Autopsy findings of suicidal hanging in Mugla,Turkey

Abstract

Introduction: External and internal autopsy findings of suicidal hanging were evaluated retrospectively in Muğla, Turkey. The relations between macroscopic autopsy findings and age, gender, nature of the ligature, position of the knot, and the ligature marks were assessed. The aim of this study was to describe autopsy findings of the hangings and discuss the regional differences. Method: The reports of 175 hanging autopsies between 2013 to 2018 were evaluated retrospectively. Macroscopic external and internal findings were evaluated and compared statistically. Results: Among the 2534 autopsies, the cause of death was suicide by hanging in 175 cases (6.9%). The male-to-female ratio was 3:1, 76%(n = 133) of the cases were male, 24% (n = 42) were female, the mean age was 44.9(SD = 19.3) years. Suicide by hanging was most prevalent in the 25–44 age group and among men. Complete hanging was more common than incomplete hanging, and softer materials were more commonly used in incomplete hangings. Females utilized soft materials more than males. Males used atypical hanging more than females. Bilateral hemorrhage in the neck muscles was more common with typical hanging. There was a significant relationship between tongue protrusion and hemorrhage at the clavicular head of sternocleidomastoid muscle. Conclusion: In this study, which includes a large series, some regional and gender differences were observed. Careful and detailed macroscopic examination was important to diagnose antemortem vitality findings.

Keywords

Hanging autopsy asphyxia ligature mark hemorrhage

Introduction

Asphyxia is a complex and rather controversial subject in the practice of forensic medicine The word ‘asphyxia’ is derived from a Greek origin meaning ‘stopping of the pulse’.⁽^1,2⁾ Saukko and Knight⁽¹⁾ emphasize that the etymological definition, i.e. ‘stopping of pulse’ is more accurate compared to the more common definition of ‘deprivation of oxygen’, since there are several other mechanisms involved in death by asphyxia. Hanging has been classified under ‘asphyxia’ in classical forensic medicine literature, and Saukko and Knight⁽¹⁾ classified it is the ‘fatal pressure on the neck’ in asphyxial death. The mechanism of death by hanging includes many anatomical and physiological factors, such as airway occlusion, occlusion of the neck veins, compression of the carotid arteries, pressure on the baroreceptors and vagal cardiac arrest Death most likely results from a combination of different mechanisms.

Hanging is a form of asphyxia, in which the fatal pressure applied to the neck with the help of ligature material, is derived from the gravitational drag of the weight of the body or part of the body. If the whole body is hanging off the ground and the full weight of the body is suspended from the neck, the hanging is considered to be ‘complete hanging/full suspension’, whereas if a part of the body is in contact with the floor or another supporting object, the hanging is classified as ‘incomplete hanging/partial suspension’. Hangings are also classified according to the position of the knot: if the knot of the ligature is at the back of the neck and ligature mark lies on the anterior region of the neck, hanging is defined as typical, and all other conditions are defined as atypical.⁽^1–5⁾

A significant number of studies focus on determining the demographic characteristics of the hanging cases, evaluating the hanging mark, and detected of vitality findings by macroscopic, histopathological and immunohistopathological examinations.⁽^3–9⁾

The Working Group on Human Asphyxia examined agonal patterns in video recordings of suicide by hanging.⁽^10,11⁾ Other similar efforts include the determination of cervical soft tissue hemorrhage together with findings of bleeding in the bowel wall,⁽¹²⁾ intervertebral hemorrhages (also known as Simon's bleedings),⁽¹³⁾ and pneumomediastinum and cervical emphysema through postmortem MRI.⁽^14–16⁾

In this study, we retrospectively evaluated the external and internal autopsy findings of suicidal hanging in Muğla, which is located in southwest of Turkey. We discuss the relation between macroscopic findings and age, gender, nature of the ligature, position of the knot, ligature mark and autopsy findings. The aim of this study is to describe autopsy findings with the intent of focusing on external and internal autopsy characteristics in hanging and discuss the regional differences.

