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The aim of this study was to describe the circumstances surrounding firework-related deaths in Denmark, locate similarities and compare findings to the other known literature. Autopsy files, including police reports, located through searches in the archives of the three Danish institutes of forensic medicine were accessed. Data describing the age, gender, toxicology findings, circumstances of the accident, cause of death, autopsy findings and type of fireworks were examined. Eight cases involving firework-related deaths matched the search criteria, two of which occurred on New Year's Eve. An unknown number of cases that had not been autopsied were confirmed to exist. Data from the included cases suggested that using illegal fireworks, being male and handling fireworks directly played a key role in deaths. Most notably, illegal fireworks account for few injuries overall but caused the most deaths found in this study. Firework-related deaths are a rare occurrence. Autopsy findings often reveal blast wave injury to be the cause of death. Only one of the eight decedents included in this study were intoxicated with alcohol. Thus it can be assumed that powerful illegal fireworks are, by themselves, a risk factor for a deadly accident, independent of alcohol intoxication.

Conversion therapy is a set of practices that aim to change or alter an individual’s sexual orientation or gender identity. It is premised on a belief that an individual’s sexual orientation or gender identity can be changed and that doing so is a desirable outcome for the individual, family, or community. Other terms used to describe this practice include sexual orientation change effort (SOCE), reparative therapy, reintegrative therapy, reorientation therapy, ex-gay therapy, and gay cure. Conversion therapy is practiced in every region of the world. We have identified sources confirming or indicating that conversion therapy is performed in over 60 countries.1 In those countries where it is performed, a wide and variable range of practices are believed to create change in an individual’s sexual orientation or gender identity. Some examples of these include: talk therapy or psychotherapy (e.g., exploring life events to identify the cause); group therapy; medication (including anti-psychotics, anti- depressants, anti-anxiety, and psychoactive drugs, and hormone injections); Eye Movement Desensitization and Reprocessing (where an individual focuses on a traumatic memory while simultaneously experiencing bilateral stimulation); electroshock or electroconvulsive therapy (ECT) (where electrodes are attached to the head and electric current is passed between them to induce seizure); aversive treatments (including electric shock to the hands and/or genitals or nausea-inducing medication administered with presentation of homoerotic stimuli); exorcism or ritual cleansing (e.g., beating the individual with a broomstick while reading holy verses or burning the individual’s head, back, and palms); force-feeding or food deprivation; forced nudity; behavioural conditioning (e.g., being forced to dress or walk in a particular way); isolation (sometimes for long periods of time, which may include solitary confinement or being kept from interacting with the outside world); verbal abuse; humiliation; hypnosis; hospital confinement; beatings; and “corrective” rape. Conversion therapy appears to be performed widely by health professionals, including medical doctors, psychiatrists, psychologists, sexologists, and therapists. It is also conducted by spiritual leaders, religious practitioners, traditional healers, and community or family members. Conversion therapy is undertaken both in contexts under state control, e.g., hospitals, schools, and juvenile detention facilities, as well as in private settings like homes, religious institutions, or youth camps and retreats. In some countries, conversion therapy is imposed by the order or instructions of public officials, judges, or the police. The practice is undertaken with both adults and minors who may be lesbian, gay, bisexual, trans, or gender diverse. Parents are also known to send their children back to their country of origin to receive it. The practice supports the belief that non-heterosexual orientations are deviations from the norm, reflecting a disease, disorder, or sin. The practitioner conveys the message that heterosexuality is the normal and healthy sexual orientation and gender identity. The purpose of this medico-legal statement is to provide legal experts, adjudicators, health care professionals, and policy makers, among others, with an understanding of: 1) the lack of medical and scientific validity of conversion therapy; 2) the likely physical and psychological consequences of undergoing conversion therapy; and 3) whether, based on these effects, conversion therapy constitutes cruel, inhuman, or degrading treatment or torture when individuals are subjected to it forcibly2 or without their consent. This medico-legal statement also addresses the responsibility of states in regulating this practice, the ethical implications of offering or performing it, and the role that health professionals and medical and mental health organisations should play with regards to this practice. Definitions of conversion therapy vary. Some include any attempt to change, suppress, or divert an individual’s sexual orientation, gender identity, or gender expression. This medico-legal statement only addresses those practices that practitioners believe can effect a genuine change in an individual’s sexual orientation or gender identity. Acts of physical and psychological violence or discrimination that aim solely to inflict pain and suffering or punish individuals due to their sexual orientation or gender identity, are not addressed, but are wholly condemned. This medico-legal statement follows along the lines of our previous publications on Anal Examinations in Cases of Alleged Homosexuality1 and on Forced Virginity Testing.2 In those statements, we opposed attempts to minimise the severity of physical and psychological pain and suffering caused by these examinations by qualifying them as medical in nature. There is no medical justification for inflicting on individuals torture or other cruel, inhuman, or degrading treatment or punishment. In addition, these statements reaffirmed that health professionals should take no role in attempting to control sexuality and knowingly or unknowingly supporting state-sponsored policing and punishing of individuals based on their sexual orientation or gender identity.

Infective endocarditis of the tricuspid valve is a known complication to intravenous drug use (IDU) and can lead to septic pulmonary embolism. This can be difficult to detect at a standard autopsy. The use of postmortem computed tomography (PMCT) is increasingly used as an important supplement to forensic autopsy. We herein present a case in which the PMCT of a 40-year-old woman with intravenous drug use (IDU) revealed multiple pulmonary infiltrates, which at the subsequent autopsy was shown to be septic pulmonary embolisms as a result of acute infective endocarditis of the tricuspid valve cusps. The endocarditis was macroscopically visible at autopsy, but the pulmonary embolisms were not. The PMCT images showed bipulmonary multiple scattered infiltrates, which were sampled and shown microscopically to be septic pulmonary embolisms. Using PMCT in this case allowed for a more targeted autopsy, and more accurate diagnosis and conclusions as to cause of death. This confirms the important role of PMCT as a complimentary examination method to autopsy.

