Indian Journal of Forensic Medicine and Pathology

1

Indian Journal of Forensic Medicine and Pathology Editor-in-Chief Bhoopendra Singh

Associate Editor Manoj Kumar Mohanty National Editorial Advisory Board Ambika Prasad Patra, JIPMER, Puducherry

Manoj Kumar Pathak, IMS, BHU, Varanasi

Amit Sharma, HIMSR, New Delhi

Mohan Kumar, IMS BHU, Varanasi

Anup Kumar Verma, KGMU, Lucknow

Nishat Ahmed Sheikh, PCMS & RC, Bhopal

Arun M., JSS MC, Mysore

P. C. Dikshit, HIMSR, New Delhi

B. G. Mahesh Krishna, PSG IMS & R, Coimbatore

P. K. Deb, NWMC, Siligurhi, WB

Basanta Kumar Behera, SVMCH & RC, Pondicherry

Pankaj N. Murkey, MGIMS, Wardha

Binaya Kumar Bastia, Gujarat

Prakash B Behera, MGIMS, Wardha

Biswajit Sukul, Medical College, Kolkata

Prateek Rastogi, KMC, Mangalore

Chandeep Singh Makhani, AFMC, Pune

Rajesh Bardale, GMC & H, Miraj

D. N. Bharadwaj, AIIMS, New Delhi

Ruma Purkait , Saugor University, Saugor

Dalbir Singh, PGIME&R, Chandigarh

S.K. Tripathy, IMS, BHU, Varanasi

Jagdeep Jadav, GMERS MC, Himmatnagar

Sandeep Sitaram Kadu, PDVVPF’s MC, Ahmednagar

J. D. Sharma, Sagar University, Sagar

Saubhagya Kumar Jena, SVMCH & RC, Pondicherry

Jakkam Surendar, KIMS, Amalapuram

Shilpa. K, AMC, Kollam

K.D. Chavan, RMC, Loni

Shreemanta Kumar Das, KIMS, Bhubaneswara

K.K. Shaha, JIPMER, Pondicherry

Sudipta Ranjan Singh, AIIMS, Bhubaneshwar

Kapil Dev, LNJN NICCS, Noida

T.K.K. Naidu, PIMS, Karimnagar

M.P. Sachdeva, DU, New Delhi

Venkatesh Maled, SDM CMS&H, Dharwad

Madhu S., GDC, Kozhikode

Vikram Palimar, KMC, Manipal

International Editorial Advisory Board Arun Kumar Agnihotri, Mauritius

R.K. Gorea, Saudi Arabia

B. L. Bhootra, South Africa

Smriti Agnihotri, Mauritius

B.N. Yadav, Nepal

Yao-Chang Chen, U.S.A

Managing Editor: A. Lal & R. Singh

Publication Editor: Manoj Kumar Singh

Indexing Information: NLM catalogue & Locator Plus, USA; Google Scholar; Index Copernicus, Poland; EBSCO Publishing`s Electronic Databases, USA; Academic Search Complete, USA; Academic Search Research & Development, USA; ProQuest, USA; Genamics JournalSeek.

All rights reserved. The views and opinions expressed are of the authors and not of the The Indian Journal of Forensic Medicine and Pathology. The Journal does not guarantee directly or indirectly the quality or efficacy of any product or service featured in the the advertisement in the journal, which are purely commercial.

Corresponding address

Red Flower Publication Pvt. Ltd. 48/41-42, DSIDC, Pocket-II, Mayur Vihar Phase-I Delhi - 110 091(India) Phone: 91-11-22754205, 45796900, Fax: 91-11-22754205 E-mail: [email protected], Web:www.rfppl.co.in

Indian Journal of Forensic Medicine and Pathology / Volume 9 Number 1 / January - March 2016

2

The Indian Journal of Forensic Medicine and Pathology (IJFMP) (pISSN: 0974–3383, eISSN: 0974-3391, Registered with registrar of newspapers for India: DELENG/2008/30937) is a major new multidisciplinary print & electronic journal designed to support the needs of this expanding community. The Indian Journal of Forensic Medicine and Pathology is a peer-reviewed and features original articles, reviews and correspondence on subjects that cover practical and theoretical areas of interest relating to the wide range of forensic medicine. Subjects covered include forensic pathology, toxicology, odontology, anthropology, criminalistics, immunochemistry, hemogenetics and forensic aspects of biological science with emphasis on DNA analysis and molecular biology. Submissions dealing with medicolegal problems such as malpractice, insurance, child abuse or ethics in medical practice are also acceptable. Letters to the Editor that relate to material published recently in the Journal or comment on any aspects of the Journal are welcomed. This publication also features authoritative contributions describing ongoing investigations and innovative solutions to unsolved problems. Subscription Information India Individual: Contact us Institutional (1 year)

INR15500/USD1550

PAYMENT METHOD By cheque/Demand Draft: Cheque should be in the name of Red Flower Publication Pvt. Ltd. payable at Delhi. By Bank Transfer/TT: Bank name: Bank of India Swift Code: BKIDINBBDOS Account Name: Red Flower Publication Pvt. Ltd. Account Number: 604320110000467 Branch: Mayur Vihar Phase-I Delhi – 110 091 (India) Send all Orders to: Red Flower Publication Pvt. Ltd., 48/41-42, DSIDC, Pocket-II, Mayur Vihar Phase-I, Delhi – 110 091, India, Phone: 91-11-22754205, 45796900, Fax: 91-11-22754205, E-mail: [email protected], Website: www.rfppl.co.in.


3

Indian Journal of Forensic Medicine and Pathology January - March 2016 Volume 9 Number 1

Contents Original Articles Profile of Burn Injury Cases and Medicolegal Formalities Done at Clinical Forensic Medicine Unit (CFMU) of MGIMS, Sewagram

5

B.H. Tirpude, I.L. Khandekar, T.D. Wankhade, P.N. Murkey, Ashish Salankar

Suicide Methods in Elderly

11

Vaibhav Sonar, Rajesh Bardale, Nitin Ninal

Adolescents Suicide - A Social and Preventable Problem

15

W. Sandhya Manohar, Boddupally Ravi Kumar, Nishat Ahmed Sheikh

Biopsy Findings in Coronary Arteries of Sudden Cardiac Death

21

Vennila Vijayasree, W. Sandhya Manohar, Sunethri Padma

Case Report Delayed Death in Hanging

29

Venkatesh Maled

Guidelines for Authors


33

Indexing information page of Index Copernicus

4


Original Article

Indian Journal of Forensic Medicine and Pathology 5 Volume 9 Number 1, January - March 2016 DOI: http://dx.doi.org/10.21088/ijfmp.0974.3383.9116.1

Profile of Burn Injury Cases and Medicolegal Formalities Done at Clinical Forensic Medicine Unit (CFMU) of MGIMS, Sewagram

B.H. Tirpude*, I.L. Khandekar**, T.D. Wankhade***, P.N. Murkey**, Ashish Salankar*** Abstract Burn injury is main issue among the people of India since long back from the history, creating a formidable public health problem. Our objective of the present study is to measure the magnitude and epidemiology of burn cases presented in the accident and emergency department of the hospital medical college and various medicolegal formalities to be followed while dealing of such cases. The present study was conducted at Clinical forensic Medicine Unit (CFMU) of the Rural Hospital of MGIMS, Sewagram. This unit is working under department of Forensic medicine and is situated at accident and emergency department of the hospital. The study only included burn cases which are reported live. In this study total 103 cases of burn injuries are observed during the period of one year. Out of these total 103 cases of 56(54.36%) were male and 47(45.63%) were female patient. Most commonly involved age group was 21-30 years. Among the various etiological type of burn injury, Flame burn was the most common type of burn injuries. Among the flame burn injuries involvement of female patient are more than male. Married female were more commonly involved than married males. Keyword: Burn Injuries; CFMU; Medicolegal Formalities.

Introduction Burns constitute a major public health problem, especially in low and middle income countries where in majority of the cases burn deaths occur. Fire related burns alone account for over 3 lakh deaths per year. However, deaths are not only part of the problem, for every person who dies as a result of their burns; many more are left with lifelong disabilities and disfigurements. For some this means living with the stigma and rejection that all too often comes with disability and disfigurement. Present study includes live cases of burn injuries brought at clinical forensic medicine unit of MGIMS, Sewagram. This unit is situated at accident and emergency department of the hospital of the MGIMS, Sewagram. CFMU in accident and emergency department look Authors Affiliation: *Professor and Head, **Professor, ***Resident, Department of Forensic Medicine MGIMS, Sewagram, Dist Wardha, Maharashtra 442012. Reprints Requests: B.H. Tirpude, Professor and Head, Department of Forensic Medicine MGIMS, Sewagram, Dist Wardha, Maharashtra 442012. E-mail: [email protected]

for all medico-legal formalities of the medico-legal cases brought in the Hospital. This unit is manned by postgraduate Student posted in department of Forensic medicine under the supervision of the forensic medicine consultant. Aims and Objectives  To study to the profile of burn injury cases brought to CFMU of Medical College.  To study the various medicolegal formalities done while dealing with these cases. Material and Methods This study is cross sectional study and conducted at Clinical Forensic Medicine Unit (CFMU) of Hospital of Medical College. Burn cases are selected from the various medico legal cases registered at CFMU during the rotational duty of the corresponding author over the period of one year. The cases which are not reported during the rotational duty of corresponding author are excluded from this study. CFMU is situated at casualty

© 2016 Journal Red Flower Publication Pvt.and Ltd.Pathology / Volume 9 Number 1 / January - March 2016 Indian of Forensic Medicine

6

B.H. Tirpude et. al. / Profile of Burn Injury Cases and Medicolegal Formalities Done at Clinical Forensic Medicine Unit (CFMU) of MGIMS, Sewagram

(accident and emergency department) of Hospital. At this Hospital whenever a patient comes to casualty, Casualty medical officer examine the patient and if he feels that the case needs medicolegal formalities then he inform it to CFMU. After that the duty doctor at CFMU examines the patient along with treating doctor as a part of team. He note down demographic details and history of the incidence, he examines the patient and do needful medicolegal formalities like informing the police, making Forensic Medical Reports i.e. injury report, collecting needful sample after taking valid consent etc. In the present study, information regarding the demographic details of the victim like age, sex, marital status, religion, domicile, time and place of incident were gathered by interviewing the patient or patient’s attendants (parents, guardian, relatives, friends, etc.). Finding like type of burn injury, whether patient fit for statement, age of the injury, causative object/evidence of combustible material, severity of injury etc. are the various medicolegal opinion given after examination of the patient. In Burns cases, as per the causes, the cases are categorized into scalds, flame, electricity, and lightening. Standard medicolegal literature was followed to identify the cause of burn [1]. The percentage of Total body surface area involved is calculated by the “Rule of Nine”. According to this rule, the head and neck, front of chest, back of chest, front of abdomen, back of abdomen, right upper limb, left upper limb, front of left lower limb, back of left lower limb, front of right lower limb, back of right lower limb, each of which constitute 9% of the whole body area and pudendal area constitute 1% of the whole body area. In case of children the total body surface area is calculated as, head and neck 15%, front of trunk 20%, back of trunk 20%, upper limbs 20%, lower limbs 20% and genitalia 0-10% of total body surface area. For small burns of irregular outline in adults the burn is compared to the palm of

victim’s hand which approximates 1% of total body surface area [1]. Findings Observation and Result In the present study maximum number of victims 42(40.77%) were in the age group of 21-30 years, followed by 30 (29.12%) cases in the age group of 3140 years. Males 56(54.36 %) outnumbered the females 47(45.63%) cases. In present study out of total 103 cases 53(51.45%) are from rural area and 50(48.54%) from urban area. Out of 103 cases of burns, 72(69.90%) cases had < 25% burns followed by 13(12.65%) cases having 2650% burn, 12(11.65%) cases having 51-75% burns and 6 (5.82%) having > 75% burns In the present study out of 103 cases maximum 47(45.63%) burn cases are due to flame burn injury, followed by 30 (29.12%) cases are due to scald burn, 25(29.12%) cases are due to electrocution and 1(0.97%) case of lightning is present. Out of these various cases female sex is predominantly involved in flame burn cases i.e. 33 (70%) out of 47 cases, while male sex predominance is seen in scald burn and electrocution cases. Out of 103 burn cases 73(70.87%) were married and 30(29.12%) cases were unmarried. Of the 47 females, 38(80.85%) were married and 9(19.14%) unmarried in contrast to 56 males, 35(62.2%) married and 21(37.5%) unmarried. Out of 103 Burn cases in 40(38.83%) Cases hair had been preserved for chemical analysis and in 63 (61.15%) cases it was not preserved similarly cloth has been preserved in 41(39%) cases out of total 103 cases. Police information was done in all burn cases (100%) which were reported to CFMU.

