Morphology of the mural and commissural atrioventricular junction of the mitral valve

OBJECTIVE

This study investigates mitral annular disjunctions (MAD) in the atrial wall-mitral annulus-ventricular wall junction along the mural mitral leaflet and commissures.

METHODS

We examined 224 adult human hearts (21.9% females, 47.9±17.6 years) devoid of cardiovascular diseases (especially mitral valve disease). These hearts were obtained during forensic medical autopsies conducted between January 2018 and June 2021. MAD was defined as a spatial displacement (≥2 mm) of the leaflet hinge line towards the left atrium. We provided a detailed morphometric analysis (disjunction height) and histological examination of MADs.

RESULTS

MADs were observed in 19.6% of all studied hearts. They appeared in 12.1% of mural leaflets. The P1 scallop was the primary site for disjunctions (8.9%), followed by the P2 scallop (5.4%) and P3 scallop (4.5%). MADs were found in 9.8% of all superolateral and 5.8% of all inferoseptal commissures. The average height for leaflet MADs was 3.0±0.6 mm, whereas that for commissural MADs was 2.1±0.5 mm (p<0.0001). The microscopical arrangement of MADs in both the mural leaflet and commissures revealed a disjunction shifted towards left atrial aspect, filled with connective tissue and covered by elongated valve annulus. The size of the MAD remained remarkably uniform and showed no correlation with other anthropometric factors (all p>0.05).

CONCLUSIONS

In the cohort of the patients with healthy hearts, MAD is present in about 20% of all studied hearts. The MADs identified tend to be localised, confined to a single scallop. Moreover, MADs in the commissures are notably smaller than those in the mural leaflet.

The Impacts of Intervertebral Disc Degeneration of the Spine, Alcohol Consumption, Smoking Tobacco Products, and Glycemic Disorders on the Expression Profiles of Neurotrophins-3 and -4

In the etiology of discogenic pain, attention is paid to the role of neurotrophic factors, which include classic neurotrophins (NTs). This study aimed to assess changes in the concentrations of NT-3 and NT-4 in the intervertebral discs (IVDs) of the lumbosacral (L/S) spine depending on the advancement of degenerative changes, pain severity, habits, and comorbidities. The study group included 113 patients who underwent microdiscectomy due to degenerative IVD disease of the L/S spine. The severity of degenerative IVD changes was assessed using the five-point Pfirrmann scale, and the pain intensity was assessed according to the visual analog scale (VAS). In turn, the control group included 81 participants from whom IVDs of the L/S section of the spine were collected post-mortem during forensic autopsy or organ donation. At the mRNA level, we noted NT-3 overexpression in the test samples compared with the controls (fold change (FC) = 9.12 ± 0.56; p < 0.05), while NT-4 transcriptional activity was decreased in the test samples compared with the controls (FC = 0.33 ± 0.07; p < 0.05). However, at the protein level, the concentrations of NT-3 (134 ± 5.78 pg/mL vs. 6.78 ± 1.17 pg/mL; p < 0.05) and NT-4 (316.77 ± 8.19 pg/mL vs. 76.92 ± 4.82 pg/mL; p < 0.05) were significantly higher in the test samples compared with the control samples. Nevertheless, the concentration of both proteins did not statistically significantly change depending on the advancement of degenerative changes and the pain intensity (p > 0.05). In addition, higher levels of NT-3 and NT-4 were noted in IVD samples from patients who consumed alcohol, smoked tobacco, were overweight/obese, or had comorbid diabetes compared with patients without these risk factors (p < 0.05). Our analysis confirmed that differences in the degenerative process of IVD, energy metabolism, and lifestyle are related to changes in the concentration profiles of NT-3 and NT-4.

Analysis of various radiological age-assessment methods in children, adolescents and young adults regarding the differences between the sexes and sides of the body - A comparative review

A total of 76 articles published within the last twenty years, indexed in the PubMed and ResearchGate databases, were reviewed in order to compare medical imaging-based methods of age estimation of children, adolescents and young adults. The evaluated studies were analyzed for any statistically significant differences between the sexes and sides of the body, sample sizes, and population age. Irrespective of the evaluation method, there were some studies that showed a statistically significant differences in ossification stages between the male and female groups. Most of the studies whose authors conducted a statistical analysis demonstrated no significant differences between the left and right side of the body.

Overkilling: A specific type of homicide - Constructing the definition: Perpetrator, weapon and circumstances

Overkilling in the Forensic Medicine is known as a specific type of homicide where the number of inflicted injuries greatly surpasses the number of fatal ones. Conducted research aimed to create a unified definition of the phenomenon and its classification criteria by analysing a vast majority of variables concerning its various characteristics. From the population of homicide victims autopsied in the authors' research facility a number of 167 cases were chosen consisting of both overkilling and other homicides. 70 cases were thoroughly analysed based on the completed court files, autopsy protocols and photographs. Second part of the research concerned the facts regarding the perpetrator, used weapon and the circumstances of the act. Conclusions of the conducted analysis allowed to add further characteristics to the overkilling definition: the perpetrators were almost exclusively men, around 35 of age, not related to the victim but might have been in a close relationship with them, often a conflicted one. They did not threaten the victim before the incident. Mostly perpetrators were not intoxicated, and they tried to cover up the homicide in various ways. Perpetrators of overkilling were in most cases mentally disturbed (and thus stated insane), had different levels of intelligence but also a low level of planning before the act - rarely taking actions as preparing the weapon in advance, choosing the scene or luring in the victim.

Pulmonary valve morphometry revisited: Clinical implications for valvular and supravalvular interventions

In this cadaver-based study, we aimed to present a novel approach to pulmonary valve (PV) anatomy, morphometry, and geometry to offer comprehensive information on PV structure. The 182 autopsied human hearts were investigated morphometrically. The largest PV area was seen for the coaptation center plane, followed by basal ring and the tubular plane (626.7 ± 191.7 mm² vs. 433.9 ± 133.6 mm² vs. 290.0 ± 110.1 mm² , p < 0.001). In all leaflets, fenestrations are noted and occur in 12.5% of PVs. Only in 31.3% of PVs, the coaptation center is located in close vicinity of the PV geometric center. Similar-sized sinuses were found in 35.7% of hearts, in the remaining cases, significant heterogeneity was seen in size. The mean sinus depth was: left anterior 15.59 ± 2.91 mm, posterior: 16.04 ± 2.82 mm and right anterior sinus: 16.21 ± 2.81 mm and the mean sinus height: left anterior 15.24 ± 3.10 mm, posterior: 19.12 ± 3.79 mm and right anterior sinus: 18.59 ± 4.03 mm. For males, the mean pulmonary root perimeters and areas were significantly larger than those for females. Multiple forward stepwise regression model showed that anthropometric variables might predict the coaptation center plane (sex, age, and heart weight; R²  = 33.8%), tubular plane (sex, age, and BSA; R²  = 20.5%) and basal ring level area (heart weight and sex; R²  = 17.1%). In conclusion, the largest pulmonary root area is observed at the coaptation center plane, followed by the basal ring and tubular plane. The PV geometric center usually does not overlap valve coaptation center. Significant heterogeneity is observed in the size of sinuses and leaflets within and between valves. Anthropometric variables may be used to predict pulmonary root dimensions.

