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Cases of asphyxial death are frequently come across and the numbers are remarkable now-a-days. The study was aimed to estimate the frequency and to determine the socio-demographic pattern of the victims of asphyxial death. It was a cross-sectional variety of descriptive study and carried out in the Department of Forensic Medicine, Dhaka Medical College, Bangladesh from 1st January 2018 to 31st December 2019. A predesigned proforma was made first, and then various data were assembled, tabulated and analyzed there. In the midst of 2199 medicolegal autopsies, there were 224 cases of asphyxial death. Male victims (62.05%) were mostly found and the most affected age group was 30-39 years (35.26%). Victims were predominantly married (53.57%) and were mainly from urban areas (38.39%). The Muslims (76.78%) were the major victims followed by the Hindus (17.41%), Christians (2.67%) and the Buddhists (1.78%). Maximum victims were unemployed (31.69%) followed by students, day laborers & cultivators. Hangings (54.01%) were mostly encountered followed by drowning (23.21%) and throttling (7.14%). Majority of the cases were suicidal (58.48%) followed by homicidal (24.55%) and accidental (16.96%). The main provoking factors in suicidal cases were unemployment (22.13%) followed by failure in examination (20.61%) and domestic violence (12.97%). Hangings were proven to be suicidal. In cases of drowning manner of death could not be given and throttling were homicidal by autopsy.

Background: Hanging is one of the most common causes of death among young adults in Norway. Our aim was to study the hospital course and cerebral function on discharge in patients admitted to our Medical Intensive Care Unit after hanging without skeletal injury., Material and Method: Retrospective study based on the medical records of patients admitted to the Medical Intensive Care Unit at Oslo University Hospital (OUS), Ullevål after hanging, from January 2010 to December 2021. Cerebral function on discharge was classified according to Cerebral Performance Category (CPC) from grade 1 (normal cerebral function) to 5 (brain death)., Results: 135 patients were admitted to OUS after hanging during the period; 60 of these were admitted to the Medical Intensive Care Unit and were included in this study. There were 35 men and 25 women. Mental illness was documented in the medical records of 43 patients, somatic illness in 24, previous substance abuse in 19, and previous suicide attempts in 19. Upon admission, 34 patients had suffered cardiac arrest, and 39 had a Glasgow Coma Scale (GCS) score of 3. The most common complication was pneumonia (n=42). Twenty-seven patients (45%) died, all with a GCS score of 3 on admission, of which 25 had pre-hospital cardiac arrest. Ten became organ donors. Among the 33 survivors, 28 had a CPC score of 1 and five had a CPC score of 2 on discharge. The median lactate concentration at admission was 8.1 mmol/L among those who died versus 3.8 mmol/L among survivors., Interpretation: Hanging has a high mortality rate. Cardiac arrest, a GCS score of 3, and lactic acidosis were more common among those who died than among the survivors. The organ donation rate was high, and most survivors had a good cerebral function, assessed by CPC score.

Abstract: Suicide is one of the worldwide leading causes of unnatural death. Pretoria is a capital city of South Africa and is the fourth most populated city in South Africa. Between 16 and 22 suicide cases are recorded daily in South Africa.Case files from the Pretoria Medico-Legal Laboratory were reviewed between 1 January 2015 to 31 December 2021, which spanned the COVID-19 pandemic. All cases of possible and probable suicides were included. One-way analysis of variance and Pearson chi 2 tests were conducted to determine statistical significance in the observed trends.A total of 1820 possible and probable suicide cases were identified. The year following the outbreak of the COVID-19 pandemic accounted for the largest number of suicides. White males were the most heavily represented population, followed by Black males. Hanging was the most common method for males, whereas poisoning via ingestion and/or overdose was more commonly used by females.Suicides in Pretoria have increased since previous studies from 9.74% and 10.2% to 13.32%. Methods used have changed among various population groups over the past two decades. This paper examined changes in suicide trends in Pretoria compared to previous studies and highlighted correlations between suicide trends and COVID-19 lockdown measures., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

