Traumatic Vulvar Epithelial Inclusion Cysts Following Female Genital Mutilation (FGM).

Background: Female genital mutilation (FGM) occurs mainly in Africa, parts of the Arabian Peninsula and parts of Asia. It is commonly associated with acute complications as well as diverse late/delayed complications. One of the most common of these late complications is progressively enlarging painless cysts of the vulva. Case Report: An 8-year-old girl from Eritrea presented to our paediatric emergency department with a progressively enlarging mass of the vulva. She had undergone a clitoridectomy and partial removal of the labia minora as an infant in Eritrea. We performed surgical excision of the cyst and reconstruction of the labia. Histology showed a traumatic squamous epithelial inclusion cyst of the vulva. Conclusion: Epithelial or dermoid cysts of the vulva following FGM are extremely rare. Symptoms often require surgical intervention. Through increasing migration, more girls and female youths with FGM are likely to present to practices and hospitals in Germany. Thus increased knowledge and awareness of the medical complications of FGM and their treatment will be necessary in years to come.

Child abuse inflicted by small children.

In cases of child abuse, usually, the parents are initial suspects. A common explanation of the parents is that the injuries were caused by a sibling. Child-on-child violence is reported to be very rare in children less than 5 years of age, and thorough investigation by the police, child protective services, and medicolegal examinations are needed to proof or disproof the parents' statement. We report two cases of physical abuse of infants by small children.

Accidental mechanical asphyxia of children in Germany between 2000 and 2008.

Accidents constitute one of the greatest risks to children, yet there are few medical reports that discuss the subject of accidental asphyxia. However, a systematic analysis of all documented cases in Germany over the years 2000-2008 has now been conducted, aiming at identifying patterns of accidental asphyxia, deducing findings, defining avoidance measures and recommending ways of increasing product safety and taking possible precautions. The analysis is based on a detailed retrospective analysis of all 91 relevant autopsy reports from 24 different German forensic institutes. A variety of demographic and morphological data was systematically collected and analysed. In 84 of the 91 cases, the sex of the victim was reported, resulting in a total of 57 boys (68 %) and 27 girls (32 %). The age spread ranged between 1 day and 14 years, with an average of 5.9 years. Most accidents occurred in the first year of life (20 %) or between the ages of 1 and 2 years (13 %). In 46 % of cases, the cause of death was strangulation, with the majority occurring in the home environment. In 31 % of all cases, the cause of death was positional asphyxia, the majority resulting from chest compression. In 23 % of cases, the cause of death was aspiration, mainly of foreign bodies. Today, accidental asphyxiation is a rare cause of death in children in Germany. Nevertheless, the majority of cases could have been avoided. Future incidence can be reduced by implementing two major precautions: increasing product safety and educating parents of potentially fatal risks. Specific recommendations relate to children's beds, toys and food.

Estimation of postmortem metabolic changes in porcine brain tissue using 1H-MR spectroscopy--preliminary results.

To investigate the potential for estimating the time since death by monitoring the evolution of different metabolites in brain tissue by (1)H-MRS, an animal model using pig heads was established. The maximum examination interval was 3 weeks. Within this time interval spectra revealed different compositions of metabolites, including metabolites observed in the normal brain and as products of bacterial decomposition processes (N-acetyl-aspartate 0-130 h, creatine 0-170 h, bound trimethylammonium, e. g. choline compounds, during the whole time course with fluctuating intensities, lactate 0-200 h, alanine and acetate during the whole time course, succinate and free trimethylammonium after approx. 100 h postmortem). The proposed approach may offer a new method to estimate later postmortem intervals although these observations have to be confirmed by further studies.

Smothering of children older than 1 year of age-diagnostic significance of morphological findings.

A homicide by smothering may leave unobtrusive or even no injuries if the victim is not able to struggle. This is especially true for infants up to 12 months of age. The differentiation between the sudden infant death syndrome and smothering, by an autopsy alone may be impossible. To establish whether this is different in older children because of their rising capacity for defence six cases of smothering in children >1 year of age were re-examined. The age of the children ranged between 1.5 and 7 years (surviving child). The smothering was inflicted with hands in three cases (including the surviving child), with a pillow in two cases, and the way of smothering remained unknown in one case (no confession of the perpetrator). Depending on the tool used for smothering, abrasions on the facial skin (hands, lesser in cases of smothering by a pillow) and petechiae (pillow/hands) could be seen by external examination. The older the children were, the more injuries could be found. Together with circumstantial evidence all cases could have been established by a thorough autopsy. This is important to prevent further offences against (surviving) siblings.

