Autopsies play a critical role in elucidating the pathogenesis of emerging infectious diseases, particularly in cases involving high-consequence pathogens such as viral haemorrhagic fevers (VHFs). While biosafety concerns have restricted post-mortem examinations in such contexts, the COVID-19 pandemic has renewed interest in autopsy-based research and highlighted both the potential and the gaps in current biosafety protocols. This narrative review outlines autopsy practices in the context of high-consequence infectious diseases (HCIDs) with a focus on VHFs, summarizes reported autopsy cases, explores alternative post-mortem methods, and examines the evolution of legal and institutional frameworks in response to the pandemic. A comparison of official international guidelines shows that while detailed autopsy protocols have been published for pathogens requiring BSL-3 containment - particularly in the United States (US) and United Kingdom (UK) - no official procedural guidance seems to be available for performing autopsies under BSL-4 conditions. Instead, current recommendations at this level are limited to post-mortem handling and disposal of the deceased. This regulatory and procedural gap underscores the urgent need for harmonized, high-containment autopsy protocols that balance biosafety with scientific value. Developing such frameworks will be essential to improve outbreak preparedness and enable evidence-based responses to future pandemics globally. Accordingly, we propose a structured, system-based approach to BSL-4 autopsy practice as a foundation for discussion and future guideline development.

This study investigates the intraindividual variability and ex-vivo stability of vitreous humor (VH) analytes for forensic thanatochemistry. VH, an anatomically isolated and robust postmortem fluid, provides valuable insights into the postmortem interval (PMI) and potential antemortem medical conditions. A total of 207 VH samples were collected from 36 cases and divided into three cohorts: serial sampling across three days postmortem, intraindividual variability assessment using triplicates, and ex-vivo stability evaluation through freeze-thaw cycles. Linear relationships between PMI and potassium, calcium, creatinine, and lactate were identified, but their non-linear trends limited PMI estimation accuracy. Sodium, chloride, and glucose demonstrated variations linked to cardiovascular and infectious conditions, while elevated urea and creatinine correlated with renal or multi-organ failure. The study highlighted the importance of interpreting these biochemical markers in conjunction with clinical and environmental factors to improve reliability. Ex-vivo stability testing revealed relevant variations in VH levels, emphasizing the need for standardized pre-analytical handling. Overall, while VH analytes offer promising forensic applications, their use for PMI estimation and medical diagnoses requires cautious interpretation within a multidisciplinary context.

All over the world, the COVID-19 pandemic has impacted mortality beyond deaths that can be directly attributed to the viral disease. This study investigates the effects of the pandemic on admissions of deceased to a large institute of legal medicine and metropolitan morgue in Germany. Employing statistical models, the general time trend was separated from the effect of the pandemic in terms of place of death, autopsy category, age and sex. In addition, the pandemic’s impact on one of the structurally most important public health determinants, poverty, on numbers of admissions in different place of death categories was analyzed. We find that the pandemic has caused a significant increase in admissions of those who died at residential addresses, which appears to be primarily driven by SARS-CoV-2 negative cases, and those who died in retirement and care facilities, with a significant overrepresentation of SARS-CoV-2 positive cases. A high degree of poverty in a neighborhood does not impact the likelihood to be admitted to the institute in those two categories before or during the pandemic. For dead bodies found in public spaces, however, a poverty variable causes a significant increase in the number of admissions during the pre-pandemic phase. Interestingly, this effect is reversed during the pandemic period. The number of admissions without an autopsy being ordered or requested increased significantly during the pandemic. Further, the COVID-19 pandemic caused a significant increase in admissions in the senile population. Our results indicate that the reluctance of treating physicians to conduct house calls to certify a death has persisted throughout the pandemic and has caused a surge of admissions of deceased to the institute of legal medicine without any criminological indications or subsequent rise in forensic autopsy orders.

