The Documentation of Injuries Caused by Traffic Accidents.

BACKGROUND: Persons injured in traffic accidents may have injuries of characteristic types that are of significance for the complex reconstruction of the accident and whose medicolegally sound clinical documentation is highly important. This is of particular relevance for the approximately 55 000 persons who are severely injured in traffic accidents in Germany each year. Gaps in documentation are often disadvantageous for the injured persons. METHODS: This review is based on pertinent publications retrieved by a selective literature review, with additional consideration of relevant textbooks in traffic medicine and legal medicine, as well as the guidelines of the AWMF (Association of the Scientific Medical Societies in Germany). RESULTS: Injuries in traffic accidents typically differ depending on the mode of participation of the injured person in traffic. They must be examined with a view toward the sequence of events of the accident and documented in medicolegally sound fashion. In particular, because of the different mechanical forces involved, it is important to document the seat that the injured person occupied in the automobile, the nature of the collision (pedestrian vs. automobile; bicycle, e-bike, e-scooter, and motorcycle accidents), and the protective devices that were in use. CONCLUSION: The precise documentation of injuries and examination findings, with critical consideration of their plausibility in relation to the sequence of events of the accident as far as it is known, is an important duty of the physician. This documentation serves as the basis for further judicial steps leading to compensation when legally appropriate.

Storage stability of phosphatidylethanol homologues in whole blood and dried blood spots of nonalcoholics at different temperatures over 60 days.

Phosphatidylethanol (PEth) has recently become a popular direct alcohol marker for evaluating drinking behavior. This study aimed at gaining further information on the long-term stability of five PEth homologues (16:0/18:1, 16:0/18:2, 16:0/20:4, 18:0/18:1, 18:0/18:2) in whole blood (WB) and dried blood spots (DBS) stored at -80°C, 4°C, and room temperature (18°C) over a period of 60 days. Venous blood was taken from 10 volunteers (five females and five males, aged 21-40 years) with a moderate drinking behavior and a negative breath alcohol test at the time of collection. 100 µL aliquots of WB were prepared in addition to 20 µL DBS samples. The initial PEth concentrations were determined on the day of the blood collection. On days 1, 3, 5, 7, 11, 17, 40, and 60, DBS were analyzed in triplicate by means of LC-MS/MS. On these days, WB aliquots having been stored until that time were used to create further DBS in triplicate, which were subsequently stored at 18°C and analyzed in a single batch after day 60. All homologues, except PEth 16:0/20:4, were stable at -80°C in DBS and WB for 60 days. The initial PEth 16:0/18:1 concentrations remained stable in both DBS and WB in all but one volunteer's specimen at 4 and 18°C. Apart from this exception, simultaneously detected PEth homologues 16:0/18:2, 18:0/18:1, and 18:0/18:2 remained stable over at least 40 days in DBS. Nevertheless, the storage time between sample collection and analysis should be kept as short as possible if an ethanol-free sample cannot be ensured.

(Un)Reliable detection of menstrual blood in forensic casework - evaluation of the Seratec® PMB test with mock samples.

The identification of the type of body fluid in crime scene evidence may be crucial, so that the efforts are high to reduce the complexity of these analyses and to minimize time and costs. Reliable immunochromatographic rapid tests for specific and sensitive identification of blood, saliva, urine and sperm secretions are already routinely used in forensic genetics. The recently introduced Seratec® PMB test is said to detect not only hemoglobin, but also differentiate menstrual blood from other secretions containing blood (cells) by detecting D-dimers. In our experimental set-up, menstrual blood could be reliably detected in mock forensic samples. Here, the result was independent of sample age and extraction buffer volume. It was also successfully demonstrated that all secretions without blood cells were negative for both, hemoglobin (P) and D-dimer (M). However, several blood cell-containing secretions/tissues comprising blood (injury), nasal blood, postmortem blood and wound crust also demonstrated positive results for D-dimer (M) and were therefore false positives. For blood (injury) and nasal blood, this result was reproduced for different extraction buffer volumes. The results of this study clearly demonstrate that the Seratec® PMB test is neither useful nor suitable for use in forensic genetics because of the great risk of false positive results which can lead to false conclusions, especially in sexual offense or violent acts.