Methods

Sample and location: We retrospectively evaluated forensic reports of the suicide by hanging cases from autopsies carried out in the Council of Forensic Medicine (Turkey)-Muğla Branch between January 2013 and December 2018. Among the 2534 autopsies, 8% (n:203) of them were asphyxial death; hanging in 175 cases (6.9%), 12 cases were traumatic and postural asphyxia, 7 cases were foreign body aspiration (choking), 4 cases were suffocation, one case was strangulation by ligature and 4 cases were manual strangulation. The autopsy reports of hanging deaths were evaluated retrospectively.

Procedures: Data concerning age, gender, place of event, nature of the ligature, the position of the knot (typical or atypical hanging), methods of hanging (complete/full or incomplete/partial), ligature mark, external and internal examination findings, hemorrhage of neck muscle, and bone and cartilage fracture of the neck structure was recorded.

We divided the cases into four age groups based on the United Nations and UNICEF definitions.⁽¹⁷⁾ For the statistical analysis, groups were divided into two with the 20-year-range age like; 24 years and below, 25–44, 45–64, and 65 years and above.

The nature of the ligatures was divided into two categories: hard materials (e.g. rope, steel rope, cable, belt, strap, duct tape, wire, laundry wire, garden hose) and soft materials (bedsheet, clothes, towel, bathrobe belt, headscarf, etc.). Shaving of pubic hair: if there is a hair shaving of pubic area (perhaps on the same day or the day before), this was recorded.

Hanging methods were classified as ‘complete hanging/full suspension’ if the whole body was off the ground with the full weight of the body suspended from the neck or as ‘incomplete hanging/partial suspension’ if a part of the body was in contact with the floor or another supporting object.⁽¹⁾ Hangings were also classified according to the position of the knot: ‘typical’ if the knot of the ligature was at the back of the neck; and ‘atypical’ if the knot was anywhere else of the neck or if there was no knot. The position of the knot was classified based on analyses of both autopsy reports and crime scene investigation reports.⁽¹⁾

For diagnosis of antemortem findings; we evaluated hemorrhage in the soft tissues of the neck structures. The term of haemorrhage was used for only as antemortem/true bruisings. The neck was evaluated after the drainage of head and neck. For our evaluation, the neck was separated into upper and lower neck regions; the upper neck region was defined as the region around and above the hanging mark, around the hyoid bone and thyroid cartilages, and around the epiglottis and the root of the tongue; whereas the lower neck region was defined as regions below and distant from the hanging mark, and the sternal and clavicular heads of the sternocleidomastoid (SCM) muscle.

Analysis: The data were analyzed using SPSS version 22.0. The chi-square test was used for the comparison of categorical data and the results were presented in frequencies and percentages.

Ethical approval: This study was approved by the Training and Scientific Research Committee of the Council of Forensic Medicine Directorate (Date: 25/12/2018, Decision number: 21589509/2018/974).

Results

Demographic findings: 76% (n = 133) of the hanging cases were male and 24% (n = 42) were female, with a male-to-female ratio of approximately 3/1. The mean age was 44.9 (SD:9.3) years (range:17–91 years). The distribution of hanging cases according to age groups and gender is presented in Table 1. The incidence of suicide by hanging was the highest between ages 25–44 (42.9%, n = 75). Gender was found to be associated with certain age groups. There were significantly more males in the ≤ 24 years’ age group, whereas subjects aged ≥ 65 years were more likely to be female (p < 0.05).

Table 1.

The distribution of hanging cases according to age groups and gender.

Age groups	Male		Female		Total
Age groups	N	%	N	%	n	%
≥24	21	15.8	2	4.8	23	13.1
25-44	57	42.8	18	42.9	75	42.9
45-64	36	27.1	9	21.4	45	25.7
≤65	19	14.3	13	30.9	32	18.2
Total	133	100.0	42	100.0	175	100.0

Pearson Chi-Square: 8.197, df: 3, p = 0.042.

