Evaluation of organ weights and ventricular thicknesses in electrocution related deaths based on autopsy reports: A biophysical approach.

OBJECTIVE: To evaluate autopsy reports of the deaths due to electrocution in terms of body mass index, body surface area, and organ weights with a biophysical perspective. METHODS: The retrospective study was conducted in Malatya, Turkiye, and comprised autopsy reports of electrocution cases that were obtained from the local branch of the Council of Forensic Medicine related to the period from 2012 to 2019. Organ weights and ventricular thicknesses were compared in terms of body mass index and body surface area. Electrical marks were also evaluated in detail. Data was analysed using SPSS 18. RESULTS: Of the 45 cases, 36(%) were male and 9(%) were female. The overall mean age was 39±13 years (range: 20-71 years). There were no significant differences in organ weights and ventricular thicknesses in different body mass index groups (p>0.05). The weights of head and heart were significantly different in relation to body surface area (p<0.05), but no significant difference were found for other organs and ventricular thickness (p>0.05). CONCLUSIONS: Comparing the organ weights in electrocution autopsies to normal organ weights may help decide the cause of death. During autopsy, electrical marks should be evaluated by considering the characteristics of the electrical current.

An experimental rat model of electric shock injury with isolated electric shock and water conduction: the histopathological changes on the skin and internal organs and the effect on biochemical parameters.

It is difficult to determine the cause of death in electric shock injuries when no trace can be determined on the skin, and this is accepted as a reason for negative autopsy. We aimed to determine useful parameters in the definition of the cause of deaths associated with electric shock and particularly those formed with water conduction. This study used a total of 42 rats, applied with fatal electric shock formed of isolated electric shock at 220 V and with water conduction. The serum NT-ProBNP and H-FABP levels were examined together with histopathological changes in the brain, cerebellum, brainstem, heart, liver and skin and the Bax, caspase-3 and HSP-60 antibody status in these tissues. A statistically significant difference was determined between the groups in respect of the serum H-FABP values and the immunohistochemical staining of the samples taken from the organs. In conclusion, this study is the first in literature with an experimental model of electric shock with water conduction. Using immunohistochemical and biochemical markers in deaths associated with isolated electric shock and electric shock with water conduction, the results of this study can contribute to the clarification of one of the reasons for negative autopsy in forensic medicine.

A 9-year retrospective review of lightning deaths from the Eastern Anatolian Region of Turkey.

In this study, deaths from lightning strikes in Eastern Turkey revealed distinct patterns in lifestyle and physical injury. Farmers, sailors, and those engaged in outdoor sports are all at risk of being struck by lightning. Death from a lightning strike is associated with cardiovascular and central nervous system damage. This study examines cases of autopsies that were performed on bodies that had suffered a lightning strike, including sociodemographic data, burns on the body, injured regions, histopathological findings, and causes of death. This retrospective evaluation included 17 cases. The cases comprised 88.2% males and 11.8% females, with a mean age of 41.5 years. The person's occupation was farmer in 29.4% of the cases and shepherd in 70.6%. Their deaths occurred most frequently in the summer months. Deaths associated with lightning strikes are more frequent in east of Turkey than in other regions, as agriculture and livestock are common sources of income. The majority of the victims among the cases were males working outside because of their occupations. Histopathologically, subarachnoid fresh bleeding was seen in five cases, subpleural fresh bleeding in the lungs in five cases, and interlobular rupture in the lungs in three cases. Deaths associated with lightning strikes have been correlated with a low level of education in this subject. This study is the largest case study of deaths associated with lightning strikes in Turkey.

Sex estimation using foramen magnum measurements, discriminant analyses and artificial neural networks on an eastern Turkish population sample.

BACKGROUND: Although many studies have been conducted using the foramen magnum for sex estimation, recent findings have indicated that the discriminant and regression models obtained from the foramen magnum may not be reliable. Artificial Neural Networks, was used as a classification technique in sex estimation studies on some other bones, did not used in sex estimation studies on the foramen magnum until now. The aim of this study was sex estimation on an Eastern Turkish population sample using foramen magnum measurements, discriminant analyses and Artificial Neural Networks. METHODOLOGY: The study was performed on the CT images of a total of 720 cases, comprising 360 males and 360 females. For sex estimation, discriminant analysis and Artificial Neural Networks were used. RESULTS: The accuracy rate was 86.7% with discriminant analysis and when sex estimation accuracy was determined according to cases with posterior probabilities above 95%, the accuracy ranged from 0% to 33.3%. With the use of the discriminant formulas of 2 other studies, obtained from different Turkish samples, sex could be determined at a rate of 84.6%. Some formulas were found to be unsuccessful in sex estimation. Sex estimation accuracy of 88.2% was achieved with Artificial Neural Networks. CONCLUSION: In this study, it was found that sex could be determined to some extent with discriminant formulas from other samples from the same population, although some formulas were unsuccessful. With the use of image processing techniques and machine learning algorithms, better results can be obtained in sex estimation.

