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Aufgrund der steigenden Lebenserwartung der Bevolkerung in Deutschland steigt auch die Zahl an multimorbiden Pflegeheimbewohnern. Insbesondere bei verstorbenen multimorbiden Pflegeheimbewohnern konnen die Leichenschau sowie die Festlegungen der Todesart und Todesursache besondere Herausforderungen darstellen. Im vorliegenden Beitrag wird die Qualitat der arztlichen Leichenschau bei verstorbenen multimorbiden Pflegeheimbewohnern anhand der Vergleiche der Todesarten und der Todesursachen auf der Todesbescheinigung mit den Obduktionsergebnissen analysiert. Retrospektiv wurden die Obduktionsgutachten sowie ggf. Zusatzgutachten von uber 60-jahrigen verstorbenen Pflegeheimbewohnern ausgewertet und mit den Angaben auf der Todesbescheinigung verglichen. Die Auswertung der 356 Falle ergab einen hohen Grad an Multimorbiditat der Verstorbenen. In etwa 10 % der als naturlich attestierten Todesfalle wurde autoptisch ein nichtnaturlicher Tod festgestellt. Umgekehrt lag in uber 40 % der als nichtnaturlich bescheinigten Todesfalle ein naturlicher Tod vor. Die Ubereinstimmungsrate der Todesursachen betrug insgesamt 53,7 %. Die Feststellungen von Todesart und Todesursache anlasslich der Leichenschau bei verstorbenen multimorbiden Pflegeheimbewohnern erfordern haufig differenzialdiagnostische Uberlegungen. Die auf einen nichtnaturlichen Tod hinweisenden Befundmuster konnen hier nur diskret ausgebildet sein oder vollig fehlen. Bei nichteindeutiger Todesart und Todesursache oder dezenten suspekten Verletzungen sollte zur weiteren Klarung eine rechtsmedizinische Obduktion angestrebt werden.

Press-fit fixation of patellar tendon bone anterior cruciate ligament autografts is an interesting technique because no hardware is necessary. To date, no biomechanical data exist describing an implant-free double-bundle press-fit procedure. The purpose of this study was to characterize the biomechanical properties of three double-bundle press-fit fixations.In a controlled laboratory study, the patellar-, quadriceps- and hamstring tendons of 10 human cadavers (age: 49.2 ± 18.5 years) were used. An inside out press-fit fixation with a knot in the semitendinosus and gracilis tendons (SG) combined with an additional bone block, with two quadriceps tendon bone block grafts (QU) was compared with press-fit fixation of two bone patellar tendon bone block (PT) grafts in 30 porcine femora. Constructs were cyclically stretched and then loaded until failure. Maximum load to failure, stiffness and elongation during failure testing and cyclical loading were investigated.The maximum load to failure was 703 ± 136 N for SG fixation, 632 ± 130 N for QU and 656 ± 127 N for PT fixation. Stiffness of the constructs averaged 138 ± 26 N/mm for SG, 159 ± 74 N/mm for QU, and 154 ± 50 N/mm for PT fixation. Elongation during initial cyclical loading was 1.2 ± 1.4 mm for SG, 2.0 ± 1.4 mm for QU, and 1.0 ± 0.6 mm for PT (significantly larger for PT and QU between the first 5 cycles compared with cycles 15-20th, P 0.01).All investigated double-bundle fixation techniques were equal in terms of maximum load to failure, stiffness, and elongation. Unlike with single-bundle press-fit fixation techniques that have been published, no difference was observed between pure tendon combined with an additional bone block and tendon bone grafts. All techniques exhibited larger elongation during initial cyclical loading. All three press-fit fixation techniques that were investigated exhibit comparable biomechanical properties. Preconditioning of the constructs is critical.

Press-fit-Fixierungen sind interessant, da diese einen zirkularen Kontakt zwischen Knochen und Transplantat ermoglichen und Fremdmaterial vermeiden. Diese Ubersichtsarbeit vergleicht etablierte mit neu entwickelten Press-fit-Fixierungen aller gangigen Transplantate und vergleicht das biomechanische Verhalten mit fremdmaterialhaltigen Fixierungen wie der Interferenzschraube. Fur die Versuche wurden 168 humane Kadavertransplantate entnommen (Alter 49,2±18,5 Jahre). Funfzehn verschiedene Fixierungen wurden miteinander verglichen. Die Konstrukte wurden zyklisch gedehnt und dann bis zum Versagen getestet. Die submaximale Versagenslast, Steifigkeit, Elongation und Versagensart wurden verglichen. Insgesamt zeigen einige Techniken vergleichbare biomechanische Qualitaten wie Fixierungen mit Implantaten. Einige Press-fit-Fixierungen erreichen eine ahnliche Primarstabilitat wie eine Transplantatverankerung mit Implantaten. Durch die gelenknahe Verpressung mit korpereigenem Material erhalt das Transplantat einen engen Kontakt zum gelenknahen kortikalen Knochen.

