Particulate matter emissions during autopsies: a method to reduce exposure.

Particulate matter emitted during autopsies can serve as a vector for numerous viruses or bacteria and can lead to infections. Reducing the exposure of those particles in indoor working environments is, therefore, an important issue. To assess the health risk for employees in forensic medicine, we measure particulate matter in the ambient air during autopsies by using an aerosol spectrometer. The autopsies were performed with either an ordinary oscillating saw or an adapted saw with a suction unit. The particle emissions from both saws were compared to each other in order to evaluate whether a technical adaption leads to a particle reduction. Furthermore, the particle exposure reduction by wearing a face mask and variations in the background concentration in the room were analyzed. High particle concentrations were measured while using the ordinary saw. By using the adapted saw or wearing a face mask, the particle exposure could mostly be avoided. On the majority of the working days, an increase in the background concentration could be observed. Based on this knowledge, the use of a proper suction unit and wearing a face mask during autopsies is necessary. Besides, it is important to have sufficient ventilation in the room so that long-lasting high background concentrations can be prevented.

Infectivity of deceased COVID-19 patients.

The duration of infectivity of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) in living patients has been demarcated. In contrast, a possible SARS-CoV-2 infectivity of corpses and subsequently its duration under post mortem circumstances remain to be elucidated. The aim of this study was to investigate the infectivity and its duration of deceased COVID-19 (coronavirus disease) patients. Four SARS-CoV-2 infected deceased patients were subjected to medicolegal autopsy. Post mortem intervals (PMI) of 1, 4, 9 and 17 days, respectively, were documented. During autopsy, swabs and organ samples were taken and examined by RT-qPCR (real-time reverse transcription-polymerase chain reaction) for the detection of SARS-CoV-2 ribonucleic acid (RNA). Determination of infectivity was performed by means of virus isolation in cell culture. In two cases, virus isolation was successful for swabs and tissue samples of the respiratory tract (PMI 4 and 17 days). The two infectious cases showed a shorter duration of COVID-19 until death than the two non-infectious cases (2 and 11 days, respectively, compared to > 19 days), which correlates with studies of living patients, in which infectivity could be narrowed to about 6 days before to 12 days after symptom onset. Most notably, infectivity was still present in one of the COVID-19 corpses after a post-mortem interval of 17 days and despite already visible signs of decomposition. To prevent SARS-CoV-2 infections in all professional groups involved in the handling and examination of COVID-19 corpses, adequate personal safety standards (reducing or avoiding aerosol formation and wearing FFP3 [filtering face piece class 3] masks) have to be enforced for routine procedures.

Fatalities of stowaways traveling in airplane wheel wells.

The earliest mention of a stowaway in the wheel well of an airplane dates back to 1947: A 30-year-old man chose this mode of travel for a trip from Lisbon to Brazil and survived (Véronneau et al., 1996). In a retrospective study, we evaluated cases with lethal outcome of stowaways in airplane wheel wells by focusing on forensic autopsy results, in particular, in regard to hypothermia, hypoxia, and injuries. In addition, the flight routes, flight altitudes, and flight durations were analyzed. Using the forensik® program, a search of all the autopsies performed between 1994-2017 at the Institute of Legal Medicine in Frankfurt am Main, Germany, was conducted, using the key words "airplane," "flights," and "wheel well." All of the thus retrieved autopsy reports, medicolegal expert reports, and police investigation reports were then evaluated. Five cases were included in our study. The decedents were all men, aged between 14 and 26 years. Four of the decedents had been discovered at the Frankfurt Main airport within airplane wheel wells; the fifth man had been discovered in a woods underlying one of the flight approach paths to the airport. Two stowaways had died of hypoxic asphyxiation, possibly in conjunction with hypothermia as a contributing factor. One stowaway died of the polytrauma he sustained when he was crushed by retracting landing gear. For a further stowaway, the cause of death could not be macroscopically determined at autopsy. In one case, only an external postmortem examination had been performed, without autopsy. Analysis of the flight routes, altitudes, and durations showed that the flights had been international flights, the flight altitudes had varied between 7000m (∼23,000ft) und 11,000m (∼36,000ft), and the flight duration had been between 4 and 9.5h. At high altitudes, the ambient conditions in wheel wells, which are not pressurized, are rarely survived by stowaways, with hypoxic asphyxiation likely posing greater peril than hypothermia. Further dangers are that of being crushed by retracting landing gear after takeoff, or of falling out of a wheel well, from a great height, when the landing gear is deployed. When it appears conceivable that a stowaway may have fallen from an aircraft wheel well during landing or takeoff, an autopsy and discovery scene investigation are essential to reconstructing the course of events.

