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Within the scope of this technical report, the feasibility of indocyanine green (ICG) as a fluorescent agent for postmortem angiography of the heart is tested. The study included 4 deceased persons with no respective medical history of heart diseases. The basic patterns of findings in ICG fluorescence angiography associated with healthy hearts are presented. The method can easily be integrated into a workflow without restricting the macroscopic or histologic diagnostics. This paper represents the fundamental technical and analytical basis for upcoming studies concerning the possibilities and limitations of fluorescence angiography in the diagnosis of heart pathology.

Postmortem detection of severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) after the exhumation of a corpse can become important, e.g. in the case of subsequent medical malpractice allegations. To date, data on possible detection periods [e.g. by reverse transcription polymerase chain reaction (RT-PCR)] or on the potential infectivity of the virus after an exhumation are rare. In the present study, these parameters were examined in two cases with a time span of approximately 4 months between day of death and exhumation. Using SARS-CoV-2 RT-PCR on swabs of both lungs and the oropharynx detection was possible with cycle threshold (Ct) values of about 30 despite signs of beginning decay. RT-PCR testing of perioral and perinasal swabs and swabs collected from the inside of the body bag, taken to estimate the risk of infection of those involved in the exhumation, was negative. Cell culture-based infectivity testing was negative for both, lung and oropharyngeal swabs. In one case, RT-PCR testing at the day of death of an oropharyngeal swab showed almost identical Ct values as postmortem testing of an oropharyngeal swab, impressively demonstrating the stability of viral RNA in the intact corpse. However, favorable climatic conditions in the grave have to be taken into account, as it was wintertime with constant low temperatures. Nevertheless, it was possible to demonstrate successful postmortem detection of SARS-CoV-2 infection following exhumation even after months in an earth grave.

Mongolian spots (MS) are congenital dermal conditions resulting from neural crest-derived melanocytes migration to the skin during embryogenesis. MS incidences are highly variable in different populations. Morphologically, MS present as hyperpigmented maculae of varying size and form, ranging from round spots of 1 cm in diameter to extensive discolorations covering predominantly the lower back and buttocks. Due to their coloring, which is also dependent on the skin type, MS may mimic hematoma thus posing a challenge on the physician conducting examinations of children in cases of suspected child abuse. In the present study, MS incidences and distribution, as well as skin types, were documented in a collective of 253 children examined on the basis of suspected child abuse. From these data, a classification scheme was derived to document MS and to help identify cases with a need for recurrent examination for unambiguous interpretation of initial findings alongside the main decisive factors for re-examination such as general circumstances of the initial examination (e. g., experience of the examiner, lighting conditions) and given dermatological conditions of the patient (e. g., diaper rash).

Introduction The estimation of age-at-death of unidentified cadavers is a central aspect of the identification process. With increasing age, the incidence of glomerulosclerosis and the thickness of the carotid wall have been observed to also increase. This correlation has been demonstrated in various international histological studies. The aim of our study was to assess whether these correlations also apply to a Western European population. Methodology In this retrospective observational study, kidney and common carotid artery samples from 216 cases autopsied at the Institute of Legal Medicine at the Justus-Liebig University in Giessen, Germany, were examined. Only cases with available tissue samples from both body sides were included. Exclusion criteria were poor sample quality and an age younger than 21 years. After histological processing, the tissue samples were assessed and digitally evaluated. Regression and classification analyses were used to investigate the correlation between age-at-death and intima-media thickness and age-at-death and the incidence of renal glomerular sclerosis. Results Of the 216 autopsy cases, 183 were included for evaluation. Analysis of the carotid artery segments showed a strong correlation (Pearson correlation coefficient r = 0.887) between the intima-media-complex thickness and chronological age. Classification of the glomerulosclerotic incidence showed a correlation of 37.7–43.1% with the predicted age group. Discussion Both the intima-media thickness and the proportion of sclerotic glomeruli can be used to estimate age in Western European cadavers. On the basis of these results, both methods are suited to supplement other already established methods for age-at-death estimation in the identification of an unknown cadaver.

Background Trisomy 21 is the most common human chromosomal abnormality. Its manifestation includes intellectual impairment and more or less typical anatomical malformations and functional deficiencies that can cause sudden or unexpected deaths. Typical medicolegal questions at autopsy are related to medical malpractice, improper care, neglect, or abuse, and, depending on the cause of death, whether the death might have been avoidable. The aim of this study was to examine whether the causes of death in individuals with trisomy 21 were linked to the known health risks for this condition and to consider how these deaths might have been prevented. Material and methods A retrospective study was performed at the Institutes for Legal Medicine in Giessen and Frankfurt am Main, Hesse, Germany. All records for forensic autopsy cases within a 20-year period from 1998 to 2017 were reviewed for the diagnosis trisomy 21”, respectively, “Down’s syndrome”. Results Twenty-three cases complied with the inclusion criteria trisomy 21 and autopsy. The age of the deceased ranged from 23 days to 61 years. Infectious diseases, mainly respiratory, were the leading cause of death, followed by accidental deaths. Conclusion The medicolegal relevance of the known health risks in Down’s syndrome could be illustrated by the autopsy findings and the results of the additional examinations. The known high susceptibility to infections, with an increased risk of a rapid course and lethal outcome, in individuals with Down’s syndrome could be confirmed in our study. A sound knowledge of the risks and abnormalities associated with trisomy 21 are helpful in medicolegal assessments, particularly, in relation to medical malpractice charges.