The objective of this study was to investigate the degradation pattern of cardiac troponin I in rats in vivo, and to determine whether the pattern was dependent on the cause of death, for the purpose of estimating the postmortem interval. The rats were categorized into three distinct groups depending on the factors leading to their demise: the control group, the group experiencing acebutolol-induced cardiotoxicity, and the group affected by asphyxia. The analysis encompassed the isolation and segregation of the protein, subsequently employing Western blotting as a means of visualizing the results. The results revealed a distinct degradation pattern of cTnI into smaller fragments over time, indicating that cardiac troponin I can serve as a reliable marker for estimating the postmortem interval. Furthermore, noteworthy variations were noted in the degradation pattern of cardiac troponin I among the different causes of death, which suggests that this method can also be used to determine whether cardiac failure was the cause of death or not., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Suicides are the second most common cause of non-natural death in Germany after accidents. Most common is death by hanging, followed by the use of firearms. More frequent "simple" suicides in which one suicide method is used are distinguished from rare "complex" suicides, in which several methods are applied, whereby the combination of gunshot and strangulation is frequently chosen. Such cases require a thorough criminalistic and forensic medical examination to check the plausibility of assumed sequences of events and to detect covered-up homicides., Material and Methods: A retrospective analysis of 5,400 post-mortem examinations at the Institute of Legal Medicine Giessen (2009-2018) revealed three cases in which gunshot and hanging were used to commit a planned complex suicide., Results: Case 1: The body of a 66-year-old carcinoma patient was found hanging from a tree in a kneeling position with a bullet through the head. The post-mortem examination revealed a penetrating head shot, uninjured soft tissues of the neck, no injuries to the hyoid bone or larynx and no signs of congestion. After autopsy, the gunshot through the head was considered as cause of death. Case 2: An 82-year-old man was found dead with two bullet wounds in the chest, hanging in free suspension in a factory hall. The necropsy showed two chest entry wounds with injuries to the heart and lungs as well as a vital ligature mark and fractures of the hyoid bone and larynx without signs of congestion. The combination of hanging and the gunshot wounds was concluded as cause of death. Case 3: The body of an 81-year-old pain patient was found in his home next to a small-caliber rifle, with a noose around his neck, attached to a suspension torn from the wall. The autopsy revealed a tangential shot through the skull with superficial injury to the frontal brain and a vital cord mark on the neck with fractures of the hyoid bone and larynx without signs of strangulation. In this case, hanging was identified as cause of death., Conclusion: Complex suicides are rare events, that require a thorough criminalistic and forensic medical examination Although being called complex suicides and one of the methods usually being suitable to cause death, the cause of death is not always a combined one., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Suicide rates in the United States have been increasing. Work-related factors may contribute to risk for suicide. These work-related factors may be reflected in a varied risk for different suicide methods between occupations. This study sought to assess occupational differences in suicide rates according to the method used., Methods: Death certificate data about suicide deaths in Massachusetts between 2010 and 2019 were used to calculate mortality rates and rate ratios with univariable and multivariable models controlling for age, sex, race ethnicity, and educational attainment for suicides overall, and for three specific methods of suicide (hanging/strangulation/suffocation, firearms, and poisoning) by occupation., Results: In multivariate models, the risk for suicide was significantly elevated for workers in arts, design, entertainment, sports, and media (relative risk [RR] = 1.84, 95% confidence interval [CI] = 1.53, 2.22); construction trades (RR = 1.68, 95% CI = 1.53, 1.84); protective services (RR = 1.49, 95% CI = 1.26, 1.77); and healthcare support occupations (RR = 1.55, 95% CI = 1.25, 1.93). Occupational risk for suicide differed across different methods. For hanging/strangulation/suffocation, workers in arts, design, entertainment, sports, and media occupations had the highest RR (2.09, 95% CI = 1.61, 2.71). For firearms, workers in protective service occupations had the highest RR (4.20, 95% CI = 3.30, 5.34). For poisoning, workers in life, physical, and social science occupations had the highest RR (2.32, 95% CI = 1.49, 3.60)., Conclusions: These findings are useful for identifying vulnerable working populations for suicide. Additionally, some of the occupational differences in the risk for suicide and for specific methods of suicide may be due to workplace factors. Further research is needed to understand these workplace factors so that interventions can be designed for prevention., (© 2024 Wiley Periodicals LLC.)

The present study aims to investigate the demographics and characteristics of scuba diving fatalities in the Philippines which can help in the identification of local trends and ultimately in the development of appropriate preventive measures. Data on scuba diving-related fatalities in the Philippines from 2008 to 2022 were manually retrieved from online news media sources. Information on age, sex, nationality, certification, purpose, and causative factors, whenever possible were collected and analysed. A total of 39 fatalities were identified having a median age of 43.5 (range 20-80). Majority of victims were males (n = 30), and of foreign ethnicity (n = 26). Asphyxia was identified as the possible disabling injury in almost half of the cases (n = 17). The causes of death based on autopsies were determined only for few cases which included drowning (n = 2), heart attack (n = 1), and traumatic injuries from a dynamite blast (n = 1). Potential vulnerable groups were identified to be the ageing population and foreign tourist divers. In the absence of an existing database, this preliminary report provides the best available evidence at this time concerning scuba diving fatalities in the Philippines., Competing Interests: Declaration of interest statement The authors declare that they have no competing interests., (Copyright © 2024 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

Extended suicide, a specific type of homicide-suicide event, has severe social consequences yet remains lacking systematic research. This retrospective study investigated 51 cases of extended suicide involving mental disorders in central China with aim of better understanding risk factors for such events and guiding prevention strategies. Over an 8-year period from 2015 to 2022, cases were collected from forensic institutions, and demographic characteristics, case details, and psychiatric data were recorded. The 51 incidents involved 51 perpetrators and 79 victims, with more female perpetrators (58.8%) and more female victims (54.4%). The average age of the perpetrators was 36.1, and most were married (88.2%). Almost all of the victims were family members of the perpetrator, like the most numerous children (64.6%), followed by spouses (24.1%). The most common homicide mode of death was mechanical asphyxia (38.0%), followed by sharp devices (36.7%) and drug poisoning (16.5%). Depressive disorders (76.5%) were the most common diagnosis of mental disorder for perpetrators. The study analyzed the unique characteristics of extended suicide to enrich such data. These findings help strengthen the screening and identification of potential perpetrators and victims to prevent such cases from occurring., Competing Interests: Declaration of competing interest The authors have no conflicts to disclose., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Avalanche fatalities are quite rare in the Czech Republic. Due to the presence of avalanche fields in the two Czech mountains, forensic pathologists at some forensic medicine departments may encounter this specific mechanism of accidental death. The authors summarize medicolegal aspects of deaths in avalanches in the territory of the Czech Republic for the twenty-three-year period between 1993-2015. Ten avalanche fatalities were recorded during study period. The studied group consisted of nine male and one female victims. The average age of the deceased was 27.9 years. Skiers or ski-alpinists died in the avalanche in five cases (50%), climbers in two cases (20%), snowboarders in one case (10%), cross-country skiers in one case (10%) and in one case it was a fatality of child playing on a snowy hill (10%). The cause of death was suffocation in four cases (40%), blunt trauma in four cases (40%), and in the remaining two cases it was the survival of trapped persons several hours after being rescued from the avalanche in the hospital; both victims subsequently died as a result of prolonged shock (20%) due to a combination of prolonged suffocation and hypothermia. The time interval from the fall of the avalanche to the rescue of the trapped person was in the range of minutes to 3 hours. The presence of alcohol or drugs was not detected in any studied case.

