Optimization of Postprocessing parameters for abdominal Forensic CT scans

Aim

Postmortem Computed Tomography (PMCT) is gradually introduced at forensic institutes. Image reconstruction software can increase diagnostic potential in CT by increasing distinction between structures and reduction of artifacts. The aim of this study was to develop and evaluate novel image reconstruction parameters for postmortem conditions, to increase image quality and diagnostic potential of CT scans.

Method

Twenty PMCT scans of deceased hereof two in severe decay were subjected to four reconstruction techniques: a standard reconstruction algorithm, the detail reconstruction algorithm and two novel algorithms based on the standard algorithm, but with different Hounsfield settings. Image quality was evaluated by visual grading analysis (VGA) by four forensic radiologist observers.

Results

The VGA did not prove that any of the reconstruction techniques were superior to the others. For standard and detail, the two pre-defined reconstruction algorithms, VGA scores were indiscernible and were superior to the equally indiscernible Hounsfield reconstructions on parameters translated into Sharpness and Low Contrast Resolution. The two alternative Hounsfield settings were superior with respect to Noise and Artifacts/Beam Hardening.

Conclusion

The study elucidates the possiblity for multiple reconstructions specialized for PMCT conditions, to accommodate the special conditions when working with the deceased. Despite the lack of clear improvements in the tested reconstructions, this study provides an insight into some of the possibilities of improving PMCT quality using reconstruction techniques.

Significantly reduced rates of interpersonal violence in an urban Danish population 2003-2021

This study aimed to describe changes in annual incidence rates and the severity of deliberate interpersonal violence based on hospital and forensic data in a Danish urban population 2003-2021. Included in the study were local victims of violence admitted to Odense University Hospital and/or subjected to medico-legal autopsy at the Institute of Forensic Medicine, University of Southern Denmark from 2003 to 2021. Based on population counts, we estimated overall and gender specific annual incidence rates in different age groups. For the 14,788 victims included in the study, the gender-specific incidence rates were 5.7 for males and 2.4 for females per 1000 population/year. The incidence rates decreased almost fourfold for both genders in all age groups. In both gender, the incidence rate of violence involving mild injuries decreased significantly, whereas incidence rate of violence involving severe injuries remained unchanged over the study period. The proportion of superficial lesions decreased and the proportion of wounds, bone fractures, and deep lesions increased. The proportion of victims with injuries from knifes increased from 3.0 to 5.4% in the study period. Overall, 0.3% died from their injuries. The present study showed a significant decreased in the incidence rate of violence based on hospital and forensic data. The decrease involved solely victims with less severe injuries. We recommend studies combining hospital, forensic, and police data.

Hymenal transections in children found by photocolposcopy in suspected sexual abuse cases is associated with a history of bleeding

OBJECTIVE

To investigate the difference in selected variables between children with and without hymenal transection, which is a healed defect that extends through the entire depth of the posterior hymenal membrane to the vaginal wall.

MATERIALS AND METHODS

All female children from Southern Denmark who were examined by photocolposcopy in a six-year period were included in a retrospective cohort study. Statistical analyses included a chi-square test and a logistic regression analysis.

RESULTS

Eighty girls under 15 years of age who were suspected to have been sexually abused were included. Sixteen of the girls had hymenal transections. There was a statistically significant correlation between the presence of hymenal transections and reported fresh bleeding after the assault.

CONCLUSION

Bleeding after an assault could indicate more severe lesions, which might explain why these patients did not heal completely.

Stranger rape; distinctions between the typical rape type and other types of rape. A study based on data from Center for Victims of Sexual Assault

OBJECTIVE

The aim of this descriptive cohort study was to characterize stranger rape compared to other types of rape.

METHOD & MATERIALS

All cases of women aged 12 years or older, who contacted a Center for Victims of Sexual Assault in the region of Southern Denmark and underwent a forensic examination in 2018, were collected and analyzed. Descriptive frequencies, Pearson's χ²-test and Fisher's exact-test were performed.

