Gunshot wounds in parenchymatous organs: the morphology mainly depends on the physical properties of the affected tissues

In contrast to gunshot wounds in skin and bone, the medico-legal literature pays little attention to the appearance of bullet penetration sites in abdominal organs. It was only in 1983 that Metter and Schulz published an article entitled "Morphological features of gunshot wounds in the liver and spleen." According to their observations, the organs in question showed stellate tears at the bullet penetration sites resembling skin wounds from contact shots to body regions having a bony support. The study presented simulated the real conditions by means of test shots to composite models consisting of porcine organs embedded in ballistic gelatin. The ammunition used was pistol cartridges 9 mm Luger with full metal jacket round nose bullets. The shots were video-documented with a high-speed camera in order to record the bullet's travel through the target. In addition, the composite models fired at underwent CT examinations followed by a macroscopic assessment of the organs. The study confirmed the findings of Metter and Schulz with regard to the star-like appearance of gunshot wounds in the liver and spleen. Likewise, the kidney showed radiating tears originating from the bullet path, whereas the wound track in pulmonary tissue was tube-shaped and lacked additional cracks. The varying wound patterns in parenchymatous organs can reasonably be explained as a consequence of the respective viscoelastic tissue properties.

Differing sizes of bullet entrance holes in skin of the anterior and posterior trunk

The aim of the present study was to establish whether the size (diameter and area) of bullet entrance holes in skin varies between distant shots to the anterior and posterior trunk, respectively, when using the same ammunition (in concreto pistol cartridges 9 mm Luger). For that purpose, specimens of porcine skin from the belly region and the back were taken (10 samples each) and shot at from a distance of 1.6 m. The entrance holes were photo-documented under standardised conditions. After image processing for contrast enhancement, the maximum diameter and the area of each skin defect were measured automatically by means of an image analysis system. Both size parameters differed significantly depending on the body region affected. On the back with its comparatively thick dermis, the skin defects were considerably smaller than those on the ventral trunk where the corium is less thick. This difference can be explained by the fact that the elastic properties of skin are strongly determined by the connective tissue which is especially rich in fibres. The study results were consistent with the authors’ casework experience and support the assumption that the entrance site of gunshot wounds has a major influence on the size of the bullet hole in skin.

Relationship Between Catheter Stability and 12-Month Success After Pulmonary Vein Isolation: A Subanalysis of the SMART-AF Trial

OBJECTIVES

This study sought to assess the correlation between catheter and tissue contact force (CF) stability and 12-month clinical success for atrial fibrillation (AF) ablation.

BACKGROUND

The SMART-AF (Thermocool Smarttouch Catheter for the Treatment of Symptomatic Paroxysmal Atrial Fibrillation) multicenter trial provided a robust dataset of AF ablation procedures, using the CF sensing ablation catheter.

METHODS

CF and CF stability were correlated with 12-month success for drug-refractory symptomatic AF ablation. CF stability was assessed by stability of ablation parameters (CF, time, location stability) over 3-dimensional electroanatomic maps of pulmonary veins (PVs) using a new proprietary software module and the percentage of time within investigator-selected CF ranges. Available data for potential "PV gaps" were retrospectively identified when stability criteria were not met and were correlated with 12-month success.

RESULTS

Average CF categories of 0 to 10, 10 to 20, and >20 g were associated with 12-month success rates of 90%, 70%, and 70%, respectively; thus, higher average CF did not correlate with treatment success. An exploratory univariate analysis showed significantly higher success rates with a CF of 6.5 to 10.3 g than with <6.5 g (odds ratio: 2.95; 95% confidence interval: 1.13 to 7.72; p = 0.028) but a CF >10 g did not improve success. When stable CF was applied ≥73% of the time within the preselected CF range, success improved. A receiver operating characteristic curve analysis revealed that PV gaps exceeding 10.6-mm distance significantly correlated with 12-month failure.

CONCLUSIONS

In the SMART-AF trial, CF stability with sufficient CF was most predictive of optimal 12-month success. (Thermocool Smarttouch Catheter for the Treatment of Symptomatic Paroxysmal Atrial Fibrillation [SMART-AF]; NCT01385202).