Introduction Lassa fever is a life-threatening viral hemorrhagic illness endemic to Nigeria and other parts of West Africa withthousands of deaths annually. Despite extensive research on its epidemiology and transmission, its tissue pathology, tropism and lethal pathway remain poorly understood due to the biosafety-risks associated with conventional autopsies. Minimally Invasive Tissue Sampling (MITS) offers a safer and culturally more acceptable alternative for post-mortem investigation, preserving body integrity while enabling detailed tissue analysis. This study aims to characterize the pathology and pathogenesis of Lassa fever through MITS and to compare findings with non-Lassa control cases. Methods This descriptive observational, ethically approved study is being conducted in Nigeria among deceased patients with confirmed Lassa fever, alongside non-Lassa controls. Eligibility is determined by clinical or laboratory confirmation of Lassa virus infection prior to death. MITS involves ultrasonographic evaluation of intra-abdominal and intrathoracic organs, followed by tissue biopsies using Tru-Cut needles. Tissue samples are analysed through histology, immunohistochemistry (IHC), and molecular techniques. From 2022 to date, 27 MITS procedures have been completed: 22 fatal Lassa fever cases and 5 controls. Results Preliminary findings from the 22 Lassa fever cases revealed relevant fluid accumulation in the pericardial, pleural, and peritoneal cavities by ultrasound. Jaundice was frequently observed (65%). Lassa virus was identified by immunohistochemistry in all examined organs, with the liver exhibiting the highest density and the kidneys the lowest. Microscopic analysis of the liver samples showed tissue necrosis and spots of inflammation, which does not with observed clinical manifestations and previously reported pathology. The kidneys showed no microscopic damage with rather low viral presence in the majority of cases, despite acute kidney injury diagnosed clinically. In one patient, we identified presence of Lassa virus in the brain. However, inter-patient variability exists. Conclusion MITS proves to be a valuable, safe and culturally acceptable tool for post-mortem investigation of viral hemorrhagic fevers such as Lassa fever. In this study, MITS showed distinctive changes to the liver but no relevant damage to the kidneys. This may indicate the liver as a focus site of Lassa fever replication and pathology, while laboratory-proven kidney involvement may be linked to inflammatory cytokines rather than direct viral injury. Further research is needed to assess the role of Lassa virus as a neuroinvasive infection These findings can support future diagnostic and therapeutic strategies and integrate MITS into outbreak response and disease surveillance efforts in resource-limited settings.

Druckulzera zählen zu den häufigsten pflegeassoziierten Komplikationen bei vulnerablen Patienten. Die COVID-19-Pandemie stellte das Versorgungssystem vor neue Herausforderungen, deren Auswirkungen sich retrospektiv rechtsmedizinisch erfassen lassen. Ziel der Studie war es, Prävalenz, Schweregrade und Charakteristika schwerer Dekubitusläsionen (Grad III/IV) bei Verstorbenen in Hamburg über einen Zeitraum von sechs Jahren (2018–2023) zu analysieren – mit besonderem Fokus auf potenzielle Veränderungen im Verlauf der Pandemie. In einer retrospektiven Querschnittstudie wurden Fälle aus rechtsmedizinischen Leichenschauen und Krematoriumsuntersuchungen erfasst, bei denen mindestens ein Dekubitus Grad III oder IV vorlag. Die erhobenen Variablen umfassten Alter, Geschlecht, Body-Mass-Index (BMI), Lokalisation und Zustand der Ulzera, Verbandqualität, Komorbiditäten, Sterbeort sowie pandemische Phase. Statistische Analysen erfolgten mittels Chi-Quadrat-Test, Mann-Whitney-U-Test und logistischer sowie linearer Regressionsverfahren. Von insgesamt 61.964 untersuchten Verstorbenen wurden 406 Fälle mit 527 Dekubitusläsionen Grad III oder IV identifiziert. Die Prävalenz stieg von 0,50

