An avenue to miscarriage: a case report.

Two men were wrongfully convicted of murder in 2017 and sentenced to life imprisonment. After a physical altercation inside a flat, the victim (A) was found dead approximately 60 m away outside a residential address. He had sustained a number of injuries including a stab wound to the left side of his neck which was found to have divided the right carotid artery. The location where A was found was not regarded as a crime scene and not subjected to a specialist forensic examination by scientists as it was assumed that the fatal injury was sustained in the flat. The pathologist, who subsequently carried out the autopsy on A, was not asked to attend the scene. A review of the blood distribution at the scene in conjunction with the pathology findings indicated however that the fatal neck wound had been inflicted outside the flat, near to where the victim was found. An appeal against the convictions for murder was upheld in 2021 and a re-trial ordered. Following this second trial, both accused were acquitted of murder and released from custody. The new pathology and blood pattern evidence introduced at the second trial was a major part of the defense strategy which led to the acquittal of the accused. The case illustrates that a more inclusive and detailed crime scene strategy had been undertaken, including an assessment of the bloodstains present, in conjunction with discussion with the pathologist, then the likelihood is that the two men subsequently charged with murder would have been eliminated as suspects and a miscarriage of justice would have been avoided.

The application of a new laminitis scoring method to model the rate and pattern of improvement from equine endocrinopathic laminitis in a clinical setting.

BACKGROUND: Endocrinopathic, or hyperinsulinaemia-associated laminitis (HAL) is a common and debilitating equine foot disease, and although no pharmacological treatments are registered, several are under development. To evaluate the effect of such treatments, an accurate and consistent method is needed to track the clinical signs of laminitis over time, and the natural history of the disease, in terms of a 'normal' pattern of improvement, needs to be understood. This study examined the improvement pattern in clinical cases of naturally-occurring HAL subjected to a range of best-practice interventions, using two different scoring methods. Eighty horses and ponies with suspected HAL were enrolled in a study conducted at 16 veterinary practices across Germany. The severity of laminitis was assessed by independent veterinarians using both the traditional Obel method and a modified Obel method developed by Meier and colleagues. Assessments were made on the day of diagnosis (d 0), then on days 4, 9, 14, 25 and 42 during the intervention period. Pain medications were withheld for 24 h prior to clinical examination in all cases. RESULTS: Time to marked improvement from laminitis varied between individuals, but was difficult to monitor accurately using the Obel method, with the median grade being 2/4 on days 0 and 4, then 0/4 from d 9 onwards. More subtle changes could be identified using the Meier method, however, and the median scores were seen to follow the form of an exponential decay model in most horses, improving from 8/12 on d 0, to 0/12 on d 25. Within this composite scoring method, considerable variation was observed in the rate of improvement of individual clinical signs, with the average time taken for each sign to reach a median score of 0 ranging from 4 days (foot lift and weight shifting) to 25 days (gait when turned in a circle) across all 80 horses. CONCLUSIONS: The Meier method provides a reliable and consistent method for monitoring the clinical status of horses with HAL, and despite the variability, the pattern of improvement described here should provide a useful benchmark against which individual cases and new treatments can be assessed.

[Pityriasis versicolor : new aspects of an old disease]. / Pityriasis versicolor : Aktuelles zu einer alten Erkrankung.

Pityriasis versicolor (PV) is one of the most common infectious skin diseases, as well as the most common dermatosis associated with pigmentation alterations of the skin. PV is prevalent in 1% of the population living in temperate climate zones and more common during the summer. In tropical areas, PV is found in up to 50% of all patients consulting a dermatologist. Of the known Malassezia species, M. globosa is currently felt to play a key role in the pathogenesis of PV, as it is most commonly found in PV lesions. In addition, its round-shaped cells may contribute to the characteristic histology of the disease ("spaghetti and meatballs"). However, the clinical appearance of PV including hyper- and hypopigmentation, fluorescence of the lesions, as well as a lack of inflammation despite high fungal load cannot fully be explained by the presence of M. globosa, which is also found on healthy skin. In M. furfur a tryptophan-dependent metabolic pathway generates a number of indole pigments, which may be associated with the clinical appearance of PV. In the model organism Ustilago maydis it was shown that the formation of the indole compounds occurs spontaneously after initial conversion of tryptophan into indole pyruvate controlled by the key enzyme aminotransferase Tam 1. We review the present knowledge of PV and highlight the potential role of Tam1 in explaining the poorly understood aspects of the disease. Promising therapeutic results using the application of Tam1 inhibitors to treat PV support the enzyme's important role in the disease pathogenesis.

