Comparison of all completed suicides in Frankfurt am Main (Hessen) before and during the early COVID-19 pandemic.

To research the effect of the COVID-19 pandemic on mental health, the prevalence and characteristics of all completed suicides in the city of Frankfurt am Main were compared for a 10-month period before the pandemic (March 2019-December 2019) with one during the early pandemic (March 2020-December 2020). Medicolegal data collected in the context of the FraPPE suicide prevention project were evaluated using descriptive statistical methods. In total, there were 81 suicides during the early pandemic period, as opposed to 86 in the pre-pandemic period. Though statistically not significant, the proportion of male suicides (73%) was higher during the early pandemic period than before (63%). The age-at-death was comparable in the pre-pandemic and pandemic periods (average, 54.8 vs. 53.1 years). Between these two periods, there was no difference in respect to the three most commonly used suicide methods by men: fall from a height (26% vs. 22%), intoxication, and strangulation (each 24% vs. 19%). For women, there was, however, a shift in methods from strangulation (38%), intoxication (28%), and fall from a height (19%) to fall from a height (50%), strangulation (18%), intoxication, and collision with a rail vehicle (14% each). There was a trend towards more suicides among non-German nationals during the early pandemic (suicide rate/100,000 inhabitants: German, 14.3 vs. 11.5; non-German, 4.4 vs. 8.8). Before the pandemic, 54% of the suicides were known to have a mental illness in contrast to 44% during the early pandemic. Overall, no increase in completed suicides could be observed in Frankfurt am Main during the early pandemic.

Respiratory viruses in medicolegal autopsies during the winter season 2021/2022: observations after reduction of coronavirus disease-19 (COVID-19) pandemic restrictions.

In the context of the coronavirus disease (COVID-19) pandemic, measures were taken to protect the population from infection. These were almost completely lifted in several countries in the spring of 2022. To obtain an overview of the spectrum of respiratory viruses encountered in autoptical routine case work, and their infectivity, all autopsy cases at the Institute of Legal Medicine in Frankfurt/M. with flu-like symptoms (among others) were examined for at least 16 different viruses via multiplex PCR and cell culture. Out of 24 cases, 10 were virus-positive in PCR: specifically, 8 cases with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), 1 with respiratory syncytial virus (RSV), and 1 with SARS-CoV-2 and the human coronavirus OC43 (HCoV-OC43), as a double infection. The RSV infection and one of the SARS-CoV-2 infections were only detected due to the autopsy. Two SARS-CoV-2 cases (postmortem interval of 8 and 10 days, respectively) showed infectious virus in cell culture; the 6 other cases did not show infectious virus. In the RSV case, virus isolation by cell culture was unsuccessful (Ct value of 23.15 for PCR on cryoconserved lung tissue). HCoV-OC43 was measured as non-infectious in cell culture, with a Ct value of 29.57. The detection of RSV and HCoV-OC43 infections may shed light on the relevance of respiratory viruses other than SARS-CoV-2 in postmortem settings; however, further, more extensive studies are needed for a robust assessment of the hazard potential due to infectious postmortem fluids and tissues in medicolegal autopsy settings.

[Spinal arteriovenous malformations]. / Spinale arteriovenöse Malformationen.

Spinal vascular malformations include various entities such as spinal arteriovenous malformations (AVM) and represent a rare disease. Patients may present with acute or progressive sensorimotor deficits and/or nonspecific symptoms such as hypoesthesia or paresthesia, diffuse back and muscle pain, or feelings of weakness. When spinal arteriovenous malformation is suspected, magnetic resonance imaging (MRI) is the first diagnostic step to rule out other differential diagnoses, followed by a selective spinal angiography. Therapeutic options include endovascular therapy by embolization and/or surgical resection. If spinal AVM is treated properly, a significant reduction in symptoms can be achieved.

Detection and infectivity of SARS-CoV-2 in exhumated corpses.

Postmortem detection of severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) after the exhumation of a corpse can become important, e.g. in the case of subsequent medical malpractice allegations. To date, data on possible detection periods [e.g. by reverse transcription polymerase chain reaction (RT-PCR)] or on the potential infectivity of the virus after an exhumation are rare. In the present study, these parameters were examined in two cases with a time span of approximately 4 months between day of death and exhumation. Using SARS-CoV-2 RT-PCR on swabs of both lungs and the oropharynx detection was possible with cycle threshold (Ct) values of about 30 despite signs of beginning decay. RT-PCR testing of perioral and perinasal swabs and swabs collected from the inside of the body bag, taken to estimate the risk of infection of those involved in the exhumation, was negative. Cell culture-based infectivity testing was negative for both, lung and oropharyngeal swabs. In one case, RT-PCR testing at the day of death of an oropharyngeal swab showed almost identical Ct values as postmortem testing of an oropharyngeal swab, impressively demonstrating the stability of viral RNA in the intact corpse. However, favorable climatic conditions in the grave have to be taken into account, as it was wintertime with constant low temperatures. Nevertheless, it was possible to demonstrate successful postmortem detection of SARS-CoV-2 infection following exhumation even after months in an earth grave.

