Stressors increase leptin receptor-expressing thymic epithelial cells in the infant/child thymus.

The thymus, the organ that is the most sensitive to stress, presents acute involution as a result of exposure to strong stress in childhood. Thymic involution is thus often considered evidence of child abuse/neglect in forensic autopsies. A portion of the thymic epithelial cells express leptin receptor, and leptin showed a thymo-protective function against stress-induced thymic involution in an animal model. Leptin receptor-expressing thymic epithelial cells (LR-TECs) may play a key role in the thymic remodeling provoked by a stressful environment. Here, we sought to clarify the changes of histopathological findings and human LR-TECs in stressful environment. We examined human thymus specimens obtained from 40 forensic autopsy cases (26 male, 14 female; age 21 to 3221 days). We divided the cases into stressor-positive (SP, n = 29) and stressor-negative (SN, n = 11) groups. Cases were classified according to the histological classification of thymic involution and investigated by leptin receptor immunostaining. The results revealed that (1) the SP group showed obvious histological thymic involution (p < 0.01) and (2) the LR-TECs/TECs ratio in the cortex was markedly and significantly increased in the SP group compared to the SN group (p < 0.01). The increase in the cortical LR-TECs/TECs ratio in the SP group may be part of the stress response mechanism in the human thymus. We thus speculate that the quantification of LR-TECs in the thymic cortex is a valuable stress marker for forensic autopsy cases.

A preliminary study on postmortem interval estimation of suffocated rats by GC-MS/MS-based plasma metabolic profiling.

Estimation of postmortem interval (PMI) is an important goal in judicial autopsy. Although many approaches can estimate PMI through physical findings and biochemical tests, accurate PMI calculation by these conventional methods remains difficult because PMI is readily affected by surrounding conditions, such as ambient temperature and humidity. In this study, Sprague-Dawley (SD) rats (10 weeks) were sacrificed by suffocation, and blood was collected by dissection at various time intervals (0, 3, 6, 12, 24, and 48 h; n = 6) after death. A total of 70 endogenous metabolites were detected in plasma by gas chromatography-tandem mass spectrometry (GC-MS/MS). Each time group was separated from each other on the principal component analysis (PCA) score plot, suggesting that the various endogenous metabolites changed with time after death. To prepare a prediction model of a PMI, a partial least squares (or projection to latent structure, PLS) regression model was constructed using the levels of significantly different metabolites determined by variable importance in the projection (VIP) score and the Kruskal-Wallis test (P < 0.05). Because the constructed PLS regression model could successfully predict each PMI, this model was validated with another validation set (n = 3). In conclusion, plasma metabolic profiling demonstrated its ability to successfully estimate PMI under a certain condition. This result can be considered to be the first step for using the metabolomics method in future forensic casework.

Current state of cause of death determinations in Japan and the need to list the precise underlying cause of death.

When death is caused by a disease, the precise cause of the death must be determined to promote health and contribute to prevention efforts. The circumstances of death should also be clarified so that measures can be taken to prevent the recurrence. Statistics regarding the cause of death must be accurate, and such statistics are shaped by the determination of the cause of death. We examined the annual cause of death rankings and the mortality rate in Japan during the 25-year period 1993-2017. We identified improvements that are needed to provide more precision in the cause of death statistics, with a focus on variations in the rankings, and we describe the peculiar and vulnerable aspects of the Vital Statistics system in Japan; for example, at one time the national government advised physicians to not list "heart failure" as the terminal stage of a condition on a death certificate, and the "heart disease" mortality rate thus tended to decline in that period. The ranking of "heart disease" as a cause of death decreased, but its mortality rate subsequently increased again. In addition, the "pneumonia" mortality rate has remained high over the past few years, but it abruptly decreased in 2017, when "aspiration pneumonia" was separated as a cause from other pneumonias. The "senility" mortality rate has increased annually, and it is a leading cause of death. It is important that physicians understand the underlying causes of death and provide that without being influenced by the reporting customs of the times.

