Injuries due to deliberate violence in Chile.

An analysis was made over a period of 6 months of the incidents involving deliberate violence as registered in 'Vicaria', the clinic for out-patients within the Cathedral of Santiago de Chile. A total of 236 victims of deliberate violence were observed. Men aged 15-24 years were found to be victims of deliberate violence most frequently. 'Under education' was the most frequently registered occupation for both sexes, and a large group of male victims were 'Unemployed'. 82% of the victims were men and 14% women, 1.5% were boys and 1.5% girls less than or equal to 14 years of age. None of the victims were alcohol intoxicated when arriving in the clinic. The incidents took place in streets for 81% of the male victims and 79% of the female victims, and in the majority of the cases the aggressor(s) was one (or several) police officer(s). Six percent of the female victims had been injured at home. There was no reporting of the aggressor being a relative or acquaintance. The most frequent type of violence was blunt violence from baton(s) (44%), while blunt violence without the use of instruments was reported less frequently (33%). The use of firearms was registered in 18% of the cases, and of sharp instruments, combustion, electro-shock and chain in 1.4%, 1.4%, 1.1% and 0.4% of the cases respectively. A total of 517 primary and secondary diagnoses were applied to the patients. Most of the victims (99%) had moderate or less serious lesions according to the Abbreviated Injury Scale (AIS) (score less than or equal to 2). Twenty-four percent of the victims had more than 4 lesions, and 7% more than 10 lesions. The head/neck region and the trunk were affected with equal frequency, the frequency of injuries of the head/neck region being comparable with that observed among torture victims and in contrast to the pronounced predominance of injuries of the head/neck region observed in a Danish emergency ward study of deliberate violence.

Injuries due to deliberate violence in areas of Argentina. I. The extent of violence. Copenhagen Study Group.

As part of a transcultural investigation of violent behaviour in Argentina and Denmark an analysis was made of the incidents involving deliberate violence as registered in the emergency wards of Hospital Fernandez and Hospital Pinero in Capital Federal Buenos Aires over a period of 13 and 17 months, respectively. In the two emergency wards a total of 281 victims of deliberate violence were observed corresponding to a rate of approximately 0.2/1000 per year in a mainly middle income area of the metropolis Buenos Aires, the catchment region of Hospital Fernandez, and 0.6/1000 per year in a mainly low income area of Buenos Aires, the catchment region of Hospital Pinero. Men aged 20-24 years and 40-49 years were found to be the most frequent victims of deliberate violence, 13% and 11%, respectively. Elderly women greater than or equal to 60 years of age were rarely found to be victims of deliberate violence (2%). Skilled and unskilled male workers were over-represented as victims of violence. Sixty-four percent of the victims were men and 29% women, 6% were boys and 0.7% girls less than or equal to 14 years of age. Twenty-one percent of the male victims and 5% of the female victims were alcohol intoxicated when arriving in the emergency ward. The incidents took place in restaurants or in the vicinity of restaurants for only 7% of the male victims, while 55% of male victims and 34% of female victims had been injured in the street, most often by non-acquainted men. Fifty-eight percent of the female victims had been subject to deliberate violence at home, in the majority of the cases beaten by their spouse. Twelve percent of the male victims and 8% of the female victims were estimated to be under the influence of drugs. The incidence of deliberate violence seems to be lower in Argentina than in Denmark. However, serious lesions appear to be considerably more frequent in male Argentinian victims compared to male Danish victims, maybe because the practice of seeking medical assistance is different in the two countries. The pattern of deliberate violence appears to be associated with socio-economic and cultural factors. Influence of alcohol does not appear to play a role that is comparable to the situation observed in Denmark. A considerably larger percentage of victims in Argentina than in Denmark had been injured in the street.

Injuries due to deliberate violence in areas of Argentina. II. Lesions. Copenhagen Study Group.

