Sudden cardiac death-update.

Sudden cardiac death (SCD) is one of the most common causes of death worldwide with a higher frequency especially in the young. Therefore, SCD is represented frequently in forensic autopsy practice, whereupon pathological findings in the heart can explain acute death. These pathological changes may not only include myocardial infarction, coronary thrombosis, or all forms of myocarditis/endocarditis but also rare diseases such as hereditary structural or arrythmogenic anomalies, lesions of the cardiac conduction system, or primary cardiac tumours.

Optimising magnetic resonance imaging-based evaluation of the ossification of the medial clavicular epiphysis: a multi-centre study.

Evaluation of the ossification of the medial clavicular epiphysis plays a key role in forensic age estimation, particularly in determining whether the age of 18 has been attained. A key research objective in the forensic age estimation field at present is to establish non-X-ray methods for investigating the clavicle. This paper looks at the use of magnetic resonance imaging for evaluating the developmental state of the medial clavicular epiphysis. Clavicle specimens obtained from autopsies of 125 female and 270 male subjects aged from 10 to 30 were examined using a 3-T magnetic resonance scanner. One FFE-3D-T1 gradient echo sequence and one 2D-T2 turbo spin echo sequence were acquired. In each case, two investigators undertook a consensual determination of the ossification stage of the medial clavicular epiphysis using recognised classification systems. To determine intra-observer and inter-observer agreement, 80 clavicle specimens were subjected to repeat evaluation. We present statistics relating to the ossification stages. The inclusion of established sub-stages of clavicular ossification offers an additional option for determining whether a subject has attained the age of 18 which is applicable in both sexes. For both sexes, the minimum ages for ossification stages 4 and 5 allow conclusions to be drawn about a subject's age at a point in time lying several years in the past. Magnetic resonance imaging is a valid investigatory procedure for determining the ossification stage of the medial clavicular epiphysis. This paper makes a contribution to expanding the range of methods available for forensic age estimation.

European Council of Legal Medicine (ECLM) accreditation of forensic pathology services in Europe.

Forensic experts play a major role in the legal process as they offer professional expert opinion and evidence within the criminal justice system adjudicating on the innocence or alleged guilt of an accused person. In this respect, medico-legal examination is an essential part of the investigation process, determining in a scientific way the cause(s) and manner of unexpected and/or unnatural death or bringing clinical evidence in case of physical, psychological, or sexual abuse in living people. From a legal perspective, these types of investigation must meet international standards, i.e., it should be independent, effective, and prompt. Ideally, the investigations should be conducted by board-certified experts in forensic medicine, endowed with a solid experience in this field, without any hierarchical relationship with the prosecuting authorities and having access to appropriate facilities in order to provide forensic reports of high quality. In this respect, there is a need for any private or public national or international authority including non-governmental organizations seeking experts qualified in forensic medicine to have at disposal a list of specialists working in accordance with high standards of professional performance within forensic pathology services that have been successfully submitted to an official accreditation/certification process using valid and acceptable criteria. To reach this goal, the National Association of Medical Examiners (NAME) has elaborated an accreditation/certification checklist which should be served as decision-making support to assist inspectors appointed to evaluate applicants. In the same spirit than NAME Accreditation Standards, European Council of Legal Medicine (ECLM) board decided to set up an ad hoc working group with the mission to elaborate an accreditation/certification procedure similar to the NAME's one but taking into account the realities of forensic medicine practices in Europe and restricted to post-mortem investigations. This accreditation process applies to services and not to individual practitioners by emphasizing policies and procedures rather than professional performance. In addition, the standards to be complied with should be considered as the minimum standards needed to get the recognition of performing and reliable forensic pathology service.

Accidental mechanical asphyxia of children in Germany between 2000 and 2008.

Accidents constitute one of the greatest risks to children, yet there are few medical reports that discuss the subject of accidental asphyxia. However, a systematic analysis of all documented cases in Germany over the years 2000-2008 has now been conducted, aiming at identifying patterns of accidental asphyxia, deducing findings, defining avoidance measures and recommending ways of increasing product safety and taking possible precautions. The analysis is based on a detailed retrospective analysis of all 91 relevant autopsy reports from 24 different German forensic institutes. A variety of demographic and morphological data was systematically collected and analysed. In 84 of the 91 cases, the sex of the victim was reported, resulting in a total of 57 boys (68 %) and 27 girls (32 %). The age spread ranged between 1 day and 14 years, with an average of 5.9 years. Most accidents occurred in the first year of life (20 %) or between the ages of 1 and 2 years (13 %). In 46 % of cases, the cause of death was strangulation, with the majority occurring in the home environment. In 31 % of all cases, the cause of death was positional asphyxia, the majority resulting from chest compression. In 23 % of cases, the cause of death was aspiration, mainly of foreign bodies. Today, accidental asphyxiation is a rare cause of death in children in Germany. Nevertheless, the majority of cases could have been avoided. Future incidence can be reduced by implementing two major precautions: increasing product safety and educating parents of potentially fatal risks. Specific recommendations relate to children's beds, toys and food.

