Effectiveness of a Long-term Home-Based Exercise Training Program in Patients With COPD After Pulmonary Rehabilitation: A Multicenter Randomized Controlled Trial

BACKGROUND

Most patients with COPD do not maintain exercise training after pulmonary rehabilitation (PR).

RESEARCH QUESTION

Does a 12-month home-based, minimal-equipment strength training program after PR have an effect on dyspnea, exercise capacity, and patient-reported outcomes in patients with COPD?

STUDY DESIGN AND METHODS

In a parallel-arm multicenter study across four Swiss PR clinics, patients with COPD were allocated randomly (1:1 ratio) into an intervention group (IG; home-based strength training program) or control group (CG; usual care). The primary outcome was change in Chronic Respiratory Questionnaire (CRQ) dyspnea scale score from baseline to 12 months. Secondary outcomes were change in exercise capacity (1-min sit-to-stand-test [1MSTST], 6-min walk test [6MWT]), health-related quality of life, exacerbations, and symptoms. We assessed the IG's experience by interviews at study end. Main analyses were based on the intention-to-treat approach, and adjusted linear regression models were used.

RESULTS

One hundred twenty-three patients with COPD (IG, n = 61; CG, n = 62) were randomized, 61 of whom were women and whose mean ± SD age was 66.8 ± 8.1 years and mean ± SD FEV₁ was 39.3 ± 15.3% predicted. One hundred four participants completed 12 months of follow-up (IG, n= 53; CG, n= 51). Of the 53 IG participants, 37 participants (70%) conducted the training until study end. We found no difference in change in CRQ dyspnea scale score over 12 months (adjusted mean difference, 0.28; 95% CI, -0.23 to 0.80; P = .27). We found moderate evidence for a difference in 1MSTST repetitions favoring the IG (adjusted mean difference, 2.6; 95% CI, 0.22-5.03; P = .033), but no evidence for an effect in other outcomes. Seventy-nine percent of the IG reported positive effects that they attributed to the training.

INTERPRETATION

The home exercise program had no effect on dyspnea, but improved 1MSTST performance and patient-perceived fitness. The supported program was well accepted by patients with COPD and may facilitate continued exercise training at home.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT03461887; URL: www.

CLINICALTRIALS

gov.

P02-11 Effectiveness and implementation of a long-term home-based exercise training programme using minimal equipment in COPD patients: A multi-centre randomised controlled trial

Background

Although exercise training is an important component of pulmonary rehabilitation (PR) in chronic obstructive pulmonary disease (COPD), a majority of COPD patients fails to maintain training after PR. This study aimed to evaluate the effectiveness and implementation of a 12-months home-based, minimal equipment strength exercise programme.

Methods

Parallel arm, multicentre study across four Swiss PR clinics, random allocation of COPD patients (1:1 ratio) into intervention (IG) or control group (CG, usual care). Primary outcome was change in dyspnoea (Chronic Respiratory Questionnaire, CRQ) from baseline to 12-months, secondary outcomes change in exercise capacity (1-minute-sit-to-stand-test [1-min-STST], 6-minute-walk-test [6MWT]), health-related quality of life, exacerbations and symptoms. Main effectiveness analyses were based on the intention-to-treat approach and adjusted linear regression models were used. To assess the implementation outcomes dose, reach, fidelity, adherence, acceptability and appropriateness, we conducted interviews with patients, coaches and stakeholder and analysed reports, diaries and notes.

Results

123 patients (IG: 61, CG: 62) were randomised, 61 females, mean (SD) age 66.8 (8.1) years, and 104 participants completed 12-months follow-up (IG: 53, CG: 51). Of 53 IG participants, 37 (70%) conducted the training until study end. We found no difference in change of CRQ dyspnoea over 12 months (adjusted mean difference 0.28, 95% CI -0.23-0.80, p = 0.27). We found moderate evidence for a difference in 1-min-STST repetitions favouring the IG (adjusted mean difference 2.6 (95% CI 0.22-5.03, p = 0.033) but no evidence for an effect in other outcomes.