Comparison of Cardiac Wall Thicknesses and Coronary Artery Obstructions Between Deaths Resulting From Acute Myocardial Infarction and Deaths From Other Causes.

Objective: The risk factors for myocardial infarction (MI) can be separated into three general categories: non-modifiable factors, modifiable risk factors, and lifestyle. This study aimed to investigate whether or not there was any effect of cardiac wall thickness and coronary artery obstructions on acute MI. Methods: In this retrospective study of histopathological examinations of autopsies, two groups were formed. The first contained 28 cases diagnosed with acute MI and the second 28 cases with no heart pathology and the cause of death was reasons other than heart disease. The subjects in the two groups were similar in age, height, weight, and body mass index. The groups were compared in terms of the left and right ventricular wall thicknesses and the degree of obstruction of the right, left, anterior descending, and circumflex coronary arteries. Results: The mean left ventricular wall thickness was 1.461±0.2767 cm in the acute MI group and 1.386±0.2460 cm in the control group, with no statistically significant difference found between the two groups (p=0.289). A statistically significant difference in the degree of obstruction of the coronary arteries was found between the groups. Conclusions: Although the mean cardiac wall thickness was greater in the acute MI cases, no statistically significant difference was found between the two groups.

An examination of the sociodemographic and psychiatric characteristics of children who have suffered penetrative and non-penetrative sexual abuse in Malatya, Eastern Turkey.

Penetrative and nonpenetrative sexual abuse can cause short- and long-term psychiatric problems in victims. This study aimed to examine the sociodemographic characteristics and psychiatric diseases of children in Malatya, eastern Turkey, according to whether the abuse was penetrative or nonpenetrative. A retrospective examination was conducted on the records of 115 cases of sexual abuse that had been referred to judicial authorities from January 1, 2012-July 30, 2019. The subjects were evaluated by a committee formed of 5-7 separate specialized department faculty members. It was determined that 51.3% (n = 59) of the cases had suffered nonpenetrative sexual abuse, and 48.7% (n = 56) had suffered penetrative sexual abuse. The majority of the perpetrators were known to the child from their close environment. A psychiatric diagnosis was made by the committee in 20.3% (n = 12) of the nonpenetrative cases and in 42.9% (n = 24) of the penetrative cases. There was a significant difference between penetrative and nonpenetrative sexual abuse in terms of psychiatric diagnoses. Of the cases of penetrative sexual abuse, 87.5% (n = 14) had attempted suicide. As a result, early diagnosis of sexual abuse, which has devastating effects on mental health in the early and late periods before it penetrates, can reduce the devastating effects on the child. For this reason, it is crucial for doctors, psychologists, social workers, and teachers who work with children to be informed about this issue.

The Use of Handwriting Changes for the Follow-up of Patients with Bipolar Disorder.

Introduction: Patients with bipolar disorder have motor skill deficiency and cognitive dysfunction. It is suggested that these deficiencies are related to the neurodevelopmental course of the disease. The aim of this study was to examine whether or not there was a change in the handwriting of patients with bipolar disorder in periods of mania and remission. Method: Two samples of handwriting and signature were taken from the cases, one on admission before treatment and one just after discharge. The first sample was taken in the period when the patients hospitalised with manic episode before medications and the second sample was taken in remission when the decision for discharge was made. The handwriting changes betwen the manic episode and the remission period were examined. Results: In the examination of the handwriting between the two periods, there was an increase in the size of the writing, pen pressure, the length of words, the spaces between words, and missing and incorrect punctuation marks in the manic episode. There were no differences in any handwriting measure on function of the specific diagnosis or the antipsychotic dose but tremor count was higher in patients using antipsychotics (p<0.05). Most of the parameters showing a change were found to be related to the Young Mania Rating Scale (YMRS) scores. Conclusion: The results of this study determined severe changes in the handwriting of patients with bipolar disorder in a period of mania. Handwriting features can be used to screen patients for discharge and can be used for prediction when a patient might switch into manic episode. Also intake YMRS scores were found as the most important feature that affect handwriting parameters in manic patients.

