Biomedical subjects
B Brinkmann
Publications and source records attributed to B Brinkmann.
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.
Analysis of 155 consecutive forensic exhumations with emphasis on undetected homicides.
A total of 155 consecutive forensic exhumations performed in Münster, Germany from 1967 to 2001 were evaluated retrospectively on the basis of the autopsy report, the police report and the death certificate. Histology and toxicology were performed in most cases. The postmortem intervals varied from 8 days to 8 years. Compared to other countries, the autopsy rate was low (1.2-1.4%) and the exhumation rate high (0.016%): principle of reciprocity. The cause of death could be clearly determined in 103 cases (66.5%) and histology or toxicology were decisive in 40%. Some findings were discernable using immunohistochemistry after considerable postmortem intervals, such as acute myocardial infarction after 1 year and pneumonia after 2 years and a diazepam intoxication was determined after 4.5 years. Major deviations between the cause of death as stated on the death certificate and as diagnosed after autopsy existed in 57 cases (37%). A more detailed analysis revealed five subgroups. 1. primary suspicion of intoxication (n=18) confirmed in 6 cases including 3 homicides (with parathion, clozapin, diazepam) which are described in more detail. 2. primary suspicion of homicide other than poisoning (n=51) confirmed in 19 cases. There was a serial killing of 15 patients by injection of air. In the remaining 4 cases, a shaken infant, craniocerebral injuries from blows with beer bottles, a craniocerebral gunshot and a multiplicity of blunt force injuries were diagnosed. The latter two cases are described in more detail. Superficial external examinations and the low autopsy rate were 2 common reasons for the occurrence of "buried homicides" (n=22)-not a single forensic autopsy had been performed directly after the death of the victims. 3. primary suspicion of medical malpractice (n=39). 4. accidents including traffic accidents (n=30). 5. clarification of the cause of death, circumstances or identity (n=17). Exhumations were frequently successful for recovering evidence which should better have been collected immediately after the death of an individual. Exhumations can also be regarded as an instrument to evaluate the quality of death certificates and death investigations.
The GEDNAP blind trial concept part II. Trends and developments.
This article presents a review of the developments in the GEDNAP blind trials over the period covering the past 10 years (1993-2003), demonstrating the changing approach to DNA investigations in the European community as a whole. The results of the trials also identify the most common types of error encountered which can also occur during routine DNA typing and ways of recognising such errors are suggested.
Evaluation of the Reid index in infants and cases of SIDS.
The Reid index is an instrument for the evaluation of chronic bronchitis. The thickness of the mucosa and of its gland layer are measured and the relationship is expressed as a gland/wall ratio. Specimens were obtained from 124 autopsies from the German National Study on SIDS (GeSID). The cases were divided into three groups: group 1 typical SIDS ( n=47), group 2 SIDS with signs of mild inflammation of the respiratory tract ( n=50) and group 3 unnatural death controls ( n=23). The Reid index was measured in sections from the trachea, bifurcation/main bronchi and bronchioli (staining HE and PAS). The Reid index was remarkably constant throughout the different levels of the respiratory tract (standard deviation range 0.06-0.10). A comparison of the three groups did not show statistically significant differences. Group 1: mean Reid index trachea 0.37, bifurcation/main bronchi 0.38, bronchioli 0.39. Group 2: mean Reid index trachea 0.40, bifurcation/main bronchi 0.38, bronchioli 0.38. Group 3: mean Reid index trachea 0.39, bifurcation/main bronchi 0.38, bronchioli 0.41. It can be concluded that the dimensions of bronchial glands do not vary in cases of SIDS as compared to controls. This demonstrates that the Reid index has no significance in the vast majority of SIDS cases and that acute inflammation commonly does not produce an elevated Reid index. In addition, the Reid index was confirmed to be a valid instrument to study the respiratory tract including the trachea due to its stability and it was found that the Reid index is age-dependent: compared to adults, the ratios in infants were higher.
Determination of aconitine in body fluids by LC-MS-MS.
