[Physical and gynecological examinations in female victims of sexual violence with special emphasis on crime-reporting behaviour]. / Ergebnisse körperlicher und gynäkologischer Untersuchungen bei weiblichen Opfern sexueller Gewalt unter besonderer Berücksichtigung des Anzeigeverhaltens.

Sexual abuse of females is a common form of violence with a high dark figure. While part of the victims decide to report the event to the police, many women are embarrassed to do so for a number of reasons. Retrospectively, examinations performed in Berne (Switzerland) between 2006 and 2008 in cases with and without report to the police were analyzed. Altogether, 207 examinations were carried out during that period (65.2% reported to the police, 34.8% without report to the police). 20% of the incidents were reported to the police after the examination. One third of the victims in both groups claimed that the perpetrator was unknown to them. More than 40% of the women in both groups had been under the influence of alcohol at the time of the incident. 73% of the victims (reporting the crime) and 61% of those not filing a crime report described penile-vaginal contacts. Blackouts were claimed in 14% of the cases reported to the police and 33% of those not reported. Genital lesions were found in about one third and extragenital injuries in more than 50% of cases in both groups. No condom had been used in a large percentage of cases or its use was uncertain. Unprotected vaginal ejaculation was reported by about one third of the victims in both groups and could not be reliably excluded in 28% of cases. In 43.8% (reported to police) and 47.1% (not reported), no contraceptive method had been applied by the women. The results of the present study show similar distributions in both groups for numerous factors (factual circumstances and injury pattern). However, in the group not filing a complaint with the police blackouts were reported more often, which may have induced the victims not to report the incident to the police at first. The fact that in about 20% of these cases the women went to the police later underlines the importance of offering documentation usable as evidence in court and preserving evidence independent of whether the incident has already been reported to the police or not. Reasons why victims present for examination may also be fear of pregnancy or sexually transmitted diseases. Clarification of these points should therefore also be offered.

Indicators for acute hypoxia--an immunohistochemical investigation in cerebellar Purkinje-cells.

The Purkinje-cells (PCs) of the cerebellum are highly vulnerable to hypoxic/ischemic insult. Calbindin-D28k is a calcium-binding protein that is strongly expressed in PCs. Following hypoxia, a decrease in its concentration has been found in animal models before any morphological change of the PCs took place. Hypoxia-inducible factor-1α (HIF-1α) and vascular endothelial growth factor (VEGF) are increasingly expressed in tissues that undergo durations of hypoxia, and also in brain tissues. We examine whether a change in expression of any of these factors, or a combination of alterations, is an indicator of acute hypoxia. We investigated the intensity of neuronal immunoreactivity of calbindin-D28k, HIF-1α and VEGF retrospectively in 141 samples of human cerebellar tissue obtained from autopsies performed at the Institute of Legal Medicine of Hanover Medical School in 2007 and 2008. Three groups were compared. The first group comprises individuals (n=48) who died due to acute hypoxia, such as drowning or asphyxia. The second is a control group comprising individuals who died due to heart failure (n=56), and the third group comprised individuals who died almost instantly of polytraumata (n=37). Our study finds a statistically significant decrease in the expression of calbindin-D28k (p<0.05) in PCs in the acute hypoxia group, relative to the control groups. No changes in the expression of HIF-1α or in the expression of VEGF were observed in any of the groups. Consequently HIF-1α and VEGF were not suitable indicators, whereas detection of a decreasing concentration of calbindin-D28k supports a diagnosis of acute hypoxia.

[Post-mortem examination prior to cremation--an instrument to verify the quality of medical post-mortems and uncover non-natural deaths?]. / Die Krematoriumsleichenschau--Instrument zur Qualitätskontrolle der ärztlichen Leichenschau und Aufdeckung nichtnatürlicher Todesfälle?