Association of BDNF / TrkB and NGF / TrkA Levels in Postmortem Brain with Major Depression and Suicide.

BACKGROUND: Suicide Attempts are the main complications of Major Depressive Episodes and are difficult to predict. There is still a lack of knowledge about its neurochemical aspects. There is increasing evidence that Brain-derived neurotrophic factor (BDNF) and Nerve growth factor (NGF) play a role in the pathophysiology and treatment of depression by binding and activating cognate receptors Tyrosine Kinase B (TrkB) and Tyrosie Kinase A (TrkA), respectively. This study was conducted to examine whether BDNF and / or TrkB as well as NGF and / or TrkA expression profiles were changed in the hippocampus of postmortem brain of individuals with depression who committed suicide. SUBJECTS AND METHODS: This study was conducted with the brain tissue of 61 victims who died as a result of suicide due to depression and 25 people who died due to traffic accidents. The psychiatric history of the cases was determined by the psychological autopsy method. Samples were taken from the hippocampus region of the brain at the forensic medicine institution. After storage under appropriate conditions, protein and mRNA levels of BDNF, TrkB, NGF and TrkA were determined in the genetics laboratory. RESULTS: Average age of the suicide group was 30 and the average age of the control group was 24.5. The suicide group consisted of 70.5% male and 29.5% female cases. There was no significant difference between the groups in terms of age (p=0.062) and gender (p=0.718). BDNF, NGF, TrkA and TrkB values were found to be lower in the suicide group compared to the control group and there was a significant difference between the groups (p≤0.001; p=0.001; p=0.001; p=0.011). CONCLUSION: Given the importance of BDNF and NGF and their cognate receptors in mediating physiological functions, including cell survival and synaptic plasticity, our findings regarding decreased expression of BDNF, TrkB, NGF and TrkA in both protein and mRNA levels of postmortem brains of suicide victims suggests that it may play an important role in the pathophysiological aspects of its behavior. Further studies in this context may be useful both in understanding the molecular basis of suicide and in designing therapeutic models targeting these molecular pathways.

Evaluation of Childhood Traumas, Depressive Symptoms, and Dissociative Experiences in Tinnitus Cases.

OBJECTIVE: Tinnitus is described as the perceived sound without any external stimulus and is a common problem, but its mechanism is not fully understood. This study aimed to evaluate childhood traumas and dissociative experiences, which may be predisposing factors in patients with tinnitus. METHODS: The study included 90 voluntary patients (45 patients with tinnitus and 45 in the control group) aged older than 18 years who applied to the otorhinolaryngology clinic between November 2018 and February 2019 and were diagnosed with subjective tinnitus. A personal information form together with childhood trauma, hospital anxiety and depression, and dissociative experiences scales were used to assess the patients. RESULTS: Of all participants, 55.60% were males, 28.90% were 20-30 years old, 71.10% were married, 40% were primary school graduates, and 68.90% were employed. In addition, 77.78% of patients did not visit a psychiatrist and 75.56% did not have any chronic diseases. The mean total score of Childhood Trauma Scale for the tinnitus group was 54.37±10.17, the mean total score of The Hospital Anxiety and Depression Scale for the tinnitus group in the depression subscale was 12.22±5.41 and in the anxiety subscale was 10.54±3.5, and Dissociative Experiences was 13.48±4.68. A positive significant relationship was found between the childhood traumas of the tinnitus cases in their depressive symptoms, and dissociative experiences (p<0.05). CONCLUSIONS: The study results found a positive relationship between the childhood traumas and dissociative experiences of tinnitus cases, which can be considered as predisposing factors in patients with tinnitus who should also be investigated for childhood trauma, and the treatment approach should be multidisciplinary.

Shaken baby syndrome resulting in death: a case series.