RESULTS

Compared to other types of rape, stranger rape were reported to the police more frequently, earlier and more frequently independently, without contact to family, friends or other authorities. In cases of stranger rape women were exposed to threats and violence more often, and clinical findings were found to coincide with the women's report more frequently. Regarding the offenders' level of planning, it was not possible to find significant differences between stranger rape and other rape types by comparing frequencies of the offenders' use of condoms and weapons and/or other remedies as surrogate markers for degree of planning.

CONCLUSION

There were several significant characteristic differences between stranger rape and other types of rape. Characterizing the 'archetypical rape' in opposition to other and more frequent types of rape, may give the public, the police, the courts and aid organizations the background needed to understand the importance of rape typologies when handling cases of sexual assault.

Increased risk of fatal intoxication and polypharmacy among psychiatric patients at death

Patients suffering from psychiatric disorders have an excess mortality and a shorter life span expectancy compared to the general population. Furthermore, they are treated with multiple drugs and are known to have an increased risk of drug abuse. In this study, we aimed at investigating the pharmaceutical drug and drug of abuse profiles of the deceased included in the Danish prospective autopsy-based forensic study on psychiatric patients, SURVIVE. Using the postmortem systematic toxicological analysis results, we identified 129 different consumed compounds in our population (n = 443). Polypharmacy (≥5 compounds) was detected in 39.5% of the deceased. Deceased with a psychiatric diagnosis or who died from a fatal intoxication had significantly more compounds at the time of their death compared to having either no psychiatric diagnosis or another cause of death, respectively. Evidence of drug abuse was present, as 29.8% of our total population had consumed either methadone or illicit drugs of abuse, excluding tetrahydrocannabinol. Of those deceased with a psychiatric diagnosis, 33.6% had either consumed methadone or illicit drugs of abuse, a greater number than those without a psychiatric diagnosis. Fatal intoxication was the most frequent cause of death (40.6%) with methadone as the major intoxicant. Here, we found that those without a psychiatric diagnosis had fewer fatal pharmaceutical drug intoxications compared to the psychiatric diagnosis groups. Our findings add further context to understanding the excess mortality of psychiatric patents, since there is an increased occurrence of fatal intoxication, polypharmacy, and drug abuse in this population.

[Findings in post-mortem CT and autopsy in a 53-year-old-man with COVID-19]

In this case report, a 53-year old man died after ten days with fever and coughing and was tested positive for coronavirus disease 2019 (COVID-19). A post-mortem CT disclosed ground-glass opacities with focal consolidation in both lungs. At autopsy, the lungs were dark and heavy with increased consistency and without pleural fibrin. Microscopy of lung tissue showed diffuse alveolar damage with hyaline membranes, sparse chronic interstitial inflammation and foci of bronchopneumonia. The deceased was a non-smoker, who did not suffer from a serious illness. He was overweight (BMI = 34 kg/m2), an emerging predictor for poor outcome of COVID-19.

