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Fractures of the base of the skull in charred bodies--post-mortem heat injuries or signs of mechanical traumatisation?

Based on a recent case, in which an expert opinion had to be prepared, the question was investigated if fractures of the base of the skull can result from the influence of heat on the human skull. Neither the retrospective analysis of autopsy records nor the prospective examination of charred bodies revealed any cases with heat-induced fractures of the base of the skull. Observation of cremations showed that the changes caused by the fire followed certain rules: fractures of the calvaria were seen after approximately 20 min; the base of the skull became exposed after about 45 to 60 min. In none of the 20 cremations watched could any fractures of the base of the skull be detected.

Adolescent↗

New ages for human occupation and climatic change at Lake Mungo, Australia.

Australia's oldest human remains, found at Lake Mungo, include the world's oldest ritual ochre burial (Mungo III) and the first recorded cremation (Mungo I). Until now, the importance of these finds has been constrained by limited chronologies and palaeoenvironmental information. Mungo III, the source of the world's oldest human mitochondrial DNA, has been variously estimated at 30 thousand years (kyr) old, 42-45 kyr old and 62 +/- 6 kyr old, while radiocarbon estimates placed the Mungo I cremation near 20-26 kyr ago. Here we report a new series of 25 optical ages showing that both burials occurred at 40 +/- 2 kyr ago and that humans were present at Lake Mungo by 50-46 kyr ago, synchronously with, or soon after, initial occupation of northern and western Australia. Stratigraphic evidence indicates fluctuations between lake-full and drier conditions from 50 to 40 kyr ago, simultaneously with increased dust deposition, human arrival and continent-wide extinction of the megafauna. This was followed by sustained aridity between 40 and 30 kyr ago. This new chronology corrects previous estimates for human burials at this important site and provides a new picture of Homo sapiens adapting to deteriorating climate in the world's driest inhabited continent.

Adaptation, Physiological↗

The case of Dr. Shipman.

On January 31, 2000, Dr. Harold Shipman was convicted at Preston, England, of murdering 15 of his patients by administering lethal doses of diamorphine (pharmaceutical heroin). Investigations indicate that, during his working life, he killed about 220 to 240 of his patients. The bodies of many victims were cremated. Twelve victims were exhumed, and 9 of these deaths were included in the indictment. Most victims were elderly and had histories of natural disease. Autopsies confirmed known natural disease but showed no evidence of acute lethal events. Analysis of skeletal muscle disclosed significant quantities of morphine, to which the deaths were attributed. Circumstantial evidence was strong, as illustrated by the convictions in 6 deaths without autopsy or toxicology, because the bodies had been cremated. Organic compounds are remarkably stable in buried bodies. Even so, detection and quantitation of morphine in exhumed bodies may become problematic after burial for 4 years or more. Morphine glucuronide is slowly converted back to free morphine in the buried corpse.

Aged↗

A plea for the heart.

Martyn Evans believes that it is a 'shocking feature' of brain-centred conceptions of death that they require us to regard as dead a person whose heart may continue to beat spontaneously. When it comes to neocortical conceptions of death, we might even be burying or cremating a 'breathing corpse'. If proponents of neocortical definitions of death suggest active interventions to stop the remaining spontaneous functions, in what sense, asks Evans, is this different from killing? Also, does it make sense to accept, as many proponents of brain-centred conceptions of death do, that it is proper to 'explant' organs from 'beating-heart cadavers', whilst squirming at the thought of cremating a 'breathing corpse'?

Attitude to Death↗

A migrating pacemaker.

A deceased 79 year old man with a permanent cardiac pacemaker was due to be cremated, but the pacemaker generator was not detectable by palpation. A hand held metal detector to locate the device so that it could be extracted before cremation.

Aged↗

Did he drown or was he murdered?

