JOURNAL OF Punjab Academy of Forensic Medicine & Toxicology ISSN: 0972-5687 Volume: 19, Number: 02 July to December Publication: Half Yearly

2019

Editor-in-Chief Dr. Parmod Kumar Goyal

A Peer Reviewed Journal on Forensic Medicine, Toxicology, Analytical Toxicology, Forensic Science, Environmental Pollution, Forensic Pathology, Clinical Forensic Medicine, Identiication, Legal Medicine, State Medicine, Medical Jurisprudence, Medical Ethics, Forensic Nursing, Forensic Odontology, Forensic Anthropology, Forensic Psychiatry and other Allied branches of Medicine and Science dedicated to administration of Justice.

Place of Publication: Bathinda (Punjab) India

• Indexed with Index Copernicus (Poland), Scopus (Elsevier Products), IndMed (ICMR New Delhi), Safetylit, Worldcat Library & WHO Hinari • JPAFMAT is also having PubMed/NLM catalogue number (NLM Unique ID: 101232466). • Available online at Indian Journals.com, pafmat.org and pafmat.com • UGC Approved (as per UGC care list) J Punjab Acad Forensic Med Toxicol 2019;19 (2) ISSN : 0972-5687

PUNJAB ACADEMY OF FORENSIC MEDICINE AND TOXICOLOGY (Registration No. 139 / 1998-99, Chandigarh) HO: Department of Forensic Medicine, Govt. Medical College Patiala (Punjab) 147001

GOVERNING COUNCIL (2019 - 2021)

President General Secretary Joint Secretary Dr. D. S. Bhullar Dr. Akashdeep Aggarwal Dr. Didar Singh Walia

Finance Secretary Vice President Web Master Dr. Shilekh Mittal Dr. Rajiv Joshi Dr. Dildar Singh

Editor-in-Chief Joint Editor Assistant Editor Dr. Parmod Kumar Goyal Dr. Amandeep Singh Dr. Satinder Pal Singh

Executive Members Dr. Ashok Chanana Dr. Preetinder S. Chahal Dr. Amit Singla Dr. Ishwar Tayal Dr. Puneet Khurana Dr. Ashwani Kumar Dr. Dasari Harish Dr. Ajay Kumar Dr. Deep Rattan Mittal

Advisors Dr. O.P. Aggarwal Dr. Gurmanjit Singh Dr. R.K. Gorea Dr. S.S. Oberoi Dr. K.K. Aggarwal Dr. Vijaypal Khanagwal Dr. Balbir Kaur Dr. R.K. Sharma

Special Invitee

Dr. Adish Goyal Dr. Mukul Chopra

FOUNDER GOVERNING COUNCIL OF PAFMAT Patron President Executive Members Dr Jagdish Gargi Dr. R. K. Gorea Dr A S Thind, Vice President Dr Jagjiv Sharma, Advisors Dr. D. S. Bhullar Dr Kuldeep Kumar, Dr J. S. Dalal Secretary Dr I. S. Bagga, Dr Harish Tuli Dr. Sat Pal Garg Dr Baljit Singh Dr Maj. Gen (Rtd.) Ajit Singh Treasurer Dr. Nirmal Dass J Punjab Acad Forensic Med Toxicol 2019;19 (2) ISSN : 0972-5687

From the Desk of Editor-in-Chief I am pleased to present the second issue of the year 2019 of Journal of Punjab Academy of Forensic Medicine & Toxicology. I am thankful to the authors and contributors for the scientific articles and research papers which are being published in this issue. I am also thankful to the editorial team for supporting me in its publication and the members of the Academy for giving me another chance to serve as Editor-in-Chief of the journal for the second term. My special thanks to Joint Editor Dr Amandeep Singh and Assistant Editor Dr Satinder Pal Singh for their support and sincere efforts for timely publication and release of this issue. The Journal publishes original research papers, review articles, case reports and review of books on Forensic Medicine and Toxicology. The Journal highlights the achievements of the academy and its members. This journal is meant for achieving the aims and goals of the academy to expand the academic activities, spread the knowledge and latest research in the field of Forensic Medicine and Toxicology. Website of the academy and journal can be accessed at pafmat.org. Authors can submit their papers by creating a user name and password on this site. The new website was officially launched on 17th November 2018 during the occasion of annual conference on Punjab Academy of Forensic Medicine and Toxicology . The Academy is very thankful to Dr Imran Sabri,Saudi Arabia for helping in designing and maintaining the new website, which is a mandatory requirement for PubMed indexing of the journal. Editorial team is trying their best for upgrading the indexing of the journal. However we need help for learned faculty for PubMed indexing of the journal. Any suggestions and advice for further improving the standards and quality of the journal will be highly appreciated and may be sent to me through email or my whattsapp no. 9876005211.

ISSN Numbers: that it is not being considered for publication elsewhere. ISSN-L: 0972-5687, p-ISSN: 0972-5687, e-ISSN: 0974- Submission of multi-authored paper implies that the consent of 083X. each author has been taken. Researchers/Authors should adhere to publication requirements that submitted work is Indexed with: original, not plagiarized, ethical and has not been published IndexCopernicushttp://journals.indexcopernicus.com/karta.p hp?id=4715 elsewhere. Every effort has been made not to publish any inaccurate or Scopus (SCI): misleading information. However, the Editor-in-Chief, the http://www.scimagojr.com/journalsearch.php?q=199001949 Joint Editor or any member of the editorial committee accept 14&ip=sid&clean=0 no liability in consequences of any such publications. For any further information/query please contact with Editor-in-Chief. Volume of Distribution: 300 copies.

Funding Bodies: Punjab Academy of Forensic Medicine & Toxicology, Donations from Philanthropists and manuscript handling charges

Address for submission of articles Online (Soft Copy): Dr Parmod Goyal [email protected], [email protected] Professor & Head (Forensic Medicine) Coordinator, Medical Education Unit Member Secretary,Ethics Committee,Adesh University Copyright: Member, Curriculum Committee No part of this publication may be reprinted or republished Convener, BOS(PG) Adesh University, Bathinda without the prior permission of Editor-in-Chief of Journal of Coordinator, Body Donation Programme FAIMER 2013, ACME 2015 Punjab Academy of Forensic Medicine & Toxicology. Editor in Chief, Journal of Punjab Academy of Forensic Submission of all papers to the journal is understood to imply Medicine and Toxicology (JPAFMAT) Adesh Institute of Medical Sciences & Research, Bathinda

1 JOURNAL OF Punjab Academy of Forensic Medicine & Toxicology ISSN: 0972-5687

Volume: 19, Number: 02 July to December Publication: Half Yearly Contents *From the Desk of Editor-in-Chief 1 *Contents 2-4 * Editorial : Travelling Between The Lines : Transgenders Study In Global Perspective 5-14 Manoj Kumar Pathak, Rohini, Srishti Rai *Original Research Papers 1. Socio-demographic Pattern and Physical Features of Firearm Injury Cases : 15-20 A Clinical Forensic Medicine Study Shekhar Chumber, Ashok Chanana, Kuldip Kumar 2. Ten years retrospective study of deaths due to poisoning 21-25 Kamaljeet Singh, Ashok Chanana, Kuldip Kumar, Manpreet Kaul, Jaspinder Pratap Singh 3. Ten Years Autopsy Study of Violent Asphyxial Deaths 26-31 Manoj Kumar Sharma, Ashok Chanana, Kuldip Kumar , Manpreet Kaul 4. Persistent Metopic Suture in Adult Cadaveric Dry Skulls of Coastal Karnataka 32-35 Lydia S. Andrade, Chandni Gupta, Sneha Guruprasad Kalthur 5. A Comparative Study of Hanging and Strangulation Cases in Agra Region 36-39 Tarun Kumar Singh, Ajay Agarwal, Jaswinder Singh, Vijay Kumar, Richa Gupta 6. Dactylographic Pattern in Relation to ABO, Rh Blood Group and Gender 40-42 among Medical Students in Navi Mumbai Amit Patil, Swati Sonawane, Somshekhar Sharma 7. Pattern of Suicidal Burn Deaths Autopsied at Central Delhi Tertiary Care Hospital 43-47 Amandeep Kaur, Monisha Pradhan 8. Anthropometric Measurements of Adult Human Skull for Determination of Sex and 48-52 Stature in a population sample from Haryana state (India) Surinder Singh Oberoi, Akash Deep Aggarwal, Didar Singh Walia 9. Impact of Methamphetamine on the life cycle stages of two forensically 53-56 important flies in AL-Diwaneyah City Hussein R. Mahmood, Malik Ali Kareem 10. Investigation of Demographic Variables and Types of Suspension in Suicidal Hanging 57-61 Azadeh Memarian, Kamran Aghakhani, Babak Soltani, Siamak Soltani, 11. Paediatric Autopsy Study at G B Pant Hospital, ANIIMS, Port Blair, 62-66 Andaman & Nicobar Islands Siddesh Revpla Channabasappa, Udayashankar Yadiyapur 12. Assessment of Sexual Dimorphism of Teeth by Dental Indices 67-72 Shakthi Dorai, N. Srikant, Karen Boaz, Amitha J Lewis, Shweta Yellapurkar, Nidhin Philip Jose 13. Analysis of death in burn cases with special reference to age, sex and complications 73-75 Yogesh Sharma, Ashish Kumar Garg 14. Physicians' Awareness towards Forensic Psychiatry, a Survey of Physicians who 76-79 Work in an Iranian General Hospital Azadeh Memarian, Seyed Mehdi Saberi, Kamran Aghakhani, leyla Abdolkarimi, Siamak Soltanti, Arezoo Amiri

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Volume: 19, Number: 02 July to December Publication: Half Yearly Contents 15. Epidemiological study of Suicide in Siliguri Commissionerate, Darjeeling 80-84 Amit Sarkar, Rajib Prasad, Priyankar Roy, Vivek Kumar, Saikat Saha, Prabir Kumar, Gautam Kumar 16. Sex determination based on thyroid cartilage parameters in Iranian population 85-89 Siamak Soltani, Hanieh Saboori Shekofte, Abbas Aghabiklooei, Mohammad Javad Hedayatshode 17. The use of water quality Index (Canadian model) to determine the validity of the 90-93 River of Al-Diwaniyah - Iraq for Irrigation Ahmed Mahmoud Falih-Al-Khalidi, Raid Kadhim Abed Al-Asady 18. Decay in Intact DNA Recovery in Semen Samples Kept at Room Temperature 94-96 Imran Sabri, Jawed Ahmad Usmani, Shaukat Arif Hanif, Asadullah Khan 19. Prevalence and Extent of Coronary Atherosclerosis and Its 97-101 Correlation with Obesity in a Female Population of South Karnataka : An Autopsy Study Haneil L D'Souza, Mehak Malhotra, Ranjit Immanuel James, Prashantha Bhagavath, Deepak Nayak 20. Comparative study of digital dermatoglyphics among congenital deaf and 102-106 control subjects in South East Nigeria Chijioke Okeke, Izuchukwu Etoniru, Victor Oforbuikem 21. Measurement of Uncertainty of Country Made Liquor by Hydrometer 107-111 Vishala Pithava, Astha Pandey 22. Developing a Module of Medical Ethics for Post MBBS 112-119 Lalit Kumar, Jyoti Barwa, J P Sharma, Puneet Ohri, M A Beg 23. Proposed Standard Operating Procedure for Use of Unclaimed Dead Bodies for 120-123 Medical Education and Research. Rajeev Varma Manukonda, Santoo Bagh, Miss. Yajnaseni Singh, Alakh Ram Verma, Bhushan Kumar Khunte 24. Characterization of country liquor for forensic purposes: A preliminary study 124-129 Rito Chophi, Praveen Kumar Yadav 25. Determination of Sex from Human Adult Sternum 130-133 Sajan Babu, Vikram Palimar, Anitha Sivaji Rao, Chandni Gupta, Vinod C Nayak, Ashwini Kumar, Shankar M Bakkannavar, Nirmal Krishnan M 26. Estimation of The Most Significant Foot Measurement In Determining 134-137 The Stature of An Individual In Karnataka Population. Nirmal Krishnan M, Vinod C Nayak, Ashwini Kumar, Vikram Palimar, Shankar M Bakkannavar, Anitha S, Chandni Gupta 27. Reinforcement of Medicolegal Knowledge of Interns to Reduce Common Medicolegal Errors. 138-141 Shilekh Mittal, Ishwer Tayal 28. Study of Snake Bite and Factors Influencing Snake bite Among the Rural 142-146 Population of Kancheepuram District Vijay Kautilya D, Shruti Prabhat Hegde, Gururaghavendra 29. Fatal Intentional Poisoning: A Five Year Retrospective Study of Autopsied 147-151 Cases from Central Delhi Amandeep Kaur, Monisha Pradhan

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Volume: 19, Number: 02 July to December Publication: Half Yearly Contents 30. Knowledge and Perception regarding Child Sexual Abuse and POCSO 152-154 Act among Medical Students in Bareilly. Jaswinder Singh, Vijay Kumar, Somshekhar Sharma 31. Awareness And Knowledge of Medical Students Regarding Surrogacy 155-157 Prasad Bhatanglikar, Manu D Sharma 32. Finger Print Patterns and Gynecological Cancer: An Empirical Study 158-161 Bijoyini Bose, Vinod C Nayak, VikramPalimar, Shankar M Bakkannavar, Anita Shivaji, Ashwini Kumar, Nirmal Krishnan, *Case Reports 1. Fatal Cardiac Tamponade Following Left Ventricular Free Wall Rupture 162-164 Post Myocardial Infarction Shweta Menon, Shankar M Bakkannavar, Vinod C Nayak, Deepak M Nayak, Vikram Palimar 2. Thymic hyperplasia and Sudden Death: A pervasive fear in Medicine 165-167 Varsha Vinod, Shankar M Bakkannavar, Vinod C Nayak, Deepak M Nayak, Vikram Palimar 3. Identification of the Skeletal Remains of a Murder Victim in Forensic 168-170 Casework by DNA Typing : A Case Report Monika Chakravarty, Prateek Pandya, Anupuma Raina, Dhruv Sharma, Naresh Kumar, Nidhi Singh, Damini Varshney 4. A Homicidal Ligature Strangulation Masquerading As Suicidal Hanging 171-172 Munish Kumar, Kanika Kohli 5. Post mortem artefacts -Importance of interpretation 173-174 Vijay Arora, Susheel Sharma 6. Sudden Death Due to Hypertrophic Obstructive Cardiomyopathy: A Medico-Social Diagnosis. 175-177 Vikram Palimar, Mr. Akash Nayak S, Vinod C Nayak, Deepal Nayak, Chandni Gupta 7. Cardiac Tamponade: A Rare Cause of Mortality 178-180 Ananya Malhotra, Vinod C Nayak, Vijay Dhankar, Shankar Bakkanavar, Vikram Palimar *Review Article

1. Honour Killing: Gruesome Murder For The Sake of False Honour 181-185 Manoj Kumar Pathak, Srishti Rai 2. Current techniques used for diatom test in diagnosis of drowning deaths 186-189 Shivam Saini, Bhuvnesh Yadav

*Commentary (Scientific Correspondence)

1. MeToo Movement a reality or Myth? 190-191 Srishti Rai, Manoj Kumar Pathak

*Instructions to Authors 192

*Life Members PAFMAT 193-194

4 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI: 10.5958/0974-083X.2020.00001.1 Editorial Travelling Between The Lines : Transgenders Study In Global Perspective 1. Manoj Kumar Pathak, Professor and Head, 2. Rohini, Research Scholar, 3. Srishti Rai, Junior Research Fellow, *Department of Forensic Medicine, Institute of Medical Sciences, BHU, Varanasi- 221005. UTTAR PRADESH, INDIA

ABSTRACT : Sexual orientation is one of the many biological phenomena which is natural and inherent in an individual and is controlled by neurological and biological factors. The science of sexuality has theorized that an individual exerts little or no control over who he/she gets attracted to. None of this is their fault, the way world perceive them and refuse to accept them, the manner in which it snatches away their rights. They are thus destitute. Estranged from family and ostracized by society the world could care less how they earn a livelihood or where their next meals come from. Transgender people may meet the criteria for a diagnosis of gender identity disorder (GID) "only if [being transgender] causes distress or disability. “This distress is referred to as gender dysphoria. The World Health Organization (WHO) recognizes this deficiency, stating that the limitation in available data “points to the fact that LGBT people often experience poorer health outcomes than the general population and face barriers to health care that profoundly affect their overall health and well- being.” How parents react to an adolescent's “coming out” has a profound effect on their child's health outcomes. For those adolescents whose parents were supportive, there was less homelessness, depression, substance use problems, and unprotected sex.

Corresponding Author : Article History: Manoj Kumar Pathak, Received: 22 February 2019 Professor and Head, Received in revised form: 23 February 2019 Accepted on: 4 March 2019 Department of Forensic Medicine, Institute of Medical Available online: 31 December 2019 Sciences, BHU, Varanasi- 221005. Uttar Pradesh, INDIA Contact : +91 9450179177 Email : [email protected]

KEYWORDS : Transgenders, LGBT, Gender Identity, Gender Dysphoria, SRS

INTRODUCTION : describes an individual's enduring physical, romantic, Gender identity, gender expression, and sexuality are not emotional, or spiritual attraction to another person, gender binary concepts—thinking of them as having two ends on a identity is one's personal sense of being a man or a [3] linear spectrum artificially limits understanding of their woman. Transgender people have more or less the same complexities [1] variety of sexual orientations as cisgender people. Transgender people have a gender identity or gender Sexual orientation is one of the many biological phenomena expression that differs from their assigned sex. They are which is natural and inherent in an individual and is controlled sometimes called transsexual if they desire medical assistance by neurological and biological factors. The science of to transition from one sex to another.[4] Being transgender is sexuality has theorized that an individual exerts little or no independent of sexual orientation: transgender people may be control over who he/she gets attracted to. Any discrimination identified as heterosexual, homosexual, bisexual, asexual, etc. on the basis of one's sexual orientation would entail a violation Transgender people may meet the criteria for a diagnosis of of the fundamental right of freedom of expression. gender identity disorder (GID) "only if [being transgender] It is the movement across a socially imposed boundary away causes distress or disability. “This distress is referred to as from an unchosen starting place. Some people move away gender dysphoria and may manifest as depression or inability from their birth assigned gender, because they feel strongly to work and form healthy relationships with others. Notably, that they properly belong to another gender, in which it would the U.S. regions with the highest rates of same-sex child [2] be better for them to live . rearing are in the Midwest, the Mountain West and the South. The concepts of gender identity and transgender identity differ In support of transgender estimates in this analysis, National from that of sexual orientation. While Sexual orientation Transgender Discrimination Survey data shows 38 % of

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transgender respondents identified as parents.[1] Barriers to used under the transgender umbrella were "female to male" care include both personal and structural. Personal barriers (FTM) for men who transitioned from female to male, and may include the patient's experience of disrespectful behavior "male to female" (MTF) for women who transitioned from and discrimination by health care providers and staff members male to female. These terms have now been superseded by and feeling threatened or experiencing a refusal of treatment "trans man" and "trans-woman", respectively, and the terms due to sexual orientation, which may cause delay or avoidance "trans-masculine" or "trans-feminine" are increasingly in use. of care. Structural barriers may include social stigma and even This shift in preference from terms highlighting biological sex abject violence, financial challenges and the lack of trained ("transsexual", "FTM") to terms highlighting gender identity providers to care for lesbian and bisexual women.[5]A lot of and expression ("transgender", "trans woman") reflects a acronyms are used by members of the T section of the broader shift in the understanding of transgender people's LGBTIQQA (Lesbian, Gay, Bisexual, Transgender, Queer, sense of self and the increasing recognition of those who Questioning and Allies). decline medical reassignment as part of the transgender Criminological and criminal justice research has typically community. been heteronormative, assuming traditional sex-based gender Many also note that transgender should be used as an adjective, roles and heterosexual orientation. “Non –normative “sexual not a nounand that transgender should be used, not orientation,gender identity, and/or gender expression remain transgendered. relatively unrecognized and certainly under-examined. What In contrast, people whose sense of personal identity has resulted, both from narrow scope of research and from the corresponds to the sex and gender assigned to them at birth – “heterosexualization “ of the fields of criminology and that is, those who are neither transgender nor non-binary or criminal justice, is failure to understand and respond to the genderqueer – are called cisgender. unique challenges that LGBT-identified individuals face.[6] In Thailand and Laos, the term kathoey is used to refer to male- TRANSGENDER TERMINOLOGIES : to-female transgender people and effeminate gay men. In The term transgender was coined by Psychiatrist John F. India, the third gender is known as Hijra.In early Medina, Oliven of Columbia University in his 1965 reference work gender-variant male to female Islamic people are Sexual Hygiene and Pathology. He wrote that the term which acknowledged as Mukhannathun. In ancient Rome, the Gallae had previously been used, transsexualism "is misleading; were castrated followers of Phrygian goddess Cybele and actually, 'transgenderism' is meant, because sexuality is not a regarded as transgenders.[4] Among the Middle Eastern major factor in primary transvestism." Akkadian people, a Salzikrum (Male daughter) was a person Virginia Prince, popularized the term by using it in the biologically female but had distinct male traits. In USA and December 1969 issue of Transvestia, a national magazine for Canada the existence of more than two genders such as Zuni cross dressers founded by her.Both the terms, trans-gender and male bodied La'manna, the Lakota male bodied, Winkte and Trans- people were in use as umbrella terms and the Mohave male- bodied Alyhaa and female-bodied Hwamee 'transgenderist' was used to describe people who wanted to live were recognized. In Mexico, the Zapotec culture includes a cross-gender without sex reassignment surgery (SRS) by mid third gender in the form of Muxe. Mahuis atraditional status in 1970s. Polynesian Cultures. In Fa'asmoa traditions, the Samoan culture allows the specific role for male to female transgender By 1984, the concept of a "transgender community" individuals as Faáfafine. developedin which transgender was used as an umbrella term.In 1985, Richard Elkins established the "Trans-Gender HEALTH RISKS Archive" at the University of Ulster.By 1992, the International The terms transsexualism, dual-role transvestism, gender Conference on Transgender Law and Employment Policy identity disorder in adolescents or adults, and gender identity defined transgender as an expansive umbrella term including disorder not otherwise specified are listed as such in the "transsexuals, transgenderist, cross dressers", and anyone International Statistical Classification of Diseases (ICD) by transitioning. In 1992, Leslie Feinberg's pamphlet's, the WHO or the American Diagnostic and Statistical Manual "Transgender Liberation: A Movement Whose Time has of Mental Disorders (DSM). Come", identified transgender as a term to unify all forms of The validity of the diagnosis and its presence in the gender nonconformity; in this way transgender has become forthcoming ICD-11 is debated.The DSM-5 refers to the topic synonymous with queer. as gender dysphoria while reinforcing the idea that being Between the mid-1990s and the early 2000s, the primary terms transgender is not considered a mental illness.[2]Gender

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dysphoria is the sense of incongruity between a person's sex RESULTS : and their gender and is a motivator in some transgender 1. History : George Catlin (1796-1872) Dance to the people's decision to begin transitioning.However, health care Berdache, depicts a ceremonial dance to celebrate two-spirit for transgender and gender non-conforming individuals persons among the Sac and Fox Indians. encompasses more than just transition related care; Prior to western contact, some American Native tribes had preventative care and sexual health are two aspects of third-gender roles, but details were only recorded after the transgender health care that are often overlooked.[4] arrival of Europeans. Roles included "Berdache" (a derogatory Lesbian and bisexual women are less likely to receive term for people who were assigned male at birth, who assumed recommended preventive screeningssuch as breast, cervical, a traditionally feminine role) and "passing women" (people and colorectal cancer screenings. Among men who have sex who were assigned female at birth who took on a traditionally with men, rates ofhuman papillomavirus–associated anal masculine role). The term "Berdache" is not a Native American cancers are 17 times higher than those of heterosexual word; rather it was of European origin and covered a range of men.Transgender individuals have a higher prevalence of HIV third-gender people in different tribes. Not all Native American infection and suicidecompared with other groups,transgender tribes recognized transgender people. adults report ever attempting suicide.Trans-men who have not One of the first accounts of transgender people in the Americas had a hysterectomy and who take testosterone are at increased was made by Jesuit missionary Joseph-François Lafitau who risk for endometrial cancer because androstenedione, which is spent six years among the Iroquois in 1711. He observed made from testosterone in the body, can be converted into "women with manly courage who prided themselves upon the estrogen, and external estrogen is a risk factor for endometrial profession of warrior" as well as "men cowardly enough to live cancer. as women. (Wikipedia) Cigarette smoking is more prevalent among transgender 2. Biological Basis : Gender identity, like other aspects of people than in heterosexuals.It can be owed to tobacco temperament awaits the third trimester, when the brain as a industry's well-documented targeted marketing to LGBT whole is growing. The time around birth may be when the groups and the use of cigarette smoking to decrease social brain's gender identity is being organized.The gender identity stress. Protective factors against smoking behaviors for young being able toenvisioned as a cognitive lens. A lens in the brain LGB women included LGBT community connections. controls who to focus on as a “TUTOR”. Transgender identity Although desire to quit did not differ between sexual minority is then the acceptance of a tutor from the opposite sex. Degrees and their heterosexual counterparts, cessation attempts did of transgender identity and of gender variance generally, differ. reflect different degrees of single-mindedness in the selection An analysis of over 60,000 women in the National Health of the tutor's gender. The development of gender identity thus Interview Survey find that being a sexual minority is depends on both brain state and early postnatal experience, associated with an elevated BMI compared to heterosexuals. because brain state indicates what the lens is, and The prevalence of obesity may not be uniform across racial and environmental experience supplies the image to be ethnic groups. photographed through the lens and ultimately developed Obesity and overweight may start at a young age in lesbian and immutably into brain circuitry. Once gender identity is set, like bisexual youth and they may conceptualize their weight other basic aspects of temperament, life proceeds from there. differently than heterosexual peers. Conversion therapy can lead to depression, anxiety, seizures, Encouraging greater LGBT acceptance and access to drug use and suicidal tendencies for the individuals involved. healthcare will be critical to improving outcomes and Although it seems to be same, transgender and Intersex activist experiences for LGBT communities.[5] communities are quite different. Intersex activism tends to focus on ending the practice of performing “normalization” surgery on infants born with noticeably ambiguous genitals; MATERIALS AND METHOD: transgender people are rightly considered to face different A thorough search related to LGBTQ was done from various kinds of problems with the medical establishment. Deborah sources including online resources (e.g. Wikipedia on LGBT Rudacille in his paper “Endocrine Disrupting Chemicals and rights in India), journals, and books available on this topic. Trans-sexualism (2001)linked transgender to falling sperm Map study was done on different organizations working for counts among human males with endocrine disrupting status improvement of LGBTQ community in different states chemicals found in pesticides and food additives in the of India. environment. Intersex conditions are far more common than

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most people realise; reliable estimates put the number at about Forces.Later that day, Joint Chiefs of Staff Chairman Joseph 1 in 2000 births.Current fairies favor sex-linked neurological Dunford announced, "there will be no modifications to the differences in the brain. current policy until the president's direction has been received 3. Symbols of pride : Transgender Pride Flag is the common by the secretary of defense and the secretary has issued symbol of pride for transgender community. It was designed by implementation guidance." Monica Helms and was first shown at a pride parade in Transgender rights in the United States vary considerably by Phoenix, Arizona, in 2000. jurisdiction. It consists of five horizontal stripes: two light blue, two pink Birth certificates are typically issued by the Vital Records with a white stripe in the center. The meaning of the flag has Office of the state (or equivalent territory, or capital district) been described by Helms as follows: where the birth occurred, and thus the listing of biological sex Ÿ The light blue colour is the traditional colour for baby as male, female or otherwise on the birth certificate (and boys, whether or not this can be changed later) is regulated by state (or equivalent) law. However, federal law regulates sex as Ÿ Pink is for girls and listed on a Consular Report of Birth Abroad, and other federal Ÿ The white in the middle is for “those who are documents that list sex or name, such as the U.S. passport. transitioning, those who feel they have a neutral Laws concerning name changes in U.S. jurisdictions are also a gender or no gender” and those who are intersex.” complex mix of federal and state rules. States vary in the extent No matter which way you fly it, it will always be correct. This to which they recognize transgender people'sgender identities, symbolizes us trying to find correctness in our own lives” often depending on the steps the person has taken in their Other transgender symbols include a butterfly, which transition (including psychological therapy, hormone therapy), symbolizes transformation or metamorphosis and a pink/light with some states making sex reassignment surgery a pre- blue yin and yang symbol. requisite of recognition. Several transgender symbol have been used to represent The federal government does not have lawsspecifically transgender people, including protecting transgender people from discrimination in employment, housing, healthcare, and adoption, but some 4. Transgender Rights in the United States : In the United lawsuits argue that the Equal Protection Clause of the federal States, a federal bill to protect workers from discrimination constitution or federal laws prohibiting discrimination based based on sexual orientation and gender identity, the on gender should be interpreted to include transgender people Employment Non-Discrimination Act, has stalled and failed and discrimination based ongender identity. U.S. President several times over the past two decades. Individual states and Barack Obama issued an executive order prohibiting cities have begun passing their own non-discrimination discrimination against transgender people in employment by ordinances. In New York, for example, GovernorDavid the federal government and its contractors.In 2016, the Paterson signed into law New York's first statute to include Departments of Education and Justice issued a letter to schools transgender protections in September 2010. receiving federal funding that interpreted Title IX protection to Nicole Maines, a trans-girl, took a case to Maine's Supreme apply to gender identity and transgender students, advising Court in June, 2013. She argued that being denied access to her schools to use a student's preferred name and pronouns and to high school's women's restroom was a violation of Maine's allow use of bathrooms and locker rooms of the student's Human Rights Act; one state judge has disagreed with her,but gender identity. Recognition and protection against Maines won her lawsuit against the Orono school district in discrimination is provided by some state and local jurisdictions January 2014 before the Maine Supreme Judicial Court.On to varying degrees. May 14, 2016, the United States Department of Education and The Supreme Court decision in Obergefell v. Hodges Department of Justice issued guidance directing public established that equal protection requires all jurisdictions to schools to allow transgender students to use bathrooms that recognize same-sex marriages, giving transgender people the match their gender identities. right to marry regardless of whether their partners are legally On June 30, 2016, the United States Department of Defense considered to be same-sex or opposite-sex. The Matthew removed the ban that prohibited transgender people from Shepard and James Byrd Jr. Hate Crimes Prevention Actadded openly serving in the US military.On July 27, 2017, President gender identity to the federal definition of a hate crime, but Donald Trump tweeted that transgender Americans will not be only some states and territories include gender identity in their allowed to serve "in any capacity" in the United States Armed hate crime laws.

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Non-binary or genderqueer people may seek legal recognition practices. of a gender identity other than that indicated by their birth sex; In one study in New York City, 13% of lesbian women and 33% in 2016, Oregon became the first state to legally recognize non- of bisexual women did not disclose their sexual orientation or binary people. When a person's gender is not officially same-sex behaviours to their health care providers due to recognized, they may seek associated changes, such as to their poorer psychological well-being. It was more likely if she was legal name, including on their birth certificate. a member of an ethnic minority group, had low educational 5. Healthcare : Transgender health care is the health related level, had children, had higher level of internalized care of preventative medicine, physical health, and mental homonegativity, and did not have a history of a medical health that transgenderpeople experience.The heightened condition.Disclosure in the electronic medical record has been levelofviolence and abuse which transgenders experience advocated in the United States by the Institute of Medicine and results in unique adverse effects on body and mental health. Joint Commission. However, being documented in the medical Additionally, transphobia in medicine has limited access to records has risks including loss of job and fear of necessary health care for transgender people. The limited discrimination within the medical system. access applies to areas of physical health such as sexually 5.2 Mental Health Care : Most mental health professionals transmitted infections and hormone replacement therapy, recommend therapy for internal conflicts about gender identity mental health, and preventative care. or discomfort in an assigned gender role, especially if one Transitioning should not be confused with sex reassignment desires to transition. surgery (SRS); it is only one possible element of transitioning. Transgender people may meet the criteria for a diagnosis of Many people who transition choose not to have SRS, or do not gender identity disorder (GID) "only if [being transgender] have the means to do so. Transitioning is more holistic and causes distress or disability.“This distress is referred to as usually includes physical, psychological, social, and gender dysphoria and may manifest as depression or inability emotional changes whereas SRS is a surgical procedure. to work and form healthy relationships with others. This Passing means being perceived and accepted by other people diagnosis is often misinterpreted as implying that transgender in a manner consistent with one's own gender identity. This can people suffer from GID; this misinterpretation has greatly be one aspect of transitioning, though genderqueer people may confused transgender people and those who seek to either choose to purposely not pass. criticize or affirm them. Transgender people who are comfortable with their gender and whose gender is not directly Going full-time refers to a person living one's everyday life as causing inner frustration or impairing their functioning do not the gender one identifies with. suffer from GID. Moreover, GID is not necessarily permanent Going stealth means to live as a gender without other people and is often resolved through therapy or transitioning. Feeling realising a person is transgender. Trans-people often go stealth oppressed by the negative attitudes and behaviors of such in public but not with family, partners, or intimate friends. others as legal entities does not indicate GID. GID does not There have been many cases of people who have lived and imply an opinion of immorality; the psychological worked as a gender identity different from their gender establishment holds that people with any kind of mental or assigned at birth. emotional problem should not receive stigma. The solution for A social transition is the aspects of transition involving social, GID is whatever will alleviate suffering and restore cosmetic, and legal changes, without regard to medical functionality; this solution often, but not always, consists of interventions Whereas, Detransitioning is the process of undergoing a gender transition. changing one's gender presentation and/or sex characteristics Clinical training lacks relevant information needed in order to back to accord with one's assigned sex.Detransitioning has adequately help transgender clients. Many mental healthcare also been calledretransitioning, though retransitioning can also providers know little about transgender issues. Those who seek mean transitioning again after detransitioning. help from these professionals often educate the professional 5.1 Identifying Sexual Orientation : Part of identifying and without receiving help.Many therapists who profess to know serving transgenders is to create a welcoming clinical space about transgender issues believe that transitioning from one where each person is cared for and respected for all of who they sex to another – the standard transsexual model – is the best or are— including their sexual orientation. The Association of only solution. American Medical Colleges (AAMC) has created a series of Therapy was not always sought by transgender people due to online videos that highlight history-taking that includes mental health needs. Prior to the seventh version of the assessments of sexual orientation, gender identity, and sexual Standards of Care (SOC), an individual had to be diagnosed

9 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI: 10.5958/0974-083X.2020.00001.1

with gender identity disorder in order to proceed with hormone heterosexual women, more recent work has described higher treatments or sexual reassignment surgery. The new version prevalence of hypertension among sexual minority women decreased the focus on diagnosis and instead emphasized the when compared with heterosexual counterparts. importance of flexibility in order to meet the diverse health 5.5 Prevention of Pulmonary Disease : Pulmonary disease care needs of transsexual, transgender, and all gender- has not been rigorously studied in TGs. The prevalence of nonconforming people. lifetime and current asthma is higher in Lesbian women, even A transgender person seeking treatment does not necessarily when statistical models are used to correct for current and past mean their gender identity is problematic. The emotional strain smoking and obesity, all of which are increased in lesbian and of dealing with stigma and experiencing transphobia pushes bisexual women. The risk goes on in case of Overweight or many transgender people to seek treatment to improve their obese lesbian and bisexual women. quality of life. Many transgender people also seek mental 5.6 Prevention of Sexually Transmitted Infections : Asking health treatment for depression and anxiety caused by the about sexual behaviours in addition to sexual identity is key stigma attached to being transgender or in order to discuss factor to identifying STI risk and advising appropriate testing other quality-of-life issues.Others regret having undergone the since risk may vary by specific sexual practice and the specific procedure and wish to detransition... pathogen. 5.3 Physical Health Care : The term "sex reassignment Chlamydial infections were higher in 14- to 24-year-old therapy" (SRT) is used as an umbrella term for physical women who reported same-sex behaviour which places a procedures required for transition. Use of the term "sex woman's future fertility at risk due to potential tubal occlusion. change" has been criticized for its emphasis on surgery, and the Some women who have a chlamydial infection do not have term "transition" is preferred.The acronyms "GRS" and symptoms. Secondary sequelae of chlamydia include intra- "SRS" refer to genital surgery/.Medical and surgical abdominal abscesses, chronic pain, and the need for multiple procedures exist for transsexual and some transgender people, surgeries. though most categories of transgender people as described In order to decrease the risk of STIs “Safer Sex Kits” have above are not known for seeking the following treatments. occasionally been distributed to WSW and WSWM, which While Hormone replacement therapy for Trans- men induces include dental dams to prevent transmission of bacteria and beard growth and masculinizes skin, hair, voice, and fat viruses from oral sex. Female latex condoms and latex gloves distribution for Trans-women, it feminizes fat distribution and may provide better protection against infectious transmission breasts. Laser hair removal or electrolysis removes excess hair from oral. Current CDC guidelines recommend that all women for trans-women. Surgical procedures for trans women should be tested once in their lifetime for HIV, and then feminize thevoice, skin, face, Adam's apple, breasts, waist, repeated according to risk factors. buttocks, and genitals, whereas for trans men, it masculinize the chest and genitals and remove the womb, ovaries, and The herpes simplex virus (HSV) can be transmitted sexually fallopian tubes. between women. The same precautions regarding the transmission of HSV should be provided to lesbian, bisexual, 5.4 Prevention of CVD : The risk of CVD is higher in sexual- and heterosexual women; there should be no sexual contact minority. It seemed most influenced by societal conditions during any prodromal symptoms that may precede a genital (i.e., cumulative minority stress) that exert negative effects on herpes outbreak or during the blister stage of the outbreak. CVD risk.The leading five modifiable risk factors for CVD are There is evidence of HPV transmission between female sexual smoking, physical inactivity, obesity, elevated lipid levels, and partners. Ten percent of lesbian women have never had sex diabetes. Three of these factors (smoking, physical inactivity, with men, yet cervical dysplasia and cervical cancer develop in and obesity) have a higher prevalence in lesbian and bisexual some of these women. All women need Papanicolaou smears, women. including lesbian women, according to timetables provided by When the effect of five stressful life events (physical abuse, professional society guidelines. sexual abuse and forced sex, homelessness, school expulsion, Trichomonas vaginalis can be transmitted easily between death of a parent), was compared between LGB women and female sexual partners. One study of women attending an STI heterosexual women, higher cardiometabolic risk scores were clinic in the United States noted that T vaginalis was the most found in LGB women, even after controlling for demographic common curable STI found in this population with a factors, socioeconomic status, health behaviors, and self- prevalence of 17% in WSW and 24% in WSWM. reported illness. Although many studies report similar hypertension prevalence among lesbian, bisexual, and According to the CDC, Bacterial vaginosis is common among

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womeneven more common among WSW. It is unknown smoking. Lesbian and bisexual women who have breast cancer whether bacterial vaginosis can be transmitted between may not want reconstruction at the same rate as heterosexual women. A study from Australia found a 27% prevalence of women and often find that breast cancer support groups focus bacterial vaginosis in women and their female partners; risk on issues for heterosexual women . factors for bacterial vaginosis were four or more lifetime 5.8B. Cervical Cancer : HPV is transmitted sexually between female sexual partners, a female partner with bacterial lesbian or heterosexual partners. All females between the ages vaginosis symptoms, and smoking at least 30 cigarettes of 12 and 26 years should receive the HPV vaccine series even weekly.. This strategy may also be used for treatment of if they never have been or plan to be sexually active with men. recurrent or hard to treat vulvo-vaginal candidiasis, which The rate of HPV immunization among lesbians is significantly technically is not considered to be sexually transmitted, but less than for heterosexual women, which creates a health anecdotally, improvement has occurred with treatment of the disparity that needs to be corrected. Papanicolaou smears index patient and female partner. should be part of lesbian and bisexual women's health care at 5.7 Prevention of Substance Use : Substance use is higher in the same intervals as for heterosexual women. In addition, LGBT people compared to heterosexuals and is especially some lesbian patients as well as their health care providers well-documented for cigarette smoking and alcohol use. In mistakenly think that lesbians do not need Papanicolaou addition, the odds of using all illicit drugs (except steroids) and smears. All lesbians need Papanicolaou smears starting at the misusing prescription drugs was greater. Furthermore, using age of 21, consistent with recommendations for Papanicolaou amphetamines other than methamphetamine, sedatives, and smears for all women. 3,4 methylenedioxy methamphetamine (MDMA; Ecstasy) 5.8 C. Lung Cancer : The rate of lung cancer is likely higher in was remarkable. LGBT community due to their increased rate of smoking. Multiple interventions have been initiated to decrease alcohol 5.8 D. Endometrial and Ovarian Cancer : Endometrial and and other substance use in lesbian and bisexual female youth. ovarian cancer is associated with nulliparity. Obesity, a known Recommendations for improving substance use treatment for risk factor for both cancers, appears to be more prevalent sexual minority persons include providing interventionists among sexual minority women. As the use of oral with training in LGB cultural sensitivity. There have been no contraceptives is protective against the development of both of specific interventions outcomes research, however, comparing these cancers, theseare lower in lesbian women than in LGBT adapted materials with routine materials. heterosexual women. 5.8 Cancer Risk, Prevention, & Treatment : However, 5.9 Prevention of Mental Disorders : emerging data suggest that sexual minority women may be at a Many of the health disparities and health risks faced by LGBT higher risk for cancer-related mortality than heterosexual people have been attributed to Meyer's theory of minority counterparts. Information from the US National Health stress, which proposes that individuals who identify as a sexual Interview Survey showed that lesbian and bisexual women minority experience chronic, additive, and unique stresses have cancer risk factors, such as tobacco use, underscoring the stemming from living in social conditions that are character- need for vigilant screenings. LGBT people face challenges in ized by prejudice and discrimination. Therefore, rather than receiving equitable care throughout the cancer care continuum identifying mental health problems as synonymous with a and may experience cancer differently and have different needs sexual minority identity or stemming from in-born association during their care.The US National Cancer Care Network with minority sexual orientation, minority stress causes mental Guidelines do not address how sexual and gender minority health challenges that stem from societal discrimination and status should be considered in site-specific guidelines The stigma borne by individuals with minority identities (and 2017 American Society for Clinical Oncology position behaviours). statement recommends five action steps to enhance LGBT cancer care and reduce disparities: (1) patient education and There is emerging evidence that being in a legally recognized support, (2) workforce development and diversity, (3) quality same-sex relationship, particularly in marriage, diminishes improvement strategies, (4) policy solutions, and (5) research mental health differences between heterosexual and lesbian, strategies. gay, and bisexual persons. In contrast, psychiatric disorders increased among lesbian, gay, and bisexual persons who live in 5.8A Breast Cancer : Studies have found the prevalence of states in the United States that enacted constitutional breast cancer in lesbians unreliable; however, lesbians do have amendments to ban same-sex marriage compared to states that an increased prevalence of risk factors predisposing to breast did not. cancer, including nulliparity, alcohol use, obesity, and

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DISCUSSION : child. Gates also estimates that nearly half of LGBT women The World Health Organization (WHO) recognizes this and a fifth of LGBT men are raising children. deficiency, stating that the limitation in available data “points Compared to heterosexuals, LGBT people have higher to the fact that LGBT people often experience poorer health exposures to violence throughout their lifetimes. Lifetime outcomes than the general population and face barriers to prevalence of sexual assault may be as high as 85%. health care that profoundly affect their overall health and well- The CDC reports that 61% of bisexual women and 44% of being.” United States has a provision of diplomatic visa of the lesbians experience rape, physical violence, and stalking by an name “G4”. According to the book Me HijraMeLaxmi, by intimate partner. These rates are higher than similar trauma in Laxminarayan Tripathi, the author shares an experience that heterosexual women (35%). Barriers to preventing LGBTQ the one thing about New York that stood out was that trans-men violence include stigma, systemic discrimination, and a lack of and trans-women are not obliged to live in gated communities, understanding of LGBTQ intimate partner violence. as they are everywhere else in the world.Transgender people Community violence is experienced more frequently by are found in virtually coveted professions in New York. But LGBT persons. In-depth interviews of 19 Flemish sexual America was not always the super-liberal place that it is today. minority victims of violence revealed the use of four coping The StonewallRiot of 1969was the starting point of the LGBT strategies: (1) avoidance, (2) assertiveness and confrontation, movement all over the world. Several LGBT persons lost their (3) cognitive change, and (4) social support. There is a lack of lives in the riot and memorial to honour them now stands at the systematic medical knowledge, however, about the care and site. It is Stonewall that is responsible for making America the understanding of lesbian and bisexual women. The World gay utopia that it is while the rest of the world is dystopia. As Health Organization (WHO) recognized this deficiency, far as I am concerned, it is society and law- indifferent as they stating that the limitation in available data “points to the fact are to me that have brought to me where I am today, where that LGBT people often experience poorer health outcomes many of us are today.It is not so much that we are abducted into than the general population and face barriers to health care that sex work, rather we are the reasons for the very existence of sex profoundly affect their overall health and well-being.” work and that is no exaggeration society and the law not only thinks that we are doing wrong but are violent towards us. Comprising roughly 4% of adult women in the United States, lesbian and bisexual women are considered a medically Changing the culture of medicine to welcome lesbian and underserved population in the United States by the National bisexual women in one's medical practice and applying one's Academy of Medicine. Furthermore, since 2016, lesbian and knowledge about the specific health issues of this underserved bisexual women—as sexual minorities—are considered a population is essential to their achieving health equity.The health disparity population by the US National Institutes of main source of official crime data in the United States is the Health. Professional medical organizations, such as the Uniform Crime Report (UCR), which is based on data reported American College of Physicians, have published position by over 17,000 law enforcement agencies. It mainly includes papers to educate and make recommendations on achieving data on four categories of violent crime (murder, forcible rape, equity for lesbian, gay, bisexual, and transgender (LGBT) robbery, and aggravated assault) and four categories of individuals in the health care system. property crime (burglary, larceny-theft, motor vehicle theft, and arson). Sexual orientation and gender identity are omitted In addition, gay and bisexual men accounted for 67% of all new from the expanded data, and sex constructs are based on binary HIV diagnoses in the United States in 2014, and they conceptions of biological sex. disproportionately contract sexually transmitted infections. In 2014, men who have sex with men accounted for 83% of The only mention of sexual orientation in the UCR appears in a primary and secondary syphilis infections in the United States separate report on bias crime, which records the number of bias where the sex of the sexual partner was known. In one study, crime incidents, offenses, victims, and known offenders based lesbian and bisexual women were 14% older in vascular terms on ''sexual orientation bias'' (anti-male homosexual, anti- than their chronological age, which was 6% greater than that of female homosexual, anti-homosexual, anti-heterosexual, anti- their heterosexual counterparts and the risk was not fully bisexual). Bias motivation codes for gender identity were explained by excessive smoking or alcohol use. In high school, added very recently (in 2012) to the bias crime report. LGB adolescents reported a higher prevalence of daily Using U.S. Census 2010 data and Gallup Daily Tracking cigarette use (22%) compared with heterosexual youth (11%). Survey data, Gates estimates that of the 650,000 same-sex A 2011 study carried out by the Williams Institute (a UCLA couples in the U.S., 19% of same-sex households have think tank) found that 41% of transgender people had children under age 18 and 37 % of LGBT adults have had a attempted suicide, with the rate being higher among people

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who experienced discrimination in access to housing or stay in touch with their families could not God have created me healthcare, harassment, physical or sexual assault, or rejection as a man/woman? Why did he make me this way? Why is he by family. The rate of HPV vaccination in lesbian women savouring this spectacle that He created? (8.5%) is less than in heterosexual women (28.4%) and Families respect you only if you have money. If you are poor, bisexual women (33.2%), which contribute to health you must expect to be abused and humiliated. disparities. Administration of the HPV vaccine is critical to the Who is responsible for what has happened to me? Did I take to prevention of cervical cancer. Despite recommendations that this profession, because I wanted to? I didn't choose this Papanicolaou testing be performed regardless of sexual profession on my own. I don't want to do what I do, but I had orientation, Papanicolaou testing varies according to identity come to accept it as my destiny. irrespective of behaviour. In a national probability sample of who underwent Papanicolaou testing, WSWM had the same “This world that exploits my youth and beauty does not know odds of testing as WSM only, whereas women with lifetime how to bring out the talent there is in me. If I have to live in female partners had lower odds of testing. Those who iden- this world, I've got to adjust its demands. So I live as I do''. tified as bisexual also had lower odds of testing. Acknowledgement CONCLUSION : Author would like to thank Faculty and Staff of Department of How parents react to an adolescent's “coming out” has a Forensic Medicine, IMS, BHU for their valuable support in profound effect on their child's health outcomes. For those preparation of this review report. Special thanks to print and adolescents whose parents were supportive, there was less electronic media for providing me with immense resource homelessness, depression, substance use problems, and materials in preparation of this article. unprotected sex. Interventions for building resilience can be Conflict of interest: Nil important in achieving a reduction in anxiety and depression. Source of funding: This research was not financially There is some evidence that online friends can serve as a buffer supported by any funding agencies. and social support, especially for LGBT youth, although in- Ethical clearance: The present study was approved by person social support appears to be more protective against “Institutional Ethical Committee” of Institute of Medical victimization. Transgender people vary greatly in choosing Sciences, Banaras Hindu University, Varanasi. All the when, whether and how to disclose their transgender status to information has been taken under consideration of medical family, close friends and others. The prevalence of ethical committee discrimination and violence against the transgender community can make coming out a risky decision. Fear of Statement of Human and Animal Rights: No human right being removed from the parental home and retaliatory and animal right is violated in this case. behaviour is a cause for transgender people to not come out to REFERENCES: their families until they reach adulthood. Parental confusion 1. Dana Peterson, Vanessa R Panfil. Handbook of LGBT and lack of acceptance of a transgender child may be met with Communities, Crime and justice.(2014). Springer New an effort to change their children back to “normal” by utilizing York Heidelberg Dordrecht London. mental health services to alter the child's sexual orientation and 2. Eckstrand K L, Ehrenfeld J M .Lesbian, Gay, Bisexual and what is seen as a “phase”. Transgender Healthcare (2016); Springer Cham The International Day of Visibility is an annual holiday on Heidelberg New York. March 31,founded by Michigan-based transgender activist 3. https://www.wikipedia.org/ Rachel Crandall. It is dedicated to raising awareness of discrimination faced by transgender people worldwide. It 4. Jameson, Fauci, Kasper, Hauser, Longo, Loscalzo. represents the reaction to the lack of LGBT holidays Harrison's Principle of Internal Medicine, 20th edition, celebrating transgender people, citing the frustration that the 2018. Mac Graw Hills education;1-8. only well-known transgender centered holiday was the 5. Maxine A. Papadakis, Stephen J. McPhee; Current Transgender Day of Remembrance which mourned the loss of Medical Diagnosis and Treatment, 2019, Mc Graw Hill transgender people to hate crimes. Education According to the book, Truth About Me: A hijra Life Story, by 6. Revathi A. Truth About Me: A Hijra Life Story, (2010), A.Revathi, the author says that If society scorns us, then we Penguin Random House India. turn towards our families, if we have a family. But if family 7. Stryker S, Transgender History, 2008, Seal Press scorns us, who do we turn to? Is this why people like me do not

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8. Tripathi Laxminarayan. meLaxmi me Hijra, (2015); Oxford University Press.

Figure 1: Global distribution of transgenders

Figure 2: Hot- Spots for transgenders around the globe.

14 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI: 10.5958/0974-083X.2020.00002.3 Original Research Paper Socio-demographic Pattern and Physical Features of Firearm Injury Cases : A Clinical Forensic Medicine Study 1. Shekhar Chumber, Junior Resident* 2. Ashok Chanana, Associate Professor* 3. Kuldip Kumar, Associate Professor* *Department of Forensic Medicine, Govt. Medical College, Amritsar-143001

ABSTRACT : Introduction: Firearm injury is one of the important causes of morbidity & mortality in India and Punjab is not an exception to this. Methods: A study of 100 firearm cases was carried out at GMC, Amritsar to analyze the details of the physical characteristics of firearm injuries. Results: Majority of victims were males belonging to Sikh community from rural area. Examination of clothing was conducted in 67% of cases in which corresponding tear/ cuts and stain was present in 85% of cases, while blackening and burning was observed in 24% cases. Entry wounds were found mostly on the Limbs; 52% in Lower Limbs, 34% in upper Limbs followed by 33% on Thorax. In most of the entry wounds 85.16 % margins were inverted and shape was oval 61. 94%. Physical characters like abrasion collar (AC) was observed in 19.35%, burning in 11.61% and contusion ring (CR) in 8.38%, blackening in 7.09% and singeing of hair in 5.8% of cases. As far as study of exit wound is concerned they were present only in 23% cases and were present mostly on the Limbs; 65.21% in upper limb and 26.09% in lower Limbs and their margins were everted in 86.96% cases. Foreign bodies were present in 60.65% cases and fracture in 15% cases while nature of Injury was simple in most of the 84% cases. Conclusions: In this study of Firearm Injuries, entry wounds were more common than exit wounds and were mostly smaller in size, circular in shape with inverted margins and showing AC, CR, blackening and singeing of hair as compare to exit wounds which were larger in size.

Corresponding Author : Article History: Dr. Ashok Chanana, Received: 20 February 2019 Associate Professor, Received in revised form: 20 March 2019 Accepted on: 20 March 2019 Department of Forensic Medicine, Available online: 31 December 2019 Govt. Medical College, Amritsar-143001 Contact : +91 9915780056 Email : [email protected]

KEYWORDS : Firearm, Entry Wound, Exit Wound, Abrasion Collar, Burning, Contusion Ring, Blackening, Wound Ballistics

INTRODUCTION : elementary knowledge of structure of a firearm, composition Firearm injury is one of the important causes of morbidity & of ammunitions and mechanism of discharge of a firearm is mortality in India. Recent spurt in the use of firearm for necessary for proper understanding and interpretation of the 3 homicide purposes is a world-wide phenomenon and Punjab is injuries produced by them. not an exception to this. There has been a continuous increase Wound ballistics is the study of effects of missiles on living in the incidence of these injuries in recent years because of an tissue. When a firearm is discharged, wound is produced by increase in inter-personal violence, dacoity, robberies, caste release of projectile accompanied by flame, smoke, burnt or feuds, terrorism, poverty, unemployment, easy availability of partly burnt powder grains, fine lead fragments and wadding illegal country made guns-Kattas and refinement in ballistics- present in the cartridge. In all the firearm injuries, there is automatic & semi-automatic firearms (rifle, revolver & usually an entrance wound, a track in tissues and an exit wound pistols). For this reason various medico legal parameters of which can be absent in cases where projectile becomes lodged firearm injuries & fatalities are being studied in different parts in the tissues after its penetration.3 1 of the world and in India. AIM AND OBJECTIVES : Firearm is any instrument or device, which propels a projectile 1. To study socio-demographic pattern of firearm injuries in by the expansion of gases generated by the combustion of an assault cases. explosive substance.2Forensic ballistics may be considered as 2. To study the physical aspects of firearm injuries in assault the science dealing with investigations of firearms, cases. ammunition and the problems attending their use. For a doctor,

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MATERIALS AND METHODS : were females. Hindu community constituted only 12 (12%) of After taking permission from institutional ethics committee, firearm injury cases. No female case of firearm injury was the present retrospective study comprised of 100 medico-legal reported from Hindu community. (Graph 2) cases of firearm injuries, who were admitted from 1-1-2017 to 31-12-2107 in emergency department of Guru Nanak Dev Hindus Hospital, Amritsar (Hospital attached to Government Medical 12% College, Amritsar). Details of following data pertaining to each case were gathered from hospital records and medico legal reports : 1. Age, sex, residence, religion and occupation. Sikhs, 88% 2. Physical characters of entry and exit wounds. 3. Nature of injury. 4. Associated mechanical injuries along with the firearm injuries. 5. Findings on clothes of the victims. 88% belonged to rural eara. (Graph 3) The data was organized by presenting it in the form of appropriate tables and graphs and statistically analysed for percentage, mean values and inferences. RESULTS : It was observed that majority of cases, 93 (93%) of the victims were males and only 7 (7%) were females. Most of the victims 41 (41%) were from the age group 21-30 years followed by 19 (19%) from 31-40 years. Least number of the cases 2 (2%) Occupation of most of the firearm injuries victims was were observed in the age group 0-10 years among both sexes. agriculture 44 (44%) followed by labourer 16 (16%), private (Graph 1) job 14 (14%), student 11 (11%), business man 7 (7%), housewives 5 (5%) and others 3 (3%). Total number of cases from both agriculture and labourer were 60 (60%). (Graph 4)

Majority 41 (41%) of the male victims were in the age group 21-30 years followed by 19 (19%) in age group 31-40 years while there were only 2 (2%) female victims in the age groups of 11-20, 41-50 and 51-60 years. No female case was reported 91 (91%) victims were literate while only 9 (9%) victims were in the age group of 21-40 years which is most common age illiterate. (Graph 5) group among males 60 (60%). Age distribution of the female victims followed reverse pattern as compared to males, However there was no female victim in age group of more than 61 years. The mean age of firearm injury cases was +/-32.6 Literate years. illiterate Majority 88 (88%) of firearm injury cases were from Sikh community, out of which 81 (81%) were males and 7 (7%)

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Examination of clothing was conducted in 67 (67%) of firearm were two in only 6 (3.87%), three in 10 (6.45%) and more than injuries cases out of total 100 medico-legal cases, 61 (91%) three in 31 (20%) cases. Three or more than three entry wounds Victims were having tears/cuts present on clothing out of were present in 41 (26.45%) cases. (Graph 8) which 57 (85%) of tears/cuts were corresponded to the injuries. Stains on clothes were present in 57 (85%) cases, while blackening or burning was present in only 16 (24%) of cases. Examination of clothing was not conducted in 33 (33%) cases because either the firearm injuries were present on uncovered body parts like head, neck, hands and feet or injured person had changed their clothes before the medico-legal examination. Clothes were handed over to the police for ballistics examination. (Graph 6)

Total No. Tear/Cuts Tear/Cuts Corresponding to injury Stain In most (85.16%) of the case, margins of entry wounds in Blackening firearm injuries were inverted while these were not-inverted in 23 (14.84%) cases out of total 155 entry wounds. (Graph 9)

As far as anatomical sites of entry wounds in firearm injuries was concerned, out of total 155 entry wounds present among 100 victims of firearm injuries, most of the entry wounds 52 (33.54%) were present in the lower limbs followed by 34 (21.94%) on upper limbs, closely followed by 33 (21.29%) on thorax and 25 (16.12%) on head & neck areas of body, in both sexes. In majority of firearm injury cases, most of entry wounds 86 (55.48%) were present on all extremities (limbs) of the body. Similar pattern was observed among males while in females 3 (1.93%) cases each were having entry wounds of As far as shape of entry wounds was concerned; in present firearm injuries on lower limbs and head and neck areas of the study it was observed that out of 155 entry wounds, 96 body, while only 1 (0.64%) case each was seen having entry (61.94%) of the wounds were oval followed by irregular in 39 wounds in thorax, upper limb and abdominal areas of body. (25.16%) and circular in only 20 (12.90%). No cruciate type (Graph 7) entry wound was seen in firearm injury cases. (Graph 10)

As far as the study of number of entrance wounds in a firearm As far as physical characters of entrance wounds were injury case was concerned, in present study in most 108 concerned; in the present study, abrasion collar was observed (69.68%) of the cases the number of entry wounds were single, in 30 (19.35%) cases, burning in 18 (11.61%) cases, contusion

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ring in 13 (8.38%) cases, blackening in 11 (7.09%) and singeing of hair in only 9 (5.8%) of cases (Graph 11)

Fractures of underlying bones were observed in 15 (16.13%) of firearm injury cases among males and no fracture was observed among female victims of firearm injuries. (Graph 14)

Exit wounds were present in only 23 (23%) as compared to 155 entry wounds among 100 victims of firearm injuries, out of these the shape of 18 (78.26%) cases was irregular, in 4 (17.39%) cases it was oval and circular in only 1 (4.35%) case. it was observed that the margins of exit wounds of firearm cases were everted in most of 20 (86.96%) cases, while in rest of cases these were not everted 3 (13.04%). No exit wound was observed among female victims. (Graph 12)

Everted In most 84 (84%) of the firearm injury cases; the nature of Not-everted injury was declared as simple while in 15 (15%) cases grievous and in only 1 (1%) cases it was dangerous to life. (Graph 15)

All of the 23 (100%) exit wounds were single in number and were corresponding to their respective entry wounds. All physical features of firearm injuries like abrasion collar, contusion ring, blackening, burning, singeing of hairs were absent in all the exit wounds. Comparative analysis of size of exit wounds in relation to their entrance wounds in firearm injuries was conducted, out of 23 Associated mechanical injuries were present in 35 (35%) cases (100%) cases of the exit wounds, 18 (78.26%) were larger and among both sexes along with firearm injuries. Among males 5 (21.74%) were smaller in size than their corresponding entry associated injuries were observed in 34 (34%) cases, while wounds. None of entry wound and exit wound was equal in observed in only 1 (1%) among female cases .The associated size. mechanical injuries were in the form of abrasions, bruises, lacerations and incised wounds in both sexes. (Graph 16) foreign bodies were present in 94 (60.65%) cases among both sexes, while these were present in 91 (62.33%) male and 3 (33.33%) female victims injuries. Foreign body means bullet or pieces of bullet, lead pellets, pieces of jacket , wad or residues of fired propellants, i.e. powder residues on clothes/skin in closed distance firing. Due to burnt, partially burnt or un-burnt powder particles. The wad may comprise of paper, coir, cloth etc. (Graph 13)

18 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI: 10.5958/0974-083X.2020.00002.3

DISCUSSION : cases, which is quite comparable to the study conducted by 4 Results of present study are more or less similar to the study Chanana et al , according to which 30.32% cases were having conducted in by Chanana et al4 in which 87.09% were males more than three entry wounds followed by 27.74% cases with and 12.91% were females. The single largest age group was of one entry wound, 24.51% cases with two entry wounds and 21-30 years which contained 45.80% cases. Least were the 17.43% cases with three entry wounds. In a study conducted by 1 cases in extreme age group, only 2.60% cases in 0-10 years age Kumari et al single entry wound was observed in 74.6% cases, group and 5.16% cases in more than 61 years age group. Most double in 6.8% and multiple entry wounds in 18.6% cases, of the victims 61.92% were in age group of 21-40 years. While, which is almost similar to the present study.\ Nance et al5 in their study concluded that 90.7% of the victims In the present study, the margins of entry wounds in firearm were males; with mean age of 16.5 years. Adolescents (age 15- injuries were inverted in 85.16% of the cases, while these were 19 years) represented more than 85% of the study population, not-inverted in 14.84% cases, out of total 155 entry wounds, which are coinciding with the present study. Similar results which is slightly lesser than the incidence observed in a study were reported by Marri et al6 according to which males by Chanana et al4 conducted in the same department, according constituted 86.15% of the victims. 32% of the victims were in to which margins of entry wounds were inverted in 98.69% their third decade of life. According to Kohli et al7 in their study cases. observed that 46.7% victims were aged between 20 and 30 As far as shape of entry wounds in firearm cases is concerned; years and 90.7% were males, which were also similar to our in present study it was observed that out of 155 entry wounds; present study. Slightly different results were seen by Fedakar et 61.94% were oval in most of the cases, followed by circular in 8 al who had observed that 17.8% were females and 82.2% were only 12.90% cases, irregular in 25.16% cases, no cruciate type males. The median age was 34 for males and 25 for females and entry wound was seen in firearm injury cases, which is 51.3% were in the age group 21–40. These observations were corresponding with the study conducted by Chanana et al4 slightly different from the present study because it was according to which the shape of most the entry wounds was conducted in different geographical region. circular/oval or irregular. As far as anatomical sites of firearm injuries were concerned, As far as physical characters of entrance wounds were in present study; out of total 155 entry wounds present among concerned; these findings are slightly different from the study 100 victims of firearm injuries,In majority of firearm injury conducted by Chanana et al 4 according to which cases, most of entry wounds 55.48% were present on all abrasion/contusion collar was observed in 37.77% cases, extremities (limbs) of the body. More or less similar pattern blackening in 03.71% cases, tattooing in 0.87% cases and was observed among males. In females 1.93% cases were burning effect was not seen in any case. In an another study having entry wounds of firearm injuries each on lower limbs conducted by Kumari et al12 , blackening and tattooing were and head & neck areas of the body, while only 0.64% case was seen in 53.1% of close shot cases, which is on the higher side as seen having entry wound each in thorax, upper limb and compared to the present study. abdomen areas of body. Similar findings were observed by In present study, the single exit wounds were present in only Nasurulla et al9 in their study, it was observed that in which 23% cases out of 100% victims of firearm injuries, most common sites of firearm injuries were situated on lower corresponding to 155 entry wounds. Out of these the shape of limbs in 30% cases, followed by abdomen pelvis 27%, head 78.26% cases was irregular, in 17.39 cases it was oval and and neck 23%, upper limbs 21% and thorax 18% cases. circular in only 4.35% case, which is consistent with study However, these observations are different from other studies. conducted by Chanana et al4, according to which shape of exit In another study conducted by Buzdar et al10 most common wounds were irregular in 92.17% cases followed by oval in sites for firearm injuries were on Chest 43.5%, abdomen & 6.17% cases and circular in 1.66% cases. In another study pelvis 13%, head, neck and face 21.7%, upper extremities conducted Quatrehomme G by et al13 exit wounds were roughly 17.4% and lower extremities 4.3%. In another study of Sachan round, oval, square, and rectangular and were always more et al11 the commonest site was abdomen in 48.49% cases, head irregular than entry wounds, which are more or less & neck 27.27%, upper extremities in 13.62% and lower comparable with the present study as these variable and depend extremities in 10.7% cases, which tally with the present study. upon the distance, velocity, direction and sometimes caliber As far as the study of number of entrance wounds in a firearm size. injury case is concerned, in present study, in most of the cases In the present study, it was observed that the margins of exit the number of entry wounds were single in 69.68%, while two wounds of firearm cases were everted in most 86.96% cases, in only 3.87%, three in 6.45% and more than three in 20% while in rest of cases these were not everted in 13.04%, which

19 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI: 10.5958/0974-083X.2020.00002.3

are slightly lower as compared to the study conducted by there will be mass causalities as a result of firearm related Chanana et al4 according to which the margins of exit wounds violence which is quite famous in other countries like U.S.A., were everted in 99.76% cases and not everted in only 0.24% Afghanistan and Pakistan. 15 cases. According to study by Prayulsatein , the exit wounds REFERENCES : commonly present a larger and more ragged appearance than 1. Kumari S, Rajput AS, Agarwal A, Arif A, Chaturvedi RK. the corresponding entrance wounds. Outshoot wounds may be Medico-legal Aspects of Firearm Injury Cases in Agra Region. of varying shapes and can be described as slit-like, stellate, Journal of Indian Acadamy of Forensic Medicine. cruciate, and irregular or gaping, which tallies with the present 2014;36(4):387-90. study. 2. Modi JP. Injuries by Mechanical Violence. A Textbook of th CONCLUSIONS : Medical Jurisprudence and Toxicology. 24 ed. Lexis Nexis. 2012:533-37. The present study was conducted with the aim to evaluate the 3. Reddy KSN. Medico legal aspects of wounds. The Essentials of demographic profile and physical characteristics of firearm Forensic Medicine and Toxicology. 33rd ed. Jaypee Brothers injuries in Majha region of Punjab. With the increase in socio- Medical Publishers. 2014:179-93. economic status of people in Punjab, there is also 4. Chanana A, Gargi J, Gorea RK. An Autopsy Study of Firearm proportionately increase in the trend of possession of firearm Injuries. Journal of forensic medicine and toxicology. weapons and its related violence. The people of Punjab have 1990;7(3&4):1-11. 5. Nance ML, Denysenko L, Durbin DR, Branas CC, Stafford PW, special affection for dangerous firearm weapons and every Schwab CW. The rural-urban continuum: variability in fourth person is having licensed firearm weapon. statewide serious firearm injuries in children and adolescents. In all firearm casualties, careful documentation is of utmost Archives of Pediatrics and Adolescent Medicine. 2002 Aug importance. This includes taking photographs and close up 1;156(8):781-85. views of each wound using a scale. The clothing must be 6. Marri MZ, Bashir MZ, Munawar AZ, Khalil ZH. Analysis of preserved, as the uppermost layer may exhibit the bullet wipe homicidal deaths in Peshawar, Pakistan. J Ayub Med Coll around entrance holes and deposition of soot and powder Abbottabad. 2006;18(4):201-10. 7. Kohli A, Aggarwal NK. Firearm fatalities in Delhi, India. Legal particles in close and medium range shots, respectively. Medicine. 2006 Oct 1;8(5):264–68. Radiographs are also a valuable tool to find projectiles lodged 8. Fedakar R, Gundogmuş UN, Turkmen N. Firearm-related deaths in body regions. The documentation should also mention the in two industrial cities of Turkey and their province. Legal size and shape of each wound, the features of wound margins Medicine. 2007 Jan 1;9(1):14-21. and their surroundings. 9. Nasrullah M, Razzak J. Firearm Injuries Presenting to a Tertiary Many cases of violence due to firearm injuries are being Care Hospital of Karachi, Pakistan. Journal of Injury and Violence Research. 2009 Jul;1(1):27–31 reported daily in various hospitals, out of which a large number 10. Buzdar ZA, Zaman FU, Hammad M, Abbasi MH, Mengal FU. of people die as a result of fatal injuries, which is a serious law Demographic Distribution of Firearm Injuries in District Quetta. and order problem. Sometimes, it is very difficult to Pakistan Journal of Medical and Health Sciences. 2016 Jan differentiate between firearm injury during scuffle and a 1;10(1):86-88. fabricated case. In such cases forensic expert opinion is 11. Sachan R, Kumar A, Verma A. Frequency of Firearm Injuries, required to differentiate between original and fabricated Deaths and Related Factors in Kanpur, India; an Original Study firearm injury. with Review of Literature. International Journal of Medical Toxicology and Forensic Medicine. 2013 Jun 11;3(3):88-95. The present study and other researches on firearm injuries 12. Kumar R. Medico-legal study of homicide by firearms and prove that certain changes may minimize mortality, disability, explosives. Journal of Evolution of Medical and Dental and costs to the community. There is a need to decrease the Sciences. 2013 Nov 4;2(44):8490-508. number of firearms used and sold in India. We need to eradicate 13. Quatrehomme G, Işcan MY. Characteristics of gunshot wounds illicit local community gun manufacturing units. It is obvious in the skull. Journal of Forensic Science. 1999 May;44(3):568- that private gun ownership should be strictly limited and the 576. illegal availability should be prevented. Elimination of illegal 14. Patowary AJ. Study of Pattern of Injuries in Homicidal Firearm countries made fire arms is of the utmost importance in order to Injury Cases. Journal of Indian Academy of Forensic Medicine. curb the high firearm fatality rate in this region. 2005;27(2):92-95. 15. Prayulsatein W. Atypical Exit Gunshot Wound of Chest, a push- To reduce the incidence of firearm related violence the Up Brassier Effect: A Case Report. Journal of Indian Academy of government should have strict rules and people should not be Forensic Medicine. 2016;38(1):127-9. provided with easy firearm licenses so frequently. Otherwise

20 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI: 10.5958/0974-083X.2020.00003.5 Original Research Paper Ten years retrospective study of deaths due to poisoning 1. Kamaljeet Singh, Junior resident* 2. Ashok Chanana, Associate Professor* 3. Kuldip Kumar, Associate professor* 4. Manpreet Kaul, lecturer* 5. Jaspinder Pratap Singh, Junior resident* *Department of Forensic Medicine and Toxicology, Government Medical College, Amritsar.

ABSTRACT Introduction: A poison is a solid, liquid or gaseous substance, which if introduced in to the living body, or brought in contact with any part produces ill effects or death by its local, systemic or both types of action. Objective: The present study was carried out with a view to study the incidence and key features of postmortem findings in poisoning and their demographic distribution in forensic autopsy cases. Methods: A ten years retrospective study of all medico-legal autopsies of poisoning deaths was undertaken between 1st January 2006 to 31st December 2015 in the department of Forensic Medicine and Toxicology, Government. Medical College, Amritsar, Punjab, India. Results: Incidence of poisoning deaths is 5.66% of total autopsies. Most common age group amongst the males was 21-30 years; Male to female sex ratio was 2.59:1. The maximum number of deceased practised Sikhism 392 (67.82%), followed by Hinduism 140(24.22%), Christianity 6 (1.04%) and Muslims 1 (0.17%). Males out numbered female victims amongst all the religion groups except Muslims. As far as the mode of intake of various poisons is concerned, oral route was most preferred one in majority. Detailed analysis of 578 cases of deaths due to various poisons has revealed that Irritant metallic & non metallic poisons 479 (82.87%) were the most common type of poisons detected in the present study, followed by cerebral -inebriant type in 17 (2.94%) cases. the colour of gastric contents was black in 112 (19.38%) cases, green in 34 (5.88%) cases, blood stained in 106 (18.37%) cases. Conclusion: As the main profession of rural population in Punjab is agriculture and in the present study three types of major poisons used as pesticides in farming have been reported i.e. aluminium phosphide, organ chloride and organophosporus compounds.

Corresponding Author : Article History: Dr Ashok Chanana, Received: 23 February 2019 MD, DNB, Associate Professor, Received in revised form: 23 March 2019 Accepted on: 23 March 2019 Department of Forensic Medicine, Available online: 31 December 2019 Govt. Medical College, Amritsar Contact : +91 9915780056 Email : [email protected]

KEYWORDS : Poison, Ten Years, Retrospective, Deaths, Amritsar

INTRODUCTION lack of data at central level. It has been estimated that about 5-6 A poison is a solid, liquid or gaseous substance, which if people per lakh of population die due to poisoning every year. introduced in to the living body, or brought in contact with any The commonest cause of poisoning in India and other part produces ill effects or death by its local, systemic or both developing countries is pesticides, The reason being types of action. This definition is unsatisfactory as a substance agriculture based economy since 1985. Aluminium phosphide in particular dose causes beneficial effects whereas in the same poisoning has been reported as the commonest cause of dose it can cause the toxic effects. Drugs that are used for the intentional poisoning in northern part of India, viz, Haryana, treatment of diseases in higher doses will produce toxicity. As Punjab and Rajasthan but this trend is changing, Paracelsus, the father of modern toxicology said, “All things organophosphorous forming the largest bulk of pesticide 2 are poison and nothing is without poison. It is the dose that poisoning. determines the poison”1 Pesticides comprise a wide range of compounds including The incidence of poisoning deaths in India is uncertain due to insecticides, herbicides, fungicides and others. Thus, far more

21 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI: 10.5958/0974-083X.2020.00003.5

than 1,000 active substances have been incorporated in Out of total 578 deaths reported due to poisoning, the approximately 35,000 preparations of pesticides used in maximum number of deceased practised Sikhism were 392 agriculture. Organophosphate compounds (OPCs), are most (67.82%), followed by Hinduism 140(24.22%), Christianity 6 commonly used among them and are gradually increasing (1.04%) and Muslims 1 (0.17%). The religion remained cause of accidental and suicidal poisoning, with high undetermined in 39(6.75%) of unknown cases. As far as sex morbidity and mortality rates, especially in developing wise distribution of the poisoning cases of Sikh victims is countries3 concerned, there were 266 (67.86%) males and 126 (32.14%) MATERIAL AND METHODS : were females, out of total 392(100%). Amongst Hindus, males were 113(80.71%) as compared to 27(19.29%) females out of 10 years retrospective study of deaths due to alleged poisoning total 140(100%) victims. Christian males were 4 (66.67%) in cases was conducted in the Department of Forensic Medicine number while females were only 2(33.33%), there was only and Toxicology, Government Medical College, Amritsar 1(100%) Muslim female victim, while no male Muslim case (Punjab) from 1st January 2006 to 31st December 2015. 578 was reported in the study. The religion could not be ascertained cases of poisoning deaths were brought for autopsy during this in 34(87.17%) male cases, out of total39(100%) unknown period. The details pertaining to the name, age, sex, address victims. (Table 2) and alleged cause of death were ascertained from police papers and their autopsy report was studied/scrutinized for visceral 55.71% of cases of poisoning were from rural area and 37.89% findings, chemical examiner report, histopathological report, belonged to urban area. In 6.40% cases of poisoning the cause of death, manner of death and special remark if any was residence was not known observed and analysed thoroughly. Mode of intake of various poisons is concerned, oral route was OBSERVATIONS : most preferred in majority 570(98.62%) of cases, out of total 578(100%) victims, 409(71.75%) were males and Out of total 10217 post mortem cases, deaths due to poisoning 161(28.25%) were females. Only 5(0.87%) males preferred accounted for 578 (5.66 %). The rest of the cases comprised of inhalational route and 1(0.17%) male used intravenous route of deaths due to violent asphyxial deaths, rail/road traffic poisoning. No female has preferred parenteral routes like accidents, natural deaths, burns, fall from height, fatal injuries inhalational or intravenous route of poisoning. The route of leading to homicide, electrocution, infanticide & administration of poisons could not be ascertained in 2 (0.35%) miscellaneous & accounted for 9639 (94.34%) cases. Table 1 cases. (Table 3) Table No.1 : Profile of Deaths Due To Poisoning As per table no 4,detailed analysis of 578 cases of deaths due Type of death No. of cases %age to various poisons has revealed that Irritant metallic & non Deaths due to poisoning 578 5.66 metallic poisons 479(82.87%) were the most common type of poisons detected in the present study, followed by cerebral - Others 9639 94.34 inebriant type in 17(2.94%) cases, 4(0.69%) male cases due to Total 10217 100.0 combination of Irritant- metallic & non-metallic and cerebral-

Table No.2 : Sex Wise Distribution of Poisoning Deaths Based On Religion Religion SEX TOTAL MALE FEMALE No. of Cases % age No. of Cases % age No. of Cases % age Sikh 266 63.79 126 78.26 392 67.82 Hindu 113 27.10 27 16.77 140 24.22 Christian 4 0.96 2 1.24 6 1.04 Muslim 0 0.00 1 0.62 1 0.17 Not known 34 8.15 5 3.11 39 6.75 Total 417 100.00 161 100.00 578 100.00

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Table No.3 : Mode of Intake Of Various Poisons In Deaths Due To Poisoning Mode of SEX TOTAL Intake MALE FEMALE No. of Cases % age No. of Cases % age No. of Cases % age Oral 409 98.08 161 100.00 570 98.62 Inhalation 5 1.20 0 0.00 5 0.87 Intravenous 1 0.24 0 0.00 1 0.17 Others 2 0.48 0 0.00 2 0.35 Total 417 100.00 161 100.00 578 100.00

inebriant type poisons, 3(0.52%) cases due to corrosives- Table No.5 : Status And Colour of Stomach Contents mineral acids and only 2(0.35%) case each due to animal and Color of content No. of cases %age corrosive-vegetable acid poisons were recorded, while no Black 112 19.38 poison could be detected in 69(11.94%) cases because chemical examiners reports are still pending in these cases. Blood stained 106 18.37 Majority of males followed the similar pattern as far as type of Normal 39 6.75 poisons is concerned as the trend observed in total number of Green 34 5.88 cases mentioned in the study. No female case was reported to Others (reddish brown, brown, 198 34.26 have died due to animal, cerebral inebriant, corrosive- grey and white) vegetable acid-poisons. Irritant poisons include aluminium phosphide, organochloro-compounds, organophosporus Not Mentioned 89 15.40 compounds, zinc phosphide and animal poisons like snake Total 578 100 bites etc. Cerebral inebriant group of poisons include ethyl As per the table number 6, regarding the conditions of the alcohol, methyl alcohol, sedatives, hypnotics and agro- walls of stomach in poisoning deaths : In majority chemical compounds. Miscellaneous group of poisons include 403(69.72%) cases these were congested and Submucosal warfarin and dextropropoxyphene drugs. Corrosive poisons haemorrhages along with congestion were observed in includes strong acids and strong alkalis. 96(16.61%) cases while only submucosal haemorrhages were As per table number 5, regarding colour of stomach observed in 62(10.73%) cases. No abnormality of the stomach contents in various poisons : Out of total 578 cases of wall was found in 17(2.94%) cases. poisoning deaths, the colour of gastric contents was black in As per table number 7,congestion of visceral organs was 112(19.38%) cases, green in 34(5.88%) cases, blood stained in seen mostly in lungs in 405(70.06%) cases followed by liver in 106(18.37%) cases and others (reddish brown,brown,grey and 400(69.20%) cases, kidneys and spleen both in 399(69.03%) white) in 198 (34.26%) cases while it was not mentioned in the cases, brain in 377(65.22%) cases, heart in 119(20.59%) cases post-mortem reports in 89(15.40%) cases. Table No.4 : Distribution of Type of Poisons Among Poisoning Deaths Poison SEX TOTAL MALE FEMALE No. of Cases % age No. of Cases % age No. of Cases % age Irritant-metallic & non- metallic 344 59.52 135 23.37 479 82.87 Cerebral-inebriant 17 2.94 0 0.00 17 2.94 Irritant &cerebral inebriant 4 0.69 0 0.00 4 0.69 Corrosives-mineral acids 2 0.35 1 0.17 3 0.52 Animal 2 0.35 0 0.00 2 0.35 Corrosive-Vegetable acid 2 0.35 0 0.00 2 0.35 Miscellaneous 1 0.17 1 0.17 2 0.35 Pending Reports of chemical examiner 45 7.79 24 4.15 69 11.94 Total 417 72.15 161 27.85 578 100.00

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and uterus & ovaries in 33(20.50%) cases only DISCUSSION : As per table number 8 observation regarding time since In this study the incidence of deaths as a result of poisoning death, according to various poisons was within 12-24 hours in accounted for 5.66% cases which is lower than the result of the most of the 333 (57.61%) irritant poisons, in 14(2.94%) other studies conducted by Gargi et al (11.55%),4 Sugandh cerebral inebriant poisons, 1 (0.17%) in corrosives poison, (13.80%), 5 Satinder et al (17.60%), 6 Sandesh et al 2(0.35%) in animal poison cases. It was within 24-36 hours in (11.13%),7Quader et al (37.16%).8 In present study the 56(9.69%) irritant poisons, 2(0.35%) cerebral-inebriant incidence of poisoning was higher than another study poisons and 1 (0.17%) in corrosives poison cases .It was within conducted by Dhaval et al (1.36%).9 This difference in the 6-12 hours in 54((9.34%) irritant poisons, 3(0.51%) cerebral incidence may be due to variations in customs, rituals, inebriant poisons and in 1 (0.17%) in corrosives poison cases. religions and lifestyle of the population. It was more than 36 hours in 17(2.94%) in irritant poisons, The data of present study shows that out of total 578 deaths 1(0.17%) in cerebral-inebriant poisons cases. Time since death reported due to poisoning, the maximum number of deceased was not recorded in 3(0.51%) cases practiced Sikhism 392 (67.82%), followed by Hinduism 140 Table No.6 : Detailed Condition of Walls of Stomach (24.22%), The probable reason for majority (67.82%) of cases belonging to Sikh religion is that Punjab is the only Sikh Condition of wall stomach No. of cases %age majority state in the country and Hindus are next second most Congested 403 69.72 populous religion of the state. This study is not coinciding with Submucosal Haemorrhage 96 16.61 another study conducted by Maharani et al according to which and congestion maximum occurrence was found among Hindus (98%) as 10 Submucosal haemorrhage 62 10.73 compared to only 1.33% Christian and 0.66% Muslims. This reverse trend is because of different demographic profile of Healthy 17 2.94 southern state Tamilnadu. The reverse was also observed by Total 578 100.00 Singh et al according to which majority of victims were Hindus (80%), Christians (15%) and Muslims (5%).11 Table No.7 : Incidence of Congestion of Visceral Organs In our study, among majority of cases the commonest mode of Name of visceral organ Congestion intake of various poisons was oral in 98.62% cases remotely Present Absent followed by inhalation route in 0.87% and intravenous route in No. % No. % 0.17% cases while other routes were observed in only 0.35% Lungs 405 70.06 173 29.93 cases. According to Sandesh et al oral route of poisoning was observed in (64.81%) followed by sting in 34.29%, inhalation Liver 400 69.20 178 30.80 in 0.54% and dermal route in (0.36%) cases,34 but in another Kidney 399 69.03 179 30.97 study conducted by Kishan et al has shown results similar to Spleen 399 69.03 179 30.97 present study according to which 93.8% victims preferred oral Brain 377 65.22 201 34.78 route and injected route in 6.1% cases.12 Heart 119 20.59 459 79.41 Regarding the conditions of the walls of stomach in poisoning Uterus and ovary 33 20.50 128 22.15 deaths is concerned, in present study, in majority 403 (69.72%)

Table No 8 : Time Since Death According To Various Poisons

Irritant Cerebral Vegetable - Corrosive Animal Unknown Time since metallic inebriant acids death No. % No. % No. % No. % No. % No. % <6 2 0.35 0 0 0 0 0 0 0 0 0 0 6-12 54 9.34 3 0.51 1 0.17 0 0 0 0 17 2.97 12-24 333 57.61 14 2.94 1 0.17 2 0.35 2 0.35 46 7.69 24-36 56 9.69 2 0.35 1 0.17 0 0 0 0 12 2.08 >36 17 2.94 1 0.17 0 0 0 0 0 0 3 0.51 Non mentioned 3 0.51 0 0 0 0 0 0 0 0 8 1.39

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cases these were congested and submucosal haemorrhages autopsy study of poisoning in the Northern region of along with congestion were observed in 96 (16.61%) cases Punjab. J Pun Acad For Med Toxicol. 2008;2 while only submucosal haemorrhages were observed in 62 5. Garg S. Medicolegal autopsy study of poisoning cases in (10.73%) cases., These findings are on the lower side in the department of Forensic Medicine and Toxicology study conducted by Sugandh according to which congestion of Amritsar. original thesis 2010; 47-62. stomach walls was present in 91.21% cases and submucosal 6. Singh SP, Aggarwal AD, Oberoi SS, Aggarwal KK, Thind haemorrhages in 67.03% cases5, findings in the stomach are of AS, Bhullar DS, Walia DS, Chahal PS. Study of undetermined type observed by Kishan et al, according to poisoning trends in north India–a perspective in relation to which stomach mucosa in untreated cases was congested in world statistics. Journal of Forensic and Legal Medicine. 1 3 . 8 0 % i n a l u m i n i u m p h o s p h i d e , 1 0 . 7 0 % i n 2013;20(1):14-8. organophosphorous and 10.90% in organochlorine and were highly congested in 53.80% in aluminium phosphide, 45.70% 7. Datir S, Petkar M, Farooqui J, Makhani C, Hussaini SN, in organophosphorous and 52.70% in organochlorine Chavan K, Bangal R. Profile of acute poisoning cases at poisons.12 pravara rural hospital, Loni. Journal of Indian Academy of Forensic Medicine. 2015;37(4):400-4. In the present study congestion of visceral organs was seen mostly in lungs in 405 (70.06%) cases followed by liver in 400 8. Quader M, Rahman MH, Kamal M, Ahmed AU, Saha SK. (69.20%) cases, in kidneys and spleen both in 399 (69.03%) Post mortem outcome of organophosphorus compound cases, in brain in 377 (65.22%) cases, in heart in 119 (20.59%) poisoning cases at Mymensingh Medical College. cases and in uterus & ovaries in 33 (20.50%) cases. These Mymensingh Medical Journal. 2010; 19(2):170-2. findings are different from the study conducted by Sugandh 9. Patel DJ, Pawan RT. Profile of organophosphorus according to which congestion of brain was present in 85.71% poisoning at Maharani Hospital, Jagdalpur, Chhattisgarh: cases, in liver 98.90%, in lungs 97.80%, in kidneys 98.90% a three years study. J Indian Acad Forensic Med. and in spleen 98.90% cases.5 2011;33(2):102. CONCLUSION : 10. Maharani B, Vijayakumari N. Profile of poisoning cases in The findings of the present study reveals that three types of a Tertiary care Hospital, Tamil Nadu, India. Journal of major poisons have been detected on autopsy in rural Applied Pharmaceutical Science. 2013;3(1):91. population of Punjab i.e. aluminium phosphide, 11. Singh K, Oberoi SS, Bhullar DS. Poisoning trends in the organochloride and organophosporus compounds Malwa region of Punjab. Journal of Punjab Academy of respectively. India is still a developing country with an Forensic Medicine and Toxicology. 2003;3:26-9. agriculture based economy and most of the people using 12. Siddapur KR, Pawar GS, Mestri SC. Trends of Poisoning pesticides in farming without any stringent legal control on and Gross Stomach Mucosal Appearance in Fatal their sale and purchase are exposed to the hazardous effects of Poisoning Cases: An Autopsy Study. Journal of Indian these pesticides. Academy of Forensic Medicine. 2011;33(2):106-11. Funding- NIL Conflict of Interest - None Ethical approval - From Institution Ethical Committee REFERENCES : 1. Dikshit PC. Textbook of Forensic medicine and toxicology principles and practice. 2thedn.2013; 438-9. 2. Prajapati T, Prajapati K, Tandon NR, Merchant S. A study of acute poisoning cases excluding animal bites at Civil Hospital, Ahmedabad. J Indian Acad Forensic Med. 2013;35(2):120-2. 3. Wahal PK, Lahiri B, Mathur KS, Kehar U, Wahi PN. Acute copper sulphate poisoning. J Assoc Physicians India. 1963;11:93-10. 4. Gargi J, Tejpal HR, Chanana A, Rai G. A retrospective

25 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI: 10.5958/0974-083X.2020.00004.7 Original Research Paper Ten Years Autopsy Study of Violent Asphyxial Deaths 1. Manoj Kumar Sharma, Junior Resident* 2. Ashok Chanana, Associate Professor* 3. Kuldip Kumar , Associate Professor* 4. Manpreet Kaul, Lecturer* *Department of Forensic Medicine and Toxicology, Government Medical College, Amritsar.

