins are a frequent occurrence during annual autumn fairs or at beer halls in South Germany and Austria. The majority of these cases are tried in court and thus being assessed by a forensic medicine expert. The article at hand gives a short overview on the injury potential of one-litre beer steins and explains the key variables to consider when analyzing beer stein injuries. On the basis of representative cases, which were assessed by specialists from the Institute of Legal Medicine of the Munich University over the last 5 years, the main biomechanical aspects and resulting injuries of one-litre beer stein assaults are discussed. Several severe and potentially life-threatening injuries have been observed after an assault with a one-litre beer stein. There is a discrepancy between the mechanical stability of brand new and used steins and the corresponding injuries, which can be explained by a decrease in impact tolerance of the steins with their use. In general, a blow with a one-litre glass or stonework beer stein to the head can cause severe and even life-threatening blunt as well as sharp trauma injuries.

Postmortem interrogation of cardiac implantable electrical devices may clarify time and cause of death.

BACKGROUND: Postmortem interrogation of cardiac implantable electrical devices (CIED) in autopsy is not routinely performed. Thus, it remains unclear whether an interrogation might clarify time and cause of death. METHODS: Seventy of 4401 patients (1.6%) undergoing autopsy in 2014 and 2015 presented with a CIED. The explanted CIED were interrogated with respect to time and possible cause of death. Battery and lead parameters, clinical and technical alerts, and arrhythmia episodes were reviewed and afterwards correlated with the results of autopsy and clinical data. RESULTS: Twenty-five implantable cardioverter defibrillators (ICD) and 45 pacemaker (PM) devices were analyzed. Death was classified as cardiac by autopsy in 17 of 70 patients. Accordingly, presumably lethal ventricular arrhythmias were documented in six patients (8.6%; 5 ICD, 1 PM). In two of 30 patients with unknown cause of death after autopsy (6.7%), interrogation revealed ventricular tachycardia as potential reason for decease (1 ICD, 1 PM). Postmortem CIED interrogation additionally allowed to make a statement regarding the day of death in 36 patients (51%; 13 ICD, 23 PM). This was in accordance with clinical data or the results of autopsy in nine patients (25%; 3 ICD, 6 PM) or could even clarify the time of death in six patients (16.7%; 4 ICD, 2 PM). CONCLUSION: Interrogation of CIED revealed potentially lethal ventricular arrhythmias in 9 of 70 patients investigated and enabled valid estimation of the day of death in 15 patients. We therefore conclude that routinely performed postmortem CIED interrogation may clarify time and cause of death.

A proclaimed accidental fall of an infant-an experimental case reconstruction study.

The differentiation between a non-accidental injury and injuries resulting from accidents, such as falls to the ground or onto various objects, is a challenge not only for forensic experts but also for all clinicians caring for children. The forensic-biomechanical analysis of accidents in infants aims at the assessment of the loading characteristics based on the reconstruction of the particular incident. It includes an evidence-based analytical comparison between the actual injuries presented and the injuries that should be expected as a result of the proclaimed accident. With the help of kinematical and dynamical parameters of the described actions and the resulting loading situations, the forensic-biomechanical analysis can assess the plausibility of the proclaimed course of the event and thus contribute to the differentiation between accidental and non-accidental injuries. The quality of such a forensic-biomechanical expert opinion depends on the accuracy and quantity of available data regarding biomechanical tolerance of tissues, organs, and body parts. Case-specific measurements can contribute significantly to the insight of the kinematics and dynamics of the proclaimed event, its feasibility, etc. The present article demonstrates, based on one case report, the potential as well as the limits of such an analysis of proclaimed accidental fall injuries.

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.

Whiplash-Associated Disorders : Clinical and medico-legal guidelines on the methods of ascertainment.

The manuscript presents the International Guidelines developed by the Working Group on Personal Injury and Damage under the patronage of the International Academy of Legal Medicine (IALM) regarding the Methods of Ascertainment of any suspected Whiplash-Associated Disorders (WAD).The document includes a detailed description of the logical and methodological steps of the ascertainment process as well as a synoptic diagram in the form of Flow Chart.

[Long-term survival after severe trauma]. / Langzeitüberleben nach schwerem Trauma.

Long-term survival after severe trauma is rarely addressed in German trauma journals although knowledge of life expectancy and identification of factors contributing to increased mortality are important for lifetime care management, development of service models, and targeting health promotion and prevention interventions. As reliable data in Germany are lacking, we compiled data mainly from the USA and Australia to describe life expectancy, risk factors, and predictors of outcome in patients experiencing traumatic spinal cord injury, traumatic brain injury, and polytrauma. Two years after trauma, life expectancy in all three categories was significantly lower than that of the general population. It depends strongly on severity of disability, age, and gender and is quantifiable. Whereas improvements in medical care have led to a marked decline in short-term mortality, surprisingly long-term survival in severe trauma has not changed over the past 30 years. Therefore, there is need to intensify long-term trauma patient care and to find new strategies to limit primary damage.

