Age-related cytokine imbalance in the thymus in sudden infant death syndrome (SIDS).

BACKGROUND: Sudden infant death syndrome (SIDS) has been considered to be triggered by a combination of underlying immune dysregulation and infections. The thymus is a crucial lymphatic organ responsible for T cell development in infancy. We hypothesized that an altered thymic immune status may be detectable by intrathymic cytokine profiling in SIDS. METHODS: 27 cytokines in protein lysates of thymus tissue and thymus weights were assessed in 26 SIDS cases and 16 infants who died of other reasons. RESULTS: Seventeen out of 27 cytokines were increased in thymic tissue of SIDS compared to controls without infections, and the most significant discrepancy was in infants younger than 20 weeks. The thymic cytokine profiles in SIDS cases were similar to those in controls with severe infection; however, the magnitude of the cytokine concentration elevation in SIDS was less pronounced, indicating sub-clinical infections in SIDS. In contrast to SIDS, intrathymic cytokine concentrations and thymus weight were increased with age in control children. CONCLUSIONS: Elevated thymic cytokine expression and thymus weight, as well as impaired age-related alterations in SIDS, may be influenced by subclinical infection, which may play a role in initiating SIDS in infants with a compromised immune response. IMPACT STATEMENT: Increased thymic weight and cytokine concentration may suggest possible subclinical infection in SIDS. Elevated thymic weight and cytokine concentration mainly in SIDS cases aged <20 weeks. Age-related impairment in the thymic weight and cytokine expression may be impaired by subclinical infection in SIDS.

Cytosine methylation in GABA B1 receptor identifies alcohol-related changes for men in blood and brain tissues.

AIMS: Alcohol use alters the reward signaling processes contributing to the development of addiction. We studied the effects of alcohol use disorder (AUD) on brain regions and blood of deceased women and men to examine sex-dependent differences in epigenetic changes associated with AUD. We investigated the effects of alcohol use on the gene promoter methylation of GABBR1 coding for GABAB receptor subunit 1 in blood and brain. METHODS: We chose six brain regions associated with addiction and the reward pathway (nucleus arcuatus, nucleus accumbens, the mamillary bodies, amygdala, hippocampus and anterior temporal cortex) and performed epigenetic profiling of the proximal promoter of the GABBR1 gene of post-mortem brain and blood samples of 17 individuals with AUD pathology (4 female, 13 male) and 31 healthy controls (10 female, 21 male). RESULTS: Our results show sex-specific effects of AUD on GABBR1 promoter methylation. Especially, CpG -4 showed significant tissue-independent changes and significantly decreased methylation levels for the AUD group in the amygdala and the mammillary bodies of men. We saw prominent and consistent change in CpG-4 across all investigated tissues. For women, no significant loci were observed. CONCLUSION: We found sex-dependent differences in GABBR1 promoter methylation in relation to AUD. CpG-4 hypomethylation in male individuals with AUD is consistent for most brain regions. Blood shows similar results without reaching significance, potentially serving as a peripheral marker for addiction-associated neuronal adaptations. Further research is needed to discover more contributing factors in the pathological alterations of alcohol addiction to offer sex-specific biomarkers and treatment.

Pulmonary thromboembolism and obesity in forensic pathologic case work.

328 autopsy cases of fatal pulmonary thromboembolism (PE) were compared to 984 age- and sex-matched controls to evaluate the association between obesity and PE in a forensic context. Both PE and control cases had a mean age of 67,8 years (male 62,9 years, females 71,7 years). The percentage of morbidly obese persons with a body mass index (BMI) of above 40 or abdominal subcutaneous adipose tissue of above 4 cm was higher in the PE group (8,39% vs. 4,67% and 29.45% vs. 23.40%, respectively). On the other side, that of very slim persons (BMI below 18.5 or adipose tissue below 3 cm) was significantly smaller (4,27% vs. 7,52% and 47.55% vs. 56,60%). We thus found a strong association between being overweight and death from PE, while slim persons seem to be at an advantage. As the group of underweight persons includes those suffering from chronic diseases with reduced mobility or hypercoagulability (e.g. tumor kachexia or sarkopenia due to immobilisation), this finding is to some extent unexpected.

Comparing DRD2 Promoter Methylation Between Blood and Brain in Alcohol Dependence.