Potential medical adverse events associated with death: a forensic pathology perspective.

OBJECTIVE: To determine the incidence of potential medical adverse events among patients undergoing forensic autopsy, and to present the characteristics of potential medical adverse events. DESIGN: Retrospective review of consecutive autopsy records. SETTING: Department of Forensic Medicine, the Jikei University School of Medicine, Tokyo, Japan. PARTICIPANTS: A total of 3355 forensic autopsy cases between 1983 and 2006. MAIN OUTCOME MEASURES: Incidence of potential medical adverse events identified in decedents undergoing forensic autopsy, classified by actual occurrence as 'confirmed', 'equivocal' and 'negative' cases; proportion of potential diagnostic, performance and system errors among potential medical adverse events. RESULTS: Of 291 autopsies (8.7%) with potential medical adverse events, 66 cases (22.7%) were confirmed, 42 cases (14.4%) were negative and 183 cases (62.9%) were equivocal. Confirmed cases consisted of potential diagnostic errors in 49 cases (74.2%) and performance errors in 17 cases (25.8%). Equivocal cases included 99 cases associated with potential diagnostic errors (54.1%) and 60 cases associated with potential system errors (32.8%). In 38 of the confirmed cases (57.5%), serious exacerbation of patient condition occurred outside the medical facility. CONCLUSIONS: Potential medical adverse events are not uncommon in decedents undergoing forensic autopsy. They are particularly associated with potential diagnostic errors. Forensic autopsy may provide information that could be used to improve care and reduce deaths due to potential medical adverse events.

A promoter polymorphism in the ALDH2 gene affects its basal and acetaldehyde/ethanol-induced gene expression in human peripheral blood leukocytes and HepG2 cells.

AIMS: To assess the effect of the -360G/A polymorphism in the promoter region of the human aldehyde dehydrogenase-2 (ALDH2) gene on its transcription, basal and acetaldehyde/ethanol-induced gene expression was examined by in vivo and in vitro experiments. METHODS: Human peripheral blood leukocytes were collected before and after alcohol ingestion (0.4 g/kg body weight) in 21 healthy young Japanese volunteers with a deficient phenotype of ALDH2 ((487)Glu/Lys), and the levels of ALDH2 mRNA were quantified by real-time RT-PCR. The transcriptional activity of the ALDH2 promoter was investigated by a reporter assay using HepG2 cells in the presence or absence of acetaldehyde/ethanol. RESULTS: The basal level of ALDH2 mRNA was significantly higher in -360A heterozygous subjects than in -360G homozygous subjects. In all subjects, regardless of the genotype, ALDH2 mRNA increased following ethanol ingestion. The promoter activity of a reporter plasmid for -360G was significantly lower than that of a reporter plasmid for -360A. Exposure to acetaldehyde induced a significant increase in the transcriptional activity of the -360G reporter, but not the -360A reporter. CONCLUSIONS: In vivo and in vitro experiments showed that the -360G allele has lower basal transcriptional activity than the -360A allele, whereas acetaldehyde/ethanol-induced gene expression, in general, seems to be more enhanced in individuals homozygous for the -360G allele than in those with the -360A allele. Thus, the promoter polymorphism may be involved in individual differences in acetaldehyde elimination.

Effects of polymorphisms in untranslated regions of the class I alcohol dehydrogenase (ADH) genes on alcohol metabolism in Japanese subjects and transcriptional activity in HepG2 cells.

