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This case report demonstrates the impact of different sampling sites on the quantification of narcotic substances. In 2020, officers secured a syringe containing a light-yellow paste-like substance, for which a drug pre-test indicated a positive result for amphetamine, inducing subsequent analyses of the sample by means of a gaschromatographic-mass spectrometric method (GC–MS) and liquid chromatography–(tandem) mass spectrometry (LC–MS/MS). Depending on the sample location, different results were obtained, with amphetamine not being detected in each sample. Amphetamine was particularly found at the outlet of the syringe, while amphetamine detection on the inside of the syringe at the plunger seal was only possible occasionally and, moreover, in lower concentrations. Based on this and with regard to the comparatively small amphetamine concentrations, contamination of the syringe (especially on the tip of the syringe) was assumed. Hence, the results strengthened the importance of the implication of different sampling sites, when either homogenization of the sample is not feasible or is not performed for reasons of plausibility checks concerning possible contamination of the sample.

Frank’s sign (named after American pulmonologist Sanders T. Frank) refers to a diagonal skin fold between the tragus and outer edge of the earlobe. Gradation is based on the bilateral presence and/or degree of the earlobe fold. The presence of this sign, referred to as the diagonal earlobe crease (DELC), has been associated with coronary artery disease (CAD), independent of other cardiovascular risk factors. Corresponding studies are predominantly based on clinical or angiographic assessments, and few autopsy studies exist. The association of DELC with CAD, cardiovascular risk factors, and causes of death was investigated via retrospective and prospective evaluations. It was also investigated whether the degree of DELC correlated with the macroscopic severity of coronary heart disease. Furthermore, the influence of age on the appearance of DELC was analyzed and compared using two age groups. Additionally, binomial logistic regression analysis was performed to investigate the influence of age on the presence of higher-grade DELC and CAD. In cases related to a lethal cardiac event, the majority (78%) showed high-grade DELC. The DELC grade correlated significantly with CAD severity (rs = 0.474, p rs = 0.606, p

Further to a previous publication by the European Council of Legal Medicine (ECLM) concerning on-site forensic and medico-legal scene and corpse investigation, this publication provides guidance for forensic medical specialists, pathologists and, where present, coroners' activity at a scene of death inspection and to harmonize the procedures for a correct search, detection, collection, sampling and storage of all elements which may be useful as evidence, and ensure documentation of all these steps. This ECLM's inspection form provides a checklist to be used on-site for the investigation of a corpse present at a crime or suspicious death scene. It permits the collection of all relevant data not only for the pathologist, but also for forensic anthropologists, odontologists, geneticists, entomologists and toxicologists, thus supporting a collaborative work approach. Detailed instructions for the completion of forms are provided.

The expression levels of intracellular heat shock proteins (Hsps), specialized chaperone proteins, increase in cases of cellular stress with protein misfolding and aggregation. In a previous study, we demonstrated that there is an extensive increase in intracellular Hsp27 and 70 expression levels in renal tissues in fire fatality cases. Hsp expression can be induced by not only heat, but also by tissue hypoxia. In cases of fatal hemorrhage, the individual suffers hypoxemia and consequently tissue hypoxia. Here, we examined 43 cases of fatal hemorrhage and a control group of 85 deaths not related to blood loss or temperature exposure. We evaluated Hsp27 and 70 protein expression levels in renal tissue using immunohistochemistry. The results revealed that no extensive Hsp27 or 70 expression is induced in the fatal hemorrhage cases. The renal Hsp levels were similar to those of the control group. Fatal blood loss does not cause relevant cell stress.

Macromorphological findings can be missing in cases of fatal hypothermia when the agonal period is very short because of a large difference between environmental and core body temperatures. Expression of heat shock proteins (Hsps) increases under endogenous and exogenous cellular stresses such as thermal stress. These stress proteins can be revealed by immunohistochemical staining. Forty-five cases of death due to hypothermia and a control group of 100 deaths without any antemortem thermal stress were examined for Hsp27, 60, and 70 expression in renal tissue because renal tissue is sensitive to cellular stress. The results revealed no significant difference between Hsp27, 60, and 70 expression in both groups (28.8% positive staining in the study group and 19.0% positive staining in the control group), which is contradictory to a previous study on expression of Hsp70 in renal tissue in cases of fatal hypothermia. Hence, it is currently unclear whether immunohistochemical staining of Hsps supports a morphological diagnosis of fatal hypothermia.