Erstmals wird uber einen Todesfall als Folge einer subkutanen Masseninjektion von Heparin in suizidaler Absicht berichtet. Eine 40-jahrige Frau wurde bewusstlos in einem PKW vorgefunden, in den Abgase eingeleitet wurden. In der Fahrgastzelle befanden sich 62 entleerte Spritzen Clexane® 80 mg sowie Tablettenschachteln von Bromazanil®, Paracetamol und Doxepin. Die Bauchdecke der Frau wies zahlreiche Injektionsstellen auf. Die vermutete Enoxaparin-Natrium-Uberdosierung wurde klinisch als prognostisch fuhrend eingeschatzt und bestimmte den klinischen Verlauf bis zum Todeseintritt masgeblich. Eine heparininduzierte Thrombozytopenie konnte ausgeschlossen werden. Die Patientin verstarb unter dem klinischen Bild eines progredienten Multiorganversagens mit finaler respiratorischer Insuffizienz infolge disseminierter intravasaler Gerinnung. Ein postmortaler laborchemischer Nachweis der Heparinuberdosierung war nicht moglich. Im Hinblick auf die Raritat vorsatzlicher, selbst applizierter Heparinuberdosierungen wird der gegenstandliche Fall unter besonderer Berucksichtigung des klinischen Krankheitsverlaufs vorgestellt.

Background: Polymorphonuclear, neutrophil granulocytes (PMN) play a major role in the control of infections, and people who abuse alcohol are susceptible to infections. Resistance against infections ensues intracellularly following initial phagocytosis of microorganisms with the oxygen-dependent respiratory burst, the key enzyme of which is the respiratory burst oxidase, whereby oxygen radicals are produced for microbial destruction. To date there is insufficient information available in connection with the process of impaired defence against infection in patients suffering from alcohol dependence. Therefore, our investigation was carried out to determine the influence of alcohol exposition on the formation of oxygen radicals and the respiratory burst. Methods: 4.5 ml of whole blood was taken from 10 healthy adults and 10 patients suffering from alcohol dependence. An additional 3.5 ml of whole blood was taken from the alcoholic patients for determination of the blood alcohol concentration. The respiratory burst of PMN was tested using the Four-Colour-Continuous Flow Cytometer. Each experimental procedure consisted of 4 test samples [negative controls, Escherichia coli, FMLP-supplement (N-formyl-l-methionyl-l-leucyl-l-phenylalanin), PMA-supplement (phorbol-12-myristate-13-acetate)]. Differing concentrations of ethanol were also introduced to each of the tests performed (0.20 to 4.00 g/l). Results: Ethanol revealed a marked decrease of burst activity in those patients suffering from alcoholism with increased alcohol concentration. A dependence between the burst activity and the ethanol concentration was seen to be statistically significant. This effect was only evident after stimulation with E. coli and FMLP in those patients with alcohol dependence. Conclusion: The results presented in this study show an impairment in the function of PMN in those patients addicted to alcohol due to the decrease in burst activity. In view of the results of the different stimuli, the second-messenger effects were not evident. A clarification of this phenomenon could well be assumed as an allosteric receptor effect on the burst oxidase, namely, a direct effect on the phagocytosis interaction between circulating granulocytes and causative organisms.

Die Totung eines Sauglings durch ein 7-jahriges Kind in einer Pflegeeinrichtung wird kasuistisch vorgestellt. In einem unbeobachteten Moment konnte sich das 7-jahrige Madchen, bei dem eine geistige Entwicklungsstorung, einhergehend u. a. mit auto- und fremdaggressiven Verhaltensweisen, bekannt war, in das Zimmer des mannlichen Sauglings begeben. Sie fugte diesem neben schwerwiegenden Kopfverletzungen u. a. mehrere Bissverletzungen zu, deren Vorhandensein allein schon aufgrund der Grosenverhaltnisse – in Erganzung zu den polizeilichen Ermittlungsergebnissen –die Annahme der Taterschaft durch ein Kind wesentlich unterstrich. Todesursache war ein Verbluten bei massiven Kopfverletzungen mit multiplen Schadeldach- und Schadelbasisbruchen sowie zahlreichen weiteren Knochenbruchen. Fur die Verursachung des Verletzungsmusters im Kopfbereich wurde ein (evtl. mehrfaches) Anschlagen gegen Widerlager diskutiert. Das an der Leiche erhobene Verletzungsmuster wird anhand fotografischer Abbildungen veranschaulicht. Das Ermittlungsverfahren gegen die Mitarbeiter des Pflegeheimes wurde eingestellt.

Background: Hemodialysis patients are in a state of oxidant stress. In renal transplantation reactive oxygen species (ROS) are considered to be important factors of ischemia-reperfusion injury. Neutrophils produce ROS as part of the host defense against invading bacteria. This study was designed to investigate whether neutrophil function in hemodialysis patients is immediately affected by renal transplantation. Methods: We evaluated the neutrophil respiratory burst and phagocytic activity in renal transplant patients with living-related donor (LRD) and cadaveric donor (CAD) grafts using flow cytometry techniques. Twenty patients (LRD = 6, CAD = 14) and 20 healthy volunteers were included in the study. Venous blood samples were drawn before anesthesia, 5 min before reperfusion, 1 h and 1, 3 and 7 days after reperfusion. Results: Before surgery, a significant increase in hydrogen peroxide production in neutrophils was seen for both renal transplantation groups compared to healthy subjects. Within 24 h after reperfusion hydrogen peroxide production almost decreased to normal values. The phagocytic capacity of neutrophils was continuously depressed. There were no differences between the CAD and LRD groups. Conclusions: We found that the enhanced respiratory burst activity of patients with chronic renal failure decreased to normal values within 1 day following renal transplantation. Our results suggest that reduced respiratory burst activity resulting in a diminished risk of tissue damage by the uncontrolled production of ROS.

