The current state of forensic age estimation of live subjects for the purpose of criminal prosecution

In recent years, many countries have experienced a sharp increase in the demand for forensic age estimates of live persons. From a legal perspective, such age estimates are carried out to determine whether a suspect without valid identity documents has reached the age of criminal responsibility and whether general criminal law in force for adults applies. In many countries, the age thresholds of relevance to criminal prosecution lie between 14 and 21 years. In line with recommendations issued by the Study Group on Forensic Age Diagnostics for determining the age of live subjects in criminal proceedings, a forensic age estimate should combine the results of a physical examination, an x-ray of the hand, and a dental examination that records dentition status and evaluates an orthopantomogram. In addition, a radiological or computed tomographic examination of the clavicles is recommended to establish whether a person has attained 21 years of age. This article addresses the influence of ethnicity on the examined developmental systems. In so doing, the authors conclude that forensic age estimates should pay due heed to the proband’s socioeconomic status and ethnic origin.     

The hormonal and metabolic response to stress in the neonate

Conclusions It is apparent that adult patients demonstrate a catabolic response to the stresses induced by operative or accidental trauma. It seems that the degree of this catabolic response may be quantitatively related to the extent of the trauma or the magnitude of associated complications such as infection. The host response to infection, traumatic injury, or major operative stress is characterized by such events as fever, pituitary and stress hormone elaboration, mineral redistribution, and increased acute-phase protein synthesis [21].The beneficial effects of this stress response consist in providing alternate energy sources to meet metabolic demands and essential building blocks for synthetic activities occuring in the postoperative period. It has been suggested that the hyperglycemic response is essential for supplying the increased glucose requirements of injured tissue [81]. In addition, the proteolytic component of the stress response provides the necessary amino acid elements for reparative protein synthesis and production of acute-phase reactants by the liver. The changes in metabolic patterns induced by the stress response are satisfied in part by increased lipolysis and ketogenesis to provide an alternate source of metabolic fuel for tissues such as the brain and skeletal muscle. Additionally, the observed gluconeogenesis may aid in maintaining the glucose supply for vital organs principally dependent on glucose [52, 160].This metabolic response has also been shown to potentiate many adverse conditions in the postoperative period and to further exacerbate the stress response. Examples include a hypermetabolic state with attendant increased VO₂, increased energy requirements, increased temperature, elevated cardiac output, and altered or impaired inflammatory or immune-responsiveness. Numerous investigators have demonstrated that adult patients exposed to severe degrees of traumatic stress are subjected to greatly increased rates of complications such as cardiac or pulmonary insufficiency, myocardial infarction, impaired hepatic and/or renal function, gastric stress ulcers, and sepsis. Furthermore, evidence exists to suggest that this response may be life-threatening if the induced catabolic activity remains excessive or unchecked for a prolonged period. Moyer et al. were able to identify with a great degree of certainty the patients who were likely to die based on a single analysis of a variety of plasma-borne substrates obtained up to 9 days prior to death [103].It is apparent that modulating or blunting the catabolic response induced by the stress state may have beneficial effects. In studies of postoperative pain management, improved pain control resulted in reduction of postoperative nitrogen loss and shortened periods of convalescence following operation [28, 88].It is evident from this review that human newborns, even those born prematurely, are capable of mounting an endocrine and metabolic response to operative stress. Unfortunately, many of the areas for which a relatively well-characterized response exists in adults are poorly documented in neonates. As is the case in adults, the response seems to be primarily catabolic in nature because the combined hormonal changes include an increased release of catabolic hormones such as catecholamines, glucagon, and corticosteroids coupled with suppression of and peripheral resistance to the effects of the primary anabolic hormone, insulin.The catecholamines may be the agents of primary importance in this response, and thus may modulate the remaining components of the hormonal response to stress as well as the metabolic changes, including inhibition of insulin release, marked hyperglycemia, and breakdown of the neonate's stores of nutrients (carbohydrate, protein, and fat). These reactions ultimately result in the release of glucose, NEFA, ketone bodies, and amino acids. Although these metabolic by-products are necessary to meet the body's altered energy needs in a time of increased metabolic demands, it is not difficult to imagine that a severe or prolonged response would be very detrimental to a previously ill neonate with limited reserves of nutrients and already high metabolic demands imposed by rapid growth, organ maturation, and adaptation to the postnatal environment. Preliminary investigations by Anand et al. outlined in this review indicate that alterations in anesthetic technique with the addition of agents such as halothane and fentanyl may be able to significantly blunt this catabolic response. In addition, it appears that modulation of the immune response may also greatly affect the postoperative catabolic response. It is hopeful that future developments and the acquisition of more detailed knowledge o the response will allow us to modify the stress response in neonates in order to further decrease their mortality and morbidity.From the Section of Pediatric Surgery, C. S. Mott Children's Hospital and University of Michigan Medical School Offprint requests to: A. G. Coran     

From Deutsche Zeitschrift to International Journal of Legal Medicine—100 years of legal medicine through the lens of journal articles

The interruption of the publication of the Deutsche Zeitschrift für die gesamte gerichtliche Medizin due to the war ended with volume 39 for the years 1948/1949. Until volume 66/1969, the journal appeared unchanged under the historical title. The 912 publications contained in the 28 volumes of these two decades cover topics from the main fields of forensic medicine, but also from related and unrelated disciplines. The topic-specific analysis of the publications shows a shift of the research focus in the German institutes since the post-war period. This is most evident in the decline in the number of publications from the fields of scientific and technical criminalistics as well as forensic psychiatry and psychology. An opposite trend with a significant increase in scientific papers was observed in alcohology, forensic genetics and traffic medicine. While the evaluated publications on most topics contain new findings that are still valid today, the use of blood group characteristics for forensic purposes came to an end as a result of the introduction of DNA analysis.

