[What are the effects of different places of death of old people?] / Welche Auswirkungen zeigen unterschiedliche Sterbeorte betagter Menschen?: Eine Analyse Münchner Todesbescheinigungen.

Background: Inadequate quality of medical postmortem examinations has been discussed in the forensic medical literature for many years. It is known that older deceased persons are less likely to have a non-natural cause of death certified and autopsies are performed less frequently compared to younger deceased persons. Methods: Death certificates of all deaths that occurred in Munich with an age of ≥ 75 years during the death period 01/01/2013-31/12/2014 were analyzed. Standardized, anonymized data entry was performed. The collected data were analyzed descriptively. Results: A total of 26,303 persons died during the study period. Of these deaths, 16,146 (60.7%) were ≥ 75 years. Most common places of death for the aged were hospital (56.1%), private address (21.8%), and nursing home (20.0%). A natural mode of death was reported in 88.5%, unexplained in 8.8%, and non-natural in 2.7%. Most common immediate causes of death were diseases of the circulatory system (23.5%), inaccurately designated or unknown causes of death (20.0%), and diseases of the respiratory system (16.3%). Autopsies were performed on 4.9%, largely judicial. The parameters studied showed large differences in the analyses depending on the place of death. Discussion: This study again shows considerable quality deficiencies in the issuance of death certificates. Despite the dual approach of the Munich health authority (control, training), the quality of death certificates could not be sustainably improved in recent years. Types and causes of death showed partly considerable differences depending on the place of death and the doctor who issued the certificate. The deficits identified in the information provided under the heading "Causes of death" are also likely to have a negative impact on the cause of death statistics.

Impact of obesity on complications and surgical outcomes of adult degenerative scoliosis with long-segment spinal fusion.

INTRODUCTION: The relationship between obesity and outcome of spine surgery has been controversial. The impact of obesity on surgical outcomes of patients undergoing long- segment (6 vertebrae or more) spinal fusion have not been studied. This study was designed to define the influence of obesity on the outcomes of patients undergoing long-segment spinal fusion. METHODS AND MATERIALS: A retrospective study of patients undergoing long-segment (6 vertebrae or more) spinal fusion was realized. Patients were divided into non-obese group and obese group. Variables such as blood loss, operative time, length of stay, complications, reoperation rates, and clinical outcome were compared between the two groups. RESULTS: Thirty-four non-obese patients (BMI: 26.43±0.87) and 27 obese ones (BMI: 35.35±1.81) were recruited. Number of fused levels in non-obese group was not significantly different from obese group (9.06±0.57 vertebrae vs 8.85±0.68 vertebrae, P=0.65). There was no significant difference between non-obese group and obese group in the blood loss during surgery (P= 0.12), the operating time (P=0.46) and the length of hospitalization (P=0.64). Similarly, no significant difference was found in surgical complications (P=0.76) and medical complications (P=0.82) between the two groups. The rate of ambulatory improvement is similar between non-obese group and obese group (P=0.64). CONCLUSION: Our study showed that there was no relationship between obesity and adverse surgical outcomes in ADS surgery with long-segment (6 vertebrae or more) spinal fusion.

Position sensitive measurement of trace lithium in the brain with NIK (neutron-induced coincidence method) in suicide.

Mood disorder is the leading intrinsic risk factor for suicidal ideation. Questioning any potency of mood-stabilizers, the monovalent cation lithium still holds the throne in medical psychiatric treatment. Furthermore, lithium`s anti-aggressive and suicide-preventive capacity in clinical practice is well established. But little is still known about trace lithium distribution and any associated metabolic effects in the human body. We applied a new technique (neutron-induced coincidence method "NIK") utilizing the 6Li(n,α)3H reaction for the position sensitive, 3D spatially resolved detection of lithium traces in post-mortem human brain tissue in suicide versus control. NIK allowed, for the first time in lithium research, to collect a three dimensional high resolution map of the regional trace lithium content in the non lithium-medicated human brain. The results show an anisotropic distribution of lithium, thus indicating a homeostatic regulation under physiological conditions as a remarkable link to essentiality. In contrast to suicide we could empirically prove significantly higher endogenous lithium concentrations in white compared to gray matter as a general trend in non-suicidal individuals and lower lithium concentrations in emotion-modulating regions in suicide.