Statement of the Independent Forensic Expert Group on Conversion Therapy

Conversion therapy is a set of practices that aim to change or alter an individual's sexual orientation or gender identity. It is premised on a belief that an individual's sexual orientation or gender identity can be changed and that doing so is a desirable outcome for the individual, family, or community. Other terms used to describe this practice include sexual orientation change effort (SOCE), reparative therapy, reintegrative therapy, reorientation therapy, ex-gay therapy, and gay cure. Conversion therapy is practiced in every region of the world. We have identified sources confirming or indicating that conversion therapy is performed in over 60 countries. In those countries where it is performed, a wide and variable range of practices are believed to create change in an individual's sexual orientation or gender identity. Some examples of these include: talk therapy or psychotherapy (e.g., exploring life events to identify the cause); group therapy; medication (including anti-psychotics, anti- depressants, anti-anxiety, and psychoactive drugs, and hormone injections); Eye Movement Desensitization and Reprocessing (where an individual focuses on a traumatic memory while simultaneously experiencing bilateral stimulation); electroshock or electroconvulsive therapy (ECT) (where electrodes are attached to the head and electric current is passed between them to induce seizure); aversive treatments (including electric shock to the hands and/or genitals or nausea-inducing medication administered with presentation of homoerotic stimuli); exorcism or ritual cleansing (e.g., beating the individual with a broomstick while reading holy verses or burning the individual's head, back, and palms); force-feeding or food deprivation; forced nudity; behavioural conditioning (e.g., being forced to dress or walk in a particular way); isolation (sometimes for long periods of time, which may include solitary confinement or being kept from interacting with the outside world); verbal abuse; humiliation; hypnosis; hospital confinement; beatings; and "corrective" rape. Conversion therapy appears to be performed widely by health professionals, including medical doctors, psychiatrists, psychologists, sexologists, and therapists. It is also conducted by spiritual leaders, religious practitioners, traditional healers, and community or family members. Conversion therapy is undertaken both in contexts under state control, e.g., hospitals, schools, and juvenile detention facilities, as well as in private settings like homes, religious institutions, or youth camps and retreats. In some countries, conversion therapy is imposed by the order or instructions of public officials, judges, or the police. The practice is undertaken with both adults and minors who may be lesbian, gay, bisexual, trans, or gender diverse. Parents are also known to send their children back to their country of origin to receive it. The practice supports the belief that non-heterosexual orientations are deviations from the norm, reflecting a disease, disorder, or sin. The practitioner conveys the message that heterosexuality is the normal and healthy sexual orientation and gender identity. The purpose of this medico-legal statement is to provide legal experts, adjudicators, health care professionals, and policy makers, among others, with an understanding of: 1) the lack of medical and scientific validity of conversion therapy; 2) the likely physical and psychological consequences of undergoing conversion therapy; and 3) whether, based on these effects, conversion therapy constitutes cruel, inhuman, or degrading treatment or torture when individuals are subjected to it forcibly2 or without their consent. This medico-legal statement also addresses the responsibility of states in regulating this practice, the ethical implications of offering or performing it, and the role that health professionals and medical and mental health organisations should play with regards to this practice. Definitions of conversion therapy vary. Some include any attempt to change, suppress, or divert an individual's sexual orientation, gender identity, or gender expression. This medico-legal statement only addresses those practices that practitioners believe can effect a genuine change in an individual's sexual orientation or gender identity. Acts of physical and psychological violence or discrimination that aim solely to inflict pain and suffering or punish individuals due to their sexual orientation or gender identity, are not addressed, but are wholly condemned. This medico-legal statement follows along the lines of our previous publications on Anal Examinations in Cases of Alleged Homosexuality1 and on Forced Virginity Testing.2 In those statements, we opposed attempts to minimise the severity of physical and psychological pain and suffering caused by these examinations by qualifying them as medical in nature. There is no medical justification for inflicting on individuals torture or other cruel, inhuman, or degrading treatment or punishment. In addition, these statements reaffirmed that health professionals should take no role in attempting to control sexuality and knowingly or unknowingly supporting state-sponsored policing and punishing of individuals based on their sexual orientation or gender identity.

Post-mortem toxicology in young sudden cardiac death victims: a nationwide cohort study

Aims

Several drugs increase the risk of ventricular fibrillation and sudden cardiac death (SCD). We aimed to investigate in detail the toxicological findings of all young SCD throughout Denmark.

Methods and results

Deaths in persons aged 1-49 years were included over a 10-year period. Death certificates and autopsy reports were retrieved and read to identify cases of sudden death and establish cause of death. All medico-legal autopsied SCD were included and toxicological reports collected. Positive toxicology was defined as the presence of any substance (licit and/or illicit). All toxicological findings had previously been evaluated not to have caused the death (i.e. lethal concentrations were excluded). We identified 620 medico-legal autopsied cases of SCD, of which 77% (n = 477) were toxicologically investigated post-mortem, and 57% (n = 270) had a positive toxicology profile. Sudden cardiac death with positive toxicology had higher rates of sudden arrhythmic death syndrome (SADS), compared with SCD with negative toxicology (56% vs. 42%, P < 0.01). In total, 752 agents were detected, and polypharmacy (defined as the presence of more than one drug) was present in 61% (n = 164), all substances combined. Psychotropic drugs were the most frequent (62%, n = 467), and 82% (n = 385) were in pharmacological or subpharmacological levels.

