Hyperacusis in tinnitus patients relates to enlarged subcortical and cortical responses to sound except at the tinnitus frequency.

Hyperacusis, a hypersensitivity to sounds of mild to moderate intensity, has been related to increased neural gain along the auditory pathway. To date, there is still uncertainty on the neural correlates of hyperacusis. Since hyperacusis often co-occurs with hearing loss and tinnitus, the effects of the three conditions on cortical and subcortical structures are often hard to separate. In this fMRI study, two groups of hearing loss and tinnitus participants, with and without hyperacusis, were compared to specifically investigate the effect of the latter in a group that often reports hyperacusis. In 35 participants with hearing loss and tinnitus, with and without hyperacusis as indicated by a cut-off score of 22 on the Hyperacusis Questionnaire (HQ), subcortical and cortical responses to sound stimulation were investigated. In addition, the frequency tuning of cortical voxels was investigated in the primary auditory cortex. In cortical and subcortical auditory structures, sound-evoked activity was higher in the group with hyperacusis. This effect was not restricted to frequencies affected by hearing loss but extended to intact frequencies. The higher subcortical and cortical activity in response to sound thus appears to be a marker of hyperacusis. In contrast, the response to the tinnitus frequency was reduced in the group with hyperacusis. This increase in subcortical and cortical activity in hyperacusis can be related to an increase in neural gain along the auditory pathway, and the reduced response to the tinnitus frequency to differences in attentional resources allocated to the tinnitus sound.

Association Between Subjective Tinnitus and Cervical Spine or Temporomandibular Disorders: A Systematic Review.

Movements of the neck and jaw may modulate the loudness and pitch of tinnitus. The aim of the present study was to systematically analyze the strength of associations between subjective tinnitus, cervical spine disorders (CSD), and temporomandibular disorders (TMD). A systematic literature search of the Medline, Embase, and Pedro databases was carried out on articles published up to September 2017. This covered studies in which tinnitus and CSD or TMD were studied as a primary or a secondary outcome and in which outcomes were compared with a control group. Included articles were evaluated on nine methodological quality criteria. Associations between tinnitus and CSD or TMD were expressed as odds ratios. In total, 2,139 articles were identified, of which 24 studies met the inclusion criteria. Twice, two studies were based on the same data set; consequently, 22 studies were included in the meta-analysis. Methodological quality was generally limited by a lack of blinding, comparability of groups, and nonvalidated instruments for assessing CSD. Results indicated that patients with tinnitus more frequently reported CSD than subjects without tinnitus. The odds ratio was 2.6 (95% CI [1.1, 6.4]). For TMD, a bidirectional association with tinnitus was found; odds ratios ranged from 2.3 (95%CI [1.5, 3.6]) for arthrogenous TMD to 6.7 (95%CI [2.4, 18.8]) for unspecified TMD. Funnel plots suggested a publication bias. After adjusting for this, the odds ratios decreased, but associations persisted. There is weak evidence for an association between subjective tinnitus and CSD and a bidirectional association between tinnitus and TMD.

Can repetitive transcranial magnetic stimulation increase muscle strength in functional neurological paresis? A proof-of-principle study.

BACKGROUND AND PURPOSE: Therapeutic options are limited in functional neurological paresis disorder. Earlier intervention studies did not control for a placebo effect, hampering assessment of effectivity. A proof-of-principle investigation was conducted into the therapeutic potential of repetitive transcranial magnetic stimulation (rTMS), using a single-blind two-period placebo-controlled cross-over design. METHODS: Eleven patients received active 15 Hz rTMS over the contralateral motor cortex (hand area), in two periods of 5 days, for 30 min once a day at 80% of resting motor threshold, with a train length of 2 s and an intertrain interval of 4 s. Eight of these eleven patients were also included in the placebo treatment condition. Primary outcome measure was change in muscle strength as measured by dynamometry after treatment. Secondary outcome measure was the subjective change in muscle strength after treatment. RESULTS: In patients who received both treatments, active rTMS induced a significantly larger median increase in objectively measured muscle strength (24%) compared to placebo rTMS (6%; P < 0.04). Subjective ratings showed no difference due to treatment, i.e. patients did not perceive these objectively measured motor improvements (P = 0.40). CONCLUSIONS: Our findings suggest that rTMS by itself can potentially improve muscle weakness in functional neurological paresis disorder. Whereas patients' muscle strength increased as measured with dynamometry, patients did not report increased functioning of the affected hand, subjectively. The results may indicate that decreased muscle strength is not the core symptom and that rTMS should be added to behavioral approaches in functional neurological paresis.