Zusammenfassung Enzephalitiden sind häufig viral bedingt und können verschiedene Hirnareale betreffen. Ihre klinische Symptomatik ist sehr variabel. Gering symptomatische zerebrale (Begleit-)Infektionen bleiben bisweilen undiagnostiziert. Es können aber auch sehr schwere klinische Symptome (Lähmungen, Krämpfe) auftreten. Vorgestellt wird der Fall eines 8-jährigen Mädchens, das wenige Tage nach einem harmlosen Sturz auf den Hinterkopf zunehmend unter Kopfschmerzen und Erbrechen litt. Der Gesundheitszustand verschlechterte sich rasant und führte 7 Tage nach dem Sturz zur Vorstellung beim Kinderarzt. Nach weiterem foudroyantem Verlauf der Krankheit wurde das Mädchen 2 Tage später unter Krämpfen und pulmonaler Obstruktion in eine Klinik aufgenommen; hier musste es reanimiert werden. Im kranialen Computertomogramm (cCT) stellten sich temporal hypodense Areale und lokale Ödeme dar. Eine Herzechokardiographie ergab eine eingeschränkte linksventrikuläre Pumpfunktion, sodass der Verdacht auf eine Enzephalitis und eine Myokarditis gestellt wurde. Trotz antiviraler und antibiotischer Therapie verstarb das Kind 2 Tage nach Aufnahme in die Klinik an intravitalem Hirntod und Multiorganversagen. Bei der rechtsmedizinischen Sektion fanden sich keine knöchernen kranialen oder intrakranialen Verletzungen oder prädisponierende Erkrankungen. Histologische Untersuchungen ergaben eine nekrotisierende Hirnstammenzephalitis.

Gunshot residues (GSR) are essentially invisible. The procedure for retrieval during crime scene investigation, external examination of the corpse and autopsy is described. Prior to autopsy x-ray examinations are useful to detect foreign bodies and to document important findings for a later reconstruction. When performing external examinations of corpses and autopsies the forensic pathologist must look for morphological evidence which allows a reconstruction of the direction of shooting and the shooting distance. The topographic preservation of GSRs on the shooter’s hand with scotch tape or polyvinyl alcohol (PVAL) is required to determine the act of shooting. Backspatter and lesions on the shooter’s hand can give independent evidence of firing the gun.

In Germany, autopsies can be ordered by the representatives of the board of health according the Epidemics Law as so called administrative autopsy. If the autopsy is not absolutely necessary, it is mandatory to take into consideration the rights of the deceased persons as well as the rights of the relatives. The decisions of the legislature concerning clinical autopsies must also be considered. The juridical aspects and different types of organising the interrogation of the relatives are explained.

Nach der Todesurachenstatistik betrug die Inzidenz des plotzlichen Kindstodes von 1985 bis 1989 in der Bundesrepublik 1,55 Falle pro 1000 Lebendgeborene (1,51 bis 1,59). Es liegen jedoch bisher keine Angaben uber die Obduktionsfrequenz vor. Deshalb wurden rechtsmedizinische und pathologische Institute mit der Bitte angeschrieben, mitzuteilen, bei wie vielen Sauglingstodesfallen in der Zeit von 1985 bis 1989 nach der Obduktion die Diagnose eines plotzlichen Kindstodes gestellt wurde. Alle angeschriebenen 53 rechtsmedizinischen und 81,1% der 376 pathologischen Institute teilten uns die Obduktionszahlen mit, die mit den Angaben der Todesursachenstatistik verglichen wurden. Dabei ergab sich eine Obduktionsfrequenz von 55,2% mit nur geringen jahrlichen Schwankungen (51,1% bis 59,3%) und erheblichen Unterschieden zwischen den einzelnen Bundeslandern. Die hochsten Obduktionsfrequenzen wurden in den Stadstaaten Berlin (West) und Hamburg erreicht. Bei den Flachenstaaten wies Niedersachsen mit 77,8% die hochste Obduktionsfrequenz auf, wahrend in Rheinland-Pfalz von allen Bundeslandern die niedrigste Rate mit 20,1% zu verzeichnen war. Sowohl unter wissenschaftlichen, forensischen und arztlichen Aspekten sollte die Obduktionsfrequenz bei plotzlich verstorbenen Sauglingen in Deutschland erhoht werden.

The determination of human insulin or its synthetic analogues in post-mortem specimens represents a challenge for forensic toxicologists due to its proven instability in post-mortem blood. We present two cases of an insulin-induced hypoglycaemia. In the first case, ante-mortem material was available for the detection of an injection with human insulin. Human insulin was detected by immunopurification with magnetic beads and liquid chromatography-tandem mass spectrometry (LC-MS/MS) analyses at a concentration of 5180 μU/ml. The molar ratio human insulin:C-peptide was 111. The second case describes a suicide by self-injection of Insulin lispro and determination of the drug after pre-extraction with methanol and immunopurification by LC-MS/MS at the injection site, in vitreous humour and organs. Apart from the well-known matrices--femoral blood and urine--the specimen vitreous humour and the injection site promise the best possibilities for a proof of insulin at autopsy. In addition to insulin analyses, the parameters C-peptide, proinsulin, glucose, lactate, and sulfonylureas should be measured in case of suspected fatal hypoglycaemia.

A nurse administered the neuromuscular blocking agent succinylcholine (SUX) to at least one patient and gave first aid in the therapy of unexpected respiratory depression. SUX is regarded as an undetectable and thus perfect poison due to its short half-life and degradation to the endogenous compounds choline and succinic acid. However, SUX and especially its metabolite succinylmonocholine (SMC) were found in plasma and urine a few hours after administration by means of high performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS). Compared to clinical studies, the window of detection was sufficient to gain definite proof; in other cases no samples were collected. The nurse enjoyed high reputation with the doctors. According to the court she wanted to present herself spectacularly as the first and decisive rescuer to demonstrate her special abilities and capacities, perhaps to receive a better job in the hospital. Considering the actual case, the hero syndrome is not limited to fire-fighters.