The majority of homicides in the world are caused by firearms and a good understanding of gunshot wounds is important for the forensic pathologist. We have analyzed all 315 homicides by gunshots in Denmark during 1992-2016 with focus on information relevant to forensic pathologists. Of the 1417 homicides in Denmark in 1992-2016, 315 (22.2%) had gunshot trauma as the primary homicide method. During 1992-2016, there has been a significant decrease in the number of gunshot homicides overall, of homicides committed with hunting weapons, and of domestic gunshot homicides. Most victims (70.5%) and offenders (93.7% of homicides with known offenders) were males. Male victims were significantly younger than female victims. Most victims were killed with handguns (43.8%) or shotguns (41.0%). Compared to all other weapons, the victims killed with shotguns had fewer entry wounds, a higher New Injury Severity Score (NISS), and a higher proportion of contact/close-range entry wounds. The head (58.1%) and thorax (46.7%) were often injured, with injuries to the head being more common in contact/close-range entry wounds. The results show that gunshot injuries in homicides are different from suicides and accidents and clearly are affected by the homicide type, the sex of the victim, and the weapon used and that these entities are intertwined. Our findings provide an evidence-based foundation for use in death investigations and for policy development in the area of interpersonal violence.

Sharp force trauma is a common homicide method. The weapon is typically a knife, which is easily accessible and does not require special skills. We have analyzed all 471 sharp force homicides in Denmark during 1992-2016 with special focus on aspects that are relevant to forensic pathologists, including the distribution of wounds and organ injuries. Most homicides were committed inside with a kitchen knife. The front left thorax was the most common area to be affected by sharp force trauma. In 18.9% of the victims, there was only one sharp injury, the majority on the thorax. The most common trajectory for stab wounds was directly posterior with no deviation to the sides or up/down followed by directly anterior. The heart (including pericardium) and lungs (including hemo- and pneumothorax) had injuries in more than 75% of the victims. 67% of victims were males. Female victims had more sharp force injuries and defense wounds than male victims. Most females were killed in domestic homicides (73.7%), most commonly in partner killings (56.4%). In contrast, many male victims were killed in a setting of nightlife/intoxication (34.0%) most by a friend/acquaintance delivering a few stab wounds. The results clearly show strong sex differences in both victims and offenders. This could be useful for shaping policies and public opinion, and as a route for understanding the developments in interpersonal violence. In the narrow setting of death investigation, our results will provide an evidence-based approach to understanding the injury patterns in sharp force homicide.

OBJECTIVE: To investigate the difference in selected variables between children with and without hymenal transection, which is a healed defect that extends through the entire depth of the posterior hymenal membrane to the vaginal wall.MATERIALS AND METHODS: All female children from Southern Denmark who were examined by photocolposcopy in a six-year period were included in a retrospective cohort study. Statistical analyses included a chi-square test and a logistic regression analysis.RESULTS: Eighty girls under 15 years of age who were suspected to have been sexually abused were included. Sixteen of the girls had hymenal transections. There was a statistically significant correlation between the presence of hymenal transections and reported fresh bleeding after the assault.CONCLUSION: Bleeding after an assault could indicate more severe lesions, which might explain why these patients did not heal completely.

Patients suffering from psychiatric disorders have an excess mortality and a shorter life span expectancy compared to the general population. Furthermore, they are treated with multiple drugs and are known to have an increased risk of drug abuse. In this study, we aimed at investigating the pharmaceutical drug and drug of abuse profiles of the deceased included in the Danish prospective autopsy-based forensic study on psychiatric patients, SURVIVE. Using the postmortem systematic toxicological analysis results, we identified 129 different consumed compounds in our population (n = 443). Polypharmacy (≥5 compounds) was detected in 39.5% of the deceased. Deceased with a psychiatric diagnosis or who died from a fatal intoxication had significantly more compounds at the time of their death compared to having either no psychiatric diagnosis or another cause of death, respectively. Evidence of drug abuse was present, as 29.8% of our total population had consumed either methadone or illicit drugs of abuse, excluding tetrahydrocannabinol. Of those deceased with a psychiatric diagnosis, 33.6% had either consumed methadone or illicit drugs of abuse, a greater number than those without a psychiatric diagnosis. Fatal intoxication was the most frequent cause of death (40.6%) with methadone as the major intoxicant. Here, we found that those without a psychiatric diagnosis had fewer fatal pharmaceutical drug intoxications compared to the psychiatric diagnosis groups. Our findings add further context to understanding the excess mortality of psychiatric patents, since there is an increased occurrence of fatal intoxication, polypharmacy, and drug abuse in this population.

Objective: The aim of this descriptive cohort study was to characterize stranger rape compared to other types of rape. Method & Materials: All cases of women aged 12 years or older, who contacted a Center for Victims of Sexual Assault in the region of Southern Denmark and underwent a forensic examination in 2018, were collected and analyzed. Descriptive frequencies, Pearson's χ2-test and Fisher's exact-test were performed. Results: Compared to other types of rape, stranger rape were reported to the police more frequently, earlier and more frequently independently, without contact to family, friends or other authorities. In cases of stranger rape women were exposed to threats and violence more often, and clinical findings were found to coincide with the women's report more frequently. Regarding the offenders' level of planning, it was not possible to find significant differences between stranger rape and other rape types by comparing frequencies of the offenders' use of condoms and weapons and/or other remedies as surrogate markers for degree of planning. Conclusion: There were several significant characteristic differences between stranger rape and other types of rape. Characterizing the ‘archetypical rape’ in opposition to other and more frequent types of rape, may give the public, the police, the courts and aid organizations the background needed to understand the importance of rape typologies when handling cases of sexual assault.

In this case report, a 53-year old man died after ten days with fever and coughing and was tested positive for coronavirus disease 2019 (COVID-19). A post-mortem CT disclosed ground-glass opacities with focal consolidation in both lungs. At autopsy, the lungs were dark and heavy with increased consistency and without pleural fibrin. Microscopy of lung tissue showed diffuse alveolar damage with hyaline membranes, sparse chronic interstitial inflammation and foci of bronchopneumonia. The deceased was a non-smoker, who did not suffer from a serious illness. He was overweight (BMI = 34 kg/m2), an emerging predictor for poor outcome of COVID-19.