An unemployed, 60-year-old Singaporean gentleman died during a brief overseas trip to another South-East Asian country. He had, presumably, drowned in the bathtub of his hotel room, which he shared with his then 44-year-old companion, who was supposedly his nephew. The relevant public health and medico-legal authorities of the host country conducted an external examination of the body at the scene, whereupon they agreed with the police that his death was probably due to accidental drowning following an episode of syncope. It would appear that this verdict was based almost entirely on circumstantial and hearsay evidence. No autopsy was performed. In its place, considerable reliance was placed on the observation that abdominal compression resulted in the outflow of a small amount of water from the mouth, as being proof of drowning. A few days later, the body was cremated in the host country and the remains (ashes) were subsequently repatriated to Singapore. It later transpired that, shortly before they embarked on the ill-fated trip, the deceased's 'nephew' had purchased, on the former's behalf, travel insurance policies (covering accidental injury and death) amounting to a total of S$800,000 from five different insurance companies, as well as a separate life policy for a further S$100,000, most of which had been issued within the fortnight prior to their departure. Interestingly, the beneficiary (later the plaintiff in the ensuing civil trial some three years later) of all of these policies, was the ex-wife of the deceased's 'nephew', with whom he had, in fact, continued to live although they were officially divorced several years ago. Whilst the claim against the life policy had been settled, the first five insurers declined to issue payment on grounds of suspicion that the deceased had been the victim of a homicide, planned or executed by the 'nephew', wherein the beneficiary was a conspirator of sorts. The author was approached by defence counsel (representing the various insurers), for assistance in this matter. It was felt that a proper forensic review was seriously hampered by the lack of a full autopsy which would have been indispensable in ascertaining the actual cause of death and in eliminating other possibilities, apart from drowning, such as death from natural causes, other forms of injury, poisoning, or homicide. It was also emphasized that the mere presence of ingested water is not diagnostic of drowning. Eventually, after a protracted but unsuccessful attempt at mediation (in the course of which, the plaintiff rejected the offer of a reduced, although apparently sizable quantum), the matter came before the High Court, which found in favour of the defendants. It appeared that the judge was more than convinced that the deceased was indeed the victim of a homicide of which the plaintiff was a conspirator and her ex-husband, the perpetrator, as even a cursory perusal of the written judgement would indicate. Accordingly, the court ruled that the plaintiff (in her capacity as both the beneficiary of the insurance policies and executor of the estate) and her ex-husband had, effectively, deprived the insurers of their contractual right (as stipulated in the insurance policies) to have an autopsy conducted on the body of the deceased and they were, therefore, entitled to deny liability. This case illustrates the difficulties inherent in conducting an independent review of a putative instance of drowning, where convincing and reliable forensic evidence and documentation are largely wanting; this being compounded by its occurrence in a foreign jurisdiction whose medico-legal practices differ substantially from that to which one is accustomed. It may even be said that the corpus delecti was destroyed, in this instance, by cremation. It is also unusual in that a de-facto finding of murder was made in a civil court (whose standard of proof is that of a balance of probabilities) and that this had, subsequently, spurred the police to undertake a criminal investigation for conspiracy to murder. In the event, the civil appeal was dismissed by the Court of Appeal, but no charge was laid against any of the suspects for want of sufficient forensic or investigative evidence of a criminal offence having been committed.

Drowning↗

An update on the Kevorkian-Reding 93 physician-assisted deaths in Michigan: is Kevorkian a savior, serial-killer or suicidal martyr?