[Nonaccidental traumatic brain injury in infants and children]. / Nichtakzidentelles Schädel-Hirn-Trauma bei Säuglingen und Kleinkindern.

Violent traumatic brain injury (TBI) can cause brain dysfunction and injury. Accidental and nonaccidental trauma are still the leading cause of childhood death worldwide. It is assumed that about 20% of TBI in children under 2 years of age are nonaccidentally caused. In all cases, nonaccidental TBI is caused by the violent impact on the brain and spinal cord by the massive shaking of the child held by the upper arms or body. This can lead to a rupture of blood vessels, especially bridge veins, as well as axonal shear injuries to the nerve connections and brain swelling. Involvement of the brain stem can lead to initial short-term respiratory arrest. The resulting clinical symptoms include poor drinking, drowsiness, apathy, cerebral seizures, breathing disorders, temperature disorders, and vomiting as a result of increased intracranial pressure. Long-term disorders can include neurological and neuropsychological disorders, hearing disorders, visual disorders up to blindness, and poor school performance. In addition, there are metaphyseal fractures and rib fractures of various forms, also of different ages. Since shaking trauma has a poor prognosis, preventive measures are useful: education!

Infectivity of deceased COVID-19 patients.

The duration of infectivity of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) in living patients has been demarcated. In contrast, a possible SARS-CoV-2 infectivity of corpses and subsequently its duration under post mortem circumstances remain to be elucidated. The aim of this study was to investigate the infectivity and its duration of deceased COVID-19 (coronavirus disease) patients. Four SARS-CoV-2 infected deceased patients were subjected to medicolegal autopsy. Post mortem intervals (PMI) of 1, 4, 9 and 17 days, respectively, were documented. During autopsy, swabs and organ samples were taken and examined by RT-qPCR (real-time reverse transcription-polymerase chain reaction) for the detection of SARS-CoV-2 ribonucleic acid (RNA). Determination of infectivity was performed by means of virus isolation in cell culture. In two cases, virus isolation was successful for swabs and tissue samples of the respiratory tract (PMI 4 and 17 days). The two infectious cases showed a shorter duration of COVID-19 until death than the two non-infectious cases (2 and 11 days, respectively, compared to > 19 days), which correlates with studies of living patients, in which infectivity could be narrowed to about 6 days before to 12 days after symptom onset. Most notably, infectivity was still present in one of the COVID-19 corpses after a post-mortem interval of 17 days and despite already visible signs of decomposition. To prevent SARS-CoV-2 infections in all professional groups involved in the handling and examination of COVID-19 corpses, adequate personal safety standards (reducing or avoiding aerosol formation and wearing FFP3 [filtering face piece class 3] masks) have to be enforced for routine procedures.

[Spinal cord vascular diseases]. / Spinale Gefäßmissbildungen.

Spinal vascular malformations include various entities, including spinal dural arteriovenous (AV) fistulas, acquired malformations and cavernous hemangiomas, and spinal arteriovenous malformations. AV fistula refers to a spinal cord vascular malformation in which there is a short-circuit connection between a dural artery and a perimedullary vein superficial to the myelon. The condition is relatively rare, initial clinical symptoms are often misinterpreted, and a definitive diagnosis is often delayed by 12 months or more. However, early diagnosis is important to prevent progression of clinical symptoms, which may include paraplegia. Early magnetic resonance imaging (MRI) is helpful, showing intramedullary edema in the T2-weighted sequences and superficial, markedly dilated veins. Treatment consists of ligation of the AV fistula, either surgically or by embolization. Cavernous hemangiomas, consisting of a large number of closely located immature blood vessels, are also relatively rare and have a low risk of bleeding (approximately 0.2-0.5%). Venous hemorrhage may also occur, resulting in clinical symptoms (including paraplegia).

[Spinal cord ischemia]. / Spinale Ischämie.