The external post-mortem examination, its deficient quality and possible causes have been the subject of numerous political and professional discussions. The external post-mortem examination is the basis for the decision whether further criminal investigations are required to clarify the cause of death. It is thus an essential instrument to ensure legal certainty. Before cremation, a second external post-mortem examination is performed by a public medical officer to make sure that errors of the first post-mortem are corrected. In the present study, cases were retrospectively analyzed in which a forensic autopsy had been ordered on the basis of the results of the post-mortem examination performed before cremation. The entries on the death certificate regarding the manner and cause of death were compared with the autopsy results. Between 1998 and 2007, 387 autopsies were ordered after external examination before cremation. In 55 cases (14.2%), the autopsy revealed a non-natural death, although a natural death had been attested on the death certificate. In descending order, a wrong manner of death was attested by clinicians, general practitioners and emergency physicians. With regard to the place where the first external post-mortem had been performed the lowest error rate was seen in nursing homes. Concerning the cause of death, discrepancies between the first post-mortem and autopsy were found in 59.4% of the cases. In this respect, general practitioners and clinicians were ranking first, whereas in nursing homes the cause of death was wrongly assessed in over 70% of cases. At present, the medical post-mortem does not meet the required quality standards, especially with regard to legal certainty. Determination of the cause of death on the basis of the external post-mortem examination is a challenging task even for the experienced medical examiner. As to the categorization of the manner of death it has to be stated that non-natural deaths are often not recognized or that the possibility to certify a death as unclear is not sufficiently used. As a result, it seems important to demand intensive, qualified, additional training in external post-mortem examinations for physicians.

SFRP1 CpG island methylation locus is associated with renal cell cancer susceptibility and disease recurrence.

Loss of the secreted Fzd-related protein 1 (SFRP1) and concurrent alteration of the SFRP1/WNT pathway are frequently observed in human cancers such as in renal cell cancer (RCC). Whether methylation of a SFRP1 CpG island locus in normal human solid tissues is associated with increased tissue specific cancer risk has not been determined to date. Here we measure the cancer risk attributable to SFRP1 DNA methylation in renal tissue. Pyrosequencing of bisulfite treated DNA was used for a case-control study including 120 normal-appearing renal tissues of autopsy specimens and 72 normal-appearing tissues obtained from tumor adjacent areas, and a cross sectional study of 96 RCCs. Association of methylation with demographic risk factor age, clinicopathological parameters and course of patients was investigated. We show significant hypermethylation of a SFRP1 CpG island locus in normal-appearing renal tissues from RCC patients compared with normal-appearing autopsy kidney tissues. Inter quartile analysis revealed a 6-, 13- and 11-fold increased cancer risk for the second, third and fourth quartiles of methylation in the age matched subgroup of tissues (p = 0.001, p = 1.3E-6, p = 6.9E-6). Methylation in autopsy tissues increased with age and methylation in tumors was an independent predictor of recurrence free survival. SFRP1 DNA methylation, accumulates with age in normal-appearing kidney tissues and is associated with increased renal cancer risk, suggesting this CGI sub region as an epigenetic susceptibility locus for RCC. Our data underline the need to further analyze the tissue specific risks conferred by methylated loci for the development of human cancers.

[Clinical forensic examination findings and legal outcome in cases of suspected physical child abuse]. / Klinisch-forensische Untersuchungsergebnisse und rechtliche Folgen bei körperlicher Kindesmisshandlung.

Clinical forensic examinations performed at the Institute of Legal Medicine of the Hanover Medical School between 1999 and 2008 in cases of suspected physical abuse of children were analyzed retrospectively with special emphasis on the legal consequences. Altogether, 192 children (85 girls, 107 boys) with a median age of 4.4 years were examined. In 47 cases (24.5 %), the clinical forensic examination findings were interpreted as accidental injuries, birth traumas or unspecific findings. 29 victims (20.0 %) had suffered a shaken baby syndrome. Only part of the presented cases ended with conviction, which was more likely if the victims were aged between 7 and 11 years. Prison terms of 2 years and more were imposed only if the child suffered potentially or acute life-threatening injuries or if additional anogenital lesions were diagnosed indicating sexual child abuse.

