[Simulation in the elective subject forensic medicine in the third section of the medical examination]. / Simulation im Wahlfach Rechtsmedizin im Dritten Abschnitt der Ärztlichen Prüfung.

During the COVID-19 pandemic the third section of the medical examination could be performed on simulation patients and simulators. Their use is also beneficial in forensic medicine, as a higher level of standardization and comparability of examination performance is achieved, and the use of real corpses is often not justifiable for medicolegal reasons. This case reports on the advantages and disadvantages of a simulation in the state examination in which a death certificate was to be completely filled out on the basis of an external postmortem examination on the simulator and an external anamnesis.

Identification and characterization of novel rapidly mutating Y-chromosomal short tandem repeat markers.

Short tandem repeat polymorphisms on the male-specific part of the human Y-chromosome (Y-STRs) are valuable tools in many areas of human genetics. Although their paternal inheritance and moderate mutation rate (~10-3 mutations per marker per meiosis) allow detecting paternal relationships, they typically fail to separate male relatives. Previously, we identified 13 Y-STR markers with untypically high mutation rates (>10-2 ), termed rapidly mutating (RM) Y-STRs, and showed that they improved male relative differentiation over standard Y-STRs. By applying a newly developed in silico search approach to the Y-chromosome reference sequence, we identified 27 novel RM Y-STR candidates. Genotyping them in 1,616 DNA-confirmed father-son pairs for mutation rate estimation empirically highlighted 12 novel RM Y-STRs. Their capacity to differentiate males related by 1, 2, and 3 meioses was 27%, 47%, and 61%, respectively, while for all 25 currently known RM Y-STRs, it was 44%, 69%, and 83%. Of the 647 Y-STR mutations observed in total, almost all were single repeat changes, repeat gains, and losses were well balanced; allele length and fathers' age were positively correlated with mutation rate. We expect these new RM Y-STRs, together with the previously known ones, to significantly improving male relative differentiation in future human genetic applications.

[Analysis of Coding Quality of Death Certificates and Autopsy Rates in Chemnitz: 2010-2013]. / Analyse der Kodierungsqualität der Leichenschauscheine und Obduktionsraten in Chemnitz, 2010­2013.

BACKGROUND: Postmortem examination as the last service of physicians has been increasingly criticized recently. The aim of this project was to study the influence of place of death, type of postmortem physician, age and sex of the deceased person on the completeness and quality of ICD-10 coding of death certificates issued by physicians in Chemnitz, Germany. METHODS: We reviewed 15 612 death certificates and 353 autopsy reports of the health office of Chemnitz for the years 2010-2013. We extracted age and sex of the deceased, causes of death as based on the primary postmortem examination and after autopsy if applicable, type of death (natural or unnatural cause of death), and complications as discovered at the second postmortem examination before cremation. In addition, we documented the place of death and type of physician carrying out the postmortem examination. Furthermore, we corrected the inappropriate or missing ICD-10 codes followed by agreement analysis. The analysis was in agreement with the rules of the German Institute of Medical Documentation and Information. RESULTS: The autopsy rate was 2.3%. The underlying condition was not documented in 34.1% of the cases. The agreement between quality-controlled ICD-10 coding of the cause of death and the original ICD-10 coding (three-digit codes) was high (96.5%). High age at death, death not occurring in hospitals, and postmortem examination not carried out in hospitals were associated with a higher probability of ICD-10 miscoding. The observed agreement of 3-digit ICD-10 coded underlying condition after primary postmortem examination and after autopsy was 26.3%. The underlying cause of death contained garbage codes in 24.2%, that is, codes that are inappropriate for cause of death statistics. CONCLUSIONS: Physicians have to be sensitized to the need for appropriate documentation of causes of death. Autopsy very frequently resulted in a change of the assessment of the underlying cause of death and therefore remains an important quality control measure for certification on the cause of death. ICD-10 coding of causes of death is not a primary task of physicians and physicians should not be required by law to carry out this task.