As part of a transcultural investigation of violent behavior in Argentina and Denmark, the lesions from accidents involving deliberate violence registered in the emergency wards of Hospital Fernandez and Hospital Pinero in Capital Federal Buenos Aires over a period of 13 and 17 months, respectively, were studied. Among the 281 victims entering the two emergency wards blunt violence without use of instruments was most often reported to be the violation method. Frequently indicated violation instruments against the male victims were batons (18.7%), sharp instruments (17.7%), and firearms (17.7%), the corresponding figures for female victims being 9.6%, 8.4% and 4.8%. The use of firearms and batons was considerably more pronounced in Argentina than in Denmark, particularly against male victims. A total of 373 primary and secondary diagnoses were reported from the patients, the most frequent diagnoses being contusions and open wounds in the head/neck region. Forty-three percent of the diagnoses were related to the head/neck region, being the most frequently injured region and the trunk the second most frequently injured region (30%). The degree of predominance of lesions in the head/neck region was much less than in the Danish material. Injuries of internal organs of the trunk were considerably more frequent in Argentina than in Denmark. Eighty-five percent of the victims had moderate or less serious lesions when assessed on the basis of the scores in the Abbreviated Injury Scale (AIS), (score less than or equal to 2). The AIS scores of the lesions in female victims were on average only slightly higher than those recorded in the Danish study, while 16.1% of the male Argentinian victims had lesions scored greater than or equal to 3 compared to 1.8% in male Danish victims. The need for treatment and hospitalization was more pronounced than in the Danish study. It may be concluded that the frequency of serious cases of deliberate violence probably would decrease if more restrictive rules for the possessing of firearms were enacted and enforced.

Injuries due to deliberate violence in areas of Denmark. V. Violence against women and children. Copenhagen Study Group.

As part of an European-South American study of deliberate violence cases of violence against women greater than or equal to 15 years of age and violence against and among children under the age of 15 years were registered at 3 Danish emergency wards and at the Institute of Forensic Medicine in Copenhagen. 352 cases of violence against women and 46 cases of violence against children were registered in the three emergency wards corresponding to rates of about 1.6/1000 per year for women, 0.6/1000 per year for boys and 0.7/1000 per year for girls in a provincial/rural district, the catchment region of Holbaek County Hospital, 3.4/1000 per year for women, 2.8/1000 per year for boys and 0.6/1000 per year for girls in a mainly middle income area of the metropolis Copenhagen, the catchment region of Frederiksberg Hospital, and 4.0/1000 per year for women, 4.0/1000 per year for boys and 0.9/1000 per year for girls in a mainly low income area of Copenhagen, the catchment region of the Rigshospital. Nineteen live adult female victims and 17 dead adult female victims of violence were registered in the Institute of Forensic Medicine in Copenhagen, where also one was registered as a victim of homicide. Nearly half of the adult live female victims of violence had been injured at home while this was the case for approximately three fourth of the dead victims. In 35% of the live cases the husband was the aggressor and in 12% a former cohabitant. In 71% of the homicide cases the husband was the aggressor. The live women appeared to have fewer but more serious lesions than men. The pattern of deliberate violence against women appears to be associated with socio-economic and cultural factors. In cases with a preceding quarrel there is statistically a link to alcohol intoxication. In half of the cases of violence against children the aggressor was known to the victim, in 15% the aggressor was one of the parents, while 42% of the cases were violence among children. The pattern of violence according to sex, and the distribution and severity of lesions for 10-14 years old children showed resemblance to the situation for adults. The lesions were more serious in young infant victims, especially boys, than in adult victims.

Injuries due to deliberate violence in areas of Denmark. IV. Alcohol intoxication in victims of violence. The Copenhagen Study Group.

A material of 1316 victims of deliberate violence was collected prospectively during a one year period in three Danish emergency wards covering a provincial/rural area and two metropolitan areas. The frequency of alcohol intoxication was determined. Forty-one percent of the patients were intoxicated. The highest frequency was found in male victims, in the provincial/rural area, in restaurants or their vicinity, in the age group 35-49, during evenings and nights and in May. It is difficult to indicate specific preventive measures. However, a more restrictive attitude is suggested with regard to serving alcohol to intoxicated persons in restaurants.

