A forensic analysis on 53 cases of complex suicides and one complicated assessed at the Bureau of Legal Medicine of Milan (Italy).

Complex suicides are highly uncommon suicides in which multiple detrimental methods are used simultaneously or in chronological succession. We retrospectively analyzed through our database the 25512 autopsy reports registered at the Bureau of Legal Medicine of Milan in the last 27 years from 1993 until 2019, where 4498 suicides were documented. We assessed 53 cases of complex suicides and only one case of complicated suicide: for all of them we analyzed both data collected during the on-site investigation and the autopsy. In our case series, we identified a total number of 113 methods chosen and variably combined by the victims, which were classified into 17 categories. On the whole the most frequent association of suicide methods resulted in the combination of the plastic bag suffocation with inert gas inhalation (13 out of 53 complex suicides; 24.5%). We also analyzed our cases of simple suicides (1993-2019), to compare them with the complex suicides. In this study, we present a complete analysis regarding our cases of complex suicides, discussing the challenges and the interpretative issues which a forensic pathologist might deal with. A thorough on-site judicial inspection and a careful autopsy examination are crucial in such cases. Moreover, the clinical history of the victims and laboratory findings are supplemental elements to be necessarily considered to establish the actual manner of death and avoid any misinterpretations.

Epidemiology, classification, treatment and mortality of distal radius fractures in adults: an observational study of 23,394 fractures from the national Swedish fracture register.

BACKGROUND: Distal radius fractures are the most common of all fractures. Optimal treatment is still debated. Previous studies report substantial changes in treatment trends in recent decades. Few nation-wide studies on distal radius fracture epidemiology and treatment exist, none of which provide detailed data on patient and injury characteristics, fracture pattern and mortality. The aim of this study was to describe the epidemiology, fracture classification, current treatment regimens and mortality of distal radius fractures in adults within the context of a large national register study. METHODS: We performed a descriptive study using prospectively registered data from the Swedish fracture register. Included were all non-pathological distal radius fractures registered between January 1st 2015 and December 31st 2017 in patients aged 18 years and above. Nominal variables were presented as proportions of all registered fractures. RESULTS: A total of 23,394 distal radius fractures in 22,962 patients were identified. The mean age was 62.7 ± 17.6 years for all, 65.4 ± 16.0 for women and 53.6 ± 20.0 for men. A simple fall was the most common cause of injury (75%, n = 17,643/23,394). One third (33%, n = 7783/21,723) of all fractures occurred at the patients' residence. 65% (n = 15,178/23,394) of all fractures were classified as extra-articular AO-23-A, 12% (n = 2770/23,394) as partially intra-articular AO-23-B and 23% (n = 5446/23,394) as intra-articular AO-23-C. The primary treatment was non-surgical for 74% (n = 17,358/23,369) and surgical for 26% (n = 6011/23,369) of all fractures. Only 18% of the AO-23-A fractures were treated surgically, compared to 48% of the AO-23-C fractures. The most frequently used surgical method was plate fixation (82%, n = 4954/5972), followed by pin/wire fixation (8.2%, n = 490/5972), external fixation (4.8%, n = 289/5972) and other methods (4.0%, n = 239/5972). The overall 30-day mortality was 0.4% (n = 98/23,394) and the 1-year mortality 2.9% (n = 679/23,394). CONCLUSION: This nation-wide observational study provides comprehensive data on the epidemiology, fracture classification and current treatment regimens of distal radius fractures in a western European setting. The most common patient was an eldery woman who sustained a distal radius fracture through a simple fall in her own residence, and whose fracture was extra-articluar and treated non-surgically.

Increased mortality after upper extremity fracture requiring inpatient care.