[Homicide by burning]. / Tötung durch Verbrennen.

Compared to the total number of deaths by heat (burning, scalding), homicides by the direct effect of thermal energy (setting the victim on fire, pouring hot liquids over them) are rare; accordingly this subject is seldom dealt with in forensic and criminological literature. From our own autopsy material three cases are presented describing some peculiarities of homicide by heat. Sometimes additional findings (e.g., residual traces of gagging or tying) primarily point in the direction of homicide.

Postmortem biochemical examination of synovial fluid--a preliminary study.

Vitreous humor chemistry is used for postmortem analysis since serum values of many components are thought to be reflected in vitreous humor and to be stable for a prolonged postmortem interval (pmi). A similar isolated compartment to vitreous humor is synovial fluid which up to now was hardly used for postmortem chemistry. The aim of the present examination was to compare the values of various analytes in both fluid compartments to get first hints for the reliability of the examination of synovial fluid. Therefore, in 74 cases of sudden death both fluids were taken and analysed for natrium, potassium, calcium, chloride, urea, creatinine, and glucose. The results show that the examination of synovial fluid as compared to vitreous humor is a reliable method to get hints on the premortal metabolic status since most analytes are stable postmortem. The range of all values is comparable in both fluids. The time course of glucose concentrations and, much more important, potassium concentrations is nearly similar. If no vitreous humor is available synovial fluid may be used with all precautions in diagnosis known from vitreous humor.

[Evidence for use of electroshock devices]. / Zum Nachweis der Anwendung von Elektroschockgeräten.

The authors tested whether use of an electro shock weapon (stun gun) leaves marks on skin which can be found in an exterior examination. On pig skin such marks could not be produced postmortally. An experiment on one of the authors caused reddish skin marks which persisted for about 2 h. Inability to act as promised by the weapons' manufacturers did not occur in our experiments, exactly as previously described by other authors. Use of an air tester which shoots barbed electrodes ought to produce bleedings if the electrodes actually penetrate the skin.

Human immunodeficiency virus type 1 infection after sexual abuse: value of nucleic acid sequence analysis in identifying the offender.

Nucleic acid sequence analysis of human immunodeficiency virus type 1-specific sequences allowed the identification of the source of infection in a case of sexual abuse of a 10-year-old girl.

ROC analysis of alcoholism markers--100% specificity.

A combination of 4 so-called markers of alcoholism, i.e. methanol, acetone + 2-propanol, gamma-glutamyltransferase and carbohydrate deficient transferrin, was investigated in 341 blood samples from alcoholics and non-alcoholics. From the history of alcohol consumption, four defined subgroups were formed: non-alcoholics divided into (A) 33 persons with no ethanol consumption during the past year and (B) 60 persons with daily consumption less than 40 g ethanol. Alcoholics were divided into (C) 177 persons with no ethanol at the time of admission/first blood sampling (withdrawal therapy) and (D) 71 persons with positive ethanol levels on admission/first blood sampling. All markers showed different extents of overlap between the collectives of alcoholics and non-alcoholics. By logistic regression, a formula was developed combining these markers with different mathematical weights. Thus an "Alc-Index" could be calculated for each individual. The ROC curve connecting all individual values gives an ideal form with 100% specificity and nearly 93% sensitivity. The threshold between the collectives of alcoholics and non-alcoholics was defined by the Alc-Index value 1.7. This was associated with no false positives among the non-alcoholics while nearly 93% of the alcoholics exceeded this index. The ROC-based calculation of the Alc-Index thus seems to be the most effective method for the diagnosis of alcoholism.

Multiple interchanging of tissue samples in cases of breast cancer.

Due to the suspicion of a gynaecologist, a pathologist was suspected of incorrect diagnoses in cases of breast cancer and the interchanging of tissue samples. Many women applied to the attorney's bureau to clarify the reproaches. The privately owned laboratory for pathology was searched and 926 histological slides, roughly the same number of paraffin blocks and about 20 formalin fixed tissue samples were confiscated. Together with other confiscated material, at least 1236 histological slides and additional 249 paraffin blocks had to be sorted. Histological slides and paraffin blocks were matched with patients as far as possible following the laboratory book. Many of the warranted samples which were diagnosed as containing the carcinoma by the pathologist were missing. A total of 160 samples were chosen and rediagnosed by two independent pathologists. The formalin fixed tissue was negative for DNA most likely due to storage in formalin for years. Most of the histological slides were positive for DNA. On the whole, 18 expertises about histological findings and the DNA results were given. In some cases only DNA results could be presented, as previous experts had only performed DNA examinations without controlling the histological diagnosis. In six cases a carcinoma could be confirmed and the DNA profile matched with patient's DNA; in seven cases a carcinoma was confirmed without match with the patient; in two cases the carcinoma could not be confirmed in the presented samples. A jurisdictional solution was impossible because the accused pathologist died during the investigation. In conclusion, it must be stated that a DNA examination of histological slides should never be performed without a rediagnosis of an independent pathologist and photographic documentation of the findings. Whenever possible, material should be left on the slide.