Medico-legal assessment of methamphetamine and amphetamine serum concentrations-what can we learn from survived intoxications?

Medico-legal experts are increasingly enlisted to assess the methamphetamine and amphetamine serum concentrations after a criminal offense. However, since criminal users rarely provide useful information to medico-legal experts regarding the substances abused, when the substance(s) was/were used, dose of ingestion tools are needed to interpret the analytical data, which can be used as objective evidence in such cases. A comparative series of methamphetamine and amphetamine serum concentrations were used to analyze the frequency of concentrations, to determine methamphetamine/amphetamine concentration ratios, and prove them as a tool to distinguish pure methamphetamine from mixed amphetamine/methamphetamine ingestion. Additionally, two cases of survived accidental methamphetamine intoxication, resulting from ingestion smuggling which was longitudinally monitored, and pharmacokinetic parameters were assessed. In a series of 628 samples where the most frequent concentration of methamphetamine exceeded the therapeutic level, there was a strong correlation suggesting pure methamphetamine consumption, when the ratios of methamphetamine/amphetamine concentrations were within the range between 3 and 10. In the two cases of methamphetamine bodypacking, the relevant serum concentrations of methamphetamine and amphetamine, which could be measured up to 9 days after ingestion, indicated a decrease of the methamphetamine/amphetamine ratios in an exponential manner. However, the ratios were not always within the range between 3 and 10. Lastly, the course of the serum concentrations suggested an increase of the apparent elimination half-life of methamphetamine. In terms of the objective evidence required in criminal law, calculating methamphetamine/amphetamine concentration ratio is not a suitable to means to distinguish pure methamphetamine intake and that of mixed amphetamine/methamphetamine abuse in an individual case. Instead, methamphetamine high serum concentrations and the possible increase in apparent elimination half-life suggest that an extended detection period may be used to distinguish between "illicit use" as compared to "therapeutic use" of methamphetamine.

Alterations of neuronal precursor cells in stages of human adult neurogenesis in heroin addicts.

BACKGROUND: Adult neurogenesis has been shown to occur throughout life and different brain pathologies were demonstrated to be associated with altered neurogenesis. Here, an impact of heroin addiction on neurogenesis in humans is hypothesised. METHODS: Post mortem hippocampal specimens of drug addicts with known heroin abuse and a group of non-addictive control subjects were analysed, using antibodies indicating different stages of neurogenesis. The subgranular zone of the dentate gyrus was examined qualitatively and quantitatively. RESULTS: The data indicate (i) a decreased number of neural precursor cells, (ii) accompanied by low rates of proliferation and (iii) a marked loss of dendritic trees in targeting cells in heroin fatalities. (iv) The age-dependent increase of differentiating cells in the healthy controls was not observed in the addicts. Additionally, double immunofluorescence labelling indicated the precursor nature of Musashi-1 positive cells in the human subgranular zone of the dentate gyrus. CONCLUSIONS: Present data firstly demonstrate the influence of drug addiction with known heroin abuse on different developmental stages of progenitors in the dentate gyrus. The patterns of antibody staining suggest a distinct inhibition of neurogenesis at the stage of neural precursor cells and revealed morphological changes in targeting cells in cases of heroin addicts as compared to healthy controls. These alterations could be considerable for memory and cognitive deficits as well as addictive behaviour in chronic drug abusers and may give rise to specific pro-neurogenic therapies.

Postmortem Examinations for the Etiological Identification of Juvenile Coronary Arteriosclerosis.

The postmortem of suddenly deceased younger adults sometimes reveals that they experienced manifest coronary arteriosclerosis. We looked at 21 cases where stenosis of the coronary arteries was at least 50%. We supplemented our postmortem findings and the results from the postmortem identification of the lipid metabolism parameters with anamnestic details. We also conducted a genetic analysis. The risk factors such as smoking and family history were relatively frequent. In most of our cases, the postmortems showed significantly deviating lipid metabolism parameters. Compared to these findings, the genetic analyses only showed a clearly increased presence of APOE genotypes 3/4, whereas we observed no abnormalities in relation to the LDL receptor. The study results illustrate the multifactor genesis of premature coronary arteriosclerosis. Despite these limitations, the unexpected finding of juvenile coronary arteriosclerosis should entail an effort to establish the individual risk factors involved as this can provide vital information for medically advising other members of the family on their hereditary risks.