BACKGROUND: The aim of this study was to raise the awareness of all healthcare personnel, primarily Emergency Department physicians, forensic physicians, and paediatricians about cases of shaken baby syndrome (SBS), which can be difficult to diagnose, require a high level of suspicion in diagnosis and there is a high likelihood of missed diagnosis. METHODS: A retrospective examination was made of 3400 forensic cases applied with autopsy between 2012 and 2018 to the Forensic Medicine Institution of Malatya Group Directorate. RESULTS: Of the total cases, 113 were aged < 2 years and head trauma was determined in 35. Eight cases were determined as SBS. Of the 8 cases that resulted in death, 75% were male and the mean age was 8.3 months. The trauma had been perpetrated by the father in 50% of cases. There was a history of seizure in 67.5% of the infants and 75% were taken to the Emergency Department with cardiopulmonary arrest. Subdural hematoma and subarachnoid hemorrhage were determined in 37.5% of the cases, subdural hematoma, subarachnoid hemorrhage and intracranial hemorrhage in 50%, and epidural hemorrhage and subarachnoid hemorrhage in 12.5%. In the microscopic examination of the medulla spinalis, focal subdural fresh bleeding was seen in 50% of cases. Bleeding around the optic nerves was determined in 37.5% of cases bilaterally and in 37.5% unilaterally. Retinal hemorrhage was determined in all the cases, which was bilateral in 75%. CONCLUSIONS: The actual worldwide incidence of SBS is not known, and in Turkey, it is thought to be much higher than has been determined. The most important reason for this is thought to be that the diagnosis of child abuse is difficult and physicians do not have a sufficient level of knowledge.

Sudden death as a result of colon perforation; Ehlers-Danlos type IV case with postmortem diagnosis.

Ehlers-Danlos Syndrome (EDS) is a connective tissue disease with heterogeneous subgroups. In type IV EDS, also known as vascular EDS (VEDS), the underlying genetic anomaly consists of a mutation of the COL3A1 gene encoding the type III procollagen. As a result of the mutation, pathological findings due to excessive brittleness of the tubular organs or vessels occur. In our case, we present a patient with sudden death due to colon perforation which was diagnosed with EDS type IV after further examination in the autopsy. Forensic medicine experts should consider the possibility of EDS type IV after the detection of spontaneous ruptures in the internal organs during the autopsy. We think that it would be appropriate to report this autosomal dominant and potentially fatal condition to family members.

Evaluation of Incest Cases: 4-Years Retrospective Study.

Incest is specific type of sexual abuse. The aim of this study was to evaluate the sociodemographic data and examination findings of cases referred to our hospital as forensic court cases of incest, and to measure the effect on mental health disorders of the nature of the sexual abuse. Retrospective examination was made of the records of 40 cases of incest victims. Evaluation was made of the age, gender, incident suffered, the perpetrator, form of abuse, examination findings, and mental status. The cases comprised 36 girls and 4 boys. Without penetration sexual abuse was determined in 25 cases and with penetration sexual abuse in 15 cases. At least one mental health disorder was determined in 20 of the cases of simple sexual abuse and in 11 of the major sexual abuse type cases. The most frequently seen mental health disorder was post-traumatic stress disorder (PTSD) in 21 cases. Mental health disorders were determined in 77.5% of the incest cases in this study, at a greater rate 80% in cases of "without penetration sexual abuse" than in cases of "with penetration sexual abuse" 74.33%. Therefore, all cases of incest must be followed up carefully without differentiation of without or with penetration abuse.

Histopathological evaluation of autopsy cases with isolated pulmonary fat embolism (IPFE): is cardiopulmonary resuscitation a main cause of death in IPFE?

Background: Fat embolism (FE) may develop following many traumatic and atraumatic clinical conditions; however, fewer data exist regarding the occurrence of isolated pulmonary FE (IPFE). Cardiopulmonary resuscitation (CPR) is an emergency procedure for maintaining blood circulation and oxygenation during cardiac arrest. In this study, we aimed to evaluate the association of CPR with IPFE in autopsy cases. Methods: A total 402 cases among 4,118 autopsies were diagnosed with IPFE, and the medical background of these cases was retrospectively evaluated. Diagnosis of FE and FE grading were performed with histopathological examinations of postmortem tissue samples, and injury-severity scores of traumatic cases were assessed. Data of traumatic and atraumatic cases were statistically compared. Results: Of the IPFE cases, 298 (741%) were male and 104 (25.9%) female, with overall mean age 53.7 (2-99) years. Causes of death of studied subjects were traumatic for 302 (75.1%) and atraumatic reasons for 100 (24.9%) cases. CPR was performed for 277 cases of which 177 (63.9%) were traumatic and 100 (36.1%) were non-traumatic. In comparison to traumatic cases, significantly higher CPR frequency was determined in atraumatic IPFE (P=0.001). High grade FE in the traumatic cases, and mild-moderate grade of FE in the nontraumatic cases were found statistically significant (P=0.001). Conclusion: This study indicates that CPR may be one of the leading factors in the development of IPFE in atraumatic conditions, and this procedure was related to mild-moderate IPFE manifestations. Regardless of whether conditions were traumatic or atraumatic, in patients who survive following CPR for manifest ventilation/perfusion problems, it should be remembered that IPFE may have developed due to CPR.

