Page 1

The Hansa City Bergen hosts the 17th Nordic Conference on Forensic Medicine, June 17-20, 2009.

CONTENTS Page Editorial:

Management of ”unnatural deaths” Dear colleagues

3 4

Proposal for an International Classification of SUDI


The Soria Moria meeting, October 7-10, 2009


17th Nordic Conference on Forensic Medicine - 17-20 june 2009

Programme Abstracts: Oral presentations Clinical Forensic Medicine Forensic Genetics Forensic Odontology Human Rights Education Forensic Pathology Forensic Anthropology

10 12 12 13 14 15 16 17 26

Poster presentations 28


Dansk Selskab for Retsmedicin Norsk Rettsmedisinsk Forening Svensk Rättsmedicinsk Förening VolumE 15 - No. 1 - 2009 - page 1 - 40

Nordisk rettsmedisin


Scandinavian Journal of

Scandinavian Journal of Forensic Science Official journal of the Danish, the Norwegian and the Swedish societies for forensic medicine. The journal will publish original articles, review articles, preliminary communications, letters to the editor and case reports in the different disciplines of forensic sciences: forensic pathology, clinical forensic medicine, forensic genetics, forensic toxicology, forensic anthropology, forensic odontology, forensic psychiatry and forensic science. Submission of articles Manuscripts prepared in accordance with Guide for authors should be sent to the editor-in-chief or to one of the national editors. Editor in chief:

Torleiv Ole Rognum, Oslo

Editorial secretary: Editorial address:

Anne Gunn Winge Rettsmedisinsk institutt, Rikshospitalet, N-0027 Oslo, Norway

National editor, Denmark: Jørgen Lange Thomsen, Odense

National editor, Norway:

Torleiv Ole Rognum, Oslo

National editor, Sweden:

Håkan Sandler, Uppsala

Accountant: Address: Account:

Sigrid I Kvaal Vallegaten 17 A, N-0454 Oslo 7874.06.45012

Clinical forensic medicine:

Markil Gregersen, Århus Kari Ormstad, Oslo Annie Vesterby, Århus

Forensic anthropology:

Per Holck, Oslo

Forensic genetics:

Marie Allen, Uppsala Bertil Lindblom, Linköping Niels Morling, Copenhagen Bjørnar Olaisen, Lovund Antti Sajantilla, Helsinki

Forensic odontology:

Sigrid I Kvaal, Oslo Sven Richter, Reykjavik

Forensic pathology:

Thomas Bajanowski, Münster Roger W Byard, Adelaide Anders Eriksson, Umeå Gunnlaugur Geirsson, Reykjavik Jorma Hirvonen, Oulu Hans Petter Hougen, Copenhagen Pekka Karhunen, Tampereen Inge Morild, Bergen Lennart Rammer, Lindköping Pekka Saukko, Turku Jørn Simonsen, Copenhagen Michael Thali, Bern Ingemar Thiblin, Uppsala

Forensic psychiatry:

Peter Kramp, Copenhagen Randi Rosenqvist, Oslo

Forensic science:

Bjarni Bogason, Reykjavik Frank Jensen, Vanløse Reidar Nilsen, Oslo

Forensic toxicology:

Johan Ahlner, Linköping Jørg Mørland, Oslo

Editorial board

Lay out: Holstad Grafisk, Oslo - Print: prografia, Oslo - ISSN 1503-9552

Dear colleagues,


ergen is the host city of the 17th Nordic Conference on Forensic Medicine in June. The people of Bergen are proud of their historical background and determined to learn from it. Bergen has a long tradition as a congress city. Ever since its foundation in 1070, Bergen has attracted people from all quarters of the world. The first major assembly took place in 1163 when Magnus Erlingsson was crowned King of Scandinavia. Naturally, Bergen has been playing host ever since, not from a sense of duty but because of the city’s genuinely hospitable nature. It is a very great pleasure for us to show you the city, which we hope will be at its best in June, and we are very happy that so many has registered for the conference. It has been a great pleasure to read all the abstracts, and it is impossible to avoid being impressed by all the knowledge, skill and creativity that exist in the extended Nordic forensic family. Many of the presented abstracts have a very high quality. Although the scientific part of the conference is important, we also have the intention, that the conference will be a meeting place where scientists from similar, but also different fields, can get to know each other and get personal contact. This will promote co-work on different projects, but also make it easier to take personal contact when faced with a practical problem. Personally, I have several times contacted Nordic colleagues and asked for their valuable opinion and help in special cases. Photos from special cases have been forwarded by e-mail, and I have always received a rapid answer. It is therefore the hope of the organizing committee, that also the social part of the meeting shall be fruitful. We are very flattered that so many scientists from other than Nordic countries have registered and we hope that this contact can be permanent, as international contact is necessary in a country like ours with so few forensic scientists. When you arrive in Bergen, we hope you will take active part, both in the scientific and in the social programme. The conference hotel is in the very centre of the city, so take a walk around in the city after the working hours and enjoy the harbour, the fish market and the mountains. The evenings will be light until late. In June, the weather, which is one of Bergen’s trade marks, usually is fairly good, but a good advice is to bring along a small umbrella, just to be sure.

Welcome to Bergen! Inge Morild

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Management of ”unnatural deaths” A matter of legal protection of adults – a health problem in infants and small children?

According to Norwegian legislation, 10 % of all deaths are categorised as “unnatural” There are nine categories of unnatural deaths: 1) Homicide 2) Suicide 3) Accident 4) Industrial accident 5) Medical malpractice 6) Drug-related deaths 7) Sudden, unexpected death from unknown cause 8) Death in custody 9) Dead body with unknown identity Accordingly, as a matter of definition, all sudden unexpected deaths in infants and small children are unnatural (7) In cases of unnatural deaths physicians are obliged to notify the police immediately. According to the regulations (Påtaleinstruksen) forensic autopsy is mandatory in homicide and in cases of unidentified corpses. In the remaining categories forensic autopsy should as a main rule be requested. When a physician is confronted with a case of unnatural death, he or she will report to the police immediately. In most cases the police will conduct a preliminary investigation and subsequently decide whether autopsy should be requested or not. Thus, these deaths are handled by the health system and the legal system. What happened to sudden deaths in infants and small children? During the SIDS epidemic in the 1980’es which in 1989 peaked when more than 2.5 ‰ of all liveborn infants died from SIDS, the police withdrew from the death scene in Norway. There had been some unfortunate episodes where uniformed police had made interrogation in an unnecessarily rude and insensitive way – resulting in a written statement (Decision in criminal case) three months later informing the parents that the case had been closed since no crime had been found. A storm of protests resulted in the withdrawal of the police from the death scene. However, nobody replaced the police. In most cases, no death scene investigation was performed at all. Luckily the SIDS epidemic came to an end in 1990. The SIDS rate has been reduced from 2.5 deaths to 0.3 deaths per 1000 live births. However, other causes of sudden infant death have not decreased similarly. During the 1980’es the sudden infant death (SUDI) population was dominated by SIDS (80 %), whereas all other causes combined only represented 20 %. This picture has changed dramatically. In average only 40 % of the SUDI are now due to SIDS, 30 % to acute illness, 10 % is due to home accidents, whereas the remaining 20 % consist of neglect, abuse and homicide. This situation requires a new approach. The legal system has to take back responsibility in the cases of sudden death in infants and small children. Therefore a research project was launched in the period 2001-2004. Venues of SUDI in Southeast Norway were visited by a police expert, employed by the project, and the forensic pathologist in charge of the autopsy. During the project period neglect was disclosed in 11 % of the cases. In the years before and after the project such cases were very seldom encountered, probably because the death scene was not examined. Furthermore, during the project suspicion raised by the police in 32 % of the cases was called off immediately after the death scene visit by the experts. These days the Norwegian Parliament unanimously wants to establish a mandatory death scene investigation by experts on request by the police in all SUDI cases. This is no radical approach since it is a duty of the police to investigate all cases of unnatural deaths – be it an octogenarian, a young adult or an infant. In spite of the view of the politicians from all parties in the Parliament, the Norwegian Government has decided to treat unnatural deaths in infants and small children as a health problem, not a legal one. As a result of this decision the health


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service will from July 1st, 2009 be responsible for death scene investigation in sudden unexpected deaths in the youngest citizens, whereas the police will remain responsible in cases involving all other subjects. The Norwegian Constitution and The European Convention on Human Rights have been invoked as an argument for the governmental decision. According to the Norwegian Constitution, house investigation can only be performed in criminal cases (§ 102). Consequently, when death scene investigation is delegated to the health service, it has to be voluntary! Actually, if the legal system – like in youngsters and adults – should be responsible for the infant death scene investigation, this would not collide with the Constitution. It is the assignment of the police to prove or disapprove crimes. When the police visits a death scene, making some investigations e.g. with the help of experts as they often do in cases of unnatural death, this does not mean that they conduct a formal search, which would need a court ruling. Whether death scene investigation in cases of sudden unexpected death in infants and small children should be regarded as a voluntary health service or a mandatory legal task, will be discussed in the Norwegian Parliament on June 15th. For the sake of the babies and small children and their families we hope that the parliamentarians will be able to convince the Government that a wrong decision has been made by excluding the youngest and the most vulnerable citizens, totally dependent on their parents or caregivers, from the same legal protection as granted the rest of us. TOR

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Proposal for an International Classification of SUDI Blair PS, Byard RW, Fleming PJ

Introduction SUDI (sudden unexpected death in infancy), sometimes described as SUD or SUID, is a term used for all unexpected infant deaths, whether the explanation is immediate, determinable after a thorough investigation or remains unknown. Traditionally all unexplained SUDI deaths have been labelled as sudden infant death syndrome (SIDS), but since the mid-1990s a number of forensic pathologists are becoming increasingly reluctant to use this diagnosis as a cause of death when certain risk factors are present (co-sleeping, prone positioning, issues surrounding appropriate parental care, minor pathological changes etc.) preferring to use the term ‘unascertained’ in the United Kingdom1, ‘borderline SIDS’ in Scandanavia2, ‘undetermined’ in Australia or cause ‘undetermined’, ‘unspecified’ or ‘unknown’ in the United States3. However, the use of these terms does not properly address the concerns of the pathologist, may unfairly stigmatise parents4, and results in an underestimation of current SIDS rates1. Since 2004 the Office for National Statistics (ONS) in England & Wales has agreed to include both SIDS and ‘unascertained’ deaths in any analysis of “unexplained infant deaths”5 whilst ‘borderline SIDS’ is also classified as SIDS in Scandinavia. The aim of this proposal is to devise a classification system for SUDI for research purposes that maintains the integrity of the SIDS definition but incorporates the gradation of contributory factors associated with some unexplained deaths. This is not an exercise in redefining SIDS, nor is it an attempt to restructure and reclassify SUDI. The rationale is to try to formalise what is already done when a suspected SIDS case needs to be categorised for research purposes; in effect to devise an international classification system that achieves consensus amongst SIDS researchers.

CORRESPONDING ADDRESS: Dr Peter S Blair, Senior Research Fellow, Department of Community Based Medicine, University of Bristol, Level D, St Michael’s Hospital, Southwell St, Bristol, BS2 8EG. Phone: 0117 9285145 or email:


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Initially our intention was to circulate this paper in draft form to a wide range of international researchers and participants in the field in an attempt to formulate a consensus statement. Unfortunately, given the diversity of subsequent opinions and the difficulties in incorporating a range of often important observations and opinions into a single document it was decided to make the original paper (with minor modifications) available in the literature, as a focus for a more structured and formal discussion at a future face-to-face meeting. This will enable all important observations and comments to then be considered. Thus this paper represents a starting point for the development of a SUDI classification system and not the definitive statement. Definition of SUDI SUDI does not have a formal definition, nor an ICD code, but is an umbrella term for all sudden unexpected deaths in infancy. Sometimes the ICD codes R98 or R99 are allotted for SUDI cases described as death due to an unknown cause. As indicated by the use of the terms ‘sudden’ and ‘unexpected’, many infants have been either well or suffering from only an apparently minor illness before death occurred. The definition developed in Avon, UK, and subsequently incorporated into the Statutory Guidance to the Children Act 2004 in the UK[4} may be of help in clarifying what is “unexpected”. This defines an unexpected infant or child death as one for which the carers (family or medi-

cal) did not anticipate that death was a significant possibility 24 hours before the death occurred, or (where there was a major collapse followed by resuscitation and survival for more than 24 hours) the sudden collapse was similarly not anticipated.4,6,7,9. SUDI includes the deaths of infants where a medical cause has been established, as well as deaths that remain unexplained (SIDS). The explained deaths can be broken down further into five broad subgroups (Table 1). The majority of SUDI deaths are registered as SIDS (around 80%)8,9 although more recent data suggests that the proportion of unexplained SUDI deaths has now fallen to around 60%.10,11 Direct comparison of the explained and unexplained deaths has shown marked socio-economic deprivation in both groups although the characteristic age distribution of SIDS, the higher prevalence of parental smoking and factors within the infant sleeping environment are significantly more common amongst the unexplained deaths.12,13 A conceptual framework Some deaths remain completely unexplained after a detailed enquiry and post mortem examination and these are labelled SIDS (white circle), some deaths turn out to be fully explained (black circle) whilst for the majority of cases the investigation identifies certain notable factors, some of which may be contributory to the death but are insufficient in themselves to sanction a full explanation (grey circles) (Figure 1). This has been termed a gradi-

Table 1 – Categories of Sudden Unexpected Deaths in Infancy SUDI


Explained Rapid infection Deaths Rapid onset of acute medical condition Unrecognised pre-existing medical condition Accidental death Non-Accidental death Unexplained SIDS/unascertained/ Deaths borderline/unknown/ undetermined/unspecified

Examples (e.g. meningitis, septicaemia, myocarditis, bronchopneumonia, gastro-enteritis etc) (e.g. anaphylaxis, acute neurological condition etc) (e.g. unrecognised congenital abnormality, metabolic disorder, long QT syndrome etc.) (e.g. road traffic accident, choking, drowning, over-laying, entrapment etc) (e.g. suffocation, abusive head trauma, infanticide etc)

Figure 1 – Conceptual Framework of SUDI

ess , in which the various professionals involved have the opportunity to review all available information as part of the process of investigation after unexpected infant deaths4,6,7,9. Incomplete investigations

Figure 2 – Conceptual Framework of SUDI (Avon)

Ia = No notable factors identified Ib = Notable factors identified but not likely to have contributed to the death IIa = Factor(s) identified that possibly contributed to the death IIb = Factor(s) identified that probably contributed to the death III = Factor(s) identified that provide a cause of death

ent of certainty in determining a cause of death.14 A proposed framework for classification of SUDI The starting point for the classification of SUDI is based on the Avon clinico-pathological system9,12 already being used in the UK but will incorporate some ideas from the work conducted by Krous et al in San Diego15 regarding incomplete investigations. The Avon system simply grades unexplained SUDI deaths from those deaths that are completely inexplicable (Ia) to those where a complete explanation has been found (III), according to the degree in which contributory factors are identified and thought to have played a part in causing death (Figure 2). A grade from Ia to III is therefore given based on i) the medical, social and family history ii) the death scene investigation and iii) the postmortem findings with a further category (including evidence of neglect or abuse) for anything not covered by the basic components of the SUDI investigation. The overall classification is equal to the highest score within the grid (see Appendix). The degree to which contributory factors play a part are flagged using this system but the death remains classified as SIDS unless a complete and sufficient cause has been found. The majority of deaths currently registered as ‘unascertained’ would most likely be given the

classification SIDS IIb in this system. In using this framework, we acknowledge that the term SIDS implies that the death is not explained within the limits of current knowledge and the investigations that have been applied. The cohort of SIDS cases is likely to include a range of underlying causes and contributory factors and as diagnostic and investigatory techniques improve, it is likely that more explained SUDI cases will be identified. A major component of this proposed classification system is to emphasise the importance of a multiagency review proc-

