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Gunshots to the human body can cause direct and indirect injuries. Direct injuries are a consequence of the projectile guiding its way through the body, creating a permanent wound channel and thereby damaging the penetrated as well as the adjacent tissue. In addition, the temporary wound cavity is responsible for indirect injuries occurring distant to the actual wound tract. This can potentially affect different types of tissue, like blood vessels, organs, or bones, that are not directly passed through by the projectile. For this case report, we describe a suicidal headshot to the temporal area where the extension of the temporary wound cavity and its subsequent collapse led to massive energy transfer to the surrounding tissue leading to breakage of the upper dental prosthesis and fractures of the lower jaw. Thereby outlining the ballistic mechanisms causing indirect injury pattern that have to be considered when examining gunshot wounds., (© 2023. The Author(s).)

Estimating postmortem intervals (PMI) is crucial in forensic investigations, providing insights into criminal cases and determining the time of death. PMI estimation relies on expert experience and a combination of thanatological data and environmental factors but is prone to errors. The lack of reliable methods for assessing PMI in bones and soft tissues necessitates a better understanding of bone decomposition. Several research groups have shown promise in PMI estimation in skeletal remains but lack valid data for forensic cases. Current methods are costly, time-consuming, and unreliable for PMIs over 5 years. Raman spectroscopy (RS) can potentially estimate PMI by studying chemical modifications in bones and teeth correlated with burial time. This review summarizes RS applications, highlighting its potential as an innovative, nondestructive, and fast technique for PMI estimation in forensic medicine., (© 2023 The Authors. Journal of Biophotonics published by Wiley-VCH GmbH.)

Pepper spray launchers are more precise and wind stable compared to conventional pepper sprays and are commonly used as a self-defensive tool. With the advanced potential, they may also harbour a greater risk for injuries, especially if they are not used within the suggested safety distance. If the shooting distance is below 1.5 m, energy densities may exceed the threshold energy density for the penetration of skin leading to skin laceration. We present a case where a man is hit by the liquid jet of a JPX Jet Protector® with an estimated shooting distance of 0.3 m. The man suffered from a bleeding skin laceration, which had to be sewed in the hospital. This case report furthermore outlines the potentially dangerous effect of pepper spray launchers and thereby their role in forensic investigations., (© 2022. The Author(s).)

Gunshot residues (GSRs) play an important role in forensic investigations of gun-related violence. The presence of GSRs has been described to help to identify the bullet entry area, as it was supposed not to be found at exit wounds. This report details the suicidal headshot of an 84-year-old male where unburned tube-like, cuboid and flake-formed powder particles have been found not only at the inside of the muzzle but also circular around the exit wound. With very short-barrelled weapons, it must be expected that part of the propellant charge leaves the barrel unburned behind the bullet. In contrast to that, the barrel length of the used weapon should lead to a complete burn-up of powder particles. The surprisingly large number of unburned powder particles present at the exit wound of the injury gave reason for further investigation to understand the underlying ballistic aspects and outlines the importance of having a close look at incidence scene photos during an investigation., (© 2022. The Author(s).)

It is challenging to estimate the post-mortem interval (PMI) of skeletal remains within a forensic context. As a result of their interactions with the environment, bones undergo several chemical and physical changes after death. So far, multiple methods have been used to follow up on post-mortem changes. There is, however, no definitive way to estimate the PMI of skeletal remains. This research aimed to propose a methodology capable of estimating the PMI using micro-computed tomography measurements of 104 human skeletal remains with PMIs between one day and 2000 years. The present study indicates that micro-computed tomography could be considered an objective and precise method of PMI evaluation in forensic medicine. The measured parameters show a significant difference regarding the PMI for Cort Porosity p < 0.001, BV/TV p > 0.001, Mean1 p > 0.001 and Mean2 p > 0.005. Using a machine learning approach, the neural network showed an accuracy of 99% for distinguishing between samples with a PMI of less than 100 years and archaeological samples.

Estimating the post-mortem interval (PMI) of human skeletal remains is a critical issue of forensic analysis, with important limitations such as sample preparation and practicability. In this work, NIR spectroscopy (NIRONE® Sensor X; Spectral Engines, 61449, Germany) was applied to estimate the PMI of 104 human bone samples between 1 day and 2000 years. Reflectance data were repeatedly collected from eight independent spectrometers between 1950 and 1550 nm with a spectral resolution of 14 nm and a step size of 2 nm, each from the external and internal bone. An Artificial Neural Network was used to analyze the 66,560 distinct diagnostic spectra, and clearly distinguished between forensic and archaeological bone material: the classification accuracies for PMIs of 0−2 weeks, 2 weeks−6 months, 6 months−1 year, 1 year−10 years, and >100 years were 0.90, 0.94, 0.94, 0.93, and 1.00, respectively. PMI of archaeological bones could be determined with an accuracy of 100%, demonstrating the adequate predictive performance of the model. Applying a handheld NIR spectrometer to estimate the PMI of human skeletal remains is rapid and extends the repertoire of forensic analyses as a distinct, novel approach.

Objectives: Recurrent laryngeal nerve (RLN) injury during thoracic surgery may result in life-threatening postoperative complications including recurrent aspiration and pneumonia. Anatomical details of the intrathoracic course are scarce. However, only an in-depth understanding of the anatomy will help reduce nerve injury. The aim of this study was to assess the anatomic variations of the intrathoracic left RLN., Methods: Left-sided vagal nerves and RLN were dissected in 100 consecutive Caucasian cadavers during routine autopsy. Anatomical details were documented. Available demographic data were assessed for possible correlations., Results: All nerves were identified during dissection. Variant courses were classified in 3 different groups according to the level at which the RLN separated from the vagal nerve: above the aortic arch, level with the aortic arch and below the aortic arch. We found 11% of RLN separating above the aortic arch and crossing the aortic arch at a considerable distance to the vagal nerve. In 48% of the RLN, the nerve split off when it was level with the aortic arch, and 41% of the RLN leave the vagal nerve in a perpendicular direction below the aortic arch. All nerves crossed the ligamentum arteriosum on the posterior side. No gender-specific differences were observed., Conclusions: Mediastinal lymph node dissection in left-sided lung cancer patients puts the RLN at risk. With more detailed anatomical knowledge about its course, it is possible to avoid risking the nerve. Visualization will help protect the nerve., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Background: We recently showed that a 3-year growth hormone (GH) treatment improves linear growth in severely short children with X-linked hypophosphatemic rickets (XLH). It is unknown if GH therapy increases adult height in XLH patients., Methods: We carried out a follow-up analysis of a randomized controlled open-label GH study in short prepubertal children with XLH on phosphate and active vitamin D treatment. The changes in SD scores (SDS) of height, sitting height, leg and arm length, and sitting height index (i.e., the ratio between sitting height and height) were analyzed in 11 out of 16 patients followed-up until adult height., Results: At baseline, XLH patients showed disproportionately short stature with reduced standardized height (-3.2 ± 0.6), sitting height (-1.7 ± 0.6), leg (-3.7 ± 0.7) and arm (-2.5 ± 0.8) length, and markedly elevated sitting height index (3.3 ± 0.6; each p < 0.01 versus healthy children). In GH-treated patients, adult height, sitting height, leg length, and arm length exceeded baseline values by 0.7 SDS, 1.7 SDS, 0.7 SDS, and 1.2 SDS respectively, although this was only significant for sitting height. In controls, no significant changes in linear body dimensions were noted. Adult height did not statistically differ between groups (-2.4 ± 0.7 vs -3.3 ± 1.2, p = 0.082). GH did not exaggerate body disproportion., Conclusions: Growth hormone treatment did not significantly increase adult height in this group of short children with XLH, which may be at least partly due to the small number of patients included in our study.