[COVID-19-associated deaths]. / COVID-19-assoziierte Sterbefälle: Erste Daten aus Münchner Todesbescheinigungen.

INTRODUCTION: In December 2019, the new infectious coronavirus disease 2019 (COVID-19) first appeared in China. So far, no systematic evaluation of death certificates of COVID-19-associated deaths has been presented. METHODS: The death certificates of all deaths in Munich during the period from 1 March to 31 July 2020 were analyzed. The previously defined inclusion criteria were the indication of corona, COVID-19 and SARS-CoV­2 in the death certificates. The variables were entered anonymously according to a developed key. The collected data were evaluated descriptively. RESULTS: In the period under investigation, a total of 5840 people died in the Munich City area. Of these deaths 332 (5.7%) were COVID-19-associated. In 281 deaths (84.6%) there was a definite COVID-19 and in 51 deaths (15.4%) the suspicion of this disease. The most frequent causes of death were acute respiratory distress syndrome or respiratory insufficiency (59.1%), multiple organ failure (21.4%) and sepsis (10%). An average of 1.8 pre-existing illnesses were reported in the death certificates. Most frequently mentioned were diseases of the circulatory system (54.8%), the nervous system (22.8%) and metabolic diseases (18.9%). The average age at death was 79 years and the most frequent place of death was a hospital (85%). An autopsy was attempted by the doctors who issued the death certificates for 18.1% of the collective, most frequently in the case of unexplained or unnatural causes of death and young age of the deceased. Clinical pathological autopsies were performed on 11% of the collective and judicial autopsies on 1%. DISCUSSION: This study is the first evaluation of death certificates with respect to the novel infectious COVID-19. Number and essential characteristics of COVID-19-associated deaths in Munich during the so-called first wave could be mapped. The interest of physicians in autopsies was rather low despite the appearance of a new infectious disease.

One-stage oblique lateral corridor antibiotic-cement reconstruction for Candida spondylodiscitis in patients with major comorbidities: Preliminary experience.

Fungal spondylodiscitis is rare (0.5%-1.6% of spondylodiscitis) and mainly caused by Candida albicans. Surgical intervention in spondylodiscitis patients is indicated for compression of neural elements, spinal instability, severe kyphosis, failure of conservative management and intractable pain. However, there is no evidence-based optimal surgical approach for spondylodiscitis. There have been only case reports of surgical treatment for Candida spondylodiscitis. We evaluated the preliminary results of the efficacy and safety of one-stage debridement via oblique lateral corridor with interbody fusion (OLIF) using stand-alone cement reconstruction after debridement for the treatment of Candida spondylodiscitis in patients with major co-morbidities. Five patients (4 males, 1 female, mean age: 64.2 years) suffering from Candida albicans lumbar spondylodiscitis who underwent this procedure were studied. Their predominant symptoms were unremitting back and leg pain and all had pre and postoperative anti-fungal therapy under microbiologist supervision. The operative time ranged from 137minutes to 260minutes (mean: 213.4minutes). The mean blood loss was 160mL (range: 100-200mL). There were no perioperative complications. At follow-up all showed major improvement in pain and ambulatory status. CT scan showed radiological stability for all patients at 6-12 months. Our preliminary results showed stand-alone anterior debridement and spinal re-construction with cement through mini-open OLIF approach might be a safe and effective option for patients with spinal fungal infection and major comorbidities.

Postmortem interrogation of cardiac implantable electrical devices may clarify time and cause of death.

BACKGROUND: Postmortem interrogation of cardiac implantable electrical devices (CIED) in autopsy is not routinely performed. Thus, it remains unclear whether an interrogation might clarify time and cause of death. METHODS: Seventy of 4401 patients (1.6%) undergoing autopsy in 2014 and 2015 presented with a CIED. The explanted CIED were interrogated with respect to time and possible cause of death. Battery and lead parameters, clinical and technical alerts, and arrhythmia episodes were reviewed and afterwards correlated with the results of autopsy and clinical data. RESULTS: Twenty-five implantable cardioverter defibrillators (ICD) and 45 pacemaker (PM) devices were analyzed. Death was classified as cardiac by autopsy in 17 of 70 patients. Accordingly, presumably lethal ventricular arrhythmias were documented in six patients (8.6%; 5 ICD, 1 PM). In two of 30 patients with unknown cause of death after autopsy (6.7%), interrogation revealed ventricular tachycardia as potential reason for decease (1 ICD, 1 PM). Postmortem CIED interrogation additionally allowed to make a statement regarding the day of death in 36 patients (51%; 13 ICD, 23 PM). This was in accordance with clinical data or the results of autopsy in nine patients (25%; 3 ICD, 6 PM) or could even clarify the time of death in six patients (16.7%; 4 ICD, 2 PM). CONCLUSION: Interrogation of CIED revealed potentially lethal ventricular arrhythmias in 9 of 70 patients investigated and enabled valid estimation of the day of death in 15 patients. We therefore conclude that routinely performed postmortem CIED interrogation may clarify time and cause of death.

