Homicidio por combinación de métodos de asfixia / Homicide by combination of methods of asphyxiation

Introducción el homicidio por combinación de métodos de asfixia se observa mayoritariamente en las personas de edad avanzada o con algún impedimento físico capaz de contrarrestar la agresión. Material y métodos se realizó un estudio observacional retrospectivo sobre 634 autopsias, cinco cumplían las características de homicidios por combinación de métodos de asfixia. Resultados dos hombres y 3 mujeres, con edad promedio de 69 años, con estudios toxicológicos negativos, víctimas de un solo agresor, presentaron lesiones cutáneas periorificiales (bucales y nasales), hemorragias musculares en el tórax, fracturas costales, lesiones contusas en la cabeza, interpretadas como de sometimiento. Discusión en la combinación de métodos de asfixia, los hallazgos que deben ser vistos en conjunto son: traumatismos craneoencefálicos para someter a la víctima, lesiones cutáneas en el cuello, la cara, la cara interna de los labios, fracturas costales y lesiones por contrapresión en la espalda, los glúteos o los codos. Contextualizados en conjunto pueden explicar la dinámica de esta modalidad homicida. (AU)

Introduction Homicide by combination of suffocation methods is observed mainly in elderly people or with some physical impediment capable of counteracting the aggression. Material and methods A retrospective observational study was carried out on 634 autopsies. Five met the characteristics of homicides by combination of asphyxiation methods. Results Two men and three women, average age 69 years, with negative toxicological studies, victims of a single aggressor, presented peri orificial skin lesions (mouth and nose), muscle hemorrhages in the thorax, rib fractures, blunt injuries to the head interpreted as like submission. Discussion In the combination of asphyxia methods the findings that must be seen together: Head injuries to subdue the victim, skin lesions on the neck, face, inner face of the lips, rib fractures, and counter-pressure injuries to the back, buttocks, or elbows. Contextualized together, can explain the dynamics of this homicidal modality. (AU)

Caracterización epidemiológica y hallazgos en homicidios por sofocación con bolsas de plástico en la ciudad de Medellín, Colombia 2008-2021 / Epidemiological characterization and findings in homicides due to suffocation with plastic bags in the city of Medellín, Colombia 2008-2021

Introducción el presente estudio describe las características de las víctimas de muertes por sofocación homicida con bolsas de plástico en el período comprendido entre 2008 y 2021, en necropsias practicadas en el Instituto Nacional de Medicina Legal y Ciencias Forenses de la ciudad de Medellín. Materiales y métodos se realizó un estudio descriptivo, retrospectivo, cuya información se obtuvo a partir de los informes de necropsia realizados por médicos forenses de la institución. Resultados de las 38.772 necropsias realizadas, 17.703 fueron homicidios de las cuales 96 (0,54%) fueron debidas a la utilización de bolsas de plástico para producir la muerte. De los 96 casos analizados el 92,7% (89) correspondieron a hombres y el 7,3% (7) a mujeres. La población masculina joven de los 15 a 27 años fue la más afectada; el 74,4% (71) ingresaron como cadáveres no identificados y en el 17,1% (14) fue considerado el diagnóstico de tortura dentro del análisis de la necropsia médico legal. Los hallazgos de sofocación en el examen externo fueron congestión facial 67,1% (55), petequias en las conjuntivas 63,4% (52), petequias en la cara 28,0% (23), lesiones en la mucosa oral interna 61,0% (50) y excoriaciones en las comisuras labiales 25,6% (21) por el uso de elementos extraños en la cavidad oral o la aplicación de maniobras asfícticas. El 58,5% (56) presentaban signos de trauma en otros sitios del cuerpo que no explicaban en sí la causa de la muerte. El 36,4% (35) presentaban bolsas de plástico cubriendo la cabeza y ajustadas al cuello con algún elemento, el 32,3% (31) cinta trasparente adherida a la bolsa plástica que cubría la cabeza y el 31,3% (30) presentaban una película plástica de nombre comercial Vinipel MR. El 76,8% (73) tenían las manos y los pies atados al momento del hallazgo del cuerpo en la escena. Conclusión ... (AU)