Background: Congenital hyperinsulinism (CHI) is a rare disease with an estimated incidence of 1:40,000 live births. Here, we characterize 11 patients treated at Munich Children's Hospital Schwabing., Methods: We analyzed data on birth, treatment and laboratory results including genetic testing and evaluated the long-term course with a follow-up visit., Results: All patients had severe, diazoxide-(DZX)-resistant hypoglycemia, beginning immediately after birth. Two patients were treated by medical therapy, eight underwent subtotal pancreatectomy and one had a partial resection. Both patients who had medical therapy still suffer from occasional hypoglycemia. Six patients with subtotal pancreatectomy were affected by mild hypoglycemia. Seventy-five percent of patients who had surgical treatment developed diabetes mellitus (DM) at a median age of 10.5 (8-13) years. In 89% of patients with available genetic testing, mutations of the ABCC8 gene were detected., Conclusions: The majority of CHI-patients not responding to DZX underwent surgery. After subtotal pancreatectomy, patients typically developed diabetes around early puberty.

Somatic mosaicism has been implicated as a causative mechanism in a number of genetic and genomic disorders. X-linked acrogigantism (XLAG) syndrome is a recently characterized genomic form of pediatric gigantism due to aggressive pituitary tumors that is caused by submicroscopic chromosome Xq26.3 duplications that include GPR101 We studied XLAG syndrome patients (n= 18) to determine if somatic mosaicism contributed to the genomic pathophysiology. Eighteen subjects with XLAG syndrome caused by Xq26.3 duplications were identified using high-definition array comparative genomic hybridization (HD-aCGH). We noted that males with XLAG had a decreased log2ratio (LR) compared with expected values, suggesting potential mosaicism, whereas females showed no such decrease. Compared with familial male XLAG cases, sporadic males had more marked evidence for mosaicism, with levels of Xq26.3 duplication between 16.1 and 53.8%. These characteristics were replicated using a novel, personalized breakpoint junction-specific quantification droplet digital polymerase chain reaction (ddPCR) technique. Using a separate ddPCR technique, we studied the feasibility of identifying XLAG syndrome cases in a distinct patient population of 64 unrelated subjects with acromegaly/gigantism, and identified one female gigantism patient who had had increased copy number variation (CNV) threshold for GPR101 that was subsequently diagnosed as having XLAG syndrome on HD-aCGH. Employing a combination of HD-aCGH and novel ddPCR approaches, we have demonstrated, for the first time, that XLAG syndrome can be caused by variable degrees of somatic mosaicism for duplications at chromosome Xq26.3. Somatic mosaicism was shown to occur in sporadic males but not in females with XLAG syndrome, although the clinical characteristics of the disease were similarly severe in both sexes., (© 2016 Society for Endocrinology.)

Background: Several genetic syndromes are associated with diabetes mellitus (DM). This study aimed to analyse data from the DPV database with regard to frequency, treatment strategies and long-term complications in paediatric DM patients with genetic syndromes, including Turner syndrome (TS), Prader-Willi syndrome (PWS), Friedreich ataxia (FA), Alström syndrome (AS), Klinefelter syndrome (KS), Bardet-Biedl syndrome (BBS), Berardinelli-Seip syndrome (BSS) and Down syndrome (DS)., Methods: Longitudinal data for 43 521 patients with DM onset at age < 20 years were collected from 309 treatment centres in Germany and Austria using the DPV software. Data included anthropometric parameters, type of diabetes, mean age, age at diabetes onset, daily insulin dose, HbA 1c , micro- and macroalbuminuria, retinopathy and dyslipidaemia. Descriptive statistics and standard statistical tests were used for data analysis., Results: In total, 205 DM patients had one of the following syndromes: DS (141 patients), TS (24), PWS (23), FA (5), AS (5), KS (4), BBS (2) and BSS (1). Diabetes-specific antibodies were positive in the majority of patients with DS, TS and FA., Conclusion: Despite the well-known association between DM and certain syndromic disorders, the number of affected patients in the German and Austrian paediatric diabetic population is very low. Nevertheless, physicians should be aware of syndromic forms of diabetes. Joint multicentre analyses are needed to draw relevant conclusions., (© J. A. Barth Verlag in Georg Thieme Verlag KG Stuttgart · New York.)

Context: Children with X-linked hypophosphatemic rickets (XLH) are prone to progressive disproportionate stunting despite oral phosphate and vitamin D treatment., Objective: Our objective was to analyze the effects of GH treatment on stature and lengths of linear body segments in short children with XLH., Design, Settings, and Patients: A 3-yr randomized controlled open-label GH study in short prepubertal children with XLH (n = 16) on phosphate and calcitriol treatment was conducted. A cohort of XLH patients (n = 76) on conservative treatment served as an XLH reference population., Main Outcome Measures: Changes in SD scores (SDS) of stature and linear body segments, i.e. sitting height, leg and arm length, and sitting height index (i.e. ratio between sitting height and stature) were the main outcome measures., Results: XLH patients presented at time of enrollment with significant impairments of stature (-3.3 SDS) and linear body segments compared with healthy children. Leg length (-3.8 SDS) was most impaired, whereas sitting height (-1.7 SDS) was best preserved. The markedly elevated mean sitting height index (+3.3 SDS) reflected severe body disproportion. GH resulted in a sustained increase in linear growth (stature, +1.1 SDS; sitting height, +1.3 SDS; leg length, +0.8 SDS; arm length, +1.1 SDS; each P < 0.05 vs. baseline), whereas no significant changes were observed in controls. Mean height SDS at 3 yr did not significantly differ between groups. Sitting height index remained stable in both the GH-treated patients and in study controls but increased further in the XLH-reference population., Conclusions: The 3-yr GH treatment improved linear growth without progression of body disproportion in short children with XLH.

