Die äußere Leichenschau ist ein zentrales, aber fehleranfälliges Instrument der Todesursachenermittlung. Anhand zweier Fälle wird gezeigt, dass zunächst als natürlich eingestufte Todesfälle mit angenommener Ösophagusvarizenblutung bei der zweiten Leichenschau als nichtnatürlich (Verdacht auf Suizid) erkannt wurden. Beide Erstbeurteilungen basierten auf ärztlichen Fehleinschätzungen trotz offensichtlicher Befunde. Die Ergebnisse unterstreichen die Notwendigkeit einer qualifizierten Ausbildung, einer offenen Fehlerkultur und der verpflichtenden Rückmeldung bei Fehleinschätzungen. Zudem wird die Bedeutung der zweiten Leichenschau vor Feuerbestattungen zur Sicherung der Rechts- und Befundqualität hervorgehoben.

Coronavirus disease 19 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become a global pandemic with significant mortality. Accurate information on the specific circumstances of death and whether patients died from or with SARS-CoV-2 is scarce. To distinguish COVID-19 from non-COVID-19 deaths, we performed a systematic review of 735 SARS-CoV-2-associated deaths in Hamburg, Germany, from March to December 2020, using conventional autopsy, ultrasound-guided minimally invasive autopsy, postmortem computed tomography and medical records. Statistical analyses including multiple logistic regression were used to compare both cohorts. 84.1% (n = 618) were classified as COVID-19 deaths, 6.4% (n = 47) as non-COVID-19 deaths, 9.5% (n = 70) remained unclear. Median age of COVID-19 deaths was 83.0 years, 54.4% were male. In the autopsy group (n = 283), the majority died of pneumonia and/or diffuse alveolar damage (73.6%; n = 187). Thromboses were found in 39.2% (n = 62/158 cases), pulmonary embolism in 22.1% (n = 56/253 cases). In 2020, annual mortality in Hamburg was about 5.5% higher than in the previous 20 years, of which 3.4% (n = 618) represented COVID-19 deaths. Our study highlights the need for mortality surveillance and postmortem examinations. The vast majority of individuals who died directly from SARS-CoV-2 infection were of advanced age and had multiple comorbidities.

Since 27th December 2020, a mRNA vaccine from BioNTech / Pfizer (Comirnaty (R)) has been used across Germany. As of 12th March 2021, 286 fatalities of vaccinated German individuals were registered at the PaulEhrlich-Institute with time intervals after vaccination between one hour to 40 days. From our catchment area in northern Germany, we have so far become aware of 22 deaths in connection with vaccination in a 5 week period (range: 0-28 days after vaccination). Three death cases after vaccination with Comirnaty (R), which were autopsied at the Institute of Legal Medicine Hamburg, are presented in more detail. All three deceased had severe cardiovascular diseases, among other comorbidities, and died in the context of these pre-existing conditions, while one case developed a COVID-19 pneumonia as cause of death. Taking into account the results of the postmortem examination a causal relation between the vaccination and the death was not established in any case. If there are indications of an allergic reaction, histological and postmortem laboratory examinations should be performed subsequent to the autopsy (tryptase, total IgE, CRP, interleukin-6, complement activity C3/C5).

Background Coronavirus disease 19 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become a global pandemic with significant mortality. Accurate information on the specific circumstances of death and whether patients died from or with SARS-CoV-2 is scarce. Methods To distinguish COVID-19 from non-COVID-19 deaths, we performed a systematic review of 735 SARS-CoV-2-associated deaths in Hamburg, Germany, from March to December 2020, using conventional autopsy, ultrasound-guided minimally invasive autopsy, postmortem computed tomography and medical records. Statistical analyses including multiple logistic regression were used to compare both cohorts. Findings 84.1% (n=618) were classified as COVID-19 deaths, 6.4% (n=47) as non-COVID-19 deaths, 9.5% (n=70) remained unclear. Median age of COVID-19 deaths was 83.0 years, 54.4% were male. In the autopsy group (n=283), the majority died of pneumonia and/or diffuse alveolar damage (73.6%; n=187). Thromboses were found in 39.2% (n=62/158 cases), pulmonary embolism in 22.1% (n=56/253 cases). In 2020, annual mortality in Hamburg was about 5.5% higher than in the previous 20 years, of which 3.4% (n=618) represented COVID-19 deaths. Interpretation Our study highlights the need for mortality surveillance and postmortem examinations. The vast majority of individuals who died directly from SARS-CoV-2 infection were of advanced age and had multiple comorbidities.