A case of fatal perimyocarditis due to a rare disease.

Although myocarditis is caused by viral infections in about 50% of cases in European countries, various other causative agents are known. We report the case of a 51-year-old man who died several months after being diagnosed with asthma by his general practitioner. This diagnosis had been confirmed by a pulmonologist approximately 6 weeks before the man's death. To rule out the possibility of medical malpractice the prosecuting authority ordered a forensic autopsy. At autopsy macroscopic indicators for perimyocarditis and pneumonia were found. Microbiological and histological examination of tissue samples confirmed a diagnosis of Churg-Strauss syndrome, also known as Eosinophilic Granulomatosis with Polyangiitis (EGPA). The cause of death was determined to be cardiac involvement in Churg-Strauss syndrome. The presence of this disease also accounted for the man's recent medical history. There were no findings to indicate that a medical error had been made. The reported case illustrates why accessory histological and microbiological examinations should always be performed when macroscopic findings at autopsy suggest myocarditis. Determining the etiology of myocarditis is a necessary step to prevent overlooking rare diseases with inflammatory myocardial involvement, especially in the clarification of alleged medical malpractice.

Post-operative fatal blood aspiration after routine lung surgery.

A routine question encountered in medicolegal practice is whether the death of a patient in proximity to a surgical procedure is due to medical malpractice. The case of a 62-year-old man who died two weeks after undergoing a VATS sleeve resection of the upper right lung lobe in conjunction with radical lymphadenectomy, a routine surgical procedure, is reported. To address the issue of medical malpractice, a forensic autopsy was ordered by the investigative authority. During the autopsy, the lungs were removed as a whole and fixed in formalin and were later dissected in cooperation with a thoracic surgeon. In the course of this dissection, a bronchovascular fistula, which had led to the occlusion of the bronchial system with clotted blood, was discovered. Bronchovascular fistulas are a rare complication of bronchial sleeve resections. Because this surgical complication is essentially always fatal, it is highly pertinent to medicolegal practice. The presented case report also lists other important complications associated with bronchial anastomosis and elucidates a pragmatic approach to obtaining an expert clinical assessment of possible medical malpractice after operations through the example of a dissection performed in cooperation with a thoracic surgeon.

Bony injuries in homicide cases (1994-2014). A retrospective study.

