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.

Substrain and light regime effects on integrated anxiety-related behavioral z-scores in male C57BL/6 mice-Hypomagnesaemia has only a small effect on avoidance behavior.

Magnesium (Mg) has been described to possess an anxiolytic function, but a number of studies present inconsistent results on this matter. In this study the effect of Mg deficiency on anxiety-related behavior, brain and blood plasma Mg in young adult male C57BL/6JOlaHsd and C57BL/6NCrl mice was studied. The animals were put on a control or Mg deficient diet from day 0 and significant hypomagnesaemia was evident from day 12 onwards in the test animals. Housing and test conditions were under either conventional light regime (white light behavioral test conditions) or reverse light regime (red light behavioral test conditions). The animals were tested in three tests for unconditioned anxiety: the modified Hole Board (day 14), the light-dark test (day 21) and the elevated plus maze (day 28). Overall integrated behavioral z-scores were calculated over these three behavioral tests. Mg showed a structure dependent distribution at the level of the brain, that differed between C57BL/6 substrain and light regime (conventional versus reverse), respectively. Likewise, total brain Mg did differ between substrain and light regime, but was not affected by the diet. Animals on the Mg deficient diet housed under conventional light regime had a higher final (day 28) blood plasma corticosterone level as compared to controls. Animals housed under reverse light regime exhibited no diet effect of plasma corticosterone levels. The significant hypomagnesaemia at blood plasma level resulted in an effect of Mg deficiency on avoidance, but not overall anxiety-related behavior. Significant differences regarding avoidance behavior were found between the two substrains and light regimes, respectively.

[Classification of periprosthetic shoulder fractures]. / Klassifikation periprothetischer Schulterfrakturen.

The key targets in the treatment of periprosthetic humeral fractures (PHF) are the preservation of bone, successful bony consolidation and provision of a stable anchoring of the prosthesis with the major goal of restoring the shoulder-arm function. A substantial problem of periprosthetic shoulder fractures is the fact that treatment is determined not only by the fracture itself but also by the implanted prosthesis and its function. Consequently, the exact preoperative shoulder function and, in the case of an implanted anatomical prosthesis, the status and function of the rotator cuff need to be assessed in order to clarify the possibility of a secondarily occurring malfunction. Of equal importance in this context is the type of implanted prosthesis. The existing classification systems of Wright and Cofield, Campbell et al., Groh et al. and Worland et al. have several drawbacks from a shoulder surgeon's point of view, such as a missing reference to the great variability of the available prostheses and the lack of an evaluation of rotator cuff function. The presented 6­stage classification for the evaluation of periprosthetic fractures of the shoulder can be considered just as simple or complex to understand as the classification of the working group for osteosynthesis problems (AO, Arbeitsgemeinschaft für Osteosynthesefragen), depending on the viewpoint. From our point of view the classification presented here encompasses the essential points of the existing classification systems and also covers the otherwise missing points, which should be considered in the assessment of such periprosthetic fractures. The classification presented here should provide helpful assistance in the daily routine to find the most convenient form of therapy.

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.

Dynamic in vitro analysis of tractile forces of the anterior cruciate ligament (ACL) transplant using patellar and semitendinosus muscle tendon: a cadaver study.