ABSTRACT : Introduction:An increasing death rate as a result of violence constitutes a large group in medico-legal autopsies especially deaths due to asphyxia which are one of the most important causes in violent deaths. Analysis and interpretations of cases of hanging, ligature strangulation, throttling, suffocation, traumatic asphyxia and drowning is presented in this paper. Aims and Objective: The present study was carried out with a view to study the incidence and postmortem finding of violent asphyxial deaths with regard to key features that help to differentiate between different violent asphyxial deaths. Method: A ten years retrospective study of all medico-legal autopsies of violent asphyxial deaths was undertaken between 1st January 2006 to 31st December 2015 in the department of Forensic Medicine and Toxicology, Government. Medical College, Amritsar, Punjab, India. Results: Incidence of violent asphyxia deaths is 3.98% of total autopsies. Hanging (50.37%) was most common method of asphyxiation followed by drowning (29.48%).Males (68.06%) outnumbered females (31.94%) with male to female ratio of 2.13:1. Most affected age group was 21-30 years among both the sexes.Most of the victims were married 233 (57.25%) compared to unmarried 100 (24.57%) and unknown 74 (18.18%) cases.Suicide (53.56%) was most common manner of death followed by homicide (19.90%), accidental was least common (17.20%) and in (9.34%) cases manner was unascertained. More cases 52.83% of violent asphyxial deaths were reported from rural area as compared to urban (27.76%) and residence status of 18.18% cases were unknown. Corresponding Author : Article History: Dr Ashok Chanana, Received: 9 February 2019 MD, DNB, Associate Professor, Received in revised form: 9 February 2019 Accepted on: 9 February 2019 Department of Forensic Medicine, Available online: 31 December 2019 Govt. Medical College, Amritsar Contact : +91 9915780056 Email : [email protected] KEYWORDS : Hanging, Drowning, Strangulation, Suffocation, Throttling, Traumatic Asphyxia, Smothering, Asphyxia, Violent Asphyxial Deaths, Autospy

INTRODUCTION and mouth, occlusion of lumen of the air passages by some Asphyxia (Greek word for “breathlessness”) is defined as the materials, restricting movement of respiratory muscles. lack of oxygen in the blood or the failure of cells to utilize Violent asphyxial deaths are very common and occur through oxygen, and a failure of the body to eliminate carbon hanging, strangulation, suffocation, traumatic asphyxia and dioxide.1In other words the term asphyxia is defined as “A drowning. Manner of death from violent asphyxial death may condition caused by interference with respiration or due to lack be accidental, suicidal or homicidal. In Forensic context, of oxygen in respired air due to which the organs and tissues asphyxia is usually obstructive in nature, where some physical are deprived of oxygen (together with failure to eliminate barrier prevents access of air to lungs. This obstruction can CO2), causing unconsciousness or death”. The classical occur at any point from the nose and mouth to the alveolar features of asphyxia are found when the air passage is membranes, other conditions in which the body cannot gain constricted by pressure applied to the neck or to the chest and sufficient oxygen may occur without any obstruction to the when there has been struggle to breathe.2 cells of the body. It is not surprising that clinical and pathological features of many different types of asphyxia vary.3 In violent asphyxial deaths, the process of respiration i.e. exchange of air between the atmosphere and the lungs beds is In death from asphyxia, usually oxygen level falls below the prevented by some violent mechanical means. Violent minimum necessary level for continuance of life. Serious asphyxia can be caused by constriction of neck, closure of nose deprivation of oxygen for 5 to10 minutes can result in the

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permanent damage of Central Nervous System and Table 2 : Profile of Violent Asphyxial Deaths Based On Cardiovascular System resulting in death. It is interesting to Methods of Asphyxiation note that in a healthy adult body, normally blood that is Type of asphyxial death No. of cases %age circulating has about one liter of oxygen held in combination. Hanging 205 50.37 Any interference with this results in asphyxia which triggers the consequence. Violent asphyxial deaths are quite common Strangulation 70 17.20 and may be classified as Hanging, Ligature strangulation, Throttling 5 1.23 Throttling Suffocation (Environmental, Smothering, Choking, Traumatic asphyxia 3 0.74 Gagging), Drowning, Traumatic asphyxia.4 Suffocation 4 0.98 MATERIAL AND METHODS : Data has been collected Drowning 120 29.48 from autopsies conducted on dead bodies of cases of violent Total 407 100.0 asphyxial deaths at the mortuary of department of Forensic Medicine and Toxicology, Govt. Medical College, Amritsar, It was observed that maximum number of cases were in the age st st during period of 10 years from 1 January 2006 to 31 group of 21-30 years, 183 (44.96%) followed by 66 (16.22%) December 2015. belonging to 31- 40 years age group. Both 11 - 20 years and 41- RESULTS : Out of 10217 post mortem cases, violent 50 years age groups constituted 54 (13.27%) of the cases each. asphyxial deaths accounted for 407 (3.98 %) (Table No. 1). Out of total 407 cases studied, males constituted the majority Table 1 : Profile of Violent Asphyxial Deaths Amongst and comprised 277(68.06 %) cases while females were only Autopsies Conducted Between 1st Jan. 2006 To st 130 (39.94 %) cases. Male to Female ratio was 2.13:1. (Table 31 Dec. 2015 No. 3) Type of death No. of cases %age Out of the total 407 violent asphyxial death autopsies Violent asphyxial deaths 407 3.98 conducted, most of the victims were married 233 (57.25%) Others 9810 96.2 compared to unmarried 100 (24.57%) and unknown 74 Total 10217 100.0 (18.18%) cases. Out of total 233(57.25%) married cases, 151(64.81%) were males and 82(35.19%) were females. Out Amongst the violent asphyxial deaths studied, hanging was the of total 100(24.57%) unmarried persons, 70(70.00%) were most common method encountered. Hanging amounted for males and 30(30.00%) were females. Among the 74(18.18%) 205(50.37%) cases of the total sample studied, followed by unknown persons included in the study 56 (75.68%) were d r o w n i n g w h i c h a c c o u n t e d f o r 1 2 0 c a s e s males and 18(24.32%) were females. The males outnumbered (29.48%).Strangulation was the method employed in 70 the females in all married, unmarried and unknown groups. (17.20%) cases.5 (1.23%) cases studied were of throttling, 4 (Table No. 4) (0.98%) cases were of suffocation and the least common was traumatic asphyxia for which only 3 (0.74%) cases were studied (Table No. 2). Table 3 : Age And Sexwise Distribution of Violent Asphyxial Deaths Age Group SEX TOTAL MALE FEMALE No. of Cases % age No. of Cases % age No. of Cases % age 0-10 13 3.19 5 1.23 18 4.42 11-20 34 8.35 20 4.91 54 13.27 21-30 114 28 69 16.95 183 44.96 31-40 48 11.79 18 4.42 66 16.22 41-50 41 10.07 13 3.19 54 13.27 51-60 16 3.93 1 0.25 17 4.18 61-70 6 1.47 2 0.49 8 1.97 71-80 5 1.23 2 0.49 7 1.72 Total 277 68.06 130 31.94 407 100.00 Mean age 32.61±14.33 28.91±12.40 31.44±13.80

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Table 4 : Distribution of Violent Asphyxial Deaths According To Marital Status Marital SEX TOTAL Status MALE FEMALE No. of Cases % age No. of Cases % age No. of Cases % age Married 151 37.10 82 20.15 233 57.25 Unmarried 70 17.20 30 70.37 100 24.57 Unknown 56 13.76 18 4.42 74 18.18 Total 277 68.06 130 31.94 407 100.00

Table 5 : Distribution of Violent Asphyxial Deaths Cases Based On Manner Of Death Type of asphyxial deaths Suicidal Accidental Homicidal Unascertained Total No. % No. % No. % No. % No. % Hanging 202 98.53 1 0.49 2 0.97 0 0 205 50.37 Strangulation 0 0.00 1 1.43 69 98.57 0 0 70 17.20 Throttling 0 0.00 0 0.00 5 100 0 0 5 1.23 Traumatic asphyxia 0 0.00 2 66.67 1 33.33 0 0 3 0.74 Suffocation 0 0.00 2 50 2 50 0 0 4 0.98 Drowing 16 13.33 64 53.33 2 1.67 38 31.67 120 29.48 Total 218 53.56 70 17.20 81 19.90 38 9.34 407 100.00

In the present study, the commonest manner of asphyxial asphyxial deaths. In drowning out of 120 cases recorded, 64 deaths were suicidal in nature 218 (53.56%) followed by (53.33%) cases of accidental drowning were reported in both homicidal manner 81(19.90%) and least encountered manner sexes, out of which 55 (45.83%) were males and 9 (7.5%) were was the accidental type which amounted for 70(17.20%) of the females. 16 (13.33%) cases of suicidal drowning were reported cases, while manner was unascertained in 38 (9.34%) cases, in both sexes out of which 12 (10%) were males and 4 (3.33%) out of total 407 cases of violent asphyxial deaths. (Table No. 5) were females while only 2 (1.67%) male cases of homicidal Amongst the male population (n=277) in 148(53.43%) cases drowning were reported and in 38 (37.67%) cases, the manner suicidal manner was seen followed by accidental in was unascertained in both sexes, out of which 33(27.5%) were 59(21.29%) cases and 37(13.36%) of them were homicidal, males and 5(4.17%) were females. while in 33 (11.91%) cases manner of death was unascertained, In throttling only 5(1.23%) cases were reported and manner of out of total 407 cases of violent asphyxial deaths. Amongst the all cases was homicidal. female group (n=130), 70(53.85%) of the cases was suicidal In cases of suffocation only 4(0.98%) cases were reported, out manner followed by homicidal in 44(33.85%) and accidental of which 2(50%) were accidental and 2 (50%) homicidal in manner of death in 11(8.46%) cases, while in 5 (3.84%) cases nature. manner of death was unascertained, out of total 407cases of In traumatic asphyxia only 3(0.74%) cases were reported out violent asphyxial deaths .Amongst all cases of hanging, of which 2 (66.67%) were accidental and only 1(33.33%) manner in both the sexes were predominantly suicidal in nature homicidal in nature. (Table No. 6) with only 1(0.49%) male case of accidental hanging and 2(0.98%) male cases of homicidal hanging were reported. In the present study of 205 cases of hanging according to area wise distribution of violent asphyxial deaths,78(38.05%) male In strangulation out of 70 cases, the manner of death was cases were from rural background as compared to 39(19.02%) predominantly homicidal in both sexes, however the trend was females and 51(24.88%) males were from urban area as more common among females with 40 (57.14%) cases as compared to 25(12.19%) females. While area wise status of compared to males with 29 (41.43%) cases. Only 1(1.43%) 11(5.34%) males and 1(0.49%) female cases could not be case of female accidental strangulation was recorded. No case established. of suicidal strangulation was reported in the post-mortem record of 10 years retrospective autopsy study of violent In present study of 70 cases of strangulation according to area wise distribution of violent asphyxial deaths, 14(20%) male

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cases were from rural background as compared to 15(21.43%) accounted for 3.98% cases which is almost equivalent to the female and 11(15.7%) male cases were from urban area as result of the other studies by Gargi et al (3.9%)5, Singh et al compared to 7(10%) females, while area status of 10(14.29%) (5.26%)8, Chaurasia et al (6.95%)12 and Patel et al (5.63%)15 . male and 13(18.57%) female cases could not be established. This difference in the incidence may be due to geographical In present study of 120 cases of drowning according to area variations in the population. In the present study among the wise distribution of violent asphyxial deaths, 57(47.50%) male violent asphyxia deaths encountered, hanging (50.37%) was cases were from rural background as compared to 7(5.83%) the most common method, followed by drowning (29.48%) females and 14(11.67%) males cases were from urban area as and least common was traumatic asphyxia (0.74%) which is compared to 4(3.33%) females, while area status of consistent with the studies by various authors like Chaurasia et 12 33(27.50%) male and 5(4.15%) female cases could not be al, in which they found that hanging (52.21%) was the most established. common method followed by drowning (55.02%) and least common was suffocation (0.55%), Reddy et al,13 in which they Area wise trend of rural population among both sexes was found that hanging (61.18%) was most common method of predominant as compared to urban in violent asphyxial deaths violent asphyxial deaths followed by drowning (31.96%) of hanging, strangulation and drowning cases. In cases of followed by strangulation (4.33%), Gurudatt et al11 in which throttling (5), suffocation (4) and traumatic asphyxia (3), no they found that hanging (61.16%) was most common method clear trend was observed as far as area wise distribution was followed by drowning (28.15%), Kumar et al16, in which they concerned. (Table No. 7) found that hanging (80.60%) followed by drowning (8.3%) DISCUSSION followed by strangulation (5.5%) and least common was In the present study the incidence of violent asphyxial deaths traumatic asphyxia (2.8%). However the results are in contrast

Table 6 : Sexwise Distribution of Violent Asphyxial Deaths Based On Manner of Death Suicidal Accidental Homicidal Unascertained Total Type of asphyxial (n=28) (n=70) (n=81) (n=38) deaths Male Female Male Female Male Female Male Female No. % No. % No. % No. % No. % No. % No. % No. % No. % Hanging 136 66.34 66 32.20 1 0.49 0 0.00 2 0.97 0 0.00 0 0.00 0 0.00 205 50.37 Strangulation 0 0.00 0 0.00 0 0.00 1 0.49 29 14.15 40 19.51 0 0.00 0 0.00 70 17.20 Throttling 0 0.00 0 0.00 0 0.00 0 0.00 2 40 3 60.00 0 0.00 0 0.00 5 1.23 Traumatic asphyxia 0 0.00 0 0.00 1 33.33 1 33.3 1 33.33 0 0.00 0 0.00 0 0.00 3 0.74 Suffocation 0 0.00 0 0.00 2 50.00 0 0.00 1 25.00 1 25.00 0 0.00 0 0.00 4 0.98 Drowing 12 10 4 3.33 55 45.83 9 7.5 2 1.67 0 0.00 33 27.5 5 4.17 120 29.48 Total 148 36.36 70 17.20 59 14.49 11 2.70 37 9.09 44 10.81 33 8.12 5 1.23 407 100.00

Table 7 : Areawise Distribution of Violent Asphyxial Deaths Based On Methods of Asphyxiation Employed Rural Urban Unkown Total Type of asphyxial deaths Male Female Male Female Male Female No. % No. % No. % No. % No. % No. % No. % Hanging 78 38.05 39 19.02 51 24.88 25 12.19 11 5.34 1 0.49 205 50.37 Strangulation 14 20 15 21.43 11 15.72 7 10 10 14.29 13 18.57 70 17.20 Throttling 0 0.00 1 20 3 60 0 0.00 1 20 0 0.00 5 1.23 Traumatic asphyxia 1 33.33 1 33.33 1 33.33 0 0.00 0 0.00 0 0.00 3 0.74 Suffocation 1 25 1 25 2 50 0 0.00 0 0.00 0 0.00 4 0.98 Drowing 57 47.50 7 5.83 14 11.67 4 3.33 33 27.50 5 4.17 120 29.48 Total 151 37.10 64 15.72 82 20.14 36 8.85 55 13.51 19 4.67 407 100.00

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to two studies conducted by Gargi et al5and Singh et al8 in reported from rural area as compared to urban 27.76% and which drowning was found to be most common method with residence status of 18.18% cases were unknown. Male was incidence of 32.4% and 59.4 % respectively. The higher more in both rural 37.10% and urban 20.14% areas as incidence of hanging could be explained due to the painless compared to females which was 15.72% in rural and 8.85% in form of death and easy availability of ligature material urban areas. In hanging 57.07% cases were from rural area and amongst the house hold articles. 37.07% cases were from urban area and in strangulation In the present study it was observed that maximum (44.96%) 41.43% cases were recovered from rural area while 25.72% number of cases were in the age group of 21-30 years, followed cases from urban area. In drowning 53.33% cases were by 31 to 40 years age group (16.22%). Which coincides with recovered from rural area and 15% cases from urban areas, this 8 similar findings in the studies by Sharma et al10(57% in age correlates with the study of Singh et al in which they found that group of 21-30 years), Chaurasia et al12(35.79% in age group of more cases of violent asphyxial deaths were reported from 21-30 years), Reddy et al13(34.95% in age group of 21-30 rural areas (51.60%) as compared to urban (48.40%), while in years), Patel et al15(32.99% in age group of 21-31 years), drowning 59.09% cases were recovered from rural areas and in Kumar et al16(38.88% in age group of 21-30 years). The hanging 66.66% cases from urban area vulnerability of the young and productive age group depicts CONCLUSION : the stressful and ambiguous lifestyle. In violent asphyxial The objectives of the study were to access the profile of violent deaths there was male preponderance which comprised 68.06 asphyxial deaths, the methods of asphyxia employed, manner % while females were 31.94 %. The male to female ratio was of death and characteristics of wounds on the body in cases of found to be 2.13:1 which correlates with studies by various asphyxial deaths in Amritsar, Punjab. 407 cases of violent 5 8 13 authors Gargi et al, Singh et al, Reddy et al (1.4:1), Patel et asphyxial deaths were studied amongst the total 10217 cases. 15 16 10 9 al (1.69:1), Kumar et al (3:1), Sharma et al (2:1), Uzun I, Males and young population constituted the bulk. Violent 11 17 Gurudatt and Momonchand. This high incidence may be asphyxial deaths were more common in married as compared because males, being the breadwinner of the family are more to unmarried. Hanging was the most common method of exposed to stress, strain and occupational hazards compared to asphyxiation followed by drowning, strangulation, throttling, females, which is similar to the observations reported in suffocation and traumatic asphyxia respectively. The most different above cited studies. common manner of death encountered was suicide in hanging, A view into the marital status of the victims revealed that homicide in strangulation and throttling while accident in higher incidence was observed in married individuals with traumatic asphyxia and drowning. 57.25% than unmarried persons which accounted for 24.57%, REFERENCES : which correlates with the study of Ajay Kumar et al16 in which 1. Dolinak D, Matshes E, Lew EO. Forensic Pathology : the incidence among males was 63.9 % and females was Principles and Practice. Elsevier; 2005; pp. 201. 36.1%. The reason could be attributed to the fact that the amount of stress carried by the married people in their day to 2. Reddy KSN. The Essentials of Forensic Medicine and day life is more than the unmarried males or females which Toxicology. 28th ed. Hyderabad: Om Sai graphics. 2009; makes them more vulnerable. pp. 299-333. In the present study, the commonest manner of asphyxial 3. Simpson.Asphyxia. Simpson's Forensic Medicine. 12th deaths was suicidal in nature (53.56%) followed by homicidal ed. London: Arnold, Odder Headline Group. 2003; pp. 92- (19.90%) and then accidental in nature which amounted for 6. 17.20% of the cases while manner was unascertained in 9.34% 4. Subramanyam BV. Modi's Medical Jurisprudence and cases. Amongst all cases of hanging the manner of death in Toxicology.22ndedn.Death from asphyxia. Butter worth both the sexes were predominantly (98.53%) suicidal in nature Ind. Pvt. Limited, New Delhi. 1999; pp. 252. followed by homicidal and accidental. While in strangulation 5. Gargi J, Gorea RK,Chanana A, Mann G. Violent the manner was homicidal in both sexes (98.57%), however Asphyxial Deaths-A six years study. Journal of Indian the trend was more common in females as compared to males. Academy of Forensic Med. 1992 ;171-6. In drowning accidental manner (55.33%) of death was more 6. Meel BL. A study on the incidence of suicide by hanging common followed by suicidal and in 31.67% cases manner in the sub- region of Transkei, South Africa. J Clin was unascertained. This correlates with studies of Gargi et al5, Forensic Med. 2003;10 (3):153 7. Meel6 , Maxeiner et al7 ,Tirmizi et al14, Kumar et al16. 7. Maxeiner H, Bockholdt B. Homicidal and suicidal Most of the cases 52.83% of violent asphyxial deaths were

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ligature strangulation-a comparison of the post mortem findings. Forensic Sci Int 2003;137(1):60-6. 8. Singh A, Singh D. Comparative study of Hanging and Strangulation cases in Northeast and Northwest Regions of Punjab. J Punjab Acad Forensic Med Toxicology. 2009;9(1):6-8. 9. Uzun I, Buyuk Y, Gupinar K. Suicidal hanging: Fatalities in Istanbul retrospective analysis of 761 autopsy cases. J Forensic Leg Med 2007;14(7):406-9. 10. Sharma BR, Harish D, Sharma A, Sharma S, Singh H. Injuries to neck structures in deaths due to constriction of neck, with a special reference to hanging.Journal of Forensic and Legal Medicine. 2008;15(5):298-305. 11. Gurudut KS, Kumar AS, Gouda HS. Analysis of fatal cases of mechanical asphyxia at Belgaum, Karnataka. Journal of Forensic Medicine & Toxicology. 2011;28:51- 3. 12. Chaurasia N, Pandey SK, Mishra A. An epidemiological study of violent asphyxial death in Varanasi region (India) a killing tool. J Forensic Res. 2012;3(10):174. 13. Srinivasa PR, Kumar R, Rudramurthy R. Asphyxial death at district hospital, Tumkur a retrospective study. J Indian Acad Forensic Med. 2012;34(2).146-7 14. Tirmizi SZ, Mirza FH, Paryar HA. Medicolegal investigation of violent asphyxial deaths - an autopsy based study. J of the Dow University of Health Sciences Karachi.2012;6(3):86-90. 15. Patel AP, Bhoot RR, Patel DJ, Patel KA. Study of violent asphyxial death. International Journal of Medical Toxicology and Forensic Medicine. 2013;3(2):48-57. 16. Kumar AS, Chandan V, Rudresh YC, Govindaraju HC, Gouda S. Study of violent asphyxial deaths in Chitradurga district of Karnataka. IJBAR. 2013;4(12):868-71. 17. Momonchand A, Devi TM, Fimate L. Violent asphyxial deaths in Imphal. Journal of Forensic Medicine & Toxicology.1998;15(1):60-4.

31 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI: 10.5958/0974-083X.2020.00005.9 Original Research Paper Persistent Metopic Suture in Adult Cadaveric Dry Skulls of Coastal Karnataka 1. Lydia S. Andrade, Assistant Professor* 2. Chandni Gupta, Associate Professor* 3. Sneha Guruprasad Kalthur, Professor & Head* *Department of Anatomy, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India – 576104

ABSTRACT : Introduction: During the fetal life, a frontal suture separates two frontal bones. This suture usually obliterates by 8th year after birth. However, in a few individuals it may persist. This persistent suture, in between two bones is known as metopic suture. Remnants of metopic suture could be found at the region of the glabella. It has been noted that these remnants of metopic suture, which may mimic a skull fracture, could mislead a radiologist, a neurosurgeon and also an inexperienced forensic expert. Interestingly, anthropologists, have studied the persistence of this suture in various races. Objectives: Therefore, the present study on adult dry skulls of coastal Karnataka was conducted to know the incidence of persistence of various forms of metopic suture. Methods: Seventy adult skulls of unknown sex were taken for the study. Results: Thirty-nine skulls showed absence of metopic suture, one skull showed complete metopic suture, six skulls showed V- shaped, nine skulls showed U-shaped, four skulls showed Y-shaped, eleven skulls showed a linear suture. Conclusion: These findings show the incidence of metopic suture in the Dravidian race that belongs to the south Indian region. Thus the findings of the present study would add on to the existing knowledge and thus would be of great importance to the forensic experts.

Corresponding Author : Article History: Dr. Lydia S. Andrade, Received: 30April 2019 Assistant Professor, Received in revised form: 7 May 2019 Accepted on: 24 June 2019 Department of Anatomy, Kasturba Medical College, Manipal, Available online: 31 December 2019 Manipal Academy of Higher Education, Manipal, Karnataka, India – 576104 Contact : +91 9845862142 Email : [email protected]

KEYWORDS : Frontal Bone, Nasion, Forensic Anthropology, Human Race

INTRODUCTION : The skull, consists of various bones, downwards and thus the suture would be obliterated. However, which are united by means of fibrous joints called sutures. The some part of the suture would persist either at the nasion or the frontal bone, which is a single bone in the adult skull, forms a bregma. This finding, in an adult skull is known as incomplete common platform for both the face and the scalp. It also metopic suture. However, in a few individuals, the suture protects the important areas concerned with emotions and would persist from nasion to bregma, which is known as judgement, of the frontal lobe of the cerebrum. It articulates complete metopic suture/ metopism[2]. This finding, could with two parietal bones posteriorly at the coronal suture mislead the surgeons or orthopedicians in differentiating (forming bregma) and with the nasal bones, in front, at the between a skull fracture in the patients with head injury[3]. It is frontonasal suture (forming nasion). On the outer surface of said that there would be two frontal bones even after birth and the squamous part of the frontal bone, a surface elevation, the the fusion would be completed by eighth year after birth[4]. glabella, is observed in the centre above the nasion. Although studies on the persistent metopic suture have been Interestingly, in the fetal life, instead of a single frontal bone, conducted in the past, in the present study, an attempt has been two frontal bones develop and these unite by a frontal suture. made to find out the persistence of metopic suture (complete or The frontal bone develops from the mesenchyme derived from incomplete) in the cadaveric dry skulls belonging to coastal the neural crest cells[1]. Soon after, the ossification process Karnataka. begins as early as two months of fetal life (from two primary MATERIALS AND METHOD : Seventy dry adult centres) at around the centre and proceeds upwards and cadaveric skulls of unknown sex belonging to coastal

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Karnataka were taken for the study. The criteria of exclusion Based on the degree of obliteration of the frontal/ metopic were applied for those skulls which were damaged and showed suture, even after the said age of an individual (eight any external deformity. The frontal bone of each skull was years),traces of the suture would be left behind anywhere along examined to check the occurrence of metopic suture. The ones the middle of the frontal bone extending from the nasion to the with metopic suture were separated into two categories – bregma [4,11]. In view of this, several authors in the past, have complete and incomplete skulls. The incomplete ones were reported the incidence of metopic suture (complete or further categorized based on the shape of the suture. The incomplete) in the adult skull. The findings of metopic suture incidence of metopism and incomplete metopic sutures were differ in different human races as shown in table 1. calculated and compared with the previous studies. Table 1. Incidence of persistent metopic suture in different RESULTS : Out of the seventy skulls, metopic suture was absent in thirty- Name of the author Year Human Race %age nine skulls (55.71%) (Fig.1A). The metopic suture was present Bryce [12] Mongoloids 5.1 in thirty-one (44.29%) skulls. Out of the thirty-one skulls, nine 1915 Europeans 8.7 skulls (12.86%) showed U-shaped metopic suture (Fig.1B). Scottish 9.5 Six skulls (8.57%) showed V-shaped metopic suture (Fig.1C). Negroes 1.2 Three skulls (4.28%) showed Y-shaped metopic suture Australian 1 (Fig.1D). Eleven skulls (15.71%) showed a linear metopic Breathnach [7] Yellow 4-5 suture (Fig.1E). One skull (1.43%) showed crisscross/zigzag 1958 Europeans 7-8 metopic suture (Fig.1F) and one skull (1.43%) showed complete metopic suture (Fig.1G). Africans 1 Woo [13] 1949 Mongoloids 10 Fakhruddin&Bhalerao [14] 1967 Indian 2 Linc& Fleischman [15] 1969 Czech 11 Das et al [16] 1973 Indian 27.98 1A 1B 1C 1D Agarwal et al [17] 1979 Indian 40.83 Ajmani et al [18] 1983 Nigerians 34.97 del Sol et al [19] 1989 Brazilian 28.75 Baaten [20] 2003 Lebanese 1.75 Castilho et al [21] 2006 Brazilian 32.4 1E 1F 1G Murlimanju et al [22] 2011 Indian 64.1

DISCUSSION : Based on the incidents of metopic suture in table 1., our study Metopic suture, is said to be an anterior extension of the showed an incident of 44.29% of persistent metopic suture sagittal suture, extending ventrally form the anterior fontanelle (complete or incomplete). Our findings nearly coincide with [17] to the nasion[5]. The fibrous tissue and the mesenchymal cells the findings of Agarwal et al . present in the sagittal suture, are responsible for the growth of Interestingly, several studies conducted on skulls belonging to the frontal bone, due to which the metopic suture could be various parts of India (as mentioned in their manuscripts) have gradually obliterated and also could increase the width of the also shown that the incidence of persistent metopic suture skull, which in turn, could increase the volume of the anterior (complete or incomplete) varies as shown in table 2. cranial fossa[6, 7]. It is said that, in humans, the obliteration of metopic suture Table 2. Incidence of persistent metopic suture in India [5] could begin as early as 1 year to 8 years after birth . However, Name of the author Year Parts of India %age in a few animals like monkeys, the metopic suture obliterates Rau [23] 1934 Dravidians of Madras 4 [8] during the fall of the deciduous teeth . It is mandatory for a Inderjit & Shah [24] 1948 Punjabi 5 metopic suture to persist even after birth since, the premature Dixit & Shukla [25] 1968 Uttar Pradesh 2.53 obliteration would lead to trigonocephaly, in which the skull Anjoo et al [26] 2010 North India 18.04 could appear as a wedge skull [9]. But, the presence or absence [5, 10] Hemalatha& Rao [27] 2016 Andhra Pradesh 6.66 of the metopic suture, does not affect the shape of the skull . Present study 2019 Coastal Karnataka 44.29

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As per the results tabulated in table 2., the present study Table 3. Reasons for the persistent metopic suture in the showed a very high incidence of persistent metopic suture adult skulls when compared to other parts of India. Views/ Reasons/ Factors for persistent metopic suture in Authors Year The above incidences of persistent metopic suture (complete the adult skulls or incomplete) may be attributed to various reasons postulated Ethnicity Berry & Berry [28] 1967 by several authors in the past as shown in table 3. Higher incidence in males than in females Various shapes of the persistent metopic suture have been Berry & Berry [28] 1967 identified by authors previously as shown in table 4. Cranial bones abnormalities Heredity, atavism Almost all the studies showed a very high incident of linear- Stenocrotaphia, plagiocephaly, type of incomplete metopic suture. The findings of the present scaphocephaly Mechanical del Sol et al [19] 1989 study also infer the same. The next, most commonly occurring causes & hormonal dysfunction incomplete metopic suture was V-shaped, followed by U- Persistence is associated with Hanihara et al [29] geographic variations 2001 shaped suture according to all the other authors. However, in Higher incidence in rural the present study, the next, most commonly occurring suture is population than urban Baaten et al [20] 2003 U-shaped (12.86%), followed by V-shaped suture (8.57%). population Apart from the shapes of incomplete metopic suture shown in Higher incidence in the population belonging to Anjoo et al [26] table 4., several other shapes like 'n-', 'H-', 'inverted Y-' shapes temperate climate than those 2010 and radiating types have also been reported[17, 18, 19]. None of living in warmer climate these types were observed in the present study. Higher incidence in people Persistent metopic suture, in the adults, has been of belonging to low-socioeconomic groups than the high- Masih et al [30] 2013 tremendous clinical importance especially for the clinicians socioeconomic groups due and the radiologists. Incidents of road traffic accidents are on a to dietary habits and rise and hence the persistent metopic suture could be nutrition effects misinterpreted by radiologists as a fracture of the frontal bone Persistence is associated Guerram A with frontal air sinus et al [31] 2014 in the victims of road traffic accidents. Therefore, predisposed abnormalities knowledge of the persistent metopic suture is of utmost Persistence could be attributed importance in order to distinguish between a fracture and a to active expression of metopic suture. It is a known fact that this suture can be clearly cytokines during cranial fusion Vikram et al [32] 2016 identified in an Anteroposterior view of the skull and hence & resorption of chondroidal tissue could differentiate between the suture and a fracture. The knowledge of many such sutural configurations is also higher incidence of persistent metopic suture[19, 21, 22]. However, necessary for a neurosurgeon prior to any cranial surgery. the skulls, in the present study, were not separated into males Several studies have shown the presence of metopic suture and females. The mean suture length of the metopic sutures has separately in male and female skulls based on the been calculated by authors in the earlier studies[5]. In the present anthropometric findings, in which the female skulls exhibited study, the mean of the suture has not been calculated.

Table 4 : Incidence of different shapes of persistent metopic suture Complete / Incomplete suture shape (percentage) Authors Year Human race Metopism /Region (percentage) U V Y H Linear Double Inderjit& Shah [24] 1948 Punjabi ------11.25 1.25 1.25 ------Das et al [16] 1973 Indian 3.31 1.01 1.93 0.28 ---- 17.57 ---- Agarwal et al [17] 1979 Indian 2.66 ---- 3.25 ------23.12 ---- Ajmani et al [18] 1983 Nigerian ------0.49 ------24.27 ---- Castilho et al [21] 2006 Brazilian ------17.39 ------69.57 13.04 Murlimanju et al [22] 2011 Indian 1.2 ---- 21 ------22.2 19.7 Jitendra et al 2014 Indian 2.5 ---- 2.5 ------11.25 ---- Present study 2019 Coastal 1.43 12.86 8.57 4.28 ---- 15.71 1.43 Karnataka (crisscross/zigzag)

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Castilho et al, 2006[21], divided the skulls based on the Association des Anatomistes) 1969; 142:1196-1202. anthropometric type of skulls and concluded that the 16. Das AC, Saxena RC, Beg MAQ. Incidence of Metopic suture in brachicraniac skulls showed higher incidence of persistent U.P. subjects. J AnatSoc India. 1973; 22:140-143 metopic suture than the mesocraniac and dolichocraniac 17. Agarwal SK, Malhotra VK, Tewari SP. Incidence of the metopic suture in adult Indian crania. ActaAnat (Basel). 1979; 105:469- skulls. However, it is said the persistence of metopic suture 474. does not have any adverse effect on the anthropometric shape 18. Ajmani ML, Mittal RK, Jain SP. Incidence of the metopic suture of the skull due to the fact that the dolichocephalic heads were in adult Nigerian skulls. J Anat. 1983; 137:177-183. almost the same in both the individuals with and without a 19. del Sol M, Binvignat O, Bolini PD, Prates JC.Metopism in persistent metopic suture. It has also been observed that there Brazilians. Rev Paul Med. 1989; 107:105-107. was no significant difference in the forehead breadths between 20. Baaten PJ, Haddad M, Abi-Nader K, Abi-Ghosn A, Al-Kutoubi the metopic and non-metopic individuals[10,34]. But, in the A, Jurjus AR. Incidence of metopism in the Lebanese present study, the skulls were not segregated into population. Clin Anat. 2003; 6:148-151. anthropometric type. 21. Castilho SMA, Oda YJ, Santana GDM.Metopism in adult skulls from Southern Brazil.Int J Morphol. 2006; 24:61-66. CONCLUSION : 22. Murlimanju BV, Prabhu LV, Pai MM, Goveas AA, Dhananjaya The presence of persistent metopic suture in the skulls KVN, Somesh MS. Median Frontal sutures – ıncidence, belonging to coastal Karnataka is of great clinical significance Morphology and Their surgical, Radiological ımportance. Turk for the clinicians and also for the anthropometrists for Neurosurg. 2011; 21(4): 489-493. 23. Rau RK. Skull showing absence of Coronal suture. J Anat. 1934; segregating the skulls into various regions. 69:109-112. REFERENCES : 24. Inderjit, Shah MA. Incidence of frontal or metopic suture 1. Kirby ML, Waldo KL. Role of neural crest in congenital heart amongst Punjabi adults. I M Gazette. 1948; 83:507-508. disease. Circulation. 1990; 82(2): 332-340. 25. Dixit CS, Shukla PL. Metopic suture in Human Crania. J 2. Bilodi AK, Agrawal BK, Mane S, Kumar A. A study of metopic AnatSoc India. 1968; 17:47. sutures in human skulls. Kathmandu Univ Med J. 2003; 2:96-99. 26. Anjoo Yadav, Vinod Kumar, Srivastava RK. Study of Metopic 3. Bademci G, Kendi T, Agalar F. Persistent metopic suture can Suture in the Adult Human Skulls of North India. J AnatSoc mimic the skull fractures in the emergency setting? India. 2010; 59(2): 144-244. Neurocirugia. 2007; 18: 238-240. 27. Hemalatha G, Rao MS. Persistent Metopic Suture in Adult 4. Moore, Dalley, Agur. Clinically Oriented Anatomy. Wolters Skulls of Andhra Pradesh. IOSR Journal of Dental and Medical Kluwer, Lippincott Williams & Wilkins. Sciences.2016; 15(12):4-6. 5. Skrzat J, Walocha J, Zawilinski J. A note on the morphology of 28. Berry CA, Berry RJ. Epigenetic variation in the human cranium. the metopic suture in the human skull. Folia Morphol. 2004; J Anat. 1967; 101:361-379. 63:481-484. 29. Hanihara T, Ishida H. Frequency variations of discrete cranial 6. Pritchard JJ, Scott JH, Girgis FG. The structure and traits in major human populations. II. Hypostotic variations. J development of cranial and facial sutures. J Anat.1956; 90:73- Anat. 2001; 198:707-725. 86. 30. Masih WF, Gupta S, Saraswat PK, Aggarwal SK. Autopsy study 7. Breathnach AS. Frazer's anatomy of the human skeleton. of metopic suture incidence in human skulls in western London: Churchill Livingstone; 1965. Rajasthan. Natl J Med Res.2013; 3(1):63-65. 8. Chopra SRK. The cranial suture closure in monkeys. Proc. Zool. 31. Guerram A, Le Minor JM, Renger S, Bierry G. Brief Soc. Lond,1957; 128:67-112. communication: The size of the human frontal sinuses in adults 9. Khanna PC, Thapa MM, Iyer RS, Prasad SS. Pictorial essay: presenting complete persistence of the metopic suture. Am J The many faces of craniosynostosis. Indian J Radiol PhysAnthropol. 2014; 154: 621-627. Imaging.2011; 21:49-56. 32. Vikram S, Padubidri JR, Dutt AR. A rare case of persistent 10. Jit I,Banga N.Metopism in north-west population of India. metopic suture in an elderly individual: Incidental autopsy JAnatSocIndia. 1988; 37:45-60. finding with clinical implications. Arch Med Health Sci. 2016; 2: 11. Romanes GJ. In Cunningham Textbook of Anatomy. London: 61. Oxford University Press; 1964. 33. BilodiAK, Agrawal BK, Mane S, Kumar A. A study of metopic 12. Bryce TH. Osteology and Arthrology. In Quain's elements of sutures in human skulls. Kathmandu Univ Med J. 2003; 2:96-99. anatomy. London: Longmans Green; 1915. 34. Torgersen J. The developmental genetics and evolutionary 13. Woo JK. Ossification and growth of the human maxilla, pre- meaning of the metopic suture. Am J Phys Anthrop.1951; 9:193- maxilla and palate bone. Anat Rec. 1949; 105:737-762. 210. 14. Fakhruddin S,Bhalerao UK. Interparietal Bone in Three Pieces- A case report. J AnatSoc India. 1967; 16:146-147 15. Linc R, Fleischman J. Incidence of Metopism in the Czech population and its causes. C R Ass Anat. (Comptesrendusdel'

35 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI: 10.5958/0974-083X.2020.00006.0 Original Research Paper A Comparative Study of Hanging and Strangulation Cases in Agra Region 1. Tarun Kumar Singh, Assistant Professor, Department of Forensic Medicine, SRMSIMS, Bareilly 2. Ajay Agarwal, Professor & Head, Department of Forensic Medicine, S.N. Medical College, Agra 3. Jaswinder Singh, Associate Professor & Head, Department of Forensic Medicine, SRMSIMS, Bareilly 4. Vijay Kumar, Assistant Professor, Department of Forensic Medicine, SRMSIMS, Bareilly 5. Richa Gupta, Assistant Professor, Department of Forensic Medicine, S.N. Medical College, Agra

ABSTRACT : Introduction : In our country, we frequently come across many cases of deaths due to hanging and strangulation which may be suicidal or homicidal. Material and Method: In this study 272 deaths caused by hanging and strangulation were analyzed out of 3224 autopsies conducted in mortuary of S. N. Medical College, Agra from March 2015 to August 2016 for the period of one and half years. Obtained data is analyzed and reviewed with respect to cause, manner, ligature material used and comparative postmortem findings of hanging and ligature strangulation. Results : Out of 272 cases 93.4 % (254 cases) deaths were due to hanging while 6.6 % (18 cases) were due to strangulation. In most cases (193 cases of hanging and 5 cases of strangulation) soft ligature material was used while hard ligature material was used in rest of the cases (61 cases of hanging and 13 cases of strangulation). Most hanging cases (98 %) were suicidal while all strangulation cases were homicidal. Postmortem findings are divided into external and internal and studied comparatively for hanging and strangulation. Conclusion: In this study, suicidal hanging and homicidal strangulation seems to be major manner of deaths. Both these indicate frustration and rage respectively on part of population resulting in increased violence in society which needs to be addressed. On basis of postmortem findings hanging and strangulation can be differentiated in majority of cases.

Corresponding Author : Article History: Dr. Jaswinder Singh, Received: 27 April 2019 Received in revised form: 18 June 2019 Associate Professor & Head, Accepted on: 18 June 2019 Department of Forensic Medicine, SRMSIMS, Bareilly Available online: 31 December 2019 Contact : +91 90458-60105 Email: [email protected]

KEYWORDS : Asphyxia, Hanging, Strangulation, Ligature Mark, Hyoid Fracture

INTRODUCTION : many cases. Therefore, in such circumstances careful and Violent asphyxial deaths constitute a major proportion of proper assessment of different post-mortem findings is unnatural deaths in our country among which hanging and necessary. strangulation are frequently encountered in day to day In this study an attempt has been made to analyze various types autopsies conducted by forensic experts. Hanging is that form of ligature material used and postmortem findings associated of asphyxia which is caused by suspension of the body by a with hanging and strangulation cases in Agra region so that ligature which encircles the neck, the constricting force being further knowledge will be added into the existing knowledge the weight of the body1. According to NCRB-2013 statistics, related to the subject with the view to assist the process of “among the methods chosen for suicidal purposes, Hanging, is crime investigation and proper utilization of resources. most common (39.8%). For Homicidal purposes, MATERIALS AND METHOD : Asphyxiation by Strangulation & Smothering is 3rd most The present study was carried out in the department of commonly chosen method2. Hanging and strangulation can be Forensic Medicine and Toxicology, S. N. Medical College, distinguished easily when presented with typical features. Agra for a period of one and half year from 1st March 2015 to However, in reality typical features are rarely present together. 31st August 2016. Total of 3224 autopsies were carried out To differentiate deaths resulting from hanging and during this period. Out of them 272 cases were of hanging and strangulation, ligature mark at the neck is considered to be strangulation. Each and every case examined as per decisive factor. But the magnitude of pressure on the neck predesigned and pretested proforma, the data is then often results in variable findings which can create doubt in

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scrutinized with the help of statistician and presented in demonstrated that homicidal hangings are virtually non- different tables to highlight the facts from various aspects of existent. However, study by Gambhir Singh et al9 had study. In present study cause, manner, ligature material used demonstrated homicidal hanging. and comparative postmortem findings in cases of hanging and In 193 cases of hanging (76 %) and 5 cases of strangulation strangulation were studied. (27.8 %) soft ligature material is used while hard ligature RESULT AND DISCUSSION : material is used in 61 cases of hanging (24 %) and 13 cases of Proportion of deaths caused by hanging and strangulation were strangulation (72.2 %). (Table 4) The use of ligature material 10 8.4 % (272 cases) of total 3224 autopsies in the present study. in study by Sharma B R et al was 56.4 % Soft material and 11 (Table 1) This proportion was lower than the studies by Gupta 43.6 % Hard material; in study by Naik S K et al was 54 % Ved Prakash, Mahanta P (9.12 %)3, but higher than studies by Soft material and 46 % Hard material; study by Vijaynath V et 12 Chaurasia N et al (3.78 %)4and by Patel Ankur P et al(4.82 %)5. al was 70 % Soft material and 30 % Hard material. The Further, this proportion is similar to the studies by Mohammed different result in different studies may be because of the fact Musaib M. Shaikh et al (8.6 %)6. The reason for variation in the that suicide is an impulsive act and for that the victim uses any proportion may be due to cultural and ethnic difference. material which is available nearby at that particular point of time. Table 1: Proportion of Hanging and Ligature Strangulation Cases Table 4: Ligature Material Used for hanging/ strangulation Total No. of autopsies from March 2015 to August 2016 3224 Ligature Material Hanging Strangulation Total No. of Hanging and Ligature Strangulation cases 272 N % N % N % Percentage of Hanging and Ligature Strangulation cases 8.4 Soft (e.g. Saree, dupatta, bed 193 76 5 27.8 198 72.8 sheets hands etc.) Out of 272 cases 93.4 % (254 cases) deaths were due to hanging while 6.6 % (18 cases) were due to strangulation. Hard (e.g. Rope, wire etc.) 61 24 13 72.2 74 27.2 (Table 2) Incidence rate of hanging in study by Patel Ankur P et al was 82.48%, by Gurudut KS, et al7was 61.16%, by Azmak Total 254 100 18 100 272 100 D8was 41.8%, by Gupta Ved Prakash, Mahanta P3was 78.12%, In all the 272 cases under present study, decomposition has not by Chaurasia N et al4 was 52.2 % and by Mohammed Musaib advanced to mask the cardinal signs of asphyxia. So, cyanosis M. Shaikh et al6 was 95.6 %. (evident as bluish discoloration of nails and lips), petechial Table 2: Case Wise Proportion of Cases hemorrhages, visceral congestion and dark fluid blood were Cause of Death N % noticed in 100% cases as also by Gambhir Singh et al9 and 13 Hanging 254 93.4 Sarangi et al. Strangulation 18 6.6 External Postmortem findings of Hanging / Strangulation Total 272 100 (Table 5) reveals that the mark on the neck was obliquely placed in all the cases of hanging and transversely placed in all 249 hanging cases (98 %) were suicidal, 2 cases were the cases of strangulation. homicidal (0.8 %) and 3 cases were accidental (1.2 %) while all Place of ligature mark at neck was below thyroid in all cases of strangulation cases were homicidal. (Table 3) strangulation but in hanging cases it is above thyroid in 16 Table 3: Manner of Death (6.3%) cases and at & above thyroid in 238(93.7%) cases. Cause of Suicidal HomicidalAccidental Total Congestion of face is present in all cases of strangulation and Death N % N % N % N % 197(77.6%) cases of hanging. Hanging 249 98 2 0.8 3 1.2 254 100 Dribbling of saliva is considered an important finding of ante Strangulation 00 00 18 100 0 0 18 100 mortem hanging as secretion of saliva being a vital function Total 249 91.5 20 7.4 3 1.1 272 100 which cannot occur after death, was recorded in 173 out of 254 cases (68.1%) of hanging whereas Vijaynath V et al12found it in It is considered that in hanging manner of death is mostly only 31.93% cases. However, these findings are consistent suicidal and in strangulation it is mostly homicidal in nature. with findings of Patel Ankur P et al5 (228 out of 320 cases Uncommonly accidental hanging does occur however forming 71.25%). homicidal hangings are very rare. Despite some case reports of “La facie sympathique” originally described by Etienne homicidal hangings, retrospective studies by Azmak D8 have

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Martin (1950) cited by Polson and Gee was not seen in any of Amit Yadav et al 18 was 15 % the cases under present study.It might be due to manual Neck muscle contusion was present in 17(6.7%) cases of alteration by relatives or police at the time of inquest hanging and all cases of strangulation. These findings are preparation. consistent with findings of Patel Ankur P et al5(6.25%) but in 12 Table 5: External Postmortem findings of Hanging / contrast to the findings of Vijaynath V et al (23.52%). Strangulation Intimal tear of carotid artery was present in 24(9.4%) cases of External Findings Hanging Strangulation hanging. N % N % Table 6: Internal postmortem findings of Hanging/ Strangulation Placement of Oblique 254 100 00 00 Internal findings Hanging Strangulation ligature Mark Transverse 00 00 18 100 Above Thyroid 16 6.3 00 00 N % N % Sub- Place of ligature At & above thyroid 00 White glistening 254 100 00 00 mark at neck 238 93.7 00 cutaneous Below thyroid 00 00 18 100 tissue Contused 00 00 18 100 Fracture of Thyroid Congestion of Face 197 77.6 18 100 00 00 7 38.9 Fracture of Hyoid Dribbling of Saliva 173 68.1 00 00 20 7.9 00 00 La facie sympathique 00 00 00 00 Neck muscle contusion 17 6.7 18 100 Intimal tear of carotid artery 9.4 Postmortem Typical 53 20.9 00 00 24 00 00 lividity On back 201 79.1 18 100 CONCLUSION : Ecchymosis along edge of mark 49 19.3 18 100 A detailed and careful forensic post mortem examination is of Discharge of Semen 37 14.6 00 00 great importance to ascertain that death is caused by hanging or Discharge of Urine/ faeces 32 12.6 00 00 strangulation. However, the frequency and distribution of Struggle marks 00 00 18 100 injuries to the internal neck structures caused by hanging and strangulation are not forth coming on multiple occasions. Post Post mortem Lividity in hanging was typical in 53(20.9%) mortem findings in cases of hanging and strangulation like cases and on back in 201(79.1%) cases. In strangulation, it was involuntary discharge of urine/fecal matter/semen, fracture of on back in all cases. hyoid bone/thyroid cartilage are non-specific and vary depending upon type of ligature material, force applied on Ecchymosis along edge of ligature mark is present in all cases neck and its duration. In doubtful cases forensic expert of strangulation but only in 49(19.3%) cases of hanging. conducting autopsy must give final opinion after considering Discharge of semen was present in 37(14.6%) cases and all available options including autopsy findings, circumstantial discharge of urine/faeces in 32(12.6%) cases of hanging. evidence and crime scene investigation. Struggle marks were present in all cases of strangulation. These were not present in any case of hanging. REFERENCES : Internal Postmortem findings of Hanging / Strangulation 1. Reddy K.S.N. Mechanical Asphyxia', The Essentials of (Table 6) reveals that in all cases of hanging the subcutaneous Forensic Medicine and Toxicology, 2017, 34th ed, p315 tissue below the mark was white glistening because of 2. Accidental& Suicidal Deaths in India-2013 NCRB. continuous pressure of ligature but contused in all cases of Ministry of Home Affairs. Govt. of India. Accessed strangulation. through website http://ncrb.gov.in None of the cases of hanging under present study showed 3. Gupta Ved Prakash, Mahanta P.A Statistical Analysis of fracture of thyroid cartilage but it was present in 7(38.9%) Asphyxial Death Cases in Medico-Legal Autopsy. cases of strangulation. IJHRMLP, 2016;2 (2): 86-9. Fracture of hyoid bone was present in 20 (7.9%) cases of 4. Chaurasia N, Pandey SK, Mishra A. An Epidemiological hanging but absent in all cases of strangulation. Fracture of Study of Violent Asphyxial Death in Varanasi Region hyoid in hanging in studies by Sarangi et al13 was 9.4 %, (India) a Killing Tool. J Forensic Res 2012 3:174. 14 15 Chormunge Patil et al was 7.14%, Tripude B H et al was 5. Patel-Ankur P, Bhoot-Rajesh R, Patel-Dhaval J, Patel 16 17 64.51 %, Sheikh M I. et al was 5.08 %, Meera et al was 3.57 Khushbu A. Study of Violent Asphyxial Death. 6 %, Mohammed Musaib M. Shaikh et al was 11.63 % and Dr. International Journal of Medical Toxicology and Forensic

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Medicine. 2013; 3(2): 48-57. 6. Mohammed Musaib M. Shaikh, H. J. Chotaliya, A.D. Modi, A. P. Parmar, S. D. Kalele A Study of Gross Postmortem Findings in Cases of Hanging and Ligature Strangulation; J Indian Acad Forensic Med. 2013;35(1):63-5. 7. GurudutKS, AjaykumarS, HareeshSGouda, Analysis of Fatal Cases of Mechanical Asphyxia at Belgaum, Karnataka Journal of Forensic Medicine & Toxicology.2011;28:51-53. 8. AzmakD. Asphyxial deaths: a retrospective study and review of the literature. Am J Forensic Med Pathol. 2006; 27(2):134-44. 9. Singh Gambhir O. A study of violent mechanical asphyxial deaths in homicide; Journal of Forensic Medicine and Toxicology. 2008;25(2):34-35. 10. Sharma BR, Harish D, Sharma A, Sharma S, Singh H. Injuries to neck structures in deaths due to constriction of neck, with a special reference to hanging. J Forensic Leg Med. 2008;5(5):298-305. 11. Naik S K. A study of fracture of hyoid bone in cases of asphyxial deaths resulting from constricting force around neck. Journal of Indian Academy of Forensic Medicine. 2005;27(3):149-153. 12. Vijaynath V, Anitha MR, Rajan K. A study of autopsy profile in cases of hanging. Journal of Forensic Medicine and Toxicology. 2009;26(1):34-36. 13. Sarangi M P. Ligature marks – in Forensic Pathologist’s Perspective. Journal of Forensic Medicine and Toxicology. 1998;15(1):99-102. 14. Chormunge P, Mahajan S. V, Bhusari P. A. Hanging vs. strangulation a comparative study. Journal of Forensic Medicine, Science and Law. 2011;20(2):1-5 15. Tripude B H, Murkey P N, Pawar V G, Shende S A. Profile of Hanging Cases on Autopsy at a Tertiary Care Hospital in Central India. Journal of Karnataka Medico-legal Society. 2010;19(2):3-7. 16. Sheikh M I, Agarwal S S. Medico-legal implications of hyoid bone fracture-a study paper. Journal of Indian Academy of Forensic Medicine. 2001;23(4):61 -3. 17. Meera T, Singh B K. Pattern of neck findings in suicidal hanging. Journal of Indian Academy of Forensic medicine. 2011;33(4):350-2. 18. Yadav A, Saxena D, Mishra P, Abhishek. International Journal of Medical and Health Research. 2018;4 (1):23-5.

39 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI: 10.5958/0974-083X.2020.00007.2 Original Research Paper Dactylographic Pattern in Relation to ABO, Rh Blood Group and Gender among Medical Students in Navi Mumbai 1. Amit Patil, Professor and Head, Department of Forensic Medicine, All India, Institute of Medical Sciences, Patna, Bihar 2. Swati Sonawane, Assistant Professor* 3. Somshekhar Sharma, Assistant Professor* *Department of Forensic Medicine and Toxicology, Dr. D.Y.Patil Medical College, Nerul, Navi Mumbai.

ABSTRACT : Introduction : Dactylography or the fingerprint system is based on the study of epidermal ridges and their configurations in the fingers, palms and soles. The chances of two persons having identical finger prints is more than one in 64 thousand millions. The combined effect of heredity and environment arbitrates the pattern of ridges. Methodology : This study was carried out in the Department of Forensic Medicine and Toxicology, Dr. D Y Patil Medical College, Nerul, Navi Mumbai during the period 2017-2018. 200 studentsbelonging to the age group 17-22 years of known blood group were randomly selected for the study with the objective of studying the pattern of finger prints on all the fingers of both hands and their association with blood groups. Results an Conclusions : It was concluded that there is indeed a relationship between blood groups and fingerprints, however no gender related differences were observed.

Corresponding Author : Article History: Dr Swati Sonawane Received: 5 March 2019 Assistant Professor, Received in revised form: 24 July 2019 Accepted on: 28 July 2019 Department of Forensic Medicine and Toxicology, Dr. D.Y. Available online: 31 December 2019 Patil Medical College, Nerul Navi Mumbai. Contact : +91 97682-08307 Email : [email protected]

KEYWORDS : Blood Groups, Dactylography, Medical Students,

INTRODUCTION: Aadhar. Fingerprint is the effective method of identification in Dermatoglyphics defined as the scientific study of natural general population. Fingerprints collected at a crime scene can occurring epidermal ridges and their configuration on the volar be used to identify suspects, victims and other persons who region of digits, palms, and soles apart from flexion crease and touched the surface, fingerprint scans can be used to validate secondary folds.(1) The fingerprint is an impression of the electronic registration, cashless catering and library access (4) friction ridges of all part of finger. A friction ridge is a raised especially in schools and colleges . section of the epidermis on the digits or on the palmar and A variety of studies have been conducted to ascertain the plantar skin, composed of one or more connected ridge units of relationship between blood groups and fingerprints and have friction ridge skin. Finger-prints may be deposited in natural given varied results in different population groups. secretions from the eccrine glands present in friction ridge skin MATERIAL AND METHODS : or they may produce by ink or other contaminants transferred This prospective study was carried out among medical from the peaks of friction skin ridges to a relatively smooth students of D.Y.Patil Medical College, Nerul. Total 200 surface(2). students belonging to the age group 17- 22 years of MBBS Blood group systems were discovered way back in 1900 by 2017 batch participated in the study. Students with permanent Karl Landsteiner. Total 19 major groups have been identified scars on their fingers or thumbs, with any hand deformities due which vary in their frequency of spreading various races of to injury, birth defect or disease, those having worn mankind. Clinically, only 'ABO' and 'Rhesus' groups are of fingerprints, extra, webbed or bandaged fingers, were excluded major importance. 'ABO' system is further differentiated as A, from the study. Written Informed consent was taken from each B, AB, O blood group types according to presence of student prior to collection of fingerprints. corresponding antigen in plasma(3). Each subject was asked to wash their hands thoroughly with Finger prints are nowadays used for many purposes including

40 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI: 10.5958/0974-083X.2020.00007.2

soap and water and dry them using a towel. They were then patterns and ABO blood groups within respective subjects, asked to press rolled fingertip on the stamp pad and then to the loops had a higher percentage of occurrence as compared to paper to transfer the fingerprint impression. The same method whorls and arches. was repeated for all the fingers of both hands. In this way, the On the analysis by Chi –square test, it was revealed that there is plain fingerprints of all the ten digits were taken separately on a strong association between fingerprint patterns and ABO the respective blocks on the same sheet of paper. Care was blood groups (p<0.05) among the selected subject population. taken to avoid sliding of fingers to prevent smudging of the Table 2: Distribution of blood group with Rh factor print. The fingerprint patterns were studied with the help of a Blood Rh+ve Rh-ve Chi- Signifi- magnifying lens and identified as: Loops, Whorls and Arches group Total square P value based on the appearance of ridge lines. The gender and age, % value cance blood group of each subject was noted on a pre-structured A 55 09 64 format and fingerprint patterns were tabulated in MS Excel B 33 03 36 worksheet and analysed with SSPS software. Outcome of AB 20 04 24 2.734 0.287 Not study data of individuals was not disclosed for any reason. O 67 09 76 significant Confidentiality of collected information was respected and Total 175 25 200 used for only academic purpose. Ethical clearance from Institutional Ethics committee was taken before initiation of Table 3: Fingerprint Pattern Distribution with gender Finger research project. Male Female Chi- Signifi- print Total square P value RESULTS : pattern 100 100 value cance 490 550 1040 A total of 200 subjects were participated in this study. Among Loop (24.5%) (27.5%) (52%) 200 subjects 100 were males and 100 were females. The 340 290 630 majority of subjects 76 (38%) belonged to blood Group “O” Whorls (17%) (14.5%) (31.5%) and followed by Group “A” having 64 subjects (32%), blood 0.546 0.354 170 160 330 Not group “B” having 36 (18%) subjects, and group “AB” with 24 Arches

(8.5 %) (8%) (16.5%) Significant (12 %) subjects. (Table 1) Total 1000 1000 2000 Table 1: Distribution of blood group with gender Blood Male Female Chi- Signifi- group Total square P value Table 4: Association Fingerprint Pattern and Blood Group 100 100 % value cance Distribution.

A 30 34 64 pattern Group Group Group Group Total Chi- B 20 16 36 A B AB O square value AB 14 10 24 4.167 0.3916 No Ph Ph Ph Ph Ph Ph Ph Ph value P

O 36 40 76 +ve -ve +ve -ve +ve -ve +ve -ve Significance Total 100 100 200 Loop 310 12 172 20 106 10 390 20 1040 when ABO-Rh blood group was considered, the prevalence Whorls was in following order O+ve (33.28%),A+ve (27.50%), B+ve 180 58 110 8 54 20 160 40 630 11.198

(16.50%) AB+ve (10%), O & A-ve (4.5%), AB-ve (2%), O-ve 0.003 Arches 60 20 48 2 40 10 120 30 330

(1,5%) respectively. Significant Both Females and males had higher percentage of O blood Total 550 90 330 30 200 40 670 90 2000 group followed by A group and lowest percentage of AB blood DISCUSSION: group. Chi-square test was applied to know the association between blood group and gender. There is no significant This study revealed the relation between distribution of correlation between them as p value was > 0.05. fingerprints, blood group and gender. In our subject population maximum participants belonged to blood group “O” followed The distribution of fingertip pattern observed that the dominant by Blood Group A, followed by blood Group B and AB. percentage was loops (52%) and followed by whorls (31.54%) Majority of the subjects were Rh-positive (87.5%), while 25 and, arches 16.5 % (Table- 2) Both the genders showed higher subjects (12.5%) were Rh-negative. percentage of loops ,followed by whorls and arches. Females had higher percentage of whorls than male. (Table- 3) Fingerprint pattern analysis yielded that loops were predominantly higher in incidence (n=1040, 52%), followed Table 4 revealed that among the distribution of fingerprint

41 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI: 10.5958/0974-083X.2020.00007.2

by whorls (n= 630, 31.5%) and arches (n=330, 16.5%). This is size for effective application feasibility testing. in accordance with studies by Shivhareet al, Singh et A limitation of the study is the small sample size and lack of al,Mahajan et al and Kshirsagar et al among different random sampling. population groups(5-8). Conflict of Interest: None In present study, loops were higher in blood group O (39.45 %) Source of Funding: Self Funded followed closely by blood group A (31.15 %), Blood group B (18.14%) was next, and lowest presence of loops were seen in REFERENCES : AB blood group (10.57%) which correlates with the study of 1. Cummins H, Midlo C. Palmar and plantar epidermal ridge Mehta et al(9). who saw highest number of loops in their configurations (dermatoglyphics) in European, subjects having blood group O, followed by Group A. This is Americans. American journal of physical anthropology. conflicting with studies by Shivhareet and Mahajan et al(5,7), 1926 Oct;9(4):471-502. who found higher percentage of loops in other blood groups. 2. Vij K. Textbook of Forensic Medicine and Toxicology. 2005;pp:89-91. In this study, the percentage of loop was highest in Rh-positive 3. Joshi S, Garg D, Bajaj P, et al. Efficacy of Fingerprint to (94.03%) and lowest in Rh-negative (5.97%), which correlated Determine Gender and Blood Group. J Denti Oral Care with Mehta et al, Kshirsagar et al and Bharadwaj et al(8-10), in Medi. 2016;2. case of Rh Negative subjects, whorls were seen more 4. Pati R K, Kumar V, Jain N. Analysis of Aadhar: A project commonly than any other type comprising 50.05 % of the Rh management perspective, Indian institute of management negative subject population. This correlates with results of Kozhikode. 2015;4:124-35. Kshirsagar et al and Bharadwaj et al, while contradicting the 5. Shivhare PR, Sharma SK, Ray SK, Minj A, Saha K. findings of Mehta et al(8-10). In our study, the percentage of loops Dermatoglyphic Pattern in Relation to ABO, Rh Blood higher in female (27.50%) and the percentage of whorls Group and Gender among the Population of Chhattisgarh. highest in male (17.25 %) which concurs with the study done Int J Sci Stud 2017;4(11):61-65. by Rastogi and Pillai(11). 6. Singh B, Jafar S, Dixit RK. Role of finger print pattern in Chi square analysis revealed a strong association between relationship with blood group and gender. J Med SciClin blood groups and fingerprint patterns among the selected study Res 2016;4:9651-5. (9,11) population as evident in studies by various authors. , 7. Mahajan AA. Dermatoglyphics and ABO Blood Group. however no significant correlation was evident between Thesis Submitted for MS Anatomy, Aurangabad; 1986. gender and fingerprints in conflict with studies by Rastogi et al, 8. Kshirsagar SV, Burgul SN, Kamkhedkar SG. Maharastra (10,11) Bharadwaj et al . A. Study of fingerprint patterns in ABO blood group. J CONCLUSION: Anat Soc India 2003;52:82-115. The purpose of this study was to report the relationship 9. A. A. Mehta, A. A. Mehta. Palmar dermatoglyphis in between various patterns of fingerprints and “ABO” blood ABO, RH Blood groups. International Journal of groups and “Rh” blood types in medical students. Although it Biological and Medical Research 2011;2(4):961–64. is established that fingerprints are unique and never change 10. Bharadwaj A, Saraswat PK, Agarwal SK, Banerji P, from birth till death, this study is an attempt to associate Bharadwaja S. Pattern of finger-prints in different ABO fingerprints with sex, different blood groups, and Rh blood blood groups. J Forensic Med Toxicol 2004;21:49-52. types which may in turn enhance the authenticity of 11. Rastogi P, Pillai KR. A study of fingerprints in relation to fingerprints in identification and forensic medicine. The study gender and blood group. J Indian Acad Forensic Med came to the following conclusions. 2010;32:11-4. Loops are the most commonly found fingerprint pattern while arches are the least common type in both genders and in all “ABO” blood groups. No significant difference was found in fingerprint distribution among the genders. The presence of loops was higher among Rh Positive subjects as compared to Rh Negative subjects. A association exists between fingerprints and genders in our study population, but needs further analysis on larger sample

42 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI: 10.5958/0974-083X.2020.00033.3 Original Research Paper Pattern of Suicidal Burn Deaths Autopsied at Central Delhi Tertiary Care Hospital

1. Amandeep Kaur, Associate Professor* 2. Monisha Pradhan, Associate Professor* *Department of Forensic Medicine, Maulana Azad Medical College & Lok Nayak Hospital, New Delhi.

ABSTRACT: Introduction: Suicides have now been a growing problem around the world. India now accounts for over a third of the world's annual female suicides and nearly a fourth of male suicides. Long standing frustrations, depressions, failures, decreasing human contact with increasing digitalization make people poor handlers of emotions and urges. Self Immolation (7.2%) being the third commonly employed method of suicide after hanging (45.6%) and Poisoning(27.9 %).This increasing suicidal rate requires addressal and pondering over it to help these troubled suicides. Material & Methods: A retrospective five year study of pattern of the suicidal burn deaths was conducted in the cases brought to mortuary of Lok Nayak Hospital, New Delhi for post-mortem, from 1st January 2014 to 31st December 2018. A total of 101 suicidal death cases due to burn was studied over this period. Results: During this five year study, a total of 649 suicidal death cases were brought to the mortuary out of which 101 were burn deaths.(15.56%)Out of these, males dominated the study with the ratio of 1.40. Most of the deceased were married and among these married people, maximum number was that of Females (57%). These cases mostly belonged to the age group of 20-30 years in both the genders. Most of them had a body surface area involvement of around 90-100% and maximum of them died within 24 hours of sustaining burns. Conclusion: Based on this study with females in the age group of 10-30 years and males in their 30-50years being the vulnerable target, they can be more directly focussed for counselling and provide medical treatment if and whenever required.

Corresponding Author : Article History: Dr. Monisha Pradhan, Received: 31 March 2019 Associate Professor Received in revised form: 1 April 2019 Accepted on: 1 April 2019 Department of Forensic Medicine, Maulana Azad Medical Available online: 31 December 2019 College & Lok Nayak Hospital, New Delhi Contact : +91 98996 82111 Email : [email protected]

KEYWORDS : Suicide, Burns, Body surface area, Age Group, Gender

INTRODUCTION : in death there are more than 20 others more attempting.(1) The 'Suicide is man's way of telling God, You can't fire me-I quit'. national crime research bureau data of India for the year 2015 Bill Maher shows an increasing rate of suicide over the last decade(2005- 20015) by 17.73%.(3) Suicide is a global phenomenon. Suicide accounted for 1.4% of all deaths worldwide, making it the 18th leading cause of According to WHO data, the age standardized suicide rate in death in 2016. It was reported that 79% of suicides occurred in India is 16.5 for both genders, with 14.5% per 100,000 for th low- and middle income countries in 2016.(1)An estimated women (4 highest in the world) and 18.5% for men (ranking th (4) 817000 suicide deaths occurred globally in 2016, accounting 46 in the world) These suicides generally are seen with for 1.5% of all deaths, with a global suicide death rate (SDR) longstanding frustrations, depression, examination failures, of 11 per 100000 population(seven per 100 000 for women and sudden mishap like rape, misunderstandings, marriage 15 per 100 000 for men).(2) disharmony, financial losses, loss of a life of near and dear ones.(5,6)But they are nowadays more commonly seen as an India accounts for a large proportion of all suicide death outburst, impulsive action, which may be because of decreased globally. There were 230314 suicide deaths in India in 2016. communication among family members or spouses or because India's contribution to global suicide deaths increased from of decreased patience.(7,8) Now, everything needs to run in 25.3% in 1990 to 36.6% in 2016 among women and from super-fast mode, no one has time to explain or convince or 18.74% to 24.3% among men. The men to women ratio of discuss things. Everyone needs results and if they aren't what SDR for India was 1.34 in 2016.(2) For every suicide that results they crave, their anger and frustrations gets the better of them

43 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI: 10.5958/0974-083X.2020.00033.3

and they hurt themselves to hurt others by committing suicide. occurrences in the age group 20-30 years for both genders, That's the mentality nowadays.Various methods of suicide are followed by the age group of 30-40 years in males and 10-20 in vogue. Depending on the accessibility, impulsive mode, years in the age group of females. Least number of cases was people resort to hanging, poisoning, drowning and burns. Less seen in 70-80 years age group. [Figure 2] commonly, gunshot, fall from height or self mutilating injuries Table 1 : Suicidal Burn Death Case Rate are also other options. Poisoning (27.9%), hanging (45.6%) , Total Cases in 5 years 5918 drowning (5.4%) and self-immolation (7.2%) were the (3) Suicidal Case in 5 years 649 primary methods used to commit suicide in 2015. % of Suicidal cases 10.97% Self immolation or self incineration, though uncommon and gruesome way to end one's life on their own terms is still seen Burns Cases 101 in India. Dowry deaths in India, be it homicidal or suicidal, % of Burn Cases 15.56% were deaths due to burns at one time.(8) It is a very painful and delayed method of death if used in comparison to other Figure 1 : Genderwise Distribution painless and rather quick methods like hanging, drowning, gunshot. These suicidal burns when committed in open are mostly meant to gain attention at large to make a point. These suicidal attempts may either end up in death on spot or after a brief or prolonged stay in hospital. This does suggest the mental turmoil of the suicide at the time of going through the whole ordeal of pouring an accelerant or striking a match, when he/she aren't thinking of how painful it is going to be but only the pain they are going to be getting rid of. These when Figure 2 : Age Group Distribution witnessed or followed during the life of the suicide by the family or close ones scar them for life too. In this study, we profiled these suicidal burns cases coming to our mortuary. MATERIAL AND METHODS: This study was based on retrospective analysis of suicidal burn deaths autopsied over a period of five years from 1st January 2014 to 31st December 2018 in the Department of Forensic Medicine and Toxicology, Maulana Azad Medical College & Lok Nayak Hospital, New Delhi. The burn cases with clear history of suicidal flame burns were included and cases which were decomposed or that of other forms of burns Most of the suicides whose marital status was known, were were excluded. Performa for study was designed and all the married and females made a large proportion of it in our relevant information and findings were collected from the study.(55.56%) [Figure 3] Among unmarried ones, males post-mortem reports like age, sex, religion, marital status, were marginally more in number. (53.33%) Also, most of the time and place of incidence, period of survival and cause of cases were Hindu in religion (90%) and rest were Muslims. death was noted. This information was compiled, tabulated and analyzed. Figure 3 : Marital Status OBSERVATIONS AND RESULTS: In the 5 year period over which this study was retrospectively done, out of total 5918 post-mortem cases conducted, 649 were suicidal (10.97%) cases. These suicidal cases had only 101 burn case (15.56%) contributors. [Table 1] The majority being hanging, poisoning. There was more of male predilection (56 cases) than females (45 cases) with male to female ratio of 1.24. [Figure 1] Suicidal burn injuries were seen in all age groups with more

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The most preferred time to commit suicidal burns was in late involvement proved to be fatal in one cases. [Figure 6] evening hours towards the end of the day(6pm-midnight), Table 2 : Period of Hospitalization followed by late morning hours from 6am-12 noon.[Figure 4] Period of Hospitalization Burn Cases %age Most cases were seen in the months of June, September& October.[Figure 5] Brought Dead 3 2.97% Figure 4 : Time of Incidence of Suicidal Burns <1day 28 27.72% 1-3days 12 11.88% 3-5days 17 16.83% 5-7days 21 20.79% 7-10days 10 9.90% >10days 10 9.90% Total 101 100%

Figure 6 : Gender wise distribution in TBSA involvement

Figure 5 : Month wise Distribution of Suicidal Burns

Another observation that was made was that among females who committed suicide by burning, two were pregnant, three were menstruating. The accelerants were known to have been used in only 75 cases, out of which 55 cases preferred kerosene, followed by petrol and turpentine oil. One case set LPG gas leak before setting herself on fire. [Figure 7] The reasons behind committing suicide was mostly not made vocal and remained unknown. Various reasons that we did come across were altercations with spouse, parents, in-laws, financial troubles, All but three cases were hospitalized and survived over a depression etc. While two cases committed suicide because of variable period, irrespective of the extent of their burn. scolding from their parents over trivial issues. Maximum cases died with 24 hours of sustaining burns (28). The selection of place to commit suicidal burns did suggest About 77% of these hospitalized burn victims died by the end some inner turmoil and effects that these self immolators and of first week. The cases who died within 24 hours succumbed suiciders were seeking. Most of these suicidal burns happened to death because of laryngeal oedema or shock (neurogenic or within their homes, while few cases happened in their hypovolemic) while the others had septicaemia. [Table 2] workplace. Among the other places, people set themselves on The extent of burns in terms of body surface area involvement fire in front of court premises, Police head quarters, on the was calculated as per “Rule of Nine”. The total body surface banks of the river Yamuna. [Figure 8] area involvement in most of the cases was seen to be 90-100% followed by 80-90% involvement. However, even 30% area

45 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI: 10.5958/0974-083X.2020.00033.3

Figure 7 : Accelerant Usage Preference in Percentage 2011).(17)The least involved group was that of less than 10 years and more than 80years. Most of the deceased were married and among married people, more were females. The reason might have been because the females in this category were known to have conflicts with their spouses or In-laws and had less opportunity to verbalise their thoughts in person at her in-laws's place. Similar studies were seen in Santosh C S et al (2013) (11) Mazumdar A et al (2013) (16) Mishra P K et al (2016) (15). Among religion variation, more cases were that of Hindus and rest were Muslims in our study. No other religion deceased were found in our study. It is Figure 8 : Place of Committing Suicidal Burns explained by Hindu dominant population in the area of our Mortuary jurisdiction. Overall, time of maximal suicidal tendency by burns was found to be in evening hours (6 pm-12 am) followed by morning hours of 6am to 12 noon. This was the time in the evenings when the spouses met after a long day in their own lives for the day and had quarrels. This was the main reason that we got in our study for committing suicidal burns by either of the spouses. This was not in sync with the observations of Udaya Shankar BS et al(2018)(18) which showed maximum cases (29%) died during morning hours 6am-12pm, followed by 27% cases in night hours 8pm-6am. September-October months had most cases (23) in our study which was similar to Uday Shankar BS et al (2018) study. (18) Most of the cases that were hospitalized were dead within first 24 hours (27%), 21% cases survived for 5-7 days. Chawla et al DISCUSSION : (2010)(19)Shaha KK and Mohanthy S(20)also observed that most Among all deaths, suicidal burn deaths accounted for 15.56% victims died at the time of the incident, or within the in this present study which is similar to the study done by subsequent 24 hours, due to hypovolemic shock. But study Gowri Shankar et al (2012)(9), but contrary to studies by Patel G done by Mishra PK et al (2016) (15) showed that only 8.4% cases J et al (2018) (10) where this rate was 7% and Santosh C S et al died within 24 hours and 28.4% within 3-6 days. (11) (2013) where the rate was found to be 17.29%. This Burns with suicidal intention generally involve more of body difference could be explained on the basis of variable number surface area especially with use of accelerant and also because of suicidal death cases considered in the respective studies. the person doesn't want to douche the fire. There was Majority of suicidal deaths however, resulted from hanging involvement of 90-100 % of total body surface area in 27% and poisoning. cases. This extreme involvement was seen 37.78% of females The gender variation seen in this study was that of male and 19.64% of males, followed by 80-90% involvement. preponderance with slight edge with the male: female ratio of Similar inclination of 90-100% cases were seen in 1.24. This was also seen with Santosh C S et al (2013),(11) but observations of Chawla et al,(19)Shruti et al(2016)(21), Paul et was not seen with the studies of Gowri Shankar et al(2016) (22)reported that severe burn was more common in al(2012)(9),Malik AK, et al(2017),(12) Sharma BR et female than male. (13) al(2004) where the gender inclination was more towards The choice of accelerants in our study suggested feasibility to females. The age group more vulnerable to self immolation obtain them especially on spur of moments in a fit of rage with was found to be of 20-30 years, for both males and females, suicidal impulse. These are the ones available in household. followed by 30-40 years in case of males and 10-20 years in Kerosene was used in most of the cases 54.46% followed by females. This age group of 20-30 years was also found to be petrol in 12.87%. Other accelerants used commonly were (14), more suicide prone in studies done in Imphal Mishra P K et turpentine oil, LPG gas, thinner, and diesel. Similar propensity (15) (16) al(2016) , Mazumdar A et al (2013) and Buchade D et al( was seen by most of the studies. (23, 24)

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When explanations were sought for people going to such an 14:142–156 extreme, horrific end, in most of the cases, relatives had no clue 9. Gowri S, Naik Vijaya A, Powar R, Honnungar what was going in the deceased's life. The self immolations in R.Epidemiology and outcome of Burn Injuries.J Ind Acad open premises were made to make a strong perceptible gesture. Foren Med 2012;34(4):312-14 Few deaths were known to be of impulsive nature, like 10. Patel GJ,Mori RK, Patel DS, Shah J, et al. J Ind Acad altercation with their spouse or their parents. In females, Foren Med2018;40(4):387-91 hormonal surges in pregnancy or during menstruation could also have been a reason but it was observed in only 4-5 cases. 11. Santosh C S, Nawaz B. Pattern of Suicidal Deaths at District Hospital Davangere. A cross sectional Study.J Ind CONCLUSION: Acad Foren Med2013;35(3):233-35 Increasing trend of suicide over the years in India has made it 12. Malik AK, Khanna K, Dhattarwal SK, Panchal K, Singla an alarming emergency which not only needs a proper K. Profile of death due to Burns in Mortuary of a Tertiary reporting of the cases, their required addressal but a strategy to Care Hospital.J Ind Acad Foren Med2017;39(4):400-3 channelize resources and fight it head on. In our study we found that the most vulnerable group was that of 20-30 years 13. Sharma BR, Singh VP, Sharma Sumedha. Unnatural for both gender followed by the age group 10-20 years for deaths in northern India-a profile. J IndAcad For females and 30-40 years for that of males. This study suggested Med2004;26(4):140-6 that these particular age groups need to be targeted by the 14. Singh P, Marak FK, Longkumar K, Momonchand A. government and social organisations to properly counsel them, Suicides in Imphal.J Ind Acad For Med2005;27(2): 85-86 provide constructive channelization of their anger and 15. Mishra PK, Tomar J, Sane MR, Saxena D, Yadav A. frustration by providing more of help centres where they can Profile of Death in Burn Cases: A Postmortem Study. .J call anonymously to seek guidance and assurance that is IndAcad For Med2016;38(1): 8-10 needed at the critical moment of life and death. 16. Mazumder A, Patowary A. A study of Pattern of Burn REFERENCES: Injury Cases. J Ind Acad Foren Med 2013;35(1):44-46 1. Suicide data. WHO Sites: Mental Health. World Health 17. Buchade D, Kukde H, Dere R, Savardekar R. Pattern of Organization. WHO( https://www.who.int) burn cases Brought to Morgue, Sion Hospital, Mumbai. A 2. Gender differentials and state variations in suicide deaths two year study. J Ind Acad Foren Med 2011;33(4):309-10 in India: the Global Burden of Disease Study 1990–2016: 18. Udaya Shankar BS, Sujatha PL, Shivakumar BC. Profile Lancet Public Health 2018; 3: e478–89 of Suicides amongst Autopsies at a Tertiary Care Centre in 3. Suicides in India (http://ncrb.nic.in/CD-ADSI-2015/ Bangalore North. J Ind Acad Foren Med 2018;40(1):38- chapter 2 suicides-11.pdf) 46 4. Suicide rates Data by country. World Health Organization. 19. Chawla R, Chanana A, Rai H, Aggrawal AD, Singh H, 2016. Retrieved 23 September 2018. Sharma G. A two-year burns fatality study. J Ind Acad 5. Andrew T, Cheng A, Tony H, Chen H, Chen CC, Jenkins Foren Med 32(4):292-7 R. Psychosocial and psychiatric risk factors for suicide: 20. Shaha KK, Mohanthy S. Alleged dowry death. A study of Case-control psychological autopsy study. The British homicidal burns. Med Sci law.2006:46(2):105-10 Journal of Psychiatry 2000;177(4):360-365. 21. Shruthi P, Varma RK , Viswakanth B. Analysis of fatal 6. Chávez-Hernández A M , Macías-García L F. burn cases in a metropolitan city of south India. J Ind Acad Understanding suicide in socially vulnerable contexts: Foren Med 2016; 38(4):400-3 psychological autopsy in a small town in mexico. Suicide 22. Paul B, Patowary A. Prospective study on the magnitude, Life Threat Behav 2016;46(1):3- 12. pattern and cause of female deaths due to burn injuries. J 7. Joiner TE, Brown JS, Wingate LR (2005). "The Ind Acad Foren Med 2016; 38(3):268-73 psychology and neurobiology of suicidal behavior". 23. Ambade VN, Godbole HV.Study of burn deaths in Annual Review of Psychology. 56: 287–314. Nagpur, Central India. Burns.2006. Nov;32(7):902-8 8. Daruwalla N, Belur J, Kumar M, Tiwari V, Sarabahi S, 24. Chakraborty S, Bisoi S, Chattopadhyay D, Mishra R, Tilley N, Osrin D (2014) A qualitative study of the Bhattacharya N, Biswas B. Indian J Public background and in-hospital medicolegal response to Health.2010;54(1):27-9 female burn injuries in India. BMC Womens Health

47 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI: 10.5958/0974-083X.2020.00034.5 Original Research Paper Anthropometric Measurements of Adult Human Skull for Determination of Sex and Stature in a population sample from Haryana state (India) 1. Surinder Singh Oberoi, Professor & Head, Department of Forensic Medicine, Adesh Medical College & Hospital, Mohri, Shahbad, Haryana, India 2. Akash Deep Aggarwal, Associate Professor, Department of Forensic Medicine, Government Medical College, Patiala 3. Didar Singh Walia, Associate Professor, Department of Forensic Medicine , Government Medical College, Amritsar

ABSTRACT : Introduction : The study of human skulls in the state of Haryana was carried out to explore the objective methods of determination of sex and stature, by using anthropometric measurements; and therefore, help in the identification of gender and stature of a person. Materials and Method : The study was carried out on 100 dead bodies, 60 males and 40 females. Measurements of length, breadth and circumference of the skull and length of the body were made directly on each deceased. The known heights of the combined data were analysed against the anthropometric variables. Significant sexual dimorphism was observed for the parameters studied. Results : The length of the mastoid process and horizontal circumference of the skull are the most important criteria for sex determination as it could sexually differentiate more than 92% of the skulls. Skulls were positively males when the maximum length of the skull is ≥ 176.59 mm, maximum breadth of the skull is ≥ 124.04 mm, length of mastoid process is ≥ 22.49 mm, depth of infra- temporal fossa is ≥ 24.03 mm and horizontal circumference of skull is ≥ 511.68 mm; and positively females when these parameters were ≤ 172.71 mm, ≤ 121.87 mm, ≤ 22.54 mm, ≤ 22.60 mm and ≤ 506.72 mm respectively. Multiplication factor (9.24 – 9.45) calculated from the maximum length of the skull is not of much significance for accurate stature estimation, however, the range of error in estimation of stature from regression analysis method is much lesser.