Injuries due to deliberate violence in areas of Denmark. III. Lesions. The Copenhagen Study Group.

As part of a transcultural investigation of violent behavior in Denmark and South America, the lesions from accidents involving deliberate violence registered in three Danish emergency wards during a 1-year period were studied. A quantity of 2211 lesions were diagnosed in 1316 patients (953 male and 363 female patients). Sixty-five percent of the lesions were in the head/neck region, 13% in truncus, 18% in the upper extremities and 5% in the lower extremities. The most frequent diagnosis was an open wound in the head/neck region. Adding contusions and fractures in the same region this amounted to more than half of the total number of lesions. In the upper extremities 62% of the lesions were contusions or open wounds. Serious lesions of internal arteries were few, however always caused by sharp instruments (knives). Serious lesions due to firearms were not recorded/reported. Strangulation had been used against 1.1% of the victims, the male/female ratio being 1:6. The main part of the lesions were of minor severity when assessed on the basis of the scores in the Abbreviated Injury Scale (AIS). The lesions were, however, more serious compared to other recent studies, and it appeared that the female victims had fewer but more serious lesions than the male victims. The need for treatment and hospitalization was in the range of other recent studies.

Injuries due to deliberate violence in areas of Denmark. II. Victims of homicide in the Copenhagen area.

As part of a transcultural investigation of injuries due to deliberate violence in Denmark and South America, homicides in the Copenhagen area were studied for a 1-year period. Forty-five cases corresponding to a rate of approximately 2/10(5) per year were recorded. The rate seems to be increasing and the pattern changing with a higher frequency of stabbing and with an increasing frequency of high blood-alcohol concentrations in the victims. The highest number were killed at home. In the majority of cases the aggressor and the victim knew each other. A reduction in alcohol consumption is indicated as a possible preventive measure.

Injuries due to deliberate violence in areas of Denmark. I. The extent of violence.

As part of a transcultural investigation of violent behavior in Denmark and South America an analysis was made during a one year period of the incidents involving deliberate violence as registered at 3 Danish emergency wards, and at the Institute of Forensic Medicine in Copenhagen. In the three emergency wards a total of 1316 victims of deliberate violence were observed corresponding to a rate of about 3.3/1000 per year in a provincial/rural district, the catchment region of Holbaek County Hospital, 5.5/1000 per year in a mainly middle income area of the metropolis Copenhagen, the catchment region of Frederiksberg Hospital, and 7.6/1000 per year in a mainly low income area of Copenhagen, the catchment region of the Rigshospital. The highest risk, 28/1000 per year, was found for young men between 15 and 19 years of age living in the low income area of Copenhagen. The risk was low for people greater than or equal to 60 years of age in all three areas investigated, ranging from 0 (men) to 1.3/1000 per year (women). Skilled and unskilled workers were greatly over represented as victims of violence, considering their share of the background population. Seventy percent of the victims were men. At least 44% of the men and 32% of the women were alcohol intoxicated when arriving in the emergency ward. The incidents took place in restaurants or in the vicinity of restaurants for 30% of the male and 11% of female victims respectively, while 45% of the women had been subject to deliberate violence at home. The rate of fatal cases of deliberate violence in the Eastern part of Denmark, the catchment area for the Institute of Forensic Medicine in Copenhagen, was found to be 0.02/1000 per year. The risk of becoming a victim of deliberate violence has not increased during the last 4 years comparing with similar investigations from other parts of Denmark. However, the rate of homicide seems to have increased, and so has the severity of the injuries caused by deliberate violence. The pattern of deliberate violence appears to be associated with socio-economic and cultural factors, and to be closely linked with alcohol intoxication.

The effect of sodium hydroxide and hydrochloric acid on pig dermis. A light microscopic study.