PURPOSE: The presented biomechanical study focused on the in vitro analysis of tractile forces working on the anterior cruciate ligament (ACL) and the ACL transplants, respectively, using a semitendinosus and/or patellar tendon during a passive flexion-extension movement (150-0°). MATERIAL AND METHODS: Overall, 15 fresh frozen human knee joint pairs were examined. At first during arthroscopy, the tibial insertion of the ACL was drilled using a special hollow drill. Thereby, a bone cylinder was exposed at which a dynamometer was attached to enable for direct registration of tractile forces on the ACL via the connection between ACL-dynamometer and computer. The ACL transplant was fixed at the femur using a so-called endo-button, whereas the dynamometer was attached to the tibial end of the ACL transplant. The dynamic part of the examination was performed using the knee kinemator device developed by Plitz and Wirth et al. using different preload. RESULTS: The curves of the tractile forces of the ACL were qualitatively homogeneous with only low force values in the middle flexion position, whereas during maximum flexion and extension the forces increased reaching a maximum in the 0° position. Also, in testing the ACL transplants a force decrease between 0 and 50° flexion was recognized with even greater forces resulting at the 150° position depending on the anterior position of the femoral drill channel for implanting the ACL transplant. The amount of pre-loading showed no influence on the form of the tractile force curve. However, by enhancing the preload to 70 N, the maximal force in the ACL transplant increased significantly. CONCLUSION: The tractile forces assessed within the ACL during passive flexion movements between 10 and 90° were not greater than the forces measured in the ACL transplants. Thus, the clinical consequence is that in the early postoperative phase passive mobilization might be performed in this motion range without putting the ACL transplant at risk for damage.

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.

In vivo evaluation of the kinematics of the long head of the biceps tendon within the pulley: a 3 T MRI motion analysis.

INTRODUCTION: To evaluate the kinetic amplitude and direction of the long head of the biceps tendon (LHB) within the pulley and the proximal bicipital groove, we performed a 3T-magnetic resonance-throwing motion analysis. MATERIALS AND METHODS: This prospective study was performed on a 3T-MRI scanner. A T2-weighted-3D sequence in three specific positions of throwing motion of the dominant shoulder was performed under isometric 5 N loading conditions or without loading, respectively. Measurements were performed in high (140°) abduction/external rotation, medium (110°) abduction/external rotation and low (45°) adduction-flexion/internal rotation. Multiplanar rotational reconstructions along the LHB in the bicipital groove allowed for the localization of the LHB including the degree of motion in the three most proximal slices. RESULTS: 12 healthy volunteers (age 22­34 years) were enrolled. Adduction led to an anterior deviation of the LHB within the bicipital groove. Loading conditions in medium (110°) elevation/external rotation furthermore led to a significant anterior deviation of the LHB. Conclusion Our findings support the thesis that pulley lesions result from movements of the LHB especially in extreme positions during throwing/overhead activities. Load application in the medium (110°) elevation/external rotation position might enable a better evaluation of patients with dedicated pulley lesions. These results need further evaluation in larger study cohorts and in patients with dedicated rotator cuff lesions, which will be the focus of ongoing studies.

[Value of cross-sectional imaging in posttraumatic low grade infection]. / Wertigkeit der Schnittbildgebung bei posttraumatischem Low-Grade-Infekt.

Regarding imaging diagnostics in case of posttraumatic or postoperative chronic osteomyelitis, x-ray should be the first choice to obtain basic information of the affected bone. Because knowledge of the exact dimensions of the inflammatory changes is essential for adequate therapy planning, diagnostics via cross-sectional imaging is indicated in most cases. In order to adequately estimate the lesion's dimensions, magnetic resonance imaging (MRI) is the method of choice in these cases. Nuclear medicine examination techniques such as bone scintigraphy using specially marked granolocyte antibodies are alternatives to be considered for the evaluation of activated chronic osteomyelitis. CT exams are only rarely performed for the diagnosis of chronic osteomyelitis if a bone sequester can not be proven by either x-ray or MRI.

Postmortem 24-h interval computed tomography findings on intrahepatic gas development and changes of liver parenchyma radiopacity.