Conclusion

We found that more than half of all toxicologically investigated SCD victims have positive post-mortem toxicological findings, and polypharmacy is displayed in a considerable proportion. SCD with positive toxicology had higher rate of SADS, suggesting that the compounds may play a proarrhythmic role in these cases.

Homicide victims concealed in a freezer

Freezing as a method for hiding a body is rare. We report here a homicide case in which three bodies were concealed in a freezer. This presented the pathologist with the problem of how to thaw the bodies and simultaneously avoid decomposition of the uppermost body. The problem was solved by slow thawing in a refrigerated morgue and by removing the bodies one after the other from top to bottom. The victims were a 27-year old mother and her two daughters, 7 and 9 years of age. The perpetrator was the 34-year old now-divorced husband and father. All were refugees from Syria. The perpetrator fled back to Syria. He was later arrested in Syria, confessed the crime and was sentenced to life imprisonment. The autopsy findings is discussed and compared to finding reported in the scientific literature.

Unusual accidental decapitation in a road traffic incident

Decapitation is an occurrence only rarely encountered in forensic medical practice. This fatality is generally most often described in pedestrians who have been run over by trains accidently or in cases of suicide, or alternatively in occupants of cars involved in high speed vehicle collisions. We report, for the first time, a case of a complete decapitation of a pedestrian as a consequence of a traffic accident. Due to a thorough medico-legal investigation of the body and the involved vehicle, we were able to reconstruct the unique dynamics of the accident and the mechanism of injury.

Suffocation caused by plastic wrap covering the face combined with nitrous oxide inhalation

Suicide using a combination of a plastic bag over the head and inhalation of a non-irritating gas, such as helium, argon or nitrogen, has been reported in the literature. Here an unusual suicide method in a 17-year old man by suffocation from covering the face with household plastic wrap, combined with nitrous oxide inhalation, is presented. The case was reviewed based on police, autopsy and hospital reports. A PubMed search for scientific literature related to nitrous oxide abuse and suicide by suffocation was performed and our findings discussed in relation to the scientific literature found. The deceased was a 17-year old man who was found with the nose and mouth closed with a piece of kitchen plastic wrap. The plastic wrap had been removed prior to autopsy. Autopsy findings were suggestive of asphyxia, but were otherwise negative. Nitrous oxide was detected in the brain and lung tissue with headspace-gas chromatography-mass spectrometry (headspace-GCMS). The cause of death was assumed to be suffocation caused by plastic wrap covering the face, combined with nitrous oxide inhalation. Suicide was suspected because of a history of depression for several months. Nitrous oxide, also known as laughing gas, has a euphoric effect and is used as a recreational inhalant drug that can be purchased legally. Deaths caused by recreational nitrous oxide abuse are rare but may occur if used in combination with a plastic bag over the head. This is the first report of suicide by suffocation by external obstruction combined with nitrous oxide inhalation.

[The risk of death caused by cardioinhibitory reflex mechanism is very small]

Danish forensic reports concerning manual strangulation routinely state that any strangulation attempt may pose a danger to life due to a cardioinhibitory reflex mechanism. There are, however, only few case reports in which a cardioinhibitory reflex mechanism was stated as a possible cause of death. Carotid stimulation may induce syncope in patients with carotid sinus syndrome, but is not associated with increased mortality. Experiments with inflatable neck collars has not led to life-threatening arrhythmias. Neck holds used in martial arts are rarely associated with any complications.

Unexpected death caused by rupture of a dilated aorta in an adult male with aortic coarctation