Apart from misdiagnosis, the Lazarus phenomenon, a spontaneous return of circulation after cardiac arrest, is a potential cause for false positive death certification. Because of medicolegal consequences and thus a negative publication bias, the incidence of false positive death certification is unknown. As a false positive death certification results in criminal prosecution and thus media interest, numerous media archives in Germany, Austria and Switzerland were searched for such reports. A total of nine cases of false positive death certification in these three countries were identified since the early 1990s of which eight occurred in an emergency medical service system setting. Apart from a lack of diligence of emergency physicians, a Lazarus phenomenon could be the reason for such incidents. As definite signs of death will not have developed only a few minutes after stopping CPR it might be difficult for an emergency physician to definitely certify a patient's death in an out-of-hospital setting with 100% safety. Thus, prehospital death certification poses a risk of error and subsequent legal prosecution of the emergency physician, as a Lazarus phenomenon may still occur in this phase. Delegation of death certification from emergency physicians to qualified physicians in a follow-up examination might increase both legal safety for emergency physicians in the field and patient safety.

Context: Only occasionally, endocrine-active tumors develop directly from hepatic tissue, and may lead to paraneoplastic syndromes (PNS). PNS mostly accompany malignancy of adulthood and are exceedingly rare in children., Patient: A girl aged 6 years and 9 months presented with a 2-month history of rapidly progressive weight gain, abdominal distension, and polyuria/pollakiuria accompanied by short episodes of abdominal pain. She showed the typical clinical features of Cushing's syndrome and a huge hepatic mass. An abdominal computed tomography (CT) scan revealed a large liver tumor. Blood glucose and serum calcium were greatly elevated., Design and Objective: Case report describing the causative relationship of the clinical findings., Methods: Physical examination; ultrasound of the abdomen; CT scan of the abdomen and the chest; conventional X-rays; routine hematology; blood chemistry and multiple parameters of calcium and phosphorus metabolism; multisteroid analysis in serum and urine; adrenocortical stimulation and suppression tests; histopathological assessment of the resected tumor; immunohistochemistry for ACTH, beta-endorphin, corticotrophin-releasing hormone (CRH), and PTH-related peptide (PTHrP); electron microscopy of tumor cells; ACTH and CRH extraction from the tumor tissue; and clinical follow-up for more than 20 years., Results: Giant hepatoblastoma (HB; approximately 1000 ml volume) of the right lobe of the liver with combined ectopic ACTH syndrome and PTHrP-induced tumor-associated hypercalcemia. Wide local excision and polychemotherapy led to complete reversal of the paraneoplastic phenotype., Conclusions: This is the first report of an endocrine-active HB causing both Cushing's syndrome and PTHrP-related 'humoral hypercalcemia of malignancy'. This information should be added to the well-known beta-human chorionic gonadotropin-related paraneoplastic effects of HB in children.

A well-established possibility to treat opiate addiction is the participation in opiate maintenance treatment programmes. For this purpose the opioids methadone and buprenorphine have been evaluated and are used nowadays in many countries. However, since 1998 also the use of slow-release oral morphine (SROM) has been legally permitted in Austria. Our data show that these morphine preparations are frequently abused and are dominating the black market in the meantime. Especially the intravenous consumption of SROM goes along with highly dangerous side effects that exceed the risks of needle sharing alone. Special galenics are supposed to ensure a 24 h effect of the otherwise quickly metabolised morphine. If dissolved and injected, insoluble contents such as talcum cause microembolisms, leading to severe damages of the inner organs. Furthermore, SROM, i.e. a drug prescribed by physicians, has been proved to be the main responsible substance in most drug related deaths since its permission and has nearly replaced heroin. Forensic physicians play a major role in the profound examination of these cases, including extensive toxicological analyses and interpretation of results. For instance, a differentiation between a recent morphine and heroin consumption is certainly possible, provided appropriate methods are used. A reliable estimation of the current situation of drug abusing habits is a premise for adequate therapeutic offers and preventive measures. Thus, well-founded and comparable data have to be collected. To facilitate data report a standardized report form has been developed that includes an obligatory statement regarding morphine or heroin consumption. This should help to enlighten the ongoing discussion on the role of SRM in drug abuse cases. Our results indicate that the prescription of SROM in opiate maintenance therapy has to be handled very strictly and should be reserved for special patients only. A slackening of the Austrian law concerning SROM is therefore objected.

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder which primarily affects motor neurons. Eight cases of ALS and seven control cases were studied with semiquantitative immunocytochemistry for chromogranin A, chromogranin B and secretogranin II that are soluble constituents of large dense core vesicles, synaptophysin as a membrane protein of small synaptic vesicles and superoxide dismutase 1. Among the chromogranin peptides, the number and staining intensity of motor neurons was highest for chromogranin A. In ALS, the staining intensity for chromogranin peptides and synaptophysin was significantly lower in the ventral horn of ALS patients due to a loss in immunoreactive motor neurons, varicose fibers and varicosities. For all chromogranins, the remaining motor neurons displayed a characteristic staining pattern consisting of an intracellular accumulation of immunoreactivity with a high staining intensity. Confocal microscopy of motor neurons revealed that superoxide dismutase 1-immunopositive intracellular aggregates also contained chromogranin A, chromogranin B and secretogranin II. These findings indicate that there is a loss of small and large dense core vesicles in presynaptic terminals. The intracellular co-occurrence of superoxide dismutase 1 and chromogranins may suggest a functional interaction between these proteins. This study should prompt further experiments to elucidate the role of chromogranins in ALS patients.

Design: The purpose of this study was to generate insulin dose (ID) percentiles for children and adolescents with type 1 diabetes mellitus (DM1) having the opportunity to assess this important parameter in relation to age and sex., Methods: Daily IDs per weight (ID/kg) were recorded in 22,177 patients with DM1 (3-25 years of age, DM1 duration of more than 2 years, 48% female) and ID percentiles (ID-Perc) were created statistically. The ID-Perc were compared between male and female, and between multiple insulin injection therapy (MIT) and continuous s.c. insulin infusion (CSII). A multivariate regression analysis was performed for ID in the third year of DM1 with ID/kg, body weight, age, gender, and insulin delivery regimen as variables., Results: The 50th ID-Perc (P50) varied among 0.67 IU/kg (age 3 years), 0.93 IU/kg (13 years), and 0.70 IU/kg (23 years) increasing from early childhood to adolescence and decreasing toward adulthood. Highest P50 ID was found at 12 years in females (0.94 IU/kg) and at 14 years in males (0.92 IU/kg). Using ICT, the ID was significantly higher compared with CSII (P50: 0.94 IU/kg versus 0.79 IU/kg at 13 years). In multivariate regression analysis, ID was significantly (P>0.001) associated with age, gender, and insulin delivery regime., Conclusion: The ID-Perc were significantly different during various periods of childhood and were influenced by gender, body weight, and insulin injection regimes. Therefore, the presented data 1) provide evidence to interpret individual ID in children and adolescents with DM1 and 2) more specifically identify children with unusually high (insulin resistance and non-compliance) or low (MODY and persistent remission) insulin requirement.

