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Background: Hangings are an infrequent wounding mechanism among patients arriving alive to hospital but are frequently encountered by the Coroner's Office. It is unclear if classically described hanging injuries, such as the Hangman's fracture, are common among contemporary hangings patients who typically do not suspend from height. This study was undertaken to define patient and injury characteristics after hangings causing death., Methods: All patients presenting to the Los Angeles County Medical Examiner/Coroner's Office (January 2016 - May 2020) who died by hanging were included. Demographics, psychiatric history, hanging details, autopsy type, and sustained injuries were collected. Data variables were summarized with descriptive statistics and the diagnostic yield of a ligature mark in the diagnosis/exclusion of cervical injuries was calculated., Results: Over the study, 1,401 patients died by hanging. Patients underwent external exam alone (n = 1,282, 92%), traditional neck autopsy (n = 114, 8%), or traditional neck autopsy plus postmortem computed tomography scan (n = 5, <1%). Home was the most frequent hanging setting (n = 1,028, 73%) followed by public spaces (n = 80, 6%) and jail (n = 28, 2%). The manner of death was almost exclusively suicide (n = 1,395, >99%) and psychiatric disease was common (n = 968, 69%). Of the patients undergoing traditional autopsy, most had a ligature mark (n = 109, 92%) and only 9 (8%) had a cervical injury (hyoid fractures, n = 6, 5%; thyroid cartilage fractures, n = 4, 3%). None had a vertebral fracture/dislocation. Sensitivity, specificity, positive predictive value, and negative predictive value of a ligature mark were 100%, 5%, 8%, and 100%., Conclusions: Hangings are a frequent cause of death in Los Angeles County. Patients typically have a psychiatric history and die almost exclusively from suicide. Hangings commonly occur at home, in public places, and in jail. Injuries were exceedingly rare and no patient sustained a Hangman's fracture, which may be related to the lack of significant suspension with modern hangings., (Copyright © 2021. Published by Elsevier Inc.)

Background: The rate of suicide in the US has increased substantially in the past two decades, and new insights are needed to support prevention efforts. The National Violent Death Reporting System (NVDRS), the nation's most comprehensive registry of suicide mortality, has qualitative text narratives that describe salient circumstances of these deaths. These texts have great potential for providing novel insights about suicide risk but may be subject to information bias., Objective: To examine the relationship between decedent characteristics and the presence and length of NVDRS text narratives (separately for coroner/medical examiner (C/ME) and law enforcement (LE) reports) among 233,108 suicide and undetermined deaths from 2003-2017., Methods: Generalized estimating equations (GEE) logistic and quasi-Poisson modeling was used to examine variation in the narratives (proportion of missing texts and character length of the non-missing texts, respectively) as a function of decedent age, sex, race/ethnicity, education, marital status, military history, and homeless status. Models adjusted for site, year, location of death, and autopsy status., Results: The frequency of missing narratives was higher for LE vs. C/ME texts (19.8% vs. 5.2%). Decedent characteristics were not consistently associated with missing text across the two types of narratives (i.e., Black decedents were more likely to be missing the LE narrative but less likely to be missing the C/ME narrative relative to non-Hispanic whites). Conditional on having a narrative, C/ME were significantly longer than LE (822.44 vs. 780.68 characters). Decedents who were older, male, had less education and some racial/ethnic minority groups had shorter narratives (both C/ME and LE) than younger, female, more educated, and non-Hispanic white decedents., Conclusion: Decedent characteristics are significantly related to the presence and length of narrative texts for suicide and undetermined deaths in the NVDRS. Findings can inform future research using these data to identify novel determinants of suicide mortality., Competing Interests: The authors have declared that no competing interests exist.

Hair analysis is capable of determining both an individual's long-term drug history and a single exposure to a drug, which can be particularly important for corroborating incidents of drug-facilitated crimes. As a source of forensic evidence that may be used in a court of law, it must be credible, impartial and reliable, yet the pathways of drug and metabolite entry into hair are still uncertain. Many variables may influence drug analysis results, most of which are outside of the control of an analyst. An individual's pharmacokinetic and metabolic responses, hair growth rates, drug incorporation routes, axial migration, ethnicity, age and gender, for example, all display interpersonal variability. At present there is little standardization of the analytical processes involved with hair analysis. Both false positives and negative results for drugs are frequently encountered, regardless of whether a person has consumed a drug or not. In this regard, we have categorized these variables and proposed a three-stage analytical approach to facilitate forensic toxicologists, hair analysis experts, judiciaries and service users in the analytical and interpretation process., (© 2020 John Wiley & Sons, Ltd.)

Background: Pulmonary bullae and blebs can result in a pneumothorax. Their prevalence in the normal population is currently unknown. Postmortem CT (PMCT) images from a forensic database were used to determine the prevalence of pulmonary bullae/blebs in the normal Dutch adult population and its consequence for diving medicine, as bullae and blebs are often considered a contraindication for diving., Methods: Forensic PMCT scans of 130 adults were analyzed for the presence of bullae and/or blebs in a cross-section of the Dutch population without pulmonary disorders. The lungs had to be unharmed, expanded, and without signs of illnesses. Normal early-stage postmortem changes in the lungs were accepted., Results: Analysis was performed per decade. Group I (aged 21-30 years) included 26 patients. Blebs were observed in four persons; one exhibited blebs and bullae. Group II (aged 31-40 years) included 28 patients; blebs were observed in nine individuals, one with bullae. Group III (aged 41-50 years) included 27 patients; blebs were noted in nine individuals, bullae in one, and bullae and blebs in four. Group IV (aged 51-60 years) included 28 patients; blebs were noted in seven individuals and two with bullae and blebs. Group V (aged 61-70 years) included 21 patients; blebs were noted in three persons, bullae and blebs in two, and isolated bullae in one. On average, most bullae/blebs were < 10 mm, and none exceeded 20 mm., Conclusions: By reassessing pulmonary PMCT scans, we found a surprisingly high incidence of small bullae and/or blebs in one-third (33.8%; 95% CI, 25.7-41.9) of the general population without underlying lung disease. This finding can have potential implications for diving medicine., (Copyright © 2019 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Understanding case identification practices, protocols, and training needs of medical examiners and coroners (MEC) may inform efforts to improve cause-of-death certification. We surveyed a U.S.-representative sample of MECs and described investigation practices and protocols used in certifying sudden unexpected infant deaths (SUID). We also identified MEC training and resource needs. Of the 377 respondents, use of the SUID Investigation Reporting Form or an equivalent was 89% for large, 87% for medium, and 52% for small jurisdictions. Routine completion of infant medical history, witness interviews, autopsy, photos or videos, and family social history for infant death investigations was ≥80%, but routine scene re-creation with a doll was 30% in small, 64% in medium, and 59% in large offices. Seventy percent of MECs reported infant death investigation training needs. Increased training and use of standardized practices may improve SUID cause-of-death certification, allowing us to better understand SUID.