Forensic aspects of 40 accidental autoerotic deaths in Northern Germany.

Between 1983 and 2003, 40 accidental autoerotic fatalities have been investigated. in the Institute of Legal Medicine in Hamburg. Only 50% (n=20) were autopsied (13 legal autopsies, 6 for scientific purposes and 1 for an insurance company). All the victims were males, aged between 13 and 79 years (among them five children and adolescents, the deceased mainly between 20 and 40 years). The paraphiliacs utilized a great range of devices and props as fetishism, sexual aids or pain-stimulating agents, like intimate feminine garments, ropes, chains, bondages, locks, pornographic magazines, condoms, rubber items, and chemical anaesthetics. The cause of death was strangulation in 20 cases (17 x hanging, 3 x ligature strangulation), 11 x suffocation (8 x under plastic bags, 3 x with face-masks, 2 x thoracic compression, 1 x positional asphyxia, and 1 x cocaine intoxication). Five cases without autopsy remained unclear because of missing morphological and toxicological findings; it could not be differentiated between asphyxiation/intoxication/natural disease, although the scene characteristics seemed to be typical for autoerotic deaths. It is emphasized that the findings at the scene, the morphological and toxicological examination of the dead body (full autopsy as prerequisite) by experienced investigators and the personal history of the deceased have to be evaluated very carefully and intensely to reconstruct the accidental fatal autoerotic course accurately and undoubtedly (to exclude the possibility of sexual homicide, neglected killing, or suicide).

Unusual phenomenology of autoerotic fatalities.

Between 1983 and 2003 forty accidental autoerotic deaths (all males, 13-79 years old) have been investigated at the Institute of Legal Medicine in Hamburg. Three cases with a rather unusual scenery are described in detail: (1) a 28-year-old fireworker was found hanging under a bridge in a peculiar bound belt system. The autopsy and the reconstruction revealed signs of asphyxiation, feminine underwear, and several layers of plastic clothing. (2) A 16-year-old pupil dressed with feminine plastic and rubber utensils fixed and strangulated himself with an electric wire. (3) A 28-year-old handicapped man suffered from progressive muscular dystrophy and was nearly unable to move. His bizarre sexual fantasies were exaggerating: he induced a nurse to draw plastic bags over his body, close his mouth with plastic strips, and put him in a rubbish container where he died from suffocation.

Fatal and non-fatal injuries caused by crossbows.

Today in modern times, traumatic injuries caused by crossbows are a rarity. The largest collection of cases so far is presented in this study, consisting of four fatalities (two homicides and two suicides) and two non-fatal injuries (grievous bodily harm and an accident). All the victims were male having an age between 31 and 54. The weapons, which were used, were mainly high-performance precision crossbows with telescopic sights and hunting bolts. The parts of the body involved were the facial/head area in three of the cases and the thorax in three of them. There were either deep or total penetration injuries to the cranium and thorax with the bolt remaining in the wound in four out of six cases. The persons with non-fatal crossbow injuries exhibited comparatively few symptoms, despite the sometimes extensive involvement of the interior of the cranium (cerebrocranial penetration, in one instance). The two cases of suicide favoured the body areas often found with gun-users. The aetiological classification of crossbow injuries may be difficult after the removal of the bolt. The external morphology is strongly dependent on the type of tip used. Multiple-bladed hunting broadheads produce radiating incised wounds, whereas conical field tips produce circular to slitlike defects. Correspondingly, the external injuries can be reminiscent of the effects of a violent attack by sharp force or of a gunshot wound. The possibility, supported by clinical data, that the victim might have the ability to act or even to survive for a period of time, even with penetration of the brain, should be taken into account when the cause of death is being investigated.