Corresponding Author : Article History: Dr. Didar Singh Walia, Received: 24 December 2019 Associate Professor, Received in revised form: 24 December 2019 Accepted on: 24 December 2019 Department of Forensic Medicine, Government Medical Available online: 31 December 2019 College, Amritsar, Punjab Contact : +91 98410-69602 Email : [email protected]

KEYWORDS : Skull, cranium, stature, height, identification.

INTRODUCTION : Sexual dimorphism manifests itself in humans by differences It is crucial to collect all possible information from human in overall body size traits. The measurements relating to remains for the purpose of identification. As one of the most cranium size, which include mandibular breadth, inter-orbital durable and recognizably human parts of the skeleton, the breadth, total height of face, and chin to ear aperture show a cranium is the most likely element to survive postmortem modest amount of sexual dimorphism. Males do show slightly taphonomic processes and be reported to authorities. greater size of cranial bones and proportionally greater length Accordingly, isolated crania are often recovered from forensic of hands and feet, which demonstrates sexual dimorphism contexts. It is essential to have methods available to estimate corresponding to their overall body size differences. the biological profile when an isolated cranium is the only Anthropometric data of the skull can be used for the positive remnant found of an unidentified individual. Stature is one identification of sex and stature in forensic investigations element of the biological profile that can help narrow the field having to deal with fragmentary human remains. of possible identifications. Stature is one of the basic indicators The skull has a high resistance to adverse environmental of the biological profile that can aid in the identification of an conditions over time, resulting in the greater stability of the individual by narrowing the field of possibilities. It can help dimorphic features as compared to other skeletal bone pieces. distinguish between multiple individuals who are the same in The sex determination of human skeletons is important in ancestry, sex, and age, providing a circumstantial or forensic and anthropological research. It can be carried out presumptive identification, and thus allowing the use of other through qualitative or quantitative analysis of morphological methods for confirmation and positive identification. A parameters of dimorphism[19]. number of studies have attempted to quantify the relationship All methods of stature estimation are based upon the between the cranium and stature through various methods[1-18].

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fundamental assumption that the longer the bone, the taller the 2. Maximum skull length: This is the maximum distance individual[20-21]. Mathematical methods, including linear between the glabella and the external occipital protuberance regression[22], use the relationship between the size of a bone or and was measured with the help of a spreading calliper. combination of bones and the height of the individual, over (Figure 2) large samples, to create a formula to estimate stature on 3. Maximum skull breadth: This is the maximum distance unidentified remains. All methods attempt to estimate stature between the two parietal eminences and was measured by the as accurately and precisely as possible; accuracy occurs when spreading calliper. (Figure 3) the prediction interval encompasses the actual stature of the individual, while precision refers to the size of that prediction (Figure 2) (Figure 3) interval[23]. Human variation, however, ensures that no method is beyond the possibility of error[21, 24]. Stature estimation is by nature not terribly precise, but it can be highly accurate[23]. Those wishing to estimate stature can only select the method, appropriate to the circumstances of the remains, that has the smallest standard error. Ideally, equations should be calculated from dry bone when 4. Length of the mastoid process: The mastoid process along they are going to be used on such material[25-28], as is often the with its tip was cleared off the skin and soft tissues adherent to case in forensic contexts. Dry bone has been shown to be it. The upper border of the external auditory meatus was shorter than “fresh” bone by approximately 2mm[22-29]. extended backwards in the form of horizontal line. Then a vertical line was drawn from this line to the tip of the mastoid MATERIAL & METHODS : process. The distance between the point where the horizontal The sample for this study consisted of positively identified and the vertical lines intersect and the tip of the mastoid north Indian adult deceased in the state of Haryana. The study process gives the length of the mastoid process which was was conducted on 100 skulls (40 female and 60 male) from measured with the help of a graduated metallic probe. adult dead bodies, in the age group of 20-55 years. The dead 5. Depth of infra-temporal fossa: An incision was given bodies were received in the mortuary, brought by the police along the upper border of the zygomatic arch. By reflecting the accompanied by relatives with inquest and identification upper skin flap, the infra temporal fossa was cleared off the soft papers for medicolegal post-mortem examination. The cases, tissues. The distance between the upper border of the in which the skulls were destroyed, fractured, diseased or zygomatic arch and the deepest point in the infra temporal abnormal in any other way and where it was not possible to fossa, when the probe was directed inwards in a horizontal take the exact length of the body were excluded from the study. direction, represented the depth of infra temporal fossa and Followings six measurements were performed based upon was measured with the help of a graduated metallic probe. their ease of reproduction. For taking the measurements of (Figure 4) the skull, the scalp was denuded off the skull, thus exposing the 6. Horizontal circumference of the skull: This was measured glabella and external occipital protuberance; the soft tissue with the help of a malleable metallic wire. One end of the wire adherent to the skull was removed. was held fixed at the glabella, extended it backwards along the 1. The length of the body was measured with the help of an side of the skull reaching the external occipital protuberance, osteometric board. The body was placed in the centre of the then going forwards along the other side of the skull till it osteometric board in supine position, lying straight with the reached the glabella again and touched the starting point of the head of the body touching the head plate of the board. The feet wire, thus encircling the whole of the skull. The length of this were kept at right angle to the body and the foot plate was wire was measured against a measuring tape and this gave the adjusted and the length of the body was recorded in horizontal circumference of the skull. (Figure 5) centimeters by noting the reading on the scale. If the body was stiff as a result of rigor mortis or burns, it was straightened (Figure 4) manually and then the length was recorded. (Figure 1)

(Figure 1) (Figure 5)

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A variety of statistical analyses were conducted on this sample, mean absolute error are measures of the accuracy of an with the data split by sex. Descriptive statistics, including equation and have been used to compare equations across mean and standard deviation, for stature and the selected studies.7,30 The standard error of the estimate is often cranial measurements were calculated using Microsoft Excel. erroneously used to provide an interval for the prediction. This study utilized simple least squares linear regression Rather, it is merely a part of the equation used to generate the analyses to estimate stature from single measurements in the true prediction interval. The correlation (r) and coefficient of craniofacial region. As cranial measurements were determination (r2) are measures of the reliability and goodness- hypothesized to be predictive of stature, the regressions were of-fit of the model. Correlation measures the strength of the performed with stature as the dependent variable and the linear relationship between the variables, and the coefficient of selected cranial measurement(s) as the independent determination provides a measure of the percent of variation in variable(s). A multiplication factor was calculated for each the dependent variable that is explained by the independent measurement by using the arithmetic-geometric mean method. variable[1]. These multiplication factors were used for estimating the It has been established by the earlier studies that the means of stature from those variables. The multiplication factor was stature reconstruction, i.e. multiplication factor or regression calculated which is the ratio of mean stature to mean formulae are both population and sex specific and thus it is somatometric variable. Derived multiplication factors and important to first identify the recovered remains and then regression formula were applied to the measurements in the relevant measurements should be taken to reconstruct the study sample. The estimated stature from the multiplication stature. Though both the methods may be used but regression factors and regression analysis was compared with the actual equations provide greater reliability in estimated stature. stature to find the error in estimated stature. From the value of the correlation coefficient, the best RESULTS & DISCUSSION : parameter was skull circumference in males (correlation The mean height of the study population was found to be coefficient 0.351) and mastoid length in females (0.402). The significantly different between genders. Gender differences regression equations for estimation of stature by the various with respect to the mean cranial length, cranial breadth and parameters were calculated. (Table 2) Correlation coefficient auricular head height were found to be significantly larger in between the stature and measured cranial dimensions were males compared to females. Similar findings have been found to be statistically significant and positive in both males reported by previous studies[4,13]. and females. Correlation coefficient for determination of The length of the mastoid process is the single most important stature from various skull parameters has been found to be as criteria for sex determination as it could identify 100% male high as 0.73 in the present study from Haryana state of India, [17] and 95% female skulls. The horizontal circumference of the whereas other studies have reported 0.19 in Maharashtra , [3] [11] skull is the next important criteria for the sex determination as 0.26 in Italy , 0.28 in Bangladesh , 0.32 in previous study [18] [14] [16] it could identify sex in 95% males and 92.5% female skulls. from Haryana , 0.38 in Mauritius , 0.49 in Bangalore , [4] [15] [7] The maximum length of the skull and the depth of infra- 0.50 in Japan , 0.52 in Punjab , 0.54 in South Africa , 0.56 in [8] [13] [9] temporal fossa are the next significant factors for sex Karnataka , 0.72 in Sri Lanka and 0.78 in north India . determination. The maximum breadth of the skull is the least In the fifth century BC, Polyclitus, a Greek sculptor, important factor out of the five factors studied for sex established that the head was one eighth of the height of the determination. body, which was agreed to by French anatomist Chrisostome The descriptive statistics including mean, the standard Martinez in 1660; celebrated anatomist Winslow, the Royal deviation, and the maximum and minimum value for stature Academy of Painting in 1740 and the famous Leonardo da [31-33] and other somatometric parameters are shown in Table 1. The Vinci, among many others in recent times . regression equation for estimation of stature, Pearson product- The gender divergence in cranial morphometry observed in our moment correlation coefficient, Coefficient of determination, study supports the previous observations[13]. Another inference Standard error of estimate, Root-mean-square error and Mean from the multiplication factors is that the cranial dimensions absolute error calculated from these measurements are shown observed in this study were greater than those observed for the in Table 2. The multiplication factor for estimation of stature, Mauritius[14], Bangladesh[11], Sri Lanka[13], Italy[3] whereas it was Standard error of estimate, Root-mean-square error and Mean smaller than Japan[4], a finding that further reinforces the racial absolute error calculated from these measurements are shown diversity in the cranial dimensions. in Table 3. The standard error of the estimate, mean squared error and

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Table 1. Multiplication factors of different skull dimensions for estimation of stature Descriptive statistics Demarcat- Skulls beyond Coefficient Standard Standard p for Measurements Max. Min. Mean deviation ing Demarcating of error of t (cm) point point variation mean Male 183.0 157.0 170.26 - - 0.04 0.79 Body 6.15 11.399 0.000 length Female 170.0 148.0 157.46 5.03 - - 0.03 0.80 Skull Male 18.9 17.2 18.01 0.37 ≥ 17.66 86.6% 0.02 0.05 14.083 0.000 length Female 17.5 16.4 17.03 0.32 ≤ 17.27 67.5% 0.02 0.05 Male 13.4 12.2 12.63 0.22 ≥ 12.40 80% 0.02 0.03 Skull 13.163 0.000 breadth Female 12.5 11.9 12.16 0.13 ≤ 12.19 45% 0.01 0.02 Male 54.6 50.6 52.35 0.86 ≥ 51.17 100% 0.02 0.11 Skull 16.359 0.000 circumference Female 50.7 46.5 49.14 1.03 ≤ 50.67 95% 0.02 0.16 Mastoid Male 2.9 2.3 2.53 0.14 ≥ 2.25 81.6% 0.06 0.02 20.028 0.000 length Female 2.3 1.9 2.03 0.11 ≤ 2.25 67.5% 0.05 0.02 Infratemporal Male 2.9 2.2 2.54 0.14 ≥ 2.40 95% 0.06 0.02 13.786 0.000 fossa Female 2.4 2.0 2.20 0.10 ≤ 2.26 92.5% 0.05 0.02

Table 2. Linear regression equations for estimation of stature from different skull dimensions Regression analysis Stature Pearson Coefficient Standard error of Mean for measurements Y = (Intercept) + correlation of determi- estimate/Root absolute p (cm) X (Slope*X) coefficient r nation r2 mean square error error Male 84.915 + 4.741 X 0.288 0.083 5.942 4.856 0.026 Skull length Female 161.021 – 0.207 X 0.013 0.000 5.099 3.494 0.937 Total -5.303 + 9.676 X 0.676 0.457 6.297 5.140 0.778 Male 112.354 + 4.588 X 0.166 0.027 6.119 5.117 0.206 Skull Female 21.942 + 11.143 X 4.873 3.394 breadth 0.295 0.087 0.065 Total -66.549 + 18.620 X 0.655 0.429 6.459 5.366 0.015 Male 38.817 + 2.512 X 0.351 0.123 5.811 4.780 0.006 Skull 121.054 + 0.742 X 3.546 circumference Female 0.151 0.023 5.040 0.352 Total -8.129 + 3.394 X 0.731 0.535 5.833 4.873 0.620 Male 151.274 + 7.507 X 0.174 0.030 6.110 5.019 0.184 Mastoid length Female 120.521 + 18.239 X 0.402 0.162 4.669 3.760 0.010 Total 113.702 + 22.069 X 0.733 0.537 5.816 4.716 0.000 Male 169.245 + 0.422 X 0.010 0.000 6.205 5.174 0.941 Infratemporal Female 184.026 – 12.030 X 0.058 3.306 fossa 0.242 4.948 0.133 Total 109.946 + 22.951 X 0.564 0.318 7.060 5.880 0.000

CONCLUSION : better than multiplication factor analysis in stature estimation. For the establishment of identity of an unknown individual in REFERENCES : forensic and anthropological studies, prediction of stature 1. Richards E. The Estimation of Stature from from incomplete and decomposing cranial remains is very Measurements of the Isolated Cranium [Internet] important. Formulae based on the cranial dimensions provide [Masters Thesis]. [San Marcos]: Texas State University; an alternative stature predictor under such circumstances. 2 0 11 [ c i t e d 2 0 1 4 A p r 11 ] . Av a i l a b l e f r o m : Mathematical formulas have been proposed for these https://digital.library.txstate.edu/handle/10877/2538 parameters for determination of height. The results indicate 2. Sarangi SK, Dadhi B, Mishra KK. Estimation of stature from somatometry of skull. J Indian Acad Forensic Med. that the range of error in estimation of stature from regression 1981;3(1 & 2):24–6. analysis method is less than that of multiplication factor 3. Introna F Jr, Di Vella G, Petrachi S. [Determination of method thus, confirming that the regression analysis method is

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height in life using multiple regression of skull Cephalo-Facial Anthropometry in 800 Haryanvi Adults. parameters]. Boll Della Soc Ital Biol Sper. 1993 Int J Plant Anim Environ Sci. 2013;3(2):42–6. Mar;69(3):153–60. 19. Cantín López M, Suazo Galdames IC, Zavando Matamala 4. Chiba M, Terazawa K. Estimation of stature from DA, Smith RL. Sexual Dimorphism Determination by somatometry of skull. Forensic Sci Int. 1998 Nov Piriform Aperture Morphometric Analysis in Brazilian 9;97(2–3):87–92. Human Skulls. Int J Morphol. 2009 Jun;27(2):327–31. 5. Patil KR, Mody RN. Determination of sex by 20. Lundy JK. The mathematical versus anatomical methods discriminant function analysis and stature by regression of stature estimate from long bones. Am J Forensic Med analysis: a lateral cephalometric study. Forensic Sci Int. Pathol. 1985 Mar;6(1):73–6. 2005 Jan 29;147(2–3):175–80. 21. Sjøvold T. Anthropology - Stature Estimation from the 6. Krishan K, Kumar R. Determination of stature from Skeleton. In: Siegel JA, Knupfer G, Saukko P, editors. cephalo-facial dimensions in a North Indian population. Encyclopedia of Forensic Sciences. Oxford: Elsevier; Leg Med Tokyo Jpn. 2007 May;9(3):128–33. 2000. p. 276–84. 7. Ryan I, Bidmos MA. Skeletal height reconstruction from 22. Trotter M, Gleser GC. Estimation of stature from long measurements of the skull in indigenous South Africans. bones of American Whites and Negroes. Am J Phys Forensic Sci Int. 2007 Mar 22;167(1):16–21. Anthropol. 1952 Dec 1;10(4):463–514. 8. Kalia S, Shetty SK, Patil K, Mahima VG. Stature 23. Ousley SD. Should We Estimate Biological or Forensic estimation using odontometry and skull anthropometry. Stature? J Forensic Sci. 1995;40(5):768–73. Indian J Dent Res Off Publ Indian Soc Dent Res. 2008 24. Raxter MH, Auerbach BM, Ruff CB. Revision of the Jun;19(2):150–4. Fully technique for estimating statures. Am J Phys 9. Krishan K. Estimation of stature from cephalo-facial Anthropol. 2006 Jul;130(3):374–84. anthropometry in north Indian population. Forensic Sci 25. Jason DR, Taylor K. Estimation of stature from the length Int. 2008 Oct 25;181(1–3):52.e1-6. of the cervical, thoracic, and lumbar segments of the spine 10. Rao PPJ, Sowmya J, Yoganarasimha K, Menezes RG, in American whites and blacks. J Forensic Sci. 1995 Kanchan T, Aswinidutt R. Estimation of stature from Jan;40(1):59–62. cranial sutures in a South Indian male population. Int J 26. Duyar İ, Pelin C. Body height estimation based on tibia Legal Med. 2009 May;123(3):271–6. length in different stature groups. Am J Phys Anthropol. 11. Akhter Z, Begum JA, Banu MLA, Alam MM, Hossain S, 2003 Sep;122(1):23–7. Amin NF, et al. Stature Estimation Using Head 27. Pelin C, Duyar I, Kayahan EM, Zağyapan R, Ağildere Measurements in Bangladeshi Garo Adult Females. AM, Erar A. Body height estimation based on dimensions Bangladesh J Anat. 2009;7(2):101–4. of sacral and coccygeal vertebrae. J Forensic Sci. 2005 12. Pelin C, Zağyapan R, Yazıcı C, Kürkçüoğlu A. Body Mar;50(2):294–7. Height Estimation from Head and Face Dimensions: A 28. Giroux CL, Wescott DJ. Stature estimation based on Different Method*. J Forensic Sci. 2010 Sep dimensions of the bony pelvis and proximal femur. J 1;55(5):1326–30. Forensic Sci. 2008 Jan;53(1):65–8. 13. Ilayperuma I. On the Prediction of Personal Stature from 29. Byers S, Akoshima K, Curran B. Determination of adult C r a n i a l D i m e n s i o n s . I n t J M o r p h o l . 2 0 1 0 stature from metatarsal length. Am J Phys Anthropol. Dec;28(4):1135–40. 1989 Jul 1;79(3):275–9. 14. Agnihotri AK, Kachhwaha S, Googoolye K, Allock A. 30. Wilson RJ, Herrmann NP, Jantz LM. Evaluation of stature Estimation of stature from cephalo-facial dimensions by estimation from the database for forensic anthropology. J regression analysis in Indo-Mauritian population. J Forensic Sci. 2010 May;55(3):684–9. Forensic Leg Med. 2011 May;18(4):167–72. 31. Drillis R, Contini R, Bluestein M. Body segment 15. Seema, Mahajan A. Estimation of personal height from parameters: A survey of measurement techniques. Artif the length of head in Punjab zone. Int J Plant Anim Limbs. 1964;25:44–66. Environ Sci. 2011;1(3):205–8. 32. Richardson T. The Art Student's Guide to the Proportions 16. Mishrikoti HP, Nagalikar AS, Padeyappanavar KV, Usha of the Human Form. Tom Richardson; 2008. 222 p. V. Estimation of Stature from Length of Head in Children. 33. Jose AM. Anatomy and Leonardo da Vinci. Yale J Biol Anat Karnataka. 2012;6(3):90–3. Med. 2001;74(3):185–95. 17. Wankhede KP, Kamdi NY, Parchand MP, Anjankar VP, Bardale RV. Estimation of stature from maxillo-facial anthropometry in a central Indian population. J Forensic Dent Sci. 2012;4(1):34–7. 18. Kumar M, Gopichand V. Estimation of Stature from

52 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI: 10.5958/0974-083X.2020.00008.4 Original Research Paper Impact of Methamphetamine on the life cycle stages of two forensically important flies in AL-Diwaneyah City 1. Hussein R. Mahmood, lecturer, University of AL-Qadisiyah, Faculty of Sciences, Iraq 2. Malik Ali Kareem, Research Scholar, Iraqi Ministry of Health. ABSTRACT : Introduction : In recent years, the entry of narcotic drugs, including Methamphetamine into Iraq by smugglers has increased the proportion of addict of this type of drugs (According to recent statistics of the Iraqi Ministry of Interior). Materials and Method : The present study aimed to search the impact of Methamphetamine on life cycle stages of Chrysomya putoria and Chrysomya albiceps in estimating the postmortem interval (PMI). The first group fed on Methamphetamine -liver mixture and the second used as control group. The weight of larvae was measured after 24 to 54 hours of exposure. The time of both Pupariation and adult emergence was also accurately studied. Results : The results confirmed that the larvae of C. putoria and C. albiceps exposed to Methamphetamine liver mixture developed faster than those in control, resulting in the conclusion that Methamphetamine impacted and motivates the growth of larva. There were no significant differences in the duration of pupariation between larvae exposed to Methamphetamine and control for both species. The adults of the two species took the same amount of time to emerge. The growth difference between both control and flies exposed to drug was observed clearly from 24 hours upwards. This provides very accurate and important information for researchers in the field of forensic sciences.

Corresponding Author : Article History: Dr. Hussein R. Mahmood, Received: 29 September 2019 Lecturer, University of AL-Qadisiyah, Faculty of Sciences, Received in revised form: 27 October 2019 Accepted on: 27 October 2019 Iraq Available online: 31 December 2019 Email : [email protected] [email protected]

KEYWORDS : Methamphetamine,PMI, Chrysomya putoria and Chrysomya albiceps

INTRODUCTION Crystalline methamphetamine is a form of solid drug similar to [5] Taking drugs in countries and communities varies according to glass fragments . their availability, cultural and social habits, life styles, and There are several ongoing studies that seek to determine the state law[1]. Methamphetamine is a tonic of the amphetamine effect of drugs on the development of insects, especially the and phenethylamine group of psychotropic drugs. In the blow fly and flesh fly. The studies aimed to eliminate the high United States, methamphetamine use was approved by the potential errors during PMI by following techniques that play Food and Drug Administration in the treatment of attention a role in determining drug-related changes for insect larvae, deficit, hyperactivity and external obesity (obesity caused by pupariation and emergence times[6-7]. The aim of this study was factors beyond the control of the patient) in both adults and to determine the effect of Methamphetamine on the life cycles children[2]. Methamphetamine is sold under the name of the most important forensically insects C. albiceps and C Desoxyn, a trademark by Danish drug company Lundbeck. In .putoria. January 2013, the brand of Desoxyn was sold to the Italian MATERIALS AND METHODS : drug company Recordation[3] Because meth has a high The Methamphetamine liver mixtures were created by potential for abuse, it is regulated under the Controlled homogenizing known weights of sheep liver with known Substances Act. Chronic addiction may lead to post- amounts of powdered pure Methamphetamine in a blender withdrawal syndrome, which can persist beyond the (MSE Atomix). withdrawal period in months or even sometimes to a year[4]. In addition to psychological damage, physical damage - mainly Fly species were placed separately on the Methamphetamine cardiovascular damage - can occur with chronic use or severe mixture and reared at 20 ° C in Plastic containers covered with overdoses and Misuse of analgesic drugs, such as gauze and tightly sealed. The day of larvae emerging from eggs Methamphetamine were responsible for thousands of deaths a was determined. 100 larvae were used for each species. Then year according to National Statistics Methamphetamine use kept for rearing at room temperature.About ten larvae of each has a significant correlation with depression and suicide species from both replicators and controls were individually

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weighed during 24- 54 hours. The larvae were moved from the The larvae susceptibled to Methamphetamine began and liver to a new culture consisting of yeast, milk, casein, agar and completed the the pupariation befor those in control, with a water[8]. To study their growth, the start and the end of difference of about 13 hours during this stage (Figure 2). There Pupariation time and the time of adult émergence was also were no significant differences In the duration of pupariation studied. between larvae exposed to Methamphetamine and control for RESULTS : both species. The larvae exposed to the drug of both species have been introduced early pupariation time (starting and end). All liver samples provided were positive for the analysis of in comparison with control treatments. When we compare both Methamphetamine. No differences in weight were found species, the C. albiceps began at 100hours and the operation between control and treatment in any species during the early ended within 120 hours, while C. putoria started at 125 hours hours. The larvae of C. albiceps in the treatment (drug- and the operation completed within 145 hours (Figure 3-4). exposed) developed faster than those control, but on the conrast with C. putoria. The larvae of C. albiceps treated with Methamphetamine developed a little in comparison with control liver after 24hours of liver contact. There was no significant difference between therapeutic treatments and control for the larvae of C. putoria. There were no significant differences for C. albiceps after 30 and 40 hour weight, but the larvae of C. putoria susceptible to drug developed significantly faster than those in control treatment. The larvae of both species grew over their controls. The C. putoria weight fed on the Methamphetamine -treated livers was twice compared to control after 54 hours after exposure, (Figure 1-2) Figure 3 : Pupariation time (in h) of each C. albiceps larva exposed to Methamphetamine

Figure 1 : Body weight (mg) of C. albiceps versus time (in h) of exposure to control and Methamphetamine treated rabbit livers. Figure 4 : Pupariation time (in h) of each C. putoria larva exposed to Methamphetamine There were significant differences in the time of adult emergence due to exposure to drugs; The flies exposed to drugs was emerged within 60 hours before control. Despite of the presence of a significant difference for each species, no significant differences appeared in the life cycle of the two species, though the pupariation of C. putoria was later than C. alpiceps The adults of the two species took the same amount of time to appear, i.e. 216 hours (Figure 5). In relation to the two species, the duration of the larval stage and the duration of the pupariation were significantly less for Figure 2 : Body weight (mg) of C. putoria larvae, versus time (in h) of exposure to control and the treatments than the controls, indicating the impact of Methamphetamine treated rabbit livers Methamphetamine on the development of dipteran. The

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development rates of larvae and pupae were compared, as were duration about for pupariation (18-36 hours) in comparison the adult onset of Methamphetamine exposed with control.in with controls and there were no significant differences in the conclusion, the drug impacted significantly (P <0.0001) (F = larval development and the weight of C. vicina wheh esposed 13.58) on the all life cycle stages. to 3 different concentrations[12]. the growth of chysomya megacephala decreased ,where the weigh and lenthg of larva exposed to butyl scopolamine was lower than control [13]. In short, the data of the current research pointed out that there were differences in responding both sarcophagids and calliphorids to drugs, and there may be differences even among species of the same family. Although insect studies are carried out on only a few species, it is possible to predict that changes result from the cocaine impact on developmental process may be present in the other Diptera species. Figure 5 : Emergence time (in h) of each species of blowfly larva exposed to Methamphetamine The obtaining of an accurate and clear explanation, toxic information associated with insect data as well as the DISCUSSION : information of death site and autopsies are very necessary to In forensic analysis, the recognition of insect species in a establish the cause of death due to poison or drugs, and decomposed bodies and the analysis of their developmental accurately estimates the PMI. Therefore, cooperation between [14] stages can be a good benefit when considering the association experts from various fields is a very important issue . with the other information of environment conditions of the CONCLUSION : crime sites. These elements can assist to estimate the PMI, The drug effects on C. albiceps and C. putoria may change the investigate if the carcasses have been transferred after death, time to develop and generates errors in estimating PMI by check for pre-death injuries, and obtain information related to insect techniques and the development of larvae and pupa for [9] the drugs or toxins found in bodies . These variables are very both species was accelerated as a result of the effect of important for forensic researchers. This study confirmed that Methamphetamine . Thus, the absence of data associated with the life cycle of forensically important insects was alterd by the drugs in the PMI estimating based on normal development of presence of drugs or foreign substances which took by persons both species may lead to serious errors. before death[10]. REFERNCES : Several drug distribution patterns were observed when they 1 Jones AW, Holmgren A, Kugelberg FC. Concentrations of compared the concentrations of drug present in human tissues cocaine and its major metabolite benzoylecgonine in and feeding and post feeding larvae , which were probably blood samples from apprehended drivers in Sweden, associated with differences in physiological patterns Forensic Sci. Int. 2008;177:133-139. Campobasso et al[11]. 2 Mack AH, Frances RJ, Miller SI. Clinical Textbook of The experiments of this study pointed out that The longer the Addictive Disorders, Third Edition. New York: The exposure period, the weight the body is affected. More Guilford Press.2005 importantly, the relationship between larval body weight was different between the two species examined . This difference is 3 Logan BK. Methamphetamine Effects on Human due to differences in species in their interactions with the drug, Performance and Behavior. Forensic Science Review. such as differences in secretion rates or bioaccumulation. 2002;14(1/2):142 These results have significant implications to estimate PMI 4 Cruickshank CC, Dyer KR. A review of the clinical through insect techniques in the cases include pharmacology of methamphetamine. Addiction. Methamphetamine. In this study, we found that the growth rate 2009;104 (7): 1085-99. varies between drug-exposed species as compared to those not 5 Darke S, Kaye S, McKetin R, Duflou J. Major physical exposed, as well as between species. The larval development and psychological harms of methamphetamine use. Drug of P. peregrina was accelerated and shorten by cocaine, and Alcohol Rev. 2008;27(3):253-62. ecgonine 30-78 hours, resulting in the early pupariation Goff 6 Carvalho LML, Linhares AX, Trigo JR. Determination of [7] et al . The effect of heroin on the larval development was drug levels and the effect of diazepam on the growth of investigated, where the larvae exposed to heroin took longer necrophagous flies of forensic importance in southeastern

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Brazil, Forensic Sci. Int. 2001;120:140-144. 7 Goff ML, Omori AI, Goodbrod JR. Effect of cocaine in tissues on the development rate of Boettcherisca peregrina (Diptera: Sarcophagidae), J. Med. Entomol. 1989; 26:91-93. 8 Leal TTS, Prado AP, Antunes AJ. Rearing the larvae of the blowfly C. chloropyga (Wiedemann) (Diptera: Calliphoridae) on oligidic diets, Revta. Bras. Zool. 1992;1:41-44. 9 Goff ML, Lord WD. Entomotoxicology: a new area for forensic investigation. Am. Forensic Med. Pathol. 1994;15:51-57. 10 Introna F, Campobasso CP, Goff ML. Entomotoxicology. Forensic Sci. Int. 2001;120:42-47. 11 Campobasso CP, Gherardi M, Caligara M, Sironi L, Introna F. Drug analysis in blowfly larvae and in human tissues: a comparative study. Int. J. Legal Med. 2004;118: 201-214. 12 Pien K, Laloup M, Marichal MP, Grootaert P, Boeck G, Samyn N et al. Toxicological data and growth characteristics of single post-feeding larvae and puparia of Calliphora vicina (Diptera: Calliphoridae) obtained from a controlled nor diazepam study. Int. J. Legal Med. 2004;118:190-193. 13 Oliveira HG, Gomes G, Morlin JJJ, Zuben CJV, Linhares AX. The effect of Buscopan on the development of the blow fly Chrysomya megacephala (F.) (Diptera: Calliphoridae), J. Forensic Sci. 2009;54:202-206. 14 Campobasso CP, Introna F. The forensic entomologist in the context of the forensic pathologist's role. Forensic Sci. Int. 2001;120:132-139.

56 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI: 10.5958/0974-083X.2020.00009.6 Original Research Paper Investigation of Demographic Variables and Types of Suspension in Suicidal Hanging 1. Azadeh Memarian, Department of Forensic Medicine, Iran University of Medical Sciences, Tehran, Iran 2. Kamran Aghakhani, Department of Forensic Medicine, Iran University of Medical Sciences, Tehran, Iran 3. Babak Soltani, Infectious Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran 4. Siamak Soltani, Department of Forensic Medicine, Iran University of Medical Sciences, Tehran, Iran

ABSTRACT : Introduction : Suicide is considered as an intentional self-killing which happened because of complex factors, its rates are various from country to country. Typically, the suicide rate for men are more than women. Selecting an effective way for suicide could influence by complex elements including social, environmental, psychological and physical factors. Materials and Methods : Present cross-sectional study done at Hafte-Tir Medical Center from March 1995 to 2015 on 99 cases of attempted suicide by hanging. Among them, 85 (85.8%) were male and 14 (14.2%) were female. Variables such as age, gender, education, mortality rate, types of suspension, and previous history of suicide attempt were evaluated for these people. Results: Majority of suicides by hanging were done by men, which mainly occurs in the third or fourth decades of their lives. Complete suspension considered as a predictive operation of death. Among the studied variables, types of hanging represented a remarkable statistical difference for prognosis (p-value,0.0001) and survival rate. Conclusions: Our results showed that the percentage of death, as a result of hanging, is higher among men rather than women which might be because of the highest number of men committed to suicide. However, we did not observe significant correlation between mortality of hanging and gender.

Corresponding Author : Article History: Siamak Soltani, Received: 10 December 2018 Assistant Professor, Received in revised form: 2 January 2019 Accepted on: 2 January 2019 Department of Forensic Medicine, Iran University of Medical Available online: 31 December 2019 Sciences, Tehran, Iran Contact : +98 02166551201 Email: [email protected]

KEYWORDS : Suicide; Hanging; Mortality rate; Suspension; Age INTRODUCTION : Typically, suicide rate for men are more than women, with the [9] Suicide is defined as an intentional self-killing arise from possible exception for India and China . Suicide has been complex and tragic outcome of mental illness[1] which makes a considered as a social phenomenon affected by both social and serious public health problem. Complete hanging referred to a human factors. Suicide risks are highly influenced by [12] situation, the body is entirely suspended and the feet are above permanent income and unemployment . Bronisch et al the ground, while in partial hanging the feet or toes have studied relationship between smoking and nicotine contact with the ground[2].Annually about more than one dependence with suicide ideation on German adolescent. million suicides and unsuccessful suicide attempts occur all Based on this assessment, cigarette and its peripherals increase [13] around the world[3]. Therefore, this self-inflicted death known the risk of suicide attempts and ideation . Heroin users are 14 as the second cause of death among youth people while, its times more prone in comparison with peers to attempt [14] global rates have increased by 60% in the last 45 years[4]. suicide . Selecting a physical method of suicide depends on Suicide behavior comes from complex factors[5-6] and its rates not only its availability for individuals but also on social [15] are various from nation to nation; for example Nigeria has the acceptability . In developed nations, specific ways are used lowest rate in contrary to Geneva (as high as 22.7/100,00)[7-8]. for suicide, such as self-poisoning by drugs, firearms, jumping [16] Generally, the highest rate of suicide belongs to Eastern from height, drowning and hanging . While in developing Europe and the lowest one is in central and south America. On countries, suicide with burning and agricultural liquids are [17-18] the other hand, continent such as Asia and Western Europe more common . Choosing one of these ways are influenced [19- shows a mid-range[9]. Suicide rates vary according to age, by social, environmental, psychological and physical factors 20] gender, race, socioeconomic, marital status, ethnic, origin, and . This study aim to assess the rate of suicidal hanging between death registration practices[10-11]. the years of 1995 to 2015 for individuals referred to Hafte Tir

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medical center, Tehran, Iran. 16.5% of them were illiterate, 2.4% had an elementary level of MATERIALS AND METHODS : education, 78.8% had a secondary education level up to diploma, and higher education diploma was seen in 2.4% of After taking approval from the ethics committee of HafteTir men. Hospital in Tehran, the present study was conducted on Ninety-nine cases of attempted suicidal hanging. Variables Distributions of cases based on previous history of suicide such as age, gender, education, previous history of suicide attempt was as per Table no. 3. 4.7% of men and 7.1% of attempt, patterns of hanging and mortality rate were evaluated women had a history of suicide (P-value = 0.541) and no for these cases. Only cases with complete documents and significant difference obtained for these two genders. referred to HafteTir Medical Center from March 1995 to 2015, Table 3 : Distribution of cases depending on previous were examined. Confidentiality of information was history of suicide attempt. maintained by not mentioning any names of the patients during Gender this research. P-value Male Female Data analysis : The results for quantitative variables Having a history 4 (4.7) 1 (7.1) expressed as mean and standard deviation, and qualitative of suicide variables were expressed as a percentage. Chi-square test and No history of suicide 81 (95.3) 13 (92.9) 0.7 Fisher's exact test was performed to compare the qualitative variables.Finally, statistical analysis was performed using Total 85 (100) 14 (100) SPSS statistical software. 96.5% of surviving persons and 28.6% of dead ones RESULTS : represented partial hanging (Table 4). Consequently, there was In total, 99 cases of attempted suicide by hanging were studied, a statistically significant difference between type of hanging which among them, 85 cases (85.8%) were male and 14 and prognosis (p-value<0.0001) (14.2%) were female. (Table 1) Table 4. Pattern of suspension for men and women Table 1 : Distribution of Suicide in Men and Women Prognosis P-value Sex Number * Age (range) Alive Dead Men 85 (85.8) 31.55 ± 14.58 (13-64) Incomplete hanging 82 (96.5) 4 (28.6) Women 14 (14.2) 33.36 ± 11.41 (18-56) Complete hanging 3 (3.5) 10 (71.4) Total 99 (100) <0.0001 In terms of age, the mean age in males was 31.55 ± 14.58 in the Total 85 (100) 14 (100) range of 13 to 64 years. While, the mean age in women was 33.36 ± 11.41 ranging from 18 to 56 years old. It was not a The frequency of mortality was shown in Table 5, in which significant difference between men and women (P-value = mortality rate in women (21.4) was higher than men (12.9), but 0.692) this difference was not statistically significant (p-value = 0.413) History of drug addiction : Table 5 : Distribution of mortality in men and women In men 25.9% addicted to opium and 18.8% addicted to Sex amphetamines. While, addiction in women to opium and P-value Male Female amphetamines were 14.3% and 14.3%, respectively (P-value = 0.538). These data showed no significant difference between Death 11 (12.9) 3 (21.4) men and women (Table 2). Alive 74 (87.1) 11 (78.6) 0.398 Table 2 : Type of substance abuse in Women and Men Gender Total 85 (100) 14 (100) P-value Male Female Consumption DISCUSSION : of opium 22 (25.9) 2 (14.3) Suicide is considered as a multifaceted phenomenon which is a Consumption [21] of amphetamines 16 (18.8) 2 (14.3) 0.538 confluence of genetic, social and psychological risk factors . No addiction 47 (55.3) 10 (71.4) Complexity and low base rate of this phenomenon cause a serious obstacle for investigation in this area. However, Total 85 (100) 14 (100)

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recognition of suicide prevention and finding effective ways to Generally, hanging is the most prevalent suicide method improve detection and cure of those suspected to suicide have compare with other methods like firearm, poisoning and been considered as a priority for public health in many jumping from high place. However, in some regions, other countries[22]. Suicidal hanging among young women have methods are more common[35,39]. Rezaeian et al considered significantly increased in some countries such as Australia and hanging as a favorable suicide method, especially among New Zealand[23-24]. Based on a research done by Gunnell and women in Tehran, Iran, during the year 2000 to 2004[40]. Also, it coworkers on suicide by hanging, most of hanging suicides has shown that the rate of hanging suicide among other occur in the community through available ligatures including methods of self-killing increased 2.3% between 1999 and rope and flex. Furthermore, many factors are involved in 2005[41]. The results of our study showed that the majority of choosing this method[25]. suspensions was incomplete hanging which most of them did Our survey has depicted that hanging suicide rates are much not lead to death, while the majority of complete hanging higher for men and decrease with age[26]. Bayramoglu et al suicides lead to death. Also, these results demonstrated a showed that rate of hanging suicide in men were higher than significant correlation between pattern of suspension and the women, but age had no effective influence on suicide prognosis outcome of patients (P< 0.001). Comparable with attempt[27]. Higher suicide rate for men attributed to the our results, Pradhan and colleagues assessed hanging on 44 influence of different lifestyle and social conditions[28]. cases with partial and complete suspension & the majority of suspension was incomplete[42]. Matsuyama et al investigated on Substance abuse or dependent smoking, has been associated factors affecting the outcome of suicidal hanging & only three with using opiates[29-30]. In relevant studies, suicide risk for individuals survived among thirty-nine patients[43]. consumption of psychotropic substances and smokers have been assessed[31-32]. Nicotine consumption has shown a direct Previously it has shown that the number of incomplete hanging connection with arising suicidal risk especially in men[33]. among females is higher than males, so, the alive outcome has [42] Holly et al studied the relationship between completed suicide been more observed among females . In another study in and drug use disorders, opioid use disorders, stratified by sex China, the fatality of hanging was observed significantly [44-45] and expressed that individuals with opioid usages endure a higher in male individuals than females . Our results higher risk for suicide[34]. However, the result of our study is in showed that the percentage of death, as a result of hanging, is opposition with those mentioned above and no correlation was higher among men rather than women which might be because observed between substance abuse (either opium or of the highest number of men committed to suicide. However, amphetamines) and the risk of suicide. we did not observe significant correlation between mortality of hanging and gender. Regarding the relation between suicide and educational level, Shojaei et al has shown that the hanging method is a frequent CONCLUSIONS : method among persons with lower educational level[35]. In spite of some limitations regarding the present study, like the According to our findings, the number of illiterate individuals low number of sample population, investigation of committed to suicide are more than educated person; however, demographic features and pattern of suspension are the no significant correlation was observed between educational remarkable strength of this study. Also, we propose larger level and the rate of suicide (P = 0.471). Also, compatible with sample along with multicenter study to achieve more precise our results, no significant association was observed between results. Since suicidal hanging is one of the most relevant suicide risk and level of education in high school students[36]. methods of self-killing all around the world, these presented Thus, the educational level might not be a reliable factor to data could reflect the fact that suicidal hanging method is more assess risk of suicide. common because of its availability and much easier to obtain Although we did not observe a significant relation between for the population. As a result, prevention of this incident history of hanging and its second commission (P value = 0.7), disaster needs authorities' attention to reasons for committing our results suggest that the number of hanging suicide among suicide rather than to the accessibility of suicidal methods, and individuals with previous history of hanging is lower than suggesting a need for research exploring changes that may be those without previous attempt. This finding is comparable adversely affecting the middle-aged. with results of González-Castro et al which demonstrated that Author's Contribution : the probability of hanging suicide decreased with increase of Concept & Design of Study : Azadeh Memarian, Siamak [37] previous attempts . Also, it has shown than men with history Soltani of hanging were observed to more likely do it again rather than Drafting : Kamran Aghakhani women, which is in consonant with our finding[38].

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Data Analysis: Babak Soltani 15. Marzuk PM, Leon AC, Tardiff K, Morgan EB, Stajic M, Revisiting Critically & Final Approval of version:: Siamak Mann JJ. The effect of access to lethal methods of injury Soltani on suicide rates. Archives of general psychiatry. 1992;49:451-8. Conflict of Interest: None 16. Cantor CH, Turrell G, Baume P. Access to Means of REFERENCES : Suicide by Young Australians: A background report: 1. Service UPH. The Surgeon General's call to action to Australian Institute for Suicide Research and Prevention. prevent suicide. Washington, DC: author; 1999. 1998;32:8-14. 2. Saukko P. Knight b. Knight's forensic pathology 3rd ed 17. Adityanjee D. Suicide Attempts and Suicides in India London: Arnold. 2004;340:513. Cross-Cultural Aspects. International Journal of Social 3. Mann JJ. Neurobiology of suicidal behaviour. Nature Psychiatry. 1986;32:64-73. Reviews Neuroscience. 2003;4:819-28. 18. Somasundaram D, Rajadurai S. War and suicide in 4. Organization WH. The World Health Report 2001: northern Sri Lanka. Acta Psychiatrica Scandinavica. Mental health: new understanding, new hope: World 1995;91:1-4. Health Organization; 2001. 19. Bille-Brahe U, Jessen G. Suicide in Denmark, 5. Taylor PJ, Gooding PA, Wood AM, Johnson J, Pratt D, 1922–1991: The choice of method. Acta Psychiatrica Tarrier N. Defeat and entrapment in schizophrenia: The Scandinavica. 1994;90(2):91-96 relationship with suicidal ideation and positive psychotic 20. Nishimura A, Shioiri T, Nushida H, Ueno Y, Ushiyama I, symptoms. Psychiatry research. 2010;178:244-8. Tanegashima A, et al. Changes in choice of method and 6. Panagioti M, Gooding P, Taylor PJ, Tarrier N. A model of lethality between last attempted and completed suicides: suicidal behavior in posttraumatic stress disorder how did suicide attempters carry out their desire? Legal (PTSD): The mediating role of defeat and entrapment. Medicine. 1999;1:150-8. Psychiatry research. 2013;209:55-9. 21. Mauri M, Oppo A, Borri C, Banti S. Suicidality in the 7. Janghorbani M, Sharifirad G. Completed and attempted Perinatal Period comparison of two self-report suicide in Ilam, Iran (1995-2002): Incidence and instruments. Results from PND-ReScU.Arch Womens associated factors. Archives of Iranian Medicine. Ment Health. 2012;15(1):39-47. 2005;8:119-26. 22. Lapierre S, Erlangsen A, Waern M, De Leo D, Oyama H, 8. La Harpe R. Suicide in the Geneva canton (1971-1990). Scocco P, et al. A systematic review of elderly suicide An analysis of the forensic medicine autopsy sample. prevention programs. Crisis. 2011;32(2):88-98. Archiv fur Kriminologie. 1994;195:65-74. 23. Wilkinson D, Gunnell D. Comparison of trends in 9. Nock MK, Borges G, Bromet EJ, Cha CB, Kessler RC, method-specific suicide rates in Australia and England & Lee S. Suicide and suicidal behavior. Epidemiologic Wales, 1968–97. Australian and New Zealand journal of reviews. 2008;30:133-54. public health. 2000;24(2):153-7. 10. O'Carroll PW, Berman AL, Maris RW, Moscicki EK, 24. Beautrais AL. Methods of youth suicide in New Zealand: Tanney BL, Silverman MM. Beyond the Tower of Babel: trends and implications for prevention. Australian NZJ a nomenclature for suicidology. Suicide and Life- Psychiatry. 2000;34(3):413-9. Threatening Behavior. 1996;26:237-52. 25. Clarke RV, Lester D. Explaining choice of method. 11. Mościcki EK. Identification of suicide risk factors using Suicide: Closing the Exits: Springer; 1989. p. 85-95. epidemiologic studies. Psychiatric Clinics of North 26. Daly MC, Mary C, Wilson DJ, Johnson NJ. Relative America. 1997;20:499-517. status and well-being: evidence from US suicide deaths. 12. Hamermesh DS, Soss NM. An economic theory of Review of Economics and Statistics. 2013;95:1480-500. suicide. Journal of Political Economy. 1974;82:83-98. 27. Bayramoglu A, Saritemur M, Gur STA, Emet M. 13. Bronisch T, Höfler M, Lieb R. Smoking predicts Demographic and clinical differences of aggressive and suicidality: findings from a prospective community study. non-aggressive suicide attempts in the emergency Journal of affective disorders. 2008;108:135-45. department in the eastern region of Turkey. Iranian Red 14. Darke S, Ross J. Suicide among heroin users: rates, risk Crescent medical journal. 2015;17(2):e24666. factors and methods. Addiction. 2002;97:1383-94. 28. Möller-Leimkühler AM. The gender gap in suicide and

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premature death or: why are men so vulnerable? European most common method of suicide in Tehran 2000–2004: archives of psychiatry and clinical neuroscience. implications for prevention. Crisis. 2008;29:164-6. 2003;253:1-8. 41. Hu G, Wilcox HC, Wissow L, Baker SP. Mid-life suicide: 29. Brook DW. Brook JS, Zhang C, Cohen P, Whiteman M. an increasing problem in US Whites, 1999–2005. Drug use and the risk of major depressive disorder, American journal of preventive medicine. 2008;35:589- alcohol dependence and substance use disorders. Arch 93. Gen Psychiatry. 2002;59(11):1039-44. 42. Pradhan A, Mandal B, Tripathi C. Hanging: nature of 30. Black DW, Zimmerman M, Coryell WH. Cigarette ligature material applied and type of hanging according to smoking and psychiatric disorder in a community sample. point of suspension. Nepal Med Coll J. 2012;14:103-6. Annals of Clinical Psychiatry. 1999;11:129-36. 43. Matsuyama T, Okuchi K, Seki T, Murao Y. Prognostic 31. Hawton K, Simkin S, Rue J, Haw C, Barbour F, Clements factors in hanging injuries. The American journal of Ae, et al. Suicide in female nurses in England and Wales. emergency medicine. 2004;22:207-10. Psychological medicine. 2002;32:239-50. 44. Sun J, Guo X, Zhang J, Wang M, Jia C, Xu A. Incidence 32. Tanskanen A, Tuomilehto J, Viinamäki H, Vartiainen E, and fatality of serious suicide attempts in a predominantly Lehtonen J, Puska P. Smoking and the risk of suicide. Acta rural population in Shandong, China: a public health Psychiatrica Scandinavica. 2000;101:243-5. surveillance study. BMJ Open. 2015;5:e006762. 33. Schneider B, Schnabel A, Weber B, Frölich L, Maurer K, 45. Farmer R, Rohde J. Effect of availability and acceptability Wetterling T. Nicotine use in suicides: a case–control of lethal instruments on suicide mortality an analysis of study. European Psychiatry. 2005;20:129-36. some international data. Acta Psychiatrica Scandinavica. 34. Wilcox HC, Conner KR, Caine ED. Association of 1980;62:436-45. alcohol and drug use disorders and completed suicide: an empirical review of cohort studies. Drug and alcohol dependence. 2004;76:S11-S9. 35. Shojaei A, Moradi S, Alaeddini F, Khodadoost M, Barzegar A, Khademi A. Association between suicide method, and gender, age, and education level in Iran over 2006-2010. Asia Pac Psychiatry. 2014;6:18-22. 36. Denny S, Farrant B, Utter J, Fleming T, Bullen P, Peiris- John R, et al. The Prevalence of Postgraduate Education in Youth Health Among High School Clinicians and Associated Student Health Outcomes. J Adolesc Health. 2016;59:555-61. 37. Gonzalez-Castro TB, Hernandez-Diaz Y, Tovilla-Zarate CA, Gonzalez-Gutierrez KP, Fresan A, Juarez-Rojop IE, et al. Differences by gender in completed suicides in a Mexican population: A psychological autopsy study. J Forensic Leg Med. 2016;38:70-4. 38. Callanan VJ, Davis MS. Gender differences in suicide methods. Soc Psychiatry Psychiatr Epidemiol. 2012;47:857-69. 39. Varnik A, Kolves K, van der Feltz-Cornelis CM, Marusic A, Oskarsson H, Palmer A, et al. Suicide methods in Europe: a gender-specific analysis of countries participating in the "European Alliance Against Depression". J Epidemiol Community Health. 2008;62:545-51. 40. Razaeian M, Mohammadi M, Akbari M, Maleki M. The

61 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00014.X Original Research Paper Paediatric Autopsy Study at G B Pant Hospital, ANIIMS, Port Blair, Andaman & Nicobar Islands 1. Siddesh Revpla Channabasappa, Assistant Professor, Department of Forensic Medicine, Saveetha Medical College, Thandalam, Chennai, Tamil Nadu 2. Udayashankar Yadiyapur, Associate Professor, Department of Forensic Medicine, ANIIMS, Port Blair, South Andaman

ABSTRACT : Introduction : There are 572 Islands in the Andaman & Nicobar group with an area measuring 8249 Sq. KM., among them only 32 islands are inhabited, Port Blair, being its capital city. Medico legal deaths claim a substantial number of lives in Andaman & Nicobar Islands including pediatric age group. Pediatrics is the branch of medical science dealing with children and their diseases. Accidents & Violence are major killers of children and adolescents under the age of 18 years throughout the world and are responsible for about 950000 deaths each year. Material and Methods : Out of 572 autopsies performed during the study period from January 2015 to December 2017 for three years, 98 victims belongs to the pediatric age group at the Department of Forensic Medicine & Toxicology, G B Pant hospital, ANIIMS, Port Blair, Andaman & Nicobar Islands. The purposes of this study were to report the autopsy findings of unnatural child deaths and to identify the prevalence of specific factors such as age, sex, postmortem findings, cause of death and manner of death. Results : The adolescent age group (12–18 years) were most commonly affected, with a significant male preponderance. Many of the cases were accidental in nature with road traffic accident & drowning being the leading causes of death. There was much coexistence of the parameters typical of both industrialization and population explosion in developing countries, indicating the epidemiological transition. Conclusions : It is important to find out the origin and causes of childhood deaths to guide health policies in preventing the unnatural deaths. Besides, different legal approaches & laws are also needed to prevent these causes.

Corresponding Author : Article History: Dr. Siddesh Revpla Channabasappa Received: 30 May 2019 Assistant Professor, Received in revised form: 25 June 2019 Accepted on: 25 June 2019 Department of Forensic Medicine, Saveetha Medical College, Available online: 31 December 2019 Thandalam, Chennai, Tamil Nadu Contact : +91 9474268729 Email : [email protected]

KEYWORDS : Pediatric autopsy, Unnatural childhood deaths, Cause of death, Manner of death.

INTRODUCTION : also relate to a sense of parents neglect to protect children from [1-2] Pediatrics is the discipline concerned with the well-being of harm . infants, children and adolescents, including their health Injuries remain the major problem because of the effects on (physical, mental, psychological), growth/development and social, physiological, economic and medical issues. Besides, their opportunity to achieve full potential as adults. Autopsies they are a severe problematic part of public health[2]. in Pediatric cases serve a variety of useful and important roles AIMS AND OBJECTIVES: not only for Forensic Medicine purpose but also for medical 1. To find out the socio-demographic profile (age, sex, socio- researches. economic status) of pediatric unnatural deaths There are 572 Islands in the Andaman & Nicobar group with 2. To report the autopsy findings an area measuring 8249 Sq. KM. Among them only 32 islands are inhabited, with population of about 8 lakh, Port Blair, 3. To find out the cause & manner of death, pattern of deaths being its capital city. Medico legal deaths claim a substantial and seasonal variation of pediatric unnatural deaths number of lives in Andaman & Nicobar Islands. G B Pant MATERIAL S AND METHODS : hospital is the only tertiary care center for whole Andaman & The Present study was conducted from 1st January 2015 to Nicobar Islands population. Paediatric autopsy includes 31st December 2017, which included a total of 572 autopsies postmortem examination of unnatural childhood deaths up to conducted at the Department of Forensic Medicine & the age of 18 years. Unnatural childhood deaths are not only Toxicology, G B Pant hospital, ANIIMS, Port Blair, Andaman associated with intense trauma and separation distress, but 62 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00014.X

& Nicobar Islands. Out of 572 autopsies performed during the deaths were due to throttling, 1(1.02%) case of assault and 2 study period, 98 (17.13%) victims belonging to the pediatric (2.04%) deaths which were classified as others were due to dog age group were the material of this study. bite & fall of wooden slab from height while playing. (Table 4) Table 3 : Age wise distribution of cases The data was collected regarding the age, sex, manner and cause of death through police inquest, direct interrogation with Age Infant Toddler Preshool School Adolescent Total the relatives/friends and autopsy reports. The data thus (Up to (1-3 (3-6 (6-12 (12-18 1 Year) Years) Years) Years) Years) obtained was statically analyzed using SPSS software. Year Pediatric deaths due to natural causes & decomposed bodies 2015 1 5 4 6 16 32 were excluded. RESULTS: 2016 1 6 3 4 14 28 Out of total 572 autopsies, 98 (17.13%) cases were pediatric 2017 2 8 6 5 17 38 unnatural deaths and the rest 474 (82.87%) cases were adult Total 4 19 13 15 47 98 autopsies. %age 4.08% 19.38% 13.26% 15.30% 47.95% 100% 32 (16.66%) cases were autopsied in 2015, 28 (15.21%) cases in 2016 and 38 (19.38%) cases in 2017 (Table-1). Table 4 : Causes of death No. Table 1 : Year Wise Distribution of Cases S l . Cause of Death %age No. of Year Total Cases Paediatric %age Cases Cases 1 Road Traffic Accident 24 24.48% 2 Accidental Drowning 18 18.36% 2015 192 32 16.66% 3 Poisoning 15 15.30% 2016 184 28 15.21% 4 Thermal Injuries 13 13.26% 5 Hanging 12 12.24% 2017 196 38 19.38% 6 Snake Bite/Scorpion Sting 06 06.12% 7 Fall From Height 05 05.10% Total 572 98 17.13% 8 Throttling 02 02.04% 9 Assult 01 01.02% In the current study out of 98 pediatric autopsies, there were 55 10 Other 02 02.04% male cases (56.12%) and 43 female cases (43.87%). (Table 2) Total 98 100% In the current study among manner of death, it showed that out Table 2 : Sex & Year wise distribution of Cases of a total of 98 Paediatric unnatural death cases autopsied, 74 Year Male Female Total (75.51 %) pediatric cases died due to accidental causes 2015 20 12 32 includes Road Traffic Accident, Accidental drowning, Accidental Poisoning, Accidental burns, scalds & 2016 15 13 28 electrocution, Snake bite / scorpion sting, fall from height & 2017 20 18 38 other causes like dog bite, fall of wooden slab from height Total 55 (56.12%) 43 (43.87%) 98 while playing , 20 (20.40 %) pediatric deaths were suicidal includes poisoning, burns & hanging and 4 (4.08 %) pediatric Out of 98 cases 4 (4.08%) were in the age group of < 1 year, 19 unnatural deaths were homicidal in manner. (Pie chart 1) (19.38%) were in the age group of 1-3 years, 13 (13.26%) were in the age group of 3-6 years, 15 (15.30%) were in the age group of 6-12 years and 47 (47.95%) were in the age group of 12-18 years (Table 3). Out of 98 cases, 24 (24.48%) deaths were due to road traffic accidents, 18 (18.36%) deaths were due to accidental drowning, 15(15.30%) deaths were due to poisoning, 13 (13.26%) deaths were due to thermal injuries like scalds (7), burns(5) and electrocution(1), 12 (12.24%) deaths were due to hanging, 6 (6.12%) deaths were due to snake bite/scorpion sting, 5 (5.10%) deaths were due to fall from height, 2 (2.04%)

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Out of 74 (75.51 %) pediatric accidental deaths cases accidents (MVAs) are the leading causes of death in children autopsied, 24 deaths were due to Road Traffic Accident, 18 aged 1-18 years, followed by suicide (predominantly by poison deaths were due to Accidental drowning, 10 cases were due to & hanging) or homicide[1-2]. Accidental burns, Scalds & Electrocution, 09 deaths were due In our study Paediatric autopsy constituted 17.13 % of total to Accidental Poisoning, 06 cases were due to Snake bite / autopsies conducted. This was almost similar to study done at Scorpion sting, 05 cases due to fall from height & 2 cases due to Manipal[3-4] (10.12 %), Jammu[5] (12.25 %), Brazil[6] (21 %), other causes like dog bite, fall of wooden slab from height Transkei region of South Africa[7] and John R Hall study[8]. Our while playing. (Table 5) study is in contrast with the study done at Kuala Lumpur which Table 5:- Pattern of accidental death accounted for only 4.9 % of total autopsies[9]. S l . Cause of Death No. In the present study out of 98 pediatric unnatural deaths, 55 No. of Cases (56.12 %) were males and 43 (43.87 %) were females and male 1 Road Traffic Accident 24 predominance was obvious. This parameter is in concurrence [3] 2 Accidental Drowning 18 with studies done at Manipal (55.5% male and 44.5% female) 3 Burns & Scalds 10 and studies done by John R Hall & coworkers[8] (50.5% male 4 Accidental Poisoning 09 and 49.5% female), Kim A Collins & coworkers[10] (57.5% 5 Snake Bite/Scorpion Sting 06 male and 42.5% female), Jonathan P Wyatt & coworkers[11] 6 Fall From Height 05 (60.5% male and 39.5% female), Frederic P Rivara & 7 Other 02 [12] Total 98 coworkers (56.5% male and 43.5% female). The reasons for male preponderance is that, they are more active compare to Among 20 (20.40 %) suicidal cases, 12 deaths were due to the female counterpart throughout the childhood days. In Hanging, 5 were due to suicidal poisoning and 3 cases were contrast to this, female predominance was noted in studies due to burns. (Table 6) conducted by Pramod Kumar & coworkers[13] (57.4% female [14] Table 6:- Pattern of Suicidal death and 42.6% male) and Byard RW & coworkers (53.3% female and 46.7% male). S l . Cause of Death No. No. of The age wise distribution of unnatural child hood death in our Cases study, shows gradual increase in the number of fatalities from 1 Hanging 12 toddler to adolescent age group and adolescent 47.95 % were 2 Suicidal Poisoning 05 predominantly involved. This was in agreement with the study Burns 03 3 [4] Total 20 done by Palimar V et al . The reasons being adolescents are more exposed to external environment and are adventurous, Among 4 (4.08 %) homicidal deaths, 2 deaths were due to rebellious in nature at this age and their impulsive nature. throttling, one each was of homicidal poisoning & assault. (Table 7) In the present study when the manner of death was taken into consideration, accidental deaths topped the list with 74 Table 7: Pattern of Homicidal death (75.51%) cases followed by 20 (20.40 %) suicide cases and the S l . Cause of Death No. of least being 4 (4.08 %) homicidal cases. These findings were No. [4] Cases correlating with the studies done by Palimar V et al and Meel [7] 1 Throttling 2 BL . 2 Poisoning 1 In the current study among accidental manner of death, out of 3 Assault 1 74 (75.51 %) pediatric accidental deaths cases autopsied, 24 Total 4 deaths were due to Road Traffic Accident, 18 deaths were due DISCUSSION: to Accidental drowning, 10 cases were due to Accidental burns, Injury and violence are major killers of children throughout the scalds & electrocution, 09 deaths were due to Accidental world, responsible for about 950000 deaths in children and Poisoning, 06 deaths were due to Snake bite / scorpion sting, 05 young people under the age of 18 years each year. In 1990, deaths were due to fall from height & 2 deaths were due to other injuries in the developing countries contributed to 13% of total causes such as dog bite, fall of wooden slab from height while disability adjusted life years among children. It is expected that playing. This was similar to the conclusions drawn by the by 2020, this share will increase to 22%. Injuries in any form paediatric Death review Committee report 2010 of the deaths remain the major killer in 44% of the death among children of 1 on the province of Ontario[15]. to 4 years of age and 74% among 15 to 18 years. Motor vehicle

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Road traffic accidents were predominated in study done at necessities of life such as food, shelter, education and Manipal[3] and studies done by Palimar V et al[4], Meel BL[7], marriage. This may be the reason of female homicidal deaths. [11] [16] Jonathan P Wyatt & coworkers , Meiers S & coworkers and CONCLUSION: Williamson LM & coworkers[17]. The road traffic accidents Accidents accounted for the majority of childhood unnatural being more common could be attributed easy access to two deaths. The Road Traffic Accidents, accidental drowning, wheelers at an early age and rash driving methods adopted by accidental burns & scalds are leading causes of death. the children and adolescents. Also reflexes may not act well in Adolescent males in the age group of 12-18 years are a child when a fast approaching vehicle is seen coming towards commonly involved. This indicates that an immense the child and the road may be a playground for the children responsibility lies with the parents and caregivers to prevent resulting in death due to a RTA. such childhood deaths. Accurate information on causes and Deaths due to accidental drowning were also more circumstances of such deaths through a process of medico- predominant, occurred mainly during summer & winter legal investigations is essential in creating an awareness holidays, out of 18 drowning deaths, 16 deaths were due to salt among the National policy makers and educators/caregivers, to water drowning as because of high accessibility to sea beaches prevent this type of childhood unnatural deaths. There is an by young children in these Andaman & Nicobar Islands, high urgent need of a policy to prevent accidental drowning cases in curiosity to venture into the sea for recreational activities like sea beaches by respective authorities of Dept. of Tourism & swimming, fishing etc., Administration. A need for further similar studies is stressed & Our study result are in consistent with other studies. Accidental maintenance of Pediatric MLC register to know the pattern of poisoning was common in children below 5 years of age childhood fatalities and legal complications and further whereas suicidal poisoning was more after 13 years of age [18]. reducing the pediatric fatalities in future. To conclude there is a Accidental poisoning predominated in another study done in very little information regarding the number of paediatric Boston[19]. autopsies in developing country like ours. This suggests that In our study, among 20 suicidal deaths, 12 committed suicide each & every centers conducting autopsies should come up by hanging and 5 terminated their life by consuming poison with such studies to reflect the magnitude of occurrence of which were commonly encountered because of their easy unnatural pediatric deaths. accessibility at their agricultural homes, which was the third Ethical Clearance: Ethical clearance is obtained from the most common cause of death in Port Blair, this was in Institutional Ethical Committee, ANIIMS, Port Blair, consistent with the study done at Manipal[3] and Canadian Andaman & Nicobar Islands. [15] statistics . Acknowledgement: We would like to thank our beloved The increase in burn fatalities and accidental consumption of Director Major General (Retd.) Dr. R P Choubey for his kind Kerosene, could be due to use of the kerosene stove or mud support in conducting this study. stove, where fire wood is used or a kerosene or pump stove is Conflict of Interest: None used, resulting in easy accessibility of stove & kerosene to Financial Assistance: Self children's. REFERENCES: The suicidal victims were predominantly females (15 adolescents), which may be due to the sudden emotional nature 1. Yavuz Y, Yürümez Y, Kuçuker H, Fidan H, Korkmaz M, of a female, sometimes blamed to the hormonal changes Traumatic childhood deaths in Afyonkarahisar. Marmara during their menstruation period which is in similarity with the Medical Journal 2007; 20(3); 167-71. studies done by Baca-Garcia E & coworkers[20] , Magos A & 2. Avachat SS, Chavan KD, Phalke DB, Bangal RS. coworkers[21] Fourestie V. & coworkers[22]. Retrospective study of autopsy cases of fatal trauma in In the present study 4 pediatric deaths were homicidal in children in a medical college hospital in rural area. Journal nature. Out of the 4 cases, 2 female were victims of throttling, 1 of Forensic Medicine, Science and Law.2013;22(1):1-5 female was a victim of poisoning and 1 male child who died 3. Bakkannavar M S, Manjunath S, Biradar G, Kumar G P. due to assault/battery, this was in consistent with the studies Paediatric Autopsy Profile at Manipal, South India. Indian done at Manipal[3], united states[14] & Virginia [23]. Here there was Journal of Forensic Medicine and Pathology. a female predominance seen, since the female child was 2011;4(3):101-8. disliked by low socio economic, illiterate families because of 4. Palimar V, Arun M. Prashantha B. Paediatric fatalities due Society stigma, facing difficulties in providing basic to trauma. Medico Legal Update. 2006; 6 (4): 10-12.

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5. Khajuria B, Sharma R, Verma A. A profile of the road children's hospital: A 2 year experience. Pediatrics. 1986; traffic accident victims in Jammu. J of clinical and 77(2): 144-151. diagnostic research. 2008; 2:639 – 642. 20. Garcia E B, Sastre C D, Leon JD, Ruiz J S. The 6. Peres LC, Silva A R. The autopsy in a tertiary teaching relationship between menstrual cycle phases and suicide hospital in Brazil. Annals of Clinical & Laboratory attempts. Psychosomatic Medicine. 62; 2000: 50–60. Science. 2005; 35(4): 387 – 390. 21. Magos A, Studd J. Suicide attempts and the menstrual 7. Meel B L. Mortality of children in the Transkei region of cycle. The Lancet. 1987; 329(8526): 217-18. South Africa. The American Journal of Forensic Medicine 22. Fourestie V, Lignieres BD, Thoraval F R, Lemaire I F, and Pathology. 2003; 24(2): 141-7. Nahoul K, Cremniter D, Fournier S, Lejonc JL. Suicide 8. Hall J R, Reyes H M, Horvat M, Meller J L, Stein R. The Attempts in Hypo-Oestrogenic Phases of the Menstrual mortality of childhood falls. The Journal of Trauma. 1989; Cycle. The Lancet. 1986; 328(8520): 1357-60. 29(9): 1273-5. 23. Virginia Violent Death Reporting System Anna Noller, 9. Bhat S R. Growth: Normal and abnormal. In: Achar's Ten Year Review of Homicide Deaths of Children 17 and textbook of paediatrics, Edited by Bhat S R. 4th Edition, Younger. http:// www.vdh.virginia.gov/ med Exam/ pdfs/ Universities press (India) private limited. 2009; 23. VVDRS_20061.pdf accessed on 02.O1.2014. 10. Collins K A, Nichols C A. A decade of pediatric homicide: A retrospective study at the Medical University of South Carolina. The American Journal of Forensic Medicine and Pathology. 1999; 20(2): 169-172. 11. Wyatt J P, Wyatt P W , Squires T J, Busuttil A. Hanging deaths in children. The American Journal of Forensic Medicine and Pathology. 1998; 19(4): 343-6. 12. Rivara F P, Barber M. Demographic analysis of childhood pedestrian injuries. Pediatrics. 1985; 76(3): 375-381. 13. Kumar P, Chirayil P T, Chittoria R. Ten years epidemiological study of paediatric burns in Manipal, India. Burns. 2000; 26: 261-4. 14. Byard RW, Knight D, James RA, Gilbert J. Murder suicides involving children. A 29- year study. The American Journal of Forensic Medicine and Pathology. 1999; 20(4): 323-7. 15. Paediatric Death Review Committee (PDRC) annual report 2010 June, http://www.mcscs.jus.gov.on.castellent/groups/public/@ mcscs/@www/ @com/ documents/ web asset /ec082796. Pdf accessed on 28.12.2013. 16. Meiers S, Baerg J. Farm accidents in children: Eleven years of experience. J Pediatr Surg 2001. 36(5): 726-9. 17. Williamson LM, Morrison A, Stone DH. Trends in head injury mortality among 0-14 year olds in Scotland (1986- 95). J Epidemiol Community Health. 2002; 56(4): 285- 8. 18. Dutta AK, Seth A, Goyal PK, Aggarwal V, Mittal SK, Sharma R. et.al Poisoning in children: Indian Scenario. Indian Journal of Forensic Medicine and Pathology. 2000; 20(4): 123-7 19. Fazen L E, Lovejoy F H, Crone R K. Acute poisoning in a

66 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00010.2 Original Research Paper Assessment of Sexual Dimorphism of Teeth by Dental Indices 1. Shakthi Dorai, MDS, Former Post graduate, Department of Oral Pathology and Microbiology* 2. N. Srikant, MDS, Professor and Head, Department of Oral Pathology and Microbiology* 3. Karen Boaz, MDS, Professor, Department of Oral Pathology and Microbiology* 4. Amitha J Lewis, MDS, Associate Professor, Department of Oral Pathology and Microbiology* 5. Shweta Yellapurkar, MDS, Assistant Professor, Department of Oral Pathology and Microbiology* 6. Nidhin Philip Jose, MDS, Reader, Department of Orthodontics* *Manipal College of Dental Sciences, Mangalore, Manipal Academy of Higher Education, Manipal, India

ABSTRACT : Background : Odontometry is an important parameter to demonstrate sexual dimorphism. Aim and Objective : The study aimed to assess the efficiency of dental indices in identifying sexual dimorphism in permanent human dentition. Material and Methods : Dental casts (n=101; 49 male and 52 female) were retrieved from the archives. The mesio-distal (MD) and bucco-lingual (BL) dimensions of the permanent teeth (from central incisor to second molar) were measured using digital Vernier Caliper. Crown area, crown module, crown index, incisor and canine index were calculated for each individual. Results and Conclusions : Sexual dimorphism in teeth are attributed to hormonal influence and Y chromosome. The BL dimension is less influenced by attrition compared to the MD dimension making it a better identifier. Discriminant function analysis showed MD dimension of mandibular left canine and crown index of right maxillary premolar as the most reliable predictors. Binary logistic regression analysis showed, the MD dimension of the lower left canine was the single best predictor of gender.

Corresponding Author : Article History: Dr. Srikant .N. Received: 8 May 2019 Professor and Head, Received in revised form: 5 July 2019 Accepted on: 5 July 2019 Department of Oral Pathology and Microbiology Available online: 31 December 2019 Manipal College of Dental Sciences, Mangalore-575001 Contact : +91 9611144234 Email : [email protected]

KEYWORDS : Sexual Dimorphism; Dental indices; Discriminant Functional Analysis; Binary Logistic Regression.