Alcohol in modest and higher doses has the potential to induce cardiac arrhythmias. The most famous alcohol-related arrhythmia is the "holiday heart syndrome". Furthermore, there is a clear association between excessive alcohol consumption and the risk of sudden cardiac death. However, the acute effects of ethanol on arrhythmia induction are not well understood. The effect of ethanol on single cardiac sodium channels has not been studied yet. To elucidate the effect of ethanol on human cardiac sodium channels we performed a patch clamp study in HEK-293 cells overexpressing the human cardiac sodium channel. We used HEK-293 cells overexpressing the human cardiac sodium channel (Na(1.5)). Single channel gating was investigated by the cell-attached patch clamp technique. Sodium channel currents were elicited by depolarizing pulses from -120 to -20mV for a duration of 150ms. Single channel availability, open probability and peak average current were assessed baseline and after addition of ethanol in increasing concentrations (0.50 per thousand (10.9mM), 1.00 per thousand (21.7mM), 2.00 per thousand (43.5mM) and 4.00 per thousand (87.0mM)). We found a concentration-dependent reduction of open probability which was statistically significant at 2.00 per thousand ethanol (66.5+/-14% of control). At higher concentrations (4.00 per thousand) also availability decreased to 66.5+/-11.0% of control. This resulted in a significant decrease of peak average current at 2.00 per thousand and at 4.00 per thousand ethanol (61.8+/-7.4 and 53.0+/-8.2% of control). For the first time the present study demonstrates acute inhibitory effects of ethanol on single cardiac sodium channel gating and provides one potential mechanism for the well known clinical observation that ethanol triggers supraventricular and ventricular arrhythmias.

There is a general agreement that blood alcohol concentrations (BACs) of about 0.05% result in impairment of the ability to drive. This fact has been supported by means of experiments. In addition, there are only a few studies to date investigating low BACs. The present study aims to investigate the extent and quality of cognitive changes in low BACs of around 0.03%. Sixteen healthy male subjects were examined in a double-blind, placebo-controlled study. During the trials the BAC was regulated to about 0.03%. As part of the study a record was made of the general level of intelligence, subjective impairments, possible depressive symptoms, general ability to perform, vigilance, divided attention, response times and performance of memory. Statistical analysis took place using the two-period crossover design. Verbal intelligence, general performance, vigilance (optical stimuli), divided attention, vigilance towards acoustic stimuli and the general response time to acoustic and visual-acoustic sequential stimuli, and memory were not impaired significantly by a BAC of around 0.03%. The total response and motor response time to optical stimuli as well as decision time about sequential optical stimuli were, however, significantly changed for BACs of around 0.03%. In conclusion, the present results show that already in BACs of around 0.03%, particular cognitive functions which rely on perception and processing of visual information, are significantly impaired. This was evident in the more complex and urgent tasks.

Haufig kann der Verdacht auf einen sexuellen Kindesmissbrauch durch medizinische Befunde nicht bewiesen werden. Der fehlende Nachweis anogenitaler Verletzungen schliest jedoch einen sexuellen Missbrauch nicht aus. Die Schwierigkeiten bei der Befundinterpretation von Genitalveranderungen im Kindesalter, wie die Unterscheidung zwischen Verletzung und Normvariante, die hormonelle Beeinflussung der hymenalen Erscheinungsform sowie die Abgrenzung zu akzidentellen oder krankheitsbedingten Veranderungen werden exemplarisch kasuistisch vorgestellt und diskutiert. Die vorgestellten Falle bestatigen die weitreichende Bedeutung rechtsmedizinischer Untersuchungen und unterstreichen die Verantwortung und den Stellenwert der Rechtsmedizin im Netzwerk der interdisziplinaren Zusammenarbeit mit der Klinik und den Ermittlungsbehorden.

A liquid chromatography–tandem mass spectrometry method using electrospray ionization in positive ionization mode was developed for the simultaneous detection of multiple opioid-type drugs in plasma. The presented assay allows the quantitative determination of alfentanil, buprenorphine, codeine, desomorphine, dextromethorphan, dextrorphan, dihydrocodeine, dihydromorphine, ethylmorphine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, naloxone, naltrexone, oxycodone, oxymorphone, pentazocine, pethidine, pholcodine, piritramide, remifentanil, sufentanil, and tramadol as well as the metabolites 6-monoacetylmorphine, bisnortilidine, morphine-3-glucuronide, morphine-6-glucuronide, naltrexol, norbuprenorphine, norfentanyl, norpethidine, nortilidine, and O -desmethyltramadol. Serum and blood samples were purified by solid-phase extraction. The analytes were separated on a phenyl–hexyl (100 mm) column by formic acid/acetonitrile gradient elution using an UPLC 1290 Infinity coupled with a 6490 Triple Quadrupole mass spectrometer. The limits of detection ranged from 0.02 to 0.6 ng/mL and the lower limits of quantification ranged from 0.1 to 2.0 ng/mL. The calibration curves were linear between Calibration Levels 1–6 for all 35 substances. Recovery rates ranged between 51 and 88% for all compounds except alfentanil, bisnortilidine, pethidine, and morphine-3-glucuronide. The matrix effect ranged from 86% for ethylmorphine to 105% for desomorphine. Using the validation procedure proposed by the German Society of Toxicological and Forensic Chemistry, acceptable precision and accuracy data for almost all analytes were obtained. The method was successfully applied to 206 authentic serum samples provided by the palliative and intensive care units of the University Medical Center and the police authorities. Furthermore, a suspected fatal intoxication is demonstrated by an analysis of the sufentanil in post mortem body fluids and tissues.