The expert panel that met in San Diego in 2004 recognised the difficulty posed by incomplete investigations and how this may impact on classification systems15, in particular how to distinguish between a death in which a component of the investigation was not conducted and an incomplete investigation where a minor or major piece of information is missing. Since SIDS is essentially a diagnosis of exclusion the term should not be used if any of the three essential components (the family history, death scene investigation and post-mortem) was not conducted. In terms of our proposed classification system this means that we need to add a classification ‘zero’ which recognises such deaths as a SUDI but also recognises that a major piece of information is missing and that no decision can be made as to whether the death was explained or unexplained. To some extent all SIDS investigations are incomplete, being influenced by parental recall, the cost of post-mortem investigations, and the fact that the deaths are almost always unobserved. Part of our remit therefore is to decide the extent to which missing information would render a SIDS diagnosis untenable and when a diagnosis can be made, but missing information flagged and perhaps included within the classification system itself (Figure 3). It is thus proposed that the zero classification is used in two ways: as a ‘0’ classification to identify when an investigation is seriously incomplete (labelling the case

Figure 3 – Conceptual Framework of SUDI (International)

0 /0 Ia Ib IIa IIb III

= Incomplete investigation (classified SUDI) = Extension used to denote that a potentially important piece of information is missing = No notable factors identified (classified SIDS) = Notable factors identified but not likely to have contributed to the death (classified SIDS) = Factor(s) identified that possibly contributed to the death (classified SIDS) = Factor(s) identified that probably contributed to the death (classified SIDS) = Factor(s) identified that provide a cause of death (classified explained SUDI) Scand J of FORENSIC SCIENCE - No 1 - 2009 - Page 1-40


as a SUDI) and as a ‘/0’ extension to allow a SIDS classification but flagging up that a potentially important piece of information is missing. Inclusion criteria An international classification system needs to be as inclusive and as simple as possible. It is proposed that deaths in the age range from birth to 2 years be included and the single criterion for inclusion being that the death was sudden and unexpected. It is recognised that some centres may wish to exclude certain deaths (e.g. road traffic accidents) or narrow the age limit (e.g.1 week to 1 year); however, in setting such wide inclusion criteria it is possible for different centres to make exclusions as they see fit. Selecting the appropriate classification Although it is important to agree to a framework within which to classify SUDI, it is much more difficult to achieve consensus on which classification should be used for individual cases. The importance we, as SIDS researchers, place on our multivariate analyses suggests that events rarely happen alone, but in combination with other factors. Risk factors themselves are subject to different levels of intensity, and thus different gradation, depending on circumstances. Risk factors and their significance change over time and our lack of complete knowledge understandably leads to differences in opinion. There are a small number of established risk factors that could certainly be described as notable (prone sleeping, co-sleeping, head-covering, over-wrapping, inappropriate sleeping environment, vulnerability at birth, exposure to tobacco smoke and parental use of alcohol and illegal drugs) but whether these were contributory in a specific case would depend on the specific circumstances of the death. For instance a 9-month-old infant routinely placed prone may be at less risk than a two-month-old infant placed prone for the first time. Similarly a co-sleeping infant with a nonsmoking mother may be at less risk than one with a mother who smokes or who has recently drunk a large quantity of alcohol. The importance of these features must be taken into account in conjunction with the recent history of the infant and family, the death scene investigation and the post-mortem results. To some extent the categories are self-explanatory and we cannot perhaps be too prescriptive because of the individual circumstances of each case. It should also be noted that any template for a written classification should include space to describe notable factors pertain-


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ing to the case that have helped assign it to a category in free text. It is proposed that we should try to achieve consensus on the framework of classification, based on this proposal, and leave any discussion of specific examples to a time when the classification has been agreed upon and adopted. Conclusion It is recognised that such a classification system may have little impact on whether infants are registered as SIDS, ‘borderline SIDS’, ‘undetermined’ or ‘unascertained’ in different countries. The degree to which a SUDI death is investigated and the constraints of time have always made it difficult to achieve a reliable diagnosis.16 However, as experts in the field, we should at least attempt to reach consensus on a simple framework that recognises the grey areas and our own shortcomings when investigating these deaths. By using a standard classification system we can more easily promote the minimal requirements needed for taking a clinical history, conducting a death scene investigation and carrying out the post mortem examination. As SIDS researchers engaged in identifying different causes of this syndrome it is perhaps more important than ever to formalise our thought processes and to create boundaries so that we can allocate the remaining deaths to the appropriate SUDI category. Acknowledgements: We would like to sincerely thank all of our colleagues who provided feedback on our original draft paper. In going ahead with the paper as it is we would hope that it will provide an impetus for further excellent and measured contributions to help bring about a workable classification system for SUDI. In particlar those present at the Paediatric Forensic Medicine and Pathology conference in Oslo 2008 and members of the International Society for the study and Prevention of perinatal and Infant Death (ISPID) References 1



Limerick SR, Bacon CJ. Terminology used by pathologists in reporting on sudden infant deaths. J Clin Pathol 2004; 57:309311. Gregersen M, , Rajs J, Laursen H et al. Pathologic criteria for the Nordic Study of SIDS, in: T.O. Rognum (Ed.), Sudden Infant Death Syndrome. New Trends in the Nineties. Scandinavian University Press, Oslo 1995, 50-58. Shapiro-Mendoza CK, Tomashek KM, Anderson RN, Wingo J. Recent national trends in sudden, unexpected infant deaths: More evidence supporting a

change in classification or reporting. Am J Epidemiol 2006;163:762-769. 4 Sudden Unexpected Death In Infancy. The report of a working group convened by the Royal College of Pathologists and the Royal College of Paediatrics and Child Health 2004 or 5 Corbin T. Investigation into sudden infant deaths and unascertained infant death in England and Wales, 1995-2003. Health Statistics Quarterly 27, Autumn 2005:1723. 6. Working together to Safeguard Children. A guide to Interagency working. UK Government. 2006 www.everychildmatters. 7. Fleming P.J.,.Blair P, Sidebotham P.,.Hayler T. Investigating sudden unexpected deaths in infancy and childhood and caring for bereaved families : an integrated multiagency approach. BMJ. 2004; 328:331-334 8 Cote A, Russo P, Michaud J. Sudden unexpected deaths in infancy, what are the causes? J Pediatr 1999;135:437-443. 9 Fleming PJ, Blair PS, Bacon C & Berry J (Eds). Sudden Unexpected Death in Infancy. The CESDI SUDI studies. The Stationery Office, London 2000. 10 Rognum TO, Byard R. Sudden infant death syndrome, etiology and epidemiology. In: Payne-James J, Byard RW, Corry TS, Henderson C. Encyclopedia of Forensic and Legal Medicine. Elsevier, London 2005, 4, 117-129. 11 Blair PS, Sidebotham P, Berry PJ, Evans M Fleming PJ. Major changes in the epidemiology of Sudden Infant Death Syndrome: a 20 year population based study of all unexpected deaths in infancy. Lancet 2006;367(9507):314-9. 12 Leach CEA, Blair PS, Fleming PJ, Smith IJ, Ward Platt M, Berry PJ, Golding J. Epidemiology of SIDS and explained sudden infant deaths. CESDI SUDI research group. Pediatrics 1999;104(4).e43 URL: 13 Vennemann MMT, Bajanowski T, Butterfab-Bahloul T et al. Do risk factors differ between explained sudden unexpected death in infancy (SUDI) and SIDS. Arch Dis Child 2006; epub ahead of print 14 Byard RW, Jensen L. Is SIDS still a ‘diagnosis’ in search of a disease? Aust J Forensic Sci 2008;40:85-92. 15 Krous HF, Beckwith JB, Byard RW, Rognum TO, Bajanowski T, Corey T, Cutz E, Hanzlick R, Keens T, Mitchell E. Sudden infant death syndrome (SIDS) and unclassified sudden infant deaths (USID): a definitional and diagnostic approach. Pediatrics 2004;114:234-238. 16 Byard RW. Inaccurate classification of infant deaths in Australia: a persistent and pervasive problem. Med J Aust 2001;175:57.

Appendix: Grid System for SUDI Classification Classification





Contributory Information Information ‘Factor present, Factor present, or potentially not collected collected, but not likely and may have causal factors’ but no factors to have contributed to identified contributed to ill health or ill health or to possibly to death death



Factor present, and certainly contributed to ill health and probably contributed to death

Factor present, and provides a complete and sufficient cause of death


(note 1) Death scene examination (note 2) Pathology (note 3) Other (specify) Other evidence or neglect or abuse? Overall classification (note 4)

Notes (1) To include a detailed history of events leading up to the death, together with medical, social and family history, plus an explicit review of any evidence suggesting past neglect or abuse of this child or other children in the family. (2) Results of a detailed review of the scene of death by the Paediatrician and police in the light of the history given by the parents or carers. (3) Pathological investigations to a standardized protocol, including gross pathology, histology, microbiology, toxicology, radiology, clinical chemistry and any relevant metabolic investigations, including frozen section of liver stained for fat. (4) This will generally equal the highest individual classification listed above.

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1 7 t h No r d i c Co n f e r e n c e o n Fo r e n s


Wednesday 17th June

1700 – 1900 1800 – 2000

Registration, Radisson SAS Hotel Norge Get together party, Maartmannshaven, Radisson SAS Hotel Norge

Thursday 18th June


0800 – 0930 0930 – 0950

Registration Opening of conference

0950 – 1030 1030 – 1045

Clinical forensic medicine Acute forensic-medical examination (FME). A state of the art nordic and international overview. Ormstad K. Medical findings in sexually abused children in cases with a conviction. Vesterby A, Hansen LA, Sabroe S.

1045 – 1100 1100 – 1115

Forensic genetics Interleukin polymorphism and sudden infant death syndrome. Ferrante L, Opdal SH, Vege Å, Rognum TO. Is there a genetic predispostion for brain edema in sids? Opdal SH, Rognum TO.

1115 – 1145

Coffee and posters

1145 – 1200 1200 – 1215 1215 – 1230

Forensic odontology An unusual and mysterious criminal case in Iceland. Richter S. Legal aspects of age assessment. Ranta H, Salo S, Varkkola O. The Tsunami in Thailand. A review of the operation and especially the dental reports on the Norwegian victims. Solheim T.

1230 – 1245 1245 – 1300 1300 – 1315

Human rights Forensic evidence as torture prevention. A forensic and juridical approach in five target countries in five continents. Hougen HP, Hansen SH, Özkalipci Ö. Forensic medicine at ICC (International Crime Court). Jääskeläinen AJ, Rinne A, Saksela E, Scheinin M, Pirjopäivi P. A forensic fact finding mission to Gaza. Thomsen JL.

1315 – 1415


1415 – 1430 1430 – 1445

Education New approach to the certification of death. Jääskeläinen AJ, Rinne A, Saksela E. The necessity of a strategic approach - Forensic medicine as a specialty in Denmark. Hougen HP, Leth P and Banner J.

1445 – 1450 1450 – 1455 1455 – 1500 1500 – 1505 1505 – 1510 1510 – 1515 1515 – 1520 1520 – 1525 1525 – 1530

Short poster presentations Genital injury in rape – what do we know? Astrup BS. Examination of sexually abused children. Presentation of the first Danish centre for the investigation and care of abused children. Vesterby A, Nødgaard H, Laursen B. Y chromosome polymorphisms and ethnic group: A combined STR and SNP approach. Cortellini V, Ravani M, Verzeletti A, Cerri N, Marino A, Garofano L, De Ferrari F. Rape in genocide. Astrup BS. Treatment with naloxone can be a deadly false sense of security. Frost L, Kristensen IB and Hansen C. Demographical, toxicological and serological characterization of drug-related death cases in Budapest, Hungary between 1994-2008. Horvath M, Fuzi A, Keller E. Systematic examinations of ethanol and narcotics in biological fluids. Thelander G, Giebe W. Three cases of 3-methylfentanyl poisonings in babies. Tõnisson M, Riikoja A. Lethal methemoglobinemia and automobile exhaust inhalation (case report). Vevelstad M, Morild I.

1530 – 1600

Coffee and posters

1600 – 1605 1605 – 1610 1610 – 1615 1615 – 1620 1620 – 1625 1625 – 1630

Sudden unexpected death due to unknown mitral valve prolapse. Andersen AM, Larsen MK, Kristensen IB. World War II prisoner of war. Güvencel A. Accidental hypothermia – how is it with the brain? Findings in an experimental pig model. Hammersborg SM, Husby P, Morild I, Lilleng PK. Excited delirium and acute psychosis: Four cases of sudden death during physical restraint. Kristensen ME, Schumacher B, Banner J. Sudden death – a retrospective genetic study of heart disease. Larsen MK, Kristensen IB, Jensen HK, Banner J. Comparison of injuries from the pistols Tokarev, Makarov and Glock 19 at firing distances of 1, 3 and 5 cm. Lepik D, Vassiljev V, Gerst-Talas U.

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Fo r e n s i c M e d i c i n e - 1 7 - 2 0 j u n e 2 0 0 9

G RA M M E 1630 – 1635 1635 – 1640 1640 – 1645 1645 – 1650 1650 – 1655 1655 – 1700

Acute coronary thrombosis associated with cocaine intoxication: A case report. Manzoni S, Poglio A, Vassalini M. Computed tomography scanning before autopsy - identification and documentation. Schumacher B, Warner Thorup Boel L, Uhrenholt L Blunt skull-brain injury of uncertain cause. Tuusov J, Vaas T, Vassiljev V. Abdominal injury among fatal road traffic crash victims. Uhrenholt L, Gaborit F, Møller Andersen L. Post-mortem injuries by a dog: A case report. Verzeletti A, Cortellini V, Vassalini M, De Ferrari F. An international database for time of death determination. Dalberg P, Opdal SH, Musse AM, Larsen AC, Stray-Pedersen AC, Saugstad OD, Rognum TO.

1900 – 2030

Reception by The Municipality of Bergen Schøtstuene, Bryggen

Friday 19th June

0900 – 0945 0945 – 1000 1000 – 1015 1015 – 1030 1030 – 1045

Forensic Pathology Terrorism and forensic science. Crane J. A comparative study of cranial, blunt trauma fractures as seen at medicolegal autopsy and by computed tomography. Jacobsen C, Bech BH, Lynnerup N. Cranial fractures caused by blunt trauma to the skull. A retrospective analysis of medico-legal autopsies in Denmark from 1999-2004. Jacobsen C, Lynnerup N. Modelling cranial fractures. Lynnerup N, Engkjaer Christensen J, Jacobsen C, Jørkov ML, Ravn Thomsen H, Sölvadottír AE. The patterns of axonal injury. Van Driessche PMI, Kubat B.