INTRODUCTION: dimorphism. Therefore, 'Dental Indices' like 'crown area', Teeth are the most stable tissues found in the human body, 'crown module' and 'crown index' were derived from simple [4] which are known to resist post-mortem, mechanical, chemical, mathematical combinations of linear measurements . physical and thermal insults[1,2].They are easily accessible for The present study aims to determine the efficiency of dental examination and can be used to identify gender. Systematic indices in predicting sexual dimorphism among the Indian difference in form (either in shape, size or colour) between population. individuals of different sexes in same species is called sexual MATERIALS AND METHODS: dimorphism[2].Teeth shows sexual dimorphism in terms of This retrospective study analysed 101 casts, which were metric and non-metric traits like Carabelli's trait of upper retrieved from the archives of the Department of Orthodontics, molar, deflecting wrinkle of lower first molars, distal MCODS, Mangalore. This included a cohort of 49 females accessory ridge of upper and lower canines and shovelling of and 52 males with intact teeth (from central incisor to second upper central incisors[3]. Among teeth, mandibular canines molar) in the age range of 12 to 38 (mean of 19.29±4.3) years. exhibit greatest sexual dimorphism as they are less exposed to All subjects were native to the administrative district of plaque, abrasion and heavy occlusal loading[1]. Dakshina Kannada, which is geographically distinctive in In the past century sexual dimorphism in relation to tooth size South India. has been explored using linear measurements [buccolingual Casts with multiple missing teeth, severe crowding, cases (BL) and mesiodistal (MD) dimensions] as well as diagonal undergoing orthodontic / prosthodontic therapy or casts with measurements of teeth. Recent studies have revealed that gross destruction due to dental caries were excluded from the linear measurements are not sensitive enough to detect sexual

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study. maxilla, the incisal index values were 81.44 in females and Mesiodistal (MD) and Buccolingual (BL) dimensions of all 79.53 in males where as in mandible it was 109.32 and 108.84 teeth from central incisor to second permanent molar were respectively. The results showed that incisor index was found measured using digital Vernier caliper with calibration of to be lower in males in both maxillary and mandibular teeth. 0.1mm. MD dimensions were recorded as the greatest In conclusion, our results suggest bucco-lingual dimension measurement between the contact points. BL dimensions were was the best to differentiate between genders as it showed 14 represented by the greatest distance between labial/buccal teeth with significantly higher values in males compared to crest of curvature and lingual crest of curvature of the crown females. The canine index was found to be the next best measured at the cervical margins. Dental indices were differentiator. calculated as follows Forward stepwise binary logistic regression analysis showed l Crown area was obtained as a product of BL x MD that inclusion of either MD and BL dimensions of upper and dimensions (linear measurements)[4] lower teeth or MD and BL dimensions of lower teeth alone or l Crown module was defined as the average of linear all indices of the lower teeth, the MD dimension of the lower measurements (BL+MD/2)[4] left canine was the best predictor of gender. Among all the indices of maxillary arch the BL dimension of the maxillary l Crown index was the ratio of two linear measurements right central incisor was the best predictor of gender. When all expressed in percentage [(BL/MD) x 100][4] the indices of upper and lower teeth were included in the l Incisor index was calculated by the formula equation we found that the MD dimension of the lower left (MDLI/MDCI) x 100 (MDLI: Mesio-distal dimension canine and the crown index of the upper right premolar were of lateral incisor, MDCI: Mesio-distal dimension of the best predictors of gender. Accordingly three equations were [5,6] central-incisor) derived from the logistic regression as shown in Table 2. l Inter-canine distance was measured between the tips of Discriminant function analysis to classify gender showed right and left mandibular canines. Mandibular canine crown index of tooth 14 and MD dimension of tooth 33 to be index(MCI) was then calculated as MCI = Mesio-distal the most effective with the following formula: crown width of mandibular canine (average of left and Discriminant function Z=1.571 (33 MD) + 0.042 (14 right canine) / Mandibular inter – canine arch width.[5,6] CROWN INDEX) -16.052 having a centroid value of 0. If the STATISTICAL ANALYSIS: discriminant function is less than 0, then there is higher The dimensions and indices were compared between males probability of the subject being a female. Using the above- and females using independent student's t-test. Classification mentioned equation, 58.4 % of the cases were correctly matrix of each of the parameters and sexual dimorphism were classified on the basis of gender. calculated using binary logistic regression and discriminant DISCUSSION: function analysis using SPSS 20. Identification of gender has been successfully determined by RESULTS : using pelvic and skull bones as teeth were not considered Independent student's t-test to compare the mean values of the useful in sex assessment[7]. However, the advantage of using dimensions and the indices showed that majority of the teeth for determination of gender is that, enamel being the dimensions and indices were higher in males compared to hardest substance in the human body, can endure drastic females. Significantly higher values were observed in males atmospheric conditions like high temperatures and humidity, with respect to Mesio-distal dimensions in 3/28 teeth, prolonged immersion, desiccation, extensive trauma as well as buccolingual dimensions in 14/28 teeth, crown area in 7/28 advanced stage of decomposition[8]and is highly resistant to teeth and crown module in 8/28 teeth.(Table 1) Crown index post-mortem changes in comparison to other skeletal showed a different trend in which 4 teeth showed higher structures. It is relatively well known that there is varying dimensions in female (not statistically significant) whereas 24 degree of sexual dimorphism in permanent teeth as observed teeth in males showed greater dimensions out of which 3 teeth by various investigators[7]. Therefore, dental morphology helps exhibited significantly higher dimensions. (Table 1) Canine in determination of sexual dimorphism, in biological and index was significantly higher in males with a mean of 0.21in anthropological studies and especially in forensic odontology maxillary teeth (mean values of females was 0.21) and 0.24in wherein gender can be determined from fragmented jaws and mandibular teeth (mean values for females was 0.23). dental remains. However, the incisal index showed inverse pattern. In the Buthz and Ehrhardt (1938) measured the crowns of permanent

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teeth to assess sexual dimorphism. Even though they found the best indicator of sexual dimorphism. The procedure of that teeth of males were larger than those of females, they measuring of MD dimensions could be compromised by concluded that the size ranges were not sufficiently distinctive crowding and rotation of teeth. Moreover, the accuracy of MD to determine sex[9]. When certain tooth variables exhibit greater dimensions may be affected by proximal wear which may vary mean of dimorphism in females, is called reverse dimorphism. with the habits of the individual. On the other hand, attrition of Among Indians, premolars show higher level of reverse the buccal and the lingual segments are less likely making the dimorphism[9]. Morphometry of teeth could be an efficient tool BL dimension more stable. This explains the higher number of in differentiating gender and is useful in medicolegal teeth showing significantly higher values in the BL investigations and identification of victims of crime, natural dimensions. disasters and mutilating accidents. The variation in tooth size We observed that the incisor index was lesser in males between the sexes can give a clue even though the general compared to females. Incisor index is calculated as the [10] morphology of teeth is similar . The present study compares percentage of ratio of Mesio-distal dimension of lateral the efficiency of linear measurements and dental indices in incisor(MDLI) to Mesio-distal dimension of central- identifying sexual dimorphism. incisor(MDCI). Morphologically we know that the lateral In all the studies reported in literature, the male teeth were incisor is smaller than the Central incisor. The more the larger. Alvesola L et al (1987) suggested that these differences difference between the two incisors, smaller will be the incisor were owing to the amount of enamel formation, while index. In our study group we found that the mean difference of Schwartz GT et al (2005) suggested that the quantity of dentin the MD dimension of the two incisors was 1.807 mm in males was the determining factor[11,12].There are various other reasons as compared to 1.606 in females. This explains why the incisor documented in the literature for the morphological and index is lower in males. developmental differences in teeth between genders. Increase Discriminant functional analysis as well as Binary logistic in the size of teeth in males has been attributed to genetic and regression analysis showed the mesiodistal dimension of 33 hormonal factors. The Y chromosome controls the thickness of and crown index of 14 as the most reliable predictors of gender. the dentin where as the X chromosome is known to play a role Mandibular canines by virtue of their morphology and location [8] in maintaining the uniform thickness of enamel .Smith et al are less prone to dental caries, plaque accumulation, abrasion, (2006) and Saunders et al (2007) in their studies have found occlusal load or to periodontal diseases[16].These teeth have that male molars and premolars have higher proportion of been reportedly recovered from the human remains even in dentin whereas average enamel thickness was greater in extreme conditions as air disasters, hurricanes, fire and females. The Y chromosome may also influence the bulk of the bacterial decompositions[8]. teeth as it is known to increase the mitotic activity in the dental Lysell and Myrberg in their study of more than 1000 subjects of lamina[10].Concentration of sex hormones also plays an Swedish population concluded that the mandibular canine important role during the development of tooth germ and exhibited the greatest sexual dimorphism (5.7%) among all therefore influences its size as reported by Schwartz et al[12]. teeth[17]. Hashim and Murshid studied the pre-treatment Higher dimension of male teeth have been observed in various orthodontic casts of 720 Saudi male and female subjects of age studies. Nandita KP et al (2016) found greater tooth 13 to 20 years and found that the only teeth to show sexual dimensions in males while assessing diagonal tooth dimorphism were mandibular canines[18]. Rao et al (1989), dimensions in both genders in a sample of South-Indian and from their study of mandibular canine index, using 384 Malaysian students aged 15-40 years[13]. Sounbayroux, Signoli females and 382 males of south Indian population in the age and Dutour (2002) retrospectively assessed osteological and group of 15-21 years, found significant sexual dimorphism and dental remains from an archaeological site in Marseilles accuracy of 85.9% was obtained in categorizing males and (France) that dated back to the 18th century and found that the females. Overall the mandibular canine index was greater in mesiodistal dimensions of teeth in males were greater than in males[16]. females and mandibular canine was the most accurate tooth for analysis of sexual dimorphism[14]. Similarly, Iscan and Kedici Garn et al (1967) in their study compared sexual dimorphism in (2003) found significant sexual dimorphism in buccolingual canines with stature, weight, bone age, menarche in girls and dimensions in Turkish individuals and reported the canines of the time of epiphysis union and found that there was a both jaws to show maximum dimorphism with an accuracy significant co-relation. Based on these associations they approximating 77% [15]. proposed that there is a direct influence of steroidal hormones of gonad and adrenal origin on tooth development and sexual Even in our study the buccolingual dimension was found to be maturation that may be the cause for the co-relation between

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the above mentioned parameters[19]. Orofac Res 2013; 3(3): 157-60. Anatomically the canines and the first premolars are positioned 9. Joseph AP, Harish RK, Mohammed R P K, Kumar V R B. in between the incisors and the molars. The latter group of teeth How reliable is sex differentiation from teeth take up the maximum occlusal loads thus sparing the canines measurements. Oral and Maxillofacial Pathology Journal. and premolars from age- and habit-related changes. These 2013, 4(1), 0976-1225. facts may explain the inclusion of these two teeth in the 10. Sabóia TM, Tannure PN, Luiz RR, Costa MC, Granjeiro discriminant function analysis formula. JM, Küchler EC et al. Sexual dimorphism involved in the CONCLUSION: mesiodistal and buccolingual dimensions of permanent Sexual dimorphism do exist in the tooth dimensions with teeth teeth. Dentistry 3000 2013; 1(1): 1-5. being larger in males than in females. Among all the 11. Alvesalo L, Tammisalo E, Therman E. 47, XXX females, measurements the BL dimensions are best suited for sex chromosomes and tooth crown structure. Hum Genet classification of gender. This study presents four equations 1987 77(4): 345-8. derived by binary logistic regression and discriminant function 12. Schwartz GT, Dean MC. Sexual dimorphism in modern analysis in a population from Dakshina Kannada region of human permanent teeth. Am J PhyAnthropol. 2005; Southern India to aid in determination of gender. Among the 128(2): 312-7 teeth mandibular canines and the maxillary premolars are the 13. Nadita KP, Boaz K, Srikant N, Lewis AJ, Manaktala N. most preferred teeth to predict gender in our sample of Gender and Race differentiation-an odontometric and population from a Southern Indian geographical district. rugoscopic analysis 2016; 8(2): 73-76. REFERENCES: 14. Soubayroux P, Signolia M, Dutour O. Sexual dimorphism 1. Ibeachu PC, Didia BC, Orish CN. Sexual Dimorphism in in teeth: discriminatory effectiveness of permanent lower mandibular canine width and intercanine distance of canine size observed in a XVIIIth century osteological university of Port- Harcourt students, Nigeria. Asian series. Forensic Science International 2002;126 :227–32. Journal of medical science 2012; 2(5): 166-169 15. Iscan MY, Kedici PC. Sexual variation in bucco-lingual 2. Boaz K, Gupta C. Dimorphism in human maxillary and dimensions in Turkish dentition. Forensic Science mandibular canines in establishment of gender. Journal of International 2003; 137:160–64. Forensic Dental Sciences 2009; 1(1): 42-44. 16. Paramkusam G, Nadendla LK, Devulapalli RV, Pokala A. 3. Narang RS, Manchanda AS, Sigh B. Sex assessment by Morphometric analysis of canine in gender determination: molar odontometrics in North Indian population. Journal Revisited in Indian. Indian Journal of Dental Research of Forensic Dental Sciences 2015; 7(1): 54-58. 2014; 25(4); 425-429. 4. Acharya AB, Mainali S. Are dental indices useful in sex 17. Lysell L, Myrberg N. Mesiodistal tooth size in deciduous assessment? J Forensic Odontostomatol 2008;27(2): 53- and permanent dentitions. Eur J orthod 1982; 4: 113-122. 59. 18. Hashmi HA, Murshid ZA. Mesiodistal tooth width-a 5. Acharya AB, Shivapathasundharam B. Forensic comparision between Saudi males and females. Eqypt Odontology. In, Rajendran R. Shafer's Textbook of Oral Dent J. 1993; 39: 343-346. Pathology, 5th edition. New Delhi, Elsevier; 2006. 1210- 19. Ayoub F, Shamseddine L, Rifai M, Cassia A, Diab A, 1211. Zaarour I, Saadeh M, Rouhana G. Mandibular Canine 6. Acharya AB, Shivapathasundharam B. Forensic Dimorphism in Establishing Sex Identity in the Lebanese Odontology. In, Rajendran R. Shafer's Textbook of Oral Population. International Journal of Dentistry 2014. th Pathology, 6 edition. New Delhi, Elsevier; 2007. 882- Article ID 235204. 1-4 883. 7. Sittiporn R, Suda R, Montip T. Sex determination from teeth size in Thais. (Preprint) the 6th CIFS academic day 2011; 14-15. Impact Muang Thong Thani, Nonthaburi (2011). 8. Grover M, Bai GR, Ram T, Puri PM, Ghodke KR. An odontologist key to sex determination: Study analysis of mandibular canine teeth in South Indian population. J

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Table 1: Independent t test for comparison of mesiodistal width, buccolingual width, crown area, crown module and crown index with gender MESIODISTAL WIDTH BUCCOLINGUAL WIDTH

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TABLE 2 : Logistic regression analysis for differentiating gender

ODDS RATIO

72 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00011.4 Original Research Paper Analysis of death in burn cases with special reference to age, sex and complications 1. Yogesh Sharma, Senior Professor & Head, Department of Forensic Medicine R.N.T.Medical College, Udaipur(Raj.) 2. Ashish Kumar Garg, Resident, Department of Forensic Medicine R.N.T.Medical College, Udaipur(Raj.)

ABSTRACT: Introduction : Fire can be considered as double edged sword. A burn is an injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or contact with chemicals. Globally, burns are a serious public health problem. Burns are the most common type of trauma worldwide, following traffic accidents, fall and interpersonal violence. Burn have medico-legal importance as they may be considered to be the commonest cause of unnatural death in India. Materials and Method : This present study is a prospective study undertaken at the mortuary of forensic medicine, R.N.T.Medical College, Udaipur, Rajasthan. The study includes all the burn injury cases coming to the mortuary for autopsy during period from 1 March 2018 to 30 September 2018.The main objectives is to find the cause of death in burn cases according to different age groups and sex . Results : Out of 86 cases, 61 were in 11-40 years of age, 57 died of shock

Corresponding Author : Article History: Dr. Ashish Kumar Garg, Received: 12 March 2019 Resident, Received in revised form: 13 March 2019 Accepted on: 13 March 2019 Department of Forensic Medicine, Available online: 31 December 2019 R.N.T. Medical College, Udaipur(Raj.) Contact : +91 Email: [email protected]

KEYWORDS : Burns, Shock, Autopsy, Epidemiological information, Dry heat.

INTRODUCTION: RESULTS: Fire has been known to human being for about 4,00,000 years. In the study period , total 780 autopsies were conducted. out of Universe is made up of five essential elements: Water, Air, total ,86 cases (11.02%) were brought with the alleged cause of Earth, Sky and Fire. Therefore fire have great importance in death as burn. As for the age of the victims , most of the victims ourlife[1-2]. Fire has become the most useful agent but it has 70.93% (61 cases) were between 11-40 years of age, followed proved to be one of the most destructive enemies of man. Burn by (14 cases) 41-50 years age groups.The least number of the injuries are caused due to contact with dry heat. By law all dry cases were in the age group of <10 years and >50 years .Out of heat have been designated as burns. Burns constitutes a major total cases males were 45(52.32%) and females were role in mortality and morbidity in the worldwide, whether (47.67%), M:F ratio of 1.09:1.0.(Table-1). accidental, suicidal or homicidal. Dowry death in India have become a problem of great concern. The aim of this study was analysis deaths with special reference to age, sex and Table 1 : Distribution of burn cases according to Age and Sex complications in burn cases brought to morgue of R.N.T. AGE GROUP TOTAL Medical College, Udaipur. (IN YEARS) MALE FEMALE CASES 1-10 05 (5.81%) 01(1.16%) 06 (6.98%) MATERIAL AND METHODS: 11-20 06(6.98%) 09(10.46%) 15(17.44%) Present study was based on autopsies conducted in the 21-30 11(12.79%) 09(10.46%) 20(23.25%) Department of Forensic Medicine & Toxicology, R.N.T. Medical College, Udaipur from 1st March 2018 to 30th 31-40 12(13.95%) 14(16.28%) 26(30.23%) September 2018. Details of the cases were collected from the 41-50 07(8.14%) 07(8.14%) 14(16.285) Police Inquest reports, Hospital records, history by the 51-60 02(2.32%) 00(0%) 02(2.32%) relatives/friends of the deceased and autopsy reports. The main objective was to find out the cause of death in different Above 60 02(2.32%) 01(0%) 03(3.49%) burn injury cases according to ages and sex. TOTAL 45(52.33%) 41(47.67%) 86(100%) CASES

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In the study most common cause of death was shock. 57 cases differences in the region from where study was carried out, (66.28%),out of 86 died due to shock followed by septicemia again it indicates that burn cases comprises of major bulk of (28 cases) and complications only one case reported.(Table 2) medico-legal autopsies in India. Table 2 : Distribution of burn cases according to Cause of In the study maximum number of cases 70.93% was observed Death in 11-40 years age group. This finding was similar with the CAUSE OF DEATH TOTAL CASES study of Batra AK[4] (71.9%) and Singh D[5] et al (67%). From SHOCK 57(66.28%) all above these studies, it is clear that aldolescents and young SEPTICEMIA 28(32.56%) adults (11-40 yrs) are commonly involved in fatal burn injuries COMPLICATIONS /OTHERS 01(1.16%) in India as this is more active group and burn may occur while TOTAL CASES 86(100%) working, where awareness and adequate safety measures are minimal. on extremes of age the incidences are less which is According to gender maximum numbers of male cases 37 similar to other studies of [1,2] . Out of 86 burn death cases, 45 (43.03%) died due to shock out of 45 cases followed by were male and 41 were females. Similar findings were reported septicemia 7 cases and only one case by complications. In by other authors[6,7].This may be explained by the facts that female gender cause of death were shock in 20 cases (23.25%) because of rapid industrialization in these countries, male & septicemia in 21 cases (24.42%). (Table 3) become more susceptible to fatal burn at work place as Table 3 : Distribution of burn cases according to Cause of compared to females. 18 males death, out of 45 were due to death and Sex electric current burn injury in spring season of year in our CAUSE MALE FEMALE TOTAL study. OF DEATH CASES Most common cause of death in burn cases was shock in the SHOCK 37(43.03%) 20(23.25%) 57(66.28%) study. 57 cases (66.28%) reported which were died due to SEPTICEMIA 07(8.14%) 21(24.42%) 28(32.56%) shock followed by septicemia 28 cases (32.56%) and only one COMPLICATIONS01(1.16%) 00(0%) 01(1.16%) /OTHERS case died due to complications. Any kind of injury including TOTAL CASES 45(52.33%) 41(47.67%) 86(100%) burn injury was the common source of infections, which In the study 57 cases which were died due to shock, out of them resulted in septicemia. Lack of care on the part of doctor and maximum 42 cases in 11-40 age groups reported. Out of 28 hospital facilities was the main reason for septicaemic deaths cases of septicemia,26 cases were in 11-50 years age groups. in the burn victims. Our study was similar to other studies of [1,3,4,5,7,8,9] [10] (Table-4) . In study of Zanjad NP et al . septicemia was the Table 4 : Distribution of burn cases according to age and most common cause of death in burn cases. Out of 45 male cause of death cases, 37(43.03%) were died due to shock. AGE COMPLI- CONCLUSIONS: GROUP TOTAL MALE FEMALE CATIONS CASES Burn injuries are Preventable. Most important step in reducing (In Yrs.) /OTHERS the incidence is through mass education. Educate the people 0-10 05(5.81%) 01(1.16%) 00(0%) 06 (6.98%) that dowry is an social evil. Effective prevention requires a 11-20 11(12.79%) 04(4.65%) 00(0%) 15(17.44%) through understanding of the major risk factors. Following 21-30 16(18.60%) 04(4.65%) 00(0%) 20(23.25%) safety measures like putting the light off while not in use, wearing tight clothes while working in kitchen, not leaving a 31-40 15(17.44%) 11(12.79%) 00(0%) 26(30.23%) fire source unattended etc. will help to reduce the incidence of 41-50 07(8.14%) 07(8.14%) 00(0%) 14(16.285) burn injuries. Doctors need to put more sincere efforts and the 51-60 02(2.32%) 00(0%) 00(0%) 02(2.32%) specialized care to seriously burned patients. The Government, N.G.O., Social groups needs to concentrates more sincere 61-70 01(1.16%) 01(1.16%) 01(1.16%) 03(3.49%) efforts in direction of burn prevention programmes and aware TOTAL 57(66.28%) 28(32.56%) 01(1.16%)86(100%) the population regarding safety measures like forest fire, gas CASES cylinder/LPG gas, industrial safety, electric safety, etc. DISCUSSION: REFERENCES: During the period of study , the fatal burn deaths comprised of 1. Vaghela PC, Ahir GN, Patel MH. Epidemiology of fatal 11.02% of total medico-legal autopsies. This findings were burn cases in GK General Hospital, Bhuj. National consistant with study of Gupta RK et al (10.79%)[3]. Inspite of Journal of Community Medicine.2012;3(2):326-329.

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2. Mangal HM, Pathak A, Rathod JS. The fire is both "A Blessings & Scourge of the mankind"JIAFM, 29(4):2007;75-77. 3. Gupta R, Kumar V, Tripathi SK. Profile of fatal burn deaths from the Varanasi region, India. J Clin and Diag Res. 2012;6(4):608-611. 4. Batra AK. Burn mortality:Recent trends and sociocultural determinants in rural India, Burns;may 2003,29(3):270-5. 5. Singh D, Singh A, Sharma AK, Sodhi L. Burn mortality in Chandigarh zone:25 years autopsy experience from a tertiary care hospital of India. Burns. 1998;24(2):150-56. 6. Tang K, Jian L,Qin Zhenjiang L, Gomez M, Beveridge M. Characteristics of burn patients at a major burn centre in Shanghai. Burns. 2006;32(8):1037-43. 7. Kobayashi K, Ikeda H, Higuchi R, Nozaki M, Yamamoto Y, Urabe M. et al. Epidemiological and outcome characteristics of major burns in Tokyo. Burns. 2005;31(Suppl 1):S3-11. 8. Patel TC, Parmer AP, Bhagora L, Bhagora RV, Shah JP, ParmerVN. Epidemiological study of fatal burn cases brought for postmortem examination at mortuary of Takhtsinhji General Hospital, Bhavnagar. Int J Res Med.2015;4(1):113-16. 9. Gupta M, Gupta OK, Yaduvanshi RK, Upadhyaya J. Burn epidemiology: the pink city scene. Burns. 1993;19(1):47-51. 10. Zanjad NP, Godbole HB. Study of fatal burn cases in medico-legal autopsies,JIAFM:2007;29(3):42-49.

75 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00012.6 Original Research Paper Physicians' Awareness towards Forensic Psychiatry, a Survey of Physicians who Work in an Iranian General Hospital 1. Azadeh Memarian, Assistant Professor of Forensic Medicine , Iran University of Medical Science, Tehran, Iran 2. Seyed Mehdi Saberi, Psychiatrist, Associate Professor of Legal Medicine Research Center, Legal Medicine Organization , Tehran,Iran 3. Kamran Aghakhani, Professor of Forensic Medicine, Iran University of Medical Science, Tehran, Iran 4. leyla Abdolkarimi, Assistant Professor of Forensic Medicine, Shahid Rajaei cardiovascular Medical and research center, Tehran, Iran 5. Siamak Soltanti, Assistant Professor of Forensic Medicine, Iran University of Medical Science, Tehran, Iran 6. Arezoo Amiri, Assistant of Forensic Medicine, Iran University of Medical Science, Tehran, Iran

ABSTRACT : Background: Forensic psychiatry has a main duty in applying medical, psychiatric, and legal information in enforcement of the criminal and civil law processes. In Iran, forensic psychiatry is a new and evolving branch of medicine and we aimed to assess the level of physicians' knowledge towards it in Iran. Methods: Cross-sectional study was performed on physicians working in Rasoul-e-Akram hospital in Tehran in 2015 by a predefined questionnaire which consisted of baseline information and the questions to assess knowledge towards professional responsibilities of forensic psychiatrists. Results: Survey showed low level of knowledge among physicians. Only 41% of all physicians could answer correctly the role of forensic psychiatry. The level of knowledge was associated with their specialized education, but not with their demographics, the university or year of graduation. Conclusion: Performing specific training schedules is essential among medical practitioners, since each may face criminal patients. Corresponding Author : Article History: Dr. Seyed Mehdi Saberi, Received: 6 November 2018 Psychiatrist, Associate Professor of Legal Medicine Research Received in revised form: 6 March 2019 Accepted on: 23 August 2019 Center, Legal Medicine Organization , Tehran,Iran Available online: 31 December 2019 Contact : E-mail : [email protected] KEYWORDS : Forensic Psychiatry, Physicians, Awareness, General Hospital, Iran INTRODUCTION : clinical practice simultaneously in both psychiatry and legal [7] Forensic psychiatry has been developed as a subspecialty of medicine . In other words, forensic psychiatry covers a psychiatry with an especial approach to criminology. In fact, variety of issues including correctional psychiatry, involuntary forensic psychiatry is based on a direct interaction between commitment, and determining mental competence to stand psychiatry and law[1]. This field of psychiatry covers some legal trial. The main duties of these psychiatrists include 1) services to help law enforcement relying on the psychological determining the offender's mental illness and its compliance state of guilty or scheduling appropriate medications or with the committing a crime, 2) determining the severity of psychotherapy to criminals to achieve correct legal judgment mental illness in custody person prepared to impose criminal [2,3]. The responsibilities of forensic psychiatrists are defined on sentences, 3) determining the gender identity disorders and three main foundations including cooperation with courts in licensing transgender operations, 4) check request of couples assessment of individual's competency to stand trial, issuing an to permit therapeutic abortion, 5) determining the amount of indictment or defense based on the mental state, and downtime for the efficiency of pension rights or insurance sentencing psychological recommendations[4,5]. In fact, these premiums, and 6) determining the severity of psychiatric [7,8] psychiatrics should be fully aware of different aspects of defects following trauma or accidents . In this regard, the psychiatry as well as legal medicine to the most correct and awareness of occupational specifications and professional wise decisions for sentencing[6]. Thus, forensic psychiatrists responsibilities of forensic psychiatrists is necessary for should apply their knowledge and skills for legal applications. physicians in different fields of medicine. Hence, we aimed to Based on the American Academy of Psychiatry and the Law, assess the level of physicians' knowledge towards forensic forensic psychiatry should embrace research activities and psychiatry in Iran.

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MATERIALS AND METHODS : Table 1: The level of knowledge to Forensic Psychiatry This cross-sectional study was performed on all physicians According to Baseline Parameters working in Rasoul-e-Akram hospital in Tehran in 2015. The Parameter No. Minimum Maximum Mean SD p-value study tool included a predefined questionnaire (Appendix-I) Gender 0.069 that was distributed among the physicians. The questionnaire Female 108 4 16 8.66 3.71 consisted of two parts including baseline information (gender, Male 99 4 15 7.80 3.05 age, field, and specialty) and the questions for assessing University 0.263 knowledge of physicians towards professional responsibilities Tehran 52 5 14 7.98 3.07 of forensic psychiatrists. The level of knowledge scored as 0 to Beheshti 40 5 16 8.75 3.56 20. The used questionnaire was structured on viewpoints of Iran 80 4 16 7.84 3.40 forensic medicine specialists and forensic psychiatrists. The Others 35 Education first study endpoint was to determine the level of physicians' 0.038 level knowledge of responsibilities of forensic psychiatrists and the General 21 4 14 7.57 3.18 second was to assess main correlates of this knowledge among Special 90 3 15 8.13 3.06 physicians. Sub-special 96 4 16 8.84 3.71 For statistical analysis, results were presented as mean ± Year of 0.628 standard deviation (SD) for quantitative variables and were graduation summarized by absolute frequencies and percentages for < 1980 40 5 16 8.20 3.40 categorical variables. Normality of data was analyzed using 1980 -1990 84 4 14 8.51 3.51 the Kolmogorov-Smirnoff test. Categorical variables were > 1990 83 3 16 8.00 3.38 compared using chi-square test or Fisher's exact test when more than 20% of cells with expected count of less than 5 were DISCUSSION : observed. Quantitative variables were also compared with t This study attempted to assess the awareness of physicians in test or Mann- Whitney U test. For the statistical analysis, the different fields of medicine with respect to forensic psychiatry statistical software SPSS version 16.0 for windows (SPSS and its-related responsibilities. To the best of our knowledge, Inc., Chicago, IL) was used. P values of 0.05 or less were our study was the first to exclusively determine the level of considered statistically significant. Iranian physicians' knowledge toward forensic psychiatry. As RESULTS : previously pointed, forensic psychiatry has a main duty in applying medical, psychiatric, and legal information in In total, 207 physicians (99 men and 108 women) were enforcement of the criminal and civil law processes. The included into the survey. Overall, 21 (10.1%) were general American Academy for forensic psychiatry was primarily practitioner, 90 (43.5%) were specialist, and 96 (46.4%) were established in 1966 for losing up lawyers and psychiatrists[9]. subspecialist. Also, 40 (19.3%) graduated before 1980, 84 Since then, law schools paid particular attention to the laws (40.6%) graduated from 1980 to 1990, and 83 (40.1%) governing mental disorders especially the need to hospitalize graduated after 1990. Regarding level of knowledge toward psychiatric patients and defense of their rights[10,11]. However, it forensic psychiatry, the lowest and the highest score was 4 and has not found its place in our country and there is limited 16, respectively (Table 1). The average score of knowledge for awareness about that among medical specialists. Besides, men was 7.80 and for women was 8.66 without significant introducing specialized medical courses led to lowering the difference (p = 0.069). The mean score of knowledge toward knowledge of general practitioners in forensic medicine forensic psychiatry was 7.57 for general practitioner, 8.13 for especially its especial subtype of forensic psychiatry. In line specialists and 8.84 for subspecialist indicating significant with the necessity for improving the level of knowledge association between the level of knowledge and level of towards this field of medicine, our survey could reveal there is education (p = 0.038). However, year of graduation did not notably low level of knowledge among physicians in different affect the level of knowledge (8.20 for physician graduated professional fields. In fact, only 41% of all physicians could before 1980, 8.51 for physician graduated between 1980 and answer to the questions about the role of forensic psychiatry 1990, and 8.00for those who graduated after 1990 (p = 0.628). correctly that seems to be considerably low. In this regard, the Also, the physicians' age was not associated with their level of level of knowledge in professionals was significantly higher knowledge to forensic psychiatry (p = 0.244). than general practitioners, but the total score was totally low. In a study by Germann et al in 2014[12], psychiatrists who were

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studied, were known themselves as experts in criminal courts 2007;33(6):337-41. that resulted in wrong diagnosis of mental disorders leading 10. Sadoff R L. Ethical issues in forensic psychiatry. Psychiatry high rate of improper hospital admission. In another study by Annals, June 1988:1-25. Saberi et al[13], It was firstly expressed that the duties of forensic 11. Zonana H. Commentary : the role of forensic psychiatry in the asylum process. J Am Acad Psychiatry Law. 2010;38(4):499- psychiatrists in the department are, performing psychiatric 501. examinations and determining mental competence of two 12. Germann U. Psychiatirsts, criminals and the law : forensic major groups of referrals: Individuals who are involved in a psychiatry in Switzerlad 1850-1950. Int J Law Psychiatry. 2014 legal problem related to civil law and individuals who are Jan-Feb;37(1):91-8. involved in criminal responsibility and/or for bearance of 13. Saberi SM, Mirsepassi GR. Forensic psychiatry in Iran. Iran J punishment such as offenders and prisoners. However, based Psychiatry Behav Sci. 2013 Spring;7(1):1-3. on their article, it has also noted a serious worry included the 14. Hassan T, Nizami AT, Hirji S. Forensic psychiatry in Pakistan. absence of a secure mental hospital devoted to the Int J Law Psychiatry. 2015 Jul-Aug;41:95-104. irresponsible mentally ill criminals. It is clear that a secure APPENDIX-I I. Preliminary Information mental hospital can be a main center for educating forensic Q 1. Name/Age/Sex of Participant psychiatry, in addition to therapeutic purposes. Tariq Hassan et Q 2. Place of Education (Name of University): [14] al in Pakistan also emphasized training in forensic a Iran University of Medical Sciences psychiatry for postgraduates as well as the assessments and b Tehran University of Medical Sciences management schedules for the mentally ill offenders. c Shahid Beheshti University of Medical Sciences According to our findings, performing these training schedules d Other Universities of Medical Sciences is essential among all fields of medicine to know professional Q 3 Entrance year: position of forensic psychiatrists and also correct guidance of Q 4 Degree sought: offenders with psychological background to issue correct a Medical doctor b Assistant of psychiatry punishments. Finally, medicine practitioners should know that c Psychiatrics they probably face with criminal patients in their field of work. d Fellowship of psychiatry It is obvious that awareness of patient's legal problem, in some e Graduadeted fellowship of Psychiatry cases, can led to a better relationship between physician ant the II. Main Information patient. Q 1. An eighty-two-year-old man who intends to grant all of his REFERENCES : properties to one of his Second-degree relatives needs the mental 1. Nambi S. Forensic psychiatry revisied. Indian J Psychiatry. 2010 health confirmation from one of the notary offices, which following Jan;52(Suppl 1):S306-8. offices are responsible for issuing the approval? 2. Asokan T V. Forensic psychiatry in India: The road ahead. Indian a. A trusted physician in the judiciary JPsychiatry. 2014 Apr;56(2) : 121-7. b. Legal medicine organization Center part 3. Hem F A, Herjanic M, Vanderpearl RH. Forensic psychiatry: c. Forensic psychiatrist diagnosis and criminal responsibility. J Nerv Ment Dis. 1976 d. A trusted psychiatrist in the judiciary Jun;162(6):423-9. Q 2. A nineteen-year-old man intends to donate one of his kidneys, 4. Smalc VF, Varda R, Grodic PF. Position and role of forensic which of the following references are targeted by donation centers for psychiatry in integrative psychiatry. Psychiatr Danub. 2008 the Confirmation of Conventional Mental Health? Sep;20(3):429-32. a. A trusted physician in the judiciary 5. Palijan TZ, Muzinic L, Redeljak S. Psychiatric comorbidity in b. Legal medicine organization Center part forensic psychiatry. Psychiatr Danub. 2009 Sep;21(3):429-36. c. Psychiatry Assistant 6. Simon, Robert and Liza Gold, ed. (2010). American Psychiatric d. Forensic psychiatrist Textbook of Forensic Psychiatry.American Psychiatric Q 3. Who undertakes approving the individual health of Driver's Publishing. License applicant ? 7. Bursztajn HJ, Scherr AE, Brodsky A. The rebirth of forenic a. Traffic Bureau psychiatry in light of recent histrical trends in criminal b. Forensic psychiatrist responsibility. Psychiatric Clinics of North America, 1994; c. A trusted Physician in Traffic Bureau 17:611-635. d. Clinical psychiatrist 8. Velinov VT, Marinov PM. Forensic psychiatric practice: Q 4. A couple intend to get divorce after three years, which of the worldwide similarties and differences. World Psychiatry. following references is targeted by the Court for the Confirmation of 2006;5(2):98-9. their Mental Health? 9. Sen P, Gordon H, Adshead G, Irons A. Ethical dilemmas in a. Clinical psychologist forensic psychiatry : two illustrative cases. J Med Ethics. b. Forensic psychiatrist

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c. Trained physician for mental health for Sex reassignment surgery for those who cannot tolerate their d. Family physician biologic identity due to this implication. Q 5. Who undertakes approving the mental health of Judicial Law Q 13. Which of the following references issues Certificate of virginity graduates working as interns? if the person request? a. A trusted physician in judiciary a. Psychiatrist b. A psychiatrist who works in the Ministry of Labor b. Gynaecologist c. A trusted physician in university c. Forensic physician d. Forensic psychiatrist d. Court Q 6. Which of the following references are targeted by the court for Q 14. Which of the following references investigates the demand of a confirming the mental health of a parent who intends to take their pregnant woman for obtaining therapeutic abortion because of mental child in custody after getting divorce? illness? a. A trusted physician in the judiciary a. Gynaecologist b. Social worker b. Psychiatrist c. Forensic psychiatrist c. A trusted physician in the judiciary d. Revolutionary Court d. Forensic psychiatrist Q 7. Which of the following references approves the mental health of Q 15. Which of the following references determines the extent of a couple who intends to adopt a baby? disability to get a benefit of pension premiums, insurance, workplace a. Attorney General transfer or residence or the supervision of the sponsor institutions? b. Judge a. Ministry of Labour c. A trusted physician in the judiciary b. Forensic psychiatrist d. Forensic psychiatrist c. Insurance Organization Q 8. Which of the following references determines the amount and d. A psychiatrist working in Ministry of Labour type of penalty after the commitment of crime? Q 16. To which of the following references can a divorcing couple a. Forensic psychiatrist refer for Psychological consultation? b. Judge a. Family counsellor c. Attorney General b. Physician d. Police Bureau c. Forensic psychiatrist Q 9. Which of the following references undertakes the treatment of d. Social worker patients with Schizophrenia who had already committed the crime? Q 17. A 60-year-old man pretends to suffer from severe forgetfulness a. Psychiatrist and anxiety due to the accident. To which of the following references b. Forensic psychiatrist does the court refer for confirmation of the aforesaid claim? c. A trusted physician in the judiciary a. Forensic psychiatrist d. Clinical psychologist b. Traffic Bureau Q 10. To which of the following references are the homeless people c. Neurologist introduced by the judicial authorities for the accommodation? d. Clinical Psychologist a. Social worker Q 18. Which of the following references undertakes the psychological b. Forensic psychiatrist examination of a man who claims in the court that his wife has sexual c. Police desire disorder and unable to do a long term sexual intercourse ? d. A trusted physician in the judiciary a. Urologist Q 11. Which of the following cases is responsible for obtaining the b. Psychiatrist consent for high risk surgery? c. A trusted physician in judiciary a. Insurance agent d. Forensic psychiatrist b. Forensic physician Q 19. Which of the following references determines the c. Psychiatrist assistant hospitalization for acute or chronic mental patients who were referred d. Forensic psychiatrist by their families or the Police and must be hospitalized in a Psychiatric hospital? Q 12. Which of the following cases are NOT considered as a duty of a. Police Forensic psychiatrist? b. Revolutionary court a. Investigating a type of offender's mental disease and c. Forensic medicine Doctor whether he or she has committed the crime with a degree of mental d. A trusted physician in judiciary illness that is a waiver of his or her criminal responsibility. Q 20. Which of the following references determines the amount of b. Investigating the type and intensity of an offender who is in damage in traffic accidents in case of driver's mental disorder (lack of jail or is supposed to take a kind of punishment mental health)? c. Examining Mental health of couples before marriage a. Insurance Bureau c. T raffic Bureau d. Approving the sexual identity disorders and giving a permit b. Forensic Psychiatrist d. Revolutionary Court

79 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00013.8 Original Research Paper Epidemiological Study of Suicide in Siliguri Commissionerate, Darjeeling 1. Amit Sarkar, Medical Officer Rural Hospital Rajganj 2. Rajib Prasad, Professor, Medical Superintendent cum Vice Principal, Government Medical College, Coochbehar. 3. Priyankar Roy, Assistant Professor, Dept. of FMT, North Bengal Medical College, Siliguri. 4. Vivek Kumar, Assistant Professor, Dept. of FMT, North Bengal Medical College, Siliguri. 5. Saikat Saha, Demonstrator, Dept. of FMT, Government Medical College, Coochbehar. 6. Prabir Kumar Dev, Principal and Professor, Dept. of FMT, North Bengal Medical College, Siliguri. 7. Gautam Kumar, Assistant Professor, Department of Forensic Medicine & Toxicology, Dumka Medical College, Dumka

ABSTRACT : Introduction : Suicide is intentional taking of one's own life. It's big social issue and forms a large proportion of disease burden in world. As per WHO, suicide is responsible for death in every 40 seconds, A person attempt for it in every 3 second. Its global mortality rate is 16 per 100,000. Materials and Method : Epidemiological data of suicide are very less in Siliguri Commissionerate area, so a study was done on all suicide cases which were broughtfor postmortem examination in North Bengal Medical College mortuary during July 2014 to June 2015. Results : 377 cases of suicide were encountered during postmortem examination in given period. We observed that every age group are under dark shadow of suicide. Death cases due to suicide is almost similar in both the gender but higher incidence is seen in Hindu population. It not only victimized old aged person of 88year, even suicidal case of 8-year-old child is also seen. Most of the victims were of lower socio-economic class belonging to rural background and highest no of cases of suicide were among illiterate. Cases of suicide is higher in married woman, unmarried man and homemaker. Internal harmony among the family member is also responsible for the suicidal intent and is observed, in joint family and among families with higher incidence of family-violence suicide rate is higher. Hanging and burn were the most common methods employed for suicide. Most of people committed suicide in between 6 PM to 6 AM. Conclusions : So, we need to look into multidimension if we really want to control on suicide not only in India but even in whole world. Corresponding Author : Article History: Dr. Gautam Kumar Received: 24 January 2019 Assistant Professor, Received in revised form: 10 May 2019 Accepted on: 10 May 2019 Department of Forensic Medicine & Toxicology, Available online: 31 December 2019 Dumka Medical College, Dumka Contact : +91 87093-18373 Email: [email protected].

KEYWORDS : Religion, Hanging; Poisoning; Burn; Drowning; Economic.

INTRODUCTION : Hence, this study was planned because of increased rate of Suicide is intentional taking of one's own life after failed to get suicide year by year, with a purpose to know the magnitude and solution of their problem and may think it as the only option. the socio-cultural factors of the problem of suicides, So, that a According to the 1998 WHO report, 3 persons attempts suicide sound prevention program could be suggested, planned and in every second and it take a life in every 40 second. A global implemented for reducing the incidence of suicides. mortality rate by suicide is 16 per 100000, the problem is Moreover, no such study is available so far in Siliguri, which is increasing year by year and projected to be 2.4% by one of the fastest growing cities in last 40 years due to its 2020.1InIndia suicide rate is 10.6/100,000 reported in 2009 geographical location. Keeping in mind the magnitude of (WHO suicide rates).1 The rates of suicide have greatly problem posed by suicidal deaths, an epidemiological and increased among youth. The cyber-suicide like event increases demographical study has been undertaken over such cases the concern which targets the youth.2,3,4Suicide is a brought for post mortem examination during the period of 1st multidimensional and complex event so a multidisciplinary July of 2014 to 30th June of 2015 at North Bengal Medical approach is needed which should includepsychologists, College and Hospital Mortuary. An endeavor has been made to psychiatrists, toxicologists, physiologists and physicians. understand the multifaceted issues in the causes of suicidal

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death. The most suicidal victims were married with married to The aim of this paper is to ascertain suicidal death patterns in unmarried victims' ratio was 1.37:1. Among the total 192 Siliguri Police Commissioner ate area. female victims, 60% were married, out of which 3% were divorcee and 8% were widows. But in cases of male, higher no MATERIALS AND METHODS : of suicide is seen in unmarried [111 (60%)] male than married A self-funded cross-sectional study includes all autopsy cases [74(40%)]. brought in the mortuary of NBMC&H, during 31st July 2014 to Our study shows suicide rate is higher in joint families (45%), 30th June 2015 with having history of suicide or suggestive followed by those who belonged to the nuclear and single autopsy finding of suicide. families (33%) and 22% victims were away from the families Study has started after the clearance from Ethics Committee, or alone. More than half (57%) of the suicide victims in present North Bengal Medical College, Darjeeling. Data has been study were victimized by domestic violence. The incidence collected after taking consent of relatives or attendants of was much higher among children and female (40%). Among deceased in preformed and pre-texted proforma by suicide victims, majority belonged to Hindu (62%) than 21% interviewing, Autopsy report, Inquest report of police or were Muslims followed by 10% and 7% were Buddhists and magistrate, Suicide note, if available were also included. Christians respectively. (Graph 3) RESULTS: During the study period, 2218 body were autopsied in which 17% (377) were fatal suicidal cases.In all cases of suicide the study population we observed was slightly more cases of suicide by woman population with male: female = 1: 1.04. (Graph 1)

Graph 3 : Distribution of cases according to religion. When we studied the demography of cases of suicide, we found death due to suicide is most commonly seen in lower middle -income group (98%) than other socioeconomic class. A large number of victims of fatal suicides belonged to the rural areas (56.6%), the rural urban ratio being (1.29:1). In the present series, we found among the cases of suicide 50% were Graph 1 : Frequency of Suicide among Male and Female Illiterate, which includes 33% female and 20% male victims. As compare to in the females, the ratio of illiterate/ low Of these victim's highest no of suicide committed by the age educated vs. higher educated is being 3.6:1, but in male it is group of 20- 29 years, followed by the 30- 39 years. The 1.9:1. (Graph 4) youngest child who committed suicide in our study was only 8 years old and the oldest was 87 years. (Graph 2)

Graph 2 : Distribution of cases according to age group along with frequency of sexes in each age Graph 4 : Frequency of suicide on the basis of groups. educational status

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Majority of the suicide victims were homemaker (31.89%), chronic illness. It has been shown that, out of 377 suicide followed by student (19%), laborer was 16%, 15% were victims, 89% had history of Psychiatric illness, out of which businessman, and 13% were farmer. majority (35%) were suffering from depression, closely In study area hanging (50.4%), burning (28.38%) and followed by Bipolar disorder (28%) and Border Line poisoning (17.24%) were the common method of suicide. Personality disorders. Suicide by drowning is also seen and it is just 3.98%. Hanging DISCUSSION : was the commonest method used by 33% males, while suicide During the study period, 2218 body autopsied, 377 were fatal by burning in 24% women victims. suicidal cases (17%). Of these victim's highest no of suicide The second commonest method employed by the male was was observed in the age group of 20- 29 years, Similar pattern poisoning 10%, while it was hanging in the case of women was observed at NCRB 2009 report where the age group is 15- victims (15%). (Graph 5) 29 years (Young) accounted for the largest proportion (34.5%) of suicides.5 Even in the study of Ramadwar (2002), the highest incidence of suicide is observed in 15 to 24 year age group[6]. Our observation that female commits suicide more than male, was similar to study of Shukla et al, Banerjee et al 7, 8 but it not corresponds study of Hedge9 (found 67% of suicide seen in male population) and the statistics of suicide in India during 2008 – 20095which is 1.78:1 (M: F).Somehowmy result be true for India because of dowry, woman illiteracy, total dependence on their husband and in laws for their close needs. (Factors Graph 5 : Mode of Suicide such as dowry, illiteracy, dependence etc. contributed for higher suicide among females) A substantial number of women (7%) also reported suicide due Results of our study says, proportion of married and unmarried to poisoning a rather uncommon method of choice for self- victims was 1.37:1. Among them married female cases was destruction by the women in India, while in case of drowning, 60% of total female suicide case but among male unmarried female victims applied more frequently than the male (3.6%). male were higher in no (60%). Similar pattern observed in Showing the study most people commit suicide at night NCRB 2009 report says,70.4% of all suicide victims in India between 6 pm to 6am (total 73.48%). In the present study, we were married and 21.9% were unmarried,4.3% in widow and 5 found the largest incidence of suicides during the month of widower. But Narang et al and Srivastava et al found opposite 10,11 September, April, January and February (42%) and a gradually and says, higher suicide in unmarried person. diminishing rate through the months of March, June and the We can see the methods of suicide is changing from time to lowest number in the month of August (4.5%). (Graph 6) time and may be from region to region. We found hanging is most common method of suicide followed by self-burning. This pattern of method is also observed in NCRB 2010 report which says, during this period suicidal methods were as follows, handing (44.5%), poisoning (20.6%) and fire (20.6%).12 But methods of according to NCRB 2009 report was different than previous.5 During this period the most common method of suicide was poisoning (33.6%), followed by hanging in 31.5% cases, burning in 9.2% cases then drowning than Jumping from buildings.5 Our study shows homemaker were higher in number among suicide victims then students, labourer, businessman and farmers. Similarly, NCRB 2010 data showing 51.4 per cent of Graph 6 : Suicidal trends on the basis of diurnal variation suicide are committed by housewives.12But LathaKS et al. had Re-attempt rate of suicide is 22.5% and the attempters ended shown some different findings and says, among suicide cases up with the final successful act within 2 years from the date of 50% of deceased were employed, whereas 12% were their last attempt. In the present study, we have found that most unemployed and some were either students or housewives.13 of the suicide victims (63%) were suffering from various

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We found highest no of suicide seen during evening and night class.There is equitable distribution of the cases according to hours. Even it has some seasonal variations says highest no of gender wise with slightly female dominance. Illiteracy/lower suicide seen during winter which is also seen through other education have positive correlation with suicide. People uses studies.14 dark hours between 6 pm to 6 am for committing suicide.62% We found that Illiteracy and low level of education is one of the of the total number of cases under study were married. A vast major contributory factors in suicidal tendency, theresult proportion of the victims belonged to the joint families while shows 50% suicides among them. Even the 2009 NCRB data (19%) belonged to nuclear families. Half of the suicide victims and M.K Shrivastava et al reveal same.510But in contrast to were housewives, followed by students, labourer, farmer and above studyLathaKS et al. found, 54% of suicide attempters businessmen. In terms of the methods adopted for committing had received high school education or higher.13 suicide, hanging constituted 50.4% of thecases, followed by those who died by inflicting burn injury on themselves A large number of victims of fatal suicides belonged to the (28.38%). 17.24% cases died due to poisoning while drowning rural areas (56.6%), the rural urban ratio being (1.29:1). Even comprised 3.98% of cases. If this analysis is made gender wise, the data of year 2000 from our country, the suicide rate was hanging was the commonest method used by males (33%), 10.8, the rate of suicide inurban areas was slightly lower at while suicidal burn injury was the commonest method used by 9.94.14 the women victims (24%).A sizeable proportion of the victims Our study shows suicide rate is higher in joint families (45%), were reported to be depressed (53%), followed by those who followed by those who belonged to the nuclear and single were insane (33%). 63 % cases were suffering from chronic families (33%) and22% victims were bring away from the and terminal illnesses. One fifth of the male victims were found families or alone. Similar result in study of Adityanjee and RK to be addicted and were in the habit of consumption of various Gupta et al. found more suicide attempters come from joint drugs like alcohol and cannabis. History of prior suicide talks, 15,16 families. But MK Srivastava et aland KS Latha et al found gesture and unsuccessful attempts were found in 22.5% of the just opposite result that cases suicide were morefrom nuclear victims. Suicide notes indicating the reason/motive for self- 10,13 families. destruction were recovered from the site of incidence in only In our study we found 22.5% of cases of suicide died in more one of the cases. than one attempts.Similarly,Sharma, et al. found, 5% of cases REFERENCES : of suicide require more than one attempt to ends their life.17 1. World Health Organization. Suicide rates per 100,000 by In the present study, we have found that most of the suicide country, year and sex. [Last accessed on 2012 Mar 27]. victims (63%) were suffering from various chronic illness. Available from: Even in NCRB reported Cancer was related to 0.6% of all http://www.who.int/mental_health/prevention/suicide_ra suicides in 2010.12 tes/en/index.html. Our study shows among all fatal suicidal case 57% cases were 2. Rajagopal S. Suicide pacts and the internet. Bmj suffering from domestic violence.Similarly, domestic violence 2004;329(7478):1298-9. is a major risk factor for suicide found in a study in Bangalore Gururaj.18 3. Birbal R, Maharajh HD, Clapperton M, Jarvis J, Ragoonath A, Uppalapati K. Cyber suicide and the It has been shown that, out of 377 suicide victims, 89% had adolescent population: Challenges of the future? Int J history of Psychiatric illness, out of which majority (35%) Adolesc Med Health 2009;21:151-9. were suffering from depression.The similar findings had been seen by Bagadia et al. found suicidal behavior is common in 4. Thomas K, Chang SS, Gunnell D. Suicide epidemics: The that of Depression (39.73%), schizophrenia (24.4%) and impact of newly emerging methods on overall suicide hysteria (14%).19 rates a time trends study. BMC Public Health 2011;11:314. CONCLUSION : 5. National Crime Records Bureau. Accidental Deaths and This study is based on 377 fatal suicide cases in which Suicides in India 2007. New Delhi: Ministry of Home medicolegal autopsy was done at the Mortuary of the Affairs, Government of India; 2009. Department of Forensic Medicine, NBMC&H, Darjeeling revealed 17% of autopsied cases are of suicidal death during 6. Ramadwar D.K, Mazumder R.D, Ketkar Y.A; an the period from 1st July 2014 to 30th June 2015.The Hindus Epidemtric Study of Suicide in Nagpore City for and young age group were more suicide prone, it is commonly Quinqueunium; Indian J of Public Health 1993- seen in rural community and in lower middle socioeconomic 97;13:144.

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7. Banerjee G, Nandi DN, Nandi S, Sarkar S, Boral GC, Ghosh A. The vulnerability of Indian women to suicide a field study. Indian J Psychiatry.1990;32:305-8. 8. Shukla GD, Verma BL, Mishra DN. Suicide in Jhansi city. Indian J Psychiatry 1990;32:44-51. 9. Hegde RS. Suicide in rural community. Indian J Psychiatry 1980;22:368-70. 10. Srivastava MK, Sahoo RN, Ghotekar LH, Dutta S, Danabalan M, Dutta TK, et al. Risk factors associated with attempted suicide. Indian J Psychiatry 2004;46:33-8. 11. Narang RL, Mishra BP, Nitesh M. Attempted suicide in Ludhiana. Indian J Psychiatry 2000;42:83-7. 12. National Crime Records Bureau. Accidental Deaths and Suicides in India 2008. New Delhi: Ministry of Home Affairs, Government of India; 2010. 13. Latha KS, Bhat SM, D'Souza P. Suicide attempters in a general hospital unit in India: Their sociodemographic and clinical profile emphasis on cross-cultural aspects. Acta PsychiatrScand 1996;94:26-30. 14. National Crime Records Bureau. Accidental Deaths and Suicides in India. New Delhi: Ministry of Home Affairs, Government of India; 2000. 15. Adityanjee DR. Suicide attempts and suicides in India: Cross-cultural aspects. Int J Soc Psychiatry 1986;32:64- 73. 16. Gupta RK, Srivastava AK. Study of fatal burns cases in Kanpur (India) Forensic Sci Int 1988;37:81-9. 17. Sharma R, Vijay L, Chaturvedi S. Suicidal behavior amongst adolescent students in South Delhi. Indian J Psychiatry 2008;50:30-3. 18. Gururaj G, Isaac MK, Subbakrishna DK, Ranjani R. Risk factors for completed suicides: A casecontrol study from Bangalore, India. Inj Control SafPromot 2004;11:183-91. 19. Bagadia VN, Abhyankar RR, Shroff P, Mehta P, Doshi J, Chawla P, et al. Suicidal behavior: A clinical study. Indian J Psychiatry 1979;21:370-5.

84 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00015.1 Original Research Paper Sex determination based on thyroid cartilage parameters in Iranian population

1. Siamak Soltani, Assistant Professor, Department of Forensic Medicine, Iran University of Medical Science, Tehran, Iran. 2. Hanieh Saboori Shekofte, Assistant of Forensic Medicine, Iran University of Medical Science, Tehran, Iran. 3. Abbas Aghabiklooei, Professor, Department of Forensic Medicine and Toxicology, Firoozgar Hospital, Iran University of Medical Science, Tehran, Iran. 4. Mohammad Javad Hedayatshode, Forensic Medicine Specialist, Legal Medicine Organization Tehran, Iran.

ABSTRACT: Introduction : In the present study we aimed to analyze the anthropological measurements of the thyroid cartilage for sex determination. Materials and Method : The study was carried out on 200 Iranian cadavers aged between 20-60 years in autopsy hall of Legal Medicine Organization. After removing the larynx as a soft tissue block, muscles carefully cleared from surrounding thyroid cartilage. Then a total of fifteen parameters were measured and the observations were compared between both sexes. Results and Conclusions : In logistic regression analysis after adjusting for BMI, just length of thyroid lamina and ventral thyroid lamina were independent sex predictors with odd's ratio of 6.01 and 2.74. Corresponding Author : Article History: Dr. Hanieh Saboori Shekofte, Received: 18 May 2019 Assistant of Forensic Medicine, Iran University of Medical Received in revised form: 18 June 2019 Accepted on: 18 June 2019 Science, Tehran, Iran. Available online: 31 December 2019 Contact : +989128311005 E-mail : [email protected]

KEYWORDS : Thyroid cartilage, sex determination, autopsy, Iranian population.

INTRODUCTION: parameters of thyroid cartilage and its relationship with gender Sex determination of amputated limbs or body remains from in Iranian population. crime scenes, natural disasters, plane crashes, etc., is an MATERIALS AND METHODS : important component for identification in forensic Present study was carried out on 200 cadavers (100 male and (1) anthropology . Sex determination using bone measurements 100 female) of Persian ethnicity in autopsy hall of Legal is one of the effective methods that is less costly than other Medicine Organization of Kahrizak, Tehran, Iran during 2017 techniques like DNA and chromosome analysis and requires and 2018. Subjects were in the age range of 20-60 years and less time and implementation for personnel who do not have included by simple consecutive sampling. Cadavers that (2-3) skeletal intelligence information . Also bone remains intact underwent forensic exploration because of unnatural death or even years after death and in some cases they are the only clues suspected causes of death were included in the study and none (4) for identifications of dead bodies . was dissected just for the purpose of this study. Cadavers with In recent years, most sex determination studies have been severe combustion and traumatic injury to thyroid cartilage conducted on the long bones, but fewer studies have focused and those who were intubated (leading to change in the on thyroid cartilage dimensions as a sex determinant(5,6). cartilage anatomy) were excluded. Also cartilages with sever However, this values have not determined for the Iranian dissymmetrical anatomy were not included in the study. population yet. Autopsies were conducted by two Forensic Medicine Thyroid cartilage is the largest cartilage in the larynx. It consist specialists who were not aware of the study objectives. In the of two plates which are connected together under different autopsy, the neck muscles were removed layer by layer and angles(7) Due to the anatomical position of thyroid cartilage and larynx extracted as a block. Then thyroid cartilage was its placement under the mandibular bone, the probability of its carefully separated from soft tissue and prevented from any damage during traumatic injuries is low. Thus the use of damage. After completely clearing the attachments on the thyroid cartilage can be helpful in authentication(8). dissected thyroid cartilage and determining the extent of the various parts of the cartilage, 15 linear measurements of The aim of this study was to determine the size of different thyroid cartilage were measured by the collies in millimeter

85 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00015.1

scale (Figure 1-2). RESULTS : Figure 1: 1. Length of left thyroid lamina. 2. Length of right In this study, demographic characteristics (age and BMI) and thyroid lamina 3. Breadth of left thyroid lamina. 4. Breadth of various dimensions of thyroid cartilage were assessed in 200 right thyroid lamina. 5. Ventral thyroid height. 6. Dorsal left fresh adult cadavers (100 males and 100 females) in the age thyroid height. 7. Dorsal right thyroid height. 8. Upper thyroid breath. 9. Lower thyroid breath. 10. Right thyroid superior range of 20 -60 years (mean=39.38+_ 11.84). Demographic horn length. 11. left thyroid superior horn length. 12. Right characteristics of male and female participants are thyroid inferior horn length. 13. Left thyroid inferior horn summarized and compared in Table 1. Both male and female length. 14. Depth of superior thyroid notch 15. Angle of groups were similar in their mean age (p=0.88). Mean weight, thyroid height and BMI in the studied cadavers were associated with sex and all were greater in male subjects (Table 1). Table 1 : Comparison of Demographic Characteristics

Charac- 1 Mini- Maxi- 2 2 teristics Sex Mean SD mum mum F P Male Age 39.25 11.179 20 60 2.29 0.88 (Years) Female 39.51 12.538 20 59 Weight Male 78.3465 98 10.18277 40 1.11 <0.001 (Kg) Female 69.9900 8.64390 55 86 Height Male 1.7579 160 185 .05788 2.84 <0.001 (meters) Female 1.6828 .06333 155 179 Male 25.2857 12.62 31.18 2.45347 1.64 0.04 BMI Female 24.6390 1.95800 21.22 30.12 Descriptive statistics of the 15 thyroid landmarks investigated in this study are shown in Table 2. While only intact and symmetric thyroid cartilages were included in the study, we assumed that bilateral variables could be integrated into one measurement. Therefore, we assessed correlation between two sides of bilateral variables and results are presented in Table 2. Due to strong correlation between two sides of all bilateral variables, we considered mean of two sides as a representative of bilateral variables. . After integration of bilateral variables into a single variable, we investigated association between 10 Figure 2 : Schematic picture of thyroid cartilage indicating the points of measurements. thyroid measurements and sex and results are summarized in Table 3. There was statistically significant association between 7 of 10 variables and sex (Table 3). Association between sex and measured dimensions may be confounded by BMI which was not matched in both groups. To find the independent sex predictors among measured variables and also adjust for BMI, Logistic Regression analysis was applied (Table 4). Multivariate Logistic Regression analysis revealed that just STATISTICS : Length of thyroid lamina (regardless of the side) and Ventral thyroid length were independent sex predictors. Demographic characteristics (sex, age, height and weight) of subjects and measured dimensions of thyroid cartilage were DISCUSSION : entered into checklists by codes regarding concealment of any In the present study we focused on details of anatomical identity of cadavers. Data were analyzed by SPSS 16 dimensions of different parts of the thyroid cartilage and their software. Independent-Sample T-test, Mann-Whitney U test, sex determination potential in a series of adult Iranian Spearman correlation test and Logistic Regression analysis population. We had greater sample size in comparison with were used in this study. Statistically significant level was many other studies. All anthropological parameters of the considered <0.05. thyroid cartilage were greater in studied males except thyroid angle which was greater in females. This is in accordance with previous studies that showed majority of the measured

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Table 2 : Characteristics of measured dimensions of thyroid cartilage in total study population Thyroid measurements Median IQR Min Max Correlation Coefficient1 Right 23.91 20.87-27.73 18.89 31.35 Length of lamina (mm) .99 Left 24.02 21.30-27.85 19.02 37.03 Right 37.15 34.25-39.95 23.50 44.11 Breadth of lamina (mm) .95 Left 37.16 34.09-39.88 23.04 44.01 Right 38.61 36.15-40.85 27.63 43.15 Dorsal height (mm) .96 Left 39.02 36.06-40.81 19.01 43.21 Right 18.16 16.11-19.54 11.58 20.89 Superior horn length (mm) .90 Left 18.39 16.40-20.01 11.99 21.09 Right 11.14 09.42-11.79 1.01 12.86 Inferior horn length (mm) .92 Left 11.07 09.61-11.95 7.13 91.47 Ventral height (mm) - 16.05 14.30-17.65 12.11 19.52 Upper breath (mm) - 48.75 43.55-51.38 15.31 53.97 Lower breath (mm) - 41.70 37.03-43.59 32.10 53.12 Depth of superior notch (mm) - 12.23 10.69-12.85 7.33 13.98 Angle of thyroid (degrees) - 89.45 85.48-92.33 52.65 98.56 IQR=Interquartile Range Min= Minimum Max=Maximum

Table 3 : 1 Spearman Correlation Test was applied for bilateral dimensions and all p-values were < 0.001 Thyroid measurements Sex Median IQR Min Max Z2 P2 Male 27.81 25.75-29.22 19.58 32.01 Mean Length of lamina (mm) -11.94 <0.001 Female 21 20.23-22.95 18.98 23.99 Male 38.34 34.88-40.53 27.94 44.06 Mean Breadth of lamina (mm) -3.91 <0.001 Female 36.09 31.03-38.50 25 41.85 Male 17.53 15.48-18.31 13.97 19.52 Ventral height (mm) -8.41 Female 15.09 13.18-16.08 12.11 18.41 <0.001 Male 38.74 37.08-40.67 27.74 43.18 Mean Dorsal height (mm) -0.02 Female 38.55 34.58-41.25 27.43 43 0.98 Male 49.32 46.73-51.18 15.31 53.86 Upper breath (mm) -1.24 Female 48.28 42.51-51.81 34.69 53.97 0.21 Male 41.59 38-42.91 32.19 52.60 Lower breath (mm) -0.1.62 Female 42.24 35.61-44.20 32.10 53.12 0.10 Male 18.55 17.02-20.03 12.07 20.97 Mean Superior horn length (mm) -2.30 Female 18.01 15.31-19.23 11.98 20.96 0.02 Male 11.62 10.34-12.33 6.40 50.26 Mean Inferior horn length (mm) -5.44 Female 10.58 8.68-11.37 7.11 12.06 <0.001 Male 12.59 11.43-13.38 7.33 13.98 Depth of superior notch (mm) -4.45 Female 11.80 10.47-12.54 8.27 13.09 <0.001 Male 88.45 85.35-91.12 52.65 95.72 Angle of thyroid (degrees) -3.37 Female 90.36 87.52-93.67 74.61 98.56 0.001 Comparison of thyroid measured dimensions between sexes

87 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00015.1

Table 4 : Logistic regression analysis for sex prediction Input variables Univariate analysis Multivariate analysis Beta Crude Odd's ratio 95% CI Beta Adjusted Odd's ratio 95% CI Mean Length of thyroid lamina* 2.06 7.84 3.75-16.4 1.79 6.01 2.80-12.88 Mean Breadth of thyroid lamina* 0.15 1.17 1.08-1.26 -0.95 0.91 0.67-1.23 Ventral thyroid height 0.89 2.44 1.91-3.11 1.01 2.74 1.08-6.98 Mean superior horn length* 0.15 1.16 1.02-1.31 -0.34 0.71 0.40-1.27 Mean superior horn length* 0.50 1.65 1.33-2.03 0.19 1.21 0.37-3.92 Depth of superior thyroid notch 0.32 1.37 1.12-1.69 0.21 1.23 0.50-3 Angle of thyroid -0.07 0.93 0.89-0.98 -0.06 0.94 0.77-1.16 BMI 0.13 1.14 1-1.31 -0.11 0.90 0.54-1.59 R square= 0.70, Model p-value <0.001 Reference dependent variable is female. CI= confidence interval for Odd's ratio Mean values are representative of bilateral measures, regardless of side

parameters are greater in males compared to females in various Subramanyam et al(3) study. However in some other researches populations(3, 7,9, 11, 13, 14, 15).According to M. Zrunek et al., the the difference was more significant(10-13) and in poletaeva et al dimensions of the thyroid parameters in men is 10-30% greater study in Russian on 70 sample the thyroid cartilage angle than women(18). showed the closest correlation with the sex (88-105 degree in (14 ) Our results showed statistically significant gender differences women vs. 66-90 in men) . in 7 anthropological parameters of the thyroid cartilage (mean The difference in race, sample size and age range of samples length of the thyroid lamina, mean breadth of the thyroid can be attributed to different observation in different studies. lamina, ventral thyroid height, mean thyroid superior horn We found that upper horns of thyroid were larger than the length, mean thyroid inferior horn length, depth of superior lower horns which was also noted in studies of poletaeva(14), thyroid notch and angle of thyroid )(p.value <0.05). kovac(9) and Ajmani(12). In Subramanyam et al. study in India length of the thyroid In Subramanyam et al(3), Jain M et al(13) and poletaeva et al(14) lamina, breadth of the thyroid lamina and ventral height of studies, length of thyroid lamina, breath of thyroid lamina and thyroid lamina were significantly different between male and angle of thyroid cartilage differs significantly between both female and the angle of thyroid was 83.88 degree in male and sexes. Also ventral thyroid height was statically different (3) 87.53 degree in female . In research carried out by kovac in between two groups in Subramanyam et al(3) and poletaeva et al eastern Slavonia on 63 samples, the same results were obtained (14-18) studies as confirmed in this study. and the thyroid Angle was on average 78.83 degree in male and It should be noted that factors such as weight, height and BMI 94.19 degree in female(9). In the study of Tayama et al. in USA may confound observed differences which was not mentioned all of measured anthropological parameters of the thyroid in other studies. Considering BMI which was not matched in cartilage were greater in male than female except the distance two sexes, the only independent predictor parameters for sex between the tips of the superior horns and the thyroid angle(10). were length of thyroid lamina and ventral height of thyroid. Ajmani measured 40 samples in Nigeria and observed high significance difference of dimensions between male and CONCLUSION: female laryngeal cartilage. All of measured parameters were In regard to this notion that different body parts express greater in male except superior horn length and thyroid angle different sexual patterns in populations, finding a forensic which was 89.92 in male and 106.38 in female. standard using a discriminant equation derived from Iranian In most of studies carried out on thyroid cartilage regardless of thyroid cartilage measurements could be helpful in forensic other anthropological parameters, the thyroid angle was medicine. In this study we provided a helpful guide for sex greater in female than male. The median thyroid angle of identification by two parameters, length of thyroid lamina and females in the current study was 89.32 degrees and 86.46 ventral thyroid height. Future studies in Iran with higher degrees in males. These values was almost similar to Sunil sample sizes can offer cut of points for sex determination by these parameters among Persians.

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Limitations to this study : Finding intact and symmetrical 9) Kovac T, Popovic B, Marjanovic K, Wertheimer V, thyroid cartilages was time consuming. There was also Kovacevic M, Nikolic V, et al. Morphometric probability of bias in manual measuring of thyroid dimensions. characteristics of thyroid cartilage in people of Eastern Despite limitations and probability of bias in this study, it was Croatia. Collegium antropologicum. 2010; 34(3):1069- the first study in an Iranian population that focused on thyroid 73. linear dimensions and their role in sex determination. 10) Tayama N, Chan RW, Kaga K, Titze IR. Geometric ETHICAL CONSIDERATIONS: characterization of the laryngeal cartilage framework for Study was approved by Ethics committee of Iran University of the purpose of biomechanical modeling. The Annals of Medical Sciences. All thyroid cartilages obtained from corpse otology, rhinology, and laryngology. 2001; 110(12):1154- that underwent neck dissection during forensic autopsy for 61. legal indications and no additional intervention was carried out 11) ShitalPatelRashmiBhardwajPriyankaParmarVasant on cadavers for this study. HVaniya. Morphometric characteristic of thyroid Conflict of interest: authors disclose no conflict of interest. cartilage in Gujarat region - A cadaveric study.Journal of Research in Medical and Dental Science.2016; 4(2):150 REFERENCES : 12) Ajmani ML. A metrical study of the laryngeal skeleton in 1) Lee J-H, Kim Y-S, Lee UY, Park D-K, Jeong Y-G, Lee NS, adult Nigerians. Journal of anatomy. 1990; 171:187-91 et al. Sex determination using upper limb bones in Korean populations.Anat Cell Biol. 2014 Sep; 47(3): 196201. 13) Jain M, Dhall U. Morphometry of the Thyroid and Cricoid Cartilages in Adults. Journal of Anatomical 2) Mitra A, Khadijeh B, Vida AP, Ali RN, Farzaneh M, Society of India.2008; 57 (2) 119-123. Maryam VF, et al. Sexing based on measurements of the femoral head parameters on pelvic radiographs. Journal of 14) Poletaeva M. The possibilities for sex determination forensic and legal medicine. 2014; 23:70-5. based on the specific anatomical features of the human thyroid cartilage. Sudebno-meditsinskaiaekspertiza. 3) Subramanyam S, Murali G, Mandal S, Bansal Y, Singh D. 2017; 60(4):21-4. Sex Determination from Anthropological Measurements of Thyroid Cartilage in the Population of Punjab. Journal 15) Pereira Jotz G., ZaquiaLeao H., Pereira Da Costa Filho O., of Indian Academy of Forensic Medicine. 2014; Fisch P., Coelho Magalhaes R., Cervantes O. The 36(4):367-70. asymmetry index of the cricoid cartilage and the external angle of the thyroid cartilage. A sex-related study. Eur J 4) Memarian A, Aghakhani K, MehrpishehSh, Fares F. Anat. 2007; 11:1-7. Gender determination from diagnostic factors on anteroposterior pelvic radiographs. Journal of the Chinese 16) Ahmed AA. Estimation of sex from the upper limb Medical Association. 2017, Volume 80, Issue 3, Pages measurements of Sudanese adults. Journal of forensic and 161-168. legal medicine. 2013; 20(8):1041-7. 5) Gonzalez PN, Bernal V, Perez SI. Geometric 17) Zrunek M, Happak W, Hermann M, Streinzer W. morphometric approach to sex estimation of human Comparative anatomy ofHuman and Sheep laryngeal pelvis. Forensic science international. 2009; 189(1-3):68- skeleton. Actaotolaryngologica. 1988; 105:155-162. 74. 18) SiamakSoltani, Maryam Ameri, Kamran Aghakhani, 6) Hayashizaki Y, Usui A, Hosokai Y, Sakai J, Funayama M. SoheilaGhorbani: Evaluation of Greater Sciatic Notch Sex determination of the pelvis using Fourier analysis of Parameters in Sex Determination of Hip Bone by Three- postmortem CT images. Forensic science international. Dimensional CT Images. Journal of Clinical and 2015; 246:122.e1-9. Diagnostic Research. 2018; 12(9). 7) Sprinzl GM, Eckel HE, Sittel C, Pototschnig C, Koebke J. Morphometric measurements of the cartilaginous larynx: An anatomic correlate of laryngeal surgery. Head Neck. 1999; 21(8):743-50. 8) Jowaheer V, Agnihotri AK. Sex identification on the basis of hand and foot measurements in Indo-Mauritian population--a model based approach. Journal of forensic and legal medicine. 2011; 18(4):173-77.

89 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00016.3 Original Research Paper The use of water quality Index (Canadian model) to determine the validity of the River of Al-Diwaniyah - Iraq for Irrigation

1. Ahmed Mahmoud Falih-Al-Khalidi, Research Scholar, Ministry of Environment, Iraq 2. Raid Kadhim Abed Al-Asady, Assistant Professor, University of AL-Qadisiyah, Faculty of Education, Iraq.

ABSTRACT: The current study was conducted to assess the water of the Diwaniyah River for Irrigation by adopting the water quality index - the Canadian model as an effective means of determining the water validity for different purposes. Five stations were selected along the course of the river between January and December 2019. and conducted some Physical and chemical tests, that include (electrical conductivity, pH, SAR, chloride, boron, lead, copper, zinc, cadmium, manganese, chromium) . Resultsconfirmed that the values of water quality guide for Irrigation has ranged between (56.12 86.72), which means that the Diwaniya River water is located between the two categories ( Marginal - Good ).

Corresponding Author : Article History: Raid Kadhim Abed Al-Asady, Received: 15 May 2019 Assistant Professor, University of AL-Qadisiyah, Faculty of Received in revised form: 11 June 2019 Accepted on: 11 June 2019 Education, Iraq. Available online: 31 December 2019 E-mail : [email protected]

KEYWORDS : Water Quality Guide, Diwaniyah River Water, CCME, Irrigation Purposes

INTRODUCTION : whose source is added water[6]. Water is the most important element of all life forms, as it is Canadian Water Quality index (CCME WQI) is an updated essential for the preservation of life on earth and is essential for version of the Canadian Council of Ministers of the the formation and regeneration of cells.Water has been defined Environment, an effective model for assessing water quality as a variable system containing both living and non-living for its ability to summarize a large number of water quality data organisms and organic and inorganic soluble and insoluble and convert it into a single number ranging from 0 to 100. It has materials, so there is a possibility of change in quality on a the flexibility to select the measured variables to define the daily basis where the transformation of the natural structure of goals and the study area [7]. the water can lead to imbalance and therefore inappropriate MATERIALS AND METHODS: water for intended consumption [1].The WQI Water Quality The Diwaniyah River is one of the main and important rivers in Index uses water quality data and helps to modify the policies the Diwaniyah province, which is one of the branches of the formulated by various environmental monitoring agencies. It River Hilla, which is in turn a branch of the Euphrates River. has been recognized that using the individual water quality During the current study, five stations were selected along the variable to describe water quality to the general public is not river's water stream in Diwaniyah city, where the first station easy to understand [2].For this reason, the WQI water quality was located at Al Saniya of Diwaniyah governorate near the index has the potential to reduce the bulk of information to a water complex (Al Maala) (N = 32 ° 00'77.5 "E = 44 ° 86 ' 61.1 single value to express data in a simplified and logical form "), the second station is located north of the city of Diwaniyah [3].This index takes information from a number of sources and within the water purification plant Diwaniya project (N = 31 ° collects them to develop a comprehensive case of a water 96'27.5": E = 44 ° 94'81.6 "). The third station was in the system [ 4 ] . Therefore, water quality indexincreases drinking water complex (N = 31 ° 94'82.1 '': E = 44 ° 96'94.8 ') understanding of water quality issues by policymakers as well while the fourth station in the south of the city of Diwaniya as the general public as users of water resources [5]. near the sewage station (N = 31 ° 72' 92.2 ": E = 44 ° 96'80.8"). The importance of studying the quality of irrigation water lies The fifth station was in Al-Hamzah area within the Al- in the containment of irrigation water and regardless of its Mansour water project (N = 32 ° 05'18.89 "E = 44 ° 77'55.28"). sources on different concentrations of dissolved salts, many of Figure (1). Field measurement was performed directly for the current problems of irrigated agriculture in many regions of electrical conductivity using a portable conductivity meter the world are a direct result of the salts accumulated in soil Model Pw9525 of Philips and pH was measured using the 3320

90 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00016.3

Jenway meter after calibration with buffer solutions before It is noted that the water quality index values showed a clear measurement. The sodium absorption ratio was calculated contrast between sites and months during the study period. according to the method adopted by Ayers et at[8]. While the During the summer months the most deterioration of the chloride/boron was measured by color method described by quality of water was due to the high chlorides, boron and Eaton AD[9] .The concentrations of heavy elements were cadmium and these variables exceeded the standards of Iraqi e s t i m a t e d u s i n g t h e F l a m e A t o m i c A b s o r p t i o n and International standards, while the pH and electrical Spectrophotometer.[9]. conductivity and the proportion of adsorption of sodium, copper, lead, chromium, manganese and zinc remained within Al Maala water complex the standards and permitted International standards (Table:1). As for spatial variations, the fourth site recorded the lowest Diwaniyah project (No. 6) values of the water quality index as it receives many of the household, industrial and agricultural wastes that are dumped into the river without treatment, as well as the animal rearing water residues directly to the river. Untreated waste water that is discharged into the river has a negative impact on water quality Sewage station and its use by humans as well as its effect on the value of the variables that were calculated[14-16]. It was obvious from the results of the Principles components Al-Mansour water project analysis (PCA) that Chloride, cadmium, copper, lead, Figure 1: The map of the study area chromium, electrical conductivity and boron are the most influential on the Index value in Site (1) and came after pH. Water Quality Index (WQI) Model of Canadian Council of (Figure 3). Ministers of the Environment (CCME WQI Model) was used to measure the water quality of the river for irrigation Figure 3 : Water quality variables responsible for changes in purposes[10]. Water quality data were collected and arranged irrigation water Index values according to the Principles according to the months and locations. 11 variables were used Components Analysis (PCA) to calculate this WQI, namely pH, chloride, electrical conductivity, sodium adsorption ratio, boron, copper, lead, cadmium, chromium, manganese and zinc. RESULT AND DISCUSSION: The results of the Present study showed that the water of the Diwaniyah River for irrigation purposes of the Canadian guide has ranged between (Marginal - Good) with the highest value of 86.72 for the month of December in the first site and the lowest value of 56.12 in the fourth site of July. (Figure 2).

CONCLUSIONS: The results of the study revealed that the river is suitable for irrigation Among the 11 parameters studied, the chloride ,cadmium and boron were out of the standards of Iraqi and International standards.the study showed that application of Figure 2 : Monthly and local changes of water quality index CWQI is a useful tool in assessing the irrigation water of river . CONFLICT OF INTEREST : None

91 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00016.3

Table 1: The range and standard deviation and mean of water quality parameters of the study sites

Electrical Conducvity (μs/cm)

## [11] *** [12] ** [13]

REFERENCES : 10125-33. 1. Ndubi D, Oyaro N, Githae E, Afullo A. Determination of 4. Karbassi A, Hosseini MM, Bagh Vand F, Nazariha M. physico-chemical properties of sources of water in Narok Development of Water quality index (WQI) for North Sub-County, Kenya. Int. Res. J. Environ. Sci. Gorganrood River. International Journal of 2015;4(1):47-51. Environmental Research.2011; 5(4): 1041-46. 2. Katyal D, Bharti N. Water quality indices used for surface 5. Nasirian M. A new water quality index for environmental water vulnerability assessment. International Journal of contamination contributed by mineral processing: a case Environmental Sciences. 2011;2(1):154-73. study of Amang (Tin Tailing) processing activity. Journal 3. Semiromi F B, Hassani AH, Torabian A, Karbassi AR, of applied sciences.2007; 7(20): 2977-87. Hosseinzadeh Lotfi F. Water quality index development 6. Najem A, Abdullah M, Khalid HB, Irrigation. Dar al- using fuzzy logic: A case study of the Karoon River of Kitab, University of Basra, Ministry of Higher Education Iran. African Journal of Biotechnology.2011;10(50): and Scientific Research, Iraq, 1980.(In Arabic ).

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7. CCME , Canadian environmental quality guidelines for the protection of aquatic life, CCME water quality index: technical report.2001; 1.0 8. Ayers RS,Westcot D W. Water quality for Agriculture, Irrigation and Drainage paper,1980; No.29, FAO, Rome. 9. Eaton AD. Standard Methods for the Examination of Water and Waste water. APHA. Washington, DC.2005; 22621pp (21st Edition). 10. CCME : Canadian Council of Ministers of the Environment .Canadian Water Quality Guidelines for Protection of Agricultural Water Uses. Excerpt from Publication.2005; No.1299.7pp. 1. 11. WHO: World Health Organization. Guidelines for Drinking-Water Quality 2nd Edition Volume 1 Recommendations, Drinking water - standards. Geneva. 1993. 12. WHO: World Health Organization. Guidelines for Drinking-Water Quality, Microbial Fact Sheet, Third Addition, Vol. 1. Geneva. 2008. 13. Iraqi standard for drinking water. Drinking Water, Iraq. First modernization, no. 417, the Council Of Ministers, Central Apparatus for Assessment and Quality Control. [ in Arabic].1986. 14. Hussien N A, Grabe S A. A Review of the Water Quality of the Mesopotamian (Southern Iraq). Marsh Bulletin.2009; 4(2): 98-120. 15. Siraj A, Samy E, Hassin JM, Rawai A, Mahmoud S. Some qualitative indicators of the water of the Tigris River in the city of Mosul. Journal of Science Rafidain.2014; 25 (1): 1- 22. 16. Torres P, Cruz CH, Patino P, Escobar JC, Pérez YA. Applying water quality indexes (WQI) to the use of water sources for human onsumption.INGENIERÍA EINVESTIGACIÓN.2010;30 (3): 86-95.

93 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00017.5 Original Research Paper Decay in Intact DNA Recovery in Semen Samples Kept at Room Temperature 1. Imran Sabri, Faculty Member, Division of Forensic Medicine, Department of Biomedical Sciences, King Faisal University, Al-Ahsa. 2. Jawed Ahmad Usmani, Professor, Department of Forensic Medicine, J.N. Medical College, AMU Aligarh 3. Shaukat Arif Hanif, Professor, Department of Forensic Medicine, J.N. Medical College, AMU Aligarh 4. Asadullah Khan, Professor, Interdisciplinary Biotechnology Unit, A.M.U. Aligarh

ABSTRACT : Background: Semen is the one of the important Forensic Sample recovered from the scene of crime however the time of recovery may differ from fresh to months. Material and Method: Semen Samples were kept at room temperature for a period of 3-6 months at room temperature to know the amount of quantitative DeoxyriboNucleic Acid [DNA] recovery from these samples. Results: We were able to recover intact DNA for about first 3-6 weeks after which the DNA yield was decreased drastically and after two months hardly any intact DNA recovered from these samples. Conclusion: There is a significant chances of intact DNA recovery in seminal samples with one day of sample analysis. The liquid semen samples recovered from scene of crime after about 1-2 months is merely considered as waste.