This report presents an update of the Kevorkian-Reding physician-assisted (or physician-aided) deaths to include the ninety-three publicly acknowledged cases as of November 25, 1998. These deaths are divided into ten distinct time phases. The following trends emerge. Over two-thirds of the decedents are women, the ratio of females to males varying widely with phase. The proportion of women seems to be the highest when Kevorkian is free to act as he wants and lowest when he seems to be acting under legal or political restraints. Based on autopsy results, only 29.0 percent of the cases are terminal, this percentage being higher among men (37.9%) than among women (25.4%). However, 66.7% of the decedents were disabled, no significant difference emerging between men and women. Further, five out of the six decedents showing no apparent anatomical sign of disease at autopsy were women. Over 80 percent of the physician-assisted deaths are cremated, approximately twice as high a proportion as that emerging for suicides in Michigan and four times as high as cremations occurring with regard to overall deaths. Finally, death by carbon monoxide decreases dramatically with time phase while the use of the contraption dubbed the "suicide machine" increases, suggesting an increasing routinization over time. Finally, during the ninth and tenth phases, Kevorkian's aims and his own suicidality emerge more clearly involving 1) harvesting organs and 2) threat of starving himself in prison if he is convicted. Phase 10 can be seen as an escalation from assisted death to overt euthanasia, repeating the same need for a demonstration (Thomas Youk) that was first exhibited in Phase I (Janet Adkins).

Chronic Disease↗

Experiments in the combustibility of the human body.

This paper provides possible explanations for two previously misunderstood circumstances surrounding cases of so-called "spontaneous human combustion"--the nearly complete cremation of human bone, and the failure of such fires to spread to nearby combustibles. Two experiments were conducted. The first involved the cremation of "healthy" and "osteoporotic" human bone and observing the resulting fragmentation and color change. Osteoporotic elements consistently displayed more discoloration and a greater degree of fragmentation than healthy ones. The second experiment involved the combustion of a sample of human tissue and observation of the flame height and burning area in order to calculate the effective heat of combustion. The resulting heat was 17kJ/g indicating a fire that is unlikely to spread. These results, which are among the first obtained for human samples, lend further support and credence to previous scientific explanations for "spontaneous human combustion."

Body Composition↗

NTP Toxicology and Carcinogenesis Studies of p-Nitroaniline (CAS No. 100-01-6) in B6C3F1 Mice (Gavage Studies).