Introduction This study describes the characteristics of the victims of deaths by homicidal suffocation with plastic bags in the period between 2008 and 2021, in autopsies performed at the National Institute of Legal Medicine and Forensic Sciences of the city of Medellín. Materials and methods A descriptive, retrospective study was carried out, whose information was obtained from the autopsy reports made by forensic doctors of the institution. Results Of the 38,772 autopsies performed, 17,703 were homicides, of which 96 (0.54%) were due to the use of plastic bags to produce death. Of the 96 cases analyzed, 92.7% (89) corresponded to men and 7.3% (7) to women. The young male population between the ages of 15 and 27 was the most affected; 74.4% (71) entered as unidentified corpses and in 17.1% (14) the diagnosis of torture was considered within the analysis of the legal medical necropsy. The findings of suffocation in the external examination were facial congestion 67.1% (55), petechiae in the conjunctivae 63.4% (52), petechiae on the face 28.0% (23), lesions in the internal oral mucosa 61.0% (50), and abrasions in the labial commissures 25.6% (21) due to the use of foreign elements in the oral cavity or application of asphyctic maneuvers. 58.5% (56) presented signs of trauma in other parts of the body that did not explain the cause of death. 36.4% (35) had plastic bags covering the head and adjusted to the neck with some element, 32.3% (31) transparent tape attached to the plastic bag that covered the head and 31.3% (30) presented a plastic film with the trade name Vinipel MR. 76.8% (73) had their hands and feet tied when the body was found at the scene. Conclusion This is the first step to obtain information on the characterization of individuals and their macroscopic findings related to homicide deaths due to suffocation with plastic bags, to warn about the actions of organized criminal groups and their practices in the transnational ... (AU)

Comportamiento y distribución del suicidio en la ciudad de Medellín durante el periodo 2015-2019 / Behavior and distribution of suicide in the city of Medellín during the period 2015-2019

Objetivo: identificar la distribución y el comportamiento del suicidio en la ciudad de Medellín durante el periodo 2015-2019.Material y métodos: es un estudio documental, de carácter retrospectivo, se acudió a fuentes secundarias de información de los casos de suicidio reportados por el Instituto Nacional de Medicina Legal y Ciencias Forenses entre 2015-2019 para la ciudad de Medellín. Se tomaron como variables sociodemográficas: el sexo, la escolaridad, el estado civil, el ciclo vital de la víctimas de suicidio; así como las razones que pudieron llevar al evento, se consolidaron los datos y se transformaron en frecuencias relativas y porcentajes.Resultados: se reportaron un total de 839 casos de suicidio, de los cuales el 81% eran hombres; se evidenció mayor ocurrencia en las edades comprendidas entre los 29 y 59 años, alcanzando hasta el 48% de los casos totales. Los solteros fueron el estado conyugal con el mayor número de casos, un 60% en los últimos 2 años; la asfixia con un 60% es el método más usado; y la temporalidad solo arrojó resultados estadísticamente significativos con respecto al día de mayor ocurrencia, siendo los domingos y lunes los más frecuentes, con el 17% cada uno.Conclusiones: se pudieron establecer las características sociodemográficas con mayor incidencia de suicidio, demostrando que tener menor nivel educativo aumenta la prevalencia del mismo, la carencia de una red de apoyo explicó la tendencia de los solteros a cometer el acto, el mecanismo causal más usado fue la asfixia (ahorcamiento) seguido de las lesiones por proyectil de un arma de fuego y el envenenamiento. (AU)

Objective: To identify the distribution and behavior of suicide in the city of Medellin during the period 2015-2019.Material and methods: Documentary study, retrospective approach, secondary sources of information on suicide cases reported by the National Institute of Legal Medicine and Forensic Sciences between 2015-2019 for the city of Medellin were used, the data was consolidated and transformed into relative frequencies and percentages.Results: A total of 839 cases of suicide were reported, 81% of which were men, with a higher occurrence in ages between 29 and 59 years, reaching 48% of the total cases. Unmarried people were the marital status with the highest number of cases, 60% in the last two years; asphyxia with 60% is the most used method and temporality only revealed statistically significant results with respect to the day of highest occurrence, being Sunday and Monday the most frequent with 17% respectively.Conclusions: It was possible to establish the sociodemographic characteristics with the highest incidence of suicide, it was shown that having lower educational level increases the prevalence of suicide, the lack of support network explained the tendency of singles to commit the act, the most used causal mechanism was asphyxia followed by injuries by projectile from a firearm and poisoning. (AU)

Relationships between cardiovascular signs and neurological signs in asphyxiated neonates in Ilorin, North Central Nigeria.