A very sensitive and specific method was developed for the determination of aconitine, the main toxic alkaloid from plants of the genus Aconitum L., in biological samples. The method comprised solid-phase extraction using mixed-mode Cs cation exchange columns followed by liquid chromatography-tandem mass spectrometry (LC-MS-MS). Chromatographic separation was achieved with a RP8 column. Detection of aconitine was achieved using electrospray in the positive ionisation mode and quantification was performed using multiple reaction monitoring with m/z 646.4 as precursor ion, i.e. [M+H]+ of aconitine and m/z 586.5, m/z 526.4 and m/z 368.4 as product ions after collision-induced dissociation. The method was fully validated for the analysis of blood samples: the limit of detection and the limit of quantitation were 0.1 ng/g and 0.5 ng/g, respectively. Within the linear calibration range of 0.5-25 ng/g, analytical recovery was 79.9%. In two fatal cases with suspected aconite intoxication, aconitine could be detected in blood samples at concentrations of 10.0 and 12.1 ng/g. In one case, aconitine could also be detected in the stomach content (3 ng/g) and in the other in the urine (180 ng/ml).
Fatal cerebro-renal oxalosis after appendectomy.
A case of a 24-year-old male with fatal cerebro-renal oxalosis assumed to be due to infusions of the sugar surrogate xylitol after appendectomy is reported. The diagnosis was established only after intensive histological investigations following the autopsy. The clinical picture was characterized by an acute seizure, coma and renal failure 2 days after the first xylitol infusion. Death occurred due to cerebral dysregulation as a very rare complication after parenteral administration of xylitol. Subendothelial double refractive calcium oxalate crystals were found in the walls of cerebral blood vessels, in particular in the stem ganglion regions and in the cortical renal tubules. The most common type of primary oxalosis was excluded by sequencing analysis. The young age, the minor surgical intervention and the otherwise unremarkable history are special features of this case. Since the genetic background of xylitol intolerance is still unclear, it is suggested that it should be banned as a sugar surrogate in clinical practice.
LC-MS determination of Taxus alkaloids in biological specimens.
A semi-quantitative LC-MS method was developed for the detection of the pseudo alkaloids of Taxus baccata (yew) from human body fluids and tissue samples. This method was used to examine the cause of death of a 43-year-old man who died several hours after he drank a decoction of taxus leaves. Autopsy and histology demonstrated early signs of myocardial hypoxia. Since investigation of the stomach content did not yield evidence of taxus ingestion, the taxus alkaloids were determined in blood, stomach content and tissue samples of the deceased by LC-MS. The samples were prepared by solid phase extraction on RP-18 columns. Chromatographic separation was achieved by HPLC on a RP-8 column, coupled to an ion trap mass spectrometer (Finnigan LCQ). An atmospheric pressure electrospray ionisation was performed. Spectra of the alkaloids were recorded in the single MS mode and in the MS-MS mode and compared with reference spectra obtained from an extract of yew leaves. In the stomach content, the kidneys, the liver and a heart blood sample of the deceased, alkaloids of Taxus baccata, predominantly taxine B and iso-taxine B, were identified. The semi-quantitative evaluation of the heart blood revealed a taxine concentration of 11 micro g taxine/g. As far as we know this is the first case in which a semi-quantitative analysis of taxine alkaloids has been performed.
Fracture properties of the human mandible.
A total of seven human mandibles were struck to breaking point under standardised conditions using a pendulum. The cortical deformation for two impact directions was measured with strain gauge strips located at eight defined sites. Fronto-median impacts led to mostly bilateral and always multiple fractures in the posterior area of the bone, especially in the collum and the condyle. The fracture threshold was between 2.5 and 3.1 kN. Lateral impact caused fractures near the impact area as direct fractures of the ipsilateral corpus. Mainly single and double fractures were observed. For lateral impact the fracture threshold was between 0.6 and 0.8 kN.
Deformation characteristics of the human mandible in low impact experiments.
A total of 11 human mandibles were subjected to physical impacts under standardised conditions. Two impact sites and directions were tested and the impact load was varied in four steps. Two occlusional strengths were applied and the influence of simulated soft tissue covering was recorded. The deformation of the bones was measured using strain gauge strips located at eight defined sites. In a series of frontal to occipital impacts the frontal areas and the collum showed the largest length changes. Increasing impact intensities led to a proportional increase of the length changes. An increase of the occlusional strength was either protective (at the collum) or it increased the deformation (frontal area). The soft tissue covering was only partly protective. Lateral impact was characterised by a compression on the side of the impact and stretching on the other side only. The intensity and speed of deformation increased with increasing distance from the site of impact. A fixed occlusion caused an increase of compression at the site of impact and an increasing stretching in the frontal part of the bone and at the opposite collum.