BackgroundPressure ulcers remain among the most common care-related complications in vulnerable patient populations. The COVID-19 pandemic challenged healthcare systems globally, and its consequences can be retrospectively assessed through legal medicine. ObjectiveThis study aimed to analyze the prevalence, severity and characteristics of advanced pressure ulcers (stage III/IV) in deceased individuals in Hamburg over a 6-year period (2018-2023), with a focus on potential changes during the pandemic. Materials and methodsA retrospective cross-sectional study was conducted using data from external post-mortem and cremation examinations documenting stage III or IV pressure ulcers. Collected variables included age, sex, body mass index (BMI), ulcer localization and condition, dressing quality, comorbidities, place of death, and pandemic phase. Statistical analyses were performed using Chi-squared test, Mann-Whitney U test, and logistic and linear regression models. ResultsAmong 61,964 examined deceased individuals, 406 cases with 527 stage III or IV pressure ulcers were identified. The prevalence increased from 0.50% in the prepandemic phase (2018/2019) to 0.77% during the pandemic (2020/2021) and remained elevated at 0.69% postpandemically (2022/2023). While total case numbers rose, the proportion of stage IV ulcers declined, accompanied by an increase in stage III lesions. A shift towards atypical anatomical ulcer locations (heel, trochanter) was observed. Higher age, BMI, and multimorbidity were associated with ulcer occurrence. ConclusionForensically collected data provide meaningful insights into care quality during crisis conditions. The systematic documentation of advanced pressure ulcers at postmortem examinations can serve as a retrospective tool to monitor and identify structural care deficits.

Abstract Objectives Infection with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) causes coronavirus disease 2019 (COVID‐19). Although an acute SARS‐CoV‐2 infection mainly presents with respiratory illness, neurologic symptoms and sequelae are increasingly recognised in the long‐term treatment of COVID‐19 patients. The pathophysiology and the neuropathogenesis behind neurologic complications of COVID‐19 remain poorly understood, but mounting evidence points to endothelial dysfunction either directly caused by viral infection or indirectly by inflammatory cytokines, followed by a local immune response that may include virus‐specific T cells. However, the type and role of central nervous system‐infiltrating T cells in COVID‐19 are complex and not fully understood. Methods We analysed distinct anatomical brain regions of patients who had deceased as a result of COVID‐19‐associated pneumonia or complications thereof and performed T cell receptor Vβ repertoire sequencing. Clonotypes were analysed for SARS‐CoV‐2 association using public TCR repertoire data. Results Our descriptive study demonstrates that SARS‐CoV‐2‐associated T cells are found in almost all brain areas of patients with fatal COVID‐19 courses. The olfactory bulb, medulla and cerebellum were brain regions showing the most SARS‐CoV‐2 specific sequence patterns. Neuropathological workup demonstrated primary CD8+ T‐cell infiltration with a perivascular infiltration pattern. Conclusion Future research is needed to better define the relationship between T‐cell infiltration and neurological symptoms and its long‐term impact on patients' cognitive and mental health.

In the past years the number of hospital autopsies have declined steadily, becoming almost excluded from medical training. Medicolegal (forensic) autopsies account for almost all autopsies, whereas hospital autopsies are becoming increasingly rare. Minimally invasive tissue sampling (MITS) using post mortem ultrasound offers the opportunity to increase the number of post mortem examinations in a clinical and even forensic context. MITS is a needle-based post mortem procedure that uses (radiological) imaging techniques to examine major organs of the body, acquire tissue samples and aspirate fluid from the body cavities or hollow organs. In this study, MITS was used to determine the presence of other co-existing diseases in a deceased infected 97-year-old woman with severe acute respiratory syndrome coronavirus 2. The examination of her body was carried out using ultrasound as an imaging tool and to gather ultrasound-guided biopsies as conventional autopsy was rejected by the next of kin. Ultrasound and histology identified an intravesical mass leading to an obstruction of the urinary outlet resulting in bilateral hydronephrosis and purulent pyelonephritis, which was unknown during her lifetime. Histopathological examination revealed the tumor mass to be a squamous cell carcinoma. This study has shown that MITS can be used to determine the cause of death and the presence of concomitant diseases in the infectious deceased.

