An Analysis of the Characteristics of Thoracic and Abdominal Injuries Due to Gunshot Homicides in Israel.

De-identified wound data from 197 homicidal gunshot postmortems were obtained between 2000 and 2008. Forensic ballistics data were only available for cases between 2004 and 2008. Males represent 91% of gunshot victims and were struck in the thorax/abdomen with an average of 2.3 bullets. The type of firearms involved were semi-automatic pistols in the predominant caliber 9-mm Luger and assault rifles in caliber 5.56 × 45 mm and caliber 7.62 × 39 mm Soviet, using full metal jacket bullets. The majority of shootings occurred at ranges of 1 m or greater. The most common bullet path was front to back in 66% of cases. Entry wounds occurred more often on the left side of the thorax, abdomen, and back. The most common critical organs/tissues to sustain bullet trauma in descending order were as follows: heart, lungs, liver, aorta, spleen, kidneys, and vena cava. Ribs were struck by most bullets that entered the thorax.

Psychosocial and medical aspects of older suicide completers in Israel: a 10-year survey.

OBJECTIVES: The rate of completed suicide among the elderly continues to be the highest of any age group worldwide. The aim of the present study was to investigate the sociodemographic data, mental and physical health characteristics, and suicide methods of the elderly population who completed suicide in Israel. METHODS: A national retrospective record-based case series study of consecutive elder (50 years or older) suicide completers who had undergone autopsy over a 10-year period was conducted. RESULTS: Three hundred and fourteen consecutive records of suicide completers, 69.6% males, and mean age 64.7 were analyzed. The largest group (38%) emigrated from the Former Soviet Union and 19% emigrated from East Europe. Immigrants from East Europe committed suicide at an older age. Hanging was the predominant suicide method. Jumping from height increased more than threefold in the 'old-old'(older than 75 years) group. Hanging and firearms were more frequently used by males. Females were more likely to employ poisoning and suffocation. A significant minority (30%) had been diagnosed as suffering from psychiatric morbidity. Most common diagnoses were depression and alcohol abuse or dependence. Physical disorders (mainly cardiovascular disease and malignancy) were present in 27% of cases. Subjects with psychiatric illness were more likely to complete suicide at a younger age compared with subjects with physical illness. CONCLUSIONS: Findings of male predominance, psychiatric morbidity, and physical illness are consistent with previously published studies. Immigrants from East Europe completed suicide at an older age and the older victims had used more lethal methods of suicide.

[Detection of wooden rod in pleural and peritoneal cavities during forensic autopsy].

INTRODUCTION: A rare event of fatal sexual assault by the insertion of a wooden rod through the anus to the upper chest is reported. Examination of the body at the scene did not raise any suspicion of assault while the subsequent autopsy revealed findings that changed the assessment of the cause of death and the circumstances. CASE HISTORY: The body of a 57 years old man with a history of psychiatric illness was found in his room. At autopsy a round wooden rod which was inserted through the anus was found in the peritoneal and pleural cavities. In addition, signs of manual pressure were detected on the neck and trunk, and on the head and extremities signs of blunt trauma were observed. DISCUSSION: In patients affected by mental disorders it is difficult to distinguish between self-inflicted anal injuries and injuries sustained during an attack. Detection of damage to other areas of the body (such as the neck) assist in determining the nature of the assault. SUMMARY: This case demonstrates the need for a full autopsy in every case of death under unclear circumstances, especially when a limited examination of the body can't determine the type of death (natural, accident, suicide or homicide).

[Combination of imaging studies and autopsy in death investigations].

The progress in quality and availability of imaging studies has made them an invaluable part of the clinical diagnostic process, so much so that the forensic medical community had to acknowledge their importance and to implement them in death investigations. Since 2011 roughly 200 post-mortem radiographic examinations were conducted, mostly followed by full autopsies. Four of those cases are given as an example of the benefits and limitations of these methods. A review of the literature and our experience so far, show that computed tomography provides better visualization and 3D reconstruction of traumatic bone injuries, as well as good assessment of air in the tissues and vascular system, gunshot wound tracts, and anthropological characteristics for identification. Imaging methods are relatively limited in definite diagnostic findings in cases of sudden death from natural causes, such as pneumonia, pulmonary embolism, acute myocardial infarction or meningitis, problems which can be partially solved with the aid of angiographic studies. These methods also do not allow for sampling of tissues for microscopic examination, nor fluid samples for cultures and toxicology. In the current cultural and social reality in Israel, imaging studies enable minimization of the autopsy and, in certain cases, its relinquishment serves as a compromise between the necessity of death investigation and beliefs in the wholeness of the body. In light of the advantages of imaging, no autopsy of a trauma-related death can be complete without it.