p-Nitroaniline is an intermediate in the preparation of several azo dyes used for coloring consumer products. Toxicology and carcinogenicity studies were conducted by administering p-nitroaniline (>99% pure) in corn oil by gavage to groups of male and female B6C3F1 mice for 14 days, 13 weeks, and 2 years. Genetic toxicology studies were conducted in Salmonella typhimurium, Chinese hamster ovary cells, mouse Iymphoma cells, and Drosophila melanogaster. 14-DAY STUDIES: Groups of five male and five female B6C3F1 mice received p-nitroaniline in corn oil by gavage at doses of 0, 10, 30, 100, 300, or 1,000 mg/kg body weight 5 days per week for 2 weeks. All mice that received 1,000 mg/kg died from chemical-related toxicity by day 4 of the studies. Final mean body weights of mice receiving 300 mg/kg or less were similar to those of the controls. Hematology results were consistent with chemical-related methemoglobinemia and regenerative anemia. Met hemoglobin concentrations in all groups of dosed mice were significantly higher than those in controls. Hematocrit values in mice that received 300 mg/kg and total erythrocyte counts in mice that received 100 or 300 mg/kg were significantly lower than those in controls. Reticulocyte counts in 300 mg/kg male mice and in 100 or 300 mg/kg females were significantly higher than controls. Heinz bodies were observed in erythrocytes of all 300 mg/kg mice and in two 100 mg/kg male mice. The absolute and relative spleen weights of 100 and 300 mg/kg mice were significantly greater than those of the controls. Hematopoiesis and pigment (hemosiderin) accumulation were observed in the splenic red pulp of males and females receiving 300 mg/kg; pigment (hemosiderin) accumulation in Kupffer cells of the liver was also seen in male mice at this dose level. 13-WEEK STUDIES: Groups of 20 male and 20 female B6C3F1 mice received p-nitroaniline in corn oil by gavage at doses of 0, 1, 3, 10, 30, or 100 mg/kg body weight 5 days per week for up to 13 weeks. Eight or nine mice in each group were evaluated at 7 weeks. There were no deaths associated with exposure to p-nitroaniline, and final mean body weights of dosed mice were similar to those of the controls. Hematologic and pathologic findings at 7 and 13 weeks were similar to those seen in the 14-day studies and occurred primarily in the 30 and 100 mg/kg groups. Met hemoglobin concentrations were increased and hematocrit levels and erythrocyte counts were decreased relative to those of the controls. Heinz bodies were observed in erythrocytes and nucleated erythrocytes and reticulocytes were increased in number. Absolute and relative spleen weights of male and female mice receiving 30 and 100 mg/kg were significantly greater than those of controls at 7 and 13 weeks. Absolute and relative liver weights of female mice necropsied at 7 weeks were significantly greater in the 30 and 100 mg/kg groups; by 13 weeks, both absolute and relative liver weights were similar to control values. The incidence or severity of splenic hematopoiesis and pigmentation (hemosiderin) increased with dose at the 7-week interim evaluations and at the end of the studies. Pigment (hemosiderin) was also present in Kupffer cells of the liver in dosed male mice. 2-YEAR STUDIES: Groups of 70 male and 70 female B6C3F1 mice received p-nitroaniline in corn oil by gavage at doses of 0, 3, 30, or 100 mg/kg body weight for 5 days per week for up to 103 weeks. The dose selection was based on the hematologic and pathologic findings of the 13-week studies. Nine or ten mice from each group were evaluated at 9 and 15 months for the presence of chemical-related lesions. Body Weights, Clinical Findings, Survival, and Hematology: Mean body weights of male and female mice that received p-nitroaniline were similar to those of control mice throughout the 2-year studies. There were no clinical findings associated with chemical exposure, and survival of dosed mice was similar to that of controls. The hematology findings at the 9 and 15-month interim evaluations were similar to those in the 14-day and 13-week s 13-week studies. The methemoglobin concentrations were significantly higher in all 30 or 100 mg/kg mice; sulfhemoglobin concentrations were significantly higher at 9 months in all 30 or 100 mg/kg female mice and at 15 months in 100 mg/kg females. Hematocrit and erythrocyte counts in 100 mg/kg mice were significantly lower than those in controls. By 9 months, reticulocyte counts were significantly higher in all 30 or 100 mg/kg mice. At 15 months, only the 100 mg/kg mice exhibited significantly higher reticulocyte counts. Neoplasms and Nonneoplastic Lesions: Lesions related to the administration of p-nitroaniline occurred in the spleen, liver, and bone marrow, primarily in mice receiving 30 or 100 mg/kg; these were observed at the 9- and 15-month interim evaluations and at the end of the studies. There were increases in the incidence or severity of splenic congestion, hematopoiesis, pigment (hemosiderin) accumulation, Kupffer cell pigmentation in the liver, and bone marrow hypercellularity (hyperplasia). The incidences of hemangiosarcoma of the liver (0 ppm, 0/50; 3 ppm, 1/50; 30 ppm, 2/50; 100 ppm, 4/50) and hemangioma or hemangiosarcoma (combined) at all sites (5/50, 3/50, 4/50, 10/50) were marginally increased in 100 mg/kg male mice. The incidence of hepatocellular adenoma or carcinoma (combined) was significantly decreased (25/50, 26/50, 25/50, 13/50) in 100 mg/kg male mice. GENETIC TOXICOLOGY: p-Nitroaniline is mutagenic in vitro. It was tested in two laboratories for induction of gene mutations in several strains of Salmonella typhimurium. Both studies showed positive results in strain TA98, with and without S9 activation; results were negative for all other strains. p-Nitroaniline was tested in two laboratories for induction of sister cremated exchanges and chromosomal aberrations in Chinese hamster ovary cells. In the sister cremated exchange study, one laboratory reported negative results without S9 and positive results with S9; the second laboratory reported equivocal results without S9 and negative results with S9. In the chromosomal aberrations study, both laboratories found positive results with S9. Without S9, one laboratory reported weakly positive results while the other reported negative results. p-Nitroaniline induced trifluorothymidine resistance in L5178Y mouse Iymphoma cells in the absence of S9; no induction of trifluorothymidine resistance was noted with S9. In contrast to the positive results in the previous tests, p-nitroaniline did not induce sex-linked recessive lethal mutations in germ cells of male Drosophila melanogaster when administered by feeding or injection to adult males or by feeding to larvae. CONCLUSIONS: Under the conditions of these 2-year gavage studies there was equivocal evidence of carcinogenic activity of p-nitroaniline in male B6C3F1 mice based on the increased incidences of hemangiosarcoma of the liver and hemangioma or hemangiosarcoma (combined) at all sites. There was no evidence of carcinogenic activity of p-nitroaniline in female B6C3F1 mice receiving doses of 3, 30, or 100 mg/kg.