Freezing as a method for hiding a body is rare. We report here a homicide case in which three bodies were concealed in a freezer. This presented the pathologist with the problem of how to thaw the bodies and simultaneously avoid decomposition of the uppermost body. The problem was solved by slow thawing in a refrigerated morgue and by removing the bodies one after the other from top to bottom. The victims were a 27-year old mother and her two daughters, 7 and 9 years of age. The perpetrator was the 34-year old now-divorced husband and father. All were refugees from Syria. The perpetrator fled back to Syria. He was later arrested in Syria, confessed the crime and was sentenced to life imprisonment. The autopsy findings is discussed and compared to finding reported in the scientific literature.

Aims: Several drugs increase the risk of ventricular fibrillation and sudden cardiac death (SCD). We aimed to investigate in detail the toxicological findings of all young SCD throughout Denmark.Methods and results: Deaths in persons aged 1-49 years were included over a 10-year period. Death certificates and autopsy reports were retrieved and read to identify cases of sudden death and establish cause of death. All medico-legal autopsied SCD were included and toxicological reports collected. Positive toxicology was defined as the presence of any substance (licit and/or illicit). All toxicological findings had previously been evaluated not to have caused the death (i.e. lethal concentrations were excluded). We identified 620 medico-legal autopsied cases of SCD, of which 77% (n = 477) were toxicologically investigated post-mortem, and 57% (n = 270) had a positive toxicology profile. Sudden cardiac death with positive toxicology had higher rates of sudden arrhythmic death syndrome (SADS), compared with SCD with negative toxicology (56% vs. 42%, P Conclusion: We found that more than half of all toxicologically investigated SCD victims have positive post-mortem toxicological findings, and polypharmacy is displayed in a considerable proportion. SCD with positive toxicology had higher rate of SADS, suggesting that the compounds may play a proarrhythmic role in these cases.

In this paper we have reviewed the literature regarding homicidal drowning. Homicide of a child by drowning occurs occasionally, but it is much rarer that an adult is murdered in this way. When the victim is a child, there will often be few or no signs of violence due to the difference in size between the assailant and the victim, unlike the evidence of a struggle that is often found in adult victims of homicidal drowning, unless the victim was incapacitated by alcohol, drugs or physical weakness, or was unexpectedly pushed into or dragged under water. The incidence of cases in which the manner of death is undetermined is high in bodies retrieved from water. Therefore, a thorough investigation of such cases is needed.

Purpose: Improve mapping and registration of longitudinal view on histopathology vessels in a three-dimensional alignment procedure for postmortem quantitative coronary plaque analyses. This new procedure is applied and results shown using calcified coronary plaque analyses within post-mortem computed tomography angiography (PMCTA), optical coherence tomography (OCT) and the gold standard of histopathology.Results: In total, 338 annotated histopathology images were included, 166 PMCTA transversal images and 285 OCT images were aligned in the comparison. The results from the comparison using the alignment procedure showed overall that the calcified plaques seem to be overestimated by PMCTA and underestimated by OCT.Conclusions: The 3D fusion approach, aligning the images of PMCTA, OCT and histopathology as gold standard allowed for a slice-based comparison of the different modalities. The results showed that PMCTA overestimates the calcified plaques while OCT underestimates these, compared to histopathology. (C) 2018 Elsevier Inc. All rights reserved.

We present the findings for homicides in Denmark for 1992–2016. There were 1417 homicide victims (62.2% males, 37.8% females) that were killed in 1321 homicide events. The most common methods were sharp force trauma (33.2%), gunshot (22.2%), blunt force trauma (21.9%) and asphyxia (17.6%), and all methods exhibited a reduction during the study period. The homicide rate was 1.05 per 100,000, 1.32 per 100,000 for males, and 0.78 per 100,000 for females.Domestic homicides were the largest main group of homicides (76.5% of all female victims vs. 23.6% of male victims). Of the non-domestic homicides, 84.2% of victims were male, the largest group being in the setting of nightlife and/or intoxication. Most female victims (76.9%) were killed by someone in their family, while the largest share of male victims (34.5%) were killed by a friend or acquaintance. The offenders were males in 87.9% of all homicides. Keywords: Homicide, Interpersonal violence, Forensic pathology

Conversion therapy is a set of practices that aim to change or alter an individual's sexual orientation or gender identity. It is practiced in every region of the world by health professionals, religious practitioners, and community or family members often by or with the support of the state. Conversion therapy is performed despite evidence that it is ineffective and likely to cause individuals significant or severe physical and mental pain and suffering with long-term harmful effects. The purpose of this medico-legal statement is to provide legal experts, adjudicators, health care professionals, and policy makers, among others, with an understanding of: 1) the lack of medical and scientific validity of conversion therapy; 2) the likely physical and psychological consequences of undergoing conversion therapy; and 3) whether, based on these effects, conversion therapy constitutes cruel, inhuman, or degrading treatment or torture when individuals are subjected to it forcibly or without their consent. This medico-legal statement also addresses the responsibility of states in regulating the practice, the ethical implications of offering or performing it, and the role that health professionals and medical and mental health organisations should play with regards to it.

Decapitation is an occurrence only rarely encountered in forensic medical practice. This fatality is generally most often described in pedestrians who have been run over by trains accidently or in cases of suicide, or alternatively in occupants of cars involved in high speed vehicle collisions. We report, for the first time, a case of a complete decapitation of a pedestrian as a consequence of a traffic accident. Due to a thorough medico-legal investigation of the body and the involved vehicle, we were able to reconstruct the unique dynamics of the accident and the mechanism of injury.