Die Begutachtung moglicher arztlicher Behandlungsfehler beim anasthesiologischen Management des schwierigen oberen Atemwegs mit Intubationsproblemen kann im Einzelfall schwierig sein. Die Frage, inwieweit ein letaler Ausgang auf einen vorwerfbaren arztlichen Behandlungsfehler zuruckzufuhren ist, erfordert eine genaue Kenntnis der Literatur und die Einholung weiterer Fachgutachten. In dieser Arbeit werden klinisch anerkannte Richtlinien zum Management und Algorithmen zur Beherrschung eines unerwartet schwierigen oberen Atemwegs vorgestellt. Mithilfe dieses Instrumentariums kann der rechtsmedizinische Gutachter beurteilen, ob ein adaquates und den Richtlinien entsprechendes Management zur Beherrschung des schwierigen Atemwegs vorgenommen wurde. Dies soll nicht dazu verleiten, dieses komplexe Begutachtungsfeld ausschlieslich forensisch zu bewerten. Vielmehr wird eine Zusammenarbeit zwischen Klinikern und Rechtsmedizinern zur konkreten Beantwortung juristischer Fragen zu Behandlungsfehlervorwurfen bei schwierigen Intubationen empfohlen.

Begutachtungen uber vermeintliche medizinische Behandlungsfehler gehoren zum Alltag der forensischen Medizin. Schnittstellen zum Fachgebiet der Urologie finden sich diesbezuglich jedoch selten. In den vergangenen Jahrzehnten sind in der Urologie zahlreiche Modifikationen von Operationsmethoden, beispielsweise bei der Schaffung kunstlicher Harnableitungen nach erfolgter radikaler Zystektomie oder bei der Behandlung der Harninkontinenz, entwickelt worden. Bei den „Routineeingriffen“ sollte insbesondere auch umfassend uber nichteingriffstypische oder seltene Komplikationen aufgeklart werden. Anhand von Fallbeispielen des Institutes fur Rechtsmedizin, Hannover, werden diesbezuglich 2 urologische Behandlungsfalle (Ileumneoblase, Inkontinenzoperation nach Stamey) dargestellt und ihre medikolegalen Aspekte diskutiert.

OBJECTIVE Should the technique of surgical cricothyroidotomy be practiced on cadavers and should it be a compulsory part of the teaching curriculum? Is it wise to use a speculum for the insertion of the endotracheal tube? What is the optimum size of the tube? METHODS A surgical cricothyroidotomy with a speculum was carried out on 30 cadavers from the Institute of Legal Medicine, Medical School Hannover. This took place as part of a official and voluntary course for students of advanced semesters, anaesthetists and emergency doctors with the subjects "cricothyroidotomy, chest drainage and venous cut-down". The surgical cricothyroidotomy without the use of a speculum was carried out on 5 cadavers by two clinicians well practiced in this technique. The elapsed time between skin incision and the insertion of the endotracheal tube was measured on all five subjects. After the course the participants were asked if they were able to carry out a cricothyroidotomy in an emergency. They were also asked whether this course should be a compulsory part of their curriculum and whether practical sessions should take place. During autopsies at the Institute of Legal Medicine the length of the ligamentum conicum was measured on 40 corpses with reclined and non-reclined heads. RESULTS The average time of storage of the cadavers was 4.2 days +/- 1.9 days. The cricothyroidotomy was possible on all 35 cadavers. In one case (3,3 %) the result was a complete rupture of the cricoid cartilage. In 5 cases (16.7 %) the horizontal incision was torn due to prising with the speculum. Difficult situations always occured when the skin incision was not exactly in the midline. The average time to place the endotracheal tube into the trachea by the surgical procedure of cricothyroidotomy was 22.4 seconds +/- 3.1 seconds (minimum 18 seconds, maximum 26 seconds). 10 % of the medical students and 50 % of the anaesthetists and emergency doctors felt they would be prepared to carry out a cricothyroidotomy in an emergency. 90 % of the students and respectively 80 % of the anaesthetists and emergency doctors stated that they would like to practice the technique on a cadaver again. Almost all participants were of the opinion that the course should be integrated as a compulsory course in a future educational curriculum. The average distance between the thyroid cartilage and the cricoid cartilage was 9.5 mm +/- 1.9 mm with non-reclined head (minimum 6 mm, maximum 14 mm) and 11.9 mm +/- 2.5 mm with reclined head (minimum 7 mm, maximum 18 mm). The average difference of distances was 2.4 mm +/- 1.2 mm (minimum 1 mm, maximum 6 mm) in reclined and non-reclined heads. CONCLUSIONS In our opinion it is highly recommended that the technique of cricothyroidotomy should be practiced on cadavers and that the course should become a compulsory part in a future educational curriculum. In addition the incision of the ligamentum conicum using dilators or a speculum is not to be recommended from the point of view of this study. The tracheal tube used in this study (reinforced wire tube, ID 6.0) was best suited for surgical cricothyroidotomy.