A death scene investigation (DSI) forms an integral part of the inquiry into death, particularly for sudden unexpected death of infants (SUDI). Global guidelines exist for DSI, however, previous studies have shown that South Africa does not routinely perform DSI for SUDI cases, nor is there a standard protocol in this regard. This was largely attributed to the large burden of SUDI cases as well as the lack of resources, due to South Africa being a developing country. This study assessed DSI practices at one of the largest mortuaries in Cape Town (Salt River Mortuary) to assess the scope of these practices within a resource-constrained context. Data were collected by retrospectively reviewing medico-legal case files (n = 454) from SUDI cases investigated at Salt River Mortuary over a two-year period. The results showed that SUDI death scenes were visited in 59.2% of cases at Salt River Mortuary, with poor and inconsistent levels of documentation. Death scenes were never investigated in cases where the infant was pronounced dead on arrival at a medical facility. The findings support the need for a locally relevant approach to DSI, coupled with specialized training for staff. Based on the limited resources, this should focus on the training of staff using the available resources and accurate use of documentation.

Objective: To identify the risk factors and assault characteristics of family violence among victims referred for forensic medical examination in Victoria, Australia., Methods: A retrospective 1:1 case-control study was conducted, comparing adult family violence victims and non-family violence victims examined by clinical forensic practitioners from the Victorian Institute of Forensic Medicine, between July 2015 and June 2016. Data were extracted from victims' forensic medical casework. Chi-square or Fisher's exact tests and Mann-Whitney U tests were used to examine group differences. A multiple logistic regression analysis was used to determine independent predictors of family violence., Results: One hundred and forty-three family violence victims (97.2% female, Mdn age  = 29, 90.2% intimate partner violence) were identified and gender- and age-matched with controls. Family violence victims had significantly higher odds of reporting a history of violence victimisation (OR = 5.20; 95% CI, 2.54 to 10.66) and current pregnancy (OR = 5.28; 95% CI, 1.09 to 25.46) than controls. Family violence was significantly more likely than non-family violence to occur in the victim's home, and to involve physical assault, use of weapon(s), trauma to the neck and anal sexual assault. Family violence victims sustained significantly more physical injuries, and were more likely to be injured to almost every bodily location, than controls., Conclusion: This study highlights the importance of assessing and managing risk for family violence following initial victimisation and throughout pregnancy. Findings further indicate that family violence is more dangerous (i.e. more likely to involve severe forms of assault and cause injury) than non-family violence.

Abstract: Objective To analyze a knowledge web of the literature published by Journal of Forensic Medicine from its founding in 1985 to 2018, describe the evolving process of forensic science research and explore the research hotspots and frontiers at present. Methods The literature that was published by Journal of Forensic Medicine from 1985 to 2018 was collected and analyzed in terms of elements, such as emerging research hotspots, high frequency keywords, authors, dispatching units, location of institution and funding, by CiteSpace5.3 information visualization analysis software. Results All disciplines of forensic medicine were continually developing and maturing, and the publication volume of the literature on forensic pathology had the highest weight; in research hotspots, the two categories, research and identification each had their own emphasis; as the main source of contributions to the journal, research institutes accounted for 38.99% of the total number of publications; Shanghai ranked first among all regions with 1 046 articles published. The number of funded articles was generally on the rise, with the number of funded articles published largest in 2015. Conclusion As an authoritative academic journal in the field of forensic science in China, Journal of Forensic Medicine carries the development of forensic science and witnesses the institutional reform of universities and colleges, and offers a wide range of communication and cooperation in terms of technicality and application. Many scholars and scientific research institutions have gained progress continually in various research directions in the form of teamwork; and emerging research hotspots will continue to play a huge role in future practical applications., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose., (Copyright© by the Editorial Department of Journal of Forensic Medicine.)

Background: The Forensic medicine reform in 2011 enabled the development of forensic units specialized in multidisciplinary care of victims of criminal offences. Thanks to an annual budgetary allocation, the Ministry of Justice handles the financing of judicial acts, while the health care facilities assume the medical, psychological and social aspects. The objective of this study was to determine the direct costs of medical care provided to rape victims (such as defined in the article 222-23 of the Penal Code) in order to see how its funding could be reconsidered to prevent any additional cost that could be caused by non-sufficient medical, psychological and social care. Furthermore, this first assessment may serve as a basis for further reflection on creating other medical judicial units but also for reviewing existing structures., Methods: The direct costs for medical care of a recent rape victim (<48hours) was quantified by including staff and consumables costs, treatments, biological tests and other expenses., Results: The overall time for the entire medical care procedure was approximately three hours, for an overall cost of 673.92€, of which 41.5 % (279.90€) was paid by the Ministry of Justice. The medical, psychological and social aspects stood for the major expenditure items (394.02€), attributable mainly to the biological screening tests for sexually transmissible infections (STIs)., Conclusion: These frequent situations require the convergence of human and material needs with a financial burden shared between the Ministry of Justice and health establishments. Authors suggest that in the annual hospital budgetary allocation allotted by the Ministry of Justice, the care of victims of sexual assault be based on the rate of day hospitalization "Medicine, medical specialties part time day or night common regime", allowing to provide optimal multidisciplinary care, which lessens the risks of complications and reduces the global cost created by these situations., (Copyright © 2018. Published by Elsevier Masson SAS.)