BCCT.core - can a computer program be used for the assessment of aesthetic outcome after breast reconstructive surgery?

Aesthetic outcome is as an important endpoint of breast cancer treatment and is associated with better psychological recovery and improved quality of life. Researchers in Portugal have developed a computerised program, BCCT.core, to objectively assess aesthetic outcome of conservation breast treatment photographs. This study aimed to investigate the correlation between the Harris Scale and the BCCT.core program in patients who have undergone mastectomy and reconstruction for breast cancer. 67 cases were assessed by five independent assessors using the Harris Scale and compared with BCCT.core software. Correlation between BCCT.core and the Harris Scale was significant for all cases (r = 0.66, p < 0.01, n = 67), unilateral cases (r = 0.70, p < 0.01, n = 50), implant reconstruction cases (r = 0.72 p < 0.01, n = 28) and latissimus dorsi flap reconstruction cases (r = 0.74, p < 0.01, n = 23). BCCT.core demonstrated correlation with the Harris Scale for measuring aesthetic outcome for unilateral surgery and suggests potential use for BCCT.core to measure aesthetics for breast reconstruction after mastectomy.

Human milk oligosaccharides promote the growth of staphylococci.

Human milk oligosaccharides (HMO), which constitute a major component of human milk, promote the growth of particular bacterial species in the infant's gastrointestinal tract. We hypothesized that HMO also interact with the bacterial communities present in human milk. To test this hypothesis, two experiments were conducted. First, milk samples were collected from healthy women (n = 16); culture-independent analysis of the bacterial communities was performed, HMO content was analyzed, and the relation between these factors was investigated. A positive correlation was observed between the relative abundance of Staphylococcus and total HMO content (r = 0.66). In a follow-up study, we conducted a series of in vitro growth curve experiments utilizing Staphylococcus aureus or Staphylococcus epidermidis and HMO isolated from human milk. HMO exhibited stimulatory effects on bacterial growth under various nutritional conditions. Analysis of culture supernatants from these experiments revealed that HMO did not measurably disappear from the culture medium, indicating that the growth-enhancing effects were not a result of bacterial metabolism of the HMO. Instead, stimulation of growth caused greater utilization of amino acids in minimal medium. Collectively, the data provide evidence that HMO may promote the growth of Staphylococcus species in the lactating mammary gland.

An observational study of skin conductance monitoring as a means of predicting hypotension from spinal anaesthesia for caesarean delivery.

BACKGROUND: Hypotension after spinal anaesthesia is a common and important complication at caesarean delivery. Skin conductance monitoring has been shown to predict post-spinal hypotension in elderly patients and may be a rapid, non-invasive means of predicting risk in the obstetric population. METHODS: Women having elective caesarean delivery were included in this observational pilot trial. Baseline data were obtained for blood pressure, heart rate and skin conductance variables before administration of spinal anaesthesia and at 1-min intervals for 20 min thereafter. Correlations between baseline data and minimum post-spinal blood pressure were calculated, and the predictive value of baseline variables was estimated by use of receiver operator characteristics. RESULTS: Forty women completed the study. Spinal anaesthesia was followed in most cases by a significant reduction from baseline in systolic blood pressure [0-9% n=2 (5%), 10-20% n=21 (52.5%), 20-30% n=12 (30%), >30% n=5 (12.5%)]. Minimum systolic blood pressure was >100 mmHg in 25 (62%), 80-100 mmHg in 12 (30%) and < 80 mmHg in 3 (7.5%) patients. Fasting times, spinal block distribution, baseline heart rate, blood pressure or baseline skin conductance did not predict post-spinal hypotension or neonatal outcome. CONCLUSION: In contrast to a previous report in elderly patients, we were unable to demonstrate a significant relationship between baseline sympathetic tone, measured by skin conductance, and hypotension following spinal anaesthesia in women undergoing elective caesarean delivery.

Skin conductance as a means to predict hypotension following spinal anaesthesia.