AIMS: The dopamine receptor D2 (DRD2) is substantially involved in several forms of addiction. In addition to genetic polymorphisms, epigenetic mechanisms have emerged as an important means of regulation. Previously, DRD2 hypo- and hyper-methylation have been observed in alcohol use disorder (AUD). Blood samples are commonly used as a surrogate marker of epigenetic alterations in epigenetic research, but few specific comparisons between blood and brain tissue samples in AUD exist. METHODS: We used post-mortem brain tissue samples of 17 deceased patients with AUD and 31 deceased controls to investigate the relationship between blood and brain methylation of the DRD2 promoter. RESULTS: When investigating individual cytosine methylation sites (CpG), several significant differences were found in the nucleus accumbens and hippocampus in the study population. Investigating binding sites with significant differences in methylation levels revealed hypomethylated CpGs targeting mainly activating transcription factors. CONCLUSION: These findings support an altered transcription of the DRD2 gene in AUD specimens with a consecutively changed reward response in the brain. While methylation between specific brain regions and blood is comparable, our study further suggests that blood methylation cannot provide meaningful perspectives on DRD2 promoter methylation in the brain.

Pulmonary immune profiling of SIDS: impaired immune maturation and age-related cytokine imbalance.

BACKGROUND: For sudden infant death syndrome (SIDS), an impaired immunocompetence has been discussed for a long time. Cytokines and chemokines are soluble immune mediators (SIM) whose balance is essential for the immune status. We hypothesized that an imbalanced immune response might contribute to the etiology of SIDS. METHODS: We investigated 27 cytokines, chemokines, and growth factors in protein lysates of lungs derived from 29 SIDS cases and 15 control children deceased for other reasons. RESULTS: Except for the CCL5, no significant differences were detected in the lungs between SIDS cases with and without mild upper respiratory tract infections. In contrast, IL-1RA, IL-7, IL-13, and G-CSF were decreased in the merged SIDS cases compared to control cases without evidence of infection. Plotting SIM concentrations against infant age resulted in increasing concentrations in control but not in SIDS lungs, indicating a disturbed immune maturation. Moreover, an age-dependent shift towards a Th2-related pattern was observed in SIDS. CONCLUSIONS: Our findings suggest that an impaired maturation of the immune system, an insufficient response to respiratory pathogens, and an immune response modulated by Th1/Th2 imbalance might play a possible role in triggering SIDS. These findings might in part be explained by chronic stress. IMPACT: Maturation of the cytokine and chemokine network may be impaired in SIDS. An imbalance between Th1- and Th2-related cytokines, which may reflect a state of chronic stress causing a more Th2 shift. An impaired immune maturation, an insufficient response to respiratory pathogens, and an immune response modulated by Th1/Th2 imbalance might play a possible role in SIDS.

Fatal anogenital exenteration of the intestine.

A case of a sadistically motivated homicide with extraordinary injuries is reported. A 32-year-old woman was naked with signs of severe blunt trauma and oral, vaginal and anal penetration. At the crime scene, the intestine lay next to the woman without connection to the body. During the trial before the criminal court, the perpetrator admitted fisting and inserting several objects into the vagina, anus and oral cavity. Moreover, after anal and vaginal insertion of the hands, large parts of the intestine were torn and pulled out through the anus and the vagina. The results of the forensic pathological examination and additional investigation are discussed and compared with the pertinent literature. This extraordinary case of a sadistically motivated homicide ended with a final judgment that is extremely rare in German jurisdiction.

Genetic association study of fatal pulmonary embolism.

Pulmonary embolism (PE) is a complex multi-factorial disease and represents one manifestation of venous thromboembolism (VTE). Most commonly PE constitutes a complication of VTE's other clinical presentation deep vein thrombosis (DVT). The majority of studies concerning risk factors do not distinguish between PE and DVT. The risk factors are often estimated to be alike, but the prevalence and the risk associated with the major genetic factor Factor V Leiden differ between the two disease states. We have investigated the association of 22 SNPs with PE in 185 PE case and 375 healthy control subjects. At p = 0.05, eight SNPs presented with nominally significant evidence of association (EOA), although no significantly different genotype distributions remained between cases and controls after Bonferroni correction. Three of these variants (rs1800790, rs3813948, rs6025) showed EOA in the main analysis, and five variants (rs169713, rs1801131, rs4524, rs5985 and rs8176592) demonstrated EOAs in subgroups. Genomic variation modulating Factor V, Factor XIII, Beta fibrinogen (FGB), TFPI or HIVEP1 should be worth to be followed in subsequent studies. The findings of this study support the view that PE represents a complex disease with many factors contributing relatively small effects. Larger sample sizes will be required to reliably detect these small effects.

