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The purpose of this study was to evaluate the added value of postmortem magnetic resonance imaging (MRI) compared to postmortem computed tomography (CT) and autopsy in cases of fatal hanging. In addition, the study analyzed the strengths of each examination method regarding typical injuries in these cases. We investigated a cohort of 25 decedents who underwent CT, MRI and autopsy. Two radiologists assessed all MR images of the head and neck as well as the corresponding CT images. The results were compared to autopsy findings by retrospectively analyzing the autopsy reports. Postmortem MRI revealed intramuscular hemorrhages in a large number of cases, however, autopsy did not confirm all of the detected hemorrhages. CT and autopsy detected fractures in several cases, whereas MRI showed a fracture in just one single case. Other previously described vital signs and relevant findings, such as fracture-related gas bubbles, soft tissue emphysema or pneumomediastinum, were observed in only a few individual cases. MRI provided added diagnostic value in the detection of soft tissue injuries and lymph node swelling in fatal hangings. As an adjunct to autopsy, postmortem MRI may reveal additional hemorrhages, which might be missed at autopsy. Since standard MRI demonstrated low sensitivity for the detection of fractures, an additional imaging modality or autopsy is required to overcome this limitation.

The detection and quantification of metabolites relevant for the diagnosis of fatal metabolic disorders by proton magnetic resonance spectroscopy (1H-MRS) was recently demonstrated. This prospective study aimed to compare the concentrations of beta-hydroxybutyrate (BHB), glucose (GLC), and lactate (LAC) derived from both biochemical analyses and 1H-MRS for the diagnosis of fatal metabolic disorders. In total, 20 cases with suspected fatal metabolic disorders were included in the study. For the agreement based on thresholds, the concentrations of BHB and GLC in the vitreous humor (VH) from the right vitreous and in cerebrospinal fluid (CSF) from the right lateral ventricle were derived from 1H-MRS and biochemical analyses. The predefined thresholds for pathological elevations were 2.5 mmol/l for BHB and 10 mmol/l for GLC based on the literature. In addition, concentrations of the same metabolites in white matter (WM) tissue from the corona radiata of the right hemisphere were analyzed experimentally using both methods. To enable the biochemical analysis, a dialysate of WM tissue was produced. For all three regions, the LAC concentration was determined by both methods. The conclusive agreement based on thresholds was almost perfect between both methods with only one disagreement in a total of 70 comparisons due to the interference of a ferromagnetic dental brace. The differences in the concentrations between both methods showed high standard deviations. Confidence intervals of the bias not including 0 were found in CSF-GLC (− 3.1 mmol/l), WM-GLC (1.1 mmol/l), and WM-LAC (− 6.5 mmol/l). Despite a considerable total error attributable to both methods, MRS derives the same forensic conclusions as conventional biochemical analyses. An adaptation of the protocol to reduce the detected errors and more data are needed for the long-term validation of MRS for the diagnosis of fatal metabolic disorders. The production of WM dialysates cannot be recommended due to high glycolytic loss.

Background Cases of external hemorrhage are difficult to recognize on postmortem computed tomography (PMCT). Purpose To investigate the effects of blood loss on CT attenuation of the spleen, liver, kidneys, and lungs on PMCT and to assess the relationship between blood loss and organ weight. Methods A total of 125 cases with blood loss were sex- and age-matched to 125 control cases without blood loss. Individual organ attenuation was measured on transverse CT images. Organ weights of the liver, spleen, kidneys, and lung were extracted from the autopsy protocols. Results Organ weight was significantly lower in cases with blood loss (lung 30%, spleen 28%, kidneys 14%, liver 18%) than in controls. CT attenuation of the lungs was significantly lower (30%) in cases with blood loss than in controls. CT attenuation of the spleen and kidneys did not significantly differ between cases and controls. CT attenuation of the liver was significantly higher (25%) in cases with blood loss than in controls. Conclusion Blood loss decreases organ weight and CT attenuation of the lungs but appears to have no significant effect on CT attenuation of the spleen and kidneys. The increased liver attenuation in cases with blood loss compared to controls was an unexpected finding and remains challenging to explain. One probable interpretation refers to different levels of hepatic glycogen; however, further work is warranted to substantiate this hypothesis.