[Sudden cardiac death. Selected forensic aspects]. / Plötzlicher Herztod. Ausgewählte rechtsmedizinische Aspekte.

Sudden cardiac death is one of the most common causes of death and a significant number of sudden deaths occurs especially in young people. Sudden cardiac death is also frequently represented in forensic autopsy practice. In such cases pathological findings in the heart can often explain the reason for the acute death. These pathological changes include not only myocardial infarction, coronary thrombosis and all forms of myocarditis/endocarditis but also rare diseases, such as hereditary structural or arrythmogenic anomalies, lesions of the cardiac conduction system or primary cardiac tumors.

Does breastfeeding reduce the risk of sudden infant death syndrome?

BACKGROUND: In the last 20 years, the prevention campaigns to reduce the risk of sudden infant death syndrome were very successful. In some countries the advice to breastfeed is included in the campaigns' messages, but in other countries it is not. OBJECTIVE: To examine the association between type of infant feeding and sudden infant death syndrome. METHODS: The German Study of Sudden Infant Death is a case-control study of 333 infants who died of sudden infant death syndrome and 998 age-matched controls. RESULTS: A total of 49.6% of cases and 82.9% of controls were breastfed at 2 weeks of age. Exclusive breastfeeding at 1 month of age halved the risk, partial breastfeeding at the age of 1 month also reduced the risk of sudden infant death syndrome, but after adjustment this risk was not significant. Being exclusively breastfed in the last month of life/before the interview reduced the risk, as did being partially breastfed. Breastfeeding survival curves showed that both partial breastfeeding and exclusive breastfeeding were associated with a reduced risk of sudden infant death syndrome. CONCLUSIONS: This study shows that breastfeeding reduced the risk of sudden infant death syndrome by approximately 50% at all ages throughout infancy. We recommend including the advice to breastfeed through 6 months of age in sudden infant death syndrome risk-reduction messages.

Prone sleeping position increases the risk of SIDS in the day more than at night.

BACKGROUND: SIDS mortality is higher during the night than in the day. AIM: (1) To examine risk factors for SIDS by time of day and (2) to see if the proportion of deaths at night has changed from prior to the 'Back to Sleep' campaign, which recommended infants sleep supine. METHODS: A large population-based SIDS matched case-control (GeSID) study conducted from 1998 to 2001 (when the prevalence of infants placed prone to sleep was 4.1%). The reference sleep of the controls was matched for the estimated time of death for the case. Risk factors for SIDS were examined for night-time and day-time deaths. The estimated time of death was compared with that from an earlier study in Germany (1990-1994 when prevalence of prone sleeping was 32.2%). RESULTS: There were 333 SIDS cases and 998 matched controls. The increased risk with placed prone to sleep was significantly different during the day [adjusted OR = 18.15 (95% CI = 5.91-55.69)] compared with during the night [adjusted OR = 3.49 (95% CI = 1.46-8.39; p-value for interaction = 0.011)]. There was no significant difference in the other risk factors examined by time of day in the multivariate analysis. The mean time found dead was 09:07. In the earlier study the mean time found dead was 08:54 and the difference was not significant (p = 0.57). CONCLUSIONS: This study confirms previous observations that prone sleeping position carries a greater risk during the day than at night. However, the reduction in infants sleeping prone has not been associated with a reduced number of deaths in the day in Germany.

Nicotine and cotinine in infants dying from sudden infant death syndrome.

