Particulate matter emissions during autopsies: a method to reduce exposure.

Particulate matter emitted during autopsies can serve as a vector for numerous viruses or bacteria and can lead to infections. Reducing the exposure of those particles in indoor working environments is, therefore, an important issue. To assess the health risk for employees in forensic medicine, we measure particulate matter in the ambient air during autopsies by using an aerosol spectrometer. The autopsies were performed with either an ordinary oscillating saw or an adapted saw with a suction unit. The particle emissions from both saws were compared to each other in order to evaluate whether a technical adaption leads to a particle reduction. Furthermore, the particle exposure reduction by wearing a face mask and variations in the background concentration in the room were analyzed. High particle concentrations were measured while using the ordinary saw. By using the adapted saw or wearing a face mask, the particle exposure could mostly be avoided. On the majority of the working days, an increase in the background concentration could be observed. Based on this knowledge, the use of a proper suction unit and wearing a face mask during autopsies is necessary. Besides, it is important to have sufficient ventilation in the room so that long-lasting high background concentrations can be prevented.

Chronic alcohol abuse may lead to high skin iron content, but not to hepatic siderosis.

INTRODUCTION: In forensic cases, ante mortem chronic alcohol abuse can be of central importance in clarifying circumstances of death. However, reliable markers of alcohol consumption, which are still available postmortem, are needed. In addition to medical history data which may not be always authentic, the determination of ethyl glucuronide (EtG) in hair as a promising parameter is of no value in cases of missing or cosmetically treated hair. On the other hand, there exist reports that iron ions accumulate in liver tissue (siderosis) during chronic, excessive alcohol consumption, which, therefore, may be useful to serve as alcohol abuse correlate. However, the influence of ethanol on iron stored in the liver has not been adequately investigated and the study situation appears to be inconsistent. AIMS: The aim of the present study was to assess the suitability of assaying iron concentrations in liver and other tissues as postmortem alcoholism marker. METHODS: The iron concentration in tissue samples (liver, brain, skin, pancreas, spleen), vitreous fluid and blood taken during autopsy was analyzed by atomic absorption spectroscopy. The analytical method has been validated before. Cases were divided into two groups: chronic alcohol abusers and non-chronic alcohol consumers including total abstainers using ethyl glucuronide levels in hair as well as anamnestic data as criteria. RESULTS: No elevated iron concentrations in the liver of chronic alcohol abusers were detected. Surprisingly, the iron concentration in skin tissue was found to be significantly higher in cases of chronic alcohol abuse, independent on whether fatty liver or liver cirrhosis was present (as diagnosedduring autopsy). In 18.5% of the cases, chronic alcohol abuse was not confirmed by the EtG concentration in hair. Thus, anamnestic data should not be overestimated. CONCLUSION: The general assumption that chronic alcohol abuse induces hepatic siderosis, i.e. high iron concentrations in liver tissue, has not been supported by results of the present study. However, there seems to exist a correlation between chronic alcohol abuse and high iron concentrations in the skin.

Fatalities of stowaways traveling in airplane wheel wells.

The earliest mention of a stowaway in the wheel well of an airplane dates back to 1947: A 30-year-old man chose this mode of travel for a trip from Lisbon to Brazil and survived (Véronneau et al., 1996). In a retrospective study, we evaluated cases with lethal outcome of stowaways in airplane wheel wells by focusing on forensic autopsy results, in particular, in regard to hypothermia, hypoxia, and injuries. In addition, the flight routes, flight altitudes, and flight durations were analyzed. Using the forensik® program, a search of all the autopsies performed between 1994-2017 at the Institute of Legal Medicine in Frankfurt am Main, Germany, was conducted, using the key words "airplane," "flights," and "wheel well." All of the thus retrieved autopsy reports, medicolegal expert reports, and police investigation reports were then evaluated. Five cases were included in our study. The decedents were all men, aged between 14 and 26 years. Four of the decedents had been discovered at the Frankfurt Main airport within airplane wheel wells; the fifth man had been discovered in a woods underlying one of the flight approach paths to the airport. Two stowaways had died of hypoxic asphyxiation, possibly in conjunction with hypothermia as a contributing factor. One stowaway died of the polytrauma he sustained when he was crushed by retracting landing gear. For a further stowaway, the cause of death could not be macroscopically determined at autopsy. In one case, only an external postmortem examination had been performed, without autopsy. Analysis of the flight routes, altitudes, and durations showed that the flights had been international flights, the flight altitudes had varied between 7000m (∼23,000ft) und 11,000m (∼36,000ft), and the flight duration had been between 4 and 9.5h. At high altitudes, the ambient conditions in wheel wells, which are not pressurized, are rarely survived by stowaways, with hypoxic asphyxiation likely posing greater peril than hypothermia. Further dangers are that of being crushed by retracting landing gear after takeoff, or of falling out of a wheel well, from a great height, when the landing gear is deployed. When it appears conceivable that a stowaway may have fallen from an aircraft wheel well during landing or takeoff, an autopsy and discovery scene investigation are essential to reconstructing the course of events.

A case of fatal perimyocarditis due to a rare disease.

Although myocarditis is caused by viral infections in about 50% of cases in European countries, various other causative agents are known. We report the case of a 51-year-old man who died several months after being diagnosed with asthma by his general practitioner. This diagnosis had been confirmed by a pulmonologist approximately 6 weeks before the man's death. To rule out the possibility of medical malpractice the prosecuting authority ordered a forensic autopsy. At autopsy macroscopic indicators for perimyocarditis and pneumonia were found. Microbiological and histological examination of tissue samples confirmed a diagnosis of Churg-Strauss syndrome, also known as Eosinophilic Granulomatosis with Polyangiitis (EGPA). The cause of death was determined to be cardiac involvement in Churg-Strauss syndrome. The presence of this disease also accounted for the man's recent medical history. There were no findings to indicate that a medical error had been made. The reported case illustrates why accessory histological and microbiological examinations should always be performed when macroscopic findings at autopsy suggest myocarditis. Determining the etiology of myocarditis is a necessary step to prevent overlooking rare diseases with inflammatory myocardial involvement, especially in the clarification of alleged medical malpractice.