1045 – 1115

Coffee and posters

1115 – 1130 1130 – 1145 1145 – 1200 1200 – 1215 1215 – 1230 1230 – 1245 1245 – 1300

Asphyxial homicides in three scandinavian cities. Hougen HP, Lilleng PK, Rogde S. Acute pulmonary emphysema in strangulation deaths. Klysner AH, Hougen HP, Lynnerup N. Abbreviated injury scale scoring in traffic fatalities: Comparison of computerized tomography and autopsy. Leth PM, Ibsen M. Postmortem diagnostic imaging findings of injuries to the cervical spine facet joints following fatal road traffic trauma. Uhrenholt L, Nielsen E, Vesterby A, Hauge EM, Gregersen M. Evaluation of passenger child safety in real world car crashes. Stray-Pedersen A, Boye Hansen T, Rognum TO, Lereim I, Næss PA. Biomechanical evaluation of shaken baby syndrome. Stray-Pedersen A, Strisland F, Blechingberg A, Weensvangen M, Holck P, Vege Å, Rognum TO. Vitreous humor hypoxanthine levels for time of death determination. Rognum TO, Opdal SH, Musse MA, Stray-Pedersen A, Larsen AC, Dahlberg P, Saugstad OD.

1300 – 1400


1400 – 1415 1415 – 1430 1430 – 1445 1445 – 1500 1500 – 1515 1515 – 1530 1530 – 1545 1545 – 1600

Malpractice and the heart. Türk EE. Medico legal autopsies in Denmark: A retrospective study. Tangmose Larsen S, Lynnerup N. Homicide by stabbing in Southern Denmark. Leth PM. Autopsy findings in cases with lethal outcome following use of police electro-shock weapons. Rogde S, Welsh J. Does Ljungan virus cause malformation, intrauterine fetal death and sudden infant death syndrome. Niklasson B, Samsioe A, Almqvist P, Papadogiannakis N, Klitz. Forensic molecular pathology; A new challenge in forensic medicine Rohde MC, Larsen MK, Banner J. Mors senilis - old, new diagnosis. Rinne A, Martikainen J, Schwesinger G, Jääskeläinen A. Presentation on FDI Singapore 2009. Penghui T.

1900 – 0100

Banquet at Mount Floien

Saturday 20th June

0930 – 0945 0945 – 1000 1000 – 1015 1015 – 1030

Forensic Anthropology Stature estimation using palm length in Indian population. Rastogi P, Yoganarasimha K. Forensic age estimation of living adolescents and young adults. Schmeling A, Olze A, Schulz R, Schmidt S. Exact determination of year-of-birth using the human eye lens. Lynnerup N, Kjeldsen H, Heegaard S, Jacobsen C, Heinemeier J. Use of photogrammetry and biomechanical gait analysis to identify individuals. Larsen PK, Lynnerup N, Hansen L, Simonsen EB, Alkjaer T, Henriksen M, Holst KK, Nielsen SF, Petersen HP, Scheike TH.

Closing of conference

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Institute of Forensic medicine, University of Oslo, Norway

Facilities established to assist victims of sexual assault should ideally cater to clinical diagnostic/therapeutic, psychosocial as well as forensic needs. The structure and organisation of these specialised outpatient clinics depend on whether they are open to all help-seeking subjects or primarily perform examinations requested by the police after a formal complaint has been filed. All aspects of the service should preferably be taken care of during one visit. To facilitate victims’ attendance as early as possible, and to secure reliable evidence in case of police investigation and court proceedings, the service should be made publicly known, easily acessible 24/7 and run by competent staff. Appropriate routines should be implemented to minimise examination-related discomfort/trauma and to secure optimal documentation of physical findings and samples for analysis. Furthermore, resources should be spent where most useful. The following issues should be considered concerning FME: - Limitation of accepted interval from assault to visit - Limitation of accepted interval from assault to trace evidence collection - Impact of victim’s decision regarding police involvement - Routines for physical examination (i.a. colposcopy) - Routines for documentation of examination and sampling (rape kit, standardised patient record, photo, video) - Routines for sampling, labelling and storage of trace evidence (rape kit, chain of custody, storage facilities) - Victims’ right to be informed about results of examination and analyses also when refusing police involvement Decisions on policy and procedures should be scientifically based and when feasible, properly adjusted according to new knowledge. Routines vary among cities and countries, partly because of different organisational and fiscal factors, partly because of more or less well-founded tradition. An international evidence-based consensus should be established, to achieve optimal medicolegal service for sexual assault victims irrespective of gender and nationality. The importance of appropriate funding and continuous education to ensure high-level professionality in involved staff should be emphasized. The human rights, legal rights and sociomedical welfare of victims are primarily at stake, but any unjustly suspected perpetrator may also benefit from professionally conducted forensic medical casework. MEDICAL FINDINGS IN SEXUALLY ABUSED CHILDREN IN CASES WITH A CONVICTION Vesterby A (1), Hansen LA (1), Sabroe S (2) Department of Forensic Medicine, Aarhus University, Brendstrupgaardsvej 100, 8200 Aarhus N, Denmark ) Department of Public Health, Section for Epidemiology, Aarhus University, Vennelyst Boulevard 6, 8000 Aarhus C, Denmark

(1) (2

The Department of Forensic Medicine, Faculty of Health Sciences, Aarhus University, Jutland, Denmark, performs medical examination including colposcopy of the anogenital area in children suspected of having been sexually abused only at the request of the police. During a 6-year period (1996-2002), 482 children were examined giving an incidence of 1.48/10,000 children from birth to 16 years of age in Jutland, Denmark. This study includes the cases in which the perpetrators were convicted in court because of substantial evidence of sexual abuse of the child. Results One hundred sixty-five perpetrators were convicted involving 149 girls and 16 boys with a median age of 11 years and 14 years, respectively. Penetration (oral, vaginal, anal or a combination) was reported for 124 children; 54 children had normal findings, 38 non-specific and 12 abnormal findings (one was unknown). Eight girls had a complete hymenal transection. Seventy perpetrators confessed to having abused the child. Abnormal anogenital findings were not related to the conviction, the age of the child, however, was. Conclusion The child’s statement, not physical findings, seems to be the single most important feature in cases of sexual abuse.


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Institute of Forensic Medicine, University of Oslo, Norway

Previous studies of Sudden infant death syndrome (SIDS) have demonstrated elevated immune activity both in tracheal wall, salivary glands, tonsils, intestinal mucosa and larynx, as well as elevated levels of IL-6 in the cerebrospinal fluid. High CSF IL-6 levels were moreover associated with increased number of IgA-cells and increased HLADR expression in laryngeal mucosa. Altogether, these studies indicate that a significant proportion of SIDS victims have an activated immune system. This immune activation could be the result of an unfavourable combination of functional polymorphisms in genes encoding components in the immune response, and the most important might be the interleukin genes. In this study we have investigated several single nucleus polymorphisms in different interleukin genes, including IL1α+4845G/T, IL1 β-511C/T, IL6-572G/C, IL8-781C/T, IL8-251A/T, IL12+1188A/C, IL13+4464A/G, IL16-295T/C, IL18-137G/C and IFNγ+874A/T. The subjects investigated consisted of 148 SIDS cases, 56 borderline SIDS cases, 41 cases of infectious death and 131 controls. No differences were found in genotype distribution between any of the groups investigated. However, in the SIDS group the genotypes IL1α-511CC/CT, IL8 -251AA/AT and IL8 -781CT/TT were significantly more frequent in the SIDS cases found dead in a prone sleeping position, compared to infants found dead in other sleeping positions (p=0.004, p=0.006 and p=0.006, respectively). In addition, cases of infectious death there was an association between fever prior to death and the gentotype IL13+4464GG (p=0.007). In conclusion, this study indicates that specific interleukin genotypes in combination with certain risk factors may be involved in SIDS.


Institute of Forensic Medicine, University of Oslo, Norway

According to the concept of a fatal triangle for the pathogenesis of SIDS there are three prerequisites: 1. A vulnerable developmental stage of the CNS and the immune system. 2. Predisposing factors e.g. polymorphisms in the cytokine genes, genes regulating the serotonergic network and the water transport in the CNS. 3. A trigger event, e.g. a common cold. Several studies report increased brain weight and edema in sudden infant death syndrome (SIDS), and we hypothesize that this is due to a disturbed water homeostasis in the brain. The major water channel in the brain and spinal cord is aquaporin 4 (AQP4). AQP4 is expressed at fluid-tissue barriers in the brain, is crucial in brain water homeostasis, and plays a significantly role in the development of brain edema. The purpose of the present study was to investigate the AQP4 gene in SIDS cases (n=141) and controls (n=179). Four single nucleotide polymorphisms (SNPs) were investigated: rs2075575, rs4800773, rs162004, and rs3763043. The T allele and the CT/TT genotypes of rs2075575 was found to be associated with SIDS (C versus T, p<0.02, CC versus CT/TT, p=0.03). Furthermore for the SNP rs2075575 an association between brain/body weight ratio and genotype in the SIDS group aged 0.52.5 months was demonstrated (p<0.01, median ratio CC 10.8, CT/TT 12.1). For the other three SNPs there were no differences in genotype frequencies between SIDS cases and controls. In conclusion, the present finding fits with the hypothesis of a fatal triangle in SIDS, indicating that rs2075575 may be of significance as predisposing factor, the CT/TT genotypes being associated with an increased brain/body weight ratio, especially in infants dying from SIDS during the vulnerable period between 0.5 and 2.5 months after birth.

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Faculty of Odontology, University of Iceland

Neskaupstaður is a busy fishing port in one of the east fjords of Iceland. On February 2004 did a diver inspecting damage to a pier in front of a fishing net service station found a human body wrapped in plastic bag, weighted down with chains. First inspection by local authorities revealed stabbing wounds suggesting a murder. The body was brought to Reykjavík for further investigation. It was soon evident that the lesions were inflicted post mortem. On radiographs and MRI scan foreign objects were observed in the stomach and intestines. Drug smuggling was suspected. On autopsy 57 capsules with at least 400 g of amphetamine were found. The drug capsules had 3 layers of latex and one outer layer of some hard material. All capsules were unbroken. Blood analysis did not reveal any traces of amphetamine. Ileus was confirmed as the cause of death. Dental examination was performed in conventional manner and post mortem dental findings recorded on the Interpol forms. The method of Kvaal et al of age estimation was used. This indicated an age of 32 years. At this point no missing person was in sight and no ante mortem data were available for comparison. Drawings of the deceased were released to the media. Fingerprints taken at the autopsy were not found in the Icelandic police collection. The prints were sent out through Interpol channels and positive ID came from Wiesbaden, with later confirmation from Vilnius that they belonged to a near 30 year old Lithuanian. Three men were arrested. One of the suspects confessed that the deceased became ill and died in the Reykjavík area. They decided to dispose of the body in Neskaupstaður, the hometown of one of the suspects. On the way they were stuck in a village nearby for 2 days due to a heavy snowstorm. The stabbing wounds were inflicted at the pier to prevent the body from floating up. The three men were sentenced to prison for 2 ½ years. It is unfortunately clear that drug trafficking is a major problem in Iceland as in most other countries.

LEGAL ASPECTS OF AGE ASSESSMENT Ranta H (1), Salo S (2), Varkkola O (1) (1) (2)

Dept. Forensic Medicine, University of Helsinki, Finland University of Oulu, Finland

The Finnish Alien Act and Decree do not give any legal guidelines for age assessment of asylum seekers and unattended minors. During recent years, an increasing number of individuals have been referred to the Department of Forensic Medicine, University of Helsinki, for age assessment by police and there is an apparent need to amend the legislation. The use of ionizing radiation for non-medical purposes is strictly regulated, and thus after application, The National Radiation Protection Authority has issued a specified permit to our Department. Taking X-rays (left hand/wrist, panoramic tomogram and intraoral) is allowed with informed consent of the legal representative and the person in question. Results of the age assessment can be released to specified authorities according to the Personal Data Protection Act. The need for age assessment is generally acknowledged. Combining different skeletal and dental methods in assessment, increasing number of critical studies and publication of reference values on various populations will provide more reliable estimates of chronological age in cases where no birth certificate is available. Notes:


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Dental Faculty, University of Oslo

The Norwegian Identification team at Kripos was sent to Thailand only 3 days after the disaster and started work the temple Bang Muang the next day. The situation was chaotic and approximately 1000 bodies lay in the sun in a state of immediate decomposition. No instructions were given. After 3 days the examination of the bodies were transferred to another temple, Yan Yao in the same area. Here instructions were given by Australian dentists. Late in January the examinations were transferred to the so called “site 2” where the Norwegian state had given a temporary mortuary with 3 autopsy units and service constructions. The computer program DVI System International was used and the computerization and comparison was done at the Information Management Centre (IMC). A bureaucratic system was set up for the handling of original papers and computers. All 81 missing Norwegians were found and identified, a remarkable result. All dental records were collected at Kripos and data transferred to the DVI System International. Radiographs and records were photographed. All data and pictures were transferred electronically to Thailand while the original documents were kept at Kripos. Despite this, several A.M. reports on Norwegian victims from Thailand had not updated dental information. The post mortem examination of the Norwegian victims was done by a number of dentists from different countries. A review of the P.M. reports showed that few were satisfactory and would not have passed the normal quality assurance measure performed in ordinary identification cases in Norway. Some examples will be shown.


Department of Forensic Medicine, Faculty of Health Sciences, University of Copenhagen, Denmark International Rehabilitation Council for Torture Victims (IRCT), Copenhagen, Denmark

The overall objective of the project is to contribute to the prevention of torture through promoting documentation of torture, facilitating investigation and prosecution of court cases concerning allegations of torture. Specific objectives: 1. Availability of high quality forensic documentation for increased reporting of torture 2. Use of, and victims’ access to, forensic documentation as evidence in legal proceeding 3. Awareness about medical forensic evidence, victims’ rights and state obligations under the United Nations´ Convention against Torture (UNCAT) to properly investigate and prosecute perpetrators The project will establish best practice examples in providing high-quality forensic documentation of torture as evidence in investigations and court cases related to torture. Forensic expertise in documenting torture will be compiled in a global focal point. The capacity to document torture will be enhanced in five target countries five different continents. Forensic reports will be made available and considered in at least 15 court cases, potentially creating precedence for thorough investigation and prosecution of perpetrators. Stakeholders’ awareness about the absolute prohibition of torture, state obligations and victims’ rights will be enhanced. Project team in Denmark: Department of Forensic Medicine, University of Copenhagen – forensic experts/administration IRCT - project manager, assistant, forensic expert, mental health, legal, financial, communication. International expert panel: Minimum 15 international forensic experts Project team in target countries: Focal point in five centres - Two health workers per centre, one administrator. Time frame: Three years, starting in 2009. Scand J of FORENSIC SCIENCE - No 1 - 2009 - Page 1-40


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FORENSIC MEDICINE AT ICC (INTERNATIONAL CRIME COURT) Jääskeläinen AJ (1), Rinne A (2), Saksela E (3), Scheinin M (4), Pirjopäivi P (5) University of Turku, Finland University of Tromsø, Norway (3) University of Helsinki, Finland (4) EUI Bologna, Italy (5) Court of Appeal, Turku, Finland (1) (2)

The International Criminal Court (ICC) is based on the Statute of Rome the 17th of July 1998 and its actions begun in Hague on the 1st of July in 2002. It works tightly with UN, but is an independent international court. It handles crimes of the violation of human rights committed after its foundation. ICC has received cases from all continents. In its previous work forensic medicine has played an important role giving evidence for the court. Forensic medicine at ICC follows the same principles as the national courts but has additional prerequisites originating from the international tension connected to the cases. The authorization of the forensic medical investigators, the acceptance of these, the mandate for the investigation and other diplomatic and juridical factors need special attention of the forensic medical community. Since the national forensic medical systems diverge, it is not self-evident how forensic medical expertise can be trusted in the investigation for ICC. Especially the different specialists working on the case should be aware of their restrictions when questions requiring special training are concerned. The court has free choice of the witnesses, but it cannot always be aware of the factual competence of the witness. Thus it is recommendable, that the international forensic medical community provides proper guidelines for the use of forensic medical experts in the international tasks and at ICC. Some guidelines are presented in this paper.