BACKGROUND AND PURPOSE: Increased mortality after hip fracture is well documented. The mortality after hospitalization for upper extremity fracture is unknown, even though these are common injuries. Here we determined mortality after hospitalization for upper extremity fracture in patients aged ≥16 years. PATIENTS AND METHODS: We collected data about the diagnosis code (ICD10), procedure code (NOMESCO), and 7 additional characteristics of 5,985 patients admitted to the trauma ward of Central Finland Hospital between 2002 and 2008. During the study, 929 women and 753 men sustained an upper extremity fracture. The patients were followed up until the end of 2012. Mortality rates were calculated using data on the population at risk. RESULTS: By the end of follow-up (mean duration 6 years), 179 women (19%) and 105 men (14%) had died. The standardized mortality ratio (SMR) for all patients was 1.5 (95% CI: 1.4-1.7). The SMR was higher for men (2.1, CI: 1.7-2.5) than for women (1.3, CI: 1.1-1.5) (p < 0.001). The SMR decreased with advancing age, and the mortality rate was highest for men with humerus fractures. INTERPRETATION: In men, the risk of death related to proximal humerus fracture was even higher than that reported previously for hip fracture. Compared to the general population, the SMR was double for humerus fracture patients, whereas wrist fracture had no effect on mortality.

Survival analysis of elderly patients with a fracture of the odontoid peg.

Fractures of the odontoid peg are common spinal injuries in the elderly. This study compares the survivorship of a cohort of elderly patients with an isolated fracture of the odontoid peg versus that of patients who have sustained a fracture of the hip or wrist. A six-year retrospective analysis was performed on all patients aged > 65 years who were admitted to our spinal unit with an isolated fracture of the odontoid peg. A Kaplan-Meier table was used to analyse survivorship from the date of fracture, which was compared with the survivorship of similar age-matched cohorts of 702 consecutive patients with a fracture of the hip and 221 consecutive patients with a fracture of the wrist. A total of 32 patients with an isolated odontoid fracture were identified. The rate of mortality was 37.5% (n = 12) at one year. The period of greatest mortality was within the first 12 weeks. Time made a lesser contribution from then to one year, and there was no impact of time on the rate of mortality thereafter. The rate of mortality at one year was 41.2% for male patients (7 of 17) compared with 33.3% for females (5 of 15). The rate of mortality at one year was 32% (225 of 702) for patients with a fracture of the hip and 4% (9 of 221) for those with a fracture of the wrist. There was no statistically significant difference in the rate of mortality following a hip fracture and an odontoid peg fracture (p = 0.95). However, the survivorship of the wrist fracture group was much better than that of the odontoid peg fracture group (p < 0.001). Thus, a fracture of the odontoid peg in the elderly is not a benign injury and is associated with a high rate of mortality, especially in the first three months after the injury.

The contributions of First Nations ethnicity, income, and delays in surgery on mortality post-fracture: a population-based analysis.

UNLABELLED: We examined the independent contributions of First Nations ethnicity and lower income to post-fracture mortality. A similar relative increase in mortality associated with fracture appears to translate into a larger absolute increase in post-fracture mortality for First Nations compared to non-First Nations peoples. Lower income also predicted increased mortality post-fracture. INTRODUCTION: First Nations peoples have a greater risk of mortality than non-First Nations peoples. We examined the independent contributions of First Nations ethnicity and income to mortality post-fracture, and associations with time to surgery post-hip fracture. METHODS: Non-traumatic fracture cases and fracture-free controls were identified from population-based administrative data repositories for Manitoba, Canada (aged≥50 years). Populations were retrospectively matched for sex, age (within 5 years), First Nations ethnicity, and number of comorbidities. Differences in mortality post-fracture of hip, wrist, or spine, 1996-2004 (population 1, n=63,081), and the hip, 1987-2002(Population 2, n=41,211) were examined using Cox proportional hazards regression to model time to death. For hip fracture, logistic regression analyses were used to model the probability of death within 30 days and 1 year. RESULTS: Population 1: First Nations ethnicity was associated with an increased mortality risk of 30-53% for each fracture type. Lower income was associated with an increased mortality risk of 18-26%. Population 2: lower income predicted mortality overall (odds ratio (OR) 1.15, 95% confidence interval (CI) 1.07-1.23) and for hip fracture cases (OR 1.18, 95%CI 1.05-1.32), as did older age, male sex, diabetes, and >5 comorbidities (all p≤0.01). Higher mortality was associated with pertrochanteric fracture (OR 1.14, 95% CI 1.03-1.27), or surgery delay of 2-3 days (OR 1.34, 95% CI 1.18-1.52) or ≥4 days (OR 2.35, 95% CI 2.07-2.67). CONCLUSION: A larger absolute increase in mortality post-fracture was observed for First Nations compared to non-First Nations peoples. Lower income and surgery delay>2 days predicted mortality post-fracture. These data have implications regarding prioritization of healthcare to ensure targeted, timely care for First Nations peoples and/or individuals with lower income.