Suicide using a combination of a plastic bag over the head and inhalation of a non-irritating gas, such as helium, argon or nitrogen, has been reported in the literature. Here an unusual suicide method in a 17-year old man by suffocation from covering the face with household plastic wrap, combined with nitrous oxide inhalation, is presented. The case was reviewed based on police, autopsy and hospital reports. A PubMed search for scientific literature related to nitrous oxide abuse and suicide by suffocation was performed and our findings discussed in relation to the scientific literature found. The deceased was a 17-year old man who was found with the nose and mouth closed with a piece of kitchen plastic wrap. The plastic wrap had been removed prior to autopsy. Autopsy findings were suggestive of asphyxia, but were otherwise negative. Nitrous oxide was detected in the brain and lung tissue with headspace-gas chromatography-mass spectrometry (headspace-GCMS). The cause of death was assumed to be suffocation caused by plastic wrap covering the face, combined with nitrous oxide inhalation. Suicide was suspected because of a history of depression for several months. Nitrous oxide, also known as laughing gas, has a euphoric effect and is used as a recreational inhalant drug that can be purchased legally. Deaths caused by recreational nitrous oxide abuse are rare but may occur if used in combination with a plastic bag over the head. This is the first report of suicide by suffocation by external obstruction combined with nitrous oxide inhalation.

Case control study of drowning fatalities investigated with autopsy and post mortem computed tomography (PMCT). 40 drowning fatalities (25 men, 15 women; 24 salt water, 16 fresh water) and 80 controls were included. The aim was to investigate the difference in lung tissue density (g/liter) and radio opacity between drowning cases compared to control cases and to determine if it was possible to differentiate saltwater and freshwater drowning by measuring a difference in radio density of blood in the hearth chambers or great vessels before and after passage through the lungs of a drowned individual or when comparing drowned individuals with controls. The lung density was measured by a combination of PMCT measured total lung volume and autopsy measured total lung weight. We found that the lung density and the lung radio density were decreased, the lung volume increased and the lung weights equal in drowning cases compared to controls, illustrating the phenomenon knows as “emphysema aquosum”. The physiological explanation could be washing out of surfactant by the drowning media, resulting in atelectasis and trapping of air in the peripheral lung regions. It was not possible to separate fresh and saltwater drowning by comparing radio opacity of blood in the hearth chambers or great vessels or by comparing the radio opacity of blood in cases and controls. We suspect that sedimentation of red blood cells after death makes such measurements meaningless.

Chest compression devices for mechanical cardiopulmonary resuscitation (CPR) have become more common. Here, we report the case of a young woman who attempted resuscitated with LUCAS™2 after she was found unconscious at home. At autopsy, we found extensive intramuscular hemorrhages in posterior neck, between the scapulae, and in the lumbar region. Investigation of internal organs showed injuries to the lung, spleen, and kidney. The extension of the injuries gave rise to suspicion of homicide by smothering, which police investigation subsequently did not support. The pattern of injury could be attributed to automatic compression decompression CPR with LUCAS™2.The injuries may have been lethal had the patient survived. For the forensic pathologists, it is important to remain updated on developments in treatment techniques to avoid pitfalls when interpreting injury.Larger studies, prospective or retrospective, may be able to qualify the possible risks of automatic compression decompression CPR even further.

This paper presents the outcome of the first international forensic radiology and imaging research summit, organized by the International Society of Forensic Radiology and Imaging, the International Association of Forensic Radiographers, the National Institute of Justice of the United States of America, and the Netherlands Forensic Institute. During this meeting, an international and multidisciplinary panel of forensic scientists discussed the current state of science in forensic radiology, and drafted a research agenda to further advance the field. Four groups for further research focus were identified: big data and statistics, identification and biological profiling, multimodal imaging, and visualization and presentation. This paper describes each of these research topics and thereby hopes to contribute to the development of this exciting new field of forensic medical science.

Subnuclear vacuolization of the renal tubular epithelium is indicative of diabetic and alcoholic ketoacidosis and has also been proposed as a postmortem marker for hypothermia. We present for the first time a fatal case of ketoacidosis in combination with exposure where a suspicion of these diagnoses was raised by a marked radiolucency of the kidneys at post-mortem computed tomography (PMCT). © 2015 Elsevier Ltd.

Danish forensic reports concerning manual strangulation routinely state that any strangulation attempt may pose a danger to life due to a cardioinhibitory reflex mechanism. There are, however, only few case reports in which a cardioinhibitory reflex mechanism was stated as a possible cause of death. Carotid stimulation may induce syncope in patients with carotid sinus syndrome, but is not associated with increased mortality. Experiments with inflatable neck collars has not led to life-threatening arrhythmias. Neck holds used in martial arts are rarely associated with any complications.

Background: Stab wounds are common in homicide cases. Post-mortem multislice computed tomography (PMCT) has proved to be a useful tool in forensic examinations of victims of sharp force trauma, but due the limited resolution of soft tissues, the radiological depiction of a stab channel is difficult. In this study, we have tried to obtain information about the shape of a knife blade by CT scanning contrast-filled experimentally inflicted stab wounds in various types of pig tissue. Methodology: The tissue samples were mounted on floral foam (oasis) with wooden sticks. Two contrast media were used: one was unmodified and easy flowing, and one was made more viscous with polyethylene glycol. Stab channels in ballistic soap were used for comparison. India ink-filled stab channels were investigated histologically to determine the pattern of leakage. Principal findings: We found that the shape of the stab wounds on the CT images from lung and muscle tissue did not correspond well to the shape of the inflicting knife. There was a better correspondence in the images obtained from liver, spleen and kidney. The viscous contrast medium was less likely than the thin (easy flowing) contrast medium to spill into to structures outside the stab channel, but some spillage was observed for both types of contrast medium. Air bubbles were only observed in the viscous contrast medium. Conclusion: Radiological evaluation of a contrast-filled stab wound in isolated tissue blocks did not permit the positive identification of the inflicting weapon, but it was, in tissue blocks from liver, spleen and kidney, possible to obtain a rough idea of the shape of the inflicting knife and to differentiate a knife from a screwdriver.

