Thanato-technics: Temporal Horizons of Death and Dying.

Advances in end-of-life technologies increasingly destabilize received notions of personhood, identity, and ethics. As notions of personhood and identity within such systems are made to conform to discrete, binary and less fluid categories, some in the West have sought guidance in the techniques and views related to the dying process cultivated in other cultures, particularly Tibetan Buddhism. This article considers such dynamics as they unfolded in research focused on the postmortem bodies of Tibetan Buddhist practitioners in India. This article introduces the term thanato-technics to highlight the temporalities, imaginary or otherwise, evoked, enabled, and invested through the use of technologies to ascertain or conjecture about the intrasubjectivity of the dead and dying.

Photon-counting CT for forensic death investigations-a glance into the future of virtual autopsy.

This article explores the potential of photon-counting computed tomography (CT) in forensic medicine for a range of forensic applications. Photon-counting CT surpasses conventional CT in several key areas. It boasts superior spatial and contrast resolution, enhanced image quality at low x-ray energies, and spectral imaging capabilities that enable more precise material differentiation. These advantages translate to superior visualization of bone structures, foreign bodies, and soft tissues in postmortem examinations. The article discusses the technical principles of photon-counting CT detectors and highlights its potential applications in forensic imaging, including high-resolution virtual autopsies, pediatric forensic CT, trauma analysis, and bone density measurements. Furthermore, advancements in vascular imaging and soft tissue contrast promise to propel CT-based death investigations to an even more prominent role. The article concludes by emphasizing the immense potential of this new technology in forensic medicine and anthropology.

Post-mortem transmission risk of infectious disease: A systematic review.

INTRODUCTION: Autopsies may expose to infectious risks. The objective of this study is to assess the risk of post-mortem transmission of HIV, HBV, HCV, Mycobacterium tuberculosis (MBT), SARS-CoV2 and prion in the workplace and to estimate the duration of their infectiousness. MATERIAL AND METHOD: the PRISMA 2020 guideline was used. Pubmed, Web of Science, Google Scholar and Sciencedirect databases were assessed until February 28, 2023. We searched for articles in any language and any date of publication. Studies involving animals, transmission between two living people or transmission outside the workplace were excluded. Risk of bias was assessed using the appropriate assessment tools for each type of study. A descriptive analysis was performed. RESULTS: A total of 46 studies were included. Cases of post-mortem transmission were certain for HIV (n = 1) and MBT (n = 18). The longest post-mortem interval for positive diagnostic tests was 17 days for HIV, 60 for HBV, 7 for HCV, 36 for MBT and 17 for SARS-CoV2. The longest post-mortem interval for positive cultures was 21 h for HIV, 6 days for HBV, 36 days for MBT, 17 days for SARS-CoV2. The methodology of the studies was heterogeneous, some of them associated with a high risk of bias. CONCLUSION: There is a lack of consistent data in the literature concerning the infectivity of cadavers, except for MBT. Legislation appears to be based on minimizing contact between the biological agent and the professional. In the absence of recent robust scientific data, workers should systematically follow the best practice recommendations.

Potential differences in receptor-mediated G-protein activation in postmortem human hippocampal membranes prepared from healthy controls and suicide victims.

AIM: Postmortem brain studies offer enormous opportunities to study molecular mechanisms associated with suicide. In the present study, conventional [35S]GTPγS binding assay and its version-up method ([35S]GTPγS binding/immunoprecipitation assay) were applied to postmortem human hippocampal membranes prepared from suicide victims and control subjects. METHODS: By using conventional [35S]GTPγS binding assay, functional activations of Gi/o proteins coupled with multiple GPCRs (5-HT1A receptor, α2A-adrenoceptor, M2/M4 mAChRs, adenosine A1 receptor, histamine H3 receptor, group II mGlu, GABAB receptor, µ-opioid receptor, δ-opioid receptor, and NOP receptor) were detected by using 15 different agonists. Furthermore, 5-HT2A receptor- and M1 mAChR-mediated Gαq/11 activation and adenosine A1 receptor-mediated Gαi-3 activation were detectable by means of [35S]GTPγS binding/immunoprecipitation assay. RESULTS: No significant differences in pharmacological parameters of all concentration-response curves investigated were found between suicide victims and control subjects. Significant correlations were obtained for the maximal percent increases between some distinct signaling pathways. CONCLUSION: Although only preliminary and auxiliary results were obtained as to the potential differences between suicide victims and control subjects because of the limited number of subjects as well as unmatched age and postmortem delay, adenosine A1 receptor-mediated Gαi/o activation and 5-HT2A receptor-mediated Gαq/11 activation appear worth focusing on in the future investigations. This study also indicates the possibility that some distinct signaling pathways are interrelated with each other, for example, functional activations of Gi/o proteins coupled to M2/M4 mAChR and 5-HT1A receptor, NOP receptor, and GABAB receptor, and NOP receptor and δ-opioid receptor.