Pathological changes of the heart in sudden infant death.
There are more than 120 different theories on the possible causes of sudden infant death (SID). In particular, dysfunctions of the central nervous system, cardiorespiratory insufficiency due to infections including atypical immune reactions, and cardiac dysregulation have been discussed during the previous decade. Reports on disturbances of the cardiac rhythmogenic function due to LQTS were among the most speculative. Based on gross histological, immunohistochemical and molecular genetic investigations of SID cases, the most important and most frequent findings of the heart are shown. The significance of different types of myocarditis, hypoxia-related changes, disturbances of the rhythmogenic function, cardiomyopathy, and other changes is discussed with regard to the cause of death. In conclusion, most of the changes reported in the literature are not sufficient to explain the cause of death. Problems in the diagnosis are shown which influence the classification of these disturbances as well as the classification of SID.
Detection of RNA viruses in sudden infant death (SID).
Continuing previous work, reverse transcriptase polymerase chain reaction approaches for the detection of RNA viruses (influenza A+B, parainfluenza virus 3, respiratory syncytial virus) were developed. A total of 118 infant deaths, including 13 cases of non-natural death (nND), 78 cases of natural death (ND) without morphological signs of interstitial pneumonia (IP), 27 cases showing IP (ND+IP), were investigated using frozen lung tissue ( N=100) and paraffin-embedded material ( N=18). In five of the autopsy cases (ND+IP) the influenza B virus genome could be detected and the other types of viruses were completely negative. Together with previous results (detection of adenoviruses and cytomegaloviruses) in the same groups, the frequency of virus detection in the cases with IP was 48% compared with 14% in the ND without IP and 7% in the nND. Significant differences in the frequency of virus detection were also obtained when the cases were divided in SIDS and non-SIDS. The results obtained indicate an association between IP and some viruses and support the hypothesis that respiratory virus infections could act as trigger in sudden infant death.
The Kaiser's tooth.
The recovery of DNA from teeth is usually associated with the destruction of the evidential tooth using, for instance a special grinding mill. In some cases, however, a minimal invasive method of DNA retrieval with a high recovery is required particularly when historical material has to be investigated. A tooth attributed to the German Emperor Wilhelm II was the only source of DNA in an analysis of a possible paternity and the DNA had to be extracted without destroying the appearance of the tooth. Here, the results of the DNA analysis are presented.
Autopsy features relevant for discrimination between suicidal and homicidal gunshot injuries.
A total of 624 consecutive gunshot autopsies from the Institutes of Legal Medicine in Münster and Hamburg was investigated retrospectively. In a subsample of 284 suicides and 293 homicides (n=577), a large variety of features such as firearm, ammunition, number and site of entrance wounds, shooting distance and direction of the internal bullet path were recorded and binary logistic regression analysis performed in the case of bullet paths. Females constituted 26.3% of the homicide victims and 10.6% of the suicides. Short-barrelled firearms outnumbered long arms in homicides by 6:1 and in suicides by 2:1. More than 1 gunshot injury was found in 5.6% of the suicides (maximum 5 gunshots) and in 53.9% of the homicides (maximum 23 gunshots). The suicidal gunshots were fired from contact or near contact range in 89% while this was the case in only 7.5% of the homicides. The typical entrance wound sites in suicides were the temple (36%), mouth (20%), forehead (11%) and left chest (15%) but uncommon entrance wound sites such as the eye, ear, and back of the neck and head were also encountered. In suicidal gunshots to the right temple (n=107), only 6% of the bullet paths were directed downwards and only 4% were directed from back-to-front. In gunshots to the left chest (n=130), bullet paths running right-to-left or parallel occurred frequently in suicides (75%) and infrequently in homicide victims (19%). From 61 suicides who fired the gun inside their mouth, only 1 pointed the gun downwards. Consequently, some bullet path directions cannot be considered indicative of suicide: downwards and back-to-front in gunshots to the temple, left-to-right in gunshots to the left chest and downwards in mouth shots. The isolated autopsy findings can only be indicative of suicide or homicide but the combined analysis of several findings can be associated with a high probability.
