So-called skin signs in acute pancreatitis.

Skin signs in acute necrotizing pancreatitis (e. g., Cullen's and Grey-Turner's sign) have been described in clinical medicine. The aim of the present study was to evaluate if, and how often, skin signs were noted in autopsy-confirmed cases of necrotizing pancreatitis. In a first step, the literature was extensively reviewed to establish which skin signs have so far been described in acute pancreatitis cases. As a second step, the reports of 16,000 autopsies performed at the Institutes of Legal Medicine in Frankfurt am Main and Giessen, Germany, were retrospectively evaluated. Twenty cases with necrotizing pancreatitis were found. In almost all of these, necrotizing pancreatitis was - either solely or in combination with other factors - the cause of death. In three cases, discolorations of the skin were found that were considered to be skin signs due to their location. At least in the evaluated medicolegal autopsy pool, skin signs in necrotizing pancreatitis thus appear to be a rare occurrence. Nevertheless, in cases of unexpected death, particularly of individuals with a history of alcohol abuse, necrotizing pancreatitis should be considered in the differential diagnosis of hematomas possibly attributed to trauma.

Suspected paradoxical undressing in a homicide case.

Paradoxical undressing is a phenomenon associated with fatalities due to severe hypothermia, which is characterized by the act of active undressing, despite low ambient temperatures, as a consequence of peripheral vasodilation. A 51-year-old man was found lying naked and inanimate on a road. Articles of his clothing were scattered in surrounding bushes. A nearby handrail showed a partially washed away bloodstain pattern. A forensic autopsy was used to distinguish whether death was due to a hypothermic fatality or whether the deceased was a victim of an accident or homicide. Medicolegal autopsy revealed craniofacial dissociation with injuries to the thorax and extremities and established choking/asphyxia due to deep aspiration of blood in combination with external blood loss as the cause of death. In the absence of hypothermia-related signs and toxicological findings the case was considered to be a homicide. Police investigation led to the conviction of a man who confessed to having kicked and hit the victim and forced him to take off his clothes in a humiliation-related scenario.

Impact of employment status and work-related factors on risk of completed suicide. A case-control psychological autopsy study.

The objective of this study was to determine the impact of work-related factors on risk for completed suicide. Psychiatric disorders and socio-demographic factors including work-related factors were assessed by a semi-structured interview using the psychological autopsy method in 163 completed suicide cases and by personal interview in 396 living population-based control persons. Unemployment (in particular, for more than six months), (early) retirement, or homemaker status were associated with highly significantly increased suicide risk, independently of categorized psychiatric diagnosis. In addition, adverse psychosocial working conditions, such as monotonous work, increased responsibility and pronounced mental strain due to contact with work clients, significantly increased suicide risk as well, again independently of categorized psychiatric diagnosis. These findings demonstrate that negative consequences of unemployment, homemaker status with no outside occupation, or (early) retirement, as well as adverse psychosocial working conditions, present relevant risk factors contributing to suicidal behavior, independently of diagnosed psychiatric disorders. Employment and a positive modification of working conditions, may possibly be preventive to important adverse mental health outcomes, including suicidality.

Is the emotional response of survivors dependent on the consequences of the suicide and the support received?

BACKGROUND: Despite numerous studies that have assessed emotional reactions of people bereaved by suicide, many questions in this field are not yet clarified. AIMS: The purpose of the present study was to explore how emotional reactions of those bereaved by suicide depend on their gender, the relationship to the deceased, the consequences ("only negative," "negative and positive," "predominantly positive") of the death for the bereaved and the professional support received. METHODS: The relationship between emotional reactions and characteristics was assessed in 163 suicide bereaved. Most bereaved, including all the parents of the suicide victims, had experienced emotions that occurred so often and so strongly that they had disturbed everyday life. The most frequently reported emotions were guilt and depressed mood. Female gender and being parents or spouses were associated with increased risk for lack of energy. Furthermore, the emotions of the bereaved depended on the consequences of the suicide and the professional support received. CONCLUSIONS: Professional support might be particularly important for suicide bereaved.

Do suicides' characteristics influence survivors' emotions?

The suicide of a related person can often induce severe negative emotional reactions. The objective of this study was to explore the relationships between sociodemographic and diagnostic data of suicides and survivors' emotions and to close this substantial gap. The main outcome of this study was that survivors' severity of emotional disturbance was inversely correlated with age of suicides. In the multivariable approach, only age remained related to the majority of the assessed survivors' emotions, whereas other characteristics, such as gender, presence of psychiatric disorder, or suicide method were not associated with survivors' emotions. Age had a dominant impact on the relationship between suicides' characteristics and survivors' emotional reactions and supersedes the effect of most suicides' characteristics including diagnoses.