Table 1: Distribution of burn cases according to age and sex (N=103) Age In Years 60 Total

Male 3 4 25 18 6 0 0 56 (54.36 %)

Female 3 2 17 12 6 1 6 47 (45.63%)

Table 2: Distribution of burn cases according to the urban/rural pattern

Total (%) 06 (5.58%) 06 (5.58%) 42 (40.77%) 30(29.12%) 12 (11.65%) 1 (0.97%) 103 (100%) (N= 103)

Type of Medico-legal case

Urban

Rural

Total

Burn

50 (48.54%)

53 (51.45%)

103



7

Table 3: Distribution of burn cases according to percentage of burns (N=103) % of Burn Up to 25 26-50 51-75 >75 Total

Number of cases 72 12 13 6 103

Percentage 69.90% 11.65% 12.62% 5.82% 100%

Table 4: Distribution of various type burn cases according to sex (N=103) Type of Burn

Male

Female

Total Number of cases

Electric Flame Lightning Scald Total

20 14 0 22 56

5 33 1 8 47

25 47 1 30 103

Table 5: Distribution of burn cases according to marital status (N=103) Marital Status

Male

Female

Total

Married Unmarried Total

35 21 56

38 9 47

73 (70.87%) 30 (29.12%) 103

Table 6: Various sample of medicolegal importance in burn cases preserved at CFMU Sample Hair for C. A. Burnt Clothes

Preserved 40 41

Not Preserved

Total

63 62

103 103

Table 7: Various documentation done and sample preserved in burn cases Documents

Done

Not done

Total

Police Information Injury Report

103 103

0 0

103 103

Discussion Maximum number 42(40.77%) cases were seen in the age group of 21-30 years, followed by 30(29.12%) cases in 31-40 years age group. It was found that 70% victims were between 21-40 years. Our results are similar to the result of study conducted by Jaiswal AK et al.2 Reason behind this could be that this age group is a productive age, more active, and they are generally exposed to hazardous situations both at home and work. Female in this age group more succumbed to burn injury as the contact with fire is more common in female due to cooking related activity. And male are exposed to burn due to his work related activity like industrial work (e.g. exposure to hot steam, boiling liquid), electric work etc. In the present study, out of total 103 cases majority of burn victims 56(54.36%) were males. This result is similar to the results of the studies conducted by Haberal et al [3], Gupta M et al [4], and Aida AFA et al [5], However, our result is not consistent with the results of Ravi KE et al [6], Kumar P et al [7], Mago V et al [8], Jaiswal AK et al [2], Ghaffer UB et al [9], and Shanmughkrishnan et al [10], where maximum

numbers of victims were females. Involvement of female is less in our study but the results of our study suggests significant contribution of female victims in burn cases i.e. 45.63%. Reason behind this could be due to female’s close proximity to fire throughout the day and night which makes female more prone for burn injury. Overall male predominance may be due to our study contains significant number of burn cases due to electrocution which involves maximum number of male victim, and male are predominantly involved in electricity related job and hence more succumbed to such injuries. However considering the flame burn female involvement is more. In case of Burns, out of 103 cases, maximum numbers 53 (51.45%) cases were from rural areas and 50 (48.54%) from urban areas. Our results are similar with the result of the study conducted by Jaiswal AK et al [2], this could be due to the traditional household practice of cooking in rural area, large scale use of unsafe stoves and use of kerosene as a fuel for cooking and lightning lamp, lack of safety system and the prevailing socio-cultural determinant. As per as percentage of burn is concerned 72 (69.90%) cases had £ 25 % TBSA (total body surface area) burns, 12(11.65%) cases had 26-50% burns, 13


8


(12.62%) cases had 51-75 % burns and 06(5.82%) had burns more than 75%. This result is similar to the results of the study conducted by Ghaffer UB et al. [9] However, our result is not consistent with the results of the study conducted by Ravi KE et al,6 Kumar P. et al [7], and Shanmugakrishnan RR et al,10 where the involvement of total body surface area was more common in between 25-50%. In our study we have included all the cases of burn reported to casualty department irrespective the severity of the case. Assessment of the percentage of burn is required to determine the severity of the wound. Considering the type of burns out of 103 cases maximum 47(45.63%) burn cases are due to flame burn, followed by 30(29.12%) cases are due to scald burn, 25(29.12%) cases are due to electrocution and 1(0.97%) case of lightning is present. Our results are similar with the studies conducted by Haberal M et al. [3] Gupta M et al [4], kumar P et al [7], Aida AFA et al [5], Mago V et al [8], where in all these studies flame burn is most common cause of the burn injuries.

study married females are more commonly involved than married males. Our results are consistent with the studies conducted by Ghaffer UB et al [9], where 72.5% burn victim were married and female outnumbers the male victims. Reason behind this could be due to increasing familial stress, day to day problem like jobs, family disputes, cooking activities etc. and hurrying through in an overcrowded room with minimal amenities inviting frequent accidents commonly among married people and mostly in female. Sample preservation like burnt hair and clothes are necessary as they can be analysed chemically for detection of the combustible material and hence has strong role in investigation. Police usually ask for these samples. In our study out of 103 Burn cases in 40(38.83%) Cases hair had been preserved for chemical analysis and in 63(61.15%) cases it was not preserved similarly cloth has been preserved in 41(39%) cases out of total 103 cases. This suggests that CFMU is very well assisting the investigating authority for collection of the evidence.

The high incidence of flame burn is explained by use of oil for lamps in villages, candle for lighting, substandard kerosene and gas stoves, use of open coal and wood fires chullha for warmth and cooking in villages and use of pressure stoves for cooking in urban areas. Female are most commonly involved in flame burn injury than males as they are more involved in cooking activities and have direct contact with fire with most of the times. Scalds can be caused by heating water too high for bathing purpose. It often results due overturn hot liquids in pans, bowls, and cups and are more likely to cause burn. Scald burn also observed among the industrial worker, due to exposure of hot liquid or steam and also among food industry worker. Another common cause of burn injury was the electrocution which was more common in male individual and main reason behind this lack of safety precaution while doing electric work.

Police information was done in all burn cases (100%) which were reported to CFMU.

Opinion regarding the cause of burn is important for the purpose of the investigation, as there are the instances, where judiciary has given benefit of doubt to the accused, when medical evidences was unable to prove conclusively the type of burn, i.e. whether flame/scald and hence we included it in our forensic medicine injury report as part of opinion column.

Clothes and hairs were preserved for further investigation by police agencyin maximum number of cases. This suggests that CFMU manned by forensic expert can very well assist the investigating authority for collection of the evidence in particular medicolegal case; hence quality medicolegal work can be done at Medical college level.

Among the victims of burns, 73(70.87%) were married and 30(29.12%) unmarried. Among 47 females, 38(80.85%) were married and 9(19.14%) were unmarried and in contrast to 56 males, 35(62.5%) married and 21(37.5%) were unmarried. As per our

Medicolegal reports done at CFMU are complete and reliable as expert are involved and opinion regarding cause of burn and combustible material is also involved in the report.

Conclusions In case of burns male outnumbered females with the ratio of 1.19: 1. Maximum numbers were reported between the age group of 21-30 years. Victims of flame burns were more followed by scalds burns and electrocution. And it also shows involvement of the female is significant. Among the flame burn injury female with 33(70.21%) cases outnumbers the male with 14 (29.78%) cases. While in case of electrocution and scald male are more commonly involved. Married females are more commonly involved in burn injury than married males.

Police information was done in 100% cases of burns.



Acknowledgement: Nil

4.

Gupta M, Gupta OK, Yaduvanshi RK, Upadhyaya J. Burn Epidemiology: The Pink City Scene. Burns. 1993; 19(1): 47-51.

Ethical Clearance

5.

Aida AFA, Sherif AA, Mandil AM, Massoud MN, Nazel MWA, Arafa MA. Epidemiological and sociocultural study of burn patients in Alexandria, Egypt. Eastern Mediterranean Health Journal. 1997; 3(3): 452-461.

6.

Ravi KE, Vijaya K. A comprenhensive study on epidemiology of medico-legal cases. Journal of Indian Academy of Forensic Medicine. 2005; 27(4): 139-151.

7.

Kumar P, Chadda A. Epidemiological study of Burn cases and their mortality experiences amongst adults from a tertiary level care hospital. Indian J of Community Med. 1997; XXII(4): 160-167.

8.

Mago V, Yaseen M, Bariar LM. Epidemiology and mortality of burns. Indian J of Community Med. 2004; 29(4): 187-191.

9.

Ghaffer UB, Husain M, Rizvi SJ. Thermal Burn: An Epidemiological Prospective Study. Journal of Indian Academy of Forensic Medicine. 2008; 30 (1): 10-14.

Ethical clearance for the present study was obtained from the institutional Ethical Committee. MGIMS, Sewagram. Source of Funding Nil. Fund was not required for this study. Conflict of Interest - Nil References 1.

Reddy KS The Essential of forensic Medicine and Toxicology 31st ed. Hyderabd K. Suguna Devi. 2012; p.297-311.

2.

Jaiswal AK, Aggarwal H, Solanki P, Lubana PS, Mathur RK, Odiya S. Epidemiological and sociocultural study of burn patients in M.Y. Hospital, Indore, India. Indian J Plast Surg. 2007; 40(2): 158-163.

3.

9

Haberal M, Ugar N, Bayraktar U, Ener Z. Analysis of 1005 patients treated in our center. Annuals of Mediterranean Burns Club. 1993; 6(2): 73-77.

10. Shanmugakrishnan R R, Narayanan V, Thirumalaikolundusubramanian P. Epidemiology of burns in a teaching hospital in south India. Indian J plast Surg. 2008; 41(1): 34-37.


10

Indian Journal of Forensic Medicine and Pathology Library Recommendation Form If you would like to recommend this journal to your library, simply complete the form below and return it to us. Please type or print the information clearly. We will forward a sample copy to your library, along with this recommendation card. Please send a sample copy to: Name of Librarian Name of Library Address of Library Recommended by: Your Name/ Title Department Address Dear Librarian, I would like to recommend that your library subscribe to the Indian Journal of Forensic Medicine and Pathology. I believe the major future uses of the journal for your library would provide: 1. useful information for members of my specialty. 2. an excellent research aid. 3. an invaluable student resource. I have a personal subscription and understand and appreciate the value an institutional subscription would mean to our staff. Should the journal you’re reading right now be a part of your University or institution’s library? To have a free sample sent to your librarian, simply fill out and mail this today!

Stock Manager Red Flower Publication Pvt. Ltd. 48/41-42, DSIDC, Pocket-II, Mayur Vihar, Phase-I Delhi - 110 091 (India) Tel: 91-11-22754205, 45796900, Fax: 91-11-22754205 E-mail: [email protected], [email protected] Website: www.rfppl.co.in



Original Article

Suicide Methods in Elderly

Vaibhav Sonar*, Rajesh Bardale**, Nitin Ninal*** Abstract The method of suicide employed varies over time, with age, gender and sociocultural factors. We retrospectively analysed over a 10 year period, from January 2001 to December 2010 for cases of suicide in individuals above the age of 65 years, at Department of Forensic Medicine, Government Medical College, Miraj, M.S. Total of 81 cases were found with an age range of 65-95 years (mean = 72.4 years) out of 4828 medicolegal autopsies. There were significantly more males than females (58:23). Hanging was found to be most common method (28/81; 34.57%), then poisoning (27/81; 33.33%). Burns and drowning cases were more in female. Keywords: Elderly Suicide; Hanging; Poisoning; Drowning; Burns.