Aortic valve fenestrations: Macroscopic assessment and functional anatomy study

Aortic valve fenestrations are defined as a loss of aortic valve leaflet tissue. They are a common but overlooked finding with unclear significance. The aim of this study was to investigate the varied functional anatomies of aortic valve fenestrations. A total of 400 formalin-fixed autopsied human hearts were macroscopically assessed and the function of the aortic valve of 16 reanimated human hearts were imaged using Visible Heart® methodologies. Aortic valve leaflet fenestrations were present in 43.0% of autopsied hearts (in one leaflet in 24.0%, in two leaflets 16.0%, in all leaflets 3.0%). Fenestrations were mostly present in left (25.5%) followed by right (23.3%) and noncoronary leaflet (16.3%). In 93.8% of cases, the fenestrations form clusters and were mainly located at the free edge of the leaflet in the commissural area (95.4%). Hearts with aortic valve fenestrations had significantly larger aortic valve diameters and aortic valve areas (p < 0.001). The average surface area sizes of fenestrations were 23.8 ± 16.6 mm² , and the areas were largest for left followed by right and noncoronary leaflet fenestrations (p < 0.001). The fenestration areas positively correlated with donor age (r = 0.31; p = 0.02). Significant hypermobility and subjective weakening of the leaflet adhesion levels of the fenestrated regions were observed. In conclusion, fenestrations of the aortic leaflets are frequent, and their sizes may be significant. They occur in all age groups, yet their size increase with aging. Fragments of leaflets with fenestrations show different behaviors during the cardiac cycle versus unchanged areas.

Restraint asphyxia. An analysis of the circumstances and mechanism of death in agitated, physically restrained individuals

W ostatnich latach media coraz częściej poruszane są przypadkami śmierci młodych zazwyczaj osób, w trakcie zatrzymywania przez policję. Śmierć w tych przypadkach dotyka zazwyczaj osoby pobudzone psychoruchowo, obezwładniane z użyciem siły, a badania pośmiertne nie wykazują jednoznacznej urazowej przyczyny zgonu. Celem pracy jest próba ustalenia mechanizmu i okoliczności zgonów w trakcie obezwładniania osób pobudzonych psychoruchowo. Analizie poddano przypadki opiniowane od 2010 roku, zarówno jako sekcje zwłok, jak i oceniane na podstawie materiału aktowego. W analizowanym okresie ZMS w Krakowie wydał opinie w 10 tego typu przypadkach, w dziewięciu na podstawie własnych sekcji zwłok, w jednym na podstawie materiału aktowego. We wszystkich nastąpiło nagłe zatrzymanie krążenia lub utrata przytomności, a resuscytacja okazywała się nieskuteczna. W sześciu przyczyną pobudzenia była ostra psychoza, w czterech działanie narkotyków, zazwyczaj w wysokim stężeniu. Tylko w pięciu przypadkach stwierdzono obecność wybroczyn w spojówkach. Najbardziej prawdopodobną przyczyną śmierci było współistnienie nasilonego wysiłku fizycznego spowodowanego patologicznym pobudzeniem psychoruchowym, z przymusowym unieruchomieniem pogarszającym funkcjonowanie układu oddechowego. Mechanizm ten jest określany jako asfiksja restrykcyjna. Restraint asphyxia. An analysis of the circumstances and mechanism of death in agitated, physically restrained individuals Recent years saw frequent media reports of young people who die while they are being arrested by the police. Death in these circumstances affects people who are agitated and restrained with the use of force, with their autopsies indicating no unequivocally traumatic cause of death. The goal of this study was to identify the mechanism and circumstances of sudden deaths in agitated individuals who are being restrained. Ten cases evaluated at our center since 2010 were included in this study: nine involved forensic postmortem examination and one involved casefile analysis. In each case there was sudden cardiac arrest or at least a loss of consciousness, and the cardiopulmonary resuscitation proved ineffective. In six cases the cause of agitation was acute psychosis, in four it was an effect of narcotics, usually in high concentration. Conjunctival petechiae were detected in only five cases. The most probable cause of death in the evaluated cases was the combination of physical exertion caused by pathological psychomotor agitation and forcible restraint, hindering the function of the respiratory system. This mechanism is known as restraint asphyxia.

Thickness of the left atrial wall surrounding the left atrial appendage orifice

INTRODUCTION

The aim of this study was to investigate the thickness of the left atrial wall surrounding the left atrial appendage (LAA) orifice.

METHODS AND RESULTS

The tissue thickness around the LAA orifice was measured at four points (superior, inferior, anterior, and posterior) in 200 randomly selected autopsied human hearts. The thickest tissue was observed at the anterior point (3.17 ± 1.41 mm), followed by the superior (2.47 ± 1.00 mm), inferior (2.22 ± 0.80 mm) and posterior (2.22 ± 0.83 mm). The chicken wing LAA type was associated with the lowest thickness at the superior point compared to the cauliflower and arrowhead shapes (p = .024). In hearts with an oval LAA orifice, the atrial wall was significantly thicker in all points than in specimens with a round LAA orifice (p > .05). Both the LAA orifice anteroposterior diameter and orifice surface area were negatively correlated with the tissue thickness in the anterior (r = -.22, p = .004 and r = -.23, p = .001) and posterior points (r = -.24, p = .001 and r = -.28, p = .005). Endocardial surface roughness was commonly in the inferior pole of the LAA orifice (75.5% of cases), while they are much less prevalent in other sectors around the orifice (anterior: 17.5%), superior: 4.0%, and posterior: 1.5%).

