[Methods of health economic evaluation for health services research]

On August 30, 2010, the German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e. V. (DNVF e. V.)] approved the Memorandum III "Methods for Health Services Research", supported by the member societies mentioned as authors and published in this Journal [Gesundheitswesen 2010; 72: 739-748]. The present paper focuses on methodological issues of economic evaluation of health care technologies. It complements the Memorandum III "Methods for Health Services Research", part 2. First, general methodological principles of the economic evaluations of health care technologies are outlined. In order to adequately reflect costs and outcomes of health care interventions in the routine health care, data from different sources are required (e. g., comparative efficacy or effectiveness studies, registers, administrative data, etc.). Therefore, various data sources, which might be used for economic evaluations, are presented, and their strengths and limitations are stated. Finally, the need for methodological advancement with regard to data collection and analysis and issues pertaining to communication and dissemination of results of health economic evaluations are discussed.

[At first a clear case: homicide by injury to the neck]

Reported is of a 33 year old female found dead in the basement of her home, manifesting strangulation/throttling marks on the neck. The attack on the throat was, however, not cause of death but a CO intoxication. This woman was killed by direct inhalation of 99% carbon monoxid administered by her husband (via a mask or hose). The carbon monoxid was obtained from a gas cylinder normally used for medical purposes.

[Ultrafiltration, an efficient method for purification of DNA from stains]

Isolating DNA from stains all pollutions are extracted, too. Restriction of the DNA can be prevented. After phenol extraction the DNA had been ultrafiltered. Photometrically measurement and fingerprinting showed, that the disturbing substances are removed.

[Quantitative determinations of Hp, Pi, Tf and GC in stored blood stains]

Quantitative analysis of serum proteins in blood stains by rocket immunoelectrophoresis showed the following results: Long elution times in processing blood stains do not produce a significantly higher yield of serum proteins in stains, and they increase the risk of structural alteration of protein molecules. The amount of proteins detected decreases with increasing age of blood stains. Some proteins are already altered in stains after a short storage time and are no longer useful for phenotyping. Our results confirm that blood stain material should be processed as soon as possible.

[Forensic medicine and criminalistics]

The supplementary designation "criminalistics" in the title of certain forensic medical institutes in the first half of this century is to be regarded as a reaction to faulty developments in our specialty, which almost led to the elimination of forensic medicine as an independent scientific discipline in the 1960s. The ability to think in terms of criminalistics and the corresponding working procedures has always been a crucial precondition for the forensic physician, since forensic medicine is the application of medical knowledge for juridical purposes. Forensic medicine originated with the appraisal of cases of violent death by doctors, i.e., reconstruction of the facts in the case. To use the term "criminalistics" in the form of a supplementary designation is thus not required. An attempt is nevertheless made to define "medical criminalistics" as a small but important component of criminalistics. They are subdivided into two phases: the first part begins at the scene of the crime or the place of discovery (local evidence). Here, the trained eye of the forensic physician is indispensable to the criminal investigation department and the prosecutor. Medical criminalistic thinking and working procedures continue at the autopsy. Here, forensic autopsy differs from that practiced by the pathologist. Without knowledge of the situation at the discovery location, the forensic physician runs the risk of not recognizing facts that are important for reconstruction and thus becoming a "destroyer of clues". The second part of medical criminalistics is the actual detection of medical clues, i.e., the investigation of medical clues with special methods, including histological and toxicological investigations.(ABSTRACT TRUNCATED AT 250 WORDS)

[Sources of error in the determination of transferrin in frozen blood samples and blood stains]

Frozen or stored blood samples often show bands in the D-area of transferrin. These alterations can be misinterpreted as D-variants. The alterations do not appear in separated serum. Isoelectric focusing of dried blood traces shows changes in the Tf-subtype system that may lead to misinterpretations.

[Hair disease or the effect of heat (fire)?]

We found alterations in the ends of a man's hair, changes that were suspected of being incendiary. The hair ends were dull, but there were no typical macroscopic signs of alteration by heat; yet the microscopic findings were clear. Spindle-shaped changes in the hair were interpreted at first as heat damage but could be explained as the results of hair-setting lotion.

[Determination of questionable suicide as a homicide by studies of criminal stains]

In a woman found dead with cuts on both arms in a domestic sauna plastered with blood were assumed next to a bleed to death. The question self-infliction or by a third party of arm injuries could not be decided. By investigation of blood traces only could be clarified the cause of death. The husband had strangled his wife and inflicted several cuts on both arms with a razor blade to simulate suicide. Afterwards, he also inflicted several cuts on himself with a razor blade with the intention of suicide. He survived these injuries.

[Dependability of ABO findings in stored blood samples]

Report on the occurrence of "acquired" A or B in stored blood samples. This bacterial alteration is of importance when an indirect experimental investigation with the absorption-elution technique is needed in advanced cases of hemolysis. One has to consider this disturbing factor in identification tests (alcoholic blood samples). In dried blood stains we did not notice this problem, but it has to be taken into account in genitals stains.

[Detection of gamma globulin and Inv markers in vaginal secretions]

The Gm 1, Gm 2, and Inv 1-factors in the vaginal secretion are in accordance with the corresponding serum features to be expected basically. Deviations are possible. They are either caused by interference factors in the vaginal secretion or other factors which are not, however, always detectable in each case. It is important to test in advance the appropriate dilutions for the particular antiserum charges and to examine extracts of the samples to find out whether they have the necessary concentration.