Injury potential of one-litre beer steins.

Injuries resulting from blows with beer steins are a frequent occurrence during annual autumn fairs or at beer halls in South Germany and Austria. The majority of these cases are tried in court and thus being assessed by a forensic medicine expert. The article at hand gives a short overview on the injury potential of one-litre beer steins and explains the key variables to consider when analyzing beer stein injuries. On the basis of representative cases, which were assessed by specialists from the Institute of Legal Medicine of the Munich University over the last 5 years, the main biomechanical aspects and resulting injuries of one-litre beer stein assaults are discussed. Several severe and potentially life-threatening injuries have been observed after an assault with a one-litre beer stein. There is a discrepancy between the mechanical stability of brand new and used steins and the corresponding injuries, which can be explained by a decrease in impact tolerance of the steins with their use. In general, a blow with a one-litre glass or stonework beer stein to the head can cause severe and even life-threatening blunt as well as sharp trauma injuries.

A proclaimed accidental fall of an infant-an experimental case reconstruction study.

The differentiation between a non-accidental injury and injuries resulting from accidents, such as falls to the ground or onto various objects, is a challenge not only for forensic experts but also for all clinicians caring for children. The forensic-biomechanical analysis of accidents in infants aims at the assessment of the loading characteristics based on the reconstruction of the particular incident. It includes an evidence-based analytical comparison between the actual injuries presented and the injuries that should be expected as a result of the proclaimed accident. With the help of kinematical and dynamical parameters of the described actions and the resulting loading situations, the forensic-biomechanical analysis can assess the plausibility of the proclaimed course of the event and thus contribute to the differentiation between accidental and non-accidental injuries. The quality of such a forensic-biomechanical expert opinion depends on the accuracy and quantity of available data regarding biomechanical tolerance of tissues, organs, and body parts. Case-specific measurements can contribute significantly to the insight of the kinematics and dynamics of the proclaimed event, its feasibility, etc. The present article demonstrates, based on one case report, the potential as well as the limits of such an analysis of proclaimed accidental fall injuries.

Micro-endoscopy of the human vas deferens: a feasibility study of a novel device in several ex vivo models.

The aim of this study was to show limitation as well as potential of micro-endoscopy techniques as an innovative diagnostic and therapeutic approach in andrology. Two kinds of custom-made micro-endoscopes (ME) were tested in ex vivo vas deferens specimen and in post-mortem whole body. The semi-rigid ME included a micro-optic (0.9 mm outer diameter [OD], 10.000 pixels, 120° vision angle [VE], 3-20 mm field depth [FD]) and an integrated fibre-optic light source. The flexible ME was composed of a micro-optic (OD = 0.6 mm, 6.000 pixels, 120° VE, 3-20 mm FD). The ex vivo study included retrograde investigation of the vas deferens (surgical specimen n = 9, radical prostatectomy n = 3). The post-mortem investigation (n = 4) included the inspection of the vas deferens via both approaches. The results showed that antegrade and retrograde rigid endoscopy of the vas deferens were achieved as a diagnostic tool. The working channel enabled therapeutic use including biopsies or baskets. Using the flexible ME, the orifices of the ejaculatory ducts were identified. In vivo cadaveric retrograde cannulation of the orifices was successful. Post-mortem changes of verumontanum hindered the examinations beyond. Orifices were identified shaded behind a thin transparent membrane. Antegrade vasoscopy using flexible ME was possible up to the internal inguinal ring. Further advancement was impossible because of anatomical angle and lack adequate vision guidance. The vas deferens interior was clearly visible and was documented by pictures and movies. Altogether, the described ME techniques were feasible and effective, offering the potential of innovative diagnostic and therapeutic approaches for use in the genital tract. Several innovative indications could be expected.