Aortic coarctation (AC) is a congenital aortic narrowing. We describe for the first time the findings obtained by unenhanced post mortem computed tomography (PMCT) in a case where the death was caused by cardiac tamponade from a ruptured aneurysmal dilatation of the ascending aorta and the aortic arch without dissection combined with aortic coarctation. The patient, a 46-year-old man, was found dead at home. PMCT showed haemopericardium and dilatation of the ascending aorta and the aortic arch. This appearance led to the mistaken interpretation that the images represented a dissecting aneurysm. The autopsy showed instead a thin-walled and floppy dilatation of the ascending aorta and aortic arch with a coarctation just proximal to the ligamentum arteriosum. A longitudinal tear was found in the posterior aortic wall just above the valves. Blood in the surrounding soft tissue intersected with a large haematoma (1000ml) in the pericardial sac. Cardiac hypertrophy (556g) was observed in the patient, though no other cardiovascular abnormalities were found. Histological analysis showed cystic medial necrosis of the ascending aortic wall. A ruptured aneurysmal dilatation of the ascending aorta and the aortic arch without aortic dissection associated with AC is an uncommon cause of haemopericardium that has only been described a few times before. The case is discussed in relation to other reported cases and in the context of the present understanding of this condition.

The use of CT scanning in forensic autopsy

Postmortem computed tomography (CT) is being used more frequently in forensic medicine. This review discusses 100 deceased individuals who underwent CT scanning, as well as a standard autopsy. The CT scan was performed and interpreted by a forensic medicine specialist. In 11 cases, important findings discovered during the CT scan were not found at autopsy, and in 58 cases, important findings revealed at autopsy were not uncovered during the CT-scan. The cause of death could be established by the CT scan and external examination in 27%; by CT scan, external examination, and forensic chemistry in 32%; and by autopsy in 95% of the cases. CT scanning was most useful in cases of traumatic death. CT is rarely a substitute for autopsy, but may contribute important new information in cases such as identifications (particularly following mass disasters), battered children, gunshot wounds, traffic accidents, and air embolisms. CT provides documentation in digital form, which is easily stored and permits review by others. CT also provides pictures that may be more suitable for presentation in court than autopsy photos. CT scanning also would be helpful during a medicolegal external examination (inquest) in the process of selecting cases for autopsy.

[Sudden deaths by hobble restraint of severely hyperactive persons]

Cardiac arrest may occur while persons are being kept in hobble restraint. It has been suggested that asphyxia caused by the restraint position, so-called restraint asphyxia, is the cause, but experimental evidence has not confirmed this theory. Some of the sudden deaths are associated with excited delirium syndrome (EDS), an acute condition characterized by a hyperactive, combative behaviour in individuals, who are influenced by psychoactive drugs or suffer from psychiatric illness. Autopsy findings fail to explain this type of deaths. The pathophysiology of EDS is complex and poorly understood. Sensibilisation of the heart by a hyperadrenergic autonomous dysfunction, metabolic acidosis and hyperthermia offer possible mechanisms.

Interobserver agreement of the injury diagnoses obtained by postmortem computed tomography of traffic fatality victims and a comparison with autopsy results

The present study investigated the interobserver variation between a radiologist and a forensic pathologist in 994 injury diagnoses obtained by postmortem computed tomography (CT) of 67 traffic fatality victims, and the results were compared with diagnoses obtained by autopsy. The injuries were coded according to the abbreviated injury scale (AIS). We found a low interobserver variability for postmortem CT injury diagnoses, and the variability was the lowest for injuries with a high AIS severity score. The radiologist diagnosed more injuries than the pathologist, especially in the skeletal system, but the pathologist diagnosed more organ injuries. We recommend the use of a radiologist as a consultant for the evaluation of postmortem CT images. Training in radiology should be included in forensic medicine postgraduate training. CT was superior to autopsy in detecting abnormal air accumulations, but autopsy was superior to CT in the detection of organ injuries and aortic ruptures. We recommend a combination of CT and autopsy for the postmortem investigation of traffic fatality victims.

Intimate partner homicide

Intimate partner homicides represent the most severe outcome of intimate partner violence, and constitute more than a quarter (26%) of all homicides in adults over 15 years of age in Southern Denmark. In our experience the victims of partner homicides are primarily women, often from socially disadvantaged families, and that these homicides usually are the result of an impulsive act, with the perpetrator often committing suicide after the act. The aim of this study was to investigate these hypotheses further, and to provide an up-to-date overview of intimate partner homicides in Southern Denmark.

[Computerized tomography in forensic autopsies]

INTRODUCTION

Computerized tomography (CT) is finding increased use in forensic medicine. In this article we present our experience with CT in medico legal deaths.