Aortic coarctation (AC) is a congenital aortic narrowing. We describe for the first time the findings obtained by unenhanced post mortem computed tomography (PMCT) in a case where the death was caused by cardiac tamponade from a ruptured aneurysmal dilatation of the ascending aorta and the aortic arch without dissection combined with aortic coarctation. The patient, a 46-year-old man, was found dead at home. PMCT showed haemopericardium and dilatation of the ascending aorta and the aortic arch. This appearance led to the mistaken interpretation that the images represented a dissecting aneurysm. The autopsy showed instead a thin-walled and floppy dilatation of the ascending aorta and aortic arch with a coarctation just proximal to the ligamentum arteriosum. A longitudinal tear was found in the posterior aortic wall just above the valves. Blood in the surrounding soft tissue intersected with a large haematoma (1000 ml) in the pericardial sac. Cardiac hypertrophy (556 g) was observed in the patient, though no other cardiovascular abnormalities were found. Histological analysis showed cystic medial necrosis of the ascending aortic wall. A ruptured aneurysmal dilatation of the ascending aorta and the aortic arch without aortic dissection associated with AC is an uncommon cause of haemopericardium that has only been described a few times before. The case is discussed in relation to other reported cases and in the context of the present understanding of this condition.

Modern diagnostic imagining techniques are gaining popularity in forensic medicine. Denmark has been involved in the development of this use of imaging techniques from the beginning. The Institute of Forensic Medicine at the University of Southern Denmark acquired a helical computed tomography (CT) scanner in 2006. This thesis presents our research on post-mortem CT (PMCT) and addresses the following research questions: 1. In how many cases can the cause of death be established by PMCT, and what characterises these cases? 2. What is the inter-method variation between autopsy and PMCT with regard to disease and injury diagnoses? 3. Can PMCT be used as a screening tool for selecting cases for autopsy, and can PMCT in some cases substitute for autopsy? 4. What is the inter-observer variation in PMCT? Who should evaluate the images? 5. How much new information is obtained by the histological examination of tissue samples? 6. Can PMCT be used for Abbreviated Injury Scale (AIS) scoring and Injury Severity Scoring (ISS) of traffic fatalities? 7. How can coronary PMCT angiography (PMCTA) be used for optimising clinical CT of the coronary arteries? 8. How can PMCT contribute to forensic autopsies? MATERIALS AND METHODS: This thesis investigated 900 forensic cases that were CT-scanned and autopsied at the Institute of Forensic Medicine, University of Southern Denmark, from 2006-2011. The scanner was a Siemens Somatom Spirit dual-slice CT-scanner with a Siemens Syngo MultiModality workstation. Contrast enhancement was not used. Autopsies were performed according to the Danish government's official guidelines. PMCT and autopsy findings were interpreted independent of each other. Diagnoses, including the cause of death and histology findings, were registered in a computer database (SPSS) together with information about the deceased and the case. We also estimated whether an autopsy could have been omitted according to a set of predetermined criteria. RESULTS: 1. Cause of death: Agreement about the cause of death was found in 66% of cases. No cause of death could be found by PMCT in 45% of cases, compared with only 15% of cases by autopsy. The agreement between PMCT and autopsy was highest in cases of accidents (85%) and lowest in cases of natural deaths (48%). 2. Inter-method agreement: A total of 70% of non-injury diagnoses and 65% of injury diagnoses were obtained by both autopsy and PMCT. PMCT was unable to detect some important non-injury diagnoses (coronary stenosis, coronary thrombosis, acute myocardial infarction, fibrotic myocardial scar, pulmonary embolism, oesophageal varices, and non-perforated gastrointestinal ulcerations). PMCT was good at detecting major haemorrhages, air and fluid collections, fatty liver, hyper- and hypotrophy, neoplasms, cysts, gallstones, kidney stones, aneurysms, and cerebral haemorrhages. PMCT was superior to autopsy in detecting fractures in the facial skeleton, spine, and extremities, but it was less reliable in detecting injuries in the inner organs, small haematomas, and aortic transections. 3. PMCT as a screening tool: It was estimated that PMCT could substitute for autopsy in at least 15% of cases, but in 6% of these cases, an important autopsy finding would be missed. There were more accidents and fewer natural deaths among the cases where an autopsy could be omitted. 4. Inter-observer variation: The inter-observer variation of PMCT injury diagnoses between a forensic pathologist and a radiologist was evaluated in a study of 67 traffic fatality victims with 994 AIS injury diagnoses. The study showed a substantial inter-observer agreement (kappa=0.65). The radiologist diagnosed more injuries than the pathologist, especially injuries in the spine and face. The radiologist diagnosed more injuries in the skeletal system, and the pathologist diagnosed more injuries in the organs and soft tissues. The difference between the two observers was smallest for lesions with a high AIS severity score. 5. Importance of histology: The histological examination confirmed the autopsy findings in 59% of all cases. Important new information was obtained in 23% of cases, and some, but less important, new information was obtained in 15% of cases. There were significantly fewer important microscopic findings (7%) in cases where it had been estimated that an autopsy could be substituted by PMCT. 6. PMCT used to assess the AIS score and ISS: This question was investigated in a study of 52 traffic fatalities. On average, there was 94% agreement between PMCT and autopsy in the detection of lesions, with kappa-values varying from 0.39 to 1.00 among the different AIS anatomical regions. When different severity scores were obtained, PMCT detected more lesions with a high severity score in the facial skeleton, pelvis, and extremities, whereas autopsy detected more lesions with high scores in soft tissues, the cranium, and ribs. In 85% of these traffic fatalities, there was no or moderate variation in the ISS (kappa=0.53). When the difference was higher, it was usually because an aortic rupture had been overlooked by PMCT. 7. Post-mortem coronary angiography: A new method was presented in which an autopsy heart was investigated with optical coherence tomography (OCT) and scanned in a chest phantom with dual-energy CT. A contrast agent that solidified after cooling was injected into the coronary arteries. The OCT and CT images were compared with their corresponding histological sections. A procedure for ensuring the correct alignment of the images was also developed. 8. Contribution of PMCT to forensic autopsy: PMCT findings in cases of fire, identifications, traffic fatalities, drowning, bolus deaths, and homicides are presented. Three case studies are summarised: detection of tablet residues in the stomach, detection of a congenital displacement of the second cervical vertebra in a newborn, and an investigation of the sacral bone from the medieval Danish King Canute the Saint. DISCUSSION: 1. Cause of death: Unenhanced PMCT could not detect several important natural causes of death, including many cardiovascular diseases, but could identify the cause of death in many cases where death was caused by injury, most likely because fractures, large haemorrhages, and pneumothoraces could be detected by PMCT relatively easily and because many deaths were caused by severe, and therefore easily identifiable, injuries. 2. Inter-method variation: PMCT was superior to autopsy in some cases, such as in diagnosing fractures, investigating areas not dissected in the autopsy, and detecting pneumothorax and other pathological gas collections, but PMCT also had some significant weaknesses, especially in the diagnosis of pathological lesions (mainly cardiovascular diseases). Several researchers have suggested strategies to overcome these diagnostic limitations, including the use of CT-guided biopsy and post-mortem angiography. 3. PMCT as a screening tool: It was possible to select some cases in which PMCT could replace autopsy. Our study included only cases selected for autopsy and should be supplemented with a study on cases not selected for autopsy. In some cases autopsy must always be performed, e.g., if an extensive histological investigation is needed or in automobile drivers to exclude natural diseases that may have caused the accident. Autopsy is mandatory by Danish law if homicide is suspected. 4. Inter-observer variation: The inter-observer variation was low, but the radiologist diagnosed more injuries than the pathologist. It is recommended that the pathologist consult a radiologist for the evaluation of CT images. 5. Importance of histology: The importance of histology and the possibility to supplement PMCT with needle biopsies were discussed. 6. PMCT used for AIS scoring and for assessment of the ISS: We found a high correlation between AIS scores obtained by autopsy and PMCT. Autopsy was best for AIS scoring of soft tissues, the cranium, and ribs, while PMCT was best for AIS scoring of the facial skeleton, pelvis, and extremities. There was moderate agreement between ISS obtained with autopsy and PMCT. Rupture of the aorta was often overlooked by PMCT, resulting in ISSs that were too low. A combination of autopsy and PMCT provided the most accurate information. 7. Post-mortem coronary angiography: The method presented can be used to determine whether CT evaluation of the coronary arteries with plaque characterisation is possible in preparation for a clinical study. 8. The contribution of PMCT to forensic autopsy: PMCT permits investigation of anatomic regions that are not routinely dissected by autopsy and depicts the anatomy in situ. PMCT provides digital documentation that is easily stored and transmitted, thereby facilitating audit and review by others, and provides images that are more aesthetically suited for court presentation than autopsy photographs. The importance of PMCT in gunshot cases, identifications, stab wounds, strangulation, drowning, intoxications, fire deaths, and pathological gas collections was discussed. The CT investigation of the bones belonging to King Canute the Saint was discussed.