The aims of this study were (1) to provide an overview of craniocervical magnetic resonance imaging (MR) findings following nonfatal strangulation (NFS), (2) to detect the time dependency of the presence of these findings, and (3) to explore the additional value of MR with regard to the forensic interpretation of NFS. All 633 victims of manual strangulation between October 2011 and March 2018 were examined, including the case history and external findings. Following written consent, 114 cases were included in the study. The duration between the event, clinical forensic examination, and MR was noted. Radiologic images were reviewed by a clinical and a forensic radiologist. The case group consisted of 90 women and 24 men with a mean age of 32.5 years. Delimitable external findings were present in 93% (N = 106) of cases. MR yielded a positive finding in 43% of cases (N = 49). There was no significant difference in the mean time interval between examinations between MR-positive and MR-negative cases. Perilaryngeal fluid accumulation was associated with difficulty swallowing and victims put in a chokehold. All cerebral MR were unremarkable, except for one patient with edema of the corpus callosum. The role of craniocervical MR following NFS is currently limited, particularly with regard to the forensic interpretation of NFS. MR may reveal internal injury in victims who report subjective symptoms of airway compression and in those who were placed in a chokehold. The presence of MR findings is not dependent on immediate examinations following the assault. • Magnetic resonance imaging does not currently provide additional value for the estimation of the severity of nonfatal manual strangulation. • Magnetic resonance imaging of the neck may reveal internal injury in cases without external findings, particularly in victims placed in a chokehold and with symptoms of airway compression. • The incidence of carotid artery dissections and laryngeal fractures is low in victims of nonfatal manual strangulation.

Pneumopericardium (PPC) describes the collection of gas in the pericardial sac. In tension Pneumopericardium (tPPC), this collection of gas may lead to cardiac tamponade. PPC following blunt trauma is considered a rare finding, as reflected by the low number of case reports on the topic. We analyzed the prevalence and pathophysiology of PPC and the associated trauma in 44 cases of falls from height. We retrospectively analyzed postmortem CT data and autopsy reports of fatal falls in the period March 2014-2017. A valid estimation of the height of the fall and a documented impact on an even and hard surface were inclusion criteria. A total of 44 cases were included in the study. We identified PPC in 18 of the 44 cases, and it was associated with an increased height of the fall, alongside aortic, pericardial, and myocardial ruptures. All cases with PPC also presented with bilateral pneumothorax. Five cases presented with a "ballooning" pericardium, indicating tPPC. PPC is a common finding in cases of falls from great heights. Due to a significant correlation with height and thus impact severity, PPC may be used as a reconstructive element in medico-legal investigations. Association with trauma makes PPC a sign of severe thoracic injury in postmortem and clinical radiology.

In a case of a fatal traffic accident, a suspicious finding was identified in the muscular tissue of the left thigh by whole-body postmortem computed tomography. To better interpret the finding, the lower extremities were investigated by magnetic resonance imaging (MRI) and proton magnetic resonance spectroscopy (

The temporary or permanent storage of human bodies in freezers following a homicide is a documented method for criminal disposal of human corpses. In these cases, the detection of characteristics which indicate that a thawed cadaver or body part was previously frozen provides crucial information for forensic casework. Previous histological and radiological approaches to detect characteristics of previous freezing are based on the formation of bubble‐like gas patterns, which are difficult to distinguish from common postmortem gas formation in the course of decomposition. The objective of this study was to detect changes in the muscle tissue and in the bone marrow after freezing and thawing by means of in situ proton magnetic resonance spectroscopy (1H‐MRS) to provide a noninvasive approach to detect postfreezing alterations in human cadavers. In this experimental study, the hind legs of seven sheep were used as substitutes for human tissue. One hind leg underwent 1H‐MRS before and daily after storage in a deep freezer (−20°C) and complete thawing at room temperature (study group: n = 7). The opposite hind leg was kept at room temperature and was measured daily (control group: n = 7). Spectra and relaxation times were measured using single voxel measurements in the muscle tissue and in the bone marrow. 1H‐MRS revealed several changes in the muscle tissue and in the bone marrow after freezing and thawing. A strongly reduced peak area ratio (