[Long-term survival after severe trauma]. / Langzeitüberleben nach schwerem Trauma.

Long-term survival after severe trauma is rarely addressed in German trauma journals although knowledge of life expectancy and identification of factors contributing to increased mortality are important for lifetime care management, development of service models, and targeting health promotion and prevention interventions. As reliable data in Germany are lacking, we compiled data mainly from the USA and Australia to describe life expectancy, risk factors, and predictors of outcome in patients experiencing traumatic spinal cord injury, traumatic brain injury, and polytrauma. Two years after trauma, life expectancy in all three categories was significantly lower than that of the general population. It depends strongly on severity of disability, age, and gender and is quantifiable. Whereas improvements in medical care have led to a marked decline in short-term mortality, surprisingly long-term survival in severe trauma has not changed over the past 30 years. Therefore, there is need to intensify long-term trauma patient care and to find new strategies to limit primary damage.

Postmortem computed tomography (PMCT) and autopsy in deadly gunshot wounds--a comparative study.

INTRODUCTION: Postmortem computed tomography (PMCT) data in gunshot-related death were evaluated by two reader groups and compared to the gold standard autopsy for the determination of forensic pathology criteria. MATERIALS AND METHODS: Reader group I consisted of two board-certified radiologists whereas one board-certified radiologist and one board-certified forensic pathologist formed group II. PMCT data of 51 gunshot-related deaths were evaluated for the forensic pathology criteria number of gun shots, localization of gunshot injury, caliber, and direction of the gunshot differentiating between entry and exit wound as well as associated injury to surrounding tissue. The results of both reader groups were compared to the each other and to autopsy findings considered as gold standard. RESULTS: Reader groups I and II and as gold standard the autopsy evaluation showed in general a good correlation between all results. The overall discrepancy rate was 12/51 (23.4%) cases for group I and 8/51 (15.6%) for group II. DISCUSSION: Ultimately, the designated reader is able to draw the following conclusion from the presented data. At first, physical autopsy is better than PMCT regarding the localization of most gunshot injuries. Second, PMCT presents with better results than physical autopsy in locating fragmented bullets/fragment clouds, and finally, PMCT results of two radiologists were equivalent to the results of one evaluating radiologist and one pathologist with the exception of caliber assessment. However, referring to the pure numbers, the slight but not significant difference in the overall discrepancy rate of both reader groups might indicate the advantage of combining expertise in evaluating imaging in cases of gunshot-related death.

Whiplash-Associated Disorders : Clinical and medico-legal guidelines on the methods of ascertainment.

The manuscript presents the International Guidelines developed by the Working Group on Personal Injury and Damage under the patronage of the International Academy of Legal Medicine (IALM) regarding the Methods of Ascertainment of any suspected Whiplash-Associated Disorders (WAD).The document includes a detailed description of the logical and methodological steps of the ascertainment process as well as a synoptic diagram in the form of Flow Chart.

The chemistry of death--Adipocere degradation in modern graveyards.

The formation of adipocere slows further decomposition and preserves corpses for decades or even centuries. This resistance to degradation is a serious problem, especially with regard to the reuse of graves after regular resting times. We present results from an exhumation series in modern graveyards where coffins from water-saturated earth graves contained adipocere embedded in black humic material after resting times of about 30 years. Based on the assumption that this humic material resulted from in situ degradation of adipocere, its presence contradicts the commonly held opinion that adipocere decomposition only occurs under aerobic conditions. To test our hypothesis, we collected black humic material, adipocere as well as soil samples above and below coffins from representative graves (n=7). A comprehensive chemical analysis of the samples substantiated our in situ degradation theory. Element compositions and fatty acid mass spectra confirmed that the humic black material originated from the corpses. A van Krevelen diagram classified the excavated adipocere material as lipid, whereas the black humic material was closer to the carbohydrate region. Mass fragmentograms of the humic material revealed the presence of large amounts of saturated vs. unsaturated nC16 and nC18 fatty acids, which is typical for adipocere. In addition, the soil samples exhibited a lipid signature deriving primarily from plant waxes and root components (C20C32). Solid-state (13)C NMR spectra of adipocere displayed well-resolved signals of saturated aliphatic chains and a signal that corresponded to carboxylic acid groups. The NMR spectra of the black humic material revealed signals characteristic of long aliphatic chains. The intensities varied in relation to the state of degradation of the sample, as did the signals of oxidized aliphatic chains, acetals and ketals, aromatic structures, esters and amids. The analyses confirmed that the black humic material was indeed derived from adipocere, so the assumption is that the components detected must have developed from aliphatic fatty acids via a number of oxidation and condensation processes. We therefore propose the existence of chemical pathway(s) for the degradation of adipocere under poikiloaerobic conditions. Possible (biogeo)chemical reaction chains include (1) the autoxidation of fatty acids enhanced by haemoglobin, methaemoglobin and haemin, (2) the use of alternative electron acceptors, which leads to the formation of H2S that then reacts abiotically with iron (from haemoglobin), rendering iron sulphide, and (3) the Maillard reaction. These findings are another step forward in understanding the chemistry of buried corpses.