Journal Article↗

Identification of traumatic injury in burned cranial bone: an experimental approach.

Interpreting patterns of injury in victims of fire-related deaths poses challenges for forensic investigators. Determining manner of death (accident, suicide or homicide) using charred remains is compounded by the thermal distortion and fragmentation of soft and skeletal tissues. Heat degrades thin cranial structures and obscures the characteristic signatures of perimortem ballistic, blunt, and sharp force trauma in bone, making differentiation from thermal trauma difficult. This study documents the survivability and features of traumatic injury through all stages of burning for soft tissue reduction and organic degradation of cranial bone. Forty cadaver heads were burned in environments simulating forensic fires. Progression of thermal degradation was photographically documented throughout the destructive stages for soft tissues and bone to establish expected burn sequence patterns for the head. In addition to testing intact vaults, a percentage were selectively traumatized to introduce the variables of soft tissue disruption, fractures, impact marks, and incisions throughout the cremation process. Skeletal materials were recovered, reconstructed, and correlated with photographs to discern burn patterns and survivability of traumatic features. This study produced two important results: (1) Identification of preexistent trauma is possible in reconstructed burned cranial bone. Signatures of ballistic (internal and external bevel, secondary fractures), blunt force (impact site, radiating fractures), and sharp force (incisions, stabs, sectioning) survive the cremation process. (2) In non-traumatized specimens, the skull does not explode from steam pressure but does fragment as a result of external forces (collapsed debris, extinguishment methods) and handling. The features of both results are sequentially described throughout the progression of thermal destruction.

Cadaver↗

Health and safety considerations following the death of a patient.

Arthur, who had spent all his life in Liverpool, came to live with his niece in Brighton. He was in his eighties and systematically prepared for his death. He told her that he would like to be cremated and the ashes returned to Liverpool. On his death in hospital, the family made arrangements for him to be cremated. Unfortunately no one remembered or checked about the fact that a heart pacemaker had been inserted many years before, and when questioned by funeral directors, no warnings were given by the family. The pacemaker exploded in the crematorium and the local authority who was responsible for its upkeep claimed compensation from the family or NHS trust. Who, if anyone, is liable?

Cause of Death↗

Genetic analysis of modern and historical burned human remains.

Burning of corpses is a well-known funeral procedure that has been performed for a long time in many cultures. Nowadays more and more corpses are burned in crematories and buried in urns, often for practical and financial reasons. In some scientific, criminal or civil cases even after cremation there is the need of genetic investigations for identification or paternity testing. Furthermore, burned remains are the only remains left in North Europe from 1200 BC to 500 AD. This makes genetic investigation of those materials interesting for anthropological reasons. We present on one hand a systematic investigation of 10 corpses before and after the cremation and on the other hand the analysis of seven historical remains representing the bronze age. We chose the ground bone powder and the less destroyed bone parts respectively and employed a slightly modified commercially available DNA extraction method. The presence of human nuclear and mitochondrial DNA was tested by a simple but highly sensitive Duplex-PCR. DNA quantification was done using real time PCR, and genetic typing was tried out using the AmpFISTR Identifiler Multiplex Kit, followed by an automatic analysis on an AbiPrism310.

DNA↗

Reliable identification of human albumin in ancient bone using ELISA and monoclonal antibodies.