Postmortem-Derived Exosomal MicroRNA 486-5p as Potential Biomarkers for Ischemic Heart Disease Diagnosis.

Exosomes are nanovesicles 30-150 nm in diameter released extracellularly. Those isolated from human body fluids reflect the characteristics of their cells or tissues of origin. Exosomes carry extensive biological information from their parent cells and have significant potential as biomarkers for disease diagnosis and prognosis. However, there are limited studies utilizing exosomes in postmortem diagnostics. In this study, we extended our initial research which identified the presence and established detection methodologies for exosomes in postmortem fluids. We analyzed exosomal miRNA extracted from plasma and pericardial fluid samples of a control group (n = 13) and subjects with acute myocardial infarction (AMI; n = 24). We employed next-generation sequencing (NGS) to investigate whether this miRNA could serve as biomarkers for coronary atherosclerosis leading to acute myocardial infarction. Our analysis revealed 29 miRNAs that were differentially expressed in the AMI group compared to the control group. Among these, five miRNAs exhibited more than a twofold increase in expression across all samples from the AMI group. Specifically, miR-486-5p levels were significantly elevated in patients with high-grade (type VI or above) atherosclerotic plaques, as per the American Heart Association criteria, highlighting its potential as a predictive biomarker for coronary atherosclerosis progression. Our results indicate that postmortem-derived exosomal microRNAs can serve as potential biomarkers for various human diseases, including cardiovascular disorders. This finding has profound implications for forensic diagnostics, a field critically lacking diagnostic markers.

Automated deep learning segmentation of high-resolution 7 Tesla postmortem MRI for quantitative analysis of structure-pathology correlations in neurodegenerative diseases.

Postmortem MRI allows brain anatomy to be examined at high resolution and to link pathology measures with morphometric measurements. However, automated segmentation methods for brain mapping in postmortem MRI are not well developed, primarily due to limited availability of labeled datasets, and heterogeneity in scanner hardware and acquisition protocols. In this work, we present a high-resolution dataset of 135 postmortem human brain tissue specimens imaged at 0.3 mm3 isotropic using a T2w sequence on a 7T whole-body MRI scanner. We developed a deep learning pipeline to segment the cortical mantle by benchmarking the performance of nine deep neural architectures, followed by post-hoc topological correction. We evaluate the reliability of this pipeline via overlap metrics with manual segmentation in 6 specimens, and intra-class correlation between cortical thickness measures extracted from the automatic segmentation and expert-generated reference measures in 36 specimens. We also segment four subcortical structures (caudate, putamen, globus pallidus, and thalamus), white matter hyperintensities, and the normal appearing white matter, providing a limited evaluation of accuracy. We show generalizing capabilities across whole-brain hemispheres in different specimens, and also on unseen images acquired at 0.28 mm3 and 0.16 mm3 isotropic T2*w fast low angle shot (FLASH) sequence at 7T. We report associations between localized cortical thickness and volumetric measurements across key regions, and semi-quantitative neuropathological ratings in a subset of 82 individuals with Alzheimer's disease (AD) continuum diagnoses. Our code, Jupyter notebooks, and the containerized executables are publicly available at the project webpage (https://pulkit-khandelwal.github.io/exvivo-brain-upenn/).

[Forensic imaging of sharp force injuries]. / Forensische Bildgebung der scharfen Gewalt.