MATERIALS AND METHODS

This is a retrospective investigation of 150 deceased individuals who were CT-scanned and autopsied. The CT-scanning was performed and interpreted by a specialist in forensic medicine. The CT-scanning and the autopsy were performed independently by two different physicians.

RESULTS

In 9% of the cases, important findings by the CT-scanning were overlooked at the autopsy, and in 51% important findings by the autopsy were not found by the CT-scanning. The cause of death could be established by CT-scanning in 30%, by autopsy in 72% and by toxicology in 21% of the cases. CT-scanning was most useful in cases of traumatic death.

CONCLUSION

CT is rarely a substitute for autopsy, but may contribute with important new information in many cases such as identifications (including mass-disasters), gunshot wounds and traffic accidents. CT provides documentation in digital form that is easily stored and copied, permits review by others and provides pictures that may be more suitable for presentation in court than autopsy photos. CT may be helpful in medico legal external examinations (inquests) in the process of selecting cases for autopsy.

[Children as victims of homicide 1972-2005]

INTRODUCTION

Child homicides are rare but serious crimes. In this study the homicide rate and the development in the crime pattern will be investigated.

MATERIAL AND METHODS

The investigation is retrospective and comprises the 34 years during which the Institute of Forensic Medicine in Odense has existed. During this period 41 children under the age of 15 were killed in 30 episodes.

RESULTS

The most frequent method of homicide was manual strangulation, and the second most frequent was blunt violence. It is demonstrated that the incidence of child homicide has decreased considerably compared to a previous investigation comprising all of Denmark. By far the largest decrease is in homicides committed by women against their own children, which have often been followed by suicide (family homicides). The decrease in family homicides committed by men is much less. Today men commit family homicides 8 times as frequently as women in the area under investigation.

DISCUSSION

A possible explanation for the decreasing number of homicides committed by women against their own children is the decreased use of gas for cooking, whereby a frequent homicide method disappeared, and by improved socio-economic life conditions and gender balance. Men are now responsible for the majority of family homicides. Preventative measures for men in socially traumatic situations such as a divorce are recommended.

[Fatal pulmonary thromoembolism]

INTRODUCTION

Fatal pulmonary thromboembolism is a relatively common autopsy finding. The aim of this investigation is to describe the magnitude of the problem in an autopsy material and factors of prophylactic importance and to discuss the importance of the autopsy.

MATERIAL

Deceased with lethal pulmonary thromboembolism diagnosed by forensic autopsy at the Department of Forensic Medicine at the University of Southern Denmark in 1992-2005, in total 58 individuals. Data were collected from autopsy- plus police reports and medical records.

METHOD

Descriptive case-only investigation.

RESULTS

The pulmonary embolism had in none of the cases been diagnosed before death. Two of the individuals in this investigation were healthy young females who used oral contraceptives, and one was a psychiatric patient who died from pulmonary embolism after five days of physical restraint.

CONCLUSION

The diagnosis is sometimes not made before the autopsy. The decreasing autopsy frequency may result in a lack of diagnosis of pulmonary embolism as cause of death.

Ethylene glycol poisoning

Ethylene glycol (EG) can be found in many agents, such as antifreeze. Ingestion of EG may cause serious poisoning. Adults are typically exposed when EG is ingested as a cheap substitute for ethanol or in suicide-attempts. Children may be exposed by accidental ingestion caused by decantation of EG to unlabeled bottles. EG has in itself a low toxicity, but is in vivo broken down to four organic acids: glycoaldehyde, glycolic acid, glyoxylic acid and oxalic acid. The metabolites are cell toxins that cause central nervous system depression, and cardio-pulmonary and renal failure. Glycolic acid causes severe acidosis, and oxalate is precipitated as calcium oxalate in the kidneys and other tissues. We present five case reports of fatal EG-poisoning, and review the literature concerning clinical presentation and diagnosis, pathological findings, treatment and prevention.