     

Potentiation of Opsonization and Phagocytosis of Streptococcus pyogenes following Growth in the Presence of Clindamycin

Streptococcus pyogenes, bearing M-protein on its surface, resists opsonization by normal human serum and subsequent phagocytosis by human polymorphonuclear leukocytes. Previous studies have shown that M-protein positive organisms are poorly opsonized by the alternate pathway of complement. In an attempt to define further the role of the surface components of S. pyogenes in this process, we examined the ability of clindamycin, an antibiotic that inhibits protein biosynthesis, to alter bacterial opsonization.     

The key role of peptidoglycan in the opsonization of Staphylococcus aureus.

In an effort to determine the staphylococcal cell surface component(s) of importance in opsonization, cell walls (peptidoglycan and teichoic acid) and peptidoglycan were isolated from Staphylococcus aureus strain H grown in [3H]glycine-containing broth. After incubation of the cell walls and peptidoglycan with various opsonic sources, uptake by human polymorphonuclear leukocytes was measured. The opsonic requirements for phagocytosis of cell walls and peptidoglycan were found to be similar to those of intact bacteria. Removal of teichoic acid from the cell wall did not affect opsonization. Likewise, a teichoic acid-deficient mutant strain of S. aureus H was opsonized in a manner similar to that of the parent strain. Immunoglobulin G functioned as the major heat-stable opsonic factor and both the classical and alternative pathways participated in opsonization. Kinetic studies revealed that opsonization of peptidoglycan, as well as C3-C9 consumption by peptidoglycan, proceeded at a slower rate via the alternative pathway (C2-deficient serum) than when the classical pathway was present (normal serum). The ability of peptidoglycan to activate C3-C9 was significantly reduced when normal and C2-deficient sera were preabsorbed with peptidoglycan at 2 degrees C suggesting that antibodies to peptidoglycan may be involved in activation of both the classical and alternative complement pathways. Thus, peptidoglycan appears to be the key cell wall component involved in staphylococcal opsonization, and it is suggested that host response to peptidoglycan, a major cell wall component of most gram-positive bacteria, may be related to the development of "natural immunity" to this group of microorganisms.     

Unassisted smothering in a pillow

We report the case of a 33-year-old man admitted to a psychiatric hospital because of paranoid schizophrenia. The man was found dead lying in his bed with the face pressed against a pillow and with elevated buttocks. The autopsy did not reveal a cause of death. The histological findings displayed the signs of the haemorrhagic–dysoric syndrome with acute emphysema; these findings are pathognomonic of obstructive asphyxia. The adverse effects of the neuroleptics demonstrated by the toxicological findings may have accelerated the loss of consciousness and facilitated the unusual position of the body. On the basis of the clinical history, the autopsy findings, the histological features and the toxicological results, asphyxia due to smothering was diagnosed as the cause of death.     

Statistical analysis and verification of forensic age estimation of living persons in the Institute of Legal Medicine of the Berlin University Hospital Charité

In recent years, the increase in international migration movements has led to a greater demand for forensic age estimation of foreigners without valid identification documents in numerous countries. The growing importance of forensic age determination is underlined by a rapid rise in the number of expert reports by the Institute of Legal Medicine of the Berlin University Hospital Charité. A total of 247 expert opinions on estimated age were given between 1992 and 31 December 2000. Subject to formal court ruling, age is estimated based on the physical inspection, in combination with an X-ray of the left hand and the clavicles as well as dental assessment. However, the statistical proof of the range of scatter for the summarized age diagnosis still remains to be clarified in the context of this assessment procedure. The age estimations made by the Institute of Legal Medicine of the Berlin University Hospital Charité were statistically analyzed with respect to the validity of the different methods. For verification of the age diagnoses, the age estimates were compared with the court records and the age determined in the course of legal proceedings. In 45 cases, the age diagnoses could be verified. In all cases where the age could be verified beyond doubt, deviations from the actual age did not exceed +/-12 months. From this, it can be concluded that the combined application of the above-mentioned methods allows forensic age estimations with a sufficiently high degree of reliability.     

Age dependence of epiphyseal ossification of the distal radius in ultrasound diagnostics

By determining the ossification stage of the distal radial epiphysis, it is possible to gain important information to help clarify the question of whether various legally relevant age limits have been exceeded. Any examination of the hand by means of projection radiography such as that used in conventional skeletal age diagnostics is strictly regulated for reasons of radiation hygiene. In many areas of the law, there are no basic legal provisions authorising the performance of X-ray examinations. The present study examines the applicability of ultrasound diagnostics in assessing ossification processes in the distal radius. To this end, the ossification stages of the distal radial epiphysis were determined in 306 female and 309 male study participants aged between 10 and 25 years. In the female gender, ossification stage III was determined at an age of 13.4 years at the earliest, and ossification stage IV at 15.0 years at the earliest. In the male gender, ossification stage III was not observed until 14.3 years, and ossification stage IV not until 15.2 years. In the practice of forensic age estimation in living persons, sonographic examination of the distal radius in areas of application with no legal basis for authorising X-ray examinations makes it possible to improve the accuracy of age diagnosis by including criteria of skeletal maturation. In view of the existing legislative basis for the use of X-rays on human subjects, the exposure of individuals to radiation can be minimised.