BACKGROUND AND OBJECTIVE: Hypotension following spinal anaesthesia (SA) is common, especially in the elderly. Elevated sympathetic tone has been shown to correlate with severe hypotension after SA. The aim of this prospective trial was to investigate skin conductance (SC), as a measure of sympathetic tone, to predict hypotension after SA. METHODS: After ethical approval and written informed consent, 30 patients undergoing SA were included. Baseline measurements of SC [number of fluctuations per second (reflecting the firing rate of skin sympathetic nerves), area under the curve (AUC) A and B (reflecting the magnitude of the sympathetic impulse)], blood pressure and heart rate were recorded. After administration of SA, all parameters were assessed every 2.5 min for a total of 15 min. Baseline readings of SC were compared with the lowest blood pressure within the study period. RESULTS: Data from 30 subjects [73 (8) years] were analysed. After SA, the mean arterial blood pressure declined an average of 21.3 (11.3) mmHg. A cut-off value of 0.35 microSs for baseline AUC B allowed prediction of more than mild hypotension (>15% from baseline) after SA with a sensitivity of 72.5% and a specificity of 77.5%. CONCLUSIONS: AUC B, as a parameter of SC, may predict severe arterial hypotension after SA in the elderly.

Non-diagnosed pulmonary hyalinizing granuloma (PHG) as a cause of sudden unexpected death.

Pulmonary hyalinizing granuloma (PHG), a very rare benign tumour of the lungs, was first reported in 1977. We present a PHG of a 32-year-old woman from Yemen who collapsed 1 day after her arrival in Germany. Tuberculosis was suspected and the health authorities nearly closed part of one of the major international airports in Europe. However, this drastic measure was avoided by autopsy and a correct interpretation of the solid-elastic and well-circumscribed lung tumour as not characteristic for tuberculosis. Although the final diagnosis of PHG was only achieved after histology, this case strongly illustrates the necessity of a profound morphological training of forensic physicians.

A gas chromatographic analysis of phosphine in biological material in a case of suicide.

In a suicide committed using aluminium phosphide (AlP) the liberated toxic phosphine gas was detected in post-mortem specimens using a headspace gas chromatographic procedure with a nitrogen-phosphorous detector (HS-GC/NPD). At autopsy a direct sampling into airtight headspace vials for a later analysis is recommended. AlP has to be considered a potent pesticide and its use and availability should be restricted as much as possible.

The expression of heat shock protein 70 in kidneys in cases of death due to hypothermia.

BACKGROUND: There exist only a few "typical" morphological signs of death due to hypothermia. For forensic practice, the identification of other reliable markers to determine hypothermia as cause of death is important. In the literature hypothermia is discussed as a stress factor for cells. It was the aim of this study to clarify wether an increased HSP 70 expression in the kidneys of fatal hypothermia victims can be observed. MATERIAL AND METHODS: Kidney tissue samples of 100 fatal cases of hypothermia and 50 control cases without hypothermia and burning were investigated. The expression of HSP 70 in both study and control group was graded after immunohistochemical staining using a 4 degrees scale from 0 up to +3. RESULTS: Altogether, in the study group 89.0% in the tubule epithelium cells and 80.0% in the glomerula presented a HSP 70 expression of different grades. In the control group, 33 out of 50 cases were diagnosed completely without any HSP 70 expression in renal tubules, 17 cases showed a slight (+1) HSP 70 expression in the tubuli. In the glomeruli 42 cases of the control group were completely negative for HSP 70 expression, 8 cases showed a slight (+1) expression in the glomeruli. CONCLUSION: Our results show, that hypothermia is a stress factor inducing HSP 70 expression in the renal tubular epithelial cells and in the glomerular podocytes. Although HSP 70 expression was increased in the kidneys in cases of hypothermia, there was no strong correlation to Wischnewski's spots.

New parameters of skin conductance compared with Bispectral Index monitoring to assess emergence from total intravenous anaesthesia.

BACKGROUND: Arousal after total i.v. anaesthesia (TIVA) has been reported to be detectable by monitoring the number of fluctuations per second (NFSC), a parameter of skin conductance (SC). However, compared with monitoring of the bispectral index (BIS), the predictive probability of NFSC was significantly lower. The aim of this study was to determine the value of the two new, not yet published parameters of SC, area under the curve (AUC) methods A and B, for monitoring emergence from TIVA compared with monitoring of NFSC and BIS. METHODS: Twenty-five patients undergoing surgery were investigated. NFSC, AUC A, AUC B, BIS, and haemodynamic parameters (mean arterial pressure and heart rate) were recorded simultaneously. The performance of the monitoring devices in distinguishing between the clinical states 'steady-state anaesthesia', 'first clinical reaction', and 'extubation' were compared using the method of prediction probability (Pk) calculation. RESULTS: BIS showed the best performance in distinguishing between 'steady-state anaesthesia' vs 'first reaction' (Pk BIS 0.95; NFSC 0.73; AUC A 0.54; AUC B 0.62) and 'steady-state anaesthesia' vs 'extubation' (Pk BIS 0.99; NFSC 0.73; AUC A 0.71; AUC B 0.67). However, the time from first BIS>60/SC>0 to a first clinical reaction was significantly shorter for BIS (median BIS((R)) 180 s; NFSC 780 s; AUC A 750 s; AUC B 690 s; P < 0.001). CONCLUSIONS: AUC A and AUC B did not improve accuracy of SC monitoring in patients waking after TIVA.