Forensic medical examination of refugees who claim to have been tortured

The United Nations Convention against torture prohibits repatriation of refugees if there is reason to believe they will be tortured on return to their country. A history of torture is therefore an important factor in making a case for asylum. In this study, the results of the medical examinations of 59 torture victims investigated at the Department of Forensic Medicine, University of Aarhus, Denmark, 1996-2002, are presented and discussed. Variables including age, sex, education, health, torture methods, condition of confinement, torture aftereffects, and findings at the forensic examination were registered in a database (Paradox) and analyzed. In 70%, aftereffects of torture could be documented. These included scars after fixation, burns, incisions, or flogging. Symptoms and signs from joints, muscles, and nerves were common in victims who had been suspended. Many of the victims of phalanga had painful feet and signs of walking impairment. A majority of the victims suffered from posttraumatic stress syndrome. An independent medical report offers an opportunity to evaluate and elaborate the story told by the victim and should be used in disputed cases. We have a duty to protect refugees against torture.

[Traumatic basal subarachnoid hemorrhage]

Massive subarachnoid hemorrhage may occur on a traumatic basis. The injury is most often sustained by a blow with a clenched fist against the posterolateral part of the cranial basis, but the injury may also occur in relation to an accident. The condition is rare, most often occurring in alcohol intoxicated men. The victim typically collapses immediately and usually dies within a few minutes. The origin of the bleeding may be the vertebral artery on the neck or the intercranial basal brain arteries. In some cases the origin of the bleeding cannot be located. The pathogenetic mechanisms have been a subject of discussion. The damage to the artery may occur in relation to a fracture of the transverse process of the atlas or in relation to subluxations in the cervical vertebral column. The arterial rupture may occur in both normal and abnormal arteries. In many of the cases the trauma may be very slight. This has, of course, important legal implications.

[Fatal accidents in house fires. The most significant causes, such as smoking and alcohol abuse, multiplied by four the incidence during the last 40 years]

A population-based descriptive investigation of housefire accidents in Denmark was carried out for the two five year periods 1953-58 and 1988-93, based on death certificates, police reports and autopsy reports. The number of deaths due to housefire accidents in Denmark has increased (1953-58: 136 (66 men and 70 women), 1988-93: 363 (212 men and 150 women), mostly due to an increase in tobacco-smoking related fire accidents. In 1988-93 the three common causes of housefire deaths were tobacco-smoking, often in combination with alcohol intoxication or handicap (51%), cooking-accidents (10%) and accidents with candles (9%). The largest risk groups were chronic alcoholics, handicapped and elderly people. In conclusion, warnings should be issued against smoking in bed and use of loose-fitting clothing while cooking on an open fire. Protective aprons and devices for use while smoking, self-extinguishing cigarettes and use of fireproof materials in furniture and clothing may prevent ignition. Smoke-alarms may secure early warning.

[Spread of teflon particles from periurethrally injected teflon paste to pulmonary tissue]

Periurethral injections of pyrolyzed teflon are used for control of urinary incontinence. Here a case is reported in which teflon-particles have spread from periurethrally injected teflon to pulmonary tissue. Teflon embolization to the lungs from artificial heart valves has previously been reported. The differences between these two forms of teflon-embolization are discussed. The risk of carcinogenicity is discussed.

[Helicobacter pylori]

Helicobacter pylori (HP) are Gram-negative spiral bacteria which occur in the human stomach. The bacteria were cultured in vitro for the first time in 1983. It is suspected that the bacteria may cause chronic gastritis of type B and may also be a contributory cause of chronic ulceration and cancer of the stomach. The bacteria are accompanied by characteristic inflammatory changes in the gastric mucosa. The significance for gastritis, chronic ulceration, non-ulcer dyspepsia and carcinoma of the stomach is discussed. HP occurs in a great proportion of the population of the world and the frequency increases with age. The route of infection is unknown but faecal-oral infection is probable. Correlation between the presence of HP and the occurrence of symptoms is poor in the individual patient. The bacteria can be demonstrated histologically, cytologically, by culture, by the urease test, by the urease expiration test or serologically. The bacteria are sensitive for a series of antibiotics and bismuth but no effective treatment is known as the recurrence rate is high.