Spinal cord ischemia is a rare disease with a poor prognosis. As with cerebral ischemia, spinal infarction typically presents with sudden symptom onset and variable clinical manifestation (depending on the lesion location). The majority of spinal ischemias occur in the supply territory of the anterior spinal artery, involving the anterior and middle third of the myelon. The most common cause of spinal ischemia is an arterial vessel occlusion, although venous ischemia and hypotensive watershed infarcts may also occur. Magnetic resonance imaging (MRI) represents the modality of choice for diagnosis of spinal cord ischemia.

Suicide among immigrants in Germany.

AIMS: The identification of high-risk groups is crucial in public health suicide prevention approaches. This study aims to compare suicide risks of Germans with nine of the largest immigrant populations living in Germany. METHODS: Based on a German national database of mortality statistics, the number of suicides in Germans and immigrants was available for the study period (2000 - 2017), stratified for gender and age groups. Standard mortality ratios (SMR) for suicide were computed since age distributions differed between populations. Moreover, SMR of immigrant populations were correlated with potential risk and resilience factors. RESULTS: The analysed dataset covers a period of 18 years, which translates to over 1.47 billion life years (LY) and 206,056 recorded suicides. 134,971,779 LY (10.1%) and 8,936 (4.3%) suicides were assigned to non-German citizens. SMR, calculated for nine of the largest immigrant populations, were lower compared with the German reference population ranging from 0.24 (Greek nationality) to 0.86 (Russian nationality). SMR in immigrants was highest in adolescents and declined with age. SMR was associated with country of origin (CO) suicide rates as well as with socio-economic factors of immigrant groups in Germany. With the global financial crisis, suicide risk of immigrants from the most affected countries decreased more strongly compared to immigrants from other CO. CONCLUSIONS: The suicide risk strongly differs between the individual immigrant groups and is associated with risk factors of the respective CO. Therefore, future suicide prevention approaches in immigrants should take CO-specific vulnerabilities into account as well as age-related risk factors.

[New trends in the treatment of bifurcation aneurysms]. / Neue Trends zur Behandlung von Bifurkationsaneurysmen.

CLINICAL ISSUE: Intracranial aneurysms most commonly occur at bifurcation sites. In case of dealing with broad based aneurysms, the risk of accidental vessel occlusion during embolization should not be underestimated. Therefore, several devices are available, e.g. WEB device and barrelsStent. Besides that, a special technique gives the opportunity to place two stents into each other or next to each other into both branches of a bifurcation. Over 300 patients included in 18 studies were treated with Y­stenting (e.g., Medline/Embase) showing a good clinical outcome in 92%. A complete occlusion was achieved in 91%. The rate of neurologic deficits was 4%, the procedure-caused mortality was 2%. Furthermore, 12% of the patients sustained a stroke during the intervention. Ruptured aneurysm was found in 19%. CONCLUSION: All in all, a high occlusion rate and a low rate of mortality and stroke were shown by using Y­stenting.

[Operative skull base approaches]. / Operative Zugänge zur Schädelbasis.

CLINICAL ISSUE: Knowledge of skull base anatomy is essential for recognizing the pathological conditions affecting the skull base structures (including cranial nerves and cerebral vasculature), for correct interpretation of their presentation on imaging studies, and finally for proper planning of surgical skull base approaches. PURPOSE OF THE ARTICLE: The main goal of the following work is to present a brief recapitulation of the regular skull base anatomy (with a focus on the bony structures) and based on this, to provide an overview of the most commonly used neurosurgical skull base approaches (illustrated using radiological case presentations). DIAGNOSTIC WORK-UP: Already at the step of the preoperative workup, the suitable radiological technique and proper choice of technical parameters for image acquisition lays the foundation for a successful surgical procedure and for the reliable assessment of operative results. CONCLUSION: Each radiologist should be familiar with basic principles of neurosurgical approaches and operative techniques used in skull base surgery and with their appearance in postoperative images.

Hammer blows to the head.