Adversities in childhood and their impact on mental health across the life course

How is the brain shaped and refined by children's early social and emotional experiences? In this colloquium, I will focus on the development of children who have endured environments marked by toxic levels of stress early in their development. These children are known to be at increased risk for a variety of health, academic, and social problems. Some of these problems appear immediately, but others may not manifest themselves until much later in development. I will highlight ways in which we can address central issues in human development by studying the quality and timing of children's social experiences. To do so, I will describe recent research involving children who have experienced child abuse and neglect, children raised in poverty, children raised in institutional settings, children who have endured traumatic life experiences, and typically developing children. Through these studies, I will highlight new insights about the developmental processes underlying children's sensitivity to their social environments as a way to understand the emergence of both adaptive and maladaptive human emotional behavior. Defining and specifying ways in which the environment creates long-term effects on brain and behavior holds tremendous promise for improving the health and well-being of children.

Disclosure of interest

The author has not supplied his declaration of competing interest.

Fat from contused adipose tissue may cause yellow discoloration of clothes in blunt trauma victims

In some fatalities from intense blunt trauma, the victims' clothes show strikingly yellow discoloration being in topographic correspondence with lacerated skin and crush damage to the underlying fatty tissue. This phenomenon is especially pronounced in light-colored textiles such as underwear made of cotton and in the absence of concomitant blood-staining. The constellation of findings seems to indicate that the fabric has been soaked with liquid body fat deriving from the contused adipose tissue. To check this hypothesis, textiles suspected to be contaminated with fat were investigated in 6 relevant cases. GC-MS-analysis proved the presence of 11 fatty acids. The fatty acid composition was similar to that of human adipose tissue with a high proportion of oleic acid (18:1). In total, the morphological and chemical findings demonstrated that the yellow discoloration of the victims' clothes was caused by fat from traumatized adipose tissue.

Muzzle imprint mark: a patterned injury which may be constituted of intradermal blood extravasations

The muzzle imprint mark in contact shots is usually regarded as a patterned pressure abrasion depicting the barrel end as well as adjacent constructional components of the weapon. Due to parching after exposure to air, the affected skin assumes a brown color, especially along the contours of the impacting structures. Apart from this well-known type of epidermal damage, the imprint mark may also be formed by intradermal hemorrhages. In some cases, these intracutaneous bleedings manifest themselves as circular, curved or straight reddish lines mirroring the surface relief of the weapon's muzzle end. To estimate the frequency of skin hematomas in muzzle imprints, 35 consecutive contact shots to the head (temple, forehead, submental and occipital region) were evaluated. In 3 cases, the muzzle imprint mark exclusively consisted of intracutaneous bruises surrounding the bullet entrance hole. In 14 cases, the muzzle imprint was composed of both excoriations and intradermal hematomas.

Tooth aspiration: its relevance in medicolegal autopsies

Tooth aspiration in adulthood is an uncommon autopsy finding. The paper presents two cases in which maxillary incisors had been avulsed and inhaled during hospital treatment and in the course of maxillofacial trauma, respectively. In the first case, repeated attempts to remove the aspirated tooth by means of flexible bronchoscopy led to perforation of the bronchial wall with consecutive bleeding into the deep airways and fatal asphyxia. In the second case, the fact of tooth aspiration remained undetected throughout the 3-day survival time until death from craniocerebral trauma. The paper points out the forensic aspects of tooth aspiration against the background of the relevant clinical literature.

Experimental simulation of reentry shots using a skin-gelatine composite model

A bullet that has passed in and out of one body segment may continue its way into another part of the body causing a second entrance ("reentry") wound, which is often said to have an atypical and sometimes confusing appearance. To analyze this problem in a systematical approach, 9-mm Parabellum full metal-jacketed projectiles were fired at skin-gelatine composite models simulating the consecutive passage of a bullet through two parts of a body. When there was a distance between the two segments, the primary exit and the reentry skin wounds did not show any distinctive features differing from usual gunshot injuries. In the case of contact between exit and reentry site, the corresponding skin wounds resembled each other as both had central tissue defects surrounded by abrasion areas. The subsequent investigation of the simulant revealed that skin particles from both the exit and the adjacent reentry site had been displaced in the direction of the shot along the whole bullet track of the second segment. The morphological findings are presented and discussed with respect to the pertinent literature, and possible physical ballistic explanations are suggested.