All involved groups perceived the strength-training exercises as appropriate, efficient for COPD patients and relevant to maintain improvements after PR. The patients' most important facilitators for long-term motivation were self-perceived improvement in strength, supervision by a coach and integration of the training in daily routine. Based on these insights, we redesigned and reworded the training material and introduced three new exercises.

Conclusions

The exercise program had no effect on dyspnoea but improved 1-min-STST performance and patient-perceived fitness. The results from the insights of the involved persons enabled us to optimize the program for sustainable further use in clinical and other settings and inform the future design of patient-centred home-based exercise programs in COPD.

First report of a blaVIM-1 metallo-β-lactamase-possessing Klebsiella michiganensis

OBJECTIVES

Klebsiella michiganensis is an emerging pathogen. Like Klebsiella pneumoniae, this species is able to acquire antibiotic resistance genes (ARGs) via mobile genetic elements. In this context, K. michiganensis isolates producing carbapenemases of KPC, NDM, IMP and OXA-48-like types have already been reported. Here we characterised a strain (BD-50-Km) isolated from a rectal swab of a Turkish patient hospitalised in Switzerland.

METHODS

Species identification was initially performed using MALDI-TOF/MS. Antimicrobial susceptibility testing was done by the microdilution method. Whole-genome sequencing (WGS) was performed with both Illumina and Nanopore platforms and was used to confirm species identification, to characterise plasmids and to perform core-genome analyses.

RESULTS

BD-50-Km was initially identified as Klebsiella oxytoca and showed reduced susceptibility to imipenem. However, WGS indicated that the isolate was actually K. michiganensis. BD-50-Km carried the bla_VIM-1 gene associated with a rare class 1 integron (In87) located on a pST1 196 kb IncC plasmid. This plasmid shares its backbone with many other IncC plasmids found in different species (including five K. michiganensis), but not the same In87 and the remaining region harbouring various ARGs. BD-50-Km belongs to the novel ST342. Moreover, core-genome analysis (single nucleotide variant analysis) showed that BD-50-Km was not closely related to any K. michiganensis strains deposited in NCBI (n = 212), including the 38 so far reported as possessing carbapenemase genes.

CONCLUSION

This is the first report of a bla_VIM-possessing K. michiganensis clinical isolate. The spread of plasmid-mediated VIM carbapenemases in this emerging pathogen represents an additional threat to our therapeutic armamentarium.

Diagnosis, Prevention and Treatment of Stable COPD and Acute Exacerbations of COPD: The Swiss Recommendations 2018

The Swiss National Guidelines 2013 for chronic obstructive pulmonary disease have been revised in order to acknowledge recent progress in diagnosis and management of this disease. The resulting new Swiss recommendations are based on best evidence from the literature, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2018 report and other published national guidelines. Misdiagnosis of chronic obstructive pulmonary disease is common and means that patients do not always receive optimal treatment. To improve the management of patients with chronic obstructive pulmonary disease in Switzerland, these recommendations encourage a more comprehensive assessment of patients, based on the combined assessment of symptoms, degree of airflow limitation, risk of exacerbation and the presence of comorbidities. Recommendations for evidence-based preventive measures, as well as pharmacological and non-pharmacological strategies for the management of both stable and acute exacerbations of chronic obstructive pulmonary disease are provided in this update.

Indacaterol and glycopyrronium versus indacaterol on body plethysmography measurements in COPD-a randomised controlled study

BACKGROUND

Dual bronchodilator therapy is recommended for symptomatic patients with chronic obstructive pulmonary disease (COPD). There are limited data on effects of a combination of two long-acting bronchodilators on lung function including body plethysmography.

METHODS

This multicentre, randomised, double-blind, single-dose, cross-over, placebo-controlled study evaluated efficacy and safety of the free combination of indacaterol maleate (IND) and glycopyrronium bromide (GLY) versus IND alone on spirometric and body plethysmography parameters, including inspiratory capacity (IC), forced expiratory volume in 1 s (FEV₁), forced vital capacity (FVC), total lung capacity (TLC) and airway resistance (Raw) in moderate-to-severe COPD patients.