Institute of Forensic Medicine, University of Southern Denmark

Israel attacked the Gaza strip on 27 Dec 2008 and followed up with an invasion on 4 Jan. The Israeli troops withdrew on 18 Jan 2009.During this period there were numerous allegations of the use of phosphorus bombs and DIME bombs and targeted attacks on civilians, including small children. The author stayed in the Gaza strip from 29 Jan and was able to get a first hand impression for documentation purposes.

EDUCATION NEW APPROACH TO THE CERTIFICATION OF DEATH Jääskeläinen AJ (1), Rinne A (2), Saksela E (3) University of Turku, Finland University of Tromsø, Norway (3) University of Helsinki, Finland (1) (2)

The death certificate is still one of the most reliable ground for monitoring the health and well fare of a population. The Scandinavian countries have adopted the guide lines of WHO in the certification of death. The classification of the death is based on the needs of societies in the 20th century. The modern society has been confronted with new challenges: environmental factors influencing the health of an individual, risks included in health endangering life style, new concepts of the death mechanisms connected for instance to the socio-economic status. This information can not be reached if the death statistics are based solely on medical diagnoses and on the existing classification. The concept of dying has been widened for instance in the concept of death process. Since the investigation of the cause of death is in a considerable part (appr. in 30 per cent of cases in Finland) based on pathologic anatomical or forensic medical autopsy, it can be complemented by the estimation of the etiological factors in the death mechanisms. The same principles can be adopted also in clinical practice. This procedure will also enhance the understanding of the multifaceted nature of death. Some proposals for the complementing of the death certificate are presented.


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THE NECESSITY OF A STRATEGIC APPROACH - FORENSIC MEDICINE AS A SPECIALTY IN DENMARK Hougen HP (1), Leth P (2) and Banner J (3) Department of Forensic Medicine, Faculty of Health Sciences, University of Copenhagen, Denmark Department of Forensic Medicine, Faculty of Health Sciences, University of Southern Denmark (3) Department of Forensic Medicine, Faculty of Health Sciences, University of Aarhus, Denmark (1) (2)

In Denmark, forensic medicine has traditionally been regarded as a branch of anatomic pathology, and for more than five decades the forensic pathologists have been recruited from the ranks of the pathologists. However, it became more and more clear that pathology and forensic medicine followed different tracks of development. In 1995 the Danish Society of Forensic Sciences applied for a specialty to the National Board of Health. However, the health authorities wanted (and still want) to reduce the number of medical specialities, and after five years the forensic pathologists gave up. As a consequence of the situation, recruitment became increasingly difficult. The idea for a new strategy based on a power analysis then rose. We needed strong allies. The right forum was the biannual meetings between the departments of forensic medicine and the Ministry of Justice, where a gloomy prognosis of the future manning was outlined. The Ministry of Justice was gradually convinced and persuaded the Ministry of Health to order the National Board of Health to assist the forensic pathologists in their struggle for a new speciality. The final decision was in the hands of The National Council for Medical Specialities. The National Board play an important role in this council, and with the board as an active co-player, two forensic pathologists - one representing the departments and the other representing the Danish Society of Forensic Sciences - lobbied intensively among the members of the council. Finally, in 2008 forensic medicine was officially accepted as a medical speciality. The training consists of 2.5 years in anatomic pathology and 2.5 years of forensic pathology and clinical forensic medicine and also includes theoretical courses both in pathology and in forensic medicine. Collaboration with Sweden is encouraged and Norwegian colleagues have also shown interest in the Danish training programme.


The Queenâ&#x20AC;&#x2122;s University of Belfast, Northern Ireland, UK


Section of Forensic Pathology, Department of Forensic Medicine, University of Copenhagen, Denmark Diagnostic Centre, Department of Radiology, Copenhagen University Hospital, Denmark

Computed Tomography (CT) has become a widely used supplement to medico legal autopsies at forensic institutes throughout the world. It has proven to be very valuable in visualising fractures of e.g. the cranium. CT scan data have in the past years been used to create head models for biomechanical trauma analysis. To create individual head models for retrograde trauma analysis we need to ascertain how well CT scan captures cranial fractures. The purpose of this study was to compare the diagnostic agreement between CT and autopsy regarding cranial fractures and especially the precision with which cranial fractures are recorded. The autopsy fracture diagnosis was compared to the diagnosis of two CT readings (by a forensic pathologist and a radiologist and using Multiplanar (MP) and Maximum Intensity Projection (MIP) reconstructions) using schematic drawings. The fractures extent was quantified by merging 3-dimensional datasets from both the autopsy (by 3D digitizer tracing) and CT scan. The results showed a good diagnostic agreement regarding fractures localised in the posterior fossa, while the fracture diagnosis in the medial and anterior fossa was difficult at the first CT scan reading. The fracture diagnosis improved during the second CT scan reading. Thus using two different CT reconstructions improved diagnosis in the medial fossa and at the impact points in the cranial vault. However, fracture diagnosis in the anterior fossa and of hairline fractures remained difficult. The study showed that the forensically important fracture systems largely were diagnosed on CT images using MP and MIP reconstructions, but difficulties remained in the minute diagnosis of hairline fractures. These inconsistencies need to be resolved in order to use CT scan data of victims for individual head modelling and trauma analysis. New generation CT scanners will probably improve the diagnostic frequency. Scand J of FORENSIC SCIENCE - No 1 - 2009 - Page 1-40


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Section of Forensic Pathology, Department of Forensic Medicine, University of Copenhagen, Denmark

Cranial fractures caused by blunt trauma are a common occurrence in forensic pathology. In this study we aimed at improving our understanding of cranial fractures based on a contemporary medico-legal autopsy material and thereby provide up-to-date knowledge for basic forensic interpretations (including post-mortem radiology), preventive measures and biomechanical studies. 428 cases with cranial fractures caused by blunt trauma were included. We retrospectively registered basic data from the autopsy and toxicology report, including the manner of death, the circumstances regarding the trauma, the autopsy findings regarding the cranial fractures, extra- and intracranial lesions. The fractures were classified as either linear fractures, depressed, multiple, ring, comminute and combination. Further subdivisions pertaining to orientation and anatomical localisation were also noted. Accidents were the most common manner of death (n=372). The cranial fractures were mainly linear (~60%) or comminute, involving the cranial base in 90% of the cases. The study showed general trends regarding an association between occipital impacts and longitudinal linear fractures (45/69; 65% CI 53%-76%) and lateral (temporal, parietal, or both) impacts and transverse linear fractures (52/80; 65% CI 54%-75%). In addition, we noted that depressed fractures most often were caused by lateral impacts (15/19, 78% CI 54%-94%). The most common intracranial lesions were subarachnoid haemorrhages and contusions (~70%). We consider the results useful in the medico-legal setting, including post mortem radiology. Furthermore the data may provide information for developing biomechanical head injury models or protective measures.

MODELLING CRANIAL FRACTURES Lynnerup N (1), Engkjaer Christensen J (1), Jacobsen C (1), Jørkov ML (2), Ravn Thomsen H (3), Sölvadottír AE (3). University of Copenhagen, Denmark University of Bournemouth, United Kingdom (3) Technical University of Denmark. (1) (2)

Blunt trauma to the head may result in the blunt instrument leaving specific imprints or fracture patterns. Being able to correctly correlate one or more possible blunt trauma mechanisms and instruments with the imprints and fractures of an actual case may be important in police investigations. However, most of our knowledge about blunt instruments and cranial imprints and fracture patterns stems from earlier tests performed on cadavers, or more recently, advanced mechanical and computer-based models. We present the results of two approaches: 1) a completely computer-based virtual model, with real time fracture pattern modeling; and 2) a very simple non-computerbased model. The first model required advanced 3-D image analyses, based on an actual CT scanning of a cranial fracture, resulting in a virtual, finite element model. The model constitutes an important step towards creating a realistic skull model to be used in forensic pathology to predict fractures. The second, much simpler model was able to produce consistent imprinting and fracture patterning, according to which four tools were used as blunt instruments. Indeed, in a blind trial we were able to correctly exclude one or more blunt instruments as the causative weapon. The two models will be discussed with a focus on practicability, and in light of the new imaging techniques currently being introduced in Scandinavian forensic pathology. Notes:


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THE PATTERNS OF AXONAL INJURY Van Driessche PMI (1), Kubat B (1) (1)

Netherlands Forensic Institute, The Hague, The Netherlands

Beta amyloid precursor protein (B-APP) detection in diffuse axonal injury (DAI) is an useful marker in accelerationdeceleration trauma (ADT). B-APP axonal pathology also occurs in other conditions (e.g. hypoxic-ischemic brain damage). In a retrospective, semi quantitative pilot study we examined patterns which might distinguish traumatic from hypoxic B-APP positive pathology. Ten cases of proven ADT and 15 cases of pure hypoxia were sampled at predilection sites of DAI and stained with B-APP antibody. We evaluated the size of the axonal bulbs (AB) versus the size of oligodendroglial nuclei and the pattern of axonal changes (delicate, moderately coarse and coarse axonal contours). Because of the preliminary status of the study we did not perform statistical analysis. We found a pattern concerning the absence of axonal bulbs (17% in ADT: 61% in HG) and numbers of medium sized AB (23% in ADT: 6% in HGC) as well as the absence of positive axons (17% ADT: 56% HG) and moderately coarse axon pattern (40% ADT: 7% HG). No difference was found in numbers of small AB (33% ADT: 20% HG) and large AB (27% ADT: 13 % HG) or in delicate axon pattern (30% ADT: 26% HG) and coarse pattern (13% ADT: 11% HG). Axonal damage in ADT and hypoxia probably has a common pathway. Distinction between the two can be problematic because secondary hypoxia often occurs in DAI. We believe that the morphologic difference we found in the two groups is explained by temporal factors. DAI leads to hypoxia and hypoxia leads to death. Thus DAI exists for a longer ante mortem period which causes the more pronounced pattern. Our results offer no absolute diagnostic tool in individual cases. However, if the diagnosis of inflicted DAI is based on the results of post mortem and extensive additional testing, the proof of B-APP positive axonal changes remains an important contributor to the diagnosis.

ASPHYXIAL HOMICIDES IN THREE SCANDINAVIAN CITIES Hougen HP (1), Lilleng PK (2), Rogde S (3) Department of Forensic Medicine, Faculty of Health Sciences, University of Copenhagen, Denmark The Gade Institute, Faculty of Medicine, University of Bergen, Norway (3) Institute of Forensic Medicine, Faculty of Medicine, University of Oslo, Norway. (1) (2)

This is an introductory part of a study of the necessary criteria for the diagnosis asphyxial death due to either manual or ligature strangulation. Fifty four consecutive cases were studied. Forty seven of the victims were strangulated manually and 17 with ligature. The material comprised 42 females and 12 males with a median age of 33.5 years. In almost half of the cases the perpetrator was the cohabitant and in only three of the cases the perpetrator was unknown to the victim. The homicides occurred as a result of quarrelling in almost half the cases, while the combination of homicide and suicide were observed in seven cases, and six of the homicides were sex related. All, but two of the victims had petechiae in the face, eyes and/or mouth and/or laryngeal mucosa. Ten of the victims did not show any skin lesions to the neck, and eight of them had no muscular haemorrhage in the neck. 23 of the victims had no fractures of the hyoid bone, thyroid or cricoid cartilage, and all but one of these ere below fifty years of age. Where the cricoid was examined routinely (28 cases), six fractures of the cricoid was observed, and in two cases this was the only fracture site. The frequency of acute pulmonary emphysema and congestion varied considerably between the three centres, pulmonary emphysema from 70 to 10 per cent and congestion from 50 to 80 per cent. Although the number of cases is relatively small, there is a consistency in the criteria for the diagnosis in the three centres, with slight variations regarding interpretation of acute pulmonary emphysema and congestion, and also the importance of routine examination of the cricoid cartilage. One of the victims with a fracture of the cricoid cartilage was strangulated with a nylon stocking, which questions the paradigm of this fracture as patognomonic for manual strangulation.

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Department of Forensic Medicine, Section of Forensic Pathology, University of Copenhagen, Denmark Section of Forensic Anthropology, Department of Forensic Medicine, Faculty of Health Sciences, University of Copenhagen, Denmark

In most cases of fatal strangulation the diagnosis is evident because of the gross pathological findings and the circumstances under which the diseased is found. However, in some cases the cause of death remains uncertain in spite of a strong suspicion of foul play, if the injuries of strangulation are few or lacking. The purpose of the study was to determine if acute pulmonary emphysema is present in fatal strangulations. This retrospective study included 37 consecutive deaths from homicidal manual or ligature strangulation in the ten year period 1998 to 2007 autopsied at the Department of Forensic Medicine in Copenhagen. The material comprised 26 women and 11 men between the ages of 17 and 87. The study was performed on 2 haematoxylin-eosin stained sections from each lung, which were examined by microscopic morphometry. The average cross-sectional area of the alveoli was measured digitally and compared with a group matched for gender and age that died of unrelated causes. The results were also compared to the description of the gross pathology of the lungs. The result of the gross evaluation shows that 28 of the 37 strangulation victims had acute pulmonary emphysema. The microscopic results are still pending. Previous studies have discovered pulmonary emphysema microscopically in fatal strangulations, but morphometry has not been used in the examination of lung tissue in these cases before. This method is useful to objectify the data and thereby in determining whether or not acute pulmonary emphysema can be used to support the diagnosis of strangulation.