The aim of this component of the German Study on Sudden Infant Death was to determine (1) nicotine concentrations in hair (NCH), as a marker of long standing exposure to tobacco, (2) cotinine concentrations in pericardial fluid (CCP) and (3) cotinine concentrations in liquor cerebrospinalis (CCL), the latter measures being markers of recent exposure to tobacco in the last few hours of life. The results obtained were compared with data on parental smoking revealed from interviews. In 100 cases of sudden infant death syndrome, material was taken at autopsy to determine NCH. In 41 cases, NCH and CCP, and in 70 cases, NCH and CCL were determined. Infants of mothers who stated having smoked during pregnancy had higher NCH than infants of non-smoking mothers (p = 0.008). Furthermore, there was a weak but statistically significant relationship between NCH's and the daily cigarette consumption of the mother during pregnancy (n = 64, r = 0.24, p = 0.05). In 43% of infants, nicotine could be detected in their hair, although the mothers had said at the interview that they did not smoke during pregnancy. On the other hand, in 33% of infants whose mother stated they had smoked during pregnancy nicotine was not detectable in the infant's hair. CCP's were strongly correlated with CCL's (r = 0.62, p = 0.0027). For this reason, both parameters were treated as equivalent for the detection of tobacco smoke exposure in the last hours before death. The influence of breast-feeding was evaluated by comparison of the nicotine concentrations in breast fed and non-breast-fed infants from smokers and non-smokers. Fivefold higher nicotine concentrations were determined in non-breast-fed infants of parents who smoked as compared to all other groups. It can be concluded that nicotine intake by passive smoking is much more important than by breast-feeding. We conclude that both interview data and biochemical measures should be sought to understand the true exposure to tobacco smoke.

Do immunisations reduce the risk for SIDS? A meta-analysis.

BACKGROUND: There are claims that immunisations cause sudden infant death syndrome (SIDS), but some studies have found either no association or that they are associated with a reduced risk of SIDS. AIMS: To conduct a meta-analysis examining the relationship between immunisation and SIDS. METHODS: Nine case-controls studies were identified examining this association, of which four adjusted for potential confounders. RESULTS: The summary odds ratio (OR) in the univariate analysis suggested that immunisations were protective, but the presence of heterogeneity makes it difficult to combine these studies. The summary OR for the studies reporting multivariate ORs was 0.54 (95% CI=0.39-0.76) with no evidence of heterogeneity. CONCLUSIONS: Immunisations are associated with a halving of the risk of SIDS. There are biological reasons why this association may be causal, but other factors, such as the healthy vaccinee effect, may be important. Immunisations should be part of the SIDS prevention campaigns.

Fibromuscular dysplasia of the basilar artery: an unusual case with medico-legal implications.

A 28-year-old male car driver was reported to suddenly loose the control over his vehicle, to hit the right and middle crash barrier, and to be unconscious as the car came to a halt in a position at right angles to the road. The car was hit in its left side by an automobile with high velocity, and the 28-year-old driver died. Examination of the brain revealed a massive isolated basal subarachnoid hemorrhage and a complete tearing of the basilar artery. A macroscopically detectable aneurysm was not found. However, histological examination of the large arteries at the base of the brain showed (i) fibromuscular dysplasia (FMD) mostly involving the basilar artery (ii) with a ruptured micro-aneurysm in its upper third part. The observations of the eye witnesses that the driver initially lost control over his car were judged in favour of the accused to be due to that rupture of the micro-aneurysm, while complete transverse tearing of the basilar artery occurred during the car crash due to hyperextension and rotation of his neck. Intracranial FMD is a rare cause in the differential diagnosis of isolated basal subarachnoid hemorrhage. The medico-legal implications of this entity are described in the presented case.

Frequent but borderline methylation of p16 (INK4a) and TIMP3 in medulloblastoma and sPNET revealed by quantitative analyses.

Certain risk groups among tumors of the central nervous system (CNS) in children take an almost inevitably fatal course. The elucidation of molecular mechanisms offers hope for improved therapy. Aberrant methylation is common in malignant brain tumors of childhood and may have implications for stratification and therapy. Methylation of p16 (INK4A), p14 (ARF), TIMP3, CDH1, p15 (INK4B )and DAPK1 in medulloblastoma (MB) and ependymoma has been discussed controversially in the literature. DUTT1 and SOCS1 have not previously been analyzed. We examined methylation in MB, sPNET and ependymoma using methylation-specific PCR (MSP), quantitative Combined Bisulfite Restriction Analysis (COBRA) and direct and clone sequencing of bisulfite PCR products. We detected methylation of p16 (INK4A) (17/43), p14 (ARF) (11/42) and TIMP3 (9/44) in MB and others by MSP. CDH1 was not only methylated in MB (31/41), but also in normal controls. Evaluation of MSP results by quantitative COBRA and sequencing yielded methylation between the detection limits of COBRA (1%) and MSP (0.1%). Only p16 (INK4A )and TIMP3 were methylated consistently in medulloblastomas (p16 (INK4A ) 14%, TIMP3 11%) and p16 (INK4A) also in anaplastic ependymomas (1/4 tumors). Methylation ranged from 1-5%. Evaluation of methylation using MSP has thus to be supplemented by quantitative methods. Our analyses raise the issue of the functional significance of low level methylation, which may disturb the delicate growth factor equilibrium within the cell. Therapeutic and diagnostic implications urge into depth analyses of methylation as a mechanism, which might fill some of the gaps of our understanding of brain tumor origin.

