External post-mortem examination in virtual reality-scalability of a monocentric application.

Conducting external post-mortem examinations is an essential skill required of physicians in various countries, regardless of their specialization. However, the quality of these examinations has been a subject of continuous debates, and notable errors were reviled. In response to these shortcomings, a virtual reality (VR) application was developed at Halle's medical department in Germany, focusing on the scene of discovery and the completion of death certificates. The initial trial of this VR application in 2020 involved 39 students and 15 early-career professionals. Based on the feedback, the application underwent improvements and was subsequently introduced to the medical department in Dresden, Germany, in 2022. Its primary objective was to showcase the VR training's adaptability and scalability across various educational structures and levels of medical expertise. Out of 73 students who participated, 63 completed the evaluation process. 93.1% (n = 58) of the evaluators reported increased confidence in conducting external post-mortem examinations, and 96.8% (n = 61) felt more assured in filling out death certificates, crediting this progress to the VR training. Additionally, 98.4% (n = 62) believed that repeating forensic medical aspects in their coursework was crucial, and 96.8% (n = 61) viewed the VR examination as a valuable addition to their academic program. Despite these positive responses, 91.6% (n = 55) of participants maintained that training with real corpses remains irreplaceable due to the insufficiency of haptic feedback in VR. Nevertheless, the potential for enhancing the VR content and expanding the training to additional locations or related disciplines warrants further exploration.

Postmortem Examinations for the Etiological Identification of Juvenile Coronary Arteriosclerosis.

The postmortem of suddenly deceased younger adults sometimes reveals that they experienced manifest coronary arteriosclerosis. We looked at 21 cases where stenosis of the coronary arteries was at least 50%. We supplemented our postmortem findings and the results from the postmortem identification of the lipid metabolism parameters with anamnestic details. We also conducted a genetic analysis. The risk factors such as smoking and family history were relatively frequent. In most of our cases, the postmortems showed significantly deviating lipid metabolism parameters. Compared to these findings, the genetic analyses only showed a clearly increased presence of APOE genotypes 3/4, whereas we observed no abnormalities in relation to the LDL receptor. The study results illustrate the multifactor genesis of premature coronary arteriosclerosis. Despite these limitations, the unexpected finding of juvenile coronary arteriosclerosis should entail an effort to establish the individual risk factors involved as this can provide vital information for medically advising other members of the family on their hereditary risks.

Detection of oral bacterial DNA in synovial fluid.

OBJECTIVES: As periodontal bacteria might be involved in the aetiology of rheumatic diseases, we analysed synovial fluid obtained from patients with rheumatoid arthritis (RA) and controls for the presence of DNA of Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythia, and Treponema denticola. METHODS: In all, 42 patients suffering from RA (mean age 53.8 ± 16.7 years, 40.4% females) and 114 controls with no rheumatic diseases (mean age 56.1 ± 15.2 years, 52.4% females) were included. DNA from synovial fluid was isolated by QiaAmp kit (Qiagen, Hilden, Germany). Polymerase chain reactions (PCRs) specific for the 16S rRNA genes of the above specified bacteria were developed. Subgingival bacterial colonization was analysed using micro-Ident(®) test (HAIN-Diagnostik, Nehren, Germany). RESULTS: In patients with RA DNA of P. gingivalis was detected in synovial fluid more often than in controls (15.7% versus 3.5%, p = 0.045). More patients than controls harboured DNA from P. gingivalis in both, oral plaque and synovial fluid (11.9% versus. 0.9%, p = 0.030). Among the patients group the number of missing teeth was correlated with the number of joints with movement restrictions caused by RA. CONCLUSIONS: DNA of periodontopathogens can be found in synovial fluid and oral bacteria may play a role in the pathogenesis of arthritis.

[Efficiency of inspections of the corpse before cremation performed in the area of the Halle University Medical Centre]. / Effizienz der Krematoriumsleichenschau im Bereich des Universitätsklinikums Halle.