Aim: AAnalysis of the choice of suicide method by gender and age of the deceased., Material and Methods: The study presented here was based on a retrospective analysis of autopsy reports from the years 2001-2010 in the Department of Forensic Medicine of the Jagiellonian University Collegium Medicum in Kraków. The basis of the research work conducted was the collection and extensive analysis of cases of suicide deaths. Subsequently, a preference analysis of the choice of suicide method was conducted, taking into account the age and gender of the deceased. The statistical analysis performed used logistic regression in Excel's XLSTAT as an analysis tool., Results: A total of 2,073 suicide cases were collected from the time frame under discussion. The predominant method of suicide was hanging (1524 cases, 1329 men and 195 women), the second most common method was jumping from the roof or window of a high floor of a building (jumping from heights; 171 cases, 100 men, 71 women). A statistically significant correlation of suicide method with gender was found for: hanging [odds ratio (OR) male (M) vs. female (F) = 3. 4; confidence interval (CI) = 2.7-4.3; p0.001]; drowning [OR: M/F =4.1; CI = 2.6-6.4; p0.001]; jumping from heights [OR: M/F=4.1; CI=2.9-5.7; p0.001] and poisoning [OR: M/F=3.2; CI = 2.1-4.9]. Suicide with the use of firearms occurred exclusively in the case of men (40 cases). The age of the victims correlated with the method of committing suicide by jumping from heights [0R=0.98; CI=0.97-0.99; p0.001] and rail suicide [OR=0.98; CI=0.96-0.99; p0.001]., Conclusions: The study revealed that both age and gender have a significant impact on the choice of suicide method. According to available epidemiological data and the authors' predictions, a predominance of male over female sex was observed in the case of hanging, while jumping from heights was relatively more often chosen by women. The elderly were less likely to choose jumping from heights and rail suicide., (Copyright © 2024 by PTMSiK.)

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., (© 2021 Issa A et al.)

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., Competing Interests: Competing interests: None declared., (© 2021 Joule Inc. or its licensors.)

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., Competing Interests: The authors report no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

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., Competing Interests: Declaration of Competing Interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

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., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Autoerotic death is a rare but recurring phenomenon in forensic medicine. This article presents two cases of unusual autoerotic death with signs of autoerotic asphyxia. Although the first case appeared to be asphyxia, the autopsy confirmed natural cause of death during solitary sexual activity of 69-year-old man found with exposed and bandaged genitals. The other case was asphyxiation utilizing a plastic bag and multiple panties wrapped around the head of 18-year-old man disguised in women´s dress.

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.

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., Competing Interests: Competing interests: All authors are members of the CONI national steering group managed by The Lullaby Trust. AW was funded by The Lullaby Trust as the national CONI coordinator from 1988 to 2015 and was employed by them from 2015 to 2018. AMc was funded by the Foundation for the Study of Infant Deaths/The Lullaby Trust between 1988 and 2013. All other authors received expenses only from The Lullaby Trust towards their CONI work but no salary. JJG has received research grants from the National Institute for Health Research (DRF 2010-0345)., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

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., (© 2020 The Authors. Journal of Forensic Sciences published by Wiley Periodicals LLC on behalf of American Academy of Forensic Sciences.)

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., (All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.)

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., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

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.

Purpose: Injury-related asphyxia is one of the most common causes of death in children in Germany. However, only a few systematic studies have analyzed the causes and circumstances of asphyxia in children and adolescents., Methods: All cases of asphyxia in children and adolescents (0-21 years of age) among the Hamburg Legal Medical Department's autopsy cases from 1998 to 2017 were retrospectively analyzed with special focus on how often external findings were completely absent., Results: Among 249 cases of fatal asphyxia, 68% were accidents, 14% were suicides, and 13% were homicides. Most of the cases involved boys. Adolescents and young adults aged 15-21 years represented the main age group. Drowning was the leading mechanism of asphyxia. Younger age was associated with less frequent detection of external signs of asphyxia in the postmortem external examination. Petechial hemorrhages were the most common visible external indication of asphyxia. No external findings indicative of asphyxia were present in 14% of the cases., Conclusion: Asphyxia in children and adolescents often involves accidents. However, postmortem external examination alone is insufficient to identify asphyxia and the manner of death.