Kurdish population data for 11 STR loci (ACTBP2, CSF1PO, FGA, TH01, TPOX, vWA, D3S1358, D5S818, D7S820, D13S317 and D21S11).
In a Kurdish population sample composed of 950 unrelated individuals from Northern Iraq, 11 tetrameric short tandem repeat (STR) loci from 10 different chromosomes (i.e., ACTBP2, CSF1PO, FGA, TH01, TPOX, vWA, D3S1358, D5S818, D7S820, D13S317 and D21S11) were typed to establish a database for immigration cases. The combined power of discrimination (PD) and the combined power of exclusion (PE) of all 11 loci were 0.99999999999994 and 0.99996, respectively.
Somatic mutations at STR loci--a reason for three-allele pattern and mosaicism.
Two families are analysed in which one of the parents exhibited a three-allele pattern at the ACTBP2 locus. Since the alleles were obviously segregated independently to the children, a generalised mosaicism must be assumed involving at least two tissues in one of them and at least four tissues in the other one. The intensity of the PCR amplified alleles in both three-allele individuals indicate an occurrence in a very early embryonic stage. Occurrence was most probably due to a single step mutation in both cases. Forensic implications would include paternity testing as well as stain analysis.
Electrocution--autopsy study with emphasis on "electrical petechiae".
Fatalities caused by electrocution (n = 37) were re-examined on the basis of the autopsy records, the police reports and the technical expertise. Accidents including two lightning deaths caused 2/3rd and suicides 1/4th of the fatalities and there were two homicides. Carelessness or ignorance were a major reason for accidental deaths while technical defects could be verified in five cases only. Low-voltage ac and male victims predominated. Electrical burns or current marks were detected in 81% including all high voltage electrocutions. The seven victims lacking burns were electrocuted in a wet environment including six cases of suicide in the bathtub with a hair drier. Petechial haemorrhages were present in 74% of the cases and the favourite sites were the skin of the eyelids, conjunctivae, visceral pleura, and the epicard. The presence of petechiae did not depend on the voltage or the current pathway relative to the heart. It is, therefore, suggested that the petechiae are not caused by asphyxia but by a combination of venous congestion due to cardiac arrest and a sudden rise in blood pressure induced by muscle contractions. Consequently, "electrical petechiae" represent a non-specific but typical finding in electrocution irrespective of the mechanism leading to death. Unlike electrical burns, petechiae also indicate the vital origin of the events. The relevance of this typical morphological sign in the examination of possible electrocution fatalities is therefore emphasised.
[Recent data for frequency of autopsy in Germany].
BACKGROUND AND OBJECTIVE: : Today clinico-pathological autopsies serve as a measure of quality assurance in clinical medicine. Furthermore reliable information on the distribution of different causes of death can only be gained by a significant autopsy rate. Medicolegal autopsies are essential for the discovery of non-natural or violent deaths. This study provides information on changes in clinico-pathological and medicolegal autopsy rates between 1994 and 1999. METHODS: : A survey of autopsy rates in 1994 and 1999 was undertaken covering all German pathological and medicolegal institutes. The autopsy figures of the different states were analysed separately. Most autopsies performed in pathological institutes were clinico-pathological autopsies and almost all autopsies performed in Institutes of Legal Medicine were medicolegal autopsies. RESULTS: Between 1994 and 1999 the frequency of clinico-pathological autopsies decreased from about 4 % to 3 % of all deaths. The medicolegal autopsy rate remained stable on a low level at about 2 %. The differences between various states are up to 4-fold for clinico-pathological autopsies and up to 5-fold for medicolegal autopsies. CONCLUSIONS: : The autopsy rates in Germany are frighteningly low compared to other European countries. Considering the dramatic decline of clinico-pathological autopsy rates the role of the post-mortem examination as a control of clinical medicine and death statistics cannot be fulfilled properly. The low medicolegal autopsy rate is responsible for the high number of undetected non-natural or violent deaths.