Influence of neuronal cell adhesion molecule (NCAM1) variants on suicidal behaviour and correlated traits.

Suicide is a public health problem all around the world. Family studies showed a strong heritability but, to date, few genetic data are available. Thus, in the present study we investigated whether a panel of single nucleotide polymorphisms (SNPs) in neuronal cell adhesion molecule 1 (NCAM) 1 was associated with suicidal behaviour as well as specific traits related to suicide. A total of two hundred and fifty-nine individuals with a positive history of suicidal behaviour and 312 healthy subjects were enrolled in the study. Rs2301228, rs1884, rs1245113, rs1369816, rs2196456 and rs584427 in NCAM1 were genotyped. No marker was significantly associated with suicidal behaviour vs. controls or with sub-types of attempted vs. completed, violent vs. non-violent, impulsive vs. non-impulsive suicide. Nonetheless rs1884 and rs2196456 SNPs were both marginally associated with the trait "inhibition of aggressiveness" in suicide attempters. Even though the investigated SNPs in NCAM1 do not seem to be directly associated with suicidal behaviour, our results could suggest that SNP variants in NCAM1 may impact on related traits, particularly by mediating inhibition of aggressiveness. However, independent studies are needed to validate these results.

"Bubbles"--a spot diagnosis.

Aspiration of blood is a phenomenon observed in violent and natural death scenarios. Bloodstain patterns evolving from expectoration of aspired blood may look suspicious of a violent genesis and thus mislead crime scene investigators. In the present case, a woman was found lying in a pool of blood on the kitchen floor. Furthermore, bloodstains covered her face, clothing, and surrounding furniture and walls. Bloodstain pattern analysis and medicolegal inspection of the suspected scene of crime were carried out and revealed dispersed stains with enclosed gas bubbles in the absence of signs of physical violence leading to the assessment of a natural manner of death. The bloodstains were attributed to expiration of blood because of an internal bleeding. Medicolegal autopsy confirmed the on-site diagnosis as a fatal esophageal varix rupture was found.

Substance use disorders as risk factors for suicide in an Eastern and a Central European city (Tallinn and Frankfurt/Main).

Cultural and regional differences on the well-known elevated suicide risk in substance use disorders have not been clarified yet. Therefore, the suicide risk associated with substance use disorders in a society of transition and in a socially and economically stable society should be identified and compared. Data from two population-based matched case-control studies were used to analyse the association between alcohol and other substance consumption and the risk of suicide. Data in Frankfurt were obtained by a semi-structured interview including the Structured Clinical Interview for DSM-IV Axis I (SCID-I) in 163 suicides that occurred in 1999 and 2000, and data from Tallinn were collected according to DSM-IV criteria on 156 deceased persons who committed suicide in 1999 by using the psychological autopsy method and in each city in matched population-based control persons by personal interview. In both cities, substance use disorders were significantly associated with suicide. Odds ratios for suicide were higher in Tallinn than in Frankfurt. The highest risk was observed in Tallinn among men with alcohol use disorders, aged 35 to 59 years. Although substance use and, in particular, alcohol use disorders were confirmed as risk factors for suicide in Tallinn and in Frankfurt, the much higher suicide risk associated with alcoholism in Tallinn than in Frankfurt indicates the importance of cultural, socio-political, and regional impact of suicide risk in alcoholism.

Does sport have a protective effect against suicide?

AIM: The association between sporting activities, or lack there of, and suicidal behaviour has not yet been clarified. The objective of this study was to determine, if sports participation has an impact on risk for completed suicide. METHODS: Axis I and Axis II disorders, sociodemographic factors, and current and former sports activities, including various sports disciplines, were assessed by a semi-structured interview by psychological autopsy method in 163 suicides and by personal interview in 396 living population-based control persons. RESULTS: Current sports activities (OR = 0.24, 95%CI, 0.15 to 0.39; OR = 0.27, 95%CI, 0.16 to 0.45) and sports activities at some point in life (OR = 0.33, 95%CI, 0.18 to 0.62; OR = 0.40, 95%CI, 0.23 to 0.68, after adjustment for axis I and II disorders or educational level, each) were associated with decreased suicide risk. CONCLUSIONS: Current sports activities and sports activities at some point in life may reduce suicide risk.

Smoking differently modifies suicide risk of affective disorders, substance use disorders, and social factors.