Elevators are mechanical transportation devices used to move vertically between different levels of a building. When first developed, elevators lacked the safety features. When safety mechanisms were developed, elevators became a common feature of multistory buildings. Despite their well-regarded safety record, elevators are not without the potential for danger of injury or death. Persons at-risk for elevator-related death include maintenance and construction workers, other employees, and those who are prone to risky behavior. Deaths may be related to asphyxia, blunt force, avulsion injuries, and various forms of environmental trauma. In this review, we report on 48 elevator-related deaths that occurred in nine different medicolegal death investigation jurisdictions within the United States over an approximately 30-year period. The data represents a cross-section of the different types of elevator-related deaths that may be encountered. The review also presents an overview of preventive strategies for the purpose of avoiding future elevator-related fatalities., (© 2019 American Academy of Forensic Sciences.)

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.

This study standardized the methods used in the determination of orofacial injuries in Victorian family violence homicides and informed potential control selection for an analytic study. Dental service contacts with family violence victims may be intervention avenues due to the presence of abusive injuries in the orofacial region. All Victorian family homicides from January 2000-September 2018 were identified by determining the kinship/relationship and grouped by age. A 20% random sample of adult cases, aged 18-64 years was selected. The median number of orofacial injuries in categories of injury mechanisms/age/gender and the nature of abusive orofacial injuries was reported for the sample. Of 357 closed cases of family homicide, 261 were adults aged 18-64 years. Offender information and injury mechanism data was available for all closed cases, enabling case selection. Of a random sample of 50 adults, 8 cases were excluded. After 2006, CT scans and photos were present in 20 (91%) and 19 (86.4%) of 22 cases, respectively. The nature and median number of orofacial injuries showed correlation to the reported injury mechanism. Strengths and limitations of the used methods were assessed. Not all cases were compatible for assessment of orofacial injuries, thus serving as an additional criterion for exclusion in our methodology. Further detailed study of the whole population of adults should be limited to the period 2006-2018 where the data is more complete. The mechanism of injury may influence control selection for analytic studies. We present preliminary evidence of the frequent occurrence of orofacial injuries in family violence homicides.

Objective: To determine if implementation of skin-to-skin care and the Baby-Friendly Hospital Initiative (BFHI) contributes to sudden unexpected infant death (SUID) and asphyxia in the first 6 days after birth., Study Design: Survey data were used to determine a correlation between BFHI and deaths from SUID and asphyxia among infants <7 days in the US and Massachusetts. Using data from the Centers for Disease Control and Prevention, implementation of BFHI was tracked from 2004-2016 and skin-to-skin care was tracked from 2007-2015. Using data from Centers for Disease Control and Prevention WONDER and the Massachusetts Department of Public Health, SUID and asphyxia were tracked from 2004-2016., Results: Nationally, births in Baby-Friendly facilities rose from 1.8% to 18.3% and the percentage of facilities in which most dyads experienced skin-to-skin care rose from 40% to 83%. SUID prevalence among infants <7 days was rare (0.72% of neonatal deaths) and decreased significantly from 2004-2009 compared with 2010-2016, from 0.033 per 1000 live births to 0.028, OR 0.85 (95% CI 0.77, 0.94). In Massachusetts, births in Baby-Friendly facilities rose from 2.8% to 13.9% and skin-to-skin care rose from 50% to 97.8%. SUID prevalence decreased from 2010-2016 compared with 2004-2009: OR 0.32 (95% CI 0.13, 0.82), with 0 asphyxia deaths during the 13-year period., Conclusion: Increasing rates of breastfeeding initiatives and skin-to-skin care are temporally associated with decreasing SUID prevalence in the first 6 days after birth in the US and Massachusetts., (Copyright © 2019 Elsevier Inc. All rights reserved.)

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., (Wiley Periodicals, Inc. © 2020 International League Against Epilepsy.)

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).

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.", Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

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., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2020 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Objectives (a) Update previous descriptions of trends in ASSB; (b) determine if factors previously associated with ASSB are replicated by updated data; and (c) generate new hypotheses about the occurrence of ASSB and racial inequalities in ASSB mortality. Methods National Center for Health Statistics files (International Classification of Diseases, Tenth Edition) Code W75 to describe race-ethnicity-specific ASSB occurrence. Results (a) ASSB mortality continues to increase significantly; for 1999-2016, 4.4-fold for NHB girls (45.8 per 100,000 in 2016), 3.5-fold for NHB boys (53.8), 2.7-fold for NHW girls (15.8) and 4.0-fold for NHW boys (25.9); (b) F actors previously associated with ASSB (unmarried mothers and mothers with low educational attainment, low infant birth weight, low gestational age, lack of prenatal care, male infant, multiple birth, high birth order) continue to be associated with both overall ASSB and inequalities adversely affecting NHB; (c) (1) geographic differences and similarities in ASSB occurrence support hypotheses related to positive deviance; (2) lower ASSB mortality for births attended by midwives as contrasted to physicians generate hypotheses related to both medical infrastructure and maternal engagement; (3) high rates of ASSB among infants born to teenage mothers generate hypotheses related to the possibility that poor maternal health may be a barrier to ASSB prevention based on education, culture and tradition. Conclusions for Practice These descriptive data may generate new hypotheses and targets for interventions for reducing both ASSB mortality and racial inequalities. Analytic epidemiologic studies designed a priori to do so are required to address these hypotheses.