Impaired Regulation of ALDH2 Protein Expression Revealing a Yet Unknown Epigenetic Impact of rs886205 on Specific Methylation of a Negative Regulatory Promoter Region in Alcohol-Dependent Patients.

Acetaldehyde, the carcinogenic metabolite of ethanol known to provoke aversive symptoms of alcohol consumption, is predominantly eliminated by aldehyde dehydrogenase 2 (ALDH2). Reduced ALDH2 activity correlates with low alcohol tolerance and low risk for alcohol dependence. The ALDH2 promoter polymorphism rs886205 (A>G) is associated with decreased promoter activity, but a molecular mechanism and allele-dependent ALDH2 protein expression has not been described yet. On the basis of allele-dependent epigenetic effects, we analyzed the rs886205 genotype, methylation rates of cytosine-phosphatidyl-guanine (CpG)-sites within a regulatory promoter region and ALDH2 protein levels in 82 alcohol-dependent patients during a 2-week withdrawal and compared them to 34 matched controls. Patients without the G-allele of rs886205 showed higher methylation of the promoter region than controls and readily adapted epigenetically as well as on protein level during withdrawal, while patients with the G-allele displayed retarded methylation readjustment and no change in ALDH2 protein levels. Our data provide novel insights into an unknown genetic-epigenetic interaction, revealing impaired ALDH2 protein expression in patients with the G-allele of rs886205. Additionally, we checked for an association between rs886205 and protection against alcohol dependence and found a trend association between the G-allele and protection against alcohol dependence that needs replication in a larger Caucasian cohort.

DNA methylation results depend on DNA integrity-role of post mortem interval.

Major questions of neurological and psychiatric mechanisms involve the brain functions on a molecular level and cannot be easily addressed due to limitations in access to tissue samples. Post mortem studies are able to partly bridge the gap between brain tissue research retrieved from animal trials and the information derived from peripheral analysis (e.g., measurements in blood cells) in patients. Here, we wanted to know how fast DNA degradation is progressing under controlled conditions in order to define thresholds for tissue quality to be used in respective trials. Our focus was on the applicability of partly degraded samples for bisulfite sequencing and the determination of simple means to define cut-off values. After opening the brain cavity, we kept two consecutive pig skulls at ambient temperature (19-21°C) and removed cortex tissue up to a post mortem interval (PMI) of 120 h. We calculated the percentage of degradation on DNA gel electrophoresis of brain DNA to estimate quality and relate this estimation spectrum to the quality of human post mortem control samples. Functional DNA quality was investigated by bisulfite sequencing of two functionally relevant genes for either the serotonin receptor 5 (SLC6A4) or aldehyde dehydrogenase 2 (ALDH2). Testing our approach in a heterogeneous collective of human blood and brain samples, we demonstrate integrity of measurement quality below the threshold of 72 h PMI. While sequencing technically worked for all timepoints irrespective of conceivable DNA degradation, there is a good correlation between variance of methylation to degradation levels documented in the gel (R (2) = 0.4311, p = 0.0392) for advancing post mortem intervals (PMI). This otherwise elusive phenomenon is an important prerequisite for the interpretation and evaluation of samples prior to in-depth processing via an affordable and easy assay to estimate identical sample quality and thereby comparable methylation measurements.

Google Glass for documentation of medical findings: evaluation in forensic medicine.