Hammer blows cause serious, often fatal injuries, especially when massive blunt violence is targeted at the head region. The evaluation of the injury potential depends not only on the body region hit, but also on the characteristics of the hammer as a weapon and on the physical characteristics of the attacker. This study aimed at elucidating the dependency between the physical constitution of a perpetrator and the intensity of hammer blows, thus to verify or refute this seemingly obvious interrelation sometimes expressed in the saying that a "strong hand strikes harder". For this purpose, 113 volunteers of different ages and sexes took part in different experimental settings. While, as expected, clear differences between male and female were detectable in the striking power of single and multiple strokes, there were no age or sex differences with regard to the maximum number of strokes per time unit. Strength differences in slamming with a hammer between men and women exceeded expectations in this study. Using the fracture forces as described by Sharkey et al. in an exemplary manner, one can expect a fracture of the skull in 9 out of 10 cases with a 300 g hammer by men for intensively executed single strokes, whereas this was only the case for approx. 2/10 women in this study. The maximum circumference of the upper arm and the width of the shoulder girdle correlate significantly with the achievable impact forces of individual hammer blows in both sexes. A simple measurement of the hand force with a manometer using the regression formula y [kN] = 0.144 × manual grip force -1.08 can be used as a rough estimation parameter for the theoretically achievable impact force. If one strikes repeatedly with the same hammer for 1 min, the magnitude of a single strike decreases continuously from 4.5 kN to 2.6 kN on average. If a 1500 g hammer is used instead of a 300 g hammer, one does not get the fivefold impact force you might expect at first sight, but only on the order of twice the impact force, about 14 kN on average. The results prove the importance of physical experiments, whose results can help to better interpret the magnitude and effects of hammer blows as a form of potentially life-threatening violence.

[Mobile Stoke Unit : Changes in the concept of stroke care over time]. / Mobile Stroke Unit (MSU) : Schlaganfall-Versorgungskonzept im Wandel der Zeit.

BACKGROUND: Stroke continues to be a major cause of death and one of the most frequent reasons for permanent disability and dependence on caregiving at an adult age, whereby ischemic stroke is regarded as a medical condition that can be treated. One of the main reasons why patients with acute stroke are not given causal or evidence-based treatment is the delay in reaching a treatment-specialized team at a suitable clinic. After the dawning of the age of neurothrombectomy, various management concepts have been established to transfer the patient to a center with the appropriate level of treatment as quickly as possible (time is brain). METHODS: The Mobile Stroke Unit (MSU) is an ambulance that contains all the equipment required to clarify the cause of a stroke and thus enables treatment and triage decision-making at the scene of the emergency. RESULTS: Due to prehospital implementation of the "need-for-speed" notion, the MSU assumes a special role. Present data indicate a benefit with regard to a shortening of time to thrombolysis and an increase in treatment rates within the first (golden) hour. In addition, it is possible to make a diagnosis-based triage decision regarding a hospital with or without an endovascular treatment option. CONCLUSIONS: The MSU allows swifter treatment and a diagnosis-based triage decision at the scene of the emergency. It is now important to continue evaluating the clinical and socioeconomic benefit of these, at first glance expensive, preclinical tools and also continue analyzing special regional aspects as well as the pros and cons of the concepts. The recently established Prehospital Stroke Treatment Organization (PRESTO) represents a promising approach.

Mobile stroke unit use for prehospital stroke treatment-an update.

BACKGROUND: Acute ischemic stroke is a treatable disease. Moreover, there is increasing evidence supporting mechanical recanalization for large-vessel occlusion, even beyond a strict time window. However, only small numbers of patients receive causal treatment. METHODS: One of the main reasons that patients do not receive causal therapy is their late arrival at the correct target hospital, which, depending on the type of stroke, is either a regional stroke unit or a comprehensive stroke center for interventional treatment. In order to triage patients correctly, a fast and complex diagnostic work-up is necessary, allowing a stroke specialist to decide on the best therapy option. As treatment possibilities become more comprehensive with the need for individualized decisions, the gap between treatment options and practical implementation is increasing. RESULTS: The "mobile stroke unit" concept encompasses the administration of prehospital acute stroke diagnostic work-up, therapy initiation, and triage to the correct hospital using a specially equipped ambulance, staffed with a team specialized in stroke. The concept, which was conceived and first put into practice in Homburg/Saar, Germany, in 2008, is currently spreading with more than 20 active mobile stroke unit centers worldwide. The use of mobile stroke units can reduce the time until stroke treatment by 50% with a tenfold increase of patients treated within the first 60 min of symptom onset. CONCLUSION: The mobile stroke unit concept for acute stroke prehospital management is spreading worldwide. Intensive research is still needed to analyze the best setting for prehospital stroke management.

Minimum time since death when the body has either reached or closely approximated equilibrium with ambient temperature.

In temperature based death time estimation the construction of a death time interval using the conventional Nomogram method (NM) is not permissible for bodies in which rectal temperature (Tr) has reached or closely approximated equilibrium with ambient temperature (Ta). We provide a logic approach to compute a minimum time since death with high probability. We also provide a simple graphical solution to be used at the crime scene for preliminary estimation. Special attention is advised in regards to cases with Ta>23°C as well as borderline cases. Proof by induction, application to test cases and one example of use are presented.

