[Medicolegal aspects of child abuse]. / Rechtsmedizinische Aspekte der Kindesmisshandlung.

CLINICAL ISSUE: The prevention and clinical diagnostics of maltreatment of children and adolescents represents a great challenge to all medical disciplines concerned; therefore, an interdisciplinary collaboration is indispensable. DIAGNOSTICS: Medicolegal experts require specific radiological examination methods for the differentiation between accidental and non-accidental injuries, depending on the corresponding point in question. In addition, a clear and structured radiological appraisal of the findings is necessary. On the other hand, radiologists require an appropriate succinctly phrased question from the medicolegal expert. PRACTICAL RECOMMENDATIONS: A close collaboration between radiologists and medicolegal experts is mandatory for a better recognition of cases of child abuse; therefore, the joint establishment of diagnostic standards and a comprehensive implementation is necessary.

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.

Petechial bleedings in sudden infant death.

The autopsy reports of 484 cases of deceased infants (201 females, 283 males) were analysed retrospectively for the existence of external and internal petechial bleedings (PET). The cases were divided into five groups on the basis of the cause of death (sudden infant death syndrome, sepsis, airway infections, asphyxia and trauma). Internal PET (pleural, pericardial, epicardial, thymic and peritoneal) were observed in each group with a lower prevalence in cases of trauma. The highest prevalence of external (cutaneous and conjunctival) PET was detected in cases of asphyxia (38% and 31%, respectively). However, even if with low prevalence, such bleedings were detected in every group. Factors like sex, age, cardiopulmonary resuscitation and its duration did not influence the presence of PET. The detection of external PET at autopsy is a suspicious finding that suggests asphyxia. Because of the possible natural origin of these bleedings, the medicolegal investigation has to be as complete as possible and has to include histology as mandatory.

Blood stain pattern analysis.

Bloodstain pattern analysis (BPA) refers to the collection, categorization and interpretation of the shape and distribution of bloodstains connected with a crime. These kinds of stains occur in a considerable proportion of homicide cases. They offer extensive information and are an important part of a functional, medically and scientifically based reconstruction of a crime. The following groups of patterns can essentially be distinguished: dripped and splashed blood, projected blood, impact patterns, cast-off stains, expirated and transferred bloodstains. A highly qualified analysis can help to estimate facts concerning the location, quality and intensity of an external force. A sequence of events may be recognized, and detailed questions connected with the reconstruction of the crime might be answered. In some cases, BPA helps to distinguish between accident, homicide and suicide or to identify bloodstains originating from a perpetrator. BPA is based on systematic training, a visit to the crime scene or alternatively good photographic documentation, and an understanding and knowledge of autopsy findings or statements made by the perpetrator and/or victim. A BPA working group has been established within the German Society of Legal Medicine aiming to put the knowledge and practical applications of this subdiscipline of forensic science on a wider basis.

[Aortocoronary bypass operation in considerably reduced left-ventricular function caused by chronic ischemia]. / Aortokoronare bypass-Operation bei erheblich reduzierter linksventrikulärer Funktion infolge chronischer Ischämie.

Among a group of 18 patients with severe angina and an ejection fraction of less than 46%, cine-angiography was performed on 18, 2-D echocardiography on 18, radionuclide ventriculography on 13 and 201Thallium myocardial scintigraphy on 13 at rest, both pre-operatively and six months after an aortocoronary bypass operation. In nine patients there was a significant increase postoperatively in the ejection fraction (P less than 0.001) (group I), while it remained practically unchanged in the remainder (group II). Similar results were obtained with radionuclide ventriculography and echocardiography. Ischaemia at rest was demonstrated by myocardial scintigraphy preoperatively in an average of 10 out of 27 sectors in group I patients, but within six months postoperatively decreased to 3.1 (P less than 0.01). In group II patients the mean number of sectors with ischaemia at rest was pre-operatively 2.5, postoperatively 6.0. With one exception there was an improvement in left-ventricular function at rest in all patients with pre-operatively 7 or more sectors showing ischaemia at rest. These results suggest that myocardial scintigraphy makes it possible to identify those patients with severe ischaemic myocardial damage who would profit from revascularization.