Analysis of mitochondrial length heteroplasmy in monozygous and non-monozygous siblings

The segregation of mitochondrial genomes and the inheritance of mitochondrial DNA are constant matters of debate. To obtain more information about this issue and to answer the question whether or not it is possible to distinguish mitochondrial DNA (mtDNA) samples from monozygous individuals by analysing heteroplasmic length variants, 290 monozygous and 121 dizygous twin pairs and 34 sets of multiples were studied by RFLP and partly by direct sequencing. A factor D describing the respective pattern of length variants in a given sample was also calculated. The results show that monozygous individuals exhibit a significantly lower median and closer distribution of D than non-monozygous siblings. Thus, a differentiation of mtDNA samples from monozygous twins by this trait is not possible. The high percentage of heteroplasmic individuals, the low median of the D values and the unexpectedly very similar distribution of length variants in monozygotic individuals support the existence of a relatively wide bottleneck or the assumption of a regeneration of length heteroplasmy following a tight bottleneck and agree with a random segregation of mtDNA genomes in dividing oocytes.

Effect of shortening the barrel in contact shots from rifles and shotguns

In a suicidal gunshot fired to the chest from a carbine, the barrel of which had been shortened to half its original length, an unexpectedly large degree of destruction of the anterior thoracic wall with extensive undermining of the subcutis was found. This phenomenon was investigated for reconstructive purposes by firing test shots from two different long guns (caliber 7.92 x 57 repeating rifle with full-jacketed pointed bullet and caliber 12/70 single-barreled shotgun with shotgun slug) into blocks of soap (38 x 25 x 25 cm). The contact shots were fired before and after shortening the barrels (repeating rifle from 60 to 30 cm and single-barreled shotgun from 72 to 36 cm). The volume of the cavities in the simulant was visualized three-dimensionally with the help of a multislice computed tomography (CT) scanner and calculated sectionally. With the repeating rifle and the single-barreled shotgun, the shots from the sawed-off barrels produced significantly larger cavity diameters in the first section of the bullet track. This effect is attributable to the fact that, with a shortened barrel, the gas pressure at the muzzle is higher, thus, leading to increased expansion in the initial part of the wound track in contact shots.

Medical criminalistics

Medical criminalistics is an essential part of legal/forensic medicine. It includes the clinical examination of surviving victims and suspects, the inspection of the scene in suspicious deaths with subsequent performance of medico-legal autopsies, the assessment of (biological) traces and the reconstruction of criminal events under medical aspects. Just as the circumstances of life and the manifestations of crime are changing with time, there is a permanent alteration regarding the issues of medical criminalistics. Legal/forensic medicine is a university subject in most countries and therefore, research work is one of the main tasks also in medical criminalistics. In contrast to clinical medicine and basic research, some common study designs are not suitable for the special needs of medical criminalistics, whereas other types are more appropriate like epidemiological evaluations, cross-sectional studies and (retrospective) observation studies. Moreover, experimental model tests and case reports also rate high in medical criminalistics.

Gunshot-related displacement of skin particles and bacteria from the exit region back into the bullet path

In previous studies, it was shown that there is a gunshot-related transport of skin particles and microorganisms from the entrance region into the depth of the bullet path. The present study deals with the question of whether gunshots may also cause a retrograde transport of skin particles and microorganisms from the bullet exit region back into the bullet path. For this purpose, we used a composite model consisting of rectangular gelatin blocks and pig skin. The skin pieces were firmly attached to the gelatin blocks on the side where the bullet was to exit. Prior to the test shots, the outer surface of the pig skin was contaminated with a thin layer of a defined bacterial suspension. After drying the skin, test shots were fired from a distance of 10 m using cartridges calibre .38 spec. with different bullet types. Subsequent analyses showed that in all shots with full penetration of the composite model, the bullet path contained displaced skin particles and microorganisms from the skin surface at the exit site. These could be regularly detected in the distal 6-8 cm of the track, occasionally up to a distance of 18 cm from the exit hole. The distribution of skin particles and microorganisms is presented and the possible mechanism of this retrograde transport is discussed.