So called extended suicides are a parents murder of his or hers own children, and sometimes also of the other parent, followed by the perpetrators suicide. Our investigation documents that these homicides has decreased in number in Denmark and that the perpetrators are now predominantly the fathers. In an earlier investigation (Homicide in Denmark 1946-70, doctoral thesis by Hart-Hansen JP) the predominant type of extended suicide was committed with carbon monoxide from household gas, but today the preferred homicide methods are much more violent. The reason for the dramatic fall in the number of extended suicides in Denmark can not be deduced from our study, but it is possible that it is related to changing social conditions for and a changed view on unmarried mothers. The motive for these killings was originally stated to be altruistic (the child should not live without the mother), but is now more often related to revenge (if the mother do not want to live with me, the children and she must die).

Determining the most probable cause of death is important, and it is sometimes tempting to assume an obvious cause of death, when it readily presents itself, and stop looking for other competing causes of death. The case story presented in the article illustrates this dilemma. The first assumption of cause of death, which was based on results from bacteriology tests, proved to be wrong when the results from the forensic toxicology testing became available. This case also illustrates how post mortem computed tomography (PMCT) findings of radio opaque material in the stomach alerted the pathologist to the possibility of tablet ingestion.

Introduction Coronary atherosclerosis is a leading cause of mortality. New technological developments in computed tomography (CT), including dual energy, iterative reconstructions and high definition scanning, could significantly improve the non-invasive identification of atherosclerosis plaques. Here, a new method for optimising cardiac coronary CT with optical coherence tomography (OCT) and histopathology is presented. Materials and methods Twenty human hearts obtained from autopsies were used. A contrast agent that solidifies after cooling was injected into the coronary arteries. CT scanning was performed on the heart alone as well as with the heart in a chest phantom. We used eight different CT protocols and the newest CT technique to image every heart. The OCT and CT images were compared with their corresponding histological sections. A procedure for ensuring the correct alignment of the images was also developed. Results We have succeeded in developing a new method for post-mortem coronary CT angiography in which an autopsy heart is placed in a chest phantom to simulate clinical CT. Conclusion The new method permits comparison of CT with OCT and histopathology. This method can also be used for evaluating coronary artery disease, including characterising plaques, and will eventually allow for the detection of rupture-prone plaques, which we will assess in a future study. Clinical testing is our ultimate goal.

During a 10-year period (1980-1989), at least 43 cases of self-incineration with lethal outcome took place in Denmark. The incidence seems to be increasing: 11 cases took place in the first 5 years and 32 cases in the last 5 years. An even sex ratio as found (male:female = 23:20). The median age was 43 years, with a broad age range (20-87). Many incidents of self-incineration as a form of political protest were reported in the press especially during the 1960s and 1970s, and the press reports often inspired others to commit suicide in the same way. None of the cases in our investigation were politically motivated or reported in the press, and only one case could have been inspired by another similar case. Other investigations have shown that self-incineration is more common in some cultures than in others, and many have found that a religious motivation was common. In our investigation, all victims were of Danish origin, and a religious motive played no significant role. Most of the victims were suffering from mental illness, and a majority had tried to commit suicide before. None of the victims left a suicide note. The scene was most often at home and indoors--only a minority committed suicide in remote areas of the countryside. Most were found dead at the scene, and the cause of death was usually heat exposure. Only a minority had a lethal carboxy-hemoglobin (CO-Hb) concentration. It is concluded that close cooperation between police, fire experts, and the forensic pathologist is necessary to permit a correct classification of the mode of death in these cases.