[Identification of unknown cadavers--multidisciplinary approach].

The comparison of fingerprints, dentition, genetic profile, imaging data and anthropological characteristics constitute the scientific basis for identification of unknown cadavers. The complexity of the identification process stems from a variety of factors such as the circumstances surrounding the death, the preservation state of the cadaver, availability of identification data and their quality, which affect the feasibility of the identification. This article reviews the most common identification techniques, the various sources of data accessible to the forensic scientist and the strategic decisions through which the unidentified body and the missing person are integrated.

[Sudden death due to eosinophilic arteritis of a major coronary artery].

Coronary arteritis is the fourth most common cause of fatal cardiac disease, after coronary atheroscLerosis, congenital anomalies and coronary dissection. Eosinophilic inflammation of the coronary arteries is extremely rare, involves the major coronaries and occurs as an isolated disease or as part of Churg-Strauss syndrome or Wegener's granulomatosis with involvement of other internal organs. A case of sudden and unexpected death of a healthy young woman is presented. Autopsy revealed eosinophilic inflammation of Left coronary artery with thrombosis of the lumen, causing a fatal cardiac failure. No other pathology was detected. We discuss the importance of performing a full autopsy, including microscopic inspection of the tissues, in order to glean the cause of death and learn about new and rare pathologies.

[Death due to hypothermia and paradoxical undressing].

Hypothermia is a rare cause of death in Israel, and usually occurs among risk groups such as elderly people, homeless persons, psychiatric patients and persons who function in cold environments or are unintentionally exposed to such conditions. Death due to hypothermia generally occurs in extremely cold conditions, although ambient temperatures of 15-20 degrees C can also be lethal. The phenomenon of paradoxical undressing that characterizes death due to hypothermia rather occurs in moderate ambient temperatures, and takes place when the victim is in extremis. A case of death of an elderly man, whose body was found naked in a field, is reported. His head was covered with a shirt, and blunt injuries were found on his body, raising suspicion that he was smothered, or was a victim of sexual violence. On autopsy, spot hemorrhages of the gastric mucosa, which are characteristic of hypothermia, were found, along with mild cerebral atrophy, moderate atherosclerosis of the coronary and cerebral vessels and myocardial sclerosis. The combination of autopsy findings, elimination of traumatic injuries as contributors to death and the circumstances in which the body was found, led to the diagnosis of death due to hypothermia.

Accidental fetal decapitation: a case of medical and ethical mishap.

Blunt trauma to the head and neck of a newborn during delivery process is a rare event. We report a peculiar case of decapitation of a live fetus during vacuum-assisted delivery, where excessive traction on the head of the full-term macrosomic fetus with shoulder dystocia resulted in overstretching of the neck up to the point of decapitation. The ethical considerations related to the case are discussed in light of the policy of complete transparency advocated by the medical profession. Despite the existence of regulations regarding full disclosure of errors to the medical institution, the Ministry of Health and to the patient, medical practitioners are reluctant to divulge all the details of adverse events to the patient.

[The prevalence of physical evidence in the anogenital area in sexual assault cases of children in Israel].

INTRODUCTION: Sexual abuse includes obscenity, rape and sodomy. Forensic medical examinations routinely include the genital area, anus and the body of the victims for signs of recent or old injury. OBJECTIVES: To evaluate the incidence of physical evidence in forensic sexual abuse cases and to compare the Israeli findings to data from other countries, including the USA. METHODS: The study was conducted during one calendar year in Israel and included 95 children from infancy to 16 years of age, of whom 83% were females. Examination results were defined by the presence of physical injury or its absence. These findings were classified by their location in the anogenital area or other body areas and findings in the anogenital area were further classified by their likelihood to have been caused by a sexual assault. The results of the examination were related to parameters such as age and sex of the participants, length of time since the last assault, and the degree of proximity between the suspected assailant and the victim. RESULTS: Evidence of physical abuse was found in 41 patients, in 37 (39%) of these cases physical abuse was detected in the anogenital area. In all these cases of anogenital abuse, 11 (12%) showed clear evidence of sexual assault and five of them had recent signs of injury; 80% of the recent injuries in the anogenital area were identified in patients within the first 24 hours after the assault. CONCLUSIONS: The prevalence of clear evidence of sexual assault in the U.S. ranges from 3-23%, in Italy 9.5%, in Thailand 32% and in Denmark 40%. In Israel, as elsewhere in the world, few cases of sexual assault in children will have clear evidence of a sexual nature. A lack of physical evidence does not rule out sexual assault, therefore, finding physical evidence during an examination is the exception rather than rule. Questioning the victim and investigating the circumstances of the case are crucial elements in all instances of presumed sexual assault on children.