Introduction Suicidal acts are multifaceted human behaviours involving many aspects of an individual’s personality, state of health, and life situations. Though suicide accounts for a significant percentage of unnatural deaths globally, rates in different populations and age groups have varied over time, as have predisposing factors and the methods that have been used. Particular problems occur in older individuals which may predispose to self-destructive acts. Social isolation with significant mental and physical illnesses tend to be more common in the elderly, who may elect to terminate their lives rather than endure painful disease or loss of independence if nursing home placement is being considered [1]. Accessibility to an appropriate means of selfdestruction has also been cited as a factor in determining the most favoured methods employed [2,3]. North American studies on suicide in older individuals have shown a preponderance of cases of fatal gunshot wounds [1,4]. Study from Australia Authors Affiliation: *Associate Professor, **Professor and Head,***Aissistant Professor, Dept. of Forensic Medicine, Govt. Medical College, Miraj, Dist. Sangli, Maharastra. Reprints Requests: Vaibhav Sonar, Associate Professor, Dept. of Forensic Medicine, Govt. Medical College, Miraj, Dist. Sangli, Maharastra-416410. E-mail: [email protected]

had shown hanging followed by gunshot wound as preferred method[5]. Studies from various parts of India revealed hanging and poisoning as most common methods [6,7]. The following study was undertaken to determine how suicide methods and rates in an elderly west Maharashtrian population compared to other groups, and whether any changes over time had occurred. Material and Methods We retrospectively analysed over a 10 year period, from January 2001 to December 2010 for cases of suicide in individuals above the age of 65 years, at Department of Forensic Medicine, Government Medical College, Miraj, M.S. Relevant data were collected from autopsy report, inquest reports, chemical analyser’s reports and hospital case records. Collected data were analysed using IBM SPSS 20 version statistical software, for gender differences and for trends over time. Results During study period (2001 -2010) total of 81 cases were found with an age range of 65-95 years (average = 72.4) which was 1.68% (81/4828) of all cases autopsied at Govt. Medical College, Miraj, M.S. There


12

Vaibhav Sonar et. al. / Suicide Methods in Elderly

were significantly more males than females (58:23). The number of suicides from 2001 to 2005 was 25 with 16 male and 9 female cases; 56 from 2006 to 2010, with male 42 and female 14 cases. There was no significant increase in suicide rate. Hanging was found to be most common method (28/81; 34.57%), then poisoning (27/81; 33.33%), followed by drowning (17/81; 20.99%), burns (8/81; 9.88%) and only one case of gunshot wound (1/81; 1.23%). Figure 1. Year wise distribution of cases were as per Figure 2. There were 25 male and 3 female hanging deaths with age range of 65- 92 years, a mean of 70.8 years with marked male predominance (p < 0.001). The age range for male was 65-92 years (mean = 70 years) and for female was 65- 90 years, mean age 77 years. There were 24 male and 3 female poisoning deaths with age range of 65- 95 years, a mean of 71.3 years with marked male predominance (p < 0.001). The age range for male was 65-95 years (mean = 71.9 years) and for female was 65- 70 years, mean age 66.66 years. Chemical analysers report revealed maximum number of organophosphorus compounds, Monocrotophos (3/27), Dichlorovus (4/ 27), Chlorphyriphos, cypermethrin (3/27), Endosulfan (Thiodan) ( 1/27), OP compounds (3/

27). Chemical analysers report was negative in 12 cases, only one case is of organochloro compound. So all cases were of insecticide poisoning. Survival period is 6 hours to 9 days, 5 cases were brought dead. There were 7 male and 10 female drowning deaths with age range of 65- 95 years, a mean of 76 years with significant more female cases (p < 0.001). The age range for male was 65-83 years (mean = 73.14) and for female was 65- 95 years, mean age 78 years. Deaths due to drowning occurred in river and well. There were 1 male and 7 female burns deaths with age range of 75- 90 years, a mean of 79 years with significant more female cases (p < 0.001). Only one case of male was found with age of 75 years and for female was 75- 90 years, mean age 79 years. Out of eight cases five cases were brought dead. Survival period was 6 hrs to two days. One case of suicidal gunshot wound (firearm) was found in the study period of 65 years old male who committed the act in temple. Gunshot wound was present over abdomen. Multivariate analysis of method of suicide with reference to age, sex, residence and marital status is shown in Table 1. It showed significant relation with method of suicide.

Fig. 1:

Fig. 2:


Vaibhav Sonar et. al. / Suicide Methods in Elderly

Table 1: Multivariate analysis between-subjects factors Group

Source Group

1 2 3 4 5

Method of Suicide

Number of cases

Poisoining Hanging Burn Drowning Gunshot

27 28 8 17 1

Dependent Variable Age Sex Residence Marital status

F 2.820 11.269 4.648 7.484

P-value .031 .000 .002 .000

Discussion Suicide in general, across various civilizations and religion has always been condemned. Although it is widely encountered, the various complexities involved are unfortunately ill understood. A proper understanding of these aspects is imperative for any suicide investigation [6]. Present study includes 81 cases of elderly suicides. This reflects 1.68% of all cases autopsied at GMC, Miraj. It was 1.6% in Manipal [6]. Male victims predominated and this finding is consistent with previous studies [5,6,7,8]. Hanging was found to be most common method (28/81; 34.57%). Deaths due to hanging was 24% in South Austaralia [5], 17.9% in Manipal, South India [6], 65.5% in Manglore, South India[8], 52% in Study in Tamilnadu [7] But differs from the studies from North America [2], where 80.7% of suicides were due to gunshot wounds. In this study one case was found due to gunshot wound. Thus choice of method of suicide differs in different populations. Gun legalisation is much stricter in Maharashtra, India and so it is possible that the significantly lower numbers of suicides in elderly Maharashtrians is due to lack of access to firearms. Poisoning deaths were 27 out of 81cases (33.33%) and deliberate consumption organophosphorus compounds being most preferred method. It is consistent with studies from Manipal [6], Manglore [8], and Tamilnadu [7]. People in this region have easy accessibility to these insecticides since these are commonly used for agriculture purpose. Drowning deaths were 17(20.99%), burns deaths were 8(9.88%), and female cases were more in these two methods of elderly suicide. These findings are consistent with previous studies [7,8]. The method of suicide employed varies over time, with age, gender and sociocultural factors. It is a general principle that elderly men adopt more violent methods than women, which may partially explain

13

the gender difference in rates. In England and Wales, hanging currently remains the most common method employed by men, while self-poisoning is most often used by women. In the USA, firearms are used by over 60% of all completed suicides, with elderly White men employing this method most frequently [9]. In our study most common method used by male were hanging followed by poisoning, female preferred burns and drowning. Extending psychiatric services to the suicide prone elderly individuals in the community may reduce incidence of suicide. Reducing the availability of means of suicide as a preventive strategy has been advocated as an important strategic initiative. Programmes aimed at suicide prevention will require data derived from specific target population so that peculiar local trends and population characteristics can be identified and appropriate preventive measures can be formulated. Acknowledgements We would like to thank Mr. C.G.Patil, Assistant Professor in Statistics and demography, G.M.C. Miraj, for his statistical advise. References 1.

Quan H, Arboledo-Florez J. Elderly suicide In Alberta: difference by gender. Can J Psychiatr. 1999; 44: 762-8.

2.

Byard RW, Markopoulos D, Prasad D, Eitzen D, James RA, Blackbourne B, Krous HF. Adolescent suicide – a comparative study. J Clin Forensic Med. 2000; 7: 6-9.

3.

Klitte A , Gilbert JD, Lokan R, Byrad RW. Adolescent suicide due to inhalation of insect spray. J Clin Forensic Med. 2002; 9: 22-4.

4.

Bennett AT, Collins KA. Elderly suicide- a 10- year retrospective study. Am J Forensic Med Pathol. 2001; 22: 169-72.

5.

Byard RW, Hanson KA, Gilbert JD. Suicide methods in the elderly in South Australia 1981- 2000. J Clin Forensic Med. 2004; 11: 71-74.

6.

Palimar V, Arun M, Bhagavath P, Raghvendra Babu YP, Mohanty MK. Fatal deliberate self harm in geriatrics. JIAFM. 2006; 28(4): 177-79.

7.

Abraham VJ, Abraham S, Jacob KS. Suicide in the elderly in Kaniyambadi block, Tamilnadu, South India. Int J Geriatr Psychiatry. 2005; 20(11): 1090-6.

8.

Kanchan T, Menon A, Rastogi P, Menenzes RG. Suicides in the elderly- A study from Manglore, South India. Int J Med Toxicol & Leg Med. 2009; 11(3).

9.

Cattel H. Suicides in the elderly. APT 2000;6:102-8.


14

Subscription Form I want to renew/subscribe international class journal “Indian Journal of Forensic Medicine and Pathology” of Red Flower Publication Pvt. Ltd. Subscription Rates: • India: Institutional: INR15500/USD1550 • Individual: Contact us Name and complete address (in capitals):

Payment detail: Demand Draft No. Date of DD Amount paid Rs./USD

1. Advance payment required by Demand Draft payable to Red Flower Publicaion Pvt. Ltd. payable at Delhi. 2. Cancellation not allowed except for duplicate payment. 3. Agents allowed 10% discount. 4. Claim must be made within six months from issue date.

Mail all orders to Red Flower Publication Pvt. Ltd. 48/41-42, DSIDC, Pocket-II, Mayur Vihar Phase-I, Delhi - 110 091 (India) Tel: 91-11-22754205, 45796900, Fax: 91-11-22754205 E-mail: [email protected], [email protected] Website: www.rfppl.co.in


Original Article


Adolescents Suicide - A Social and Preventable Problem

W. Sandhya Manohar*, Boddupally Ravi Kumar**, Nishat Ahmed Sheikh*** Abstract Background: Adolescence is a period in the life of human being, wherein they are subjected to face multiple factors which challenge their survival. Many people are facing them successfully. Some are becoming victimised for them and committing suicides. The study made on adolescents suicides to find out the precipitating factors which motivated to commit suicide. Many of these deaths can be prevented, because all the factors are found to be avoidable. Aims and Objectives: To analyse the age related problems faced by the adolescents which are leading to commit suicide, and to identify the precipitating factors in causation of such deaths. Study Design: It’s a cross sectional Prospective study. Material and Method: The medico legal Post-Mortem Examinations were conducted on the victims of suicides in the age group of thirteen to eighteen years in one year beginning from January to December. Data were collected from the Inquest, Panchanama of the scene of offence, hospital records, suicide notes and information gathered by personal enquiry with the relatives. Observation and Discussion: Physical illness is leading (24.8%) Table No. 1, among all suicides in adolescents. 12 students died among the 19 educated males for failure in their studies. Students who could not succeed in their competitive examinations were 8 in the present study, failed in 10th class were 3 and one student died for not clearing the 7th class. Punishments given by Parents and/or Teachers have resulted in 11 deaths in males and 8 deaths in females. The number of deaths occurring in the late period of adolescent i.e. 16 to 18 years are more, as they are reaching the adult stage do experience lot of stress and emotional turmoil. The rising expectations and responsibilities may create pressures for many of them. Conclusion: The identification of more specific risk factors of suicide will help better prediction of Suicidality and hence, better assessment process, better treatment and more targeted prevention programs. Keywords: Adolescence; Suicide; Precipitating Factors.

Introduction Adolescent suicide is a complex topic, which can be approached from many different angles. During the past quarter-century, suicide among the young has emerged as a significant global public health problem. In many countries, youth suicide is one of Authors Affiliation: *Associate Professor, **Assistant Professor of Forensic Medicine, Kamineni Institute of Medical Sciences, Narketpally, District Nalgonda, State Telangana. ***Professor of Forensic Medicine, People’s college of Medical sciences & Research Centre, Bhopal. Reprints Requests: Nishat Ahmed Sheikh, Professor of Forensic Medicine, Department of Forensic Medicine, People’s College of Medical sciences & Research Centre, People’s University, Bhanpur, Bhopal, Madhya Pradesh 462037. E-mail: [email protected]

the leading causes of death. (World Health Organization 2002). Human being faces a spectrum of continuous changes occurring throughout, at different phases of the life. Adolescence is the transition period in the human life, which brings about changes in the anatomical, physiological, biochemical, psychological, social, educational, environmental and economical strata of a person [1,2,3,4]. All these changes are reflected in their morphology and their behaviour. Some of these changes are acceptable and pleasant to them and some of them cause discomfort and inconvenience. Unpleasant morphological changes include the pains from different origins viz, mastalgia, dysmenorrhoea, headache, insomnia etc. Changes, which are seen in the behaviour, are more distressing to self and to their care takers [2,5]. He/she becomes reluctant to seek the help or counselling from elders because of several


16

W. Sandhya Manohar et. al. / Adolescents Suicide - A Social and Preventable Problem

reasons [6]. The reasons for such changes in the behaviour are multidisciplinary and are because of the milieu interior and exterior. Suicidal ideation refers to thoughts of harming or killing oneself. Attempted suicide is a non-fatal, selfinflicted destructive act with explicit or inferred intent to die. Suicide is a fatal self-inflicted destructive act with explicit or inferred intent to die. Suicidality refers to all suicide-related behaviours and thoughts including completing or attempting suicide, suicidal ideation or communications. The present day concept of nuclear and small families causes a lot of changes and pressures on these tender aged persons because of the expectations of their parents. Some of the girls are getting married in this age group, wherein they are expected to live in their in-laws houses, which are unknown and different from their maternal environment. All these factors are playing an important role and abetting them to victimize for suicides. It became second leading cause of death among the adolescents [7]. The present study is made on these factors and their role in committing suicides in the age group of thirteen to eighteen years.