Pathologic features of suicidal deaths caused by explosives.

Suicidal explosions that lack a terrorist background are only rarely encountered in the field of forensic pathology. The investigation of explosion-related fatalities can be a substantial challenge in medicolegal casework. Determining whether the manner of death is suicide, homicide, or accident in such cases can present an especially difficult task to the forensic pathologist. This study considers the pathologic features of suicidal deaths caused by explosives without a terrorist background. The modus operandi of the decedents reflected familiarity and proficiency, or at least a degree of specialized knowledge, with the construction and use of explosive devices. All explosions were set off in confined spaces. The injury patterns consisted of a combination of primary blast injuries (e.g. decapitation, traumatic amputation of limbs, gross lacerations of the body surface, blast injuries of gas-containing and hollow organs), secondary blast injuries (e.g. splinter-induced penetrating trauma), tertiary blast injuries (e.g. abrasions and contusions), and burn injuries (mostly of the flash type). The previously described symmetric distribution pattern of injuries in suicidal explosions was apparent only to a certain degree in the present series. Our observation of superficially sharp-edged wound margins with bridging in the depths of the lesion in blast-induced lacerations of the skin should deserve further attention in forthcoming cases of explosion-related fatalities because this finding is a diagnostic possibility that may support the theory of an explosion-related fatality under special circumstances, e.g. when the body has been dumped away from the place of death. Because a terrorist attack may be initially suspected in each case of suicide involving explosives, the importance of a joint inquiry based on expertise from police investigators, bomb experts, and forensic pathologists is evident.

Accidental firearm fatalities. Forensic and preventive implications.

Out of a total of 624 consecutive gunshot autopsies from Münster and Hamburg, Germany, 32 cases (5.1%) were accidental. The accidents were self-inflicted in 3 cases while another person fired the gun in the remaining 29 cases. More than half of the victims were younger than 25 years and 75% were male. A single gunshot injury was present in all cases and the head was struck in 47% but a detailed analysis of the entrance wound sites did not show any preferential anatomical sites. A surprising finding was the presence of five contact or near contact gunshots (16%). The reasons for these and most other accidents were extreme carelessness when handling a firearm, the involvement of children or adolescents or a foolish behaviour with a gun intended to impress others. Gun-cleaning accidents occurred rarely and there were no major technical defects of the weapons. Preventive measures should concentrate on strict inaccessibility of guns to children and on increased educational efforts to subgroups at risk such as hunters and members of the armed forces. A single non-contact gunshot injury from a long-barrelled firearm can be considered typical for an accident but the great variety and the possible presence of "disguised" suicides and homicides requires a careful forensic investigation including inspection of the scene and reconstruction of the events. It is recommended that a case should always be considered to be non-accidental in the beginning of an investigation.

Autopsy features relevant for discrimination between suicidal and homicidal gunshot injuries.