Corresponding Author : Article History: Dr Imran Sabri, MD Received: 16 April 2019 Faculty Member, Forensic Medicine Division, Received in revised form: 24 June 2019 Accepted on: 24 June 2019 Department of Bio-Medical Sciences, College of Medicine, Available online: 31 December 2019 King Faisal University, P.O. Box No. 400 Al-Ahsa-[31982]. KSA Contact : +966-13-589-7810 Email : [email protected], [email protected]

KEYWORDS : DNA, time, semen, decay, room temperature, yield

INTRODUCTION : collecting Seminal samples for DNA analysis. The DNA Semen is the one of the important Forensic Sample recovered recovery dropped for most with each timed collection from the scene of crime however the time of recovery may regardless of standard or enhanced Y-STR method where differ from fresh to months. Most of the time semen was sent to statistical differences in DNA recovery between timings (0-4 [1-8] the Forensic Laboratory for DNA isolation and the days, 4-7 days, and 7-9 days) . investigation agencies thought that it is a minor work to do, MATERIAL AND METHODS: which is not so. Our study is based on the fact that the DNA The study was conducted in Forensic DNA Laboratory of [1] yield decreases with time but what is that time period after Department of Forensic Medicine, Jawaharlal Nehru Medical which we are unable to isolate the intact DNA from these College, Aligarh Muslim University, Aligarh. A total of eight samples. Although there is no hard and fast rule that this is the samples were taken to study. The semen samples were time after which we are unable to recover intact DNA from the obtained from healthy consenting volunteers. Zero Time was samples but our study just show chances of recovery. In the the time when the first recovery was done which was same or first phase of our study we took only one type of sample [liquid different from time of Sample collection from the subject or Semen] so as to avoid any confusion. In forensic conditions scene of crime. Before this time, the time was calculated as semen is found in various states like dried stains or sometimes negative value i.e.: minus one hour or minus one day etc. 2.5 ml liquid state, but only liquid semen is taken so as to guide the of Semen samples were diluted to 20 ml. 2.5 ml of diluted investigating agencies about the chances of recovery of intact semen sample was taken to isolate the DNA using phenol DNA from semen samples. The samples must be recovered as extraction method[2]. The optical density (OD) of isolated early as possible to recover intact DNA from them. The DNA was done by spectrophotometer. seminal samples must be collected within 1-2 months from Concentration of DNA (µg/ml) = OD260 X 50µg/ml X scene of crime until and unless the climate is cold enough to Dilution Factor X Total Vol. in ml increases decay time. This study will be useful for the investigating authorities which can make errors while Formula: OD260 x conversion factor = µg/ml of nucleic acid 94 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00017.5

OD260 Unit = 50µg/ml for dsDNA phenol-chloroform method[2] However there are protocols Dilution Factor (Note: This is a ratio hence do not have unit) = available to recover DNA from semen even after 3-4 months Amount of water or buffer used for dilution / Amount of which are not included in our study. In the light of above study Sample ( Isolated DNA dissolved in TE Buffer ). it has been concluded that diluted semen samples recovered from scene of crime after about 1-2 months is not very useful as OBSERVATIONS: far as DNA recovery is concern. The samples must be Table 1 : Showing yield of DeoxyriboNucleic Acid [DNA] in recovered as early as possible to recover intact DNA from diluted semen samples at Room temperature over a period them. The samples must be collected within 1-2 months from of twelve weeks time scene of crime until and unless the climate is cold enough to Time Mean DNA Yield Percent increases decay time. in µg/ml Decrease in [Mean ± S.D.] DNA Yield It is concluded that there is a significant chances of intact DNA Zero 844.5± 130 recovery in seminal samples with one day of sample analysis. One Week 564±145 33 After this period there is a significant fall in DNA damage, Two Weeks 431±123 48.96 which directly impacted chances of intact DNA recovery. It is Four Weeks 230±43 73 also concluded that the liquid semen samples recovered from 8-10 Weeks 180±104 78.7 scene of crime after about 1-2 months is merely considered as 11- 12 Weeks 160±38 81 waste. :a yieldśĂ■ Ŧof╜ś D▄ŕN ◘Aź in5 bseminal! ╜■ ℓś sample▓╜■Ă▄ at room Limitations of the Study ﻵ Figure C1:╜┼ Showingĵ ʼnś temperatursamplese at room temperature 1. Sample size is limited subject to the availability. 2. The study does not measure the sperm quality and 1000 motility. 3. The study is applicability is limited to forensic samples .only و śʼn╜śℓ } 500 l m / g µ n i Conflict of interest: No conflict of interest ﮭ ľ ■ ◘ ľ ! b 5 Ç╜▓ ś Ethical remarks: Ethical approval has been taken from the competent authority. Formal informed consent has been taken DISCUSSION: from all the subjects The yield of DNA decreases with time as lysis of DNA occurs REFERENCES: in the samples as a result of enzymatic action so the amount of 1. Bomjen G, Raina A, Sulaiman IM, Hasnain SE, Dogra recovery is expected to be decreased with time. The question TD, Effect of storage of blood samples on DNA yield, arises is that what is the time [in Indian environment] after quality and fingerprinting: a forensic approach, Indian J which we are unable to recover DNA from these samples. Exp Biol. 1996 ;34(4):384-6. After a period of 12 weeks there is less chances to recover 2. Sambrook, J. Molecular Cloning, 2nd ed.: A Laboratory DNA from blood samples kept at room temperature. The curve Manual (Cold Spring Harbor Laboratory Press, becomes parallel showing some amount of recovery even after Plainview, NY, 1989). 12 weeks. The DNA damage was significantly increased (<.05), with one day [7]. 3. Raina A, Dogra TD, Methods of Collection, Preservation and Forwarding of Biological material for DNA CONCLUSION : fingerprinting, Indian Internet J For Med & Tox. The recovery of DNA in diluted semen sample kept at room 2003;1(2). temperature decreases with time. After one month there is less 4. Bruce A. Roe, Judy S. Crabtree, Akbar S. Khan, Protocols or no chance of seminal recovery of intact DNA from these For Recombinant DNA Isolation, Cloning and samples until and unless the environmental conditions are Sequensing Published by John Wiley & Sons(1996), Isbn favorable to preserving the DNA. The study shows marked 0-471-97324-0. decrease in Recovery of intact DeoxyriboNucleic Acid [DNA] after a period of 1-2 months so we can conclude here is that 5. Sabri I, Usmani JA, Hanif SA, Khan AU. Effect of there are hardly any chances of intact DNA recovery after a temperature and ageing on recovery of DNA in forensic period of 2 months in samples found at room temperature by blood samples. Ind. Int. Jour. of For. Med. & Tox. 2008;6(3).

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6. Imran Sabri, J.A. Usmani, S.A. Hanif, A.U.Khan (2010): Decay in intact DNA recovery in blood samples kept at room temperature. J Indian Acad Forensic Med. April- June 2010; 32[2]: 142-43. ISSN-0971-0973.5. 7. I. Ahmed, S. Abdelateef, M. Laqqan, H. Amor, M. A. Abdel-Lah and M. E. Hammadeh, Influence of extended incubation time on Human sperm chromatin condensation, sperm DNA strand breaks and their effect on fertilisation rate, Andrologia, 50, 4, (2018). 8. Patricia M Speck, Jack Ballantyne. Post Coital DNA Recovery Study, March 2015: Report number: 248682 Affiliation: U. S. Department of Justice.

96 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00018.7 Original Research Paper Prevalence and Extent of Coronary Atherosclerosis and Its Correlation with Obesity in a Female Population of South Karnataka : An Autopsy Study 1. Haneil L D'Souza, Associate Professor, Department of Forensic Medicine, Kasturba Medical College,Mangalore, Manipal Academy of Higher Education 2. Mehak Malhotra, Intern, Kasturba Medical College, Manipal, Manipal Academy of Higher Education 3. Ranjit Immanuel James, Assistant Professor, Department of Forensic Medicine, Christian Medical College, Vellore, Tamil Nadu 4. Prashantha Bhagavath, Forensic Specialist, International Committee of the Red Cross New Delhi Regional Delegation 5. Deepak Nayak, Associate Professor, Department of Pathology, Kasturba Medical College,Manipal, Manipal Academy of Higher Education

ABSTRACT: Introduction: Obesity and coronary artery disease (CAD) have had a controversial relationship for decades, though obesity is considered to be an independent risk factor that influences the development of coronary atherosclerosis / Coronary Artery Disease (CAD). However, there are recent studies with results proving otherwise. Aim & Objectives: To find a correlation, if any, between the level of coronary atherosclerosis and any of the nourishment/obesity indicators. Material and Method :This was a prospective study which involved 30 female patients. The study period was from May 2015 to May 2016.Before autopsy, the nourishment/obesity indicators such as waist circumference (WC), hip circumference (HC), length, and weight were taken in order to compare with the coronary atherosclerotic changes. Results:No such association was established between high BMI /other obesity indicators in relation to the development of coronary atherosclerosis in all the three major coronary arteries. Conclusion:This study could not prove the association between anthropometric measurements and the development of coronary artery atherosclerosis.

Corresponding Author : Article History: Ranjit Immanuel James, Received: 19 February 2019 Received in revised form: 3 April 2019 Assistant Professor, Accepted on: 3 April 2019 Department of Forensic Medicine, Christian Medical Available online: 31 December 2019 College, Vellore, Tamil Nadu Contact : +91 8105694947 Email : [email protected]

KEYWORDS :

INTRODUCTION: The Body Mass Index (BMI) assessment is considered a fairly The positive correlation between coronary artery disease and accurate indicator of the obesity status of a person. It has been 2 obesity has always been a controversial one. Recent studies stated that a BMI more than 30.0 kg/m has a higher incidence (4) however state that such an association may not be as clear cut. of developing coronary artery disease . To be specific, it is Some risk factors have been linked to the development of considered that when there is a high order of obesity (i.e. BMI 2 atherosclerosis, a significant contributor to morbidity and more than 35 kg/m ) it will result in higher overall mortality (5) mortality. Among the modifiable risk factors, a major one is rates .It is well known that the manifestations and obesity. The Framingham heart study and American Heart presentations of coronary artery diseases differ between men Association (AHA) considers obesity as an independent factor and women. An avenue of research that is often neglected is the that hastens the development of coronary artery disease extent to which a modifiable risk factor, such as obesity, affects (CAD)(1-3). However, the extent to which it contributes to women particularly; whether these factors affect men and plaque development in different populations may vary. Also, women equally and if not, the reasons for it. the variation between the sexes is often overlooked.

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AIM AND OBJECTIVES: MATERIALS AND METHODS: Ÿ To assess the prevalence of coronary atherosclerosis Adult females (>18 years of age) autopsied at Kasturba among women of Udupi and neighbouring districts by a Medical College (KMC), Manipal between May 2015 and histologic study of coronary arteries. May 2016 (total of 30 cases were studied) were assessed for Ÿ To determine the level of coronary atherosclerosis by fatty streaks and atherosclerosis in the major coronary vessels. microscopic grading. Written informed consent from the investigating authorities and legal heirs of the deceased was obtained in all cases. Ÿ To determine the nourishment/obesity status of women by Autopsy and gross specimen dissection were done by the measuring various parameters. faculty of the Department of Forensic Medicine, KMC Ÿ To look for a correlation, if any, between the level of Manipal. In those cases, where atherosclerosis was present, coronary atherosclerosis and any of the nourishment/ various gross and histologic parameters related to the lesion obesity indicators. were determined. These parameters included: Ÿ Artery involved LITERATURE REVIEW: Ÿ Type of lesions A study conducted by Rastogi P and his colleagues to Ÿ The degree of luminal narrowing study/observe the correlation between coronary Ÿ Status of the internal elastic lamina atherosclerosis and indices related to obesity in men, showed a positive association between both the parameters (6). The study Ÿ Content and position of plaques from occluded arteries done by Bhanvadia and his colleagues among autopsy cases in Histopathological reporting for the study was done by the same Jamnagar showed that the young population was found to have faculty of the Department of Pathology, KMC Manipal in an increased number of intermediate lesions, indicating that order to eliminate inter-observer bias. Obesity indicators such interventions to reduce risk factors should be started from an as BMI, waist circumference and waist-hip ratio were early age (7).The incidence of obesity has been increasing measured and calculated by standard method/formulae. among Indian women because of urbanisation and improving Measurements were taken by one of the investigators economic status (8). conducting the study. Studies show that the individuals who fall under class II Ÿ Classification of the degree of occlusion was as per the obesity (i.e. BMI of more than 35 kg/m2) are at higher risk of modified American Heart Association (AHA) grading cardiovascular mortality(9). Surprisingly, the individuals whose scale. BMI is less than 18.5 had the highest mortality risk even after ü Grade 0 – Sections showing normal histology or the parameters were adjusted to minimise the errors adaptive thickening without macrophages or foam (9-11) concerning age, sex and cardiovascular risk factors . The cells relationship between coronary heart disease (CHD) and ü Grade 1 – presence of isolated macrophages and foam obesity is taken as U-shaped (12,13). Several explanations have cells been given to explain this paradox. One such explanation is that it could be attributed to the weak association of lean body ü Grade 2 – mainly intracellular lipid accumulation mass and body fat; both of which have different sequelae in ü Grade 3 – along with grade 2 findings; small cardiovascular disease (14). A person with an android variety of extracellular lipid pools also present distribution of fat with a higher body fat percentage will have ü Grade 4 – along with grade 2 findings;presence of the same body mass index as that of a person who has gynoid extracellular lipid core variety of fat distribution with more lean mass (15). ü Grade 5 – multiple lipid cores and fibrotic lipid layers To overcome this issue, waist to hip ratio (WHR) or waist ü Grade 6 – presence of a surface defect, haematoma, circumference (WC) has been recommended as an alternative formation of thrombus or haemorrhage to BMI. Unfortunately, here too the results conflict at times(13,16).However, some studies do state that the waist Measurement of the nourishment status: circumference strongly corresponds to the adipose tissue Ÿ B ased on body mass index ( B M I =Weight in located in the intra-peritoneal region as studied by dual energy kilograms/Height in meters)2 individual were classified X-ray absorptiometry (DXA) or computed tomography into the following categories (17,18) (CT) . 1. <18.5- underweight

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2. 18.5-24.9- normal weight elsewhere in the course of the artery, that particular segment 3. 25-29.9- overweight block measuring 3 x 2 cm was taken for histopathological exmination. The grading of occlusion of the coronary arteries 4. 30-34.9- class 1 obesity was grouped into three groups for statistical analysis. They 5. 35-39.9- class 2 obesity were as follows, group I which consists grade 0 occlusion, 6. ≥ 40- class 3 obesity group II comprises of grade 1 & 2 occlusion and group III •Hip and Waist circumference were measured using a consists of grade 3,4,5 & 6. measuring tape. The descriptive data with relation to the left circumflex artery Statistical Methods: (LCX), left anterior descending artery (LAD) & right coronary artery (RCA), and the degree of occlusion is shown in Data were summarised using mean (SD) for continuous Table No.2 & Diagram No.1 variables and categorical data were expressed as frequency along with a percentage. ANOVA was used to compare the Table No.2 : Showing the descriptive data anthropometric measurements among the grades. All analysis concerning the coronary arteries was performed using STATA I/C 15.0 and their degree of occlusion RESULTS: Group RCA LAD LCX (n=30) (n=30) (n=30) The descriptive summary with relation to anthropometric measurements and obesity indices and measurements are I (Grade 0) 15 17 17 depicted in Table no.1 II (Grade 1&2) 10 8 6 Table No.1 : Shows descriptive summary with relation to anthropometric measurements and obesity III (Grade 3-6) 5 5 7 indices and measurements Total no. Mean Minimum Maximum Trait Diagram No. 1 : Showing the descriptive data of cases (SD) Value Value concerning the coronary arteries and their 156.20 cm Height 30 142 cm 172 cm degree of occlusion (7.09) 59.03 kg Weight 36 kg 92 kg 30 (15.72) 24.25 BMI 30 (6.43) 15 37.5 96.52 cm Waist circum 30 67.5 cm 110 cm -ference (12.84)

Hip circum 89.88 cm 30 70 cm 115 cm -ference (12.22) Waist hip 30 0.93 (0.02) 0.89 0.96 ratio

The mean value of BMI in the 30 cases studied is 24.25, with the minimum value 15 and the maximum 37.5. In the same way, the mean waist-hip ratio is 0.93, with the minimum and In most of the cases there is grade 0 occlusion present in the maximum values of 0.89 and 0.96, respectively. RCA, LAD, LCX arteries which amounts to 50%, 56.67% & Total of 90 arteries were studied as sectioned from 30 females 56.67% of cases respectively. Group II occlusions in RCA, and examined to look for the degree of occlusion. Two blocks LAD, LCX arteries amount to 33.33%, 26.67% & 20 % of the were taken for histopathological examination, one block cases, respectively. Group III occlusions in RCA, LAD, LCX measuring 3 x 2 cm was taken from the origin of the left arteries amount to 16.67%, 16.67% and 23.33% of the cases coronary artery which contained the portions of both left respectively. circumflex artery (LCX) and left anterior descending artery When the number of arteries involved in these cases was (LAD). The second block measuring 2 x 2 cm was taken from analysed to determine whether it is a single, double or triple the origin of the right coronary artery (RCA). However in vessel changes, the observation was as follows, none of the certain cases where the maximum degree of block was major coronary arteries were involved in 9 cases which

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amounts to 30% of the total cases, single artery was involved in disease was established (21). 8 cases which accounts for 26.67% of the total cases; double According to McGill et al., a higher BMI indicates increased vessel involvement was seen is 6 cases which contributes to LDL levels which are considered to be a high-risk factor for the 20% of the total cases; and triple vessel changes were found in development of coronary artery disease; in addition, high BMI 7 cases, which is 23.33% of the total cases. is inversely related to the levels of HDL(22).Again, contrary to The association between the degree of occlusion of RCA, their results, our study showed no such significant relationship LAD, LCX concerning BMI, WC, HC and WHRis shown in between BMI and atherosclerosis of coronary arteries. In a Table no.3 study conducted by Zamboni et al., it was observed that there DISCUSSION: was a lack of association between BMI, subcutaneous fat and angiographically demonstrated disease of the coronary arteries Waist-hip ratio (WHR) along with Waist circumference (WC) (23). This was supported by our study finding which fails to are seen as fairly accurate indicators of total body fat & fat establish conclusively the association between BMI and mass of the intra-abdominal region, as suggested by the World atherosclerosis of the coronary arteries. Health Organisation (WHO) (19). Increased central or visceral fat deposition is considered to be more dangerous for Thus, it is observed from the latest studies that the BMI cannot cardiovascular complications rather than subcutaneous fat(6). be an ideal independent indicator for anticipating the coronary (6) Obesity causes dysfunction of the endothelium which results atherosclerosis grading . This study did not show any in the initiation of atherosclerosis; thus increasing the correlation between high BMI and other indices of obesity interaction with lymphocytes and macrophages(20). In the towards the development of coronary atherosclerosis. present study, we were unable to establish the association However the drawbacks of this study were the small sample between any of the indices of obesity and development of size analysed. It is possible that a larger study size may give coronary atherosclerosis. This is contrary to the results different results. obtained in a study conducted by Alexander where the CONCLUSION: association between central obesity and coronary artery In conclusion, this study could not conclusively establish the

Table No 3 : Showing the association between the degree of occlusion of RCA, LAD, LCX concerning BMI, WC, HC and WHR Trait BMI (SD) WC (SD) HC (SD) WHR (SD) RCA Group I 22.91 (4.9) 88.67 (12.56) 95.11 (12.97) 0.93 (0.02) Group II 24.73 (7.52) 89.13 (14.32) 95.39 (15.13) 0.93 (0.02) Group III 27.28 (8.35) 95 (5.39) 103 (5.34) 0.92 (0.01) p value 0.4181 0.6037 0.4810 0.5233 LAD Group I 23.78 (5.9) 90.82 (11.98) 97.48 (12.17) 0.93 (0.02) Group II 25.16 (7.12) 88.04 (13.74) 93.93 (15.45) 0.94 (0.02) Group III 24.38 (8.33) 89.60 (12.93) 97.40 (12.93) 0.92 (0.02) p value 0.8875 0.8747 0.8113 0.1952 LCX Group I 23.48 (6.6) 88.88 (12.11) 95.81 (12.74) 0.93 (0.02) Group II 25.07 (4.21) 92.13 (9.06) 98.65 (10.19) 0.93 (0.02) Group III 25.40 (8.06) 90.36 (15.93) 96.43 (16.49) 0.94 (0.02) p value 0.7675 0.8576 0.9032 0.5316

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association between anthropometric measurements and the 2014; 164(4):336-44. development of coronary artery atherosclerosis. The major 12. Castelli WP. Epidemiology of coronary heart disease: The short coming of this study was the small sample size. This was Framingham study. Am J Med 1984; 76(2): 412. due to the time constraint as the study period was one year. It is 13. De Schutter A, Lavie CJ, Milani RV. The impact of obesity advisable to include larger samples and other parameters and on risk factors and prevalence and prognosis of coronary risk factors involved with atherosclerosis to find out the heart disease: The obesity paradox. Prog Cardiovasc Dis correlation between these indices. 2014; 56: 401-8. Funding & Conflict of interest: None to declare 14. Romero-Corral A, Somers VK, Sierra-Johnson J, Jensen REFERENCES : MD, Thomas RJ, Squires RW, et al. Diagnostic 1. Eckel RH. Obesity and heart disease: a statement for performance of body mass index to detect obesity in healthcare professionals from the nutrition committee, patients with coronary artery disease. Eur Heart J 2007; American Heart Association. Circulation 1997; 96: 28: 2087-93. 3248–3250. 15. Hassan Alkhawam et al., Coronary artery disease in 2. Krauss RM, Winston M, Fletcher RN, Grundy SM. patients with body mass index ≥30 kg/m2: a retrospective Obesity: impact of cardiovascular disease. Circulation chart analysis. Journal of Community Hospital Internal 1998; 98: 1472–1476. M e d i c i n e P e r s p e c t i v e s . 2 0 1 6 ; 6 ( 3 1 4 8 3 ) : 3. Hubert HB, Feinleib M, McNamara PM, Castelli WP. http://dx.doi.org./10.3402/jchimp.v6.31483 Obesity as an independent risk factor for cardiovascular 16. McAuley PA, Artero EG, Sui X, Lee DC, Church TS, disease: a 26-year follow up of participants in the Lavie CJ, et al. The obesity paradox, cardiorespiratory Framingham Heart Study. Circulation 1983; 67:968–977. fitness, and coronary heart disease. Mayo Clin Proc 2012; 4. Flegal KM, Graubard BI, Williamson DF, et al. Excess 87: 443-51. deaths associated with underweight, overweight, and 17. Jansen I, Heymsfield SB, Allison DB, et al. Body mass obesity. JAMA 2004; 293:1861–67. index and waist circumference independently contribute 5. Flegal KM, Kit BK, Orpana H, et al. Association of all- to the prediction of nonabdominal, abdominal cause mortality with overweight and obesity using subcutaneous, and visceral fat. Am J Clin Nutr 2002; standard body mass index categories: a systematic review 75:683–8. and meta-analysis. JAMA2013; 309:71–82. 18. Chan DC, Watts GF, Barrett, et al. Waist circumference, 6. Rastogi P, Pinto DS, Pai MR, Kanchan T: An autopsy waist-hip ratio and body mass index as predictors of study of coronary atherosclerosis and its relation to adipose tissue compartments in men. Q J Med 2003; anthropometric measurements/ indices of overweight and 96:441–7. obesity in men. J Forensic Leg Med. 2012 Jan; 19(1):12- 19. Park K. Park's textbook of preventive and social medicine. 17. 18th ed. Jabalpur: Banarsidas Bhanot Publishers; 2005. 7. Viral M. Bhanvadia, Nandini J. Desai, Neeru M. Agarwal: Pp. 285-328. Study of coronary atherosclerosis by modified American 20. Kumar V, Abbas AK, Fausto N. Robbin's and Cotran Heart Association classification of atherosclerosis- an pathologic basis of disease. 7th ed. Philadelphia: W.B. autopsy study. J Clin Diagn Res. 2013 Nov;7(11):2494-97 Saunders Company; 2004. Pp. 415-554. 8. Gouda J, Prusty RK: Overweight and obesity among 21. Alexander JK. Obesity and coronary heart disease. Am J women by economic stratum in urban India. J Health Med Sci 2001; 321(4):215-24. Popul Nutr. 2014 Mar;32(1):79-88 22. McGill HC, McMahan A, Herderick EE, Zieske AW, 9. Todd Miller M, Lavie CJ, White CJ. Impact of obesity on Malcom GT, Tracy RE, et al. Obesity accelerates the the pathogenesis and prognosis of coronary heart disease. progression of coronary atherosclerosis in young men. J Cardiometab Syndrome 2008; 3: 162-67. Circulation 2002; 105:2712-8. 10. Ades PA, Savage PD. Potential benefits of weight loss in 23. Zamboni M, Armellini F, Sheiban I, De Marchi M, coronary heart disease. Prog Cardiovasc Dis 2014; 56: Todesco T, BergamoAndreis IA, et al. Relation of fat 448-56. distribution in men and degree of coronary narrowings in 11. Jahangir E, De Schutter A, Lavie CJ. The relationship coronary artery disease. Am J Cardiol 1992; 70:1135-8. between obesity and coronary artery disease. Transl Res

101 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00019.9 Original Research Paper Comparative study of digital dermatoglyphics among congenital deaf and control subjects in South East Nigeria 1. Chijioke Okeke, Lecturer, Department of Anatomy, Nnamdi Azikiwe University, Nnewi Campus 2. Izuchukwu Etoniru, Lecturer, Department of Anatomy, Chukwuemeka Odimegwu Ojukwu University, Uli 2. Victor Oforbuikem, Anatomy Graduate, Department of Anatomy, Nnamdi Azikiwe University, Nnewi Campus

ABSTRACT : Background: Some genetically determined diseases have been associated with specific patterns of dermatoglyphics and this is useful in early diagnosis and intervention. The aim of this study was to ascertain whether congenital deafness is associated with any peculiar dermatoglyphic pattern in our environment. Materials and Methods: It was a cross sectional study. The sample included 150 subjects (75 males and 75 females) with congenital deafness and 150 subjects (75 males and 75 females) as control. Fingerprint was obtained by ink method. Digital dermatoglyphic pattern and total ridge count (TRC) were studied. Results: In both the control and deaf group, the order of occurrence of fingerprint pattern was ulnar loop, whorls, arch and radial loop, in descending order of frequency. This was same in both right and left hands and in both males and females. In males, there was no significant difference in the frequency of fingerprint pattern among the control and deaf group. In females, the deaf group had significantly more arches than the control, and the control group had significantly more radial loops than the deaf group. There was no significant difference in the rest of the patterns in females. In both males and females, the control group had significantly higher TRC than the deaf group. In the control group, males had significantly higher TRC than females, but in the deaf group, males had insignificantly higher TRC than females. Conclusion: Subjects with congenital deafness had peculiar dermatoglyphic parameters in our environment which is different from control group.

Corresponding Author : Article History: Dr. Chijioke Okeke, Received: 26 December 2018 Received in revised form: 15 October 2019 Lecturer, Department of Anatomy, Nnamdi Azikiwe Accepted on: 15 October 2019 University, Nnewi Campus Available online: 31 December 2019 Contact : +2348030465528 E-mail : [email protected] KEYWORDS : Fingerprint, Dermatoglyphics, Congenital Deafness, South East Nigeria

INTRODUCTION : agenesis.3,4 Congenital deafness can be differentiated from 4 Dermatoglyphics refers to the study of epidermal and friction acquired deafness by a simple occulo-vestibular reflex. ridges found on the volar surface of the hands and feet. The Occulo-vestibular reflex means the movement of the eyes to development of the friction ridges is genetically determined, the opposite side when the head is passively turned to one side. and it occurs between the third and fourth month of fetal life.1 This reflex is absent in congenital deafness but present in 4 Once developed, the friction ridges remain permanent acquired deafness. throughout life. Dermatoglyphics is a term coined by Harold The developmental anomaly in congenital deafness occurs Cummins2 in 1926. In his research, Harold Cummins2 reported almost at about the same time with the development of the that plantar and palmar ridges are unique, unalterable and finger dermatoglyphics, which is between 5 weeks and 12 cannot be duplicated in other people. weeks.3 Thus it may be possible that certain dermatoglyphic Congenital deafness is a hearing loss that occurs before birth. patterns could be linked with congenital deafness. About 50% of congenital deafness is genetically determined,1,3 Dermatoglyphics has been linked with some genetically whereas other causes may be from maternal infections like determined disease conditions. Down syndrome is linked with cytomegalovirus, toxoplasmosis and some other conditions palmar single flexion (Simian) crease, distal transverse like anoxia and hyperbilirubinemia.3 The pattern of inheritance (Sydney) crease and mental retardation.4,5Hassan et al6 also of genetically determined congenital deafness may be reported that beta-thalassemia has a peculiar finger print dominant or recessive and the primary pathology may be pattern. malformation of the vestibulo cochlear structures or

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Congenitally deaf children are also mute. This is because it In the 'whorl' pattern, the ridges spiral around a core forming takes hearing reflex to develop speech. Hearing impairment concentric rings around the core. The spirals can be in poses serious challenge to the social, emotional, behavioral clockwise or anticlockwise direction. 'Whorl' pattern has and academic development of children. Early diagnosis is minimum of two triradii (Figure 1). 4 therefore important for better outcome. The total ridge count (TRC) is the sum total of the ridge counts Dermatoglyphic study in congenital deafness has not been in all ten fingers. In order to determine the ridge count of a carried out in our environment. The aim of this study was finger, the tri-radius and the central core were first identified. A therefore to ascertain whether there exists any characteristic straight line was then drawn connecting the tri-radius to the finger print dermatoglyphic pattern in subjects with congenital core using a sharp pencil and a ruler. The ridges intervening deafness in our environment. between the core and the tri radius were then counted. MATERIALS AND METHODS : Statistical analysis was done using the Statistical Package for The study was a cross sectional study which was conducted in Social Sciences (SPSS) version 20. Test of significance was the Department of Anatomy of Nnamdi Azikiwe University, done using Chi-square and t test. P value was set at 0.05 Nnewi Campus. A total of 300 subjects were recruited for the Figure 1: Different types of fingerprint pattern study. This included 150 subjects (75 males and 75 females) with congenital deafness (deaf group) and 150 subjects (75 males and 75 females) without congenital deafness (control group). Subjects in the deaf group were recruited from two special schools of the deaf and dumb in Anambra State and Imo State; both in the South East region of Nigeria. Subjects in the control group consisted of students of Nnamdi Azikiwe University Nnewi Campus. All the subjects were of Igbo origin. Subjects in the deaf group had no other congenital abnormality apart from congenital deafness. Ethical approval was obtained from the Ethics Committee of the Faculty of Basic Medical Sciences of our Institution, and from the relevant authorities of the schools of deaf and dumb. Individual consent was obtained from the subjects. Fingerprints were obtained using the ink pad method. The subjects watched their hands with soap and water and dried (a)Whorl (b) Arch (c) ulnar loop (d) radial loop them with a dry towel. Fingerprints were obtained using the RESULTS : modified Purvis-Smith method as described by Malla et The mean age for the deaf group was 17.9 years (SD 2.40) and al.7Finger prints were obtained from both hands of the deaf the mean age for the control group was 22.1 years (SD 2.39). group as well as the control group. By the help of magnifying hand lens and needle, the finger print patterns and the total The finger print pattern with the highest frequency was ulnar ridge counts were studied. The finger print pattern was either loop. This was followed by the whorl pattern and then the arch; an 'arch', 'ulnar loop', 'radial loop' or 'whorl'. while the radial loop was the least frequent. This order of frequency was observed in the right and left hands of both The 'arch' is formed by succession of parallel ridges, which males (Table 1) and females (Table 2) and in both control traverse the pattern area and forms a small curve that is group and deaf group. concave proximally (Figure 1). It has neither a core nor triradii. Triradius is the meeting point of three different ridge In the right hand of males (Table 1), the deaf group had more systems. whorls and arch than the control group, while the control group had more ulnar loop and radial loop than the deaf group. A 'loop' is formed when parallel ridges enter the pattern area on However, these differences were not statistically significant (p one side of the digit, re-curves sharply and leaves the pattern > 0.05). Similar difference in frequencies of patterns was also area on the same side. Loop pattern has one triradius. If the observed in the left hand of males and the differences were not loop opens to the ulnar side (towards the little finger), it is also statistically significant (p > 0.05). referred to as 'ulnar loop'. If the loop opens to the radial side (towards the thumb), it is referred to as 'radial loop' (Figure 1). In females (Table 2), the deaf group had more whorls and arch in both right and left hands. The difference in the frequencies of

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Table 1: Finger Print Pattern Distribution in Males Type of pattern Right hand Left hand Chi square P value Control Deaf Control Deaf Whorl 105 (28.0%) 112 (29.9%) 109 (29.1%) 125 (31.2%) 0.147 0.701 Ulnar loop 239 (63.7%) 171 (45.6%) 226 (60.3%) 158 (51.2%) 0.026 0.872 Radial loop 12 (3.2%) 10 (2.7%) 10 (2.7%) 6 (2.1%) 0.240 0.624 Arch 19 (5.1%) 82 (21.9%) 30 (8.0%) 86 (22.9%) 1.535 0.215 Total 375 (100%) 375 (100%) 375 (100%) 375 (100%)

Table 2: Finger Print Pattern Distribution in Females Type of pattern Right hand Left hand Chi square P value Control Deaf Control Deaf Whorl 97 (25.9%) 110 (29.3%) 102 (27.2%) 103 (27.5%) 0.346 0.556 Ulnar loop 216 (57.6%) 201 (53.6%) 219 (58.4%) 180 (48.0%) 0.781 0.377 Radial loop 25 (6.7%) 5 (1.3%) 30(8.0%) 20 (5.3%) 4.752 0.029 Arch 37 (9.9%) 59 (15.7%) 24 (6.4%) 72 (19.2%) 4.061 0.044 Total 375 (100%) 375 (100%) 375 (100%) 375 (100%)

9,10 occurrence of whorls was not statistically significant (p > 0.05) well as in population variation study. Fingerprint whereas the difference in the frequencies of occurrence of arch dermatoglyphics has been reported to be helpful in the early pattern was statistically significant (p < 0.05). There were more diagnosis of certain disease conditions which include the 11 12 ulnar loops and radial loops in the control than in the deaf coronary heart disease, gynaecological cancers, pituitary 13 14 15 group in both the right and left hands of the females. The tumor, Diabetes mellitus, multiple sclerosis and bronchial 16 difference in the frequency of ulnar loops was not statistically asthma. The present study compared the fingerprint significant (p > 0.05) while the difference in the frequency of dermatoglyphics between a deaf and control groups with the radial loop was statistically significant (p < 0.05). aim of finding out whether there is any peculiarity in the fingerprint dermatoglyphics parameters among subjects with Table 3 shows the mean and standard deviations of the TRC. congenital deafness. In both males and females, the control group had higher values of the TRC than the deaf group and the differences were The fingerprint patterns observed in the current research were statistically significant. ulnar loop, whorls, arch and radial loop, in decreasing order of frequency. This was observed among males and females in Considering the control group (Table 3), males had both right and left hands and in both control and case groups. significantly higher value of the TRC than females (t = 4.581, p This order of frequency was similar to the findings of = 0.000). Similarly, in the deaf group, males had higher value 2 4 4 Cummins and Osunwoke et al. The work of Osunwoke et al of the TRC, but the difference was not significant (t = 0.938, p was conducted in South South region of Nigeria among = 0.350) congenital deaf subjects. They reported that the percentage Table 3: Comparison of total ridge count (TRC) among frequency for the ulnar loop in males (deaf) was 48.68 and males and females 45.78 and females was 55.07 and 66.18 for right and left hands Males Females respectively; whorls for males was 31.58 and 38.55 and Control Deaf Control Deaf females was 24.64 and 22.06 for right and left hands Mean TRC 98.23±22.13 75.91±33.79 83.25±22.13 71.33±25.32 respectively, arches for males was 17.11 and 15.66 and females was15.94 and 11.76 respectively and radial loop for males was T value 4.786 3.345 2.63 and females 4.35 for right hand. These values were P value 0.000 0.001 comparable with our findings in the deaf group which were: ulnar loop in males (45.6 and 51.2) and females (53.6 and 48.0) DISCUSSION : for right and left hands respectively; whorls for males (29.9 Dermatoglyphics as a tool is helpful in forensics, criminology, and 31.2) and females (29.3 and 27.5) for right and left hands 8 medicine, genetic research, psychiatry and anthropology as respectively; arches for males (21.9 and 22.9) and

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females(15.7 and 19.2)for the right and left hands respectively between the control (98.23) and the deaf group (75.91). and radial loop for males(2.7 and 2.1) and females (1.3 and 5.3) Similarly in females, there was significant difference in the for right and left hands respectively. mean TRC between the control group (83.25) and deaf group The order of frequency of the fingerprint patterns reported in (71.33). In both sexes, the value of the TRC in control was 17 our work was also similar to the findings of Anu et al3 in greater than that of the deaf group. Suresh et al reported females, but not in males. In the males, the radial loop was significant difference in the values of TRC between the control more frequent than the arches (control group) while the whorls and deaf groups in both males and females, which was similar were more frequent than ulnar loop (deaf group). However, the with the findings of the present study. However, their values order of pattern frequency in the present research was different were well higher than that of the present study: males (control from the study of Padma et al1 in which they reported whorls, 202.26, deaf 141.54) and females (control 180.4, deaf 150.58). loop and arch in descending order of frequency in the right and In each case, the TRC of control was higher than that of the left hands among deaf and mute subjects. The difference may deaf. The higher values reported in their study may be due to be explained by ethnic variation. racial differences. Among males in the present research, the deaf group had more REFERENCES : whorls and arches than the control group in both right and left 1. Padma KB, Bhumika KB, Aruna CN, Sandhya C, Nithin hands but had less loops (ulnar and radial) than the control N. Dermatoglyphics-A new diagnostic tool in detection group (Table 1). However, these differences were not of dental caries among deaf and mute children. Int. Journal statistically significant in males. As pertaining to the females of Clinical Dental Science. 2011; 2(4):80-84. (Table 2), the deaf group had more whorls and arches than the 2. Cummins H. Palmar and Plantar epidermal ridge control group. However, whereas the difference in the arches configuration in Europeans and Americans. Am J Phys was statistically significant, the difference in the whorl pattern Anthropol. 1926; 179:141-802. was not significant. Also, the deaf group among females had 3. Anu S, Poonam S,Veena S. Palmar and digital less loops (ulnar and radial) than the control. The difference in dermatoglyphics in congenital deaf subjects. Journal of the radial loop was significant while the difference in the ulnar Punjab Academy of Forensic Medicine and Toxicology. loop was not statistically significant. 2007;7(1):11-21. Suresh et al17 reported increase in the frequencies of arches and 4. Osunwoke EA, Amah-Tariah FS, Sapira MK, Onosigho loops in male deaf group as compared with the control. They A. Dermatoglyphic Patterns in congenital deaf and mute also reported increase in the frequencies of ulnar loops when in South-South Nigeria. Afr J Med Phy, Biomed Eng & Sc; compared with the controls. But they did not indicate whether 2010( 2): 98 – 101 the differences were statistically significant or not. However, their findings were different from ours. Their study was 5. Vashist M, Yadav R, Neelkamal, kumar A. Axial triradius conducted in India while ours was conducted in Nigeria. Thus as a preliminary diagnostic tool in patients of mental variation in race may have played a role in the difference of retardation. The Internet Journal of Biological observation. Anthropology. 2009;4(1):1-5. Anu et al3 reported statistically significant difference in the 6. Hassan S, Mojgan H, Mohammad LDN, Hamid-Reza fingerprint pattern distribution in the right hands of males. This KV, Maryam RN. Diagnostic value of fingerprint observation was different from ours. However, they also patterns: An explorative study on beta-thalassemia reported that the whorls and arches in the left hands of males diagnosis. Bangladesh Med Res Counc Bull. 2010; 36: were more in the deaf than the control groups, which was 27-31 similar to the findings of our study. They went further to report 7. Malla TM, Srivastava P, Ganesh N. Dermatoglyphic that in females, there was higher frequency of radial loop and variations among clinically diagnosed Down's syndrome arches in the deaf (left hands and both hands considered cases: a cohort study. Biomed. Pharmacol. J. together), but it was not statistically significant. This was 2008;1(2):475-78. different from the findings of our work. Their work also 8. Bhardwaj N, Bhardwaj P, Tewari V, Siddiqui MS. showed that when the fingerprints of both hands of both sexes Dermatoglyphic analysis of fingertip and palmer print were taken together, the fingerprint frequency in the deaf patterns of obese children. International Journal of showed no significant difference than the control. Medical Science and Public Health. 2015;4(7):946-49. In the present study, there was statistically significant 9. Igbigbi PS, Msamati BC. Palmar and digital difference in the mean total ridge count (TRC) in males

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dermatoglphic traits of Kenyan and Tanzanian subjects. West African Journal of Medicine. 2005;24(1):26-30. 10. Biswas S. Finger and palmar dermatoglyphic study among the Dhimals of North Bengal, India. Anthropologist. 2011; 13(3):235-238 11. Hong L, Wenli Q, Zhi G, Youjing S, Haochen Y, Zhanbing M, Zhenghao H. Dermatoglyphs in coronary artery disease among Ningxia population of North China. J Clin Diagn Res. 2015;9(12):1-5. 12. Sakineh A, Mina R. Dermatoglyphic patterns on fingers and gynecological cancers. European journal of Obstetrics & Gynecology and reproductive biology. 2018; 222: 39-44 13. Marina G, Martina MO, Dario D, Ines B. Assessment of environmental and hereditary influence on development of pituitary tumors using dermatoglyphic traits and their potential as screening markers. Int J Environ Res Public Health. 2016;13(3):1-9. 14. Molly RM, Bjoern CL, Evan S, Mahelet NM, Jay HS. A new method to assess asymmetry in fingerprints could be used as an early indicator of type 2 Diabetes Mellitus. J Diabetes Sci Technol. 2016; 10(4): 864–871. 15. Vedat S, Seyda C, Kezban K, Ertugrul B, Mehmet C. Dermatoglyphic features in patients with multiple sclerosis. Neurosciences (Riyadh). 2014 Oct; 19(4): 281–285 16. Sahana BN, Bannur BM, Patil BG, Hadimani GA, Arun PJ. Dermatoglyphic pattern in patients with bronchial asthma – a qualitative and quantitative study. International J. of Healthcare and Biomedical Research. 2016; 5(1): 68- 72 17. Suresh S, Raghavendra AY. Variations in palmar dermatoglyphics among congenital deaf cases: a comparative study. National Journal of Clinical Anatomy. 2014; 3(4): 193- 197

106 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00020.5 Original Research Paper Measurement of Uncertainty of Country Made Liquor by Hydrometer

1. Vishala Pithava, Technical Assistant, Food Research Laboratory, Gandhinagar-382007 2. Astha Pandey, Associate Professor, Institute of Forensic Science, Gujarat Forensic Sciences University, Gandhinagar.

ABSTRACT: Background: The advancement in the analytical forensic chemistry has been facing many challenges. One among them is measurement of uncertainty. There are several factors like environmental and non-environmental, which might affect the measurements. As various bodies accredit most of the forensic science laboratories across the world, like in India it is NABL (National Accreditation Board for Testing and Calibration Laboratories). It becomes mandatory to show the uncertainty in the measurements related to any instrumental method being used in the analysis of various kinds of unknown sample. Density is one small parameter used to assess the percentage of alcohol in country made liquor. Objective: To estimate the uncertainty measurement when hydrometer is used to measure the density. Material and Method: Total 20 samples of country liquor were collected and tested with hydrometer for multiple times, further the % uncertainty was determined for each of the sample. Result: It was found that the uncertainty obtained of all the samples was almost zero. Conclusion: The present study indicates that the density of country made liquor can be measured with hydrometer, a more economical based method.

Corresponding Author : Article History: Dr. Astha Pandey, Received: 19 January 2019 Received in revised form: 6 July 2019 Associate Professor, Accepted on: 6 July 2019 Institute of Forensic Science, Gujarat Forensic Sciences Available online: 31 December 2019 University, Gandhinagar-382007 Contact : +91 9601996653 Email: [email protected] KEYWORDS : Forensic Sciences, Forensic Chemistry, Country made liquor, Hydrometer, Uncertainty measurement, NABL

INTRODUCTION: charge for country liquor is small and the excise duties are [3] Liquor is an alcoholic beverage produced from distilled spirit lower than the other liquor . Consumption of alcohol is and containing different flavours such as fruits, cream, flowers, debarred in few states of India like Bihar, Gujarat and sugar or sweeteners[1]. Alcoholic beverages contain about 3- Nagaland. 40% by volume alcohol that, frequently used and abused in the There are two types of liquor mainly found i.e. country made modern societies. Consuming and using alcohol plays a major and foreign liquor. The foreign liquor includes wine, whisky, social role in many cultures. Most of the countries have laws vodka, cider, gin, rum, brandy etc. The country made liquor is for the regulation of production, sale and consumption of also known as Desi Daru and Indian Made Foreign Liquor [4].In alcohol[2]. However, consumption of alcohol is prohibited in addition to this arrack, tharra, toddy, fenny and tari also comes some of the countries and some of the states. India is the third under the Country made liquor. largest global spirits market by volume in the world, just Country made liquor is the most common beverage among the behind China and Russia. Indian alcohol production market is poor Indians to relax their mood. It mainly contains about 0- also one of the rapidly developing markets in the world. In 10% of alcohol. It is mainly prepared from molasses the waste India due to the high taxes like GST (goods and service tax) product obtained during the preparation of sugar from and inestimable ruling governing it, the Indian alcoholic sugarcane by fermentation and distillation. It includes toddy, beverage industry is one of the high-risk industry. The Indian beers, wine, pashwai etc. The country made liquors are mostly alcoholic beverage industry comprises the Indian Made sold domestically[4-7]. It is cheap and obtained across India[4]. Foreign Liquor (IMFL), country made liquor, foreign Liquor The term desi daru usually refers to legal alcohol while other Bottled in Origin (BIO), banned or illicit alcohol, beer and types of desi liquor (arrack and palm toddy) may be wine segments. Country made liquor are mostly manufactured categorised as Moonshine alcohol[8-9]. These type of alcohols in local licensed distilleries and made up of cheap raw material, detained in bulk and further send to the forensic science primarily rectified spirits of grains or molasses. The making laboratory for the analysis. Mainly, only one parameter is

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checked i.e. density from which percentage of alcohol is matter how delicate and precise our methods and instruments, measured. at the end of the day there are limits on what we can measure. The present study was conducted at Regional Forensic Science For many reasons, forensic toxicologists are being asked to Laboratory, Surat where innumerable samples are received determine and report their measurement uncertainty in blood everyday. In a year total 25,000 samples are received in the alcohol analysis. While understood conceptually, the elements laboratory which includes both country made and foreign and computations involved in determining measurement liquors. The samples are received in such large numbers as it is uncertainty are generally foreign to most forensic considered as a dry state and there are possibilities of illegal toxicologists. Several established and well-documented circulation of liquors within the state. Moreover there are methods are available to determine and report the uncertainty chances of mixing of country made liquor with several other in blood alcohol measurement. A straightforward bottom-up chemicals resulting in poisoning cases. Therefore there is an approach is presented that includes: (1) specifying the urgent need to identify and establish the methods of measurand, (2) identifying the major components of identification of country made liquors. Density is one of the uncertainty, (3) quantifying the components, (4) statistically [12] most important physical parameter for the measurement of combining the components and (5) reporting the results . matter. It is the ratio of mass and volume. It is denoted by ρ. Estimating the uncertainty: The metrology literature will However, the Latin letter D can also be used. describe the components of uncertainty as either Type A or [13] ρ = M Type B i.e. Random uncertainty (Type A) and Systematic uncertainty (Type B). V Type A is defined as a method of evaluation of uncertainty by Here, M = Mass of the sample. statistical analysis of series of observations. V = Volume of the sample. Type B uncertainty is defined as the method of evaluation of The density of pure substance is equal to the mass uncertainty more than statistical analysis of series of concentration of the substance. The density of a substance vary observation. Here, in this experiment random uncertainty with respect to temperature and pressure. The density measurement is carried out with the help of hydrometer. measurement is carried out to determine the percentage of A hydrometer or aerometer is an instrument that measures the alcohol present in the beverage. This is a simple method specific gravity (relative density) of liquids—the ratio of the carried out within the limited facilities available in the density of the liquid to the density of water. A hydrometer is laboratory. usually made of glass, and consists of a cylindrical stem and a One important and main consideration in density measurement bulb. The bulb is weighted with mercury or lead balls, so that it is uncertainty. Measurement uncertainty is defined as a can float upright. The liquid to be tested is poured into a “parameter characterizing the dispersion of the quantity values graduated cylinder, and the hydrometer is gently lowered into [10] being attributed to a measurand” . In the world of forensics, the liquid until it floats freely. The point at which the surface of we report all kinds of results. For example in DNA testing, we the liquid touches the stem of the hydrometer correlates to may report a match with a population frequency of 1 in density. A variety of scales exist for different contexts. It is 5,000,000. In crime scene reconstruction, we may report that a usually two separate instrument used for heavy liquids on bloodstain was caused by a 42º incident angle. And in which 1.00 marking is at the top of the stem which is the mark toxicology, we may report that methamphetamine metabolite of water and in light liquids 1.00 marking is at the bottom of levels in a urine sample were 2000 ng/mL. At the very heart of stem. It covers specific ranges from 1.0 – 0.95, 0.95 – 0.9. the issue, uncertainty asks us, “just how sure are you?” Since MATERIALS AND METHOD: we work in accredited labs with great people, our first response may be something like, “I'm 100% sure,” but there is a catch. Materials: Hydrometer/ Densitometer, Measuring Cylinder Uncertainty asks these follow-up questions: a) could it be 1 in of Borosil make were used for the measurements. 5,000,001 or are you sure about 1 in 5,000,000, b) Is the Method: Total 20 samples of country made liquor were incident angle 42.0000º or could it be 42.0004º, and c) is the collected from the cases received in the Surat Forensic Science level really 2000 ng/mL or could it be 2000.00003 ng/mL? [11]. Laboratory. 100 mL of sample in measuring cylinder was taken Uncertainty is all about not overstating our ability to answer a and then the hydrometer was lowered down and the readings question. For most of us using typical lab equipment and were obtained. The same process was repeated for 3 times and methods, we would have to say that we really could not tell the each reading was noted down. This procedure was carried out difference for any of the examples listed above. Moreover, no at different corners of laboratory.

108 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00020.5

Calculations: = 0 The mean of deviation was calculated as follows: 1.73

N Ʃi = 1di σ1 = 0 gm.

N Standard error of mean σ1 = 0 gm. The standard deviation is defined as: Standard error of mean / K (K = 2) N 2 = ± 0/2 σ1 = √Ʃi = 1di i N – 1 = ± 0 And it is calculated as follows: Standard uncertainty = ± 0 gm, N Degree of Freedom = ± 0/ N – 1 σ1 = √Ʃi = (W1 + W2 + W3) = ± 0/ 3 – 1 N – 1 = ± 0/2 Standard deviation of mean (SDOM): = ± 0 σ1 = σW’ % uncertainty = ± 0 √3 0 Standard error of mean / K (K = 2). Table 1: % of alcohol at different specific gravity at 20 C Specific Alcohol Specific Alcohol Specific Alcohol Degree of Freedom = ± 0/ N – 1. gravity % gravity % gravity % Here % of ethanol can be obtained from the Table 1: .000 0.00 .970 24.75 .940 45.58 SAMPLE 1: .999 0.07 .969 25.62 .939 46.12 Calculation: .998 1.34 .968 26.50 .938 46.67 The mean of deviation: .997 2.02 .967 27.36 .937 47.20 .996 2.70 .966 28.29 .936 47.73 iN = 1di Ʃ .995 3.40 .965 29.03 .935 48.26 N .994 4.11 .964 29.85 .934 48.78 = (0 + 0 + 0) .993 4.84 .963 30.66 .933 49.30 3 .992 5.58 .962 31.44 .932 49.80 .991 6.34 .961 32.21 .931 50.31 = 0 .990 7.12 .960 32.96 .930 50.81 The standard deviation is defined as: .989 7.90 .959 33.69 .929 51.31 N 2 σ1 = √Ʃi = 1di i .988 8.71 .958 34.11 .928 51.80 N – 1 .987 9.54 .957 35.12 .927 52.29 .986 10.36 .956 35.82 .926 52.79 Calculation standard deviation: .985 11.19 .955 36.49 .925 53.27 σ = [√ iN = 1di2i]1/2 1 Ʃ .984 12.04 .954 37.16 .924 53.76 N – 1 .983 12.90 .953 37.82 .923 54.24 .982 13.77 .952 38.10 .922 54.72 = (W1 + W2 + W3) .981 14.66 .951 39.10 .921 54.19 3 – 1 .980 15.55 .950 39.73 .920 55.67 = (0)1/2 .979 16.46 .949 40.35 .919 56.14 2 .978 17.38 .948 40.96 .918 56.60 = 0 .977 18.31 .947 41.56 .917 57.07 σW' = 0 .976 19.26 .946 42.15 .916 57.53 .975 20.20 .945 42.74 .915 57.99 Standard deviation of mean (SDOM): .974 21.14 .944 43.33 .914 50.44 σ = σW’ 1 .973 22.05 .943 43.90 .913 58.89 √3 .972 22.96 .942 44.16 .912 59.34 .971 23.87 .941 43.02 .911 59.79

109 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00020.5

RESULTS & DISCUSSIONS: Court is another factor requiring one of four criteria for The Table 1 was referred from manual of RFSL (Regional admissibility to be “ … the technique's known or potential rate [16] Forensic Science Laboratory), Surat which showed the amount of error … ” . of % of alcohol at particular specific gravity. The measurement A careful reading of the ASCLD/LAB-International policy on of density was carried out for all the samples by hydrometer uncertainty reveals that no specific approach to performing and the readings were observed. Percentage of alcohol were these calculations is required or suggested. Indeed, many valid referred from table no. 1 and calculations were carried out computational approaches exist. Slight changes in protocol or which was also referred from the manual of RFSL (Regional components of traceability will also change the computational Forensic Science Laboratory), Surat. Calculation of sample details. Toxicologists must consider the details of their own no. 1 was performed and accordingly the calculations of programs to incorporate the appropriate elements and measurement of uncertainty were done for other samples. The statistical procedures. Many very useful resources exist that uncertainty was calculated where it was found that the further explain and illustrate these concepts [17-19]. uncertainty obtained of all the samples was almost zero as Traceability is a very important component that will exist in shown in the Table 2 & 3. every quantitative measurement program. Traceability is Table 2: Uncertainty Calculation in Liquor Cases: defined as the “property of a measurement result whereby the

R result can be related to a reference through a documented

E E E T

G % A unbroken chain of calibrations, each contributing to the M T E G G

N [10] -W' O I Y R

OF A A measurement uncertainty” . M

D T E D R R O (W) N N C A

ETOH E E I di x R

di=W CONCLUSION: E A N V V D R R U (W') A A

Y The present study done on measurement of uncertainty of H percentage of alcohol in country made liquor by hydrometer is 0.988 8.71 0 0 0 one of the best methods with the limited resourses. 0.988 8.71 8.71% 0 0 0 0 Conflict of Interest : Nil 0.988 8.71 0 0 0 Source of Funding : Self Table 3: Random Uncertainty of Samples : Ethical Clearance : Not Applicable as it does not involve any Sample Random Uncertanity Random Uncertanity No. (Scientist 1) (Scientist 2) invasive technique. Sample 1-6 0 0 REFERENCE: Sample 7 0.814 0.814 1. Liqueur.In Wikipedia, the free encyclopedia. Available Sample 8-20 0 0 from https://en.wikipedia.org/wiki/Liqueur (Accessed 21 October 2017) The American Society of Crime Laboratory Directors 2. Minimum Legal Age Limits. In International Alliance for (ASCLD/LAB)- International accreditation program, as well R e s p o n s i b l e D r i n k i n g . Av a i l a b l e f r o m as other accrediting agencies, is developed from the ISO/IEC http://www.iard.org/policy-tables/minimum-legal-age- International Organization for Standardization (ISO) and the limits/ (Retrieved 23 June 2016) International Electrotechnical Commission (IEC)17025 program and requires, in part, that, “…all applicant and 3. Sowmya Shree KL, Kavya C, Nagaraja GN. An overview accredited laboratories in the ASCLD/LAB-International of Indian alcohol industry. IRACST International Journal program to have completed estimating uncertainty of of Commerce and Business Management. 2016;9(1):80- measurement for all reported 'measurements that matter'” [14]. 86. Some jurisdictions, moreover, have legislation requiring 4. Dhanuraj D, Kumar RV. Liberalizing liquor Trade in accreditation. Another factor bringing attention to the issue is India. Centre for Public Policy Research. 2014, the recent National Academy of Science (NAS) Report, November 11. Strengthening Forensic Science in the United States: A Path 5. Patel B. Happy Hours: The Penguin Book of Cocktails. Forward [15]. Penguin Books Limited. 2009, October. ISBN 978-81- The NAS report states, “All results for every forensic science 8475-162-8. pp. 206. method should indicate the uncertainty in the measurements 6. Shaftel D. "Boom time for country liquor". Livemint. that are made …” The Daubert decision of the U.S. Supreme Available from

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http://www.livemint.com/Companies/thwR3uoMpibRW 17. International Organization for Standardization, ISO. W73gRKzAK/Boom-time-for-country-liquor.html Guide to the expression of uncertainty in measurement. (Retrieved 2015-08-03). 2008, Geneva, Switzerland. Available from 7. Bhushan R, Kurian B. "Manufacturing norms for country http://www.bipm.org/utils/common/documents/jcgm/JC liquor on anvil". Times of India. Available from GM_100_2008_E (Accessed May 2011) Articles.economictimes.indiatimes.com. (Retrieved 18. S L R Ellison, A. W. EURACHEM/CITAC Guide 2015-08-03). Quantifying Uncertainty in Analytical Measurement. 8. "Desi daroo - definition of Desi daroo". The Free Eurochem. 2011 May. pp. 1-131. Dictionary. Available from 19. Kuyatt BN. Guidelines for Evaluating and Expressing the www.thefreedictionary.com/Desi+daroo (Retrieved Uncertainty of NIST Measurement Results. NIST 2015-08-03). Technical Note 1297 1994 Edition. Gaithersburg, US: United States Department of Commerce Technology 9. India`s deadly moonshine in the spotlight. Dawn. Administration: National Institute of Standards and ( e d i t o r i a l ) 2 0 0 9 , J u l y 1 3 . Av a i l a b l e f r o m Technology. 1994 September. https://www.dawn.com/news/821495 (Retrieved 22 September 2015). 10. Estimating the Uncertainty by Jeff Salyards, 01/02/2008. International Organization for Standardization, International vocabulary of basic and general terms in metrology (VIM), 2008, 3rd edition, Switzerland ISO, Genevavia http://www.bipm.org/utils/common/documents/jcgm/JC GM_200_2008 (Accessed May 2011). 11. Gullberg RG. Estimating the Measurement Uncertainty in Forensic Blood Alcohol Analysis. J Anal Toxicol., Volume 36, Issue 3, 2012, April 1, Pages 153–161, Available from https://doi.org/10.1093/jat/bks012. 12. Hibbert DB. Quality assurance for the analytical chemistry laboratory. 2007 New York, NY, Oxford University Press. 13. International Organization for Standardization, ISO. Guide to the expression of uncertainty in measurement Figure 1 : Types of Hydrometer 2008. Geneva, Switzerland. Available from http://www.bipm.org/utils/common/documents/jcgm/JC GM_100_2008_E (Accessed May 2011). 14. ASCLD/LAB. Updated approach to uncertainty of measurement requirements in the ASCLD/LAB- International accreditation program for testing laboratories. Available from http://www.ascld- lab.org/international/pdf/alpd3033 (Accessed May 2011). 15. National Academy of Science. Strengthening forensic science in the United States: A Path Forward. National Research Council 2009 Washington, DC. The National Read at Bottom of Meniscus reading : 22.5 Academies Press. 16. Daubert V. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579 (1993).Available from https://supreme.justia.com/cases/federal/us/509/579/cas e.html#. Figure 2 : Markings on Hydrometer.

111 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00021.7 Original Research Paper Developing a Module of Medical Ethics for Post MBBS 1. Lalit Kumar, Professor & Head, Department of Forensic Medicine and Toxicology* 3. Jyoti Barwa , Associate Professor, Department of Forensic Medicine and Toxicology, AIIMS Bathinda 4. J P Sharma, Professor, Department of Surgery* 5. Puneet Ohri, Professor & Head, Department of Community Medicine* 6. M A Beg, Professor, Department of Pharmacology* *Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun

ABSTRACT : Introduction : Medical ethics is a system of moral principles that affect values and judgments to the practice of medical profession. A number of characteristics are associated with medical ethics such as autonomy, confidentiality, nonmaleficence, beneficence, honesty, justice, and dignity. Medical professionals' decisions are based not only on clinical and technical grounds but also on ethical grounds. Doctors are expected to be professionally sound with all required competencies. Now days with the change in complexities in health care delivery, the doctors are now encountering an increased number of litigations against them most of which are related to ethical issues. Aim and Objectives: Imparting training to fresh medical graduate in these soft- skills is the need of the hour, for which to prepare a module of medical ethics for post MBBS. Methodology: The project was carried at SGRRIM & HS, Dehradun. A core committee and involved faculty members were trained for curriculum designing. Assessment of topics was done by preparing feedback form, peer validated, ascertained by conducting a round of Delphi on medical graduates (Alumnae, Private professionals and government doctors). After getting feedback, training curriculum/module was formed, based on MCI 2002 code of Medical Ethics and problems faced by doctors. The prepared module was peer validated by experts. Feedback questionnaire for evaluation of pilot run and module delivery was prepared and peer validated for content and face validity. As a pilot run, the module was delivered to 45 interns of the college in the form of 2 days workshop. Feedback after module delivery was taken. After feedback, the necessary changes in the module were carried out and formulated a structured and standardized module of medical ethics for post MBBS. Findings: A total of 15 faculty members, including 9 core committee members participated in the training on curriculum development and 203 alumni completed the round of Delphi. After peer review by experts, a module of 15 broad areas was developed and was pilot run on 45 interns. Based on the feedback from pilot run, a standardized, validated 12 h module of medical ethics for post MBBS for patient care was developed. Conclusion: Pilot study proves that curriculum innovation in the form of medical ethics training to Medical graduate; when as they actively participate in patient care will go a long way in inculcating soft skills like ethics, empathy and communication in them.

Corresponding Author Article History: Dr. Lalit Kumar Received: 29 December 2018 Professor and Head, Received in revised form: 28 January 2019 Accepted on: 28 January 2019 Department of Forensic Medicine and Toxicology, Shri Guru Available online: 31 December 2019 Ram Rai Institute of Medical and Health Sciences, Dehradun Contact : +91 9358507650 E-mail : [email protected]

KEYWORDS : Curriculum, Communication Skills, Empathy, Medical Ethics, Module, Post MBBS

INTRODUCTION : Medical professionals' decisions are based not only on clinical Medical ethics is a structure of moral values that affect and technical grounds but also on ethical grounds.[2] values and judgments to the practice of medical profession. Doctors are expected to be professionally sound with all A number of characteristics are associated with medical required competencies and expected that while they are ethics such as autonomy, confidentiality, nonmaleficence, practicing medicines and are dealing with patients, attendants, dignity, honesty, justice, and beneficence.[1] Medical ethics has relatives of patients; they practice ethical behaviour with [3] developed over centuries, commencing from the time of relevant competencies. Now days with the change in Hippocrates and over time several codes have been complexities in health care delivery, the doctors are now developed.[2] encountering an increased number of litigations against

112 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00021.7

them most of which are related to ethical issues. Specific Objectives: Media description is rife with increase in the incidences of • Sensitization in faculty members for the importance of doctor-patients' conflict, and this partly is due to Medical ethics. communication gap and unethical practices being adopted by • Need assessment in medical ethics for health care the doctors. It was said that some doctors in lieu of professionals. commission refer patients to specific hospitals and • Prepare a module of medical ethics for post MBBS, which diagnostic labs for various tests. Many time It was reported can train the medical graduate- to develop soft skills, to that doctors sometimes prescribe unnecessary tests to the develop empathy, enhance communication skills and patients.[4,5] Due to lack of knowledge or ignorance of medical maintain doctor- patient relationship. ethics and jurisprudence the relationship between patient and doctors are deteriorating day by day. The impact of this, there • To pilot run the module of medical Ethics for development is a lot of increase in the incidence of violence against doctors of soft skills. day by day, not only violence, there is so much increase in the • Perception of students and faculty about the utility and case of litigation of medical negligence and many more over delivery of module. the doctors. METHODOLOGY : There is adequate evidence of lack of ethical practices on the The project was carried in Shri Guru Ram Rai institute of part of physicians, and lack of formal training in medical ethics Medical and Health Sciences, Dehradun with attached tertiary during medical teaching can be one of the reasons for the care hospital, Shri Mahant Indresh hospital, Dehradun in 2018- [6,7] same. Though Medical Council of India (MCI) introduced 2019. After Approval from the Institutional Ethics Committee, Code of Ethics Regulations in 2002, the same has not been a core committee consisting of faculty members from different made the part of the undergraduate training in India. Training departments was formed. A workshop on curriculum module of Medical Ethics has earlier been introduced at designing was conducted in the Institute, for the training undergraduate level in various countries; which either run as a of the core committee and other faculty members. capsule-course for 1–2-week duration or is the part of regular Sensitization programme was conducted for the participating undergraduate training and is conducted for the entire duration faculty on medical ethics. Assessment of topics was done by [8] of undergraduate course. In 1999, the World Medical preparing feedback form including open ended questions Association “strongly recommended” to medical schools that (qualitative assessment) and identification of problems by the teaching of ethics and human rights should be made Close ended questionnaire (quantitative assessment) which [9] compulsory in their curricula. Although Medical Council was peer validated by core committee members. of India (MCI) introduced Code of Ethics Regulations in These feedback cum need assessment form was ascertained 2002, the same has not been made the part of the by conducting a round of Delphi on college alumni, who undergraduate training in India.[6] Our regular curriculum were already working as Senior Residents, Postgraduate fails to impart any training in ethical issues in patient students, Medical Officers, Private practitioners. After care. Although medical ethic were thought in 2nd professional getting feedback, training curriculum/module was formed by curriculum but at that time students learn these topics for pass core committee in meetings after discussion as well as purpose only, so before being a complete doctor and getting online discussion on whatsapp group, based on MCI 2002 registered with council to be a registered doctor there is need to code of Medical Ethics and problems faced by doctors. refresh their knowledge of medical ethics. This is important Flow chart for preparing Module of Medical Ethics time to refresh knowledge and sensitize the medical graduate to medical ethics. This study is planned to prepare a module of medical Ethics for imparting training for development of soft skills in fresh medical graduate. To improve / maintain doctor- patient relationship, for making more receptive to laws related to Health profession, to make them aware with Duties and rights of doctors and patients, able to differentiate between ethical medical practice and unethical medical practice, to implement ethics in daily Practice and able to communicate and document the events in disease management like consent etc. with some

113 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00021.7

The prepared module was peer validated by experts for validated. Teaching Method and faculty guide for every content. A multiple choice questions test was framed for pre & session was prepared and duration of each topic was specified post workshop and peer validated. Feedback questionnaire for as in Table 1. evaluation of pilot run and module delivery was prepared and After pilot run, we found that 11 students out of 45 scored > peer validated for content and face validity. As a pilot run, the than 50% marks in pre workshop while this number increased module was delivered to 45 interns of the college in the to 40 Students out of 45 students scored > than 50 % marks. form of 2 days workshop, after taking oral consent. (Table 2) Feedback after module delivery was taken. After feedback, the Table 2 : Pre and Post workshop score of participants after necessary changes in the module were carried out to formulate pilot run a structured and standardized modules of medical ethics for post MBBS. >35% >50% >60% Total Participants Score Score Score (n=45) OBSERVATIONS AND RESULTS Pre Workshop 25 11 2 45 A total of 15 faculty members, including 9 core committee Post Workshop 44 40 35 45 members participated in the training on curriculum development. Participating faculty was sensitized to medical Table 3 reflect that Professionalism & empathy to the patient, ethics by detailed discussion. 25 topics for module as need Communication skills and identification of barriers and assessment were short listed by core faculty members. These Conflict of interest was the most interesting topic by 31.11% topics were: Medical oath and its relevance- including (14) participants, followed by Consent and Child Abuse by Hippocratic oath, Charak's oath, Declaration of Helsinki, 13.33% (6) participants. Medical oath, Human rights & Declaration of geneva; Professional conduct, etiquette and NHRC and doctors, Torture and human right & Clinical ethic regulation 2002, Professionalism & empathy to the research and ethics were least interesting topics in the patient, Medical Negligence and essential components, workshop. Consent – Type, Parts, conditions, rules and legal implication; Infamous conduct and punishments, Consumer protection act, Table 4 showed Professional secrecy, Rights and duties of Professional secrecy and its clauses, Rights and duties of- Doctor and Patient was the most important topic by 7 (15.56%) Doctor and Patient, Record keeping and certificates, Principles participants followed by Consent and Evidences in courts of of handling pressure- Types. Causes and sources, Skills of law by 6 (13.33% each) participants while no participant management; Conflict of interest, Communication skills and suggest importance of Clinical research and ethics. 2 identification of barriers, Human rights & NHRC and doctors, participant (4.44%) suggest all topic to be important. Ethics and HIV, Clinical research and ethics, Stem cell From Table 5 and Figure 1 showed Feedback after module research, Torture and human right, Body and organ donation, delivery. 44 interns out of 45 were agreed and strongly agreed MTP act & criminal abortion, Euthanasia and legal issues, on 5 point liker scale for increase in the knowledge in Medical PCPNDT Act, Child Abuse, Duty in poisoning, Evidences in Ethics, increased your work potential in health care settings, courts of law. helpful for making better doctor –patient relationship and For the round of Delphi, these topics were sent to 457 Medical believe to conduct regular workshop on Medical Ethics. Professionals with the instructions – to identify the area which Based on feedback of interns, changes in the teaching-learning needs to be inserted in the module from their personal methodology and case scenarios were made and a standardized experience and to suggest five topics separately which they validated 12 h teaching module on medical ethics for post think must be part of module; and if they want that any other MBBS was prepared. topic (besides 25 already suggested) to be included in the Figure-1 Perception of participants after Module Delivery module. 203 Medical Professionals reverted back and based on their feedback, five topics on which consensus was built were: Duties and rights of doctors and patients, Record keeping and certificates, Principles of handling pressure, Consent and MTP act & criminal abortion in the same order of preference. After core faculty members meetings, considering MCI code of medical ethics 2002, 15 topics for 2 days' workshop were finalized as mentioned in Table 1. Based on these finalized topics, a module along with hand-outs was developed and peer

114 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00021.7

Table 1 : Curriculum for Module of Medical ethics for Post MBBS S No Broad Topic Learning Objective Teaching Method Duration DAY 1 1 Medical Oath Hippocratic oath, Charak's oath, Declaration of Helsinki, Declaration of geneva and its relevance, Rights of patients Interactive lecture 30 min and Ethical principles as reflected in various Followed by oaths/declarations jig-saw method 2 Professional conduct, Appraise the MCI Professional conduct, Etiquette and Ethics Regulations, Enlist essential ethical principles in Interactive lecture, etiquette and ethic Flipped classroom regulation 2002 patient care and unethical practices. Professional misconduct and Punishments, Dichotomy, Functions and 45 Min role of Medical Council of India and State Medical Councils, Indian Medical register, Warning notice and penal erasure

3 Professional secrecy, Relate the concept of confidentiality in patient care, Analyze Interactive lecture Rights and duties of the information which is confidential, Privileged Group activity 60 Min Doctor and Patient communication. Review rights and duties of doctors Assess Case-based duties and rights of patients learning

4 Consent Type, Parts, conditions, rules and legal implication of Brainstorming, consent, Importance of consent in relation to age, Interactive lecture, emergency situation, mental illness and alcohol intoxication Role play 45 Min Administer informed consent in simulated conditions

5 Human rights & NHRC Assess human rights, Various forms of torture, Difference Interactive lecture, and doctors, Torture between torture and right, Identification of injuries caused Role play and human right by torture and its sequalae, guidelines and Protocols of 45 Min National Human Rights Commission regarding torture, Working of NHRC Professionalism & 6 Identify the common barriers in effective communication Role play empathy to the patient, with patients, Resolutions for avoiding conflicts, able to Interactive lecture Communication skills demonstrate the professionalism while dealing with victims Cinemeducation and identification of of torture and human right violations, sexual assaults, Group activity, barriers and Conflict psychological consultation, rehabilitation. Identify the Case-based learning of interest structured way of breaking bad news to the patient in an 75 Min empathetic manner, communication between doctors, public and media Distinguish the different scenarios of conflict of interest in medicine, Conflict resolution techniques

7 Principles of handling Types, Causes and sources of pressure while patient Cinemeducation, pressure management and any unforeseen circumstances, Skills of Case-based learning 60 Min management in any adverse situation

DAY 2 8 Medical Negligence Differentiate between medical negligence and professional Interactive lecture, and essential misconduct including civil and criminal negligence, Case based learning components, contributory negligence, corporate negligence, vicarious liability, Res Ipsa Loquitor, prevention of medical Consumer Protection 60 Min Act negligence and defenses in medical negligence litigations, Explain vicarious liability, Explain the consumer protection act, documented punishment in various judgments, Highlights of Consumer Protection Act

115 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00021.7

S No Broad Topic Learning Objective TL Method Duration 9 Record keeping component of certificates, Precaution in record keeping, Group discussion, and certificates medicolegal examinations, Medical Certificates and Case based learning medicolegal reports especially Maintenance of patient case records, discharge summary, MCCD filling, Common 45 Min Patient Case file errors, Impact of report and certificate on judgments

10 Duty of a Doctor Duty of Doctor to Patient in case of poisoning, Duty of Case-based learning Doctor towards state in case of poisoning, Sample while handling 30 Min a case of poisoning preservation, Various sections of law related to poisoning Group activity

11 Evidences in Courts Describe Courts in India and their powers, Issue of Case based learning, of law Summons, conduct money, types of witnesses, recording of Case simulation evidence oath, affirmation, examination in chief, cross examination, re-examination and court questions, recording 60 Min of evidence & conduct of doctor in witness box Preparation before court evidence, conduct money, precaution in giving evidence in court,Offenses in Court including Perjury 12 Clinical research and Ethics of clinical research Punishment for unethical Interactive lecture ethics research, constitution and functions of ethical committees, 30 Min Biomedical Research on Human Subjects & Animals 13 Euthanasia and Define euthanasia Differentiate between different types of Interactive lecture euthanasia Enlist conditions where passive euthanasia is Cinemeducation legal issues 30 Min permissible in India Critically analyze ethical, social, and Group activity. emotional issues associated with euthanasia Case based learning

14 Child Abuse Define child abuse, Battered baby syndrome, Munchausen Interactive lecture 45 Min syndrome by proxy, child sexual abuse 15 MTP act & criminal Select the conditions under which abortion and medical Interactive lecture abortion, termination of pregnancy is permissible under law Illustrate Case-based learning 60 Min PCPNDT Act the legal, ethical and social issues involved in abortion and medical termination of pregnancy, Highlights of PCPNDT act

Table 5 : Perception of participants after module delivery Strongly Strongly Participants (n=45) Agree Disagree S. No. agree Neutral disagree Do you feel this workshop helped in increase 1 in the knowledge in Medical Ethics? 31 13 1 0 0 This workshop will increased your work 2 potential in health care settings. 29 15 1 0 0 This activity is helpful for making better 3 doctor –patient relationship. 30 14 1 0 0 You believe to conduct regular 4 workshop on Medical Ethics. 30 14 0 0 1

DISCUSSION : doctors in lieu of commission refer patients to specific Medical ethics has developed over centuries, commencing hospitals and diagnostic labs for various tests. Lack of formal from the time of Hippocrates and over time several codes have training in medical ethics during medical teaching can be one been developed. Medical professionals' decisions are based of the reasons for the same. It is generally believed that soft not only on clinical and technical grounds but also on ethical skills such as professionalism, ethics, and communication are grounds. Recently, media was rife with many reports of caught, and not taught, and there is no need to have a structured unethical practices by Indian physicians. It was said that some curriculum for learning these soft skills. In 1999, the World

116 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00021.7

Table 3 : Most interesting topic identified by participant S. No. Topic No of Participants %age 1 Medical oath 0 0.00 2 Professional conduct, etiquette and ethic regulation 2002 1 2.22 3 Professional secrecy, Rights and duties of Doctor and Patient 2 4.44 4 Consent 6 13.33 5 Human rights & NHRC and doctors, Torture and human right 0 0.00 6 Professionalism & empathy to the patient, Communication skills and 14 31.11 identification of barriers and Conflict of interest 7 Principles of handling pressure 5 11.11 8 Medical Negligence and essential components, Consumer Protection Act 3 6.67 9 Record keeping and certificates 1 2.22 10 Duty of a Doctor while handling a case of poisoning 1 2.22 11 Evidences in courts of law 1 2.22 12 Clinical research and ethics 0 0.00 13 Euthanasia and legal issues 4 8.89 14 Child Abuse 6 13.33 15 MTP act & criminal abortion, PCPNDT Act 1 2.22 16 Total 45 100.00

Medical Association “strongly recommended” to medical schools graduate feels the importance of professional secrecy, rights of that the teaching of ethics and human rights should be made doctors and patients, duties and liability of doctor and patient compulsory in their curricula. Our project of development of so they made them on top priorities in feedback after module Module of medical ethics for Post MBBS is based on the need delivery. assessment by Delphi method which actually representing the Due to ignorance of medical ethics and jurisprudence, the actual need of the medical health professional for serving the relationship between patient and doctors are deteriorating day human community. by day. As result, increase in the incidence of violence against In our study after pilot run we found that number increased from 11 doctors, not only violence, there is so much increase in the case to 40 participants who score >50 % score in pre and post workshop of litigation of medical negligence and many more over the questionnaire which is due to increase in the knowledge by the doctors. This module based on need assessment and module training. As Most of heath care is delivered by the MBBS indentified problem of health professionals would be able to doctors in the India and apart of this MBBS doctors are the first train Indian medical graduate in communication skills and qualitative contact in the most of the state of India in Government long life learner to improve doctor- patient relationship. and private settings. Considering these points, it was concluded Although Medical Council of India (MCI) introduced Code of that a training module of Medical Ethics for Post MBBS is the Ethics Regulations in 2002, the same has not been made the need of the hour. Thus, in this innovation research project, a part of the undergraduate training in India. Training module of module for Medical graduates in medical ethics in patients' care Medical Ethics has earlier been introduced at undergraduate was designed, validated, and standardized through pilot run. level in various countries; which either run as a capsule course Professionalism & empathy was the most interesting topic in the for 1–2-week duration or is the part of regular undergraduate training as the upcoming medical graduates are more aware and training and is conducted for the entire duration of sensitize to the need of professionalism and empathy to improve undergraduate course. This module is designed as short term the doctor and patient relationship while managing the patients. As workshop to sensitize, develop soft skills with empathy and to increase in incidences of medical negligence and litigation against develop better communication skills with protection of rights health professional are increasing day by day, these medical

117 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00021.7

Table 4 : Most important topic identified by participant S. No. Topic No of Participants %age 1 Medical oath 1 2.22 2 Professional conduct, etiquette and ethic regulation 2002 2 4.44 3 Professional secrecy, Rights and duties of Doctor and Patient 7 15.56 4 Consent 6 13.33 5 Human rights & NHRC and doctors, Torture and human right 1 2.22 6 Professionalism & empathy to the patient, Communication skills and 4 8.89 identification of barriers and Conflict of interest 7 Principles of handling pressure 2 4.44 8 Medical Negligence and essential components, Consumer Protection Act 3 6.67 9 Record keeping and certificates 2 4.44 10 Duty in poisoning 1 2.22 11 Evidences in courts of law 6 13.33 12 Clinical research and ethics 0 0.00 13 Euthanasia and legal issues 3 6.67 14 Child Abuse 1 2.22 15 MTP act & criminal abortion, PCPNDT Act 4 8.89 16 All Topics 2 4.44 17 Total 45 100

of medical graduate as well as patients. This module is PowerPoint presentations, day-to-day case scenarios, video prepared while keeping in mind the medico- legal problems clips, and role plays[14]. Our project is a 2 days module which are going to be increased day by day. incorporating Interactive lecture, Flipped classroom, Modules for ethical training has been developed and Brainstorming, Interactive lecture, Role play, Group activity, implemented in some institutes already, based on institutional Case-based learning, Cinemeducation, case simulation as needs, but most of these curricula address the residency teaching-learning strategies. The module has been developed programs[10]; although efforts have been made to include the after need-assessment through Delphi. Like our study other same to the fresh undergraduate[11,12], and now most medical studies have largely tried to assess the knowledge, attitudes, schools in the USA and UK have ethical curricula as integral and practices of doctors and students in medical ethics and part of undergraduate training[12]. In other institutes, sporadic communication, without imparting any training or developing [15-16] efforts have been made to develop and implement ethical any structured module . teaching on experimental basis, but reports of including it as a CONCLUSION : part of curricula are lacking. In a similar sounding project, 2- Health professional, completing their training by module day workshop on teaching effective communication skills and would be trained in the soft skills of medical ethics, more principles of medical ethics conducted at Foundation receptive to laws related to Health profession and will be aware University Medical College, Pakistan, where 102 last year with Duties and rights of doctors and patients. After this medical students participated. In India, St. John's Medical training the participant will be able to differentiate between College, Bengaluru is running a longitudinal program in ethical and unethical medical practice, able to implement medical ethics since 1988, and the same has been adopted by ethics in daily Practice, manage medico- legal issues, its affiliating university-Rajiv Gandhi University of Health communicate and document the events in disease management Sciences in the form of 40 h program throughout MBBS (like consent) and making better record for any future [13] training . Teaching strategies included interactive complication or litigations. discussions on basic principles of doctor–patient relationship,

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In the long term outcome these health professional, completing teachers for students and society. Indian J Urol 2009; their training by module would be able to decrease in the 25:337-9. incidence of violence against doctors and litigation and able to 14. A h s i n A , S h a h i d A , G o n d a l G M . Te a c h i n g improve in the image of medical profession. communication skills and medical ethics to undergraduate LIMITATIONS: medical student. J Adv Med Prof 2013; 1:72-6. The current study is also limited in the sense that it is a pilot 15. Dash SK. Medical ethics, duties & medical negligence run. Further refinement will happen in the module, with use awareness among the practitioners in a teaching medical and experience. college, hospital-A survey. J Indian Acad Forensic Med REFERENCES : 2010;32:153-6 1. Munyaradzi M. Critical reflections on the principle of 16. Mohammad M, Ahmad F, Rahman SZ, Gupta V, Salman beneficence in biomedicine. Pan Afr Med J 2012;11:29. T. Knowledge, Attitudes and Practices of Bioethics among Doctors in a Tertiary Care Government Teaching 2. World Health Organization. Module for Teaching Hospital in India. Clin Res Bioeth 2011; 2:118. Medical Ethics to Undergraduates. Regional office for South East Asia, New Delhi: World Health O rg a n i z a t i o n ; 2 0 0 9 . P. 1 . Av a i l a b l e f r o m : http://www.apps.searo.who.int/PDS_DOCS/B4401 3. Mahajan R, Aruldhas BW, Sharma M, Badyal DK, Singh T. Professionalism and ethics: A proposed curriculum for undergraduates. Int J Appl Basic Med Res 2016; 6:157-63. 4. Bansal RK, Das S. Unethical relationship between doctors and drug companies. JIAFM 2005; 27:40-2. 5. Chatterjee C, Srinivasan V. Ethical issues in health care sector in India. IIMB Manag Rev 2013; 25:49-62. 6. Berger D. Corruption ruins the doctor-patient relationship in India. BMJ 2014; 348:g3169. 7. Mook WN, Gorter SL, DeGrave WS, Luijk SJ, Wass V, Zwaveling JH, et al. Bad apples spoil the barrel: Addressing unprofessional behaviour. Med Teach 2010; 32:891-8. 8. Medical Council of India. Professional Conduct, Etiquette, and Ethics Regulations; 2002. Available from: h t t p : / / w w w . m c i i n d i a . o r g / R u l e s - a n d - Regulation/Ethics%20Regulations-2002.pdf. 9. World Medical Association. Medical Ethics Manual. 1ed. Ferney-Voltaire Cedex, France: World Medical Association; 2005. 10. Arnold RM, Forrow L, Wartman SA, Teno J. Teaching clinical medical ethics: A model programme for primary care residency. J Med Ethics 1988; 14:91-6. 11. Miles SH, Lane LW, Bickel J, Walker RM, Cassel CK. Medical ethics education: Coming of age. Acad Med 1989; 64:705-14. 12. Fox E, Arnold RM, Brody B. Medical ethics education: Past, present, and future. Acad Med 1995; 70:761-9. 13. Ramesh K. Ethics in medical curriculum; ethics by the

119 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00022.9 Original Research Paper Proposed Standard Operating Procedure for Use of Unclaimed Dead Bodies for Medical Education and Research. 1. Rajeev Varma Manukonda, Assistant Professor, Department of Forensic Medicine and Toxicology* 2. Santoo Bagh, Demonstrator, Department of Forensic Medicine and Toxicology* 3. Miss. Yajnaseni Singh, II Professional MBBS Student* 4. Alakh Ram Verma, Associate Professor, Department of Physiology* 5. Bhushan Kumar Khunte, Demonstrator, Department of Forensic Medicine and Toxicology* *Govt. Medical College, Ambikapur, Chhattisgarh.