Objectives: to identify characteristics of victims of sexual assault or domestic violence who consulted in a Department of Forensic Medicine without a formal complaint to the police., Methods: observational study (03/01/2014-08/31/2015) of individuals (age>15years) consulting in a Department of Forensic Medicine near Paris, France, after a sexual assault or domestic violence. Among the individuals who were examined in the department of Forensic Medicine, we compared the individuals who had not complained to the police to those who had complained to the police., Results: A hundred and nine individuals have consulted without a prior complaint to the police, including 73 persons after domestic violence (i.e. 4% of all persons examined with or without a complaint to the police) and 36 persons after a sexual assault (i.e. 8% of all persons examined). Regarding domestic violence, the proportion of persons presenting recent traumatic injuries was lower among those who did not complain to the police than among those who did (64% vs. 78%, P=0.008). Regarding sexual violence, the persons who did not complain to the police were more frequently uncertain about the assault (42% vs. 13%, P<0.001), reported more frequently a recent alcohol or drug intake (42% vs. 26%, P=0.039) and less frequently showed extragenital traumatic injuries than the persons who did complain to the police (22% vs. 43%, P=0.016)., Conclusion: the persons examined who had not complained to the police accounted for less than one in 20. The extension of the activity of a Department of Forensic Medicine to persons who do not want to be involved in a judicial process is not sufficient for the majority of victims to consult a forensic physician., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Despite the fact that the ever growing relevance of the problem of the inappropriate medical care was long ago brought to the worldwide attention, it has not been practically addressed in the Ukraine since the country gained independence in 1991. The objective of the present study was to consider the specific features of expert examination of the cases of inappropriate medical care as exemplified by the materials of the legal actions and lawsuits instituted against healthcare specialists violating their occupational duties. The results of forensic medical examination by the local Bureaux of forensic medical expertise concerning the 350 so-called malpractice suits instituted in the Ternopol, Zhitomir, and Chernovtsy regions during the period from 207 to 2016 were available for the analysis. The facts of inadequate and inappropriate medical care were documented in 245 (72.0%) cases. The frequency of diagnostic and therapeutic errors amounted to 29.7% and 26.9% respectively while the improper formulation of the medical documentation was recorded in 21.3% of the cases. The cases of poor organization of the diagnostic and treatment process accounted for 14.6% of the total whereas the improper behaviour of the medical personnel was reported in 7.5% of all the known cases of provision of the healthcare services. It is concluded that in the majority of the cases, the citizens of the modern-day Ukraine receive the inappropriate (insufficient and untimely) medical care. Over 80% of the cases of the inappropriate medical care currently provided in the country can be accounted for by the objective reasons, with each fifths case being due to the violation of professional responsibilities by the healthcare providers.

Aim: Elder abuse is a health and human rights problem that may occur among every race and ethnic group all around the world. This study aims at describing all cases of physical abuse of elderly which have been reported to, and investigated by Eskisehir - a western city of Turkey., Methods: Physical abuse incidents above 65 years of age which were evaluated by the Eskisehir Council of Forensic Medicine for expert witness opinion during 5year period between 01.01.2010 and 12.31.2014 are examined in this descriptive, cross-sectional study., Results: 253 cases are found and evaluated in the scope of the study. It is determined that all aggressors are the acquaintance of the victim, and for 114 cases (45.1%) the aggressor is the victim's son. It is found that only investigation procedures of cases are completed, but no protection and rehabilitation program has been issued., Conclusion: In conclusion, it is determined that elder victims are abused by family members and relatives who are mostly the care givers. It is seen that emergency physicians play a great role in the detection of abuse., (Copyright © 2017 Elsevier B.V. All rights reserved.)

The Aim: The aim of the study was to identify the relationship between the level of burnout subdomains and alexithymia among forensic physicians working in forensic institutions in Romania., Material and Methods: A number of 37 forensic physicians were included in the survey. Burnout and alexithymia were measured by using the Maslach Burnout Inventory and Toronto Alexithymia Scale. The obtained data were processed using the SPSS 17.00 statistical software., Results: The subjects obtained an average of 43.27±3.71, which corresponds to a low level of alexithymia. For burnout scores, we have obtained M=14.97±13.13 for emotional exhaustion, M=7.91±6.87 for depersonalization and M=33.18±10.59 for personal accomplishment (low-level for emotional exhaustion and medium-level burnout for the other two factors). Among the socio-demographic variables, only the age correlated positively with the burnout factor personal accomplishment. Positive correlations were identified between burnout factors and TAS-20. Comparative analysis results are important for the presence of insomnia, depression, teaching activity and looking for professional support after critical events., Conclusions: Scores for forensic physicians are low-level for emotional exhaustion and medium-level for two subdomains and low-level for alexithymia. Factors revealed by the comparative analysis are important to adjust professional activity and to find strategies to cope with stressful professional events.