Self-inflicted injuries with negative political overtones

The report deals with two adolescents (a 17-year-old Turkish boy and a 15-year-old German girl) who simulated right-wing assaults by cutting National Socialist symbols into their own skin. The fact that Nazi symbols were chosen was obviously due to the idea that the alleged commission of the offense by right-wingers would not be doubted due to the negative image of this group. The alleged victims did not inform the police until the family or close friends urged them to report the incident. The rapid elucidation of the facts was possible because medicolegal experts were called in at an early stage of the investigations. The injuries showed typical morphological features of self-infliction (localization in easily accessible parts of the body, multitude of singular lesions with a linear or slightly curved course, equally shallow and non-penetrating cuts, arrangement in groups or over a defined area, lack of defense injuries, no corresponding damage to the clothing).

A case of Munchausen syndrome by proxy with subsequent suicide of the mother

Munchausen syndrome by proxy is a subtle and difficult to diagnose form of child abuse in which the carer (usually the mother) simulates, manipulates or produces symptoms of illness in the victim. In most cases the detrimental effect is caused by applying foreign substances or by airway obstruction. In the presented case a 20-month-old girl developed a spreading soft-tissue infection resistant to treatment on the left upper arm after vaccination, which required a number of surgical interventions. Repeatedly, microorganisms from the intestinal flora were isolated from the wound secretion. After the girl suffered respiratory and circulatory arrest, which required resuscitation measures, chemical toxicological tests revealed not medically prescribed benzodiazepines in serum and urine. When the mother, a trained nurse, was confronted with the allegation to have manipulated the symptoms of the illness she committed suicide. The forensic autopsy of the suicide produced numerous hints suggesting chronic self-damaging behaviour described as Munchausen syndrome. This case shows a number of manipulation forms with the maintenance of a chronic skin and soft tissue infection belonging to the rarer forms of inflicting damage to the child. It also illustrates that confrontation with the allegation of Munchausen syndrome by proxy creates a very stressful emotional situation that may lead to a suicidal act.

Gunshot-related transport of micro-organisms from the skin of the entrance region into the bullet path

The skin defect of a gunshot entrance wound is caused by the retrograde and anterograde displacement of skin particles. In the present study, we investigated whether gunshots to bacterially contaminated skin are associated with the transport of micro-organisms into the bullet path. The shots were fired into composite models of pig skin and gelatin blocks. The outer surface of the skin was covered with a thin layer of a defined bacterial suspension [green fluorescent protein-labelled Escherichia coli in the preliminary test and Staphylococcus epidermidis, DSM 1798, in the main test series]. After the bacterially contaminated fluid had dried, test shots were fired from a distance of 5 and 10 m using calibre .38 Special cartridges with different bullet types (round nose, truncated cone, hollow point and flat nose). Subsequent bacteriological analyses showed that all the bullet tracks in the gelatin serving as tissue simulant contained displaced micro-organisms from the skin surface. The results are presented and discussed with reference to the transport of skin particles into the depth of the wound track.