BACKGROUND: Perinatal asphyxia is a condition associated with multiple organ dysfunctions inclusive of cardiovascular dysfunction. Neurologic predictors of survival have been studied, but little has been reported regarding cardiovascular signs and their role in determining outcome in asphyxia. OBJECTIVE: The study aimed to determine the relationship between cardiovascular signs and outcomes in asphyxiated newborns with hypoxic ischaemic encephalopathy. METHODS: This was a cross sectional study involving asphyxiated new-born babies recruited within the first 24 hours of life. Hypoxic ischaemic encephalopathy staging was done using Sarnat and Sarnat staging. All patients had a detailed cardiovascular examination on admission, after initial resuscitation (30 - 60 minutes) into admission, and were followed till final outcome: discharge or death. RESULTS: Eighty-five asphyxiated new-borns with HIE were studied over seven months. Abnormal cardiovascular-related signs identified in the patients included respiratory distress (64.7%), small volume pulse (57.6%), hypotension (52.9%), hypoxemia (48.2%) and shock (32.9%). Five babies died. None of the clinical signs had a significant relationship with mortality. CONCLUSION: Abnormal cardiovascular signs increased with the progression of HIE staging but had no relationship with mortality.

Changes over time in means of suicide in Canada: an analysis of mortality data from 1981 to 2018.

BACKGROUND: Ongoing surveillance of the means of suicide is necessary for effective prevention. We examined how mortality rates owing to different means of suicide changed in Canada from 1981 to 2018. METHODS: We obtained data from 1981 to 2018 on suicide deaths of individuals aged 10 years and older, from the Canadian Vital Statistics Death Database. We used joinpoint regression analysis to examine changes over time in the suicide mortality rate for the 3 most common means of suicide. RESULTS: The age-standardized suicide mortality rate declined in earlier decades for both sexes, but did not significantly change in recent decades for either sex. The age-standardized rate of suicide by suffocation increased from 1993 for females (2.1% per year) and from 1996 for males (0.4% per year). The age-standardized rate of suicide by poisoning decreased for females (2.2% per year) and males (2.1% per year) from 1981 to 2018. The age-standardized rate of suicide by firearm decreased from 1981 to 2008 (7.4% per year) but did not significantly change there-after for females; for males, it decreased 2.1% per year from 1981 to 1993 and 5.7% per year from 1993 to 2007, but did not significantly change thereafter. INTERPRETATION: For both sexes, the rate of suicide by poisoning is decreasing, the rate of suicide by suffocation is increasing, and the rate of suicide by firearm has not significantly changed in the last decade. Given the high proportion of suicide deaths by suffocation, its increasing rate and the difficulty of restricting the means of suffocation, other approaches to suicide prevention are needed.

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.

Pattern of Suicide Methods and Postmortem Toxicological Findings in Suicide-Related Deaths: A Retrospective 7-Year Forensic-Based Study in Iran.

ABSTRACT: Suicide is a public health threat that leads to morbidity and mortality worldwide. In this study, we evaluated postmortem toxicological finding among forensic autopsies on suicidal deaths from 2010 to 2016 at the Legal Medicine Center of Zanjan Province (northwest of Iran). All suicide fatal cases were investigated to define the cause and manner of death. Toxicological analyses were performed using thin-layer chromatography, high-performance liquid chromatography, gas chromatography/mass spectrometry, headspace gas chromatography, and gas chromatography equipped with nitrogen phosphorus detector. Demographic data (age, sex, educational level, residential location, and marital status), cause of death, and postmortem toxicological findings were extracted from forensic reports and were entered into the designed questioners. During this period, a total of 181 cases of suicide deaths were investigated. Among them, 74% were male. The most often used suicide method was hanging, followed by self-poisoning in young people. Aluminum phosphide was the most frequent poison detected in the fatal suicidal cases (33 cases), followed by opioids. Hanging and self-poisoning were the frequent suicidal method in young male population. It seems that psychological and social supports in young people along with restriction to easy access to drugs and poisons should be considered by policy making and healthcare authorities.

Suicide by helium inhalation in the Netherlands between 2012 and 2019.