The goal of this study was to investigate the usefulness of various photographic techniques in visualizing previous tattoos under cover-up tattoos. Ten volunteers with 11 known cover-up tattoos were examined using different photographic techniques: A Canon EOS 6D full-frame digital single-lens reflex camera used in conjunction with a SB600 off-camera flash system and an extension cord; and a Leica M8 digital imaging system camera in conjunction with two different infrared filters (715 nm and 850 nm) and a Metz CL-45 handle-mount flash. A Lumatec Superlite 400 forensic light source was used along with the Canon EOS 6D as a third system. The best results for black cover-up tattoos were achieved with the full-frame digital single-lens reflex camera in conjunction with the off-camera flash system and, for colored cover-up tattoos, with IR-photography at a wavelength of 850 nm. The Lumatec Superlite 400 light source did not provide better results for conventional photography than those obtained with flash lighting. In nine out of eleven cover-up tattoos, the previous tattoos could, at least, be partially visualized. The quality of the visualization depended on the color, pattern, density, and quality of the cover-up tattoo as well as on the photographic technique. None of the examined photographic techniques could satisfactorily image the previous tattoo if the cover-up tattoo was large and black, especially not if it was densely inked. Depending on the color of the cover-up tattoo, a full-frame digital single-lens reflex camera in conjunction with a SB600 off-camera flash system (for black cover-ups) or infrared photography with flash lighting and an 850 nm filter (for colored cover-ups) proved to be the best of the investigated techniques to visualize a previous tattoo under a cover-up tattoo.

Ein 78 Jahre alter Mann wurde leblos vor seinem Auto auf dem Boden liegend aufgefunden. Es wurden umgehend Reanimationsmasnahmen eingeleitet. Bei der Leichenschau fielen ein hautdurchtrennender, nichtadaptierbarer Defekt mit umgebenden Vertrocknungen im Bereich des Brustbeins sowie in Projektion darauf ein Materialdefekt des zum Zeitpunkt des Auffindens getragenen Pullovers auf. Aufgrund des Verdachts auf eine Schussverletzung wurde eine gerichtliche Leichenoffnung angeordnet. Die bei der Obduktion erhobenen Befunde sprachen fur ein akut auf chronisches, globales Herzversagen als Todesursache. Als Ursache des brustbeinnahen Defektes konnte ein Kallus der 5. Rippe mit Knochensporn identifiziert werden, der als Widerlager wahrend der kardiopulmonalen Reanimation (CPR) mittels eines mechanischen Gerates gewirkt hatte. Dieser Fall zeigt, dass die Folgen von derartigen Reanimationsmasnahmen v. a. bei rechtsmedizinischen Laien Gewalt durch fremde Hand vortauschen konnen.

The sudden infant death syndrome (SIDS) is one of the leading causes of postneonatal infant death. It has been shown that there exists a complex relationship between SIDS and inherited cardiac disease. Next-generation sequencing and surveillance of cardiac channelopathy and cardiomyopathy genes represent an important tool for investigating the cause of death in SIDS cases. In the present study, targeted sequencing of 80 genes associated with genetic heart diseases in a cohort of 31 SIDS cases was performed. To determine the spectrum and prevalence of genetic heart disease associated mutations as a potential monogenic basis for SIDS, a stringent variant classification was applied and the percentage of rare (minor allele frequency ≤ 0.2%) and ultra-rare variants (minor allele frequency ≤ 0.005%) in these genes was assessed. With a minor allele frequency of ≤ 0.005%, about 20% of the SIDS cases exhibited a variant of uncertain significance (VUS), but in only 6% of these cases, gene variants proved to be “potentially informative.” The present study shows the importance of careful variant interpretation. Applying stringent criteria misinterpretations are avoided, as the results of genetic analyses may have an important impact of the family members involved. Electronic supplementary material The online version of this article (10.1007/s00414-020-02394-x) contains supplementary material, which is available to authorized users.

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 (Veronneau 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.

Arrest-related deaths in the context of Conducted Electrical Weapon (CEW) deployment are rare. The evaluation of such complex events is a challenge for the forensic scientist. We present a case of a 49-year old man, who was exposed to a Taser X26P during a confrontation with the police. He lost consciousness, vomited, aspirated and died after having been hospitalized for several days at the ICU. Based on the patient´s medical history, autopsy findings, witness testimonies, and reliable clinical and toxicological blood parameters, the most probable cause and mechanisms of his death are discussed. The present work demonstrates, based on one case report, the possibilities as well as limitations of forensic assessment in CEW-related deaths.

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.

Objectives This study explored whether age-relevant information may be hidden in density histograms of computed tomography (CT) images of calvaria and whether this information can be extracted by a novel "histogram's functional shape" (HFS) analysis method. The method was compared with other CT-based bone analysis methods. Materials and Methods Software was written that reanalyzed flat-panel CT data from European human skulls (120 female; 221 male). Calvarial data were segmented from these CT images and density histograms were produced thereof. A nonlinear curve fit was then used to calculate the HFS method. Seventeen multinomial logistic regression (MLR) model calculations were performed in a competition calculation in which the results of the HFS method, and other radiologically defined bone image markers were used as covariates to predict age-at-death (AAD). Age predictions for individual skulls were calculated for five equidistant age groups ranging from 0 to 100 years. Results and Conclusions The HFS method could be applied successfully. Chi 2 HFS was «0.05 in all 675 skull density histogram analyses. When MLR model calculations that use covariates from one method only were compared, the HFS method had a higher AAD prediction power. The overall ranking list is led by the models that used multiple covariates from different methods: The best correct group assignment was 62.5% (Nagelkerke's pseudo R 2 (NR 2 ) =0.76) for females, and 51.6% (NR 2 =0.43) for males. Hence, a novel image marker was introduced, and it was shown that the use of combined methods is superior to individual methods.