Transformation of 2,4,6-trinitrotoluene (TNT) by Raoultella terrigena.

Manufacture of nitroorganic explosives generates toxic wastes leading to contamination of soils and waters, especially groundwater. For that reason bacteria living in environments highly contaminated with 2,4,6-trinitrotoluene (TNT) and other nitroorganic compounds were investigated for their capacity for TNT degradation. One isolate, Raoultella terrigena strain HB, removed TNT at concentrations between 10 and 100 mg l(-1) completely from culture supernatants under optimum aerobic conditions within several hours. Only low concentrations of nutrient supplements were needed for the cometabolic transformation process. Radioactivity measurements with ring-labelled (14)C-TNT detected about 10-20% of the initial radioactivity in the culture supernatant and the residual 80-90% as water-insoluble organic compounds in the cellular pellet. HPLC analysis identified aminodinitrotoluenes (2-ADNT, 4-ADNT) and diaminonitrotoluenes (2,4-DANT) as the metabolites which remained soluble in the culture medium and azoxy-dimers as the main products in the cell extracts. Hence, the new isolate could be useful for the removal of TNT from contaminated waters.

Wischnewsky's spots in an ectopic stomach.

Wischnewsky's spots in the mucosa of the stomach have been a well-known sign of death due to hypothermia for many years. Furthermore it is reported that those spots can rarely be found in the esophagus as well. We now report on a case concerning a 93-year-old woman who presented an ectopic stomach with erosions of the mucosa in the intrathoracic part of the stomach that were assessed as Wischnewsky's spots. When she was found dead in her flat, she was completely undressed and showed an injury to the head. The autopsy findings are presented and discussed in view of a possible genesis and pathophysiology of Wischnewsky's spots.

Pancreatic changes in cases of death due to hypothermia.

Several morphological alterations of the pancreatic tissue have been described as common findings in hypothermia (e.g. bleedings, pancreatitis, vacuoles). The frequency of these findings varies a lot. It was the aim of this study to clarify the kind and frequency of pancreatic changes in cases of death due to hypothermia. The autopsy reports of 143 cases of fatal hypothermia were, retrospectively, evaluated with regard to describe macroscopic findings in the pancreas. Additionally, microscopic investigations of tissue samples of the pancreas were carried out in 62 cases. As a control group, pancreatic samples of 25 autopsy cases without hypothermia and without alcoholism were collected. Additionally, pancreatic samples of 25 further autopsy cases with an alcoholic disease in the case history were investigated. In only 5 out of 143 cases of the study group, macroscopic bleedings in the pancreas were described. One case of acute and one of chronic pancreatitis was found in the autopsy reports. In 11 (17.7%) out of 62 cases, microscopic investigations yielded bleedings in the pancreatic tissue and in 24 (38.7%) out of 62 cases, optically empty vacuoles in the adenoid cells were found. In 15 out of 62 cases (24.2%), autolysis was too pronounced to gain utilisable results. In the control group without alcoholism, 12 out of 25 cases (48%) were diagnosed without pathological findings, five cases showed bleedings, one case an acute pancreatitis, one case a chronic pancreatitis and in six cases, the pancreatic tissue was autolytic. Vacuoles in the adenoid cells were not found. In the additional collective with alcoholism in the case history, 13 cases presented signs of an acute or a chronic pancreatitis. In 3 out of these 13 cases, vacuoles in the adenoid cells were found, but no case with vacuoles and without signs of a chronic pancreatitis was observed. The high frequency of pancreatic bleedings in cases of fatal hypothermia as described in the literature cannot be confirmed by our investigations. Only the vacuoles in the adenoid cells of the pancreas seem to be an additional sign of death due to hypothermia or associated with hypothermia.