In 2005 a serious case of child sexual abuse from the region of Southern Denmark was revealed to the Danish public. The case became known as the 'Tønder-case'. It was the first in a series of 4-5 serious cases of child maltreatment in Denmark, cases which spurred heavy public debate. In this study all the cases of child sexual abuse referred for forensic examination in a 12 year period, a total of 368 cases, were systematically evaluated. In order to identify any trends that could be correlated to an impact of the 'Tønder-case', cases from 2000 to 2002 and cases from 2009 to 2011 underwent an in-depth analysis. In the 12 year period there was a significant increase in numbers of cases. In the subgroups, comprised of 113 cases meeting the inclusion criteria, we found a significant increase in the frequency of cases involving incest and systematic abuse, as well as an uncorrelated increase in the frequency of cases where children were placed in foster care prior to the examination. These results were countered by a significant decrease in the number cases police reported child sexual abuse in the same period. The possible impact that cases like the 'Tønder-case' and the following press coverage may have on disclosure and the handling of this type of case by authorities is discussed, as well as further perspectives of extensive press coverage., (Copyright © 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

The impact of criminal justice involvement and clinical characteristics on the cost of public treatment services for adults with serious mental illnesses is unknown. The authors examined differential effects of justice involvement on behavioral health treatment costs by primary psychiatric diagnosis (schizophrenia or bipolar disorder) and also by substance use diagnosis among 25,133 adult clients of Connecticut's public behavioral health system in fiscal years 2006 and 2007. Justice-involved adults with schizophrenia had the highest costs, strongly driven by forensic hospitalizations. Addressing the cross-system burdens of forensic hospitalizations may be a sensible starting point in the effort to reduce costs in both the public behavioral health and justice systems.

The elements of the scientometric survey were applied for the analysis of the character, structure, and subject-matter of the articles related to toxicological (forensic) chemistry that had been published in the journal <> during the period from 2004 to 2013. The data on the number of publications and their authors are presented. The emphasis is laid on the merits and demerits of the papers submitted for publications.

This paper reports the results of the analysis of the subject-matter and the structure of scientific articles related to forensic biology published in the journal "Sudebno-meditsinskaya ekspertiza" over the period from 1960 till 2010. The sceintometric analysis made it possible to distinguish the main avenues along which forensic biology developed during its most productive period. The results of this analytical study have provided in the summarized form the entire spectrum of the main trends in the forensic biology throughout the half-century period.

Emergency medical research is subject to special conditions. Emergency patients e.g. are generally considered to be non-capable of giving consent. This results in sparse emergency medical data when compared to clinical observation studies under controlled conditions. After emergency medical treatment, deceased patients are not rarely subject to forensic investigation. The cooperation between emergency and forensic medicine has not only emergency medical training potential in individual cases, but also scientific innovation potential especially with respect to the retrospective evaluation of pre-hospital emergency measures. Such partnerships (like in Berlin at the Charité - Universitätsmedizin Berlin between the Institute of Legal Medicine and the Center for Musculoskeletal Surgery or in Hamburg between the Institute for Legal Medicine at the University Hospital and the Municipal Fire Brigade with the Emergency Medical Service) are yet exceptional in Germany., (© Georg Thieme Verlag Stuttgart · New York.)

Introduction: The Coroners Department (CD) records hold important demographic, injury and death details for victims of burn injuries derived from various sources yet this rich source of data has been infrequently utilised previously in describing the epidemiology of burn related mortality. The aim of this study was to use CD data to comprehensively investigate burn related mortality in the Greater Manchester region of United Kingdom., Materials and Methods: A retrospective study design was used to collect data for deceased demographics, injury details, site of death and cause of death from four CD offices in GM over an 11-year period (2000-2010 inclusive). Office of National Statistics (ONS) population metrics were used to calculate age- and gender-specific population denominators and mortality rates. Index of Multiple Deprivation (IMD) was used to correlate mortality with deprivation. Linear regression and Pearson's/Spearman's rank correlation were used to calculate trends and correlations. Poisson regression was used to calculate relative risk (IRR) between age- and gender groups., Results: There were 314 recorded deaths in the region over the study period and thermal injury was 3-times less likely to result in death in 2010 compared to 2000. The largest proportion of these deaths (24.8%) was comprised of individuals ≥75 years in age. The relative risk of mortality in males was nearly 1.5-times higher and a significant majority of victims (77%) sustained their burn injury at their own home/residence. Inhalation injury without cutaneous burns was the most frequent type of injury (33%) and accidental house fires caused nearly half (49%) the injuries resulting in death. Sixty-five percent of deaths during this period were recorded to have occurred outside of regional burn service (RBS) hospitals and the commonest cause of immediate death on the death certificates was "inhalation of products of combustion" (32.1%). Within the >75 years age group the risk of death significantly increased with every quintile reduction in deprivation., Conclusion: Our data shows that despite reducing overall mortality, certain age groups and causation patterns are associated with significantly higher risks of mortality in our region. Further reduction in burn mortality should focus on the use of prevention efforts with established effectiveness in these high-risk groups. In addition, as a significant proportion of deaths occur outside a burn service environment hence epidemiology data based solely on mortality statistics from burn services will underestimate true burn related mortality., (Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.)

The objective of the present study was to formulate the principles of coding and identification of the primary cause of death from the diseases induced by the human immunodeficiency virus in accordance with the 10th edition of the international classification of diseases (ICD-10) taking into consideration the official amendments introduced by WHO. The rules of formulation of medical death certificates and peculiarities of formulation of forensic medical diagnoses in the cases of death from the diseases induced by the human immunodeficiency virus are considered. The authors emphasize the importance to observe these rules in order to ensure obtaining the statistically significant information about the mortality caused by H IV infection.

Sexual offenses are an important global health problem threatening people of all age groups. There are no reported studies regarding sexual violence among children in Jordan. Therefore, this study aimed to examine the problem of sexual violence among children in the Northern region of Jordan. A retrospective design was adopted to review all reports from the Forensic Medicine Teaching Center of North of Jordan clinic on cases of sexual-related assaults that occurred between 2003 and 2007. Reports were reviewed for age, gender, toxicological analysis, and relevant information provided by victims and their relatives. Results indicated that 53% of the cases were male victims, with a male to female ratio of 1:1. Ages ranged from 3 to 18 years with a mean age of 12.5 years. Most cases were considered indecent assaults, while 37.1% were cases of rape. In most cases, offenders were strangers. It could be concluded that Jordanian children are as susceptible to sexual assaults as their counterparts worldwide. This study is the first to report sexual offenses among children in Jordan. As such, it provides baseline data that can be used to inform policy and prevention strategies focused on reducing sexual violence among this vulnerable segment of the Jordanian population.