A total of 624 consecutive gunshot autopsies from the Institutes of Legal Medicine in Münster and Hamburg was investigated retrospectively. In a subsample of 284 suicides and 293 homicides (n=577), a large variety of features such as firearm, ammunition, number and site of entrance wounds, shooting distance and direction of the internal bullet path were recorded and binary logistic regression analysis performed in the case of bullet paths. Females constituted 26.3% of the homicide victims and 10.6% of the suicides. Short-barrelled firearms outnumbered long arms in homicides by 6:1 and in suicides by 2:1. More than 1 gunshot injury was found in 5.6% of the suicides (maximum 5 gunshots) and in 53.9% of the homicides (maximum 23 gunshots). The suicidal gunshots were fired from contact or near contact range in 89% while this was the case in only 7.5% of the homicides. The typical entrance wound sites in suicides were the temple (36%), mouth (20%), forehead (11%) and left chest (15%) but uncommon entrance wound sites such as the eye, ear, and back of the neck and head were also encountered. In suicidal gunshots to the right temple (n=107), only 6% of the bullet paths were directed downwards and only 4% were directed from back-to-front. In gunshots to the left chest (n=130), bullet paths running right-to-left or parallel occurred frequently in suicides (75%) and infrequently in homicide victims (19%). From 61 suicides who fired the gun inside their mouth, only 1 pointed the gun downwards. Consequently, some bullet path directions cannot be considered indicative of suicide: downwards and back-to-front in gunshots to the temple, left-to-right in gunshots to the left chest and downwards in mouth shots. The isolated autopsy findings can only be indicative of suicide or homicide but the combined analysis of several findings can be associated with a high probability.

Head injury by gunshots from blank cartridges.

BACKGROUND: Blank cartridge handguns are generally underestimated in their capacity to inflict serious and potentially life threatening injuries. The predominant reasons for these injuries are suicide or suicide attempts, followed by accidental injuries. METHODS: A series of 26 gas gunshots to the neurocranium is presented. The injury pattern relevant to neurosurgical practice is illustrated in a case summary of 7 selected cases and the clinical courses as well as outcomes are presented. RESULTS: The injury pattern demonstrates that the energy density of the gas jet and the high temperatures of the exploding gas volume cause extensive soft tissue injuries. In close-range shots the gas jet takes on physical properties of a projectile. In these injuries impression fractures and dislocation of bone fragments are common. CONCLUSIONS: Gas handguns, contrary to public opinion, are dangerous weapons and may inflict potentially fatal injuries to the neurocranium when fired at close range. These weapons are frequently used in criminal or careless activities predominantly by young males. Extensive CNS injuries including hematomas, subarachnoid hemorrhage, foreign body contamination, and increased intracranial pressure are frequently observed.

[Severe mediastinal emphysema after temporal gunshot with a gas revolver]. / Ausgedehntes Mediastinalemphysem nach temporaler Schussverletzung mit einem Gasrevolver.

Injuries after a close contact gunshot with clear or tear gas cartridges can lead to severe and life threatening complications. The high pressure of the gas may damage soft tissue, bones and organs. This mechanism is able to cause mediastinal emphysema, rupture of upper and lower pharyngeal, esophageal and tracheal structures far away from the initial trauma with diagnostic findings which are may be difficult to interpret. This case report presents a mediastinal emphysema in a 17 year old man following a temporal shot with a gas revolver. The diagnostics, focussed on CT and X-ray imaging, and the therapeutic concept of such cases will be discussed.

Fatal aviation accidents in Lower Saxony from 1979 to 1996.

So far no national or regional studies have been published in Germany regarding the number of fatal aviation accidents and results of autopsy findings. Therefore, we evaluated all fatal aviation accidents occurring in Lower Saxony from 1979 to 1996. A total of 96 aviation accidents occurred in this period involving 73 aeroplanes. The crashes resulted in the death of 154 people ranging in age from 19 to 68 years. The greatest number of victims in a single crash of an aircraft was (n=7). Other types of fatal accidents were crashes of aircraft and helicopter while on the ground (n=5), hot-air balloons (n=2), parachutes (n=10), hang glider accidents (n=5) and the striking of a bystander by a model airplane. Autopsies were performed on 68 of the 154 victims (44.2%), including 39 of the 73 pilots (53.4%). Some of the autopsies yielded findings relevant to the cause of the accident: gunshot wounds, the presence of alcohol or drugs in blood and preexisting diseases. Our findings emphasize the need for autopsy on all aviation accident victims, especially pilots, as this is the only reliable method to uncover all factors contributing to an accident.

[Once again: risk of injury caused by blank pistols]. / Noch einmal: Verletzungsgefahren durch Schreckschusswaffen.