Background: Since electric scooters were introduced as an urban means of transportation in Hamburg in June 2019, a high number of violations of the current laws regarding alcohol consumption by e-scooter riders have been recorded. Objective: The aim of this study is to obtain an overview of traffic offences committed by e-scooter drivers under the influence of alcohol, to classify their relevance in relation to other road user groups, and to draw a first interim balance with respect to their frequency after 1.5 years.Material and methods: The data of all e-scooter drivers (n = 342) examined concerning their blood alcohol values analyzed at the Institute of Legal Medicine of the University Medical Centre Hamburg-Eppendorf between 15.06.2019 and 31.12.2020 were retrospectively evaluated with respect to their demographic information and the medical examination results. These were brought into context with the total number of offences against the road traffic regulations with subsequent blood alcohol measurement.Results: 9.6% of the total number of offences against the road traffic regulations in connection with subsequent determination of the blood alcohol concentration were committed by e-scooter drivers. 87.7% of those examined were male. The blood alcohol concentration was above the limit of 1.10 parts per thousand for absolute driving incapacity when using a passenger car in 76.9% of those examined. An accumulation of cases was particularly noticeable at night and at weekends.Due to imprecise records, a certain number of unreported e-scooter incidents can be assumed among the unspecified motor vehicles.Conclusion: As e-scooter drivers make up a considerable proportion of drunken road users and the accidents mostly occur at night and at weekends, increased education and, if necessary, a driving ban at these times would seem to make sense.

Background:Since the spread of the so-called electric scooters (e-scooters) through rental services in Hamburg as of June 2019, accidents due to the use of this means of transportation have been regularly registered. The most frequent injury patterns among e‑scooter riders involved accidents concerning the upper extremities and the head. There was a relevant accumulation of drunk drivers among the injured persons.Objective:The aim of the study is to compare injury patterns in drunk versus non-drunk e‑scooter riders who had an accident.Material and methods:Data from the Department of Trauma Surgery at the University Medical Center Hamburg-Eppendorf were retrospectively analyzed for accidents involving e‑scooters and the resulting injury patterns. For this purpose, the gender, age, injury pattern of the persons, the course of the accident, and information on previous alcohol consumption were recorded descriptively for the period from June 2019 to December 2021.Results:Drivers were on average 32 (interval: 15-88 years) years old and those under the influence of alcohol were predominantly male (69.9%). Accidents occurred mainly in summer and at night. Common injury patterns were injuries to the face, head, and extremities.Conclusion:It should be noted that injuries to the face and head occurred more frequently under the influence of alcohol than in the cohort without alcohol. Education about the health and legal consequences of riding an e‑scooter under the influence of alcohol should be provided to all users. In addition, wearing a helmet or banning driving at night are possible measures to reduce accidents associated with drunk riding.

In pandemics or to further study highly contagious infectious diseases, new strategies are needed for the collection of post-mortem tissue samples to identify the pathogen as well as its morphological impact. In this study, an ultrasound-guided minimally invasive tissue sampling (MITS) protocol was developed and validated for post-mortem use. The histological and microbiological qualities of post-mortem specimens were evaluated and compared between MITS and conventional autopsy (CA) in a series of COVID-19 deaths. Thirty-six ultrasound-guided MITS were performed. In five cases more, specimens for histological and virological examination were also obtained and compared during the subsequently performed CA. Summary statistics and qualitative interpretations (positive, negative) were calculated for each organ tissue sample from MITS and CA, and target genes were determined for both human cell count (beta-globin) and virus (SARS-CoV-2 specific E gene). There are no significant differences between MITS and CA with respect to the detectability of viral load in individual organs, which is why MITS can be of utmost importance and an useful alternative, especially during outbreaks of infectious diseases.

Dysautonomia has substantially impacted acute COVID-19 severity as well as symptom burden after recovery from COVID-19 (long COVID), yet the underlying causes remain unknown. Here, we hypothesized that vagus nerves are affected in COVID-19 which might contribute to autonomic dysfunction. We performed a histopathological characterization of postmortem vagus nerves from COVID-19 patients and controls, and detected SARS-CoV-2 RNA together with inflammatory cell infiltration composed primarily of monocytes. Furthermore, we performed RNA sequencing which revealed a strong inflammatory response of neurons, endothelial cells, and Schwann cells which correlated with SARS-CoV-2 RNA load. Lastly, we screened a clinical cohort of 323 patients to detect a clinical phenotype of vagus nerve affection and found a decreased respiratory rate in non-survivors of critical COVID-19. Our data suggest that SARS-CoV-2 induces vagus nerve inflammation followed by autonomic dysfunction which contributes to critical disease courses and might contribute to dysautonomia observed in long COVID.