PURPOSE: The purpose of this study was to assess and analyze the development of intrahepatic gas and its distribution over time as well as radiopacity changes of the liver parenchyma after non-traumatic death during a period of 24h using postmortem computed tomography (PMCT). MATERIALS AND METHODS: Five male corpses (age range 24-64 yrs) who had died for any other reason than trauma were enrolled in this study. Whole body multi detector row computed tomography (MDCT) scans (Brilliance 64-channel, Philips, Amsterdam, NL) were performed for 24 h with one examination per hour. At an average of 6h after the corpses were found on scene the first CT-exam took place. For the analysis of the intrahepatic gas development and distribution within 24h after death the liver was virtually divided into four parts. Each examination was analyzed for gas bubbles and the possible increase over time using a semiquantitative/visual assessment employing a four-grade scale. The changes of the radiopacity of the liver parenchyma were assessed in a similar way. In each of the four parts of the liver three regions of interest of the same size were placed and recorded over time. Three radiologists and one coroner independently performed the analysis of the gas development and radiopacity changes. RESULTS: In two corpses the amount of gas and its distribution did not change over the observation period whereas in the other three corpses the gas content increased within the first four to seven hours and was most pronounced in the left liver lobe and least in the right posterior liver lobe. In all five corpses the radiopacity of the liver parenchyma did not change significantly over time with the highest radiopacity in the right posterior liver lobe. Good interobserver reliability concerning the assessment of intrahepatic gas accumulation was found. DISCUSSION: Our results indicate that PMCT is useful to detect intrahepatic gas. However, several reasons for these findings besides putrefaction e.g. trauma, resuscitation exist. For an elucidation of the exact causation of the gas accumulation further studies are required with longer postmortem examination times (24-72 h) to detect more pronounced changes of gas and organ radiopacity but also an earlier start of examination after death is desirable. Moreover, it has to be elucidated whether other organs exhibit a similar behavior and how temperature of the CT-room and the body impacts on these parameters.

Identifying emotional adaptation: behavioural habituation to novelty and immediate early gene expression in two inbred mouse strains.

Normal anxiety is an adaptive emotional response. However, when anxiety appears to lack adaptive value, it might be defined as pathological. Adaptation in animals can be assessed for example by changes in behavioural responses over time, i.e. habituation. We hypothesize that non-adaptive anxiety might be reflected by impaired habituation. To test our hypothesis, we repeatedly exposed male mice from two inbred strains to a novel environment, the modified hole board. BALB/cJ mice were found to be initially highly anxious, but subsequently habituated to the test environment. In contrast, 129P3/J mice initially showed less anxiety-related behaviour compared with the BALB/cJ mice but no habituation in anxiety-related behaviour was observed. Notably, anxiety-related behaviour even increased during the experimental period. Complementary, 129P3/J mice did not show habituation in other parameters such as locomotor and exploratory activity, whereas significant changes appeared in these behaviours in BALB/c mice. Finally, the expression of the immediate early gene c-fos differed between the two strains in distinct brain areas, known to regulate the integration of emotional and cognitive processes. These results suggest that 129P3/J mice might be a promising (neuro)-behavioural animal model for non-adaptive, i.e. pathological anxiety.

Detection of recurrent hernia and intraabdominal adhesions following incisional hernia repair: a functional cine MRI-study.

BACKGROUND: To non-invasively identify incisional hernia repair implanted synthetic meshes with MRI, and also focusing on the evaluation of postsurgical complications such as adhesions. METHODS: A total of 43 patients underwent either laparoscopic intraperitoneal onlay-mesh or open abdominal wall repair using preperitoneal layers. The patients were examined using a true-fast-imaging-with-steady-state-precession (trueFISP)-sequence in transverse/sagittal orientation with a section-by-section dynamic depiction of induced visceral slide. A 9-segment-abdominal-map was used to document the adhesion location/type. The MR-images were analysed regarding hernia relapse, layer-morphology, rectus-abdominis muscle-condition, and abdominal wall mobility. In 12 patients pre- and postsurgery-MRI was performed. RESULTS: Time range between surgery and examination was 6-36 months. In all laparoscopy-patients the meshes were identified. For open surgery the mesh was not visualized in 20, but was seen in 6 cases. A total of 11 cases showed a recurrent hernia. Seventy intraabdominal adhesions were detected. Fifteen patients had restricted mobility. 20 patients showed an rectus-abdominis-muscle-asymmetry. Comparing pre- and post-op-MRI, 6 out of 8 patients with open repair showed thick scar-plaques. Three patients with open repair had new adhesion-formations postoperatively. CONCLUSION: Functional cine MRI is suitable for follow-up studies in patients after hernia repair to detect and evaluate the implanted meshes. Typical complications like intestinal adhesions and abdominal wall dysmotility can be assessed as well.