INTRODUCTION: In 2012 and 2013 a movie and a book about a 'dignified end of life' were published in the Netherlands. These items described suicide using an 'exit bag' to establish asphyxiation using helium (the helium method). 'Right-to-die-organisations' inform the elderly about this method. The purpose of this study is to investigate whether the use of suicidal asphyxiation by means of the helium method substituted other, related, methods following its publication in the Netherlands. MATERIAL AND METHODS: We analysed suicides in the Netherlands over the period from 1 July 2012 to 30 June 2019. We compared the number of deaths caused by the helium method with other, related, cases. Secondly, we related these deaths to the total number of inhabitants and suicides recorded by Statistics Netherlands. RESULTS: The study showed a stable trend in the use of the helium method in the period 2012-2019 and this was the same for the other, related methods. Individuals using the helium method were significantly younger than those using other, related, methods. At the scene of death, information about suicide and suicide notes were found more often at 'helium method' cases than with the 'other, related, methods' cases. Family was significantly more often present during a helium method suicide than during suicide by other, related, methods. DISCUSSION: The number of suicides by the helium method and other, related, cases is stable in the Netherlands over the past years. Therefore, we conclude that there is no substitution effect within this category of suicides. Whilst 'right-to-die-organisations' strive to inform the old and sick of the helium method, it is noteworthy that the individuals using the helium method are significantly younger than the individuals who choose other, related, methods.

Urban-rural Differences in Suicide Rates, by Sex and Three Leading Methods: United States, 2000-2018.

Suicide has remained the 10th leading cause of death in the United States since 2008, with deaths due to firearms, suffocation (including hangings), and poisoning representing the leading methods of suicide (1,2). There are known differences in suicide rates by sex and geographic distribution (3). This report uses final mortality data from the National Vital Statistics System to present trends in suicide mortality from 2000 through 2018 among all ages by urban-rural classification of the decedent's county of residence and sex for the leading methods of suicide-firearms, suffocation, and poisoning.

[Death due to physical restraint in healthcare institutions]. / Overlijden door fysieke fixatie in zorginstellingen.

Physical restraint is frequently used in healthcare institutions, usually in situations where the safety of the person (e.g. fall risk) or that of others (e.g. aggressive behaviour) is compromised, or where essential medical treatment is at stake. The implementation has a major impact with possible psychological consequences, physical injury and even fatal outcomes. In this retrospective study, fifteen deaths due to physical restraint are described. These have been investigated by the Forensic Medicine departments of UZ Leuven (1998 - 2018) and UZ Antwerpen (1999 - 2018). Death was caused by mechanical suffocation in all instances, mainly as a result of inadequate use of bedrails or belt restraint. These avoidable deaths are an urgent plea for a cautious and careful policy on physical restraint. Institutional guidelines and (further) training of health care personnel are of utmost importance. Central aspects are multidisciplinarity (deliberate decision-making), treatment (provoking factors), reticence (search for alternatives), proportionality (least intrusive method), due care (technical implementation), safety (increased supervision), temporality (re-evaluation of moment and duration), registration (accountability and liability) and communication (with all involved).

Risk factors for female and male homicidal strangulation in Johannesburg, South Africa.

BACKGROUND: There is a paucity of research on homicidal strangulation by gender. OBJECTIVES: A sex-disaggregated and comparative research approach was used to investigate individual-level risk factors for female and male homicidal strangulation in Johannesburg, South Africa (2001 - 2010). METHODS: Data were drawn from the National Injury Mortality Surveillance System. Logistic regressions were used to examine associations between each of the independent variables and homicidal strangulation in females and males relative to all other female and male homicides, respectively. RESULTS: The risk of fatal strangulation was high for both females and males aged ≥60 years, but markedly high only for male children and adolescents. Temporal risk for females was undifferentiated for day of the week, and the risk for males was high during weekdays. Females were more likely to be strangled in public places, and males in private locations. CONCLUSIONS: The study underlines the importance of disaggregating homicide by external cause and gender.

The role of restraint in fatal excited delirium: a research synthesis and pooled analysis.