Cooling experiments using dummies covered by leaves.

One main method to estimate the time of death is the measurement of the body temperature. The cooling of a corpse depends on a number of conditions including the surroundings. In cases where the cooling conditions differ from the defined standard, a corrective factor is used to characterise the influence of clothing, air movement, the properties of the supporting base and the humidity. Nothing is known about the significance of other circumstances, for example of a tegument by leaves or wet leaves. Therefore, the cooling of dummies which were placed on a 2-cm-thick layer of wet/dry leaves and covered by a 10-cm-thick layer of leaves was investigated. Corrective factors of 1.0 for wet leaves on the ground and of 1.3 and 1.5 for drier leaves were found. If the dummies were additionally covered, corrective factors ranged between 1.8 and 2.7.

Sudden infant death syndrome: no increased risk after immunisation.

BACKGROUND: Although previous studies have shown either no association between immunisation and SIDS or even a decreased risk of SIDS, adverse effects, including death, from immunisations continue to cause concern, especially when a new vaccine is introduced. METHODS: A large case control study with immunisation data on 307 SIDS cases and 971 controls. RESULTS: SIDS cases were immunised less frequently and later than controls. Furthermore there was no increased risk of SIDS in the 14 days following immunisation. There was no evidence to suggest the recently introduced hexavalent vaccines were associated with an increased risk of SIDS. CONCLUSIONS: This study provides further support that immunisations may reduce the risk of SIDS.

Do risk factors differ between explained sudden unexpected death in infancy and sudden infant death syndrome?

BACKGROUND: In Germany, 2910 infants died in 2004; for many infants the reason was clear, especially prematurity or congenital abnormalities. However, 394 babies die every year suddenly and unexpectedly. The cause may be immediately clear, but is often not obvious. AIMS: (1) To describe the causes of explained sudden unexpected death in infancy (SUDI) and (2) to compare risk factors for sudden infant death syndrome (SIDS) and explained SUDI. METHODS: A 3-year population-based case-control study in Germany, 1998-2001. RESULTS: 455 deaths, of which 51 (11.2%) were explained. Most of these deaths were due to respiratory or generalised infections. The risk factors for SIDS and explained SUDI were remarkably similar except for sleep position and breast feeding. Prone sleeping position is a major risk factor for SIDS (adjusted odds ratio (OR) 7.16, 95% confidence interval (CI) 3.85 to 13.31) but not for explained SUDI (adjusted OR 1.71, 95% CI 0.25 to 11.57). Not being breast fed in the first 2 weeks of life is a risk factor for SIDS (adjusted OR 2.37, 95% CI 1.46 to 3.84) but not for explained SUDI (adjusted OR 0.39, 95% CI 0.08 to 1.83). CONCLUSIONS: Prone sleeping position is a unique risk factor for SIDS. Socioeconomic disadvantage and maternal smoking are risk factors for both SIDS and explained SUDI, and provide an opportunity for targeted intervention.

Perforation of the pulmonary artery by a bronchial wall stent.

Implantation of stents into the bronchial walls is a newly developed method to treat lung emphysema, which is now being tested clinically. During this procedure, a bronchoscope carrying a Doppler ultrasonography head is placed into a segmental bronchus and the blood vessels running in parallel to the bronchus are localized. Once a safe location without blood vessels is found, the bronchial wall is perforated and a stent is placed within the wall to improve the expiratory volume of these "bypasses" to the adjacent lung parenchyma. We observed a fatal complication with this method in a 60-year-old man. The bronchial wall and the pulmonary artery were perforated by one of the stents inducing massive bleeding, which could not be stopped. The patient died due to aspiration of blood in combination with massive loss of blood. The general risk to perforate the pulmonary artery during this procedure cannot be estimated from this single observation but should be considered regarding the legal and clinical aspects.

Coincidence of different structures of mucosa-associated lymphoid tissue (MALT) in the respiratory tract of children: no indications for enhanced mucosal immunostimulation in sudden infant death syndrome (SIDS).