We write to you today to suggest the need for standardisation of terminology used in the forensic/autopsy journals in the ever increasing number of publications in the emerging field post-mortem cross-sectionalimaging.Inouropinion,thereare too many different terms used currently both as words and/or abbreviations and the time has come to propose within the forensic literature that common terminology be applied to this field. The introduction of standardised terminology is critical, not only for those endeavouring to write and publish their work but also for those attempting to find references by keyword searches. We suggest the following terminology be introduced to initiate the process of standardisation: 1. Currently, the two modalities emerging as dominant in post-mortem imaging are computed tomography and magnetic resonance imaging. We propose, as has been adopted within the UK, these be generically referred to as post-mortem cross-sectional imaging, so both modalities are covered by a single phrase. Authors could then go on to specify which of the two modalities, i.e. post-mortem computed tomography or postmortem magnetic resonance imaging or both, are referred to within their work. 2. In the case of post-mortem computed tomography, we propose the abbreviation PMCT be used. In the case of

Hvis et menneske dør under anholdelse eller i myndighedernes varetægt, skal omstændighederne undersøges nøje. Advokater vil ofte blive involveret i disse sager enten som repræsentant for familien til den afdøde eller for de personer,som foretog fastholdelsen. Få det lægefaglige indblik i de ofte meget komplekse årsager til dødsfaldet.

The present study investigated the interobserver variation between a radiologist and a forensic pathologist in 994 injury diagnoses obtained by postmortem computed tomography (CT) of 67 traffic fatality victims, and the results were compared with diagnoses obtained by autopsy. The injuries were coded according to the abbreviated injury scale (AIS). We found a low interobserver variability for postmortem CT injury diagnoses, and the variability was the lowest for injuries with a high AIS severity score. The radiologist diagnosed more injuries than the pathologist, especially in the skeletal system, but the pathologist diagnosed more organ injuries. We recommend the use of a radiologist as a consultant for the evaluation of postmortem CT images. Training in radiology should be included in forensic medicine postgraduate training. CT was superior to autopsy in detecting abnormal air accumulations, but autopsy was superior to CT in the detection of organ injuries and aortic ruptures. We recommend a combination of CT and autopsy for the postmortem investigation of traffic fatality victims.

Cardiac arrest may occur while persons are being kept in hobble restraint. It has been suggested that asphyxia caused by the restraint position, so-called restraint asphyxia, is the cause, but experimental evidence has not confirmed this theory. Some of the sudden deaths are associated with excited delirium syndrome (EDS), an acute condition characterized by a hyperactive, combative behaviour in individuals, who are influenced by psychoactive drugs or suffer from psychiatric illness. Autopsy findings fail to explain this type of deaths. The pathophysiology of EDS is complex and poorly understood. Sensibilisation of the heart by a hyperadrenergic autonomous dysfunction, metabolic acidosis and hyperthermia offer possible mechanisms.

Når et menneske dør i myndighedernes varetægt er det en alvorlig sag som må undersøges grundigt. Nogle af disse dødsfald indtræffer i umiddelbar tilslutning til kortvarig tvangsfiksering, hvor en person bliver lagt ned og fikseret på arme og ben, hvorefter der pludselig indtræder hjertestop. I forsøget på at forklare disse dødsfald har det været foreslået, at fikseringsstillingen kunne hæmme vejrtrækningen i en sådan grad, at der var risiko for kvælningsdød, men flere eksperimentelle undersøgelser har ikke kunne bekræfte denne teori. Man hælder i dag til den antagelse, at mange af disse dødsfald må henføres til et syndrom som betegnes excited delirium syndrome (EDS), en akut indsættende tilstand karakteriseret ved en hyperaktiv og voldelig adfærd, næsten overmenneskelig styrke og immunitet for smerte. Obduktion viser ikke forandringer som kan forklare dødsfaldet. Årsagen til EDS er ukendt. En form for hyperadrenerg autonom dysfunktion med hjertepåvirkning og vaskulært kollaps kan være et element. De fleste som udvikler EDS er påvirket af psykoaktive stoffer, især kokain, og nogle er sindslidende. For at undgå disse dødsfald bør tvangsfiksering undgås hvis det er muligt. Medicinsk intervention med hurtigtvirkende sedativa er vigtig. Ved dødsfald er det vigtigt at en grundig politimæssig efterforskning og retsmedicinske undersøgelser iværksættes uden forsinkelse.

The purpose of this investigation was to provide an analysis of the 166 homicidal deaths that occurred in Southern Denmark during 25 years.The inspiration came from increased press coverage of certain homicides that I as a forensic pathologist felt did not mirror the real situation. Extensive press coverage of a few serious cases has left the public with the impression that the number of homicides was escalating, and this has been cause for public concern, and has prompted various harsh legislative steps. A lot of public interest has been focused on knife homicides, on honor killings among Muslims, on gang homicides and on homicides committed by psychotic individuals. The political response to public opinion has to some degree been focused on increased punishment for violence. With this in mind, the aim of the investigation was to answer the following research questions: : Research Question 1: What was the homicide rate in the study area, and has it changed during the 25-year study period? Research Question 2: How were the homicides distributed according to motive? Research Question 3: How often was the homicide motivated by a psychosis? Research Question 4: Has the ratio between intra- and extra-family homicides changed? Research Question 5: How often were weapons used? Research Question 6: Is it possible to identify some important social factors characterizing homicide victims? Research Question 7: Has the homicide pattern described changed over time? Research Question 8: What are the implications of this study for homicide prevention strategies?