Diabetic coma is the most severe form of hyperglycaemic metabolic disorders. The post-mortem diagnosis of this disorder of glucose metabolism can be difficult and vague due to a lack of characteristic morphological findings. Six death cases caused by diabetic coma are described with special focus on biochemical (and histological) findings. The possible glycaemia markers glucose, lactate, HbA1c, fructosamine, anhydroglucitol, and ketone bodies were measured and the usefulness of these parameters is evaluated and discussed. Estimations of glucose concentrations in vitreous humour or cerebrospinal fluid and of ketone bodies in blood or other matrices are obligatory while measurements of HbA1c, fructosamine, or anhydroglucitol can only provide additional information on the long-term adjustment of diabetes in the deceased. Lactate concentrations (addition of glucose and lactate levels to form the sum formula of Traub) do not give more information than the glucose concentration itself and can be therefore omitted.

An external postmortem examination is of significance in three different circumstances: death certification, as part of the autopsy, and for identification purposes. The most important, of course, is the external examination for death certification. In addition to the certification of death, the cause and manner of death have to be determined. The cause of death is of great importance for mortality statistics and epidemiology and the manner of death is important for legal security. According to the international guidelines of the World Health Organization, in the confidential part of the death certificate, the immediate cause of death and the underlying cause of death have to be indicated. To certify the cause of death, knowledge of the patient's history is of utmost importance. Certification of the cause and manner of death will be described in detail in this article and problem areas will be addressed.

Dying and death are continuous biological processes. In the great majority of cases, individual death is attributed to irreversible cessation of respiratory and circulatory functions. Circulatory and respiratory arrest are followed by early postmortem changes such as postmortem lividity and rigor mortis. However, metabolism of tissues continues for some hours after death. In this supravital period, reactions of tissues on excitation are much like those in life. Supravital reactions as well as the time-dependent criteria of postmortem lividity and rigor mortis are used for estimating the time since death. Different exogenous and endogenous factors contribute to destruction and decomposition. Endogenous factors are autolysis, putrefaction, and decay, while exogenous factors include animal predation, exposure to the elements, and mechanical injury. While these natural processes lead to dissolution and disintegration of the cadaver down to bones and tendons, special environmental conditions may preserve a body. Preservation processes include mummification or adipocere formation. It can also be found in bog bodies and permafrost corpses.

A preliminary initial cloned enzyme donor immunoassay (CEDIA) was optimized for serum and urine drug testing with respect to the German per se limits for driving under the influence of drugs (serum) and lowered cut-offs in cases of driving licence re-granting (urine). The tests were performed on an Olympus AU 400 auto analyzer. Validation revealed sensitivities between 93% and 100% based on comparison with data from gas or liquid chromatography coupled with mass spectrometry. Even if specificity ranged between 83% and 98 %, the tests can be considered useful for forensic purposes. Receiver operating characteristic (ROC) curves, Youden indices, as well as positive and negative predictive values are presented.

We report about a fatal cytisine intoxication in a 20-year-old man who, according to his mother, had drunken tea prepared from plant material of Laburnum anagyroides with the toxic pyridine-like alkaloid as ingredient, which exhibits pharmacological effects similar to nicotine. Using a liquid chromatographic–mass spectrometric (LC–MS) procedure cytisine was quantified in post-mortem specimens. By exclusion of other causes of death an intoxication was determined as the cause of death with respiratory failure as the pathophysiological mechanism.

Validation studies were carried out on the short tandem repeat (STR) locus D12S391 including the determination of the allele frequencies, forensic application and sequence analysis of variant alleles. A total of 16 alleles were found in a population survey of 158 unrelated individuals from the Rhine area, none of which exceeded the 0.20 frequency level. In 316 alleles analysed so far 18 alleles were found with an incomplete repeat unit in the 5′-end of the repeat region. The statistical values were similar to those of other European populations and no deviation from Hardy-Weinberg equilibrium (HWE) was observed.

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

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

Autopsies from 34 fatalities in nursing homes covering a 10-year period (1991-2000) were retrospectively analyzed with regard to criminal investigative issues, causes of death and relevance of the forensic medical findings for the outcome of the criminal investigations. The material consisted of 22 females and 12 males, with the ages ranging from 62 to 102. The allegations to be investigated comprised wrongful death, improper nursing, medical maltreatment, suspicion of poisoning and the causal relationship between falls and the occurrence of death. The manner of death, respectively cause of death encountered included 21 deaths from natural cause (coronary insufficiency, pneumonia), 9 accidental deaths (hypothermia, choking, scalding burns and injuries due to fall) and 4 cases which remained undetermined. In 30 out of 34 cases, the cause of death was unequivocally established. In every case, the medicolegal investigation provided adequate evidence for the legal assessment. Of particular significance was the exclusion of a causal relationship between falls and the occurrence of death. Without exception, all investigations failed to uncover criminal causes for death in this sample.