From 1993 to 2007, the Institute of Forensic Medicine in Halle conducted 882 post-mortems before cremation. These records were now used for a systematic analysis of these cases to assess the efficiency of so-called second inspections of the corpse carried out in the area covered by the Halle University Hospital. In the period under review, considerable fluctuations were found from year to year, but these are mainly attributable to changes in the Saxony-Anhalt burial law introduced in 2002. Our 882 post-mortems were based on 84,677 corpse inspections before cremation; thus, an autopsy was performed in about 1% of all cases. Males were significantly overrepresented, younger age groups were dominant and there was a relatively high percentage where the first inspection of the corpse could not determine the manner of death or had to declare death by an unnatural cause. With regard to the manner and cause of death, the results of the first inspection and the post-mortem differed significantly. In 17.6% of our 882 cases, only the post-mortem revealed that death had been due to an unnatural cause. Despite the presence of sometimes strong clues to an unnatural cause, 156 of these cases were classified as natural deaths (56.4%) or the manner of death was stated as undetermined (43.6%). For more than two thirds of these 156 cases we were able to inspect the records kept by the Departments of Public Prosecution. 105 of these at first overlooked cases of unnatural deaths turned out to be deaths by accident. The other cases included 11 suicides, and 36 deaths related to medical treatment. In the remaining four cases, the autopsy results strongly suggested homicide, but only in one of these four cases subsequent police investigations were able to identify the perpetrator. This outcome demonstrates that the rule of inspecting the corpse a second time before cremation is clearly indispensable, even in its currently rather limited form.

External bleeding from femoro-crural vein bypass with aneurysmal dilation.

Deaths due to external bleeding outside the hospital setting are often suspected to involve violence. However, some disease-related causes, can also lead to fatal external bleeding. While bleeding from natural body orifices is a common end stage of non-curable gastrointestinal bleeding, fatal bleeding via newly formed skin defects is quite rare and highly suspicious in light of external impact. Reliable clarification of the source and cause of bleeding is only possible in the context of an autopsy. The reported case involves the death of a man early 60 s who bled to death as a result of rupture of a femoro-crural bypass. The rupture originated from a rare true aneurysm of an autologous femoro-crural vein bypass implanted 8 years before due to peripheral arterial occlusive disease (PAD) with gangrene. The aneurysm rupture passed all subcutaneous and skin layers leading to fatal external bleeding.

Medical examination of fitness for police custody in two large German towns.

Worldwide, there is a high risk of medical complications or death in police custody. This risk is often increased by unclear legislation, a lack of clearly defined responsibility and medical examination standards. Any solution to these problems requires as a very basis the systematic analysis of the medical examinations that determine whether a person is fit to be detained in custody. We analysed a total of 3,674 medical records on fitness for custody, taken from two large German towns (Halle/S and Bremen). The examined individuals were predominantly males or of a younger age. The indication in the majority of cases was acute alcoholic intoxication or drug withdrawal syndromes. Traumata and internal or mental diseases were also quite frequent. For approximately 50% of all cases, fitness for custody was declared on certain conditions. Only 39.8% were found to be unconditionally fit for detention in custody. In just under 10% of the cases, the person was found unfit for custody. These cases concerned mainly persons with psychological symptoms and advanced alcohol or drug withdrawal syndromes. We were able to show that the recent introduction of new police custody regulations in Halle/S had a significant influence on the medical decision on fitness for custody. Our detailed assessment has provided us with the basis to develop solutions for the improvement of medical care in police custody. The focus lies here on the organisation and legal regulation of the medical aspects of custody but also on policing and medical work.

["Natural" death of a person under the care of a custodian]. / Der "natürliche" Tod einer Betreuten.

An ambulance service doctor was called to the death of a 76-year-old woman and attested cardiac arrest and psycho-organic brain syndrome as the cause of death on the death certificate. At the second external examination mandatory before cremation, extensive hematomas were detected on the right thorax and multiple haematomas in the face and on the forehead. The autopsy initially ordered by the public health officer revealed serial rib fractures and a fractured skull. After notifying the prosecutor, a forensic autopsy was ordered and death was found to have been caused by fat embolism following massive blunt force to the thorax with serial rib fractures and haematopneumothorax. After that, the adopted son, who had been appointed care custodian for the woman, and his wife were suspected, because they had given contradictory explanations for the injuries. At first, they were only suspected of failure to render assistance, but in the end they were both charged with murder. Only because of the second external examination prescribed by the law still in force could the errors of the improper first external examination be corrected.

[Student training in forensic medicine in Germany: testing and evaluation]. / Studentische Ausbildung im Fach Rechtsmedizin in Deutschland: Prüfungen und Evaluation.

The implementation of the Medical Licensure Act in 2002 led to remarkable changes in teaching, testing and evaluation in undergraduate medical education. Using an online questionnaire the current situation among German institutes for forensic medicine was evaluated. The return rate of the questionnaires was 80%. The results point at a preponderance of testing of factual knowledge. A change to testing of practical skills appears necessary to match the learning objectives of practical teaching. The evaluation results represent a high level of student contentment with teaching in forensic medicine. Clinical electives can be offered by more of 90% of the institutes. Teaching time in forensic medicine is thought to be inadequate by a relevant number of institutes.