Fatal rupture of an undiagnosed aneurysm of the splenic artery--medico-legal implications.

Aneurysms of the visceral arteries are a rather common feature appearing in 0.1-2% of the population. The clinical relevance of those anomalies varies a lot. The wide range of descriptions reaches from asymptomatic cases to fatalities in particular due to haemorrhages. The latter will be discussed in a case report concerning a 60-year-old man who collapsed at his work place and died 4 h after admission to the intensive care unit of a hospital nearby. The ruptured aneurysm remained undiagnosed in hospital and was found by autopsy. The case is presented and discussed in view of medico-legal questions.

[Outcome of preliminary proceedings against medical practitioners suspected of malpractice]. / Ausgang strafrechtlicher Ermittlungsverfahren gegen Arzte wegen Verdachts eines Behandlungsfehlers.

BACKGROUND AND OBJECTIVE: There are no reliable data in Germany on the incidence of medical malpractice, preliminary proceedings against medical practitioners and the results of such proceedings. Preliminary proceedings are especially felt by medical practioners to be a significant burden on them. MATERIAL AND METHODS: A retrospective study was carried out of all criminal proceedings involving accusations of medical malpractice, dealt with at the Institute of Forensic Medicine of the University of Bonn between 1989 and 2003. RESULTS: The analysis comprised 210 preliminary proceedings. The accusations mainly concerned offences against the patient's life or health (negligent bodily injury, section sign 229 StGB; negligent manslaughter, [section sign] 222 StGB). Most of the preliminary proceedings were started without the services of a lawyer representing the injured/bereaved. Many accused medical practitioners also had not engaged a lawyer, probably because they did not even know of the preliminary proceeding. 87% of the proceedings were closed according to [section sign] 170 Abs. 2 StPO or the verdict was acquittal. 7.6% of the cases were completed according to [section sign] 153a Abs. 1 StPO or the result was a conviction. CONCLUSION: Preliminary proceedings against medical practitioners due to medical malpractice are predominantly closed according to [section sign] 170 Abs. 2 StPO. The study reveals that, especially in cases ending in death, autopsy findings often exonerate medical practitioners from accusations of medical malpractice. Medical practitioners themselves should for this reasons officially report the manner of death as of undetermined in order to prepare a basis for later objective explanation of the cause of death by legal autopsy.

Immunohistochemical detection of hemoglobin in frost erythema.

Reddish discoloration of exposed skin areas, called frost erythema, is an important criterion for the diagnosis of fatal hypothermia. In the present study, we used immunohistochemistry in a prospective trial to show that on the molecular level, the correlate of frost erythema is hemoglobin without hemorrhage. Furthermore, we compared routine histological and immunohistochemical features of frost erythema, hematoma and livor mortis and established some criteria for their histological differentiation.

Fatty degeneration of myocardial cells as a sign of death due to hypothermia versus degenerative deposition of lipofuscin.

Lipid-deposits in internal organs, e.g. nephrons, are discussed as reliable marker to determine hypothermia as cause of death. While investigations concerning lipid vacuoles in the epithelium of the renal tubules are already published, there is no systematic information available about hypothermia and lipid deposits in cardiomyocytes. Therefore, this retrospective study presents the first results of lipid-stainings of myocardial samples taken by autopsies in hypothermia-cases in comparison to samples from a control group. It was the aim of the study to clarify the conceivable causal relationship between death due to hypothermia and lipid-deposits apart from lipofuscin and fatty degeneration, respectively, in cardiomyocytes.

Non-diagnosed pheochromocytoma as a cause of sudden death in a 49-year-old man: a case report with medico-legal implications.

Pheochromocytomas are known to be rare causes of sudden death. A 49-year-old man with a medical history of arterial hypertension and diabetes mellitus complained about nausea and malaise in the morning. During the day his condition deteriorated. He went to the emergency department, where he was given intravenous drugs against nausea and was sent home. On the way back, his condition deteriorated dramatically so that his wife drove back to the emergency room, where he collapsed and sustained cardiac arrest; resuscitation efforts were unsuccessful. Autopsy revealed a large tumour of the left adrenal gland. The strong suspicion of pheochromocytoma was confirmed by histology, immunohistochemistry and biochemical investigations. An acute hypertensive crisis, caused by the hitherto unknown pheochromocytoma was ascertained as the cause of death. The morphological findings are presented, the difficulty to diagnose pheochromocytoma and the medico-legal implications are discussed.