Background: Skeletal surveys are routinely performed in cases of suspected child abuse, but there are limited data regarding the yield of high-detail skeletal surveys in infants., Objective: To determine the diagnostic yield of high-detail radiographic skeletal surveys in suspected infant abuse., Material and Methods: We reviewed the high-detail American College of Radiology standardized skeletal surveys performed for suspected abuse in 567 infants (median: 4.4 months, SD 3.47; range: 4 days-12 months) at a large urban children's hospital between 2005 and 2013. Skeletal survey images, radiology reports and medical records were reviewed. A skeletal survey was considered positive when it showed at least one unsuspected fracture., Results: In 313 of 567 infants (55%), 1,029 definite fractures were found. Twenty-one percent (119/567) of the patients had a positive skeletal survey with a total of 789 (77%) unsuspected fractures. Long-bone fractures were the most common injuries, present in 145 children (26%). The skull was the site of fracture in 138 infants (24%); rib cage in 77 (14%), clavicle in 24 (4.2%) and uncommon fractures (including spine, scapula, hands and feet and pelvis) were noted in 26 infants (4.6%). Of the 425 infants with neuroimaging, 154 (36%) had intracranial injury. No significant correlation between positive skeletal survey and associated intracranial injury was found. Scapular fractures and complex skull fractures showed a statistically significant correlation with intracranial injury (P = 0.029, P = 0.007, respectively)., Conclusion: Previously unsuspected fractures are noted on skeletal surveys in 20% of cases of suspected infant abuse. These data may be helpful in the design and optimization of global skeletal imaging in this vulnerable population.

In 2008 only 55 % of all deaths not deemed to be natural in Sweden underwent a medicolegal autopsy. In the present study we describe and compare the characteristics of unnatural deaths in three counties through review of death certificates for unnatural deaths and, when applicable, corresponding police reports. The majority of unnatural deaths that were not reported to the police were among elderly decedents, with the deaths most often resulting from a fall-related fracture or head injury. One subgroup among these deaths that were not recognized as reportable by the involved physician, estimated by extrapolation to a total of approximately 300 annually, nationwide, was considered to be at elevated risk for a criminal death (homicide). The causes of death in this group were due to, for example, high energy or sharp force trauma, gunshot injury, asphyxia, and drug and/or alcohol intoxication. We conclude that additional training in the handling of unnatural deaths is indicated for Swedish physicians.

The objective of the present study was the comparative analysis of the deaths among the elderly and senile subjects taking into consideration the growing costs of forensic medical expertise at the Nizhni Novgorod Regional Bureau of Forensic Medical Expertise.

The objective of the present study was to analyse the financial support of forensic medical research with the application of mathematical methods based at the Nizhni Novgorod Regional Bureau of Forensic Medical Expertise. The authors elaborated the prognosis of the expenses for the forensic medical expertise of the corpses of the elderly and senile subjects.

The objective of the present study was to characterize the main requirements for the correct construction of classifications used in forensic medicine, with special reference to the errors that occur in the relevant text-books, guidelines, and manuals and the ways to avoid them. This publication continues the series of thematic articles of the authors devoted to the logical errors in the expert conclusions. The preparation of further publications is underway to report the results of the in-depth analysis of the logical errors encountered in expert conclusions, text-books, guidelines, and manuals.

This study uses statistical techniques to evaluate reports on suicide scenes; it utilizes 80 reports from different locations in Brazil, randomly collected from both federal and state jurisdictions. We aimed to assess a heterogeneous group of cases in order to obtain an overall perspective of the problem. We evaluated variables regarding the characteristics of the crime scene, such as the detected traces (blood, instruments and clothes) that were found and we addressed the methodology employed by the experts. A qualitative approach using basic statistics revealed a wide distribution as to how the issue was addressed in the documents. We examined a quantitative approach involving an empirical equation and we used multivariate procedures to validate the quantitative methodology proposed for this empirical equation. The methodology successfully identified the main differences in the information presented in the reports, showing that there is no standardized method of analyzing evidences., (Copyright © 2014 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

The present study has revealed a tendency toward a decrease in the frequency of cases of fatal outcomes of drug intoxication throughout the Almaty region during the 5 year period from 2007 till 2011 years. It is concluded that this positive trend is attributable to the improved quality of preventive measures undertaken by public healthcare services and law enforcement authorities in the Republic of Kazakhstan.

Background: We determined the intra- and inter-rater reliability of data from digital image color analysis between an expert and novice analyst., Methods: Following training, the expert and novice independently analyzed 210 randomly ordered images. Both analysts used Adobe(®) Photoshop lasso or color sampler tools based on the type of image file. After color correction with Pictocolor(®) in camera software, they recorded L*a*b* (L*=light/dark; a*=red/green; b*=yellow/blue) color values for all skin sites. We computed intra-rater and inter-rater agreement within anatomical region, color value (L*, a*, b*), and technique (lasso, color sampler) using a series of one-way intra-class correlation coefficients (ICCs)., Results: Results of ICCs for intra-rater agreement showed high levels of internal consistency reliability within each rater for the lasso technique (ICC ≥ 0.99) and somewhat lower, yet acceptable, level of agreement for the color sampler technique (ICC = 0.91 for expert, ICC = 0.81 for novice). Skin L*, skin b*, and labia L* values reached the highest level of agreement (ICC ≥ 0.92) and skin a*, labia b*, and vaginal wall b* were the lowest (ICC ≥ 0.64)., Conclusion: Data from novice analysts can achieve high levels of agreement with data from expert analysts with training and the use of a detailed, standard protocol., (© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

The comparative structural and systemic analysis of 303 forensic medical expert conclusion (acts) made it possible to reveal and systematize errors encountered in forensic medical practice at the stages of investigation, interpretation, and estimation of the obtained results. The authors distinguish between performance errors and cognitive errors in the course of forensic medical expertise. The definition of the notion of "expert error" is proposed. The process of error analysis is described with special reference to forensic medical activities.

