Armin Fieguth

Body and head position, covering of the head by bedding and risk of sudden infant death (SID)

Abstract We examined the position of the body and head, and the covering of the head by bedding on discovery in cases of sudden infant death (SID) in Lower Saxony. Between 1.1.1986 and 31.12.1992 structured, questionnaire-based interviews were carried out with parents of 140 SID victims. Control data were taken from a population-based cross-sectional study on infant sleeping position performed by the German Health Office (BGA) in autumn 1991. Of the SID cases 86.4% were discovered in the prone position [odds ratio (OR) = 7.4, 95% confidence interval (CI) = 4.3, 12.7] and 41.4% were found with the head covered. These infants were significantly older than those where the head was uncovered (p < 0.001) and covering of the head showed a significant association with a risk of SID (OR = 20.8; 95% CI = 11.5–37.6). Of the SID cases 27.9% were discovered in the face-down position. These infants were significantly younger than the infants who were discovered with the head in a side or supine position (p < 0.001). This study confirms the increased risk of SID associated with the prone position and suggests that this association could be related to the development of hypoxaemia or hypercapnia. Together with other factors such as heat stress or an infection, hypoxaemia or hypercapnia could culminate in SID if the arousal from sleep and auto-resuscitation apparently fails.

Lethal child neglect

The jurisdiction of the Hannover Institute of Legal Medicine recently experienced an unusually high incidence of lethal child neglect, with three cases in a 5-month period in 1999. Case 1: A girl received an inappropriate and inadequate diet of tea and oatmeal. The child was never breastfed, nor did it ever receive any other formula. The parents report the infant to have been healthy until she suddenly began projectile vomiting at the age of 13 weeks. For the next 3 days the infant was not able to maintain an adequate intake. The mother reports finding the child dead in its bed on the morning of the fourth day. Attempts by medical personnel to revive the child were unsuccessful. Case 2: A mother began spoon-feeding the infant puree on the fourth day of life, which according to the manufacturers specifications is suitable for children between 4 and 8 months of age. At the age of 5 weeks, the infant was reported to have vomited half the just previously ingested meal, after which she took a nap. Some time later the parents observed the infant to be quite pale, however, assumed this was a result of sleep. When the mother finally did pick her up, the child was lifeless, and the parents brought her to the hospital. Medical personnel could however, only declare the infant dead, documenting a rectal temperature of 30 degrees C. Case 3: A 3.5-year-old girl died after her mother left the locked apartment and did not return for several weeks. The body of the child was found lying dressed on the floor in a state of advanced decay and mummification. Common findings in all three cases include lack of prenatal care, home birth without the help of a midwife, low socioeconomic status or maternal alcohol abuse, body weights below the 3rd percentile, extreme dehydration, fatty hepatic degeneration, thymic atrophy and signs of aspiration.

The time-dependent expression of fibronectin, MRP8, MRP14 and defensin in surgically treated human skin wounds.

Fibronectin, MRP8, MRP14 and defensin were detected immunohistochemically in 46 surgically treated, fresh (hours old) human wounds and in wounds of 13 individuals who died immediately from fatal trauma (airplane crashes or train rollovers). In immediate fatal trauma, it was not possible to detect fibronectin outside of bleeding areas nor could inflammatory cells be visualized in the interstitium using MRP8, MRP14, or defensin antibodies. Fibronectin staining could be regularly demonstrated in wounds at least 20 min-old. Granulocytic infiltrates limited to the perivasal space could be detected 20-30 min after infliction of the wound expressing MRP8, MRP14 and defensin. It was also possible to detect fibronectin networks and MRP8-, MRP14-, and defensin-positive granulocytes and macrophages in particular wounds up to 30 days-old. No differences between the expression of MRP8 and MRP14 could be demonstrated in the wounds, the majority of which were only several hours old. As wound age increased, the number of defensin-positive granulocytes detected decreased. The immunohistochemical detection of fibronectin is a useful way to demonstrate vitality in fresh wounds, beginning about 20-30 min post-trauma. However, detection of MRP8, MRP14 and defensin provides no advantage over the routine histological detection of granulocytes and macrophages in wounds under 1-2 days old.