CONCLUSIONS

Although a significant heterogeneity in the atrial wall thickness around the LAA orifice was observed, the thickness in the respective points is quite conservative and depends only on LAA orifice size and shape, as well as LAA body shape. Thin atrial wall and endocardial surface roughness might challenge invasive procedures within this region.

Morphology of the Left Atrial Appendage: Introduction of a New Simplified Shape-Based Classification System

BACKGROUND

The left atrial appendage (LAA) is a heart structure with known prothrombogenic and pro-arrhythmogenic properties.

AIM

The aim of this study was to evaluate the specific anatomy of the LAA and to create a simple classification system based on the shape of its body.

METHOD AND RESULTS

This study investigated 200 randomly selected autopsied human hearts (25.0% females, 46.6±19.1 years old). Three (3) types of LAAs were distinguished: the cauliflower type (no bend, limited overall length, compact structure [36.5%]); the chicken wing type (substantial bend in the dominant lobe [37.5%]), and the arrowhead type (no bend, one dominant lobe of substantial length [26.0%]). Additional accessory lobes were present in 55.5% of all LAAs. Significant variations between category types were noted in LAA length (chicken wing: 35.7±9.8 mm, arrowhead: 30.8±10.1 mm, cauliflower: 22.3±9.6 mm [p<0.001]) and in the thickness of pectinate muscles located within the LAA apex (arrowhead: 1.2±0.7 mm; cauliflower: 1.1±0.6 mm; chicken wing: 0.9±0.6 mm [p<0.001]). Left atrial appendage volume and orifice size were not affected by the type of LAA shape. The age of the donor was positively correlated with LAA volume (r=0.29, p=0.005), body length (r=0.26, p=0.012), and area of the orifice (r=0.36, p<0.001). Donors with an oval LAA orifice were significantly older than those with round orifices (50.2±16.6 vs 43.7±20.4 years [p=0.014]) and had significantly heavier hearts (458.2±104.8 vs 409.6±114.1g [p=0.002]).

CONCLUSIONS

This study delivered a new simple classification system of the LAA based on its body shape. An increase in age and heart weight was associated with LAA enlargement and a more oval-shaped orifice. Results of current study may help to estimate the different thrombogenic properties associated with each LAA type and be an assistance during planning and performing interventions on LAA.

Topographical anatomy of the right atrial appendage vestibule and its isthmuses

INTRODUCTION

The right atrial appendage (RAA) vestibule is an area located in the right atrium between the RAA orifice and the right atrioventricular valve annulus and may be a target for invasive transcatheter procedures.

METHODS AND RESULTS

We examined 200 autopsied human hearts. Three isthmuses (an inferior, a middle, and a superior isthmus) were detected. The average length of the vestibule was 67.4 ± 10.1 mm. Crevices and diverticula were observed within the vestibule in 15.3% of specimens. The isthmuses had varying heights: superior: 14.0 ± 3.4 mm, middle: 11.2 ± 3.1 mm, and inferior: 10.1 ± 2.7 mm (p < .001). The superior isthmus had the thickest atrial wall (at midlevel: 16.7 ± 5.6 mm), the middle isthmus had the second thickest wall (13.5 ± 4.2 mm), and the inferior isthmus had the thinnest wall (9.3 ± 3.0 mm; p < .001). This same pattern was observed when analyzing the thickness of the adipose layer (superior isthmus had a thickness of 15.4 ± 5.6 mm, middle: 11.7 ± 4.1 mm and inferior: 7.1 ± 3.1 mm; p < .001). The average myocardial thickness did not vary between isthmuses (superior isthmus: 1.3 ± 0.5 mm, middle isthmus: 1.8 ± 0.8 mm, inferior isthmus: 1.6 ± 0.5 mm; p > .05). Within each isthmus, there were variations in the thickness of the entire atrial wall and of the adipose layer. These were thickest near the valve annulus and thinnest near the RAA orifice (p < .001). The thickness of the myocardial layer followed an inverse trend (p < .001).

CONCLUSIONS

This study was the first to describe the detailed topographical anatomy of the RAA vestibule and that of its adjoining isthmuses. The substantial variability in the structure and dimensions of the RAA isthmuses may play a role in planning interventions within this anatomic region.

Morphometric characteristics of myocardial sleeves of the pulmonary veins

BACKGROUND

The pulmonary veins are covered by a myocardial layer, which is often an electrical substrate for atrial fibrillation. The aim of this study was to study the morphologic characteristics of the myocardial sleeves of pulmonary veins by examining a large group of freshly autopsied human material.

METHODS AND RESULTS

The study macroscopically examined a total of 498 pulmonary veins draining the left atrium (120 unpreserved human hearts). In 75.0% of specimens, a classical pulmonary venous pattern was observed. The remainder of specimens either had an additional middle right pulmonary vein (20.0% of cases) or a common left pulmonary vein (5.0% of cases). Among all the veins seen in the classical pulmonary venous drainage type, the left superior pulmonary vein had the longest myocardial sleeves (9.4 ± 4.6 mm; coverage = 60.1 ± 19.4%), followed by the left inferior pulmonary vein (6.6 ± 3.5 mm; coverage = 47.6 ± 18.3%), the right superior pulmonary vein (6.0 ± 2.7 mm; coverage = 50.5 ± 13.9%) and then the right inferior pulmonary vein (5.0 ± 2.8 mm; coverage = 45.6 ± 16.2%; analysis of variance p < .001). In hearts with an additional right pulmonary vein, this vessel had the shortest myocardial sleeves (2.7 ± 1.1 mm; coverage = 36.0 ± 11.6%). In hearts with a common left pulmonary vein, the myocardial sleeves had the longest course for the common vein (13.7 ± 4.4 mm; coverage = 79.7 ± 4.9%).

CONCLUSIONS

Myocardial sleeves of the pulmonary veins were seen in each examined specimen, however, their length varied significantly. In hearts with a classical venous drainage pattern, the left superior pulmonary vein had the longest sleeves. When present, an additional middle right pulmonary vein had the shortest myocardial sleeves, while the left common pulmonary vein had the longest sleeves.

Topography of the oblique vein of the left atrium (vein of Marshall)

BACKGROUND

The oblique vein of the left atrium is of interest for electrophysiologists working in the field of both basic science and clinical practice.

AIMS

We aimed to examine the topographic anatomy of the oblique vein and to assess the vein's location and relationships with surrounding cardiac structures.