Human class I ADH is a dimmer formed by the random association of three types of subunits (alpha, beta and gamma) encoded by ADH1A, ADH1B, and ADH1C, respectively. Different kinetic properties were reported due to polymorphisms of ADH1B Arg47His and ADHIC Ile349Val. Besides these polymorphisms in the coding region, various mutations in the promoter region and 3' untranslated (UTR) region, which possibly affect expression and degradation rate, were recently reported. In this study, to asses the involvement of each genotype in alcohol metabolism in humans, our previously collected data set of blood EtOH and AcH changes were reanalyzed with regard to the ALDH2 Glu487Lys genotype. The effects of genotypes and haplo-types on transcriptional activity were also examined by a luciferase reporter assay by cloning the promoter region and 3' UTR corresponding to each polymorphism and transfecting into HepG2 cells. Among the nine polymorphisms, including ADH1B Arg47His and ADH1C Ile349Val, blood EtOH levels were significantly affected by polymorphisms ADH1B -451G>T, ADH1B +52A>G, ADH1B +531G>A, ADH1B +1176AG>del. and ADH1A -55C>T in ALDH2 Glu/Glu subjects. In the ALDH2 Glu/Lys genotype background, only ADH1C -254G>C and ADH1B His47Arg showed significant effects on blood EtOH. These five loci (and the two loci which had significant effect on blood EtOH in ALDH2 Glu/Glu and Glu/Lys subjects) also showed strong linkage disequilibrium. In comparison to the in vivo study on alcohol metabolism, significantly higher transcriptional activities in ADH1B -451T (rather than C) promoter and ADH1C-254 G (rather than C) promoter were observed in a luciferase assay in HepG2 cells. In conclusion, polymorphisms in the untranslated regions of ADH class I genes were demonstrated to clearly affect individual differences in alcohol metabolism. Especially, ADH1B -451G>T, ADH1C-254G>C polymorphisms were suggested to have functional significance with regard to transcriptional activity to the linkage equilibrium of polymorphisms ADH1B His47Arg and ADH1C Ile349Val.

Effects of functional polymorphisms related to catecholaminergic systems on changes in blood catecholamine and cardiovascular measures after alcohol ingestion in the Japanese population.

BACKGROUND: The polymorphism of human aldehyde dehyrogenase-2 (ALDH2) Glu(487)Lys is well known to be a crucial factor underlying the genetic background for alcohol sensitivity in Asian populations. Subjects with the inactive Lys(487) allele show a marked increase in blood acetaldehyde level after alcohol intake, which results in facial flushing and various cardiovascular-related symptoms. However, other polymorphisms related to catecholaminergic systems that tightly regulate the activity of the sympathetic nervous system may also influence the physiological changes after acute alcohol intake. METHODS: We investigated whether, together with the ALDH2 Gly(487)Lys and ADH1B Arg(47)His genotype, putative functionally important polymorphisms, including 9 loci in 7 human genes, were associated with changes in blood catecholamine levels and cardiovascular measures after alcohol ingestion. Forty-nine young Japanese males were subjected to blood catecholamine analysis after alcohol ingestion. Among them, 28 were also subjected to heart rate variability and blood pressure analysis. The contribution of polymorphisms to the alcohol-induced response was analyzed by multiple regression analysis. RESULTS: Among the polymorphisms examined in this study, haplotypes of the phenylethanolamine N-methyltransferase (PNMT) promoter [(-182bpG/A)_(-387bpG/A)] and catechol-O-methyltransferase (COMT) exon 4 [(Ex4 + 119bpC/G)_(Ex4 + 138bpG/A), Leu(136)Leu_Val(158)Met] are suggested to have functionally important effects on alcohol-induced cardiovascular symptoms by affecting blood catecholamine levels. The neuropeptide Y (NPY) promoter C-1450T genotype is also suggested to be involved in the individual differences in regulation of catecholamine secretion. CONCLUSIONS: This study suggested that these common polymorphisms of genes related to catecholaminergic systems, as well as those of the alcohol metabolizing system, are significant for understanding the basis of individual differences in alcohol sensitivity.

Risk factors, diagnosis and prevention of sudden unexpected infant death.