Between 1978 and 1997 the Institute of Legal Medicine of the Hannover Medical School examined 17 fatal autoerotic deaths. The incidence for the Hannover region was 0.49 cases per million inhabitants per year. The victims included 17 men with an average age of 36.8 years; a peak in the age distribution was seen between 20 and 29 years. Twelve of the men were found by friends or family in a domestic environment, while other situations in which the victims were found included the victim’s own car, a hotel room, a canal embankment, a public parking lot as well as the holding cell of the youth detention center. The men were of varying socioeconomic status and held a number of different types of jobs or still attended school. Five of the men were found completely nude, while five were only undressed below the waist. Four men wore women’s clothes and two were fully clothed with exposed genitals. Besides women’s clothes, other objects found at the scene included various types of sexual aids, including ropes, chains, metal bars, locks, sex magazines, condoms, plastic bags, rubber items, etc. In four cases blood alcohol levels between 0.1 and 2.5‰ (urine alcohol levels between 0.2 and 2.5‰) were found. Toxicologic examination revealed chloroform, ketamin, a propane–butane gas mixture in one case each, and in two cases cocaine and morphine. Causes of death included central paralysis after strangulation (seven cases), asphyxiation (4), subarachnoid hemorrhage (2), intoxication (1), hypothermia (1), left heart failure (1), and drowning (1). The history, findings at scene, and autopsy findings and, in individual cases, other investigations are of utmost importance to accurately reconstruct a fatal autoerotic accident.

In suizidaler Absicht herbeigefuhrte Kohlenmonoxidintoxikationen unter Verwendung von Holzkohlegrills als alternative Kohlenmonoxidquelle werden zunehmend beobachtet. Ein derartiger Fall wird unter besonderer Berucksichtigung der ungewohnlichen Auffindungssituation mit Vorfinden eines Holzkohlegrills im Kofferraum eines Pkw kasuistisch dargestellt. Die Obduktion des 47-jahrigen mannlichen Suizidenten und die chemisch-toxikologischen Untersuchungsergebnisse erbrachten den Nachweis einer todesursachlichen Kohlenmonoxidintoxikation. Die polizeilichen Ermittlungen ergaben ein plausibles Motiv fur den Suizid.

Der Kurs Rechtsmedizin an der Medizinischen Hochschule Hannover sah im Wintersemester 1998/99 fur jeden Studierenden ¶26 Pflichtstunden vor. Er bestand aus mehreren 2-stundigen Seminaren und einer kursbegleitenden Vorlesung. Die Seminare hatten folgende Inhalte: Praktische Durchfuhrung einer Leichenschau, Teilnahme an einer Sektion mit Protokollerstellung und Nachbesprechung, Berufsrecht und -kunde sowie klinische Rechtsmedizin mit Verletzungsbegutachtung. Zusammen mit den zusatzlichen Lehrangeboten umfasste die Lehre fur das Fach Rechtsmedizin etwa 15 Semesterwochenstunden. Die Akzeptanz des Curriculums sollte durch eine Befragung der Studierenden uberpruft werden. Von insgesamt 361 Studierenden beteiligten sich 72% an der Befragung. Auf einer Notenskala von 1–6 wurde der Kurs insgesamt mit der Durchschnittsnote 1,7 bewertet. Auf einer Skala von 1 (= trifft nicht zu) bis 7 (= trifft zu) wurden Aussagen zu Struktur und Inhalt von Vorlesungen und Seminaren eingeordnet. Mit einer durchschnittlichen Bewertung von uber 6 Punkten wurden logischer Aufbau, Organisation, Anschaulichkeit und interessante Darbietung des Stoffes bewertet. Auch fur die kommenden Semester ist eine kontinuierliche Lehrevaluation vorgesehen.

Press-fit fixation of hamstring tendon autografts for anterior cruciate ligament reconstruction is an interesting technique because no hardware is necessary. This study compares the biomechanical properties of press-fit fixations to an interference screw fixation.Twenty-eight human cadaveric knees were used for hamstring tendon explantation. An additional bone block was harvested from the tibia. We used 28 porcine femora for graft fixation. Constructs were cyclically stretched and then loaded until failure. Maximum load to failure, stiffness and elongation during failure testing and cyclic loading were investigated.The maximum load to failure was 970±83 N for the press-fit tape fixation (T), 572±151 N for the bone bridge fixation (TS), 544±109 N for the interference screw fixation (I), 402±77 N for the press-fit suture fixation (S) and 290±74 N for the bone block fixation technique (F). The T fixation had a significantly better maximum load to failure compared to all other techniques (p0.001).This study demonstrates that a tibial press-fit technique which uses an additional bone block has better maximum load to failure results compared to a simple interference screw fixation.