Several articles have described the use of postmortem computed tomography (CT) and postmortem magnetic resonance imaging (MRI) in forensic medicine. Although access to CT scanners and, particularly, access to MRI scanners, is still limited for several institutes, both modalities are being applied with increasing frequency in the forensic setting. Certainly, postmortem imaging can provide crucial information prior to autopsy, and this method has even been considered a replacement to autopsy in selected cases by some forensic institutes. However, the role of postmortem imaging has to be assessed individually according to various injury categories and causes of death. Therefore, this systematic review focuses on the role of postmortem CT and MRI in cases of hanging and ligature and manual strangulation. We assessed the most common and relevant findings on CT and MRI in cases of strangulation and compared the detectability of these findings among CT, MRI and autopsy. According to the available literature, mainly fractures of the hyoid bone or thyroid cartilage were investigated using postmortem CT. Compared to autopsy, CT demonstrated equivalent results concerning the detection of these fractures. A currently described "gas bubble sign" may even facilitate the detection of laryngeal fractures on CT. Regarding the detection of hemorrhages in the soft tissue of the neck, postmortem MRI is more suitable for the detection of this "vital sign" in strangulation. Compared to autopsy, postmortem MRI is almost equally accurate for the detection of hemorrhages in the neck. Another "vital sign", gas within the soft tissue in hanging, which is hardly detectable by conventional autopsy, can be clearly depicted by CT and MRI. The number of cases of manual and ligature strangulation that were investigated by means of postmortem CT and MRI is much smaller than the number of cases of hanging that were investigated by CT and MRI. Likewise, judicial hanging and the hangman's fracture on postmortem imaging were described in only a few cases. Based on the results of this systematic review, we discuss the additional value of CT and MRI in fatal strangulation compared to autopsy, and we reflect on where the literature is currently lacking.

We report a case of a contraindicated attachment of a speaking valve to a tracheal tube with an inflated cuff, which rapidly resulted in the patient’s death. The attached one-way valve allowed unrestrained inspiration through the tracheal tube but prevented physiological expiration. The increased pulmonary pressure resulted in alveolar rupture and replaced expiration with a steady release of air into the peribronchial sheaths and the mediastinum, resulting in what is commonly known as the Macklin effect. From the mediastinum, air inflated both pleural cavities, the peritoneum, and the subcutaneous tissue of the entire body. No gas was found in the blood vessels, the brain, the bones, or in the inner organs. The entire air volume was estimated by radiological segmentation to be more than 25 l. This implies continuous inspiration, while expiration turned into an aberrant pulmonary decompression by whole-body gas-enclosure. Death ultimately resulted from asphyxia following bilateral (tension) pneumothorax.

A case of rapid demise following an undiagnosed stercoral perforation is reported. A 57-year-old woman on chronic opioid replacement therapy presented with constipation and abdominal pain to the hospital. Following an unremarkable abdominal radiograph and admission for laxation and pain therapy, she was found dead only 18 h later. To exclude medical malpractice, a postmortem investigation was ordered. Postmortem computed tomography and autopsy revealed fatal fecal peritonitis based on a stercoral perforation of the rectosigmoid, which had been undiagnosed. This report highlights the need for early cross-sectional imaging and contributes to the data collection concerning this ever-growing, vulnerable group of patients undergoing opioid replacement.

We report a fetal loss following maternal ketoacidosis in a case of cryptic pregnancy. Biochemical analysis of peripheral blood revealed highly elevated levels of beta-hydroxybutyrate (BHB) in the mother (9.2 mmol/l) and the fetus (4.2 mmol/l). Fetal ketoacidosis with hypoxic-ischemic brain damage was determined to be the cause of death. 1H-MRS of the right cerebral hemisphere presented with distinctive resonances of BHB and acetone. Acetoacetate and glucose were not detected. Due to reported chronic abuse of ethanol and a period of fasting, alcoholic ketoacidosis was concluded to be the cause of the metabolic disorder. 1H-MRS is a viable examination for the postmortem detection of ketone bodies and may be a key supplement to noninvasive fetal autopsy for the diagnosis of ketoacidosis.