[Clinical forensic examination findings and legal outcome in cases of suspected sexual child abuse]. / Klinisch-forensische Untersuchungsergebnisse und rechtliche Folgen bei sexuellem Kindesmissbrauch.

The clinical forensic examinations conducted at the Institute of Legal Medicine of the Hanover Medical School between 1999 and 2008 in cases of suspected sexual abuse of children were evaluated retrospectively and analysed with regard to their legal outcome. In total, the study included 223 children (172 girls, 51 boys) with a median age of 8.6 years. In 34 children (15.2%), forensically relevant diagnostic findings due to anogenital injury and/or detection of semen were recorded. Perpetrators were convicted more often when they were not a member of the victim's family. In cases with victims aged seven years or older, conviction was more common. The study shows that medical findings can best be preserved by an immediate clinical forensic examination. Suspected sexual child abuse can often not be proved by medical examination results, but in some cases diagnostic findings are not mandatory for conviction.

[Suicide in children, youths and young adults]. / Suizide von Kindern, Jugendlichen und Heranwachsenden.

Suicides among children and youths are tragic events. The suicide cases of children, youths and young adults examined between 1995 and 2009 at the Institute of Legal Medicine of the Hanover Medical School were retrospectively analyzed. Altogether, 54 suicides among children, youths and young adults (37 males, 17 females; median age 17.5 years) were evaluated. The suicide victims were predominantly male (68.5%). The vast majority used "hard" methods such as hanging, jumping from a height or being run over by a train. In seven cases (13.0%) psychiatric disorders were known. Seven victims (13.0%) left a suicide note. Suicide was most frequently (40.7%) committed in the open air (40.7%). In addition, the evaluation shows that at the time of committing suicide more than 40% of the youths and adolescents, in whom a chemical toxicological examination was performed, were under the influence of alcohol, medical and/or illegal drugs.

[Examination reports on survived strangulation cases]. / Untersuchungsergebnisse nach überlebter Gewalteinwirkung gegen den Hals.

Clinical-forensic examination of strangulation victims is an increasing part of the routine of many forensic pathology institutes. The cases examined between 2004 and 2008 at the Institute of Legal Medicine of the Hanover Medical School were retrospectively analysed. In total, the study material comprised 218 victims (175 females and 43 males). In 80.7 %, the clinical-forensic examination was performed within 24 hours after the incident. In the overwhelming number of cases, the alleged perpetrator was no stranger. 128 victims (58.7 %) had strangulation marks, 32 victims (14.7 %) ligature marks and 65 victims (29.8 %) nail marks. Four victims showed injuries of the laryngeal and pharyngeal structures (reddening, hematomas, swelling and in one case a fracture of the cricoid cartilage on both sides). Extensive petechiae were predominantly seen in the conjunctivae, the buccal mucosa and the skin of the face in cases where the victims suffered a loss of consciousness. 87 cases (39.9% were classified as potentially life-threatening and 30 cases (13.8 %) as acute life-threatening events. This classification is of legal relevance for the penalty. In addition, 60 victims experienced sexual violence. These results suggest that early clinical-forensic examination is crucial for documenting forensic evidence in support of police investigations and may deliver significant details relevant in court.

[Placental findings in perinatal cases of death]. / Plazentabefunde bei perinatalen Todesfällen.

Autopsy is an indispensable tool to clarify the cause of death in perinatal cases of death. The authors report on two cases of perinatal death, in which not only a forensic autopsy including histological and microbiological examinations had been performed, but the placenta had also been pathologically assessed. Only on the basis of the placental findings was it possible to clarify the cause of death and to answer the question if the physician had committed medical malpractice. The results underline the importance of examining the placenta in perinatal deaths as a matter of routine. In forensic cases, the police should therefore not only confiscate the infant's body, but also the placenta.

[Homicide by bow and arrow]. / Homizid durch Pfeil und Bogen.

Since the invention of firearms, arrow wounds represent a rarity in the daily routine of forensic pathologists. In the present paper, we describe a homicide by a broadhead arrow shot from a compound bow in a domestic environment. Based on this homicide, we discuss the characteristics of the lesion caused by broadhead arrows and field-tip arrows. We look critically at the free saleability of this equipment mostly used for sport shooting in Germany.