In forensic case work, blood stain pattern analysis frequently aids in deducing the chain of actions or parts thereof taking place during an event leading to blood loss. Wiped single blood stains and/or groups of blood stains are seen at a majority of complex crime scenes. The appearance of wiped blood stains depends on droplet volume and stain age (as a function of blood viscosity and the degree of stain skeletonization) and characteristics of the stained surface (i.e., texture, temperature). Furthermore, based on the biochemical and biophysical properties of blood, not only the drying processes, but also complex coagulation cascades are relevant to the assessment of wiped blood stains. This study was designed to determine if anticoagulation therapies markedly affect the wipeability of blood stains over times elapsed since deposition and the overall drying process. A total of 813 blood stains, originating from donors being treated with acetylsalicylic acid (ASA), clopidogrel + ASA, low-molecular-weight heparin, or rivaroxaban, were dropped on common household tiles. Wipeability at an ambient temperature of 20 °C was tested for 22 time periods (1, 2, 3, 5, 10, 15…105 min since deposition). Whereas stains consisting of untreated blood were dried within 55 min, wipeability of all droplets originating from donors with prior anticoagulation treatment showed pronounced delays compared with the control, ranging from 20 min (ASA and clopidogrel + ASA) to 45 min (rivaroxaban). This pronounced effect was not seen in earlier studies, which might be explained by the higher volume of droplets used in this study, which resulted in a shift in relevance from drying to clotting processes. Significant differences between the drying times of the various anticoagulation regimes might be attributed to anticoagulant activity against different targets in the coagulation cascades. In conclusion, anticoagulation treatment prior to blood loss significantly affected the wipeability of blood stains. Anticoagulation therapy should therefore be taken into account in the analysis of blood stain patterns.

Background A few publications in the literature have already dealt with bathtub deaths related to pre-existing disease; however, none have so far examined how often the pre-existing disease was previously known in these fatalities, nor have there been attempts to identify possible preventive measures. Our study addresses both of these open issues.

Approximately during the 30th week of pregnancy, a woman gave birth to a still-born child in a hospital. After first citing an extraneous cause for the premature still-birth, the woman later admitted to having self-induced the abortion by injecting the antiseptic Rivanol® (active agent: ethacridine lactate) through her abdominal wall into the amniotic cavity. The investigating authorities ordered an autopsy of the fetus along with additional toxicological investigations. To the naked eye, no obvious cause of death was apparent. The main autopsy findings were four skin defects (puncture/stabbing wounds) on the ball of the fetus's left thumb, with slight bleeding around the punctures and into the underlying fatty tissue, and a yellowish discoloration of the fetus's body surface, especially of the umbilical cord and fingernails. On basis of the results, the child would have been viable. Femoral vein blood and urine from the fetus were analyzed for ethacridine, as were an amniotic fluid sample and maternal blood and urine samples, which had been collected as evidence. The concentration of ethacridine in the amniotic fluid was 16mg/l. In the postmortem fetal blood and urine samples, the concentrations were 0.36mg/l and 0.34mg/l, respectively, while concentrations of 0.091mg/l and 0.42mg/l, respectively, were found in the serum and urine samples from the mother. In many countries, foremost in China, ethacridine lactate, to which both mother and child are exposed, is widely used as safe abortion method. Although the ethacridine concentrations found in blood and urine samples of the mother in our case are consistent with published values, we believe to be the first to report postmortem ethacridine concentrations in a fetus. While exposure to ethacridine is not toxicologically relevant for the mother, it is fatal for the fetus because it causes the placental decidua capsularis to separate from the decidua parietalis or decidua placentalis, respectively. Prostaglandins that are then produced induce labor. In medicolegal contexts, the proof for an abortion through the administration of ethacridine lactate lies in the typical yellow discoloration of the fetus in conjunction with the toxicological demonstration of the substance in fetal body fluids, and if possible also in maternal body fluids.

Introduction Non-natural deaths associated with sexual activity may occur either with or without the involvement of other persons. Aim The present study provides an overview of cases of non-natural death related to sexual activities as well as recommendations of how to handle these cases and to identify potentially dangerous pleasure-enhancing techniques. Methods This medicolegal, postmortem, retrospective, and prospective study is based on data of autopsies performed at the Institute of Legal Medicine at University Hospital, Goethe University, Frankfurt, Germany. Main Outcome Measure Identification of circumstances, sexual practices, and gender distribution of cases of non-natural death in this context. Results Between 1993 and 2017 (25 years), 16,437 medicolegal autopsies were performed, of which 74 cases (43 males, 31 females) of non-natural death were found to relate to sexual activities (0.45%). One female and 21 males had died in the course of autoerotic practices (group I, n = 22). Nine males and 14 females had performed sexual practices with mutual consent (group II, n = 23), and 13 males and 16 females without mutual consent (group III, n = 29). The average age in group I was 45.4 years; in group II, 40.6 years; and in group III, 39.2 years. Most of the deceased were found in their own apartments. Forms of stimulation included vaginal, anal, and oral intercourse; insertion of foreign bodies; use of chemical substances; and tools for respiratory depression/hypoxia. Three cases of death occurred during sexual activities involving bondage and discipline, sadism, and masochism (BDSM). Death due to strangulation was the main cause in group I, whereas intoxications were predominant in group II. Sharp force (eg, knife) was mainly responsible for death in group III. Anogenital injuries were documented in all groups in approximately equal percentages. Clinical Implications The cases presented show a high variety of circumstances in which non-natural death connected to sexual activity may occur. Strengths & Limitations This study presents a large postmortem collection of non-natural death cases with associated sexual activity. As the main limiting factor, it must be stated that mutual consent for a sexual practice or consumption of substances was presumed based on the information provided and a lack of evidence against this assumption. Conclusion In cases of death associated with sexual activity, medical staff should perform thorough unbiased examinations and documentations. Strangulation and the consumption of stimulants should be classified as life-threatening, pleasure-enhancing techniques. Patients and young people should be informed about these risks.