Assessment of radiation exposure on a dual-source computed tomography-scanner performing coronary computed tomography-angiography.

OBJECTIVE: The radiation exposure of a dual-source-64-channel multi-detector-computed-tomography-scanner (Somatom-Defintion, Siemens, Germany) was assessed in a phantom-study performing coronary-CT-angiography (CTCA) in comparison to patients' data randomly selected from routine scanning. METHODS: 240 CT-acquisitions of a computed tomography dose index (CTDI)-phantom (PTW, Freiburg, Germany) were performed using a synthetically generated Electrocardiography (ECG)-signal with variable heart rates (30-180 beats per minute (bpm)). 120 measurements were acquired using continuous tube-output; 120 measurements were performed using ECG-synchronized tube-modulation. The pulsing window was set at minimum duration at 65% of the cardiac cycle between 30 and 75 bpm. From 90-180 bpm the pulsing window was set at 30-70% of the cardiac cycle. Automated pitch adaptation was always used. A comparison between phantom CTDI and two patient groups' CTDI corresponding to the two pulsing groups was performed. RESULTS: Without ECG-tube-modulation CDTI-values were affected by heart-rate-changes resulting in 85.7 mGray (mGy) at 30 and 45 bpm, 65.5 mGy/60 bpm, 54.7 mGy/75 bpm, 46.5 mGy/90 bpm, 34.2 mGy/120 bpm, 27.0 mGy/150 bpm and 22.1 mGy/180 bpm equal to effective doses between 14.5 mSievert (mSv) at 30/45 bpm and 3.6 mSv at 180 bpm. Using ECG-tube-modulation these CTDI-values resulted: 32.6 mGy/30 bpm, 36.6 mGy/45 bpm, 31.4 mGy/60 bpm, 26.8 mGy/75 bpm, 23.7 mGy/90 bpm, 19.4 mGy/120 bpm, 17.2 mGy/150 bpm and 15.6 mGy/180 bpm equal to effective doses between 5.5 mSv at 30 bpm and 2.6 mSv at 180 bpm. Significant CTDI-differences were found between patients with lower/moderate and higher heart rates in comparison to the phantom CTDI-results. CONCLUSIONS: Dual source CTCA is particularly dose efficient at high heart rates when automated pitch adaptation, especially in combination with ECG-based tube-modulation is used. However in clinical routine scanning for patients with higher heart rates and corresponding enlarged pulsing window a significant different dose resulted.

[Sarcoidosis of lymph nodes in the submandibular compartment]. / Lymphknotensarkoidose der Submandibularisloge.

Sarcoidosis is a granulomatous systemic disease of unknown etiology. Besides the landmark pulmonary lesions, extrathoracic manifestations of the disease can also occur. We report the case of a 53-year-old woman with an obscure swelling of both submandibular compartments. The radiological and pathohistological evaluations confirmed the uncommon diagnosis of sarcoidosis of the submandibular compartment. The tumor in each compartment consisted of a huge lymph node conglomerate respectively displacing the submandibular gland. The major salivary glands and the thorax were not involved.

Stage-dependant management of septic arthritis of the shoulder in adults.