Zusammenfassung Hintergrund Im Rahmen der COVID-19-Pandemie sind Inzidenz und Mortalität entscheidende Determinanten, um Ausbreitungsdynamik und Gefahrenpotenzial zu beurteilen. Untersucht wird, ob ein systematisches mikrobiologisches Monitoring von Todesfällen eine relevante Untererfassung der Mortalität aufzeigen kann, und ob sich ggf. eine Sterbekohorte zuvor nicht erfasster Fälle von einer Hellfeldkohorte unterscheidet (Soziografie, Todesursache). Methode Es erfolgte eine systematische Reverse-Transkriptase(RT)-qPCR(quantitative Polymerasekettenreaktion)-Testung von Verstorbenen in zentralen Leichenhallen in Hamburg (Institut für Rechtsmedizin, Krematorium) auf eine SARS-CoV‑2-Infektion mittels Nasen-Rachen-Abstrich über 8 Wochen ab Auftreten pandemiebezogener Todesfälle mit vergleichender Analyse der Hell- und Dunkelfeldkollektive. Ergebnisse Unter insgesamt 1231 verdachtsunabhängig getesteten Verstorbenen lag bei 29 Fällen (2,4 %) eine zuvor nicht bekannte SARS-CoV‑2-Infektion vor. In der ersten Phase der Pandemie überwogen Zufallsentdeckungen unter unklaren und nichtnatürlichen Todesfällen in der Rechtsmedizin, die vermehrt jüngere Altersgruppen, v. a. aus häuslicher Umgebung, umfassten. Im Krematorium zeigten sich mit weiterem Verlauf zunehmend Zufallsentdeckungen bei Todesfällen aus stationären Pflegeinstitutionen. Das Gesamtkollektiv wies soziodemografisch keine signifikanten Unterschiede zu einem Vergleichskollektiv bekannter/registrierter SARS-CoV‑2-assoziierter Todesfälle auf. In der Dunkelfeldkohorte war die Todesursache COVID-19 signifikant seltener. Schlussfolgerung Ein systematisches verdachtsunabhängiges PCR-basiertes Monitoring von Todesfällen ermöglicht eine vollständigere Erfassung von SARS-CoV‑2-positiven Sterbefällen insbesondere im nichtklinischen Sektor. Durch die Erfassung eines Dunkelfelds, das einer Routineleichenschau bislang entgeht, kann ein präventiver epidemiologischer Beitrag geleistet werden.

The affiliation of the author Martin Aepfelbacher was incorrectly assigned in the manuscript. Martin Aepfelbacher is affiliated to the Institute of Microbiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany, instead.

Background. Coronavirus disease 2019 (COVID-19), a disease caused by the new coronavirus (SARS-CoV-2), is a particular threat to old people. At the end of March 2020, the first and so far largest outbreak of the disease occurred in a retirement home in Hamburg. Methods. Analysis of procedures in dealing with a residential unit affected by SARS-CoV-2, accommodating a risk group of 60 seniors with dementia is presented as well as a detailed presentation of post-mortem examination results of all 8 deceased tested positive for SARS-CoV-2. Results. Out of 60 residents, 39 were infected by SARS-CoV-2. Due to preventive procedures it was possible to stop further spreading of the infection to other residential areas. In all 8 fatal cases, the autopsy diagnosis was death due to COVID-19. Autopsies revealed all COVID-19 patients to have a fatal (broncho)pneumonia and signs of relevant pre-existing cardiac, renal and pulmonary conditions in all cases. In 75% (n= 6) of the cases a fresh venous thrombosis was found. In 66.7% (n= 4) of the cases thrombotic events were combined with peripheral pulmonary artery thromboembolisms. Conclusion. The cohort of SARS-CoV-2 infected residents of a nursing home is characteristic for clinical and epidemiological features of the new coronavirus disease. Due to a centralized evaluation of all fatalities at the Institute of Legal Medicine in Hamburg, a detailed examination of all deceased positive for SARS-CoV-2 was possible. Thereby, increased case fatality rates of approximately 20% could in all cases be assigned to a relevant number of pre-existing comorbidities of multiple organ systems, which was consistent with the clinical data available.