RESULTS

Seventy-eight patients with FEV₁ % pred. (mean ± SD) 56 ± 13% were randomised. The combination of IND + GLY versus IND presented a numerically higher peak-IC (Δ = 0.076 L, 95% confidence interval [CI]: -0.010 - 0.161 L; p = 0.083), with a statistically significant difference in mean IC over 4 h (Δ = 0.054 L, 95%CI 0.022 - 0.086 L; p = 0.001). FEV₁, FVC and Raw, but not TLC, were consistently significantly improved by IND + GLY compared to IND alone. Safety profiles of both treatments were comparable.

CONCLUSION

The free combination of IND + GLY improved lung function parameters as evaluated by spirometry and body plethysmography, with a similar safety profile compared to IND alone.

TRIAL REGISTRATION

NCT01699685.

Diagnostic accuracy of methacholine challenge tests assessing airway hyperreactivity in asthmatic patients - a multifunctional approach

BACKGROUND

There are few studies comparing diagnostic accuracy of different lung function parameters evaluating dose-response characteristics of methacholine (MCH) challenge tests (MCT) as quantitative outcome of airway hyperreactivity (AHR) in asthmatic patients. The aim of this retrospectively analysis of our database (Clinic Barmelweid, Switzerland) was, to assess diagnostic accuracy of several lung function parameters quantitating AHR by dose-response characteristics.

METHODS

Changes in effective specific airway conductance (sG_eff) as estimate of the degree of bronchial obstruction were compared with concomitantly measured forced expiratory volume in 1 s (FEV₁) and forced expiratory flows at 50% forced vital capacity (FEF₅₀). According to the GINA Guidelines the patients (n = 484) were classified into asthmatic patients (n = 337) and non-asthmatic subjects (n = 147). Whole-body plethysmography (CareFusion, Würzburg, Germany) was performed using ATS-ERS criteria, and for the MCTs a standardised computer controlled protocol with 3 consecutive cumulative provocation doses (PD₁: 0.2 mg; PD₂: 1.0 mg; PD₃: 2.2 mg) was used. Break off criterion for the MCTs were when a decrease in FEV₁ of 20% was reached or respiratory symptoms occurred.

RESULTS

In the assessment of AHR, whole-body plethysmography offers in addition to spirometry indices of airways conductance and thoracic lung volumes, which are incorporated in the parameter sG_eff, derived from spontaneous tidal breathing. The cumulative percent dose-responses at each provocation step were at the 1^st level step (0.2 mg MCH) 3.7 times, at the 2^nd level step (1 mg MCH) 2.4 times, and at the 3^rd level step (2.2 mg MCH) 2.0 times more pronounced for sG_eff, compared to FEV₁. A much better diagnostic odds ratio of sG_eff (7.855) over FEV₁ (6.893) and FEF₅₀ (4.001) could be found. Moreover, the so-called dysanapsis, and changes of end-expiratory lung volume were found to be important determinants of AHR.

CONCLUSIONS

Applying plethysmographic tidal breathing analysis in addition to spirometry in MCTs provides relevant advantages. The absence of deep and maximal inhalations and forced expiratory manoeuvres improve the subject's cooperation and coordination, and provide sensitive and differentiated test results, improving diagnostic accuracy. Moreover, by the combined assessment, pulmonary hyperinflation and dysanapsis can be respected in the differentiation between "asthmatics" and "non-asthmatics".

Influence of procalcitonin on decision to start antibiotic treatment in patients with a lower respiratory tract infection: insight from the observational multicentric ProREAL surveillance