The German case-control scene investigation study on SIDS: epidemiological approach and main results.

The present study, which was part of the German SIDS Study (GeSID), enrolled sudden infant death syndrome (SIDS) cases and population controls and obtained objective scene data via specifically trained observers shortly after discovery of each dead infant. Infants who had died suddenly and unexpectedly at ages between 8 and 365 days were enrolled in five regions of Germany between November 1998 and October 2001. Shortly after discovery of each dead infant, a specially trained doctor of legal medicine visited the bereaved family at home. Data were obtained by measurements and observations. Dead infants underwent a standardised autopsy, additional information being obtained by standardised parent interviews. Investigation of the sleep environment and wake-up scene in matched controls followed the same protocol. A total of 52 SIDS cases and 154 controls were enrolled, 58% were boys, and median age of cases vs. controls was 126 vs. 129 days. Risk factors in the sleeping environment were pillow use (adjusted OR 4.3; 95%CI 1.6-11.6), heavy duvets (OR 4.4; 1.5-13.3), soft underlay (OR 3.0; 1.1-8.7), face covered by bedding (OR 15.8; 2.5-102.1) and entire body covered by bedding (OR 35.5; 5.5-228.3). Using a standardised protocol, including objective measurements of the sleep environment and a case-control design, this study was able to confirm many risk factors for SIDS.

An avoidable death in police custody?

An obviously inebriated 36-year-old man was found in a helpless condition on a pavement. When he was brought to a police station, a doctor certified the individual to be fit to be held in custody. He was unresponsive when the officers tried to wake him the next morning but was allowed to sleep on until he was found dead in his cell at mid day. An autopsy revealed as cause of death an epidural hematoma and cerebral contusion with fracture of the calvarium. The expert report stressed the point that the monitoring of the state of consciousness had been objectively insufficient throughout the entire time period, both in terms of frequency as well as in terms of the monitoring methods. However, neither the police officers involved nor the doctor, was subjected to prosecution mainly because of the high burden of proof required by German criminal law. The article will discuss conclusions for the avoidance of such deaths (such as training of police officers, legal regulations on monitoring procedures, etc).

Deaths in German police custody.

BACKGROUND: According to the ministries of the interior of all German federal states, a total of 128 persons died in police custody between 1993 and 2003. METHODS: An inquiry to the forensic university institutes and regional court doctors showed that, within this period, post mortems were conducted in 75 of these cases. We were able to include 60 of these 75 cases in our evaluation and deficiency analysis, which were carried out under assessment of the post mortem records and partly by making use of the subsequent medical expert reports and the results of criminal investigation. RESULTS: The most frequent cause of death was acute alcoholic intoxication, followed by cerebrocranial traumata, internal diseases and fatal poisonings with medical or illegal drugs. In 23 cases, the person taken into custody had been seen by a physician in order to determine the person's fitness for detention in custody. Of these 23 cases, 15 (65.2%) revealed deficiencies in various areas of medical activity. Police officers had made mistakes in 33 of the 60 cases (55.0%), mainly because they failed to seek medical assistance or did not monitor the person with sufficient frequency. Our retrospective study however showed that in 16 cases (26.6%) death was very probably not preventable even if the person had received all necessary care. CONCLUSIONS: Our study gives recommendations on how to improve various measures to increase the quality of medical attention given to persons taken into police custody.

Individual and institutional influencing factors on completion rates in a medical education master's program in Germany.

Background: The increasing significance of didactic aspects in medical education has also led to the development of special postgraduate programs. Completion rates represent an important outcome criterion for these programs of study. Up to today, detailed studies on what factors influence these completion rates have been lacking. Methods: Within the framework of outcomes research, a semi-structured online survey of students was conducted in the Master of Medical Education Germany program. Of the 90 items, 21 referred to the master's thesis that is required for graduation. Results: 157 out of 246 (63.8%) of students from classes 1-10 of the program (study period 2004-2014) participated in the survey. 109 participants had submitted a master's thesis, whereas 45 participants had not completed their studies by submitting a master's thesis. Influencing factors of successful completion were, among other things, little difficulty in choosing the topic, retention of the originally chosen topic, general support by the program administration in the modules and ensuring timely feedback from the advisor, and the provision of temporal, staff and financial resources by the home faculty. The failure to turn in the project report and a lengthy interruption of master thesi's work could be identified as critical parameters. Conclusion: Taking into account these results can contribute to increasing completion rates in medical education graduate programs. Systematic outcomes research leads, moreover, to quality assurance. Such studies should be conducted in a standardized manner in the future, in order to facilitate comparisons between medical education programs.

Deaths in police custody.