The diagnosis of the cause of sudden unexpected infant death (SUID) is often difficult work for forensic pathologists. Its misdiagnosis or misclassification is the cause of crucial epidemiological and medicolegal problems. During the sudden infant death syndrome (SIDS) epidemic, many reports described the risk factors of SIDS as well as mechanical suffocation during sleep. Meadow's report has invited worldwide debate over whether the cause of SUID is attributable to SIDS or suffocation. On the basis of this background, the problems concerning causal diagnosis and risk factors, particularly the accidental suffocation of infants during sleep, and the specific pattern of suffocation, was reviewed from the forensic pathological viewpoint. The following tasks remain to be done for the future: (1) to avoid preventable SUIDs, the most effective measure worldwide is to identify high-risk factors for all SUIDs, including SIDS, accidental suffocation and undetermined causes, and then transmit this information to the public. (2) SIDS should be uniformly defined and diagnosed as strictly as possible to gain its reliability in the public health community and in a legal framework.

Suicidal tendencies among the elderly in Mie Prefecture, Japan, between 1996 and 2002.

This study aims to show the causative factors of suicide among the elderly (over 65) in Mie Prefecture, and to discuss the prevention of the factors contributing to suicide in the elderly group. We obtained an agreement from the Mie Prefectural Police Headquarters and investigated all inquest records collected between 1996 and 2002 in Mie Prefecture and focused on suicide in the elderly group. During the test period, the number of suicides in the elderly group was 842. In causative factors, the two major causative factors of suicide were "suffering from physical illness" and "psychiatric disorders". In particular, the three most frequent physical illnesses were "cardiovascular disease", "orthopedic disorder", and "digestive organ disease", and these physical illnesses are mentally stressful, and thus have a psychiatric component, the same as psychiatric illnesses do. Consequently, it is concluded that improvements in the home nursing and mental health care should include the prevention of suicide in the elderly who "suffer from physical illness" and "psychiatric disorders" to prevent suicide. In addition, medical staff and the general public should be educated on the factors that can influence elderly persons' mental condition, and should be cautioned to observe elderly persons for suicidal signs and symptoms.

The correlation between unemployment and suicide rates in Japan between 1978 and 2004.

The number of suicides in Japan has increased from approximately 22,000 per year from 1988 to 1997 to over 30,000 per year since then; this increase is among the most important problems facing Japan. Moreover, the unemployment rate in Japan has increased rapidly since 1998. In this study, we examined the total number of suicides and both the suicide and unemployment rates in Japan from 1978 to 2004. We also focused on the correlation between annual suicide rates in Japan and the annual unemployment rates during the study period. During that period, 455,357 males and 225,012 females committed suicide in Japan, and the suicide rates by sex were 27.8 males and 13.3 females per 100,000 population (P<0.05). The annual suicide rates among males correlated significantly with the annual unemployment rates: r(27)=0.94, P<0.001, while the female suicide rates did not correlate with the unemployment rates: r(27)=0.39, P=0.05. Thus, when unemployed men are observed to be depressed, it is important for those close to them, as well as their health care professionals, to pay careful attention to their behavior to detect suicidal tendencies or intentions.

A correlation between increases in suicide rates and increases in male unemployment rates in Mie prefecture, Japan.

The number of suicides in Japan has increased from approximately 22,000 per year in 1988-1997 to over 30,000 per year since then. It has also increased in Mie prefecture during that period. In the present study, we investigated the correlation between annual suicide rates in Mie prefecture, Japan from 1996-2002 and the annual unemployment rate in Japan from 1996-2002 among males. Among the results, annual suicide rates in total correlated with the unemployment rate in Japan, but the relation was not statistically significant: r(7)=0.76, r(2)(7)=0.58, p=0.05 (y=3.54x+6.37); the rates in males, however, correlated significantly with the unemployment rate in Japan: r(7)=0.85, r(2)(7)=0.73, p=0.01 (y=5.72x+4.49). In addition, we found that annual suicide rates in total correlated significantly with the male unemployment rates. When a patient is unemployed and in a bad situation, the medical staff and the family should be aware of the correspondence between suicide rates and unemployment.

Detection of butane gas inhalation at 16days after hypoxic encephalopathy: A case report.