Introduction: While the central role of HbA1c levels for the prediction of micro- and macrovascular complications in patients with type 1 diabetes is generally accepted; recommendations in current guidelines and the level of metabolic control actually achieved during routine care differ widely. Limited information is available on factors that influence metabolic control in the pediatric age group and during the transition from pediatric to adult diabetes care. In a large prospective multicenter database (DPV-Wiss), 338,330 individual HbA1c measurements from 27,035 patients with type-1 diabetes (94,074 observation years) were recorded between 1995 and 2005. Data were anonymously transmitted from 207 institutions. HbA1c values were mathematically standardized to the DCCT normal range (4.05-6.05%). The SAS 9.1 software was used for statistical analysis using nonparametric statistics. Median HbA1c for all measurements was 7.8%, with a strong effect of diabetes duration: median HbA1c at onset was 9.1%, during the first 2 years of diabetes 7.1% with a subsequent increase to 7.9% in patients beyond the remission phase (>2 years, 20,314 patients); a strong age dependency was present. HbA1c above the recommended guidelines was found in 23%. For all age groups, girls/women had higher HbA1c values compared to boys (mean difference 0.1%, p<0.0001). Seasonal variation was remarkably small with the lowest HbA1c values in September (mean: 7.86%) and highest values in January (8.08%; p<0.0001). Some improvement in HbA1c was observed comparing three periods: 1995-1997, 1998-2000 and 2001-2005; after remission the median HbA1c decreases from 8.5% to 7.6%. In a multivariate model, a significant influence on HbA1c was detected for age (p<0001), duration of diabetes (p<0.0001), gender (p<0.02), minority status (p<0.0001), season (p<0.0001), treatment period (p<0.0001), insulin therapy (p<0.0001) and center effect (p<0.0001)., Conclusions: Both patient-related and treatment-related variables have a strong influence on metabolic control achieved in pediatric and young adult patients with T1DM. In contrast to wide-spread belief, metabolic control is only marginally better in summer compared to winter. Some improvement in metabolic control was observed during the last 10 years.

Infections with orthopoxviruses usually lead to cross-protection among all species of the family. This has been a prerequisite for successful eradication of smallpox. Here we report the rare case of a 17-year-old male, who survived a generalised cowpox virus infection of unusual severity but surprisingly did not show a proper seroconversion. Only a very weak antibody production was observed in early and late serum samples, which initially appeared to be cowpox virus specific in immunofluorescence. No neutralising antibodies were detected and in Western blotting antibody specificity was restricted to the orthopoxvirus H3L protein only. The patient had been hospitalised for alcohol and cannabis intoxication 2 months prior to the orthopoxvirus infection and high levels of cannabinoids have been found repeatedly in the urine and upon one occasion also benzodiazepines. As these substances are known to interfere with antibody production and no immunodeficiencies were detected, drug-induced immunosuppression can be suspected as the most likely cause. Therefore a possible link between "soft" drug use and sufficient immunosuppression to warrant alterations in vaccine policies using live virus vaccines like smallpox vaccine should be further studied.

Idiopathic dilated cardiomyopathy (IDCM) is a primary myocardial disease of unknown cause characterized by ventricular chamber enlargement with impaired contractile function. In familial forms of IDCM, mutations of genes coding for cytoskeletal proteins related to force transmission, such as dystrophin, cardiac actin, desmin, and delta-sarcoglycan, have been identified. Here, we report the data of a retrospective investigation carried out to evaluate the expression of atrial natriuretic peptide (ANP), CD34, troponin T and nestin in the myocardium of patients affected with IDCM. Formalin-fixed and paraffin-embedded consecutive tissue sections from the ventricular wall of 10 human normal hearts (NH) following forensic autopsy and 22 IDCM (living explanted hearts) were studied using primary monoclonal antibodies against ANP, CD34, troponin T and nestin by immunohistochemistry. Myocardial fibers were counted independently by three pathologists. Statistics included analysis of variance, log-rank test for Kaplan-Meier analysis, and kappa assessment for intra- and inter-observer variability. ANP and CD34 were significantly overexpressed in IDCM compared to NH (p<0.05). Conversely, troponin T and nestin expression levels did not show significant variation. Inter-observer kappa statistics showed a value of 0.87 and intra-observer kappa statistics a value of 0.98. Evaluation of the marker distribution in the myocardium of patients with IDCM CD34 expression curve was similar to that of troponin T (p<0.0001), although two groups could be identified. Patients with a difference of more than 20 myocardial fibers in expression of CD34 and troponin T had a somewhat less favorable survival although the difference was not significant. The analysis of cells positive for troponin T resulted in a similar number of cardiac fibers between NH and IDCM. This is in agreement with cardiac enlargement present in IDCM, which is due to ventricular dilatation rather than increased number of myocytes. Moreover, the expression of nestin, a marker of activation of myocardial precursors, did not change either, and this may confirm that there are no hyperplastic phenomena in the IDCM pathogenesis. The increase in ANP-positive cells in IDCM could be a consequence of neurohormonal activation due to a decline in the impaired myocyte contractility. Furthermore, since it was already shown that ANP could be important in the control of vascular remodeling, we postulated that the increase in CD34-positive cells might be functionally correlated with the increase in ANP production. Differential expression of CD34 and troponin T might be used in future studies to evaluate their prognostic value.