Atlas occipitalization in a supersonic fighter pilot involved in a midair collision: a case report.

We report a case of a midair collision between two F16 fighter aircraft, in which one pilot survived and the other was ejected upon impact and his remains recovered from sea. In autopsy, no patholgy was detected, other than the expected evidence of mechanical trauma. No defects in the aircraft or faults in the parachute or ejection mechanism were found. Reconstruction of the shattered skull base and the cervical vertebrae revealed fusion of the atlanto-occipital joint (occipitalization) and a left paracondylar process. The effective diameter of the spinal canal was decreased by the abnormal articulation. Such malformations can cause a wide range of neurologic deficits. Considering the skill and alertness needed to operate a supersonic fighter aircraft, with the pressure applied by the heavy protective head gear and various G forces endured by the spinal column during flight, we postulate that the collision was related to the pilot's sudden incapacitation.

Infantile asphyxia due to aberrant uvula--an anatomic misadventure.

A case of unexpected death of an infant with an abnormally elongated uvula is presented. The child, born prematurely, was recovering from protracted treatment in hospital, including surgical interventions and periods of ventilation support necessitating recurrent intubations and anesthesia. She was discharged home in good general health, affected by episodes of cough, and was found dead in her crib a week later. The proximity of the aberrant uvula to the vocal cords may have caused intermittent laryngospasm, with subsequent symptoms of cough and airway obstruction, ending in a fatal outcome. Recurrent airway irritation may have contributed to uvular hypertrophy, due to inflammatory and reactive changes. It is pertinent for the pathologist to thoroughly examine the structures of the pharynx, and the uvula in particular, in any case of pediatric death suspected to result from asphyxia or sudden infant death syndrome (SIDS).

The elusive slug: bullet intestinal "embolism".

Bullet retrieval from the body of a gunshot victim is one of many tasks in post-mortem forensic examination. Rarely, it is complicated by the migration of the missile away from the entry point by vessel embolism. Abdominal firearm injuries, in which the bullet enters the intestines and moves inside the lumen away from the point of penetration, are even less common. We present a case of postmortem recovery of a bullet from the intestines of a gunshot victim who died 18 days after being shot in the trunk by three low velocity bullets. A missile had moved within the colon during hospitalization and postmortem handling of the body and was recovered from the sigmoid colon. This case demonstrates an extremely rare type of bullet "embolism" and emphasizes the usefulness of CT scanning in the location of projectiles.

Sudden cardiac death of a woman during extramarital sex: a case report and review of the literature.

Sudden death of cardiac patients related to sexual activity has been widely reported in the medical and forensic literature, specifically of male partners in heterosexual relationships, usually with extramarital partners. We present a unique case of a 46 year old woman who died during a sexual encounter with her lover. Cause of death was an acute cardiac failure due to hypertensive chronic cardiovascular disease, following sexual activity. The factors which contributed to her death are discussed and reviewed in light of similar reports in men.

["Scared to death"--lethal cardiac arrhythmia caused by emotional stress].

BACKGROUND: The cause of death in cases of sudden and unexpected death is determined by the forensic pathologist based on autopsy findings and toxicological analysis. In cases where no acute pathology or lethal injury are detected, and the circumstances surrounding the death were highly stressful or emotional, it is possible to attribute the inciting event as contributory to the death by causing cardiac dysrhythmia. METHOD: Ten cases of sudden death related to stressful events were examined over a period of 2 years in the National Center of Forensic Pathology, all of which lacked findings of acute disease or serious injury. All suffered from variable degrees of chronic cardiac pathology, which probably contributed to dysrhythmia and death. DISCUSSION: Since the seventies of the previous century, forensic pathologists are entitled to determine mode of death as homicide or manslaughter, due to an acute cardiac event which cannot be diagnosed in an autopsy and which was a direct result of the circumstances prior to death. Later, these conditions were adjusted to include cases where no morphological findings were detected or when death is delayed by medical treatment. The physiological mechanisms responsible include an increase in catecholamine levels, an increase in blood pressure and platelet aggregation and a delay in cardiac and vascular recovery from stress. CONCLUSIONS: Victims of sudden death caused by emotional stress, during a criminal act, usually have a background of chronic cardiac disease and/or are more susceptible physiologically to suffer an amplified reaction to stress. Legally, their deaths are considered as homicide or manslaughter.