Nature of the ligature: Hard material was used in 92.5% (n = 148) of the cases, and most commonly a rope (78.1%, n 116). Other hard materials used for hanging included cable, wire, belt, or hose. Only 7.5% (n = 12) of the cases had used soft material for hanging (i.e. clothes, robe belt, linens, headscarf, etc.). Females utilised soft materials significantly more than males (p < 0.05).

The ligature mark: in all hanging cases, the ligature mark was above the thyroid cartilages. The mark was usually oblique from bottom to top, and raised high to a gap. All cases were evaluated as a suicidal hanging according to the ligature marks and crime scene investigation reports.

Position of the knot: 61.7% of the cases were ‘typical hanging’, where the knot was at the back of the neck. In 11.4% of the cases, there was no mark caused by a knot, and the hanging marks indicated multiple noose. Males used atypical hanging significantly more than females (p < 0.05). The distribution of the position of the knot by gender is presented in Table 2.

Table 2.

The distribution of the position of the knot by gender.

The positions of the knot*	Male		Female		Total
The positions of the knot*	n	%	N	%	n	%
Typical (on the back)	76	57.1	32	76.2	108	61.7
Atypical (on the left)	23	17.3	5	11.9	28	16.0
Atypical (on the right)	17	12.8	1	2.4	18	10.3
Atypical (no knot, more than one noose)	16	12.0	4	9.5	20	11.4
Atypical (on the front)	1	0.8	0	0.0	1	0.6
Total	133		42		175	100.0

Pearson Chi-Square: 4.901, df:1, p = 0.027*. *comparing typical and atypical hangings.

Methods of hanging (complete hanging/full suspension or incomplete hanging/partial suspension): Forensic reports of 58 examined cases did not include information regarding the method of hanging. 72 (61.5%) of the remaining 117 hangings were complete hanging (full suspension) and 45 (38.5%) were incomplete hanging (partial suspension). The method of hanging was not found to be associated with gender but was significantly associated with the properties of the hanging mark. We found that complete hanging (full suspension) was more commonly atypical compared to incomplete hanging (partial suspension) (p < 0.05), and that soft materials were more commonly used in incomplete hanging (partial suspension) (p < 0.05). Method of hanging, the position of the knot and nature of the ligature distributions are presented in Table 3.

Table 3.

The distribution of the methods and the type of hanging and nature of the ligature.

	Complete hanging		Incomplete hanging		Total
	n	%	n	%	N	%
Hard materials	71	65.1	38	34.9	109	100.0	Fisher's exact test p = 0.005
Soft maerials	1	12.5	7	87.5	8	100.0
Total	72	61.5	45	38.5	117	100.0
Typical hanging	39	53.4	34	46.7	73	100.0	Pearson Chi-Square: 5.399 df:1, p = 0.020
Atypical hanging	33	75.0	11	25.0	44	100.0
Total	72	61.5	45	38.5	117	100.0

Shaving of pubic hair: In 57.1% (n: 100) of cases had a shaving of pubic hair. There was a significant relationship between gender and pubic hair shaving (p < 0.001). While the pubic hair shaving rate is 47.4% in men, and 88.1% in women.

External autopsy findings:

Facial congestion: 144 (82.3%) cases had facial congestion, and 39.6% (n = 57) of them were atypical hangings. Other 25 (14.3%) cases had no facial congestion and 20% (n = 5) of them were atypical hanging, and in 6 (3.4%) cases were unknown. Although the rate of congestion was higher in atypical hanging, there was no statistically significant difference (p > 0.05). Facial congestion were significantly associated with hemorrhage in the clavicular head of the SCM muscle. 66% of the cases with congestion had SCM muscles hemorrhage, and 36% of the cases without congestion had SCM muscles hemorrhage (p < 0.005).