Giardia duodenalis infection is highly prevalent and a cause of underweight in pre-school children in rural Rwanda. The present study aimed at assessing the age-pattern of Giardia infection and its manifestation in older children, i.e., during school age. Stool samples were collected from 622 schoolchildren at two schools in the Huye district of southern Rwanda (rural, 301; urban, 321) and subjected to G. duodenalis specific PCR assays. Clinical and anthropometric data, socio-economic status and factors potentially associated with G. duodenalis infection were assessed. Of the 622 children (mean age, 10.4 years), 35.7% were infected with G. duodenalis (rural, 43.9%; urban, 28.0%; P0.0001). Only few indicators of low socio-economic status were found to be associated with infection. In rural but not urban schoolchildren, infection prevalence declined significantly with age. G. duodenalis infection more than doubled the odds of stunting in both rural (adjusted OR, 2.35 (95%CI, 1.25-4.41)) and urban children (adjusted OR, 2.27 (95%CI, 1.01-5.09)). In the study area of rural southern Rwanda, G. duodenalis prevalence among children declined throughout school-age. The data suggest that while lacking overt clinical manifestation at high endemicity, G. duodenalis infection is a common cause of stunting in schoolchildren.

Pneumopericardium (PPC) and Tension Pneumopericardium (TPPC) refer to collections of gas in the pericardial cavity, the latter resulting in air tamponade and cardiac compromise. Following penetrating chest injuries, PPC and TPPC appear to be uncommon findings associated with a high mortality and correlated with other thoracic trauma. Diagnosis of PPC and TPPC is difficult relying on conventional autopsy alone, while postmortem computed tomography (PMCT) shows a high sensitivity for the detection of internal gas collections. Possibly due to difficulty in detection, PPC and TPPC have not been discussed from a forensic point of view and many lethal cases of PPC and TPPC might have been missed in medicolegal investigations. In this report, we present a case with suicidal, penetrating stab wounds to the chest resulting in a TPPC with lethal air tamponade documented by PMCT.

Radiologic forensic identification is usually performed by comparing antemortem and postmortem radiographs. While computed tomography (CT) has become a valuable addition to radiologic identification, magnetic resonance (MR) imaging has only rarely been used for this purpose. In our case, identification was accomplished using fused MR- and CT images in a survivor of a gunshot injury to the head. This case supports and highlights the possibility to perform intermodality radiologic identification comparing preexisting MR imaging to subsequently aquired CT data in living (or deceased) humans as long as manual modifications of windowing, color and contrast enable differentiation of the two modalities in the fused image.

Diabetic ketoacidosis (DKA) is a metabolic complication of diabetes mellitus that takes a lethal course if untreated. In this way relevant to forensic medicine, secure diagnosis of DKA usually involves the evidence of elevated levels of glucose and the ketone bodies acetone, acetoacetate, and β-hydroxybutyrate in corpse fluids. We conducted a postmortem hydrogen proton magnetic resonance spectroscopy (

Post mortem computed tomography (PMCT) can be used as a triage tool to better identify cases with a possibly non-natural cause of death, especially when high caseloads make it impossible to perform autopsies on all cases. Substantial data can be generated by modern medical scanners, especially in a forensic setting where the entire body is documented at high resolution. A solution for the resulting issues could be the use of deep learning techniques for automatic analysis of radiological images. In this article, we wanted to test the feasibility of such methods for forensic imaging by hypothesizing that deep learning methods can detect and segment a hemopericardium in PMCT. For deep learning image analysis software, we used the ViDi Suite 2.0. We retrospectively selected 28 cases with, and 24 cases without, hemopericardium. Based on these data, we trained two separate deep learning networks. The first one classified images into hemopericardium/not hemopericardium, and the second one segmented the blood content. We randomly selected 50% of the data for training and 50% for validation. This process was repeated 20 times. The best performing classification network classified all cases of hemopericardium from the validation images correctly with only a few false positives. The best performing segmentation network would tend to underestimate the amount of blood in the pericardium, which is the case for most networks. This is the first study that shows that deep learning has potential for automated image analysis of radiological images in forensic medicine.