[Post-mortal detection of clostridia--putrefaction or infection?]. / Postmortaler Nachweis von Clostridien--Fäulnisbakterien oder Infektionskeime?

Clostridia are often found in the heart blood and organs of corpses showing putrefactive changes, and it can sometimes be difficult to distinguish between an ante-mortem infection caused by these gram-positive, anaerobic, spore-forming bacteria and post-mortal putrefactive changes. Microbiological tests ordered by the Institute of Legal Medicine of the Hanover Medical School following autopsy between July 2006 and June 2009 were analyzed retrospectively. In all, 50 bacteriological analyses were performed. In 2006, no clostridia were detected, whereas in 2007 the bacteria were demonstrated in 3 (18.8%), in 2008 in 4 (23.5%) and in 2009 in 5 (33.3%) cases. In 50% of the cases, there had been an ante-mortal clostridia infection. The remaining 50% were due to post-mortem transmigration of clostridia species. The results of this study underline the importance of additional post-mortem bacteriological and histological investigations.

[Analysis of clinical forensic examination reports on sexually abused children]. / Analyse der Untersuchungsergebnisse bei sexuellem Kindesmissbrauch.

Clinical forensic examinations of children suspected of having been sexually abused are increasingly part of the routine of medicolegal institutes. The findings collected from 2005 until 2007 at the Institute of Legal Medicine of the Hanover Medical School were analysed retrospectively. Altogether, 91 children (74 females, 17 males, mean age 8.7 years) were examined. In 87.9% of the cases, the examination had been ordered by the police. In 73.6%, the victim knew the suspected perpetrator well or he was a family member. 40.7% of the children were seen within 72 hours after the alleged abuse. 12.1% of the children had extragenital lesions. In 27% of the victims, marked anogenital injuries were found, which were characteristic of sexual abuse in 9%. In 18 cases (20.2%), swabs were taken for spermatozoa detection. 3 of 17 vaginal smears showed positive test results for sperm up to 21 hours after the incident. No spermatozoa could be detected in 4 anal and 2 oral swabs as well as in one swab taken from the skin of the victim's thigh. In summary, the evaluation shows that early clinical forensic examination of children suspected of having been sexually abused is crucial to document evidence that is highly significant for the investigation and court proceedings. Often suspected sexual child abuse cannot be proved by medical findings alone. Of course, the absence of anogenital injuries does nor rule out sexual abuse.

Analysis of clinical forensic examination reports on sexual assault.

Medical-forensic examination of sexual assault victims and alleged offenders is a common task of many forensic institutes. In the current study, the results from samples taken at the Institute of Legal Medicine, Hanover Medical School, during a period from 2005 to 2007 were retrospectively evaluated. In total, 292 victims (283 females and nine males) and 88 suspects were examined. At the time of the assault, 41.8% of the victims and 43.2% of the alleged perpetrators were under the influence of alcohol. Injuries were found in 84.9% of the victims and 39.8% of the suspects. Thirty victims (10.3%) reported having been choked or strangled. Cytology was performed in 218 victims. In 81 cases (38.0%), sperm could be detected in vaginal swabs up to 3 days post-assault. In seven (18.9%) out of 37 anal samples, evidence of sperm could be found 24 h post-assault. None of 22 oral samples was positive for sperm. Out of 301 sexual assault cases, 171 could be proved by means of medical-forensic examination. In summary, our evaluation shows that an early medical-forensic examination of both victim and suspect can secure numerous medical findings. Furthermore, persons intoxicated by alcohol, handicapped persons and persons with psychiatric disorders are more vulnerable to become a sexual assault victim.

[Clinical forensic examination findings in assault cases among adolescents]. / Untersuchungsergebnisse bei Gewaltdelikten unter Jugendlichen.