[Efficiency of inspections of the corpse before cremation performed in the area of the Halle University Medical Centre]. / Effizienz der Krematoriumsleichenschau im Bereich des Universitätsklinikums Halle.

From 1993 to 2007, the Institute of Forensic Medicine in Halle conducted 882 post-mortems before cremation. These records were now used for a systematic analysis of these cases to assess the efficiency of so-called second inspections of the corpse carried out in the area covered by the Halle University Hospital. In the period under review, considerable fluctuations were found from year to year, but these are mainly attributable to changes in the Saxony-Anhalt burial law introduced in 2002. Our 882 post-mortems were based on 84,677 corpse inspections before cremation; thus, an autopsy was performed in about 1% of all cases. Males were significantly overrepresented, younger age groups were dominant and there was a relatively high percentage where the first inspection of the corpse could not determine the manner of death or had to declare death by an unnatural cause. With regard to the manner and cause of death, the results of the first inspection and the post-mortem differed significantly. In 17.6% of our 882 cases, only the post-mortem revealed that death had been due to an unnatural cause. Despite the presence of sometimes strong clues to an unnatural cause, 156 of these cases were classified as natural deaths (56.4%) or the manner of death was stated as undetermined (43.6%). For more than two thirds of these 156 cases we were able to inspect the records kept by the Departments of Public Prosecution. 105 of these at first overlooked cases of unnatural deaths turned out to be deaths by accident. The other cases included 11 suicides, and 36 deaths related to medical treatment. In the remaining four cases, the autopsy results strongly suggested homicide, but only in one of these four cases subsequent police investigations were able to identify the perpetrator. This outcome demonstrates that the rule of inspecting the corpse a second time before cremation is clearly indispensable, even in its currently rather limited form.

Protein kinase inhibitor analysis with the core-shell separation technique.

Here, we describe the application of the core-shell separation technology in the field of protein kinase inhibitor analysis with the HPLC-diode-array detector (DAD) technique. A Kinetex 2.6 µm C8 100 Å, 150 × 4.6 mm column maintained at 30 ± 1 °C was used for the separation, and further, a connection of two core-shell HPLC columns with a total column dimension of 250 × 4.6 mm was also applied. The analytes were eluted with a mobile phase consisting of 0.05 M H(3)PO(4)/KH(2)PO(4) (pH = 2.3)-acetonitrile (7:3, v/v), with a flow rate of 0.7 mL/min. A liquid-liquid extraction with 1-chlorobutane was used for the sample preparation. The validation of the canertinib analytical method resulted in recoveries in the range of 74-79 % and in relative standard deviation and accuracy lower than 15 %, both for between- and within-batch calculations. A very good linearity in the validated range (5-10,000 ng/mL) and a limit of quantification (LOQ) of 5 ng/mL were achieved. Peak width, height and peak area of six protein kinase inhibitors analysed with a core-shell column and with a conventional fully porous particle column were compared. The results showed that, for most inhibitors analysed with the core-shell analytical column, the peaks were about two to three times narrower and two to three times higher, with areas that remained almost unchanged. The presented study revealed that the application of this separation technology is a very cost-effective way to bring the LOQ of the protein kinase inhibitor analysis with an HPLC closer to the possibilities of the LC-MS/MS technique.

HPLC-DAD protein kinase inhibitor analysis in human serum.