BACKGROUND: Answering legal questions is everyday routine in forensic medicine. The reconstruction of violent crimes following attacks with sharp and/or pointed instruments is usually complex and can hardly be adequately answered using traditional forensic methods such as autopsies. For this reason, clinical and postmortem radiology has become the ideal complement to forensic medicine. METHODS: While classic X­ray is unsuitable to image soft tissue injuries, and magnetic resonance imaging is too expensive, too complex and also not available everywhere, multislice computed tomography (MSCT) has now emerged as the method of choice in forensic imaging for the assessment of the consequences of sharp force injuries. ACHIEVEMENTS: Forensic imaging, especially MSCT, offers an indispensable addition to reconstruction, particularly after stab wounds. In many cases, it is at least equal to, and in some cases superior to, the classic autopsy in the assessment of stab wounds, the reconstruction of the sequence of events or the assessment of (life-threatening) injuries. CONCLUSIONS: The forensic radiological assessment after sharp violence requires experience in both the field of radiology and forensic medicine. Provided that both disciplines work closely together, forensic radiology can be an essential tool in the care for victims of violence.

[Blunt force trauma in forensic radiology]. / Stumpfe Gewalt in der forensischen Radiologie.

OBJECTIVE: Description of the main forensic radiological examination modalities and findings in blunt force trauma in living and deceased adults. METHODS: Elaboration of the essential points based on the authors' own experiences and relevant literature. RESULTS AND CONCLUSION: Injury-related consequences of blunt force are frequently observed in forensic radiological diagnostics, especially in the context of accidents and suicides, and less frequently in homicides. The method of choice for radiological imaging of blunt force in deceased persons is native postmortem computed tomography (PMCT). In principle, the radiological effects of blunt force in PMCT do not differ significantly from those in living persons. Postmortem magnetic resonance imaging (PMMRI) is very suitable for imaging blunt soft tissue injuries in the shorter postmortem interval. In the case of living individuals with the consequences of blunt force trauma, imaging is primarily indicated for clinical diagnostic reasons. Common indications are domestic violence, violence against the elderly, and disputes in public spaces. The choice of radiological examination method depends on the clinical history and symptoms, and the radiological examinations can be subjected to a forensic assessment.

An assessment of the Henssge method for forensic death time estimation in the early post-mortem interval.

BACKGROUND: Time-since-death (TSD) diagnostics are crucial in forensic medical casework. The compound method by Henssge and Madea, which combines temperature and non-temperature-based techniques, is widely used to estimate TSD. This study aims to validate the predictive ability of this method in a cohort of 76 deceased individuals with known times of death (TOD). METHODS: A convenience sample of 76 deceased individuals was examined at the Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf. The study included individuals who died at the hospital and those with sudden death in public. Exclusion criteria included age under 18, known infection or sepsis, polytrauma, bleeding, and hyperthermia. The TSD interval was calculated using the Deathtime software. RESULTS: The overall agreement between the actual TOD and the 95% prediction interval for the TSD was 36.8% (95% CI: 26.1 to 48.7). Warm-stored corpses showed a higher agreement (61.9% [95% CI: 38.4 to 81.9]) compared to cold-stored corpses (27.3% [95% CI: 16.1 to 41.0]). Factors such as body mass index (BMI) and body surface area (BSA) were found to influence the odds of agreement. Assuming a plausible range of ambient temperatures between death and admission improved the agreement in cold-stored cases. CONCLUSION: The study found low to moderate agreement between the actual TOD and the 95% prediction interval using the Henssge method. Incorporating BMI and BSA could improve the predictive accuracy of TSD estimations. Further research with larger sample sizes and external validation is recommended to refine the model.

Post-mortem Interval estimate based on dental pulp: A histomorphology approach.