Medico legal post-mortem examinations in the mortuary of Kakatiya Medical College, Warangal, including the deaths occurred in hospitals and also unattended deaths. Exclusion Criteria Deaths of persons whose age is not certain as, in unidentified bodies, and where a suspicion expressed in the Panchanama about homicide or accident.

Fig. 1: Incidence of suicide deaths in the adolescent age group

Observation and Discussion Aims and Objectives To analyse the age related problems faced by the adolescents which are leading to commit suicide, and to identify the precipitating factors in causation of such deaths. Material and Methods It is a cross-sectional study done in the mortuary associated with Department of Forensic Medicine and Toxicology of Kakatiya Medical College, Warangal. The medico legal Post-Mortem Examinations were conducted on the victims of suicides in the age group of thirteen to eighteen years in one year beginning from January to December. Data were collected from the Inquest, Panchanama of the scene of offence, hospital records, suicide notes and information gathered by personal enquiry with the relatives. The data was incorporated into a computerised data collection sheet and statistically analysed in the MS office excel spread sheet.

Total 117 no cases were included in the study, and out this 34.2% were Males and 65.8%were of Females Fig. No 1. The male to female ratio is 1:1.93. The most vulnerable age group found to be between 16 – 18 years, with a ratio of 2.77:1 in relation to the age group between 13 – 15 years. Females dying in the age group of 16 – 18 years are outnumbered (49%) of all adolescent suicidal deaths. However a few studies on adolescent suicide from south India pointed out a male preponderance over females. One of the reasons for disagreement could be due to the different category of suicides studied; our findings are in line with Nandi et.al, who had noted female preponderance of suicides. Corresponding to the Indian report, in western countries too males have a suicide rate higher than females though the difference between the two is gradually narrowing.

Inclusion Criteria Cases were included where person died in the age group of thirteen to eighteen years, from both genders, who committed suicide (according to the Panchanama), cadavers of whom were subjected to

Fig. 2: Educational status



17

Majority of the adolescent suicide in the present study are illiterate or had only primary education. Fig 2. This is contrary to the study observed by Chandrasekaran et al., 2003 Different domiciliary background could be the reason for this observation. Education influences coping and problem solving skills probably.

In our study of Adolescent suicides out of 117 cases, 42.7% belong to student group whereas 22.2% were Labourer, housewife account to 19.7%, whereas 15.4% were jobless with no occupation Fig. No. 3 There is a fairly strong association between unemployment rates and suicide, but the nature of this association is complex. Unemployment may drive up the suicide risk through factors such as

Fig. 3: Occupation

Fig. 4: History of previous suicidal attempts

Table 1: Precipitating factors for committing suicides Motive Behind Committing Suicide Physical Illness Failure in studies Punishment Failure in love Domestic problems Financial problems Demand for Dowry Premarital Pregnancy Others

Males 13 – 15 yr 16 – 18 yr 0 4 7 0 0 0 0 0 0

poverty, social deprivation, domestic difficulties, and hopelessness [15]. The total number of completed suicides committed by adolescents is significant. However it does not reflect the number of suicidal attempts made by the people in that age group. When we analyse the motive and/or precipitating factors for committing suicides, a number of facts came in to the light. Physical illness is leading (24.8%) Table No. 1, among all suicides in adolescents. Most of the males were having incurable pain abdomen and females had dysmenorrhoea. 12 students died among the 19 educated males for failure in their studies. Students who could not succeed in their competitive examinations were 8 in the present study, failed in 10th class were 3 and one student died for not clearing the 7 th class. Among the 38 educated females, 7 girls committed suicide for failure in their examinations, 2 of them for not getting through competitive examinations and other 5 for not passing 10th class. Punishments given by Parents

10 8 4 2 1 3 0 0 1

Females 13 – 15 yr 16 – 18 yr 4 5 6 2 0 0 2 0 1

15 2 2 8 11 9 7 1 2

Total 29(24.8%) 19(16.2%) 19(16.2%) 12(10.3%) 12(10.3%) 12(10.3%) 9(7.7%) 1(0.8%) 4(3.4%)

and/or Teachers have resulted in 11 deaths in males and 8 deaths in females. These punishments were awarded for their misbehaviour and indiscipline in males and for other social reasons like step children in females. Failure in love killed 2 males and 10 females. Of course the adolescent males may not be serious about their love, but it is in contrast for the females it is taken seriously. Domestic problems as maladjustment with the newly came step mother, made a boy to commit suicide. Maladjustment in the in-laws house killed 11 females. Financial crisis is also one important factor found to result in committing suicides in adolescents. It killed 3 males and 9 females. Out of 3 housewives in the age group of 13 to 15 years, 2 died for the demand of dowry and 7 died out of 20 married women in the age group of 16 to 18 years, for the demand of dowry. It clearly shows the impact of dowry in committing the suicides. One girl committed suicide for having premarital pregnancy. The causes were not clearly stated in the inquest in other 4 deaths.


18


Warning signs for adolescent suicide: The following are some common warning signs of adolescent suicide: Sudden change in behaviour, Apathy, Withdrawal, Change in eating patterns, Unusual preoccupation with death or dying, The giving away of valued personal possessions, Signs of depression, Moodiness, Hopelessness. Adapted from the Canadian Mental Health Association [14]. Adolescent period is identified by different ages as 10 – 19 years by W.H.O; [8] 10 – 24 years in US; [9]15 – 19 years in Canada;[10] In the present study the age group selected for Adolescence is 13 – 18 years, because a significant change is seen in the behaviour of person during this age group. And in India a person is called an Adult when he/she complete 18 years. Females being a weak gender are victimised more for suicides in the present study. The same observation was made in South Delhi [11]. The number of deaths occurring in the late period of adolescent i.e. 16 to 18 years are more, as they are reaching the adult stage do experience lot of stress and emotional turmoil. The rising expectations and responsibilities may create pressures for many of them [11]. People from lower and middle socio economic group and from rural background are becoming more vulnerable because of lack of resources for their mental support [12]. The ambitions and pressures on these people are significantly high especially on the students. The environment in which they are placed is not compatible. Women after marriage are unable to adjust in the new environment and making them to become uncomfortable. As per the statistics it is observed that in many of the deaths there was no contributing factor as suicidal attempts made by others which provoked them. Even there are very few people who succeeded in their subsequent attempts. Ultimately it is physical illness that is more blamed for committing suicides in adolescent period in all the sectors. Failure in studies and threat of punishment was more considered by males than females in both age groups. Failure in love, domestic maladjustment and financial issues were making the women more to victimise and that to in late adolescent period. It clearly shows the early understanding and immaturity thoughts in women about their life. However, Demand for dowry and premarital pregnancy are unique to females. Other non-specified or undetermined factors also were bad enough to kill females more.

Conclusion The study was made on suicidal deaths of adolescents in Telangana region, where there is mixing of cultures and customs present. Adolescent suicide remains an important clinical problem and a major cause of death in young people. Nonfatal suicidal behaviour is also associated with a great deal of morbidity and suffering. Suicide will claim the lives of more young patients than any other disease. Completed suicide is only the tip of the iceberg of the psychosocial pathology that exists for adolescents in crisis. There are a growing number of resources available to assist family physicians in identifying, diagnosing, treating, and referring adolescents with mental health concerns. While it is recognized that the numbers in this study are small, the current data support this contention, with the numbers of deaths due to adolescent suicide representing only a small fraction of suicides overall. Although adolescent suicide may be increasing, this may not be a general phenomenon as the trends in, and method of, adolescent suicide may vary considerably from community to community and place to place. Major problems that remain to be solved are under-standing some of the social and psychological variables that underlie suicidal behaviour; and assessing existing suicide prevention programs for adolescents in different settings. Proper counselling and care would certainly bring down the mortality. The identification of more specific risk factors of suicide will help better prediction of Suicidality and hence, better assessment process, better treatment and more targeted prevention programs. Acknowledgements The author her pays sincere thanks to the Teaching Staff of Kakatiya Medical College, Warangal, for creating a conducive environment in collecting the data and information. Conflict of Interest The author declares no conflict of interest in the present study Author Disclosures Authors have no conflict of interest. This study was a part of departmental research activities of Forensic Medicine at Kamineni Institute of Medical Sciences, Narketpally.



health services; An agenda for change. Geneva; World health Organisation; 2002.

References 1.

2.

3.

4.

Emmanuel Nii - BoyeQuarshie, Joseph Osafo, Charity S. Akotia& Jennifer Peprah – ‘Adolescent suicide in Ghana: A content analysis of media reports’ – Int. J Qualitative Stud Health Well-being 2015; 10. Aleksandra Rajewska - Rager, Natalia Lepczyñska, Piotr Sibilski - ‘Risk factors for suicide among children and youths with spectrum and early bipolar disorder’ - Psychiatr. Pol. 2015; 49(3): 477–488. Yan Cheng, et al - ‘The Association Between Social Support and Mental Health Among Vulnerable Adolescents in Five Cities: Findings From the Study of the Well-Being of Adolescents in Vulnerable Environments’ - Journal of Adolescent Health. 2014; 2014: S31eS38. Aravind Pillai, Teddy Andrews and Vikram Patel ‘Violence, psychological distress and the risk of suicidal behaviour in young people in India’ - International Journal of Epidemiology. 2009; 38: 459–469.

5.

Nishat Ahmed Sheikh et.al. Suicides in Andhra Pradesh: Magnitude of problem, socio-demographic profile and causes, Indian Journal of Forensic Medicine and Toxicology, January-June 2014; 8(1): 62-67.

6.

Iris WagmanBorowsky, Lindsay A. Taliaferro, Barbara J. McMorris, – ‘Suicidal Thinking and BehaviorAmong Youth Involved in Verbal and Social Bullying: Risk and Protective Factors’ Journal of Adolescent Health. 2013; 53: S4eS12.

7.

8.

Erin M. Sullivan, Joseph L. Annest, Thomas R Simon, Feijun Luo, Linda L. Dahlberg, – ‘Suicide Trends Among Persons Aged 10–24 Years — United States, 1994–2012’ - MMWR. March 6, 2015; 64(8): 201-205. World Health Organization. Adolescent friendly

19

9.

Nishat Ahmed Sheikh et.al. Married Men’s Suicide : a Silent Epidemic in India. Indian Journal of Forensic Medicine and Pathology. January - March 2015; 8(1): 11-16.

10. Jean-Jacques Breton et al – ‘Protective Factors Against Depression and Suicidal Behaviour in Adolescence’ - Can J Psychiatry. 2015; 60(2 Suppl 1): S5–S15. 11. Rahul Sharma, Vijay L. Grover, and Sanjay Chaturvedi – ‘Suicidal behavior amongst adolescent students in south Delhi’ - Indian J Psychiatry. JanMar 2008; l50(1): 30–33. 12. Nishat Ahmed Sheikh et.al. Psychiatric CoMorbidity in Deliberate Self Harm patient at Rural Medical College of South India, International Journal of Recent Advances in Multidisciplinary Research. December, 2014; 1(12): 0119-0123. 13. Yan Cheng, XianChen, Chaohua Lou, Freya L. Sonenstein, Amanda Kalamar, Shireen Jejeebhoy, Sinead Delany-Moretlwe, HeenaBrahmbhatt, Adesola OluwafunmilolaOlumide, and OladosuOjengbede, – ‘The Association Between Social Support and Mental Health Among Vulnerable Adolescents in Five Cities: Findings From the Study of the Well-Being of Adolescents in Vulnerable Environments’ - Journal of Adolescent Health. 2014; 55: S31eS38 –12. 14. Canadian Mental Health Association [website]. Youth and suicide. Ottawa, ON: Canadian Mental Health Association; 2010. Available from: www.cmha.ca/bins/content_page.asp?cid=3-101104&lang=1. Accessed 2010 Jun 16. 15. Mohanty S, Sahu G, Mohanty MK, Patnaik M. Suicide in India: A four year retrospective study. J Forensic Leg Med. 2007; 14: 185-9.