Determination of the ethanol concentration in corpses with MRS would allow a reproducible forensic assessment by which evidence is collected in a noninvasive manner. However, although MRS has been successfully used to detect ethanol in vivo, it has not been applied to postmortem ethanol quantification in situ. The present study examined the feasibility of the noninvasive measurement of the ethanol concentration in human corpses with MRS. A total of 15 corpses with suspected alcohol consumption before demise underwent examination in a 3 T whole body scanner. To address the partial overlap of the ethanol and lactate signal in the postmortem spectrum, non-water-suppressed single voxel spectra were recorded in the cerebrospinal fluid (CSF) of the left lateral ventricle via the metabolite cycling technique. The ethanol signals were quantified using the internal water as reference standard, as well as based on a reference signal acquired in a phantom. The measured values were compared with biochemically determined concentrations in the blood (BAC) and CSF (CSFAC). In 8 of the 15 corpses a BAC above zero was determined (range 0.03-1.68 g/kg). In all of these 8 corpses, ethanol was measured in CSF with the proposed MRS protocol. The two applied MRS calibration strategies resulted in similar concentrations. However, the MRS measurements generally overestimated the ethanol concentration by 0.09 g/kg (4%) to 0.72 g/kg (45%) as compared with the CSFAC value. The presented MRS protocol allows the measurement of ethanol in the CSF in human corpses and provides an estimation of the ethanol concentration prior to autopsy. Observed deviations from biochemically determined concentrations are mainly explained by the approximate correction of the relaxation attenuation of the ethanol signal.

Objectives Preventive chemotherapy of schoolchildren against soil-transmitted helminths (STHs) is widely implemented in Rwanda. However, data on its actual efficacy are lacking. We assessed prevalence, associated factors and manifestation of STH infection among schoolchildren in southern highland Rwanda as well as cure and reinfection rates. Methods Six hundred and twenty-two children (rural, 301; urban, 321) were included preceding the administration of a single dose of 500 mg mebendazole. Before treatment, and after 2 and 15 weeks, STH infection was determined by Kato-Katz smears and by PCR assays for Ascaris lumbricoides. Clinical and anthropometric data, socio-economic status and factors potentially associated with STH infection were assessed. Results Soil-transmitted helminth (STH) infection was present in 38% of rural and in 13% of urban schoolchildren. Ascaris lumbricoides accounted for 96% of infections. Of these, one-third was detected by PCR exclusively. Factors associated with STH infection differed greatly between rural and urban children. Likewise, STH infection was associated with stunting and anaemia only among urban children. The cure rate after 2 weeks was 92%. Among eight non-cleared A. lumbricoides infections, seven were submicroscopic. Reinfection within 3 months occurred in 7%, but the rate was higher among rural children, and with initially present infection, particularly at comparatively high intensity. Conclusions The rural–urban difference in factors associated with STH infection and in reinfection rates highlights the need for targeted interventions to reduce transmission. PCR assays may help in detecting low-level infections persisting after treatment. In southern Rwanda, mebendazole is highly effective against the STH infections predominated by A. lumbricoides. Objectifs Evaluer les connaissances, attitudes et comportements des etudiants universitaires sur l'utilisation des antibiotiques Methodes Un questionnaire sur les connaissances-attitudes-pratiques a ete developpe et distribue aux etudiants de premier cycle de l'Universite Xi'an Jiaotong, comprenant 18 ecoles/colleges dans la province du Shaanxi, en Chine occidentale. Le test du chi carre et l'analyse de regression logistique ont ete appliques pour identifier les facteurs de risque associes a l'automedication avec des antibiotiques. Resultats Parmi les 731 repondants (taux de reponse = 73,1%), 294 (40,2%) avaient recouru a l'automedication avec des antibiotiques durant les six derniers mois. La plupart des antibiotiques (59,2%) pour l'automedication ont ete achetes sans ordonnance dans des officines pharmaceutiques. Le score median des connaissances des etudiants sur le sujet des antibiotiques etait de 4 (IQR: 3-6) sur un score maximum possible de 10. Les etudiants avaient des croyances de precision moderee sur antibiotiques. Plus de la moitie des eleves (56,5%) stockaient frequemment des antibiotiques. Au cours de l'automedication, 16,7% des eleves ont affirme avoir eu des reactions indesirables et 30,6% avaient utilise des antibiotiques pour prevenir le rhume commun. La majorite des etudiants preferaient utiliser des antibiotiques a large spectre et pres de la moitie preferait des antibiotiques par voie intraveineuse. Plus de 44% des etudiants ont change la posologie des antibiotiques et 36,5% ont change d'antibiotique en cours de traitement. L'analyse de regression logistique a identifie le college et la ville d'accueil comme des facteurs de risque independants de l'automedication avec des antibiotiques (p