A rare case of fatal venous and cerebral air embolism.

A venous air embolism can occur as a result of circumstances that include blunt head or chest trauma, thoracentesis, arterial catheterization, neurosurgery, cardiac surgery, and Caisson disease. The formation of a venous air embolism requires an air source, interaction between the air source and the vessel, and a pressure gradient supporting air migration into the vessel. Air enters through the impaired venous structure and travels to the right side of the heart and the pulmonary arteries, and depending on the amount of air, may occasionally be fatal. This report is the description of the case of a 3-year-old child who developed a fatal venous and cerebral embolism during neurosurgery for the treatment of skull fractures with epidural and subdural bleeding due to blunt head and chest trauma resulting from a television falling on her. The pathophysiology of death and notes regarding the medico-legal autopsy procedure in such cases are discussed. Meticulous autopsy techniques must be used to determine the presence of an air embolism in cases of blunt trauma, especially in patients with blunt trauma to the head who die during neurosurgery, and possible future malpractice claims should be kept in mind.

Cut throat injuries and honor killings: review of 15 cases in eastern Turkey.

Throat cuts could be of homicidal, suicidal or accidental origin. In the cases of death from cut throat, suicide can be distinguished from homicide based on the type and location of the wound and crime scene investigation. The purpose of the current study is to attract attention to the instructive findings for origin determination in deaths by cut throat according to the number and characteristics of the wounds and crime scene investigation. We have reviewed the files of autopsies performed between the years of 2000 and 2010, and compared with previously published case reports; all results were summarized in the current study. The results showed that 60% of cases were male, 40% were female, with 27.9 years of average age. The mean number of wounds was calculated to be 34.3 per case for honor homicides, 7.4 per case for other homicides, and 2.0 per case for suicides. Numbers of wounds were approximately 5 times higher in the honor homicides compared to other homicides. If the number of wounds were excessive, possibility of honor killings should be taken into account. When the killer was a parent not in psychosis, hesitation cuts were detected. Additional lesions were present in 46.7% of the cases, and they were assessed as homicide. Presence of vertebral notch and spinal cord cuts, which require a substantial amount of force and pressure via sharp tools, indicates homicide.

Traumatic thrombosis of internal carotid artery sustained by transfer of kinetic energy.

A 31-year-old male patient with a fatal thrombosis of the internal carotid artery caused by gun shot injury was presented in this case report. The patient was referred to the hospital with a diffuse edema on his left cheek. On otolaryngologic examination, there was a bullet entrance hole at the left mandibular corpus. No exit hole could be found. The finding from his axial computed tomography of neck and paranasal sinuses was normal. On neurological examination, a dense right hemiparesis was observed. In his cerebral angiogram, left common carotid artery was totally obliterated. Diffuse ischemia was observed in the left cerebral hemisphere. Despite intensive interventions, the patient died 4 days after the accident. In the autopsy, a large thrombosis was obtained in the left common carotid artery. This case emphasizes a fatal kinetic energy effect in vascular structures. It is stressed that a gun shot injury could be fatal with its indirect kinetic energy effects at subacute phase.

Forearm bones and sexual variation in Turkish population.