ABSTRACT : Introduction: Unclaimed bodies are routinely cremated after postmortem examination. We in this study proposed the use of such bodies for the purpose of medical education and research. Materials and Methods : Data was collected for a period of 3 years from 1st January 2015 to 31st December 2017 on demographic profile, cause and manner of death of unclaimed bodies autopsied at department of forensic medicine, Govt Medical College, Ambikapur. Perusal of Anatomy Acts was done and standard operating procedure was proposed for use of such bodies for medical education. Results: Development of an institutional SOP (I-SOP) for disposal of Unclaimed dead bodies and generation of scientific material for medical education and research. Conclusion: The standard operating procedure have been developed on the backdrop of Chhattisgarh Anatomy act. All the stakeholders, particularly the police personnel should be made aware of the provisions of Anatomy act safeguarding them from the legal complications while handling biomedical tissues. Time is precious. A lethargic effort is not going to fetch the desired result. Corresponding Author : Article History: Dr. Rajeev Varma Manukonda, Received: 8 January 2019 Assistant Professor, Received in revised form: 8 February 2019 Accepted on: 8 February 2019 Department of Forensic Medicine and Toxicology, Available online: 31 December 2019 Govt. Medical College, Ambikapur, Chhattisgarh. Contact : E-mail : [email protected] KEYWORDS : Unclaimed dead body, Standard operation procedure, Anatomy act, Medical education and research.

INTRODUCTION : generated within the hospital in a legal and ethical manner and Losing one's identity is one of the scariest things that can reach the respective departments. Over a period of time the happen in today’s world. A person without an identity is institution becomes self-sustainable. If such a system considered as not existing unless proved otherwise. When such succeeds, it can keep a check on the illegal trade and a person without an identity dies, the legal impediment exploitation of human organs as well. increases many a fold. The first, foremost, and tedious task is to A questionnaire received from The Rajya Sabha, Govt of India identify such persons. When every such effort fails the person and Chhattisgarh state Vidhan Sabha requesting information will be considered as an unidentified person and the dead body regarding the statistics and standard operating procedure will be considered as unclaimed when the body is not claimed (SOP) for disposal of unclaimed dead bodies had initiated the within the time period as prescribed. thought of taking up this research. The specific objective of this If the legal complications surrounding this unclaimed dead research was to develop an institutional SOP (I-SOP) for body can be addressed in a timely phased approach, the tedious disposal of unclaimed dead bodies wherein all the legal hurdles task of disposing the body can be converted into a precious are taken care off in a phased manner and scientific material is scientific material for medical education and research. generated for the purpose of medical education and research. Imagine a situation where the Anatomy department need not MATERIALS AND METHODS : go in search of cadavers for human anatomy dissection, the After taking approval from Institutional Ethical Review Forensic medicine and other departments need not spend huge Board, Present study was conducted on 44 unidentified amounts in procuring the wet museum specimens and individuals which were autopsied over a period of three years microscopic slides, instead the scientific material gets from January 2015 to December 2017. Detailed history of

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cases were collected from investigating officers. The Causes of death: It was observed that natural and unnatural circumstances relating to the death were carefully analysed. events accounted for 48% and 52% of cases respectively with a Data was cross checked to keep missing data to zero percent. slight higher predominance towards unnatural death. Similar Age, Sex, Cause & manner of death was checked in each case. results were reported by Saurav et al[3] and Buyuk et al[4]. Only Adult unclaimed bodies were taken for study & infants Majority of the victims were found dead on the road side were excluded in the study. (59.09%) followed by death inside the hospital (40.90%). The RESULTS : most common natural causes of death in our study was chronic respiratory and gastro-intestinal diseases. Respiratory A total of 1398 autopsies were performed during the study pathologies included tuberculosis, COPD, lung abscess and period. Out of which 44 (3.14%) individual's identities was not fibrosis. The gastro-intestinal pathologies included hepatitis, known at the time of autopsy. Among all the cases, 30 were cirrhosis and pancreatitis. These homeless individuals because males (68.18%) and females were 14 (31.81%). Majority of of lack of education, poverty and addictions expose the victims (55.34%) belong to 51-60 years age group themselves to the ill effects of unhealthy lifestyle leading to followed by 61-70 years. 51-70 years accounted for majority low immunity and coupled with tobacco use may account for of the victims (69.81%). Majority of the victims were found high incidence of both acute and chronic lung diseases[5-7]. dead on the road side (59.09%) followed by deaths inside the Accidental causes were identified as the second most common hospital (40.90%). (Table 1-2) cause of mortality in our study. Among accidental causes, road Table 1: Gender Wise Distribution traffic accidents causing severe head injury and polytrauma Gender N % leading to haemorrhagic shock accounted for the majority of Male 30 68.18% the cases. The high prevalence of road traffic accidents is Female 14 31.81% understood by the fact that people occupying the pavements are at risk of heavy traffic, lack of visibility at night and rash Table 2: Age Wise Distribution driving. Homicidal and suicidal causes were not observed in Age Percentage Distribution our study. 51-60 years 55.34% 70% The Anatomy Act: In India, Anatomy Act was enacted in 61-70 years 14.47% 1948. It is a state Act promoted by legislature and published in the state Government Gazette. The Bombay Anatomy Act, The In 21 cases (47.72%) the manner of death was natural and in 23 Delhi Anatomy Act, The Karnataka Anatomy Act and The cases (52.27%) the manner was unnatural. Majority of the Chhattisgarh Anatomy Act are some to name[8-11]. The Act unnatural deaths were due to road traffic accidents. Majority of provide for supply of unclaimed bodies of deceased person natural deaths were related to respiratory tract pathologies (and for donation before death by a person of his body or any followed by pathology in gastrointestinal system. Head part thereof after his death) to hospital and medical teaching injuries and polytrauma was present in most cases of unnatural institution for therapeutic purpose or for the purpose of deaths (Table 3). medical education or research including anatomical Table 3: Manner of Death examination and dissection. The Act defines 'Unclaimed body’ Manner N % as the body of deceased person who has no near relative or Natural¥ 21 47.72% whose body has not been claimed by any of his near relatives £ within 48-72 hrs. After this period the investigation officer can Un-natural 23 52.27% hand over the body to the in-charge of approved hospital for ¥Respiratory and Gastro-intestinal pathologies. medical education & research purpose or can order a £Majority of the unnatural deaths were due to road traffic cremation. Most of the police personnel has no knowledge accidents regarding the potential uses of unclaimed dead body for research purpose or they wish to avoid donating the body for DISCUSSION : research for fear of legal complications. It is the responsibility Prevalence of unclaimed dead bodies: The male of the doctors who are in the chain of events to educate and predominance in this study (68.18%) can be understood by the counsel the IO for body donation. It will be easy to convince fact that males form the major working and migratory group these officers if the standard operating procedure for disposal and are constantly involved in outdoor activities. Similar of unclaimed dead body has been clearly explained and [1] results were reported in studies by Yadav et al and Kumar et followed. Act clarifies 'Approved institution- means a hospital [2] al . or a medical or teaching institution approved by State

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Government.' All Govt Medical Colleges of Chhattisgarh state From the flow diagram it is very evident that the Authorized are recognized as approved institutions. In cases of certified officer/Investigating officer and the Authorized in-charge of natural death cases, A certificate stating the cause of death approved hospital are the corner stones of the entire procedure. signed by RMP (Registered Medical Practitioner) attending These two individuals are the decision-making authorities the deceased or RMP called in after the death of such person is which will decide the fate of an unclaimed dead bodies as to necessary. This certificate shall be delivered together with the whether the body should be cremated or used for medical body to authority in charge of an approved institution[11]. When education and research. The first in line is the Authorized the investigation officer decides to donate the body to the officer/Investigating officer who receives the dead body. Once approved institution and where death occurred outside the the information regarding the unidentified dead body is approved hospital, the IO should collect the death certificate received, the IO conducts the preliminary investigation under issued by a registered medical practitioner. The in-charge of Sec 174 CrPC. If the death seems to be natural, no injuries are the approved institution (Which is generally the Medical present on the body and no foul play is suspected, the IO will superintendent of the Hospital or in some case the Dean of the conclude the case as a natural death. If any foul play is Medical college) shall not accept the unclaimed dead body suspected and or injuries are present on the body it will be without this death certificate. concluded as an unnatural death. In both the cases the Before handing over the unclaimed body for medical unidentified dead body will be preserved in cold storage to education every effort has to be made by the investigation avoid any type of decomposition for a prescribed period authority to trace relatives of the deceased. Print and electronic generally for a period ranging from 48 hrs. to 72 hrs. During mass media communications such as local and national this period if the body remains unclaimed it will be considered newspapers, radio, television and social media platforms as an unclaimed dead body. In case of natural death, the IO will should be used in dissemination of information regarding the order for a cremation and in unnatural death the body will be deceased. If Cause of Death not clear or suspicious, then IO sent for postmortem examination after which it will be shall submit the body for postmortem examination and usually cremated. This can be considered as the first check point. It is at body is cremated after postmortem examination. this point the IO should be counselled and advised that the body not to be cremated but instead should be forwarded to the Proposed SOP for disposal of unclaimed dead bodies: The Authorized in-charge of approved hospital. flow diagram (Figure 1) has been prepared based on the Chhattisgarh Anatomy Act which provides guidelines for The Authorized in-charge of approved hospital on receiving dealing with unclaimed dead bodies. such unclaimed dead body can order for disposing the body to medical education and research such as organ retrieval in Figure 1 mutilated bodies and anatomical dissection in intact bodies or reject the body and advise the IO for cremation if the body is grossly decomposed or mutilated beyond usage. This can be considered as the second check point. Both the check points (Red arrows) are the potential places where this scientific material will be lost. Many of the IO are not aware of these steps and it is the responsibility of the hospital where the body is stored for the prescribed period to suggest, counsel and advise the IO. The question to be answered here is who is the one, who will take up this task of coordinating, advising, suggesting and counselling? It is here advised that the public relationship officer (PRO) of the hospital will be the best person to take up this task (Figure 2). PRO can act as bridge between the IO and Authorized in-charge of approved hospital. The responsibilities of PRO include educating and counselling the IO, getting approval from Authorized in-charge of approved hospital and mobilizing the concerned departments. The flow of information and work progress is bidirectional (Figure 3) and the PRO should act as a dynamic two-way valve between

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Authorized officer/Investigating officer and the Authorized in- REFERENCES : charge of approved hospital. The concerned departments 1. Yadav A, Kumar A, Swain R, Gupta SK. Five-year study should be informed at the earliest and the departments should of unidentified/unclaimed and unknown deaths brought respond quickly. Every department involved should be well for medicolegal autopsy at Premier Hospital in New prepared in advance facing such situations. Delhi, India. Med Sci Law. 2017;57(1):33–8. Figure 2 2. Kumar A, Harish D, Chavali KH, Singh A. Patterns of Cause of Death in Unknown Dead Bodies A Three Year Study in a Tertiary Care Hospital. 2012;34(4):304–8. 3. Saurav C, Aayushi G, Behera C, Karthik K, Millo T, Gupta S. Medico-legal autopsy of 1355 unclaimed dead bodies brought to a tertiary care hospital in Delhi, India (2006- 2012). Med Leg J. 2014;82(3):112–5. 4. Buyuk Y, Uzun I, Eke M, Cetin G. Homeless deaths in Istanbul, Turkey. J Forensic Leg Med. 2008 Jul;15(5):318–21. 5. Chattopadhyay S, Shee B, Sukul B. Unidentified bodies in Figure 3 autopsy - A disaster in disguise. Egypt J Forensic Sci. 2013;3(4):112–5. 6. Altun G, Yilmaz A, Azmak D. Deaths among homeless people in Istanbul. Forensic Sci Int. 1999 The proposed institutional SOP is implemented in the present Jan;99(2):143–7. institution in a phased manner. In the initial phase the Dept of 7. Schanzer B, Dominguez B, Shrout PE, Caton CLM. Forensic medicine has succeeded in procuring eight wet Homelessness, Health Status, and Health Care Use. Am J specimens and twenty seven bones of forensic interest for Public Health. 2007 Mar 7;97(3):464–9. academic teaching and museum display. With the inter- 8. Mrunal D, Ravindra R J, Sachin S B, Sankalp R H, Amol departmental cooperation from Dept of OBGY, we succeeded M D. The Anatomy Act. J Ayurveda Hol Med. in procuring seven fetuses of various ages. The fetus will be 2015;3(1):26–26. used for demonstrating fetal autopsy and other medico-legal issues involving dead fetus for undergraduate students. A 9. Pampilly VS. Cadavers for anatomical dissection. Indian workshop is planned for judicial officers for educating them J Med Ethics [Internet]. 2005;(1). regarding the Chhattisgarh anatomy act and implementation of 10. Bombay High Court, India. Bombay Anatomy Act SOP for disposal of unclaimed dead bodies. This SOP will be [ I n t e r n e t ] . 1 9 4 9 . A v a i l a b l e f r o m : implemented in a phased manner and results will be analyzed http://bombayhighcourt.nic.in/libweb/acts/1949.11.pdf at a later stage for modifications if any for better outcome. 11. Chhattisgarh e-gazzette, The Chhattisgarh anatomy act, CONCLUSION : 1954. Notification No. F 21-08/2013/Nine/55-4(3). 2014. The standard operating procedure has been developed on the backdrop of Chhattisgarh Anatomy act. The SOP is intended to be implemented at institutional level and results will be analyzed at a later stage. All the individuals involved has to put in that minor effort at the right place and at the right time to preserve this precious scientific material from getting lost. Time is precious. A lethargic effort is not going to fetch the desired result. DISCLOSURES : Funding: No funding or grant support Conflicts of interest: The author has no financial disclosures

123 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00023.0 Original Research Paper Characterization of country liquor for forensic purposes: A preliminary study 1. Rito Chophi, M.Sc, Department of Forensic Science, Punjabi University Patiala, Punjab, India 2. Praveen Kumar Yadav, Senior Research Fellow, Department of Forensic Science, Punjabi University Patiala, Punjab, India

ABSTRACT : Alcohol is one of the most frequent toxic substances encountered in forensic laboratories. It forms a huge workload and therefore a quick and sensitive method to differentiate various types of liquor brand is necessary. In the present study, an attempt has been made to characterize the country made liquors in Punjab by using Head Space Gas Chromatography-Mass spectrometry (HS-GC-MS). Analyses were performed on five brands of Indian Made Foreign Liquor (IMFL) and four brands of country liquor. Many compounds of acid, ester, alcohol and other compounds were profiled. Benzyl alcohol and propylene glycol were found only in country made liquors and can be used to discriminate the country made liquors from IMFL brand.

Corresponding Author : Article History: Rito Chophi Received: 5 March 2019 Department of Forensic Science, Punjabi University Patiala, Received in revised form: 8 October 2019 Accepted on: 8 October 2019 Punjab, India, 147002 Available online: 31 December 2019 Contact : Email : [email protected]

KEYWORDS : Forensic, liquor, toxic, HS-GC-MS, characterization

INTRODUCTION : isopropanol, methanol, ethylene glycol, propanal, butanol, Alcohol is one of the most frequent toxic substances pentanol etc. However any alcohol can be toxic if ingested in encountered in Forensic Toxicology laboratories for a simple large quantities. Alcohol greater than 250 mg/dl causes coma [8] reason that drunkenness leads to many fatal accidents, and death can happen at level greater than 400 mg/dl . Deaths suicides, crime of violence and antisocial behavior. It also due to methyl poisoning cases have been reported in different comes to laboratory in cases of poisoning deaths[1]. Liquors parts of India, especially among people belonging to rural [9] come to Forensic Chemistry laboratories as and when areas . Methanol poisoning causes blindness, metabolic encountered in illegal sale and possession, adulteration, acidosis, coma, seizure, cardiac collapse, respiratory failure evasion of taxes, transportation from one district to another and death. The lethal dose of pure methanol is 1-2 ml/kg body [10] [11] district or to other states and in cases involving alleged history weight . However, as little as 4 ml may cause blindness . of driving under the influence of alcohol[2, 3]. Sometimes liquors METHODS AND MATERIALS : are sent to laboratory for analyzing various drugs content Sample collection: In this study, 9 liquor samples were [4] especially date rape drug like Rophynol . Thus it is expected collected from the district of Patiala and Ludhiana in the state of Forensic laboratories to quickly and sensitively identify the of Punjab, India. 5 brands of IMFL (S. No: 1-5) were collected liquor when such cases are received. The characterization of from Patiala while 4 brands of country liquor were procured liquor is possible as the type of major active components and from Ludhiana (S. No: 6-9). Detail description of samples is volatile congeners in liquor vary with different types of liquor given in Table 1. [5] brand . The congener content also varies with different Table 1 : Description of liquor samples fermentation process, distillation process and also with respect S.No: Brands Color Sample to geographical origin of substrate used for producing Code alcohol[6]. The analysis of congeners is helpful in identifying 1 Royal arms Golden brown RA the type of liquor and is useful to check the plausibility of post- 2 Spark Colorless SV offence drinking claims in forensic toxicology[7]. Thus 3 John Silver Red JS characterization of liquors helps not only in discriminating 4 Officers Choice Golden brown OC various types of liquor brands but also gives an insight into 5 Beer Light brown B possible geographical region where it might have originated. 6 Tiger gin Colorless TG TOXICITY : 7 Ranjba Samofi Colorless RS 8 Doaba Raspberry Golden brown DR The toxicity of alcohol is contributed by compounds like 9 Dollar Red DO

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Sample preparation: 1µL of samples were taken in 22 ml vial Analysis by GC-MS showed many compounds of alcohols, and sealed. The vial was then heated at 100° C for 5 min. 1µL of acids, esters, alkane and alkyl groups, ketones and Amines. headspace was injected into the injection port of GC through Alcohol: Alcohols are chemicals containing carbon and head space transfer line which was maintained at 110°C. Hydrogen atoms and a hydroxyl groups. The primary GC-MS parameters: The sample was analyzed using compound of any alcoholic beverage is ethanol. It is formed SHIMADZU GC-MS-QP2010 ULTRA Rtx-5mil MS of from fermentation of sugar and other sources of carbohydrates thickness 0.25µm, 30cm length, and 0.25 mm diameter. The with yeast and has a slight sweet fruity like odor[2]. Propanol injection port used was Spl 1, and Injection heat port was Inj 1. has a pleasant sweetish odor. Phenyl ethanol introduces a rose The injection mode split ratio was kept at 2:1, and column oven like aroma while higher alcohols if present in excess can result temperature was kept at 40°C. The sampling time was 1 minute in strong pungent smell and taste [11]. The compounds of alcohol and the carrier gas used was Helium. The pressure was found in IMFL brands include: (1-Pentalnol, 2-Butoxy adjusted to 160 KPa and the total flow was 2ml/min. The ethanol, Veratryl alcohol, 2-nitro ethanol, 3-methyl-1-butanol, column flow, purge flow, and split flow was 5 ml/min, 3 1-2-propanediol) and in country liquor include: (1-pentanol, 2- ml/min, and 2:1 respectively. The linear velocity was 62.5 phenoxy ethanol, Propylene glycol, 3-methyl-1-butanol, 1-2- cm/sec. The ion source temperature was kept at 200° C and the propanediol, 1-2-ethane diol, 2- Propanol, Benzyl alcohol, 1- solvent cut time was 2 minutes. Butanol). RESULTS AND DISCUSSION : Acids: Acids constitute an important group of volatile This study was conducted to identify the components present compounds that contribute vinegar like odor and provide [12] in country liquor, and also characterize the liquor by bitterness to the liquor . The compounds of acids in IMFL comparing the components against the compounds present in brand include: (Pentadecanoic acid, 1-2 Benzene dicarboxylic IMFL brands. Figure 1 shows the total ion chromatogram of a acid, di-isopropyl-phenylamine Thiophosphine acid, Propyl- representative liquor sample. Propanedioc acid, dl-Alanyl-dl-Phenylalamine, dl-Cystine,

Figure 1 : Total ion chromatogram of liquor sample represented by Royal Arms (RA)

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Octadecanioc acid, Carborane, Acetic acid, and Butanoic carboxoamide, Ethane diamine, 3-(methyl amino )- acid), and in country liquor include: (1-2 Benzene dicarboxylic Propanenitrile and Propanamide. Few compounds of ketones acid, Acetic acid and Butanoic acid, Propanoic acid, Hydrazine were found and it include compounds like Benzephenone, carboxylic acid, Alanine, Sarcosine and Murexide ). These Bornanone, Thiazolone and 3-(Ethyl-Hydrazonol)- Butan-2- compounds are known to provide bitter taste to liquor. one. Ester: The compounds of ester contribute the most of the The compounds belonging to alkane/alkyl groups include: distillate's aroma and quality. Esters are responsible for the Decamethyl, Tetradecane, Eicosane, 3-Isopropoxy 1,1,7,7,7, flowery and fruity aroma of distillates[13]. The compounds of hexamethyl, hexane etc. Other components include ester found were: (Isopentyl hexanoate, Ethyl acetate, 2- cyclohexasiloxane, Nonanal, 2-methylthio-3-(2- thienylthio) dibutyl Phosphinyl methyl allophanate, Diethyl Phthalate, thiophene etc. dodecyl ester and 3-methyl acetate ). Beer: Brewery first started In India at Kasauli in the year 1830 Many amino compounds were also found and it include [14]. Beer is an undistilled alcoholic beverage made from any compounds like Benzene-ethamine, Acrylothiamide, malted grain, but the most common source is malted barley. It Table 2 : Common compounds present in country liquor samples Sl.no Name of compound Country liquor DR DO RS TG 1 Propylene Glycol + - + + 2 1-2-Ethandiol,bis-o-{dimethyl(2-pent-2-yl) + - - - 3 Styramate + - - - 4 3-(N-Acetyl-N-Methylamino)propanoic acid + - - - 5 Butanoic acid,ethyl ester + - - - 6 1-Butanol-3-methyl acetate + - - - 7 1-2 hydrazine dicarboxamide + - - - 8 Ethanol 2-butoxy + - - - 9 Ethanol-2- phenoxy + + + + 10 Diethyl Phthalate + - + + 11 1-2-Benzenedicarboxylic acid bis (2-methyl p) + - + + 12 Benzyl alcohol - + + + 13 P-trimethylsilyloxypheny - + - + 14 l(trimethlsilyloxy)Anethole - - + + 15 Napthallene 2-methy - + - - 16 lN-fructose 1,3,4,5,6,Pentaacetate - + - - 17 Endosulfan - + - - 18 N-acetyl,N butyryl urea - - + - 19 Hydrazine carboximidothoic acid ethyl ester - - + - 20 1-Alanine,N –Butyryl- methyl ester - - - + 21 Alpha Terpineol - - - + 22 Nonanol - - + - 23 Propanenitrile,3-(mrthylamino)- - - + - 24 2,3-dihydro-2,2-dimethyl-1H-phenothiazin-4 - - - + 25 1,6-octadiene-3-ol,3,7,dimethyl - - - + (+) indicates present, and (-)indicates absent

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is manufactured in licensed breweries, and more than 60 components may be used for identifying brands of the brands of beer are available in the market. Hops is added to respective liquors. Results of this study will be useful in provide distinct bitter taste to beer. The alcohol percentage various forensic cases related to liquors. Ethanol 2-phenoxy varies from 2-8% v/v[15]. The compounds found in beer in this was present in all distilled alcoholic beverages. Benzyl present study were characteristic, and it could easily be alcohol and propylene glycol was found only in country made differentiated from IMFL and country liquor as it is liquors and could be used to discriminate the country made undistilled. liquors from the Indian made foreign liquors and illicit liquor. Common compounds present in country liquors: Table-2 Further studies are required in order to find out more gives the common compounds present in country liquor components which can provide better differentiation between samples. Diethyl Phthalate, Propylene Glycol, 1-2- the samples of alcoholic beverages. Benzenedicarboxylic acid bis (2-methyl-p) were found present Conflict of interest: The authors declare that there is no in all country liquor samples except in Dollar (DO). Similarly, conflict of interest. Ethanol-2- phenoxy and Benzyl alcohol were found present in Acknowledgement: The authors would like to thank Dr. R.M. all country liquor except Doaba Raspberry (DR). Benzyl Sharma, Professor in the Department of Forensic Science, alcohol has been reported to be present in ethnic agave Punjabi University Patiala for his valuable guidance. alcoholic beverages, and in 'Drenja' alcoholic beverage as a REFERENCES : minor volatile component[11,16]. On comparing the common compounds present in country liquor with IMFL brands as 1. Mittal BV, Desai AP, Khade KR. Methyl alcohol given in Table-3, Diethyl Phthalate, 1-2-Benzenedicarboxylic poisoning: an autopsy study of 28 cases. J. Postgrad. Med. acid bis (2-methyl-p), and Ethanol-2- phenoxy were also found 1991; 37: 9-13. present as common compounds in IMFL brands. Propylene 2. Tiwari SN. Laboratory manual on liquors and narcotics. glycol and Benzyl alcohol were found present in Vodka sample Government of India. 1984. (SV), but was absent in Whiskey samples in agreement with 3. Behera C, Jaiswal AK, Lalwani S, Bharadwaj DN, [17,18] the work of the referred authors . The results of this study Sharma R.K. Alcohol content in country made liquors: [19] were also compared with the work of Punia et al. 2017 , on Forensic consideration. Ind. Medica journals. 2007; 7: 1- analysis of illicit liquor in Punjab. Components such as 1- 7. propanol, 1-pentanol, 1-butanol, d-limonene, phenyl-ethyl 4. Negrusz A, Gaensslen RE. Toxicological investigations in alcohols, Anethole, Decanoic acid, Octanoic acid, and drug-facilitated sexual assault. Zagadnieñ Nauk Pentanoic acids which were reported to occur frequently in Sdowych. 2000; 41: 7-26. illicit liquor, (and which were used for characterizing illicit liquor) were also found present in the present study except d- 5. Kostik V, Memeti S, Bauer B. Gas-Chromatographic limonene. analysis of some volatile congeners in different types of strong alcoholic fruit spirits. Journal of Hygenic Past literature record has shown that alcohols can be Engineering and Design. 2008; 663: 543-44. characterized based on the specific components present only in that particular liquors. Thus propylene glycol and Benzyl 6. Luke NR, Jochen B, Dimitri G, Olaf HD. Alcohol alcohol were compounds present only in country liquor congener analysis and the source of alcohol: a review. besides Spark Vodka and so it can be used for characterizing Forensic Science, Medicine, and Pathology. 2013. DOI the country liquor. The present profile of components in 10.1007/s12024-013-9411-0. various types of liquor brands would help the law enforcement 7. Schultz K, Schlenz K, Metasch R, Malt S, Romhild W, agencies when any cases of illicit liquor, illegal trading and Dressler J. Determination of anethole in serum samples by transportation, tax evasion and various illegal activity such as headspace solid-phase microextraction-gas- adulteration is encountered. chromatography- massspectrometry for congener CONCLUSION : analysis. Journal of Chromatography. 2008; 1200: 235- 41. In the present study an attempt has been made to analyze and characterize the components of samples of IMFL and country 8. Ekka M, Aggarwal P. Toxic Alcohols. Journal of Mahatma made liquors collected from the state of Punjab. HS-GC-MS Gandhi Institute of Medical Sciences. 2015; 20: 38-45. proves to be a very sensitive technique in characterization of 9. Nand L, Chander S, Kashyap R, Gupta D, Jhobta A. alcoholic beverages. Many components of alcohol, acids, Methyl alcohol poisoning: A manifestation of typical esters, ketones and other compounds have been profiled. These toxicity and outcome. Journal of the Association of

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Physicians of India. 2014;62: 756-759. (Mangifera indica L) by GC - MS. Indian J Microbiol. 10. Kruse JA. Methanol poisoning. Intensive care Medical. 2010; 50(2): 183-191. 1992; 18:391-397. 22. Cordoba BV, Cordova AFG, Montoya MDCE. Tequila 11. Tesevic V, Nikicevic N, Jevic SM, Bajic D, Vajs V, volatile characterization and ethyl ester determination by Vuckovic I et al. Characterization of volatile compounds solid phase microextraction Gas Chromatography-Mass of 'Drenja', an alcoholic beverage obtained from the fruits Spectrometry analysis. Journal of Agricultural and Food of cornelian cherry. Journal of the Serbian Chemical Chemistry. 2004; 52: 5567-71. Society. 2009; 74(2): 117-28. 12. Shale K, Mukamugema J, Lues R.J, Venter P, Mokoena K. Characterization of selected volatile organic compounds in Rwandan indigenous beer 'Urwagwa' by dynamic headspace gas chromatography-Mass spectrometry. African Journal of Biotechnology. 2013; 12(20): 2990-96. 13. Garcia MS, Herrero C, Pena R.M, Barciela J. Solid-Phase microextraction gaschromatography-mass spectrometry (HS-SPME-GC-MS) determination of volatile compounds in orujo spirits: Multivariate chemometric characterization. Food Chemistry2010; 118: 456-61. 14. Mathur AK. Alcoholic beverages industry in India: an exploratory study. Eduved Global Management Research. 2014; 1 (1). 15. Sapsis D. Malts and Adjuncts. Beer Judge Certification Program. Fifth edition.2015.pp40. 16. Rodriguez ADL, Minakata PE, Garcia MIJ, Acevedo LOG, Flores JI, Ana P et al. Characterization of volatile compounds from Ethnic Agave alcoholic beverages by Gas Chromatography-Mass Spectoscometry.Food technol, Biotechnol. 2008; 46(4): 448-55. 17. Takeshi S, Brian H. Chenometric profiling of whiskey using the 5977A GC/MSD. Agilent Technologies.Inc. Printed in US 2013. 18. Wisniewska P, Namiesnic J, Wardinski W. Chemical composition analysis and authentication of whiskey. Journal of the science in food and agriculture. 2015; DOI.10.1002/ jsfa6960. 19. Punia BS, Yadav PK, Bumbrah GS, Sharma RM. Analysis of illicit liquor by Head Space- Gas Chromatography-Mass Spectrometry (HS-GC-MS): A preliminary study. Journal of AOAC international. 2017; 100 (1): 109-125. 20. Coldea TE, Socaciu C, Moldovan Z, Mudura E. Minor volatile compounds in traditional Home-made fruit brandies from Transylvania-Romania, as detected by GC- MS analysis. Notulae Botanicae Horti Agro botanici Cluj- Napoca. 2014; 42(2): 530-537. 21. Reddy LVA, Kumar YS, Reddy OVS. Analysis of volatile constituents of wine Produced from Indian mango

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Table 3 : Common compounds present in IMFL liquor samples Sl.no Name of compound IMFL brands RA JS SV B OC 1 1-Penatanol + - - - - 2 p-Trimethylsilyloxyphenyl-(trimethylsilyloxy + - - - - 3 Butylated Hydroxytoluene + - - - + 4 Ethanol-2-phenoxy- + + + - + 5 1,1,1,3,5,7,9,11,11,11-Decamethyl-5-(trimeth + - - - + 6 Diethyl phthalate + + + - - 7 Bis(tridecyl)phthalate + - - - - 8 Tetradecane + - - - - 9 Benzophenone + - + - - 10 Eicosane + - - - - 11 Pentadecanoic acid,ethyl ester + - - - - 12 3-Isoprppoxy-1,1,1,7,7,7,-hexamethyl 1-3,5-tr + + - - + 13 1,2-Benzenedicarboxylic acid, bis(2-methylp + + + - - 14 Hexane2,2,4-trimethyl - + - - - 15 Phosphonoacetic acid - + - - - 16 Carbamic acid,tricyclo{2.2.1.0(2,6)}hept-3 - + - - - 17 Pyridine,1-acetyl-5-(1-formyl-2-piperidinyl) - + - - - 18 Octanoic acid, ethyl ester - + - - - 19 Lochneridine - + - - - 20 Sarcosine,n-hexanoyl propyl ester - + - - - 21 4-acetamido-1-pentanol - + - - - 22 3-Epimacronine - + - - + 23 Isopentyl hexanoate - - - - - 24 dl-Alanyl-1-phenylalanine - - + - - 25 Ethanol-2-butoxy - - + - - 26 Dl-Cystine - - + - - 27 2-bromo-5-nitroanisol - - + - + 28 Murexide - - - - + 29 N,N-Diethyl-3-ethoxycarbonylmethyl amino - - - - + 30 Phenethylamine,N-hexyl - - - + 31 Boron Trihydro pyridine - - - - 32 Propylene Glycol - - + - 33 Benzyl alcohol - - + (+) indicates present, and (-)indicates absent

129 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00024.2 Original Research Paper Determination of Sex from Human Adult Sternum 1. Sajan Babu, Assistant Surgeon, General Hospital Adoor, Kerala 2. Vikram Palimar, Professor of Forensic Medicine and Toxicology* 3. Anitha Sivaji Rao, Associate Professor of Forensic Medicine and Toxicology* 4. Chandni Gupta, Associate Professor of Anatomy* 5. Vinod C Nayak, Professor and Head of Forensic Medicine and Toxicology* 6. Ashwini Kumar, Associate Professor of Forensic Medicine and Toxicology* 7. Shankar M Bakkannavar, Associate Professor of Forensic Medicine and Toxicology* 8. Nirmal Krishnan M, Assistant Professor of Forensic Medicine and Toxicology* *Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India. ABSTRACT : Background: Forensic Medicine is a growing medical field with many subareas. General public usually associate the subject with the dead and autopsies alone. Forensic Anthropology is the sub field in physical anthropology, especially for solving criminal cases by applying skeletal analysis. The present study was done to study, compare, analyze the sternal measurements among both sexes and evaluate the reliability of different parameters of the adult sternum to determine the sex of an individual. Materials and Methods: Present study was a prospective study done at Department of Forensic Medicine at Kasturba Medical College, Manipal during the period of 2015-2018 on 92 dead individuals belonging to the South India, whose age was more than 18 years. The study population comprised of 47 males and 45 females and statistical analysis was done. The following measurements were obtained, M1-Length of manubrium; M2-Length of mesosternum; M1+M2-Combined lengths of manubrium and mesosternum; MCI-Manubrio corpus index; W4-Width of the sternum at the level of the fourth rib. Results and Conclusion: All the parameters were observed to be statistically highly significant with a p<0.001. This study reinforces that sexing of human sternum is possible with reasonable accuracy with combinations of new parameters.

Corresponding Author : Article History: Dr. Vikram Palimar Received: 10 February 2019 Professor of Forensic Medicine and Toxicology, Received in revised form: 9 October 2019 Accepted on: 9 October 2019 Kasturba Medical College, Manipal, Manipal Academy of Available online: 31 December 2019 Higher Education, Manipal, Karnataka, India. Contact : +91 9886-40969 Email: [email protected]

KEYWORDS : Forensic anthropology, Human identification, sternum, sex determination, discriminant function analysis.

INTRODUCTION then identity becomes the first question to be answered. If there Forensic Anthropology helps in the determination of sex, are no other evidences to make sure of the identity, stature, age and ancestry in cases of mass disasters such as identification must be based on the primary characteristics of armed conflicts, terrorist massacres, airplane crashes, war sex, age, race and stature. Also situations are not uncommon related crimes, natural disasters, explosions, etc. when badly where the police have nothing to go by except the bones, either decomposed, mutilated or damaged human remains consisting in full or in fragments and then it is up to the Forensic surgeon of only a few bones or their fragments are recovered from the to try to give some direction to the investigation. Identity may site. The information so gained is of immense significance for prove to be vital in such situations and one will have to do realizing a solution towards the identity crisis, which is everything possible to establish a complete identity rather than admittedly, a giant step in the Forensic Investigation. a partial one. Identification is the right of a person from the womb to the The deduction of possible physiognomy along with the correct tomb. The first step of identification is making the biologic sex and most probable age will act as the magic key to any profile of an individual, where the basic requirement is sex. complex lock of identity. Sex is the fundamental category of the biologic profile. With the advent of modern techniques like DNA fingerprinting Recovery of an unknown body in full, in part or in the form of and digital superimposition one may get inclined to consider remnants is a day to-day affair in medico legal practice and ideas like stature estimations, race identification etc., as

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obsolete. But these modern techniques even though better in measurements of the sternum the sternum is placed back in the terms of high precision, are not that better in terms of cost and body. availability in many parts of the world. More importantly, these techniques require detailed ante mortem data for comparison and are more complex in nature. The value of each bone in the determination of sex is prioritized with maximum importance to the pelvis and the skull as per the textbook of Krogman. In this study, we are trying to correlate various measurements of sternum in determining the sex. Sternum is a flat bone located vertically within the median and anterior a part of pectoral Skelton. The study of bone as a single parameter for determination of sex has been tried by varied employees. RESULTS : MATERIALS AND METHOD : The various parameters used in the study are tabulated below Present study is a prospective study consisted of 92 human along with the actual range. Mean lengths of the various sterna: 45 females and 47 males, of the age of 18 to 65. The parameters along with the standard deviation for each specimens were taken from cases subjected to autopsy, at parameter, demarking point, calculated range and limiting Department of Forensic Medicine at Kasturba Medical point are listed in the Table 1. College, Manipal during the period of 2015-2018. Both of the sexes having more than 18 years were included, the bodies are DISCUSSION : opened up using a linear 'I' shaped standard midline incision. In the study conducted by Dwight1, it was noted that males had The acromioclavicular joint and clavicles are disarticulated. a mean manubrium length of 51.80 mm compared to females The sternal margins which articulate with the cartilages of the with a mean manubrium length of 46.70 mm. In the studies rib were carefully cut at the costosternal junction. The sternum conducted during the previous decade by Mahajan2et al & was removed from the thoracic cage. Margins and soft tissues Osunwoke3 et al it was noted that male sternums had a larger were cleared and the below mentioned parameters were manubrium length: 57.86 mm & 60.70 mm respectively measured using Vernier calipers. The sternum of those subjects compared to female sternums which had a manubrium length with Age less than 18 years, fractured sternum, Unidentified of 46.96 mm & 46.00 mm respectively. Recent studies on the sex group, Deformities of sternum were excluded from the sternum conducted by Puttabanthi4et al, revealed male study manubriums of length 47.48mm, compared to female 1) Manubrial length: length of manubrium measured from manubriums of length 21.68mm.The manubrium lengths the suprasternal notch/manubriosternal notch to ranged 40 mm-89 mm, for the males and 30 mm-69 mm for the manubrio-mesosternal junction[M1]. females in the studies conducted by Osunwoke3 et al. It is 2) Mesosternal Length: Length of mesosternum measured interesting to note that in none of the studies conducted till date from manubrium-mesosternum junction to mesosternum- the mean manubrium lengths of female sternum have exceeded xiphoid process junction[M2]. the mean manubrium lengths of male sternum. 3) Combined length: Manubrial length + mesosternal length[M1+M2]. WHETHER THE STUDY OBEYS HYRTL'S LAW? 4) Manubrio corpus Index : Length of Manubrium x 100 Hyrtls law is the relation between length of manubrium and Length of Mesosternum mesosternum. By Hyrtl's law, the ratio of length of the 5) Width of sternum at the level of fourth rib. manubrium and mesosternum is more than 1:2 for female and, and less in case of males. Three readings each were taken keeping the bone over a flat surface and reading was recorded with appropriate The results in the present study correlate to most of the studies instruments, then the average of the 3 results were recorded conducted by different researchers with 81% of female millimeter. The data base of measurements and indices are sternums obeying Hyrtl's law compared to 43% of male statistically analysed and conclusions drawn. After the sternums obeying Hyrtl's law.

131 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00024.2

Table 1: Table Showing Results Obtained: Range, Mean Length, Standard Deviation, Demarking Point, Calculated Range, Limiting Point.

Parameters Sex Range Mean Standard Demarking Calculated Limiting length Point Range point (mm) (mm) Deviation (mm) (mm) (mm)

MALE 46-54 50.73 1.943 >51.1 44.90-56.56 M1 48 FEMALE 41-50 44.30 2.268 <44.90 37.5-51.1

MALE 83-106 99.73 6.361 >107.69 80.65-118.81 M2 98 FEMALE 64-98 82.48 8.404 <80.65 57.27-107.69

MALE 129-158 150.46 7.933 >157.35 126.66-174.26 M1+M2 148 FEMALE 105-148 126.77 10.193 <126.66 96.19-157.35

MALE 48-58 50.99 2.357 <66.73 43.92-58.06 MCI 51 FEMALE 48-65 54.08 4.218 >43.92 41.43-66.73

MALE 44-54 51.09 2.155 >55.03 44.63-57.56 W4 48 FEMALE 42-53 45.11 3.308 <44.63 35.19-55.03

Application of Ashley's Rule of 149 And Rule of 136 to the mesosternum, 83.3% of male sterna and 100% of female sterna Present Study : could be sexed accurately. With the parameter, Ashley formulated the Rule of 149 on the European population manubriocorpus index/sternal index, 66.7% of male sterna and for the combined length (M1+M2) and stated that the 81.8 % of female sterna could be sexed correctly. The last th combined lengths of sternum measuring beyond 149 mm can parameter, width of the sternum at the level of 4 rib, reveals be said to be a male and those below 149 mm, a female. In the that 91.7 % of male sterna and 84.1% of female sterna could be present study it was observed that out of 92 sterna, 84 sterna sexed accurately. Among the five parameters included it was obeyed Ashley's rule of 149 accounting to 91.30%.Similarly, proven that the length of manubrium was the most reliable Ashley formulated the Rule of 136 on the African population parameter in determining the sex. Though multiple researchers for the combined length and stated that the combined lengths had worked on different parameters earlier, not much work was th of sternum measuring beyond 136 mm can be said to be a male done on the width of the sternum at the level of 4 rib, which and those below 136 mm, a female. In the present study it was showed a better result. Hence by including such a parameter in observed that out of 92 sterna, 78 sterna obeyed Ashley's rule the study, this study has explored the path for more such less of 136 accounting to 84%. known parameters and encourages us to include such parameters in future research works.The application of Hyrtl's SUMMARY AND CONCLUSION law to the study proved that 43% of male sterna and 82% of All the parameters were observed to be statistically highly female sterna obeyed Hyrtl's law. The application of Ashley's significant with a p<0.001. From the parameter, length of the rule of 149 and 136 were tried and it was noted that 91% and manubrium, 89.60% of male sterna and 90.90% of female 85% of sterna could be sexed accurately.Limitation of this sterna could be sexed accurately. Using the parameter, length study is in measurement of sternum which are not macerated, of the mesosternum, 79.2% of male sterna and 100% of female even though this study was performed by a single examiner sterna could be sexed accurately. error can happen while measuring sternum with soft tissues. In By using the combined length of the manubrium and cases where multiple observers are there, the sternum should

132 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00024.2

be properly macerated for reducing observer bias. (This paper was presented in 26th Annual Conference of K a r n a t a k a M e d i c o l e g a l S o c i e t y C o n f e re n c e KAMLSCON-2018 held at Kasturba Medical College, Manipal, MAHE on 2nd to 4th November 2018.) REFERENCES : 1. Dwight T.The sternum as an index of sex,height and age. Journal of Anatomy.1890;24:527-35 2. Mahajan A, Batra APS, Khurana BS, Sharma SR. Sex determination of Human sterna in North Indians.J Punjab Acad Forensic Med and Toxicology.2009;9(1):12-15 3. Osunwoke EA,Gwunireama IU, Orish CN, Ordu KS, EboweI. A.Study of sexual dimorphism of the human sternum in the southern Nigerian population. J.Appl.Biosci.2010:1636-39. 4. Puttabanthi S, Velichety SD, Padi TR, Boddeti RK, Priyanka R. Sexing of unknown adult human sterna by metric analysis. International Journal of Biological and Medical Research.2012;3(2):1516-19.

133 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00025.4 Original Research Paper Estimation of the Most Significant Foot Measurement in Determining the Stature of an Individual in Karnataka Population. 1. Nirmal Krishnan M, Assistant Professor, Department of Forensic Medicine* 2. Vinod C Nayak, Professor and Head, Department of Forensic Medicine* 3. Ashwini Kumar, Associate Professor, Department of Forensic Medicine* 4. Vikram Palimar, Professor,Department of Forensic Medicine* 5. Shankar M Bakkannavar, Associate Professor, Department of Forensic Medicine* 6. Anitha S, Associate Professor, Department of Forensic Medicine* 7. Chandni Gupta, Associate Professor,Department of Anatomy* *Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal

ABSTRACT: Identity is described as “the distinguishing character or personality of an individual” by Webster's dictionary. It is synonymous with individuality. An individual need to be identified every moment while living in a society as well as after death. The significance of establishing identity of an individual is of immense importance for the society. In case of mass disasters, air plane crashes or bomb blasts, the parts of human bodies get piled up resulting in the difficulty in identifying different parts belonging to each individual. Several studies have been conducted by different anthropologists to establish a relationship between the stature and different extremities, gender based differences, handedness and the stature. Here in the study we attempted to determine most significant measurement of the foot which can be used to determine the stature in Karnataka population in both the genders.

Corresponding Author : Article History: Dr Vikram Palimar Received: 27 February 2019 Professor, Received in revised form: 24 June 2019 Accepted on: 24 June 2019 Department of Forensic Medicine, Kasturba Medical College, Available online: 31 December 2019 Manipal, Manipal Academy of Higher Education, Manipal Contact : +91 9886340969 Email : [email protected]

KEYWORDS : Stature, Foot measurements.

INTRODUCTION: be used to determine the stature in Karnataka population in Establishment of the identity of a person is a major challenge both the genders. in the medico legal investigations. Identity of a person can be MATERIALS AND METHODS: determined with the help of various factors like age, gender, A cross sectional study was done in Manipal among a total of race, and stature. These four features are considered as the “big 110 individuals belonging to Karnataka population, out of four” parameters of identification in forensic anthropology. which 55 were males and 55 were females. The population The foot is protected inside shoes and other covered foot wears sample was obtained from the staff members of the Manipal in cases of fire, industrial accidents and mass disasters. Hence, University and the Department of Forensic Medicine and foot measurements has been used for determining the stature Toxicology, Manipal along with the general public (by by many workers. But even then not much have been explored standers of the patients admitted to Kasturba hospital, considering foot parameters to estimate stature till date. The Manipal). The data was collected between 11/01/2016 to review of literature indicates scarce of research in foot 14/05/2017 in Clinical Forensic Medicine Unit room, measurements for identification. Kasturba Hospital, Manipal. Even though various attempts has been made to determine the Inclusion criteria: stature from foot measurements, the most dependable variable 1) The age of the subjects were between 21 to 45 years. among the measurements kept varying based on the regional 2) Persons belonging to Karnataka state having parents and gender differences. Here in the study we attempted to hailing from Karnataka. determine most significant measurement of the foot which can

134 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00025.4

Exclusion criteria: back of the heel to the tip of the right fifth toe. 1) Subjects with skeletal and vertebral deformities and Rbab: The distance between the most prominent part of the any disease and fractures of the long bones. ball of the right great toe to the most prominent part of the ball 2) Subjects with congenital deformities, metabolic of the right little toe. disorders and developmental disorders. Rbah: The distance between the broadest part of the right heel. Written informed consent was taken from each individual prior LT1: The distance between the most prominent part of the to the collection of data. The whole procedure was explained to back of the heel to the tip of the left great toe. him / her in their own understandable language and LT2: The distance between the most prominent part of the opportunity was given to clear any doubts and all the questions back of the heel to the tip of the left second toe. were answered. LT3: The distance between the most prominent part of the Method for foot measurements: back of the heel to the tip of the left third toe. Measurements of the foot were taken separately for the left and LT4: The distance between the most prominent part of the the right foot. All the measurements were taken in the person back of the heel to the tip of the left fourth toe. standing on a white piece of paper with the heel of the foot LT5: The distance between the most prominent part of the placed at a distance of 10 cm between each other and the angle back of the heel to the tip of the left fifth toe. of 20 degrees to 40 degreeswas maintained between two feet 2. Lbab: The distance between the most prominent part of the Foot dimensions were measured separately in both the feet. ball of the left great toe to the most prominent part of the ball of Measurements were recorded under the following titles in the left little toe. millimeters. (Figure 1) Lbah: The distance between the broadest part of the left heel. RESULTS :

Correlation between height and different foot measurements in males.

Variable Correlation RT1 .674 RT2 .659 RT3 .666 RT4 .679 RT5 .707 Rbab .730 Rbah .440 LT1 .687 RT1: The distance between the most prominent part of the LT2 .673 back of the heel to the tip of the right great toe. RT2: The distance between the most prominent part of the LT3 .637 back of the heel to the tip of the right second toe. LT4 .664 RT3: The distance between the most prominent part of the LT5 .700 back of the heel to the tip of the right third toe. RT4: The distance between the most prominent part of the Lbab .716 back of the heel to the tip of the right fourth toe. Lbah .391 RT5: The distance between the most prominent part of the

135 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00025.4

Correlation between height and different foot measurements in measurements of both genders separately. The mean age of the males were 39 and mean age of females Variable Correlation were 32. Lower limit was fixed as 21 years based on the 1 RT1 .704 presumption that skeletal development completes by 21 years and the upper limit was taken as 45 years as age related changes RT2 .730 can manifest as early as 45 years3. RT3 .661 The male subjects exhibit greater dimensions than the female subjects, for foot and stature. Mean height in male was 1711.02 RT4 .614 mm with a standard deviation of 49.01 mm. the mean height in RT5 .511 females was 1550.18 mm with a standard deviation of 42.27 mm. The significant differences in stature and foot Rbab .342 measurements in males and females can be attributed to fact Rbah .353 that fusion of epiphyses of bones occurs earlier in girls and later in boys8. LT1 .683 In our study we considered female and male foot LT2 .691 measurements separately, and also considered the LT3 .665 measurements from the individual toes.A paired t test was performed to compare the measurements of the left and the LT4 .566 right foot and we found that there is statistically no major LT5 .457 differences between the measurements belonging to same person.( p value was <0.001). In the value of RT1-LT1 in Lbab .385 females (p value < 0.05 ) which is statistically significant. Lbah .356 Muktha rani and et al9 conducted a study in students belonging to various colleges in Delhi aged between 18 to 22 years which The Rbab values are the ones which shows maximum showed a significant difference in bilateral foot measurements correlation with the height in male foot measurements with a with left sided preponderence, which was contrary to our study. value of 0.730 and Lbah value was found to be 0.391 which In the study conducted in sub adult female population (N=149) was the least correlation. in North India aged between 13 to 18 years by Krishan10 et al In correlation with the height, Rbab showed maximum they discovered that there in significant difference between correlation and Lbah showed minimum correlation. right and left sided foot breadth but not in foot length. The correlation studies between the foot measurements and the Right foot showed better corelation with stature than that of left height showed a positive trend with every measurement foot measurements in both genders contrary to the showing significant correlation. RT2 showed maximum recommendation of the International agreement for paired correlation with height in females with value of 0.730 and measurements at Geneva [1912]11. Rbah showed minimum correlation of 0.353 Even in the works done by Krishan K et al left foot DISCUSSION: measurements were considered more relaibale than right foot This study was an attempt to estimation of stature from various measurements to estimate stature10. 4,5,6,7 foot measurements and derive a regression formula for In males the breadth of the foot (Rbab) at the toe end was Karnataka population. It was a cross sectional study, done showing maximum correlation with the height with a value of among random population in Karnataka including the 0.730 and in females maximum correlation was shown by foot university staff and the bystanders of the patients in Kasturba length from right second toe to heel (RT2) with a value of 0.730 Medical College, Manipal. A total number of 110 individuals itself. For males minimum corelation was with (Lbah) with a were studied among them 55 were males and 55 were females, value of 0.391 and females the minimum correlation was with which was considered to be adequate sample size as per the (Rbab) with a value of 0.342. statistician. Confirmation as to origin and belongingness to Muktha et. al found that the the foot length measurements give Karnataka were done beforehand to validate the study by a better prediction of the stature than the foot breadth minimizing geographic variation. Linear regression equations measurements9. and multiple regression equations were derived for various

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A similar study conducted by Sen.J among Rajbhansi 11. Curdy GGM. International Congress of Prehistoric populatuion in bengal showed that the foot length was a better Anthropology and Archeology, Geneva. American predictor of the stature than the foot breadth[12]. Anthropologist New Series. 14: 4 ; 1912, 621-31 Krishan K et.al, concluded Left foot length (LT1 = 0.661) and 12. Sen J, Ghosh S. Estimation of stature from foot length and the Right foot length (RT1= 0.581) showed good correlation foot breadth among Rajbhanshi: an indigenous population with the height. Among them LT1 showed maximum of North Bengal. Forensic Sci Int.2008;18(1-3):1-6 correlation. The higher correlation coefficient between stature and certain foot measurements over that of stature and other measurements being more accurate in estimating stature does not rule out the importance of all the measurements in stature estimation in medico legal cases as there may be situations when only a part of foot may be available for analysis, where only few dimensions can be measured. (This paper was presented in 26th Annual Conference of K a r n a t a k a M e d i c o l e g a l S o c i e t y C o n f e re n c e KAMLSCON-2018 held at Kasturba Medical College, Manipal, MAHE on 2nd to 4th November 2018.) REFERENCES: 1. Dolinak D, Matshes E, Emma O. Forensic Pathology: Principles and Practice ; Lew.587. 1 ed. 2. Schmidt S, Koch B, Schulz R, Reisinger W, Schmeling A. Studies in use of the Greulich–Pyle skeletal age method to assess criminal liability. Legal Medicine. 2008;10(4):190–195. 3. Galloway A. Estimating actual height in the older individual. Journal of Forensic Sciences 1988;33(1):126- 36. 4. Agnihotri AK. Estimation of stature by foot length. Journal of Forensic and Legal Medicine. 2007;14: 279-83. 5. Singh J P , Stature Estimation from the Dimensions of Foot in Females. Antrocom Online Journal of Anthropology. 2013;9(2):237-41. 6. Shukla RK. Stature estimation from footprint: A study on Central Indian population. Eur J Forensic Sci. 2017;14(2): 11-19. 7. Jee S C, Kwon S. Analysis of stature prediction from foot anthropometry: a South Korean case study. Australian Journal of Forensic Sciences.2017;49:9-21. 8. Shim KS. Pubertal growth and epiphyseal fusion. Ann Pediatr Endocrinol Metab. 2015;20(1):8-12. 9. Rani M. Stature estimates from foot measurements. J Punjab Acad Forensic Med Toxicol 2011;11(1):26-30 . 10. Krishan K, Estimation of stature from the foot and its segments in a sub-adult female population of North India. Journal of Foot and Ankle Research 2011, 4:24.

137 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00026.6 Original Research Paper Reinforcement of Medicolegal Knowledge of Interns to Reduce Common Medicolegal Errors.

1. Shilekh Mittal, Professor, 2. Ishwer Tayal, Assistant Professor, *Department of Forensic Medicine, Guru Gobind Singh Medical College, Faridkot

ABSTRACT : Introduction : The medicolegal duties like preparing injury certificates and PM reports, doing various medicolegal duties as MO, in field ar done by the Medical officers. These MOs committee multiple common errors while performing medicolegal duties, which leads to miscarriage of justice. The reinforcement of the medicolegal knowledge of interns can reduce common medicolegal errors done by MOs. Materials and Methods : This prospective, observational study was conducted on Interns of Guru Gobind Singh Medical College, Faridkot in the Department of Forensic Medicine after approval from Institutional Ethics Committee. The consent of the interns was taken beforehand. A Pre-test and Post-test questioner with structured open-ended questions were prepared to assess the medicolegal knowledge about the common medicolegal issues (there was no need for validation of questioner as the questions were of basic knowledge). The study begins after brief introduction, pre-test was taken to assess the medicolegal knowledge of the interns, followed by 1-hour lecture each day for a period of two weeks regarding medicolegal issues, along with this small group discussions were also done about common medicolegal issues. After the re-enforcement of knowledge delivered to interns, a post-test with structured open-ended questions to assess the knowledge gained by the interns was taken after the gap of 2 weeks of re-enforcement of medicolegal knowledge. The marks obtained by the interns in both the tests were compared, assessed and then analyzed statistically with the help of Microsoft Excel 2007 sheet. The P value was calculated by Wilcoxen signed rank test. The comparison between the mean and standard deviation of pre-test and post-test marks obtained from questioners of various topics. Results and Conclusions : The mean and standard deviation of marks of Pre-test and Post-test of various topics shows that there was significant increase in medicolegal knowledge. And 'p' valve was found to be highly significant among all the topics of the both the questioners. Forensic Medicine posting for Interns, which is at present optional, should be made compulsory. This program if implemented will provide the core for the development of a high quality of Medico-legal services.

Corresponding Author : Article History: Dr. Shilekh Mittal, Received: 28 June 2019 Professor, Received in revised form: 18 October 2019 Accepted on: 19 October 2019 Department of Forensic Medicine, Guru Gobind Singh Medical Available online: 31 December 2019 College, Faridkot-151203, Punjab, India Contact : +91-9814457445, 01639 251111 E-mail : [email protected], [email protected]

KEYWORDS : Reinforcement, Medicolegal Knowledge, Interns.

INTRODUCTION : medicine which deals with the application of the principles and Medical Jurisprudence, or, as it is sometimes called, Forensic, knowledge of medicine for the purpose of law, both civil and [1-2] Legal, or State Medicine may be defined to be that science criminal . which teaches the application of every branch of medical The public is now conscious about their legal rights as patient knowledge to the purpose of the law; hence its limits are, on the and judiciary system is passing negative remarks about one hand, the requirements of the law, and on the other, the doctors. The aim of medical institutions should be to provide whole range of medicine. Anatomy, Physiology, Medicine, interns and residents sufficient medicolegal training in Surgery, Chemistry, Physics and Botany lend their aid as addition to the subject taught in M.B.B.S. 2nd Prof, to refresh necessity arises; and in some cases all these branches of their knowledge because they are likely to forget after passing, science are required to enable a Court of Law to arrive at a most of the times without realizing its important role in future. proper conclusion on a contested question affecting life or Same situation exists for practical training of postmortem property. The word 'Forensic' is derived from the Latin word examination as there is no compulsory rotatory internship like forensis, meaning 'of the forum'. It denote the branch of in other subjects[3-4].

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Shortcomings in medicolegal examination in assault cases, negative impact on judicial proceedings. injury report preparation, preservation of stomach wash and MATERIALS AND METHODS: vomited material at the time of treating poisoning, and while After taking approval from the Institutional Ethics Committee giving opinion in courts has exposed doctors badly due to lack and consent from the participants, present study was of medicolegal knowledge. At the same time, gross violation of conducted in the Department of Forensic Medicine on 37 various guidelines by doctors while handling medicolegal MBBS interns of Guru Gobind Singh Medical College, cases is leading to miscarriage of justice[5-6]. The training period Faridkot. Pre-test and Post-test questionnaire was prepared ( is critical time for interns and postgraduates. During this Table 1) after discussions with the faculty of the department on period transition from student to physician takes place with common medicolegal errors committed by the Medical better understanding to learn medicolegal work[7-8]. For proper officers (MOs). There was no need for validation of training of medicolegal examination, the casualty must be questionnire as the questions were of basic knowledge. The attached to and supervised by the Forensic Medicine study began after brief introduction to the interns and pre-test department and posting of interns and postgraduates in was taken to assess the medicolegal knowledge of the interns, Forensic Medicine should be made compulsory[2]. It should be followed by 1-hour dedicated lecture along with small group realized by all doctors that they have to deal with medicolegal discussions, each day for a period of two weeks regarding cases throughout their carrier irrespective of the faculty they medicolegal issues.After the re-enforcement of knowledge , a choose. So, having knowledge about the subject is very post-test with structured open-ended questions to assess the important while working in hospital or in private clinic. Also, knowledge gained by the interns was taken. the medical ethics and various acts related to medical practice should be emphasized in the undergraduate and postgraduate The marks obtained by the interns in both the tests were levels[9-12]. compared, assessed and then analyzed statistically with the help of Microsoft Excel 2007 sheet. The P value was calculated Medico-legal cases constitute an important subset of patients by Wilcoxen signed rank test. seen in the Emergency. Accurate and comprehensive evaluation of medico-legal cases and preparation of a proper RESULTS : written forensic report is important for the protection of the Table No. 2 and Figure 1 shows the comparison between the rights and freedoms of persons suspected of involvement in the mean and standard deviation of pre-test and post-test marks crime. However, when evaluated in the emergency setting, obtained from questioners of various topics & shows insufficient knowledge regarding forensic medical issues significant increase in medicolegal knowledge. 'P' value was causes the problems in this process. As a result of these found to be highly significant among all the topics. problems, patients and their relatives may face legal Table No. 2 Comparison of Pre-Test and Post-test marks difficulties and physicians can be subject to criminal Topic Name of topics Pre-Test MarksPost-test Marks sanctions[13]. No Mean SD Mean SD Theoretical and Practical medicolegal training given to MBBS 1 Legal Procedures 2.59 0.798 5.49 0.607 students during the 2nd Professional year is not sufficient.As 2 Death 2.19 0.739 2.68 0.475 3 Ethics 1.16 0.442 1.68 0.475 per Graduate Medical Education regulations of Medical 4 Duties of doctor 0.38 0.492 1.00 0 Council of India, Internship in the subject of forensic medicine 5 Injuries 0.51 0.507 1.41 0.498 is optional. As per Medical council of India, postgraduate 6 Sexual Offences 0.38 0.492 1.00 0 graduate curriculum, medicolegal training to postgraduate 7 Law in relation to 0.38 0.492 1.00 0 students other than forensic medicine is not mandatory. Such doctor doctors when posted in the field and do medicolegal work, 8 Abortion/Infanticide 0.59 0.498 1.00 0 commit errors while preparing medicolegal reports which 9 Toxicology 0.62 0.492 1.38 0.492 creates confusion to law enforcing agencies and lead to 10 Asphyxia 0.59 0.498 1.00 0 miscarriage of justice and delays in judicial proceedings. Preferably Medicolegal reports be prepared by forensic DISCUSSION : medicine specialists, but due to lack of suffiecient trained The findings of present study were consistent with Mohite P M, personnel in this branch, most of the medicolegal work in et al on students and similar results with significant ‘P’ value actual practice is done by simple mbbs doctors or doctors of were observed. It is need of the hour to reframe the under other speciliaties. And as stated earlier these doctors commit graduate curriculum and introduce clinical posting for them in errors or prepare incomplete and inaccurate reports which have the subject of Forensic Medicine for making a competent

139 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00026.6

Table 1 : Pre Test and Post Test S No Topic Q. No Questions 1 Legal 1 What is the role of Doctor as a witness in the court? Procedures 2 In which cases the Magistrate inquest is conducted? 3 What are Summons? 4 What do you mean by Cross Examination? 5 When a witness is said to be Hostile witness? 6 How will you proceed if a patient under your care wishes to make dying declaration? 2 Death 7 Objectives and formalities of medicolegal autopsy? 8 What do you mean Post mortem staining and its medicolegal aspects? 9 Mention the early changes that occur after death? 3 Ethics 10 What is Informed consent? 11 What Is Res-Ipsa-Loqltur? 4 Duties of doctor 12 Describe in brief the various types of medical certificates and medico legal reports required to be issued by a doctor in medical practice? 5 Injuries 13 Enumerate all the clauses of grievous hurt? 14 What is Abrasion and different types of abrasions 6 Sexual Offences 15 Describe the unnatural sexual offences? What things will you preserve during examination of the victim? 7 Law in relation 16 What is PNDT Act? to doctor 8 Abortion 17 What is hydrostatic test? / Infanticide 9 Toxicology 18 Discuss general principles of treatment of acute poisoning? 19 What are the Contra indications & indications of Gastric lavage? 10 Asphyxia 20 Write in brief about Cafe coronary?

Figure 1: Comparison of mean of the marks obtained from contents of the medicolegal reports. These mistakes can be questioners of various topics. reduced considerably by giving high importance to under and post-graduate forensic medicine education. Periodic on-the- job training must be organized for creating a better awareness among doctors regarding their legal responsibilities.16 Medico- legal knowledge is very much essential for all doctors (in- service and private practice). Medico-legal work form a very important part of the duties of Medical Officers working in different Government Hospitals and other Institutions such as dispensaries, primary health centers etc. Since this work is a vital link in the dispensation of justice, it goes without saying that careful attention and promptness is quite essential in dealing with it. These errors lead to issuing misleading inappropriate reports and opinion which creates confusion in law enforcing agencies and medical graduates to handle the cases of Medico legal mischarge of justice which can be markedly reduced, If the importance.15 Another study by Serinken M et al, 2011, knowledge of medicolegal work is reinforced to the interns conducted on emergency doctors with aim to evaluate the before exposure of clinical practice. judicial reports that were prepared by them and found that the common medicolegal mistakes were made by assessing their OUTCOMES: WHAT THIS STUDY ADDS The table agenda was put before the general body meeting of

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Punjab Academy of Forensic Medicine at annual conference JIAFM. 2005; 27(4): 247-51. for recommendation from state academy of Forensic Medicine 3. Medical Council of India (Undergraduate medical to MCI/NMC for making internship in Forensic Medicine education) regulations, 1997. Compulsory, which was accepted, and representation will be 4. Medical Council of India (Postgraduate medical sent. education) regulations, 2000. LIMITATIONS: 5. Mittal S, Garg S, Singh M M. Need of Forensic Medicine in trauma care. Medico-Legal Update2007; 7 (3): 81-86. First limitation was small sample size. Only, interns were 6. Dash SK. Medical ethics, duties and medical negligence included in the study, more postgraduate students or MOs can awareness among the practitioners in a Teaching Medical be included. The study lacked the exploration of long-term College, Hospital-A survey. J Indian Acad Forensic Med. effects. Further this study is questionnaire-based study and 2010; 32 (2): 153-6. depends on the responses of the participants but when this 7. Khandekar I, Tirpude B, Murkey P, Pawar V. reinforcement of the medicolegal knowledge will have the Development of Clinical Forensic Medicine in India: A impact on the medicolegal report writing or while performing need of time. J Indian Acad Forensic Med. 2012; 32(1): various medicolegal duties by these doctors in future, the 85-90. actual results can be assessed. This study was conducted in 8. Mayeda M, Takase K. Need for enforcement of ethic only in one medical college and on limited number of interns. ledged Education an analysis of the survey of CONCLUSIONS : postgraduate clinical trainees. BMC Medical Ethics. The medico-legal work is comparatively of a specialized 2005; 6:8. nature. It should therefore be delegated to Medical Officers 9. Selvaraj K, Sivaprakas S P, Nelson SB, Kumar M. who have knowledge about it or who have been trained to do Perception of interns and postgraduates towards medical so. Since the quality of medico-legal work has its ethics education. Int J CurrMicrobiol App Sci. 2013; 2 (9): repercussions on law proceedings and since occasions where 198-203. strictures are passed by law courts on Medical Officers are not 10. Pratibha A. Mardikar, Arti A. Kasulkar. To Assess the uncommon, the distribution of medico-legal work in a hospital Need of Medicolegal Education in Interns and assumes significant importance. On the other hand, Postgraduates in Medical Institution. Journal of Evolution Government Medical Officers must accept that such work is an of Medical and Dental Sciences, 2015; 4(17): 2885-9. inescapable part of their duty. They should therefore strive to 11. Kokila Selvaraj, P. Sivaprakasam, B.T. Sudhir Ben achieve efficiency in this work. By reinforcement of Nelson, G.H. Midhun Kumar, Perception of interns and knowledge, I hope that under-and post-graduate training on the postgraduates towards Medical Ethics Education, medicolegal issues can be made better. Int.J.Curr.Microbiol.App.Sci(2013) 2(9): 198-203. ACKNOWLEDGEMENTS : 12. G Venkat Rao, N Hari. Medico-legal knowledge assessment of interns and post graduate students in a I acknowledge the faculty and postgraduates of Department of medical institution. IAIM, 2016; 3(10): 105-110. Forensic Medicine, Guru Gobind Singh Medical College, 13. Kotabagi RB, Pathak PR, Charati SC. Common Faridkot for sparing their valuable time for this project. Medicolegal Problems faced by Medical Officers of Without their support this project would not have been Armed Forces Medical Services. MJAFI, 2002; 58(3): feasible. I would also like to thank the Interns to participate in 234-40. this study and showing their enthusiasm to learn. I would like 14. Aktas N, Gulacti U, Lok U, Aydin I, Borta T, Celik M: to express my gratitude towards Mr. Baltej Singh, Assistant Characteristics of the Traumatic Forensic Cases Admitted Professor, Department of Community Medicine for providing to Emergency Department and Errors in the Forensic necessary support during the statistical analysis of the data Report Writing; Bull Emerg Trauma 2018;6(1):64-70. collected. 15. Prakash M Mohite, Anil J Anjankar, Tripti Srivastava, REFERENCES : Clinical Teaching in Forensic Medicine: Need of the 1. Mathiharan K, Patnaik A K . Modi's Medical Hour, J Indian Acad Forensic Med. 2015;37( 3):275-7 Jurisprudence and Toxicology. History of Forensic 16. Serinken M, Türkçüer İ, Acar K, Ozen M. Evaluation of rd Medicine. 23 ed. New Delhi: LexisNexis Butterworths medicolegal reports written by physicians in the India; 2005. p. 3-18. emergency unit with regard to deficiencies and mistakes. 2. Sharma BR, Harish D, Cavalli KH. Teaching, training and Ulus TravmaAcilCerrahiDerg. 2011;17(1):23-8. practice of Forensic Medicine in India. An overview.

141 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00035.7 Original Research Paper Study of Snake Bite and Factors Influencing Snake bite Among the Rural Population of Kancheepuram District 1. Vijay Kautilya D, Professor, Department of Forensic Medicine & Toxicology* 2. Shruti Prabhat Hegde, Associate Professor, Department of Ophthalmology* 3. Gururaghavendra, MBBS Student* *Shri Sathya Sai Medical College & Research Institute, Ammapettai, Chennai-603108

ABSTRACT: Introduction: India is an agricultural country, the majority of the population still lives in rural areas. The nature of work being agriculture, further increases the risk of snakebite among the rural population. This study attempts to evaluate the risk factors predisposing to snake bite and also to evaluate the awareness among the rural population about the precautions to be necessarily taken to reduce the risk of snake bite. Methodology: A cross-sectional interview based survey was carried out among the rural residents of Kancheepuram district over a period of four months. Data related to history of snake bite in the volunteer or the family member, sighting of snakes, site of the bite, season of the bite, place of the bite, housing, living conditions, house design, kitchen, bathroom, lighting in the house and the bathroom, sleeping habits and safety precautions were studied and are reported. Results: The study sample consisted of 184 households from Kancheepuram district. 71.2% of the subjects were farmers by occupation and 26. % of the subjects reported to have sustained snake or scorpion bites. 52.2% of the bites occurred at night and 43.5% of the bites were reported near their homes.A majority of the farmers had poor living conditions and 95.7% of them did not follow any precautions for snake bite. Conclusion: Simple measures like improving the working and living conditions among the rural populations can reduce the risk of snake bites. Awareness has to be generated among the people to change their habits as snake bit is certainly a preventable disease.

Corresponding Author : Article History: Dr. Vijay Kautilya D, Received: 3 April 2019 Professor, Received in revised form: 10 May 2019 Accepted on: 10 May 2019 Department of Forensic medicine & Toxicology, Available online: 31 December 2019 Shri Sathya Sai Medical College & Research Institute. Contact : +91 9094943338, 9448651848 Email : [email protected]

KEYWORDS : Snake bite, Risk factors, farmers, lifestyle modification.

INTRODUCTION: increases the risk of snakebite among the rural population.3 Snake bite has been a major problem of the rural community in The highest rates of bites were seen in the rural and agricultural India and around the world. The problem of snakebite is so areas and one of the most affected group of subjects were extensive that WHO has declared snakebite to be a neglected farmers in most of the studies. As reported by Ediriweera et. al. Tropical disease.1 Annually there are about 1,00,000 deaths snakebite incidence was significantly less among the non- due to snake bite and India alone contributes to nearly half the agricultural communities and snakebite incidence increased as deaths world wide.2 There are over 200 species of snakes the proportion of agricultural workers in a community 4 found in India and of these about 50 or more are venomous.3 increased. Adding to this problem is the fact that the factors influencing the risk of snakebite among the rural population India is an agricultural country, majority of the population still have not been effectively studied. live in rural areas. And snake bite is certainly a rural issue as the snakes are more commonly found in rural areas. This is In this study, we have attempted to understand the pattern of primarily due to the vegetation and climatic conditions which snakebite among the rural population of Kancheepuram favor dwelling of snakes. This puts the rural population district. This study attempts to evaluate the risk factors directly in the path of confrontation with the snakes.4 predisposing to snake bite and also to evaluate the awareness among the rural population about the precautions to be Low socioeconomic status, poor living conditions and necessarily taken to reduce the risk of snake bite. The data availability of facilities add to the disease burden in the collected in this study will help to design an effective action community. The nature of work being agriculture, further

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plan to reduce the morbidity and mortality associated with Pattern of Snake Bite among the subjects: snake bite by suggesting necessary precautions to prevent Among the study subjects it was noted that 26.1% (n=48) snake bite. reported to have sustained snake or scorpion bite at some point MATERIALS AND METHOD: in their life. Further, it was noted that 75% (n=138) had a A cross-sectional interview based survey was carried out family member or a friend who has had snake bite. 42% (n=78) among the rural residents of Kancheepuram district over a of the victims of snake bite were male and 32.6% (n=60) were period of four months. The one residents form every female. The place of snake bite was also probed and is depicted volunteering household was interviewed based on a face in Table 2. validated questionnaire. Institutional ethics committee Table 1: Distribution of subjects based on Occupation. clearance was taken before the onset of data collection and Occupation Frequency Percentage written informed consent was taken from the person volunteering for the interview. Cook 4 2.2% Coolie 10 5.4% The interview was conducted in the mother tongue of the volunteer and demographic data related to the sex, age, Driver 4 2.2% occupational history, educational status and work experience Electricians 1 0.5% was collected. During the interview, data related to the history Engineers 4 2.2% of snake bite in the volunteer or the family member, sighting of Farmers 131 71.2% snakes, site of the bite, season of the bite, place of the bite and Trained In Herbal 1 0.5% time of the bite were also collected. Medicine Further data related to the housing, living conditions, house design, kitchen, bathroom, lighting in the house and the Labours 8 4.4% bathroom, sleeping habits, etc. were noted. The volunteers Students 8 4.3% were also shown pictures of four common snakes (Common Teachers 4 2.2% Kait, Common Cobra, Russels viper, Saw Scaled viper and rat snake) for identification. Information related to the protective Table 2 : Distribution based on the place of snake bite measures for snake bite taken by the volunteers and knowledge Place of Bite Frequency Percentage about the first aid was also collected. Field 42 22.8% The Data thus collected was tabulated and statistically Home 80 43.5% analyzed using SPSS statistical software version 20. Pickwood 4 2.2% Descriptive statistics were analyzed and the data is being Others 12 6.5% presented in the forms of rates ratios and percentages. Not Applicable 46 25.0%

RESULTS: The bites were more common during the night, as 42.4% (n=78) reported the snake bite to happen after 6 pm. No The Study consisted of residents of 184 households of significant seasonal difference was noted as the subjects Kancheepuram District in Tamil Nadu. The Sample consisted reported 22.8% of the bites in summer, 20.7% of the bites in of 130 (70.7%) males and 54 (29.3%) females with the mean winter and 31.5% of the bites in rainy season. age of the subjects being 50 years. On an average they had been residing in Kancheepuram district for 30 Years. Half of the Further on inquiry about the site of bite, it was noted that 54.3% volunteers participating in the study belonged to lower (n=100) of the subjects sustained the bite on the foot and socioeconomic groups. The occupational distribution of the 20.7% of the subjects sustained the bite on the hand. As subjects is given in Table 1. reported by the subjects 71.7% (n=131) victims died immediately after the bite compared to 3.3% (n=6) who Even among the farmers, who formed a large part of the Study survived for more than an hour. 4.3% (n=8) also reported snake subjects, 51% (n=94) were farm laborers. 38% (n=70) of the bite in the cattle. Study subjects were illiterate and the rest of the subjects had some form of education ranging from primary schooling Housing Conditions and risk factors for snake bite: (38.9%) to graduation (15.2%). A majority of them, 52.2% Most of the study subjects being Socio-economically poor had (n=96) went to work between 8 am to 6 pm. compromised living conditions. Table 3 depicts the various housing condition of the subjects who participated in the study.

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Some of these are proven risk factors for the snake bite. subjects were employed in farming. Even among these more All the subjects reported to have frequent snake sighting near than 50% of the farmers were farm laborers and about 38% of their houses and Table 4 shows the place of common snake them had not attended any form of education. They have to sightings at home. work from 8 am to 6pm in the fields, thus spending a most of the day with the risk of snake bite. The subjects were also asked about certain precautions for outdoor work and living in order to prevent the risk of snake Table 4 : Place of snake sighting at home: bite. Table 5 depicts the safety precautions taken by the Area of sighting in the house Frequency Percentage subjects. Kitchen 20 10.4% DISCUSSION : Bathroom 34 18.5% Snake Bite is most certainly the problem of the rural living as Cattle Shed 12 6.6% most of the cases of snakebite are reported from the villages Other (courtyard, garden, footpath etc) 96 52.1% and suburbs of cities. This most probably is influenced by the fact that the snakes are more frequently found in rural areas due No Snake sighting Near Home 44 23.9% to the rich vegetation and congenial habitat for the snakes. Our study sample consisted of 184 subjects from rural households Table 5: Safety precautions taken by the subjects for snake bite. near Kancheepuram district. The majority of the study subjects Precautions taken from Frequency Percentage were male and about half belonged to low socioeconomic snake bite status group. This is a major risk factor for snake bite as Shoe 2 1.1% economic factors have a wide influence on the various other factors, like education, occupation, housing, and safety Glove 4 2.2% precautions etc. Torch After Dark 2 1.1% From the Table 1 it can be noted that more than 70% of the None of the above 176 95.7%

Table 3: Housing Conditions and risk factors for snake bite. Factors being Frequency distribution among various categories analyzed Housing Condition Thatched% (n) Concrete Housing% (n) 59.8% (110) 40.2% (74) Flooring Type Tiles Mud Flooring 42.4% (78) 57.6% (106) Cattle shed within Present Absent the house 35.9% (66) 64.1% (118) Window design Open Window Grilled Window No Window 37%(68) 51.1% (94) 12% (22) Lighting in the Well Lit Dark Rely only on artificial light house 59.8% (110) 2.2% (4) 38% (70) Sleeping habits in Sleep in Open yard On bed On the floor the house 15.2% (28) 33.7% (62) 51% (92) Kitchen Design Elevated Kitchen Floor Floor Kitchen 57.6% (106) 42.4% (78) Fuel used to cook Wood LPG Both wood & LPD 45.7% (84) 50% (92) 4.3% (8) Bathroom Present in the house Absent 58.7% (108) 41.3%(76) Light in the Present Absent Not applicable ( No Bathroom) Bathroom 57.6% (106) 1/1% (2) 41.3%(76)

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Considering the history of snake bite it is astonishing that 75% night. of the subjects had family members or friends bitten by snakes. In a study it was found that found that 20.44% of the victims th Nearly 1/4 the study subjects were themselves bitten by were bitten in the house,further 18.25% were bitten within the snakes. These findings show that there is a high prevalence of residence. The risk factor of being bitten by a snake was snake bite among the rural population in Kancheepuram. There walking along a farm or a ranch with masses of grass or was no significant difference between the male and females undergrowth during the night without self-prevention and bitten by snakes. This is similar to many other researchers who good caution.5 have also found a higher prevalence of snake bites among the Further from table no 4 it can be noted that most of the snake rural population.(2,3,5,6,7) However, some researchers have found sightings near the house was in the garden, footpath, courtyard, higher prevalence of snake bite among men compared to etc. All the subjects reported snake sightings near their homes. women.(2,8) Many studies have reported that the incidence of Considering the majority of the subjects who reported to sleep snake bite among males is twice as that of females.2 Edirweera on the floor, it is interesting to note that 15% also reported to et al also reported higher rates of snake bite in among the rural sleep outside the house every day. These practices further population, specially among the farmers and low increase the risk of snakebite among the rural subjects as socioeconomic groups.4 Bharadwaj et al reported that, most snakes are abundantly found in the vicinity of their homes. (75.3%) snakebites occurred while the person was cutting grass, working in the fields or walking in the hills.5 As can be noted from table no 5, only 1.1% of the subjects wore shoes, and 2.2% wore gloves during their work. Considering Further, it can be noted from this study that most of the bites the large agricultural background of the study subjects, this is (table no 2) occurred close to the home followed by the fields. alarming as the farmers are at constant risk for snake bite This suggested that the living conditions and habits might have during work in the fields. Only 1.1% of the subjects used an influence on human and snake encounters. Nearly half the torches when they walked out of the houses in the dark. This snake bites occurred after 6pm in the evening. The incidence of decreased visibility along with the high risk behavior certainly, the bite was slightly higher in the rainy season. Most contributes to the increases risk of snake bites among the rural researchers have reported diurnal variations in the bite. Krait population. Similar findings were reported in studies all over bites were more common during the night compared to cobra the world.(2,5,6,7,9) and viper bites which were common during the day.2 CONCLUSION: More than 50% of the victims sustained snake bite over the foot. And 2/3 of the victims died immediately. This suggests Snake bite is a major occupational and lifestyle hazard. And that there is a very narrow window available for effective this is endemic in rural areas in India. Low socioeconomic treatment. Further, considering that most of the bites are on the status, lack of awareness, poor living conditions, the nature of foot, it can be concluded that these bites are accidental in the work done and avoidance of safety precaution are the nature as most intentional bites or bites due to provocation are primary causes for snake and human encounters. Simple reported on the hand.9 Majority of the researchers reported that measures like improving the working and living conditions 60-80% of the bites were at the foot. Bites on other sites were among the rural populations can reduce the risk of snake bites. more common in night biting species.2 Clearing the vegetations near the houses, provision of street lights, torches and bathrooms can certainly reduce the risk of From table no 3 the living and housing conditions of the rural snake bite. Simple measures like wearing shoes can protect the population can be understood. Nearly than 2/3 of the subjects rural subjects from snake bite. Awareness has to be generated were living in thatched houses with 42% having mud flooring. among the people to change their habits as snake bit is certainly Though 59% had well lit houses 37% didn't have grills on the a preventable disease. window. These conditions provide easy access for the insects and snakes to enter. About 42% of the houses had floor kitchens Acknowledgements: None and 45% of them stored firewood in the house. This not only REFERENCES: provides a warm habitat by the firewood provides good cover 1. Pathak I, Metgud C. Knowledge, attitude and practice for the snakes to hide. Nearly 35% of the subjects also had regarding snakes and snake bite among rural adult of cattle sheds inside the house. Belagavi, Karnataka. International Journal Of 41% of the houses didn't have bathrooms and this would make Community Medicine And Public Health. 2017 Nov it necessary for the subjects to head out to the woods in the 23;4(12):4527-31. night for privacy. This is a major risk factor for snake bites as 2. Alirol E, Sharma SK, Bawaskar HS, Kuch U, Chappuis F. people usually wander into relatively poorly lit areas in the Snake bite in South Asia: a review. PLoS neglected

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tropical diseases. 2010 Jan 26;4(1):e603. 3. Butt KZ, Anwar F, Rizwan M. Snake bite; experience in a Filed Hospital. Professional Med J Jun 2010;17(2): 263- 268. 4. Ediriweera DS, Kasturiratne A, Pathmeswaran A, Gunawardena NK, Wijayawickrama BA, Jayamanne SF, Isbister GK, Dawson A, Giorgi E, Diggle PJ, Lalloo DG. Mapping the risk of snakebite in Sri Lanka-a national survey with geospatial analysis. PLoS neglected tropical diseases. 2016 Jul 8;10(7):e0004813. 5. Bhardwaj A, Sokhey J. Snake bites in the hills of north India. The National medical journal of India. 1998;11(6):264-5. 6. Dumavibhat B. A study of epidemiology, risk factors and preventive measures against snake bites. Journal of the Medical Association of Thailand= Chotmaihet thangphaet. 1997 Sep;80(9):547-56. 7. Harrison RA, Hargreaves A, Wagstaff SC, Faragher B, Lalloo DG. Snake envenoming: a disease of poverty. P LoS neglected tropical diseases. 2009 Dec 22;3(12):e569. 8. Looareesuwan S, Viravan C, Warrell DA. Factors contributing to fatal snake bite in the rural tropics: analysis of 46 cases in Thailand. Transactions of the Royal Society of Tropical Medicine and Hygiene. 1988 Nov 1;82(6):930-4. 9. Morandi N, Williams J. Snakebite injuries: contributing factors and intentionality of exposure. Wilderness & environmental medicine. 1997 Aug 1;8(3):152-5. 10. Suchithra N, Pappachan JM, Sujathan P. Snakebite envenoming in Kerala, South India: clinical profile and factors involved in adverse outcomes. Emergency Medicine Journal. 2008 Apr 1;25(4):200-4.