First detection of ethylphenidate in human fatalities after ethylphenidate intake.

Methylphenidate, a psychostimulant drug from the group of amphetamines is, among others, established in the treatment of attention deficit hyperactivity disorder and narcolepsy. It is also known to have a certain potential of abuse. In combination with alcohol, the metabolite ethylphenidate was detected in human plasma in small amounts. However, ethylphenidate is sold as "research chemical" via the Internet. It was put under German narcotics law in July 2013. In a recent case, where a deceased person was found in his apartment, the police seized a plastic bag with the inscription "ethylphenidate". An autopsy of the 32-year-old man yielded a mitral valve endocarditis, which must have persisted a while before death, in combination with a pneumonia. At the Forensic Toxicological Centre (FTC) in Munich femoral blood, liver, pericardium fluid, urine, stomach content and hair of the deceased were analyzed for ethylphenidate after sample preparation by an LC-Triple TOF 5600. Calibration curves were spiked with a methanolic 1mg/mL solution of ethylphenidate (substance provided by the State Office of Criminal Investigation in Munich) in whole blood in comparison to liver and femoral blood, in serum in comparison to pericardium fluid and in urine in comparison to urine and stomach content, respectively. Ethylphenidate was detected in all analyzed matrices. The spectrums of the human specimen were compared to those obtained from the calibration curves and identified as ethylphenidate. The measured concentrations were for femoral blood 110ng/mL, for liver 180ng/g, for pericardium fluid 131ng/mL, for urine 987ng/mL and for stomach content 20.7ng/mL, respectively. The stomach contained 200mL of a brownish-coloured liquid, resulting in a total amount of 4000ng ethylphenidate. The lowest calibrator for whole blood and serum was 1ng/mL and for urine 10ng/mL. As far as it is known to the authors, these are the first ethylphenidate levels measured in a case of ethylphenidate intake. Therefore these results can only be compared to methylphenidate concentrations with therapeutic levels ranging from 5 to 60ng/mL in serum. As the toxic levels for methylphenidate start from approximately 500ng/mL serum, we estimate that ethylphenidate in the concentrations mentioned above is not in a directly lethal range. But it has to be considered, that amphetamine-like drugs as methylphenidate are known for their cardiovascular side effects (like tachycardia and arrhythmia) and might therefore have contributed to death, which was attributed to endocarditis in combination with pneumonia.

The validation and application of a finite element human head model for frontal skull fracture analysis.

Traumatic head injuries can result from vehicular accidents, sports, falls or assaults. The current advances in computational methods and the detailed finite element models of the human head provide a significant opportunity for biomechanical study of human head injuries. The biomechanical characteristics of the human head through head impact scenarios can be studied in detail by using the finite element models. Skull fracture is one of the most frequent occurring types of head injuries. The purpose of this study is to analyse the experimental head impacts on cadavers by means of the Strasbourg University Finite Element Head Model (SUFEHM). The results of the numerical model and experimental data are compared for validation purpose. The finite element model has also been applied to predict the skull bone fracture in frontal impacts. The head model includes the scalp, the facial bone, the skull, the cerebral spinal fluid, the meninges, the cerebrum and the cerebellum. The model is used to simulate the experimental frontal head impact tests using a cylindrical padded impactor. Results of the computational simulation shows that the model correlated well with a number of experimental data and a global fracture pattern has been predicted well by the model. Therefore the presented numerical model could be used for reconstruction of head impacts in different impact conditions also the forensic application of the head model would provide a tool for investigation of the causes and mechanism of head injuries.