20

Instructions to Authors Submission to the journal must comply with the Guidelines for Authors. Non-compliant submission will be returned to the author for correction. To access the online submission system and for the most up-to-date version of the Guide for Authors please visit: http://www.rfppl.co.in Technical problems or general questions on publishing with IJFMP are supported by Red Flower Publication Pvt. Ltd’s Author Support team (http://www.rfppl.co.in) Alternatively, please contact the Journal’s Editorial Office for further assistance. Publication-in-Charge

Indian Journal of Forensic Medicine and Pathology Red Flower Publication Pvt. Ltd. 48/41-42, DSIDC, Pocket-II Mayur Vihar Phase-I Delhi – 110 091 India Phone: 91-11-22754205, 45796900, Fax: 91-11-22754205 E-mail: [email protected], [email protected] Website: www.rfppl.co.in


Original Article


Biopsy Findings in Coronary Arteries of Sudden Cardiac Death

Vennila Vijayasree*, W. Sandhya Manohar**, Sunethri Padma*** Abstract Background: Coronary artery disease (CAD) is a leading cause of death of women and men worldwide. Approximately17.5 million people per year die due to this cause, representing 30% of all deaths in the world; of these, 7.6 million were caused by coronary heart disease. Aims and Objectives: To demonstrate the histopathological changes in the coronary arteries of the dead bodies of the sudden cardiac death. Study Design: It’s a cross sectional Prospective study. Materials and methods: We performed an autopsy analysis (n=16, 5women, 11 men of SCD which occurred in patients aged over 50 years during 2011 to 2014. The following variables were considered: sex, age, medical history, autopsy findings to macroscopic and histological evaluation of the heart. The autopsies were performed according to standard techniques. In all subjects, the heart was dissected following standard autopsy protocol and a 5 cm section of the right coronary artery (RCA) in the atrio-ventricular groove from its origin, a 5 cm segment of the left anterior descending artery (LADA) distal to the origin of the circumflex artery, but including the region of origin of the circumflex branch and left coronary artery (LCA) from its origin till the circumflex branch were excised, dissected out, fixed in 10% formalin, marked for identification and sent for histopathological analysis. Observation and Discussion: Atherosclerotic plaques were identified in 6.5% of specimens, 69% of males and 31% of female. Such plaques were typically concentric and more represented with necrosis, calcification, cholesterol crystals, and giant cells, as well as had a higher inflammatory cell count. Furthermore, intima and media thickness of coronary arteries were significantly higher in studied specimens with visualize the connective tissue layers of the adventitia and the fatty acid containing adipose cells in the periadventitial tissue. Conclusion: In this study, age estimate to be a risk factor for coronary atherosclerosis in individuals more than 50 years old and may be used to predict SCD. Altogether, an enhanced understanding of the pathobiologic processes responsible for atherosclerotic changes might allow for early identification of a high-risk coronary plaque and there by provide a rationale for innovative diagnostic and/or therapeutic strategies for the management of coronary patients and prevention of acute coronary syndromes. Keywords: Adolescence; Suicide; Precipitating Factors.

Background Coronary artery disease (CAD) is a leading cause of death of women and men worldwide. An estimated Authors Affiliation: *Associate Professor, Department of Pathology, **Associate Professor, Department of Forensic Medicine, Kamineni Institute of Medical Sciences, Narketpally Nalgonda-Dist Telangana-state, 508254. ***Assistant Professor, Department of Pathology, Gandhi Medical College, Secunderabad, Telangana 500003. Reprints Requests: V.Vijayasree, H.No:8-2-109/3/2/ A, Road.No:3, APSEB Colony, Vaishali Nagar Post, LB Nagar Municipality, Hyderabad-500079. E-mail: [email protected]

17.5 million people died from this cause in 2005, representing 30 % of all deaths in the world; of these, 7.6 million were caused by coronary heart disease [1]. Aging is associated with structural and functional changes of the vessel wall, which result in decreased vascular distensibility and elevated arterial stiffness [1], As a consequence of arterial stiffness, systolic blood pressure increases, causing a rise in left ventricular workload and subsequent hypertrophy, and diastolic blood pressure decreases, leading to an impaired coronary perfusion [2], Chronic systemic inflammation has been implicated in atherogenesis, and may play a role in destabilizing vulnerable coronary plaques, thereby precipitating acute thrombosis and clinical coronary vessel events [3].

Indian of Forensic Medicine © 2016 Journal Red Flower Publication Pvt.and Ltd.Pathology / Volume 9 Number 1 / January - March 2016

22

Vennila Vijayasree et. al. / Biopsy Findings in Coronary Arteries of Sudden Cardiac Death

Atherosclerosis is a pathologically diverse disease with heterogeneous mechanisms of progression. Irreversible atherosclerotic plaques begin with smooth muscle cell-rich lipid pool lesions referred to as pathologic intimal thickening and it is a lipid-driven, chronic inflammatory disease of the vessel wall in which both innate and adaptive immune responses play a role. Moreover, atherosclerosis is a complex process involving inflammation and cellular proliferation in the arterial wall that is mediated by a variety of growth factors, cytokines, thrombotic factors, and vasoactive molecules .Mature lesions exhibit calcification, which is mediated by cells similar to osteoblasts. Infectious agents may be involved in the initiation and/or progression of atherosclerotic lesions [4]. Coronary calcium is a specific marker of atherosclerosis, that has been included in the Coronary Artery Risk Development in Young Adults Study [5], and in subgroups in the Atherosclerosis Risk in Communities Study and the Cardiovascular Health Study [6]. Coronary artery calcification (CAC) is a linear estimate of the total burden of coronary atherosclerosis that highly correlates with autopsy and intravascular ultrasound assessment [7]. In fact, CAC provides a better estimate of burden of disease than luminal stenosis as determined by angiography [8], since less-obstructive plaques actually give rise to more occlusions than moreobstructive plaques because of their greater number. In fact, 70 % of patients with acute MI have stenosis of less than 50 % in their culprit artery on angiography. Therefore, stress testing, which typically diagnoses the physiological effects of highgrade stenosis, will fail to identify a significant number of persons at risk for a hard event [9]. CAC detection by computed tomography directly detects only hard or calcified plaque, but the calcification found essentially serves as a surrogate marker for soft or non-calcified plaque as well, since in the vast majority of patients both types of plaques coexist proportionally[10]. It should be noted that no current imaging test is able to identify plaque that is prone to rupture, and that the presence of calcification in a coronary artery does not necessarily indicate a stenosis at that site; the value of CAC assessment is, rather, in its ability to reflect the overall burden of coronary atherosclerosis [11]. The objective of the study was to determine the possible association between the histopathological changes of the coronary atherosclerotic lesions and the risk of sudden cardiac death (SCD) and acute myocardial infarction (AMI) using autopsy cases.

Materials &Methods This study was conducted from 2011 to 2014 in the Mortuary of Gandhi medical college, Secunderabad, Telangana state, India with sudden cardiac death and death due to myocardial infarction. The hearts of 16 patients (5 women, 11men) were collected at autopsy within 8-10 hrs after death. Inclusion criteria were age over 50 years and an autopsy had to be intended. All cause of death were sudden cardiac death and acute myocardial infarction. Human hearts were obtained for a pathologic study of sudden cardiac death due to atherosclerosis and coronary artery thrombosis. The hearts were washed in water without further fixation or staining. The heart was dissected following standard autopsy protocol at autopsy. The coronary arteries were cannulated, washed with 0.1 mol/L PBS (pH 7.4), and perfused with 1 L of freshly prepared 4 % (wt/vol) paraformaldehyde in 0.1 mol/L sodium phosphate (pH 7.4) at 100 mmHg. Next, the heart was immersed in 4 % paraformaldehyde for at least 24 h at 4°C. A 5 cm section of the right coronary artery (RCA) in the atrio-ventricular groove from its origin, a 5 cm segment of the left anterior descending artery (LADA) distal to the origin of the circumflex artery, but including the region of origin of the circumflex branch and left coronary artery (LCA) from its origin till the circumflex branch were excised and dissected out. All the sections of coronary arteries from each case were fixed in 10 % formalin, marked for identification and sent for histopathological analysis. Paraffin sections were made and the sections stained using Hematoxylin and Eosin (H & E) dyes. In all the subjects, the heart was fixed with 10% formalin. All specimens of coronary arteries were taken from each heart for histopathological examination. Twenty-six blocks from the right and left coronary artery were cut into thick serial sections and each section was stained with hematoxylin and eosin stains. When necessary, samples were partially decalcified by acid extraction before sectioning. The atherosclerotic lesion type of each section was carefully classified by 2 investigators simultaneously using a double-headed light microscope. Two pathologists independently estimated the percentage of the tunica intimal and medial surfaces area involved with fatty streaks and raised lesions in the coronary arteries. The consensus lesion grade was the average of the grades of 2 pathologists and raised lesions mostly included an area of hemorrhage, thrombosis, ulceration, or calcification.



Results Histopathologically, moderate to severe atheromatous lesions were observed in the coronary arteries. The subendothelial space was dilated by an extracellular network containing large amounts of fibrin/collagen composite materials in sections stained with H&E. In some cases, a numerous number of macrophages and occasionally lymphoplasmacyterich infiltrates were detected in the subendothelial space with lipid deposition (Fig. A and Fig. E). The intimal and medial smooth muscle cells usually had swollen nuclei and abundant cytoplasm. In most cases, severe atheromatous lesions containing abundant chronic inflammatory cells infiltration (Lymphocytes were the dominant inflammatory cells) and calcium deposits were frequently observed in the tunica media and adventitia of coronary arteries (Fig. G). These histologic changes were consistent with atherosclerotic deposits, early aneurysm formation, and chronic and acute hemorrhage (Fig. B). Numerous macrophages with foamy cytoplasm infiltrated the tunica intima and media. In severe lesions, the tunica media contained enlarged macrophages with foamy cytoplasm, hyaline material, fibrofatty plaque, and mineralized material. The lesions were characterized by the deposition of lipids and infiltration of lipid-laden foamy cells in the tunica intima and tunica media, sometimes forming fibrofatty plaques (Fig. B), containing abundant cholesterol clefts (Fig. D and E) and mineralized material. The lesions started in the tunica intima and extended to the tunica media and tunica adventitia. In some cases, lesions were characterized by dense intimal fibrosis with necrotic debris and foam cells typical of a therosclerosis. Restenotic lesions were characterized by an increased proportion of loose fibroproliferative tissue, as well as all types of lesion pathology were observed in proximal, mid, distal and branch segments in these 13 cases. However, proximal lesions were more commonly atheromatous plaques (Fig. D) as compared with distal narrowing. Moreover, the combination of densely layered collagen and degenerating tissue was significantly more common in specimens from pathologic lesions, whereas loosely arranged proliferative tissue was significantly more common in tissue from atherosclerotic lesions (Fig. F). Furthermore, the study has revealed that ruptured plaques of

23

human autopsied affected were characterized by the presence of a more severe inflammatory infiltrate (Fig. A), constituted by monocytes, macrophages, and lymphocyte cells. Areas of necrosis and the existence of giant cells were also more frequent in segments with luminal atherosclerotic plaques. Inflammatory cells were more abundant within segments with luminal atherosclerotic plaques (Fig. G). Calcium deposits were more commonly seen in segments containing luminal atherosclerotic plaques. Whereas the presence of calcium deposits had an excellent specificity of luminal atherosclerotic plaques, the majority of atherosclerotic plaques (Fig. D) were not calcified, and hence, sensitivity was much lower. Although we had not stained the internal elastic lamina because of extreme superficiality of the calcified areas, we supposed that most of them were intimal in location. In the present study, calcium in the coronary plaque is often fragmented and may be located deep in the plaque or close to the surface (Fig. F). However the frequency of calcified nodules (with surface thrombus), a form of calcification that results in irregular nodules of calcium (Fig. C), is higher in coronary disease. Finally, the most important findings were the presence of pseudocalcium deposits and arterial wall degeneration. Proliferative lesions have been found in the coronary arteries of sixteen specimens of human autopsy. In the present study, 69 % of male and 31 % of female showed atherosclerosis.