Objective: Extracorporeal circulation is considered the gold standard in the treatment of hypothermic cardiocirculatory arrest; however, few centers use extracorporeal membrane oxygenation instead of standard extracorporeal circulation for this indication. The aim of this study was to evaluate whether extracorporeal membrane oxygenation-assisted resuscitation improves survival in patients with hypothermic cardiac arrest., Methods: A consecutive series of 59 patients with accidental hypothermia in cardiocirculatory arrest between 1987 and 2006 were included. Thirty-four patients (57.6%) were resuscitated by standard extracorporeal circulation, and 25 patients (42.4%) were resuscitated by extracorporeal membrane oxygenation. Accidental hypothermia was caused by avalanche in 22 patients (37.3%), drowning in 22 patients (37.3%), exposure to cold in 8 patients (13.5%), and falling into a crevasse in 7 patients (11.9%). Multivariate logistic regression analysis was used to compare extracorporeal membrane oxygenation with extracorporeal circulation resuscitation, with adjustment for relevant parameters., Results: Restoration of spontaneous circulation was achieved in 32 patients (54.2%). A total of 12 patients (20.3%) survived hypothermia. In the extracorporeal circulation group, 64% of the nonsurviving patients who underwent restoration of spontaneous circulation died of severe pulmonary edema, but none died in the extracorporeal membrane oxygenation group. In multivariate analysis, extracorporeal membrane oxygenation-assisted resuscitation showed a 6.6-fold higher chance for survival (relative risk: 6.6, 95% confidence interval: 1.2-49.3, P = .042). Asphyxia-related hypothermia (avalanche or drowning) was the most predictive adverse factor for survival (relative risk: 0.09, 95% confidence interval: 0.01-0.60, P = .013). Potassium and pH failed to show statistical significance in the multivariate analysis., Conclusions: Extracorporeal rewarming with an extracorporeal membrane oxygenation system allows prolonged cardiorespiratory support after initial resuscitation. Our data indicate that prolonged extracorporeal membrane oxygenation support reduces the risk of intractable cardiorespiratory failure commonly observed after rewarming.

Legal driving limits are set coequally with 0.5 g/L blood alcohol concentration (BAC) or 0.25 mg/L breath alcohol concentration (BrAC) in Austria as well as in other European countries. As mostly some time elapses between BrAC measurement and driving offence, a back calculation of alcohol concentrations is often required. The calculation of hourly BrAC elimination rates can thereby help to avoid unnecessary variances. A study with 59 participants was performed under social conditions. BrAC was determined with the legally accredited Alcotest 7110 MK III A every 30 min, and concomitantly venous blood samples were drawn. Five hundred and four BrAC/BAC value pairs were evaluated. The overall mean peak BrAC was calculated with 0.456 mg/L (+/-0.119 mg/L standard deviation). The mean hourly BrAC elimination rate was overall determined with 0.082 mg/L per h (0.050-0.114, 95% range). Mean rate of females (0.087 mg/L h(-1)) and the according 95% limits were statistically significantly higher than of males (mean rate 0.078 mg/L h(-1), p<0.04). Our results confirm the possibility to implement hourly BrAC elimination rates, provided that adequate statistical ranges and basic forensic scientific rules that have been set up for alcohol back calculations are observed.

The benzodiazepine tetrazepam is primarily muscle relaxant with comparably lower central sedating effects and is therefore commonly prescribed for muscle spasms of different origins. To evaluate tetrazepam metabolism, a study was conducted with ten healthy volunteers. Blood and urine samples were regularly collected after the intake of 50 mg tetrazepam. Toxicological analyses revealed that tetrazepam is also metabolized to diazepam and further to nordazepam, which has not yet been reported. Tetrazepam and diazepam could be detected in urine samples at least 72 h after intake, the diazepam concentration being 33% (+/-14% SD), on average, of the tetrazepam concentration. On the basis of three case histories, the importance of the detection of these newly described metabolites is shown as necessary to prevent false accusations and potential negative legal consequences for examined persons.

Most cases of ecstasy overdose turn out to be accidental, whereas suicide attempts with designer drugs occur only sporadically. We report an announced suicide by means of a combination of 3,4-methylenedioxymethamphetamine (MDMA) and 3,4-methylenedioxyethylamphetamine (MDEA). During autopsy, sampling for toxicological investigation (peripheral blood, urine, cerebrospinal fluid, bile and gastric contents) occurred. Serum concentrations as high as 13.33 mg/l for MDMA, 7.32 mg/l for MDEA and 0.43 mg/l for 3,4-methylenedioxyamphetamine were found. Ecstasy tablets, which were confiscated by the police a few days earlier, showed also a combination of MDMA and MDEA. This fact suggests that the ingested tablets probably came from the same source as the seized pills.

Objective: Several products are being widely promoted for reduction of the concentration of alcohol in the human body. One of these preparations, the fructose soft drink Outox, claims to noticeably increase the alcohol elimination rate (beta 60). Theories to explain this 'fructose effect' are based on the assumption that NAD+, the coenzyme for alcohol dehydrogenase, is regenerated faster in the presence of fructose., Method: A randomized double-blind, placebo-controlled cross-over study was performed with 30 volunteers in two drinking sessions each. Under strictly identical conditions, the same amount of alcohol was consumed, followed by the consumption of either 250 ml Outox or 250 ml placebo. Periodical measurements of blood (BAC), breath (BrAC) and urine alcohol concentration (UAC) were performed., Results: Analyses revealed a significant difference (P<0.0001) between the mean alcohol levels of the Outox and the placebo drinking sessions. The overall mean BAC difference was 0.077 g/l (BAC 0.748 g/l without vs 0.671 g/l with Outox), equivalent to 10.3%. The mean BrAC difference was 0.045 mg/l (BrAC 0.314 mg/l without vs 0.269 mg/l with Outox), equivalent to 14.3%. Differences were lower for women than for men. A significant difference between the alcohol elimination rates (beta 60) was not found., Conclusions: The results show that the soft drink Outox may decrease the alcohol concentration by about 10%. However, BAC and BrAC differences are rather a consequence of slower gastric absorption of alcohol, because Outox does not increase the alcohol elimination rate. Our study demonstrates that the claim of Outox or other fructose drinks to work as a 'soberade' cannot be proven from a scientific point of view. It should be the task of physicians to warn potential consumers, especially in connection with drinking and driving.

The aim of the present in vitro study was to evaluate migrational characteristics of cementless primary hip arthroplasty stems in combination with a diameter 50 mm head (hemiarthroplasty) and a diameter 28 mm head in and with a polyethylene cup (total hip arthroplasty) in fresh-frozen human specimens. Two different types (Endo SL, FMT) were implanted into seven pairs of fresh-frozen human femoral specimens. The implanted stems were combined with a diameter 50 mm head (hemiarthroplasty) on one side and with a polyethylene cup and a 28 mm head (total hip arthroplasty) on the other side. Dynamic mechanical loading was applied for 50,000 cycles while recording relative motions between stem and bone stock using a 3-D motion analysis system. The Endo SL stem showed a significantly higher amplitude of relative motion in all translational and rotational components regardless of the head used. In both stem types a strong tendency for higher axial migration with the diameter 50 mm head in comparison to the THA head was found. The lowest axial migration was found in the FMTstem in combination with the small head and a PE cup. The highest axial migration was found in the Endo SL stem combined with the diameter 50 mm head. Our results indicate that the head might play an important role for axial migration of cementless stems.