Procalcitonin (PCT)-guided antibiotic stewardship is a successful strategy to decrease antibiotic use. We assessed if clinical judgement affected compliance with a PCT-algorithm for antibiotic prescribing in a multicenter surveillance of patients with lower respiratory tract infections (LRTI). Initiation and duration of antibiotic therapy, adherence to a PCT algorithm and outcome were monitored in consecutive adults with LRTI who were enrolled in a prospective observational quality control. We correlated initial clinical judgment of the treating physician with algorithm compliance and assessed the influence of PCT on the final decision to initiate antibiotic therapy. PCT levels correlated with physicians' estimates of the likelihood of bacterial infection (p for trend <0.02). PCT influenced the post-test probability of antibiotic initiation with a greater effect in patients with non-pneumonia LRTI (e.g., for bronchitis: -23 % if PCT ≤ 0.25 μg/L and +31 % if PCT > 0.25 μg/L), in European centers (e.g., in France -22 % if PCT ≤ 0.25 μg/L and +13 % if PCT > 0.25 μg/L) and in centers, which had previous experience with the PCT-algorithm (-16 % if PCT ≤ 0.25 μg/L and +19 % if PCT > 0.25 μg/L). Algorithm non-compliance, i.e. antibiotic prescribing despite low PCT-levels, was independently predicted by the likelihood of a bacterial infection as judged by the treating physician. Compliance was significantly associated with identification of a bacterial etiology (p = 0.01). Compliance with PCT-guided antibiotic stewardship was affected by geographically and culturally-influenced subjective clinical judgment. Initiation of antibiotic therapy was altered by PCT levels. Differential compliance with antibiotic stewardship efforts contributes to geographical differences in antibiotic prescribing habits and potentially influences antibiotic resistance rates.

Optimised patient transfer using an innovative multidisciplinary assessment in Kanton Aargau (OPTIMA I): an observational survey in lower respiratory tract infections

BACKGROUND

Current medical scores have limited efficiency and safety profiles to enable assignment to the most appropriate treatment site in patients with lower respiratory tract infections (LRTIs). We describe our current triage practice and assess the potential of a combination of CURB65 with proadrenomedullin (ProADM) levels for triage decisions.

METHODS

Consecutive patients with LRTIs presenting to our emergency department were prospectively followed and retrospectively classified according to CURB65 and ProADM levels (CURB65-A). Low medical risk patients were further subgrouped according to biopsychosocial and functional risks. We compared the proportion of patients virtually allocated to triage sites with actual triage decisions and assessed the added impact of ProADM in a subgroup.

RESULTS

Overall, 93% of 146 patients were hospitalised. Among the 138 patients with available CURB65-A, 17.4% had a low medical risk indicating possible treatment in an outpatient or non-acute medical setting; 34.1% had an intermediate medical risk (short-hospitalisation); and 48.6% had a high medical risk (hospitalisation). Fewer patients were in a low CURB65-A class (I) than a low CURB65 class (0,1) (17.4% vs. 46.3%, p <0.001). Mean length of hospitalisation was 9.8 days including 3.6 days after reaching medical stability. In 60.3% of patients, hospitalisation was prolonged after medical stability mainly for medical reasons.

CONCLUSIONS

Current rates of hospitalisation are high in patients with LRTI and length of stay frequently extended beyond time of medical stabilization. The lower proportion of patients reclassified as low risk by adding ProADM to the CURB65 score might improve confidence in the triage algorithm.

Pulmonary Mycobacterium sherrisii infection in a human immunodeficiency virus type 1-infected patient

We report the first case of a pulmonary infection with Mycobacterium sherrisii in a patient with advanced human immunodeficiency virus infection. Mycobacterium sherrisii is a newly described nontuberculous mycobacterium related to Mycobacterium simiae. Sequencing of the 16S rRNA gene was used for species identification. Treatment and antibiotic susceptibilities are described.

Determination of firing distance using the rhodizonate staining technique

The histological staining technique using rhodizonate is also effective for the determination of the firing distance by examining the distribution and intensity of the staining reaction. The differentiation between absolute close-range shots and long-range shots is generally possible without any doubt. The method is not recommended for routine examinations but it is very useful for cases lacking the possibility to investigate smoke and powder deposits in a criminalistic manner, i.e. surgical skin biopsies of hospitalised victims and skin highly altered by the effects of fire, water or by post-mortem decomposition.