Cases of death resulting from placing a plastic bag on the victim's head are very rare. In the last 20 years, in the Department of Forensic Medicine in Krakow, there were fourteen such cases examined. Their number is, however, noticeably growing, amounting to as many as few cases per year. Death resulting from this mechanism is difficult from the diagnostic point of view and often the only indicative evidence is a presence of a plastic bag on the head.

This research explores the question - how do practices in key justice institutions affect the incidence and success of prosecutions of torture perpetrators in Egypt? The research question is grounded in the theory that torture prosecutions are crucial to ending the practice of torture, and based on the judgment that the number of prosecutions of torture perpetrators in Egypt is very small compared to the widespread practice of torture. This research observes practices in three main justice institutions: the Department of Public Prosecutions, the Department of Forensic Medicine and the criminal courts. Based on international and local literature, but also on interviews conducted with lawyers, forensic doctors and human rights activists, the research observes the practices most common to the three institutions, while analyzing their impact on the incidence and success of prosecutions. The research finds that different practices, backed by Egyptian legislation, and endorsed by poor institutional capabilities, violate the international standards for investigations, and affect the incidence and outcome of prosecutions.

This paper is devoted to the analysis of expert errors made in the course of implementation of the Medical Criteria for the estimation of the severity of harm to human health. In 2010, the Moscow Regional Bureau of Forensic Medical Expertise issued 11 180 primary expert judgments and acts of forensic medical examination of the total number of 26 196 expertises performed (43%). They include 2797 cases of severe harm to health, 2881 cases of moderate and 5502 cases of mild harm to health. Only 74 (1.3%) of the 5678 cases of severe and moderate harm to health were misinterpreted by the experts. Thirty three (0.6%) judgments were considered as doubtful. Sixty one of the 74 cases of harm to health were erroneously described as severe and 13 ones as moderate. The main source of the errors was misapplication of the respective articles of the Medical Criteria for the estimation of the severity of harm to human health. Only 20 (0.4%) of the 5502 cases estimated as mild harm to health proved erroneous. Fifty four (1%) judgments were recognized to be doubtful. A total of 264 forensic medical expertises were performed by expert commissions during 2010 of which 118 (45%) were designed to estimate the harm to human health. In more than two thirds of the cases, the errors of primary expertise of the severity of harm to human health due to the misapplication of the Medical Criteria were either revised or corrected; the remaining one third of the judgments were left unaltered (i.e. the results of the primary expertise were confirmed).

Objective: To evaluate and characterise the causes of sudden natural deaths (SNDs) that occurred in medical cases in an African referral centre., Design: A descriptive retrospective study., Setting: University of Benin Teaching Hospital, between January 2005 and December 2011., Subjects: Autopsy reports of 626 cases that were referred to the coroner., Results: A total of 626 cases of SNDswere identified representing 30.3% of all autopsies performed within the period. There were 390 (62.3%) males and 236 (37.7%) females with a M:F ratio of 1.7:1. The age range of the cases was 19-105 years with a mean age of 51 ± 17 years. The modal age group was 40-49 years which accounted for 19.8% of the cases, and most of the cases (56.8%) were seen in the 30-59 year age groups. In majority of cases (39.3%), the cause of death was related to the cardio-vascular system-principally death due to complications of hypertension which was seen in 88.2% of the cardio-vascular system diseases. Immune/infectious diseases (mainly AIDS), gastro-intestinal/hepatic lesions and respiratory diseases were seen in 15.2, 14.1 and 12.5% of cases respectively. SNDs due to malignant neoplasms were not a common finding as they occurred in 5.1% of cases., Conclusion: This study shows that with the increasing, modernisation of our lifestyle and dietary habits, cardio-vascular system diseases-particularly complications of hypertension have become the leading cause of sudden natural death in our environment.

Pathologists at veterinary diagnostic laboratories receive medico-legal cases from a variety of animal species for postmortem examination. A search of computerized records of the Animal Health Laboratory, University of Guelph, Guelph, Ontario, Canada from 1998 to 2010 identified 1706 medicolegal cases. These were categorized according to the history as criminal investigations, anesthetic-related deaths, insurance, litigation, malpractice cases, and regulatory cases. Statistically significant linear trends in the proportion of medicolegal cases for all animals and criminal cases for companion animals were identified over the 12 year period. Companion animals had significantly greater odds of being a medicolegal case in all categories except for insurance and regulatory cases, compared to noncompanion animals. Based on pathology reports for the 271 criminal cases, 43.1% were consistent with neglect, 29.2% were compatible with non-accidental injury, 4.80% were poisonings, 10.7% were deemed to be due to natural disease, and 11.43% were inconclusive., (© 2012 American Academy of Forensic Sciences.)

Victims of sexual assault are often advised to seek postassault medical care to have a forensic exam, which includes evidence collection (termed a sexual assault kit [SAK]). After the exam, law enforcement personnel are supposed to submit the SAK to a crime laboratory for analysis. However, recent media reports suggest that in many communities throughout the United States, thousands of SAKs are left untested. Few studies have examined the rate at which law enforcement submits SAKs to crime labs or the factors that may predict them to do so. Thus, the purpose of this exploratory study is twofold: (a) to examine the percentage of SAKs law enforcement submits to crime labs in cases in which a sexual assault nurse examiner (SANE) performed the exam with adult victims and (b) to explore whether assault and law enforcement characteristics predict whether SAKs are submitted to a crime lab. This study found that only 58.6% of the SAKs were submitted to the crime lab within a large Midwestern county. Using binary logistic regression, this study found that kits were significantly as likely to be submitted when there were documented physical (nonanogenital) injuries compared with kits that did not have documented physical injuries. In addition, kits that were handled by a law enforcement agency that had a high level of engagement with the SANE program were significantly as likely to be submitted as law enforcement agencies with a low or medium level of engagement. Kits were significantly less likely to be submitted when victims cleaned themselves after the sexual assault (e.g., bathing). No association was found between kit submission and the victim-offender relationship, suspected drug-facilitated sexual assault, anogenital injury, and when the victim consumed alcohol or drugs before the assault. This article concludes with a discussion of the implications for research and practice.