The conversion factor Q, obtained by division of blood alcohol concentration (BAC) by breath alcohol concentration (BrAC) is a widely discussed topic due to its great variance. By Austrian law, regulations frequently require an estimation of a corresponding BAC by a measured BrAC. It is known that Q depends among other things, on the alcohol kinetic state of the person being tested, which mathematically can be transformed to a dependency on the BrAC. Theoretically calculated Q values per BrAC level form a hyperbola shaped curve, thus decreasing with increasing BrAC values. Applying Austrian forensic standards for BAC and BrAC measurements, these calculations were verified in a study under practical conditions with BAC and BrAC data of 390 individuals. Q decreases from 2629 (+/- 455) for BrAC levels < 0.1 mg/l to 2229 (+/- 160) for a BrAC range of 0.4-0.5 mg/l and increases again to 2428 (+/- 124) for BrAC levels > 0.6 mg/l. Since these results were obtained under realistic practical conditions they can be directly applied in routine forensic expert opinion and can eliminate avoidable variances in the calculation of Q.

When testing the Microgenics CEDIA assay for immunological buprenorphine analysis, cross-reactivity between the buprenorphine reagents and opiates was observed at concentrations higher than 120 mg/l morphine, 320 mg/l methadone, 30 mg/l codeine, 60 mg/l dihydrocodeine and 520 mg/l morphine-3-glucuronide. The cross-reactivity with morphine has the greatest impact on routine screening as opiate maintenance therapy in Austria is also performed with slow-release oral morphine. The use of a second cutoff value of 30 mug/l for urine samples that are (immunologically) positive for opiates is therefore suggested, compared to the cutoff value of 5 microg/l proposed by the manufacturer.

Fatalities due to 3,4-methylenedioxymethamphetamine (MDMA, "ecstasy") are rare in Austria, although the use of designer drugs has become quite common. This is the first published case of a fatal MDMA intoxication in Austria. A 19-year-old girl died after the consumption of ecstasy tablets in the apartment of a friend. Blood analysis gave a concentration of MDMA as 3.8 mg/L and traces of its metabolite MDA. Cannabinoids were found as well. This case shows that the consumption of MDMA, without physical stress, can lead to death.

Objective: Fractured ribs and sternum are frequent complications of thoracic compression during CPR in adults. This study was conducted to determine whether findings of plain chest radiography (CXR) correlate with post-mortem findings in patients who underwent cardiopulmonary resuscitation (CPR) after out-of-hospital cardiac arrest., Methods: CXR findings and autopsy results of CPR-related chest injuries comprising rib and sternum fractures were compared prospectively in 19 patients., Results: Fractures were diagnosed in nine of 19 patients by means of radiology and in 18 of 19 patients by autopsy (rib fractures in 6/19 versus 17/19, P=0.002; sternum fractures in 5/19 versus in 9/19, P=0.227. The total number of isolated bone fractures detected by CXR was 18 (12 rib and six sternum fractures) and by autopsy 92 (83 rib and nine sternum fractures). The majority of rib fractures was located in the anterior part of the thoracic cage. Sternum fractures predominantly occurred in the lower third. Eight of 19 patients received either thrombolytic or antithrombotic treatment during CPR but no major bleeding complication associated with CPR was detected by autopsy., Conclusions: The findings of this study indicate that fractures associated with CPR are underreported in conventional radiographic investigations. No major bleeding complications related to CPR-associated fractures was detected.

A total of 34 deployed driver and passenger airbags from altogether 20 vehicles after frontal collisions were investigated. In 80% of the airbags possible biological traces could be located with an alternative light source (ALS, Polilight) at a wavelength of 450-470 nm. These traces were swabbed, a part of them additionally cut and subjected to DNA analysis, which led to comparable SGMplus profiles in about 60%. In the 20% of the airbags on which no possible biological traces could be located, the whole surfaces were swabbed. In these cases subsequent DNA profiling mostly led to non-interpretable results. For the evaluation and interpretation of the data, buccal swab samples provided by drivers and co-drivers were analysed. The results and conclusions from DNA analyses and the declarations from the involved passengers were always concordant. Thus, molecular biological analysis of deployed airbags can help to determine the occupants positions within a vehicle (driver or passenger status) at the time of impact.

A 47-year-old male patient died unexpectedly 10 years after replacement of the aortic valve with a Carbomedics heart valve prosthesis required for post-endocarditic valve stenosis. The man was in regular medical attendance by his general practitioner and in hospital. Clinical data and examinations did not suggest the reoccurrence of endocarditis. Three months before his death a haemolytic anaemia of unknown genesis was diagnosed. One afternoon, while lifting a heavy object, the man suffered acute chest pain and collapsed. Resuscitation failed and the patient died in hospital. Autopsy revealed the completely detached valve prosthesis within the ascending aorta. Histological examination confirmed a chronic endocarditis at the site of the valve implantation.

This paper describes a systematic study of the influence of optical, physical, and chemical methods used for fingerprint enhancement on subsequent DNA analysis of biological stains. Latent fingerprints as well as fingerprints in contact with blood and saliva on different surfaces were treated with dactyloscopic methods. As a general finding, subsequent STR profiling of the blood/saliva traces led to good results after all the enhancement methods included in this study. Concerning blood enhancement procedures, the airbrush technique showed deleterious effects on subsequent STR analysis in some cases. We therefore recommend the implementation of the layer technique, as it brings advantages for fingerprint enhancement as well. It could also be shown that, as can be necessary in practical casework, two enhancement methods can be performed on a single stain without having influence on STR profiling. In terms of methodological variety, this paper reflects a comprehensive study performed on STR profiling after fingerprint enhancement methods, including rare methods and variations of techniques, which can be a useful alternative in certain case scenarios.

A fatal accident after isoflurane abuse is presented in this report. A hospital employee was found dead in the operating area with a plastic bag over his head. In his locker an almost empty bottle of isoflurane was found. Autopsy revealed signs of asphyxiation and toxicological examination revealed nordazepam and isoflurane in non-toxic concentrations in the blood. Quantification of the anaesthetic was also carried out in urine, gastric contents, liver, kidney and brain samples, and in addition, oxazepam, prothipendyl and metabolites of midazolam and prothipendyl were found in the urine. Although the drug problems of the deceased were known before, no efforts had been made to restrict access to these drugs.