Estimating the post-mortem interval (PMI) of human remains based on the histomorphology of dental pulp parameters is promising, but available evidence is scarce and sometimes contradictory without a scientific model. The aim of the study is to characterise the histomorphological changes of dental pulp associated with the decomposition of human remains by a qualitative and quantitative approach. The main aim is to establish a correlation based on post-mortem (PM) dental pulp histomorphology and the PMI, and whether pulp degradation could be an available medico-legal tool for PMI estimation beyond the first week after death (late PMI). The eligible sample consisted of 27 sound teeth from 16 healthy patients aged 16 to 72 years due to orthodontic or oral surgery treatment, to create PMI's simulating the death of the subject as the time elapsed from tooth avulsion. Data collected from patients (sex, date of birth, tooth position, date and hour of the avulsion, date and hour of pulp extraction) were anonymised in accordance with the requirements of Faculty of Dental Medicine of the University of Lisbon. The sample was divided into 9 groups of 3 teeth according to different PMI sets from T0 (baseline) up to 2 weeks (T0, 7, 12, 24, 36, 48, and 72 hours, 1 and 2 weeks). All the dental samples were stored at room temperature up to the time of pulp extraction and then prepared with haematoxylin and eosin stain. High-resolution microscopy was performed to obtain histological images. An operator performed the qualitative evaluation of blood vessels, collagen fibres, and the extra-cellular matrix (ECM) in PM pulps and measured the variation in cells/nuclei density by counting 6 different ROIs (Regions of Interest) for each pulp manually and automatically (quantitative analysis). Qualitative results showed that the degeneration of dental pulp appears 7 hours after death but histological changes in vessels, fibres, and ECM in PM dental pulp are characterised by high variability, consequently it is not possible to generalise the results for early PMIs. Quantitative measurements proved that cell count cannot be standardised due to the presence of superimposed layers of cells and nuclei fragmentation. Odontoblasts did not demonstrate evidence of cellular or nuclear lysis up to 14 PM suggesting their applicability in late PMIs. Future research will focus on late PMIs and different techniques of tooth preparation.

Differential regulation of physicochemical properties and myofibrillar protein degradation of yak meat by interactions between reactive oxygen species and reactive nitrogen species during postmortem aging.

BACKGROUND: This study aimed to explore how interactions between reactive oxygen species (ROS) and reactive nitrogen species (RNS) affect oxidative properties, nitrosative properties, and myofibrillar protein degradation during postmortem aging of yak meat. RESULTS: Yak longissimus dorsi was incubated with saline, ROS activator (H2O2)/inhibitor N-Acetyl-L-cysteine (NAC) and RNS activator S-Nitrosoglutathione (GSNO)/inhibitor L-NAME hydrochloride (L-NAME) combined treatments at 4 °C for 12, 24, 72, 120, and 168 h. The results indicated that regardless of whether RNS was activated or inhibited, activated ROS played a dominant role in myofibrillar protein degradation by oxidative modification to increase carbonyl content, disulfide bonds, surface hydrophobicity, and dimerized tyrosine while decreasing sulfhydryl content, thereby degrading nebulin, titin, troponin-t and desmin. Notably, the Warner-Bratzler shear force (WBSF) of the H2O2 + L-NAME group was the smallest, whereas that of the NAC + GSNO group was smaller than that of the NAC + L-NAME group. CONCLUSION: These findings provide new insights into meat tenderization patterns through the interaction between ROS and RNS. © 2024 Society of Chemical Industry.

Forensic significance of postmortem pink teeth: A narrative review.

OBJECTIVE: To review the phenomenon of postmortem pink teeth, exploring its etiology, correlation with the cause of death, and the potential forensic significance of this medico-legal finding. METHODS: A comprehensive literature search was conducted using databases such as PubMed, Scopus, and B-on, employing keywords like "Forensic Pathology," "Forensic Dentistry," "Pink Teeth," and "Medico-legal aspects." The search included studies without temporal limits to gather extensive data on the postmortem pink teeth phenomenon. RESULTS: The postmortem pink teeth phenomenon is characterized by a red-pink discoloration of the dentin, typically sparing the enamel. It is most often observed in moist environments and cases involving water immersion, strangulation, and carbon monoxide poisoning. The study found no consistent relationship between the pink discoloration and specific causes of death, suggesting the phenomenon is more closely related to environmental conditions and the state of decomposition. The pink coloration is more prevalent in anterior, single-rooted teeth and younger individuals. CONCLUSION: The postmortem pink teeth phenomenon remains a complex and enigmatic finding in forensic science. While it does not conclusively indicate a specific cause of death, understanding its occurrence can aid forensic investigations. Further research is needed to elucidate this phenomenon's mechanisms and validate its forensic relevance.

A Case of Hanging with Limited Specific Postmortem Brain Imaging.