Die durch das neue Coronavirus (SARS-CoV-2) bedingte Erkrankung Coronavirus-Krankheit 2019 (COVID-19) stellt eine Gefährdung für Ältere dar. Ende März 2020 kam es zu einem ersten, bislang größten Infektionsausbruch in einem Seniorenpflegewohnheim in Hamburg. Analyse von Verfahrensabläufen in einer von SARS-Coronavirus-2 (SARS-CoV‑2) betroffenen Wohneinheit mit 60 demenziell vorerkrankten Senioren sowie umfassende Darstellung der Obduktionsbefunde SARS-CoV-2-positiv getesteter dortiger Sterbefälle. In 39 von 60 Fällen infizierten sich Pflegeheimbewohner mit SARS-CoV‑2. Eine Ausbreitung der Infektionswelle auf andere Wohnbereiche ließ sich verhindern. In allen 8 Sterbefällen wurde durch die Obduktion die Diagnose eines COVID-19-bedingten Todes gestellt. Autoptisch fanden sich eine todesursächliche (Broncho‑)Pneumonie sowie Korrelate relevanter kardialer, renaler und pulmonaler Vorerkrankungen in allen Fällen. In 75 % (n = 6) der Fälle waren frische Unterschenkelvenenthrombosen, in 66,7 % (n = 4) kombiniert mit peripheren Lungenarterienthromboembolien, nachweisbar. Das im deutschsprachigen Raum erstmals systematisch beschriebene Kollektiv von SARS-CoV-2-Infizierten in einer Pflegeeinrichtung ist charakteristisch für die bislang bekannten klinischen und epidemiologischen Besonderheiten der neuen Coronainfektion. Durch die zentralisierte Evaluation aller Todesfälle in Hamburg war eine gezielte Aufarbeitung der SARS-CoV-2-positiven Sterbefälle unter den betroffenen Heimbewohnern möglich. Der deutlich erhöhten Letalität von ca. 20 % konnten in allen Fällen relevante Komorbiditäten multipler Organsysteme zugeordnet werden – die mit den klinischen Daten im Einklang standen.

Blood at crime scenes is one of the most significant traces of evidence in investigation proceedings. Cleaning up these traces with household cleaning products, often containing bleaching agents, inhibits or complicates the detection of DNA. In this study, human blood was applied onto different floor coverings (carpet, laminate, parquet, PVC, tile) and subsequently cleaned with water and bleaching agents (hydrogen peroxide, sodium hypochlorite, DanKlorix®, Vanish Oxi Action®) at different times. Samples have been collected afterwards from the floors. The samples underwent a quantitative and qualitative DNA analysis. Cleaning smooth surfaces with water is usually sufficed to prohibit retrieving a DNA profile in most of the cases. Cleaning carpets was more difficult due to their absorbent surface whereas the use of bleaching agents caused an additional reduction of verifiable DNA concentrations. Retrieving partial or complete profiles after the use of bleaching agents was only possible when cleaning with low concentrations of 3% hydrogen peroxide.

Background: Reaming of the acetabular cavity and cup implantation directly influence the hip rotation center and contact area between implant and bone. Previous studies have reported on an altered rotation center after total hip arthroplasty, but have not studied the influence of reaming and cup implantation separately. Aim of this study was therefore to analyze the individual influence of acetabular reaming and subsequent cup implantation on the rotation center and how this influences the contact conditions at the bone-implant interface. Methods: Acetabular press-fit cups were implanted into the left and right hips of three full cadavers (n = 6). CT scans were performed to calculate the change in hip rotation center after reaming and prior to liner insertion. 3D models of the cups were used to determine the polar gap, the contact conditions and the effective press-fit. Findings: Reaming the acetabular cavity shifted the rotation center medially (median 5.8 mm, range 4.8-9.1), superiorly (5.3 mm, 3.0-7.0) and posteriorly (2.9 mm, 1.0-5.3). With cup implantation, the rotation center shifted back towards the native position, but no full restoration was observed. The degree of shift increased with the size of polar gap (r(s) = 0.829, P = .042), which inversely reduced the contact area (r(s) = 0.886, P = .019). Interpretation: This study reveals that the dominant factor in hip rotation center restoration is the reaming process, while the cup implantation for a given nominal press-fit has only a small influence. Increasing the press fit would improve the restoration but bares the danger of insufficient bone coverage and periprosthetic fractures due to the high forces needed.