Fatal trauma to the neck: immunohistochemical study of local injuries

As fatal trauma to the neck is often associated with short survival times, proof of vitality may often be difficult using standard histochemical techniques. Soft tissue neck injuries resulting from strangulation by ligature or manual strangulation were examined immunohistochemically using antibodies to myoglobin, fibronectin, C5b-9 and MRP14, and compared to controls consisting of accidental soft tissue neck injuries as well as undamaged neck soft tissue. Although survival times in the study and control groups were unknown and certainly some individual variation may be expected in the time course of normal wound development, both the study and control groups demonstrated similar time courses in the immunohistochemical detection of antigen. Myoglobin was always found in those samples in which only one antigen was shown to be involved in an injury-specific pattern; myoglobin and fibronectin were found in samples with dual antigen involvement. Samples involving three antigens always included C5b-9 in addition to myoglobin and fibronectin. The single positive MRP14 sample in the study and control groups was simultaneously positive for the other markers used. Myoglobin, fibronectin, C5b-9 and MRP14 are therefore suitable for immunohistochemical detection of vital reactions and estimation of temporal relationships in the early posttraumatic period after neck trauma.

Intracartilaginous haemorrhagic lesions in strangulation

Abstract. This case control study was designed to investigate if laryngeal haemorrhages occur in cases of strangulation and whether these lesions are specific to strangulation. In the study 30 larynxes from victims of fatal strangulation were examined (7 cases of manual strangulation, 12 cases of ligature strangulation, 11 cases of combined manual and ligature strangulation). The control group comprised 40 cases of death without any neck injuries and another group consisted of 5 cases of death caused by trauma with findings of non-strangulation neck injuries. In all the groups, only four solitary haemorrhages (two cases, one control, one non-strangulation neck injury) were observed that did not occur in the proximity of areas of blood accumulation. The results of our investigation suggest that histological evidence of blood accumulation or of haemorrhages in thyroid cartilage is not a reliable criterion to distinguish between haemorrhagic lesions due to strangulation and other types of blood accumulation or artefacts.

Aneurysma dissecans – keine so seltene Erkrankung@@@Aortic Dissection – a Not so Rare Disease

ZusammenfassungHintergrund und Ziel:Akute Aortendissektionen stellen eine lebensbedrohliche Erkrankung mit einer hohen Mortalitätsrate dar. Durch eine Spaltbildung der aortalen Wandschichten mit nach distal fortschreitender Wühlblutung können eine Vielzahl von unterschiedlichen und wechselhaften Symptomen auftreten. Aortendissektionen erfordern eine unverzügliche Diagnosestellung und Therapie.Methodik:Am Institut für Rechtsmedizin der Medizinischen Hochschule Hannover wurden in den Jahren 2006 bis 2009 34 Verstorbene mit einem Aneurysma dissecans obduziert. Die Fälle wurden retrospektiv analysiert.Ergebnisse:Die Mehrzahl der verstorbenen Personen (55,9%) hatte unmittelbar vor dem Tod einen Arzt aufgesucht. Nur in einem Fall konnte ein disseziierendes Aortenaneurysma verspätet diagnostiziert werden.Schlussfolgerung:Ein hohes Maß an klinischem Verdacht auf das Vorliegen einer Aortendissektion ist für die richtige Diagnosefindung erforderlich. Ursächlich kommen auch hereditäre Erkrankungen (Marfan-Syndrom, Ehlers- Danlos-Syndrom, Loeys-Dietz-Syndrom) in Betracht. Bei allen ungeklärten Todesfällen von jungen Erwachsenen sollte eine Obduktion durchgeführt werden, um die Todesursache zu klären und im Falle einer vorliegenden Aortendissektion eine genetische Testung und Information der Familienmitglieder vornehmen zu können.AbstractBackground and Purpose:Acute aortic dissection is a life-threatening disease with a high rate of mortality. The dissection of the artery with a distal blood flow can explain the variable and changeable symptoms. Aortic dissections require immediate diagnosis and therapy.Methods:In the Institute of Legal Medicine of the Hannover Medical School, 34 cases of aortic dissection were found during autopsy between 2006 and 2009. The cases were analysed retrospectively.Results:In the majority of cases (55.9%) an antemortem medical consultation has taken place. In only one case an aortic dissection could be diagnosed at a later time.Conclusion:Key in the managment of acute aortic dissection is to maintain a high clinical index of suspicion for this diagnosis. Etiologically hereditary diseases (Marfan syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome) should be taken into consideration as a possible cause. In all unexpected deaths of young adults an autopsy should be performed to detect the cause of death and for genetic testing to provide information for the relatives in case an aortic aneurysm can be found.