The purpose of the present study was to perform a comprehensive scientific literature review and pooled data risk factor analysis of excited delirium syndrome (ExDS) and agitated delirium (AgDS). All cases of ExDS or AgDS described individually in the literature published before April 23, 2020 were used to create a database of cases, including demographics, use of force, drug intoxication, mental illness, and survival outcome. Odds ratios were used to quantify the association between death and diagnosis (ExDS vs. AgDS) across the covariates. There were 61 articles describing 168 cases of ExDS or AgDS, of which 104 (62%) were fatal. ExDS was diagnosed in 120 (71%) cases, and AgDS in 48 (29%). Fatalities were more likely to be diagnosed as ExDS (OR: 9.9, p < 0.0001). Aggressive restraint (i.e. manhandling, handcuffs, and hobble ties) was more common in ExDS (ORs: 4.7, 14, 29.2, respectively, p < 0.0001) and fatal cases (ORs: 7.4, 10.7, 50, respectively, p < 0.0001). Sedation was more common in AgDS and survived cases (OR:11, 25, respectively, p < 0.0001). The results of the study indicate that a diagnosis of ExDS is far more likely to be associated with both aggressive restraint and death, in comparison with AgDS. There is no evidence to support ExDS as a cause of death in the absence of restraint. These findings are at odds with previously published theories indicating that ExDS-related death is due to an occult pathophysiologic process. When death has occurred in an aggressively restrained individual who fits the profile of either ExDS or AgDS, restraint-related asphyxia must be considered a likely cause of the death.

Asphyxia Homicides in Finland, 1983-2012.

Finland has one of the highest homicide rates in Western Europe, and almost every tenth homicide is caused by asphyxiation. Reliable statistics, a strict legislation, and an exceptionally high medico-legal autopsy rate formed a base for a nationwide analysis of asphyxia homicides (n = 383) during 30 years. The cases were identified through multiple records, and all the forensic pathology case files were studied in detail. In more than one out of five cases, there were indications of staging, and the homicide was revealed first at autopsy in close to one in ten cases. The vast majority of the homicides took place in private locations and involved persons known to each other. Every third victim was an intimate partner, and every tenth a child. Almost half of the victims died from manual strangulation, one in three from ligature strangulation. Smothering, choking, neck compression with a firm object, and thoracic compression were more rare methods. Drownings were excluded from this study material. Of all the victims, 7% had no observable external injuries. Petechiae were recorded in approximately in 61%, laryngohyoid fractures in 47%, and vocal cord hemorrhages in 16% of the cases. Every tenth female victim had genital injuries. Toxicological analyses were performed in close to all of the cases, and almost three out of four victims tested positive for blood alcohol. The various aspects of the demographics and autopsy findings covered in this study contribute reliable and accurate data to further strengthen the spectrum of observable medico-legal characteristics of asphyxia homicides.

Recurrent sudden unexpected death in infancy: a case series of sibling deaths.

OBJECTIVES: To determine the rate of sudden unexpected death in infancy (SUDI) for infants born after a previous SUDI in the same family, and to establish the causes of death and the frequency of child protection concerns in families with recurrent SUDI. DESIGN: Observational study using clinical case records. SETTING: The UK's Care of Next Infant (CONI) programme, which provides additional care to families who have experienced SUDI with their subsequent children. PATIENTS: Infants registered on CONI between January 2000 and December 2015. MAIN OUTCOME MEASURES: Cause of death, presence of modifiable risk factors for SUDI and child protection concerns. RESULTS: There were 6608 live-born infants registered in CONI with 29 deaths. 26 families had 2 deaths, and 3 families had 3 deaths. The SUDI rate for infants born after one SUDI is 3.93 (95% CI 2.7 to 5.8) per 1000 live births. Cause of death was unexplained for 19 first and 15 CONI deaths. Accidental asphyxia accounted for 2 first and 6 CONI deaths; medical causes for 3 first and 4 CONI deaths; and homicide for 2 first and 4 CONI deaths. 10 families had child protection concerns. CONCLUSIONS: The SUDI rate for siblings is 10 times higher than the current UK SUDI rate. Homicide presenting as recurrent SUDI is very rare. Many parents continued to smoke and exposed infants to hazardous co-sleeping situations, with these directly leading to or contributing to the death of six siblings. SUDI parents need support to improve parenting skills and reduce risk to subsequent infants.

Autoerotic Deaths in Hamburg, Germany: Autoerotic accident or death from internal cause in an autoerotic setting? A retrospective study from 2004-2018.