BACKGROUND: Google Glass is a promising premarket device that includes an optical head-mounted display. Several proof of concept reports exist, but there is little scientific evidence regarding its use in a medical setting. OBJECTIVE: The objective of this study was to empirically determine the feasibility of deploying Glass in a forensics setting. METHODS: Glass was used in combination with a self-developed app that allowed for hands-free operation during autopsy and postmortem examinations of 4 decedents performed by 2 physicians. A digital single-lens reflex (DSLR) camera was used for image comparison. In addition, 6 forensic examiners (3 male, 3 female; age range 23-48 years, age mean 32.8 years, SD 9.6; mean work experience 6.2 years, SD 8.5) were asked to evaluate 159 images for image quality on a 5-point Likert scale, specifically color discrimination, brightness, sharpness, and their satisfaction with the acquired region of interest. Statistical evaluations were performed to determine how Glass compares with conventionally acquired digital images. RESULTS: All images received good (median 4) and very good ratings (median 5) for all 4 categories. Autopsy images taken by Glass (n=32) received significantly lower ratings than those acquired by DSLR camera (n=17) (region of interest: z=-5.154, P<.001; sharpness: z=-7.898, P<.001; color: z=-4.407, P<.001, brightness: z=-3.187, P=.001). For 110 images of postmortem examinations (Glass: n=54, DSLR camera: n=56), ratings for region of interest (z=-8.390, P<.001) and brightness (z=-540, P=.007) were significantly lower. For interrater reliability, intraclass correlation (ICC) values were good for autopsy (ICC=.723, 95% CI .667-.771, P<.001) and postmortem examination (ICC=.758, 95% CI .727-.787, P<.001). Postmortem examinations performed using Glass took 42.6 seconds longer than those done with the DSLR camera (z=-2.100, P=.04 using Wilcoxon signed rank test). The battery charge of Glass quickly decreased; an average 5.5% (SD 1.85) of its battery capacity was spent per postmortem examination (0.81% per minute or 0.79% per picture). CONCLUSIONS: Glass was efficient for acquiring images for documentation in forensic medicine, but the image quality was inferior compared to a DSLR camera. Images taken with Glass received significantly lower ratings for all 4 categories in an autopsy setting and for region of interest and brightness in postmortem examination. The effort necessary for achieving the objectives was higher when using the device compared to the DSLR camera thus extending the postmortem examination duration. Its relative high power consumption and low battery capacity is also a disadvantage. At the current stage of development, Glass may be an adequate tool for education. For deployment in clinical care, issues such as hygiene, data protection, and privacy need to be addressed and are currently limiting chances for professional use.

[Suicide in advanced age--report on an unusual case of hanging in a lying position]. / Suizid im hohen Alter--Fallbericht eines ungewöhnlichen Erhängens in liegender Position.

Hanging is still the most common suicide method among men and women, even in high age groups. There are many variations of hanging. As compared to the body weight, only a relatively small force is necessary to obstruct the carotid arteries. In this way hanging in a sitting, kneeling or even lying position is possible. Such an exceptional case is presented here. A 99-year-old, multi-morbid man (47 kg, 159 cm) was found lying strangled in his hospital bed. The ligature used was a stiff spiral cable for remote control of the bed, which was directly attached to the wall behind its head end. The position allowed compression of the neck vessels, which resulted in marked congestion of the head, numerous petechial and confluent haemorrhages in the facial skin as well as blood loss from both ear canals. In the cervical soft tissue above the ligature, bleeding into the muscles and connective tissue as well as multiple haemorrhages in the tongue were found. Reconstruction at scene showed that suicide was possible. In such unusual cases, extensive police investigations, forensic autopsy and reconstruction of the course of events to prove feasibility are essential.

[Death by erotic asphyxiation (breath control play)]. / Tod durch Atemreduktion.

Most cases of sexual asphyxia are due to autoerotic activity. Asphyxia due to oronasal occlusion is mostly seen in very old or very young victims. Oronasal occlusion is also used in sadomasochistic sexual practices like "breath control play" or "erotic asphyxiation". If life saving time limitations of oronasal occlusion are not observed, conviction for homicide caused by negligence is possible.

Two cases of suicide by asphyxiation due to helium and argon.

Numerous death cases due to suffocation in a toxic or oxygen deficient gas atmosphere have been described in the literature, but unfortunately especially cases involving inert gases like helium are often presented without detailed toxicological findings. Observations on two suicides are reported, one by helium and the other by argon inhalation. During autopsies gas samples from the lungs were collected directly into headspace vials by a procedure ensuring minimal loss and dilution. Qualitative gas analyses were performed using headspace gas chromatography-mass spectrometry (HS-GC/MS). For carrier gas the commonly used helium was replaced by hydrogen. Qualitative positive results were obtained in the argon case, but the case involving helium revealed negative findings. The use of HS-GC/MS enables in principle to detect inert gases like argon or helium. However, a number of factors may later influence the results as, e.g. a longer period of time between death and sampling or pre-analytical artefacts during sampling of such highly volatile substances. In absence of analytical data supporting helium exposure, the causes of death in the actual cases were found to be asphyxia and in both cases the manner was suicide.

Visualisation of the temporary cavity by computed tomography using contrast material.