Fig. 1a: Photomicrograph demonstrates the fatty deposits in adventitia and inflammatory cells surrounding the media of this arteriole are seen (H&E, 200 X’)


24


Fig. 1b: Shows the deposition of lipids and infiltration of lipid-laden foamy cells in the tunica intima and tunica media together with severe narrowing by atherosclerotic plaque, with several hemorrhagic necrotic cores (H&E, 400 X’)

Fig. 1c: Photomicrograph of a coronary plaque (H&E stain) showing intraplaque hemorrhage with the necrotic core with a form of calcification that result in irregular nodules of calcium (H&E, 200 X ’)

Fig. 1d: Magnification H&E 200, H&E stain. Note thickened media, which contained cholesterol crystals within the tunica media together with lesions with fibromuscular fibrous

Fig. 1e:. shows lymphoplasmacyte-rich infiltrates and fibroproliferative tissue together with areas of free cholesterol crystals (H&E, 400 X ’)

Fig. 1f: Photomicrograph of thick part of atheroma and shows extracellular lipid forms a confluent core in the musculoelastic layer of eccentric adaptive thickening that is always present in this location and the lipid core also contains cholesterol crystals and dark staining aggregates of microcrystalline calcium (H&E, 400 X ’)

Fig. 1g:. Photomicrograph demonstrates severe atheromatous lesions containing abundant lymphocytes cells infiltration and the deposition of lipids and infiltration of lipid-laden foamy cells in the tunica intima and tunica media (H&E, 400 X’)



Discussion Atherosclerosis is a disease of large- and mediumsized muscular arteries, characterized by inflammation of smooth muscle cells and formation of atherosclerotic plaques composed of necrotic cores; calcium deposits; and an accumulation of modified lipids, endothelial cells, leukocytes, and foam cells [12]. Many components of the vascular, metabolic, and immune systems are involved in this process [13]. Buildup of material and infiltrates leads to vascular remodeling, acute and chronic luminal obstruction, abnormalities of blood flow and diminished oxygen supply to target organs. In human beings, atherosclerosis is the most common pathologic process leading to cardiovascular disease. The autopsy study provides a means of understanding the basic process which sets a stage for clinically significant atherosclerotic cardiovascular disease. There is no valid method of sampling of living population. It was, therefore, considered that death suspected due to cardiovascular pathology, probably provide the best sample of the living population for studying atherosclerosis. In this study, the histological examination of the serially sectioned coronary arteries from 16 men and women who died suddenly and unexpectedly revealed the frequent presence of early atherosclerotic lesions in 16 cases. The lesions are marked by infiltration in the intima and media of coronary artery, monocytes/foam cells, rich-lymphocytes and deposits of mineral material, mainly composed of cellular matrix network, as well as fragmentation of the elastic fiber system. Age is a powerful risk factor for coronary heart disease. The development of atherosclerosis increases markedly with age up to an age of about 65, regardless of sex and ethnic background [14]. The autopsy findings of coronary arthrosclerosis in different reports are variable in relation of age and sex. In an autopsy study by Yusuf S et al. [15] among 124 men who died of non - cardiac causes, 10.3% had onevessel, 2.8% had two-vessel, and 1.4% had three- in age group between 52 and 83 years. This prevalence of coronary atherosclerosis is higher but supported by other investigators. The coronary atherosclerosis is also increasing with rapid pace in older age group also. Autopsies performed on casualties of the Korean War revealed coronary artery involvement in 77.3% of the hearts studied, and data after the Vietnam War noted the presence of atherosclerosis in 45% of

25

casualties with severe disease in 5%. One hundred eleven victims of non-cardiac trauma underwent pathologic examination of their coronary arteries to estimate the presence and severity of coronary atherosclerosis. Sudden coronary death (SCD) in older individuals is generally associated with extensive coronary atherosclerosis, although it may be the first manifestation of ischemic heart disease. In younger age-groups, SCD may occur in the presence of less severe disease [16]. Low-density lipoprotein remains the most important risk factor for development of atherosclerosis in humans and has been also associated with atherosclerosis in animals [11], However, immune and inflammatory mechanisms of atherosclerosis have gained tremendous interest in the past 20 years [13]. New data suggest an important role for chemokines and chemokine receptors in atherosclerosis and highlight a network of cytokines that modulate the immune response and inflammation of the arterial wall [12,13]. Because it has been shown in humans that all phases of atherosclerosis are regulated by inflammatory mechanisms, the possible impact of chronic inflammation in the development of atherosclerosis in animals and the importance of preventive diagnosis should be considered [12,13]. In our study, an increased number of inflammatory cells, the presence of giant cells and areas of necrosis and calcification were more frequent in segments containing atherosclerotic plaques, consistent with findings from studies on atherosclerosis of coronary arteries .Moreover, lymphocytes were more abundant in sections containing atherosclerotic plaques. However, contrary to what has been reported from the analysis of arterial plaques, in our study, lymphocytes were the predominant inflammatory cells in the majority of atherosclerotic plaques. The findings of a study by van der Wal et al. [17] also suggested a predominance of lymphocytes in venous compared with arterial plaques. Although the reasons for a predominance of lymphocytes in vessel atherosclerotic lesions need further investigation, it has been suggested that dendritic cells and lymphocytes co-accumulate in atherosclerotic vein grafts, suggesting an immunemediated antigen presentation to lymphocytes. It might be the case that in human venous plaques, lymphocytes are dominant inflammatory cells that render the venous plaques more vulnerable to rupture or disruption because of interferonproduction, which reduces the fibrous cap thickness.


26


In the present study, it was observed that eleven cases (69%) were males and five (31%) were females, which are concordant with other researchers findings that showed 74.8% males and 24.2% females, and another study found 66.5% males and 33.5 % females [18]. In the present study, 69 % of male showed atherosclerosis & 31 % of female showed atherosclerosis which are concordant with the study of Thej et al., showed 62 % were males & 50 % were females in Indian population [19]. Study reported by Yazdi SAT et al., showed 73 % males and 61 % females had atherosclerosis in a population of Iran. This difference is again explained by the demographic, geographic, racial, lifestyle & dietary variation in population Singh H et al., have reported the incidence of atherosclerosis in the coronaries to be 68% in males and 27% in females [20]. Coronary artery calcium (CAC) has been demonstrated to be associated with the risk of coronary heart disease. Our study showed that the information provided here can be used to examine whether a patient has a high CAC score relative to others with the same age, gender, and race/ethnicity who do not have clinical cardiovascular disease or treated diabetes. Rumberger et al. have made additional recommendations for specific cut points for mild, moderate, and severe coronary artery calcium that have been used frequently in clinical practice .Calcium score indicates greater likelihood of disease and may be consistent with moderate to high risk of a cardiovascular event during that time period. However, some post-mortem pathologic analyses of coronary arteries reported that calcium was a frequent feature of plaque rupture. Other reports have been shown that ruptured plaques were less likely to be calcified in acute coronary syndrome patients. Thus, coronary calcium is not a marker for neither unstable nor stable plaques. If calcium does have a different impact on risk depending on race, then the observed CAC should be evaluated relative to subjects of the same age, gender, and race/ethnicity, as presented here. It is premature to use percentiles from either this study or others to make medical decisions. In other words, at this time, the information presented here cannot necessarily be used to conclude that a patient is at high risk, but can indicate whether they have a high calcium score relative to others with the same age, gender, and race/ethnicity [21]. Atherosclerosis and coronary artery disease are huge health concerns in Iran. They constitute the largest single cause of death and exact a financial burden of billions of dollars annually. It is well known that lifestyle modification and drug therapy

in selected individuals can reduce the risk of hard cardiac events, but current Framingham risk assessment is suboptimal. Conclusions Our study suggested that although calcification is found more frequently in advanced lesions, it may also occur in small amounts in earlier lesions, which appear in the second and third decades of life. Histopathological investigation has shown that plaques with microscopic evidence of mineralization are larger and associated with larger coronary arteries than plaques or arteries without calcification. The relation of arterial calcification to the probability of plaque rupture is unknown. Although the amount of coronary calcium correlates with the amount of atherosclerosis in different individuals and to a lesser extent in segments of the coronary tree in the same individuals, it is not known if the quantity of calcification tracks the quantity of atherosclerosis over time in the same individuals. Further research is needed to better elucidate the relation of calcification to the pathogenesis of both atherosclerosis and plaque rupture. Finally, histopathological studies provide the most accurate clues to a better understanding of human coronary artery disease. With better insight into disease pathophysiology, novel interventions could be introduced to improve care and future outcomes for patients undergoing coronary artery disease. References 1.

Bairey NCB, Merz BD, Johnson BL, Sharaf WISE. Hypoestrogenemia of hypothalamic origin and coronary artery disease in premenopausal women. J Am Coll Cardiol. 2003; 41: 413-419.

2.

Bertomeu A et al.Preclinical coronary atherosclerosis in a population with low incidence of myocardial infarction: cross sectional autopsy study. British Med J. 2003; 327(7415): 591-592.

3.

Sharma K, Gulati M. Coronary artery disease in women: a 2013 update. Glob Heart. 2013; 8(2): 105-12

4.

Campbell LA, Rosenfeld ME. Infection and Atherosclerosis Development. Arch Med Res. 2015 May 21.

5.

Bielak LF, Yu P, Ryan KA, Rumberger JA, Sheedy PF, Turner ST, Post W, Shuldiner AR, Mitchell BD, Peyser PA. Differences in prevalence and severity of coronary artery calcification between two nonHispanic white populations with diverse lifestyles. Atherosclerosis. 2008; 196(2): 888-95.



6.

Newman AB, Naydeck BL, Whittle J. Racial differences in coronary calcification in older adults. Arterioscl Thromb Vasc Biol. 2002; 22: 424-30.

7.

Budoff MJ. Atherosclerosis imaging in calcified plaque: coronary artery risk assessment. Prog Cardiovasc Dis. 2003; 46: 135-148.

8.

Anaka A, Shimada K, Namba M. Relationship between longitudinal morphology of ruptured plaques and TIMI flow grade in acute coronary syndrome: a three-dimensional intravascular ultrasound imaging study. Eur Heart J. 2008; 29: 38-44.

9.

He ZX, Hedrick TD, Pratt CM. Severity of coronary artery calcification by electron beam computed tomography predicts silent myocardial ischemia. Circulation. 2000; 101: 244-251.

10. Mollet N, Maffei E, Martini C, Weustink A, van Mieghem C, Baks T, McFadden E, de Feyter P. Coronary plaque burden in patients with stable and unstable coronary artery disease using multislice CT coronary angiography. Radiol Med. 2011; 116(8): 1174-87.

27

prevention of cardiovascular disease and stroke: 2002 update: Circulation. 2002; 106: 388-91. 15. Yusuf S, Reddy S, A”unpuu S, Anand S. Global Burden of Cardiovascular Diseases Part II: Variations in Cardiovascular Disease by Specific Ethnic Groups and Geographic Regions and Prevention Strategies. Circulation. 2001; 104: 2855-64. 16. Ford ES. C-reactive protein concentration and cardiovascular disease risk factors in children: findings from the National Health and Nutrition Examination Survey 1999-2000. Circulation. 2003; 108: 1053-8. 17. Van der Wal AC, Becker AE, Elbers JRJ, Das PK. An immunocytochemical analysis of rapidly progressive atherosclerosis in human vein grafts. Eur J Cardiothorac Surg. 1992; 6: 469-474. 18. Packard RR, Lichtman AH, Libby P. Innate and adaptive immunity in atherosclerosis. Semin Immunopathol. 2009; 31: 5-22.

11. Racial/ethnic and socioeconomic disparities in multiple risk factors for heart disease and stroke. MMWR Morb Mortal Wkly Rep. 2005; 54: 113-7.

19. Thej MJ, Kalyani R, Kiran J. Atherosclerosis in coronary artery and aorta in a semi-urban population by applying modified American Heart Association classification of atherosclerosis: An autopsy study. J Cardiovasc Dis Res. 2012; 3(4): 265-71.