Wound ballistic evaluation of the Taser® XREP ammunition.

The Taser® eXtended Range Electronic Projectile (XREP®) is a wireless conducted electrical weapon (CEW) designed to incapacitate a person from a larger distance. The aim of this study was to analyze the ballistic injury potential of the XREP. Twenty rounds were fired from the Taser®X12 TM shotgun into ballistic soap covered with artificial skin and clothing at different shooting distances (1-25 m). One shot was fired at pig skin at a shooting distance of 10 m. The average projectile velocity was 67.0 m/s. The kinetic energy levels on impact varied from 28-52 J. Depending on the intermediate target, the projectiles penetrated up to 4.2 cm into the ballistic soap. On impact the nose assembly did not separate from the chassis, and no electrical activation was registered. Upon impact, a skin penetration of the XREP cannot be excluded. However, it is very unlikely at shooting distances of 10 m or more. Clothing and a high elasticity limit of the target body area can significantly reduce the penetration risk on impact.

Graveyards - special landfills.

Graveyards have been a matter of controversial debate for many years in terms of the risk they pose to the environment. However, literature data are inconclusive and there are no systematic studies available from modern graveyards with special reference to soil found in the vicinity of the coffin. To our knowledge, the present study is the first to systematically investigate a comprehensive exhumation series (involving 40 graves) in order to determine burial-related changes in matter and element content. Human burials lead to the accumulation of certain elements, with higher than normal levels of N, C, Zn, Ba, Ca and Na being observed in soils below coffins. Decomposition material inside coffins has much higher levels of heavy metals and alkaline elements than the surrounding soil. However, the major problem observed was the large quantity of synthetic bedding material which is more likely to lead to the formation of adipocere under the moist conditions given. Adipocere formation, which is the result of the anaerobic bacterial hydrolysis of fat, is known to interrupt the natural decomposition process and delay the post-mortem release of elements. We assume that once the inhumed matter has completely decomposed, much higher than normal levels of pollutants will be released into and have an ecological effect on the soil and water environment.

Postmortem 24-h interval computed tomography findings on intrahepatic gas development and changes of liver parenchyma radiopacity.

PURPOSE: The purpose of this study was to assess and analyze the development of intrahepatic gas and its distribution over time as well as radiopacity changes of the liver parenchyma after non-traumatic death during a period of 24h using postmortem computed tomography (PMCT). MATERIALS AND METHODS: Five male corpses (age range 24-64 yrs) who had died for any other reason than trauma were enrolled in this study. Whole body multi detector row computed tomography (MDCT) scans (Brilliance 64-channel, Philips, Amsterdam, NL) were performed for 24 h with one examination per hour. At an average of 6h after the corpses were found on scene the first CT-exam took place. For the analysis of the intrahepatic gas development and distribution within 24h after death the liver was virtually divided into four parts. Each examination was analyzed for gas bubbles and the possible increase over time using a semiquantitative/visual assessment employing a four-grade scale. The changes of the radiopacity of the liver parenchyma were assessed in a similar way. In each of the four parts of the liver three regions of interest of the same size were placed and recorded over time. Three radiologists and one coroner independently performed the analysis of the gas development and radiopacity changes. RESULTS: In two corpses the amount of gas and its distribution did not change over the observation period whereas in the other three corpses the gas content increased within the first four to seven hours and was most pronounced in the left liver lobe and least in the right posterior liver lobe. In all five corpses the radiopacity of the liver parenchyma did not change significantly over time with the highest radiopacity in the right posterior liver lobe. Good interobserver reliability concerning the assessment of intrahepatic gas accumulation was found. DISCUSSION: Our results indicate that PMCT is useful to detect intrahepatic gas. However, several reasons for these findings besides putrefaction e.g. trauma, resuscitation exist. For an elucidation of the exact causation of the gas accumulation further studies are required with longer postmortem examination times (24-72 h) to detect more pronounced changes of gas and organ radiopacity but also an earlier start of examination after death is desirable. Moreover, it has to be elucidated whether other organs exhibit a similar behavior and how temperature of the CT-room and the body impacts on these parameters.