In sex determination from crania, a “vertical” forehead is considered a female feature, while a “sloping” forehead is considered a male feature. Precise description of frontal inclination with a quantitative measure like an angle is considerably more difficult as it requires accurate identification of clearly defined craniometric points. In the literature, the morphognostic terms “frontal bone inclination,” or “frontal profile,” are defined in numerous ways. The aim of this study was to determine which of these frontal inclination definitions is best suited for sex estimation. In a study in the context of the digital forensic osteology project, 10 of the frontal angle definitions described in the literature were assessed for their usefulness in sex determination on 211 virtual crania, reconstructed from postmortem CT-data. Custom-developed software was used for the automated measurement of frontal bone inclination angles from lateral-profile, volume-rendered 3D cranial images in which 10 anthropometric landmarks had been manually marked. Discriminant function analysis was performed to determine if satisfactory accuracy rates for the classification of sex could be achieved with defined variables. Four of the ten examined definitions were found to be highly significant for sex determination; three of these, also provided satisfactory intra- and inter-observer reliability. The frontal angle according to Schwalbe provided the best accuracy rate of 75.4% and a critical discriminatory value (separation value) of 88.6°: angles greater than this, suggest female sex; angles smaller than this, suggest male sex. Further, the open-source, custom-developed software introduced here proved compatible with commonly used image-processing and statistical programs and allowed quick, automated, valid measurement of numerous cranial angles. Other craniometric angles can, thus, also be quickly and easily determined with this software.

Bei dem Todesfall eines 26 Jahre alt gewordenen polizeibekannten BTM-Konsumenten in der JVA deuteten die Auffindesituation sowie erste kriminalpolizeiliche Ermittlungen auf eine todesursachliche (Drogen-)Intoxikation hin. Die gerichtliche Leichenoffnung sowie systematische Zusatzuntersuchungen ergaben einen naturlichen Tod infolge einer desquamativen interstitiellen Pneumonie. Diese zahlt zu den sogenannten „seltenen Erkrankungen“, an die im Rahmen der rechtsmedizinischen Tatigkeit gedacht werden sollte. Der vorgestellte Fall unterstreicht die Wichtigkeit von Obduktion und Anschlussuntersuchungen, insbesondere der Histologie.

Introduction Repatriated corpses may have been autopsied abroad. The aim of the study was to compare the findings from second medico-legal autopsies with those from primary autopsies abroad to spotlight possible implications for the management of repatriated corpses. Material and Methods All autopsies from a 20-year period at the Institute of Legal Medicine in Frankfurt am Main on repatriated corpses of German citizens were reviewed. The results were compared with the information from the body passports, the protocols of the autopsies in the country of death, and the police files. Results In total, 151 corpses repatriated from 56 different countries were autopsied. The interval between death and autopsy in Germany was 2–603 days (median: 11 days). 91 of the repatriated corpses (59.5%) had previously been autopsied abroad. Three body cavities had been opened in 78.0% (71/91) of the original autopsies; among them, there were 11 cases (15.5%) with dissection of all organs, as opposed to 7 cases (9.9%) with all organs intact and in situ. Of the previously autopsied corpses, 62.6% were accompanied by a body passport that noted the cause of death. In nearly 75% of these cases, the stated cause of death was compatible with that established at second autopsy. In 5 cases (10.2%), the cause of death established in the second autopsy disagreed with that on the body passport. The most prominent disparity was a cranial gunshot wound rather than the stated fatal fall. Discussion This analysis of individual cases spotlights the problematics of an uncritical approval of the body passport. In light of the different procedural autopsy standards around the world, the validity of an autopsy abroad is discussed in the context of the second autopsy results. Conclusion A second external postmortem examination by qualified medical practitioners should be obligatory in all cases of repatriated corpses, with notification of the criminal police in all cases of non-natural or undetermined death. A timely second autopsy is recommended even in cases with previous autopsy abroad.

Background and purpose: The astroglial protein GFAP is a blood biomarker indicative of intracerebral hemorrhage in patients with acute stroke. Due to its brain specificity and the necessity of brain damage for its detectability in blood, we hypothesized that GFAP could be an interesting marker in cases with primary cerebral cause of death, e.g., traumatic brain injury. Methods: All corpses scheduled for an autopsy in the Frankfurt Department of Forensic medicine within a 15-month period were included in the study. Cases with a known history of brain disease in the 3 months before death were excluded. During autopsy, blood was collected and GFAP serum levels were determined using a commercially available ELISA. The autopsy protocols were reviewed for the presence of a primary cerebral or a primary non-cerebral cause of death. Agony time was also determined. Results: A total of 129 autopsy cases were included. GFAP concentrations did not differ between cerebral (median 0.96 μg/l, IQR 5.03) and non-cerebral causes of death (1.21 μg/l, 3.58). GFAP levels were found to be unaffected by hemolysis or post-mortem interval. GFAP levels were found to be increased in cases with prolonged agony times (median 1.76 μg/l [IQR 4.70]) compared to short (0.58 μg/l [0.58]; p

Cases of sudden cardiac death (SCD) in young and apparently healthy individuals represent a devastating event in affected families. Hereditary arrhythmia syndromes, which include primary electrical heart disorders as well as cardiomyopathies, are known to contribute to a significant number of these sudden death cases. We performed postmortem genetic analyses in young sudden death cases (aged45years) by means of a defined gene panel using massive parallel sequencing (MPS). The data were evaluated bioinformatically and detected sequence variants were assessed using common databases and applying in silico prediction tools. In this study, we identified variants with likely pathogenic effect in 6 of 9 sudden unexpected death (SUD) cases. Due to the detection of numerous unknown and unclassified variants, interpretation of the results proved to be challenging. However, by means of an appropriate evaluation of the findings, MPS represents an important tool to support the forensic investigation and implies great progress for relatives of young SCD victims facilitating adequate risk stratification and genetic counseling.