In order to compare the dermal changes after exposure to direct current (d.c.) with changes after influence of acid and base influence, the skin of fully anaesthetized Danish Landrace pigs were exposed to acid and basic solutions. Biopsies were obtained immediately after and up to day 7 after the injury. Collagen fibres with increased affinity for eosin and irregular cross-striation in polarized light together with shrunken cells with dark stained nuclei were found just beneath the epidermis immediately after application of 1 N HCl. Immediately after exposure to 1 N NaOH dispersed collagen fibres showed increased eosinophilia and a fine densely spaced cross-striation in polarized light and vesicular nuclei were present within dermal cells. During the following days a narrow demarcation zone of neutrophilic granulocytes separated the zone containing abnormal collagen fibres from normal tissue below. Calcified collagen fibres were not observed and no other abnormal histochemical reactions were present. It is concluded that the morphology of acid induced lesions and base induced lesions shows resemblance to the morphology of anode and cathode lesions, respectively, but not to heat lesions. The reason for not finding depositions of calcium salts on collagen fibres in skin exposed to basic solutions could be a non-optimal pH in the tissue or that other electrochemical processes than shift in pH are necessary for the calcification process.

The occurrence of calcium salt deposition on dermal collagen fibres following electrical injury to porcine skin.

Deposition of calcium salts on collagen fibres has been shown to occur in cathode areas from 2 days to 2 months after exposure to direct current (d.c.) via contact knobs measuring 12 mm in diameter using energy level from 0.5 to 96 J and on day 7 after exposure to alternating current (a.c.) via pointed electrodes using energy level from 30 to 50 J. In order to determine the statistical relation of this histological observation to the type of energy applied 1095 biopsies from 49 pigs including biopsies from skin areas exposed to heat, 50 Hz a.c., 100 kHz a.c. and d.c. as well as from unexposed skin were examined. The specificity was 1.0 using calcium deposition as the test criterium. The sensitivity for cathode areas was found to vary from 0.52 to 1.0 depending on the biopsy technique and the number of days after exposure. Calcium salts on collagen fibres seem uniformly to be present in the cathode area from day 4 to 7, the positive test answer being depending on the biopsy technique. For 50 Hz a.c. the sensitivity using a pointed electrode was found to vary from 0.08 to 0.27 dependent on the number of days after exposure. For all other types of energy the sensitivity was 0.

Ultrastructural changes in dermal pig skin after exposure to heat and electric energy and acid and basic solutions.

In order to describe the ultrastructure of the histopathological changes in dermis after exposure to electrical energy, heat energy and acid and basic solutions the skin of fully anaesthetized Danish Landrace pigs were exposed to direct current, heat (80 degrees C and 450 degrees C) and acid and basic solutions. Biopsies were obtained immediately after the exposure from all types of injury. Biopsies from the cathode areas biopsies were also taken on day 1 and day 2.5 in order to describe the initial calcium deposits. Homogeneous collagen fibres without any birefringence from heat exposed areas were ultrastructurally composed of filamentous materials. Collagen fibres with fine densely spaced cross-striation from cathode areas and areas exposed to basic solutions were shown ultrastructurally to consist of parallelly arranged collagen fibrils with regular waves. It is concluded that the cross-striation of the collagen fibres observed in polarized light are due to a periodic change in the orientation of the fibres seen as waves of the fibres. The ultrastructure of dermal cells were similar to that of epidermal cells following the different types of influence. Characteristically the nuclei were condensed following heat and more electron-lucent following direct current (d.c.) and acid and basic solutions. In cathode areas and areas influenced by basic solutions the electron-lucent nuclei contained fine fibrils. The ultrastructural study supports the suggestion from light microscopic studies that the morphology of anode and cathode lesions shows resemblance to acid induced and basic induced lesions, respectively. Apatite crystals were observed on day 2.5 at the periphery of the collagen fibrils and in the matrix of elastic fibres.

The morphogenesis of electrically and heat-induced dermal changes in pig skin.