Institute of Forensic Medicine, University of Southern Denmark

This article presents a comparison of AIS-score obtained by autopsy and by post mortem CT in 52 traffic fatalities. On average there was a 94 % agreement between autopsy and CT in detecting the presence or absence of lesions in the various anatomical regions, and the severity scores were the same in 90 % of all cases (range 75 â&#x20AC;&#x201C; 100 %). When different severity scoring was obtained, CT detected more lesions with a high severity score in the facial skeleton, pelvis and extremities, whereas autopsy detected more lesions with high scores in soft tissues (especially in the aorta), cranium and ribs. The ISS scores obtained by CT and by autopsy were calculated, and were found to be with no important variation in 85 %. Conclusion: CT may be used as an acceptable alternative to autopsy for AIS- and ISS-scoring in traffic fatalities, although slightly better results may be obtained by a combination of these two methods. Notes:


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POSTMORTEM DIAGNOSTIC IMAGING FINDINGS OF INJURIES TO THE CERVICAL SPINE FACET JOINTS FOLLOWING FATAL ROAD TRAFFIC TRAUMA Uhrenholt L (1), Nielsen E (2), Vesterby A (1), Hauge EM (3), Gregersen M (1) Department of Forensic Medicine, Faculty of Health Science, University of Aarhus, Denmark Department of Neuroradiology, Aarhus Sygehus (NBG), Aarhus University Hospital, Denmark (3) Department of Rheumatology, Aarhus Sygehus (NBG), Aarhus University Hospital, Denmark (1) (2)

Background and Research Question Cervical spine injuries are common in people killed in road traffic crashes, although facet joint injuries have rarely been described. The purpose of this study was to examine whether discrete injuries could be detected in these joints of road traffic crash fatalities, using advanced diagnostic imaging procedures. Materials and Methods The cervical spine facet joints (C4-Th1) from 19 persons killed in road traffic crashes and 21 persons due to natural death (12 females and 28 males, median age 35 years) were retrieved during autopsy. Each specimen was examined by two independent radiologists using conventional X-rays, computed tomography (CT), and magnetic resonance imaging (MRI), compared with microscopical findings with regard to fractures and bleeding in the joints. Results Four of 11 discrete fractures were identified on diagnostic imaging, CT being the most sensitive. Haemarthrosis could not be determined reliably on any diagnostic imaging modality. Interobserver agreement for detection of fractures on all imaging modalities was “substantial” (k= 0.66–0.79 [range 0.37-1.09], p < 0.001). There was poor agreement with regard to haemarthrosis (k = 0.17 [range 0.00-0.34], p < 0.05). Facet fractures and haemarthrosis were common in the road traffic crash fatalities despite negative diagnostic imaging. Discussion In agreement with previous studies, discrete fractures and soft tissue lesions were common and difficult to identify on diagnostic imaging. Diverging interobservational agreement scores indicate that post-mortem diagnostic imaging is challenging to the interpreter. Conclusion Discrete injuries to the facet joints were common following fatal traffic trauma. Despite histological evidence of injury, many injuries could not be identified on diagnostic imaging. There is an urgent need for scientific evidence of validity and reliability of diagnostic imaging procedures in forensic settings.

EVALUATION OF PASSENGER CHILD SAFETY IN REAL WORLD CAR CRASHES Stray-Pedersen A (1), Boye Hansen T (2), Rognum TO (1), Lereim I (3), Næss PA (2) Institute of Forensic Medicine, University of Oslo, Norway Oslo University Hospital, Ullevaal, University of Oslo, Norway (3) Norwegian University of Science and Technology (NTNU), Trondheim Norway, (1) (2)

Aims: During the last two decades major improvements in design of child car seats and in car safety overall have been made. Nevertheless, 9 child passengers below 15 years of age in Norway died and 16 were seriously injured in motor vehicle accidents (MVAs) in 2008. On that background a prospective, interdisciplinary study was initiated to analyze the injury mechanisms involved MVAs and evaluate if improper use of motor vehicle restraints in children might influence outcome. Methods: MVAs in South-east Norway resulting in death or serious injuries to drivers or passengers are included if at least one child <15 years of age was involved. The Emergency Dispatch Centres (EDC) in the region inform the crash investigation team, which within 24 hours of the accident are dispatched to the crash scene following consent from the local police authorities. A standardized protocol has been implemented for the investigation of vehicle dynamics, child occupant contact points and interior crash environment in the vehicle. The on-scene investigation is supplemented by information from police reports, crash victims and medical records. Preliminary results: As of march 2009, MVAs including a total of 8 crashed cars have been included. The driver suffered fatal or serious injuries in 3 out of 8 cars. Out of 16 child passengers 3 were killed (age 2, 10 and 12 years), 5 were seriously injured (age 5, 5, 7, 10 and 13 years) and 8 were minimally or non-injured (age 0, 1, 1, 1, 3, 4, 10 and 12 years). Seven out of 8 fatally or severely injured children were inadequately protected: 4 had improperly fastened seat belts, 2 were injured due to unsecured moving luggage, and 1 used a size-inappropriate child seat. Conclusion: Appropriate crash investigations may provide important information regarding injury mechanisms of patients. The preliminary results indicate that fatal and severe injuries in children might be prevented to a large extent by appropriate safety measures including proper use of motor vehicle res Scand J of FORENSIC SCIENCE - No 1 - 2009 - Page 1-40


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BIOMECHANICAL EVALUATION OF SHAKEN BABY SYNDROME Stray-Pedersen A (1), Strisland F (2), Blechingberg A (3), Weensvangen M (4), Holck P (5), Vege Å (1), Rognum TO (1) Institute of Forensic Medicine, University of Oslo, Norway SINTEF ICT, Oslo, Norway (3) Faculty of Mathematics and Natural Sciences, University of Oslo Norway, (4) Oslo Police Department, Norway (5) Institute of Anatomy, University of Oslo, Norway (1) (2)

Aims: The Shaken baby syndrome (SBS) is characterized by the clinical findings of subdural hematoma, retinal hemorrhages and brain injury, accompanied by an incomplete history of trauma. Fractures of the extremities or ribs may also be present. Whether violent shaking alone may produce the acceleration forces required for such severe injuries have been questioned by previous biomechanical studies. Critics have argued that the typical injuries in SBS are more likely to be caused by direct impact to the head. We sought to evaluate the biomechanics of violent shaking by a laboratory dummy model experiment. Methods: An anthropomorphic crash test dummy (Q0) matching an infant at 3.5 kg was assembled. The head interior was equipped with accelerometers enabling assessment of three-axial acceleration forces. Fifteen volunteers were asked to shake the dummy vigorously holding a firm grip around the torso. Results: The median duration of shaking was 15.5 sec (range 5-54). Typical acceleration/deceleration traces were produced after 2-3 shakes with a steady state shaking motion at a pace of 4-6 times cycles (back and forth) per second. The peak acceleration forces in the skull centre were measured to 36G, 10G and 22G in the X-, Y-, and Z-axis respectively. The peak tangential velocity at the vertex of the head was calculated to 3.5–4.0 m/s. Conclusion: This dummy experiment shows that large acceleration forces may be generated by a few seconds of violent shaking. Forces of such magnitude are likely to cause head injuries. Biomechanical study findings must be interpreted with caution, but may increase our knowledge of injury mechanisms in child abuse. VITREOUS HUMOR HYPOXANTHINE LEVELS FOR TIME OF DEATH DETERMINATION Rognum TO (1), Opdal SH (1), Musse MA (1), Stray-Pedersen A (1), Larsen AC (1), Dahlberg P (1), Saugstad OD (2). (1) (2)

Inst of Forensic Medicine, Oslo, Norway Dept of Pediatric Research, University of Oslo, Oslo University Hospital, Norway

After the first publication of vitreous humor hypoxanthine (Hx) measurement as adjunct in determination of time of death (TOD)(1), the method has been refined. New standard diagrams have been developed both for Hx and potassium (K): vitreous humor from 17 live patients undergoing vitrectomy as well as from 130 dead subjects with known time of death were studied. The dead subjects were kept at environmental temperatures varying from 5ºC and 23ºC. One sample from each case was investigated and slopes for Hx- and K increase per hour for different environmental temperatures were constructed. For Hx the 95% CI was ±36 minutes for the first 6 pm hrs; ± 1,3 hr between 6 – 12 hrs; ±2.6 hrs between 12 – 24 hrs; ±5.2 hrs between 24 – 48 hrs; ±7.8 hrs between 48 – 72 hrs; and ±10.3 hrs between 72 – 96 hrs. The method might thus be used for 96 hours. Applying the new standard curves the Hx- and K- method (TOD-kit) has during the last 6 years been tested in 55 consecutive cases of unnatural deaths in which the scene of crime had been investigated by a forensic pathologist from the institute of forensic medicine in Oslo. In 27 cases the time of death could be determined based on tactical information such as electronic traces. In 24 of these cases (89%) the CI of the Hx based estimated corresponded with the tactical information. In the remaining 3 cases (11%) the CI of the Hx method did not correspond with the tactical information: one failure might be explained by the fact that the victim of stab wounds also had an extensive, sub-acute heart infarction (7x5 cm). Vitreous humor had been sampled 7 hrs pm, and time since death had been overestimated with 1½ hour. Dying heart muscle cells probably had caused ante mortem tissue hypoxia and Hx release. Interestingly K measurement gave similar time of death as Hx. In the second failure the victim of blunt and sharp violence had had both eyes damaged and vitreous humor was miscolored and contaminated with blood. Time since death was overestimated with ca 1.5 hrs by the Hx-method whereas the K-method underestimated time since death. The last failure was a case of shot in the head, in which the time since death was underestimated with 2.5 hrs by the Hxmethod. Since the K- level in the same sample taken 5 hrs prior to death was 3.2 mmol/l, we think that this failure might be due to human error, e.g. exchange of syringes. We are currently testing possible errors such as contamination of vitreous humor with blood and tissue debris. The method should be further developed, making it less vulnerable for changes in environmental temperature. We therefore plan to establish a network of researchers for cooperation in improving the database and the standard curves both for HX- and K- based time of death estimation.


(1) Rognum TO, Hauge S, Øyasaeter S, Saugstad OD. A new biochemical method for estimation of postmortem time. Forensic Sci Int 1991; 51:139-146 Scand J of FORENSIC SCIENCE - No 1 - 2009 - Page 1-40

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East Midlands Forensic Pathology Unit, Leicester Royal Infirmary, United Kingdom

Malpractice claims can relate to the diagnosis of a disease, to therapeutic intervention, prophylaxis, aftercare and many more. In malpractice-related fatalities, the medico-legal autopsy plays an important role in substantiating or dismissing the malpractice claim, and thus has substantial influence on the legal outcome in many cases. In the present study, 265 alleged malpractice cases associated with cardiac fatalities were examined in order to establish which groups of doctors are most commonly affected, which factors influence the rate of mistakes made by physicians, which charges are most frequently brought against physicians and what the legal outcome in these cases is. The cases were divided into two groups, namely complications of interventions and missed diagnosis of cardiac disease. Factors influencing the doctors’ mistake rates were their specialty, patient age, patient symptoms at presentation and the past medical history of the patient. Knowledge of these factors is important for the development of effective strategies to prevent malpractice in the future. Although charges were brought against the doctors in all cases, guilty verdicts were relatively rare, and in many cases, the suspicion of malpractice could be dismissed based on the autopsy findings. Thus, the medico-legal autopsy is an important gateway in the legal outcome of alleged malpractice cases. MEDICO LEGAL AUTOPSIES IN DENMARK: A RETROSPECTIVE STUDY Tangmose Larsen S (1), Lynnerup N (1) (1)

University of Copenhagen, Denmark

We performed a retrospective study of medico legal autopsies in Denmark at the three forensic institutes in Aarhus, Odense and Copenhagen. The aim of our study was to analyse trends in case numbers as well as basic data such as age, sex and case type. Furthermore, the aim was to provide forecasts for the number of medico legal autopsies in the future. Methods: We searched the computerized archives at the three local institutes for the period 1996 – 2005. Results: During the study period the total number of autopsies was 14990. Except for 1996 and 1997 where the figures were higher, the yearly average number of autopsies was 1450. Throughout the whole period the proportion of manner of death (accidents, homicide, natural, suicide or unknown) was relatively constant. The proportion of younger individuals (20-39 yrs.) seemed to decrease over time, while the opposite trend was noted for older individuals (40-59 yrs.). Discussion: While our result show certain constancy for medico legal autopsies in Denmark in terms of basic data and numbers, there may be trends in the age make up. When correlated with the demographics of the general population over the same period, the noted trends may reflect a decrease in the younger generations. This may have a bearing on future number of medico legal autopsies.


Institute of Forensic Medicine, University of Southern Denmark

54 homicides by stabbing with 57 victims (32 men and 25 women) took place in Southern Denmark (approximately 730.000 inhabitants) in the period 1983- 2007. The rate for homicides by stabbing was constant throughout these 25 years. Many of the victims were socially disadvantaged, half was alcohol intoxicated at the time of death and almost a third had a chronic abuse problem. The majority of these homicides were committed at home by a family member, and the murder weapon was in two thirds of cases a kitchen knife. Agitation, jealousy and psychosis were the most common motives. Homicides in the night life committed by a flick-knife or dagger has received much press coverage, but was found to be very rare. The injury pattern and the degree of violence were described. A ban against knifes must be recommended, but would only prevent few homicides. Increased penalties will probably have a very limited effect. Scand J of FORENSIC SCIENCE - No 1 - 2009 - Page 1-40


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Institute of Forensic Medicine, University of Oslo, Norway Amnesty International, London, United Kingdom

The conducted energy device (CED), frequently known under a manufacturer’s trademark name, Taser, was introduced to law enforcement personnel as a less lethal alternative to firearms. However, more than 300 deaths have been reported in the USA following the use of such devices over the past two decades. The role of the device in these deaths remains a contentious issue. In order to elucidate this, we have reviewed 93 autopsy reports from various US states in cases where death occurred in close temporal proximity to the use of a CED. Half of the population was designated as White while the other half was either African American or Hispanic, and the median age was 38 (range 18-63). All were male. In 41 cases at least one hit was reported, in 23 at least two, and in 27 cases three or more (the maximum number of hits exceeding 20). In 37 cases central nervous stimulants were detected, in 10 cases central nervous depressants and in 18 cases both. The cause of death was often given as multiple factors, and it was sometimes difficult to interpret the underlying cause of death. However, in 17 cases the use of CED was given as cause of death, either together with other factors or as the only cause. In 15 cases the use of a CED was seen as a contributory factor. In two cases the cause of death was given as electrocution, while in other cases the use of the CED was specifically ruled out as playing any role in the death due to the low amperage of the device. The most common factor given in cause of death was drug effects (N=53) and in 33 cases excited delirium was mentioned. The manner of death was given as accident in 42% and as homicide in 26%. The significance of these findings in the light of current literature will be discussed.