In Japan, there are increasing reports of death by poisoning following butane abuse. To determine the specific cause of death in such cases, it is important to confirm the presence of fuel gas components in the body, although careful analysis is required because of their volatile properties. In most reported cases, the subject died suddenly during or immediately after butane aspiration. Thus, the butane concentration in the samples from the deceased should be relatively high. Herein, we present a case of an 18-year-old man found with cardiopulmonary arrest, who then exhibited hypoxic encephalopathy for 16days in a hospital. At autopsy, we detected hypoxic encephalopathy, pneumonia, and ischemia-reperfusion injury of the myocardium, while the cause of cardiac arrest remained unclear. Toxicological analysis was then performed for fuel gas components in several specimens collected at autopsy. Results showed that n-butane and isobutane were detected in the adipose tissue at 16days after inhalation, indicating a role of butane gas inhalation as the cause of death. These data suggest that adipose tissue may be the most appropriate analysis sample to be collected at postmortem in cases where involvement of volatile and fat-soluble gas inhalation is suspected.

Effect of -361 G/A polymorphism of aldehyde dehydrogenase-2 gene on alcohol metabolism and its expression in human peripheral blood leukocytes.

The deficiency in activity of aldehyde dehydrogenase-2 (ALDH2), commonly found in Asians, is due to a mutation at position 487 in exon 12, encoded by the ALDH2*2 allele, which is a crucial factor for deficient ability to acetaldehyde (AcH) oxidation. In addition to this locus, polymorphism in -361 G/A mutation of this gene at 5'flanking region, commonly found in multi-racial populations, is one of the suggestive polymorphisms which may affect on the enzyme activity because it has been reported to affect on the transcriptional activity in hepatoma cells. We aimed to examine the individual differences in alcohol metabolism in Japanese population based on the genotypes of both ALDH2 exon 12 and -361 G/A promoter region. Following genotyping of 2 loci, subject groups based on the promoter genotype was defined as variant A carrier (A+; A/A and G/A) or not (A-; G/G). Under the condition with 0.4 g/kg body weight of alcohol ingestion, significant differences in AcH peak levels, that reached at 30 or 60 minutes in most subjects, was not detected between promoter A+ and A- groups both in exon 12 ALDH2*1/*1 and ALDH2*1/*2 subjects. Furthermore, we developed a real-time RT-PCR method to detect and quantitate the ALDH2 mRNA levels in easily accessible peripheral blood leukocytes (PBLs) to examine whether this promoter mutation affects on the amount of ALDH2 mRNA in normal human tissue at pre- and post-alcohol ingestion phase in ALDH2*1/*1 subjects. Significant increase of mRNA was observed only in A- group at 2 hours after alcohol ingestion. Maximal changing rates of mRNA in PBLs within 3 hours after alcohol intake were +48 % and +17 % in A and A' groups, respectively. These results suggest that the individual differences in ALDH2 enzyme activity may be intricately regulated by the common polymorphisms in these two loci in Asian populations.

A Long-term Study of the Association between the Relative Poverty Rate and Suicide Rate in Japan.

The annual number of suicides in Japan totaled around 23,000 in 1997 and abruptly increased to around 31,000 in 1998. This figure has remained high since then. This abrupt increase in the number of suicides was primarily due to an increase in suicides occasioned by economic concerns. The association between various economic factors and suicide must be studied in detail and over the long term in order to ascertain the association between economic concerns and suicide. This study examined the relative poverty rate and the suicide rate in Japan over 30 years and discussed the association between those two rates. The results suggest that the relative poverty rate may be associated with the suicide rate for both sexes. This association is true for men in particular. The organizations and professionals involved in implementing suicide prevention measures should be cognizant of the current findings and consider formulating additional specific measures.

A rare case of steering wheel injury causing coronal-plane pancreatic lacerations.

The incidence of pancreatic injury after blunt abdominal trauma is extremely low. A timely and accurate diagnosis is important, as a delay could be life-threatening. In this case, a 70-year-old driver crashed a car into a concrete wall at low speed. He was transported to the emergency hospital but died about 9.5h later with the cause of death unknown. An autopsy revealed that his pancreas was lacerated in the coronal plane and there was mesenteric contusion. Cause of death was determined to be blood loss resulting from pancreatic and mesenteric contusion. The mechanism of the injury was considered to be a very rare "degloving," caused by the impact from the steering wheel. It is therefore important to keep in mind possible pancreatic damage when examining blunt trauma to the abdomen, especially in traffic accident cases.