Protrusion of tongue: In 51.4% of the cases, it was observed that the tongue protruded and stuck between the teeth, leading to ecchymosis and abrasion of the tongue where it was stuck and dehydrated (parchment like) where it was exposed to air. The protrusion of the tongue was not associated with the hanging tool, the method of hanging, or the nature of ligature (p > 0.05).

Skin blister on the hanging mark: 17 cases had skin blisters on their hanging marks. Among these, 10 were typical and 7 were atypical hangings. 5 of the atypical hanging cases had multiple hanging marks with no knot mark, 12 were complete hanging/full suspension, and 15 used hard materials. Skin blister formation was not correlated with hanging materials, the position of the knot or the method of hanging (p > 0.05).

Internal autopsy findings:

3.8.1 Soft tissue haemorrhage in neck structure: 79.4% (n = 139) and 61.1% (n = 107) of the cases had soft tissue hemorrhage in the upper and lower neck regions, respectively. Hemorrhages were most significantly observed in the clavicular origin of the SCM muscle or the supraclavicular region. 24 out of 36 subjects without upper neck hemorrhage had bleeding in the lower neck region, and 56 out of 68 subjects without lower neck hemorrhage had bleeding in the upper neck region. The comparison of the upper cervical soft tissue hemorrhage findings with the position of the knot is presented in Table 4. Bilateral hemorrhage was more likely in typical hanging (p < 0.05). The position of the knot was not found to be significantly associated with lower neck hemorrhages (p > 0.05).

Table 4.

The distribution of the position of the knot and hemorrhage of the upper region of the neck.

Position of the knot	Hemorrhage in upper region of the neck*
Position of the knot	Bilateral (n)	Right (n)	Left (n)	Total (n)
Typical (on the back)	53	15	20	88
Atypical	22	20	9	51
Atypical (on the left)	12	4	3	19
Atypical (on the right)	2	8	4	14
Atypical (more than one noose)	8	7	2	17
Atypical (on the front)	0	1	0	1
Total	75	35	29	139

Pearson Chi-Square: 8.450, df:2, p = 0.015 (comparing typical and atypical hangings). * the upper neck region was defined around and above the hanging mark, around the hyoid bone and thyroid cartilages, around the epiglottis and the root of the tongue.

Hemorrhage in the clavicular head of the SCM muscle was found to be significantly correlated with the protrusion of the tongue. Hemorrhage was determined in the clavicular origin of SCM in 72.2% of subjects with, and in only 49.4% of those without tongue protrusion. Hence, this finding is associated with tongue protrusion (Pearson Chi-Square: 9.574, df: 1, p = 0.002).

Bone and cartilage fractures in neck: Bone and cartilage fractures were only evaluated by dissection. 61.1% (n:107) of cases had fractures in bone and/or cartilage tissues in the neck (i.e. hyoid bone, thyroid cartilage, and cervical vertebrae) accompanied by soft tissue hemorrhage in the surrounding regions. 37.7% (n:66) of all cases had hyoid bone fracture, 29.1% (n:51) had thyroid cartilage fracture, and 5.7% (n:10) had vertebral fracture. Table 5 shows the localization of the fractures of bone and cartilage in the neck and in relation with the type of hanging, the method of hanging and the ligature materials. However, there were not any statistically significant results (p > 0.05). We found that thyroid cartilage fracture was positively correlated with age (p < 0.05, Table 6). Only 8.7% of cases aged ≤ 24 years had thyroid cartilage fracture whereas this rate was 46.9% for cases aged ≥ 65 years.

Table 5.

Localization of fractures of bone and cartilage in the neck and in relation with the type of hanging, the method of hanging and the ligature materials. .

		Fractures areas
		Hyoid bone (n = 66)	P value	Thyroid cartilage (n = 51)	P value	Cervical bone (n = 10)	P value
Ligature materials	Hard	60	p > 0.05	45	p > 0.05	8	p > 0.05
Ligature materials	Soft	4	p > 0.05	2	p > 0.05	0	p > 0.05
Type of hanging	Typical	31	p > 0.05	21	p > 0.05	4	p > 0.05
Type of hanging	Atypical	15	p > 0.05	14	p > 0.05	2	p > 0.05
Method of hanging	Complete	43	p > 0.05	26	p > 0.05	8	p > 0.05
Method of hanging	Incomplete	23	p > 0.05	25	p > 0.05	2	p > 0.05

Table 6.