INTRODUCTION: Autoerotic deaths are rare events. The death scene is often bizarre and the death unexpected, thus often requiring forensic autopsies. Our analysis will provide an overview of the expected range of causes and manners of death in cases of autoerotic deaths. METHODS: A retrospective analysis was carried out on all scientific and forensic autopsies and postmortem examinations performed at the Department of Legal Medicine in Hamburg, Germany, over the period of 2004-2018. RESULTS: 25 cases of autoerotic fatalities were identified over this 15-year-period or one to two cases per year, respectively. Autopsies were carried out on 23 of these cases. 16 (64%) of the cases involved autoerotic accidents and 7 (28%) from internal causes of death during an autoerotic act. Two cases had not undergone an autopsy. On average, those who were involved in autoerotic accidents had been younger in age (average age: 37 years) than the individuals who died from internal disease (average age: 61 years). Only one woman was involved. The most common cause of death in autoerotic accidents was strangulation (hanging: 8 cases, ligature strangulation: 1 case), followed by smothering of the respiratory tract (4 cases). Fatal intoxication was diagnosed in three of the cases. Fatalities with natural cause of death solely involved cardiovascular causes of death. CONCLUSIONS: Autoerotic deaths involved a wide range of natural and non-natural causes of death. The reconstruction of such unusual cases and detection of non-natural fatalities requires thorough investigation of the scene of death as well as a postmortem external and internal examination including a chemical toxicological and blood alcohol analysis.

Doble mecanismo de estrangulación. A propósito de un caso / Double mechanism of strangulation. Apropos of a case

RESUMEN Las asfixias mecánicas son aquellas que resultan del impedimento mecánico a la penetración del aire en las vías respiratorias, suelen clasificarse atendiendo a la naturaleza del medio mecánico que las origina y a su modo de actuar. La estrangulación puede definirse como la constricción del cuello mediante la aplicación de una fuerza activa, ajena al peso del cuerpo, que actúa por intermedio de un lazo, las manos, el antebrazo o cualquier otra estructura rígida. En la estrangulación antebraquial, la constricción del cuello se lleva a cabo normalmente rodeando al individuo con el brazo y el antebrazo. Cuando el mecanismo de la compresión del cuello es lateral, no se afectan las vías aéreas, la compresión de las arterias carótidas hace que se produzca una isquemia cerebral y pérdida de conocimiento en 10-15 segundos. El mecanismo de muerte en estos casos será la anoxia cefálica. Si la compresión del cuello es anterior, actúa ocluyendo las vías aéreas, la presión sobre los cartílagos tiroides y cricoides puede producir fracturas y el mecanismo de muerte será la obstrucción respiratoria. El presente trabajo constituyó un caso poco común de estrangulación, donde se utilizó un mecanismo combinado que llevó al occiso al deceso final. Para la realización de la discusión del caso se tuvo en cuenta los elementos del lugar del hecho, el examen del exterior y el interior del cadáver (AU).

ABSTRACT Mechanical asphyxias are those resulting from the mechanical obstruction of the air penetration in the airways. They are usually classified according to the nature of the mechanical mean producing it and the way it performs. Strangulation may be defined as neck constriction through the application of an active force not proper to the body weight, acting by means of a knot, hands, forearm or any stiff structure. In ante brachial strangulation, neck constriction is normally performed surrounding the individual with the arm and forearm. When the neck constriction mechanism is lateral, the airways are not affected: carotid arteries constriction produces a brain stroke and loss of consciousness in 10-15 s. The death mechanism in these cases will be cephalic anoxia. If the neck compression is anterior, it occludes the airways; the pressure on thyroidal and cricoid cartilages may produce fractures and death mechanism will be respiratory obstruction. The current work deals with an uncommon strangulation case, where a combined mechanism led the person to the final decease. For the case discussion the authors took into account the elements of the place, and the examination of the exterior and the inside of the corpse (AU).

Accidental deaths in young people with epilepsy and psychiatric comorbidity-A Danish nationwide cohort study.