DOES LJUNGAN VIRUS CAUSE MALFORMATION, INTRAUTERINE FETAL DEATH AND SUDDEN INFANT DEATH SYNDROME? Bo Niklasson (1), Annika Samsioe (2), Petra Råsten Almqvist (3), Nikos Papadogiannakis (4), William Klitz (5) Department of Medical Cell Biology, Uppsala University, Sweden Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Section of Internal Medicine, Sweden (3) National Board of Forensic Medicine in Stockholm, Sweden (4) Department of pathology, Karolinska University Hospital, Huddinge, Sweden (5) School of Public Health, University of California, USA (1) (2)

Objective: The Ljungan virus (LV), a member of the Parecho virus genus, and Picornaviridae family, was originally isolated from its wild reservoir, the bank vole (Myodes glareolus), at the Ljungan River in central Sweden. Ljungan virus is associated with diseases such as myocarditis, encephalitis, pregnancy-related diseases and diabetes in several species of wild rodents. The same outcomes can be induced in CD-1 mice under controlled laboratory conditions. The present study investigates whether malformation, intrauterine fetal deaths (IUFD) and sudden infant death syndrome (SIDS) in humans may have Ljungan virus as a common zoonotic etiology. Methods: Formalin fixed tissues from IUFD, SIDS and hydrocephalus cases were investigated using LV specific immunohistochemistry (IHC). Tissues from elective abortions due to Trisomia 21 were used as controls. Frozen specimens were analyzed for presence of LV specific RNA using a real time RT PCR. Results: Ljungan virus was detected by IHC in the majority of IUFD (7/16), SIDS (6/8) and hydrocephalus (9/10) cases while only 1 of 18 Trisomia 21 control cases investigated by immunohistochemistry. The IHC results have been confirmed by RT PCR. Conclusions: The available evidence points to a widespread role for Ljungan virus in a variety of perinatal conditions. This newly identified agent may prove to be a major explanatory factor in a number or reproductive outcomes, each with currently unsolved etiologies.


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Department of Forensic Medicine, Aarhus University, Denmark

To reach new areas and to achieve new tools for diagnostics and documentation we have established a Molecular Forensic Laboratory at Forensic Medicine in Aarhus, DK. Knowledge about cellular pathophysiology is important for understanding and prevention of deaths. The lab has the necessary facilities for molecular pathology, with focus on isolation and analysis of DNA, RNA and proteins, including real time PCR. Molecular pathological research: Medium chain Acyl-CoA dehydrogenasis deficiency (MCAD): This study found a higher prevalence of genetic defects in a group of children from 1-4 years old, and led to the inclusion of MCAD in the national screening program for newborns in Denmark, which now offers screening for over 20 in-born errors of metabolism. Cell stress response: Heat stress activates Heat Shock Response and anti-oxidant system in cells. A study of SIDS(Sudden Infant Death Syndrome) vs. Controls show interpersonal variation in activity in genes representing cellular stress response. Both groups show a significant response to heat stress compared to base levels. We found higher activity in the SIDS group, indicating that they may be overexposed or show a deviated response. Heart diseases and genetic disorders: A proportion of heart diseases are inherited. These may potentially have arrhythmia or death as first presentation. We are examining extracted blood and paraffin embedded tissue from selected forensic autopsies for genetic causes of ischaemic (familial hypercholesterolaemia) and non ischaemic (cardiomyopathy, long QT syndrome, Brugada syndrome etc.) heart diseases. We wish to present and discuss perspectives and possibilities with access to unique materials and new molecular methods that can be applied to Forensic Case work and research.

MORS SENILIS - OLD, NEW DIAGNOSIS Rinne A (1), Martikainen J (2), Schwesinger G (3), Jääskeläinen A (4) (1)

University of Tromsø, Norway (2) Finnish Cancer Society, Oulu, Finland, (3) University of Greifswald, Germany (4) University of Turku, Finland

Robert Rössle, Berlin, presented in the 1930’s the idea, that mors senilis, the death of an old person, represented the only natural death. The aging process begins at the fertilization of the egg cell. The individual borne pays the costs of specialization to the death. Only the one cell organisms were considered to have an eternal life. Later on it could be demonstrated, that even the life of that kind of organism could not continue forever. The telomeres were defining the length of life. Thus, the death of the one cell organisms and individuals could be considered as a concept of genetically programmed death. Physiologically the death of a cell is called necrobiosis (Virchow) or apoptosis. Correspondingly the death of an individual in connection to the mors senilis could be called individual necrobiosis or apoptosis. In the practical work there are occasions, when an old person has died without any single defined cause of death having only the degenerative processes connected to the aging. In these cases it should be possible to use the chief medical diagnosis of mors senilis. These cases will probably increase in the population, when the protecting net of the society will further develop. The criteria of the diagnosis of mors senilis need further discussion. Notes:

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Kasturba Medical College, Mangalore, India VMKV Medical College, Salem, India

Introduction Stature is a valuable tool for identification. As every body part bears more or less constant relationship with stature, present study attempts to estimate stature of an individual from palm length. This study may prove useful in conditions where only a part of the hand is brought for identification. Material & Methods Present study was conducted over 500 north and south Indian subjects in Manipal, India. Palm length was measured from mid-point of distal transverse crease of forearm to mid-point of proximal flexion crease of middle finger using vernier calipers and stature was measured using stadiometer. Measurements were analyzed statistically to establish the relation between palm length and stature. Results Mean stature and palm length in males was significantly (p< 0.001) greater than females among north and south Indians. However, the difference in mean stature and palm length between north and south Indians was insignificant (p > 0.05) for the same sex and for difference in measurements of palm length between dominant and non dominant hand. Standard error was least (3.951) for south Indian females and maximum for south Indian males (5.702). Significant correlation coefficient was evident in all groups, while the predictive value was best for north Indian females (0.463). Conclusion Equations derived for one sex can not be used to estimate stature for other sex. In persons of different population groups (belonging to the same race) geographical variations do not have much influence on body proportions. Dominance of a hand does not have a significant role to play while estimating stature from palm length. The study shows that palm length bears a significant relation to stature and can be an important tool for stature estimation in the Indian population if only amputated hand is found and brought for examination and other body parts are unavailable. Key Words: Stature; Palm length; Identification.

USE OF PHOTOGRAMMETRY AND BIOMECHANICAL GAIT ANALYSIS TO IDENTIFY INDIVIDUALS Larsen PK (1), Lynnerup N (1), Hansen L (1), Simonsen EB (1) Alkjaer T (1), Henriksen M (2), Holst KK (1), Nielsen SF (1), Petersen HP (1), Scheike TH (1) (1)

University of Copenhagen, (2) Frederiksberg Hospital, Copenhagen, Denmark

Photogrammetry and recognition of gait patterns are valuable tools to help identify perpetrators based on surveillance recordings. We have found that stature could be reproduced within Âą 1.5 cm using 3D photogrammetry but only few other measures could be used to distinguish between people of similar stature due to low reproducibility in locating hidden body-points such as the joints. Several gait variables (among joint angles, segment angles and net joint moments) with high recognition rates were found. Especially the variables located in the frontal plane are interesting due to large inter-individual differences in time course patterns. The variables with high recognition rates seem preferable for use in forensic gait analysis and as input variables to waveform analysis techniques such as principal component analysis resulting in marginal scores, which are difficult to interpret individually. Finally, a new gait model is presented based on functional principal component analysis with potentials for detecting individual gait patterns where time course patterns can be marginally interpreted directly in terms of the input variables. In this presentation, the above methods will be discussed exemplified with forensic cases.


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EXACT DETERMINATION OF YEAR-OF-BIRTH USING THE HUMAN EYE LENS Lynnerup N (1), Kjeldsen H (2), Heegaard S (1), Jacobsen C (1), Heinemeier J (2). (1) (2)

University of Copenhagen, Denmark University of Aarhus, Denmark

Lens crystallines are special proteins in the eye lens that never remodel. Human tissue ultimately derives its 14C content from the atmospheric carbon dioxide. The 14C content of the lens proteins thus reflects the atmospheric content of 14C when the lens crystallines were formed. Precise radiocarbon dating is made possible by comparing the 14C content of the lens crystallines to the so-called bomb pulse, i.e. a plot of the atmospheric 14C content since the Second World War, when there was a significant increase due to nuclear-bomb testing. Since the change in concentration is significant even on a yearly basis this allows very accurate dating. We are able to demonstrate a close relationship between the formation date of the lens crystallines and the birth year of the individual. A forensic application of this relationship is to determine the year of birth of an unidentified corpse. The eye lens is extracted (a minimally invasive procedure), radiocarbon dating of the lens crystallines is performed, and then, based on a mathematical expression on the formation rates and bomb pulse, the year of birth may be calculated to within +/- 1.5 years. An actual case involving determination of year of birth of three dead new-born babies found in a deep-freezer is presented. We were able to show with this method that the babies were born ca. 1986, 1988 and 2002. FORENSIC AGE ESTIMATION OF LIVING ADOLESCENTS AND YOUNG ADULTS Schmeling A (1), Olze A (2), Schulz R (1), Schmidt S (1) (1) (2)

Institute of Legal Medicine M端nster, Germany Institute of Legal Medicine Berlin, Germany

As a result of the global increase in migration movements in recent years, there is a growing demand for age estimates of living persons. The persons under examination are mostly foreigners without valid identification documents whose genuine age needs to be clarified for legal purposes. In many countries, the age thresholds relevant for criminal, civil, and asylum proceedings lie between 14 and 22 years of age. In accordance with the updated recommendations for age estimation in criminal proceedings of the Study Group on Forensic Age Diagnostics for an age estimation, a physical examination with determination of anthropometric measures, inspection of signs of sexual maturation, as well as identification of age-relevant developmental disorders, an X-ray examination of the left hand as well as a dental examination including the determination of the dental status and evaluation of an orthopantomogram should be performed. If the skeletal development of the hand is completed, an additional Xray examination or CT scan of the clavicles should be carried out. The individual methods are presented as well as instructions for how to interpret the findings.



Advancing Dentistry at the Crossroads of the World FDI congresses are internationally recognised events that focus on the latest scientific topics affecting the profession globally. We are delighted to offer a wide selection of topics and speakers from all over the world. Among the topics are: Forensic Odontology and Disaster Victim Identification (DVI) - The Role of the Practitioner.

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Institute of Forensic Medicine, University of Southern Denmark

At the present time the low conviction rate for crimes of sexual assault is an ongoing topic of debate in both the public and in the judicial community in many countries. In their report ‘Case Closed’ (Sept 2008), Amnesty International has recently criticized the Police and Court of Law in the Nordic countries for inadequate handling of such cases. Clinical forensic pathologists have also been addressing the problem for years, and some research has been carried out. This has in part been directed at the presence or non-presence of genital injury – and has come up with a variety of conclusions. In this article the state of forensic investigation of rape in Denmark is reviewed with reference to injury prevalence, investigative methods and correlation with judicial outcome to the extent that this information is available. The results are compared with both Nordic and international data. Literature on the subject will is also reviewed. Conclusions show that the Nordic countries are very similar in most of the areas investigated, while the disparities are small and, with a few exceptions, irrelevant. There is, of course, room for improvement, and several possible ways of refining investigative procedures are proposed and new research fields are suggested.

EXAMINATION OF SEXUALLY ABUSED CHILDREN. PRESENTATION OF THE FIRST DANISH CENTRE FOR THE INVESTIGATION AND CARE OF ABUSED CHILDREN Vesterby A (1), Nødgaard H (2), Laursen B (3) Department of Forensic Medicine, Aarhus University, Brendstrupgaardsvej 100, 8200 Aarhus N, Denmark Paediatric Department, Aarhus University Hospital, Skejby, Brendstrupgaardsvej 100, 8200 Aarhus N, Denmark (3) East Jutland Police, Aarhus, Ridderstræde 1, 8000 Aarhus C, Denmark (1) (2)

The prevalence of sexual abuse of children in the Nordic countries is unknown, but has been estimated to be around 5%. Very few cases of sexual abuse are reported to the police. The police may request a medical examination to document or verify the child’s testimony. Until now the child and the child’s family have had to go to the police station to give a videotaped interview to the police, go to a medical or a forensic doctor with examination rooms located in another place followed by paediatric evaluation and treatment and psychosocial follow-up at yet another place. In November 2007, the first Danish centre for the protection of abused children was established at Aarhus University Hospital, Skejby. The centre, which receives all kinds of child abuse, is located in a building neighbouring the Department of Forensic Medicine, Aarhus, and headed by a steering group with representatives from the Paediatric Department, the police and the Department of Forensic Medicine; the centre is managed by a paediatric consultant. Videotaped interviews by the police are performed at the centre as well as the forensic medical examination, paediatric and psychosocial evaluation and follow-up. Experience and perspectives from the first Danish child protection centre for the forensic community will be presented.


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Y CHROMOSOME POLYMORPHISMS AND ETHNIC GROUP: A COMBINED STR AND SNP APPROACH Cortellini V (1), Ravani M (1) Verzeletti A (1), Cerri N (1), Marino A (2), Garofano L (2), De Ferrari F (1) (1) (2)

University of Brescia, Italy Raggruppamento Carabinieri Investigazioni Scientifiche, Parma, Italy

Human biological material is often identified at a crime scene. The opportunity to go back to the ethnic group of the individual who left that material could be very useful for investigators. This element is very important in some urban areas, like Brescia (Northern Italy), where a great number of foreigners of different ethnic groups are often involved in violent crimes. The recent introduction of new markers, mainly on Y chromosome, seems offer good discriminatory possibilities in order to define sub-populations of various ethnic groups. The aim of this study is to compare a group of males from Brescia with a sample of each of the three main ethnic groups living in Brescia area (Pakistanis, Albanians, Nord Africans), typed both for Y-STRs and Y-SNPs systems. Combining the results of the two different markers, even on the basis of preliminary data, suggests a good power of discrimination between Brescia population and the three different ethnic groups analysed. This could become potentially useful in order to have some indications on the subject’s ethnic group to which the biological material belongs.

RAPE IN GENOCIDE Astrup BS (1) (1)

Institute of Forensic Medicine, University of Southern Denmark

Rape as a weapon of war is as old as war itself. The many wars of Europe in the 19th and 20th centuries led to the formulation of the ‘Geneva Conventions’, hereby setting the standards of international law on humanitarian issues during war. Rape is included in the fourth Geneva Convention of 1949 but was not independently prosecuted by international war tribunals until 1997, when the International Criminal Tribunal for the former Yugoslavia prosecuted rape as a ‘crime against humanity’. The Rwanda Tribunal prosecuted rape as a form of genocide in 1998. This paper investigates the well-documented incidences of genocidal rape in the 20th century with regard to their occurrence in history, degree of systematization, purpose(s), sub-types, implementation, and with reference to the response of the international community and possible prosecution by a war tribunal. Three levels of genocidal rape are seen. 1. The individual soldier: In wars with genocidal elements, the alienation of the enemy, including women and children, is a prerequisite for committing atrocities and in this environment rape is prevalent. 2. The generals: Systematic rape of civilians in enemy communities is a very effective tool of demoralization and is often ordered by officers. 3. The political leadership behind the war: Genocidal rape and forced pregnancy is also a highly effective tool for ‘ethnic cleansing’ and is implemented as a separate, articulated policy of war. Rape is a widely used and highly efficient weapon in genocidal warfare and ethnic cleansing. Used wisely, rape can destroy the infrastructure of entire communities, and, leaving little physical evidence, it can be difficult to prove for a tribunal. Rape was not used in the Nazi and Kampuchean genocides of the 20th century, and one can argue that these killing machines were so effective that they rendered rape as a weapon of terror superfluous. The use of rape as a weapon has been perfected in the on-going conflict in Darfur. The death-toll it involves is not so astronomical that it forces the international community into action, but due to this stealth weapon 2-3 million people’s lives are shattered, probably beyond redemption.