More than just blood, saliva, or sperm-setup of a workflow for body fluid identification by DNA methylation analysis.

The determination of cellular origin of DNA is a useful method in forensic genetics and complements identification of the DNA donor by STR analysis, since it could provide helpful information for the reconstruction of crime scenes and verify or disprove the descriptions of involved people. There already exist several rapid/pre-tests for several secretions (blood, sperm secretion, saliva, and urine), RNA-based expression analyses (blood, menstrual blood, saliva, vaginal secretion, nasal secretion, and sperm secretion), or specific CpG methylation analyses (nasal blood, blood, saliva, vaginal secretion, nasal secretion, and sperm secretion) for determining the cell type.To identify and to discriminate seven different body fluids and mixtures thereof in a simple workflow from each other, assays based on specific methylation patterns at several CpGs combined with pre-/rapid tests were set up in this study. For each of the seven secretions listed above, we selected the CpG marker achieving the highest possible discrimination (out of 30 markers tested). Validation studies confirmed a definite identification for saliva, vaginal secretion, and semen secretion in 100% of samples as well as discrimination from all other secretions. Moreover, the unambiguously correctly determined proportion of nasal samples, blood and menstrual blood varied between 61% (nasal blood) and 85% (nasal secretion).In summary, our workflow proved to be an easy and useful tool in forensic analysis for the identification and discrimination of seven different body fluids often found at a crime scene.

Formation of phosphatidylethanol and ethylglucuronide after low to moderate alcohol consumption in volunteers with a previous three-week alcohol abstinence.

AIMS: Phosphatidylethanol (PEth) is only formed when ethanol is present in blood. This direct alcohol marker has been widely discussed, including the minimum amount of ethanol being necessary to form as much PEth as to exceed the threshold of 20 ng/mL in previously PEth negative subjects. In order to corroborate hitherto existing results, a drinking study including 18 participants after a 3-week alcohol abstinence was performed. METHODS: They consumed a pre-calculated amount of ethanol to reach a blood alcohol concentration (BAC) of at least 0.6 g/kg. Blood was drawn before and periodically seven times after alcohol administration on day 1. Blood and urine were also collected the next morning. Dried blood spots (DBS) were prepared immediately from collected venous blood. BAC was determined by head space gas chromatography and the concentrations of both PEth (16:0/18:1, 16:0/18:2 and five additional homologues) and ethyl glucuronide (EtG) were analysed using liquid chromatography-tandem mass spectrometry. RESULTS: Out of 18, 5 participants had concentrations of PEth 16:0/18:1 above the threshold of 20 ng/mL, and 11 out of the 18 subjects had concentrations between 10 and 20 ng/mL. In addition, four persons had PEth 16:0/18:2 concentrations above 20 ng/mL the following morning. All test subjects tested positive for EtG in DBS (≥ 3 ng/mL) and urine (≥100 ng/mL) upon 20-21 h after alcohol administration. CONCLUSION: By combining both a lower cutoff of 10 ng/mL and the homologue PEth 16:0/18:2, the sensitivity to detect a single alcohol intake after a 3-week abstinence increases to 72.2%.

The "Mellanby effect" in alcoholised e-scooter drivers.

PURPOSE: Several studies tried to discuss and clarify the so-called Mellanby effect: Similar blood alcohol concentrations (BACs) supposedly lead to more signs of impairment in the phase of alcohol resorption than elimination. To assess this effect for alcoholised e-scooter driving, results of a real-driving fitness study were subanalysed. METHODS: Sixteen subjects (9 females; 7 males) who completed runs at comparable BACs in the phases of alcohol resorption and elimination were chosen to assess a possible "Mellanby effect". The data of the subjects was taken from a prior e-scooter study by Zube et al., which included 63 subjects in total. RESULTS: In the phase of alcohol resorption, the relative driving performance was approx. 92% of the phase of elimination (p value 0.21). Statistically significant more demerits were allocated to the obstacle "narrowing track" in the phase of resorption than elimination. Subjects also needed significantly more time to pass the obstacles "narrowing track", "driving in circles counterclockwise" and "thresholds" in the phase of resorption than elimination. DISCUSSION: The most relevant obstacle to discriminate between the two different states of alcoholisation was the narrowing track. Insofar, measurements of the standard deviation of the lateral position (SDLP) might also be a sensitive component for the detection of central nervous driving impairment during shorter trips with an e-scooter. Additionally, driving slower during the phase of alcohol resorption seems to be the attempt to compensate alcohol-related deficits. CONCLUSION: The results of the study suggest a slight Mellanby effect in e-scooter drivers.