METHODS

A total of 200 autopsied adult human hearts were examined.

RESULTS

The oblique vein was observed in 71% of the hearts. Its mean (SD) total length was 30.8 (13.6) mm. In hearts with the oblique vein, a larger distance was observed between the left inferior pulmonary vein (LIPV) and great cardiac vein (mean [SD], 18.6 [5.1] mm vs 16.3 [4.8] mm; P = 0.004), between the left atrial appendage (LAA) and LIPV (mean [SD], 17.8 [6.8] mm vs 15.1 [5.2] mm; P = 0.007), and between the LAA and left superior pulmonary vein (LSPV; mean [SD], 28.5 [7.2] mm vs 21.3 [6.4] mm; P <0.001). Hearts with a classic pattern of left‑sided pulmonary veins were categorized into 4 types based on the length of oblique vein extension. In type I, the vein extended below the level of the LIPV (21.9%); in type II, to the level of the LIPV (47.7%); in type III, to the level of the interpulmonary area (17.2%); and in type IV, to the level of the LSPV (13.3%). In each type, the distance between the oblique vein and LIPV was shorter than that between the oblique vein and LAA Conclusions: The oblique vein had a variable course and differing lengths of extension. The presence of the oblique vein was connected with a greater distance between the left‑sided pulmonary veins and LAA.

Topographic characteristics of the left atrial medial isthmus

BACKGROUND

The purpose of this study was to provide detailed topography of the left atrial medial isthmus (situated between the right inferior pulmonary vein ostium and the medial part of the mitral annulus).

METHODS

Two hundred human hearts (Caucasian, 22.5% females, 48.7 ± 4.9 years old) were investigated.

RESULTS

The mean length of the medial isthmus was 42.4 ± 8.6 mm. Additionally, the medial isthmus line was divided by the oval fossa into three sections with equal mean lengths (upper: 14.2 ± 7.2 vs middle: 14.1 ± 6.1 vs lower: 14.9 ± 4.6 mm; P > .05). The left upper section of the atrial wall was thinner than the lower section (2.5 ± 1.1 vs 3.4 ± 1.6 mm; P < .0001). This study noted three separate spatial arrangements of the isthmus line. Type I (54.5%) had an oval fossa located outside the isthmus line; type II (32.5%) had an oval fossa crossed by the isthmus line, and type III (13.0%) had an oval fossa rim located tangentially to the isthmus line. In 68.5% of the examined specimens, the isthmus area had a smooth surface. Conversely, the remaining 31.5% had additional structures within its borders such as diverticula, recesses, and tissue bridges.

CONCLUSION

This study is the first to describe the morphometric and topographical features of the left atrial medial isthmus. Interventions within the medial isthmus line should be performed cautiously, especially when they are transected by the oval fossa (32.5%). Careful navigation of the area is also recommended due to the possibility of existent additional structures. The latter could lead to catheter entrapment during ablation procedures.

Microscale's relationship between Young's modulus and tissue density. Prediction of displacements

The study presents an experimental verification of Wagner et al.'s relationship in microscale and proposes a modification of this relationship. For this purpose, 11 cubic specimens were microcomputed tomography scanned and mechanically tested with the displacement full-field measurements using a digital image correlation system. Then, numerical simulations of the compression tests were performed using a finite elements method. The Young's modulus distributions assigned to the finite elements models were calculated using both of Wagner et al.'s relationships: original and modified. Comparison of the experimental and numerical results indicated the accuracy of numerical solutions for both relationships.

Medicolegal aspects of PMA-related deaths

Unlike amphetamine, amphetamine-like substances accessible on the drug market are less expensive and more easily available; they also produce hallucinogenic effects expected by the users. Such properties render them more attractive as compared to amphetamine. On the other hand, the knowledge of the toxicity of these compounds is very limited, what in consequence generates problems that create ever-expanding research areas, including analytical, clinical and medicolegal issues, thus leading to development of systemic databases. An example here is paramethoxyamphetamine (PMA), which appeared on the drug market in recent years as a result of creative inventiveness of producers of psychoactive substances, who aimed at PMA replacing the popular ecstasy (MDMA) as a less expensive and more available product. It is more potent than MDMA, but has a slower onset of action, which encourages users to take more. The problem is illustrated in the present paper by three fatal cases involving PMA, which were comprehensively investigated taking into consideration case histories, pathological and toxicological findings obtained with the use of LC-MS-MS method. In blood samples taken from all the three victims, very high concentrations of PMA were found (in the range of 10-27mg/L) and thus the cause of deaths was determined as overdoses of PMA with the underlying mechanism of acute cardiorespiratory failure.

Prediction of Young׳s modulus of trabeculae in microscale using macro-scale׳s relationships between bone density and mechanical properties

According to the literature, there are many mathematical relationships between density of the trabecular bone and mechanical properties obtained in macro-scale testing. In micro-scale, the measurements provide only the ranges of Young׳s modulus of trabeculae, but there are no experimentally tested relationships allowing the calculation of the distribution of Young׳s modulus of trabeculae within these experimental ranges. This study examined the applicability of relationships between bone density and mechanical properties obtained in macro-scale testing for the calculation of Young׳s modulus distribution in micro-scale. Twelve cubic specimens from eleven femoral heads were cut out and micro-computed tomography (micro-CT) scanned. A mechanical compression test and Digital Image Correlation (DIC) measurements were performed to obtain the experimental displacement and strain full-field evaluation for each specimen. Five relationships between bone density and Young׳s modulus were selected for the test; those were given by Carter and Hayes (1977), Ciarelli et al. (2000), Kaneko et al. (2004), Keller (1994) for the human femur, and Li and Aspden, 1997. Using these relationships, five separate finite element (FE) models were prepared, with different distribution of Young׳s modulus of trabeculae for each specimen. In total, 60 FE analyses were carried out. The obtained displacement and strain full-field measurements from numerical calculations and experiment were compared. The results indicate that the highest accuracy of the numerical calculation was obtained for the Ciarelli et al. (2000) relationship, where the relative error was 17.87% for displacements and 50.94 % for strains. Therefore, the application of the Ciarelli et al. (2000) relationship in the microscale linear FE analysis is possible, but mainly to determine bone displacement.