In Japan, the number of autopsies has steadily decreased. Therefore, postmortem imaging methods have positioned as valuable supplemental or complementary tools in autopsy procedures. We clinicians are increasingly faced with the need to infer cause of death from postmortem imaging findings. We report computed tomography (CT) and magnetic resonance imaging (MRI) findings of a 41-year-old man who committed suicide by hanging. CT revealed fractures of the left superior horn of the thyroid cartilage. Head MRI showed high signal intensity in the basal ganglia on the T1-weighted image and high-intensity rims along the cerebral cortex on the diffusion-weighted image; however, these were considered normal postmortem changes. There were no significant findings in the heart, major blood vessels, or abdominal organs. The contents of the stomach were minimal, and no tablets or other evidence suggestive of drug overdose were identified. Traumatic changes were not observed. Based on the scene and his circumstances, it was speculated that he died by hanging and an autopsy was not performed. This case highlights the importance of understanding normal postmortem brain imaging changes to estimate the true cause of death.

Development and age estimation of the intrapuparial period of Phormia regina (Diptera: Calliphoridae) for postmortem interval estimation.

Phormia regina (Meigen, 1826; Diptera: Calliphoridae) is a Holarctic species that rapidly colonizes carcasses and has been used as an indicator for determining the minimum postmortem interval. However, studies using morphological methods to estimate the intrapuparial age of P. regina are lacking. In this study, morphological changes within the puparium were observed under a stereomicroscope at 7 constant temperatures ranging from 16 °C to 34 °C. The intrapuparial period was categorized into 12 substages. Morphological indicators, including compound eyes, mouthparts, antennae, thorax, legs, wings, and abdomen, were recorded in detail. The observed morphological changes were divided into 6-10 substages, and the duration of each substage was also recorded in detail. The results of this study provide primary data for using the intrapuparial morphology of P. regina when pupae are collected at a crime scene and estimating the minimum postmortem interval.

Microglial process convergence onto injured axonal swellings, a human postmortem brain tissue study.

Traumatic brain injury (TBI) affects millions globally, with a majority of TBI cases being classified as mild, in which diffuse pathologies prevail. Two of the pathological hallmarks of TBI are diffuse axonal injury (DAI) and microglial activation. While progress has been made investigating the breadth of TBI-induced axonal injury and microglial changes in rodents, the neuroinflammatory progression and interaction between microglia and injured axons in humans is less well understood. Our group previously investigated microglial process convergence (MPC), in which processes of non-phagocytic microglia directly contact injured proximal axonal swellings, in rats and micropigs acutely following TBI. These studies demonstrated that MPC occurred on injured axons in the micropig, but not in the rat, following diffuse TBI. While it has been shown that microglia co-exist and interact with injured axons in humans post-TBI, the occurrence of MPC has not been quantitatively measured in the human brain. Therefore, in the current study we sought to validate our pig findings in human postmortem tissue. We investigated MPC onto injured axonal swellings and intact myelinated fibers in cases from individuals with confirmed DAI and control human brain tissue using multiplex immunofluorescent histochemistry. We found an increase in MPC onto injured axonal swellings, consistent with our previous findings in micropigs, indicating that MPC is a clinically relevant phenomenon that warrants further investigation.

The Effect of Soil Type and Moisture on the Development of Forensically Important Megaselia scalaris and Dohrniphora cornuta (Diptera: Phoridae).

Necrophagous phorid flies are common insects found on buried corpses, and their developmental data play a crucial role in estimating the post-burial interval (PBI). This study aimed to investigate the effects of soil type and moisture content on some life cycle parameters of two forensically important insects, Megaselia scalaris (Loew, 1866) and Dohrniphora cornuta (Bigot, 1857) (Diptera: Phoridae). Larval and pupal survival, development time, and larval body length of M. scalaris and D. cornuta were observed in three different soil types (loamy sand, sandy loam A, and sandy loam B) with six moisture contents (0%, 20%, 40%, 60%, 80%, and 100%). The results indicated that soil types, soil moisture, and their interaction significantly influenced the growth and development of both species, with moisture being the most influential factor. In each soil, 20% and 40% moisture contents were more suitable for their growth and development. Both the development time and maximum larval body length were significantly different among soil types and moisture contents. The larval period of both species lasted the longest in all soils with 0% moisture content. Additionally, a regression analysis of the relationship between larval body length and development time was performed at different moisture contents in three soils. This study expanded our knowledge of the factors that influence the development of necrophagous insects and provided some reference data for applications of M. scalaris and D. cornuta in PBI estimation.

Research Status of Sarcosaprophagous Beetles as Forensic Indicators.