Relationship between age groups and thyroid cartilage fractures.

Age groups	Thyroid cartilage fractures				Total
	positive		negative		Total
	n	%	n	%	n	%
≥24	2	8.7	21	91.3	23	100.0
25-44	20	26.7	55	73.3	75	100.0
45-64	14	31.1	31	68.9	45	100.0
≤65	15	46.9	17	53.1	32	100.0
Total	51	29.1	124	70.9	175	100.0

Pearson Chi-Square: 9.836, df:3, p = 0.020.

Discussion

In the present study, suicide by hanging comprised 6.9% of all autopsies in last 6 years in Muğla (Turkey), and the male/female ratio was 3/1. Almost all relevant studies emphasize the majority of males in cases of suicide by hanging.⁽^{3–8,18–30}⁾ In our study, the incidence of suicide by hanging was the highest between ages 25–44 (Table 1). The gender and age distributions of suicide by hanging in our study are compatible with the literatures.

The manner (origin) of death was suicide in all our cases according to the crime scene investigation findings. The antemortem vitality findings were detected in the soft tissues meant that the individuals were alive during the hanging process.

In a previous study from Turkey, it was reported that there were some common preparatory rituals before the suicide such as daily axillary and pubic hair shaving.⁽¹⁹⁾ In our study, we found that 57.1% of cases had a pubic hair shaving. This was perhaps an incidental finding, but nonetheless remarkable. There was a significant relationship between gender and pubic hair shaving, more in women than in men. This action may be a religious ritual, specific to some regions within Muslim countries, and could represent a form of mental preparation prior to suicide.

The nature of ligature: Among the many different materials, rope is the most commonly used for suicide by hanging.⁽^{20,21,22–25}⁾ Rawat et al.⁽²²⁾ and Sahoo et al.⁽²⁵⁾ reported hard material usage rates to be 53.46 and 51.95%, respectively, whereas Üzün et al.⁽²⁰⁾ reported that 85.68% of suicide by hanging cases involved ropes. We evaluated whether use of soft or hard materials as a hanging tool would make a difference in internal and external autopsy findings.

In our study, hard materials, especially rope, were the most commonly used material. Females preferred soft materials significantly more than males. Sheets were especially common as a hanging tool in cases from prisons.

The position of the knot: Hangings are classified as typical or atypical according to the position of the knot around the neck.⁽^1–5⁾ Studies report different rates of typical and atypical hanging. Sharma et al.,⁽²⁶⁾ Kurtulus et al.,⁽³⁾ Russo et al.⁽⁴⁾ and Talukder et al.⁽²⁷⁾ reported atypical hanging rates to be 88%, 47.1%, 24% and 78.78%, respectively. We found that 61.7% of hanging cases were ‘typical hanging’, where the knot is at the back of the neck. We also observed that the incidence of atypical hanging was significantly higher among males (Table 2).

The methods of hanging: Russo et al.,⁽⁴⁾ Faduyile et al.,⁽¹⁸⁾ Dean et al.⁽²⁸⁾ Rao et al.⁽²⁹⁾ and Sharma et al.⁽²³⁾ reported complete hanging / full suspension rates to be 71%, 86.4%, 16.6%, 88% and 83.5% respectively. The most commonly used hanging method varied depending on region and country. In our cases, 61.5% were complete hanging/ full suspension and 38.5% were incomplete hanging / partial suspension. Sahoo et al.⁽²⁵⁾ reported the complete hanging/ full suspension rate to be 88.32% and that the male-to-female ratios were not significantly different for the two different methods. Similarly, we did not find a correlation between gender and the method of hanging. However, the method of hanging was significantly associated with the properties of the hanging mark. We found that the incidence of atypical hanging was higher in complete hanging/ full suspension, and that soft materials were more commonly used in incomplete hanging/ partial suspension (Table 3).