[An unusual case of suicidal carbon monoxide poisoning committed using a portable barbecue grill]

Fatal carbon monoxide poisoning is relatively often encountered in medico-legal practice. Although we usually deal with events of an accidental nature, cases of suicidal character are also quite common, both in Poland and in other European countries. The source of a poisonous gas that is used by a suicide to take his life are usually exhaust fumes from cars and home gas water-heaters that are released in closed spaces. In the present report, the authors present an atypical case--the only such instance in the history of the Krakow Department--where a high carbon monoxide concentration level was achieved by burning briquetted coal in a typical portable barbecue grill. A 65-year old male lit the grill in a room locked from inside, where he had previously sealed all cracks and vents; he left a written message by the entrance where he warned his flatmates about the presence of gas. The investigation determined that the predominant underlying reason of his committing suicide were health problems. As it follows from the analysis of literature on the subject, despite extensively available materials, such a suicide method is exceptionally rare in the European or American culture, where isolated cases only are presented. On the other hand, the authors emphasize the fact that within the last score of years, using barbecue grills in suicidal poisoning has become exceedingly common in the Far East countries. The present report points to certain historical and cultural determinants that may affect such a distinct geographical polarization of the discussed method being used in some Asian countries and refers to a widely discussed by specialists significant role of mass media in popularization of such a suicide method.

[Validity of post-mortem computed tomography angiography (PMCTA) in medico-legal diagnostic management of stab and incised wounds]

The report presents an analysis of results of multi-phase post-mortem computed tomography angiography (MPMCTA) scans performed at the Chair of Forensic Medicine, Jagiellonian University Medical College, in cases of stab wounds and incised wounds, as confronted with the results of conventional medico-legal autopsies. The analysis of the material points to a validity of PMCTA scans as supplementing post-mortem medico-legal examinations and being capable of providing significant data that affect final conclusions and adding new quality to recording post-mortem observations.

[Modus operandi of insane offenders in multiple homicides]

Homicides committed by insane offenders have been rarely investigated from the forensic point of view in a comprehensive and detailed manner. The objective of the study was to describe and characterize the modus operandi and personal characteristics in cases when more than one victim was killed and the perpetrator was deemed insane in judicial proceedings. Differences between single and multiple-vitim homicides in the population of insane murderers were also examined. Complete dossiers and forensic examination reports of 21 homicide victims killed by 9 individuals were retrospectively analyzed. The comparative control group consisted of 41 cases with only one victim killed by a single insane perpetrator. The offence and offender variables were subjected to a comparative statistical analysis. The results indicated some specific factors that can be regarded as distinctive features more commonly observed in multiple vs. single victim killings perpetrated by insane individuals. There was a significant correlation between, psychosis with depressive delusions, emotional/affective motivation, common domicile and a positive relationship between the perpetrator and the victim, infanticide committed in the perpetrator's offspring, actions with elements of planning, attacking victims while asleep, attacking from the back rather than from the front, concentration and clustering of injuries in one region of the body and multiple psychotic homicides. The results and conclusions of this study can provide practical, useful implications for homicide investigations, offender profiling or forensic psychiatric and psychological evidence.

[Common paths of psychiatry and forensic medicine--history and evolution of insanity defense concept from antiquity to modern times]

Forensic psychiatry and psychology were in their beginnings inseparably associated with the forensic medicine, constituting one of its related branches of knowledge. Progress and development of these disciplines, education and the practical application for the purposes of the law were a contribution of a several generations of forensic pathologists in the 19th and 20th centuries. One of the major issues of common interest was opinionating on the sanity of offenders. However, the problem of criminal responsibility of the mentally ill perpetrators dates back to much earlier times and has its roots in the distant beginnings of human civilization. In this paper, the history and evolution of the insanity concept (as a circumstance excluding the guilt of the offender) were presented, from the oldest theories to ideas underlying modern codifications.

[Mental state and the criminal responsibility--legal regulations and medical criteria in Poland and other countries]

In contemporary civilized legal systems, sanity is a prerequisite for criminal responsibility of the perpetrator. Thus, insanity resulting from certain psychiatric and psychological disorders is a circumstance excluding the guilt. General assumptions of insanity criteria are close and similar in legal systems of the majority of countries; however, certain essential differences appear in details of their interpretation and acceptance. These differences in particular appear among systems of continental European states as opposed to these, in which the judiciary system is derived from the English law. The paper presents and discusses in detail the legal and medical considerations of insanity defense in Poland, as well as outlines the legal foundations of this issue in other countries of Europe, North America and Australia.

[Homicides in recent years researched in cooperation with "Archiwum X"]

In the paper 5 cases of hiding corpses after homicides were presented, in two cases corpses were buried, in two cases walled up inside buildings and in one case burned down. Time period between homicide and corpse finding was from one year to 14 years.

Corpse dismemberment in the material collected by the Department of Forensic Medicine, Cracow, Poland

In this study, we present 23 cases of dismembered bodies examined by the Cracow Department of Forensic Medicine in 1968-2005 period. Presented material includes 17 instances of defensive mutilation, three instances of offensive mutilation and two cases when dismemberment (decapitation) was a direct cause of death. One case is hard to classified, the perpetrator dissected free skin from the all torso. Analysis of all presented cases and other publications concentrating on the problem of dismemberment gave us the possibility to perform some conclusions. Apart from rare cases of necrophilia, the victim of dismemberment is always a victim of homicide. Homicides ending with corpse dismemberment are most commonly committed by a person close to, or at least acquainted with the victim and they are performed at the site of homicide, generally in the place inhabited by the victim, the perpetrator or shared by both. Such instances are generally not planned by the perpetrator and rarely serial in character.

An unusual case of corpse dismemberment

A case of corpse dismemberment into 850 fragments was investigated at the Cracow Department of Forensic Medicine. The perpetrator employed various tools to divide the body into fragments and subsequently boiled the pieces to reduce their volume. The thus-prepared body decreased its volume to 30 kg. Subsequently, the perpetrator placed the body fragments in 2 large pots, which were then positioned in the space under the stairs and walled in.

[Myocardial ischemia of the driver as a cause of a traffic road accident. Immunohistochemical C9 staining method in diagnostics of early myocardial infarction]

The authors presented a case of verification of pathological lesions as a cause of traffic accident where the driver--the culprit--was a fatal victim due to multiple injuries. Histopathological examination of postmortem samples of myocardium was conducted, using the hematoxylin-eosin, Nielsen-Selye and immunohistochemical C9 staining methods in order to verify the hypothesis about a possible myocardial ischemia triggering the accident. The results of "routine" (H&E) and--especially--immunohistochemical C9 staining showed myocardial damage due to ischemia, which was a morphological indicator evidencing the cause of "misbehavior" of the driver.