Even when human skeletal remains are found in contexts indicative of body disposal after homicide, none of the bones may manifest injuries. When skeletons are incomplete, there are two possibilities, the injured bones are missing or none were injured. This leads to the question how frequently bones are injured during homicide, where the injuries tend to be placed, and whether the frequency of injury is related to the type of homicide. To answer these questions, the postmortem reports from all autopsies performed for homicide victims at the Institute of Legal Medicine at the University Hospital in Frankfurt am Main, Germany, between 1994 and 2014, were retrospectively evaluated for bony injuries discovered during autopsy. In 90 cases, a preliminary postmortem computed tomography (pmCT) examination had been performed. The cases were categorized into the following five groups by type of fatal trauma: blunt force, sharp force, gunshot injury, strangulation, or other. In total, the postmortem reports for 897 homicides (527 male, 370 female) were evaluated. The number of victims per trauma category were sharp force, 309; blunt force, 179; gunshot injury, 242; strangulation, 92; and other, 75. Bony injuries had been reported in 70.9 % of the homicides. The "gunshot" category contained the highest proportion of victims with bony injuries (92.6 %). With 80.4 %, the second-highest proportion of victims with bony injuries was in the "blunt force" category, followed by 66.3 % of victims in the "sharp force" group. In contrast, with 53.3 %, the second-lowest proportion of victims with bony injuries was in the "strangulation" category, which contained a preponderance of female victims, followed by 17.3 % of victims with bony injuries in the "other" category. Bony injuries thus occurred in the majority of homicides. Forensic osteological analysis should, therefore, always be performed on badly decomposed human remains. Where necessary, the additional use of visualization techniques, in particular, pmCT, or maceration may be considered. The absence of bony injuries does not rule out homicide; e.g., in strangulations, bony injuries are manifest in only half the victims, even when the skeleton is intact. The relevant structures are also easily lost to decomposition, scavenging, or scattering.

[Skull fracture or accessory suture in a child?]. / Schädelfraktur oder akzessorische Sutur bei einem Kind?

Differentiation between accessory sutures and fractures in the skull of an infant can be difficult. Apart from the regular sutures there is a multitude of variations that may be mistaken for a fracture line. Such variations include for instance the intraparietal suture between the two ossification centers of the parietal bone or the mendosal suture between the supraoccipital and interparietal bone of the occipital squama. The presented case refers to an approximately 20-month-old female child. During autopsy, a discontinuity in the right paramedian posterior cranial fossa parallel to the internal occipital crest with connection to the foramen magnum was observed. The macroscopic findings suggested a fracture line because of its course. However, neither a hemorrhage in the soft tissue nor callus formation was discernible. The discontinuity was preserved with the adjacent parts of the occipital bone for further histological examination. In the report of a cranial CT, which was carried out five days before the child's death, an accessory suture paramedially in the right posterior cranial fossa was described. When the clinical CT records were re-evaluated, a similar discontinuity at the corresponding position on the other side was detected, though of noticeably shorter length. Additionally, the preserved occipital bone fragment including the discontinuity was histologically processed. In the radiological literature, precise (radiological) criteria for differential diagnosis are indicated. A zigzag pattern with sclerotic borders and a bilateral and fairly symmetric occurrence indicate a suture, whereas a sharp lucency with non-sclerotic edges and a unilateral occurrence indicate a fracture. Taking all the findings into account, the depicted discontinuity was regarded as an accessory suture. This case demonstrates that differentiation between a fracture and an accessory suture may be difficult in the autopsy of a child and underlines the importance of a postmortem CT examination.

[Human frontal inclination of the skull as a trait of sexual dimorphism--terminology and quantification]. / Die Stirnneigung am knöchernen Schädel als Geschlechtsdiskriminierungsmerkmal--Begriffsdefinition und Quantifizierung.

The skull presents a variety of morphological traits suitable for sex discrimination due to the degree of their development. The vertical frontal inclination has been established. as another marker of sex discrimination, as a steep forehead is considered as a female and a receding frontal inclination as a male attribute. In the literature, there are many different ways to define the morphognostic term "frontal inclination" and "forehead profile" respectively. As part of the project "Digital Forensic Osteology" definitions of the frontal inclination commonly found in the literature have been tested with regard to their applicability to virtual skulls based on post-mortem CT data. The actual angle measurements were carried out automatically using software developed by the authors of this article. For the investigations, profile images of skulls generated from volume-rendered CT data were used in which anthropometric measuring points had been set manually. With the help of discriminant analysis it was tested whether sex discrimination on virtual skulls based on defined variables can be carried out with sufficient sensitivity. The measurement accuracy of the defined variables on the volume-rendered images turned out to be good. No significant sex differences regarding the tested variables were found. Using all the four selected variables the sensitivity for female skulls was only about 66%, whereas for male skulls it was not much higher than the rate of coincidence (53%). The results of this pilot study suggest that apart from extending the sample size the inclusion of additional variables based on strict consideration of validity and reliability criteria should be critically tested.