Post-operative fatal blood aspiration after routine lung surgery.

A routine question encountered in medicolegal practice is whether the death of a patient in proximity to a surgical procedure is due to medical malpractice. The case of a 62-year-old man who died two weeks after undergoing a VATS sleeve resection of the upper right lung lobe in conjunction with radical lymphadenectomy, a routine surgical procedure, is reported. To address the issue of medical malpractice, a forensic autopsy was ordered by the investigative authority. During the autopsy, the lungs were removed as a whole and fixed in formalin and were later dissected in cooperation with a thoracic surgeon. In the course of this dissection, a bronchovascular fistula, which had led to the occlusion of the bronchial system with clotted blood, was discovered. Bronchovascular fistulas are a rare complication of bronchial sleeve resections. Because this surgical complication is essentially always fatal, it is highly pertinent to medicolegal practice. The presented case report also lists other important complications associated with bronchial anastomosis and elucidates a pragmatic approach to obtaining an expert clinical assessment of possible medical malpractice after operations through the example of a dissection performed in cooperation with a thoracic surgeon.

Self-induced illegal abortion with Rivanol®: A medicolegal-toxicological case report.

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

[Sauna deaths in Hesse, Germany, between 1994 and 2014]. / Saunatodesfälle in Hessen 1994-2014.

Due to the high ambient temperature, sauna deaths show a few confounding particularities, such as an accelerated onset of the postmortem changes, that can make correct assessment of the manner of death difficult and severely constrain the accuracy of post- mortem interval estimates. This retrospective study, performed at the medicolegal institutes in Hesse, Germany, reviewed all autopsy reports from the years 1994-2014 for sauna-related deaths. 9 relevant cases were found involving one woman and eight men aged between 52 and 80 years (mean and median value: 67 years). Of the individuals who had died of a natural cause, four were found to have had coronary heart disease, which, in the setting of heart hypertrophy and exposure to high temperatures, ultimately led to cardiac failure. In three other cases, a non-natural cause of death had been diagnosed; however, all were attributable to accidents. In two of these, blood alcohol concentrations (BAC) of over two per mil were found. In our opinion, the manner of death should be classified as undetermined in sauna-related fatalities. Such cases require a court-ordered autopsy to reliably identify the actual cause of death.

[The medicolegal relevance of benign and malignant coronary artery anomalies]. / Uber die Relevanz von benignen und malignen Koronaranomalien in der Rechtsmedizin.

Isolated coronary anomalies are rare abnormalities that can be divided into benign and malignant forms. Malignant coronary artery abnormalities generally present already during infancy or early childhood by causing symptoms or sudden death. Benign abnormalities often remain asymptomatic because they are hemodynamically irrelevant. Among the 12,985 autopsies performed at the Institute of Legal Medicine at the University of Frankfurt (Germany) between 1995 and 2013, there were eight cases (0.062%) with isolated coronary artery abnormalities. Five of these cases (0.039%) could be included in our retrospective study. These involved one deceased female and four deceased male subjects, aged between 2 and 57 years. In three of these cases (aged 6, 9, and 11 years old), the coronary anomaly was classified as malignant and was recorded as the cause of death. Benign isolated coronary anomalies are often incidental findings during autopsies. However, in one of the cases in our study, coronary sclerosis in precisely the anomalous vessel was found to be the origin of a fatal myocardial infarction. Malignant isolated coronary artery anomalies attain medicolegal significance when they remain undetected despite advanced early detection protocols and cause sudden death in childhood.

5-Lipoxygenase is a candidate target for therapeutic management of stem cell-like cells in acute myeloid leukemia.

Nonsteroidal anti-inflammatory drugs such as sulindac inhibit Wnt signaling, which is critical to maintain cancer stem cell-like cells (CSC), but they also suppress the activity of 5-lipoxygenase (5-LO) at clinically feasible concentrations. Recently, 5-LO was shown to be critical to maintain CSC in a model of chronic myeloid leukemia. For these reasons, we hypothesized that 5-LO may offer a therapeutic target to improve the management of acute myeloid leukemia (AML), an aggressive disease driven by CSCs. Pharmacologic and genetic approaches were used to evaluate the effects of 5-LO blockade in a PML/RARα-positive model of AML. As CSC models, we used Sca-1(+)/lin(-) murine hematopoietic stem and progenitor cells (HSPC), which were retrovirally transduced with PML/RARα. We found that pharmacologic inhibition of 5-LO interfered strongly with the aberrant stem cell capacity of PML/RARα-expressing HSPCs. Through small-molecule inhibitor studies and genetic disruption of 5-LO, we also found that Wnt and CSC inhibition is mediated by the enzymatically inactive form of 5-LO, which hinders nuclear translocation of ß-catenin. Overall, our findings revealed that 5-LO inhibitors also inhibit Wnt signaling, not due to the interruption of 5-LO-mediated lipid signaling but rather due to the generation of a catalytically inactive form of 5-LO, which assumes a new function. Given the evidence that CSCs mediate AML relapse after remission, eradication of CSCs in this setting by 5-LO inhibition may offer a new clinical approach for immediate evaluation in patients with AML. Cancer Res; 74(18); 5244-55. ©2014 AACR.