In cases of crimes involving blood, the perpetrators often attempt to remove the traces they have left behind. Setting fire to the crime scene, aside from cleaning measures, seems to achieve this goal and presents a major challenge for crime scene investigators. There is only very little published information available on the effect of fire and extreme heat on blood and the detection thereof. After exposure to high temperatures of or exceeding 1.000 °C, blood is deemed to be undetectable. This study exposed 11 different potentially crime-relevant objects using a standardized and controlled procedure to temperatures of 300 °C, 700 °C, and 1.000 °C documenting the influence of heat on bloodstains and the detection of blood. The results of the forensic collection of blood traces with and without liquid latex confirmed the advantage of using the latex method. Almost all objects showed a clear luminescence-caused visualization of traces of blood after removing the soot with a latex lift. There were also fewer false positive results than in tests not using latex.

Implant loosening and periprosthetic fracture are two major revision causes for uncemented hip stems. The chosen method of cavity preparation could play a key role for both failure mechanisms. The aim of this study was to determine the dependence of the broach type as well as patient bone mineral density (BMD) on densification and contact conditions at the bone-implant interface. Hip stems were implanted into cadaveric femora using compaction, blunt extraction or sharp extraction broaches with computed tomography scans performed prior to broaching, after broaching and after stem implantation. Proximal periprosthetic bone densification as well as press-fit, contact area and stem seating relative to the last broach were determined. Median bone densification was higher with the compaction and blunt extraction broaches compared to sharp extraction broaches (181% and 177%, respectively, p = 0.002). The bone densification of femora prepared with compaction broaching increased with higher BMD (R-2 = 0.183, p = 0.037), while stem seating decreased with higher BMD for all broach types (R-2 = 0.259, p = 0.001). Incomplete seated prostheses were associated with smaller press-fit and bone-implant contact area (R-2 = 0.249, p = 0.001; R-2 = 0.287, p < 0.001). Clinical Significance: The results suggest that compaction broaching maximizes bone densification in patients with higher bone density. However, there appears to be an increased risk of insufficient stem seating in high-density bone that could limit the benefits for primary stability. For lower quality bone, the broach type appears to play a lesser role, but care must be taken to limit extensive stem seating which might increase periprosthetic fracture risk. (c) 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1580-1589, 2019.

Vascular air embolism is caused by penetration of air into veins or arteries through a surgical wound or other connection between the external and internal aspects of the body. Vascular air embolism has various causes, and iatrogenic air embolisms are the most frequently described. We report a case of fatal air embolism in an 83-year-old woman who was admitted to hospital. At the time of the incident, she was alone in her ward receiving an intravenous infusion of antibiotics via a peripheral line in her right forearm. She was also inhaling air through a mask, which was connected via a tubing system to a compressed air connection in the wall behind her bed. Autopsy and postmortem computed tomography (PMCT) findings are presented. The case illustrates the high diagnostic value of PMCT, which is an effective procedure for detecting the presence of air or gas.

Im Rahmen der Blutspurenmusteranalyse bietet die Interpretation von Schleuderspuren („cast-off pattern“) einen entscheidenden Ansatz bei der Rekonstruktion kriminalistisch relevanter Geschehensabläufe. Der einer blutigen Schleuderspur zugehörige Bereich runder bzw. senkrecht aufgetroffener Antragungen definiert die Position der Beteiligten; hierzu finden sich in der Literatur unterschiedliche Angaben.