The prevalence of developmental asymmetry between left and right sides of the body in the third molar tooth and medial clavicular epiphysis is examined in a contemporary Australian population (92% Caucasian). The contention that differences between left and right side developmental timing is statistically insignificant, and can therefore be ignored in forensic age estimation procedures, is questioned. It was found that of a population sample of 604 individuals, 177 displayed asymmetrical timing in development between antimeres of the third molar, the medial clavicle or both. There was no correlation found between the third molar tooth and medial clavicular epiphysis in terms of left/right synchronicity. For those individuals differing in development by two or more developmental stages in either age marker or one stage in both age markers, the effect upon the accuracy of forensic age estimations can be significant. Differences in age estimates for each side were as much as 3.1 years. Age estimations based on one side only may not provide the best estimate for an individual, and more accurate results can be achieved if both sides are taken into consideration. A protocol for dealing with asymmetrical development is discussed with reference to the multifactorial age estimation method proposed by the same authors in previous research.

Background: According to the regulations of the National Health Act, all 'sudden and unexpected' deaths in South Africa should be referred to Forensic Pathology Services (FPS) for further investigation., Objectives: We aimed to determine the final outcomes of forensic postmortem examinations in 'sudden and unexpected' adult deaths referred to Tygerberg FPS between 2001 and 2005., Methods: The study was a retrospective descriptive study. Demographic and autopsy data from adult cases of 'sudden and unexpected deaths' referred to Tygerberg FPS were collected and analysed. Results. Some 816 adult cases of 'sudden' deaths were studied. The presumed manner of death was natural in 645 (79.0%) cases, unnatural in 99 (12.2%), and undetermined in 72 (8.8%). Diseases of the cardiovascular, respiratory and central nervous systems accounted for the majority of natural deaths. Infectious diseases accounted for most deaths in the youngest age group studied (18 - 29 years); however, ischaemic heart disease was the most prevalent cause of death in the total study population., Conclusions: This study highlighted the lack of useful pre-autopsy information and therefore the performance of 'unnecessary' medicolegal autopsies in a resource-limited country. Clinicians could ease the burden by giving useful information when referring cases to FPS. Feedback should be given to family members, especially where the cause of death may have an impact on surviving family members.

This publication deals with the analysis of application of the "Medical criteria for the harm to human health" put into force on September 16, 2008, as exemplified by the work of the Bureau of forensic medical expertise (BFME), Central Health Department of the Moscow region, during the period from 2007 and 2010. The data were borrowed from the materials of departmental statistical reporting (F.42) on forensic medical examinations of the harm to human health carried out during the period between 2007 and 2010. In addition, the statistical report of BFME on the application of the medical criteria in 2010 was used. The number of forensic medical expertises for the estimation of the degree of harm to human health was shown to decrease by 9% but remain 3% higher than the average across the country. The number of expertises of severe harm to the health increased by 15% as in the whole of the country with the concomitant 20% reduction in the number expertises of mild and moderate harm. These trends are unrelated ether to the changes in the frequency of crimes leading to the serious harm to the health or to the number of subjects convicted of such crimes. It was found that p.p. 6.1.1 - 6.1.30 of the "Medical criteria" that list life-threatening injuries are most frequently (in 58% of the cases) used to document facts of severe harm to the health. The same is true of p.p. 6.11. - 6.11.11 listing the injuries responsible for the persistent loss of occupational capacity (by at least one third). The frequency of application of concrete paragraphs of the (Medical criteria, is determined within each group. The largest number of expert errors (3.2%) were committed while estimating serious harm to the health based on the paragraphs listing the injuries responsible for the persistent loss of occupational capacity (by at least one third). The minimal number of such errors (1%) were committed while estimating serious harm to the health from life-threatening injuries.

The European mosaic of socio-cultural, economic and legal realities is reflected in forensic and legal medicine, in which a great variety of operational modes of forensic medical services, organisational systems, structures, functional competences and scientific research strategies can be observed. The present work analyses the European bio-medicolegal scientific output of the last 5.5 years (exact time window, January 1, 2005-June 1, 2010), categorising papers by nationality of the corresponding author and forensic sub-discipline in question, in order to identify the peculiarities of national sub-specialised competences and to build up international research projects. This country-based bibliometric analysis, based on the number of articles and the impact factor produced by each European country, also considering its economic profile (gross domestic product and per capita gross domestic product), highlights the prevailing productive role of Western and Southern Europe (Germany, Great Britain, Italy, Switzerland, Spain and France). Categorising scientific output by forensic sub-discipline and branch, significant in terms of impact factor are contributions from Germany (coming first in Pathology, Toxicology, Genetics, Anthropology and Biological Criminalistics), Great Britain (first in Clinical Forensic Medicine, Malpractice and Invalidity-Social Insurance), Switzerland (first in Criminology), Italy (second in Toxicology, Anthropology and Invalidity-Social Insurance), The Netherlands (third in Clinical Forensic Medicine and Medical Law and Ethics), Spain (third in Genetics, Criminalistics and Invalidity-Social Insurance) and France (third in Toxicology and Malpractice). Interestingly, several countries with low gross domestic product, such as Poland, Turkey and other Eastern European nations, show notable scientific production in specific sub-disciplines such as Pathology, Toxicology and Forensic Genetics, suggesting that fruitful international cooperation could be planned and be of interest to funding sources within the European Community, also taking into account funds reserved for depressed areas undergoing development.