In assessing abstinence from drug or alcohol abuse, hair analysis plays an important role. Cosmetic hair treatment influences the content of deposited drugs which is not always detectable during analysis. Since oxidation of melanin leads to an increase in fluorescence, a microscopic method was developed to distinguish natural from cosmetically treated hair. For validation, natural hair samples were treated with different types of cosmetics and inspected by fluorescence microscopy. Hair samples from 20 volunteers with documented cosmetic treatment and as a proof of concept 100 hair samples from forensic cases were analyzed by this method. Apart from autofluorescence with excitation at 365 nm, no obvious fluorescence was observed in untreated hair samples. Tinting and a natural plant product had no influence on fluorescence, but dyeing procedures including oxidation led to a marked increase in fluorescence. Proof of cosmetic treatment was achieved in hair samples from the 20 volunteers. In 100 forensic cases, 13 samples were characterized as oxidatively treated, which was in accordance with the respective disclosure except for one case where treatment was not admitted. This fluorescence microscopic procedure proved to be fast, easy, and reliable to identify oxidatively treated hair samples, which must be considered especially in evaluating cases of negative drug results. Copyright © 2015 John Wiley & Sons, Ltd.

In the practice of legal medicine in Germany, the assessment of brain death is of minor importance and attracts little attention. However, since several years, international criticism on the concept of brain death has culminated. By reviewing literature and the results of a questionnaire distributed among the participants of the 93rd Annual Congress of the Germany Society of Legal Medicine, the state of knowledge and the current views on brain death were evaluated. Literature search of recent publications regarding brain death was performed (PubMed database, references of legal medicine, Report of the President’s Council on Bioethics, USA 2008). A questionnaire was developed and distributed among the participants of the Congress. The assumption that individual and brain death are synonymous is criticized. Internationally, there are trends to harmonize the very different clinical criteria to assess brain death. The diagnostic advantage of novel techniques such as CT angiography is controversially discussed. It becomes apparent that procedures which record the blood flow and perfusion of the brain will be applied more in the future. Regrettably, these developments are not described in the literature of legal medicine. Moreover, among German forensic scientists, different views concerning brain death exist. The majority favors its equivalent treatment with individual death. The thanatological background can be improved concerning certain aspects of brain death as well as its legal implications. Teaching and research in legal medicine should include the subject brain death. Expertise in forensic science may contribute to the interdisciplinary discussion on brain death. The transfer of actual knowledge, also on disputed ethical aspects of thanatology, to physicians of all disciplines is of great importance.

The increased number of adolescents and young adults with unknown or inaccurately given date of birth is a current issue in justice and legal medicine. The objective of this study was to determine the extent to which third molar calcification stages assessed on panoramic X-rays could be useful as additional criteria for forensic age estimation in living individuals, focusing on the legally important ages 17 and 18. In a retrospective multi-center study, the developmental stage of each individual's third molar was analyzed using Demirjian's scale in 2360 cases. Additionally, sex, age and ancestry were assessed. Individuals with the lowest calcification stage of all present molars in stage H were ≥18 years with a likelihood of ≥99.05% in the female (n=388), and ≥99.24% in the male (n=482) population. The lowest calcification stage of all present third molars proved to be useful as an additional reliable criterion for the determination of an age ≥18 years.

Sequence variants in the ion channel genes KCNH2 and SCN5A may cause the cardiac disorder long QT syndrome (LQTS). This disorder is associated with incomplete penetrance and variable expression in KCNH2- or SCN5A-mutation carriers. Common genetic variants, if associated with a mutation, may affect the severity of this cardiac disorder. This study identified rare mutations in the cardiac ion channel genes KCNH2 and SCN5A in a SCD case, as well as in a LQTS-affected family with a history of SCD. Moreover, common variants were found to occur together within the same genes. These findings support the concept that common single-nucleotide polymorphisms (SNPs) in genes encoding cardiac ion channels can directly modulate the functional effect of mutations and therefore enhance or weaken the risk of cardiac events.

Background Although sexual activity can cause moderate stress, it can cause natural death in individuals with pre-existing illness. The aim of this study was to identify additional pre-existing health problems, sexual practices, and potential circumstances that may trigger fatal events. Methods This medicolegal postmortem, retrospective, and prospective study is based on data of autopsies performed at the Institute of Legal Medicine of the University hospital, Goethe-University, Frankfurt/Main, Germany. Outcomes Identification of pre-existing health problems, sexual practices, and potential circumstances than could trigger fatal events. Results From 1972 to 2016 (45 years) approximately 38,000 medicolegal autopsies were performed, of which 99 cases of natural death were connected to sexual activities (0.26%). Except for eight women, men represented most cases. The women’s mean age was 45 years (median = 45) and the men’s mean age was 57.2 years (median = 57). Causes of death were coronary heart disease (n = 28), myocardial infarction (n = 21) and reinfarction (n = 17), cerebral hemorrhage (n = 12), rupture of aortic aneurysms (n = 8), cardiomyopathy (n = 8), acute heart failure (n = 2), sudden cardiac arrest (n = 1), myocarditis (n = 1), and a combination of post myocardial infarction and cocaine intoxication (n = 1). Most cases showed increased heart weights and body mass indices. Death occurred mainly during the summer and spring and in the home of the deceased. If sexual partners were identified, 34 men died during or after sexual contact with a female prostitute, two cases at least two female prostitutes. Nine men died during or after sexual intercourse with their wife, in seven cases the sexual partner was a mistress, and in four cases the life partner. Five men died during homosexual contacts. Based on the situation 30 men were found in, death occurred during masturbation. Of the women, five died during intercourse with the life partner, two died during intercourse with a lover or friend, and in one case no information was provided. Clinical Translation Natural deaths connected with sexual activity appear to be associated with male sex and pre-existing cardiovascular disorders. Most cases recorded occurred with mistresses, prostitutes, or during masturbation. If death occurs, the spouse or life partner might need psychological support. Strength and Limitations To our knowledge, the present study contains the largest collection of postmortem data on natural deaths connected with sexual activities. However, the cases presented were of forensic interest; a larger number of undetected cases especially in the marital or stable relationship sector must be assumed. Conclusion Patients should be informed about the circumstances that could trigger the “love death.”