Press-fit fixation of anterior cruciate ligament autografts is an interesting technique because no hardware is necessary. A total of 168 cadaveric human patellar, quadriceps and hamstring tendons (average age 49.2 +/- 18.5 years) were used and 15 different fixation methods were tested. Constructs were cyclically stretched and then loaded until failure. Maximum load to failure, stiffness and elongation during failure testing and cyclical loading were compared. Some techniques showed comparable biomechanical qualities to interference screw fixation. All investigated double bundle fixation techniques were equal in terms of maximum load to failure, stiffness and elongation. All techniques exhibited greater elongation during initial cyclical loading. Some of the press-fit fixation techniques investigated exhibited comparable biomechanical properties and preconditioning of the constructs is critical. Press-fit fixation enhances tendon to bone contact at the entry of the bone tunnel to the joint.

The accuracy of breath alcohol measurements in intubated patients with assisted ventilation was evaluated. The breath alcohol concentration was measured in 24 patients undergoing percutaneous alcohol injection therapy for hepatocellular carcinoma with Alcotest 7410 med, from Dräger, Germany. The blood ethanol concentrations (BACs) were determined in each blood serum applying the German forensic criteria standard, namely, two alcohol dehydrogenase (ADH) and two gas chromatography (GC) measurements. The blood alcohol concentrations were between 0.07 and 1.51 per thousand in the central venous samples and 0.02-1.66 per thousand in the arterial samples. An excellent correlation between both the venous and arterial blood alcohol concentrations (r2=0.94), as well as between the breath alcohol concentrations and the venous (r2=0.84) or arterial alcohol concentration (r2=0.89), p0.01 for both parameters was revealed. Determination of breath alcohol concentration using the Alcotest in intubated patients is reliable and reflects the blood alcohol values.

This article analyses three cases of death following a spontaneous rupture of the urinary bladder. One case is based on an extensive tamponade of the bladder eight days after a transurethral resection of the prostate gland. Two other cases of death by spontaneous rupture resulted from increased alcohol consumption. The paper presents an overview of pathomorphological findings such as the typical intraperitoneal rupture localisation at the posterior wall of the urinary bladder or bladder dome and the subsequent diagnosed causes of death. In addition predisposing (anamnestic) influencing factors such as chronic alcoholism are highlighted and their relevance for the clinical urologist and the forensic pathologist are discussed.

To find out whether a certain cause of death or a certain length of an agonal period shows specific adrenaline or noradrenaline profiles, heart blood, femoral vein blood, liquor, urine and vitreous humour were taken from corpses (n = 98) at the Medical School Hannover, and noradrenaline and adrenaline were determined using high-performance liquid chromatography (HPLC). Corpses were classified according to the following five categories: short agony, long agony, state after hanging, state after asphyxiation and state after CPR with documented administration of epinephrine. Once results were collected the adrenaline/noradrenaline quotient was determined. It became clear that there were no significant differences regarding the concentration of adrenaline and noradrenaline in the various body fluids in relation to the above-mentioned categories. The means adrenaline/noradrenaline quotients in femoral vein blood were 0.21 +/- 0.29 for hanged persons, 0.38 +/- 0.47 for asphyxiated persons, 0.17 +/- 0.19 for those with short agony and 0.42 +/- 0.43 for those with long agony, significantly below 1 (p0.001; p = 0.001; p = 0.003). For condition after CPR we found an adrenaline/noradrenaline quotient of 2.81 +/- 5.8. In liquor the adrenaline/noradrenaline quotients for short agony was 0.17 +/- 0.17, for hanged persons 0.18 +/- 0.19 and for asphyxiated ones 0.30 +/- 0.38, significantly lower than 1 (p0.001). In urine the adrenaline/noradrenaline quotients for all categories are lower than 1 (p0.001); short agony (0.13 +/- 0.09), long agony (0.21 +/- 0.16), hanged (0.15 +/- 0.16), asphyxiated (0.14 +/- 0.08) and CPR (0.14 +/- 0.06). In vitreous humour the quotients for short agony (0.14 +/- 0.28), long agony (0.13 +/- 0.12), hanged (0.07 +/- 0.09) and asphyxiated (0.09 +/- 0.11) are lower than 1 (p0.001). The spread of data for the adrenaline/noradrenaline quotient did not allow for any conclusions about cause of death and length of agony in individual cases.

The lingual tonsillar hyperplasia (LTH) is a rare and dangerous condition of the upper airway because it is one of several risks during intubation which can cause serious complications like cardiac arrest, cerebral anoxia, and death. The LTH is rarely detectable during a routine oropharyngeal examination. The lingual tonsil is of particular interest to forensic medicine to assess cases with malpractice in connection with intubation difficulties. Our study looked at how often autopsy specimens had enlarged lingual tonsils and whether any relationship existed between LTH and tonsillectomies. In total, 497 corpses were examined. Only in 16 cases (3.2%), an enlarged lingual tonsil was detected. Of the 16 cases, 10 (62.5%) had normal palatine tonsils; the other 6 cases (37.5%) had no palatine tonsils or were scarred, atrophied, or only remnants remained. Statistically, it was not possible to prove any relationship between enlarged lingual tonsils and tonsillectomies. From the forensic point of view, a description of the lingual tonsil should appear in special cases in autopsy reports. When reviewing malpractice cases, special anatomic features should be described.