146 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00036.9 Original Research Paper Fatal Intentional Poisoning: A Five Year Retrospective Study of Autopsied Cases from Central Delhi 1. Amandeep Kaur, Associate Professor* 2. Monisha Pradhan, Associate Professor* *Department of Forensic Medicine, Maulana Azad Medical College, New Delhi.

ABSTRACT : Introduction : There are various means of suicide out of which intentional or deliberate poisoning is one of the leading. Materials and Method : The present study is a retrospective analysis of 203 cases of death resulting from suicidal consumption of poisons. The cases were autopsied in a 5 year period between 2014 to 2018. The cases represented 3.4 % of the total autopsies during that period. Data were analyzed with respect to age, sex, type of poison, place of incidence, survival period, cause of death, seasonal variation. Results and Conclusions : The poisoning deaths occurred most commonly in the age group 20 to 30 years (30.54%) with male predominance (60.09%). The cases presented in the Monsoon season most frequently. Deaths were mostly due to ingestion of pesticides i.e organophosphates and aluminium phosphide(14.28%) followed by corrosives (11.82%). 89.10% of the cases poisoning occurred in homes. Intention was known only in 9.85 % of the cases.

Corresponding Author : Article History: Dr. Monisha Pradhan, Received: 31 March 2019 Associate Professor Received in revised form: 1 April 2019 Accepted on: 1 April 2019 Department of Forensic Medicine, Maulana Azad Medical Available online: 31 December 2019 College, New Delhi Contact : +91 98996-82111 Email : [email protected]

KEYWORDS : Poison, Autopsy, Organophosphates, Corrosives

INTRODUCTION : aluminum phosphide tops the list of the commonest substance 6-8 Suicide ranks among the top three causes of mortality causing poisoning. Other compounds used for self poisoning worldwide. There are various means of suicide out of which other than household pesticides include common household intentional or deliberate poisoning is one of the leading means products like household cleaners, thermometer mercury, especially in agrarian countries. Self poisoning means naphthalene balls, antiseptics, kerosene, paint thinner, intentionally and often impulsively taking poisons or an camphor, silica gel, hair dye, nail polish remover, cosmetics, 9 overdose of drugs due to some dispute or psychological adhesives etc. This is in complete contrast to western data, disturbance. Poisoning as a means of suicide is more prevalent where the common poisons causing self poisoning were the in developing nations as compared to developed nations.1) over-the-counter (OTC) medications, alcohol and prescription Consumption of poison ranked second (27.9%) after hanging sedatives. Drugs like paracetamol, ibuprofen, fluoxetine, (45.6%) as a means of suicide followed by self immolation ethanol, quetiapine, paracetamol/opioid combinations, (7.2%) and drowning (5.4%) as per recent national data of sertraline and escitalopram etc were most commonly 10,11 2015. This shows a decrease in the ranking from first to second implicated for such poisonings in developed nations. position from the previous five year report.2 The methods used Epidemiological and toxicological data suggest that many of in developed countries include firearms, car exhaust these deaths might have been prevented if the use of pesticides asphyxiation.3 most toxic to humans was restricted, pesticides storage safety Various toxic compounds are used for this purpose which improved and accessibility reduced. Unfortunately, the varies from country to country and also within states and absence of will of authorities in implementing existent districts. It is well established that agrochemical poisons are regulations regarding the sale and purchase of toxic the leading substances causing self-poisoning which accounts compounds has failed to minimize and prevent such deaths in for about one-third of the world's suicides similar to the Indian this country. The banning of toxic compounds like pesticides data.4,5 In India, the seventies showed barbiturates and copper showed significant reduction in mortality and morbidity by 40 sulfate as the commonest poisons causing mortality, which in % in countries like Sri Lanka. This indicates that regulations the eighties was replaced by organophosphates. Presently are an effective means to curb such avoidable deaths. Also

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timely and quality treatment would help reduce the burden of Table 2 : Seasonal distribution of cases such deaths faced by the society. To seek further insight into Season No of cases %age this rampant health and social problem this study was Summer Season 59 29.06 undertaken. The current trends in a largely urbane district Rainy Season 63 31.03 would depict the actual scenario of self poisoning in such Winter Season 62 30.54 regions and the collected data is expected to help in analyzing Autumn Season 19 9.35 the problem for policy making in prevention of such avoidable Table 3 : Gender wise distribution of cases deaths in future. Gender No of cases %age MATERIALS AND METHODS : Male 122 60.09 The present study included all the cases of self poisoning Female 81 39.9 brought for medico legal autopsy to the Forensic Medicine Department of Maulana Azad Medical College, New Delhi The most common age group was 20-30 years (30.54%) which caters to the Central district of Delhi and includes deaths followed by 30 to 40 (22.66%) and thereafter a decreasing occurring in its associated hospitals and also referred from trend with increase in age was seen (Table 4). neighbouring districts and states. Retrospective five year data Table 4 : Age wise distribution of cases from the autopsy records were collected from 2014 to 2018. Age Group No of cases %age The information regarding manner of poisoning being 10-20 39 19.21 intentional was based on the history provided by the next of kin 21-30 62 30.54 which was the only criterion for inclusion. All other manners of 31-40 46 22.66 poisoning were excluded from the study. The information 41-50 34 16.7 regarding means of suicide, type of poison, time and place of 51-60 14 6.89 incidence, survival period, were gathered from the hospital 61-70 5 2.46 records and inquest papers. Seasons were classified as per the 71-80 3 1.47 Indian Meteorological Department (IMD) where winter included December to March, summer from April to June, The types of poisons reported were organophosphates and Monsoon or rainy season from July to September and autumn aluminium phosphide in same frequency (n=29 each), season from October to November. Collected data were followed by corrosives (n=24), toilet cleaners (n=13), analyzed using SPSS. prescription drugs (n=5), paint thinner (n=4), copper RESULTS : compounds (n=3), alcohol, kerosene, pyrethroids (n=2 each), hair remover, hair dye, organochlorine and glue (n=1 each). In Total 5918 cases were autopsied during the five year period. 86 cases the history of the type of poison consumed was not Suicidal deaths accounted for 649 cases (31.27%) of the of all. known. (Table 5) Of these, 203 cases were of self-poisoning (constituted 3.4%). The trend in poisoning cases showed a decline in consecutive years (Table 1). Table 5 : Distribution of cases in various types of poisons Type of poison No of cases %age Table 1 : Year wise distribution of suicidal poisoning cases Organophosphates 29 14.28 Year No of cases %age Aluminium Phosphide 29 14.28 2014 49 24.1 Corrosives 24 11.82 2015 47 23.1 Toilet cleaner 13 6.40 2016 40 19.7 Prescription Drugs 5 2.46 2017 41 20.1 Paint thinner 4 1.97 2018 26 12.80 Copper compounds 3 1.47 Total no of cases 203 Alcohol 2 0.98 Pyrethroids 2 0.98 The seasonal variation showed maximum cases of suicidal Kerosene 2 0.98 poisoning in the Monsoon season (31.03%) followed by winter Hair revemover 1 0.49 (30.54%), summer (29.06%) and the least frequency was Glue 1 0.49 reported in autumn season (9.35%). (Table 2) Hair dye 1 0.49 122 cases (60.09%) were males & 80 (39.9%) were females, Ocrganochlorines 1 0.49 showing male predominance (M: F = 1.5 : 1) (Table 3). Not known 86 42.36

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The place of occurrence was predominantly in homes (n=180) Table 9 : Alleged Precipitating event followed by workplace (n=3). 10 cases were in non domestic Alleged Pprecipitating event No of cases settings, which included custody (n=2), railway station (n=2) Domestic dispute 8 and community park (n=2). (Table 6) Viscera were preserved Psychiatric illness 5 in all the cases. However, the subsequent opinion after the Chronic illness 4 receipt of viscera were not analysed in this study. Custody 2 Table 6 : Place of incidence Poor school examination results 1 Place of incidence No of cases %age DISCUSSION : Home 180 89.10 In the present study, self poisoning constituted 3.4% of the Others 10 4.95 total autopsies in the centre. This is lower than other studies Workshop 3 1.4 3,15,16 Not Known 10 4.92 from the country and neighbouring states. This difference can be explained by the more urban nature of the population The time of survival i.e from consumption of poison till death, involved in this study versus the rural population of other in descending order of frequency was 1-6 hours (17.73%), 6- studies. Regions with rural background will have higher and 12 hours (14.77%), 12-48 h (12.80%), 3 days to 1 week easier accessibility to agrochemical poisons making it a more (11.33%), 1-2 weeks (10.34%), 2-4 weeks (2.95%), spot dead common means of suicide. (2.95%), less than 1 hour (1.47%). (Table 7) The self poisoning deaths accounted for 31.27% of the total Table 7 : Survival Period (from incidence till death) suicidal cases which is similar to the latest national data Survival time (hours) No of cases %age reported where poisoning ranked second to hanging.2 Spot dead 6 2.95 The slight male predominance seen in this study (1.5:1) is <1hr 3 1.47 similar to most studies by various authors from all over the 1-6 h 36 17.73 country where male to female ratio is almost equal. (3-15) Very 6-12 h 30 14.77 few national studies report a larger male predominance i.e 12-24 h 26 12.80 about 2:1.7,12 While suicide is said to be more prevalent in males 24-48 h 26 12.80 globally, the Indian data is contrary to this.18 The equal rate of 48-72 h 5 2.46 female suicides maybe be due to socio-cultural reasons 3 d -1 week 23 11.33 existing in this country like arranged marriage, dowry related 1-2 weeks 21 10.34 2-4 weeks 6 2.95 issues, patriarchy etc. Also as females resort to other means of Not Known 21 10.34 suicide more than poisoning like hanging and self immolation. The only study where self poisoning deaths were reported 17 The provisional cause of death was reported as pending more in female was from a study from Manipur. (n=176), perforation peritonitis (n=11), shock (n=8), sepsis The age group commonly involved in self poisoning deaths in (n=5), aspiration pneumonitis (n=3). (Table 8). this study were between the second and third decade maximum Table 8 : Cause of death being between 20-30 years (30.54%) followed by 30 to 40 Cause of death No of cases %age years (22.66%). This observation was similar to most studies Pending (awaiting reports) 176 86.69 from the country. The minimum age was 12 years and Perforation peritonitis 11 5.44 maximum was 78 years. The age group shows a younger Shock 8 3.96 population being involved in suicide which is similar to the Sepsis 5 2.47 trend which is currently present in the world. However, the Aspiration pneumonitis 3 1.48 global data shows the next peak in the elderly group above 60 years, which is contrasting to this study and most studies from The motive for committing suicide was documented in only 20 India. 18 This can be explained by the majority of population of cases (9.85%) out of which domestic dispute with spouse India being in the young adult group. It could also imply the accounted for 8 cases, mental illness viz. depression in 5 cases, growing impulsiveness of young adults while dealing with chronic illness in 4 cases, self poisoning in custody in 2 cases, 1 pressures of modern day lifestyle. case of bad examination result. (Table 9) The types of poisons reported showed equal propensity to organophosphates and aluminium phosphide (14.28% each). This is similar to other studies from other parts of the country

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where the same toxic compounds are the leading cause of self lives of such patients. Expedition of transport of patients and poisoning.3-9,12-14Though studies from southern and western part early emergency treatment of such patients is the need of the of thecountry report organophsphates as the dominant hour. Facilities and infrastructure need to be upgraded in order compound19-210, Northern Indian studies reports aluminium to tackle this medical emergency. phosphide as the leading culprit responsible for such The cause of death was reported as pending in 86.69 % of the 2 2 , 2 3 deaths. A study from Chandigarh reports that cases as chemical anlysis report was awaited. In only 13.30% organophosphates was the most common poison between 1977 cases cause of death was definitely ascertained to be due to and 1982 while aluminum phosphide became the commonest complication of poisoning. The definite cause of deaths were 6 poison since 1982. Organophosphates was relatively seen perforation peritonitis, shock, sepsis and aspiration more in males and phosphides were seen more in females as pneumonitis. (Table 8) Definitive cause of death opined after 12 per one study. autopsy could not be found in the literature. One study showed Corrosives was the third leading cause of poisoning in this that in poisoning cases of suspected poisoning in only 15 cases study (11.82%) and lagged behind organophosphates and poison was detected out of 108 cases studied.27 This phosphides by a very close margin. This observation is unique observation is highly important for conclusion of the cases. In to this study. Corrosives as one of the larger contributor of self the authors experience too, viscera reports are many times poisoning is not reported frequently. The National Poison negative even in a well documented clinically diagnosed case Information Center (NPIC), AIIMS reports household of poisoning. In such cases ultimately the clinical records and cleaners as the second leading cause of poisoning after autopsy findings have to be relied upon for ascertaining the pesticides.9 Though the manner of death is not specified in this cause of death through exclusion. However, unfortunately report. Recent change in laws have laid down stricter most such cases ultimately are categorized as 'uncertain” cause regulations in place regarding sale and purchase of corrosives. of death even after all investigations. However, the presence of corrosives in household products The precipitating factors for commission of suicide was most like commonly used toilet cleaners will make such fatalities commonly domestic dispute followed by mental illness and impossible to prevent. Toilet cleaners contain hydrochloric chronic illness which is similar to other national studies.26,28 acid, citric acid, sodium hypochlorite, sodium hydroxide etc in CONCLUSION : various combinations, therefore will cause corrosive effects. Other poisons used for suicide in this study were prescription Intentional poisoning is a highly fatal emergency condition drugs, paint thinner, copper compounds, alcohol, kerosene, which results in inevitable mortality and morbidity. It is a pyrethroids,hair remover,hair dye, organochlorine and glue. problematic health and social issue in the Indian subcontinent The incidence of these poisons are similar to that reported by which urgently needs to be addressed. To curb this problem NPIC.9 many factors have to be considered and improved upon. The areas that need to be improved by health authorities are better The place of occurrence was predominantly homes of the transport facilities, availability of high quality emergency deceased and negligible instances of poisoning in outdoor medicine services in all places, timely diagnosis of the type of spaces was seen. This observation is similar to other studies poison and treatment. Preventive measures, however, will be where home was the most common place for committing more effective in minimizing this issue. Stricter regulations for suicide.24-26 Only one study reported maximum suicidal deaths prevention of sale and purchase of poisonous substances will in the workplace.6 have to be placed. Though there are existing laws in this regard, The time of survival i.e from consumption of poison till death, they have to be well implemented by every State. This article in descending order of frequency was 1-6 hours (17.73%), 6- aims to apprise the State governing authorities about the 12 hours (14.77%), 12-48 h (12.80%), 3 days to 1 week current trends of intentional poisoning and its health and social (11.33%), 1-2 weeks (10.34%), 2-4 weeks (2.95%), spot dead impact for future policies regarding poisons. (2.95%), less than 1 hour (1.47%). This observation depicts the REFERENCES : fatality of the poisons consumed which caused maximum deaths within 1-6 hours of consumption of poison. Most deaths 1. Modi. A Textbook of Medical Jurisprudence and occurred within 2 days of the poisoning. It is well known that Toxicology.2012, Lexis Nexis Butterworths Wadhwa, all the drugs listed in this study are fatal and highly toxic 24th Edition. compounds causing immediate fatality especially phosphides 2. National Crime Records Bureau, 2015. 1 and organophosphates. This shows that the medical and 3. Singh B, Kishore K, Chaudhary K. Epidemiological surgical treatment needs to be as early as possible to save the Profile of Complete Suicidal Poisoning Cases Autopsied

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at Autopsy Centre, RIMS, Ranchi. International Journal 16. Dhattarawl SK, Singh H. Profile of deaths due to of Medical Toxicology and Forensic Medicine. 2017;7(1): poisoning in Rohtak, Haryana. J Forensic Med Toxicol. 32-42. 2001;18:28-9. 4. Bhowmick K, Ghosh B, Pain S.A Study on Deliberately 17. Taruni NG, Bijoy TH, Moomonchand. A. profile of Self-Poisoned In-Hospital Patients in a Tertiary Health poisoning cases admitted in RIMS hospital, India. J Care Center in Northeast India: A Cross-Sectional Forensic Med. Toxicol. 2001;18:31-3. Review.J Emerg Med. 2019;56(5):512-18. 18. R. Radhakrishnan, A Chittaranjan. Suicide: An Indian 5. Mahender G, Brethis, Damodar G, Kumar L, Ananda YP. Perspective, Indian J Psychiatry, 2010 Oct-Dec; Study of the Pattern of Deaths Due to Suicidal Poisoning 54(4):304-319. at R I M S Kadapa, A P.Medico-Legal Update, 19. Kumar TS, kancha T, Yuganarasimha K, Kumar GP. 2018;18(2):38-42. Profiloe of Unnatural deaths in Manipal, Southern India 6. Singh D1, Jit I, Tyagi S.Changing trends in acute 1994-2004. J clin Forensic Med, 2006;13 (3):117-20. poisoning in Chandigarh zone: a 25-year autopsy 20. Sahin HA, Sahin I, Arabaci F. Sociodemographic factors experience from a tertiary care hospital in northern India. in organophosphate poisoning; a prospective study. Hum Am J Forensic Med Pathol. 1999;20(2):203-10. Exp Toxicol.2003;22 (7):349-53 7. Gargi J, Rai H, Chanana A, Rai G, Sharma G, Bagga IJ. 21. Sharma BR, Harish D, Sharma V. Poisoning in Northern Current trend of poisoning--a hospital profile.Indian Med India: changings trends, causes and prevention there of. Assoc. 2006;104(2):72-3 Med Sci Law. 2002;42(3):251-7 8. Heethal JN, Saralaa PN, Venkatarathnammab TNK. 22. Singh S, Wig N, Chaudhary D, Sood N, Sharma B. Different types of poisoning in a tertiary care hospital in Changing pattern of acute poisoning in adults: experience rural south india Food and chemical toxicology. of a large North West India hospital (1970-1989). J Assoc 2011;49(1):248-250. Physicians India. 1997;45(3):194-7. 9. Peshin SS, Gupta YK. Poisoning due to household 23. Singh B, Sinha A, Dogra TC. Present status of poisoning products: A ten years retrospective analysis of telephone in India. Indian Medical Gazette. 1998; CXXX (II):364- calls to the National Poisons Information Centre, All India 8. Institute of Medical Sciences, New Delhi, India.J 24. Bhatia MS, Verma SK, Murty OP. Suicide notes: Forensic Leg Med. 2018;58:205-211. Psychological and clinical profile. Int J Psychiatry 10. Kang AM. Substances Involved in Suicidal Poisonings in Med.2006;36:163-70. the United States. Suicide Life Threat Behav. 2018 Nov 25. Mohanty S, Sahu G, Mohanty Mk, Patnaik M. Suicide in 15.1,2,3. India.: A four year retrospective study. J forensic leg 11. Cairns R, Karanges EA, Wong A, Brown JA, Robinson J, med.2007;14:185-9. Pearson SA et al. Trends in self-poisoning and 26. Ponnudurai R, Patnaik KA, Sathianathan R, Subhan KA. psychotropic drug use in people aged 5-19 years: a study on the venues of suicide. Indian J Psychiatry. population-based retrospective cohort study in 1997;39:34-6. Australia.BMJ Open. 2019 Feb 20;9(2). 27. Sobhan KD. Role of Chemical Examination in Formation 12. Kanchan T, Menezes RG. Suicidal poisoning in Southern of Opinion as to Cause of Death. JIAFM, 2007;29(1):28- India: gender differences.J Forensic Leg Med. 2008 31. Jan;15(1):7-14. 28. Dandona R, Bertozzi-Villa A, Kumar GA, Dandona L. 13. Kanchan T, Menezes RG, Kumar TS, Bakkannavar SM, Lessons from a decade of suicide surveillance in India: Bukelo MJ, Sharma PS et al. Toxico epidemiology of fatal who, why and how?Int J Epidemiol. 2017;46(3):983-993. poisonings in Southern India.J Forensic Leg Med. 2010 Aug;17(6):344-7 14. Guntheti BK, Singh UP. The Pattern of Poisoning in Khammam J Indian Acad Forensic Med. 2011; 33(4):296- 300. 15. Aggarwal NK, Aggarwal BBL. Trends of poisoning in Delhi. J Indian Acad Forensic Med, 1998; 20:32-36.

151 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00037.0 Original Research Paper Knowledge and Perception regarding Child Sexual Abuse and POCSO Act among Medical Students in Bareilly. 1. Jaswinder Singh, Associate Professor, Department of Forensic Medicine*, 2. Vijay Kumar, Assistant Professor, Department of Forensic Medicine*, 3. Somshekhar Sharma, Assistant Professor, Professor, Department of Forensic Medicine, Dr. D.Y.Patil Medical College, Navi Mumbai *Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly. U.P.

ABSTRACT : The study aims to ascertain the level of knowledge and perception of medical students in first, second and third year of MBBS course in Bareilly. The students reported high level of knowledge regarding child sexual abuse and its deleterious impact on society, however a third of the respondents were unable to give correct responses regarding the legal aspects and preventive measures as well as reporting of such crimes.

Corresponding Author : Article History: Dr. Vijay Kumar, Received: 21 February 2019 Assistant Professor, Department of Forensic Medicine, Shri Received in revised form: 12 April 2019 Accepted on: 12 April 2019 Ram Murti Smarak Institute of Medical Sciences, Bareilly. U.P. Available online: 31 December 2019 Contact : +91 94587-02246 Email : [email protected]

KEYWORDS : CHILD SEXUAL ABUSE, Medical Students, POCSO

INTRODUCTION: questionnaire based study conducted among 200 students of Violence against children, especially Child Sexual Abuse first, second and third years of M.B.B.S course, studying at (CSA), is one of India's most grave and disconcerting Shri Ram Murti Smarak Institute of Medical Sciences, challenges. Despite several efforts including legislations and Bareilly, U.P. over a period of 4 months from November 2017 legal provisions formulated and implemented to control this to February 2018. The students were given instruction on abhorrent crime, CSA remains widespread across the maintaining anonymity and providing honest responses prior country.(1) It is well-established that positive change to address to the study. The study was completely voluntary in nature and any sociological or developmental challenge cannot ride on no compulsion was shown in participation. The students were such systemic and procedural tools alone, and preventing or given copies of the questionnaire and were instructed to submit eliminating CSA is no exception. Human knowledge and to their respective class representatives within 7 days, who perceptions are as critical and significant as legal provisions in would then submit it to the investigators. Institutional ethical curbing or ending CSA. In fact, these perceptions often approval was obtained prior to commencement of the study. become so entrenched in communities as human behaviour Incompletely filled questionnaires and those bearing any that they can seriously hinder progress towards reducing and identification apart from class and gender were excluded from eliminating CSA. Furthermore, perceptions and knowledge the study. levels among youth are even more important. This is because OBSERVATIONS: young adults can help accelerate any transformational The total number of young adults who participated in the (2) agenda. The medical curriculum provides for a detailed study present study was 200, of which 116 (58% of the total on sexual violence from a medicolegal stand point but actual respondents) were females and 84 (42% of the total awareness levels may not be adequately flourishing in respondents) were males. The average age of the responders educated medical students. The present study aims to ascertain was 21.5 years, with minimum age of 20 years and maximum the level of knowledge among medical students in Bareilly, of 23 years. Uttar Pradesh regarding child sexual abuse as well ascertain During study, respondents were asked whether they are aware the prevalence of false perceptions. of various forms of sexual abuse towards children (CSA). The MATERIALS AND METHOD : majority of respondents (n=188, 94%) showed overall The present study is a cross sectional observational awareness as related to CSA. The level of awareness was

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higher among females (n=112, 97%) as compared to their clarity of legislation among professionals (medical officers and males (n=76, 91%) in the present study group. 98% of the total police), and general lack of professional support for victims of responders agreed that the issue of child sexual abuse in India CSA create potential problems for implementation in the is a serious or very serious issue, while 2 % individuals stated Indian context(5). that the issue is not serious. In terms of what constitutes child The present study shows that majority of respondents agreed sexual abuse, majority of the responders agreed on forms such that CSA is a criminal offence that has serious implications in as Rape, Sodomy, Touching or Fondling of private parts, the legal framework of the country, which is in accordance by a undressing etc however 42% (n=84) felt passing inappropriate variety of studies in India and abroad that showed similar comments, staring etc do not constitute child sexual abuse. The levels of awareness(1,6,7). above included 21 males and 63 females (25% and 54%). Though individuals are aware of the names and in majority In regards to knowledge regarding tackling or management of about the broad outlines of legalities of CSA, almost a third of cases of CSA, 94% respondents replied that they are aware of the respondents fail to understand and recall the specific POCSO Act and that CSA is a criminally punishable offence. punishments, and procedures for care and prevention of further However 38% (n=76) of the total respondents were unaware of victimization of the survivors of CSA. This is in accordance the helpline number for reporting such crimes. The source of with studies that state that a lack of awareness among health information for above was cited as Teachers by 44% (n=88) care providers, family members etc can lead to unreported respondents, Internet and social media by 40% (n=80), the rest cases of child sexual abuse(8,9). varied between Newspapers, posters and public service The issue of CSA is still a taboo in India. In India, majority of announcements. the people remain numb about this issue. It is reported that On specific clauses of POCSO act, 36% (n=72) respondents silence is due to the fear of indignity, denial from the reported that POCSO is not a gender neutral act in terms of the community, social stigma, not being able to trust government victim, while 17% (n=34) were not sure. Among the above 36 bodies, and gap in communication between parents and % respondents, 54 were males and 18 females. Regarding children about this issue.Majority of the healthcare investigative and court proceedings, 32 % (n=64) made professionals do not have the abilities and are not trained to incorrect replies. 28 % respondents did not know whether the examine and manage cases of CSA. A chief concern in India is identity of the victim is revealed in cases of sexual assault of the dearth of good monitoring of various juvenile residential not. 45% (n=90) respondents were unaware that provisions for institutes and there is no punishment for institutes that do not in camera proceedings exist. follow the laws(7,10). In summary, it was found that though majority of students CONCLUSION: agreed that CSA is a serious issue in the country and that it is a The prevalence of CSA is alarming; hence, stringent measures criminal offence with laws to prosecute the criminals, the should be taken for its prevention and control. Doctors are students still needed further awareness in the legalities and generally the first point contact of a child and must be aware of nuances involved. the signs, symptoms and management (physical and DISCUSSION: psychological) of a victim of CSA. Possesing adequate The reviewed literature estimates that 4–41% of the girls and knowledge and developing a caring attitude towards victims of 10–55% of the boys in school and college have experienced CSA is a mandatory part of medical training and must be one form (contact, non-contact, forced) of CSA in India. The imparted in specific modules with urgent focus. The study is prevalence figures are much higher among commercial sex limited by its small sample size and inadequate random workers, street adolescents and children, children working as sampling. Further studies are needed to ascertain the domestic laborers, MSMs (Men who have sex with men) and comparibility of our results. women with mental health problems. In addition to Conflict of Interest : Nil highlighting the high frequency of occurrence, a variety of Source of Funding : Self Funded. studies highlighted the ecological determinants of CSA experience and perpetration along with adverse impact of CSA REFERENCES: on social functioning, behavioral issues, mental health, and 1. Carson DK, Foster JM, Tripathi N. Child sexual physical health.(2,3) As per the NCRB statistics for 2015, the abuse in India: current issues and research. legislative framework in India- The POCSO Act, 2012 has Psychological Studies. 2013;58(3):318-25. (4) resulted in increased reporting of CSA . However, the issues 2. Child-Sexual-Abuse-Awareness-and-Perception- related to mandatory reporting of the CSA incidents, lack of

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Among-Young-Adults-in-India.pdf accessed from https://satyarthi.org.in/assets/pdf. On 20th Nov 2017. 3. Choudhry V, Dayal R, Pillai D, Kalokhe AS, Beier K, Patel V. Child sexual abuse in India: A systematic review. PLoS ONE. 2018;13(10). 4. Belur J, Singh BB. Child sexual abuse and the law in India: a commentary. Crime Science. 2015 Dec;4(1):26. 5. National Crime Records Bureau, 2015. Crime in India. 6. Maniglio R. The impact of child sexual abuse on health: A systematic review of reviews. Clinical psychology review. 2009 Nov 1;29(7):647-57. 7. S i n g h M M , P a r s e k a r S S , N a i r S N . A n epidemiological overview of child sexual abuse. Journal of family medicine and primary care. 2014 Oct;3(4):430. 8. KackerLoveleen, VardanSrinivas, Kumar P. Study on Child Abuse: India 2007. Ministry of Women and Child Development, Government of India, 2007. 9. Charak R, Koot HM. Abuse and neglect in adolescents of Jammu, India: The role of gender, family structure, and parental education. Journal of anxiety disorders. 2014 ;28(6):590-8. 10. Behere PB, Rao TS, Mulmule AN. Sexual abuse in women with special reference to children: Barriers, boundaries and beyond. Indian journal of psychiatry. 2013 Oct;55(4):316.

154 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00038.2 Original Research Paper Awareness And Knowledge of Medical Students Regarding Surrogacy

1. Prasad Bhatanglikar, Assistant Professor, Department of Forensic Medicine, Dr. D.Y. Patil Medical College, Navi Mumbai, 2. Manu D Sharma, Assistant Professor, Department of Forensic Medicine, Government Medical College, Gondia, Maharashtra. ABSTRACT: Introduction : As the population is becoming more aware regarding the doctor-patient relationship, it has become imperative that the clinician becomes more aware as well. Surrogacy is a procedure being increasingly used by childless couples, and it involves a direct relationship between the doctor and the biological as well as intending parents. Materials and Method : The present study was conducted to assess the knowledge and attitude of medical students regarding surrogacy and its legal aspects. Results and Conclusions : The study revealed that though the students are well aware of the science and principles behind surrogacy, there exists a lacunae as far as the knowledge of its legal framework and guidelines are concerned.

Corresponding Author : Article History: Dr. Manu D Sharma, Received: 7 March 2019 Assistant Professor, Received in revised form: 24 June 2019 Accepted on: 24 June 2019 Department of Forensic Medicine, Government Medical Available online: 31 December 2019 College, Gondia, Maharashtra. Contact : +91 Email : [email protected]

KEYWORDS : Knowledge, Medical Students, Surrogacy,

INTRODUCTION: Navi Mumbai, Maharashtra. Surrogacy is an arrangement, often supported by a legal MATERIALS AND METHOD : agreement, whereby a woman agrees to become pregnant, Undergraduate students were recruited from a medical college carry the pregnancy to due term, and give birth to a child or in Navi Mumbai, Maharshtra during four month period of children, all of this for another person or persons, who are or September-December 2018. They were asked to complete and (1) will ultimately become the parent(s) of the child or children. submit a completed multiple choice questionnaire (Table 1), Recently Indian legislators passed a bill in the lower house of without name or number, mentioning only their gender and age Parliament which made some drastic changes to the prevalent in years and months. Ethics approval was granted by the scenario in surrogacy in India. Commercial surrogacy, which institutional ethics review board. A sample of 68 males (mean was defined as commercialization of surrogacy services or age 20.4 years) and 82 females (mean age 21.6 years), procedures or its component services or component participated in this study. The mean age of the entire sample procedures including selling or buying of human embryo or was 21 years. This sample can be considered academically trading in the sale or purchase of human embryo or gametes or privileged with access to on campus health promotion and selling or buying or trading the services of surrogate educational resources. The questionnaire comprised of 15 motherhood by way of giving payment, reward, benefit, fees, questions divided in three subsets dealing with Knowledge of remuneration or monetary incentive in cash or kind, to the surrogacy, awareness regarding the legal aspects of it and third surrogate mother or her dependents or her representative, subset dealing with perceptions regarding it.The frequency of except the medical expenses incurred on the surrogate mother the responses was tabulated on a MS Excel Spreadsheet and (2) and the insurance coverage for the surrogate mother was statistical analysis was done using SPSS version-16 software. banned completely and only altruistic surrogacy, between OBSERVATION: close relatives has been permitted. There have been studies that have documented the lack of awareness, knowledge and The study comprised 150 subjects comprising 82 females and skewed perceptions regarding assisted reproductive 68 males. The subjects were asked whether they understood techniques and its legal aspects among well educated strata of the terms infertility, and various methods of assisted society.(3,4) The present study aimed to assess the perception, reproduction including surrogacy. 98% (n=147) subjects knowledge and awareness regarding surrogacy and its related replied correctly, while 3 subjects could not answer correctly legislation among medical students in a teaching institution in regarding infertility. 86% (n=129) candidates responded

155 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00038.2

Table 1 : Questionnaire Don't Agree

Don't Don't Agree Know Don't Don't Agree Know Don't Know

Specialized Don't Set UP Know Don't Don't Agree Know Don't Don't Agree Know Don't Don't Agree Know Don't Know Don't Know

correctly regarding the types of surrogacy. On being asked subjects stated that no consent required from husband. On about consent from spouse, 68% (n=102) answered correctly being questioned regarding the procedure, 59% (n=88) that both the spouses must consent, while 22%(n=33) stated subjects stated that one donor must be from the intended that only one spouse must necessarily consent, 10% (n=15) parents, while 38% (n=57) stated that intended parents need

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not be donors, while 5 subjects stated that both intended positive attitude and perception towards surrogacy, the level of parents need to be donors. knowledge still needed to be improved so that awareness is 30% (n=45) subjects stated that there are no guidelines or more. legislations regarding surrogacy in the country, while 62% CONCLUSION: This study has some limitations that should (n=93) reported that there are in fact legislations governing be considered when using the results of the study. Firstly, the surrogacy in India, 8% (n=12) subjects were not sure or data were gathered with the self report of subjects and had just unaware of any guidelines or legislations. 16% (n=24) subjects assessed the viewpoint of students and did not assess specific replied that any Registered Medical Practitioner is eligible to viewpoints from married individuals about gestational undertake surrogacy practice in his clinic, while 84 % (n=126) surrogacy as all the subjects were unmarried. Another subjects stated that specialists with a certified set up can limitation is the small sample size and non diverse population undertake surrogacy. 64% (n=96) subjects stated that of study. We concluded that medical students were aware of the reimbursement is given to all surrogate mothers, while 36 concept of surrogacy and had some credible knowledge %(n=54) stated that no payment except medical and insurance regarding the same, however a clear knowledge of the legal payment can be made to the surrogate mother. aspects of surrogacy was still sub par and needed 94% (n=141) subjects stated that surrogacy is a positive step improvement. for infertile couples, while only 6% (n=9) subjects stated that it REFERENCES: is not a good option for infertility. 56% (n=84) subjects stated 1. Imrie, Susan; Jadva, Vasanti (4 July 2014). "The long- that they would opt for surrogacy, while 44% (n=66) subjects term experiences of surrogates: relationships and contact said they would prefer other options. with surrogacy families in genetic and gestational surrogacy arrangements". Reproductive BioMedicine Females and males showed no significant differences in their Online. 29 (4): 424–435. responses except in case of the last question regarding opting 2. The Surrogacy (regulation) Bill, 2018, Accessed from for surrogacy, wherein males opted for surrogacy as compared http://164.100.47.4/BillsTexts/LSBillTexts/PassedLoksa to females, who were less. bha/257-C%20_2016_Eng..pdf on 9th January 2019. DISCUSSION: Surrogacy is a procedure that has many 3. Adashi EY, Cohen J, Hamberfer L, Jones HW, de Krestser concerns raised by the physician, the donors, intended and DM, Jr LB, et al: Public perception on infertility and its treatment: an international survey. Human Reprod 2000, biological parents and society at large. These concerns mainly 15:330–334. include the relation of the newborn baby to his genetic and 4. Sabarre. A qualitative study of Ottawa university students' surrogate mothers. There are also concerns regarding awareness, knowledge and perceptions of infertility, surrogacy laws. Therefore, this study was planned to evaluate infertility risk factors and assisted reproductive knowledge of medical students, and their attitudes to technologies (ART). Reproductive Health 2013 10:41. surrogacy. In a study in Iran, it was reported that over half 5. Faramarzi A, Hosseini A, Borzouie Z, Khalili MA. A infertile couples had no knowledge of surrogacy methods and survey of infertile women's attitudes towards surrogacy. did not approve of surrogacy for infertile patients.(5) However Journal of Jahrom University of Medical Sciences. 2014 in our study, we had well educated individuals, who in a Jan 15;11. majority had knowledge of the procedure of surrogacy and 6. Rahmani A, Sattarzadeh N, Gholizadeh L, Sheikhalipour over half of them stated that they themselves would opt for Z, Allahbakhshian A, Hassankhani H. Gestational surrogacy: Viewpoint of Iranian infertile women. Journal surrogacy. In another study in the same region of Iran, it was of human reproductive sciences. 2011 Sep;4(3):138. reported that 89.9% of the infertile women had positive view of (6) 7. Poote AE, van den Akker OB. British women's attitudes to surrogacy, which is concurrent with our study where we surrogacy. Human reproduction. 2008 Sep 14;24(1):139- found that 94 % subjects responded positively to practice of 45. surrogacy. The level of knowledge regarding who can perform 8. Suzuki K, Hoshi K, Minai J, Yanaihara T, Takeda Y, surrogacy was average in our study, as compared to a study Yamagata Z. Analysis of national representative opinion wherein 37 % female subjects did not know whether surrogacy surveys concerning gestational surrogacy in Japan. Eur J required a licensed clinic or not (7) A majority of subjects were ObstetGynecolReprod Biol. 2006;126:39–47. aware that legislations exist concerning surrogacy in India, this 9. Sills ES, Healy CM. Building Irish families through is in concurrence with a study wherein a majority of educated surrogacy: Medical and judicial issues for the advanced responders were aware that there are legislations/ guidelines reproductive technologies. Reprod Health. 2008;5:9. governing surrogacy and that it must be followed.(8,9) In summarizing, it was shown that though medical students had a

157 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00039.4 Original Research Paper Finger Print Patterns and Gynecological Cancer: An Empirical Study 1. Bijoyini Bose, MBBS student, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India. 2. Vinod C Nayak, Professor and Head, 3. VikramPalimar, Professor, 4. Shankar M Bakkannavar, Associate Professor*, 5. Anita Shivaji, Associate Professor*, 6. Ashwini Kumar, Associate Professor*, 7. Nirmal Krishnan, Assistant Professor*, *Department of Forensic Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India.

ABSTRACT : Dermatoglyphy is genetically transmitted and controlled through generations, which is similar to all other physical features of the body. Finger prints have been adopted as a tool to determine the incidence of diseases. The objective of this paper is to determine the association between gynecological cancer and finger print ridge pattern. This study is undertaken on 150 women diagnosed with gynecological cancer reported at a teaching hospital. Analysis displayed that the loops pattern of finger prints on more than 6 fingers had significant incidence among cases reported.

Corresponding Author : Article History: Vinod C Nayak, Received: 14 April 2019 Professor and Head, Received in revised form: 25 September 2019 Accepted on: 3 October 2019 Department of Forensic Medicine, Kasturba Medical College, Available online: 31 December 2019 Manipal Academy of Higher Education, Manipal, India. Contact : +91 8121121253 Email : [email protected]

KEYWORDS : Dermatoglyphic pattern, gynecological cancer, India

INTRODUCTION : A lot of research have made headway to study the behavior and Dermatoglyphy is genetically transmitted and controlled etiology of the heterogeneous group of ovarian cancers, and through generations, which is similar to all other physical several studies by Indian scientists demonstrate the features of the body. Yet, it is uncertain on how these lines are development in this direction. A study of 957 ovarian i n n a t e , s i n c e n o t w o i n d i v i d u a l s h a v e t h e neoplasms displayed that most of the benign tumors occurred similardermatoglyphic patterns [ 1 , 2 ] . Fingerprints are among women in the age group of 20to 40 years of age. While individualistic, constant, and one of the most dependable tool the malignant lesions were present commonly occurred among of identification. Faulds[3] concluded that the pattern of the women in the age group of 41 and 50 years of age.[7]Deodhar papillary ridges remain unchanged in every individual for a et al. studied the prevalence of HPV types in cervical lesions lifetime. Galton [4] classified the finger print patterns from women in rural Western India. Cervical cancer is a form depending upon their primary pattern as loops, whorl and of preventable cancer and in developed countries regular Pap arches. smears have long been adopted as a tool for cervical cancer. This clearly is displayed in the low-incidence rates of cervical Gynecological cancers are among the most common cited cancer in developing economies. Unfortunately, in form of cancer among women and hence has emerged to be developing countries such as India, most women have public health issue of paramount importance. Worldwide and presented in the advanced stages of cervical cancer. This is in India, ovarian cancers and cervical are the most common primarily attributed to due to lack of awareness programs and form of gynecological cancers affecting women. Though no formal screening programs to promote early detection. incidence of cervical cancer is on a deteriorating trend, yet it is Fingerprint patterns have been estimated to have a significant the second most reported type of cancer among women, after correlation with some genetic diseases like the Down's breast cancer. Annually, in India, 122,844 women are syndrome and the Klinefelter syndrome (8). Researchers have diagnosed with cervical form of cancer out of whom 67,477 also explored the association between cancer and fingerprint succumb to this disease. [5] Over the past years, many Indian patterns(breast cancer [9, 10]; cervix cancer [11]). These researchers have published studies in gynecologic oncology, research findings suggest that dermatoglyphics may support in and this review discusses the important work done in this field.

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the estimation and the treatment of cancer [8; 10; 12]. The RESULTS : association between gastrointestinal cancers and finger print is Descriptive analysis of the data captured in presented in Table also established by Zivanovic-Posilovic et al., 2003. [13]. 1. The association between gynecological cancers and rick In the Indian Context, ovarian and cervical cancers are mostly factors is determined using Chi-square tests and the P values diagnosed type of gynecological cancer. Though, cervical were considered to determine the significance of each of the cancer is on a diminishing trend, but still remains the second risk factors. most reported form of cancer among women, in India. Table 1: Descriptive statistics of samples groups (N=150) 122,844 women are reported with cervical cancer every year Groups Casses (%) and 67,477 die from this disease(ICO Information Centre on Age * <40 63 (42) HPV and Cancer (2014). Hence the objective of this study is to >40 87 (58) establish a correlation between the finger print patterns and Marital Status*** Single 16 (10) gynecological cancer among women. Finger print pattern can Married 134 (90) be a tool to screengenetic diseases and to identify individuals Age at Menarche *** <12 87 (58) who might be more susceptible to incidence of gynecological >12 63 (42) cancer and may aid in the early detection of cancer. Family History of Cancer *** Yes 52 (34) MATERIALS AND METHODS : No. 98 (66) *=p value is significant, **=moderately significant, This is a cross-sectional study undertaken among a sample size ***=highly significant of 150 who were diagnosed with gynecological cancer. As the samples of the study were those patients having a form of In the present study (N=150), 42 per cent of the samples were gynecological cancer, clinical records of patients were less than the age of 40 at the time of study and interestingly it is appropriately scrutinized to establish history. On such explored that age was not a highly significant factor screening, the patients were considered to be a part of the study. determining gynecological cancer (p<0.05). Majority (90 per Informed consent was obtained from such patients to cent, p<0.01) were married and 58 per cent reported age at participate in this study. This study was approved by the menarche as less than 12 years (p<0.01). Majority (66 per cent) Research Ethics committee of the Kasturba Medical College, of the respondents had reported a strong family history of Manipal, Manipal Academy of Higher Education Manipal. In cancer. Our analysis displayed that family history of cancer addition to the finger print patterns, demographic information was significantly (p<0.01) associated with incidence of of the samples were also captured. gynecological cancers. Geographically, the samples were from Glass slab-Inking Roller method[4]: The materials which regions in South Karnataka and Kerala states of India. were used for this study were Printer black Ink-Kores quick Finger print pattern among the samples captured was analyzed drying duplicating ink, ink roller, foldable magnifying lens, (Table 2). It is observed that 51 (34 per cent) of the samples had glass plate (12x12inches), pencil, measuring scale and a loop finger print patternin more than 6 fingers , 33 samples proforma. The subjects were asked to wash their hands with an (22 per cent) had a whorl pattern of finger print in more than 6 objective of removing dirt. Clean towel was provided to dry fingers and the rest of the 14 per cent of the samples have arch their hands. Then the finger bulbs were rolled on the glass slab. type in more than 6 fingers. It is observed that loops pattern of The thumbs were rolled towards the subjects body and the finger print if the most common pattern of finger print among fingers were rolled away from the body i.e. thumb in fingers out patients in the study area, followed by patients with whorl method. For each individual entire print of ten fingers were pattern of finger print and only 14 per cent of the samples had prepared. arches pattern of finger print in more than 6 fingers. The finger print samples were collected in the respective Table 2: Pattern of Finger Print patterns blocks on the same sheet of paper. Sufficient care was taken to Pattern of Finger Print Number ( N = 150), % avoid sliding of fingers that could result into smudging and Loops (>6) 51 (34) inaccurate collection of data. Finger print patters were studied Whorls (>6) 33(22) with the help of magnifying glasses and whorls, loops and Arches (>6) 21(14 ) arches based on the ridge pattern were identified. Total 150 ( 100) Data Analysis : Data captured from the samples is tabulated Additionally, cross tabulation analysis was undertaken among and analyzed using SPSS 18 version. the demographic factors and finger print patterns. It is observed that samples with whorl type of finger print who had age at

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menarche <12 years had more probability of gynecological strengthen generalizability. Additionally, dermatoglyphic cancer than women who had reported an age at menarche analysis can be used as a biological marker to early diagnosis at>12 years (p<0.01). Interestingly, samples who had reported of malignancies of such cancers among women. family history of cancer had predominantly loop (p<0.05) and REFERENCES : whorl (0.01) finger print pattern had a significantly higher 1. Kasey W. Embryology, physiology, and morphology. In: incidence of gynecological cancers than arches pattern of Fingerpr Source.: Washington, DC:United States finger print. Department of Justice National Institute of Justice; 2011. DISCUSSION : 2. Lakshmi Prabha J, Thenmozhi R. A Short Review on Dermatoglyphics has been used aninvestigative tool for Dermatoglyphics. J Pharm Sci& Res.2014;6(4):200-2.’ assessment of patients with various diseases and is adopted as a 3. Faulds H. The Skin Furrows of the Hand Nahest tool to detect screening of abnormal anomalies. Researchers in 1880;22:605. the past have used finger print analysis as a tool to detect breast cancer, prostate cancer, cervical cancer and oral cavity cancer. 4. Galton F. Finger Prints, Macmillan & Co,1892. The present study attempts to establish an association between 5. ICO Information Centre on HPV and Cancer (Summary finger print pattern and gynecological cancers(placental mole, Report 2014.08.22). Human Papillomavirus and Related ovarian and uterine) among the Indian women population. Diseases in India; 2014[Google Scholar] Interestingly, demographic characteristics like Age at 6. Mondal SK, Banyopadhyay R, Nag DR, Roychowdhury Menarche have been established as a significant pre-cursors S, Mondal PK, Sinha SK. Histologic pattern, bilaterality among women population with a whorl type of finger print and clinical evaluation of 957 ovarian neoplasms: A 10- pattern. Additionally, family history is also established as a year study in a tertiary hospital of Eastern India. J Cancer significant antecedent of gynecological cancers among women Res Ther. 2011;7:433–7. [PubMed] [Google Scholar] in India. To fulfill the objective of this paper was to establish an 7. Deodhar K, Gheit T, Vaccarella S, Romao CC, Tenet V, association between finger print pattern and incidence of Nene BM, Jayant K, Kelkar R, Malvi SG, Sylla BS, gynecological cancers. This objective was fulfilled by Franceschi S, Jeronimo J, Shastri S, Sankaranarayanan R, calculating the odds ratio to determine which pattern of finger Tommasino MJ Med Virol. 2012 Jul; 84(7):1054-60. print has the most rick factor of incidence of genealogical cancers. Results indicate a statistically significant association 8. Katznelson MB, Bejerano M, Yakovenko K, Kobyliansky between loop pattern of finger pattern and incidence of E. Relationship between genetic anomalies of different gynecological cancers. levels and deviations in dermatoglyphic traits. Part 4: Dermatoglyphic peculiarities of males and females with The results of this study display contrary results from studies Down syndrome. Family study. AnthropolAnz undertaken by researchers in other geographies. Arches pattern 1999;57(3):193-255. Epub 1999/12/10. of finger print has been established to have a significant association with cervical cancer [14]. However, loop pattern of 9. AbbasiSakineh, RasouliMina.Dermatoglyphic patterns finger print was reported to have significant association with on fingers and gynecological cancers.European Journal of breast cancer among Indian women[15]. Additionally, studies Obstetrics and Gynecology and Reproductive Biology undertaken in Iran by Abbasil et al. (2006) [9] revealed six or https://doi.org/10.1016/j.ejogrb.2017.10.020 more whorls in the finger print pattern were statistically 10. Chintamani, Khandelwal R, Mittal A, Saijanani S, Tuteja significant among cancer patients as compared to the A, Bansal A, et al. Qualitative and quantitative controlled groups. Sridevi et al. (2010) reported no statistically dermatoglyphic traits in patients with breast cancer: a significant difference among cases and control groups with prospective clinical study. BMC Cancer. 2007;7:44. Epub respect to arch pattern of finger print pattern. [16]. 2007/04/03. CONCLUSION : 11. Kashinathappa BS, Khanzode LS. Study of palmar In conclusion, we report that loop pattern of finger print has dermatoglyphics in carcinoma of cervix. International statistically significant association with gynecological cancer. Journal of Cur Res Rev. 2013;5(4):136-40 Women having loop pattern of finger print pattern have a 12. Wijerathne BT, Meier RJ, Agampodi TC, Agampodi SB. significant higher probability of incidence of gynecological Dermatoglyphics in hypertension: A Review. J cancers. This study in undertaken in the Indian context and this PhysiolAnthropol. 2015;34:29. Epub 2015/08/13. hypothesis needs to be tested in other geographies. This study 13. Zivanović-Posilović G, Milicić J and Bozicević D (2003). can also be undertaken with a larger sample size to further Dermatoglyphs and gastric cancer. Coll. Antropol. 27:

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213-219. 14. Pal GP, Routal RV, Bhagwat SS. Dermatoglyphics in the carcinoma of the cervix. Journal of Anatomical society of India. 1985;34(3):157 – 61. 15. Kashinathappa BS, Khanzode LS. Study of palmar dermatoglyphics in carcinoma of cervix. IntJ Cur Res Rev. 2013;5(4):136-40. 16. Sridevi NS, Delphine Silvia CR, Kulkarni R, Seshagiri C. Palmar dermatoglyphics in carcinoma breast of Indian women. Rom J MorpholEmbryol. 2010;51(3):547-50. Epub 2010/09/03.

161 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00027.8 A Case Report Fatal Cardiac Tamponade Following Left Ventricular Free Wall Rupture Post Myocardial Infarction 1. Shweta Menon, Undergraduate Student*, 2. Shankar M Bakkannavar, Associate professor, Department of Forensic Medicine and Toxicology*, 3. Vinod C Nayak, Professor, Department of Forensic Medicine and Toxicology*, 4. Deepak M Nayak, Associate professor, Department of Pathology*, 5. Vikram Palimar, Professor, Department of Forensic Medicine and Toxicology*, *Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka

ABSTRACT : The cardiac diseases are the most common causes of sudden death. Time and time again people have fallen prey to undiagnosed cardiac diseases. Even though Health authorities encourage regular cardiac check-ups after a certain age, this is often overlooked by people and not taken care of. Myocardial infarction (MI) due to coronary artery occlusion is the most important form of ischemic heart diseases and its risk is ever increasing in Indian Population. Hemopericardium due to rupture of heart is one of the major complications of acute MI. We report a case of sudden cardiac death with undiagnosed coronary artery disease leading to MI. The deceased suffered rupture of heart and died due to cardiac tamponade.

Corresponding Author : Article History: Dr. Shankar M Bakkannavar Received: 24 June 2019 Received in revised form: 24 June 2019 Associate Professor, Accepted on: 24 June 2019 Department of Forensic Medicine and Toxicology, Available online: 31 December 2019 Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka Contact : +91 98453-03881, 91102-40992 Email: [email protected]

KEYWORDS : Cardiac sudden death; Coronary artery disease; Myocardial infarction

INTRODUCTION: initiation may save the life of the patient5. We present one such According to World Health Organization (WHO), Sudden case wherein the adult died due to haemopericardium due to death is defined as one which has taken place within 24 hours rupture of the ventricular wall following MI. from the onset of symptoms and signs of disease.1Cardiac CASE REPORT: disease and its complications arises as one of the most common A 60-year-old female with no previous history of coronary causes of sudden death. Incidence of sudden cardiac death has artery disease was brought dead to the causality. To complete been steadily increasing all over the world. While knowing the the legal formalities of the law of the land, the body was sent to cause of sudden cardiac death is one of the favorites of the mortuary for postmortem examination. physicians involved with these cases.It is a very difficult and At autopsy; on external examination, the body was challenging task for the forensic physician. moderately built, nourished and conjunctiva of both the eyes Probably the most common cause of death recorded in autopsy were pale. Horizontally placed old healed scar was present is myocardial infarction (MI) due to coronary artery over the front of the abdomen in its lower aspect. There were no 1 insufficiency . In India, studies have reported increasing external injuries present over the body. On internal Coronary heart disease prevalence over the last 60 years, from examination; Pericardium showed bluish discolouration 1% to 9%-10% in urban population and <1% to 4%-6% in rural which on opening showed hemopericardium (Figure 1). 2 population . The major complications of MI include, ischemic Pericardial cavity contained 150ml frank blood with 500g of damages, heart failure, pericarditis, myocardial rupture, blood clots. Heart weighed 234g and a laceration measuring 2 arrhythmias, aneurysms and C N S or peripheral x 0.3 cm x myocardial cavity deep, was present over the 3,4 embolization . posterior surface of the left ventricle situated 4cm above the Hemopericardium due to rupture of heart has been described as apex, with associated hyperemia (Figure 2). Right and left a complication in approximately 10% of patients with fatal MI ventricles were enlarged. Left circumflex artery showed 20% which is clinically predicable and immediate treatment occlusion of its lumen. Aorta showed multiple atheromatous

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streaks and plaques throughout its course. Lungs were soft, DISCUSSION : congested, oedematous and showed presence of blood stained Myocardial rupture is an early and life threatening frothy fluid on cut-section. complication of Acute Myocardial Infarction (AMI) with Postmortem blood sent for Laboratory Investigations bimodal peak of incidence (within 24 hrs and 3-5 days), range revealed: elevated levels of Cardiac Markers: Troponin T hs: being 1-14 days. The rupture could be in the form of ventricular 0.505 ng/ml, Creatinine Phosphokinase CPK: 466U/L, CK- septal rupture (VSR), ventricular free wall rupture (VFWR) or MB (Mass): 5.3 ng/ml and NT-PRO BNP: 906 pg/ml papillary muscle rupture (PMR)6,7. Among these, VFWR is ten 8 Cardiac tissue collected at autopsy sent for histopathological times more common than others .Left ventricular free wall examination revealed infarcted and leucocyte- infiltrated rupture (LVFWR) following acute myocardial infarction myocardium with hematoma (H&E stain 200X) (Figure 3) (AMI), occurs in approximately 2% of cases, and is often fatal and right and left coronary arteries showing severe degree of because of the development of hemopericardium and 9 atherosclerosis. tamponade . Figure 1 : Hemopericardium Myocardial wall rupture after MI is two times more common in males than females10. But other studies have different opinion about gender preponderance11 - 14. It classically occurs 3 to 6 days following MI, but in some studies, they have been reported in less than 24 hours in up to 50% of cases11. In 25% cases, history of previous MI is present but often the first presentation of ischemic heart disease would be left ventricular free wall rupture (LVFWR)15. In our case the subject previously apparently healthy female died due to left ventricular free wall rupture leading to haemopericardium and cardiac tamponade. She had a laceration on the posterior surface of the left ventricle that too near the apex which increases its rarity. The patients may Figure 2 : Laceration measuring 2 x 0.3 cm x myocardial survive for a relatively long period from rupture to cavity deep, present over the posterior surface of 16 the left ventricle situated 4cm above the apex, death which is evident in our case as the 500 grams of blood clot suggest some time following the rupture. Another striking feature of this case is that the patient did not have any previous history of heart disease. Myocardial infarction can occur in 'normal' coronary arteries. The proposed mechanism for this include coronary vasospasm, coronary thrombosis in situ or embolization from a distant source with spontaneous lysis. Since the patient in our case is an old lady the most likely explanation for her MI might be due to the rupture of any atheromatous plaques that initiated an inflammatory response. This response resulted in thrombosis and superimposed vasospasm which compromised the coronary perfusion and precipitated the MI. Figure 3: Slide showing infarcted myocardium with Regarding the complications of MI, hemopericardium is one of the major complications. It is the collection of blood in the pericardial sac of the heart. Depending on the volume and rapidity with which it develops, may cause cardiac tamponade. Cardiac tamponade is a grave condition which requires about 200 ml of blood if develops rapidly and may require greater than 2000 ml in slowly developing stage17,18. In our case the patient had 150 ml of blood including 500 gms of clots in her pericardium which produced the tamponade. The filling of

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blood, limits the expansion of heart in diastole. This leads to 10. Tanaka K, Sato N, Yasutake M, Takeda S, Takano T, incomplete filling of ventricles and great vessels ultimately Tanaka S. Clinical course, timing of rupture and resulting in low stroke volume and failing of heart18. relationship with coronary recanalization therapy in 77 CONCLUSION : patients with ventricular free wall rupture following acute m y o c a r d i a l i n f a r c t i o n . J N i p p o n M e d S c h . The effective management of post MI complications is equally 2002;69:481–8. important. In MI, a number of factors like age, gender, previous myocardial infarct, site of infarct, ventricular 11. Becker AE, Anderson RH. Cardiac Pathology. An hypertrophy, wall thickness affected and intake of non- integrated text and colour atlas. London: Gower Medical steroidal anti-inflammatory drugs, play a role in rupturing the Publishing; 1983. myocardium. The treating physician should always assess the 12. Reddy SG, Roberts WC. Frequency of rupture of the left patient based on these factors and can be prepared to combat ventricular free wall or ventricular septum among such complications. necropsy cases of fatal acute myocardial infarction since REFERENCES : introduction of coronary care units. Am J Cardiol. 1989;63:906–11. 1. Rao D, Sood D, Pathak P, Dongre SD. A cause of Sudden Cardiac Deaths on Autopsy Findings; a Four-Year Report. 13. Yip HK, Wu CJ, Chang HW. Cardiac rupture Emerg (Tehran). 2014;2(1):12–17. complicating acute myocardial infarction in the direct percutaneous coronary intervention reperfusion era. 2. Gupta R, Mohan I, Narula J. Trends in Coronary Heart Chest. 2003;124:565–71. Disease Epidemiology in India. Annals of Global Health. 2016; 82(2): 307-315. 14. Batts KP, Ackermann DM, Edwards WD. Postinfarction rupture of the left ventricular free wall: Clinicopathologic 3. Mullasari AS, Balaji P, Khando T. Managing correlates in 100 consecutive autopsy cases. Hum Pathol. complications in acute myocardial infarction. J Assoc 1990;21:530–5. Physicians India. 2011;59( Suppl):43-8. 15. Shirani J, Berezowski K, Roberts WC. Out-of-hospital 4. Grasso AW, Brener SJ. Complications of Acute sudden death from left ventricular free wall rupture during Myocardial Infarction, Center for Continuing Education, acute myocardial infarction as the first and only Cleveland Clinic. Accessed at manifestation of atherosclerotic coronary artery disease. https://teachmemedicine.org/cleveland-clinic- Am J Cardiol. 1994;73:88–92. complications-of-acute-myocardial-infarction/ on 16. Che J, Li G, Chen K, Liu T. Post-MI free wall rupture 10.12.2019. syndrome. Case report, literature review, and new 5. Oliva PB, Hammill SC, Edwards WD.Cardiac rupture, a terminology. Clin Case Rep. 2016;4(6):576–583. clinically predictable complication of acute myocardial Published 2016 May 6. doi:10.1002/ccr3.565. infarction: report of 70 cases with clinicopathologic 17. Braunwald E. Pericardial Diseases. In: Longo DL, Fauci correlations.J Am CollCardiol. 1993 Sep;22(3):720-6. AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J. 6. Mahajan K, Patel H.Myocardial Infarction, Post Infarct Harrison's principles of internal medicine. 18th ed. New Ventricular Septal Rupture. Treasure Island (FL): York: McGraw Hill, Health Professions Division; 2012. p. StatPearls Publishing. 2019 Jan. 1972-74. 7. Rentoukas EI, Lazaros GA, Kaoukis AP, Matsakas EP. 18. Knight B, Saukko P. Knight's Forensic Pathology, 3rd ed. Double rupture of interventricular septum and free wall of London: Arnold; 2004. p. 502 the left ventricle, as a mechanical complication of acute myocardial infarction: a case report. J Med Case Rep. 2008; 2:85. 8. Bates RJ, Beutler S, Resnekov L, Anagnostopoulos CE. Cardiac rupture-challenge in diagnosis and management. American Journal of Cardiology. 1977;40:429–437. 9. Moreno R, Lopez de Sa E, Lopez-Sendon JL. Frequency of left ventricular free-wall rupture in patients with acute myocardial infarction treated with primary angioplasty. Am J Cardiol. 2000;85:757–60.

164 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00028.X A Case Report Thymic hyperplasia and Sudden Death: A pervasive fear in Medicine 1. Varsha Vinod, Undergraduate Student* 2. Shankar M Bakkannavar, Associate professor, Department of Forensic Medicine and Toxicology* 3. Vinod C Nayak, Professor, Department of Forensic Medicine and Toxicology* 4. Deepak M Nayak, Associate professor, Department of Pathology* 5. Vikram Palimar, Professor, Department of Forensic Medicine and Toxicology* 6. Nirmal Krishnan M, Assistant Professor, Department of Forensic Medicine and Toxicology* *Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka ABSTRACT: Status thymo-lymphaticusor simply “lymphatism” which is diagnosed based on enlargement of the thymus. This condition involves a combination of constitutional anomalies: hypertrophy of the thymus, general hyperplasia of the lymphatic system (such as the spleen and lymph nodes), hypoplasia of the cardiovascular system with aortic narrowing, and hypoadrenal. The condition is sometimes terminated by sudden death usually in children, but few cases have been reported in adults.

Corresponding Author : Article History: Dr. Shankar M Bakkannavar Received: 24 June 2019 Associate professor, Received in revised form: 24 June 2019 Accepted on: 24 June 2019 Department of Forensic Medicine and Toxicology, Available online: 31 December 2019 Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka Contact : +91 98453-03881, 91102-40992 Email: [email protected] KEYWORDS : Thymus hyperplasia, SUDA (sudden unexpected death in adults), Ectopic thymus

INTRODUCTION: in the midline. Brain was found to be congested and The thymus, a lobulated and a capsulated organ is located in edematous. Heart and other organs did not show any the mediastinum of the thoracic cavity antero-superior to the significant changes. The neck sent for histopathology heart and behind the sternum. It is a primary lymphatic organ examination was found out to be thymic tissue which showed that remains active only until puberty[1]. After birth, the gland features of hyperplasia (Figure 1). continues to grow reaching its maximum absolute weight at Figure1: Histopathology showing thymic hyperplasia and puberty. The gland subsequently undergoes a process called reddish areas of haemorrhage [H & E Stain, (a) involution, which is defined as a decrease in the size and 10X and (b) 40X]. weight of the gland with advancing age[2]. During involution, the epithelial component atrophies, resulting in scattered small lymphocytes in abundant adipose tissue. Sometimes the gland may be enlarged referred to as hyperplasia of the thymus which is a rare phenomenon after puberty. This thymic hyperplasia can cause sudden unexpected death in adults (SUDA)[3].Here, we report a fatal case of thymic hyperplasia. Awareness of this (a) (b) condition is essential for proper monitoring and treatment so that fatalities due to these conditions can be prevented. And also the abnormal tissue present in the lungs was revealed CASE DETAILS: to be an accessory thymus. The viscera sent to regional A body of an adult female aged 28 years was brought for forensic science laboratory were non-reactive for the tests to postmortem examination. History suggested that the deceased detect poison. was upset in life over her severe chest pain and headache that DISCUSSION: gave her problem from time to time. On the fatal day, she slept The thymus develops from the ventral wing of third after dinner and did not wake up in the morning. pharyngeal pouch on each side[4]. After birth, the gland At autopsy, a mass measuring 4 x 3 cm was present in the neck continues to grow reaching its maximum absolute weight at

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puberty. The gland subsequently undergoes a process called a secondary manifestation of a constitutive condition. It can involution, which is a decrease in size and weight of the gland also be said that thymic hyperplasia increased significantly the with advancing age. The process of involution is never risk of SUDA (6.9 folds) in both male and females[3]. SUDA complete and bits of the thymus tissue that remains are was quite commonly associated with this entity in the younger sufficient to maintain its lymphoid function[3]. age group (22.5 average). Several studies have also concluded If any thymic tissue is trapped in the neck during the descent that there was a male predominance in the occurrence of this usually along the pathway from the mandible to the entity[3]. It is thought that the thymus atrophy is due to the manubrium sterni, the tissue can form an ectopic thymus in the increased circulating level of sex hormones, and chemical or neck[5].The incidence this ectopic thymus in the neck varies as physical castration of an adult results in the thymus increasing per different studies done in the past. The incidences were in size and activity[11]. Any abnormality in the circulating levels recorded as 12.1% in Zielinski et al study[6] whereas 32% in of these hormones poses a significant risk for this constitutive Jaretzki and Wolf study[7]. Ectopic thymus is usually anomaly. asymptomatic and only 6% have symptoms in the form of CONCLUSION: stridor, dyspnoea and dysphagia[8]. It is hypothesised that, the The patients with thymic hyperplasia show diversity in close relation of a cervical ectopic thymus to the trachea, vagus histology, disease conditions and causes of death. In most cases nerve and the great vessels affords a reason for the sudden enlargement of the thymus could not be diagnosed during life death. An accessory thymus can induce abnormal until post-mortem. SUDA can be reduced by effectively inflammatory/immune reaction. These reactions can screening this asymptomatic but potentially lethal condition. subsequently increase the risk of acute haemorrhagic The forensic pathologist must consider this entity while pancreatitis in the patients with thymic hyperplasia. Likewise, ascertaining the cause of death in cases of sudden deaths. infectious diseases and immune-related diseases account for a REFERENCES: higher proportion of deaths in patients with thymic hyperplasia 1. Robert M. Sargis. An Overview of the Thymus The Gland than those without it[8]. that Protects You Long after It's Gone.Accessed at Cardiac ryanodine receptor gene (RyR2) mutations sometimes https://www.endocrineweb.com/endocrinology/overvie result in sudden cardiac death due to fatal arrhythmias. These w-thymus on 15.1.2019 cases show hypertrophy of thymus and lymphatic tissue. RyR2 is expressed in epithelial cells of thymic medulla. This has 2. Gui J, Mustachio LM, Su DM, Craig RW. Thymus Size been a striking histologic finding in sudden deaths associated and Age-related Thymic Involution: Early Programming, with thymic hyperplasia[9]. Sexual Dimorphism, Progenitors and Stroma. Aging Dis. In all such cases, the diagnosis is usually first made at autopsy 2012 Jun; 3(3): 280–290. and the majority of affected individuals died during the very 3. Liping Zou, Ye Zhang, Rong Zhu (2017) Thymic early phase of the condition. Hypertrophy and Sudden Unexpected Death In Adults –A There have been cases of sudden death being associated Retrospective Study Of 56 Autopsy Cases. International thymic hyperplasia in the past. The death of patients occurred Journal of Human Anatomy - 1(1):9-20. suddenly, from an acute hypocorticoidism developing in 4. Pansky B. The Pharyngeal Clefts and Pouches. In: Review connection with a surgical operation. In one case of of Medical Embryology. London: Mc Milan. 1982. thymicolymphatic state (TLS) with anomalies of sex organs 5. Kakuno Y, Yamada T, Mori H, Matsuki M, Narabayashi was observed in a woman of 27 years. She died suddenly I.Ectopic thymus presenting as neck mass.Nihon Igaku within 2 hours after the operation of colpopoiesis from the Hoshasen Gakkai Zasshi. 2002 Nov;62(13):747-8. pelvic peritoneum. Acute hypocorticoidism in this case was connected with the adrenal hypoplasia characteristic of TLS in 6. Zieliński M, Kuzdzal J, Szlubowski A, Soja J. which thymic hyperplasia was a manifestation of a congenital Comparison of late results of basic transsternal and immune-endocrine insufficiency. In another one, 30 years old extended transsternal thymectomies in the treatment of woman with normal duration of pregnancy suddenly died myasthenia gravis. Ann Thorac Surg. 2004;78:253–8. following caesarean operation. The hypocorticoidism in this 7. Jaretzki A, 3rd, Wolff M. Maximal thymectomy for case was due to the adrenal atrophy developing apparently as a myasthenia gravis. Surgical anatomy and operative result of focal sclerosis of the adenohypophysis. Hyperplasia technique. J Thorac Cardiovasc Surg. 1988;96:711–6. of the thymus in this case was secondary and reflects the degree 8. Lin WL, Tsai CH, Liu CL, Yang LC, ChaoWR.Bilateral [10] of adrenal insufficiency . cervical ectopic thymic nodules with accessory thyroid From the above cases it is clear that thymic hyperplasia can be tissue and an ectopic parathyroid in the neck region.

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Journal of Dental Sciences. 2011: 6, 61-64. 9. Nishio H, Okudaira N, Matsushita K, Yoshimoto T, Sato T, Suzuki K. Hypertrophy of lymphoid organs is a possible phenotypic characteristic of R420W mutation of the cardiac ryanodine receptor gene: a study using a knock-in mouse model. Legal medicine. 2014: 16 (6):326-32. 10. Popov MS, Zairatiants OV. Primary and secondary (reactive) thymus hyperplasia in cases of sudden death. Arkh Patol. 1984;46(11):74-9. 11. Brelinska R. Thymic epithelial cells in age-dependent involution. Microsc Res Tech. 2003 Dec 15; 62(6):488- 500.

167 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00029.1 A Case Report Identification of the Skeletal Remains of a Murder Victim in Forensic Casework by DNA Typing : A Case Report 1. Monika Chakravarty, Forensic Science Laboratory, Home Department, Govt. of NCT of Delhi, Rohini 2. Prateek Pandya, Assistant Professor, Amity University, Noida 3. Anupuma Raina, Senior Scientist, AIIMS, Delhi 4. Dhruv Sharma, AD Biology, FSL Delhi 5. Naresh Kumar, SSO Biology, FSL Delhi 6. Nidhi Singh, LA Biology, FSL Delhi 7. Damini Varshney, SA Biology, FSL Delhi

ABSTRACT : We report the identification of skeletal remains using DNA technology. DNA was isolated from severely decomposed human remains using pre-extraction decalcification followed by optimized phenol/chloroform DNA extraction procedure. Additionally DNA from the reference samples of the relatives was extracted using the Automate Express DNA extraction system. QuantifilerTM Human DNA quantification kit was used for DNA quantification. AmpFl STR Identifiler plus PCR amplification kit was used to simultaneously amplify 15 autosomal Short Tandem Repeat (STR) loci alongwith the gender specific locus amelogenin.

Corresponding Author Article History: Ms. Monika Chakravarty, Received: 19 November 2018 Forensic Science Laboratory, Home Department, Govt. of Received in revised form: 19 December 2018 Accepted on: 20 December 2018 NCT of Delhi, Rohini, Available online: 31 December 2019 Contact : +91 98689-31045 E-mail : [email protected]

KEYWORDS : Forensics, Bone, DNA, PCR, STR

INTRODUCTION : been used to identify human remains & the choice of the [5] The detection of polymorphism at the molecular level i.e. protocol depends on the condition of the remains. Here, we deoxyribonucleic acid has been a powerful tool in human report a case, where the identification of human skeletal identification since its first use in forensics by Jefferey et al.[1] remains found in a wooded area after the person was reported Tandemly repeated DNA sequences, which are found in missing. Multiplex PCR system-the Amp FlSTR Identifiler abundance throughout the human genome, being polymorphic plus PCR amplification DNA typing kit was used to confirm makes them important genetic markers for mapping studies the identification. DNA profiles from femur bone from the and human identity testing.[2] Short tandem repeats (STRs) remains was compared with the profiles derived from the torn contain repeat units that are 2-6 bp in length & are amplifiable clothes recovered near the remains and with the relatives of the with the polymerase chain reaction (PCR). With the advent of victim. STR technology, low amounts of DNA, even in a degraded CASE DETAILS : form, can be typed with success. The development of the A missing report of the deceased was lodged by his son. technology related to DNA polymorphism & its validation [3] Despite the efforts no clue regarding the whereabouts of studies has been very rapid. High molecular weight DNA, i.e. deceased could be found. FIR under section 365 IPC was the DNA which can be typed, in human remains is very less registered regarding abduction by unknown person on the due to degradation of the genetic material. Microbes, statement of his son. After few days an information regarding environmental agents and organic compounds to which the arrest of three accused persons was received at police station corpses were exposed, also add to loss of informative DNA. from Haryana, where the accused persons had confessed to Due to this, bones have been shown to be very useful because commit murder. During interrogation they disclosed that they of their long preservation. Hochmeister et. al. described the had abducted the deceased in car, took him to the fields of a first case using commercially available kits. The Ampli Type village in Delhi and then murdered him by firing bullets on PM PCR kit and the GenePrinto STR Triplex kit were used to head and stomach. Police inspected the crime scene and confirm the identity of human remains found in a wooded area, [4] recovered bones, torn clothes, money and other articles from after being missing since an year. Various procedures have the fields. Doctor opined two months time since death. The

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case was deposited in the biology division of FSL (Forensic Table1: Genotype Analysis Using AmpFl STR® Identifiler® Science Laboratory, Delhi) for examination. MATERIALS & METHODS : LOCI Sample '1' Sample'2' Sample '3' Sample '4' Bone Cloth Blood Blood SAMPLE PREPARATION : For the bone sample, the pieces sample of sample of exterior was sanded clean to remove potential contaminants. son of wife of Bone surface was cleaned from remnant soft tissue and soil deceased deceased traces. The sample was then successively washed in 5% D8S1179 14,14 14,14 14,15 14,15 bleach, sterile distilled water and 100% ethanol and D21S11 30.2,30.2 30.2,30.2 29,30.2 27,29 subsequently air dried. The thoroughly dried sample was pulverized using a sterilized blender. The powder was then D7S820 8,11 8,11 8,11 8,8 transferred to sterile 15 ml conical tube. An EDTA CSFIPO 10,12 10,12 11,12 11,12 decalcification step was used for the sample. Extractions were D3S1358 16,18 16,18 16,17 16,17 performed using phenol-chloroform DNA extraction protocol.[6] TH01 6,9.3 6,9.3 6,6 6,9 Reference Samples : 02 (Blood samples) from the son and D13S317 11,12 11,12 11,11 11,11 wife of deceased were extracted using the Automate Express D16S539 10,11 10,11 9,10 9,9 DNA extraction system using the PrepfilerR. Express Forensic [7] 17,25 DNA extraction kit . D2S1338 20,24 20,24 17,24 DNA QUANTIFICATION : D19S433 15,16 15,16 14,15 14,15.2 The DNA concentration was determined using the Quantifiler VWA 14,18 14,18 14,17 17,17 [8] Human DNA Quantification kit (Thermo Fisher Scientific). TPOX 8,8 8,8 8,11 9,11 The reaction was carried out in the ABI 7500 Real-Time PCR D18S51 12,16 12,16 14,16 13,14 system according to manufacturer's recommendations. DNA AMPLIFICATION AND ELECTROPHORESIS: D5S818 13,13 13,13 12,13 12,12 PCR amplification was carried out using the Applied FGA 23,25 23,25 21,25 21,21 R Biosystems Veriti, thermocycler according to manufacturer's AME LO X,Y X,Y X,Y X,X recommendations. The AmpFlSTR Identifiler plus PCR -GENIN amplification kit was used to simultaneously amplify 15 STR Figure1: Comparative analysis of DNA profiles loci: (D8S1179, D21S11, D7S820, CSF1PO, D3S1358, Electropherogram showing panel 3 & 4 of Sample '1' TH01, D13S317, D16S539, D2S1338, D19S433, vWA, TPOX, D18S51, D5S818, FGA) as well as the gender determination locus, Amelogenin.[9] Electrophoresis of the amplified product was performed on an ABI 3500xl Automated Genetic Analyzer using 36 cm capillary on POP 4 polymer. (Thermo Fisher Scientific). 0.5 µl of the amplified DNA was mixed with 9.5 µl HiDi Formamide and 0.3 µl Gene Scan 500 Liz size standard. Mixture was denatured at 95oC for 3 minutes followed by lowering the temperature to 4oC for 3 minutes. The denatured samples were loaded on to samples tray and transferred to auto sampler. Allelic ladder was run as a part of batch of samples. DATA ANALYSIS : Gene MapperR IDx Software v 1.4 was used for the analysis of samples. The samples were sized according to internal size RESULTS AND DISCUSSIONS : standard. The software uses the internal size standard to assign The comparison of the DNA profiles of the bone, torn clothes , [10] a fragment size and a sizing quality value to each peak. the son and wife of the deceased proved conclusively a non excluded paternity case. In this case no genetic discrepancy for

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Electropherogram showing panel 3 & 4 of Sample '2' inhibitors. Calcified tissues (bones and teeth) pose a challenge to a forensic DNA scientist. The phenol/chloroform method is the best, is based on removing protein thus purifying the nucleic acids which are extracted in aqueous solution, but the disadvantage here is that the method is cumbersome and the reagents used are toxic. With proper extraction procedures, subsequent DNA analysis is successful. The problem that forensic scientists mostly face when extracting DNA from bones and teeth samples is either DNA degradation or contamination. To minimize the risk of contamination, 10% bleach was used. All reagents and tips provided with filters and micro centrifuge tubes were sterilized by autoclave and Electropherogram Showing Panel 3 & 4 of Sample '3' exposed to UV light before use. Laboratory coats, disposable caps and gloves were used during extraction and amplification. REFERENCES : 1. Jefferey A.J., Brookfield JFY, Semeonoff R. positive Identification of an immigration test case using human DNA fingerprints, Nature 1985;317:818-9. 2. Edwards A, Civitello A, Hammond, H A, Caskey C T. DNA typing and genetic mapping with trimeric and tetrameric tandem repeats. Am.J. Hum. Genet. 1991;49: 746-756. 3. Iwamura ESM, Muno JR. Human identification and Electropherogram Showing Panel 3 & 4 of Sample '4' analysis of DNA in bones. Rev.Hosp.Clin.Fac.Med.S. Paulo.2004;59(6):383-388. 4. Hochmeister MN, Budowle B, Borer UV, Rudin O, Bohnert M, Dirnhofer R. confirmation of the Identity of human skeletal remains using multiplex PCR amplification and typing kits. J Forensic Sci 1994;40:701- 5. 5. Andelinoic S, Sutilovic D, Erceg Ivkosic l, Skaro V, Ivkosic A, Paic F et.al. Twelve-year experience in identification of skeletal remains from mass graves. Croat Med J. 2005; 46: 530-9. 6. Davoren J, Vanek D, Konjhodzic R, Crews J, Huffine E, Parsons T. Highly effective DNA extraction method for nuclear short tandem repeat testing of skeletal remains the child, father and mother relationship was observed in any from mass graves. Croat Med J. 2007; 48: 478-85. of the 15 STR loci studied. Hence the remains found on the 7. Automate Express TM DNA Extraction system User’s spot were confirmed to be of the father of the complainant. Guide, Thermofischer Scientific. Now a days, genetic typing by STR loci has become a primary 8. Quantifiler “Human DNA Quanitification” Duo Kits method of choice for human remains identification.[11] Any Product Bulletin, Thermo Fisher Scientific body tissue that has not been degraded is a potential source of 9. Applied Biosystems, AmplFlSTR Identifiler plus PCR DNA. Bone is one of the best source of DNA from amplification kit, user’s Manual. Thermo Fisher Scientific decomposed human remains, DNA extraction from fresh 10. Genemapper IDx software 1.4 user’s manual, Thermo samples with abundant DNA such as blood, semen or saliva is Fisher Scientific not difficult and amplifiable DNA could be easily obtained. In 11. Amir M D. Identification of human remains from the mixed substrate e.g. vaginal swabs from rape victims, male second world war mass graves uncovered in Bosnia and and female DNA can be separated by differential lysis. Herzegounia Croat Med, J. 2015;56: 257-62. Putrefied or degraded samples have DNA alongwith PCR

170 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00030.8 A Case Report A Homicidal Ligature Strangulation Masquerading as Suicidal Hanging 1. Munish Kumar, Junior Resident* 2. Kanika Kohli, Associate Professor* *Department of Forensic Medicine, MMIMSR, MMDU, Mullana, Ambala, Haryana, India

ABSTRACT : Death due to constriction of neck by ligature material may result due to hanging or strangulation. It can be homicidal, suicidal or in few cases it can be accidental. In some cases even police officials get confused about the case, whether it is homicidal or suicidal. And they interpret the case wrongly and at that point of time the role of forensic expert becomes important. A meticulous post- mortem examination of the body and proper diagnosis can help police officials to direct the investigation towards the right path. One such case is being discussed here wherein the cause of death was guessed by police officials as suicidal hanging, but thorough post- mortem examination revealed it to be a case of homicidal strangulation. This helped the police to register a case U/S 302 IPC and apprehend the accused.