Orthopaedic injuries associated with hip fractures in those aged over 60 years: a study of patterns of injury and outcomes for 1971 patients.

INTRODUCTION: There has been little research into the consequence of suffering a hip fracture and associated orthopaedic injures. The aim of this research paper is to describe the patient characteristics, patterns of injury and to define the effect on outcomes of orthopaedic injuries occurring simultaneously with hip fractures. PATIENTS AND METHODS: Hip fracture data was collected prospectively. Patients under 60 years of age were excluded from the study. Between 2004 and 2010 we treated 1971 consecutive patients aged 60 years or older with a hip fracture. RESULTS: 81 (4.1%) patients sustained a simultaneous fracture or dislocation. 90% (73/81) of these injuries were in the upper limb and 88% (71/81) were ipsilateral, with the wrist (34 cases) and the proximal humerus (21 cases) being the commonest site of injury. Median hospital stay was significantly longer for those with additional injures. Pubic rami fractures were not seen in association with a hip fracture. Those patients who sustained a concomitant wrist fracture tended to be slightly fitter than those without associated injuries whist those with an associated humeral fracture were slightly frailer. Mortality was increased for those with an associated proximal humeral fracture but was lower with an associated wrist fracture. DISCUSSION AND CONCLUSION: Simultaneous injuries occurring with hip fractures are mainly seen in the ipsilateral upper limb. They present a greater challenge to the multidisciplinary team than a solitary hip fracture, experiencing a longer hospital stay and inevitably a higher financial cost. Those patients with wrist fractures have the best prognosis in terms of mortality, whereas a proximal humerus fracture may indicate a higher risk of mortality.

Characteristics of young suicides by violent methods in rural China.

Suicide is one of the most common public health problems in the world. Information on 392 completed suicides aged 15-34 years were consecutively collected from 16 counties in three provinces of China. Information on each suicide was obtained from two informants. The results showed ingesting pesticides or other poisons (73.5%) and hanging (10.5%) were the two most common methods of suicide. Suicides happened more in autumn (30.10%) or summer (27.29%), nighttime (68.3%), and at home (73.6%). However, suicides with violent methods were more common in winter and spring and outside of home. Season (autumn or summer), place (at home), and pesticide stored in home were negatively while depression was positively associated with violent methods of suicide. Characteristics of the suicides by violent methods are different from those by nonviolent methods. Investigations into the methods of rural young suicides are necessary for suicide prevention in China.

Mortality rates after incident non-traumatic fractures in older men and women.

UNLABELLED: Non-traumatic fractures at typical osteoporotic sites are associated with increased mortality across all age groups, particularly in men. Furthermore, in certain age subgroups of women and men, this rate remained elevated beyond 5 years for fractures of the hip, vertebrae, humerus, and other sites. INTRODUCTION: Increased mortality rates have been documented following non-traumatic hip, vertebral, and shoulder fractures. However, data are lacking as to the duration of excess mortality and whether there is increased mortality following fractures at other sites. We determined mortality up to 15 years following incident fractures at typical osteoporotic sites. METHODS: Using healthcare databases for the Province of Manitoba, Canada, we identified individuals 50 years and older with an incident non-traumatic fracture between 1986 and 2007. Each fracture case was matched to three fracture-free controls. Generalized linear models were used to test for trends in mortality and to estimate the relative risk for cases after adjusting for co-morbidity and living arrangements. RESULTS: During the study period, we identified 21,067 incident fractures in men followed by 10,724 (50.1%) deaths and 49,197 incident fractures in women followed by 22,018 deaths (44.8%). Seventy-six percent of the fractures were at sites other than the hip and vertebrae. After adjustment for age, number of co-morbidities, and level of dependence in living arrangements, the risk of death in cases, relative to controls, was increased in both sexes for hip, vertebral, humerus, wrist (in men only), and other fracture sites. Post-fracture mortality was higher in men than women. Relative mortality was the highest in the younger age groups across the spectrum of fracture sites. CONCLUSIONS: Fractures at typical osteoporotic sites are associated with increased mortality across all age groups, particularly in men. Better understanding of factors associated with increased post-fracture mortality should inform the development of management strategies.