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.

Die forensische Bildgebung mit radiologischen Methoden hat in den vergangenen zwei Jahrzehnten in der diagnostischen Routine der rechtsmedizinischen Institute im deutschsprachigen Raum stetig an Bedeutung gewonnen und sich als eigenstandiges Forschungsgebiet in der Rechtsmedizin etabliert. Dem wurde durch die Grundung der Arbeitsgemeinschaft Forensische Bildgebung der Deutschen Gesellschaft fur Rechtsmedizin im Jahre 2014 Rechnung getragen. Die Arbeitsgemeinschaft setzte sich als initiale Ziele die Erarbeitung eines CT-Indikationskatalogs sowie die Erstellung einer Bestandsaufnahme zum Stand der Implementierung der forensischen Bildgebung in den rechtsmedizinischen Instituten in Osterreich, der Schweiz und in Deutschland. Die vorliegende Arbeit stellt die Ergebnisse dieser Bestandsaufnahme in Bezug auf vorhandene diagnostische Modalitaten, Kooperationsmoglichkeiten sowie Beauftragungs- und Vergutungsmodalitaten vor.

Introduction Aging human remains is a critical issue in anthropology and forensic medicine, and the search for accurate, new age-estimation methods is ongoing. In our study, we, therefore, explored a new approach to investigate a possible correlation between age-at-death (aad) and geometric irregularities in the bone structure of human skull caps. We applied the concept of fractal geometry and fractal dimension D analysis to describe heterogeneity within the bone structure. Methods A high-resolution flat-panel computed tomography scanner (eXplore Locus Ultra) was used to obtain 229,500 images from 221 male and 120 female (total 341) European human skulls. Automated image analysis software was developed to evaluate the fractal dimension D, using the mass radius method. The frontal and the occipital portions of the skull caps of adult females and males were investigated separately. The age dependence of the fractal dimension D was studied by correlation analysis, and the prediction accuracy of age-at-death (aad) estimates for individual observations was calculated. Results D values for human skull caps scatter strongly as a function of age. We found sex-dependent correlation coefficients (CC) between D and age for adults (females CC = −0.67; males CC = −0.05). Prediction errors for aad estimates for individual observations were in the range of ±18 years at a 75% confidence interval. Conclusions The detailed quantitative description of age-dependent irregularities in the bone microarchitecture of skull vaults through fractal dimension analysis does not, as we had hoped, enable a new aging method. Severe scattering of the data leads to an estimation error that is too great for this method to be of practical relevance in aad estimates. Thus, we disclosed an interesting sex difference.

So far, studies investigating the comparability of breath alcohol concentration (BrAC) with blood alcohol concentration (BAC) have focused on the accuracy of BrAC testing instruments. The presented study, conducted with cases from the district of the Middle Hessian Police Headquarters, is to the best of our knowledge the first to compare both methods under real-life conditions in normal policing situations. For a 1-year period, alcohol-impaired drunk-driving suspects, who were by criminal procedure required to give a blood sample, were offered a voluntary, additional BrAC test with a "Drager Alcotest 7110 Evidential". The BrAC test was to be administered as soon as possible after the suspect had been apprehended, without, however, delaying the collection of the blood sample. Ninety-two cases could be included in our study. In 30 cases, a blood sample was not taken; in 11 cases, a BrAC test could not be performed. In the remaining 51 cases, we found the following pairings of BrAC and BAC results: BrAC≥0.55 mg/l and BAC≥1.1‰ (n=39); 0.25 mg/l≤BrAC

The assessment of the ossification status of the medial clavicular epiphysis plays a decisive role in forensic age diagnostics to determine whether a person has completed his or her 18th or, respectively, 21st year of life. Currently, computed tomography is the gold standard method for age diagnostics of this kind. However, efforts are being made to establish non-ionizing methods, such as ultrasonography, predominantly, in an attempt to reduce the radiation exposure load of living persons. The present study is the first to score and to compare the ossification status of both medial clavicular epiphyses of the same subjects by sonography, computed tomography, and, in some of the cases, by macroscopy. Our study was conducted on five male corpses, ranging in age from 15.8-28.8 years. In the comparison of high-resolution sonography (frequency, 12-15 MHz) and thin slice computed tomography (slice thickness, 0.6 mm), performed separately for left and right clavicles, the results from these two methods differed in seven of ten cases. In six cases, the ossification stage of the medial clavicle, determined by sonography and classified according to Schulz et al. (2008), was scored higher than with computed tomography. In one case, it was rated lower. There was only one subject for whom both the sonographic and computed tomography findings agreed for both body sides.

A skull without lower jaw was found and brought in for identification. It was suspected to be that of a man reported missing five years ago. An undated antemortal dental chart and two dental films of the 1st and 2nd dental quadrants, both taken about 4 years before the man went missing, were available for comparison. The method of choice in solving the identity question was comparative dental radiography. Despite numerous attempts, it was not possible to obtain radiographs of the upper jaw that duplicated the X-ray beam angulation of the antemortem dental films. The skull was thus scanned with a multislice computed tomography (MSCT) scanner, and virtual radiographs with the desired angulation were generated from the data with the maximum intensity projection (MIP) technique. The resulting virtual radiographs could, however, not be used for superimposition with the antemortem radiographs because of their poor resolution and the occurrence of artifacts caused by metallic dental fillings. The upper jaw was therefore scanned again, this time with a high resolution eLU-CT (eXplore Locus Ultra flat panel CT). The resulting eLU-CT datasets were visualized with the MIP technique and yielded virtual radiographs that could be compared with the antemortem radiographs. Positive identification could be assumed with near certainty after dental features could be matched in the superimposition of antemortem and postmortem radiographs. In the presented case, eLU-CT was used for the first time for a comparative dental radiographic identification.