Diagnostic and therapeutic standards relating to septic conditions of the shoulder are rarely documented in the literature. For this study, patients suffering from septic shoulder arthritis were prospectively enrolled. Staging was based on the criteria of Gächter (Stutz et al., Knee Surg Sports Traumatol Arthrosc 8:270-274, 2000), and assessment of functional outcome was based on a self-assessed Constant score (Boehm et al., Unfallchirurg 107:397-402, 2004). Patients were separated into three groups according to the CEBI-classification reported by Pfeiffenberger and Meiss (Arch Orthop Trauma Surg 115:325-331, 1996). Forty-three patients were enrolled. Group I contained 21% of patients, while 23% were assigned to group II, and 56% to group III. Staphylococcus aureus was found in 71%. Eight patients were treated arthroscopically, and 35 received open surgery. None of the implants could be preserved. The mean self-assessed Constant score after 26 +/- 7 months was 74 +/- 9 points in group I, 63 +/- 14 points in group II, and 53 +/- 14 points in group III. Diagnostic work-up consisted of laboratory analysis including CRP and joint aspiration. Arthroscopic procedures can be effective when implemented early. With regard to implants and chronic symptoms, primary removal should be critically reconsidered.

Is post-mortem CT of the dentition adequate for correct forensic identification?: comparison of dental computed tomograpy and visual dental record.

The gold standard for identification of the dead is the visual dental record. In this context, several authors emphasize computed tomography (CT) as valuable supportive tool for forensic medicine. However, studies focusing on diagnostic accuracy of post-mortem computed tomography (PMCT) are still missing. Therefore, the aim of this study was to compare diagnostic accuracy of the visual dental record and post-mortem computed tomography (PMCT) of the dentition for identification of the dead. Ten whole skulls were included into the study. The entire dentition of each skull was first examined with the visual dental record as a gold standard and second using dental PMCT scans, performed on a 64-multi-detector CT (MDCT). 3D reformations, multi-planar reformations (MPR), and CT-orthopantomography (OPG) were performed in the post-processing. All examinations were analyzed by three independent investigators regarding the criteria for identification of the dead, e.g., in case of disaster. PMCT for the dental identification of the dead was difficult to perform and time consuming. Due to dental overlays and corresponding artifacts, the definite periphery of the dental fillings/inlays was not accurately defined resulting in 2.9% incorrect and 64.1% false negative findings, especially synthetic inlays were hardly or not recognizable at all. For the identification of the dead especially in case of disasters with large numbers of victims, the visual dental record is still to be considered the gold standard. In the identification process itself, there is no room for error at all, although some non-concordant information may occur. Thus, PMCT should only be performed for identification in individual cases due to the relatively high error rate.

Functional role of connexin43 gap junction channels in adult mouse heart assessed by inducible gene deletion.

The gap junction protein Connexin43 (Cx43) is expressed in various cell types during embryonic development and in adult mice. Cx43 null mice (Cx43-/-) die perinatally due to cardiac malformation. In order to define the major functional role of Cx43 gap junction channels in adult mice and to circumvent perinatal death as well as direct or indirect compensation of Cx43 deficiency during development, we established a novel conditional Cx43 mouse mutant. To ablate Cx43 in adult mice in all cells that express Cx43 at a certain time, we targeted the 4-hydroxytamoxifen inducible Cre recombinase, Cre-ER(T), into the endogenous Cx43 locus. This approach left only one Cx43 coding region to be deleted upon induction of Cre-ER(T) activity. Highly efficient inducible ablation of Cx43 was shown in an embryonic stem cell test system and in adult mice. Although Cx43 protein was decreased in different tissues after induction of Cre-ER(T)-mediated recombination, cardiac abnormalities most likely account for death of those mice. Surface and telemetric ECG recordings revealed significant delay of ventricular activation and death during periods of bradyarrhythmia preceded by tachycardias. This novel approach of inducible ablation of Cx43 highlights the functional importance of normal activation of ventricular cardiomyocytes mediated by Cx43 gap junction channels in adult mouse heart to prevent initiation of fatal arrhythmias. The new mouse model should be useful for further analyses of molecular changes initiated by acute loss of Cx43 expression in various cell types.