BACKGROUND: Although an association between smoking and suicide has repeatedly been shown, information about a modifying influence of smoking on other risk factors for suicide is lacking. METHODS: Axis I and Axis II disorders, sociodemographic factors, and tobacco use were assessed by a semi-structured interview including the Structured Clinical Interview for DSM-IV Axis I (SCID-I) and Personality Disorders (SCID-II) in 163 suicides (mean age 49.6+/-19.3 years; 64.4% men;) by psychological autopsy method and by personal interview in 396 living population-based control persons (mean age 51.6+/-17.0 years; 55.8% men). RESULTS: Smoking status (current smokers, lifetime non-smokers, and former smokers) differently modifies the effects of psychiatric disorders and sociodemographic variables on suicide risk. Former and current smoking modified suicide risk associated with affective disorders, but only current smoking increased suicide risk for substance use disorders. Ex-smokers with affective disorders, particularly with major depression, had less increased suicide risk than current smokers and non-smokers with affective disorders. Estimated suicide risks for personality disorders and 'no professional training' were strongly increased by smoking. LIMITATIONS: Due to the small size of some of the subgroups, confidence intervals are wide. Therefore, precise risk estimation is not possible. CONCLUSIONS: Clinicians should interpret smoking as an indicator of increased risk of suicide for individuals with substance use disorders, personality disorders, and adverse social factors. Further studies are needed to investigate the effects of smoking cessation on suicide risk of patients with psychiatric disorders such as major depression and substance use disorders.

How do personality disorders modify suicide risk?

There is a lack of psychological autopsy studies assessing the influence of axis II disorders on other risk factors for suicide. Therefore, we investigated if the estimated suicide risk for axis I disorders and socio-demographic factors was modified by personality disorders. Psychiatric disorders were evaluated by a semi-structured interview including the Structured Clinical Interview for DSM-IV Axis I (SCID-I) and Personality Disorders (SCID-II) by psychological autopsy method in 163 completed suicides and by personal interview in 396 population-based control persons. Personality disorders modify suicide risk, differently for affective disorders, substance use disorders, smoking, life events during the last three months, and socio-demographic factors such as being single. Estimated suicide risk for socio-demographic factors and life events is not substantially altered following adjustment for affective disorders or substance use disorders. These findings suggest that treatment of personality disorders is essential for suicide prevention.

Estrogen receptor gene 1 variants are not associated with suicidal behavior.

Estrogen is thought to be involved in the pathophysiology of depression and suicidal behaviors. We studied gene variants of estrogen receptor alpha (rs827421, rs1913474, rs1801132, rs722207, rs974276 and rs910416) in 167 German suicide attempters (affective spectrum n=107, schizophrenia spectrum n=35, borderline personality disorder n=25), 92 German individuals who committed suicide and 312 German healthy subjects. Single markers and haplotype analysis in relation to suicidal behaviors (suicide attempters/completers) did not reveal any significant association. These were also not associated with related features, such as violence or impulsivity of suicide attempt, State-Trait Anger Expression Inventory (STAXI) and Questionnaire for Measuring Factors of Aggression (FAF) scores. In conclusion, our study does not support the hypothesis that estrogen receptor alpha gene variants are major contributors to suicide or to anger- or aggression-related behaviors.

Dopa decarboxylase and tyrosine hydroxylase gene variants in suicidal behavior.

The dopaminergic system has been previously associated to behavioral facilitation and aggression, hence making the pathway a good candidate for suicidal behavior. We studied gene variants in the tyrosine hydroxylase (rs3842727, rs6356) and DOPA decarboxylase (rs1451371, rs1470750, rs998850) genes in a sample of 571 individuals consisting of 167 German suicide attempters (affective spectrum n = 107, schizophrenia spectrum n = 35, borderline personality disorder n = 25), 92 Caucasian individuals who committed suicide and 312 German control subjects. TH variants were not associated with suicide (uncorrected P = 0.023) and related traits. Some marginal associations could be observed for DDC with suicide, violence, anger, and aggression. In conclusion, our study does not support the involvement of TH gene variants as major contributors to suicide, whereas DDC variants could mediate some features related to suicide and be involved in violent suicidal behavior.

NOS-I and -III gene variants are differentially associated with facets of suicidal behavior and aggression-related traits.