Temperature variations in automobiles in various weather conditions. An experimental contribution to the determination of time of death

From January 1995 through March 2000, temperatures in the passenger compartment of automobiles of different sizes were measured under varying weather conditions (sunshine, cloudy skies, rain) at two locations in eastern Switzerland. During the cold season, the interior temperature rose to 21 degrees C when cars were exposed to sunshine, whereas in summer interior temperature extremes of up to 89 degrees C were recorded. Make, model, and color of the vehicles were of only minor influence.

["Crow's feet wrinkles" as a sign of preserved consciousness]

We report on 3 deaths after the influence of high voltage current, fire and traumatic injury respectively. In all cases we found radial bands beside the eyes--so called "crow's feet". They are a sign of vital reaction in the cases of traumatic and thermic injury, possibly also in high-voltage burns due to sparking. In general, the "crow's feet" show that the person was conscious at the moment of the event.

[Death by burning in open spaces. Death caused by suicide or homicide?]

The authors report on four cases of suicidal fire deaths in the open air. In three cases the proper cause of death was severe burning and in one case deep cuts of the neck. In all these events the concentrations of CO-Hb were < 30%. Kerosene was indicated in lipophile tissue or lung in two cases. There was no evidence of incapacitation preceding the exposition to fire. The autopsy findings and the scene allowed a reconstruction of the course of events. All victims had motives of suicide. The authors conclude that close cooperation between police, fire experts and forensic medicine is necessary to permit a correct classification of the mode of death in such cases.

[Methane in cadaver blood--homicide by natural gas or postmortem formation?]

A man had a quarrel with his wife. Suddenly he collapsed and became cyanotic. The woman supposed him to be dead. Because she was afraid of familiar requital, she opened the gas-cock of the cooking-range to pretend a suicide; methane emitted. The autopsy revealed a fresh cardiac infarction. Postmortem chemical analysis established methane in the blood. The question was, whether the methane had any importance for the death. By experimental inhalation of a methane-air-mixture (3%) we could expose, that the methane concentration in postmortem blood didn't have any relevance for the death.

[Using muscle histology for assessment of vitality in hanging]

The external and internal signs of vitality of hanging were often absent in a retrospective study of 55 cases of hanging. The histological examination of the cervical muscles however revealed in the majority of the cases "vital" changes in the muscle fibres, e.g. segmental or discoid fragmentation of the muscle fibres with loss of the sarcoplasmatic cross-striation. The histological examination is therefore a valid instrument for proofing the vitality of hanging and other forms of strangulation.

[Medical procedures in gunshot injuries]

In this paper the basic knowledge about the morphology of gunshot wounds is presented, which should help the physician to answer the most important questions imposed on a criminal case. The paramount measures to be taken are the documentation of the gunshot wounds, the excision of the injury and separate debridement of each lip of the wound, the careful observation of the projectile, the cataloging of the victim's clothes and the omission of cleaning the hands of the victim. Some forensic aspects are demonstrated, particularly the professional discretion respectively the obligation to notify the authorities.

[Confusing muscular hemorrhage in a drowned cadaver. A contribution to differentiation between vital and postmortem changes]

The autopsy on an body recovered from the water showed evidence of drowning and, in addition, the occurrence of extensive intramuscular bleeding on the neck, in the area of the shoulder girdle and the upper arms. There was a suspicion that criminal violence had been used, and the police carried out extensive investigations; these were inconclusive. The subsequent histological examination of the affected musculature revealed "reactive" changes throughout which corresponded to post mortem damage. The case presented here serves to illustrate the usefulness of muscle histology for differentiating between the occurrence of intramuscular bleeding before and after death; the corresponding histological criteria are outlined.

Measurement of the skin temperature at the entry wound by means of infrared thermography. An investigation involving the use of .22- to .38- caliber handguns

This study examines the temperatures at the point that bullets impact human skin. With the assistance of infrared thermography, measurements were taken after shots were fired by .22-, .25-, .32-, .38-special-caliber, and 9-mm Luger pistols and revolvers. The highest temperature readings at the entry point were recorded with the .22 caliber and the lowest with the .32 caliber. The measurement of projectile temperatures in flight resulted in readings of 147 degrees-152 degrees C for the 9-mm Luger.