OBJECTIVE: The objective of this study was to investigate the accident-related mortality among people younger than 55 years of age with epilepsy compared with the general population and to study how psychiatric comorbidity influences this risk. METHODS: This is a population-based cohort study of individuals born in Denmark between 1960 and 2015 (n = 3, 665 616). Persons diagnosed with epilepsy and psychiatric disorders were identified in the Danish National Patient Register and the Danish Central Psychiatric Central Register. We estimated the hazard ratio (HR) with 95% confidence intervals (CIs) of accidental death in people with epilepsy compared with persons without epilepsy. RESULTS: We identified 61 330 persons (1.7%) diagnosed with epilepsy. Median age at end of follow-up was 27.8 years. In people with epilepsy, 5253 died during follow-up, 480 (9%) of whom died from accidents. Among people without epilepsy, 52 588 died during follow-up, of whom 1280 (2.4%) died from accidents. People with epilepsy had a 3.7-fold (95% CI 3.4-4.1) increased risk of accidental death compared with persons without epilepsy. When we adjusted for psychiatric disorders, the risk remained significantly elevated in people with epilepsy compared to people without epilepsy (adjusted HR [aHR] 2.44, 95% CI 2.22-2.69). When stratifying the analyses on epilepsy and psychiatric disorders, people with epilepsy and psychiatric disorders had an aHR of 4.95 (95% CI 3.82-6.41) when compared with persons without epilepsy and psychiatric disorders. SIGNIFICANCE: The risk of accidental death was increased in people with epilepsy and was particularly high among people with epilepsy with psychiatric comorbidity. The findings highlight the need for awareness and prevention strategies in people with epilepsy, especially in people with comorbid psychiatric disorders.

Review of the pattern of traumatic limb lesions sustained in cases of hanging.

This retrospective study sought to identify a regular pattern of limb bruising which occurs in association with suicidal or accidental hanging. Following exclusion of cases suspicious for homicide, 82 consecutive cases of hanging from a 10-year period were retrospectively reviewed to identify the pattern of traumatic limb injury in each case. Relevant information such as location, toxicology, and type of suspension was also noted. 72% of the reviewed cases had traumatic limb lesions, the majority of which occurred on the posterior upper limb and the anterior lower limb. Although the distribution of limb injury in our study mirrored that found in the literature, the incidence is much higher than in previous studies (7.4-20%). This could either be due to differences in confounding factors such as intoxication and location of hanging or differences in the practice of recording of limb trauma in hanging between centres. Neither type of suspension nor location of hanging were significantly associated with an increased incidence of traumatic limb injury. Positive toxicology was found to increase the likelihood of sustaining limb injury (p = .044084). In conclusion, the presence of this well documented pattern of traumatic limb lesions in cases of hanging should not always raise suspicion of foul play.

An 8-Year Retrospective Study on Suicides in Washington, DC.

The suicide rate in the United States has been increasing steadily over the previous 10 years. In DC, these results are not mirrored. The suicide rate has a tendency to be lower than the rest of the country. During this retrospective review of suicides in DC, factors such as medical history and toxicology results were examined.In this study performed over 8 years (2009-2016), 394 suicides occurred. It was found that decedents committed suicide mostly by hanging (31.2%), firearms (20.3%), or drug intoxication (15.7%). The average age was 44.5 years. Similar to national statistics, male individuals committed suicide at a higher rate (77.9%) than did female individuals (22.1%). The toxicology data showed that ethanol (26.4%), antidepressants (20.1%), opioids (14.9%), and benzodiazepines (12.9%) were the drugs most frequently involved, although the finding of no drugs was most common (33.7%). Ethanol was present in 5 methods of suicide that include death by hanging, drowning, firearm, suffocation, and poisoning.This research provides information that may be useful for public health officials when confronting the issue of suicide. It is hoped that it will encourage other medical examiner offices to perform toxicological analysis and autopsy of all suicide cases.

Trends and patterns in homicides in Italy: A 34-year descriptive study.

AIMS: We aimed at analyzing homicide trends and patterns in Italy over the period 1980-2014. METHODS: We collected data from the Italian Mortality Database (Italian National Institute of Statistics), for the study period. Temporal trends were analyzed using joinpoint regression analysis, with estimated annual percentage change computed for each detected trend. The possible effect of the mafia subculture was examined using an indicator of mafia social penetration. Differences between age classes, genders, geographical regions, and homicide methods were also analyzed. RESULTS: The analyses showed an overall reduction in homicides during the study period, including a reduction in homicides by firearm. Further, we found significant differences between homicides involving male and female victims. A peak in male homicides, observed in the early 1990s, was significantly associated with mafia penetration. CONCLUSIONS: The overall reduction in homicides can be interpreted as an expression of a "civilizing process."