Wound ballistic evaluation of the Taser® XREP ammunition.

The Taser® eXtended Range Electronic Projectile (XREP®) is a wireless conducted electrical weapon (CEW) designed to incapacitate a person from a larger distance. The aim of this study was to analyze the ballistic injury potential of the XREP. Twenty rounds were fired from the Taser®X12 TM shotgun into ballistic soap covered with artificial skin and clothing at different shooting distances (1-25 m). One shot was fired at pig skin at a shooting distance of 10 m. The average projectile velocity was 67.0 m/s. The kinetic energy levels on impact varied from 28-52 J. Depending on the intermediate target, the projectiles penetrated up to 4.2 cm into the ballistic soap. On impact the nose assembly did not separate from the chassis, and no electrical activation was registered. Upon impact, a skin penetration of the XREP cannot be excluded. However, it is very unlikely at shooting distances of 10 m or more. Clothing and a high elasticity limit of the target body area can significantly reduce the penetration risk on impact.

[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.

Impact of obesity on complications and surgical outcomes of adult degenerative scoliosis with long-segment spinal fusion.

INTRODUCTION: The relationship between obesity and outcome of spine surgery has been controversial. The impact of obesity on surgical outcomes of patients undergoing long- segment (6 vertebrae or more) spinal fusion have not been studied. This study was designed to define the influence of obesity on the outcomes of patients undergoing long-segment spinal fusion. METHODS AND MATERIALS: A retrospective study of patients undergoing long-segment (6 vertebrae or more) spinal fusion was realized. Patients were divided into non-obese group and obese group. Variables such as blood loss, operative time, length of stay, complications, reoperation rates, and clinical outcome were compared between the two groups. RESULTS: Thirty-four non-obese patients (BMI: 26.43±0.87) and 27 obese ones (BMI: 35.35±1.81) were recruited. Number of fused levels in non-obese group was not significantly different from obese group (9.06±0.57 vertebrae vs 8.85±0.68 vertebrae, P=0.65). There was no significant difference between non-obese group and obese group in the blood loss during surgery (P= 0.12), the operating time (P=0.46) and the length of hospitalization (P=0.64). Similarly, no significant difference was found in surgical complications (P=0.76) and medical complications (P=0.82) between the two groups. The rate of ambulatory improvement is similar between non-obese group and obese group (P=0.64). CONCLUSION: Our study showed that there was no relationship between obesity and adverse surgical outcomes in ADS surgery with long-segment (6 vertebrae or more) spinal fusion.

[COVID-19-associated deaths]. / COVID-19-assoziierte Sterbefälle: Erste Daten aus Münchner Todesbescheinigungen.

INTRODUCTION: In December 2019, the new infectious coronavirus disease 2019 (COVID-19) first appeared in China. So far, no systematic evaluation of death certificates of COVID-19-associated deaths has been presented. METHODS: The death certificates of all deaths in Munich during the period from 1 March to 31 July 2020 were analyzed. The previously defined inclusion criteria were the indication of corona, COVID-19 and SARS-CoV­2 in the death certificates. The variables were entered anonymously according to a developed key. The collected data were evaluated descriptively. RESULTS: In the period under investigation, a total of 5840 people died in the Munich City area. Of these deaths 332 (5.7%) were COVID-19-associated. In 281 deaths (84.6%) there was a definite COVID-19 and in 51 deaths (15.4%) the suspicion of this disease. The most frequent causes of death were acute respiratory distress syndrome or respiratory insufficiency (59.1%), multiple organ failure (21.4%) and sepsis (10%). An average of 1.8 pre-existing illnesses were reported in the death certificates. Most frequently mentioned were diseases of the circulatory system (54.8%), the nervous system (22.8%) and metabolic diseases (18.9%). The average age at death was 79 years and the most frequent place of death was a hospital (85%). An autopsy was attempted by the doctors who issued the death certificates for 18.1% of the collective, most frequently in the case of unexplained or unnatural causes of death and young age of the deceased. Clinical pathological autopsies were performed on 11% of the collective and judicial autopsies on 1%. DISCUSSION: This study is the first evaluation of death certificates with respect to the novel infectious COVID-19. Number and essential characteristics of COVID-19-associated deaths in Munich during the so-called first wave could be mapped. The interest of physicians in autopsies was rather low despite the appearance of a new infectious disease.