[Ethanol content of Kefir water]

The question of the influence of kefir on blood-alcohol-level has been asked in a legal proceeding. The questioned recipe consisted of 21 water, 6 soup-spoons of kefir granules (about 120 g), 150 g sugar, 2 figs and one lemon. The consumption took place after two days of fermentation. Experimentally we found, that one liter of this kefir product may contain up to 38 g/l ethanol after 7 to 10 days. On the second day we measured up to 16 g/l ethanol. Our results may be import for expert appraisements concerning unability of driving.

[Carboxyhemoglobinemia caused by dichloromethane exposure with dermatologic effects]

In seven winter seasons a young watchmaker was severely disabled by the development of swelling and reddening of the skin, blistering and paraesthesiae affecting his hands. Hospital examination led to a diagnosis of "Raynaud syndrome of undetermined origin". Treatment with corticosteroids was unsuccessful. Not until the young man changed his job did the disorder disappear for good. Investigations at his place of work revealed that the man had inhaled dichloromethane fumes (methylenchloride; CH2Cl2) while cleaning watch parts in a small room that was not ventilated during the winter months. This led to endogenous carboxyneogenesis and subsequently to chronically recurring carboxyhaemoglobinaemia (13%, 10% and 10.7% COHb in three different blood samples). The significance of dichloromethane-induced CO poisoning in the development of dermatological changes is still the subject of controversial discussion.

[Epidural hematoma with atypical clinical course]

The prognosis of epidural haematomas (EDH) is generally favourable if an operation is carried out in good time. Suspected EDH is mostly diagnosed as a result of a "typical" neurological manifestation (initial unconsciousness/asymptomatic interval/loss of consciousness), which then leads to an in-depth diagnosis (X-ray of the skull, CT, MRI). However, atypical clinical manifestations are frequent and can result in dangerous delays in diagnosis and treatment. A decisive factor in the early detection of EDH is close clinical-neurological monitoring by specially trained staff and their prompt reaction when changes occur, no matter how minor. Qualitative changes in the patient's state of consciousness and behaviour are just as important in this respect as quantitative ones.

[Amputation of fingers or a hand. Accident or self-mutilation]

Among the high number of cases of hand injuries investigated each year by accident insurance companies, cases continually occur which give rise to the suspicion of attempted insurance fraud by means of purposely inflicted injuries. Such cases are often difficult to prove. Based on 3 case reports (amputation by means of a chain saw, a blow with an axe and a cutting machine), reconstruction at the place of the crime is shown to be extremely advantageous. The reconstruction of the crime is one of the most important evidential elements. It is recommended for all cases where there is any doubt.

[Death sounds--a postmortem phenomenon]

"Death sounds" are monotonous sounds produced by a corpse without rigor mortis. Such sounds may be mistaken for signs of life, which may be of importance under criminal aspects. Three relevant cases are discussed.

[Iatrogenic methadone poisoning]

Two young drug addicts received in the course of their treatment a 10-fold overdose of methadone by error. One person died, the other was severely intoxicated but survived. The cause for the mistreatment was the unawareness of the medical personnel, that did not realize the change in concentration of the methadone stock solution from 0.1% to 1.0%, provided by the pharmacy. To prevent such mistakes in the future a change in labelling of the bottle giving directions for correct dosing is suggested.

[Fatal exsanguination from a small venous injury]

Report on a 34 year old man who bled to death sitting in an empty bath-tub by suicidal cutting in his groin. The source of the bleeding was a small lesion of the femoral vein with a diameter of 2 mm. No endogenous or exogenous coagulopathies could be established.

[Xanthogranuloma of the choroid plexus of the lateral ventricle (case report)]

We report on a case of a 59-year old man. During work he died suddenly and unexpectedly. Autopsy revealed myocardial infarction as cause of death. We also found symmetrical granulomatous proliferations proceeding from choroid plexuses of the lateral ventricles of the brain. Results of histological and chemical investigation proved the tumours to be xanthogranulomas. Despite their unusual size they did not cause any neurological or psychiatric symptoms. The patient had been known to have hypercholesterinemia for years.