Alcohol and driver fatalities in Israel: an examination of the current problem.

BACKGROUND: The role of alcohol in driver fatalities in Israel is unknown, and monitoring blood alcohol concentration among drivers is not routine. Moreover, over the past decade, self-reported access to and consumption of alcohol in Israel has been on the rise. OBJECTIVES: To use available data to characterize alcohol-related driver fatalities. METHODS: The prevalence of alcohol-related driver fatalities were estimated for 443 drivers, aged 17+ years, using data from Israel's National Center for Forensic Medicine for 2000-2004. RESULTS: Between 8% and 17% of driver fatalities had a BAC > or = 0.05 g/dl. Most drivers with alcohol exceeding this level were males aged 21-30 years who died on weekends. Recreational and/or medicinal drugs were found in 6%-11% of driver fatalities. Mean BAC among driver fatalities with BAC > or = 0.05 g/dl was threefold higher than the legal driving limit and appears to be increasing with time. CONCLUSIONS: In light of the evidence suggesting an increasing mean BAC over time as well as reported increasing trends in access to alcohol and consumption, this study should serve as a basis for future research to comprehensively characterize the extent of this problem.

[Gunshot wounds to the head--common errors of clinicians in diagnosing direction and range of fire].

BACKGROUND: Evaluating direction and range of fire based on gunshot wound characteristics requires theoretical and/or practical training in terminal ballistics. Clinicians specializing in trauma, surgery and neurosurgery are sometimes called upon to assess direction of fire without prior knowledge or experience in the field. Descriptions of gunshot wounds and determination of bullet direction are documented in medical records. When data from hospital records concerning cases of gunshot wounds to the head were compared with autopsy findings, numerous discrepancies were found with often tragic consequences. OBJECTIVE: To describe possible inconsistencies between evaluations of gunshot wounds by clinicians and autopsy results and interpretation of medical records by forensic pathologists, as well as provide basic tools to facilitate a more accurate description of injuries by physicians. PATIENTS: Three cases of shooting victims treated in medical facilities, two patients underwent autopsy and the third case was re-evaluated by a forensic pathologist based on medical records. CONCLUSIONS: Clinicians often base their diagnosis of direction of fire solely on the size of the head wounds, without taking into consideration additional characteristics, such as the range of fire, powder residue and others. Misdiagnosis of the direction and range of fire has long term psychological and legal consequences. SUMMARY: Clinicians are therefore advised to avoid determining direction and range of fire without prior experience and expertise in the field and, if needed, to consult forensic pathologists proficient in terminal ballistics.

Cardiac perforation by a pectus bar after surgical correction of pectus excavatum: case report and review of the literature.

Pectus excavatum (PE) is a congenital sternal depression. The two most popular methods of correction are the highly modified Ravitch repair (HMRR) and the Nuss procedure. Presented here is a case of PE surgical correction in a 17.5-year-old male, beginning with the Nuss technique and converting to the HMRR during surgery, due to unsatisfying results. The procedure inadvertently culminated in perforation of the heart and lungs by the inserted pectus bar, with aggravation of the damage by resuscitation efforts. This article analyzes the chain of events leading to the patient's death and reviews the literature on the subject.

Self-inflicted gunshot wound mimicking assault: a rare variant of factitious disorder.

This paper presents the case of 52-year-old man who died in an attempt to prove factitious allegations of persecution. To the best of our knowledge, there are no other reported cases of a self-inflicted, long-distance gunshot injury causing death. We discuss other cases of crime-scene "staging" and review the literature on factitious disorders and malingering in our search for motive, and stress again the importance of crime scene analysis and investigation of circumstances in determining the manner of death.

The forensic expert witness--an issue of competency.

Scientists submitting expert opinions within the legal system are expected to be knowledgeable in the forensic aspects of their particular science, as well as to be ethical and unbiased. Scientists are seldom able to decline a request to provide an expert opinion in their field, even when their forensic expertise is minimal. The competence of scientists providing expert opinions in forensic cases is reviewed here. Three examples of the perils of uninformed "expertise" in forensic biology, medicine and anthropology are presented.