Forensic suicidology is a growing discipline as the world struggles to reduce escalating suicide rates. Most research focuses on trends and risks, but no study examines the relationship between cultural identity and suicide modality as a means of understanding hyper-local risk factors. This study cross-referenced race and suicide method for 720 coroner decedents. More than half (58%) of Asian suicides are asphyxial, while 20% are firearm-related. Comparatively, 26% of White suicides are asphyxial; 35% are firearm-related. Males outnumber females at greater than 2:1 in every racial category except Asian. While the study demographic is unique, many trends confirm conventional suicide wisdom. The finding of male predominance in the White and Hispanic groups confirms long-standing clinical knowledge regarding sex-related risk for suicide. Understanding patterns unique to a locality can leverage policy and practices that reduce access to suicide means, aiding preventative efforts, and benefitting the growing field of death investigation., (© 2019 American Academy of Forensic Sciences.)

Childhood and adolescent suicides have been increasing worldwide in recent years, and the investigation of such deaths is often complex. Forensic pathologists frequently find themselves having to opine as to the manner of death in these difficult cases. The present study was undertaken to identify distinguishing features in childhood and adolescent suicides to assist in the investigation and prevention of these deaths. A 25-year review of pediatric suicides in a metropolitan area was performed, which showed a steady increase in pediatric suicides over time. Male pediatric suicides were more common than female, with both having an average age of 15 years. Gunshots wounds and hanging were the most common methodologies seen, with drug toxicity being more common in females and gunshot wounds more common in males. Approximately 20% of decedents had a psychiatric history, 25% had a previous history of a suicide attempt or ideation, and 24% had a history of drug use. Only a minority of decedents made their intentions known prior to the suicidal act (16%) or left a note of intent (16%). In 62% of cases, a temporal, precipitating event could be identified, of which conflict with a significant other (boyfriend or girlfriend) was the most common. No specific trends over time were identified. While these features may assist forensic pathologists in assessing a possible suicidal death in the pediatric age group, medicolegal death investigators must approach these deaths as they would any violent death in an attempt to accurately determine the manner of death regardless of the societal and familial implications of such a determination.

Gene expression has become an interesting research area in forensic pathology to investigate the process of death at the molecular level. The aims of this study were to analyze changes in gene expression patterns in relation to the cause of death, and to propose new molecular markers of myocardial ischemia of potential use for the postmortem diagnosis of early ischemic heart damage in cases of sudden cardiac death (SCD). We determined mRNA levels of five proteins related with ischemic myocardial damage and repair - TNNI3, MYL3, TGFB1, MMP9 and VEGFA - in specific sites of the myocardium, blood and pericardial fluid in samples from 30 cadavers with different causes of death (SCD, multiple trauma, mechanical asphyxia, and other natural deaths). TNNI3 expression in blood, and MMP9 expression in pericardial fluid, were significantly higher when the cause of death was mechanical asphyxia, probably because of the more sensitive response of these proteins to acute systemic hypoxia/ischemia. Specifically, among SCD cases, increased MYL3, VEGFA and MMP9 values in the anterior wall of the right ventricle were found when the confirmed cause of death was acute myocardial infarction (AMI). Higher TGFB1 expression was found in the interventricular septum when AMI was not the cause of death, most likely as a reflection of the short duration of ischemia. Molecular biology techniques can provide complementary tools for the forensic diagnosis of early ischemic myocardial damage and AMI, and may make it possible to determine the duration and severity of myocardial ischemia., (Copyright © 2019 Elsevier B.V. All rights reserved.)

According to World Health Organization (WHO) estimations, approximately 6 million people lose their lives yearly due to some kind of injury, while one-third of these incidents are due to violent acts. Violent deaths include accidents (road traffic accidents, drownings, falls, heat effects etc), suicides as well as homicides. Elderly people seem to be at greater risk due to their special characteristics as a vulnerable social group. The aim of this study was to investigate violent deaths (accidents, suicides and homicides) among elderly people in Attica, Greece, during the period 2011-2015 by examining manner of death with respect to demographic data (gender and age) and toxicological examination results. A total of 546 violent deaths among people over 65 years old were included in this study. Autopsy findings along with toxicological examination results were collected from the archives of the Department of Forensic Medicine and Toxicology of the National and Kapodistrian University of Athens. The findings of the study showed that most of the victims were male (63.74%). The overwhelming majority of violent deaths (425 cases) were accidents, 92 cases suicides, and the remaining 29 cases homicides. Drowning was the leading cause of all accidental deaths, followed by road traffic accidents. Hangings prevailed among violent suicide methods and asphyxiation presented as a predominant homicide method., (Copyright © 2019 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Introduction: Bereavement is usually difficult to come to terms with. However, sudden, violent or traumatic death can be particularly hard to accept for any family, group or nation as a whole. A retrospective study of all autopsies on unnatural and traumatic deaths of medico-legal importance was made at the Komfo Anokye Teaching Hospital from 2008 to 2016., Methods: Information on cause of death and other relevant detail as well as demographics were extracted from the Autopsy Log Book of the department of pathology, Komfo Anokye Teaching Hospital where data on cause of death from autopsy findings and other relevant data were gathered and kept secured. The data was then analyzed using SPSS version 22., Results: Findings from the study showed that Road Traffic Accidents (RTA) contributed to 58.51% of the total forensic death cases of a total of the 1470 registered unnatural deaths. Males accounted for 75.37% of deaths as compared to 24.63% for females. The mean age for the various cause of unnatural deaths was 34 years. The age ranges from a minimum of 0.02 year (1 week) to a maximum of 97 years with median age of 33. The modal age is 30 years with 75 cases. 1108 males and 362 females were involved, resulting in a gender ratio of 3:1. The age group 30-39 recorded the highest percentage of deaths due to Hanging, Gunshots, RTA and Falls with 22.45%, 34.69%, 21.75% and 25.44% respectively. Children aged ≤9 recorded the highest number of deaths due to chemical poisoning and drowning with 25.5 8% and 40.00% of cases respectively. People in the extremes of ages (≤9 and ≥ 70) recorded the least number of death cases by percentage., Conclusion: Road traffic accident is therefore the leading cause of unnatural traumatic deaths as it accounted for more than half of all unnatural traumatic death cases reported in the forensics department. Men, especially the youth are also more prone to violent unnatural deaths compared to women in general. It is shown that, men die more in the various categories than women. Males are likely to die on the average, 3 times more than the females by any of the manner of deaths., (Copyright © 2019 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