The analysis of blood traces is often of significant reconstructive and evidence-gathering importance. Perpetrators deliberately set fires to destroy evidence. There is little literature regarding the effect of fire and extreme heat on blood and the detection of blood. Blood and DNA are believed to be no longer traceable after exposure to a temperature of 1000 °C. This study exposed different objects of a standardized procedure to temperatures of 300, 700, and 1000 °C. It documented the influence of heat on blood traces through the use of luminol. DNA analysis confirmed that fewer DNA profiles can be created with increasing temperature. However, even after exposure up to a max. of 1000 °C, it was still possible to produce a complete DNA pattern from approx. 60% of the samples. Consequently, crime scenes that have been destroyed by fire should be evaluated with the same attention to detail as the unburned areas.

Es wird über 2 ungewöhnliche Strangulationsfälle junger Männer berichtet. Gemeinsam ist diesen das typische Vorliegen von Strangmarke und Weichteilblutungen. Zudem fanden sich Zerreißungen der Bandstrukturen zwischen Ring- und Schildknorpel sowie vollständige und partielle Rupturen der Karotiden, die nur selten gesehen werden. Definitionsgemäß handelt es sich bei einem horizontalen Intimaeinriss unterhalb der Karotisbifurkation um das sog. Amussat-Zeichen; bei gleichzeitigem Nachweis von Gefäßwandeinblutungen gilt die vitale Strangulation als gesichert. Todesursächlich war Ersticken durch Blutaspiration infolge massiver Verletzungen der Halsorgane. Initial auffällig erwies sich in beiden Fällen die fehlende Nähe zum Strangulationsort bzw. zum Strangwerkzeug, in einem Fall mit erhaltender Handlungsfähigkeit und Zurücklegen einer Gehstrecke von 300 m. Anhand der vorgestellten Fälle wird das Auftreten typischer Verletzungen am Hals, einschließlich des Amussat-Zeichens, als Strangulationsfolge diskutiert.

An in-vitro experiment was designed to investigate the mode of failure following shear fatigue loading of lumbar motion-segments. Human male lumbar motion-segments (age 32-42 years, n=6) were immersed in Ringer solution at 37°C and repeatedly loaded, using a modified materials testing machine. Fatigue loading consisted of a sinusoidal shear load from 0 N to 1,500 N (750 N±750 N) applied to the upper vertebra of the motion-segment, at a frequency of 5 Hz. During fatigue experiments, several failure events were observed in the dynamic creep curves. Post-test x-ray, CT and dissection revealed that all specimens had delamination of the intervertebral disc. Anterior shear fatigue predominantly resulted in fracture of the apophyseal processes of the upper vertebrae (n=4). Exposure to the anterior shear fatigue loading caused motion-segment instability and resulted in vertebral slip corresponding to grade I and 'mild' grade II spondylolisthesis, as observed clinically.

Understanding fatigue failure of the spine is important to establish dynamic loading limits for occupational health and safety. In this study experimental data were combined with published data to develop a description of the predictive parameters for spinal fatigue failure. 41 lumbar functional spinal units (FSUs) from cadaveric spines (age 49.0 ± 11.9 yr) where cyclically loaded. Three different levels of sinusoidal axial compression (0-3 kN, 0-2kN or 1-3kN) were applied for 300,000 cycles. Further, published data consisted of 70 thoracic and lumbar FSUs loaded in axial compression for 5000 cycles. Cyclic forces ranged from lower peaks (Fmin) of 0.7-1kN to upper peaks (Fmax) of 1.2-7.1 kN. Based on Wöhler analysis, a fatigue model was developed accounting for three parameters: I) specimen-specific scaling based on the endplate area, II) specimen-specific strength dependency on age or bone mineral density, III) load-specific correction factors based on Fmax and Fmin. The most predictive model was achieved for a combination of Fmax, endplate area and bone mineral density; this model explained 61% of variation (p<0.001). A model including Fmax, endplate area and age explained only 28% of variation (p<0.001). Inclusion of a load-specific correction factor did not significantly improve model prediction of fatigue failure. This analysis presents the basis for the prediction of specimen-specific fatigue failure of the lumbar spine, provided the endplate area and bone mineral density can be derived.