[Spinaltrauma : Clinical diagnosis and initial care]. / Wirbelsäulentraumata : Klinische Diagnostik und Erstversorgung.

DIAGNOSTIC WORK-UP: The rescue, treatment and transport of patients with an injured spine require a systematic scheme with the subsequent rating of the findings and suspected diagnoses. In addition to the assessment of temporal urgency, the available resources and personnel, the duration and complexity of any possible technical measures that might be anticipated, the rational selection of immobilisation tools also plays a significant role. The most important medical rescue aids are the scoop stretcher and the spine board; the spine board, vacuum mattress and cervical collar are used to immobilise the patient. PRACTICAL RECOMMENDATIONS: This article is focused on the diagnosis and initial treatment of isolated spinal injuries. The prehospital care of polytraumatised patients and/or those with multiple injuries differs significantly and has different priorities.

Prehospital Imaging-Based Triage of Head Trauma with a Mobile Stroke Unit: First Evidence and Literature Review.

BACKGROUND: An ambulance equipped with a computed tomography (CT) scanner, point-of-care laboratory, and telemedicine capabilities (Mobile Stroke Unit [MSU]) has been shown to enable delivery of thrombolysis to stroke patients at the emergency site, thereby significantly decreasing time to treatment. However, the MSU frequently assesses patients with cerebral disorders other than stroke. For some of these disorders, prehospital CT scanning may also be beneficial. METHODS: Our institution manages a program investigating prehospital stroke treatment of patients with neurological emergencies. We assessed a patient with head trauma for whom prehospital CT scanning and laboratory tests allowed cause-based triage to the most appropriate hospital. We examined implications of this case for clinical practice in light of a literature review. RESULTS: The MSU was dispatched to assess a 74-year-old woman with suspected head trauma or stroke, found lying on the floor with a left frontal laceration. Her Glasgow Coma Scale score was 13, apart from drowsiness she exhibited no neurologic deficit. A CT scan ruled out intracranial hemorrhage and skull fracture. On the basis of these prehospital diagnostic findings, the patient was taken to the nearest primary care hospital rather than to a trauma center with neurosurgery facilities. CONCLUSION: Patients with neurologic disorders other than stroke, such as traumatic brain injury, may also benefit from prehospital CT studies. This case report and the results of our analysis of the literature support the potential benefit of prehospital imaging in correctly triaging patients with suspected traumatic brain injury to the appropriate target hospital.

The ring phenomenon of diluted blood droplets.

Bloodstain pattern analysis is occasionally required in practical forensic casework. Misinterpretations may occur in cases in which diluted bloodstains are formed either within the course of the crime or during cleaning attempts after the original crime. The resulting pale or diluted aspect of the bloodstains may also be produced by passive serum separation. To differentiate between diluted and non-diluted stains and the artifacts of pure serum separation, dripping experiments were performed using droplets of multiple sizes and dilutions dripped onto common indoor and fabric surfaces. In addition, pools of blood of different volumes were applied to solid surfaces with different inclinations to determine the conditions and properties of serum separation. This study yielded morphological characteristics that enable differentiation between stains of diluted and non-diluted blood: a prominent ring phenomenon indicates dilution with water. To elucidate the underlying physical mechanism of particle distribution within a blood stain, photomicrographs were taken during the drying process. The so-called contact line pinning effect was identified as the formation mechanism of this ring phenomenon. Serum separation was highly dependent on the applied blood volume, the ambient temperature, the time elapsed since the initial deposition, and the degree of floor inclination.

IPV--bridging the juridical gap between scratches and DNA detection under fingernails of cohabitating partners.

Intimate partner violence (IPV) is a global health issue with lifetime prevalences of physical and sexual violence against women of 12-71% in various populations. Due to its clandestine nature third party eye witnesses are scarce and prosecution of these cases has to rely on medical examination results, e.g. injury patterns of the victim and the perpetrator. Medicolegal assessment of DNA of the male partner found in fingernail specimen of the female partner after an assault is difficult since cohabitating couples are known to carry DNA of the respective partner in 17% of examined couples. In this study, male and total DNA content in fingernail specimen of 34 couples was analyzed after vigorous scratching of the male partners flank. Scratching and non-scratching fingers showed a highly significant difference in absolute and relative male DNA content allowing for the differentiation of DNA transfer caused by normal cohabitation and scratching during an assault.