A retrospective analysis of 2000 intentional homicide cases from the State Forensic Medicine Service (Vilnius, Lithuania) was carried out in order to evaluate the portrait of homicide victims and mechanisms of death between 2004 and 2016. The definition of intentional homicide appears to be quite straightforward, as a homicide occurs when one person's cause of death can be attributed to another one. Moreover, homicide is accomplished by conscious, active, intentional, or unintentional activities or inaction. All included cases of homicide were qualified as intentional murder. Children rarely become victims of intentional homicide. The group of child intentional murder made only 4.2% of all homicide cases. Seventy-three percent of homicide victims were male. The female victims were older than male and were murdered using a larger variety of objects (p < 0.001). Heavily alcohol-intoxicated victims were murdered using more traumatic affliction by sharp, stabbing-cutting objects (p < 0.001). The largest number of traumatic afflictions was associated with using a blunt object (p < 0.001). Lithuania differs from other European countries in terms of death by shooting: while 13% of homicides resulted from gunshot wounds in Europe, in Lithuania, only 5.6% of homicides did. This fact can be attributed to a relatively lower firearm ownership in Lithuania. This research is the first study that evaluates homicide in Lithuania based on autopsy findings. This study is highly important for homicide investigation tactics, as it emphasizes the portrait of the victim, providing valuable information about the most common mechanism of death, used weapons and traumatic afflictions for the law enforcement agencies., (Copyright © 2019 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Objective: Self-inflicted burns typically result in extensive injuries requiring intensive care and attention in a specialised burn unit. Burn units should be familiar with the optimal management of self-inflicted burns, including the psychological and psychiatric treatment. This paper describes the experiences of managing these challenging injuries in a German burn centre., Methods: A retrospective review of patients with self-inflicted burns admitted to the burn centre between 2000 and 2017. Demographics, details of injury, presence of psychiatric disorder, clinical course, operative management and patient outcomes were recorded and compared with a control group without self-inflicted burns. Outcome measures included graft take rate, complications and need for further surgery., Results: There were a total of 2055 burn patient admissions, with 17 cases (0.8%) of self-inflicted burns. The mean age was 36±11 years with an mean percentage total body surface area (%TBSA) burned of 43.5±22.5% which was not significantly different from the control group (p=0.184). Schizophrenia and personality disorder were the most common diagnoses in the self-inflicted burns patients (n=11; 65%). Of these, four had sustained previous self-inflicted burns. Length of hospital stay was significantly longer in the self-inflicted burn group than in the control group (49.0±16.7 days, respectively, p=0.002)., Conclusion: Attempted suicide by self-inflicted burns represents <1% of burn admissions. This population demonstrates a high incidence of prior psychiatric disorders. Successful treatment includes multidisciplinary management of acute medical, surgical, and psychiatric care.

To describe the technical characteristics of fatal diving mishaps and to elucidate the causes of death using a sequence analysis and a multidisciplinary investigation of diving-related fatalities. All cases of diving deaths recorded on the coast of Girona (Spain) between January 2009 and May 2018 were analyzed. Most data were obtained from the police technical reports and the forensic pathology service. Each accident was analyzed in order to identify the trigger, disabling agent, disabling injury, and cause of death. During the study period 25 diving-related fatalities were recorded. Most of the victims were males aged 50-69 years, and 11 were experienced divers. Almost all victims were using open-circuit SCUBA to breathe with compressed air as their sole gas supply. None of the victims were diving alone. The most common identified triggers included exertion, panic, buoyancy problems, disorientation and confusion. The main factors identified as disabling agents were rapid ascent, a cardiac incident, panic and entrapment. Asphyxia, lung over expansion, and myocardial ischemia were the most frequent disabling injuries. Finally, drowning represented the main cause of death, followed by arterial gas embolism and natural causes or internal diseases. A differential diagnosis, performed in the setting of a multidisciplinary investigation, is essential for elucidating the cause of death in diving-related fatalities. The proposed sequence analysis allows to clarify underlying problems in these cases and to identify risk factors and unsafe behaviors in diving.