Jeder niedergelassene Arzt muss in der Lage sein, eine vorschriftsmasige Leichenschau durchzufuhren. Das Leichenschaurecht ist allerdings Landesrecht. Uber die jeweils geltenden Gesetze muss sich der Arzt selbst informieren. Der vorliegende Beitrag beschreibt das richtige Vorgehen bei einem Todesfall bzw. bei der Untersuchung eines Leichnams. Die Leitlinie der Deutschen Gesellschaft fur Rechtsmedizin (DGRM) zur Durchfuhrung der arztlichen Leichenschau und die wichtigsten Gesetze zur Leichenschau werden praxisnah erlautert.

Foreign body granulomas in the lungs following acute singular or long time intravenous drug abuse are frequent findings during microscopic investigation of the lungs. Most cases present single granulomas. Cases with multiple foreign body granulomas, already palpable during autopsy and leading to pulmonary granulomatosis with multiple granulomas are less frequent. We report the case of a 32-year old man, dying suddenly and unexpectedly after a well-known history of drug abuse for more than a decade. The granulomas are caused by foreign particle embolization immediately after intravenous injection of not only the drug itself but also of adulterants, e.g. cotton fibers, potato starch or microcrystalline cellulose. At the end, a reduction in the size of the pulmonary bed had occurred followed by pulmonary hypertension. For the first time, lung dust in such a case was characterised by energy dispersive X-ray (EDX).

Because of the increasing lack of recent bone collections, ethical issues concerning maceration procedures, and progress in radiological imaging techniques, computed tomography (CT) scans offer an alternative to traditional anthropological bone collection. The present study examined volume-rendered cranial CT (CCT) scans from 50 crania to morphologically evaluate sex characteristics. CCT scans were performed and scored by two teams (Teams A and B) of two examiners each (2x50=100 examinations) to evaluate the occurrence and/or absence of morphological traits. Altogether, 60 of 100 crania (31 Team A+29 Team B) crania were determined to be male, and 40 (19 Team A+21 Team B) were determined to be female when using the scoring system adapted from Knussmann. These results imply a sex determination accuracy rate of 96%. Only in one case was recalculation of weighting factors necessary to determine one additional correct classification. As a single parameter, arcus superciliaris evaluation permitted the most accurate sex determination (female, 84.2%; male, 85.5%). No significant difference in accuracy rates was observed between the two sexes (p

In a retrospective study, the results from 786 samples of alleged sexual assaults during a 5-year period were evaluated. Of the samples, 758 were from female victims and 28 were from male victims. The material examined during this 5-year period consisted of 561 cotton swabs with swabs taken from the genitals, mouth, anus, or skin surface. In addition, textile products were examined 191 times, paper products 23 times, and other evidentiary materials 11 times. The acid phosphatase (acP) test was performed as a preliminary test for all samples, followed by microscopy after Baecchi staining. DNA analysis was performed on 74 samples following individual court orders. The retrospectively evaluated results from this period indicate that additional tests for the detection of sperm on textiles and paper products are dispensable after a negative acP test. This is different for genital swabs, since sperm could be found microscopically in 3% of cases with a negative acP test, and DNA analysis was also successful. However, an individual investigative strategy has to be determined for each case, as, depending on the structure of the case, the evidence of male DNA on a female victim, or on her clothes, for instance, can also have evidentiary value without microscopic proof for sperm.

Estimating age from the skeletons of adults is difficult. The accuracy decreases for old age. Ossification of the neurocranial sutures has been used as an age characteristic since Broca's time (1824–1880). Although the sutures traverse the bone, current approaches only encompass the ecto- and endocranial sutures. Evaluating the cross-section of sutures necessitates the destruction of the neurocranium. In the context of the "Digital Forensic Osteology" project that ran in cooperation with the Virtopsy ® -Project it emerged that the resolution of conventional MSCT-data sets was not high enough to image sutures. The eXplore Locus Ultra (eLU) Flat-Panel-CT-Scanner from GE was used for these experiments. During autopsy, the skullcap was scanned and then immediately returned to the corpse. To date, the skullcaps of 221 individuals have been scanned. The data sets were reconstructed in 3D. The cross sections of the sutures of 14 segments could be evaluated in the cross-sectional view. Seven stages of ossification were defined and each segment was assessed for these. Several regression formulae for age estimation were developed from the results. This examination method is a suitable means for non-invasively evaluating the ossification degree of cranial sutures in the entire cross-section and for the entire calvarium. An increase in the number of examined individuals in this ongoing project and a look at extreme values will further heighten the conclusiveness of the results.

When two human corpses are found in temporal and locational context the assumption of a non-natural cause of death is close at hand. Suicide, extended suicide, homicide or accident (particularly with carbon monoxide) come to mind. When, however, a natural cause of death emerges for both after autopsy and further examinations, this provokes the question whether this incidence is coincidental. In our two presented cases, a married couple each was found dead together. In both cases, the wife needed nursing and was being cared for by a husband who died of cardiac disease shortly before the wife died. In one case, the wife died of acute uncompensated chronic congestive heart failure. In the other case, the cause of death of the wife was hypovolemic shock due to acute gastrointestinal bleeding from recurrent gastric mucosal erosion. It is to be discussed for both cases whether, given the pre-existing illness, the acute stress of the situation in view to the husbands' death may at least have favored the occurrence of death and may, thus, have led to the criminologically conspicuous situation of finding.