[When the patient has to go to court - an evaluation of medical certificates]. / Wenn Patientin oder Patient vor Gericht muss - eine Evaluation ärztlicher Atteste.

If the patient is unable to appear in court due to illness, a certificate of incapacity to stand trial or travel (civil resp. criminal law) must be submitted. METHODS: Over a period of 2;2 years, 34 certificates submitted in the context of criminal or civil proceedings at 4 different district and regional courts were analyzed anonymously. RESULTS: Major deficiencies in the content of the certificates were revealed. As a rule, certificates were submitted without justification for the stated inability to stand trial, or certificates of incapacity for work were submitted instead. The role of the physician as an expert witness, which should enable the court to make an independent decision, was exercised only very occasionally. DISCUSSION: The deficiencies shown are probably due to uncertainties in the issuance of the certificates. It is important that the certificate contains a diagnosis, the underlying diagnostics, the type and probable duration of the assumed incapacity and a generally understandable, sufficient justification for this.

Core body temperatures during final stages of life-an evaluation of data from in-hospital decedents.

Temperature-based methods are widely accepted as the gold standard for death time estimation. In the absence of any other information, the nomogram method generally assumes that a person died with a core body temperature of approximately 37.2 °C. Nevertheless, several external and internal factors may alter the body temperature during agony. A retrospective medical record analysis was carried out on in-hospital death cases from two consecutive years of surgical intensive care units to determine the effects of factors influencing the core body temperature at the point of death. Data from 103 case files were included in the statistical data evaluation. The body temperature fluctuated between and within individuals over time. No clear correlation to certain death groups was observed. Even primary cardiac deaths showed broad intervals of temperatures at the point of death. Men seem to die with higher body temperatures than women. The presented data highlight potential biases for death time estimations when generally assuming a core body temperature of 37.2 °C. In conclusion, the estimation of the time of death should include various methods, including a non-temperature-dependent method. Any uncertainties regarding the body temperature at point of death need to be resolved (e.g. by identifying fever constellations) and elucidated if elimination is not possible.

Cycling under the influence of alcohol-criminal offenses in a German metropolis.

INTRODUCTION: Real or simulated cycling tests under the influence of alcohol might be biased by laboratory settings. Accident analyses consider incidents with injuries only. Herein, criminal offenses consisting of drunk cycling are evaluated in detail to fill this gap. MATERIAL AND METHODS: All police-recorded cases of cycling under the influence of alcohol that took place in Düsseldorf, Germany, from 2009 to 2018 were identified. A total of 388 respective prosecutor's files were available for analyses. RESULTS: Mean blood alcohol concentrations were approximately 2 g/kg in both men and women. Men were overrepresented (6:1). Almost 60% of the cases were recorded between Friday and Sunday (the "weekend"). The average blood alcohol concentration (BAC) at night (01:00-05:59) was 0.39 g/kg lower than that during the day (06:00-17:59). Drinking after cycling allegations appear almost irrelevant among (German) cyclists. On average, the legal outcomes show 33 daily rates (median: 30). Additionally, the presented data raise doubts about whether the utilized medical tests or the ways in which they are carried out reliably discriminate between different grades of intoxication. Negative tests did not exclude high BACs, nor did positive tests correlate well with BACs. DISCUSSION/CONCLUSION: In practice, CUI is seen with BACs above 1.60 g/kg in most cases. BACs below 1.60 g/kg either seem to be a minor problem or they have been incompletely addressed thus far. In summary, to be prosecuted, drunk cyclists have to ride their bikes in either a highly insecure or rude manner or they must cause an accident.