12. Hansson GK, Libby P. The immune response in atherosclerosis: a double-edged sword. Nat Rev Immunol. 2006; 6: 508-519.

20. Singh H, Oberoi SS, Gorea RK, Bal MS. Atherosclerosis in coronaries in Malwa region of Punjab. JIAFM. 2005; 27: 236-9.

13. Galkina E, Ley K. Immune and inflammatory mechanisms of atherosclerosis. Annu Rev Immunol. 2009; 27: 165-197.

21. Taylor AJ, Burke AP, Malley PG. A comparison of the Framingham risk index, coronary artery calcification, and culprit plaque morphology in sudden cardiac death. Circulation. 2000; 101: 1243-8.

14.

Pearson TA, Blair SN, Daniels SR, Eckel RH, Fair JM, Fortmann SP. AHA guidelines for primary


28

STATEMENT ABOUT OWNERSHIP AND OTHER PARTICULARS “Indian Journal of Forensic Medicine and Pathology” (See Rule 8) 1. Place of Publication

:

Delhi

2. Periodicity of Publication

:

Quarterly

3. Printer’s Name

:

Asharfi Lal

Nationality

:

Address

:

3/258-259, Trilok Puri, Delhi-91

:

Asharfi Lal

Nationality

:

Indian

Address

:


5. Editor’s Name

:

Asharfi Lal (Editor-in-Chief)

Nationality

:

Indian

Address

:


:

Asharfi Lal

4. Publisher’s Name

6. Name & Address of Individuals

who own the newspaper and particulars of :

Indian


shareholders holding more than one per cent of the total capital I Asharfi Lal, hereby declare that the particulars given above are true to the best of my knowledge and belief. Sd/(Asharfi Lal)

Special Note! Please note that our all Customers, Advertisers, Authors, Editorial Board Members and Editor-in-chief are advised to pay any type of charges against Article Processing, Editorial Board Membership Fees, Postage & Handling Charges of author copy, Purchase of Subscription, Single issue Purchase and Advertisement in any Journal directly to Red Flower Publication Pvt. Ltd. Nobody is authorized to collect the payment on behalf of Red Flower Publication Pvt. Ltd. and company is not responsible of respective services ordered for.



Case Report

Delayed Death in Hanging

Venkatesh Maled Abstract Hanging is a popular mean for suicide in India; the attempt frequently results in death. There are few cases reported in literature in which death has occurred after a certain period of time or the patient has survived after prolonged resuscitative measures. Most of such cases develop respiratory and neurological complications immediately after the incidence. Pulmonary edema is one of the most common complications that occur in patient of survivors of suicidal hanging. We report a case of suicidal hanging who developed pulmonary edema following the incidence. Keywords: Hanging; Survival; Suicidal; Pulmonary Edema.

Introduction Hanging is a popular mean for suicide in India, the attempt frequently results in death[1]. In majority of cases death of the individual occur instantaneously. However, a few cases have been reported in literature in which death has occurred after a certain period of time or the patient has survived after prolonged resuscitative measures[2]. Most of the patients develop respiratory and neurological complications immediately after the incidence. Pulmonary edema is one of the most common complication that occur in patients immediately following their rescue from acute airway obstruction or suicidal hanging[3,4]. We report a case of suicidal hanging who developed pulmonary edema following the incidence. She presented in unconscious state with decerebrating movements to hospital. Intensive therapy was directed towards improvement in oxygenation, reduction in raised intracranial pressure and prevention of neurological consequences by cerebral resuscitation.

Case Report A 29 year old female was admitted to the hospital in an unconscious state. She was found hangingat her residence by her relatives, who brought her down from suspension immediately and she was rushed to the hospital in an unconscious state. She has clinically diagnosed to have suffered hypoxic ischemic encephalopathy and severe bronchospasm due to hanging. The patient was on mechanical ventilator for 17 days then she succumbed to pulmonary edema. Post mortem examination revealed partially healed ligature mark on the neck (Fig. 1, 2), with tracheostomy wound. No other external injuries present on the body. On further dissection of neck structures using bloodless dissection of neck technique, findings were unremarkable both in soft (neck muscles) and hard (hyoid bone) tissues.

Authors Affiliation: Associate Professor, Dept of Forensic Medicine, SDM College of Medical Sciences & Hospital, Dharwad- 580009, Karnataka, India. Reprints Requests: Venkatesh Maled, Associate Professor, Dept of Forensic Medicine, SDM College of Medical Sciences & Hospital, Dharwad- 580009, Karnataka, India. E-mail: [email protected]

Fig. 1: Partially healed ligature mark with trachiostomy wound


30

Venkatesh Maled / Delayed Death in Hanging

Fig. 2: Partially healed ligature mark with tracheostomy wound

Discussion Hanging is suspending the body by ligature material encircled around the neck, body weight acting as constricting force.Hanging is known as a painless mode of death with a very narrow failure rate[5]. It is a very common mode of suicide particularly in young adults[6]. Its incidence in India is approximately 25% of total cases of suicide[7]. In suicidal hangingcervical injuries are rare and death is often a slow process, which takes about 8-10 minutes. Death in suicidal hanging is secondary to hypoxia and cerebral ischemia due to compression of airway and major blood vessels of neck caused by ligature applied around the neck and the force of compression being the body weight[8]. If patient is rescued within few minutes of hanging, may be saved by applying specific resuscitative measures. However in judicial hanging death is instantaneous due to fall of body for few meters in the air, causing fracture and/dislocation of cervical vertebrae and vasovagal shock. The clinical features of hanging involve respiratory and central nervous system. The common respiratory signs are respiratory distress, hypoxia, pulmonary edema etc. The signs related to CNS are like restlessness, unconsciousness, muscular rigidity, convulsions, amnesia, hemiplegia etc[8]. Deceased had unconsciousness, respiratory distress and hypoxia at the time of admission. She developed pulmonary edema during controlled ventilation through endotracheal tube followed by tracheostomy. Pulmonary edema has been reported in literature following a sudden relief from upper airway obstruction[9]. Its onset is very rapid, generally appears within minutes of the event but some time it may be delayed. The cause of delay is not clear but it might be related to rate of onset of edema and severity

of airway obstruction.[4] The exact mechanism of development of pulmonary edema after rescue from hanging is still not clear. Some workers postulate that cerebral hypoxia during hanging causes release of vasoactive substances like histamine, serotonin and kinins. These mediators along with hypoxia lead to pulmonary vasoconstriction, pulmonary hypertension and pulmonary congestion.[10,11] Second theory suggests that pulmonary capillary membrane is damaged leading to increased capillary permeability and hence pulmonary edema [3]. Third theory suggests that the cause of pulmonary edema is hyperemia in the lungs. If pulmonary obstruction is suddenly removed there is an abrupt fall in intrapulmonary pressure, which suddenly increases the venous return and hence increases pulmonary hyperemia [11]. Thus any patient having hypoxia following rescue from hanging or relief from upper airway obstruction with clear chest may be considered as a case of hyperemia and such patient may develop delayed frank pulmonary edema during therapy. Airway obstruction and compression of blood vessels in neck causes cerebral edema, hypoxic insult, raised intracranial pressure and neurological manifestation To conclude, upper airway obstruction is a recognized mechanism that can produce noncardiogenic pulmonary edema. Airway obstruction is the main cause of morbidity and subsequent mortality in the survivors of suicidal hanging. Pulmonary edema may develop subsequently in such patients. In most instances, post obstructive pulmonary edema is a reversible process once recognized and properly treated[12]. Hence irrespective of the condition after resuscitation in survivors of hanging patient even with clear chest must be treated with aggressive oxygen therapy and put on ventilator to prevent pulmonary edema. References 1.

Pradeep KG, Kanthaswamy V. Survival in hanging. Am J Forensic Med Pathol. 1993; 14(1): 80-1.

2.

Aggarwal NK, Kishore U, Agarwal B. Hangingdelayed death (a rare phenomenon). Med Sci Law. 2000; 40(3): 270-2.

3.

Oswalt CE, Gates GA, Holmstrom. Pulmonary edema as a complication of acute air way obstruction. JAMA. 1977; 238: 1833-35.

4.

Lang SA, Duncan PG, Shephard DA, Ha HC. Pulmonary oedema associated with airway obstruction. A Review. Can J Anaesth. 1990; 37: 210-18.


Venkatesh Maled / Delayed Death in Hanging

31

5.

Gambhir Singh O, Sarma PC, Lepcha C. Near hanging: a case report. J Punjab Acad Forensic Med Toxicol. 2009; 9(1): 24-6.

9.

Mantha S, Rao SM. Noncardiogenic pulmonary oedema after attempted suicide by hanging. Anaesth. 1990; 45: 993-4.

6.

Lowy A, Burton P, Briggs A. Increasing suicide rates in young adults. Brit Med J. 1990; 300: 643.

7.

Trivedi JK, Srivastava R, Tandon R. Sucide: An Indian Perspective. JIMA. 2005; 103: 78-84.

10. Fischman CM, Goldsmith MS, Gardner LB. Suicidal hanging an association with the adult respiratory distress syndrome. Chest. 1977; 71: 225-27.

8.

Gorden I, Shapiro HA, Berson SD. Deaths usually initiated by hypoxic hypoxia or anoxic anoxia. Forensic Medicine- A guide to principles. 3rded 1998; 95-127.

11. Galvis AG, Stool SE, Bluestone CD. Pulmonary edema following relief of acute upper airway obstruction. Ann Otol. 1980; 89: 124-28. 12. Aggarwal R, Anant S, Harsh V. Pulmonary oedema in a survivor of suicidal hanging. MJAFI. 2004; 60: 188-9.

Advertisement


32 Revised Rates for 2016 (Institutional) Title Dermatology International Gastroenterology International Indian Journal of Agriculture Business Indian Journal of Anatomy Indian Journal of Ancient Medicine and Yoga Indian Journal of Anesthesia and Analgesia Indian Journal of Anthropology Indian Journal of Biology Indian Journal of Cancer Education and Research Indian Journal of Communicable Diseases Indian Journal of Dental Education Indian Journal of Forensic Medicine and Pathology Indian Journal of Forensic Odontology Indian Journal of Genetics and Molecular Research Indian Journal of Law and Human Behavior Indian Journal of Library and Information Science Indian Journal of Maternal-Fetal & Neonatal Medicine Indian Journal of Medical & Health Sciences Indian Journal of Obstetrics and Gynecology Indian Journal of Pathology: Research and Practice Indian Journal of Plant and Soil Indian Journal of Preventive Medicine International Journal of Food, Nutrition & Dietetics International Journal of History International Journal of Neurology and Neurosurgery International Journal of Political Science International Journal of Practical Nursing International Physiology Journal of Animal Feed Science and Technology Journal of Cardiovascular Medicine and Surgery Journal of Forensic Chemistry and Toxicology Journal of Microbiology and Related Research Journal of Orthopaedic Education Journal of Pharmaceutical and Medicinal Chemistry Journal of Practical Biochemistry and Biophysics Journal of Social Welfare and Management New Indian Journal of Surgery Ophthalmology and Allied Sciences Otolaryngology International Pediatric Education and Research Physiotherapy and Occupational Therapy Journal Urology, Nephrology and Andrology International

Frequency 2 2 2 3 4 3 2 2 2 2 4 4 2 2 2 3 2 2 3 3 2 2 3 2 2 2 3 2 2 2 2 2 2 2 2 3 3 2 2 3 4 2

Rate (Rs): India 5000 5500 5000 8000 7500 7000 12000 4000 8500 8000 4500 15500 4500 6500 5500 9000 9000 6500 7000 11500 5500 6500 5000 6500 10000 5500 5000 7000 4100 9100 9000 8000 5000 16000 5500 7500 7100 5500 5000 7000 8500 7000

Rate ($):ROW 500 550 500 800 750 700 1200 400 850 800 450 1550 450 650 550 900 900 650 700 1150 550 650 500 650 1000 550 500 700 410 910 900 800 500 1600 550 750 710 550 500 700 850 700

SUPER SPECIALITY JOURNALS Indian Journal of Emergency Medicine Indian Journal of Surgical Nursing Indian Journal of Trauma & Emergency Pediatrics International Journal of Pediatric Nursing Journal of Community and Public Health Nurisng Journal of Geriatric Nursing Journal of Medical Images and Case Reports Journal of Nurse Midwifery and Maternal Health Journal of Organ Transplantation Journal of Psychiatric Nursing Psychiatry and Mental Health

2 3 3 3 2 2 2 3 2 3 2

12000 5000 9000 5000 5000 5000 5000 5000 25900 5000 7500

1200 500 900 500 500 500 500 500 2590 500 750

Terms of Supply: 1. Advance payment required by Demand Draft payable to Red Flower Publicaion Pvt. Ltd. payable at Delhi. 2. Cancellation not allowed except for duplicate payment. 3. Agents allowed 10% discount. 4. Claim must be made within six months from issue date. Order from Red Flower Publication Pvt. Ltd., 48/41-42, DSIDC, Pocket-II, Mayur Vihar Phase-I, Delhi - 110 091 (India), Tel: 91-11-22754205, 45796900, Fax: 9111-22754205. E-mail: [email protected], [email protected], Website: www.rfppl.co.in


Guidelines for Authors Manuscripts must be prepared in accordance with “Uniform requirements for Manuscripts submitted to Biomedical Journal” developed by international committee of medical Journal Editors. Types of Manuscripts and Limits Original articles: Up to 3000 words excluding references and abstract and up to 10 references. Review articles: Up to 2500 words excluding references and abstract and up to 10 references. Case reports: Up to 1000 words excluding references and abstract and up to 10 references. Online Submission of the Manuscripts

33

22754205, E-mail: [email protected]. Website: www.rfppl.co.in Preparation of the Manuscript The text of observational and experimental articles should be divided into sections with the headings: Introduction, Methods, Results, Discussion, References, Tables, Figures, Figure legends, and Acknowledgment. Do not make subheadings in these sections. Title Page The title page should carry 1) Type of manuscript (e.g. Original article, Review article, Case Report)

Articles can also be submitted online from http:// rfppl.co.in/customer_index.php.