A Screening for the Occurrence of Autoreactive Antibodies in Sera of Pregnant and Non-pregnant Bitches

Sera of healthy pregnant (group I, n = 11) and non-pregnant (group II, n = 11) bitches were screened for autoantibodies (AAb). In both groups, blood samples were drawn every fifth day between days 5 and 55 after mating. Serum was analysed via indirect immunofluorescence (IIF) with the Canine ANA HEp-2 Screening Kit. In all animals, anticytoplasmic AAb were detected. Utilizing primate-heart substrate slides AAb against contractile proteins of the cytoplasm could be observed. The predominating fluorescence pattern in pregnant animals resembled above all desmin, which was proven via Western blot. The sera were then pre-incubated with tropomyosin, actin, vimentin, vinculin and keratin solutions, and assessed on HEp-2 slides and on human and canine fibroblasts as well. The latter substrate was used to verify whether the detected Ab were in fact AAb. Utilizing tropomyosin, revealed elimination of the cytoplasmic fluorescences on all three substrates. It is therefore assumed, that in sera of healthy dogs, AAb against contractile structure proteins of the cytoplasm are present regularly. The majority of pregnant bitches presented with higher end-point titres (EPT), than to be found in non-pregnant dogs. AAb against desmin played the key role in those patterns. In addition, sera were screened for thyroid specific AAb, namely thyroglobulin, thyroid peroxidase (TPO), T3 and T4, and for AAb against insulin by ELISA or Western blot (TPO). Only in two of the pregnant bitches a weak positive reaction (1:100) for T3-AAb was detected.

Death by hanging while watching violent pornographic videos on the Internet - suicide or accidental autoerotic death?

In deaths by hanging, it may sometimes be difficult to differentiate between autoerotic accident and suicide. Our report deals with a 30-year-old man who was found hanged in the living room of his flat. The deceased was wearing headphones connected to a PC. Within the deceased's view was a computer screen showing the last picture of a video file downloaded from the Internet with the head of an unclothed, allegedly hanged female. The deceased's left hand was inside his trousers in the genital region. The autopsy did not only show findings typical for hanging, but also advanced sarcoidosis, which was known to the victim. Although this basic illness could have been a possible motive for suicide, the circumstances in the presented case pointed more in the direction of an accidental autoerotic death. As far as we know, this is the first description of a death during autoerotic activity in which sexual stimulation was achieved by watching a video file downloaded from the Internet.

Autoantibodies against bactericidal/permeability–increasing protein (BPI–ANCA) in cystic fibrosis patients treated with azithromycin

Autoantibodies against bactericidal/permeability-increasing protein (BPI-ANCA) were found in patients with cystic fibrosis (CF). It is speculated that they represent a marker of the chronic endobronchial infection and sustained inflammatory response in CF. Our aim was to evaluate whether azithromycin (AZM), through its antiinflammatory effect, could affect the level of BPI-ANCA in CF patients. Eighteen patients with CF aged 5.5-36.3 years (median 15.1) were enrolled in a randomised, double-blind, placebo-controlled trial of AZM (250 mg twice a week to 10 patients) or placebo (8 patients) for 12 weeks. BPI-ANCA levels were recorded pre- and post-treatment and compared to a group of 18 matched healthy controls. Chi-square analysis, Kruskal-Wallis and Mann-Whitney tests were used to compare between the groups. Pre- and post-treatment values were compared using the Wilcoxon Signed-Ranked test. BPI-ANCA was found in 12 CF patients (67%) and four (22%) healthy subjects (P<0.001). The mean BPI-ANCA level was 3.94+/-6.15 U/ml (mean+/-SD) in healthy subjects and 38.11+/-42.34 U/ml in CF patients (P=0.023). The mean BPI-ANCA level was higher in patients with Pseudomonas aeruginosa compared to those without (64+/-35 U/ml and 25+/-41 U/ml respectively, P=0.032). No change in BPI-ANCA levels occurred in the AZM-treated patients [35 (0-127) U/ml (median (range) and 30 (0-120) U/ml, respectively] or in the placebo group [10 (0-66) U/ml and 13 (0-83) U/ml, respectively]. BPI-ANCA levels are significantly higher in patients with CF compared to healthy controls. BPIANCA levels are higher among patients colonised with P. aeruginosa. Twelve weeks of AZM therapy did not lower the BPI-ANCA level in patients with CF.

Contact shot with unusual soot pattern

In a suicidal shot to the temple two roundish zones of powder soot blackening were found above the entrance wound. The paired zones of powder soot blackening were caused by two gas outlets located on the upper side of the muzzle end of the weapon used (converted blank cartridge pistol of make Rhöner). The conclusions that can be drawn from this particular soot pattern with regard to the type of the weapon, the muzzle-to-target distance, the direction of fire and the way of holding the weapon are discussed.

