T. Bajanowski

Bed sharing and the risk of sudden infant death syndrome: can we resolve the debate?

OBJECTIVEnTo conduct a meta-analysis on the relationship between bed sharing and sudden infant death syndrome (SIDS) risk.nnnSTUDY DESIGNnData from PubMed and Medline were searched for studies published after Jan 1, 1970. The search strategy included articles with the terms sudden infant death syndrome, sudden unexpected death, and cot death with bed sharing or co-sleeping. To further specify the potential risk of bed sharing and SIDS, subgroup analyses were performed.nnnRESULTSnEleven studies met inclusion criteria and were included in the final meta-analysis. The combined OR for SIDS in all bed sharing versus non-bed sharing infants was 2.89 (95% CI, 1.99-4.18). The risk was highest for infants of smoking mothers (OR, 6.27; 95% CI, 3.94-9.99), and infants <12 weeks old (OR, 10.37; 95% CI, 4.44-24.21).nnnCONCLUSIONSnBed sharing is a risk factor for SIDS and is especially enhanced in smoking parents and in very young infants.

German study on sudden infant death (GeSID): design, epidemiological and pathological profile

The German study on sudden infant death (GeSID) is a multi-centre case-control study aiming at the assessment of etiological factors and risk factors of SIDS. This report describes the study design and the methods applied and presents some general findings. Between 1998 and 2001, 455 cases of sudden and unexpected death of infants aged between 8 and 365 days were recruited into the study. The study comprised at least 11 out of the 16 German states with 18 centres involved. In 1999 and 2000, 75% of all SIDS cases registered with the Federal Office of Statistics (ICD 10/R95, n=384) in the study area were recruited into the study (n=286). A standardised autopsy including extended histology, microbiology, virology, toxicology and neuropathology investigations was carried out. Of the parents 82% (n=373) agreed to fill in an extensive questionnaire containing 120 questions reflecting all important aspects of the infant’s development. For each SIDS case, the parents of three living control infants were interviewed. These controls were matched for age, gender and region (n=1,118). The response rate of the controls was 58.7%. Data were linked with medical records obtained from obstetrics departments, the children’s hospitals, and general practitioners. Death scene investigation was performed in 4 study areas (cases: n=64, controls: n=191). All cases were classified into one of 4 categories using defined criteria: 7.3% of the children were assigned to category 1 (no pathological findings: SIDS), 61.1% to category 2 (minor findings: SIDS+), 20.4% to category 3 (severe findings: SIDS+) and 11.2% to category 4 (findings which explained the death: non-SIDS). In case conferences the previous history and circumstantial factors were included and an extended category (E-cat.) was defined. The consideration of these factors for the final classification is of great importance in the causal explanation of some cases. An analysis of 18 main variables in cases of categories 1–3 (SIDS) compared to the cases of category 4 (non-SIDS) showed significant differences for the sleeping position, coughing the day before death and breast-feeding indicating that the cases of both groups should be separated for further analyses.

Incidence of alcohol dependence among drunken drivers

To discriminate alcoholics and non-alcoholics, individual Alc-Indices (determined by methanol, acetone, 2-propanol, gamma-GT and CDT-concentrations) were calculated in a collective of 327 alcohol-impaired drivers with regard to the blood alcohol concentration, the time of the event and the age of the drivers. Applying this new defined Alc-Index, 48% of the drivers investigated could be characterised as alcohol dependent. The prevalence of alcoholics among individuals with blood alcohol concentrations (BAC) higher than 1.9per thousand was more than 80%. The diagnostic value of alcohol concentrations for the recognition of alcoholics, considering the legal limit in Germany (1.1per thousand) as well as statistically calculated limits, were compared to the Alc-Index.

Proof of fatal air embolism

Venous air embolism is a rare cause of death. Entry of gas into the circulation is caused by trauma, mostly surgical or therapeutic, and sometimes resulting from criminal intervention. The detection of air embolisms requires special precautions during autopsy. An aspirometer has to be used for the detection, measurement and storage of gas originating from the heart ventricles. The aspirometer has to be filled completely with distilled water containing two drops of Tween 80 to reduce the surface tension of the water and to prevent adherence of small air bubbles to the wall of the aspirometer. Subsequently the gas has to be analysed by gas chromatography. When the results correspond with the main criteria defined by Pierucci and Gherson [2] the diagnosis “air embolism” is justified. The technique for the detection of air embolism is simple but requires a careful procedure which is described in detail.