[Do injuries of the upper extremity in geriatric patients end up in helplessness? A prospective study for the outcome of distal radius and proximal humerus fractures in individuals over 65]. / Frakturen der oberen Extremität beim geriatrischen Patienten - Harmlose Monoverletzung oder Ende der Selbstständigkeit? Eine prospektive Studie zum Outcome nach distaler Radius- und proximaler Humerusfraktur bei über 65-jährigen.

In a prospective study 104 patients >or=65 years with distal radius fractures (DRF; n=52) and proximal forearm fractures (PHF; n=52) were followed up for a period of 4 months after injury. As an inception- cohort study, influence on treatment pattern was not part of the examination. A total of 53% of the DRF and 74% of the PHF patients underwent surgery. There were no significant changes in the ability of daily living management (IADL) with either fracture form. Functional outcome was better in PHF than DRF patients. PHF patients showed a high incidence in "fear of falling" throughout the whole study, whereas fear of falling rose significantly in DRF patients. 4% of DRF and 9.6% of PHF patients died during the observation period, while 6% of DRF and even 17% of PHF patients had to give up their own housekeeping. One third of both patient groups did not receive physiotherapy. In only 12% of DRF and 6% of PHF patients was osteoporosis treated. In both groups of patients there was a significant worsening in the ability of walking after injury, leading to two or more new falls in 24% of DRF and 28% of PHF patients.

Risk of wrist fracture in women is heritable and is influenced by genes that are largely independent of those influencing BMD.

UNLABELLED: Using a classical twin design study, we estimated the genetic contribution to liability of wrist fracture in women to be statistically and clinically significant. BMD is highly heritable, but statistical models showed very little overlap of shared genes between the two traits. INTRODUCTION: Studies have observed contradictory evidence for genetic effects influencing the outcome of osteoporotic fracture, in part because of the methodological problems involved in analyzing age-related "censored" outcomes. Although a shared genetic etiology is often assumed between fracture and low BMD, this has not been shown to be the case. MATERIALS AND METHODS: In a study of 6570 white healthy female volunteer twins between 18 and 80 years of age, we identified and validated 220 nontraumatic wrist fracture cases. From this we estimated the population prevalence, case-wise twin concordance, heritability in liability to wrist fracture (WF), and the genetic contribution to WFs controlling for age by analyzing the survival outcome using generalized linear mixed models implemented in Winbugs software. We included forearm BMD as a co-variate in some of the models to test whether there is a shared genetic etiology between WFs and BMD. RESULTS: The prevalence of WFs in women was estimated to be 3.3% with a case-wise concordance in monozygotic twins of 0.28 and 0.11 in dizygotic twins. The additive polygenic heritability in liability was approximately 54%, and a significant genetic etiology was confirmed by analyzing WFs as a survival outcome. The magnitude of the genetic influence on risk of WFs reduced very little when BMD was included as a co-variate in the survival analysis model. CONCLUSIONS: There is an important genetic contribution to the risk of WFs, but for the most part, these genes are unlikely to play a direct etiological role in the development of low BMD. If these results are confirmed for other sites, fracture and low BMD will have their own specific genetic risk factors that are unlikely to be shared between the two traits. This has important clinical and research implications.