E-scooter driving under the acute influence of alcohol-a real-driving fitness study.

PURPOSE: To assess the effects of alcohol on the ability to drive an e-scooter, driving tests reflecting real-life situations accompanied by medical examinations focusing on balance were conducted at different blood alcohol concentrations (BACs). METHODS: Fifty-seven subjects who consumed alcohol (28 female, 29 male) and 6 consistently sober subjects (3 female, 3 male) participated in the study. Alcohol was administered on a fixed schedule, and the individual drinking quantity was individually calculated in advance using the Widmark formula. Repeated runs through a fixed course were performed. Following each ride, a blood sample was taken for BAC determination, and medical tests were performed. RESULTS: Even at low BACs (0.21-0.60 g/kg), subjects showed a significant decrease in driving performance, to approximately 60% of the initial level. Differences in driving performance at different BAC ranges were observed for different obstacles, especially for the narrowing track, gate passage, slalom, and driving in circles obstacles. Furthermore, worse Romberg and Unterberger test results were correlated with worse driving performance. It cannot be assumed that learning effects during the study had a relevant effect, as shown in the comparison of the driving performance of the alcohol-consuming group with that of the control group. Sex-specific differences were not found. DISCUSSION: Significant deteriorations in driving performance at BACs below 1.10 g/kg confirmed alcohol-related risk potential when using e-scooters. At this time, these findings may lead to the assumption of "relative driving impairment" in Germany. The Romberg and Unterberger tests could be considered a complementary investigation method for the assessment of e-scooter driving impairment. CONCLUSION: Even at rather low BACs between 0.21 and 0.40 g/kg, there was a significant deterioration in driving performance under the influence of alcohol compared to sober, which highlights the negative effects of alcohol on e-scooter driving.

[Died from or with dementia? The relationship between dementia and cause of death]. / Verstorben an oder mit Demenz? Die Beziehung zwischen demenzieller Erkrankung und Todesursache.

Specifying a singular specific cause of death or an appropriate causal chain in the death certificate can be challenging, especially in cases of elderly, multimorbid deceased persons.The German cause of death statistics suggest that mental illnesses, including dementia, are beneath the most frequent causes of death. But when looking at death certificates in the context of dementia considerable information gaps and a lack of plausibility in the causal chain can be observed quite regularly.In this article we give recommendations for the correct designation of the cause of death and underlying diseases in the death certificate. These recommendations are not only to be seen against an academic background. The correct registration of dementia in the causes of death statistics may be a basis for decision making in health politics and is hence in the interest of optimal patient care.

A rare cause of sudden unexpected death syndrome (SUDS) in the first year of life: endomyocardial fibroelastosis (EFE) due to two compound heterozygous MYBPC3 mutations.

BACKGROUND: Autopsies regularly aim to clarify the cause of death; however, relatives may directly benefit from autopsy results in the setting of heritable traits ("mortui vivos docent"). CASE PRESENTATION: A case of a sudden unexpected cardiac death of a 5.5-months-old child is presented. Autopsy and thorough postmortem cardiac examinations revealed a massively enlarged heart with endomyocardial fibroelastosis. Postmortem molecular testing (molecular autopsy) revealed an unusual combination of two biparental MYBPC3 gene mutations likely to underlie the cardiac abnormalities. Thus, the molecular autoptic findings also had consequences for the relatives of the deceased child and impact on further family planning. CONCLUSIONS: The presented case highlights the need for clinical autopsies including cardiac examinations and postmortem molecular testing; it also paves the way for further cascade screening of family members for cardiac disease, if a distinct genetic disorder is suspected.

Estimation of time since death after a post-mortem change in ambient temperature: Evaluation of a back-calculation approach.