[Sauna deaths in Hesse, Germany, between 1994 and 2014]. / Saunatodesfälle in Hessen 1994-2014.

Due to the high ambient temperature, sauna deaths show a few confounding particularities, such as an accelerated onset of the postmortem changes, that can make correct assessment of the manner of death difficult and severely constrain the accuracy of post- mortem interval estimates. This retrospective study, performed at the medicolegal institutes in Hesse, Germany, reviewed all autopsy reports from the years 1994-2014 for sauna-related deaths. 9 relevant cases were found involving one woman and eight men aged between 52 and 80 years (mean and median value: 67 years). Of the individuals who had died of a natural cause, four were found to have had coronary heart disease, which, in the setting of heart hypertrophy and exposure to high temperatures, ultimately led to cardiac failure. In three other cases, a non-natural cause of death had been diagnosed; however, all were attributable to accidents. In two of these, blood alcohol concentrations (BAC) of over two per mil were found. In our opinion, the manner of death should be classified as undetermined in sauna-related fatalities. Such cases require a court-ordered autopsy to reliably identify the actual cause of death.

[The medicolegal relevance of benign and malignant coronary artery anomalies]. / Uber die Relevanz von benignen und malignen Koronaranomalien in der Rechtsmedizin.

Isolated coronary anomalies are rare abnormalities that can be divided into benign and malignant forms. Malignant coronary artery abnormalities generally present already during infancy or early childhood by causing symptoms or sudden death. Benign abnormalities often remain asymptomatic because they are hemodynamically irrelevant. Among the 12,985 autopsies performed at the Institute of Legal Medicine at the University of Frankfurt (Germany) between 1995 and 2013, there were eight cases (0.062%) with isolated coronary artery abnormalities. Five of these cases (0.039%) could be included in our retrospective study. These involved one deceased female and four deceased male subjects, aged between 2 and 57 years. In three of these cases (aged 6, 9, and 11 years old), the coronary anomaly was classified as malignant and was recorded as the cause of death. Benign isolated coronary anomalies are often incidental findings during autopsies. However, in one of the cases in our study, coronary sclerosis in precisely the anomalous vessel was found to be the origin of a fatal myocardial infarction. Malignant isolated coronary artery anomalies attain medicolegal significance when they remain undetected despite advanced early detection protocols and cause sudden death in childhood.

Disturbed sleep/wake rhythms and neuronal cell loss in lateral hypothalamus and retina of mice with a spontaneous deletion in the ubiquitin carboxyl-terminal hydrolase L1 gene.

Many neurodegenerative disorders including Parkinson's disease (PD) and Alzheimer's disease (AD) are associated with sleep disturbances with presumably multifactorial etiology. Ubiquitin C-terminal hydrolase L1 (UCH-L1) is involved in the pathophysiology of PD and AD. In the present study, we analyzed locomotor rhythms, orexin A-immunoreaction (Ir) in the lateral hypothalamus (LH) and melanopsin-Ir in the retina of gracile axonal dystrophy (gad) mice with a spontaneous deletion in the Uch-l1 gene. In constant darkness, gad mice showed circadian rhythms in locomotor activity, indicating the integrity of the endogenous circadian rhythm generator. However, gad mice showed an increased activity during subjective day and a decreased number of orexin A-immunoreactive neurons in the LH compared with the wild type (WT). In addition, gad mice showed increased locomotor activity in the light period when kept in a standard photoperiod and entrainment to phase shifts was significantly slower than in WT. Moreover, melanopsin-Ir was significantly reduced in the retina of gad mice, suggesting an impairment of circadian light perception in gad mice.