We here describe an HPLC-DAD method to analyse different protein kinase inhibitors. Potential applications of this method are pharmacokinetic studies and therapeutic drug monitoring. Optimised chromatography conditions resulted in a very good separation of seven inhibitors (vatalanib, bosutinib, canertinib, tandutinib, pazopanib, dasatinib - internal standard and erlotinib). The good sensitivity makes this method competitive with LC/MS/MS. The separation was performed with a Lichrospher 100-5 RP8, 250 mm × 4 mm column maintained at 30 ± 1 °C, and with a mobile phase of 0.05 M H(3)PO(4)/KH(2)PO(4) (pH=2.3)-acetonitrile (7:3, v/v) at a flow rate of 0.7 mL/min. A simple and fast sample preparation sequence with liquid-liquid extraction led to good recoveries (73-90%) of all analytes. The recovery hardly reached 50% only for pazopanib. This method can also be used for targeted protein kinase inhibitor quantification. A perfect linearity in the validated range (20-10,000 ng/mL) and an LOQ of 20 ng/mL were achieved. The relative standard deviations and accuracies of all examined drug concentrations gave values much lower than 15% both for between- and within-batch calculations. All analysed PKIs were stable for 6 months in a 1mg/mL dimethyl sulfoxide stock solution. Vatalanib, bosutinib and erlotinib were also stable in human serum in the whole examined concentration range.

Medical examination of fitness for police custody in two large German towns.

Worldwide, there is a high risk of medical complications or death in police custody. This risk is often increased by unclear legislation, a lack of clearly defined responsibility and medical examination standards. Any solution to these problems requires as a very basis the systematic analysis of the medical examinations that determine whether a person is fit to be detained in custody. We analysed a total of 3,674 medical records on fitness for custody, taken from two large German towns (Halle/S and Bremen). The examined individuals were predominantly males or of a younger age. The indication in the majority of cases was acute alcoholic intoxication or drug withdrawal syndromes. Traumata and internal or mental diseases were also quite frequent. For approximately 50% of all cases, fitness for custody was declared on certain conditions. Only 39.8% were found to be unconditionally fit for detention in custody. In just under 10% of the cases, the person was found unfit for custody. These cases concerned mainly persons with psychological symptoms and advanced alcohol or drug withdrawal syndromes. We were able to show that the recent introduction of new police custody regulations in Halle/S had a significant influence on the medical decision on fitness for custody. Our detailed assessment has provided us with the basis to develop solutions for the improvement of medical care in police custody. The focus lies here on the organisation and legal regulation of the medical aspects of custody but also on policing and medical work.

Long QT syndrome mutation detection by SNaPshot technique.

Long QT syndrome (LQTS) is a cardiac disorder with an abnormality of cardiac rhythm associated with sudden death especially in younger, apparently healthy individuals. If there is no clear cause of death detectable during comprehensive coroner's inquest (autopsy-negative cases), you have to consider LQTS and other heritable arrhythmia syndromes. A molecular genetic screening regarding mutations in associated genes can help to ensure the cause of death and to protect affected family members. Genetic testing of LQTS, currently performed mainly by sequencing, is still very expensive and time consuming. With this study we present a rapid and reasonable method for the simultaneously screening of some of the most common mutations associated with LQTS, focused on the KCNQ1 and KCNH2 genes. With the method of SNaPshot minisequencing, a total of 58 mutations were analyzed in four multiplex assays which were successfully established and optimized. The comparison with samples previously analyzed by direct sequencing showed concordance. Furthermore, autopsy-negative cases were tested but no mutations could be observed in any of the specimen. The presented method is well suitable for LQTS mutation screening. An enhancement to further mutations and population-based investigations regarding mutation frequencies should be the aim of prospective studies.

Survived ileocecal blowout from compressed air.

Industrial accidents with compressed air entering the gastro-intestinal tract often run fatally. The pressures usually over-exceed those used by medical applications such as colonoscopy and lead to vast injuries of the intestines with high mortality. The case described in this report is of a 26-year-old man who was harmed by compressed air that entered through the anus. He survived because of fast emergency operation. This case underlines necessity of explicit instruction considering hazards handling compressed air devices to maintain safety at work. Further, our observations support the hypothesis that the mucosa is the most elastic layer of the intestine wall.