Child and youth criminality has risen markedly over the past 25 years and causes increasing concern to the general public. The clinical forensic examination cases of youth violence victims examined at the Institute of Legal Medicine of the Hanover Medical School and its Oldenburg Branch between 1999 and 2008 were retrospectively analyzed. In all, 55 adolescents (37 females, 18 males; median age 15.5 years) were examined. In most cases the suspect was a close (40.0%) or passing (23.6%) acquaintance. 16 assaults were committed by two or more adolescents jointly. Most of the juveniles were victims of sexual assaults (56.4%). In 15 victims of sexual offences (51.7%) diagnostic findings were obtained on the basis of anogenital injuries and/or the presence of sperm. In summary, the analysis shows that adolescents frequently become victims of sexual assault. In addition, youth violence is often committed in a group.

[Examination results and autopsy findings in assaults on elderly people]. / Untersuchungsergebnisse und Obduktionsbefunde bei Gewaltdelikten gegen ältere Menschen.

As the percentage of elderly people in the population grows, violence against persons of advanced age constitutes an increasing social problem. The findings of the clinical forensic examinations (CE group) and autopsies performed on elderly violence victims (> or = 60 years) between 1999 and 2008 at the Institute of Legal Medicine of the Hanover Medical School were retrospectively analysed. In all, the study material comprised 55 victims of the CE group (35 females and 20 males, median age 73.5 years) and 55 autopsies (33 females and 22 males, median age 72.7 years). In most of the autopsy cases, the suspect was a family member or partner. In contrast, the alleged perpetrator was a stranger in most cases of the CE group. Blunt force injuries were most often found in the CE group victims (63.6%). Altogether, 38.2% (CE group) and 20.0% (autopsy cases) of the violent assaults were associated with robbery. In the majority of the CE cases, the victims suffered potentially or acute life-threatening injuries. In summary, the analysis shows that elderly people frequently become victims of robbery and blunt force injury. In most homicides of old people, the perpetrator is familiar to the victim. In surviving elderly violence victims, the assault is more likely to be reported to the police if the suspect is a stranger.

[Aortic dissection - a not so rare disease]. / Aneurysma dissecans - keine so seltene Erkrankung.

BACKGROUND AND PURPOSE: Acute aortic dissection is a life-threatening disease with a high rate of mortality. The dissection of the artery with a distal blood flow can explain the variable and changeable symptoms. Aortic dissections require immediate diagnosis and therapy. METHODS: In the Institute of Legal Medicine of the Hannover Medical School, 34 cases of aortic dissection were found during autopsy between 2006 and 2009. The cases were analysed retrospectively. RESULTS: In the majority of cases (55.9%) an antemortem medical consultation has taken place. In only one case an aortic dissection could be diagnosed at a later time. CONCLUSION: Key in the management of acute aortic dissection is to maintain a high clinical index of suspicion for this diagnosis. Etiologically hereditary diseases (Marfan syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome) should be taken into consideration as a possible cause. In all unexpected deaths of young adults an autopsy should be performed to detect the cause of death and for genetic testing to provide information for the relatives in case an aortic aneurysm can be found.

[Postnatal sepsis due to group A Streptococcus in a mother and her newborn]. / Postnatale Sepsis bei Mutter und Kind durch Streptokokken der Gruppe A.

Nowadays, postnatal sepsis caused by group A Streptococcus (Str. pyogenes) is a rare condition. However, the mortality due to this uncommon disease is still high, and it has been described in the literature more frequently in the last few years. The authors present the case of a female newborn who died 15 hours after spontaneous delivery in the 40th week of gestation. Autopsy revealed a lung edema and solid lung parenchyma with normal findings of the other organs on macroscopic examination. Additional bacteriological testing detected Streptococcus pyogenes in the child. Aspiration pneumonia and signs of sepsis were discovered in the histological examination. Three days postpartum, the mother was hospitalized with Streptococcus pyogenes sepsis. Streptococcus pyogenes colonization of the mother's vaginal flora was assumed to be the origin of the infection. The problem in this case was the macromorphological diagnosis of sepsis and pneumonia in the newborn. The importance of microbiological analysis as a matter of routine is emphasized.