Detection and analysis of tracers in experimental drowning.

Abstract In animal experiments, studies on the mechanisms involved in drowning were carried out using latex and gold tracers of defined size and concentration. The tracers were detectable by fluorescence microscopy (latex tracers) and by electron microscopy (gold tracers) in the lungs, kidneys and lymph nodes and were analysed further by X-ray microanalysis using a transmission scanning electron microscope. Tracers with small diameters were shown to penetrate intercellular gaps of the alveolar epithelium and the larger tracers were incorporated into the epithelial and endothelial cells by active pinocytotic mechanisms thus passing through the air-blood barrier. The detection and analysis of tracers in organs of the systemic circulation originating from the immersion fluid can assist in understanding the pathophysiology of drowning and in some selected cases, in making a more definitive diagnosis.

CMV-DNA detection in parenchymatous organs in cases of SIDS

A nested PCR approach has been developed especially for the detection of small amounts of cytomegalovirus (CMV) DNA in autopsy samples. Lung tissue and submandibular glands in 118 cases of infant death (92 SIDS cases, 13 natural deaths due to other defined causes and 13 unnatural deaths) were investigated by this technique and compared to the results obtained by other CMV detection methods (histology, immunohistochemistry, in situ hybridization and PCR). CMV-DNA could be detected in the lung tissue in 7 cases of SIDS using nested PCR. Compared to conventional PCR (3 positive cases in lung tissue) the nested approach always gave glear results and showed less additional bands. In all cases where CMV could be detected in the lungs, positive results were also obtained in the submandibular glands. The nested PCR method proved to be a more sensitive technique than the other detection methods including PCR and hot start, and. even minimal amounts of target DNA could be detected in the presence of human and bacterial background DNA.ZusammenfassungEs wurde eine nested PCR Methode speziell für den Nachweis geringer Mengen von Zytomegalievirus DNA in Autopsiematerial entwickelt. In 118 plötzlichen Todesfällen von Säuglingen und Kleinkindern (92 SIDS-Fälle, 13 natürliche Todesfälle anderer definierter Ursache, 13 nichtnatürliche Todesfälle) wurde Lungengewebe und Gewebe der Glandula submandibularis mittels dieser Technik untersucht und mit den Ergebnissen herkömmlicher Methoden (Histologie, Immunhistochemie, in situ Hybridisierung, PCR) verglichen. CMV-DNA konnte dabei durch nested PCR in 7 Fällen im Lungenparenchym nachgewiesen werden. Die “konventionelle” PCR (einschließlich hol Start) ergab in 3 Fällen teils schwach positive Ergebnisse. Beim Vergleich beider Methoden zeigte die nested PCR klarere Ergebnisse und weniger Zusatzbanden. In allen Fällen, in denen in der Lunge positive Ergebnisse erzielt wurden, konnte auch in den Speicheldrüsen CMV DNA nachgewiesen werden. Die nested PCR ist demzufolge verglichen mit PCR und hot start die sensitivste der Methoden und gerade zum Nachweis geringer Mengen von target DNA in Gegenwart von humaner und bakterieller Background DNA geeignet. Die Methode kann sowohl für Formalinfixiertes, paraffineingebettetes wie auch für tiefgefrorenes Material angewendet werden. Sie ist auch zum Virusnachweis in anderen parenchymatösen Organen (Leber, Nieren) geeignet.

Proof of air embolism after exhumation

Abstract The detection, storage, and analysis of gas taken from the heart ventricle is necessary to diagnose a fatal air embolism and this requires special precautions during autopsy. When the results of gas analysis correspond to the criteria defined by Pierucci and Gherson [1] the diagnosis “air embolism” is justified. In cases showing putrefaction the diagnostic value of gas analysis was negated [2]. In a series of 15 patients who were assumed to have been killed by air injection in a peripheral vein the corpses were exhumed and a full medico-legal examination was carried out including gas analysis. In 8 cases results could be obtained indicating a mixture of embolised air and gases of putrefaction. In two control groups comprising 10 exhumed bodies and 30 cases showing advanced putrefaction, gas analysis showed putrefaction gases except in 5 cases with gas volumes less than 5 ml in the right ventricle. Therefore gas analysis can be helpful to diagnose fatal air embolism even in cases showing putrefaction while the diagnosis of putrefaction gases only does not exclude this diagnosis.