The nature and extent of the use of blank pistols in Hamburg (according to the Hamburg crime statistics about 300 to 400 such cases per year; 34 cases involving head and neck wounds from 1989 to 1999 were investigated at our institute; among these 8 suicides, no homicide) as well as patterns of injuries caused by close distance blank pistol shots were analysed. 7 of these cases are described in detail. The results of our studies corroborate the warning statements made by many criminological and medico-legal experts regarding the danger inherent in these allegedly harmless weapons. Blank cartridge pistols can, when shot from a close distance, cause most severe injuries involving penetration into body cavities and bodily organs (especially in the head and neck), and even perforation of the skull. Therefore, we call for a much stricter control of weapons of this kind.

[Postmortem dog bites after sexually motivated homicide with multiple stab wounds--differential diagnostic aspects]. / Postmortaler Hundefrass nach sexuell motiviertem Homizid mit multiplen Stichverletzungen--differentialdiagnostische Aspekte.

The body of a 20-year-old woman that had undergone significant putrefaction was found lying on the bed of her apartment in a supine position. The legs were straddled and apart from a T-shirt, she was naked. The inner side of the right thigh showed a circumscribed 20 cm x 40 cm defect exposing the underlying muscles. The wound margin was ragged and superficial scratch-type abrasions were found in the vicinity of the injury margin. The investigating police officers classified the injuries to be caused postmortem by a crossbreed dog that was inside the apartment. No other signs of external force were found on the body at the death scene and due to the previous history of the deceased, a drug death was assumed. Autopsy revealed 13 vital stab wounds in the neck and aspiration of blood in the lungs as well as signs of manual strangulation. The observed coincidence of injuries due to postmortem animal depredation and stab wounds, although in different localization, can be regarded as a rare entity in the light of the literature. The morphological appearance of traumatic injuries due to other causes can be modified by the simultaneous presence of postmortem injuries caused by animals and difficulties can arise concerning the differential diagnosis especially under poor conditions (e.g. advanced putrefaction) at the death scene.

Skin and soft tissue artifacts due to postmortem damage caused by rodents.

Five cases of postmortem bite-injuries inflicted by rodents are presented (five males between 41 and 89 years; three cases caused by mice, one case by rats, one case of possible mixed rodent activity by rats and mice). The study presents a spectrum of phenomenological aspects of postmortem artifacts due to rodent activity to fresh skin and soft tissue: the majority of the injuries have a circular appearance. The wound margins are finely serrated with irregular edges and circumscribed 1-2 mm intervals within, partly showing protruding indentations up to 5 mm. Distinct parallel cutaneous lacerations deriving from the biting action of the upper and lower pairs of the rodents incisors are diagnostic for tooth marks of rodent origin but cannot always be found. No claw-induced damage can be found in the skin beyond the wound margins. Areas involved in the present study were: exposed and unprotected parts of the body, such as eyelids, nose and mouth (representing moist parts of the face); and the back of the hands. Postmortem rodent activity may occasionally be expected on clothed and therefore protected parts of the body. The phenomenon of postmortem rodent activity to human bodies can be found indoors especially under circumstances of low socioeconomic settings; outdoors this finding is particularly observed among fatalities among homeless people.

Proof of air embolism after exhumation.

The detection, storage, and analysis of gas taken from the heart ventricle is necessary to diagnose a fatal air embolism and this requires special precautions during autopsy. When the results of gas analysis correspond to the criteria defined by Pierucci and Gherson the diagnosis "air embolism" is justified. In cases showing putrefaction the diagnostic value of gas analysis was negated. In a series of 15 patients who were assumed to have been killed by air injection in a peripheral vein the corpses were exhumed and a full medico-legal examination was carried out including gas analysis. In 8 cases results could be obtained indicating a mixture of embolised air and gases of putrefaction. In two control groups comprising 10 exhumed bodies and 30 cases showing advanced putrefaction, gas analysis showed putrefaction gases except in 5 cases with gas volumes less than 5 ml in the right ventricle. Therefore gas analysis can be helpful to diagnose fatal air embolism even in cases showing putrefaction while the diagnosis of putrefaction gases only does not exclude this diagnosis.