Mutability of Y-chromosomal microsatellites: rates, characteristics, molecular bases, and forensic implications.

Nonrecombining Y-chromosomal microsatellites (Y-STRs) are widely used to infer population histories, discover genealogical relationships, and identify males for criminal justice purposes. Although a key requirement for their application is reliable mutability knowledge, empirical data are only available for a small number of Y-STRs thus far. To rectify this, we analyzed a large number of 186 Y-STR markers in nearly 2000 DNA-confirmed father-son pairs, covering an overall number of 352,999 meiotic transfers. Following confirmation by DNA sequence analysis, the retrieved mutation data were modeled via a Bayesian approach, resulting in mutation rates from 3.78 × 10(-4) (95% credible interval [CI], 1.38 × 10(-5) - 2.02 × 10(-3)) to 7.44 × 10(-2) (95% CI, 6.51 × 10(-2) - 9.09 × 10(-2)) per marker per generation. With the 924 mutations at 120 Y-STR markers, a nonsignificant excess of repeat losses versus gains (1.16:1), as well as a strong and significant excess of single-repeat versus multirepeat changes (25.23:1), was observed. Although the total repeat number influenced Y-STR locus mutability most strongly, repeat complexity, the length in base pairs of the repeated motif, and the father's age also contributed to Y-STR mutability. To exemplify how to practically utilize this knowledge, we analyzed the 13 most mutable Y-STRs in an independent sample set and empirically proved their suitability for distinguishing close and distantly related males. This finding is expected to revolutionize Y-chromosomal applications in forensic biology, from previous male lineage differentiation toward future male individual identification.

[Reliability of the diagnoses of external post-mortem examinations in non-natural deaths before and after the German reunification]. / Zur Reliabilität von Leichenschaudiagnosen bei nichtnatürlichen Todesfällen vor und nach der Wiedervereinigung Deutschlands.

In Germany, the unsatisfactory quality of external post-mortem examinations and the low autopsy rate of only 5 % of all deaths are often criticized. Based on the autopsy protocols of 8,593 cases of non-natural death of the Leipzig Institute of Legal Medicine (1985 to 1989--practice in the former German Democratic Republic; 1990 to 1994 - time around the fall of the Berlin wall, and 2000 to 2004--practice in the Federal Republic of Germany) the diagnosis indicated in the death certificate was compared with that of the autopsy report. Beside a drastic decrease in the number of autopsies performed, it was found that in 72% of the cases the clinical and the autoptical cause of death corresponded completely, whereas in 9.2% there was only partial and in 15.4% no correspondence at all. The lack of correspondence increased from 13.8% (1985-1989) to 18.0% (2000-2004). The low rate of correspondence in the causes of domestic deaths was particularly alarming. There were obvious differences in quality among different groups of specialists in determining the cause of death.

Comprehensive mutation analysis of 17 Y-chromosomal short tandem repeat polymorphisms included in the AmpFlSTR Yfiler PCR amplification kit.

The Y-chromosomal short tandem repeat (Y-STR) polymorphisms included in the AmpFlSTR Yfiler polymerase chain reaction amplification kit have become widely used for forensic and evolutionary applications where a reliable knowledge on mutation properties is necessary for correct data interpretation. Therefore, we investigated the 17 Yfiler Y-STRs in 1,730-1,764 DNA-confirmed father-son pairs per locus and found 84 sequence-confirmed mutations among the 29,792 meiotic transfers covered. Of the 84 mutations, 83 (98.8%) were single-repeat changes and one (1.2%) was a double-repeat change (ratio, 1:0.01), as well as 43 (51.2%) were repeat gains and 41 (48.8%) repeat losses (ratio, 1:0.95). Medians from Bayesian estimation of locus-specific mutation rates ranged from 0.0003 for DYS448 to 0.0074 for DYS458, with a median rate across all 17 Y-STRs of 0.0025. The mean age (at the time of son's birth) of fathers with mutations was with 34.40 (+/-11.63) years higher than that of fathers without ones at 30.32 (+/-10.22) years, a difference that is highly statistically significant (p < 0.001). A Poisson-based modeling revealed that the Y-STR mutation rate increased with increasing father's age on a statistically significant level (alpha = 0.0294, 2.5% quantile = 0.0001). From combining our data with those previously published, considering all together 135,212 meiotic events and 331 mutations, we conclude for the Yfiler Y-STRs that (1) none had a mutation rate of >1%, 12 had mutation rates of >0.1% and four of <0.1%, (2) single-repeat changes were strongly favored over multiple-repeat ones for all loci but 1 and (3) considerable variation existed among loci in the ratio of repeat gains versus losses. Our finding of three Y-STR mutations in one father-son pair (and two pairs with two mutations each) has consequences for determining the threshold of allelic differences to conclude exclusion constellations in future applications of Y-STRs in paternity testing and pedigree analyses.