OBJECTIVES:: The purpose of this investigation is to evaluate the value of postmortem computerized tomography (CT) for Abbreviated Injury Scale (AIS) scoring and Injury Severity Scoring (ISS) of traffic fatalities. MATERIAL:: This is a prospective investigation of a consecutive series of 52 traffic fatalities from Southern Denmark that were CT scanned and autopsied. The AIS and ISS scores based on CT and autopsy (AU) were registered in a computer database and compared. Kappa values for reproducibility of AIS-severity scores and ISS scores were calculated. RESULTS:: On an average, there was a 94% agreement between AU and CT in detecting the presence or absence of lesions in the various anatomic regions, and the severity scores were the same in 90% of all cases (range, 75-100%). When different severity scoring was obtained, CT detected more lesions with a high severity score in the facial skeleton, pelvis, and extremities, whereas AU detected more lesions with high scores in the soft tissues (especially in the aorta), cranium, and ribs. The kappa value for reproducibility of AIS scores confirmed that the agreement between the two methods was good. The lowest kappa values (>0.6) were found for the facial skeleton, cerebellum, meninges, neck organs, lungs, kidneys, and gastrointestinal tract. In these areas, the kappa value provided moderate agreement between CT and AU. For all other areas, there was a substantial agreement between the two methods. The ISS scores obtained by CT and by AU were calculated and were found to be with no or moderate variation in 85%. Rupture of the aorta was often overlooked by CT, resulting in too low ISS scoring. DISCUSSION:: The most precise postmortem AIS and ISS scorings of traffic fatalities was obtained by a combination of AU and CT. If it is not possible to perform an AU, then CT may be used as an acceptable alternative for AIS scoring. We have identified one important obstacle for postmortem ISS scoring, namely that aorta ruptures are not easily detected by post mortem CT. Language: en

This is a prospective investigation of a consecutive series of 250 deceased individuals who were computerized tomography (CT)-scanned and autopsied. In 13% of patients, important findings at the CT-scanning were not found at the autopsy, and in 48% of patients, important autopsy findings were not found at the CT-scanning. The cause of death could be established by CT in 31%, by autopsy in 74%, and by toxicology in 22%. CT combined with data from the inquest could establish the cause of death in a majority of deaths due to severe trauma, but only in a minority of deaths caused by disease or poisoning. We found the Siemens Somatom Spirit dual-slice CT-scanner cost effective, quick, and well suited as a supplement to the routine autopsy. CT is useful in identifications, gunshot lesions, and traffic accidents. CT allows investigation of anatomic regions that are not easily available by autopsy and allows fractures and inner organs to be seen "in situ." CT provides documentation in digital form - easily stored - permits review by others and provides pictures that may be more suitable for presentation in court than autopsy photos.

Intimate partner homicides represent the most severe outcome of intimate partner violence, and constitute more than a quarter (26%) of all homicides in adults over 15 years of age in Southern Denmark. In our experience the victims of partner homicides are primarily women, often from socially disadvantaged families, and that these homicides usually are the result of an impulsive act, with the perpetrator often committing suicide after the act. The aim of this study was to investigate these hypotheses further, and to provide an up-to-date overview of intimate partner homicides in Southern Denmark.

In 4929 consecutive autopsies performed during a period of 4 years, 222 cases (4.5%) of cirrhosis were found, of which 149 (3%) were detected while the patients were alive (diagnosed cirrhosis) and 73 (1.5%) were not detected while the patients were living (undiagnosed cirrhosis). Fifty-three of the 73 undiagnosed patients appeared to be completely without signs of cirrhosis (silent cirrhosis). In the diagnosed group, 70% of patients died from hepatic causes, in contrast to 16% in the undiagnosed group. At autopsy, the following complications of cirrhosis were found more frequently in the diagnosed group than in the undiagnosed group: ascites (41% vs. 8%), oesophageal varices (44% vs. 10%), splenomegaly (52% vs. 29%). The prevalence of hepatocellular carcinoma did not differ significantly in the two groups (12% vs. 8%). It is concluded that cirrhosis without obvious signs occurs relatively frequently, and that no sensitive non-invasive screening methods are available at present.

UNLABELLED: A case of perinatally acquired spinal cord injury (SCI) is presented. The foetus was vigorous until birth, the breech presented and delivery was performed by a non-traumatic Caesarean section. The infant displayed symptoms of severe SCI but diagnosis was delayed due to severe co-morbidity. Diagnostic considerations are briefly reviewed. Ventilatory support was withdrawn at the age of 20 days when the infant had still not exhibited any respiratory effort or spontaneous movements. Autopsy revealed a serious congenital malalignment of the upper cervical vertebrae and at the histological examination extensive reactive changes were observed in the same area. To our knowledge such findings have not been published previously.CONCLUSION: In cases of serious perinatally acquired SCI, claim of malpractice is often apparent. In this case a hidden congenital malformation of the cervical vertebrae was revealed, highlighting the need of careful postmortem examinations in such cases.

Computerized tomography (CT) is finding increased use in forensic medicine. In this article we present our experience with CT in medico legal deaths.This is a retrospective investigation of 150 deceased individuals who were CT-scanned and autopsied. The CT-scanning was performed and interpreted by a specialist in forensic medicine. The CT-scanning and the autopsy were performed independently by two different physicians.In 9% of the cases, important findings by the CT-scanning were overlooked at the autopsy, and in 51% important findings by the autopsy were not found by the CT-scanning. The cause of death could be established by CT-scanning in 30%, by autopsy in 72% and by toxicology in 21% of the cases. CT-scanning was most useful in cases of traumatic death.CT is rarely a substitute for autopsy, but may contribute with important new information in many cases such as identifications (including mass-disasters), gunshot wounds and traffic accidents. CT provides documentation in digital form that is easily stored and copied, permits review by others and provides pictures that may be more suitable for presentation in court than autopsy photos. CT may be helpful in medico legal external examinations (inquests) in the process of selecting cases for autopsy.