Corresponding Author : Article History: Dr. Kanika Kohli Received: 10 January 2019 Received in revised form: 23 September 2019 Associate Professor Accepted on: 23 September 2019 Department of Forensic Medicine, MMIMSR, MMDU, Available online: 31 December 2019 Mullana, Ambala, Haryana, India Contact : +91- 9728405109 Email: [email protected] KEYWORDS : Hanging, Strangulation, Police, Suicidal, Homicidal, Ligature Mark

INTRODUCTION : registered a case U/S 346 IPC on 06/12/2017 as deceased was Ligature mark present at the neck is considered to be decisive missing from 02/12/2017 from Home and body was recovered in the deaths which results due to hanging and ligature on 12/12/2017 from a jungle. The case was referred from one strangulation. But in many cases of hanging and strangulation District Civil Hospital of Haryana as body of the deceased was ligature mark creates doubt. If the deceased person is having in advanced stage of putrefaction. The Post-mortem classical features, then it is easy to conclude hanging or examination was conducted by a panel of two doctors of strangulation. But application of pressure on the neck often Forensic Medicine Department of MMIMSR, MMDU, results in variable findings. Therefore a proper assessment of Mullana. various post-mortem findings is necessary under such AUTOPSY FINDINGS : circumstances. A lot of curiosity is generated in the mind of On examination, it was decomposed body of a male. Rigor autopsy surgeon during day to day post-mortem examination mortis had disappeared and decomposition changes had due to atypical ligature mark, apart from typical ligature started. Maggots were present on the body and the face was 1 marks. So attempt to study external as well as internal features swollen. A ligature material (chunni) was present around the in the neck in cases of neck compression mainly hanging and neck and neck was swollen. After removal of ligature material, strangulation is essential. a well-defined ligature mark was present at the level of thyroid Analysis of ligature mark, should include findings such as cartilage, placed horizontally and encircling the neck level of ligature mark, obliquity and discontinuity of ligature completely. Multiple abrasions were present around the mark. These help to differentiate hanging from ligature ligature mark. On dissection, subcutaneous connective tissue strangulation because of homicidal nature in strangulation and under the ligature mark was ecchymosed. The neck muscles, suicidal in hanging.2 Laryngeal cartilages, tracheal rings and carotid arteries were CASE HISTORY : found injured. The thyroid cartilage was found fractured. On 13/12/2017, a dead body of a male aged 22 years was DISCUSSION : brought for post-mortem examination in Maharishi In this case, the preliminary investigation by police as narrated Markandeshwar Institute of Medical Science and Research, before post-mortem examination was death due to hanging but Mullana with alleged history of suicidal hanging as per the post-mortem findings included a well-defined ligature information furnished in police inquest. The police had mark was present at the level of thyroid cartilage, placed

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horizontally and encircling the neck completely. Multiple REFERENCES : abrasions were present around the ligature mark. On 1) Shaikh MMM, Chotaliya HJ, Modi AD, Parmar AP, dissection, subcutaneous connective tissue under the ligature Kalele SD. A Study of Gross Postmortem Findings in mark was ecchymosed. The neck muscles, Laryngeal Cases of Hanging and Ligature Strangulation. JIAFM cartilages, tracheal rings and carotid arteries were found 2013; 35 (1): 63-5. injured. The thyroid cartilage was found fractured. All these 2) Patel J B, Bambhaniya A B, Chaudhari K R, Upadhyay M post-mortem findings strongly suggests a case of ligature C. Study of death due to compression of neck by ligature. strangulation. As the body was in advanced stage of IJHSR 2015; 5(8): 76-81. putrefaction, it presented all the more challenge to analyse the ligature mark. However detailed and thorough examination 3) Sauvageau A, Booghossian E. Classification of asphyxia; helped us arrive at our conclusion. The need for standardization. J Forensic Sci. 2010; 55: 1259-67. Hanging in its face value goes in favour of being suicidal in nature. Strangulation should not be used as a synonym for 4) Parikh's Textbook of Medical Jurisprudence Forensic hanging. Strangulation is defined as asphyxia by closure of the Medicine and Toxicology 6th Edition CBS Publishers blood vessels and/ or air passages of the neck as a result of New Delhi 2011; 3:53. external pressure on the neck.3 5) Ueno Y, Fukunaga T, Nakagawa K, Imabayashi T, The criteria to differentiate between hanging and strangulation Fujiwara S, Adachi J et al, A homicidal strangulation by is mostly based on the Ligature mark which is usually ligature, disguised as a suicidal hanging, Nihon Hoigaku incomplete, oblique and placed above the thyroid cartilage in Zasshi. 1989 Feb;43(1):46-51. case of hanging whereas it is horizontal, completely encircling 6) Sirohiwal BL, Paliwal PK, Bharat Bhushan, Yadav DR. A the neck and located at or below the level of thyroid cartilage in case of strangulation fabricated as hanging. Anil strangulation. The ligature mark in strangulation is Aggarwal's Internet Journal of Forensic Medicine and accompanied with abrasions and bruises and underlying Toxicology 2001; 2(2). subcutaneous tissue is ecchymosed. Fracture of the laryngeal 7) Bhullar DS, Aggarwal KK, Aggarwal AD, Goyal A, skeleton and tracheal rings is usually associated with Sangwan C. Death due to constriction of neck: A case 4 strangulation and rarely seen in case of hanging. report 2013; 13(2): 93-6. Numerous case reports have been published which bring forth 8) Fernando DMG, Izzath MHMA, Ligature Strangulation the eternal dilemma faced by the forensic experts when case Masquerading As Suicidal Hanging, Conference Paper · such as this is brought for post-mortem examination. Much 12th Annual Academic Sessions of the College of depends upon the observations made by the investigating Forensic Pathologists, At Sri Lanka, March 2014. officer regarding the scene of crime, nature and presence of ligature material on the deceased and any other associated findings. However a detailed, meticulous post-mortem examination especially of the neck structures is essential to arrive at the final cause of death.5,6,7,8 In the present study the investigating officer was mislead to believe it as a case of suicidal hanging. However based on the input provided by the forensic experts, the investigation was directed in the right path and the accused was apprehended and the case was registered U/S 302 IPC. CONCLUSION : In cases of death due to compression of neck using ligature, either hanging or strangulation the investigating officers look up to the forensic experts for cause of death to direct their investigation in the right path. Thus it is the responsibility of the autopsy surgeon to conduct a meticulous and thorough post-mortem examination to aid in administration of Justice, thus fulfilling our duty and obligation.

172 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00031.X A Case Report Post mortem artefacts -Importance of interpretation 1. Vijay Arora, Professor and Head* 2. Susheel Sharma, Associate Professor*, *Department of Forensic Medicine, Dr. R. P. Govt. Medical College, Kangra at Tanda, HP-176001

ABSTRACT : Artefact is a structure or substance not normally present but produced by some external agency or action. Misinterpretation may lead to wrong cause and manner of death and miscarriage of justice Therefore the doctor should learn to draw conclusion logically and correctly instead of forming hasty judgement.

Corresponding Author : Article History: Dr.Vijay Arora Received: 22 January 2019 Professor and Head , Received in revised form: 23 October 2019 Accepted on: 23 October 2019 Department of Forensic Medicine, Dr. R. P. Govt. Medical Available online: 31 December 2019 College, Kangra at Tanda, HP-176001 Contact : +91 9418089939 Email : [email protected]

KEYWORDS : Artefact, Decomposition, Corrosion.

INTRODUCTION: was informed and the spot was visited by Forensic Science Artefact is any change caused or feature introduced in a body team also. No blood, no vomitus, no live electric wire or any after death that is likely to lead to misinterpretation of medico other source of current was present at the spot as per Police. legally significant ante mortem findings. Post mortem artefacts Relatives had a suspicion that she was assaulted and died due to are classified as: burn like lesion over the neck. Post mortem examination was 1. Artefacts of decomposition conducted . 2. Third party artefacts like artefacts due to animal bites, POSTMORTEM FINDINGS : insect activity, medical treatment, embalming etc. A reddish brown discoloured area with epidermis peeled off 3. Artefacts of environment like Post mortem burning , Post from it, measuring 7.5 x7.0 c.m. was present on left postero mortem corrosion and Post mortem maceration. lateral aspect of neck, 1.2 c.m. below lower part of pinna of left 4. Other artefacts like artefacts due to storage, handling, ear. There was no blood infiltration , no clotted blood on exhumation of the body etc. dissection of the area, under lying tissues were pale, Here in this article we will discuss a rare artefact i.e. artefact parchmentized . Similar areas of peeled off epidermis were due to corrosion. Dead bodies exposed or lying in Kerosene , present on the left side of face and back of right knee also. water , gasoline etc. show chemical injuries. The epithelium No ante mortem injury was appreciable over the body. The detaches while handling the body and then the underlying organs were congested. dermis turns yellow to brown. Such lesions are interpreted as Skin from the neck was sent for Histopathological examination ante mortem chemical injury or abrasive force or burns. Lack . Heart was soft and flabby and was sent for Histopathological of vital reaction and absence of singeing of hairs from such examination. Liver had a cyst in it and was sent for denuded skin may avoid confusion. Histopathological examination. Viscera and blood were sent CASE HISTORY: for chemical analysis also. The dead body of a 75 year old lady was brought for autopsy in Chemical Analysis Report : No poison detected. the mortuary of Dept. of Forensic Medicine, Dr. R.P. Govt. Histopathology Report: Skin tissue showed dermal fibrosis. Medical College Kangra at Tanda with the history of sudden Section of Liver examined showed a cyst focally lined by death. The lady was left alone at her home by her daughter in flattened epithelium and surrounding focal acute and chronic the morning and after about 2 hours of leaving her at home she inflammation. Section of Heart examined showed features was informed telephonically by her neighbours that the old consistent with mild Hypertrophy. lady is lying dead in the court yard of her home. On coming DISCUSSION: back she saw her lying in the court yard and shifted her to the So in the absence of any fatal ante mortem injury over the body, varandah with the help of some other persons when they absence of poison and the presence of soft, flabby Heart along noticed some burn like lesion over left side of her neck. Police with features of Hypertrophy, the cause of death was given as

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Cardiac arrhythmias in a case of Cardiac Hypertrophy. Figure 2: Photograph showing a reddish brown The discoloured hard area present over the neck was discoloured area with epidermis peeled off interpretated as artefact due to corrosion as the body remained from it, measuring 7.5 x7.0 c.m. on left postero lying over the wet grass for significant time i.e. at least few lateral aspect of neck hours which lead to the slippage of epidermal layer of the skin and then further shifting of the dead body from that place lead to hard, parchmentized underlying tissues. Every Forensic Medicine expert and even every doctor must familiarise himself with these post mortem artefacts that are liable to misinterpretation. As the misinterpretation of this finding over the neck in this case as some injury or burn could have lead to wrong judgement regarding cause of death. So besides having vast experience of conducting autopsies, one should train himself to make precise and correct interpretation of findings. REFERENCES: 1. Hodgson E, Levi P.E,Chronic Toxicity, A Text book of Figure 3: Photograph showing a cyst in Liver Modern Toxicology,2000,2nd edition, Mc Graw –Hill Book company , Singapore: 190-91. 2. Pillay V V ,Comprehensive Medical Toxicology,2008,2nd Edition, Paras Medical Publisher,Hyderabad: 100- 02,266-67 3. Pillay V V ,Textbook of Forensic Medicine and Toxicology, 2016,17 t h edition, Paras Medical Publisher,Hyderabad: 514-16 4. Reddy KSN , Murthy OP, The Essentials of Forensic Medicine and Toxicology,2014,33rd Edition, Jaypee Brothers Medical Publishers Pvt. Ltd : 527-28

Figure 1: Photograph showing a reddish brown discoloured area with epidermis peeled off from it, measuring 7.5 x7.0 c.m. on left postero lateral aspect of neck.

174 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00032.1 A Case Report Sudden Death Due to Hypertrophic Obstructive Cardiomyopathy: A Medico-Social Diagnosis. 1. Vikram Palimar, Professor of Forensic Medicine and Toxicology* 2. Mr. Akash Nayak S, 5th Semester, MBBS student* 3. Vinod C Nayak, Professor and Head of Forensic Medicine & Toxicology* 4. Deepal Nayak, Associate Professor of Pathology* 5. Chandni Gupta, Associate Professor of Anatomy* *Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

ABSTRACT : A 22-year-old male was rushed to the hospital and was declared dead on arrival, a case was registered with the police under section 174 Cr.P.C. The deceased complained of chest pain the night before and acidity the morning of the incident. Autopsy revealed a congested and edematous brain and congested lung, liver, spleen, kidneys. The left ventricular heart wall was 2.4 cm thick and the right ventricular wall was 0.9 cm thick with unremarkable valves and coronaries. Histopathological examination of heart revealed features compatible with hypertrophic obstructive cardiomyopathy. Blood tests revealed increased CPK, CK-MB, Troponin T levels. DNA analysis revealed mutations. In the interest of the relatives of the deceased, the family members were informed of the genetic mutation which is autosomal dominant and was advised to undergo genetic counselling. Hypertrophic obstructive cardiomyopathy is a condition in which a portion of the myocardium is enlarged, hence cardiac output falls. It is a common cause of death among athletes. It can be diagnosed by echocardiogram and has no preventive measure or cure. This disease is mostly asymptomatic or may present as dyspnea, angina, and palpitations or may lead to sudden death. When a case of sudden death is diagnosed to be due to hypertrophic obstructive cardiomyopathy does it have a genetic basis? Will the results obtained be useful even though it is a retrospective diagnosis? It is absolutely essential to ascertain if the cause of the disease was due to genetic mutation as this is autosomal dominant and the chances of it appearing in the family is high. The results will be useful as the relatives can be given genetic counselling. There is no preventive measure towards the mutations but checkups at regular intervals can lead to an early detection of hypertrophic myocardium which can be cured by medicine or surgery. Hence it is essential to screen for the mutations leading to hypertrophic obstructive cardiomyopathy and use this information to counsel the family in view of the well-being of the community.

Corresponding Author : Article History: Dr. Vikram Palimar Received: 15 February 2019 Professor of Forensic Medicine and Toxicology, Received in revised form: 24 June 2019 Accepted on: 24 June 2019 Kasturba Medical College, Manipal, Manipal Academy of Available online: 31 December 2019 Higher Education, Manipal, Karnataka, India. Contact : +91 98863-40969 Email : [email protected]

KEYWORDS : Genetic Counselling, Hypertrophic Obstructive Cardiomyopathy, Mutation, Sudden Death

INTRODUCTION : the cardiac sarcomere(>1,400 variants) are responsible for/ [3] Sudden death as per International classification of diseases, associated with hypertrophic cardiomyopathy . version 10 (ICD-10) is non-violent and not otherwise Although most patients are asymptomatic, the clinical feature explained, occurring less than 24 hours from the onset of of hypertrophic obstructive cardiomyopathy are exertion symptoms [1]. angina, dyspnea, palpitations, fatigue, syncope and sudden [4] Hypertrophic obstructive cardiomyopathy is defined as a cardiac death . disease in which a portion of the myocardium is hypertrophic Ventricular hypertrophy reduces end diastolic volume without any obvious cause, creating functional impairment of reducing cardiac output. In cases of left ventricular outflow the heart [2]. Mutations in 11 or more genes encoding proteins of tract obstruction there is increased oxygen demand, cell death,

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and replacement fibrosis [5]. Blood tests revealed increased CPK, CK-MB, Troponin T The incidence of sudden cardiac death (SCD) in young levels. athletes on the playing field is 0.61 in 100,000[6]. DNA analysis revealed autosomal dominant mutations: CASE REPORT : missense mutations in MYBPC3, HCN4 and frame shift mutation in KCNH2. A 22 year old male was rushed to the hospital and was declared dead on arrival, a case was registered with the police under In the interest of the relatives of the deceased, the family section 174 Criminal Procedure Code. The deceased members were approached and informed of the genetic complained of chest pain the night before and acidity the mutation which is autosomal dominant and were advised to morning of the incident. An autopsy was conducted. undergo genetic testing. They were informed about the genetic predisposition and high incidence among close relatives. External examination blood tinged frothy fluid oozed from the mouth and the congestion in both eyes. DISCUSSION : Internal examination revealed blood tinged froth in the Sudden death due to hypertrophic obstructive cardiomyopathy airways, a congested and edematous brain and congested lung, is a retrospective diagnosis and has great significance to the liver, spleen, kidneys. The left ventricular heart wall was 2.4 community. The mutations involved show an autosomal cm thick (Normal: 0.6-1cm) and the right ventricular wall was dominant pattern of inheritance and hence, have a high 0.9 cm (Normal: 0.3-0.5 cm) thick with unremarkable valves incidence rate among family members. and coronaries. MYBPC3 (Cardiac myosin-binding protein C) is arrayed transversely A-bands and binds myosin heavy chain in thick Histopathological examination of heart revealed features filaments and titin in elastic filaments. KCNH2 encodes a compatible with hypertrophic obstructive cardiomyopathy potassium channel that plays an essential role in final (Figure 1 & Figure 2). repolarization of the ventricular action potential. HCN4 encodes another potassium channel necessary for cardiac pace making process. Many of the patients are not symptomatic during the course of the disease and thus may not seek investigations. Early diagnosis of this condition is important because it allows patients to seek treatment and may also prompt the screening of family members for the disease. Increase in awareness of the disease among doctors working in community combined with advances in technology and good access to tertiary care centers will result in increased Figure 1: Cut section of the heart showing septal and knowledge of the disease, better access to management options posterior ventricular wall thickening for patients and a more thorough genetic evaluation of the family members suffering from this disease. As physicians, it is thus our responsibility to identify signs of the disease as early as possible since early diagnosis aids better management of the patient and opens up a wider array of therapeutic options. It is also important to notify the family and advise them to undergo genetic counselling. Early detection within a family can yield better outcomes. This can be of great value to the community in the future. CONCLUSION : It is essential to screen for the mutations leading to hypertrophic obstructive cardiomyopathy and use this information to counsel the family in view of the well-being of the community. The disease has a high incidence among young athletes, which justifies the need for a more thorough approach Figure 2: “Leiomyoma”-like arrangement of cardiac to screening among susceptible individuals. Although the myocytes (H&E 400 X)

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disease cannot be prevented, the complications can be managed and incidence of sudden death can be reduced among relatives. ACKNOWLEDGEMENT : The authors like to thank Dr Sathya Murthy K, Director and his team at School of Life Sciences, Manipal Academy of Higher Education, Manipal for the DNA analysis of the blood sample. (This paper was presented in 26th Annual Conference of K a r n a t a k a M e d i c o l e g a l S o c i e t y C o n f e re n c e KAMLSCON-2018 held at Kasturba Medical College, Manipal, MAHE on 2nd to 4th November 2018.) REFERENCES : 1. International classification of diseases (ICD-10). Geneva, World Health Organization, 2005. 2. Maron BJ. Hypertrophic cardiomyopathy: a systematic review. JAMA. 2002;287(10):1308-20. 3. Maron B, Maron M, Semsarian C. Genetics of Hypertrophic Cardiomyopathy After 20 Years. Journal of the American College of Cardiology.2012;60(8):705-15. 4. Bonow R, Braunwald E, Zipes DP, Libby P. "The Cardiomyopathies". Braunwald's heart disease: a textbook of cardiovascular medicine (7th ed.). Philadelphia: WB Saunders. 2005. ISBN 1-4160-0014-3. 5. Elliott P, Gimeno J, Tome M, McKenna W. Left ventricular outflow tract obstruction and sudden death in hypertrophic cardiomyopathy. European Heart Journal. 2005;27(24):3073. 6. Maron BJ, Doerer JJ, Haas TS. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006. Circulation 2009;119:1085-92.

177 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00043.6 A Case Report Cardiac Tamponade: A Rare Cause of Mortality

1. Ananya Malhotra, Undergraduate MBBS student, Kasturba Medical College, Manipal, Karnataka 2. Vinod C Nayak, Professor and Head Forensic Medicine and Toxicology, Kasturba Medical College, Manipal, Karnataka 3. Vijay Dhankar, Specialist and HOD Forensic Medicine, Dr. Baba Saheb Ambedkar Hospital and Medical College, New Delhi 4. Shankar M Bakkannavar, Associates Professor, Forensic Medicine and Toxicology, Kasturba Medical College, Manipal, Karnataka 5. Vikram Palimar, Professor, Forensic Medicine and Toxicology, Kasturba Medical College, Manipal, Karnataka

ABSTRACT : This report describes two cases of death due to cardiac tamponade secondary to Aortic Dissection and Blunt traumatic cardiac rupture of right ventricle. Cardiac tamponade is the accumulation of pericardial fluid, blood, pus, or air within the pericardial space that creates an increase in intra-pericardial pressure, restricting cardiac filling and decreasing cardiac output. Cardiac tamponade is a cardiac emergency and can be fatal if it is not quickly diagnosed and treated promptly. Initial diagnosis of cardiac tamponade can be challenging, as there are several differential diagnoses, including tension pneumothorax and acute heart failure. The mortality rate is extremely high. Rapid prehospital transportation, general treatment of shock, a higher index of suspicion and prompt surgical intervention can save a life. Proper protocols in hospitals can be made to diagnose this emergency.

Corresponding Author : Article History: Dr. Vinod C Nayak, Received: 24 April 2019 Professor and Head, Received in revised form: 24 June 2019 Accepted on: 24 June 2019 Forensic Medicine and Toxicology, Kasturba Medical College, Available online: 31 December 2019 Manipal, Karnataka Contact : +91 98452-40393 E-mail : [email protected]

KEYWORDS : Cardiac Tamponade, Aortic Dissection, Blunt traumatic cardiac rupture, cardiac emergency

INTRODUCTION : tamponade after aortic root dissection and blunt force trauma Cardiac tamponade is the accumulation of pericardial fluid, after fall which are amongst the rare causes of cardiac blood, pus, or air within the pericardial space that creates an tamponade. increase in intra-pericardial pressure, restricting cardiac filling CASE REPORTS : [1] and decreasing cardiac output Signs of classical cardiac 1. A 58 years old man collapsed and became unconscious, tamponade include three signs: hypotension, JVD, Muffled when taken to the hospital, was declared brought dead. [2] heart sounds, known as Beck's triad Pulsus paradoxus Unremarkable features observed on external examination. On (decrease in systolic blood pressure>10mm Hg) is internal examination, pericardial cavity contained clots [3] characteristic. Tamponade is a very rare condition. One measuring 265g and 150ml of frank blood was present. A false estimate from the United States places it at 2 per 10,000 per lumen measuring 22 cm was present over the posterior aspect [4] year Cardiac tamponade is a cardiac emergency and can be of the root of aorta (aortic dissection). The root of aorta showed [2] [4] fatal if it is not quickly diagnosed and treated promptly a defect, measuring 0.5×0.2 cm over the posterior aspect. Causes of cardiac tamponade include cancer, kidney failure, Multiple atheromatous streaks and plaques were present over [1] chest trauma, pericarditis , connective tissues diseases, the aortic intima of the true lumen at several places. Deceased [4-5] hypothyroidism, aortic rupture , complications of cardiac died due to pericardial tamponade secondary to rupture of the [3] [4] surgery , Penetrating and blunt force trauma , drugs (e.g. aorta. (Figure 1-5) hydralazine, procainamide, isoniazid, minoxidil)[11] SLE[5]. This present report reviews two patients who sustained cardiac

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2. An 18-year-old man had a fall from height, was declared 2. ECG brought dead when taken to the hospital. On external • Low voltage examination abraded contusion, reddish in colour, 7cm × 5cm • Sinus tachycardia present over upper outer part of left side of front of the chest was found. On internal examination, both lungs were • PR segment depression unremarkable. Pericardium was tense and showed a bluish red • ST segment elevation appearance. Pericardial cavity contained about 200 cc of fluid 3. Echocardiography: Imaging of choice and clotted blood. Heart was ruptured with a laceration 4 cm x 4. Chest CT scan or MRI – detect amount and 3 cm x cavity deep present over the right ventricle. Visceral composition of fluid organs were unremarkable. Death was due to cardiac rupture and tamponade consequent to injury to the chest caused by • Prompt surgical intervention: blunt force / surface impact and may be sustained in a fall from • Pericardiocentesis- Aspiration of fluid from height. pericardial cavity [9] DISCUSSION : • Pericardial window [6] – fluid drained in chest cavity • Rare condition: The frequency of tamponade is very less. • Pericardiectomy- complete or partial One estimate from the United States places it at 2 per • Proper protocols in hospitals can be made to diagnose this [11]. 10,000 per year emergency e.g. Ritter rules [10] • Differential Diagnosis: Initial diagnosis of cardiac REFERENCES : tamponade can be challenging, as there are several 1. Richardson, L (November 2014). "Cardiac tamponade". differential diagnoses, including: JAAPA: Official Journal of the American Academy of ª cardiogenic shock of other etiology P h y s i c i a n A s s i s t a n t s . 2 7 ( 1 1 ) : 5 0 1 . ª constrictive pericarditis doi:10.1097/01.jaa.0000455653.42543.8a. PMID ª restrictive cardiomegaly 25343435. ª pulmonary embolism 2. Sagristà-Sauleda, J; Mercé, AS; Soler-Soler, J (26 May 2011). "Diagnosis and management of pericardial ª pleural effusion effusion". World Journal of Cardiology. 3 (5): 135 43. ª COPD doi:10.4330/wjc.v3.i5.135. PMC 3110902. PMID ª Bronchogenic cyst [4] 21666814 ª tension pneumothorax [6] 3. Schiavone, WA (February 2013). "Cardiac tamponade: 12 ª acute heart failure etc. pearls in diagnosis and management". Cleveland Clinic J o u r n a l o f M e d i c i n e . 8 0 ( 2 ) : 1 0 9 – 1 6 . • Extremely high mortality rate: [7] Patients coming alive to doi:10.3949/ccjm.80a.12052. PMID 23376916 the hospital is rare, thus the diagnosis sometimes is not even entertained. Often it is misdiagnosed, and it is difficult to 4. Kahan, Scott (2008). In a Page: Medicine. Lippincott identify the underlying cause. Cardiac tamponade can lead to Williams & Wilkins. p. 20. ISBN 9780781770354. shock and death [4]. Archived from the original on 2016-10-02. Steps To Save A Life : 5. Isselbacher EM, Cigarroa JE, Eagle KA (Nov 1994). "Cardiac tamponade complicating proximal (retrograde) • Rapid prehospital transportation [8] aortic dissection. Is pericardiocentesis harmful?". • General treatment of shock C i r c u l a t i o n . 9 0 ( 5 ) : 2 3 7 5 – 8 . •A higher index of suspicion: tamponade should be considered doi:10.1161/01.CIR.90.5.2375. PMID 7955196 in all patients who experience Pulseless Electrical Activity 6. Gwinnutt CL, Driscoll PA (2003). Trauma Resuscitation: [4] (PEA) The Team Approach (2nd ed.). Oxford: BIOS. ISBN 978- • Diagnostic tools: 1-85996-009-7. 1. Chest X ray 7. Blunt traumatic cardiac rupture. A 5-year experience.C E • water bottle' heart Brathwaite, A Rodriguez, S Z Turney, C M Dunham, and R Cowley • rib fracture 8. Prehospital mechanical ventilation of a critical cardiac

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tamponade. 2009 Oct;27(8)Barthélémy R1, Bounes V, Figure2: Photograph showing true and false lumen at root Minville V, Houze-Cerfon CH, Ducassé JL. 9. Ultrasound guided procedures in emergency medicine practice "Pericardiocentesis". Archived from the original on 7 March 2016. 10. johnritterfoundation.org/ritter-rules/ 11. Sternbach G (1988). "Claude Beck: cardiac compression triads". J Emerg Med. 6 (5): 417–9. doi:10.1016/0736- 4679(88)90017-0 12. P o r th , C ar o l; C ar o l M atts o n P o r th ( 2 0 0 5 ) . Pathophysiology: concepts of altered health states (7th ed.). Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 978-0-7817-4988-6 13. Systemic lupus erythematosus presenting with cardiac tamponade due to a haemorrhagic pericardial effusion T. Figure3: Photograph of root of aorta, showing two lumens Rudra, P.A. Evans and E.N. O'Brien Department formed ofMedicine, Enfield District Hospital, Southgate, London N21, UK

Figure1: Photograph showing frank blood and blood clots taken from pericardial cavity during autopsy

Figure 5: Photograph showing frank blood and blood clots

Figure 4: Photograph showing frank blood and blood clots in the pericardial cavity during autopsy

180 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00040.0 Review Article Honour Killing: Gruesome Murder For The Sake of False Honour 1. Manoj Kumar Pathak, Professor and Head* 2. Srishti Rai, Research Scholar* *Department of Forensic Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India

ABSTRACT : The phenomenon of honour killing is the outcome of that socio-psychic milieu of typical societies where certain patterns of the behaviour of human beings, particularly the females, are recognised as marking dishonour to their families and communities and the lost honour is reimbursed by killing them.These killings are a form of extreme violence against humanity. Though majority of the victims of this ruthless crime are females but it would be wrong to limit it to only one gender. In India the crime is mainly focused on women. These homicides or rather brutal murders are carried out in order to satisfy patriarchal society's ego. Matriarch are also involved in cases where it is believed that the dishonour bestowed on the family will affect the marriage prospects of other female members of the family.Our honour is very dear to us. In India nothing is more precious than honour, not even the life of a loved member of the family. Corresponding Author : Article History: Manoj Kumar Pathak, Received: 27 June 2019 Professor and Head, Received in revised form: 16 July 2019 Accepted on: 17 July 2019 Department of Forensic Medicine, Institute of Medical Available online: 31 December 2019 Sciences, BHU, Varanasi- 221005. Uttar Pradesh, INDIA Contact : +91 9450179177 Email : [email protected]

KEYWORDS : Patriarchal Society, Khap Panchayats, Caste System, Adultery, Homosexuality INTRODUCTION : Table 1 : NCRB Data of Honour Killing 2015-2016 An Honour killing or shame killing is the murder of member of No. of Honour No. of Honour STATE killings in Year. killings in Year. a family, due to perpetrators belief that the victim has brought 2015 2016 shame or dishonour upon the family, or has violated the Madhya Pradesh 14 18 [1] principles of a community or a religion . It is the permanent Uttar Pradesh 131 16 elimination of the member known to bring disgrace to the Gujrat 21 10 family[2]. These killings are a form of extreme violence against humanity. Though majority of the victims of this ruthless crime The actual figures are assumed to be 4-5 times higher than the are females but it would be wrong to limit it to only one gender. reported figures as many of these cases go unreported and In India the crime is mainly focused on women. These many are labelled as suicide. Hence, it is very difficult to obtain homicides or rather brutal murders are carried out in order to actual figures. satisfy patriarchal society's ego. Matriarch are also involved in cases where it is believed that the dishonour bestowed on the Indian States Depicting High Incidence of Honour Killing family will affect the marriage prospects of other female [picture courtesy- google images] members of the family. Marrying outside one's caste, adultery, illicit relationship, dressing in ways not acceptable by the society and sometimes mere conversation with an unknown male is sufficient to trigger reasons which can justify this heinous crime. Statistics from the United Nation suggest that 5000 women are killed in honour killings every year.According to this statistics, the countries in which honour killing are reported highest are India and Pakistan[3]. According to the NCRB statistics 2016 maximum number of honour killing have been reported in Madhya Pradesh followed by U.P and Gujrat[4] (Table 1).

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What is Honour Killing? have a firm grip over the development of our society. Our honour is very dear to us. In India nothing is more precious 4. Lack of Awareness and ineffective laws regarding than honour, not even the life of a loved member of the family. Honour killing: people are unaware of their basic rights and Indian society is a society which nests many cultures. These they do not know how to claim the rights guaranteed to them. cultural beliefs and norms regulate the life of a citizen. Being a Governments have displayed criminal negligence in their patriarchal society we tend to exercise more control on our approach to these crimes. There is no definition of the crime, no women. Women are considered as bearer of honour of a family. legal recognition of various aspects of the crime, no protection Any attempt by a person i.e., a man or specifically a women to afforded to self- choice couples, no measures to prevent such cross the boundary set by the community is perceived as a crimes, no accountability and no punishment. These killings threat to the honour of that family and community to which the are reported only under two categories – Murder (section 302 person belongs. In order to restore the honour and to send a of Indian Penal Code) and Culpable Homicide (Section 304 of message to the whole community as what are the consequences IPC). Due to this, most of the killings are unreported or of living a life at your own terms is honour killing and is reported under murder. Hence there is no proper statistics of practiced in many cultures. It is a social evil practiced against a such killings in India. person who has breached the honour of the community. These Triggers of Honour Killing are also known as customary killing. The phenomenon of 1. Love marriage: when a member of the family honour killing is the outcome of that socio-psychic milieu of decides to go against the marriage arranged by the typical societies where certain patterns of the behaviour of family, the decision is considered to bring disgrace to human beings, particularly the females, are recognised as the family. It is not acceptable for the family and the marking dishonour to their families and communities and the family decides to kill that member in order to preserve lost honour is reimbursed by killing them.[5] their honour. Factors for Prevalence of Honour killing 2. Inter-caste marriages: society does not want the 1. Male Dominated Society: honour is linked to women and caste system to get uprooted. Marrying someone from men are assigned the duty to guard the honour. It is no surprise a lower caste brings down the prestige of upper caste the father and brother of a women are the ones to plan and people. They would rather prefer to kill the member execute honour killing. Everything a women does is under who has done so then to suffer humiliation from their strict vigilance of the society. What she wears, with whom she community members. talks, whom she wants to marry, when she should marry, at 3. Adultery: engaging in sexual act outside the what time she comes back home everything is monitored and it marriage or engaging in activities that are not is her duty that she follows the norms of the society or she may considered appropriate by the society for a married prove dangerous for the honour of her family and community. women. It is necessary that the society stops evaluating the life choices of a women according to their rusted norms. 4. Women seeking divorce: when a women decides to rescind the mental and physical harassment she is 2. Belief in Khap Panchayats: a khap is a community suffering and live a peaceful life, it does not go well organisation representing a clan or a group of related clans. with the patriarchal society. A women returning back They are found mostly in northern India, particularly among to her maternal house or getting separated from her the Jat people of Western Uttar Pradesh and Haryana, although husband is thought to set a bad example for other historically the term has also been used among other family members and is also considered to bring communities. Khaps are not affiliated with the formally elected shame to the family. government bodies and are instead concerned with the affairs of the Khap it represents. In many cases these Khap Panchayats 5. Rumours and allegations: rumours and allegations order honour killing. Conducting Khap Panchayats has been about immoral behaviour of the family member are considered illegal in India. sometimes enough to trigger an attack. Killing the member is known to bring back the lost prestige. The 3. Deep Rooted Caste System: Caste is still a major issue in irony is that sometimes the family doesn't even make India, inter caste marriages are one of the leading cause of an effort to know the truth behind the stupid gossips. honour killing. This curse is destroying nation as a whole. It is not only affecting the growth of our nation but is also a leading 6. Dressing inappropriately: dressing in ways that are reason behind the killing of innocent boys and girls. Though unacceptable by the family or the community our nation is said to be progressing but some social issues still members.

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7. Rape victims: rape victims are known to bring shame completion of 18 years and not before. Unless a particular to the family. Instead of accepting the victim and personal law specifies otherwise, every person domiciled in supporting her the family thinks that due to rape the India is deemed to have attained majority upon completion of life of the female is already over, the society is not 18 years of age. However, in the case of a minor for whose going to accept her so it is better to kill her. person or property, or both, a guardian has been appointed or 8. Homo-sexuality: people still find it difficult to accept declared by any court of justice before the age of 18 years, and individual's choice. Someone's personal life is not in case of every minor the superintendence of whose property society's matter. When a couple of the same sex wants has been alleged by the Court of Wards, age of majority will be to live together the family or the society does not 21 years and not 18. The Act is relevant in cases where Khap permit it and in turn creates problems, blame them of Panchayats have forcibly separated married couples who are of ruining the image of family and provoke the family to eligible ages to get married. It is a violation of the provisions take steps against the couple. under this Act. Methods of Honour killing: The Special Marriage Act, 1954 is an Act of the Parliament of India enacted to provide a special form of marriage for the The methods of honour killing include stoning, stabbing, people of India and all Indian nationals in foreign countries, beating, burning, beheading, hanging, throat slashing, lethal irrespective of the religion or faith followed by either party. acid attacks, shooting, strangulation and forced suicide as The main reason behind the enactment of Act,was that it substitute.[6] provides for protection of human rights of every individual and Provisions for Honour killing constitution of Commissions and Courts for securing the Honour killing are cases of homicide and murder which are respective objective. In spite of such legislation, still there is grave crimes under the Indian Penal Code (IPC). Section 299 prevalence of honour killing practices leading to grave and 301 of the IPC deal with culpable homicide not amounting violation of human rights.[7] to murder while Section 300 deals with murder.Honour killing The Protection of Women from Domestic Violence Act, amounts to homicide and murder because the acts are done 2005, The Act seeks to cover those women who are or have with the intention of murdering the victims as they have been in a relationship with the abuser where both parties have purportedly brought dishonour upon the family. The lived together in a shared household and are related by perpetrators can be punished as per Section 302 of the IPC. consanguinity, marriage or a relationship in the nature of The Khap Panchayats or family members can also be booked marriage, or adoption; in addition relationship with family under Section 302 of IPC for instigating to suicide those who members living together as a joint family are also included. violate the norms of the community. Such killings also violate Even those women who are sisters, widows, mothers, single Articles 14, 15(1) and (3), 17, 18, 19 and 21 of the Constitution women, or living with them are entitled to get legal protection of India. Article 14 of the Indian Constitution guarantees to under the proposed Act "Domestic violence" includes actual every person the right to equality before the law or the equal abuse or the threat of abuse that is physical, sexual, verbal, [6] protection of the laws. emotional and economic. Harassment the way of unlawful Article 14 and 15 of the Indian Constitution deals about dowry demands to the woman or her relatives would also be equality before law and equal rights before law which means covered under this definition. The other relief envisaged under each and every citizen of India shall be treated equally without the Act is that of the power of the court to pass protection orders any discrimination on the grounds of caste, sex, creed, race etc. that prevent the abuser from aiding or committing an act of but in the case of honour killing, the women is been murdered domestic violence or any other specified act, entering a which forms gender violation. Article 19 and 21 of the Indian workplace or any other place frequented visited by the abused, Constitution deals about Right to Freedom and Right to life attempting to communicate with the abused, isolating any asset and personal liberty respectively. In the case of honour killing used by both the parties and causing violence to the abused, her the right to freedom is been violated. It is the freedom of every relatives and others assistance in protecting her from the citizen to choose their life where no person has the right to domestic violence. The draft Act provides for appointment of infringe and compel the citizen to act as per the wish of others. Protection Officers and NGOs to provide assistance to the Every citizen has the right to life and liberty which is the most woman w.r.t medical examination, legal aid, safe shelter, etc. important fundamental right. The Act provides for breach of protection order or interim The Indian Majority Act, Section-3, 1857, states that every protection order by the respondent as a cognizable and non- person domiciled in India shall attain the age of majority on bailable offence punishable with imprisonment for a term

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which may extend to one year or with fine which may extend to primarily involved in execution of this crime. Price of honour twenty thousand rupees or with both. Similarly, non- is paid by women. The culture feels threatened when a member compliance or discharge of duties by the Protection Officer is of the society crosses the limits set by cultural leaders. There is also sought to be made an offence under the Act with similar no logic in hating the feeling of love. Every individual has right punishment. to decide what he/she wants to do with his/her life and Whom Highlighted Cases of Honour Killing the individual wants as life partner. Honour killing are specifically targeted towards women. The men of the family 1.The Manoj–Babli honour killing case was the honour have traditional cultural belief that their honour and their status killing of Indian newly weds Manoj Banwala and Babli in June in the community depends upon the control they exercise on 2007 and the subsequent court case which historically the women of their family. It is better to kill a person than to convicted defendants for an honour killing. The accused in the face humiliation from the community the family belongs to. murder included relatives of Babli (grandfather Gangaraj, who The community may agree with a person or it may not but this is said to have been a Khap leader,brother, maternal and does not mean that such extreme steps should be taken. No one paternal uncles and two cousins). Relatives of Manoj, has the right to decide about who should be allowed to live and especially his mother, defended the relationship. The killing who should be killed. An individual is not in the ownership of a was ordered by a khap panchayat. tribe, community or culture. This concept needs to be The Khap panchayat's ruling was based on the assumption that understood by the Indian society and judicial system. There Manoj and Babli belonged to the Banwala gotra, a Jat should be separate inclusion of this crime in IPC/ CrPC and community, and were therefore considered to be siblings provision of harsh punishment should be made so that society despite not being directly related and any union between them gets deterrence from this sort of crime. Citizens of a country are would be invalid and incestuous. not allowed to take laws in their own hand and then shield In March 2010, a Karnal district court sentenced the five themselves behind culture and customs. Someone's life is perpetrators to be executed, the first time an Indian court had more important than culture or honour. done so in an honour killing case. The khap head who ordered Acknowledgement: but did not take part in the killings received a life sentence, and Authors would like to thank print and electronic media for the driver involved in the abduction a seven-year prison term.[8] providing us with immense resource materials in preparation 2.Qandeel, 26, was murdered in July 2016, allegedly by her of this article. brother Muhammad Waseem, who said he killed her in the Conflict of interest : Nil name of 'honour.'Waseem is alleged to have drugged and strangled her, saying that she "brought dishonour to the Baloch Source of funding: This research was financially supported by name" due to her risqué videos and statements posted on social UGC. media.[9] Ethical clearance : The present study was approved by 3. Saba was 18 when she eloped to marry a young man she “Institutional Ethical Committee” of Institute of Medical loved. When her father called her home – supposedly to Sciences, Banaras Hindu University, Varanasi. All the reconcile – he and her uncle beat her, shot her in the head, put information has been taken under consideration of medical her in a bag and threw her in a river in Pakistan. They said she ethical committee. had brought dishonour on her family and that they had done the Statement of Informed consent: This is a review study done “right thing”. by going through various online content. No consent was Amazingly, Saba survived and was able to get help. However, required. while her father and uncle were arrested, authorities had to Statement of Human and Animal Rights: No human right drop the charges because of a loophole in Pakistan's law that and animal right is violated in this case. allows perpetrators to go free if the victim – or the victim's REFERENCES: family – “forgives” them.[10] 1. Honor killing [Internet]. En.wikipedia.org. 2019 [cited 1 CONCLUSION : June 2019]. Available from: Home is a place which offers you safety and security. The https://en.wikipedia.org/wiki/Honor_killing family protects you from external evil but what happens when 2. Preethi R, Sreelatha A. Honour Killing in India. your family is the one who wants you dead. Honour killing is International Journal of Pure And Applied Mathematics heinous crime, the murderer is no one but those people who the [internet]. 2018 [cited 19 May 2019];120 (Special Issue). victim will look up for help. The men of the family are

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Available from: http://http;www.acadpuble.eu/hun/ 3. Kanchan T, Tandon A, Krishan K. Honor Killing: Where Pride Defeats Reason. Science and Engineering Ethics. 2015;22(6):1861-1862. 4. Crime Statistics 2016, National Crime Record Bureau (NCRB), Ministry of Home Affairs, 2016 Govt. of India New Delhi. Available from http://ncrb.gov.in/StatPublications/CII/CII2016/cii2016. html2016_Rev1_1.Pdf Accessed on May. 16, 2019 5. Deol S. Honour Killings in India: A Study of the Punjab State [Internet]. Isca.in. 2014 [cited 19 May 2019]. Available from: http://www.isca.in/IJSS/Archive/v3/i6/2.ISCA-IRJSS- 2014-70.php 6. Hosseini S, Basavaraju C. Study on Honor Kiiling As A Crime In India-cause And Solution [Internet]. 2019 [cited 22 May 2019]. Available from: https://www.academia.edu/25720837/Study_on_Honor_ Killing_as_a_Crime_in_India-Cause_and_Solutions 7. Shenoi K, Pandiaraj S. Honour Killing in India- A Socio Legal Study [Internet]. Acadpubl.eu. 2018 [cited 25 May 2019]. Available from: https://acadpubl.eu/hub/2018- 120-5/4/399.pdf 8. Manoj–Babli honour killing case [Internet]. En.wikipedia.org. 2019 [cited 20 June 2019]. Available from: https://en.wikipedia.org/wiki/Manoj%E2%80%93Babli _honour_killing_case 9. Qandeel Baloch Killed at the Behest of Cleric, Father Tells Pakistan Court [Internet]. News18. 2019 [cited 22 June 2019]. Available from: https://www.news18.com/news/world/qandeel-baloch- killed-at-the-behest-of-cleric-father-tells-pakistan-court- 1561817.html 10. A Girl in the River's Oscar win gives Pakistan chance to end honour killings | Yasmeen Hassan [Internet]. the Guardian. 2019 [cited 22 June 2019]. Available from: h t t p s : / / w w w . t h e g u a r d i a n . c o m / g l o b a l - development/2016/mar/04/a-girl-in-the-river -oscar-win- pakistan-end-honour-killings

185 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00041.2 Review Article Current techniques used for diatom test in diagnosis of drowning deaths 1. Shivam Saini, PhD. Scholar* 2. Bhuvnesh Yadav, Assistant Professor* *Department of Chemistry, Biochemistry and Forensic Science, Amity School of Applied Sciences, Amity University, Gurugram, Haryana, India

ABSTRACT : Diatoms are well known water planktons with variable number of shape and sizes, and they are found in almost all types of water bodies. They (diatoms) are very important in Forensic Science in solving cases where death has occurred due to drowning. When a person drowns in water he tends to grasps for air due to which water along with diatoms enters the lungs, and from lungs into the blood stream and from blood stream the diatoms get lodged into the distant organs of the body. The identification of diatoms is based on the morphology of their structure by using light microscopy or scanning electron microscope. In an investigation of a case in which the body has been recovered from a water body, two preliminary queries arise i.e. whether the drowning is post-mortem or ante-mortem. Since symptoms of drowning diminishes with the passage of time; hence diatom test act as a revival tool in solving the cases pertaining to deaths by drowning. This paper reviews the progress made in the recent years in the diagnosis of diatoms pertaining to deaths by drowning.

Corresponding Author : Article History: Bhuvnesh Yadav Received: 18 January 2019 Assistant Professor, Received in revised form: 19 August 2019 Accepted on: 19 August 2019 Department of Chemistry, Biochemistry and Forensic Available online: 31 December 2019 Science, Amity School of Applied Sciences, Amity University, Gurugram, Haryana, India Contact : +91 9899402613 Email: [email protected].

KEYWORDS : diatom, post-mortem, acid digestion, proteinase K, scanning electron microscope

INTRODUCTION : obliterate signs of crime. The main factors which are to be Diatoms are microscopic, aquatic unicellular eukaryotic algae. considered for ante-mortem drowning or post-mortem They are photosynthetic (autotrophic) algae belonging to the drowning are hairs, clothing, washer woman symptoms on Kingdom Protista and Class Bacillariophyceae[1]. One of the palm and sole, copious leathery froth from mouth and nostrils. most conspicuous feature of diatom is that they have silica cell But these findings are not confirmatory and are not present in [7] wall. They are either radially symmetric (centric diatoms) or every case . Therefore under such circumstances medico- bilaterally symmetric (pennate diatoms). The frustules of legal/algological collaboration is required to confirm the cause diatoms consist of two halves (thecas) and their lids of death. For algological analysis tissue samples from the (hypotheca and epitheca). They have lace like patterns with recovered body and water sample must be analyzed on the nanometer scaled pores and these patterns delineate them into basis of microscopical-algological analysis. This should different species[2]. record the qualitative, quantitative and morphological aspects of every sample for diatoms. The diatom test is based on the According to Mann and Droop[3] there are more than 200000 diatom density in the medium in which drowning occurred and species of diatoms; however Guiry[4] had estimated that there number of diatoms which have passed from lungs to blood[8]. are about 20000 species of diatoms. Diatoms occurs in almost every type of habitat, but some species of diatoms have a With the help of diatom test from tissue sample and water narrow range of distribution due to preferable mode of habitat sample collected from the site of drowning, we can ascertain and thus they can be used for biomonitoring[5].Diatoms have three possibilities from the corpse recovered from the water different environmental preferences on the basis of pH, light, body: temperature, moisture condition, salinity, oxygen, organic and I) If the diatoms were not detected in tissue samples then this inorganic nutrients[6]. indicates that victim was dead before entering the water body. One of the commonest way of suicidal death is drowning. ii) If the diatoms detected in tissue samples matched with the Criminals dump dead bodies of victims into water bodies to

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control water sample taken from the spot then this indicate that and the recovery rate was also found to be higher [12]. victim had drowned in the same spot where body was Detection of diatoms by enzymatic digestion method recovered. Takeichi and Kitamura (2009) in their study showed that iii) If the diatoms detected in the tissue samples did not match formalin fixed samples can also be used for the detection of with the control water sample this indicates that victim had diatoms by using enzymatic digestion method. The lungs drowned in different water site. samples were heated in 0.01 M Tris-HCl buffer (pH 7.5) All these factors make diatom one of the most suitable containing sodium dodecyl sulphate (SDS) with or without organisms for forensic investigations. Since their silica cell glycine. Thereafter the lungs samples were subjected to wall is also indestructible, present in almost all types of water enzymatic digestion with proteinase K. Then the samples were bodies and capability to penetrate from lungs to blood make heated at 800C for 6-12 hours and then the samples were them suitable microorganisms to be used for investigations of analyzed microscopically. In their study they showed that drowning deaths. incubation of digested samples with this method were more Methods of extraction of diatoms appropriate for qualitative and quantitative analysis of diatom [13]. Extraction of diatoms from various tissue samples required a complete destruction of tissue sample. Therefore the criteria Ming et al (2007) in their study compared the four digestive which is to be set up for the diatom test is based on time methods (nitric acid and hydrogen peroxide, proteinase K, required for samples digestion, digestive capability of the nitric acid in disorganization can and soluene-350) and showed method used, reclaiming of diatoms after digestion and that structure of diatoms under scanning electron microscope extraction and destruction of diatom frustules. Some earlier (SEM) were remained perfect after digestion with proteinase studies conducted on diatom test directly utilized tissue K. While the diatoms recovered by other three methods were samples for microscopic examination, but with the found destroyed to some extent. Therefore in their study they intervention of new technologies, the diatom test has been showed that majority of diatoms can be extracted from [14] improvised and standardized. proteinase K method with higher recovery rate . Detection of diatoms by using acid digestion method Kakizaki and Yukawa (2015) proposed a new protocol for solubilizing lung tissue by using Qiagen proteinase K, qiagen Acid digestion method is one the most commonly used method buffer ATL and 5N HCl. They detected about 60-23000 valves for the digestion of tissue samples. This test involves the use of in twenty lung samples from ten victims of drowning deaths[15]. nitric acid, hydrochloric acid (HCl), sulphuric acid (H2SO4) Seo et al (2013) developed a method for detecting of diatoms and hydrogen peroxide (H2O2) with various versions. Bortolotti et al[9] used nitric acid for the digestion of lung tissue from heart blood in drowning victims. For extraction of samples at 600C for 48 hours and Digiancamillo et al[10] used diatoms from blood DNA binding ability of diatom frustules hydrochloric acid and hydrogen peroxide to perform various they utilize chaotropic agents. They used proteinase K for experiments on animal tissue samples pertaining to drowning DNA purification from blood and chaotropic agent for deaths. denaturation. DNA/diatom complex formed was then recovered by ethanol precipitation and then DNA was digested Fucci (2012) in his study showed that classical acid digestion by DNAase. Purified diatoms were seen under microscope[16]. method used for the detection of diatoms is distructive and can destroy the diatoms frustules. A newly developed method is by Detection of Diatoms using molecular biological techniques taking 30% H2SO4 and then treat the samples with the diluted solution has an advantage over the classical method. The Molecular biological techniques involve analysis and advantage of this method was that there is decrease in the manipulation of DNA, RNA, protein and lipids. presence of destroyed diatoms fragments and moreover other Morphological methods used for the detection of diatoms are microorganisms like radiolarians could also be detected by this labour-intensive and susceptible to subjective interpretation. method[11]. With the help of molecular biological techniques the detection Wang et al (2015) developed a new digestion method by using limits of diatoms are also increases many folds as compared to morphological methods. Lefort aqua regia solution (3:1 HNO3 to HCl) to evaluate the digestive capability, diatom destruction and diatom recovery. Various authors advocated the use of DNA and RNA for the The samples digestives with Leforts aqua regia digestion analysis of diatoms from the tissue samples. Idota et al (2017) method were found superior as compared to conventional acid in their study presented that molecular biological techniques digestion method. The structures of diatoms were found intact are more appropriate than acid digestion method for detection

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of diatoms. They advocated the use of temperature gradient gel Recovery of diatoms from various tissue samples without loss, electrophoresis (TGGE) by targeting the 16S rDNA. In these destruction and contamination is the foremost criteria for the studies, DNA was extracted from the water samples from diatom test. Various methods used for diatom test in case of drowning site and tissue samples of heart and liver collected drowning deaths are acid digestion method, enzymatic from 27 bodies. After amplification of 16S rDNA by method, molecular biological techniques and microwave polymerase chain reaction and bands pattern observed with digestion method. Negative results of the drowning deaths TGGE represents a specific genomes which can be used for does not exclude drowning as it also depends on the identification of species and named it spiddo (Species concentration of diatoms in the site of drowning and the identification dot). In their study they observed that there was a volume of tissue used for digestion as well as digestive higher correspondence between the 16s rDNA from the site of method. The diatom test currently used for drowning deaths water and blood or liver samples and rate was higher than that needs to be improved by more sensitive methods so that test achieved from acid digestive method[17]. While He et al also may play a more important role for detection than ever. detected plankton DNA from various organs like lung, liver, However more scientific research is required to increase the kidney, blood and brain of drowned victims and thus showed sensitivity and specificity of this test in ther future. that this method is most accurate for the detection of diatoms in REFERENCES : the tissue samples of human[18]. 1. Round FE, Crawford RM, Mann GD. The Diatoms: Molecular biological techniques by detection of 16S rRNA Biology & Morphology of the Genera. Cambridge subunits of ribosomal RNA can be used for the detection of University Press, Cambridge. 1990. planktons in tissue samples and thus indicated the inhalation of 2. Gross M. The mysteries of the diatoms. Cur Bio. diatoms in drowning deaths[19]. 2012;22(15):581-85. Han et al (2013) in 40 drowning cases study showed that 3. Mann DG, Droop SJM. Biodiversity, bio geography and plankton rDNA PCR method is most appropriate for diatom conservation of diatoms. Hydrobiologia. 1996;336:19-32. detection than nitric acid digestion method. From the study they concluded that detection rate from plankton rDNA PCR 4. Guiry MD. How many species of algae are there? J method from liver and kidney was 80% each while from nitric Psychology. 2012;48:1057-1063. acid digestion method it was found to be 40% and 30% 5. Collins A, Ohandja DG, Hoare D, Voulvoulis N. respectively[20]. Implementing the water framework directive: a transition Detection of diatoms by using microwave digestion- from established monitoring networks in England and vacuum filtration-automated scanning electron Wales. Env Sci &Policy. 2012;17:49-61. microscopy 6. Van Dam H, Mertens A, Sinkeldam J. A coded checklist Tissue samples used for digestion with microwave digestion and ecological indicator values of freshwater diatoms method have a vacuum infiltration with pore size of filter from the Netherlands. Netherlands J Aqua Ecol. membrane 0.45µm and scanning electron microscope with 1994;28:117-133. 400 X magnification [21]. Zhao et al in their study of 128 water 7. Shrivastava N, Satpati DK, Kumar A. Easy confirmation related deaths showed that microwave digestion-vacuum of drowning by detection of diatoms in Trachea. J Indian filtration-automated scanning electron microscopy (MD-VF- Acad For Med. 2015;37(4): 352-354. Auto SEM) achieved a higher recovery rate of diatoms as 8. Hurlimann J, Feer P, Elber F, Neiderberger K, Dirnhofer [22] compared to conventional forensic diatom test . Microwave R, Wyler D. Diatom detection in the diagnosis of death by digestion method used for tissue sample digestion is simple, drowning. Int J Legal Med.2000;114:6-14. causes less damage to diatoms frustules and also minimizes the 9. Batolotti F, Del Balzo G, Calza R et al. Testing the loss of diatoms during centrifugation due to membrane specificity of diatom test: search for false positives. Med infiltration. Moreover the samples digested with this method Sci Law. 2011;51:7-10. produces less organic matter and thus they can be easily identified with SEM. Detection of diatoms by using SEM 10. Digiancamillo A, Domeneghini C, Gibelli D, Cattaneo C. allows a features of high resolution and excellent depth which Diatom extraction with HCL from animal tissue: a allows save of labor and time required for analysis. technical note. Legal Med. 2011;13:268-71. 11. Fucci N. A new procedure for Diatom extraction in the diagnosis of drowning. J Clin Exp Pharma. 2012;2(1):1-3. CONCLUSION : 12. Wang H, Liu Y, Zhao J, Hu S, Wang Y, Liu C, Zhang Y. A

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Simple digestion method with a lefort aqua regia solution for diatom extraction. J For Sci. 2015;60(1):227-30. 13. Takeichi T, Kitamura O. Detection of diatom in formalin fixed tissue by proteinase K digestion. For Sci Int. 2009;190(3):19-23. 14. Ming M, Meng X, Wang E. Evaluation of four digestive methods for extracting diatoms. For Sci Int. 2007;170(1):29-34. 15. Kakizaki E, Yukawa N. Simple protocol for extracting diatoms from lung tissues of suspected drowning cases within 3h: First practical application. Forensic Sci Int. 2015;251:179-85. 16. Seo Y, Sato S, Kuroki K, Kishido T. A simple DNA coprecipitation method for the detection of diatoms in heart blood. For Sci Int.2013;232(1):154-159. 17. Idota N, Tsuboi H, Takosa M, Tojo M, Kinebuchi T et al. Comparison between Temperature Gradient Gel Electrophoresis of bacterial 16S rDNA and diatom test for diagnosis of drowning. J For Sci. 2017;63(3):1-6. 18. He F, Huang D, Liu l, Shu X, Yin H, Li X. A novel PCR- DGGE based method for identifying plankton 16S rDNA for the diagnosis of drowning. For Sci Int.2008;176:152- 156. 19. Nubel U, Garcia-Pichel F, Muyzer G. PCR primers to amplify 16S rRNA genes from cyanobacteria. Appl Environ. Microbiol. 1997:63:3337-332. 20. Han JG, Wang CB, Li XB et al. Comparative analysis between diatom nitric acid digestion method and plankton 1 6 S r D N A P C R m e t h o d . F a Yi X u e Z a Zhi.2013;29(5):356-59. 21. Zhao J, Wang Y, Wang G, Ma Y et al. Application of the microwave digestion-vacuum filtration-automated scanning electron microscopy method for diatom detection in the diagnosis of drowning. J For& Legal Med. 2015;33:125-128. 22. Zhao J, Liu C, Bardeesi ASA, WU Y, Ma Y et al. The diagnostic value of quantitative assessment of diatom test for drowning: An analysis of 128 water related death cases using microwave digestion-vacuum filtration-automated scanning electron microscopy. J For Sci. 2017;62 (6): 1638-1642.

189 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 DOI:10.5958/0974-083X.2020.00042.4 Commentary (Scientific Correspondence) MeToo Movement a reality or Myth? 1. Srishti Rai, Research Scholar, Department of Forensic Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India, 2. Manoj Kumar Pathak, Professor and Head, Department of Forensic Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India,

ABSTRACT: #MeToo movement was formed by Tarana Burke. The movement is getting derailed and has lost its way. It is true that harassment at work place is increasing at alarming rate. The avalanche of false allegations is ruining the pace of the movement. Men are now afraid to heir women, to mentor young ladies, to go on business trips or even to stay on the same floor as them in a hotel. IPC section 354 and section 509 deals with this issue competently.

Corresponding Author : Article History: Manoj Kumar Pathak, Received: 16 July 2019 Professor and Head, Forensic Medicine, Department of Received in revised form: 17 July 2019 Accepted on: 17 July 2019 Forensic Medicine, Institute of Medical Sciences, Banaras Available online: 31 December 2019 Hindu University, Varanasi, India, Contact : +91 9450179177 Email : [email protected]

KEYWORDS : MeToo, Stalking, Blackmail Game, Patriarchal Society

INTRODUCTION: go on business trips or even to stay on the same floor as them in #MeToo movement was formed by Tarana Burke. She is a civil a hotel. The fear of false accusation is so strong that there is a right activist from Bronx. She founded the movement in 2006 marked increase in number of men who are afraid of working [3] to help the survivors of sexual abuse. The idea was to with a women alone. Men find it confusing to determine what empathise with the survivors to tell them that they were not type of action or behaviour is permissible and acceptable by alone and there is a certain section of the society which is women community. Due to this confusion they prefer not to willing to help and to listen. She considered this a movement interact with a women at all. Women are becoming more and not a viral campaign.[1] sensitive towards sexual abuse. Women today have become courageous. They do not shy away from reporting the incident The movement is getting derailed and has lost its way. It is of harassment and want the culprit to be punished. The turning into a gender war, circle of accusation against drawback is that some women are using this movement for powerful men. According to Modi government's disclosure in their personal gain. It is turning into a tool for easy promotions, the Lok Sabha, 2535 complaints of sexual harassment in office success and blackmail game. spaces have been registered during the last four years from 2014-2018. The number is steadily increasing. It was 372 in The point is that a few baseless allegations have uprooted the 2014 and was up by 57% in 2017. IPC section 354A, 354D base of the movement and paved the way for objections even (stalking) and section 509 deals with this issue competently.[2] on true charges. The real loss has to be faced by the women community only. There will be lesser job opportunities as men It is true that harassment at work place is increasing at have started avoiding women colleagues. They do not want to alarming rate. Most of the men forget their boundaries and guide them through projects. According to the Art of courtesy being brought up in a patriarchal society, but are the Mentoring, an Australian report done post MeToo, 25% of men men to be blamed entirely? What creates a positive stir has admitted they were nervous about working alone with female negative impact too. colleague and in US, research found the number of men in The avalanche of false allegations is ruining the pace of the senior roles feeling “uncomfortable” about mentoring a movement. Incidents of false allegations against powerful women had tripled, just because some women have used the men in order to gain profit are popping up. This in turn in movement as a licence to destroy men.[4] An example is of a creating a negative impact by damaging the work Genpact employee who was accused of sexual harassment by environment. two of women employee in the company. The day Swaroop Men are now afraid to heir women, to mentor young ladies, to Ray assistant Vice President was accused, he was found dead

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in his apartment the following night. The suicide note read as Post #MeToo? [Internet]. Forbes.com. 2019 [cited 06 June “the allegations are baseless but the entire Genpact will know 2019]. Available from: about it, hence I do not have the courage to face everyone. I https://www.forbes.com/sites/prudygourguechon/2018/0 want you to be strong and live your life with respect because 8/06/why-in-the-world-would-men-stop-mentoring- [5] your husband did not do anything”. women-post-metoo/ CONCLUSION 4. Real cost of 'scared' #MeToo men [Internet]. Just because a few women fail to understand the agenda of a NewsComAu. 2019 [cited 10 June 2019]. Available from: movement they are ruining the movement. If the allegations h t t p s : / / w w w. n e w s . c o m . a u / fi n a n c e / w o r k / a t - are true then this will pave the way for women encouragement work/strategies-used-by-men-scared-of-metoo- and women empowerment. The guilty men who suppose them movement-could-be-negatively-affecting-women/news- to be powerful than women and have a mentality that they can story/42d945a126b5a3d2d4f97f41374732d4 physically or mentally torture the women whenever and 5. Genpact Swaroop Raj suicide: Genpact management, two wherever they can. This will be checked by MeToo movement. staffers booked | Noida News - Times of India [Internet]. MeToo movement is just like a double edged sword as for The Times of India. 2019 [cited 23 June 2019]. Available example in cases of feigned charges or allegations there are from: high chances that women may lose some better career https://timesofindia.indiatimes.com/city/noida/avps- prospects and job opportunities. s u i c i d e - g e n p a c t - m a n a g e m e n t - t w o - s t a ff e r s - Acknowledgement: booked/articleshow/67186860.cms Authors would like to thank print and electronic media for providing us with immense resource materials in preparation of this article. Conflict of interest: Nil Source of funding: This research was financially supported by UGC. Ethical clearance: The present study was approved by “Institutional Ethical Committee” of Institute of Medical Sciences, Banaras Hindu University, Varanasi. All the information has been taken under consideration of medical ethical committee. Statement of Informed consent:This is a review study done by going through various online contents. No consent was required. Statement of Human and Animal Rights:No human right and animal right is violated in this case. REFERENCES: 1. Meet Tarana Burke, the woman who founded the #MeToo movement [Internet]. India Today. 2019 [cited 03 June 2019]. Available from: https://www.indiatoday.in/education-today/gk-current- affairs/story/meet-tarana-burke-the-woman-who- founded-the-metoo-movement-1360183-2018-10-10 2. Why Men Should Not Be Afraid Of #MeToo | NewsClick [Internet]. NewsClick. 2019 [cited 15 June 2019]. Available from: https://www.newsclick.in/why-men- should-not-be-afraid-metoo 3. Why In The World Would Men Stop Mentoring Women

190 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687

INSTRUCTIONS TO AUTHORS •Unpublished, Ethical, Un-Plagiarised original manuscript written in English should be sent to: Dr. Parmod Kumar Goyal, Editor-in-Chief, Journal of Punjab Academy of Forensic Medicine and Toxicology by email at: [email protected] •Images (Good quality) should be sent separately in JPEG format. •References should be in Vancouver Style only. The Publication Particulars The JPAFMAT is the official publication of the Punjab Academy of Forensic Medicine & Toxicology, published since 2001. The Contents of the Journal The journal accepts a range of articles of interest, under several feature sections as follows: Original Papers: Includes conventional observational and experimental research. Commentary: Intended for Reviews, Case Reports, Preliminary Report and Scientific Correspondences. Letter to the Editor Designed to be an avenue for dialogue between the authors of the papers published in the journal and the readers restricted to the options expressing reviews, criticisms etc. It could also publish letters on behalf of the current affairs in the field of Forensic Medicine in the country. Editorial Intended as a platform, for the Editor-in-Chief and for others with a keen interest in forensic medicine that wished to comment on the current affairs. Special Features In the History of Indian Forensic Medicine, Book Review, Abstracts, Announcement etc, which appear frequently, but not necessarily in every issue. News and Notes Intended for providing information of members and activities of the Academy and other such other organizations affiliated to the Academy may appear frequently and not in every issue. General Principles The text of observational and experimental articles is usually (but not necessarily) divided into the following sections: Introduction, Methods, Results, and Discussion. This so-called “IMRAD” structure is not an arbitrary publication format but rather a direct reflection of the process of scientific discovery. Long articles may need subheadings within some sections (especially Results and Discussion) to clarify their content. Other types of articles, such as case reports, reviews, and editorials, probably need to be formatted differently. Electronic formats have created opportunities for adding details or whole sections, layering information, cross linking or extracting portions of articles, and the like only in the electronic version. Double spacing all portions of the manuscript— including the title page, abstract, text, acknowledgments, references, individual tables, and legends—and generous margins make it possible for editors and reviewers to edit the text line by line and add comments and queries directly on the paper copy. If manuscripts are submitted electronically, the files should be double-spaced to facilitate printing for reviewing and editing. Authors should number all of the pages of the manuscript consecutively, beginning with the title page, to facilitate the editorial process. International Uniform Requirements Please visit http://www.icmje.org/ for detailed instructions for manuscript submission. Note : Manuscript handling charges Rs. 1500/- to be paid after acceptance for Indian Authors.

192 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 Life Members (PAFMAT) No. Name No. Name No. Name 1 Dr. R.K. Gorea 43 Dr. Mian Abdur Rashid 85 Dr Iram Khan 2 Late Dr. Sat Pal Garg 44 Dr. Shilekh Mittal 86 Dr Charanpreet K. Pawar 3 Dr. D.S. Bhullar 45 Dr. B.R. Sharma 87 Dr Mukul Chopra 4 Late Dr. A.S. Thind 46 Dr. D.Harish 88 Dr Mohit Gupta 5 Dr. Hakumat Rai 47 Dr. Krishna D. Chavali 89 Dr Rahul Chawla 6 Dr. K.K. Aggarwal 48 Dr. Ashwani Kumar 90 Dr Maneel Grover 7 Dr. Jaswinder Singh 49 Dr. Vikram Bains 91 Dr Y.S. Bansal 8 Dr. Karamjit Singh 50 Late Dr. Kirpal Singh 92 Dr C.S. Gautam 9 Dr. Harjinder Singh 51 Dr. Gurbachan Singh 93 Dr S.P. Mandal 10 Dr. Virender Pal Singh 52 Dr. Sangeet Dhillon 94 Dr Murli . G 11 Dr. Ashok Chanana 53 Dr. Sukhbir Singh Chauhan 95 Dr Anil Kumar Mittal 12 Dr. J.S. Dalal 54 Dr. Parminder Singh Bhatti 96 Dr G.A. Sunil Kumar Sharma 13 Dr. Jagdish Gargi 55 Dr. Rakesh Kumar 97 Dr Abhishek Yadav 14 Dr. R.S. Parsad 56 Dr. Jagbir Singh 98 Dr Jagdev Kullar 15 Late Dr. Ajit Singh 57 Dr. Karnveer Singh 99 Dr Gurpreet Kaur Randhawa 16 Dr. Harish Tuli 58 Dr. Rajiv K. Chowdhary 100 Dr Gursirat Singh Khokhar 17 Dr. S.K. Bal 59 Dr. Parmod Kumar Goyal 101 Dr Saginder Samara 18 Dr. S.S. Sandhu 60 Dr. Ajay Kumar 102 Dr Saginder Samaraj 19 Dr. Akashdeep Aggarwal 61 Dr RK Sharma 103 Dr Neha Sharma 20 Dr. Kuldeep Singh 62 Dr Brij M. Gupta 104 Dr Sunil Mahajan 21 Dr. Vishal Garg 63 Dr Sunil Gambhi 105 Dr Harshdeep Kashyap 22 Dr. S.S. Oberoi 64 Dr Vijal Pal Khangwal 106 Dr Kiran Kumar 23 Late Dr. Ram Lubhaya 65 Dr Rajiv Joshi 107 Dr Swati Tyagi 24 Dr. Amandeep Singh 66 Dr Manpreet Kaul 108 Dr Mini 25 Dr. Harkirat Singh 67 Dr Sheikh AnayatUllah 109 Dr Mandeep Kaur 26 Dr. I.S. Bagga 68 Dr Satinder Pal Singh 110 Dr Gurinder Singh 27 Dr. Harpreet Singh 69 Dr Preetinder Singh Chahal 111 Dr Minal 28 Dr. Parminder Singh 70 Dr Kulbhushan Garg 112 Dr Kanchan Jyoti Heera 29 Dr. Anil Garg 71 Dr Imran Sabri 113 Dr Manpinder Kaur Bhullar 30 Dr. O.P. Aggarwal 72 Dr Bindu Aggarwal 114 Dr Arashdeep Singh 31 Dr. Gaurav Sharma 73 Dr Adish Goyal 115 Dr Chamandeep Singh Bains 32 Late Dr. Madhur Tayal 74 Dr Charak Sangwan 116 Dr Maninder Singh 33 Dr. Gurmanjit Rai Mann 75 Dr Pardeep Singh 117 Dr Akhilesh Agarwal 34 Dr. Didar Singh 76 Dr Ishwer Tayal 118 Dr Guneet 35 Dr. Kuldeep Singh 77 Dr Ripan Chanana 119 Dr Hitesh Bhatia 36 Dr. Pankaj Gupta 78 Dr Gurvinder Singh Kakkar 120 Dr. Deep Rattan Mittal 37 Dr. Karam Singh 79 Dr Ravdeep Singh 121 Dr. Arun Kumar Maria 38 Dr. Baljit Singh 80 Dr Rohit Kumar Singal 122 Dr. S Valliappan 39 Dr. Puneet Khurana 81 Dr Prabhdeep Singh 123 Dr. Preet Inder Singh 40 Dr. Puneet Arora 82 Dr Jasbir Singh 124 Dr. Harvinder Singh Chhabra 41 Dr. Prabhsharan Singh 83 Dr Jatinder Pal Singh 125 Dr. Bhoj Kumar Sahu 42 Dr. Dildar Singh 84 Dr Alok Kandpal 126 Dr. Amarnath Mishra

193 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687 Life Members (PAFMAT) No. Name No. Name 127 Dr. Shekhar Chumber 165 Dr. Vivekanshu Verma 128 Dr. Navroz Goyal 166 Dr. B.V. Naga Mohan Rao 129 Dr. Gurjeet Singh 167 Dr. Anju Gupta 130 Dr. Deepika Kanwar 168 Dr. Guriqbal Singh 131 Dr. Mohd. Amjad Bhatt 169 Dr. Prashanthi Krishna Dharma 132 Dr. Nikhil Mehta 170 Dr. Amarjit Singh 133 Dr. Charan Kamal 171 Dr. Keshav Soni 134 Dr. Amit Singla 172 Dr. Faisal Nasim Gilani 135 Dr. Sukhdeep Singh 173 Dr. Ashok Sagar 136 Dr. Munish Kumar 174 Dr. Suresh Chand 137 Dr. Arindam Chatterjee 175 Dr. Jaswinder Singh 138 Dr. Ranjodh Jeet Singh 176 Dr. Prateek Rastogi 139 Dr. Kanika Kohli 177 Dr. Varun Garg 140 Dr. Vinka Maini 178 Dr. Hitesh Chawla 141 Dr. Ravi Tejpal 179 Dr. Sanjeev Buri 142 Dr. Preet Mohinder Singh 180 Dr. Sunil M Doshi 143 Dr. Satbir Singh 181 Dr. Sanjay Kumar 144 Dr. Kamaljit Singh 182 Dr. Akhilesh Pathak 145 Dr. Mrinal Kanti Jha 183 Dr. Raghvendra Kumar Vidua 146 Dr. Vijay Arora 184 Dr. Jitendra Kumar Gupta 147 Dr. Vivek Srivastava 185 Dr. Manoj Kumar Pathak 148 Dr. Pankaj Chhikara 186 Dr. Surendra Kumar Pandey 149 Dr. Lalit Kumar 187 Dr. Mayank Gupta 150 Dr. Prem Chandra 188 Dr. Amandeep Kaur Srivastava 189 Dr. Mukesh Kumar Meena 151 Dr. Niraj Kumar 190 Dr. Jitender Kumar Jakhar 152 Dr. Om Parkash Saini 191 Dr. Kamal Singla 153 Dr. Rajesh Kumar Verma 192 Dr. Rajender Kumar Saini 154 Dr. Shailender Kumar 193 Dr. Chandra Pal 155 Dr. B.L. Chaudhary 194 Dr. Rattan Singh 156 Dr. Parmod Kumar Saini 195 Dr. Jyoti Barwa 157 Dr. Rajendra Singh Kulhari 158 Dr. Nidhi Sachdeva Agarwal 159 Dr. Rajeev Varma 160 Dr. Pragnesh Bharatkumar Parmar 161 Dr. Yatiraj Singi 162 Dr. Navpreet Kaur 163 Dr. Kunal Khanna 164 Dr. Smitha Rani Shetty

194 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687

Punjab Academy of Forensic Medicine & Toxicology Undertaking format for organizing PAFMATCON/Any Other CME/Workshop under the banner of PAFMAT To The President / General Secretary Punjab Academy of Forensic Medicine & Toxicology Subject : Consent for Holding the Conference. Dear Sir As discussed and decided in the general / executive body meeting of the academy dated ……………………….at ……..……………………………………(name the venue), I give my consent to hold the ………………annual conference of Punjab Academy of Forensic Medicine & Toxicology on ..……………………...... ……(Tentative date) in ……………………………………… (Name of the medical college / venue) Subject to the following:- a. The conference and / or the CME programme shall be under the auspices of Punjab Academy of Forensic Medicine & Toxicology. The banner showing the same will be displayed at a suitable area on the main venue. b. The President and the General Secretary of the Academy will be suitably seated on the dais during the inaugural programme. The President will address the gathering about the policies, programs or other relevant aspects of the Academy. The General Secretary will read out the annual report. c. The registration of the President, General Secretary, Secretary Finance and the Editor-in-Chief of the Academy will be complimentary. d. The conference will get accredited with at least 4 CME Credit hours from Punjab Medical Council. e. The President and / or General Secretary of the Academy along with one member of Punjab Medical Council will be the signatory to the certificate issued to delegate attending the conference / CME / workshop. f. The organizing committee will send formal invitation to all the office bearers of the academy. g. The Journal of the Academy will be released during the inaugural programme. The Editor-in-Chief and the Joint Editor will be invited to the dais for the release ceremony. h. The Organizing Secretary of the programme will hand over the list of the delegates to the General Secretary of the Academy at the end of the conference. i. The Organizing Committee will collect Rs. 100/- ( Rupees one hundred only) per delegate of the programme and will deposit the collected amount in the account of the Journal of PAFMAT / hand over the Cheque for the collected amount favoring Journal of Pb. Aca. Of Forensic Med. & Toxicology to the Editor-in-Chief after the conference.

Sd/-

Organizing Chairman / Secretary Name: PAFMATCON :

195 J Punjab Acad Forensic Med Toxicol 2019;19(2) ISSN : 0972-5687

Format of Application for Subscription of Journal To The Editor-in-Chief Journal of Punjab Academy of Forensic Medicine & Toxicology (JPAFMAT) Dear Sir, I wish to Subscribe the Journal of Punjab Academy of Forensic Medicine & Toxicology. I am furnishing the required particulars below with a request to subscribe the Journal. The fee of Rs. 1000/4000 for Journal of Punjab Academy of Forensic Medicine is enclosed. PARTICULARS 1. Full Name ( in block letters ) 2. Father's / Husband's name 3. Date of Birth 4. Qualification ( with name of university & date of passing ) 5. Official Designation & Place of Posting 6. Permanent Address 7. Address for Correspondence ( subsequent change of address to be intimated) 8. Phone No. & Email 9. Photo 10. Copy of Medical Council Registration Certificate Place Yours Sincerely Date (Signature)

Note : 1. Payment can be made through online transfer in the Journal Account. For any query related to subscription of the Journal, feel free to talk/whattsapp on mobile no. 98760-05211 2. The above information can be sent by email to editor-in-chief 3. Subscribers of the Journal are entitled for Five (5) CME credit hours per year as per CME Accredition Guidelines issued by Punjab Medical Council.

196 J Punjab Acad Forensic Med Toxicol 2019;19 (2) ISSN : 0972-5687 Glimpse of 2019 J Punjab Acad Forensic Med Toxicol 2019;19 (2) ISSN : 0972-5687 Editorial Board

Editor-in-Chief Joint Editor Assistant Editor Web Master Dr Parmod Kumar Goyal Dr Amandeep Singh Dr Satinder Pal Singh Dr Dildar Singh National Advisory Editorial Committee: Manuscript Review Committee Board Dr S. S. Oberoi Dr OP Murti Dr. Vivek Srivastava Dr T.D. Dogra Dr Sangeet Dhillon Dr V. V. Pillay Dr. Pardeep Singh Dr J.S. Dalal Dr Ishwar Tayal Dr Shiv Kochhar Dr. Monika Gupta Dr R.K. Gorea Dr Kuldeep Singh Dr R.K. Sharma Dr. Navita Aggarwal Dr O P Aggarwal Dr Harjinder Singh Dr N K Aggarwal Dr. Tanvir Kaur Sidhu Dr K K Aggarwal Dr Harpreet Singh Dr Amitabh Shrivastva Dr. Sandeep Kaur Dr Balbir Kaur Dr Parul Kher Dr Shankar M. Bakkannavar Dr. Priti Chaudhary Dr K. Vij Dr Antara DebBarman Dr Mukesh Yadav Dr. Vijay Suri Dr Dalbir Singh Dr Gurpreet S. Sandhu Dr C.B. Jani Dr. Saranpal Singh Dr Sanjoy Dass Dr S K Dhattarwal Dr. Vijal Pal Khanagwal Dr. Lovleen Marwaha Dr E.J. Rodrigeus Dr Jaskaran Singh Dr. Samita Sinha Dr. Tanuj Kanchan Dr Gurudatta Pawar Dr Manoj Pathak Dr. Manjot Kaur Dr. Raghuvendra K. Vidua Dr D.S. Badkur Dr Jaswinder Singh Dr. Karan Maheshwari Dr. Vivek Kumar (Siliguri) Dr Jagadeesh. N. Dr PC Srivastava Mrs. Ritika Gupta, FSL Bathinda Dr. Pragnesh Kumar Dr Pramod Kumar Dr Om Parkash Saini Dr. Nidhi Sachdeva Dr. Imran Sabri

Subscription Information Claims for Missing Issue Members of PAFMAT will receive the journal free of cost. A c o p y w i l l b e s e n t t o t h e Subscription rates for Non-Members and Institutions for Year 2020 member / subscriber provided the Personal: Rs. 1,000/- Institutions: Rs. 5,000/- claim is made within 2 months of the Abroad : Postal Charges Extra publication of the issue and Rs. l Subscription request be sent on email to 50/- deposited in the Journal [email protected] account as postal Charges. l Payments be made in Bank Account of Journal of Punjab Academy of Forensic Medicine (A/c No. 65075504236, State Bank of India, Branch Rajindra Hospital Patiala, IFS Code SBIN0050263 Printed & Published by: Printed at: Dr Parmod Kumar Goyal Subhash Mittal Printing Press Professor & Head, Hospital Bazar, Bathinda Department of Forensic Medicine & Toxicology M. 99880-11022 Adesh Institute of Medical Sciences & Research, e-mail: [email protected] Bathinda (Pb.) India M. 9876005211, 0164-5055073 E-mail: [email protected]