Mucosa-associated lymphoid tissue (MALT) is the principal inductive site for mucosal immune responses that are capable of T and B cell responses and antigen-specific responses. In previous independent studies different structures of MALT, e.g. bronchus-, larynx- and nose-associated lymphoid tissue (BALT, LALT, NALT) have been described separately in various frequencies in the human respiratory tract over life spans. Because upper respiratory tract infections are common in infants, dysregulations of mucosal immune responses might be seriously involved in the aetiology of sudden infant death syndrome (SIDS). In the present study the coincidental occurrence of the three different MALT structures in the respiratory tract within the same patients were studied, and cases of SIDS and children who had died from different traumatic and natural causes of death (non-SIDS) were compared. First, the frequency of BALT and LALT in 46 children (35 SIDS, 11 non-SIDS) with or without NALT were examined. A tendency was found of a coincidence of respiratory MALT structures. In 50 additional cases of infant death (30 SIDS, 20 non-SIDS) from the multi-centric German Study on Sudden Infant Death Syndrome (GeSID) where death had occurred in the first year of life, the coincidence was evaluated. A coincidental occurrence of BALT, LALT and NALT or BALT and LALT (each about 30%) was found in both groups, whereby the coincidence in SIDS and the control patients did not differ. Interestingly, the children with coincidental MALT were strikingly older, supporting the hypothesis of respiratory MALT formation via environmental stimulation over time.

Are autopsies of help to the parents of SIDS victims? A follow-up on SIDS families.

Little is known about what bereaved parents feel about the autopsy performed on their child. A multi-centre case control study of sudden infant death syndrome (SIDS) victims was carried out in Germany between 1998 and 2001, in which all infants had been autopsied. We performed a follow-up study 4-7 years after the parents had lost their child. A total of 141 parents filled in the questionnaire, which were sent to them by the study centre. Of these, 71% had had another child after the SIDS/sudden unexpected death in infancy. The majority (83%) of the participating parents found the autopsy helped them to cope better with the death. A large proportion (46%) did not want any professional help after the death, and 55% did not wish to have any contact with a self-help group. We conclude that the autopsy is helpful to the majority of bereaved parents. Professional help and self-help groups should be offered to the parents even if the majority in our study did not want to use either.

Prevention of sudden infant death syndrome (SIDS) due to an active health monitoring system 20 years prior to the public "Back to Sleep" campaigns.

BACKGROUND: Before reunification, the post-neonatal mortality rate was lower in East Germany than in West Germany. Moreover, the incidence of SIDS (sudden infant death syndrome) was much lower in the East. METHODS: Mortality data on sudden infant death syndrome (SIDS) from West and East Germany since 1980 as well as post-neonatal mortality data for both states since 1970 were examined. 95% Confidence intervals were calculated for the rates. Witnesses from the former East Germany who were involved at the time were also interviewed and archives were searched. RESULTS: We found that as early as 1972 active monitoring of infant and child mortality rates in East Germany had shown that the prone sleeping position was dangerous for infants: the post-neonatal mortality rate was approximately 1 per 1000 live births lower in East than in West Germany during the 20 years before reunification. In contrast, in the West, prone sleeping was only discovered to be a risk factor for SIDS in the early 1990s. CONCLUSIONS: Active monitoring is an effective tool in the early detection of risk factors and serves to prevent unnecessary deaths.

The San Diego definition of SIDS: practical application and comparison with the GeSID classification.

The new definition of the term sudden infant death syndrome (SIDS) and the criteria introduced in San Diego for the subclassification of cases have been used to re-classify the first 100 consecutive cases of sudden and unexpected infant deaths that were registered with the German SIDS study (GeSID). Although there are 30 different variables that have to be considered in the general and stratified sections of the San Diego definition, it is practical, in particular, as an international standard to perform scientific studies. The comparison of the San Diego definition and the classification used for GeSID shows similarities in the methods but differences in the criteria used. Nevertheless, the numbers of cases classified as SIDS and borderline SIDS are similar (San Diego n=69, GeSID n=74). The SIDS IA criteria of the San Diego definition were not fulfilled by any case because metabolic screening and vitreous chemistry were not included in the GeSID investigation scheme. An important advantage of the San Diego definition is the introduction of the category of unclassified sudden infant death, which includes cases for which no autopsy was performed. This demonstrates that such cases cannot be classified as SIDS. In conclusion, we recommend the universal acceptance and use of the San Diego SIDS definition.