[Vitality and possible causes of punctate hemorrhages in the lower brain stem of a burned corpse]. / Zur Frage der Vitalität und möglichen Ursachen von punktförmigen Blutungen im unteren Hirnstamm bei einer Brandleiche.

The case under discussion of a burn victim with dot haemorrhages into the caudal brain stem confirms other observations which have only rarely been published that these dot haemorrhages are not necessarily the sequelae of an intra vitam trauma. A reliable assessment of such cases demands a comprehensive pathologic and if possible neuropathologic autopsy including follow-up investigation considering police inquiry.

[Impression traces from firearms on cadaver skin]. / Abdruckspuren von Schusswaffen auf der Leichenhaut.

Guns may occasionally leave traces on human skin, for example by compression/impression of the tissue (esp. in the area of livores), by contact-transfer of dirt, oil, and rust, or by forming the pattern of blood-smears. The case of a 31-year-old drug-addict is presented in detail: The man committed suicide by shooting himself (entrance hole under the chin). When the dead body was found there was no weapon at the scene. By careful securing of evidence and analyzing the pattern of metallisations (identified as rust from the old pistol) it was reconstructed that the suicident held the pistol (identified as Russian Tokarew TT33-7.62 mm) in his hand for many hours postmortem until it was removed by an unknown thief.

[Gunshot fatalities in connection with hunting and hunting rifles--causes, prevention and expert evaluation]. / Schusstodesfälle im Zusammenhang mit der Jagd sowie durch Jagdwaffen-Ursachen, Verhütung und Beurteilung.

Fatalities due to gunshot injury by hunting firearm or during hunting, that had been investigated in the Institute of Legal Medicine of Hamburg University during the last 20 years, were retrospectively analyzed from the view points of epidemiology, morphology, criminology and ballistics. Thirteen accidents, 23 suicides and 13 homicides were included in this study. Female victims were observed in only 2 cases. In the accidents, the age of the most victims ranged from 30 to 60 years. Seven of 13 accidental victims killed themselves; remaining 6 were shot by other hunters. Nine accidents happened during hunting. The most frequently used firearm in cases of suicide and homicide was a shotgun whereas accidents preferably occurred with rifles. In some homicidal cases pistols were also used. The entrance wound was localized mostly in the head, neck or breast. Shooting in the mouth was observed in many suicidal cases. Although many victims were shot in the hunting ground, 15 of 23 suicides were performed at home. In 3 homicides which occurred in the hunting ground, the murderer committed another crime with the robbed hunting firearm of the victim. Three accidents occurred during training in the shooting-gallery. Blood alcohol concentration (BAC) was determined in 28 cases. Different degrees of drunkeness were observed in 2 self-inflicted accidents, 5 suicides and 2 homicidal cases. No BAC determinations were performed on the shooters. Ten case histories are presented. The discussion concentrates on the effect of the kind of firearm and ammunition on the appearance of the wound, prevention of accidents, and the principles of reconstruction, especially concerning the differentiation accident/suicide. The forensic expert investigating gunshot injuries during hunting should have personal experience in this field. The most frequent cause of accidents was careless handling of the loaded firearm and violation of invulnerable rules for safety during hunting.

[Unusual suicide by gunshot wound to the head with a signal pistol]. / Ungewöhnlicher Suizid durch Kopfschuss mit einer Signalpistole.

The professional access to weapons plays a role in the choice of suicide instruments. Light and signalling ammunition is used by police forces, in the military, in sports, and professional navigation. An unusual suicide of a shipowner by means of a signal-pistol is presented. The signal cartridge was shot into the head. Penetrating the skull the cartridge entered the brain. The burning-out of the signal-set--taking about 10 seconds--initiated a flat-burning.--This case shows once more the dangerous misuse of light and signal ammunition.