To investigate the pattern of neck injuries and the role of toxicology in cases of hanging and manual/homicidal ligature strangulation in Ireland between 2016 - 2020: A retrospective review and analysis.

The pattern of neck injuries sustained in fatal cases of external compression to the neck is recorded during Post Mortem Examinations (PME), to assist in the interpretation of the circumstances that led to death. In this study, the PMEs performed for 298 cases of hanging and strangulation occurring between 2016 and 2020 in Ireland were retrospectively reviewed for the purpose of recording and collating the external and internal neck injuries observed during each PME, as well as the toxicology results for each decedent. Statistical analysis was performed to investigate potential novel associations between anthropometric variables pertaining to the decedents and the PME findings in cases of hanging and strangulation, serving to add further data to the existing body of research in this area and to assist in the resolution of future cases of hanging or strangulation where there are conflicting findings. In completing statistical analysis, it was found that there was no discernible association between the occurrences of cartilaginous neck fractures (CNFs) with increasing ligature width. Positive associations between increasing weight and BMI of the decedents were identified, and a significantly positive association between the increasing height of the decedent and the incidence of CNFs were identified. Analysis of the toxicology demonstrated that antipsychotics were implicated most frequently in cases of incomplete and complete hanging associated with CNFs and that opioids were implicated most frequently in cases of manual and ligature strangulation associated with CNFs. OBJECTIVE: To record the pattern of neck injuries sustained in retrospective cases of hanging and manual/ligature strangulation and to collate these findings so as to provide scientific evidence to support the interpretation of the findings in future cases of suicidal hanging and homicidal manual/ligature strangulation for the purpose of medicolegal investigation. To analyse the associations between the occurrence of neck fractures and anthropometric variables pertaining to the victims in cases of complete hanging. STUDY DESIGN: The reports of 298 Post Mortem Examinations (PMEs) performed for cases of hanging and manual/homicidal ligature strangulation between 2016 and 2020 in Ireland were retrospectively reviewed. Pseudoanonymised data sets were recorded for each report, which included the following parameters: neck injuries (soft tissue and cartilaginous), weight, height, BMI and ligature width, toxicology, noose position, ligature material, tongue protrusion, sex and age. Permission for the use of this data was sought from the pathologists and coroners involved in these cases. The data was analysed according to descriptive statistical methods and logistic regression analysis. RESULTS: Logistic regression analysis was undertaken to examine the associations between unit increases in ligature width and increases in a set of physical characteristics of the decedents (weight, BMI and height) with the occurrence of CNFs. Increasing ligature width was not found to increase the likelihood of a CNF occurring, where the Odds Ratio (OR) for this event occurring was 0.9596. Unit increases in body weight and BMI were found to increase the likelihood of the occurrence of a CNF with ORs of 1.0166 and 1.0607 respectively. Increasing height of the decedent yielded an OR = 4.64, demonstrating that CNFs are significantly more likely to occur with increasing height (CI 95 %: 0.2915, 73.9559). CONCLUSIONS: According to the statistical analysis performed for this study, increasing weight, height and BMI are parameters of the decedents which increase the likelihood of the occurrence of CNFs in cases of complete hanging.

Thoracic vasculitis presenting as surgical problems.

We present four patients with vasculitis manifesting with unusual clinical or pathological features, generating surgical problems. Two cases presented with pulmonary hypertension, with investigations and radiological evidence prompting clinical suspicion of pulmonary thrombo-embolic disease. First case, with an antecedant history of Wegener's granulomatosis (WG), demonstrated following "embolectomy", WG involving the large pulmonary elastic arteries. The second case of inoperable "pulmonary thrombo-embolic disease" was subsequently found at limited post mortem to have giant cell arteritis, which affected widespread small peripheral pulmonary arterial vessels. The other two cases were of aortitis occurring in the background of immune-mediated disease, which had been treated with aggressive immunosuppression regimens. The first of these was a case of Cogan's syndrome complicated by descending aortitis, a rarely reported phenomenon, with co-existent acute endocarditis of the aortic valve leaflets. Most cases of endocarditis in this context occur secondary to and in continuity with ascending aortitis. That this case, and a case of ascending aortitis occurring in the context of relapsing polychondritis occurred in the face of aggressive immunosuppression with an apparent clinical response, underscores the need to not accept a clinical picture at face value. This has implications for clinical management, particularly in the follow-up of surgical prosthetic devices such as grafts which may be used in these cases. All four cases emphasise the continued importance of histology and the post-mortem examination in elucidating previously undetected or unsuspected disease.