Prolonged QT interval and sudden infant death--report of two cases.

In the two cases where infants died suddenly and unexpectedly the electrocardiogram (ECG) of a younger sibling (case 1) and of a living twin (case 2) led to the suspicion that the two infants could have died from long QT syndrome (LQTS). In case 1, a His bundle (HB) dispersion and a pronounced hypoplasia of the right external nucleus arcuatus were detected. In case 2, a severe interstitial pneumonia and an accompanying mild myocarditis were found by histology. Molecular genetic investigations of the coding regions of the genes, HERG, KVLQT1 and SCN5A gave no indication for the mutations, thus, affecting related myocardial ion channels as possible sources of inhomogeneity of repolarisation. Since a molecular genetic deviation could not yet be elaborated the possible role of related disturbance remains unknown.

Bizarre Impalement Fatalities—Where Is the Implement?

Two fatalities due to unusual impalement injuries are reported. (1) A large branch broken off during a storm had entered a passing car and perforated the chest of the driver and the back of the seat. The chest organs were grossly lacerated. The car was subsequently stopped by another tree and this second impact removed the wood from the body. (2) A man suffered anorectal impalement by the leg of a stool turned upside down. He had introduced one stool leg into his anus for sexual stimulation and fell onto it. This resulted in a wound channel 36 cm long including perforation of the rectum, urinary bladder, mesentery, transverse mesocolon and liver. Before autopsy, the mode of death was unclear because the man had removed the stool leg himself, his wife had hidden the stool from the scene, and there were no relevant external injuries. In both cases, a reliable reconstruction required investigation of the scene and consideration of extremely unlikely circumstances or of bizarre human activities.

Empfehlungen der Arbeitsgemeinschaft Forensisch-pädiatrische Diagnostik der Deutschen Gesellschaft für Rechtsmedizin:

ZusammenfassungRegelmäßige weiterführende Untersuchungen im Anschluss an die makroskopische Obduktion von Neugeborenen, Säuglingen oder Kleinkindern sind histologische Untersuchungen sowie toxikologische Analysen mit Blutalkoholbestimmung. DNA-Analysen können im Hinblick auf Täternachweis oder Abstammungsbegutachtung, aber auch als molekulargenetische Untersuchungen auf Erbkrankheiten durchgeführt werden. Außerdem kann der Nachweis einer Stoffwechselstörung aus dem Blut eine Rolle spielen. In seltenen Fällen kann die Forensische Entomologie Relevanz erlangen. Für diese Untersuchungsaufgaben ist die geeignete Asservierung repräsentativer Proben eine zwingende Voraussetzung. Bei Kindern stehen Körperflüssigkeiten oft nur in begrenztem Maße zur Verfügung. Deshalb kann die gleichzeitige Asservierung mehrerer alternativer Proben notwendig sein. Insbesondere bei komplexen Fragestellungen mit unterschiedlichen Untersuchungsanforderungen ist der Einsatz des begrenzten Untersuchungsmaterials unter möglicher Abwägung der Prioritäten als Aufgabe des Rechtsmediziners anzusehen.AbstractFurther regular tests following the macroscopic autopsy of newborns, infants and toddlers are histological examinations as well as toxicological analyses, including a blood alcohol determination. DNA-analyses can be performed with regard to identify a perpetrator or establish genetic relationships, as well as for molecular genetic investigations of hereditary disease. Evidence for a metabolic disorder from blood can also be relevant. In rare cases, forensic entomology can gain importance. The proper storage of representative samples is an essential prerequisite for these examinations. Body fluids are often only available in limited amounts from children. For this reason, a concomitant storage of several alternative samples may be necessary. Particularly in cases with complex questions and diverse testing needs, the use of these limited samples, along with a possible weighing of priorities, must be left to the discretion of the medical examiner.