Should the technique of surgical cricothyroidotomy be practiced on cadavers and should it be a compulsory part of the teaching curriculum? Is it wise to use a speculum for the insertion of the endotracheal tube? What is the optimum size of the tube?A surgical cricothyroidotomy with a speculum was carried out on 30 cadavers from the Institute of Legal Medicine, Medical School Hannover. This took place as part of a official and voluntary course for students of advanced semesters, anaesthetists and emergency doctors with the subjects "cricothyroidotomy, chest drainage and venous cut-down". The surgical cricothyroidotomy without the use of a speculum was carried out on 5 cadavers by two clinicians well practiced in this technique. The elapsed time between skin incision and the insertion of the endotracheal tube was measured on all five subjects. After the course the participants were asked if they were able to carry out a cricothyroidotomy in an emergency. They were also asked whether this course should be a compulsory part of their curriculum and whether practical sessions should take place. During autopsies at the Institute of Legal Medicine the length of the ligamentum conicum was measured on 40 corpses with reclined and non-reclined heads.The average time of storage of the cadavers was 4.2 days +/- 1.9 days. The cricothyroidotomy was possible on all 35 cadavers. In one case (3,3 %) the result was a complete rupture of the cricoid cartilage. In 5 cases (16.7 %) the horizontal incision was torn due to prising with the speculum. Difficult situations always occured when the skin incision was not exactly in the midline. The average time to place the endotracheal tube into the trachea by the surgical procedure of cricothyroidotomy was 22.4 seconds +/- 3.1 seconds (minimum 18 seconds, maximum 26 seconds). 10 % of the medical students and 50 % of the anaesthetists and emergency doctors felt they would be prepared to carry out a cricothyroidotomy in an emergency. 90 % of the students and respectively 80 % of the anaesthetists and emergency doctors stated that they would like to practice the technique on a cadaver again. Almost all participants were of the opinion that the course should be integrated as a compulsory course in a future educational curriculum. The average distance between the thyroid cartilage and the cricoid cartilage was 9.5 mm +/- 1.9 mm with non-reclined head (minimum 6 mm, maximum 14 mm) and 11.9 mm +/- 2.5 mm with reclined head (minimum 7 mm, maximum 18 mm). The average difference of distances was 2.4 mm +/- 1.2 mm (minimum 1 mm, maximum 6 mm) in reclined and non-reclined heads.In our opinion it is highly recommended that the technique of cricothyroidotomy should be practiced on cadavers and that the course should become a compulsory part in a future educational curriculum. In addition the incision of the ligamentum conicum using dilators or a speculum is not to be recommended from the point of view of this study. The tracheal tube used in this study (reinforced wire tube, ID 6.0) was best suited for surgical cricothyroidotomy.

To determine how long pathological findings persist after burial and which factors play a role in decomposition of a corpse, we evaluated all bodies exhumed under the auspices of the Institute of Legal Medicine at the Hannover Medical School between 1978 and 1997. A total of 87 exhumations (54 men, 33 women) were performed in this period. The time bodies remained buried varied between 5 days and 16.8 years (mean 1.5 years, median 2.3 months). Fifty-six percent of the bodies were exhumed after at most 3 months, 10% remained buried for greater than 3 years. Pathomorphological changes of the soft tissues and the internal organs remained evident after several months, in some cases after several years of burial. Overall, it was possible to evaluate internal organs after 5 years of burial. Bodies became mostly decomposed after approximately 8 years at the earliest, although it was still possible to evaluate some soft tissue remnants after 16.8 years. In stepwise logistic regression, both the length of time the body was buried (p < 0.00005) and the time of year (p < 0.0019) clearly affected the rate of physical change. The variables of sex (p = 0.33), age (p = 0.61) and changes in the integrity of the body before burial (trauma, autopsy before burial; p = 0.15) did not influence the physical state of the body after exhumation. Our data show that much information may be gained from an exhumation even after significant time has passed since burial.

Background. Cardiac tamponade is a serious complication of central venous catheter (CVC) insertion. Current guidelines strongly advise that the CVC tip should be located in the superior vena cava (SVC) and outside the pericardial sac. This may be difficult to verify as the exact location of the pericardium cannot be seen on a normal chest x-ray. The carina is an alternative radiographic marker for correct CVC placement, suggested on the basis of studies of embalmed cadavers. Methods. We set out to confirm this radiographic landmark in 39 fresh cadavers (age 58.4 (3.4) (mean and SE) yr) and to compare the results with those from ethanol‐formalin-fixed cadavers. Results. We found that the carina was 0.8 (0.05) cm above the pericardial sac as it transverses the SVC. In no case was the carina inferior to the pericardial reflection and our study confirmed the previous findings. All the measured distances were significantly greater in fresh cadavers. Conclusions. We confirm that the carina is a reliable, simple anatomical landmark that can be identified in vivo for the correct placement of CVCs outside the boundaries of the pericardial sac. Br J Anaesth 2004; 92: 75‐7