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Department of Forensic Medicine, Aarhus University, Denmark Section for Toxicology and Drug Analysis, Aarhus University, Denmark

Introduction: Naloxone (Narcanti ®) is often used in emergencies as an antidote to opioides, e.g. heroine, morphine and methadone. However, the half-time and time of duration of naloxone are shorter than those of opioids (T½ 30-90 minutes versus 2-3 hours). Therefore, serious or even fatal intoxication may recur upon elimination of naloxone, a phenomenon known as re-entering overdose. Materials: Police report, case record, autopsy findings and toxicology results. Methods: Evaluation of the autopsy results. Results: In the period 2000-2008 we have at the Department of Forensic Medicine, Aarhus University, reported five cases of fatal opioid intoxication in drug addicts due to re-entry and inappropriate medical observation subsequent to the administration of naloxone. Discussion and conclusions: The cases illustrate the importance of medical observations upon administration of naloxone. It is recommended that this pitfall is emphasized in “” and similar medicine catalogues.


National Board of Forensic Medicine, Department of Forensic Medicine, Uppsala, Sweden Department of Forensic and Insurance Medicine, Semmelweis University, Budapest, Hungary

Drug use is a widespread phenomenon that has been slowly but gradually increasing worldwide for the past 15 years. The use of illegal substances became accelerated in Hungary after 1989, when the change of regime also resulted in the opening of the borders and an easier access to illegal drugs of abuse. In the beginning Hungary was only a “transit” country, but it soon became a “target” country, and a growing demand for drugs of abuse appeared. Together with an increased demand and use of illicit drugs, the effects of drug abuse also became more visible, such as the appearance of drug related death (DRD) cases. In Hungary all unnatural causes of death, e.g. DRDs, have to undergo forensic autopsy. In Budapest all forensic post-mortem examinations are performed at the Department of Forensic and Insurance Medicine at Semmelweis University. Toxicological examinations and serological tests for HIV, HBV, HCV and syphilis were performed. The cause and manner of death were determined after evaluating the circumstances of death, toxicology data, autopsy results and police reports as well as family interviews and medical records when available. DRDs according to EMCDDA recommendations were divided into direct, overdose related DRDs, indirect DRDs and delayed DRDs (e.g. due to infections, lifestyle). In Budapest we detected the first illicit DRD in 1994. Within a few years the number of DRDs constantly increased until it peaked in 2001. After a rapid decrease it showed slow but constant increase, having reached a plateau for the past two years. In overall, we analysed 373 DRD cases out of which 77% were direct DRDs. The majority of overdoses (78%) were caused by opiates, especially heroin. Most of the victims of DRDs were male (85%) with a mean age of 27 years. We also examined the incidence of infectious diseases in the population. There was practically no HIV present within the victims (there was only one HIV positive case) but the incidence of HCV was 36%, of syphilis 7% and of HBV 5%.


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The National Board of Forensic Medicine , Department of Forensic Genetics and Forensic Toxicology, Linköping, Sweden Department of Forensic Medicine, Stockholm, Sweden

The most commonly collected specimens at medico-legal autopsies in Sweden, include peripheral blood, urine and vitreous humor. In cases with severe postmortem changes these fluids are not available in sufficient quality or quantity for toxicological analysis. Legal drugs and some narcotics can be examined in muscle or liver tissue, but for alcohol analysis there is another need of biological fluid. In cases with severe putrefaction, there is often possible to collect other biological matrices such as bile, liquid from squeezed lung or pleural effusions. A study was designed to improve the possibility to investigate poisonings in autopsy cases with severe putrefaction. Different biological fluids were collected from 200 cases at the Department of Forensic Medicine in Stockholm and analysis of alcohol as well as drugs was performed at the laboratory in Linköping. Comparative results were obtained from ethanol analysis of blood versus bile, cerebrospinal fluid, liquid from lung and pleural effusions. There was a correlation between blood and the different matrices. In the upper concentration range, results from these matrices can be used to prove over consumption. Of course, consideration may always be taken to postmortem production or degradation of ethanol. However, determinations of legal drugs and narcotics in these biological fluids could only be considered qualitatively, because of no correlation. Analysis of bile could prove useful because most drugs are found in bile in significantly higher amounts than in blood. Findings of drugs in the bile may indicate previous use. Regarding intake of heroin, we detected 6-acetylmorphine in bile in some cases that presented negative in blood. Further investigations will be made, but bile might be a helpful complement to the traditional matrices in the toxicological analysis.


Estonian Forensic Science Institute, Estonia University of Tartu, Estonia

Introduction: From the beginning of XXI century, drug abusers in Estonia have replaced the poppy straw and heroin with synthetic opioids, fentanyl and 3-methylfentanyl. Using of 3-methylfentanyl begins usually in young age. At present the young female drug abusers of synthetic opioids have started to get their first babies. Aims: To perform a pilot study of the clinical findings of babies with 3-methylfentanyl poisoning. Methods: Analysis of data from the clinical documentation and police reports in 3 cases of 3-methylfentanyl poisoning in babies at 2, 6 and 10 months age. Results: At the moment of hospitalization, all 3 babies were somnolent and hard to awake, their breathing was short and irregular. Their lips were cyanotic and SpO2 levels were low. There were clear signs of orthostatic hypotension. From the urine of babies 3-methylfentanyl was found, but interestingly no marks of injection were detected. In all cases the babies were born with strong symptoms of drug withdrawal syndrome. Two of the cases were treated with methadone in hospital. It is highly likely that the drug abusing parents administered 3-methylfentanyl to diminish the agitation of their babies at home. Conclusion: We might further see a new generation of drug-dependent persons, babies, whose life is probably endangered by their own parents.

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Division of Forensic Toxicology and Drug Abuse, Norwegian Institute of Public Health (NIPH), Norway Section of Pathology, The Gade Institute, University of Bergen and Haukeland University Hospital, Norway

Aim and introduction: We question whether methemoglobinemia, a functional anaemia, could be of importance in automobile exhaust inhalation deaths. Inhalation of exhaust gas often leads to death by CO intoxication, but in some cases the measured carbon monoxide hemoglobin saturation level (COHb) in blood is considerably below what is considered to be lethal. The death in such cases is often attributed to a combination of a high CO2 and a low O2 tension. However, exhaust fumes contain nitrogen oxide gases (NOx), that by inhalation and absorption can result in acquired and severe methemoglobinemia (MetHba). Acquired MetHba induced by numerous chemicals is not uncommon in living subjects, but reports of post-mortem cases are surprisingly scarce, with only one earlier report relating MetHba to exhaust gas deaths. Methemoglobin (MetHb) results when the normally ferrous iron in the heme molecules of hemoglobin is oxidized to the ferric state, with resulting inability to reversibly bind oxygen, and also an unfavourable left shift in the oxygen dissociation curve of the residual hemoglobin. High-degree MetHba (in adults MetHb above 45-55% of hemoglobin) causes serious tissue hypoxia, leading to unconsciousness, arrhythmia and death. Methods and results: A case history will be presented, of a young man found dead in a car equipped with a catalytic converter, with a hose leading exhaust from the engine to the interior of the car. Autopsy revealed no injuries or macroscopic/microscopic signs of disease. Analysis of post-mortem femoral blood revealed a moderately elevated COHb of 18% (HS-GC/atomic absorption spectrophotometry), and a high MetHb of 56% (six-wavelength IL682 CO-Oximeter). No ethanol, narcotics or drugs were detected in blood. Conclusion: After scrutinizing the literature in this field, including the issue of post-mortem stability of MetHb, the knowledge that exhaust fumes contain nitrogen oxide gases (NOx) led us to postulate that this death could possibly be attributed to a combination of methemoglobinemia and a moderately high COHb concentration. Key Words: Methemoglobin; MetHb, Hemoglobin; Carbon monoxide intoxication; COHb; Automobile exhaust gas; Postmortem changes SUDDEN UNEXPECTED DEATH DUE TO UNKNOWN MITRAL VALVE PROLAPSE Andersen AM (1) Larsen MK (1), Kristensen IB (1) (1) Department of Forensic Medicine, Aarhus University, Denmark Introduction: Idiopathic mitral valve prolapse (MVP) is probably the most common valve disease among adults with an estimated prevalence of 2,4 % in the general population. It is a non-inflammatory process, which affects either cusp, partially or completely, and is usually due to degenerative changes associated with ageing or congenital abnormality of the heart. The most common early symptoms are palpitations, fatigue and dyspnoea, but mild cases may be asymptomatic for many years. The auscultatory findings in MVP, when present, consist of a mid-systolic click and/or a late systolic murmur. The diagnosis can usually be confirmed by transesophageal echocardiography. MVP may occur in association with other syndromes (Marfan syndrome, Ehlers-Danlos, osteogenesis imperfecta) or may have no identifiable co-morbidity. Four different loci on chromosome 11, 13, 16 and X have been found to be linked with MVP, but no specific gene has been described. MVP is associated with an increased incidence of infective endocarditis, cardiac arrhythmias, embolic strokes and congestive heart failure.Sudden unexpected death is a well-known but rare complication in mitral valve prolapse. Results and conclusions: Two cases of sudden unexpected death due to unknown MVP are presented. In both cases there were no symptoms. Sudden death due to MVP is rare. These cases illustrate the undisputed value of autopsy to establish the cause of death in cases with undiagnosed diseases. References:

Grau JB et al. The genetics of mitral valve prolapse. Clin Genet 2007: 72: 288-295. Vesterby A. et al. Sudden death in mitral valve prolapse: Associated accessory atrioventricular pathways. Forensic Science International, 19 (1982) 125-133


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SUDDEN DEATH – A RETROSPECTIVE GENETIC STUDY OF HEART DISEASE Larsen MK (1), Kristensen IB (1), Jensen HK (2), Banner J (1). (1) (2)

Department of Forensic Medicine, Aarhus University, Denmark Aarhus University Hospital, Skejby, Department of Cardiology, Denmark

Introduction: Several cases of sudden death on basis of genetic heart disease have inspired to a retrospective study. The aim of this study is to examine inherited heart disease from selected forensic autopsies. Materials and methods: Purified DNA from blood of approximately 180 selected autopsies will be examined. The following genetic heart diseases will be emphasized; long QT-syndrome and Brugada syndrome due to defects in cardiac ion channel proteins, catecholaminergic polymorph ventricular tachycardia due to defects in the ryanodine receptor, arrhythmogenic right ventricular cardiomyopathy due to defects in the desmosome proteins, hypertrophic, dilated and restrictive cardiomyopathy due to defects in the contractile proteins. Results: Two cases of sudden cardiac death due to genetic heart disease are presented; a 25 year-old man, with a microscopic diagnosed hypertrophic cardiomyopathy, had a mutation in the myosin binding protein C (MYBPC3) and a 21 year-old woman with a normal heart, had a mutation, F29L in the HERG gene associated with long QT 2 syndrom. Discussion: Muttions in the genes of the above mentioned proteins are known to present as arrhythmia or sudden death. Diagnosed cases of sudden cardiac death in the Danish population are few (1), despite the estimated higher number of cases in the literature (1,2). The perspective of the study is to determine the molecular cause of sudden cardiac death in order to intervene and prevent sudden cardiac death in relatives to cases with proven genetic heart disease. References: 1. Dansk Cardiologisk Selskab.Rapport om screening af unge idrætsudøvere i Danmark. Oktober 2006 2. Priori SG, Aliot E, Blomstrom-Lundqvist C et al.Task Force on Sudden Cardiac Death of the European Society of Cardiology. Eur Heart J.2001; 22:1374-1450


Insitute of Legal Medicine, University of Brescia (Italy)

Myocardial infarction is a well-known complication of acute cocaine intoxication, although the finding of acute coronary thrombosis is quite uncommon. This report describes a 40 years old male who suddenly died a few hours after a scuffle. The autopsy revealed a complete thrombotic occlusion of the left main coronary artery and left circumflex artery. Histochemical staining revealed recent thrombus and intact ateromasic plaque with 40% lumen obstruction. Toxicological findings shown a positivity for cocaine and benzoilecgonine in blood (0.40 μg/ml) and in urine (639 μg/ml). Those values are compatible with cocaine acute intoxication, moreover the high urine concentration of cocaine and its metabolites suggests an iterated absunction of cocaine before the last one; hair lack didn’t permit cocaine detection on keratinic matrices. Apart from cocaine’s effect as vasoconstrictor, which causes decrease in oxigen supply, previous reports have demonstrated that cocaine has thrombophilic effects stimulating the release of substances from vascular endothelium or circulating platelets that promote thrombosis and inhibit thrombolysis. At least, the cause of death was referred to a cardiac shock, induced by a cocaine-associated coronary thrombosis triggered by a combination of arterial vasoconstriction, platelet aggregation and fibrin deposition. No causal role has been attributed at the lesions produced during the scuffle. Therefore the Authors emphasize the mandatory toxicological analysis particularly in case of sudden death.

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WORLD WAR II PRISONER OF WAR Güvencel A (1) (1) Department of Forensic Medicine, Umeå University, Sweden In August 2004 two tourists found the skeletal remains of a human body in a rock formation in the remote mountains in northwestern Sweden. Among other things, uniform remains and an identity card marked “STALAG IIA 81059” were found. Through a search in the war archives, a historian found that this card belonged to a WW II prisoner at the prison camp Stalag 2A, Neubrandenburg, Northern Germany. The prisoner’s name was the Russian sounding Alexej Matvejev who escaped from a camp in Norway before the end of year 1944. The historian assumed that Alexej Matvejev had been relocated from the camp in Germany to a camp in northern Norway where the German military used prisoners to build railway lines. The human remains were examined at the Department of Forensic Medicine in Umeå. It was concluded that the remains belonged to a male with the height of 169-177 cm, 30-35 years old at the time of death. An anthropological examination of the shape of the skull indicated that the male originated from Eastern Europe. Further, signs of periodontitis, caries and iron deficiency were present. By estimating the growing paste of lichen colonizing the bones, the time of death was estimated to the 1940’s. DNA analyses confirmed male sex, and studying the gene frequencies it was assumed that ethnic origin of the man was Eastern European or Russian. The DNA analyses were complete enough to confirm relationship with close relatives, if DNA for comparison should become available. Despite reports in the Russian newspaper Pravda, requesting information concerning Matvejev, no relatives were found. The remains were buried in Arjeplog on May 23, 2007, with the attendance of among others the Russian Ambassador in Sweden, a Russian orthodox priest, a Military Attaché and staff from the Department of Forensic Medicine in Umeå.