The present study was carried out to check whether classic osteometric parameters can be determined from the 3D reconstructions of MSCT (multislice computed tomography) scans acquired in the context of the Virtopsy project. To this end, four isolated and macerated skulls were examined by six examiners. First the skulls were conventionally (manually) measured using 32 internationally accepted linear measurements. Then the skulls were scanned by the use of MSCT with slice thicknesses of 1.25 mm and 0.63 mm, and the 33 measurements were virtually determined on the digital 3D reconstructions of the skulls. The results of the traditional and the digital measurements were compared for each examiner to figure out variations. Furthermore, several parameters were measured on the cranium and postcranium during an autopsy and compared to the values that had been measured on a 3D reconstruction from a previously acquired postmortem MSCT scan. The results indicate that equivalent osteometric values can be obtained from digital 3D reconstructions from MSCT scans using a slice thickness of 1.25 mm, and from conventional manual examinations. The measurements taken from a corpse during an autopsy could also be validated with the methods used for the digital 3D reconstructions in the context of the Virtopsy project. Future aims are the assessment and biostatistical evaluation in respect to sex, age and stature of all data sets stored in the Virtopsy project so far, as well as of future data sets. Furthermore, a definition of new parameters, only measurable with the aid of MSCT data would be conceivable.

The assessment of ossification of the medial clavicular epiphysis plays a decisive role in the forensic age estimation of living subjects. Primarily for reasons of minimizing the radiation exposure currently associated with such evaluations, non-ionizing methods would be an advance. This study pursued the question whether full union of the medial clavicular epiphysis, visualized by high-frequency sonography, is a reliable criterion for age-threshold determinations. The ossification stage of the medial clavicular epiphysis of 215 female and 195 male volunteers, aged between 14 and 26 years, was evaluated in bilateral sonograms. Stage 4, defined as complete fusion by Schulz et al. (Int J Legal Med 122:163–167, 2008), was observed on at least one body side in 48 of 334 individuals younger than 21 years (14.4 %) and in 32 of 264 individuals younger than 18 years (12.1 %). With the high-frequency ultrasound used in this study, even the smallest convexities of the medial clavicular ending can be visualized. This may have led to overestimation of the ossification stage. It is not clear whether any observed roundings in the sonograms should actually be interpreted in terms of stages 3 and 4 as defined by Schulz. Also, due to the low penetration depth of high-frequency ultrasound waves, epiphyseal plate residues and ossification centers may have remained undetected. Reliable differentiation of the stages 1–4 with high-frequency sonography is thus difficult, and the results suggest that this method is not a radiation-free alternative to computed tomography, the current gold standard for determining age thresholds.

Immunoassays are presently used worldwide for the rapid screening of drugs. Despite the fact that they are a highly valuable tool for the testing of legal and illicit drugs, there is a real risk of false-positive and false-negative findings and many pitfalls must be taken into account when these tests are used in an uncritical manner and without valid confirmation procedures. In a long-standing successful cooperation with a large psychiatric hospital, we checked doubtful and nonplausible immunochemical findings in urine with gas chromatography-mass spectrometry (GC-MS) confirmation methods. The reported case histories demonstrate typical pitfalls, for example, influence of changing nutritional habits, use of sweeteners (cyclamate), uncritical creatinine correction, impaired elimination, or cross-reactivities of simultaneous therapeutic medication. In accordance with national and international associations, immunoassays are recommended as a useful tool for screening. However, confirmation analysis with conclusive methods (GC-MS or liquid chromatography-MS) is unavoidable for valid substance identification, discrimination between active and inactive metabolites, detection of congeners, and accurate determination of concentrations in body fluids.

As fatalities attributable to novel H1N1/S-OIV infections are currently rising, an increasing number of autopsies will have to be performed on these cases. In view of this challenge, adequate safety precautions and recommendations for autopsy procedures and the sampling and handling of specimens have to be established. Based on current literature, procedures for daily autopsy practice are proposed, particularly in regard to personal protection equipment, swab usage, and autopsy hygiene.

This is a report about a traffic accident without an apparent external cause. The driver responsible for the accident was diagnosed with acute bacterial meningitis. From a forensic aspect the meningitis was determined as the underlying reason for the accident, but it could not be assumed that the driver should have recognized the danger in time.

Domestic accidents involving electricity, as well as other types of accident involving power lines, the use of electricity with suicidal intent, and high voltage are seen in medical forensic practice. Electricity is rarely used with homicidal intent. Knowledge about the effects of electricity has been gained from its use in executions (the “electric chair”). Electricity is also used as a weapon to incapacitate an individual for the purposes of detainment (the Taser gun).

Classic haemogenetics involving the analysis of erythrocyte membrane antigens as well as ABO and Rhesus blood group testing no longer plays an important role in modern forensic practice. Thus a brief review is sufficient for the purpose of this chapter. In 1901, Karl Landsteiner (1868–1943) discovered the ABO blood group system. Thanks to Paul Uhlenhuth (1870–1957), it also became possible to differentiate human from animal blood (species-specific protein differentiation). Together, these methods laid the foundations for techniques of attributing biological evidence to a suspect as well as for paternity testing. Other blood group systems of erythrocyte membranes were later discovered, as well as other plasma protein polymorphisms. Attribute systems needed to show

In routine practice, underage victims of sexual abuse rarely usually undergo gynecological examination by a forensic expert, but rather by a gynecologist. However, forensic medical experts are called upon to gather extragenital findings and to interpret findings in the context of the reported patient history and overall findings. The absence of evidence of abuse is not evidence of the absence of abuse. At the same time, self-inflicted injury sometimes needs to be considered in the case of older children.

A central task of forensic medicine is to assess injuries in order to establish their origin. How and when they originated play an important role here. Often, the objective of an assessment is to support or refute specific allegations or to establish which of varying reports on the sequence of events is more probable, e.g., on the cause of uni- or bilateral periorbital hematomas (monocle hematoma or “raccoon eyes,” Fig. 8.1).