In forensic entomology, research focused on sarcosaprophagous flies, but the sarcosaprophagous beetles, as important "forensic indicator species" of late-stage PMI in cadaver decomposition, received less attention. To increase attention on, and use and understanding of, sarcosaprophagous beetles in forensic entomology, this paper presents a bibliometric analysis of the available relevant literature. The occurrence frequency of beetle families and species from succession studies, actual cases, and experiments were calculated and illustrated using graphs. As a result, a total of 14 families and 1077 species associated with carcasses were collected, with Staphylinidae being the most frequently recorded among the families, and Necrobia rufipes (Fabricius, 1781) (Coleoptera: Cleridae) being the most frequently recorded species. In addition, a brief introduction of the cadaver-related beetles of each family is given, and research on the species identification of the immature stages, age estimation of the immature stages, and estimation of the arrival time of sarcosaprophagous beetles are discussed and prospected. This work will aid in the increased use of sarcosaprophagous beetles in forensic science practice in the future.

Medico-legal recommendations to fight the silent war of femicide in Europe.

Femicide is a global phenomenon; yet there is no commonly accepted understanding of what counts as femicide. Different disciplines and approaches offer different definitions. Defining the term femicide is not only a purely lexical matter but also involves the aspect of data collection. Owing to the lack of a standardized definition, data collected by countries under this label are not comparable and cannot be used for global or regional estimates to provide an indication of the scale of this phenomenon. One tool to fight this silent war against women is certainly medical-legal diagnosis, with everything that the body of a victim of femicide can reveal. Autopsies are crucial; they can help differentiate between female homicide and femicide and the search for a formal, agreed-upon definition of femicide may be derived precisely from forensic pathology research and necropsy evidence. The autopsies performed and studies written on femicide cases are of extraordinary importance because they make it easy to identify which anatomical districts are most affected, which weapons are most frequently used, and where the bodies of victims of femicide are most often found. To curb this phenomenon, it is essential to act on several levels, starting with the national one. It is necessary to develop a data collection and processing system involving both law enforcement and forensic centers. It is also emphasized the relevance of creating a universal database that can be easily consulted, along the lines of the one that already exists in the United States.

Sex estimation using skull silhouette images from postmortem computed tomography by deep learning.

Prompt personal identification is required during disasters that can result in many casualties. To rapidly estimate sex based on skull structure, this study applied deep learning using two-dimensional silhouette images, obtained from head postmortem computed tomography (PMCT), to enhance the outline shape of the skull. We investigated the process of sex estimation using silhouette images viewed from different angles and majority votes. A total of 264 PMCT cases (132 cases for each sex) were used for transfer learning with two deep-learning models (AlexNet and VGG16). VGG16 exhibited the highest accuracy (89.8%) for lateral projections. The accuracy improved to 91.7% when implementing a majority vote based on the results of multiple projection angles. Moreover, silhouette images can be obtained from simple and popular X-ray imaging in addition to PMCT. Thus, this study demonstrated the feasibility of sex estimation by combining silhouette images with deep learning. The results implied that X-ray images can be used for personal identification.

Exploring factors associated with increased suicides during the COVID-19 pandemic in Japan: A study using data from postmortem examinations conducted in an urban area.

Aim: The purpose of this study is to examine factors associated with increased suicide deaths during the coronavirus disease 2019 (COVID-19) pandemic in Japan using primary data from postmortem examinations. Methods: We explored factors associated with suicides that occurred during the COVID-19 pandemic (February 2020 to December 2021) using data from 115 postmortem examinations of suicides that occurred in one city in the Kanto region between January 2017 and December 2021. Results: Multivariate analysis using graphical modelling and logistic regression analysis showed that both female sex (adjusted odds ratio: 3.732; 95% confidence interval: 1.044-13.345) and multiple mental disorders (adjusted odds ratio: 7.344; 95% confidence interval: 1.316-40.987) were significantly associated with suicide during the COVID-19 pandemic among the young age group (39 years or under). Conclusion: The study results suggest that in addition to the factor of female sex previously identified, morbidity due to multiple mental disorders may be associated with the increased suicides in Japan during the COVID-19 pandemic. Furthermore, this study presented the new methodological possibility of analyzing background factors of suicide using postmortem examination data. In preparation for similar emergencies in the future, it is necessary to establish a system that provides care for multiple mental disorders and a continuous suicide-monitoring system that combines methods such as psychological autopsies with other methods.