Sudden infant death (SID) is the most common cause of death among infants aged 2 to 12 months in Austria. The complete autopsy required in order to diagnose SID, including the additional investigations, and the comprehensive autopsies needed for epidemiological studies are not common practice because of the different statutory regulations in the provinces and the absence of a uniform federal law in this regard. According to statistics, in the last four years only 83% (1997) to 70% (1999) of the reported SID cases in Austria were autopsied. Our survey in the forensic medicine and pathological institutes of Austria also revealed markedly different practices in regard of the manner in which autopsies are performed and parents are interviewed and followed up. For this reason, the SIDS Consensus Work Group of Austrian centers for the prevention of sudden infant death recommends the following: a) a comprehensive autopsy by a trained specialist to be established as a prerequisite for diagnosing "SIDS"; b) performing autopsies on a centralized basis in those forensic or pathological institutes that have agreed to adhere to protocol-based autopsy standards; c) the introduction of quality control in terms of a regional clinical-pathological conference; and d) standardizing the elements of the interview with parents of SID victims. Implementing these measures and entering the collected information into a data base in which the master data are encoded by the individual institutions, will help to evaluate the role of major epidemiological risk factors that information campaigns are focused upon, namely sleeping in prone position, the role of nicotine, etc. In addition, it will be necessary to formulate federal laws that standardize the divergent provincial regulations.

A case of suicide with the insecticide omethoate is reported. An 18-year-old apprentice gardener had ingested an unknown amount of omethoate. His body was found in his room lying in the storage space under his bed. The autopsy first showed multiple superficial incisions in the skin of his wrists, furthermore hemorrhagic pulmonary oedema, dilation of the right cardiac ventricle and oedema of the brain. The gastric mucosa was swollen and showed a dark brownish colour. An intensive, chemical-like smell rose from the corpse and organs. Toxicological analysis detected omethoate in cardiac blood (208 micro g/ml), urine (225 micro g/ml) and bile (524 micro g/ml), in the liver (341 micro g/ml) and kidneys (505 micro g/ml). In the gastric content the level was 48223 micro g/ml. The amount of the active AChE in peripheral blood serum was reduced to less than 0.2% of the normal level. To our knowledge no case of a fatal suicide by ingestion of omethoate has been reported in literature.

Unlabelled: Analysis of a German database comprising a total of 54 patients with neonatal manifestations of persistent hyperinsulinism revealed 5 patients in whom hyperinsulinism was associated with additional clinical symptoms, suggesting an underlying syndromal disorder. Three of the patients presented with a similar yet unknown clinical entity characterized by severe psychomotor retardation, chronic pulmonary disease, hypothyroidism and congenital heart defects. A fourth patient was affected by severe congenital central hypoventilation syndrome. The fifth patient presented with Beckwith-Wiedemann syndrome, with unusually severe and persistent hyperinsulinism requiring subtotal pancreatectomy., Conclusion: Our results indicate that, in addition to the well-known biochemical pathways, more complex pathophysiological mechanisms can result in persistent hyperinsulinism that presents clinically with a disease involving multiple organs.

In earlier studies, our group has established a new "immunological" hypothesis for atherogenesis supported by experimental and clinical studies showing that inflammatory immunological reactions against heat shock protein 60 initiate the development of atherosclerosis. In the present study, we describe the discovery of a so-far-unknown network of dendritic cells in the innermost layer of arteries, the intima, but not veins of healthy humans and rabbits. The number of these dendritic cells is comparable to that of Langerhans cells in the skin, and dendritic cells show a similar phenotype (CD1a(+) S-100(+) lag(+) CD31(-) CD83(-) CD86(-) and no staining for von Willebrand factor or smooth muscle cell myosin). These vascular-associated dendritic cells accumulate most densely in those arterial regions that are subjected to major hemodynamic stress by turbulent flow conditions and are known to be predisposed for the later development of atherosclerosis. These results open new perspectives for the activation of the immune system within the arterial wall.

Most cases of acute poisoning by butane and other volatile compounds occur in young people as a consequence of substance abuse by inhalation. Clinical symptoms are caused by asphyxia and mainly affect the cardiovascular, respiratory and central nervous system. There are also reported deaths from intoxication of butane inhalation, mostly by cardiac arrhythmia. We report the case of a healthy 14 year-old boy who inhaled butane gas from an aerosol can for refilling cigarette lighters. Despite successful resuscitation and defibrillation, he died two days later from multiple organ failure involving the central nervous system, cardiovascular system, pulmonary system and the liver. Although such incidents are rare in middle European countries, emergency and intensive care medicine staff should be instructed on the consequences and management of butane gas poisoning.

In April 1994, an intervention campaign to reduce the incidence of sudden infant death syndrome (SIDS) was established in the Tyrol. The campaign was intended to increase knowledge concerning risk factors for SIDS in the general community and to improve individual care for infants at risk. In contrast to interventional programmes in other federal states of Austria (i.e. Vorarlberg, Styria), this programme did not utilise polysomnography for identifying infants at risk. A part of the intervention programme was the "Styrian risk questionnaire", a standardised questionnaire concerning risk factors for SIDS. Individual instructions for health care of children at risk (risk score > or = 7) were provided and, if necessary, subscription of home monitoring was performed at the out-patient department (SIDS out-patient service) of the Department of Paediatrics in Innsbruck and other paediatric departments throughout the Tyrol. The educational programme also included information concerning basic life support. Psychological support was offered to parents of SIDS infants. Risk factors for SIDS in the Tyrol before the campaign were assessed in a retrospective case-control study (time period 1984-1994; 99 SIDS infants, 136 controls). The risk of SIDS was markedly reduced when parents had detailed knowledge of the risk factors of SIDS (odds ratio (OR) 0.03; p < 0.001), which emphasises the importance of information and educational programmes. The incidence of SIDS declined after the beginning of the intervention campaign from 1.83/1000 live births (average incidence from 1984-1994) to 0.4/1000 live births and remained at this level thereafter. Post-neonatal mortality also declined from 3.9 to 1.3/1000 live births. The prevalence of the prone sleeping position declined immediately after the campaign (53.7% vs. 5.4%, p < 0.001), as did the frequency of maternal smoking during pregnancy (22.9% vs. 14.5%, p < 0.01). Breast feeding became more popular. In all, the low-cost intervention programme in the Tyrol proved to be highly efficient in reducing the risk of SIDS and in maintaining this effect for several years.

Thiamine responsive megaloblastic anemia (TRMA) is an autosomal recessive disorder with a triad of symptoms: megaloblastic anemia, deafness, and non-type 1 diabetes mellitus. Occasionally, cardiac abnormalities and abnormalities of the optic nerve and retina occur as well. Patients with TRMA often respond to treatment with pharmacological doses of thiamine. Recently, mutations were found in patients with TRMA in a thiamine transporter gene (SLC19A2). We here describe the mutations found in eight additional families. We found four novel mutations and three that were previously described. Of the novel ones, one is a nonsense mutation in exon 1 (E65X), two are missense mutations in exon 2 (S142F, D93H), and another is a mutation in the splicing donor site at the 5' end of intron 4 (C1223+1G>A). We also summarize the state of knowledge on all mutations found to date in TRMA patients. SLC19A2 is the first thiamine transporter gene to be described in humans. Reviewing the location and effect of the disease causing mutations can shed light on the way the protein functions and suggest ways to continue its investigation., (Copyright 2000 Wiley-Liss, Inc.)