Underlying factors for the rapid increase of suicide in Mie Prefecture, Japan.

The number of suicides in Japan increased from about 22,000 per year during the period 1988 to 1997 to over 30,000 since 1998. The number of suicides has also been increasing in Mie Prefecture. In the present study we examined the incidence and the circumstances for all suicidal cases during the seven-year period, 1996-2002, that were reported to Mie Prefectural Police Headquarters. In Mie Prefecture, the number of suicides per year averaged 421 cases: from a minimum of 319 in 1997 to a maximum of 501 in 1998. The most frequent month for suicides was July, while the lowest number occurred in February. Suicide was most common in the 50-59 year age group in men, and in the 70-79 year group in women. Regarding the means of suicide, hanging was the most frequent (61.6%) in both sexes. Psychiatric disorders were the most serious causative factors in all generations, accounting for 23.8% in general but being especially prevalent in the younger generation of people under 39 years. Further reasons for suicide were economic problems for the 40-64 age-group in men and suffering from illness for the elderly age-groups in both sexes. In order to prevent suicide, urgent strategies for effective medical treatments and improved working circumstances are required.

Multiple infectious pseudoaneurysms: An autopsy case.

A 47-year-old Japanese woman died unexpectedly 11 days after admission due to acute cerebellar infarction. The patient had a history of Sjögren syndrome with long-term steroid therapy, hypertension, thalamic infarction and amphetamine psychosis. Multiple pseudoaneurysms in both the aorta and coronary artery were found at autopsy, and one located in the aortic root had ruptured into the pericardium resulting in sudden unexpected death. The detailed examination suggested that the pseudoaneurysms resulted from microbial infection to the arterial wall via the vasa vasorum. Immunosuppression induced by the long-term steroid therapy and abused drug injection could have influenced the formation of pseudoaneurysms.

Evaluation of thymic volume by postmortem computed tomography.

The thymus is exceedingly sensitive to stress and undergoes abrupt involution as a result of exposure to strong stress in early childhood. Therefore, thymic involution is often utilized to assess the presence of a stressful environment, such as an environment involving child abuse, in forensic medicine. In recent years, computed tomography (CT) has been commonly used in the daily practice of forensic medicine. We have focused on the thymic volume in postmortem CT images to evaluate the presence of a stressful antemortem environment. We calculated the thymus volume from postmortem CT images of children under six years old and demonstrated that the volume showed a positive correlation with the real weight obtained from an autopsy. The evaluation of thymic volume by CT may make it possible for us to identify child maltreatment. The most useful feature of this application of CT is to be able to demonstrate thymic involution less invasively in a surviving victim.

Inquest results on the aged: comparison between Mie Prefecture and three Medical Examiners' Offices in Japan.

In Japan, the medical examiner system was enforced only in three large cities, Tokyo metropolitan, Osaka and Kobe Cities. In other areas without this system, autopsy rates are much lower than in the areas with the system. Since the population of the aged (>/=65 years old) has been increasing recently, the subjects for medicolegal investigations seem to be also increasing. In the present study, between Mie Prefecture and those three Medical Examiner's Offices in Japan, the inquest results during the 5-year-period from 1996 to 2000, especially on the aged, were compared. The aged accounted for approximately 50% of all inquest cases in those areas. Autopsy rates for the aged were 16, 24 and 75% in Tokyo, Osaka and Kobe, respectively. Seventy-five to eighty percent was classified in deaths due to disease. Seventy to seventy-five percent of death due to disease was subclassified in circulatory diseases. The highest incidence of vascular diseases was observed in Kobe whose autopsy ratio was the highest. On the contrary, ambiguous causes of deaths, e.g. heart failure or unknown, were still frequent in Mie Prefecture.