Nitric oxide (NO) is a neurotransmitter which modulates depressive and aggressive behaviors. We studied gene variants of NOS-I (rs2682826;rs1353939;rs2293049;rs693534) and NOS-III (rs2070744;rs1799983;rs891512) in a total of 571 cases (167 German suicide attempters, 92 Caucasian suicide completers and 312 German healthy subjects). A NOS-I risk haplotype C-G-G (rs2682826-rs1353939-rs693534) was associated with suicidal behavior (P = 0.01), and more specifically with suicide attempts (P = 0.01). Sliding windows analysis showed similar results for the haplotype G-G (rs1353939-rs693534) being a risk factor for suicidal behavior (P = 0.01) again especially in suicide attempters (P = 0.004). Additionally, the G-allele of rs693534 was associated with suicidal behavior (P = 0.005) and more specifically with suicide attempts (P = 0.003). Interestingly, the same haplotype (G-G) as well as the rs693534 G-allele were also associated with increased aggression. Regarding NOS-III, a protective haplotype C-T-A (rs2070744-rs1799983-rs891512) was observed (P = 0.01) with a pronounced effect against suicide completion (P = 0.005). Sliding window analysis showed the same effect of haplotype T-A (rs1799983-rs891512) (P = 0.01) which was again protective against suicide completion (P = 0.006). Single marker analysis showed the same protective effect of the rs891512 A-allele (P = 0.009) again especially against suicide completion (P = 0.007). Additionally, a second haplotype (T-T-G) was associated with increased aggression (P = 0.0002; sliding haplotype T-G, P = 0.002). In conclusion, our study suggests a possible involvement of NOS-I and NOS-III gene variants in suicidal behavior and related intermediate phenotypes.

Gene expression profiling of post-mortem orbitofrontal cortex in violent suicide victims.

The neurobiological basis of suicidal behaviour is multifactorial and complex. Several lines of evidence indicate that environmental factors as well as multiple genes and interactions of both are implicated in its aetiology. The aim of this study was to establish the transcriptomic expression profile of post-mortem brain tissue of suicide victims in order to identify new candidate genes and biological patterns for suicidal behaviour. Post-mortem orbitofrontal cortex tissue was derived from 11 suicide victims and 10 non-psychiatric controls carefully selected from a brain bank of over 150 brains, and the expression of more than 23000 messenger RNAs was assessed in this case-control study. Validation experiments were carried out using quantitative RT-PCR as an independent method. A classification of the differentially expressed genes according to their biological function and statistical analyses of the data were performed in order to identify biological pathways that are over-represented in the suicide group. In total, 124 transcripts demonstrated significant changes (fold changes > or = 1.3, p value < or = 0.01), with 59 showing under-, and 65 over-expression in the suicide group. The results could be validated for nine particularly interesting transcripts (CDCA7L, CDH12, EFEMP1, MLC1, PCDHB5, PTPRR, S100A13, SCN2B, and ZFP36). The pathway analysis showed that the Gene Ontology categories 'central nervous system development', 'homophilic cell adhesion', 'regulation of cell proliferation' and 'transmission of nerve impulse' were significantly enriched. The differentially expressed genes and significant biological processes might be involved in the pathophysiology of suicide and warrant further attention.

Tachykinin receptor 1 variants associated with aggression in suicidal behavior.

Substance P is involved in the modulation of depression, anxiety, and suicidal-related behaviors. We studied gene variants of Tachykinin Receptor 1 (TACR1-rs3771810, rs3771825, rs726506, rs1477157) in 167 German suicide attempters (affective spectrum n = 107, schizophrenia spectrum n = 35, borderline personality disorder n = 25), 92 Caucasian individuals who committed suicide and 312 German healthy subjects. Single markers and haplotype analysis in relation to suicidal behaviors (suicide attempters/completers) did not reveal any significant association. The rarest rs3771825 T allele however showed a marginal association with higher Reactive Aggression scores on the Questionnaire for Measuring Factors of Aggression (FAF) (F = 9.86, df = 1; P = 0.0017). Haplotype analyses confirmed the finding. Violence or impulsivity of suicide attempt and State-Trait Anger Expression Inventory (STAXI) scores were not associated with gene variants. In conclusion, our study suggests that TACR1 gene variants have no major influence on suicidal behavior but may modulate aggression features.

HTR2C and HTR1A gene variants in German and Italian suicide attempters and completers.