ISFG: Recommendations on biostatistics in paternity testing.

The Paternity Testing Commission (PTC) of the International Society for Forensic Genetics has taken up the task of establishing the biostatistical recommendations in accordance with the ISO 17025 standards and a previous set of ISFG recommendations specific to the genetic investigations in paternity cases. In the initial set, the PTC recommended that biostatistical evaluations of paternity are based on a likelihood ratio principle - yielding the paternity index, PI. Here, we have made five supplementary biostatistical recommendations. The first recommendation clarifies and defines basic concepts of genetic hypotheses and calculation concerns needed to produce valid PIs. The second and third recommendations address issues associated with population genetics (allele probabilities, Y-chromosome markers, mtDNA, and population substructuring) and special circumstances (deficiency/reconstruction and immigration cases), respectively. The fourth recommendation considers strategies regarding genetic evidence against paternity. The fifth recommendation covers necessary documentation, reporting details and assumptions underlying calculations. The PTC strongly suggests that these recommendations should be adopted by all laboratories involved in paternity testing as the basis for their biostatistical analysis.

ErbB-3 predicts survival in ovarian cancer.

BACKGROUND: HER3 (erbB-3) is a member of the epidermal growth factor receptor (EGFR) family. After dimerization with other members of the EGFR family several signal transduction cascades can be activated, including phosphoinosite 3'-kinase (PI3-K)/Akt and extracellular signal-regulated kinase (ERK1/2). Here, we studied a possible association between HER3 expression and prognosis in patients with ovarian cancer. METHODS: Tumor tissue of 116 consecutive patients diagnosed with primary epithelial ovarian cancer between 1986 and 1995 was analyzed immunohistochemically for HER3 expression. A possible influence of HER3 expression on survival was studied by multivariate Cox regression adjusting for established clinical prognostic factors. RESULTS: A positive HER3 expression was observed in 53.4% of the patients. HER3 expression was associated with decreased survival in proportional hazard modeling, including the International Federation of Gynecology and Obstetrics (FIGO) stage, histologic grade and type, residual disease, and age. After likelihood ratio forward as well as backward selection, only HER3 expression (hazard ratio, 1.71; 95% CI, 1.10 to 2.67; P = .018), FIGO stage (hazard ratio, 4.78; 95% CI, 1.89 to 12.08; P = .001), residual tumor (hazard ratio, 2.69; 95% CI, 1.40 to 5.17; P = .003), and age (hazard ratio, 2.06; 95% CI, 1.17 to 3.65; P = .013) were found to be significant. Kaplan-Meier plots demonstrated a clear influence of HER3 expression on survival time. Median survival time was 3.31 years (95% CI, 1.93 to 4.68) for patients with low HER3 expression, compared with only 1.80 years (95% CI, 0.83 to 2.78) for patients with HER3 overexpression (log-rank test P = .0034). CONCLUSION: HER3 may represent a new prognostic factor in primary epithelial ovarian cancer. Pending validation, exploration of therapeutic strategies to block HER3 could be warranted.