Tissue defect at the gunshot entrance wound: what happens to the skin?

To investigate the question what happens to the tissue lost at the entrance wound, experimental studies were performed on composite models consisting of dyed pig skin and gelatin blocks. For the test shots to the skin-gelatin preparations, cartridges calibre .38 spec. with different bullet types (round nose, hollow point, flat nose, truncated cone) were used. In all shots, a multitude of coloured skin particles were macroscopically discernible along the bullet tracks. In addition, small cell aggregations could be demonstrated microscopically even in those sections of the bullet paths which did not show skin fragments visible to the naked eye. The distribution of the skin particles showed certain peculiarities depending on the type of projectile.

Elucidation of a strange gunshot injury

A 50-year-old obese man sought medical treatment for bleeding injuries in the abdomen and thigh. According to his statement he felt a dull blow on the front of the trunk while he was feeding swans at a lake. The forensic wound findings and the examination of the clothing suggested that the injuries were caused by a single close-range gunshot with the bullet path running nearly vertically downwards and having a total length of 38 cm. The bullet primarily entered in the right mesogastrium, left the body in the right inguinal region, re-entered and ultimately lodged in the right thigh. After confronting the man with the results of the forensic examination he admitted that he himself had caused the gunshot injury accidentally when cleaning his small-bore revolver.

Gunshot injuries as a topic of medicolegal research in the German-speaking countries from the beginning of the 20th century up to the present time

The 100th anniversary of the foundation of the German Society of Legal Medicine is a good opportunity to review its contributions to forensic wound ballistics. The present article gives an overview of the scientific development in this field with special emphasis on work pioneering new developments and findings valid up to the present day, for example the presence of carboxyhemoglobin in the vicinity of the entrance wound as a sign of a contact or close-range shot [A. Paltauf, Wien. Klin. Wochenschr. 3 (1890) 984-991, 1015-1017]; the correct interpretation of the muzzle imprint [A. Werkgartner, Beitr. Gerichtl. Med. 6 (1924) 148-161] and the retrograde ballooning of the bullet entrance region in contact shots [F. Hausbrandt, Dtsch. Z. ges. Gerichtl. Med. 38 (1944) 45-76; H. Elbel, Med. Welt 20 (1958) 343-345]; wound patterns from captive-bolt livestock stunners [H. Czursiedel, Dtsch. Z. ges. Gerichtl. Med. 28 (1937) 132-133]; singeing of synthetic fiber textiles in close-range shots with nitro powder ammunition [S. Berg, Arch. Kriminol. 124 (1959) 5-8,17-22]; the wound ballistic processes on penetration of the bullet and the origin of the abrasion collar [K. Sellier, Beitr. Gerichtl. Med. 25 (1969) 265-270]. More recently medicolegal research in the German-speaking countries covered the following subjects: studies of the dynamic bullet-target interactions in experimental gunshots to simulants and composite body models; use of modern imaging techniques (CT, MRI) in the pre-autopsy diagnosis of lethal gunshot injuries; injuries from blank guns; mechanisms of incapacitation by gunshot injuries; development of improved methods for the evidence of gunshot residues on the firing hand; backspatter from close-range shots; medicolegal contributions in the discrimination of accidental, homicidal and suicidal gunshot injuries.

Detachment of the periosteum and soot staining of its underside in contact shots to the cerebral cranium

Contact gunshot wounds are usually characterized by a muzzle imprint, a powder cavity ("pocket"), the presence of carboxyhemoglobin and often also stellate tears of the skin radiating from the bullet entrance hole. In shots to the cerebral cranium an additional sign may be observed around the bone defect: the periosteum is detached and reflected with soot on the underside. The frequency and possible causes of these periosteal findings are discussed on the basis of 68 contact gunshot wounds from forensic autopsy material and experimental shots fired against the frontal bone of a slaughtered calf.