Introduction: Understanding patterns of avalanche fatalities can aid prevention and rescue strategies. In 2007, we published a report reviewing avalanche deaths in Utah between the 1989-1990 and 2005-2006 winter seasons. In the current report, we discuss Utah avalanche fatalities from the 2006-2007 to 2017-2018 seasons., Methods: Avalanche fatality data were obtained from the Utah Avalanche Center and Utah State Office of the Medical Examiner. Autopsy reports were reviewed to determine demographic information, type of autopsy (external vs internal), injuries, and cause of death., Results: Thirty-two avalanche deaths occurred in Utah during the study period. The mean (±SD) age of victims was 32±13 (8-54) y. Thirty victims (94%) were male and 2 (6%) were female. Seventy-two percent of deaths were from asphyxiation, 19% from trauma alone, and 9% from a combination of asphyxiation and trauma. Snowmobilers accounted for the largest percentage of avalanche fatalities (15 victims; 47%) during the 2007-2018 period., Conclusions: Asphyxia continues to be the most prevalent killer in avalanche burial. Patterns of ongoing avalanche deaths continue to suggest that rapid recovery and techniques that prolong survival while buried may decrease fatality rates. Trauma is a significant factor in many avalanche fatalities. Education and technologies focused on reducing traumatic injuries such as improved education in techniques for avalanche risk avoidance and/or use of avalanche airbags may further decrease fatality rates. Snowmobilers represent an increasing percentage of Utah avalanche deaths and now make up the majority of victims; increased education targeting this demographic in the basics of avalanche rescue gear and avalanche rescue may also reduce fatalities., (Copyright © 2019 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

In Taiwan, unintentional injury is the leading cause of death among children <10 years old. Low socioeconomic status is a risk factor associated with a high prevalence of injuries and our study aimed to explore the geographic distribution of mortality due to unintentional injury in this age group assessing the association between this type of injury on the one hand and socioeconomic disadvantages and family structure on the other using cluster and spatial regression analyses. Using exploratory factor analysis, we assembled nine socioeconomic variables into four composite factors including area-level poverty, family burden, family fragility and unemployment. We found significant spatial clusters of childhood deaths due to unintentional injury and identified three major causes of death involved, i.e. traffic accidents, drowning and suffocation. Significant associations were found between death due to unintentional injury and area-level social disadvantages including poverty, family fragility, family economic burden and unemployment, while controlling for spatial autocorrelation. Our conclusion is that socioeconomic disadvantages need to be addressed to reduce the number of deaths due to childhood unintentional injury.

Purpose: Given limited resources, it is essential to determine which Mechanisms of Injury (MOIs) to prioritize for injury prevention policy and research. We developed objective, evidence-based Injury Prevention Priority Scores (IPPSs) for Canadian children across three prevention perspectives: mortality, injury severity, and resource utilization., Methods: We performed a retrospective cohort study of all injuries in Canada in individuals aged 0 to 19 years old from 2009 to 2014. For each MOI, an IPPS was calculated as a balanced measure of frequency and either mortality rate, median ICD-10 derived Injury Severity Score (ICISS), or median cost per hospitalization., Results: Of 87,017 injuries, 83,112 were nonfatal hospitalizations, and 3905 were deaths. Overall mortality rate was 0.04 deaths/injury, median ICISS was 0.994 (IQR 0.75-0.996), and median cost per hospitalization was CAD$3262 (IQR $2118-$5001). The top three mechanisms were falls (IPPS 72), intentional self-harm (IPPS 68), and drowning (IPPS 65) for mortality, falls (IPPS73), drowning (IPPS 61), and suffocation (IPPS 61) for injury severity and falls (IPPS 70), fires (IPPS 65), and intentional self-harm (IPPS 60) for resource utilization., Conclusion: Falls, if prevented, would provide the most benefit to the largest proportion of the Canadian pediatric population and should be targeted for injury prevention., Level of Evidence: Level III., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Homicide patterns are a useful indicator of social stress in a community, and they provide law-enforcement authorities with helpful information. This study was undertaken at the All India Institute of Medical Sciences, New Delhi, India, in order to understand the regional pattern of homicide. Data from the last 20 years were analysed. There were a total of 1048 male and 323 female homicide cases. The male/female ratio was about 3:1, and the proportion of total autopsies was approximately 4% for both sexes. The most common age group was 11-40 years old. Female cases were more common during the monsoon season, but male cases did not show any such variation. Blunt-force head injury, stabbing, strangulation and shooting were the most common methods, and the head, neck and chest were the most commonly targeted areas. Defence injuries were seen in 7.9% cases, significantly more often amongst men, most of which were active and in the form of incised wounds. About 17% of cases survived in hospital for up to a month before succumbing to their injuries, with males being in their 50s and 60s and females in younger age groups. Most of these cases suffered a gunshot wound, followed by a head injury and a stab wound.