Forensic anthropologists are aware that there are considerable differences between human populations and therefore develop study models for each skeletal population. The purpose of this study was to analyze forearm bones obtained from forensic settings in Turkey. The sample consists of 42 males and 38 females with an average age of 40 and 36 years, respectively. Numerous measurements were taken from the radius and ulna including lengths (in millimeters), midshaft diameters, and epiphyseal breadths (0.01 mm). Individuals with any anomaly and pathology were not included in the investigation. A stepwise analysis, when applied to individual bones, selected only length and midshaft transverse dimension in the radius and length only in the ulna. When the length was excluded from the statistic, head diameter and distal breadth of the radius and distal minimum head and midshaft anteroposterior diameters of the ulna provided the best predicting functions. Classification results were 92% for the radius and 91% for the ulna. For the incomplete bones, the accuracy rates were about 92% and 83%, respectively. In conclusion, a sex determination was made, in different rates of accuracy, in the human skeleton. Correct assessment can vary among populations. Dimorphism in our region forearm bones is greater than American whites. This supported the hypothesis that human variation is diverse, and population difference should be taken into account when osteometric standards are applied to others. Further studies are needed to understand why the forearm is more dimorphic in Turks.

Total body height estimation using sacrum height in Anatolian Caucasians: multidetector computed tomography-based virtual anthropometry.

OBJECTIVE: Estimation of total body height is a major step when a subject has to be identified from his/her skeletal structures. In the presence of decomposed skeletons and missing bones, estimation is usually based on regression equation for intact long bones. If these bones are fragmented or missing, alternative structures must be used. In this study, the value of sacrum height (SH) in total body height (TBH) estimation was investigated in a contemporary population of adult Anatolian Caucasians. MATERIALS AND METHODS: Sixty-six men (41.6 ± 14.9 years) and 43 women (41.1 ± 14.2 years) were scanned with 64-row multidetector computed tomography (MDCT) to obtain high-resolution anthropometric data. SH of midsagittal sections was electronically measured. The technique and methodology were validated on a standard skeletal model. RESULTS: Sacrum height was 111.2 ± 12.6 mm (77-138 mm) in men and 104.7 ± 8.2 (89-125 mm) in women. The difference between the two sexes regarding SH was significant (p < 0.0001). SH did not significantly correlate with age in men, whereas the correlation was significant in women (p < 0.03). The correlation between SH and the stature was significant in men (r = 0.427, p < 0.0001) and was insignificant in women. For men the regression equation was [Formula: see text] (r = 0.54, SEE = 56.9, p < 0.0001). CONCLUSION: Sacrum height is not susceptible to sex, or to age in men. In the presence of incomplete male skeletons, SH helps to determine the stature. This study is also one of the initial applications of MDCT in virtual anthropometric research.

Investigation of lead mobilization from the buckshot residues to the critical organs.

Lead exposure causes neurotoxicity, reproductive system dysfunction, renal failure, and blood and endocrine system disorders in human and experimental animals. In this study, we investigated lead mobilization from gunshot fragments to the critical organs (brain, heart, liver, and kidney) and its interaction with essential trace elements on experimental rat model. Thirty-five rats were randomly divided in five groups. The first group was a control and the others were subjected to buckshot implantation in their skeletal muscles (second and third groups) and abdomen (fourth and fifth groups). The control group and the second and fourth groups were sacrificed 1 month after the onset of experiment while the third and fifth groups were followed after 2 months. Blood lead levels were significantly elevated in both 2 month-followed groups and 1 month-followed intraabdominal group. There were significant increases in brain lead levels of both 2 month-followed groups. For the 1 month-followed groups, kidney lead levels were also significantly higher than those of controls. Results show that lead mobilizes from the buckshot residues in distance tissues to the critical organs and interacts with iron, copper, and zinc even though blood lead level sometimes remains unchanged. Our findings are crucial in revealing lead accumulation in critical organs of subjects carrying any gunshot fragments. These subjects and physicians should be in alert for emergence of lead-induced manifestations.

Foreigners dying in Istanbul.

The study included 411 deaths selected from 14,647 medicolegal deaths autopsied in the Morgue Department of Forensic Medicine Institute Directorate, affiliated with the Ministry of Justice, between 1998 and 2002. Data were collected from court documents, coroner's investigation reports, and autopsy reports. The parameters of age, gender, nationality and origin, cause and place of death in foreigners dying in Istanbul were evaluated in the study. Out of 14,647 medicolegal deaths, 3.5% were foreigners from 34 different nationalities. The nationality with the highest rate of foreigner deaths (34%) was Romanian. Out of 411 deaths, 74.3% were male and 25.7% were female. Of all cases, 64.4% were tourists visiting Istanbul and 35.6% had a job in Istanbul. Of 146 foreigners employed in Istanbul, 94.5% did not have a work permit, while only 5.5% had a work permit.