Deaths in police custody often attract a huge amount of public interest and are frequently associated with controversy related to causation. While systematic investigations of deaths in police custody are currently available for countries in Europe, North America and Australia, the different inclusion and exclusion criteria and the lack of a uniform definition limits their comparability. Rates of death vary by age and gender with some similarities across different countries and continents. The male dominance is essentially due to the fact that around the world women are much less frequently taken into police custody than men. Similarly, in the U.S., the most common cause of custody death was natural illness and disease progression such as heart disease and cancer; along with high rates of suicide deaths. In most European countries there is a considerable dominance of non-natural deaths. The causes of death are dominated by alcohol, drugs and medications, but suicide, injury and trauma are also common. Deaths in custody require careful investigation to determine causality as well as culpability when appropriate. While many deaths may not be preventable, some are. Further systematic research of this issue, including detailed analyses and investigations of such cases, is necessary to develop general and specific preventative measures to reduce the risk of death in the custody population.

Healthcare and forensic medical aspects of police detainees, suspects and complainants in Europe.

Death and harm is well-recognised in detainees in police custody worldwide. Based on the results of previous global surveys and the CPT (European Committee for the Prevention of Torture) recommendations a questionnaire was developed to summarise the current medical aspects of police custody in European countries. The survey was distributed to named contacts in all European countries. Data from 25 European countries was obtained. The results reveal significant differences in the regulations among the different countries, with nothing close to a harmonised European standard in place at present. This study has identified interesting variations in the methods and standards of healthcare and forensic medical services to detainees in police custody (e.g. quantitative mode of monitoring, qualification of the doctors, maximum time allowed for holding a detainee in police custody, body or an organisation that investigates complaints against the police). There are both very detailed legal regulations in some countries while in others there are only generally observed provisions that sometimes are only given in the form of recommendations. A multinational, multiprofessional expert group is required to identify best practices, recommend basic standards of care and identify qualifications which would be appropriate for healthcare professionals working in this field.

[A hopeless case?]. / Ein aussichtsloser Fall?

In a hollow covered with earth, a herb gatherer discovered a severely decomposed corpse mutilated by scavenging animals. Only small areas of the skin had remained intact. A conspicuous tattoo could still be distinguished on the left upper arm. Despite concrete evidence of violence (fracture in the occipital bone, subdural hemorrhage with a volume of 20 ml), the exact cause of death could no longer be established. Police enquiries identified a person in whom such a conspicuous tattoo had been photographed in an earlier criminal case. Eventually, the deceased person could be identified by DNA analysis of a stored blood alcohol specimen. Considered together, the autopsy findings and the results of the investigation of traces of blood on the putative tool used in the crime indicated that the man had been struck dead and the body had afterwards been buried in the wood. Although the prospects of success had been initially slight, it was not only possible to identify the victim, but also to reconstruct the crime.

Collision victim travels for "seven kilometres" on top of the car that hit him.

CASE REPORT: A 26-year-old man, after a drinking binge, drove into a tram building site and collided with a track-grinding machine which left a fist-size hole in his windscreen. He then hit a construction worker who was catapulted onto the car roof. The worker held on to the antenna and the windscreen hole, while the car drove on for 7 km, reaching speeds of 90 km h(-1). The victim suffered several fractures and survived with relatively little consequential damage. The investigation showed the driver to have been under the influence of alcohol and cannabis. In trial, he claimed loss of memory and stated that he had noticed neither the accident nor the man on his car roof.

Apolipoprotein E (apoE) polymorphism: a risk factor for fatal coronary sclerosis?

OBJECTIVE: The association of apoE polymorphism and coronary heart disease has been examined in numerous clinical studies. However, there are only very few autopsy studies on this topic, there having been none in Germany for instance. METHODS: In a retrospective study, we examined 121 cases where the autopsy revealed premature coronary sclerosis. The collected data included the maximum degree of stenosis of the coronary arteries, the body mass index and a potential left heart hypertrophy. Coronary sclerosis was the cause of death in 47 and a relevant secondary finding in 74 of the cases. The control group consisted of 253 healthy blood donors and 79 patients who had undergone cardiac catheterization and did not show coronary macro-angiopathy. Genotyping of apoE polymorphism was performed by using blood. RESULTS: When assessing the influence of apoE genotype or allele no significant influence on premature death was found. However, a subdivision of deceased according to their coronary state showed that the carriers of apoE epsilon4-allele had a higher risk of coronary artery sclerosis with a significantly higher degree of stenosis. CONCLUSION: In cases of fatal premature coronary sclerosis and proven apoE epsilon4-allele, blood relatives should receive advice.