One-stage oblique lateral corridor antibiotic-cement reconstruction for Candida spondylodiscitis in patients with major comorbidities: Preliminary experience.

Fungal spondylodiscitis is rare (0.5%-1.6% of spondylodiscitis) and mainly caused by Candida albicans. Surgical intervention in spondylodiscitis patients is indicated for compression of neural elements, spinal instability, severe kyphosis, failure of conservative management and intractable pain. However, there is no evidence-based optimal surgical approach for spondylodiscitis. There have been only case reports of surgical treatment for Candida spondylodiscitis. We evaluated the preliminary results of the efficacy and safety of one-stage debridement via oblique lateral corridor with interbody fusion (OLIF) using stand-alone cement reconstruction after debridement for the treatment of Candida spondylodiscitis in patients with major co-morbidities. Five patients (4 males, 1 female, mean age: 64.2 years) suffering from Candida albicans lumbar spondylodiscitis who underwent this procedure were studied. Their predominant symptoms were unremitting back and leg pain and all had pre and postoperative anti-fungal therapy under microbiologist supervision. The operative time ranged from 137minutes to 260minutes (mean: 213.4minutes). The mean blood loss was 160mL (range: 100-200mL). There were no perioperative complications. At follow-up all showed major improvement in pain and ambulatory status. CT scan showed radiological stability for all patients at 6-12 months. Our preliminary results showed stand-alone anterior debridement and spinal re-construction with cement through mini-open OLIF approach might be a safe and effective option for patients with spinal fungal infection and major comorbidities.

Position sensitive measurement of trace lithium in the brain with NIK (neutron-induced coincidence method) in suicide.

Mood disorder is the leading intrinsic risk factor for suicidal ideation. Questioning any potency of mood-stabilizers, the monovalent cation lithium still holds the throne in medical psychiatric treatment. Furthermore, lithium`s anti-aggressive and suicide-preventive capacity in clinical practice is well established. But little is still known about trace lithium distribution and any associated metabolic effects in the human body. We applied a new technique (neutron-induced coincidence method "NIK") utilizing the 6Li(n,α)3H reaction for the position sensitive, 3D spatially resolved detection of lithium traces in post-mortem human brain tissue in suicide versus control. NIK allowed, for the first time in lithium research, to collect a three dimensional high resolution map of the regional trace lithium content in the non lithium-medicated human brain. The results show an anisotropic distribution of lithium, thus indicating a homeostatic regulation under physiological conditions as a remarkable link to essentiality. In contrast to suicide we could empirically prove significantly higher endogenous lithium concentrations in white compared to gray matter as a general trend in non-suicidal individuals and lower lithium concentrations in emotion-modulating regions in suicide.

[Death in seclusion - a worldwide phenomenon illustrated on fringe groups in Munich]. / Der Einsame Tod - Sterben in Randgruppen in München.

100 randomised cases where a person lived and died in isolation in Munich were analysed. Factors such as social background, living situation, education, physiological and psychological state of health were evaluated. Personal isolation (=seclusion) seems to depend on various social, financial, psychological or physical reasons. Lack of contact with other people not only leads to psychological problems, but isolation also contributes to increased illness and early death. In order to improve the present social situation in Munich preventive social measures are necessary to achieve increase in health status for the elder and a decrease in mortality rate.

A regression model applied to gender-specific ethanol elimination rates from blood and breath measurements in non-alcoholics.

As elimination rates for alcohol are suggested to be gender specific, a novel regression model has been applied to estimate these rates for both men and women using experimentally measured data from 81 female and 96 male volunteers described in previous papers. Breath alcohol measurements were done with the Alcotest 7110 Evidential device and were coupled with concomitant sampling of venous blood. Statistical analyses involved use of a mixed linear model for blood alcohol concentration (BAC) and breath alcohol concentration (BrAC), respectively. The model takes regression lines for each test subject into account with an individual starting value (2 h after the end of drinking) and with an individual alcohol elimination rate per hour (coincidental effects). Further, the data was modeled so that an average alcohol elimination rate per hour could be estimated separately for both genders (constant effects). This enables us to methodically correctly estimate the back calculation. The elimination rates beta (60), which can be used for minimum and maximum back calculations for the BAC, were 0.115 g/kg/h and 0.260 g/kg/h, respectively, for women and 0.096 g/kg/h and 0.241 g/kg/h, respectively, for men. These figures widely deviate from gender-unspecific values commonly used in Germany (0.1 and 0.2 g/kg/h, respectively). The corresponding values for the BrAC were 0.061 mg/l/h and 0.124 mg/l/h for women and 0.049 mg/l/h and 0.112 mg/l/h for men. The probability of an over- or underestimation of the abovementioned extreme values is 0.3% in each case.