The quality of the endothelial cell layer is a major criterion for the approval of organ-cultured human donor-corneas for transplantation. We wanted to compare the predictive capacities of initial endothelial density and endothelium cell morphology for the approval of donor corneas for transplantation and for the clinical outcome after transplantation. The endothelial density and endothelium morphology in organ culture were examined by semiautomatic assessment of 1031 donor corneas. We performed a statistical analysis for correlations of donor-data and cultivation parameters regarding their predictive capacities for the final approval of donor corneas for transplantation and the clinical outcome of 202 transplanted patients. Corneal endothelium cell density proved to be the only parameter with a certain predictive capacity with regard to the final decision, whether donor corneas are suitable for transplantation — however, the correlation was low (area under the curve [AUC] = 0.655). Endothelial cell morphology lacked any predictive power (AUC = 0.597). The clinical outcome regarding visual acuity seemed to be largely independent from both corneal endothelial cell density and morphology. Sub-analyses on transplanted patients stratified for their diagnoses vindicated these findings. Higher endothelial density (above a cut-off level of 2000 cells/mm2), as well as better endothelial morphology do not seem to be critical for transplant-corneal functionality in organ culture and up to 2 years after transplantation. Comparable long-term studies on graft survival are recommended to determine, whether the present endothelial density cut-off levels might be too stringent.

Zusammenfassung Hintergrund Seit der Verbreitung der sog. Elektro-Scooter durch Verleihservices in Hamburg ab Juni 2019 sind Unfälle durch die Nutzung dieser Fortbewegungsmittel regelmäßig registriert worden. Die häufigsten Verletzungsmuster bei verunfallten E‑Scooter-Fahrern betrafen die obere Extremität und den Kopf. Es zeigte sich dabei eine relevante Anhäufung alkoholisierter Fahrer unter den verletzten Personen. Ziel der Arbeit Ziel der vorliegenden Studie ist der Vergleich zwischen den Unfallmustern alkoholisierter und nichtalkoholisierter E‑Scooter-Fahrer. Material und Methoden Die Daten der Unfallchirurgie des Universitätsklinikums Hamburg-Eppendorf wurden retrospektiv zu Unfällen mit E‑Scootern und hieraus resultierenden Verletzungsmustern ausgewertet. Hierfür wurden das Geschlecht, das Alter, das Verletzungsmuster der Personen, der Unfallhergang sowie Informationen über einen vorangegangenen Alkoholkonsum deskriptiv für den Zeitraum Juni 2019 bis Dezember 2021 erfasst. Ergebnisse Die Fahrer der Gesamtkohorte waren durchschnittlich 32 (Intervall: 15 bis 88 Jahre) Jahre alt und diejenigen unter Alkoholeinfluss überwiegend männlich (69,9 %). Unfälle fanden v. a. im Sommer und nachts statt. Häufige Verletzungsmuster waren Verletzungen des Gesichts, des Kopfes und der Extremitäten. Schlussfolgerung Festzuhalten ist, dass unter Alkoholeinfluss häufiger Verletzungen des Gesichts und des Kopfes vorlagen als bei Nüchternheit. Die Sensibilität für gesundheitliche und rechtliche Folgen von E‑Scooter-Fahrten unter Alkoholeinfluss muss verbessert werden. Zudem stellen eine Helmpflicht oder nächtliche Fahrverbote mögliche Maßnahmen zur Reduktion von Unfällen mit E‑Scootern dar.