The role of psychoactive substances in the treatment of mental disorders and the risk of suicide are major public health issues. This cross-sectional study examined the prevalence of antidepressants and antipsychotics detected in toxicological screenings in suicides. Cases from the Institute of Legal Medicine of the Charité-University Medicine Berlin were reviewed over a 4-year-period. All cases (n = 477) with positive toxicology for antidepressants and antipsychotics in blood or organ tissue were included. Frequencies of the detected substances in non-suicide cases (n = 212; male n = 177, 55.2%; female n = 95, 52.5%) and suicide cases (n = 235; male n = 149, 63.4%; female n = 86, 36.6%) were examined. Tricyclic antidepressants (48.1%) were found most frequently in suicides, followed by atypical neuroleptics (37.0%), selective serotonin reuptake inhibitors (28.1%), typical neuroleptics (17.4%), tetracyclic antidepressants (16.2%) and other substances (8.9%). Alcohol was detected in 37.2% of suicides. The leading cause of death was drug poisoning (35.6%) followed by polytrauma (26.8%) and death by hanging (18.5%). A mental disorder (depression, schizophrenia, bipolar disorder, suicidality) was known in 22.9% of suicides. The most common location of death was the person's own house (63.8%) followed by public places (28.1%) and hospitals (8.1%) The five most common substances in the suicide group were doxepin (20%) citalopram (15.3%), mirtazapine (14.9%), quetiapine (13.6%) and amitriptyline (12.3%). Toxicological findings from cross-sectional studies provide insight into how often certain types of antidepressants and antipsychotics are associated with suicide. A complementary approach is valuable for assessing the risk of suicide during medical treatment because the various available approaches (analysis of suicidal behavior/ideation, toxicity of drugs) each have strengths and limitations.

Background: The national Adverse Events Following Immunization (AEFI) surveillance system in China (CNAEFIS) has collected AEFI reports -including deaths following all vaccines used in China since 2008., Aims: To review reports of AEFI-associated death cases from 2010 to 2015 to assess potential vaccine safety issues., Methods: Descriptive analysis of epidemiologic characteristic of AEFI-associated death cases and standard causality assessment for reported causes of deaths. To estimate the risk of death after vaccination, we used population data, administered doses and live births to calculate denominators., Results: During 2010-2015, 753 deaths were reported to CNAEFIS from mainland China. Highest numbers were reported in 2013 and 2014 when reporting peak of AEFI-associated deaths occurred after media reports concerning "death following Hepatitis B vaccination" in China. About 95% of deaths were in children <5 years of age and males accounted for 60%. Most common vaccines associated with reports of fatal AEFIs were vaccines in national immunization schedule. In causality assessment, 120 (16.0%) deaths were classified as vaccine-associated reactions such as anaphylactic reactions and disseminated BCG infections; 594 (78.9%) deaths were identified as coincidental events. The main causes of death were asphyxia, and Sudden Infant Death Syndrome. The overall estimated AEFI-associated death rates were: 0.26 per million vaccination doses administered and 0.09 per million population. The neonatal AEFI death rate was 0.77 per million live births., Conclusions: These data provide reassuring information about the small risk of death following immunization. They also illustrate sensitivity of passive reporting to public information and that peaks in serious AEFI reports should be interpreted with caution. Continuous monitoring and scientific causality assessment for serious AEFIs, including AEFI-associated deaths is imperative to ensure public confidence in the immunization program., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

The aim of this study was to collect all available data from 2009 to 2016 focusing on the epidemiological, clinical and pharmacological issues only related to acute intoxication fatalities in the Unit of Legal Medicine of the Department of Medicine and Surgery at the University of Parma. All death certificates and autopsy reports were retrieved from the archives and evaluated to identify cases in which only acute intoxication from xenobiotics could be defined as the cause of death, however statistical and descriptive analyses were applied to all the data. A more comprehensive analysis on all causes of death showed that out of 1005 total cases the most common is haemorrhagic shock/traumatic shock (36.5%), followed by cardiogenic shock with 27.4%; asphyxia ranks as the third cause of death (11.8%); concerning encephalic injuries, our data show 10.9% of cases, while acute intoxication by xenobiotics accounts for 5.7%. Data show that the majority of subjects are poly-abuser (75.4%); people not enrolled within a preventive treatment (59.4%) were more likely to commit suicide (28.1%), whereas only 6.2% in the sub-population in treatment (40.6%) committed suicide: therefore, data strongly suggest the evidence that joining a preventive programme can decrease the probability of extreme action. Access to a full case history may indeed save considerable time and expense in carrying out tests, but also valuable targeted samplings. The investigating officer should, therefore, submit as much information as possible about the case, as this may influence the type and extent of analysis undertaken, as well as the interpretation of analytical results., (Copyright © 2019 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Objective: Sudden Unexpected Infant Deaths (SUID) is defined as a combination of Sudden Infant Death Syndrome (SIDS), Unknown Cause of Death (UCD) and Accidental Suffocation and Strangulation in Bed (ASSB). Overall rates from 2000 to 2015 have been trending down. Racial differences in occurrence are seen., Study Design and Setting: Using the CDC Wonder Database, the total rates of SUID and its subsets were examined., Results: Non-Caucasian infant death rates for the total SUID group, and the SIDS component, are trending downward significantly faster than for Caucasians. UCD trends in rates show an apparent small, non-significant, decline for non-Caucasians, and are unchanged for Caucasians. ASSB rates are trending upward slightly more rapidly (not significantly) for non-Caucasians than Caucasians., Conclusion: The trend showing ASSB trending upward more in non-Caucasians than Caucasians may suggest: 1) A racial difference that certifiers are more willing to certify SIDS than ASSB in Caucasians, and/or 2) Certifiers are biased towards certifying more ASSB than SIDS in non-Caucasians, and/or 3) Asphyxia risks may be increasing more in non-Caucasian SUIDs. Option #1 would require educational efforts to recognize the asphyxia risks in Caucasians. Option #2 would require documentation of racial bias in infant death certification followed by efforts to reduce the bias. Option #3 would require focused targeting of non-Caucasian populations to reduce asphyxia risks. Potentially all three scenarios could co-exist., (Copyright © 2019 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)