2) The title of the article, should be concise and informative;

I) First Page File: Prepare the title page, covering letter, acknowledgement, etc. using a word processor program. All information which can reveal your identity should be here. use text/rtf/doc/PDF files. Do not zip the files.

3) Running title or short title not more than 50 characters;

2) Article file: The main text of the article, beginning from Abstract till References (including tables) should be in this file. Do not include any information (such as acknowledgement, your name in page headers, etc.) in this file. Use text/rtf/doc/PDF files. Do not zip the files. Limit the file size to 400 Kb. Do not incorporate images in the file. If file size is large, graphs can be submitted as images separately without incorporating them in the article file to reduce the size of the file. 3) Images: Submit good quality color images. Each image should be less than 100 Kb in size. Size of the image can be reduced by decreasing the actual height and width of the images (keep up to 400 pixels or 3 inches). All image formats (jpeg, tiff, gif, bmp, png, eps etc.) are acceptable; jpeg is most suitable. Legends: Legends for the figures/images should be included at the end of the article file. If the manuscript is submitted online, the contributors’ form and copyright transfer form has to be submitted in original with the signatures of all the contributors within two weeks from submission. Hard copies of the images (3 sets), for articles submitted online, should be sent to the journal office at the time of submission of a revised ma nuscript. Editorial office: Re d Flower Publication Pvt. Ltd., 48/41-42, DSIDC, Pocket-II, Mayur Vihar Phase-I, Delhi – 110 091, India, Phone: 91-11-22754205, 45796900, Fax: 91-11-

4) The name by which each contributor is known (Last name, First name and initials of middle name), with his or her highest academic degree(s) and institutional affiliation; 5) The name of the department(s) and institution(s) to which the work should be attributed; 6) The name, address, phone numbers, facsimile numbers and e-mail address of the contributor responsible for correspondence about the manuscript; should be mentoined. 7) The total number of pages, total number of photographs and word counts separately for abstract and for the text (excluding the references and abstract); 8) Source(s) of support in the form of grants, equipment, drugs, or all of these; 9) Acknowledgement, if any; and l0) If the manuscript was presented as part at a meeting, the organization, place, and exact date on which it was read. Abstract Page The second page should carry the full title of the manuscript and an abstract (of no more than 150 words for case reports, brief reports and 250 words for original articles). The abstract should be structured and state the Context (Background), Aims, Settings and Design, Methods and Materials, Statistical analysis used, Results and Conclusions. Below the abstract should provide 3 to 10 keywords.



34

Introduction State the background of the study and purpose of the study and summarize the rationale for the study or observation.

mechanisms, clinical research). Do not repeat in detail data or other material given in the Introduction or the Results section. References

Methods The methods section should include only information that was available at the time the plan or protocol for the study was written such as study approach, design, type of sample, sample size, sampling technique, setting of the study, description of data collection tools and methods; all information obtained during the conduct of the study belongs in the Results section. Reports of randomized clinical trials should be based on the CONSORT Statement (http://www. consort-statement. org). When reporting experiments on human subjects, indicate whether the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional or regional) and with the Helsinki Declaration of 1975, as revised in 2000 (available at http://www.wma.net/e/policy/l 7c_e.html). Results Present your results in logical sequence in the text, tables, and illustrations, giving the main or most important findings first. Do not repeat in the text all the data in the tables or illustrations; emphasize or summarize only important observations. Extra or supplementary materials and technical details can be placed in an appendix where it will be accessible but will not interrupt the flow of the text; alternatively, it can be published only in the electronic version of the journal.

List references in alphabetical order. Each listed reference should be cited in text (not in alphabetic order), and each text citation should be listed in the References section. Identify references in text, tables, and legends by Arabic numerals in square bracket (e.g. [10]). Please refer to ICMJE Guidelines (http://www.nlm.nih.gov/bsd/uniform_ requirements.html) for more examples. Standard journal article [1] Flink H, Tegelberg Å, Thörn M, Lagerlöf F. Effect of oral iron supplementation on unstimulated salivary flow rate: A randomized, double-blind, placebo-controlled trial. J Oral Pathol Med 2006; 35: 540-7. [2] Twetman S, Axelsson S, Dahlgren H, Holm AK, Källestål C, Lagerlöf F, et al. Caries-preventive effect of fluoride toothpaste: A systematic review. Acta Odontol Scand 2003; 61: 347-55. Article in supplement or special issue [3] Fleischer W, Reimer K. Povidone iodine antisepsis. State of the art. Dermatology 1997; 195 Suppl 2: 3-9. Corporate (collective) author [4] American Academy of Periodontology. Sonic and ultrasonic scalers in periodontics. J Periodontol 2000; 71: 1792-801. Unpublished article

Discussion Include summary of key findings (primary outcome measures, secondary outcome measures, results as they relate to a prior hypothesis); Strengths and limitations of the study (study question, study design, data collection, analysis and interpretation); Interpretation and implications in the context of the totality of evidence (is there a systematic review to refer to, if not, could one be reasonably done here and now?, What this study adds to the available evidence, effects on patient care and health policy, possible mechanisms)? Controversies raised by this study; and Future research directions (for this particular research collaboration, underlying

[5] Garoushi S, Lassila LV, Tezvergil A, Vallittu PK. Static and fatigue compression test for particulate filler composite resin with fiber-reinforced composite substructure. Dent Mater 2006. Personal author(s) [6] Hosmer D, Lemeshow S. Applied logistic regression, 2nd edn. New York: Wiley-Interscience; 2000. Chapter in book [7] Nauntofte B, Tenovuo J, Lagerlöf F. Secretion and composition of saliva. In: Fejerskov O, Kidd EAM,



editors. Dental caries: The disease and its clinical management. Oxford: Blackwell Munksgaard; 2003. p. 7-27. No author given [8] World Health Organization. Oral health surveys - basic methods, 4th edn. Geneva: World Health Organization; 1997. Reference from electronic media [9] National Statistics Online—Trends in suicide by method in England and Wales, 1979-2001. www.statistics.gov.uk/downloads/theme_health/ HSQ 20.pdf (accessed Jan 24, 2005): 7-18. Only verified references against the original documents should be cited. Authors are responsible for the accuracy and completeness of their references and for correct text citation. The number of reference should be kept limited to 20 in case of major communications and 10 for short communications. More information about other reference types is available at www.nlm.nih.gov/bsd/uniform_ requirements.html, but observes some minor deviations (no full stop after journal title, no issue or date after volume, etc).

35

Type or print out legends (maximum 40 words, excluding the credit line) for illustrations using double spacing, with Arabic numerals corresponding to the illustrations. Sending a revised manuscript While submitting a revised manuscript, contributors are requested to include, along with single copy of the final revised manuscript, a photocopy of the revised manuscript with the changes underlined in red and copy of the comments with the point to point clarification to each comment. The manuscript number should be written on each of these documents. If the manuscript is submitted online, the contributors’ form and copyright transfer form has to be submitted in original with the signatures of all the contributors within two weeks of submission. Hard copies of images should be sent to the office of the journal. There is no need to send printed manuscript for articles submitted online. Reprints Journal provides no free printed reprints, however a author copy is sent to the main author and additional copies are available on payment (ask to the journal office).

Tables Tables should be self-explanatory and should not duplicate textual material. Tables with more than 10 columns and 25 rows are not acceptable. Table numbers should be in Arabic numerals, consecutively in the order of their first citation in the text and supply a brief title for each. Explain in footnotes all non-standard abbreviations that are used in each table. For footnotes use the following symbols, in this sequence: *, ¶, †, ‡‡, Illustrations (Figures) Graphics files are welcome if supplied as Tiff, EPS, or PowerPoint files of minimum 1200x1600 pixel size. The minimum line weight for line art is 0.5 point for optimal printing. When possible, please place symbol legends below the figure instead of to the side. Original color figures can be printed in color at the editor’s and publisher’s discretion provided the author agrees to pay.

Copyrights The whole of the literary matter in the journal is copyright and cannot be reproduced without the written permission. Declaration A declaration should be submitted stating that the manuscript represents valid work and that neither this manuscript nor one with substantially similar content under the present authorship has been published or is being considered for publication elsewhere and the authorship of this article will not be contested by any one whose name (s) is/are not listed here, and that the order of authorship as placed in the manuscript is final and accepted by the coauthors. Declarations should be signed by all the authors in the order in which they are mentioned in the original manuscript. Matters appearing in the Journal are covered by copyright but no objection will be made to their reproduction provided permission is obtained from the Editor prior to publication and due acknowledgment of the source is made.


36


Abbreviations Standard abbreviations should be used and be spelt out when first used in the text. Abbreviations should not be used in the title or abstract.

•

Abbreviations spelt out in full for the first time. Numerals from 1 to l0 spelt out

•

Numerals at the beginning of the sentence spelt out

Checklist

Tables and figures

•

Manuscript Title

•

Covering letter: Signed by all contributors

• •

•

No repetition of data in tables and graphs and in text.

Previous publication/ presentations mentioned, Source of funding mentioned

•

Actual numbers from which graphs drawn, provided.

Conflicts of interest disclosed

•

Figures necessary and of good quality (color)

•

Table and figure numbers in Arabic letters (not Roman).

•

Labels pasted on back of the photographs (no names written)

Authors •

Middle name initials provided.

•

Author for correspondence, with e-mail address provided.

•

Figure legends provided (not more than 40 words)

•

Number of contributors restricted as per the instructions.

•

Patients’ privacy maintained, (if not permission taken)

•

Identity not revealed in paper except title page (e.g.name of the institute in Methods, citing previous study as ‘our study’)

•

Credit note for borrowed figures/tables provided

•

Manuscript provided on a CDROM (with double spacing)

Presentation and Format •

Double spacing

•

Margins 2.5 cm from all four sides

•

Title page contains all the desired information. Running title provided (not more than 50 characters)

•

Abstract page contains the full title of the manuscript

•

Abstract provided: Structured abstract provided for an original article.

•

Key words provided (three or more)

•

Introduction of 75-100 words

•

Headings in title case (not ALL CAPITALS). References cited in square brackets

•

References according to the journal’s instructions Language and grammar

•

Uniformly American English

Submitting the Manuscript •

Is the journal editor’s contact information current?

•

Is the cover letter included with the manuscript? Does the letter:

1.

Include the author’s postal address, e-mail address, telephone number, and fax number for future correspondence?

2.

State that the manuscript is original, not previously published, and not under concurrent consideration elsewhere?

3.

Inform the journal editor of the existence of any similar published manuscripts written by the author?

4.

Mention any supplemental material you are submitting for the online version of your article. Contributors’ Form (to be modified as applicable and one signed copy attached with the manuscript)