[Detection of hereditary enzyme characteristics in vaginal secretion]

Upon investigation of semen- and blood-free vaginal swabs using starch gel electrophoresis the Phosphoglucomutase type was clearly identified in about 40%. Using cellulose acetate membrane electrophoresis PGM could not be demonstrated. In all cases the results correspond with those obtained in blood. No relation was found between secretor type (determined in saliva) and PGM typing. In vaginal material the following could not be determined: Adenylatkinase (AK) using starch gel electrophoresis, Esterase D (EsD) using cellulose acetate membrane electrophoresis, and Glyoxalase I (GLO) using agarose gel thin-layer electrophoresis.

[Medical secrecy and the pathologist's obligation of notification (author's transl)]

The pathologist, like every other doctor, is pledged to secrecy. The pledge of secrecy also extends to what he has found in the body of the deceased be they secrets of the patient or of a third party. Third party secrets are not protected by the obligation of secrecy if safequarding them would be against the "projected interests of the patient". The present obligation to notify according to the burial laws of some states applies to pathologists even when possible medical contributary faults are established, but he faces a dilemma which cannot be solved juridically at present. Alteration of the law should take this into account.

[The detection of gamma globulin and Inv-factors in semen and saliva and of haptoglobins in semen (author's transl)]

Gm- 1-, 2-, and Inv 1-factors can be demonstrated in semen and saliva. For the examination of traces it is necessary to verify the suitable dilutions for the different charges of antisera and to test the eluates of the samples if they have a sufficient concentration. We observed some incorrect negative results in seminal and saliva stains which were apparently caused by insufficient material. The demonstration was independent of the secretor type. Haptoglobin could not be determined in semen and saliva.

[The detection of inherited enzyme polymorphism in semen (author's transl)]

Our investigation of the occurrence of the enzymes phosphoglucomutase (PGM), glutamate-pyruvate-transaminase (GPT), adenylatkinase (AK), adenosine-desaminase (ADA), and 6-phophogluconate-dehydrogenase (6-PGD) produced the following results: The phosphoglucomutase type was demonstrated in the most sperm samples and seminal stains in accordance with the corresponding blood type. This enzyme is rather stable and could still be demonstrated well in 1-month old stains. The glutamate-pyruvate-transaminase can only seldom be determined in semen and seminal stains. We only found the GPT 1 type, which is known to have usually the strongest activity. The adenylatekinase was demonstrable in the most fresh ejaculates (not older than 24 h) and in about half the seminal stains (not older than 7 days)--The AK--2-band gets weak with increasing lay days, which may lead to incorrect determinations. The adenosine-desaminase could not be determined in sperm. On the contrary, 6-phosphogluconate-dehydrogenase could be demonstrated in fresh semen samples and also partly in seminal stains up to 7 days. The demonstration of the enzymes did not depend in any system on the secretor type.

Carboxyhaemoglobin and methaemoglobin findings in burnt bodies

The often observed absence of carboxyhaemoglobin in burnt (charred) bodies is re-discussed in the light of two new cases in which the inhalation of very hot gases obviously led to reflex breathing and circulation arrest. (Macro and microscopic evaluations of the upper respiratory tract can give significant information as to whether a person was still alive at the time of the fire outbreak.) In the cadaver blood of people who survived a given period after a fire, high methaemoglobin values (up to 37%) were found. This was caused by the inhalation of nitrogen oxides that were produced by burning plastic.

[On the proof of MN-differentiation from blood samples (author's transl)]

1. The results of MN testing are--so far as the factor N is concerned--especially in the case of older samples to be used only with caution. 2. The provision for a reliable result demands several good sera that have been previously used in testing and found to be satisfactory. 3. It is especially necessary to work with two different methods. The mixed agglutination method is no longer reliable in cases of months-old or very dryly stored samples.

[Influencing factors of previous testing on blood determination (author's transl)]

The demonstration of individual characteristics, especially those of the blood group types are substantially disturbed through the hydrogenperoxide- and the luminol spray procedure, which when it is previously employed, can cause changes in the blood spot. These changes are expecially by very small blood spots to be expected, but even larger ones under intensive spraying can be effected. Only with great caution are such spray procedures to be used and then only if it is impossible any other way to gather information about the existance of blood spots.

[Forensic dentistry as an important part of legal medicine]

Forensic dentistry is divided into two main subjects: 1. Dental jurisprudence and ethics and 2. Dental criminology. Dental jurisprudence and ethics include the legal duties of the dentist. They concern foremost the contractual relations between him and the patient and the duties which result from his actual dental activities, especially concerning his therapeutic measures. In major disasters successful identification is possible if a careful register is taken of dental states by all dentists.

[Demonstration of hemoglobin using the porphyrin test (author's transl)]

The demonstration of hemoglobin after its transformation into Porphyrin is specific and extremely sensitive. It is possible to detect amounts as small as a microgram. The use of sulphuric acid as a reagent is superior to the hydrochloricthioglycol acid method. After obtaining a speciman from a blood stain (usually through soaking) it is recommended that it be concentrated by allowing the speciman once again to dry out. Prejudicial effects due to the extreme sensitivity of this test are therefore avoided.

[Concerning evidence of parathion (E 605) in an exhumed corpse after 21 months (author's transl)]

In a corpse exhumed after 21 months evidence of E 605 could still be found in the stomach and in the intestinal contents after isolation by steam distillation, extraction with either followed by identification with palladium chloride reagent, as well as by thin layer chromatographicenzymatic detection. A ccording to investigation and analysis, the dose of E 605 administered in the present murder case should have but slightly exceeded the lethal dose.