The serotonin 2C (HTR2C) and 1A (HTR1A) receptors have been involved in suicide-related behaviors. We studied gene variants of both receptors in suicide attempters and completers. The sample was composed of 167 German suicide attempters (affective spectrum n = 107, schizophrenia spectrum n = 35, borderline personality disorder n = 25), 92 Caucasian individuals who committed suicide, 312 German healthy subjects, 152 Italian suicide attempters (major depression n = 68 and bipolar disorder n = 84), and 131 Italian healthy volunteers. HTR2C (SNP: rs547536, rs2192372, rs6318, rs2428707, rs4272555, rs1801412) and HTR1A (SNP: rs1423691, rs878567, and rs6295) variants were analyzed in the German sample. HTR2C rs6318 and HTR1A rs6295 were analyzed in the Italian sample. Haplotype analysis in relation to suicidal behaviors did not reveal any significant association. Single markers and haplotypes were not or only marginally associated with other related features, such as violence of suicide attempt, family history for suicide attempt or State-Trait Anger Expression Inventory (STAXI) and Questionnaire for Measuring Factors of Aggression (FAF) scores. In conclusion, our study does not support the notion that HTR2C and HTR1A gene variants are major contributors to suicide-, anger-, or aggression-related behaviors in our sample.

ABCG1 gene variants in suicidal behavior and aggression-related traits.

The ABCG1 transporter seems to be involved in human cholesterol and sterol homeostasis. As alterations in cholesterol homeostasis have been widely linked to aggression, violence and suicidal behavior, we considered ABCG1 as a candidate gene for these traits. We studied 5 gene variants of ABCG1 in a sample of 571 suicide attempters, healthy controls and suicide completers. We also analyzed the relation to aggression-related traits, assessed by STAXI and FAF. Regarding the genotypes, there was no association with completed or attempted suicide with the tested SNPs. Regarding alleles, only one SNP (rs1044317) showed a slight association with suicide attempters in comparison to the controls. Interestingly, rs225374 G allele carriers had higher scores on the STAXI subscales "State Anger" and "Anger Out", as well as on the FAF subscales "Spontaneous Aggression", "Irritability" and "Aggression". Carriers of the rs914189 G allele scored higher on the FAF subscales "Spontaneous Aggression", "Reactive Aggression" and "Aggression". Carriers of the rs1044317 G allele had lower scores for STAXI "Trait Anger" and "Trait Temperament", and higher scores for STAXI "Anger Control". Our results provide evidence that the ABCG1 may influence aggression-related traits. Given that these represent intermediate phenotypes of suicidal behavior, ABCG1 might also act on suicidal behavior through these traits. The observed associations warrant further replications.

[Risk factors for suicide in substance-related disorders]. / Risikofaktoren für Suizid bei Störungen im Zusammenhang mit psychotropen Substanzen.

OBJECTIVE: To assess the contribution of sociodemographic and psychopathologic predictors for suicide in alcohol-related disorders and in substance-related disorders in general and to examine the constellations of risk factors for suicide. METHODS: Out of 163 suicides (using psychological autopsy method) and 396 population-based control persons, 67 suicides and 67 controls with substance-related disorders (DSM-IV; alcohol-related disorders: suicides: n = 36, controls: n = 27) were assessed. RESULTS: Affective disorders, suffering from substance dependence, and low education independently predicted increased suicide risk in alcohol-related disorders as well as in substance-related disorders in general, severe nicotine consumption only in alcohol-related disorders. CONCLUSIONS: There are common risk factors for suicide in alcoholism and substance-related disorders in general. Effective suicide prevention strategies must include a focus on substance dependence as well as on affective disorders.

Axis I disorders and personality disorders as risk factors for suicide.

There is a lack of psychological autopsy studies assessing the influence of axis I disorders on axis II disorders as risk factors for suicide. Therefore, we investigated the association between personality disorders, axis I disorders, and suicide. Psychiatric disorders were evaluated by a semi-structured interview including the Structured Clinical Interview for DSM-IV Axis I (SCID-I) and Personality Disorders (SCID-II) in 163 completed suicides (mean age 49.6 +/- 19.3 years; 64.4% men) and by personal interview in 396 population-based control persons (mean age 51.6 +/- 17.0 years; 55.8% men). In both genders, suicides significantly more often had personality disorders of all clusters than controls, also after adjustment for axis I disorders (p < 0.001, each). In addition, alcohol-related disorders, major depression, and co-occurrence of personality disorders of more than one cluster (men: OR = 16.13; women: OR = 20.43) remained independent predictors for suicide in both genders, "pure" cluster B personality disorders only in women and "pure" cluster C personality disorders only in men. In both genders, co-occurrence of personality disorders of more than one cluster contributed to risk of completed suicide after control for axis I psychiatric disorders and has to be considered as an independent risk factor for suicide.