In order to help reconstruct ancient dietary, domestic, and ritual behaviour, a method was developed to identify the blood protein albumin in ancient skeletal material. This was an inhibition enzyme-linked immunosorbent assay (ELISA) using a monoclonal antibody of IgG class against human albumin. With fresh material, the technique gave consistent and specific results and could detect as little as 10 ng of albumin. Extracts of bone from the English Civil War (A.D. 1644), Mediaeval (A.D. 1100-1400), Early Saxon (A.D. 450-600), Roman (A.D. 100-200), Iron Age (ca 400 B.C.) and Bronze Age (2200-1700 B.C. cal.) periods were then tested, samples of fresh human and animal bone being included as positive and negative controls, respectively. Albumin was demonstrated in human bone from all periods; there was no evidence of cross-reactivity with animal material. Detection seemed to depend largely on amount of sample and chronological age; other factors, such as physical integrity of the specimen and soil characteristics, appeared to be less important. Preliminary studies of other ancient skeletal remains showed that animal species could be readily identified and that albumin was probably still detectable in cremated material. It is concluded that our method provides a tool specific and sensitive enough for the reliable identification of the species-origin of small fragments of bone (and possibly of blood stains) and will thus allow insight into past behaviour patterns. ELISA may also be suitable for identifying other molecules (such as HLA and ABO) which would help determine racial affiliation and disease predisposition among ancient populations.

Albumins↗

Lateral angle: a method for sexing using the petrous bone.

We report on the results of applying the so-called lateral angle method for sex determination on skeletal remains. The lateral angle denotes the angle of the internal auditory canal in relation to the medial surface of the petrous part of the temporal bone. The method involves making a small cast of the proximal part of the internal acoustic canal and determining the angle at which the canal opens up to the surface of the petrous bone. The method has the great advantage of utilizing one of the sturdiest bone elements of the human skeleton, and may thus be especially suited for analyses of very fragmented skeletal remains or cremated bones, where the petrous bone may still be readily recognizable. The method was tested using a forensic sample of 113 petrous bones with known sex. Intra- and interobserver testing was also performed. We found a statistically significant difference in angle size between males and females (mean angle size of males, 39.3 degrees ; mean angle size of females, 48.2 degrees ; P < 0.001). There was no bilateral difference in angle size. In blind trials, 83.2% of petrous bones were assigned to the correct sex. We also tested the lateral angle method against an archaeological skeletal sample. True sex was not known for this sample; instead, sexing had been carried out by assessing pelvic and cranial morphology in independent trials. We found a higher concordance between the lateral angle and "pelvic" sex than for lateral angle and "cranial" sex. Finally, we note that subadult sexing may also be possible with this method.

Adult↗

[Individual age determination using growth rings in the cementum of buried human teeth].

Incremental lines of the dental cementum were used for individual age determination in 102 teeth. 66 of them come from different historic periods, 15 teeth were cremated. 36 modern teeth of known age were use as controls. The incremental lines were investigated by use of 100 microns thin cross-sections of the root. Age determination by this method was possible in every tooth, independent of incinaration of various burial conditions. The individual age was determined by adding the mean value of the repeatedly counted incremental lines to the sex-specific eruption age of the tooth in question. Since average deviation from known age is +/- 3.23 years only, counting the incremental lines represent a very advantageous, quantitative method for individual age determination.

Adolescent↗

[High-grade pressure sores in frail older high-risk persons. A retrospective postmortem case-control-study].