The temperature-based "Henssge method" is widely applied for death time estimation. For cases with a sudden post-mortem (pm) change in ambient temperature (e.g., by bringing the deceased into a cooling chamber), a mathematical approach has already been proposed [1] that enables estimation of the time of death by back-calculation of body temperature. This approach was evaluated under clinically controlled conditions. Twenty-five individuals who died in a neurosurgical intensive care unit were brought to cooling storage after approximately 3 h pm. Body temperature was repeatedly measured on the ward and in cooling storage over a period of 9 h pm. Back-calculation of body temperature was carried out on the basis of the proposed mathematical approach for cases with pm changes in ambient temperature; the results were compared to the known body temperatures. In many cases, the back-calculated and true body temperatures differed widely. Bodies regularly cooled down slower after being brought into cooling storage than the back-calculations indicated. The sudden change in ambient temperature could only be addressed roughly by the proposed method of back-calculation. In conclusion, the evaluated approach for addressing pm changes in ambient temperature should only be applied with great caution.

Pupillary effects in habitual cannabis consumers quantified with pupillography.

Driving under the influence of alcohol (DUIA) and drugs (DUID) is considered an elevated risk for traffic safety. When assessing a driver's fitness to drive, standardized and objective measurement methods are still required, in order to clarify the question whether an individual is under the influence of substances acting on the central nervous system (CNS). We exposed healthy test subjects (n=41) as well as persons who were under the influence of cannabis after repeated inhalation to multiple light stimuli using infrared technology and measured the pupillary light reflex (PLR). Toxicological tests of blood samples taken from every subject followed. The aims of this study were to assess the differences in pupillography response between cannabis consumers after a washout period and no cannabis consumers as well as the dose related effects on pupillography parameters of cannabis in cannabis consumers. All four pupillary parameters changed according to a weakened pupil function after acute administration of cannabis in all test subjects. Furthermore, it could be observed that habitual cannabis consumers showed an altered pupillary function just before the first dose was taken, suggesting that the long-term effects and addiction also have to be taken into account, when effects of the CNS are discussed. The results of the present study show that almost all pupil parameters could be reliable indicators for the detection of subjects under the acute effect of cannabis.

Rupture of intracranial aneurysms in patients with blunt head trauma: Review of the literature.

INTRODUCTION: With a prevalence of 1-5 %, intracranial aneurysms are common. However, only 20-50 % of these aneurysms will rupture during a person's lifetime. This often happens spontaneously without exogenous factors. In the present study we reviewed the literature concerning the relation between trauma and rupture of a pre-existing aneurysm. METHODS: All studies that reported a causal relation between trauma and rupture of a pre-existing aneurysm were included, irrespective of study design. They were limited though to those written in English or German. Excluded were studies with traumatic aneurysms, studies where the rupture of an aneurysm lead to trauma and studies with doubts about the order of events. RESULTS: Thirteen studies with twenty-two cases of ruptured aneurysm in context with trauma and two unpublished cases were included. Fourteen patients were involved in a fight, seven patients in a bike/motorbike/bus accident and three got hit on the head in a setting outside of interpersonal violence. The aneurysm was located in internal carotid artery in most cases (7/24). The clear majority of patients (19/24) did not survive. CONCLUSION: Arteries and aneurysms can rupture in context with head trauma although this is rarely the case. Patients after head trauma with typical blood pattern for aneurysmal SAH in the native CT scan should receive conventional angiography to exclude a vascular or aneurysmal rupture, even when CT-angiography is inconspicuous.

Ophthalmologic examinations under the acute influence of alcohol.

Alcohol is the most widely used recreational drug in Western countries. It affects the psychophysical performance in different ways, e.g. by reducing cognitive functions, causing coordination disturbances or impairing vision. Visual impairments both concern oculomotor and visual sensory functions, such as decreased mesopic vision, decreased field of vision and an increase of saccadic eye movements. During cycling trials with alcoholised test persons, repeated measurements of (1.) the time needed to read a 50-word text, (2.) the time to perform a swing test by tenfold touching the moving fingertip of the examiner, and (3.) the amplitude of fusion were carried out. The results of these tests were further evaluated to test the hypothesis that impaired vision is significantly correlated to reduced cycling performances of alcoholised persons. In a second step, it was examined which test is most useful to identify alcohol intoxicated cyclists. The ophthalmologic examination results of the groups of best and worst cycling-performing test persons at blood alcohol levels between 0.10% and 0.15% were set into relation to the documented allocated demerits. Additionally, the individual results of these persons were compared to the state of soberness. The time needed to read a 50-word text significantly correlated with the cycling performance. As this is an easy and objective test, it might contribute to a synoptic evaluation of the psychophysical performance of a drunken cyclist.