[Depression and legal capacity to stand trial]

The criteria for assessment of legal capacity to stand trial have long been a significant issue in the Polish criminal law. The main problem in opinionating practice is the fact that the code of penal procedure and the executive penal code do not provide any univocal criteria of a mental disease that should be met according to the legal regulations in force. Because of their nature and lack of uniformity, depression and affective disorders pose a particularly great problem for experts who should opinionate on the legal capacity of the suspected and the accused to stand trial. On the one hand, it cannot be accepted that a mental illness renders a person unable to substantially understand legal proceedings and to make a rational defense. On the other hand, however, emotional reactions and mild-degree depression disorders that are only natural when an individual violates law should not be allowed to be regarded as a grave disease and to paralyze legal proceedings. In the present study, the authors have attempted to describe the guidelines that should be followed by court-appointed experts in psychiatry that are commissioned by the court to assess the mental state of an individual. The report emphasizes that in such cases, a thorough analysis, based on medical and legal premises and the experience of the involved court experts are necessary.

[Completed suicide in outline--on basis of Cracow's Institute of Forensic Medicine data in 1991-2000 years]

The study presents the results of research into completed suicide. The authors have analyzed cases of completed suicide committed in Cracow and it's environs in the years 1991-2000. The aim of the research is to describe some features of this phenomenon with it's transformations in the last periods. The presented material bases on archival data of postmortem examinations made in Cracow's Institute of Forensic Medicine. Analyses' were executed in reference of victims' sex, age and place of residence, number and frequency of suicides in Cracow population, methods, predictors and possible motives. The authors also present a sketch of the bibliography regarding the topic, and the comparison between the results of the present study and the results of earlier studies from Cracow environs of the phenomenon of suicide. 1933 cases of completed suicides were analysed, from what over a half concerned occupants of our city. The average coefficient for 100 000 occupants carried out 13.2. There were 1485 men and 448 women among victims, in age from 13 to 95 years. Male to female avarage ratio carried out 3.3:1 in the described period.. Average age carried out 45.5 years, for men 44.5, and for women 48.8 years. The superiority of men is strongly visible in groups of young persons and in "middle age". Results from archival data show that, hanging was the the most frequent way of suicide. In studied material there were more then 63% cases of suicidal hanging. Falls from height, poisonings and drownings were next in line. In very considerable number of cases (almost 60%) the presence of mental disorder in anamnesis was affirmed. This concerned particularly women where the most frequent were depression disorders. For men, first of all factors was dependence from acohol. Over one third of the victims were pensioners and unemployeds. The level of ethanol in blood in 718 cases was crossed 0.5 promille.

Determination of oxcarbazepine and its metabolites in postmortem blood and hair by means of liquid chromatography with mass detection (HPLC/APCI/MS)

A typical use of hair analysis in forensic toxicology is the documentation of previous drug administration. This is illustrated in a suicidal death of a 58-year-old epileptic patient who was treated with oxcarbazepine and probably with levomepromazine. The toxicological analysis carried out by HPLC/APCI/MS included also the hair (6 cm length) besides postmortem blood. The method was validated for levomepromazine, oxcarbazepine (OXCBZ) and its two metabolites, 10-hydroxycarbazepine (CBZ-10OH) and trans-diol-carbazepine (CBZ-diOH) in various biological matrices. The analysis of the postmortem blood indicated oxcarbazepine and its two main metabolites were present at therapeutic concentrations; levomepromazine was detected at a fatal concentration. In three 2-cm segments of hair, oxcarbazepine and its two metabolites were detected; however, levomepromazine was not detected in this specimen. As a result of complex chemical-toxicological investigation it was confirmed the information that the decedent. was an epileptic patient and was treated with oxcarbazepine for at least 6 months before death. In addition, he took a toxic dose of levomepromazine in order to commit suicide. The analysis revealed differences between the concentration levels of oxcarbazepine and its active metabolite CBZ-10OH in postmortem specimens and hair, suggesting different mechanisms of penetration of metabolites and their precursors into this matrix.

[Physical illness as an aim in suicidal mutilations]

This study presents five cases of completed suicides in which injures were situated in parts of the body changed by illness or in areas related to medical treatment. Following early research, physical illness has been identified as an important risk factor for suicide and for suicidal behavior. It is an unusual and rare problem when opposition to somatic disease is signified by the localization and character of suicidal injures. These cases illustrate such a phenomenon, where the body--in a symbolic way is engaged in expression of human stress and frustration. This is caused by the loss of the possibility to control one's own life. The authors also discussed this problem in the view of the literature.

Suicide and suicide attempts in adolescents and young adults in Kraków in the years 2002-2003

The aim of the study was to present the increasingly alarming phenomenon of completed suicide in adolescents and young adults. The material analysed had been drawn from the records of post-mortem examinations conducted by the Institute of Forensic Medicine in Kraków. The analysis covered cases of completed suicide committed by 15-30 years old inhabitants of Kraków or its environs between the September 2002 and the September 2003. The group of subjects analysed comprised 47 individuals (9 females and 38 males); 57.4% of these had resided in a big city (Kraków), and the remaining 42.6%--in villages or little towns near Kraków. The data regarding cases of completed suicide were compared with the data regarding suicide attempts by self-intoxication in the period under consideration, extracted from the documentation of the Department of Clinical Toxicology in Kraków. The latter data encompassed 233 cases of suicide attempts by individuals ranging in age from 15 to 29 years, with females constituting 62.2% of these, and males--37.8%. 65% of the attempters had been residents of Kraków. The analysis of the data from the Institute of Forensic Medicine revealed that nearly half of the suicide victims concerned had been treated for mental disorders, mainly depression and addictive disorders. The occurrence of suicide attempts prior to the fatal act was established in the case of 17 subjects (18.5%). Over half of the subjects (48.9%) committed suicide by hanging themselves, 17%--by falling from a height, 8.6%--by drowning, and 19.1%--by self-intoxication with medicaments. 77.2% of the subjects committed suicide at home. In the case of 23 subjects (48.9%), the post-mortem examination revealed the presence of alcohol. The analysis of the cases of suicide attempts by self-intoxication revealed a significant percentage of depressive disorders (26%)--of high occurrence especially in the case of females, whereas alcohol addiction was the predominant diagnosis in the case of males. Furthermore, the majority of the attempters exhibited situational reactions or personality disorders. Suicide attempts constitute an essential part of the issue of suicide in adolescents and young adults and require further research. What attracts notice, is a high percentage of males among suicide victims, and a high percentage of suicide victims with earlier suicide attempts. The results of the study should be taken into consideration in suicide prevention in groups especially endangered by the risk of completed suicide, such as adolescents and young adults after suicide attempts.