[Forensic medicine experiences in cremation autopsy in Bonn]. / Rechtsmedizinische Erfahrungen bei der Kremationsleichenschau in Bonn.

2016 coroner's crematorial inquests of the Bonn Institute of Legal Medicine over a 3 years' period were evaluated and the statements in the death certificates were compared to those ones of the Statistical Country Office of Northrhine-Westphalia. No significant differences were found with respect to age, gender and reason of death. However, the number of insufficiently classified deaths with respect to the reason of death were overrepresented especially in cases of older women, while the number of unnatural deaths was generally underrepresented. According to legal medical criteria 2 1/4 per cent of the deaths were falsely classified as natural. Only in 2 cases an autopsy was accomplished. Other author's statements on the validity of death certificates were confirmed.

Suicide of a diabetic by inducing hyperglycemic coma.

Deaths due to hyperglycemic and hyperosmolar coma in diabetics are usually disease-related. In the exceptional case reported here there was evidence for an intentional ingestion of a sugar solution, the person was a diabetic and known to be depressive suggesting a suicidal intention. The autopsy findings were inconspicuous and only further laboratory findings led to the final diagnosis.

Influence of different staining techniques on the DNA analysis of histological sections.

The use of stained histological sections as a source for DNA may be necessary in forensic case work if confusion of tissue is suspected, for identification or paternity cases. To elucidate the influence of different staining techniques on the PCR amplification of DNA, histological sections of liver tissue were prepared using eight different staining techniques and two histochemical methods. The DNA of the sections was extracted by a modified Chelex extraction and amplified using a commercial triplex kit. Staining with hematoxylin-eosin, hemalum-eosin, azan, periodic acid-schiff and prussian blue showed no adverse effect on the amplification of DNA while the extracts of tissue stained by Masson-Goldner, Ladewig and elastica-van Gieson methods had to be purified before amplification was possible. Staining with phosphoric tungsten acid hematoxylin and Gomori led to a degradation of DNA probably due to the use of potassium permanganate solution.

[Confusing tissue samples: causes, consequences, prevention]. / Präparateverwechslungen: Ursachen, Auswirkung, Prävention.

The rising numbers of tissue samples for securing a diagnosis has led to a multitude of tissue samples in pathology institutes. Criteria and measures for ensuring the quality of histological diagnosis have been developed. Corresponding rules for the organization of the tissue sampling up to their processing do not yet exist. Suspicion of interchanged samples occurs much more often than it actually happens; however, it is important to be aware of the possibility so as to inform the clinician and to eliminate any possible causes of the confusion. The civil and penal consequences of such an interchanging, the subsequent "incorrect" diagnosis and the therapeutic measures are secondary compared to the potentially dramatic consequences for the patient. Important causes for an interchanging and possible preventive measures are presented.

The role of clinical forensic medicine in cases of sexual child abuse.

The work of specialists in forensic medicine in those cases of child abuse that result in the killing of a child is defined and well known. It is less well defined in cases of (suspected) sexual abuse. The cases presented show the difficulties that arise if medical doctors and prosecutors are uncertain about the procedures that have to be followed or do not appreciate the value of objective findings. It is concluded that knowledge about necessary examinations by physicians, police officers and prosecutors has to be promoted in order to improve handling and (legal) outcome of these cases.

[Exhumation and no end. A comparative analysis]. / Exhumierungen und kein Ende. Eine vergleichende Analyse.

If the order to carry out an autopsy has been neglected, exhumation is the only possibility to obtain findings which allow conclusions on the manner of death, cause of death and chain of events. The quality of findings will however be influenced by advanced states of putrifaction. In spite of identical legislature the number of exhumations carried out at the institutes of legal medicine in München and Münster differs considerably, as demonstrated by a comparison of the data from the years 1993-1996. As previously described by other authors, there is a reciprocal correlation between the number of autopsies and the exhumation rate. The frequency of autopsies which are ordered can be explained by the varying application of the statutory framework by the investigation procedure. In some cases where an exhumation has been carried out, it was difficult to comprehend why an autopsy was not originally ordered.