Some old persons at risk do develop, but others, at comparable risk, do not develop high-grade pressure sores. To evaluate potentially different risk factors, we performed a post mortem case-control study in old persons who developed high-grade pressure sores within six months until 14 days before death. Consecutive cases with pressure sores grade >/=3 and potential controls at comparably high risk for pressure sores were examined before cremation. After written informed consent had been obtained by the next relatives, all available nursing and medical records of the deceased were thoroughly evaluated. Cases and controls were matched according to age, gender, immobility, and cachexia.A total of 100 cases with 71 pressure sores grade 3 and 29 pressure sores grade 4 were compared to 100 controls with 27 pressure sores grade </=2 and maximal risk as assessed by the Norton scale. The mean age was 86 years, 80% were females, 86% were bedridden, and cachexia was found in 66%. The cases were more often seriously disabled, had more often contractions of joints, and were on more drugs with intended or unwanted depressive/sedative effects (neuroleptics, benzodiazepines, centrally acting analgesics). Patient's impaired ability or low intention to comply/cooperate with preventive and/or therapeutic measures was more often recorded in cases than controls.A high degree of disablement and immobility, in particular, are risk factors for high-grade pressure sores in frail older high-risk persons. Sedative drug effects and impaired patient compliance with preventive and therapeutic measures may also be associated with the development of high-grade pressure sores in old persons at high risk.

Aged↗

[Severe decubitus ulcer: risk factors and nursing requirements in the terminal life phase].

UNLABELLED: We present an analysis of the risk factors, the origin and the nursing and medical practice of 140 deaths with high-grade pressure sores which had been detected by post-mortem examination before cremation. METHODS: All available nursing and medical records from nursing homes and hospitals were screened; in addition, relatives and head nurses were interviewed. The data sources were screened for individual risk factors, information about pressure sore prevention and treatment activities by nursing staff and general practitioners. Moreover, the utilization of pressure relieving devices for patients before and after development of the final decubitus was analyzed. RESULTS: More than 50% of the pressure ulcers had been incident in nursing homes. The mean duration of the disease was 307 days (median duration 123 days); the maximum duration ranged up to about 6 years. As far as it could be judged from the nursing records, there was a shortfall of nursing quality in terms of prevention efforts which appeared to be frequently inadequate in relation to the risk profile of the residents. Standardized pressure sore record files were missing in most of the cases. General practitioners were not involved in the treatment in 20% of all cases; some of them prescribed an obsolete wound management. In this study 52% of the patients had been classified into the maximum grade within the three-stage German nursing care insurance scheme. In cases of private care information about utilization of financial support and of professional help should be enforced. DISCUSSION: Being an indicator of nursing quality, shortfalls of prevention measures should be combatted by a broad pattern of quality management strategies which could be adapted from the clinical sector.

Adult↗

Pressure sores: epidemiology, medico-legal implications and forensic argumentation concerning causality.

The aim of the present investigation was to identify the frequency and grading of pressure sores in a large series of unselected consecutive deceased subjects before cremation and to discuss aspects of the forensic argumentation concerning causality. A total of 10,222 corpses were examined prospectively over a 1-year-period (1998) for the occurrence, localization and grading of pressure sores. Epidemiological aspects (e.g. age, sex, underlying and contributing causes of death, place of death etc.) were taken from the death certificate. The mean prevalence of pressure sores was 11.2% (87.1% isolated sores; predominant localization of advanced grades on the sacrum in 69.6%). There was a positive correlation between the prevalence of sores and advanced age resulting in a clear female predominance in the age group of 80 years and over because of differences in life expectancy. A significant correlation was found between the prevalence of pressure sores and certain underlying diseases, e.g. trauma, senile dementia, neurological diseases, apoplexy and marasmus. Pressure sores of all grades were more frequently found in the deceased when a senior citizen's or nursing home was given on the death certificate as the domicile in the last period of life. The forensic argumentation for the causal relationship of a pressure sore as the focus of fatal infectious complications or septicemia has to be based on the results of clinical expertises and forensic investigations (evaluation of the institutional documentation of the patient's course, autopsy findings, histology, immunohistochemistry). The vast majority of physicians seem to pay only little attention to the potentially fatal outcome of pressure sores and fatalities associated with this condition are clearly underreported. From the point of view of social medicine, the prevalence of pressure sores in a defined population can be seen as a parameter for the quality of nursing and medical care. In bringing these fatalities to light, the field of legal medicine contributes to a general quality control of standards of nursing and medical care.

Age Factors↗