[Committed suicide in the background of the history of previous suicide attempts--a 5-year prospective study of suicide attempts]

The aim of the study was to estimate the risk factors for eventual suicide in the case of individuals hospitalised for a suicide attempts (or attempted suicide). The group examined comprised 238 patients, who, in the years 2000-2001, were hospitalised in the Department of Clinical Toxicology CM UJ in Kraków for suicidal self-intoxication with medical drugs. The group consisted of 63 males and 175 females ranging in age from 17 to 79 years (the mean age was 36 years). The instruments applied in the examination included a structured interview and a set of psychological tests; complementary information was obtained from the patients' case histories. In the year 2005, on the basis of the data from the Institute of Forensic Medicine in Kraków, it was established that 10 of the patients under consideration--6 females, and 4 males--had eventually committed suicide within the period concerned. The retrospective analysis of the case of each of these 10 individuals revealed that the majority of them had been treated psychiatrically for depression or alcoholic addiction, had experienced parental or marital bereavement, or had experienced serious financial difficulties. The subjects' case histories informed also about the cases of suicidal death in the families of several subjects. As should be pointed out, the results of psychological tests obtained earlier by the 10 subjects concerned did not unequivocally indicated high endangerment by the risk of eventually committing suicide. Finally, it is necessary to observe that alcoholism and depression were the most frequently diagnosed mental disorders in the case of the male suicides. In the case of the female suicides, the results of the analysis reveal a variety of psychological, psychiatric and socio-demographic factors that, eventually, could lead to suicide.

[Influence of weather factors on suicidal hangings]

The paper presents a certain biometeorological problem. The evaluation of influence of weather factors on frequency of suicidal cases by hanging in the area of Cracow City during 1991-2002 was examined. Rapid changes of air pressure, air temperature, hot, sweltering and sultry days, very frosty days, days with strong or foehn wind, days with thunderstorms, fog and haze were selected as unfavourable weather factors. They give an occasion for strong psychical stress. The results of detailed investigations are next: more frequency of cases of suicide during the advance of cold fronts, rapid decreases of air pressure during hot, sweltering and sultry days, days with thunderstorms and foehn winds in the Tatra Mountains.

[Hair analysis in the evaluation of complex drug-poisonings for medico-legal purposes]

Among various alternative materials used in toxicological analysis the most important is hair, in which xenobiotics deposited create a possibility to observe the history of their administration in the period determined by the hair-length. In this paper the authors have tried to outline the course of the application of hair analysis in forensic toxicology for medicolegal purposes. The undertaken subject has been recorded in four cases of complex drug poisonings in which hair analysis was used in the toxicological evaluation. Drugs detected in the hair of the examined subjects inform about the history of pharmacological therapy in confrontation with those administered in order to commit suicide. The analysis confirms a model of dependence and proves drinking of alcohol and use of cocaine during the pharmacological therapy of dependence.

[Medical and legal aspects of inability to participate in legal proceedings and the execution of imprisonment resulting from mental illness]

A mental disorder of the criminal can be the cause of reprieving penal conduct or the execution of imprisonment. In the present study the matter of ability to take part in legal proceedings and arrest in preliminary custody were considered. The possibility and propriety of staying in conditions of imprisonment mentally ill persons was also considered. Legal settlements relating to this problem were submitted. We paid attention to medical circumstances in which judicial experts should act in such cases.

[Hair analysis as a document of oxcarbazepine therapy in fatal levomepromazine poisoning]

A development of contemporary analytical methods makes possible to use hairs in toxicological analysis for documentation history of drug administration. An undertaken subject has been illustrated by a suicidal fatal poisoning of 58-year-old man with a neuroleptic drug--levomepromazine. Toxicological analysis carried out by HPLC/APCI/MS, besides of standardized postmortem specimen as blood, urine, liver and cerebrospinal fluid included also victim hairs. As a result of analytical procedure levomepromazine at high concentrations was revealed, which may be responsible for death. Moreover, and antiepileptic drug--oxcarbazepine and two main metabolites at therapeutic concentrations were revealed parallel. In three 2-cm segments of hair oxcarbazepine and two metabolites were detected, levomepromazine, in contrary, was not detected in this specimen. Complex chemical-toxicological investigation confirmed information that victim was an epileptic patient and was treated with oxcarbazepine at least 6 months before death while toxic dose of levomepromazine, as one could suppose, he took to commit suicide.

[Male and female suicides in the material of Department of Forensic Medicine in Krakow--comparative analysis]

The study presents the results of research into completed suicide obtained by cooperation between the Department of Forensic Medicine and the University Psychiatry Department in Kraków. The aim of the research is to determine similarities and differences among the cases of completed suicide depending on the sex of the subjects. The authors analyzed cases of completed suicide committed in Kraków and its environs in the years 1991-2000. The groups of females and males have been compared from the point of view of medical-forensic and psychosocial aspects. The authors also present a sketch of the bibliography regarding the topic, and the comparison between the results of the present study and the results of earlier studies from Kraków environs on the phenomenon of suicide.

[Chest stab wound comparison in suicidal and homicidal cases]

In view of the appearance of cases of homicides by stabbing in which the killer claims that the victim committed suicide cases of homicides and suicides of this type have been compared. Contrary to the opinions appearing in the medico-legal issues stating that the commonly described features of the suicidal wounds such as tentative wounds, stabbing in the intercostals space, "removal" of clothes do not appear in some of the suicides, a few of these features do appear in each of the examined cases. Having considered the horizontal wound arrangement in the skin, which is a newly described feature, the differentiation between homicides and suicides are more categorical. In addition to that, the low level of alcohol in the blood is an extremely characteristic feature of the suicide by chest stabbing. On the contrary, typical features of suicidal death don't appear in cases of "aggressive self-destruction", self inflicted fatal wounds inflicted by a person with mental disorders.