The temporary cavity of a missile produces radial tears in ordnance gelatine, which correlate to the energy transfer. Computed tomography is a useful and non-destructive method to examine gelatine blocks. However, the tears give only few radiocontrast by air filling, which decreases with the time past shooting. Therefore, systematically, a radiocontrast material was searched to enhance the contrast. Different contrast materials were amalgamated to acryl paint, and about 7 g was sealed in a foil bag, which was integrated in the front of a standard 10% gelatine cylinder. Shots with Action-5 expanding bullets were performed from a 5-m distance. Gelatine was scanned by multi-slice computed tomography. The multiplanar reconstructed images were compared to mechanically cut slices of 1 cm thickness. It was shown experimentally that iodine containing water-soluble contrast material did not give sufficient contrast and caused diffusion artefacts. Best results were obtained by barium sulphate emulsion. The amount of acryl paint was sufficient to colour the tears for optical scanning. The radiocontrast of barium leads to satisfying imaging of tears and allowed the creation of a three-dimensional reconstruction of the temporary cavity. Comparison of optical and radiological results showed an excellent correlation, but absolute measures in computed tomographic (CT) images remained lower compared with optically gathered values in the gelatine slices. Combination of paint and contrast material for CT examination will facilitate the evaluation of complex ballistic models and increase accuracy.

[Suicide in children, youths and young adults]. / Suizide von Kindern, Jugendlichen und Heranwachsenden.

Suicides among children and youths are tragic events. The suicide cases of children, youths and young adults examined between 1995 and 2009 at the Institute of Legal Medicine of the Hanover Medical School were retrospectively analyzed. Altogether, 54 suicides among children, youths and young adults (37 males, 17 females; median age 17.5 years) were evaluated. The suicide victims were predominantly male (68.5%). The vast majority used "hard" methods such as hanging, jumping from a height or being run over by a train. In seven cases (13.0%) psychiatric disorders were known. Seven victims (13.0%) left a suicide note. Suicide was most frequently (40.7%) committed in the open air (40.7%). In addition, the evaluation shows that at the time of committing suicide more than 40% of the youths and adolescents, in whom a chemical toxicological examination was performed, were under the influence of alcohol, medical and/or illegal drugs.

Suicide by head explosion: unusual blast wave injuries to the cardiovascular system.

A 57-year-old employee in a military scientific institute was found acephalous in a supine position in an anteroom to the bunker. On the walls was abundant spattering of blood and tissue, concentrated above shoulder height. A mobile ignition device stood on the control desk. The complete destruction of the head down to the cervical spine suggested that the explosive charge (RDX) detonated in his mouth. The hands were virtually uninjured. The pressure effect in vessels caused numerous tears to the wall of the carotid arteries and the left vertebral artery, a tear-off of the left carotid artery of the aortic arch, and a 2.5-cm long crack of the thoracic aorta with 540-ml blood in the pericardial sac and a shredded window-like disruption of the left aortic valve cusp. The autopsy also showed an infraction of the sternum from the inside, and a contusion of the superior lobes of both lungs. The trace pattern on the right arm suggested suicide. A bone fragment of the mandible penetrated the right biceps muscle as a secondary projectile.

[Post-mortem diagnosis of diabetic crisis in the presence of suspicious findings at the scene]. / Postmortale Diagnose diabetischer Stoffwechselentgleisungen bei verdächtigen Auffindungssituationen.

In Germany, approximately 8 million people suffer from diabetes mellitus, of which over 90% have type 2 diabetes. Worldwide, there are around 246 million people with diabetes mellitus. As diabetes is often symptomless for a long time, around 2.5% of the population have diabetes without knowing it. Diabetic coma is a life-threatening complication, which affects up to 1.2% of all diabetics annually and is associated with a mortality rate of 20-25%. Since in 25% of patients the diabetic coma is the first manifestation of the disease, a valid post-mortem biochemical method for the diagnosis of the metabolic crisis is very important. The article presents cases from the authors' own autopsy material showing that the analysis of the vitreous humour is indispensable for the reconstruction of the events leading to death even in cases in which the cause of death is seemingly clear.

[Cable tie used for suicidal ligature strangulation--a case report]. / Kabelbinder als Tatwerkzeug bei suizidalem Erdrosseln--ein Fallbericht.

Based on a case of self-strangulation committed with two connected cable ties, criteria for the differentiation of homicidal and suicidal ligature strangulation are discussed. Differentiation may be difficult and demands close cooperation between the police and the forensic experts. Apart from the history and general circumstances of the case, not only the kind of strangulation, but also the presence of any concomitant injuries, the degree of congestion and any internal injuries are of relevance for the criminalistic evaluation. As self-strangulations are rare, these cases demand special attention.