In order to establish pathological evidence in dermis for distinguishing between sequelae of electrical torture and those of other superficial injuries, the skin of eleven fully anaesthetized Danish Landrace pigs have been exposed to heat and electrical energy from either 50 Hz alternating current (a.c.) or direct current (d.c.) via 12 mm large contact knobs or via a pointed 0.5 mm large electrode (only 50 Hz a.c.). The lesions have been examined from 1 to 126 days after the injury. While heat lesions exposed to energy lower than 60 joule only gave minor changes, heat lesions exposed to more than 60 joule showed changes in both collagen fibres (basophilic or eosinophilic fibres without any birefringence or coarse cross-striation in polarized light, respectively) and dermal cells (granular cytoplasm). Areas exposed to 50 Hz a.c. via 0.5 mm. electrode showed basophilic collagen fibres and in a few biopsies on day 7 calcium salts on collagen fibres. Using 12 mm large electrodes the changes were minor, but basophilic and eosinophilic collagen fibres with no birefringence or with fine/coarse cross-striation respectively were seen. Even cells with 'vesicular nuclei' were seen on day 1 and 2 after the injury. The changes in the anode area showed resemblance to that of heat lesions (basophilic collagen fibres). Eosinophilic collagen fibres with fine densely spaced cross-striation in polarized light and 'vesicular nuclei' as well as collagen fibres with calcium salts were seen in the cathode lesions. It is concluded that the dermal changes in the cathode area are specific for electrical injury from day 1 to 14. However, earlier studies have demonstrated dermal changes specific for electrical injury at day 0 and the presence of calcified collagen fibres up to 2 months after injury. The dermal changes in anode lesions were non specific and could not be differentiated from those found in heat lesions. Alternating current lesions (50 Hz) were specific from day 1 to day 7, when the pointed electrode was used, but only in a few days when the energy was transferred via the 12-mm electrodes.

Electrically-induced collagen calcification in pig skin. A histopathologic and histochemical study.

Deposition of calcium salts on collagen fibres in skin of fully anaesthetized pigs was induced by exposure to direct current (d.c.). In biopsies obtained from cathode areas successively from day 1 to day 7 after exposure the histopathologic and histochemical changes before and after the initial deposition of calcium salts have been examined. For comparison skin sites with intradermal injected calcium hydroxyapatite crystals were studied in addition. Small areas of calcified collagen and elastic fibres were noted in viable tissue 2 days after d.c. exposure. In succeeding days the calcified areas enlarged with new deposits always more superficial and closer to the epidermis than the original calcium deposits. Preconditions for calcification appear to be (1) a pH change in basic direction and/or the electrochemical processes specific to the cathode area and (2) a viable tissue. Elastic fibres appear to have a lower calcification threshold than collagen fibres. A positive staining for glycoproteins (PAS) and glycosaminoglycans (alcian blue pH 2.5) was noted in the calcified collagen fibres simultaneously with the calcification. In succeeding days the intensity of the staining reactions increased. Whether changes in the glycoproteins, collagen and its intimately bound glycosaminoglycans precede the calcification or the staining reactions develop secondarily to this deposition is not known. However, seven days after intradermal injections of Ca-apatite crystals in pig skin small and large crystals were observed ultrastructurally without any relation to collagen fibrils, but the calcified tissue presented a positive PAS and alcian blue reaction from day 2. Thus the PAS and alcian blue stainings in this model develop secondary to the deposition of calcium salts.

Immediate dermal changes in pig skin after exposure to moderate amounts of heat and electrical energy.

Pig skin was exposed to approximately 80 joules of heat and electrical energy [50 Hz alternating current (a.c.) and direct current (d.c.)], respectively, under controlled conditions in order to find methods to document electrical torture. Biopsies were obtained immediately after exposure, and the morphology of the electrical lesions was compared with that of heat lesions and unexposed skin by using normal and polarized light microscopy. In areas exposed to 50 Hz a.c. and in cathode areas after d.c., where calcified collagen fibers have been found 2 days after injury, the collagen fibers showed a regular, densely spaced, cross-striation. This type of cross-striation was not found in heat or anode lesions. It was possible to blindly group all biopsies correctly with regard to influence of heat, 50 a.c. and d.c.

Prevalence of Legionnaires' disease in pneumonia patients admitted to a Danish department of infectious diseases.