Recommendations for the forensic diagnosis of sex and age from skeletons.

In both diagnostic fields a two-stage strategy is recommended: to first use "field" methods that are quick and easy but more imprecise and then "laboratory" methods that are time consuming but more precise. In preparing skeletal work, individuality of a skeleton should be checked, traces of diseases sought and time since death assessed. For sexing non-adults, the field methods are tooth mineralisation, long bone length and a few morphological skull and pelvis characteristics, for adults it is the morphology of pelvis and skull, and for both age groups the advanced laboratory method is molecular biology. For ageing non-adults the methods are mineralisation of teeth, long bone length and epiphysis development. For ageing adults the advanced laboratory method is aspartic acid racemisation. Less accurate laboratory methods are cement ring counts and histology of bones and teeth. Quick morphological methods using the pubic symphysis and other traits in combinations follow. Finally, cranial sutures and tooth number give a quick and rough impression. For the selection of a method and the assessment of its value the stochastic error produced for the reference sample is the decisive criterion; it should also be used to assess the reliability of a single diagnosis. Prerequisites for all work with skeletons are not only a complete knowledge of the relevant biology as well as specific techniques but also initial detailed instructions and with forensic applications, personal experience.

Micro-endoscopy of the human vas deferens: a feasibility study of a novel device in several ex vivo models.

The aim of this study was to show limitation as well as potential of micro-endoscopy techniques as an innovative diagnostic and therapeutic approach in andrology. Two kinds of custom-made micro-endoscopes (ME) were tested in ex vivo vas deferens specimen and in post-mortem whole body. The semi-rigid ME included a micro-optic (0.9 mm outer diameter [OD], 10.000 pixels, 120° vision angle [VE], 3-20 mm field depth [FD]) and an integrated fibre-optic light source. The flexible ME was composed of a micro-optic (OD = 0.6 mm, 6.000 pixels, 120° VE, 3-20 mm FD). The ex vivo study included retrograde investigation of the vas deferens (surgical specimen n = 9, radical prostatectomy n = 3). The post-mortem investigation (n = 4) included the inspection of the vas deferens via both approaches. The results showed that antegrade and retrograde rigid endoscopy of the vas deferens were achieved as a diagnostic tool. The working channel enabled therapeutic use including biopsies or baskets. Using the flexible ME, the orifices of the ejaculatory ducts were identified. In vivo cadaveric retrograde cannulation of the orifices was successful. Post-mortem changes of verumontanum hindered the examinations beyond. Orifices were identified shaded behind a thin transparent membrane. Antegrade vasoscopy using flexible ME was possible up to the internal inguinal ring. Further advancement was impossible because of anatomical angle and lack adequate vision guidance. The vas deferens interior was clearly visible and was documented by pictures and movies. Altogether, the described ME techniques were feasible and effective, offering the potential of innovative diagnostic and therapeutic approaches for use in the genital tract. Several innovative indications could be expected.

The petrified heart in sepsis.

We report the case of a 33-year-old transsexual man who developed severe sepsis after an accidental intravenous injection of urine (3-5 ml) instead of methadone. He died unexpectedly 28 days after the onset of sepsis. On postmortem examination, the outstanding findings were restricted to the heart with an unusual macroscopic presentation. On histological examination extensive calcifications of the heart muscle, particularly of the left ventricle were found. The pattern of calcifications on the right ventricle was also striking. In contrast, the entire cardial conduction system was unaffected. Furthermore, there were no calcium deposits in other organs and tissues. The advanced widespread cardial calcifications in the present case can be attributed to endotoxin-related myocarditis in severe long-term sepsis. The only treatment would have been an urgent heart transplantation. Without prior knowledge of such a condition, it is impossible for clinicians to correctly recognize, diagnose and treat or prevent in due time such a complication.

Course of the meatus acusticus internus as criterion for sex differentiation.

The importance of features that allow the determination of an individual's gender even with skulls that have been largely destroyed is undisputed in archaeological and anthropological practice. Due to its extreme mechanical strength, the pars petrosa ossis temporalis is usually preserved in skulls and the sex dimorphisms of this skeletal part are therefore of particular significance. In the present study, we aimed at clarifying the controversial question whether the course of the meatus acusticus internus (M.a.i.) beneath the superior surface also reveals sex-specific differences. Using 410 forensically modern petrous portions, the course of the canal was examined and the respective angles determined using a specifically developed casting and cutting technique. The median values certainly reveal sex differences: the lateral angle on the male petrous portions is 10 degrees smaller than that of females; the medial angles on female petrous portions are approximately 5 degrees smaller than those of male skulls. Using discriminant analysis, approximately 66% of the specimens can be determined accurately.