This paper is devoted to the practical application of the medical criteria (MC) for the harm to health (HH) put into force on September 16, 2008. The authors undertook the analysis of procedures of forensic medical expertises for the estimation of the harm to health during the periods before and after putting MC into action (between 2007 and 2010). The results of this analysis were compared with the number of documented criminal actions that caused harm to health and the number of subjects convicted of such crimes. It is shown that the frequency of crimes leading to the serious harm to health has increased (by 22%) in parallel to the roughly similar decrease in the frequency of crimes responsible for the moderate harm. These trends are unrelated to the changes in the number of subjects convicted of such crimes. The frequency of intentional infliction of the serious harm to health decreased by 12% and the number of subjects convicted of the crimes that caused serious (Criminal Code of the Russian Federation, parts 1-3, article 111) and moderate (Criminal Code, article 112) harm to health decreased in 2010 by 5% compared with 2007. The rise in the frequency of the crimes responsible for the serious harm to health (Medical Criteria, pp. 6.11.1-6.11.11) revealed during forensic medical expertises is unrelated to the number of documented crimes and subjects convicted of them under parts 1,2, article 264 of the Criminal Code. The number of documented crimes and subjects convicted of them after the new medical criteria had been put into force (2009 and 2010) decreased by 23% and 15% respectively. It is concluded that putting into effect the new regulations and medical criteria did not result in a substantial change in the relative frequency of the serious and moderate harm to health. Nor did the law enforcement practice gives evidence of any change in the relationship between cases of moderate and serious harm to health and in the number of grave crimes causing the harm to health. The new medical criteria allowed to put in order and present in a structured fashion the data on the harm to health depending on the degree of its severity.

The purpose of this study was to characterize cases of violence against children and adolescents examined at the Forensic Medicine Institute in Maceió, Alagoas State, Brazil. Three hundred and three cases from September, 2008 to March, 2009, were analyzed. Victims were interviewed and data were collected on the type of violence, victim's gender, age, schooling, and economic class, maternal schooling, characteristics of the aggressor and person reporting the case, location, and repeat offenses. Violence against children and adolescents in this sample was concentrated in lower income groups, and girls were victimized more frequently than boys. Most perpetrators were non-relatives, but known to the family. Sexual abuse was more common among younger children, while physical assault was more common against adolescents. The victim's home was the most frequent site of the violence. Further studies are needed to determine whether violence in other socioeconomic groups and against males actually does not occur, or whether it simply is not reported to the Forensic Medicine Institute and thus remains invisible.

Introduction: At 2.7% in 1970, the Danish medico-legal autopsy frequency was lower than recent frequencies observed in the Nordic countries (4-24%). The aim of this study was to analyse trends in the number and frequency of Danish medico-legal autopsies., Material and Methods: Data were collected from the computerized archives in the Danish departments of forensic medicine, Statistics Denmark and the Danish National Board of Health., Results: During the 1996-2005 study period, a total of 14,990 medico-legal autopsies were performed. This yielded a medico-legal autopsy frequency of between 2.4% and 2.8%. Our results revealed a certain constancy in the number of medico-legal autopsies and frequency of autopsy with regard to manner of death, sex and number, but we also observed changes in the age composition which involved a decrease in the proportion of young (20-39 years) and an increase in the proportion of middle-aged persons (40-59 years)., Conclusion: Denmark has a lower autopsy frequency than other Nordic countries and this may constitute a problem for quality of death-statistics and research based on autopsy results. If the patterns in medico-legal autopsy frequencies continue, a decrease in the number of medico-legal autopsies is to be expected. As a consequence, education and training of forensic pathologists may be impaired.

This cross-sectional study aimed to determine the profile of physical abuse against older people who underwent forensic examination at the Institute of Forensic Medicine in Recife, Pernambuco State, Brazil. The cases, with data from 1,027 forensic reports, were described according to characteristics of the incident, victim, and aggressor. Most cases of violence were produced by mechanical energy, either with blunt objects or by empty-handed attack; the most common day of the week was Sunday, most frequently in the evening, and in the victim's home; typical cases involved mild injuries on more than one part of the victim's body. The majority of the victims were men, 60 to 69 years of age, brown (mixed-race), married or living with a partner, and retirees/pensioners. The majority of the aggressors were men, known to the victim, and attacking alone. The social transcendence of violence against older people clearly calls for investment in programs to deal with the problem in order to ensure better quality of life for the elderly.

Objective: To determine the rate and risk of suicide and accidental fatal drug overdose (ie, overdose deemed not to have been suicide) in individuals who had been medically ascertained as having been sexually abused during childhood., Design: A historical cohort linkage study of suicide and accidental drug-induced death among victims of child sexual abuse (CSA)., Setting and Patients: Forensic medical records of 2759 victims of CSA who were assessed between 1964 and 1995 were obtained from the Victorian Institute of Forensic Medicine and linked with coronial data representing a follow-up period of up to 44 years., Main Outcome Measures: Rates of suicide and accidental fatal drug overdose recorded in coronial databases between 1991 and 2008, and rates of psychiatric disorders and substance use recorded in public mental health databases., Results: Twenty-one cases of fatal self-harm were recorded. Relative risks for suicide and accidental fatal overdose among CSA victims, compared with age-limited national data for the general population, were 18.09 (95% CI, 10.96-29.85; population-attributable risk, 0.37%), and 49.22 (95% CI, 36.11-67.09; population-attributable risk, 0.01%) respectively. Relative risks were higher for female victims. Similar to the general population, CSA victims who died as a result of self-harm were predominantly aged in their 30s at time of death. Most had contact with the public mental health system and half were recorded as being diagnosed with an anxiety disorder., Conclusion: Our data highlight that CSA victims are at increased risk of suicide and accidental fatal drug overdose. CSA is a risk factor that mediates suicide and fatal overdose.