[Separation of stomach contents using the sieve-tower technique]

The authors present a method to separate and preserve stomach contents for forensic purpose. Analysis by "sieve tower" technique is simple and quickly done during autopsy. Solid phases of stomach content are arranged size up and can be stored for subsequent examinations. With the fluid phase drug analysis or microscopic analysis to confirm identy of the foodstuffs may be done. By adding alcohol (70%) enzymatic digestion and bacterial degradation of the stomach content are stopped.

[The "inner gunshot residue"--a gunshot entry marker in gunshot of ridged skin]

Gunshot residue below the surface of the skin is typical of a contact gunshot wound. However, in a case of our own, when a taxi-robber was shot by the cab driver through his right hand at a distance of several yards, this finding provoked quite a confusion. Only when experimental shots at thick glabrous skin were performed, it could be established that long range shots led to intraepidermal gunshot deposit too. The explanation of this phenomenon lies in the tenacity of thick skin. Unlike the thin hairy skin, which is punched out by the penetrating projectile, the thicker and more tenacious plantar/palmar epidermis gets displaced radially, the stratum germinativum tears and the projectile casts its gunshot residue in the pouch formed in such a manner. Therefore, intraepidermal gunshot residue is proof of an entrance gunshot wound but not always a sign of contact shot if the wound is located in the palmar or plantar region. It is typically produced by shots at thick skin.

["Self-asphyxia"--a forensic medicine-criminal challenge]

In judicial and police circles - sometimes even in circles of medical professionals - it is still often thought that suicidal strangulation by ligature is impossible. Reviewing the forensic literature we could find more than 200 cases that have been published earlier. We report another 4 cases of suicidal strangulation. The main problems of criminalists and medical examiners in such cases are discussed. Primary investigation of the corpse in original position by a forensic scientist is of high importance.

[Changes in skeletal muscles in death caused by hypothermia]

The review of 32 deaths resulting from hypothermia yielded mostly the common pathological findings as bright red livores, haemolytic frost marks of the skin and Wichnewski erosions of the gastric mucosa. In addition the muscle system of the body core (musc. ileopsoas) showed hemorrhages and histologically necrosis of its fibres in form of segmental and discoid sarcoplasmatic alteration. These changes are a quite specific sign of death due to hypothermia, as far as mechanical injury can be excluded. For best result however a special autopsy technique and an appropriate histological staining are advisable.

[Homicide by asphyxia--yes or no? On the use of muscle histology]

In two cases of death autopsy revealed large hemorrhages in the muscles of the neck, which lead to the conclusion of a murder by strangulation, e.g. with a soft tool. Histologic examination of the injured muscles didn't show any sign of vital reaction, which means, that they had developed post mortem. There was no reason for further suspicion of a violent crime. Later it became obvious, that neck lesions resulted from inadequate recovery and transport of the corpses. "Vital" type of muscular alteration is characterized by segmental or disk-like fragmentation of muscle fibres, loss of sarcoplasmatic cross-striation and appearance of pathologic longitudinal fibrillar structures. These signs are missing in case of a postmortal injury, whereas the cross striation is intact. The slides should be stained with PTAH. With these two cases we would like to demonstrate the importance of histologic examination of injured muscles, when question for intravital or postmortal injury rises.

[Myocardial dysplasia of the right ventricle (Uhl's anomaly) as a possible cause of sudden, unexpected death]

Partial absence and fatty replacement of the myocardial compacta of the right ventricular wall was observed in five young male adults, four of whom died suddenly and unexpectedly and one in a car accident. In one of these cases there was only one coronary orifice. Four cases of the so-called Uhl anomaly had histological findings indicating dysmorphic myocardial cells associated with minimal lymphohistiocytic infiltrates within the fatty tissue. In one case, chronic destructive inflammation was a prominent feature. Marked dysmorphic alterations in the myocardial fibers suggested the occurrence of arrhythmic episodes as the main cause of sudden heart failure and death.