Diagnostic value and forensic relevance of a novel photorealistic 3D reconstruction technique in post-mortem CT.

OBJECTIVES: Evaluation of performance and forensic relevance of a novel, photorealistic, 3D reconstruction method (cinematic rendering, (CR)) in comparison with conventional post-mortem CT (PMCT) and volume rendering (VR) technique for visualization of traumatic injuries. METHODS: 112 pathologies (fractures, soft tissue injuries and foreign bodies) from 33 human cadavers undergoing whole body PMCT after traumatic death were retrospectively analyzed. Pathologies were reconstructed with CR and VR techniques. Fractures were classified according to their dislocation. Images were evaluated according to their expressiveness and judicial relevance by two forensic pathologists using a five-level Likert-scale (1: high expressiveness, 5: low expressiveness). They decided whether CR reconstructions were suitable for judicial reviews. The detection rate of pathologies was determined by two radiologists. RESULTS: CR was more expressive than VR for all three trauma categories (p < 0.01) and than conventional CT when used for fractures with dislocation (p < 0.001), injuries of the ventral body surface (p < 0.001), and demonstration of foreign bodies (p = 0.033). CR and VR became more expressive with a higher grade of fracture dislocation (p < 0.001). 20% of all pathologies in the CR and VR reconstructions were not detectable by radiologists. CONCLUSION: CR reconstructions are superior to VR regarding the expressiveness. For fractures with substantial dislocation, soft tissue injuries, and foreign bodies in situ, CR showed a significantly better expressiveness than conventional PMCT. CR and VR have significant limitations in cases of fractures with minor dislocations and covered soft tissue injuries. ADVANCES IN KNOWLEDGE: CR is a helpful tool to present pathologies found in PMCT for judicial reviews.

Hand-foot syndrome induced changes of the palmar epidermal ridge configurations during and after treatment with capecitabine.

Palmar plantar erythrodysesthesia (hand-foot syndrome, HFS) is a common adverse event of treatment with cytostatic chemotherapeutics such as capecitabine. Histopathological findings are nonspecific and may even include generalized epidermal necrolysis. A total of 50 patients were examined before and after the intake of capecitabine to assess if HFS may result in relevant changes of the palmar epidermal ridge configurations with possible consequences for the patients who want to travel abroad. In total, 14 of the 50 patients developed HFS (28%) with HFS grades 1-3 observed. HFS grade 4 was not observed. HFS of grade 2 and 3 was associated with a temporary macroscopic loss of the epidermal ridges. No dactyloscopic changes that might have led to a false identification were seen in those cases. Patients with a risk of HFS development who want to travel abroad should carry a medical pass of the chemotherapeutic treatment to prevent them from difficulties in identification controls.

A simple approach to use hand vein patterns as a tool for identification.

INTRODUCTION: In a case of child pornography, only the dorsum of the offender's hand was clearly visible. After identification of a suspect, the question arose of whether and how it is possible to identify or exclude the suspect as perpetrator according to the morphology of the hand vein pattern. MATERIAL AND METHODS: A simple approach to use the hand vein pattern in crime suspects as a tool for identification was tested. In this study, the hand vein patterns of 30 study participants were analysed from conventional frames on videography. A standardised grid system consisting of six lines and four sectors was applied on the dorsum of the hands. Vein branchings within the sectors and line crossings of the veins were counted, leading to a total of 11 variables for each hand. RESULTS: A positive identification of each of the 30 test participants was possible for each hand when taking only the first five variables into account. A random overlapping prediction was obtained by statistically simulating hand vein patterns of different numbers of persons using this sample. Considering the hand vein frequencies in this sample, the results indicate that the chance for two persons having the same pattern is smaller than 1:1000. CONCLUSIONS: It can be concluded that the introduced grid system approach can be an appropriate simple and non-costly tool for the analysis of the pattern of hand veins for identification purposes.