In a prospective study of 38 cadavers of patients older than 18 without previous chest injury or cardiopulmonary resuscitation (CPR), active compression-decompression (ACD) resuscitation manoeuvres were performed to determine possible factors influencing sternal and/or rib fractures. ACD was performed for 60 s, with compression and decompression forces being continuously recorded. A stepwise logistic regression analysis was applied. Factors analyzed were age, gender, use of a compression cushion beneath the piston of the ACD device (Ambu CardioPump), and maximal compression and decompression forces. After ACD, the cadavers were autopsied and thoracic injuries were assessed. There was a significant correlation between sternal fractures and gender (P = 0.008), and between rib fractures and age (P = 0.008). Women were found to have a higher risk for sternal fractures, whereas older patients had a higher risk for rib fractures. Maximal compression force was another factor in sternal and/or rib fracture (P = 0.048). Even though a significantly higher incidence of sternal fractures was observed when the compression cushion was used (P = 0.045), inclusion of this variable in the regression analysis only marginally improved the prediction for correct classification of sternal fractures. In conclusion, when well controlled ACD-CPR is performed in cadavers, age is the most important factor determining the incidence of rib fracture. Sternal fractures were more common in female cadavers.

A prospective, randomised out-of-hospital study in a two-tiered system with active compression-decompression (ACD) cardiopulmonary resuscitation (CPR) versus standard (STD) CPR in patients following non-traumatic cardiac arrest was planned to test the hypothesis that ACD-CPR by the first tier may increase the occurrence of ventricular fibrillation as compared with STD-CPR. Furthermore, in a later phase of the study, sternal and rib fractures induced by both CPR methods were determined by extensive autopsy. After enrolling 90 patients the study was terminated because of a high frequency of chest injuries found at autopsy. Forty-two patients received STD-CPR from the first tier and ACD-CPR from the second tier. Thirty-three patients received ACD-CPR only by the first and the second tier, while 15 patients received STD-CPR only from the first and second tiers. In order to obtain a sufficiently large control group for autopsy findings after STD-CPR, STD-CPR was performed in an additional 33 patients within a second period of 4 months. There was no improvement in the number of patients found in ventricular fibrillation after ACD-CPR as compared to STD-CPR performed by the first tier. In patients undergoing autopsy (n = 35) there were significantly more sternal fractures with ACD-CPR versus STD-CPR (14/15 vs. 6/20; P <0.005) and rib fractures (13/15 vs. 11/20; P < 0.05) In conclusion, ACD-CPR appears to cause more CPR-related injuries than does standard CPR, but as a result of a number of limitations on this study, this fact cannot be proven beyond doubt.

Samples of lung tissues were obtained and analysed for Aspergillus carriage in 56 patients undergoing thoracic surgical intervention and 18 people who had an unexpected death. Out of 74 samples, 46 (63%) had evidence of pulmonary fungal colonization. The surgery population had a rate of 62% of fungal growth. Aspergillus was present in 39%. The autopsy population had a rate of 61% of fungal colonization. Aspergillus was present in 41%. In these cases eradication of fungal spores residing in the lung prior to aggressive chemotherapy and prevention of further spore uptake during hospitalization is indispensable in preventing pulmonary aspergillosis.

Fetal male sexual differentiation is driven by two testicular hormones: testosterone (synthesized by interstitial Leydig cells) and antimüllerian hormone (AMH; produced by Sertoli cells present in the seminiferous tubules). Intersex states result either from gonadal dysgenesis, in which both Leydig and Sertoli cell populations are affected, or from impaired secretion or action of either testosterone or AMH. Until now, only Leydig cell function has been assessed in children with ambiguous genitalia, by means of testosterone assay. To determine whether serum AMH would help in the diagnosis of intersex conditions, we assayed serum AMH levels in 107 patients with ambiguous genitalia of various etiologies. In XY patients, AMH was low when the intersex condition was caused by abnormal testicular determination (including pure and partial gonadal dysgenesis) but was normal or elevated in patients with impaired testosterone secretion, whereas serum testosterone was low in both groups. AMH was also elevated during the first year of life and at puberty in intersex states caused by androgen insensitivity. In 46,XX patients with a normal male phenotype or ambiguous genitalia, in whom the diagnosis of female pseudohermaphroditism had been excluded, serum AMH levels higher than 75 pmol/L were indicative of the presence of testicular tissue and correlated with the mass of functional testicular parenchyma. In conclusion, serum AMH determination is a powerful tool to assess Sertoli cell function in children with intersex states, and it helps to distinguish between defects of male sexual differentiation caused by abnormal testicular determination and those resulting from isolated impairment of testosterone secretion or action.

Wolfram syndrome is an autosomal recessive disorder characterized by juvenile diabetes mellitus, diabetes insipidus, optic atrophy and a number of neurological symptoms including deafness, ataxia and peripheral neuropathy. Mitochondrial DNA deletions have been described in a few patients and a locus has been mapped to 4p16 by linkage analysis. Susceptibility to psychiatric illness is reported to be high in affected individuals and increased in heterozygous carriers in Wolfram syndrome families. We screened four candidate genes in a refined critical linkage interval covered by an unfinished genomic sequence of 600 kb. One of these genes, subsequently named wolframin, codes for a predicted transmembrane protein which was expressed in various tissues, including brain and pancreas, and carried loss-of-function mutations in both alleles in Wolfram syndrome patients.

In recent years our laboratory has developed an immunological hypothesis for the pathogenesis of atherosclerosis. We have shown that cellular and humoral immune reactions against heat shock proteins (Hsps) 60/65 expressed on the surface of stressed endothelial cells comprise the initial event in the pathogenesis of this disease. In the course of these studies, we also investigated normal, unaffected arteries for control purposes (carotid bifurcations from children aged 8 weeks to 10 years). This investigation led to the unexpected and previously unknown finding that mononuclear cells pre-exist in the intima at bifurcation sites. Our findings can be summarized as follows: Mononuclear cells are always found in the intima, primarily at sites subjected to major hemodynamic stress. Although the proportion of macrophages vs CD3(+) T-cells differs, overall the latter clearly predominate. Most of the T-cells express the T-cell receptor (TCR)alpha/beta, but TCRgamma/delta cells are also present. We also identified dendritic cells and mast cells in the intima. Analogous to the mucosa-associated lymphoid tissue (MALT) we coined the designation "vascular-associated lymphoid tissue" (VALT) for these newly discovered cellular aggregates in the arterial intima.