[Completed suicide and depression in the elderly]

The aim of the study was to present problems of completed suicide and depression in the elderly. Postmortem examinations were conducted in the Institute of Forensic Medicine of the Jagiellonian University. The analysis included cases of completed suicide in adults, from which all the cases of individuals aged over 65 who in the years 1998, 1999, and 2000 committed suicide within the area of Kraków the City were selected for the present study. The examined group consisted of 92 individuals ranging in age from 65 to 89 years, including 34 females and 58 males. The mean age was 72.5 for the entire group. 44.5% of the subjects had resided in a big city (Kraków); the remainder of the group had resided in villages and towns around Kraków. 57.6% of the subjects committed suicide by hanging, 16.3%--by falling from a height, and 13%--by drowning. In the majority of cases (77.2%), the suicide was committed at home. In 17 cases (18.5%), the post mortem revealed the presence of alcohol. As regards somatic diseases in the examined population, the data from the anamnesis (often incomplete) indicate frequent occurrence of cardiovascular diseases. 43.5% of the subjects, who committed suicide, had been treated for mental disorders, mainly for depression, organic brain disorders, and alcohol addiction. 17 of the subjects (18.5%) had previously attempted to commit suicide. The above results indicate that a typical representative of the elderly committing suicide is a septuagenarian residing in the country or in a small town, and most typically committing suicide by hanging at home. The attention must be paid to the high number of mental disorders, especially depression, detected among both male and female subjects. The close relation between suicide and depression in the elderly is an important guideline on suicide prevention programs and therapy of psychogeriatric patients.

[The completed and attempted suicide in Krakow: similarities and differences]

The study presents the results of the interdisciplinary research conducted on the basis of cooperation between the Institute of Forensic Medicine, the Department of Clinical Toxicology, and the Clinic of Psychiatry in Kraków. The aim of the research was to determine similarities and differences between attempted and completed suicide from the point of view of socio-demographic and clinical traits. The authors analysed 220 cases of completed suicide committed in Kraków and its environs in the year 2000. The material presented in the study was based on the archive data from post mortem examinations conducted in the Institute of Forensic Medicine in Kraków. The sample consisted of 177 males and 43 females ranging in age from 13 to 89 years. The mean age was 43.6 years for the entire group, 42 years for males and 50 years for females. The majority of subjects were males, either unemployed, or pensioners. A similar tendency was observed in the group of female subjects. Mental disorders and alcoholic addiction in anamnesis were discovered in a significant number of cases, both in the group of males and in the group of females. Subjects, in whom serious somatic diseases had been detected, constituted a separate group of cases. According to the archive data, in the last century, suicide was most frequently committed by hanging. Similarly, in the sample examined, in 133 cases, suicide was committed by hanging. In 37% of cases, the level of alcohol in the suicides' blood was between 0.5 and 3 or more g/L. In 2000/2001, within the analogical period of 12 months, the group of 200 patients after a suicide attempt by drug intoxication was examined in the Department of Clinical of Toxicology Jagiellonian University College of Medicine. This group included 49 males and 150 females, ranging in age from 18 to 79 years (mean age 35). The examination was conducted by means of structured investigation and medical documentation. Contrary to completed suicide, in the group of suicide attempters, females outnumbered males. Young people under thirty, living in a large city, possessing elementary or secondary education, and either unemployed, or pensioners, constituted the majority of the examined group. A significant percentage of females was divorced and lived with their children only. The majority of the examined population of suicide attempters had used alcohol during the attempt, had suffered from depression, personality or behavioural disorders, had undergone psychiatric treatment, or had had cases of suicide among their friends or relatives.

[Medicolegal problems of "dyadic death"]

The authors present 9 cases of homicide followed by suicide of the perpetrator--so called dyadic death from the practice of the Cracow Forensic Medicine Chair. The circumstances of the event, medico legal and psychiatric problems were discussed in view of the literature. A typical picture of the perpetrator is male of the average age 49, killing his spouse or children. The major reasons of dyadic death are: breakdown in a relationship, mental and somatic diseases, financial stress. Very uncommon in dyadic death are cases of murder of people from outside the closest family.

[Criminalistic and penal problems with "dyadic deaths"]

This paper is a supplement to the article "Medico legal problems of dyadic death" elaborated by the same authors. Recalling the cases presented there. It is also an attempt to present the basic criminalistic, penal and definitional problems of dyadic death called also postagressional suicide. Criminalistic problems of dyadic death were presented in view of widely known "rule of seven golden questions"--what?, where?, when?, how?, why?, what method? and who? Criminalistic analysis of cases makes some differences in conclusions but it seemed interesting to match both--criminalistc and forensic points of views to the presented material.

[Fatal suicidal poisoning using chemicals and drugs in the Jagiellonian University Institute of Forensic Medicine, in the years 1991-2000]

191 cases of fatal suicidal poisonings in the years 1991-2000 were analysed. Postmortem examinations were conducted in the Institute of Forensic Medicine of the Jagiellonian University. The group of poisonings was selected from a total of 1937 fatal suicidal cases examined in our Institute. Frequency of suicidal attempts, kind of chemicals/drugs used, age and sex relationships, probable motives and seasonal a variables were taken into account in our investigation. The results were compared to previous studies. Poisonings comprise about 10% of the total number of suicidal cases. The most frequent are poisonings using drugs, then using chemicals. The number of cases of males committing suicide by poisoning is about twice as many as seen in females in such cases. The most important motives were mental disturbances, the latter most frequent motives were alcoholism and somatic illnesses. The peak of number of cases was noted in the summer months, June and July (about 1/3 of the total number of cases). In the last decade we systematically observed both a rise in the total number of suicides and a lower percentage of poisonings.

[Crimes against life in the material of Cracow's Institute of Forensic Medicine--comparative analysis in the years 1986-2000 and 1996-2000]

The authors presented a comparative analysis of crimes against life in five year periods of the past and present political systems based on autopsy material of Cracow's Institute of Forensic Medicine. Investigation of these types of crime confirmed sociological observations of arising the criminal trends in the last years. The incident of these types of crimes arose in the last period by about 40% in a relation of male to female victims 3.7:1. Probable motives of these crimes were: drinking 8%, decline in family relationships 12%, fight and revenge 9% robbery 8%, sexual offenses only in 1%. In 61% of analyzed cases the motives were unknown. Among the weapons of crime the most often used were blunt objects and death due to stabbings and cuts. A very high incidence of fire arm crimes in comparison to previous period was observed--from 2 cases in 1986-1990 to 25 in the five year period of 1996-2000. 78% of victims were in a state of insobriety at the moment of crime.