Between 1978 and 1997 the Institute of Legal Medicine of the Hannover Medical School examined 17 fatal autoerotic deaths. The incidence for the Hannover region was 0.49 cases per million inhabitants per year. The victims included 17 men with an average age of 36.8 years; a peak in the age distribution was seen between 20 and 29 years. Twelve of the men were found by friends or family in a domestic environment, while other situations in which the victims were found included the victim's own car, a hotel room, a canal embankment, a public parking lot as well as the holding cell of the youth detention center. The men were of varying socioeconomic status and held a number of different types of jobs or still attended school. Five of the men were found completely nude, while five were only undressed below the waist. Four men wore women's clothes and two were fully clothed with exposed genitals. Besides women's clothes, other objects found at the scene included various types of sexual aids, including ropes, chains, metal bars, locks, sex magazines, condoms, plastic bags, rubber items, etc. In four cases blood alcohol levels between 0.1 and 2.5 per thousand (urine alcohol levels between 0.2 and 2.5 per thousand ) were found. Toxicologic examination revealed chloroform, ketamine, a propane-butane gas mixture in one case each, and in two cases cocaine and morphine. Causes of death included central paralysis after strangulation (seven cases), asphyxiation (4), subarachnoid hemorrhage (2), intoxication (1), hypothermia (1), left heart failure (1), and drowning (1). The history, findings at scene, and autopsy findings and, in individual cases, other investigations are of utmost importance to accurately reconstruct a fatal autoerotic accident.

We present a rare case of an autoerotic accident involving a fatal combination of asphyxia by suffocation and intoxication with self-administered intravenous ketamine. Of note in this case is the fact that the victim was an emergency medical technician. Ketamine causes complete analgesia with superficial unconciousness and amnesia called “dissociative anasthesia”. Futhermore low anaesthetic doses of ketamine induce alterations in mood, cognition and body image and the substance is an emerging drug of abuse. We discuss the death scene investigation, findings at autopsy and the toxicological report.

The inhibition of the glucoamylase-maltase-catalyzed maltose and maltooligosaccharide hydrolysis by acarbose and 1-deoxynojirimycin has been demonstrated. Acarbose and 1-deoxynojirimycin act as potent competitive inhibitors with Ki = 0.8 microM for the hydrolysis of maltose and with Ki values of 0.4 and 0.3 microM, respectively, for the hydrolysis of maltooligosaccharides. In a previous work (Gunther et al., Arch. Biochem. Biophys. 327, 295-302, 1996) using maltitol and maltobionate as inhibitors we were able to discriminate two different binding modes for glucoamylase-maltase: a maltose and an oligosaccharide binding mode. Here we found that structurally quite different substances, namely, the pseudotetrasaccharide acarbose and the monomeric glucose analog 1-deoxynojirimycin, act as competitive inhibitors for maltose and maltooligosaccharide hydrolysis. The Ki values for all used maltooligosaccharides are nearly equal, but for maltose hydrolysis the Ki values are significantly higher by a magnitude factor of two. The differences concerning Ki values can be explained by means of the two-binding-mode model.

Die therapeutische Bedeutung einer D2-Lymphadenektomie beim Magenkarzinom wird nach wie vor kontrovers diskutiert. Nach den bisherigen eigenen Daten scheinen jedoch besonders Patienten mit den Tumorstadien II und IIIA von einer Lymphknotendissektion in den Kompartments I und II zu profitieren [4]. Die sich haufenden Mitteilungen, das diese Prognoseverbesserungen ausschlieslich durch eine Stadienverschiebung („Stage migration“) — auch als Will-Rogers-Phanomen bezeichnet — bedingt sind [1, 3], haben uns zu einer erneuten Auswertung des eigenen Patientenkollektives veranlast.

The hydrolysis of maltose and isomaltose and of sucrose and isomaltose at two different catalytic sites of sucrase-isomaltase has been demonstrated. Maltose and sucrose are competing for the same catalytic center. This competing can be described by alternative substrate kinetics. Steady-state kinetic parameters Km and k0 (maximal reaction velocity per mol enzyme) for linear alpha-1,4 and alpha-1,6 glucosyloligosaccharides has been determined. Using these parameters subsite affinities for the catalytic sites of sucrase and isomaltase were computed. The different numbers of subsites for sucrase (2 subsites) and isomaltase (4 subsites) indicate, that the binding patterns for maltooligosaccharides and isomaltooligosaccharides are different. That means that for sucrase unproductive enzyme-maltooligosaccharide complexes are definitely less probable than the productive one. As in human small intestinal glucoamylase-maltase in the isomaltase moiety four subsites can be evaluated with affinity values (Ai): A1 = 2.6 (+/- 0.91), A2 = 13.8 (+/- 0.70), A3 = 1.1 (+/- 0.13) and A4 = 1.5 (+/- 0.13) kJ/mol using isomaltooligosaccharides. The two subsites of sucrase are evaluated to be A1 = 4.9 (+/- 0.70) and A2 = 16.7 (+/- 0.51) kJ/mol using maltooligosaccharides. The four subsite model for isomaltase and glucoamylase-maltase is an indication that these two enzymes are mechanistically homologous in binding linear glucosyl-oligosaccharides.