[Unusual clinical forms of extrapleural (epipleural) hematoma on the chest x-ray]

Two cases of extrapleural hematoma, proven during autopsy, are presented. Plain chest films did not demonstrate the typical signs of an extrapleural mass lesion. The roentgenologic differential diagnosis of a free or partially encapsulated pleural effusion and the pathogenesis of extrapleural hematoma are discussed.

[Death by peroral ingestion of soluble glass (sodium silicate)]

The intake of 0.51 of water glass (sodium metasilicate; colloid pH 12.5) led to death within 1-1.5 h. Autopsy revealed alkali burns of the stomach mucosa. The stomach contained a small amount of liquid with a pH of 11.5. Histologically, numerous bronchioles and alveoles were filled with amorphous material. This material was chemically proved to be condensed water glass. The obstruction of large parts of the lungs by water glass led to an inhibition of alveolar gas diffusion, which may have been the cause of death. The transformation of the water glass from liquid to solid occurred in the lungs by means of the carbonic acid of expiration air. This was made possible because the pH of water glass had been changed by gastric secretions from 12.5 to 11.5. Water glass starts to solidify around pH 11.4-11.3.

Continuous microbiological and pathological study of 70 sudden and unexpected infant deaths: toxigenic intestinal clostridium botulinum infection in 9 cases of sudden infant death syndrome

As part of a programme to exclude infection as the cause of death in infants who died suddenly and unexpectedly necropsies were carried out on 70 such infants. In 11 cases (15%), a pathological diagnosis could be made at necropsy; in 9 of these, causative bacteria or viruses were found. The 59 cases in which the cause of death could not be found had histological features characteristic of sudden infant death syndrome (SIDS). Botulinum toxin was found in 9 SIDS cases (15%). 8 of these infants had botulinum toxin and organisms of different types (A, B, C, F, G) in the contents of the ileojejunum or colon. 4 of them also had toxin in the serum. No botulinum toxin or organisms were found in the 11 infants who died of identified causes or 18 other infants who died in hospital of known causes.

[Formation of epidermal damage at entry by gunshot with a contact weapon]

Examination of contact bullet wounds shows the patterned inprint of the muzzle on the skin ("stanzmark") and further ragged structures around the periphery to be the remainders of the abraded epithelium. Usually these are turned outwards and from arch-shaped intraepithelial recesses, which contain residual amounts of propellant. The damage and soiling around the point of entry are the result of two factors in combination: the combustion gases and the gases escaping between the skin surface and the front of the barrel. This leads to different amounts of skin abrasion dependent on the amount and pressure of the gases. In this way, the frequently seen difference in size and shape of the stanzmark and the muzzle front can be explained.

[Suicide by cutting the radial artery of the wrist. Report of 2 cases]

Suicide attempts made by cutting the wrist artery (A. radialis et ulnaris) are usually unsuccessful if the vessel wall or blood clotting has not changed pathologically. Fatal exsanguination, however, can also result even if the arteries are not completely severed crosswise--which is usually not the case--but are instead slit open lengthwise or partially severed crosswise. For this reason, the invagination processes of the artery stumps controlled by the elastic structure of the vessel walls and consequently the spontaneous arterial hemostasis are obstructed. The importance in establishing the type and position of the cut artery is demonstrated by means of an exactly dissected model limb.

[Intrapartum death or infanticide? A contribution to intrapartum asphyxia]

On occasion of the autopsy of a 32-34-week-old fetus delivered with fetal membrane intact (caul/amnion birth), heavy hypoxic changes in the cardiac muscle, the liver and the kidney epithelia were found. On the other hand, there was no sign of aspiration although a sign of aspiration was to be expected, as the fetus was lying in the amniotic fluids. The systematic examination of 68 cases of intrapartal deaths of various causes demonstrated that intrapartal aspiration in the amniotic fluid only takes place, when the function of the umbilical cord is obstructed. If pressure is lacking, as for example, in amniotic (fluid) substances, or meconium, in the respiratory tract is either found not at all, or only in small quantities. For the purposes of forensic medicine, this means that death by intrapartal asphyxia can also be assumed when findings demonstrate simultaneously that aspiration is absent and hypoxic changes of the organs are present.