Funeral home and crematorium workers are an important occupational group in the corona crisis. The occupational setting led to concerns about an increased risk of infection with SARS-CoV-2. The seroprevalence in this occupational group is unclear. A questionnaire-based retrospective survey of funeral home and crematorium staff was conducted in December 2020. A second survey of funeral and crematorium staff was conducted 6 months later, in June 2021, to determine changes in pandemic management. Seroprevalence or vaccination status for SARS-CoV-2 was determined at these two time points. In December 2020, a seroprevalence of 2.3% (n = 1/44) was detected in funeral home and crematorium workers. In June 2021, one additional participant tested positive for the SARS-CoV-2 nucleocapsid. Of the participants, 48.5% (n = 16) were vaccinated at this time. The risk of SARS-CoV-2 infection for funeral home and crematorium workers is more similar to that of the general population in Hamburg, Germany. We found no evidence of an increased risk of infection at these two time points in our cohort. Further education on communicable diseases or appropriate protective measures in this occupational group for other infectious diseases would be useful in the future.

Background: Since the spread of the so-called electric scooters (e-scooters) through rental services in Hamburg as of June 2019, accidents due to the use of this means of transportation have been regularly registered. The most frequent injury patterns among e-scooter riders involved accidents concerning the upper extremities and the head. There was a relevant accumulation of drunk drivers among the injured persons.Objective: The aim of the study is to compare injury patterns in drunk versus non drunk e-scooter riders who had an accident.Material and methods: Data from the Department of Trauma Surgery at the University Medical Center Hamburg-Eppendorf were retrospectively analyzed for accidents involving e-scooters and the resulting injury patterns. For this purpose, the gender, age, injury pattern of the persons, the course of the accident, and information on previous alcohol consumption were recorded descriptively for the period from June 2019 to December 2021.Results: Drivers were on average 32 (interval: 15-88 years) years old and those under the influence of alcohol were predominantly male (69.9%). Accidents occurred mainly in summer and at night. Common injury patterns were injuries to the face, head, and extremities.Conclusion: It should be noted that injuries to the face and head occurred more frequently under the influence of alcohol than in the cohort without alcohol. Education about the health and legal consequences of riding an e-scooter under the influence of alcohol should be provided to all users. In addition, wearing a helmet or banning driving at night are possible measures to reduce accidents associated with drunk riding.

Aims Cardiac involvement in COVID-19 is associated with adverse outcome. However, it is unclear whether cell-specific consequences are associated with cardiac SARS-CoV-2 infection. Therefore, we investigated heart tissue utilizing in situ hybridization, immunohistochemistry, and RNA-sequencing in consecutive autopsy cases to quantify virus load and characterize cardiac involvement in COVID-19. Methods and results In this study, 95 SARS-CoV-2-positive autopsy cases were included. A relevant SARS-CoV-2 virus load in the cardiac tissue was detected in 41/95 deceased (43%). Massive analysis of cDNA ends (MACE)-RNA-sequencing was performed to identify molecular pathomechanisms caused by the infection of the heart. A signature matrix was generated based on the single-cell dataset ‘Heart Cell Atlas’ and used for digital cytometry on the MACE-RNA-sequencing data. Thus, immune cell fractions were estimated and revealed no difference in immune cell numbers in cases with and without cardiac infection. This result was confirmed by quantitative immunohistological diagnosis. MACE-RNA-sequencing revealed 19 differentially expressed genes (DEGs) with a q-value <0.05 (e.g. up: IFI44L, IFT3, TRIM25; down: NPPB, MB, MYPN). The upregulated DEGs were linked to interferon pathways and originate predominantly from endothelial cells. In contrast, the downregulated DEGs originate predominately from cardiomyocytes. Immunofluorescent staining showed viral protein in cells positive for the endothelial marker ICAM1 but rarely in cardiomyocytes. The Gene Ontology (GO) term analysis revealed that downregulated GO terms were linked to cardiomyocyte structure, whereas upregulated GO terms were linked to anti-virus immune response. Conclusion This study reveals that cardiac infection induced transcriptomic alterations mainly linked to immune response and destruction of cardiomyocytes. While endothelial cells are primarily targeted by the virus, we suggest cardiomyocyte destruction by paracrine effects. Increased pro-inflammatory gene expression was detected in SARS-CoV-2-infected cardiac tissue but no increased SARS-CoV-2 associated immune cell infiltration was observed.