During a 14-month study period, 92 patients admitted to the University Clinic for Infectious Diseases with pneumonia were investigated to determine the prevalence and severity of Legionnaires' disease (LD). The diagnosis of LD was based on positive serology. Antibodies to 10 different legionella antigens--Legionella pneumophila serogroups 1-6, Fluoribacter (Legionella) bozemanae, F. dumoffii, F. gormanii, and Tatlockia (Legionella) micdadei--were measured by the microagglutination (MA) and indirect fluorescent antibody (IFA) techniques. LD was diagnosed in 22 patients showing a 4-fold or greater rise of MA titers. 10 patients showed a 4-fold or greater rise of IFA titer, 2 had standing high titer. One patient died. Legionella infection was the second most common cause of pneumonia. However, in half of the cases legionella infection occurred concomitantly with Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydia psittaci, or viral infections. All 22 LD cases were sporadic. LD had been contracted abroad by 6 patients. Two of the legionella pneumonias were hospital-acquired. Half of the LD patients were older than 60 years. The majority of cases occurred during the winter months. Neither clinical chemistry parameters nor clinical features could distinguish LD from other types of pneumonia.

Tracing the use of electrical torture.

With the aim of being able to trace skin sequelae to electrical torture, an interdisciplinary group of scientists (the "electrical group" of Anti-Torture Research, ATR) has performed controlled morphological studies on skin biopsies from experiments with fully anesthetized pigs. "Vesicular nuclei" in epidermis and a characteristic pattern of collagen calcification in dermis were found to be typical of electrical damage. These alterations were produced by alternating current as well as by direct current.

Comparison of a micro-agglutination test and the indirect immunofluorescence test for Legionella antibodies in patients.

A micro-agglutination (MA) test for antibodies to 10 different Legionella antigens was compared with the indirect immunofluorescence (IF) test. The antigens used were prepared from Legionella (L.) pneumophila serogroups (SG) 1-6, L. micdadei, L.bozemanii, L.dumoffii, and L.gormanii. Sera from 728 patients suspected of suffering from Legionella pneumonia were investigated by both tests. Thirty-five patients showed a significant rise in IF titre to greater than or equal to 128, and 43 had single or static titres of greater than or equal to 256 while the remaining 150 had negative IF titres. The results of the comparison indicate that the MA test offers at least the same sensitivity as the IF test in demonstrating diagnostic titre rises. It may be used as a screening test for selection of sera for further analysis by the IF test. In contrast to the IF test, MA is simple and inexpensive.

Agglutinating antibody titers to members of the family Legionellaceae in cystic fibrosis patients as a result of cross-reacting antibodies to Pseudomonas aeruginosa.

The objective of this study was to evaluate the prevalence and significance of antibody titers to organisms in the family Legionellaceae in 128 serum samples collected from cystic fibrosis patients at routine examinations. Antibody titers were determined for 10 antigenic types of Legionellaceae; Legionella pneumophila serogroups 1 to 6, Fluoribacter (Legionella) bozemanae, Fluoribacter (Legionella) dumoffii, Fluoribacter (Legionella) gormanii, and Tatlockia (Legionella) micdadei. The method of antibody titer determination was the microagglutination test. Elevated titers (greater than or equal to 1:64) to one or more antigens were found in 41.3% of cystic fibrosis patients but in only 9.7% of 103 normal control subjects (P less than 0.01). Titers to 8 of the 10 antigens were directly correlated with the number of Pseudomonas aeruginosa precipitating antibodies in patient sera, as determined by crossed immunoelectrophoresis (correlation coefficients, greater than or equal to 0.74). Cross-reactions between P. aeruginosa and L. pneumophila were substantiated by crossed immunoelectrophoresis of hyperimmune rabbit serum as well as patient sera against P. aeruginosa and Legionellaceae antigens. Monospecific antibody to the "common antigen" of P. aeruginosa was used to demonstrate the presence of this antigen in L. pneumophila. The presence of cross-reacting antibodies in cystic fibrosis patients chronically infected with P. aeruginosa emphasizes the need for cautious interpretation of antibody titers to members of the family Legionellaceae.