Department of anesthesia and intensive care, Institute for Surgical Sciences and Section of Pathology,The Gade Institute,University of Bergen, Haukeland University Hospital, Norway

Accidental hypothermia results in increased fluid extravasation from the vascular to the interstitial space. In surface cooling several reports have demonstrated that the extravasated fluid essentially is water, electrolytes and proteins, suggesting that inflammatory mechanisms are involved, and that fluid leakage leads to tissue oedema affecting vital organs including the brain. The aim of this work was to study total water content and morphological changes in two groups of hypothermic piglets, one group simulating accidental cooling in ice water, the second group cooled to the same temperature by core cooling using a commercial intravascular catheter placed in Vena Cava Inferior. Two normothermic piglets were used as controls. All animals were monitored during four hours measuring intracranial pressure and total tissue water content, then killed at the end of the experiment with saturated potassium chloride. Formalin-fixed material from each organ was studied histologically. Brain tissue was stained according to special procedures. The results shows an acute inflammatory response in some of the piglets brains, more pronounced in the surface cooling group than in the core group. The response may lead to a local breakdown of the blood-brain barrier. We suggest that the local inflammation is caused by cooling and may be an important factor in nevroprotection of the brain. Key words: Hypothermia, surface cooling, core cooling, meningitis, microdialysis, brain Notes:


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Department of Forensic Medicine, University of Aarhus, Denmark

Introduction: We present four cases of death classified as excited delirium, following physical fixation. Usually no obvious cause of death is found at the autopsy. The underlying mechanism is thought to be a combination of the normal physiological changes in response to stress leading to high levels of adrenaline, electrolyte imbalances and acidosis, predisposing to cardiac arrhythmias. Illicit drugs, medications, alcohol or psychosis may be involved, but there is no clear cut definition of excited delirium. Case Histories: All cases had known mental disorders, and were, at the time of death, in an acute psychotic state. Preceding death, three cases acted violently, and were restrained by one or more people, and one case was in a physical restraint, struggling to escape. During restraint, all cases suddenly went limb with cardiac arrest. Two were resuscitated, but died a short time later. The autopsies revealed nonspecific findings; excoriations, atherosclerosis and cerebral oedema. No signs of violence were found. The supplementary examinations showed no alcohol or drugs, no toxic levels of medication, and changes in the brain typical of anoxia. Discussion: Death due to excited delirium is still somewhat controversial and remains complex to interpret; there are no pathognomonic signs, and other conditions must be excluded, including positional asphyxia. Nor is it possible to measure relevant electrolytes and metabolites post mortem. If resuscitated, findings will reflect results of inadequate circulation. Circumstances of the death often lead to police or medical personnel being suspected of misconduct. Emphasis is placed on thorough examination of all relevant cases, on acquiring circumstantial facts, as well on the need for more knowledge of excited delirium.


Department of Pathological Anatomy and Forensic Medicine, University of Tartu, Ravila 19, 50411 Tartu, Estonia

The intensity and distribution of soot and gunpowder residue deposits is related to the firing distance and other factors, i.e. the type of the weapon and the ammunition. The aim of the study was to characterize the bullet entrance injuries from the most common pistols in Estonia with the most common makes of ammunition. Test firings were performed at pieces of human skin (autopsy material) and the skin was examined macro- and microscopically. Results: The Tokarev left a large amount of soot arranged in zones and a lot of gunpowder residue particles (especially at a firing distance of 5 cm). The soot and powder residues were seen on the histological tissue slides, which originated 1 to 4 cm from the centre of the skin defect, and they had penetrated into the skin up to the depth of 580 µm. Also several intraepithelial tears and recesses containing soot were seen. The Makarov left a lot of soot (especially at a distance of 1 cm) arranged in zones and when fired at 5 cm, only a few powder grains also were seen. The fine soot was found up to 3 cm (firing distance 1 cm) and up to 4 cm (fired at 3 and 5 cm) from the centre of the skin defect and it was on and in the epidermis. The gunpowder particles were present at 1 to 2 cm from the centre of skin defect up to the depth of 100 µm (fired at 3 cm) and 170 µm (fired at 5 cm) in the skin. The Glock 19 left little soot at all distances, but there were a lot of powder grains densely deposited around the skin defect when fired at 3 cm and 5 cm. Histologically the gunpowder residues were found in the epidermis and in the dermis up to the depth of 400 µm. On slides stained with Na-rhodizonate for heavy metal detection, scarlet red deposits on the skin surface were seen. Conclusion: In the case of the Tokarev, a lot of soot and powder residues and intraepithelial tears were seen, whereas the Makarov left only a few gunpowder particles superficially with fine soot and the Glock the least soot and a lot of gunpowder particles. Scand J of FORENSIC SCIENCE - No 1 - 2009 - Page 1-40


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Department of Forensic Medicine, Faculty of Health Science, University of Aarhus, Denmark

Background and Research Question Post mortem tomography (CT) as an adjunct to autopsy has been shown to improve the sensitivity of forensic investigations especially with regard to identification cases and documentation of foreign metallic materials. Materials and Methods At the Department of Forensic Medicine in Aarhus we performed whole body CT-scanning prior to the autopsy in death cases due to accidents, homicides and in identification cases. The CT-scanner is a Siemens Somatom Definition, Dual Energy 64 slice scanner, which allows sub-millimetre resolution of the images. Results We present a number of cases, in which the contributions from the CT-scanner have had impact on the postmortem investigation. Some of the advantages of supplemental advanced diagnostic imaging to forensic medicine could be identified in these cases and were presented, including visualisation of a bullet and its trajectory through the body and ante-mortem surgical sequelae positively identifying a deceased. Discussion This study highlights some of the major advantages of forensic diagnostic imaging. This illustrative presentation visualized these, although we maintain the opinion that such procedures remains adjunct to the post-mortem autopsy, in accordance with the current literature. Conclusion This study presents some of the major advantages in forensic settings of advanced diagnostic imaging in the field of gunshot wounds and identification. Although the advantages are obvious, such procedures do suffer from limitations and these must be considered on a case by case basis.

BLUNT SKULL-BRAIN INJURY OF UNCERTAIN CAUSE Tuusov J (1), Vaas T (1), Vassiljev V (1) (1)

Estonian Forensic Science Institute, Estonia

45 years-old male was hospitalized to intensive care unit (department) on 15.12.07. Eight lacerations of the skin in lobar-temporal region and a massive wound containing brain tissue and skull fragments in occipital region were diagnosed. Patients blood alcohol level was 2,72 mg/g. Examination of the wound in the occipital region revealed depressed fragmented fracture 6 x 4 cm, bone fragments were found in the occipital lobe and intracerebral hematoma was located in the same region. Patient told that he was hit several times on head with a bottle of vodka (the bottle did not break into pieces). Patient´s sister who was the eyewitness of the case gave uncertain explanations. So the mechanism of the injury in the occipital region remained unclear for the investigator. The wooden armrest of the sofa from the crime scene was performed to the expert of radiology and forensics and 3 dimensional reconstruction of the scull was carried out. This reconstruction showed that the dimensions and characteristics of the scull fracture correlate to the characteristics of the armrest. The conclusion: the injury of the occipital region was possibly caused by the fall, head striking the armrest.


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ABDOMINAL INJURY AMONG FATAL ROAD TRAFFIC CRASH VICTIMS Uhrenholt L (1), Gaborit F (1), Møller Andersen L (1) (1)

Department of Forensic Medicine, Faculty of Health Science, University of Aarhus, Denmark

Background and Research Question In clinical settings abdominal injuries can be challenging and knowledge of common topographic distribution of injuries may be helpful. There is literature suggesting that injury to the abdominal organs may be common following road traffic crash exposure. This study examined the impact of factors such as mode of transportation and type of crash scenario on abdominal injury in a group of people killed in road traffic crashes who subsequently underwent autopsy. Materials and Methods Autopsies performed during the period 2000-2004, involving road traffic crash victims were included. Data from autopsy and police records were retrieved from an internal database and evaluated with regard to mode of transportation, type of crash, and presence of injury to abdominal organs. Details concerning age, gender, influence of alcohol and drugs/medication were retrieved. Results A total of 180 road traffic crash fatalities (passenger car, motorcycle, moped and bicycles) were included. Overall, 53% of the subjects had injury to one or more abdominal organ, the liver being the most commonly affected followed by the spleen, intestines and kidneys. Lateral impact increased the likelihood of injury in passengercar victims. Injuries were more common among passenger car victims compared with other road users. Alcohol test was positive in 38% of 146 tested subjects (55/146), and 39% of 46 tested subjects (18/46) were positive for drugs/ medication. Discussion Injuries to the liver and spleen were found to be the most common abdominal injuries following fatal road traffic crashes. Interestingly, only minor differences were observed in prevalence of abdominal injury in car passengers versus less protected road users (motorcycle, moped and bicycle). Conclusions This study shows that injuries to the abdominal organs are very common following fatal road traffic crashes. Future investigations into the mechanisms and pathology of abdominal injury are needed.


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POST-MORTEM INJURIES BY A DOG: A CASE REPORT Verzeletti A (1), Cortellini V (1), Vassalini M(1), De Ferrari F (1) (1)

University of Brescia, Italy

Post-mortem animal depredation is sometimes encountered in forensic pathology. In this work a case of post-mortem animal injuring by a domestic dog is presented. Some time ago, a woman was found unconsciousness in her house, where two cats and one dog were wandering freely. She was recovered in the morning by her husband, lying on the floor of the bathroom, with a lot of lesions on her face. On the woman’s night-dress a small amount of blood was found. Blood stains were almost totally absent at the scene. The woman was transported to the hospital and a cardio-pulmonary resuscitation was performed, but all the procedures were ineffective. To clarify the cause of death and to verify the suspected post-mortem animal interference a forensic autopsy was carried out. At post-mortem examination, the corpse showed a large wound on her face: the nose and the upper lip were missing and, especially on the right side of the face, a lot of punctured wounds and groups of multiple small cuts were appreciated. Defence injuries were not found. There was no vital haemorrhage or subcutaneous bleeding in the wound margins and the histological examination of some wound edges showed no vital reaction. Cause of death was the rupture of an aneurism of the basilar artery. A small fragment of cheek was submitted to species diagnosis and tested for human, dog, cat and rabbit antigens and it resulted positive only for human and dog antigens, confirming the presence of dog’s biological material. Considering that the woman’s face was cleaned at the hospital, the positive reaction at the species test underline that a lot of biological material of the dog was present on the woman’s face. This work, showing an unusual pattern of post-mortem injuries inflicted by a domestic dog, evidences that the animal attack can occur soon after the death, and that a simple, fast and economic test, such as serological species diagnosis, can contribute to the correct reconstruction of the case.

AN INTERNATIONAL DATABASE FOR TIME OF DEATH DETERMINATION Dahlberg P (1), Opdal SH (1) Musse MA (1), Larsen AC (1), Stray-Pedersen A (1), Saugstad OD (2), Rognum TO (1) (1) (2)

Inst of Forensic Medicine, University of Oslo, Oslo University Hospital, Norway Dept of Pediatric Research, University of Oslo, Oslo University Hospital, Norway

The establishment of an international database for time of death estimation based on hypoxanthine and potassium levels in vitreous humor (1) is planned. Our group has gathered a significant amount of material which proves the reliability of the post-mortem slope of these two chemical markers. We are currently seeking partners for a multicenter cooperation to expand the material of the database further and thereby ensure the statistical reliability and judicial impact of the method. The database is planned both as a mathematical tool and as a forum in which experiences and cases can be shared. Certain statistical subgroups will need to be addressed, since concrete intrinsic and extrinsic factors may prove to have an impact on the slope. We are planning to make a certification course for professionals that want to use the method and the database. The vitreous humor extraction method has proven to be crucial, and only clearly agreed upon and specified quantification methods should be allowed. The database will be organised as a non-profit foundation. It will seek to include comparable methods for postmortem interval determination, and be an accessible tool to accelerate the scientific development in the forensic society. 1. Rognum TO, Hauge S, Øyasaeter S, Saugstad OD. A new biochemical method for estimation of post mortem time. Forensic Sci Int 1991;51:139-146


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The Soria Moria meeting, October 7-10, 2009 October 7 Open meeting in Norwegian language: Samfunnets ansvar ved barnemishandling Mange aktører har en rolle når det gjelder å avdekke og å gripe inn ved barnemishandling: helsetjenesten, skoletannlegen, barnevernet, politiet og forskjellige typer sakkyndige. Arbeidet for de mest ubeskyttede, de som mishandles av sine nærmeste, kaller på økt samhandling. Soria Moria møtet 7. oktober har som mål å samle de forskjellige aktørene for samtale rundt en felles strategi.

Barneombud Reidar Hjermann: Åpning

Førsteamanuensis Reidun Follesø fra Høyskolen i Bodø har forsket på oppfølging av mishandlede barn. Hun ser utfordringen fra Barnevernets perspektiv. Tema: Hva forteller barnevernsbarna? Hva var det som hjalp? Kom hjelpen for sent?

Klinikksjef Jens Grøgaard Tema:

ved Barnesenteret, Ullevål Universitetssykehus har gått nye veier når det gjelder samarbeid med politiet i barnemishandlingssaker. Sammen med pob Finn Abrahamsen har de kommet frem til radikalt nye rutiner. Drivkrefter og motkrefter i arbeidet for barnas beste.

Psykolog Magne Raundalen. Tema: Bedre hjelp til barn som lever med vold i familien.

Politioverbetjent Eva Gaukstad fra Agder har utarbeidet en plan sammen med helsetjenesten for behandling av mishandlingssaker. Tema: Politiets rolle i samhandlingen.

Prosjektleder Marianne Borgen fra Redd Barna. Tema: Vennligst forstyrr!-kampanjen, hjelper den?

Hvordan bør helsetjeneste, barnevern og politi samhandle? Sakkyndigrollen er i sin natur helt forskjellig fra behandlerrollen. En behandler skal behandle skader så det ikke blir varig mén. En sakkyndig skal vurdere skader opp mot et oppgitt hendelsesforløp med spørsmålsstillingen: «Stemmer historien?«

Førsteamanuensis MD PhD, Arne Stray-Pedersen har gått nye veier i forskningen omkring skademekanismer. Tema: Kan kollisjonsdukker anvendes for å belyse hendelsesforløp?

Møtet avsluttes med en plenumsdiskusjon der foredragsholderne deltar. The English part of the Soria Moria meeting, October 8-10 One of the most exciting sessions during the Soria Moria meeting 2008 was addressed difficult cases from all over the world. Child maltreatment is extremely difficult to investigate since the perpetrators often are the only witnesses. We will gather experts from different fields: forensic pathologists, paediatric pathologists, neuropathologists, radiologists, neurosurgeons, paediatricians in the discussion. We invite you to submit problem cases. The last Soria Moria meeting was a milestone in the world for a common classification of sudden unexpected death in infancy (SUDI). In this issue of Scand J Forens Sci the discussion during the Soria Moria meeting and later input from the participants and the members of ISPID, summerized in an article by Blair, Byard and Fleming. During the Soria Moria meeting 2009, we hope to reach final consensus as to classification. New research has always been focused during the 20 years of Soria Moria meetings. We therefore invite researchers in the field of sudden death in infants and small children, and in stillbirths to submit abstracts. Welcome to Soria Moria 2009! For more information:

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Leica FS M New Forensic Comparison Macroscope The new Leica FS M forensic comparison macroscope provides superior optical and mechanical performance to forensic scientists. Offering flexibility, convenience, and user comfort, the Leica FS M is the universal instrument for high-precision firearm and toolmark examinations. The highly stable comparison bridge, the ergononmic design and the highest optical performance combined with versatile illumination options makes this system ideal for the simultaneous observation of evidence during training and consultation.

Living up to Life

No. 1, 2009  

Scandinavian Journal of Forensic Science, no.1 2009