Facial congestion: The presence of facial congestion is among the classic but non specific signs of asphyxia. Congestion, which is non-specific finding, is caused by obstruction of the venous return caused by neck compression. In our study, we detected that the rate of congestion was higher in atypical hanging. However, this difference was not statistically significant. This might be due to including hangings without a knot in the ligature where the ligature is wrapped around the neck multiple times as atypical. We found that facial congestion was significantly associated with hemorrhage in the clavicular head of the SCM muscle.

The protrusion of tongue: The protrusion of the tongue is explained by the compression of the laryngeal and tracheal lumens in the neck due to hanging, which causes a contraction that pushes the root of the tongue upwards.⁽²²⁾ In our study, we observed that the tongue had protruded in 51.4% of the cases. Pal et al.,⁽³⁰⁾ Rawat et al.⁽²²⁾ and Sahoo et al.⁽²⁵⁾ reported tongue protrusion rates of 64.75%, 50.5% and 31% respectively. The protrusion of the tongue was not associated with the nature of the ligature, method of hanging, or the positions of the knot.

Skin blister on the hanging mark: In our study, we observed skin blister formation in 17 cases. Skin blister formation was not correlated with the hanging tool, the position of the knot or the method of hanging. One study reported that skin blister formation was especially common in hangings with more than one noose, where the skin and soft tissues got stuck between the loops and called this the ‘pinching effect’.⁽³¹⁾ We think this is caused by the similar mechanism.

Soft tissue haemorrhage in the neck as an antemortem findings: 79.4% of the cases had soft tissue hemorrhage in the upper neck region, and 61.1% in the lower neck region. In our hanging cases, the amount of hemorrhage areas tends to be minimal or millimetric. The presence of bleeding in deep soft tissues in the neck away from the ligature mark, especially with no bleeding under the ligature mark, showed that detailed full examination at autopsy is important.

Hemorrhages were most commonly observed in the clavicular origin of the SCM muscle or the supraclavicular region. The medical examiner must continue their examination even after determining hemorrhage in the upper neck region.⁽^32–34⁾ Hejna and Zatopkova⁽³²⁾ reported that hemorrhage in the clavicular origin of the sternocleidomastoid muscles is a hanging-related autopsy finding and that they observed this finding in 110 of 178 cases (62%), where there was a statistically significant correlation between hemorrhage and complete/full hanging. They explain that bilateral clavicular SCM hemorrhage was more common in complete / full hanging where the whole weight of the body is suspended by the neck, and explained this phenomenon by the prolonged longitudinal stretching of the SCM muscle which caused hemorrhage at the clavicular origin of SCM. They reported that unilateral hemorrhage was more common in atypical hanging, where the knot is at the side of the neck, hemorrhage was ipsilateral to the knot. They did not find a significant correlation between SCM hemorrhage and age, gender or body weight.

Since the knot is not always perfectly in the midline, the right or the left, soft tissue hemorrhage localizations can vary. Bilateral hemorrhage was found to be more likely in typical hanging. The position of the knot was not found to be significantly associated with lower neck region hemorrhages.

In our study, hemorrhage in the clavicular head of the SCM muscle was found to be significantly correlated with the protrusion of the tongue. Previous studies report hemorrhage rates of 30 to 66% in neck muscles.⁽^3,25,32–36⁾ Kurtulus et al.⁽³⁾ found hemorrhage in the neck muscles of 43 (42.2%) subjects, 62.8% of which were associated with atypical hanging. SuárezPeñaranda et al.⁽³⁵⁾ and Azmak⁽³⁶⁾ reported intramuscular hemorrhage rates to be in 55.8%, and 51.7% respectively. Sharma et al.⁽²⁶⁾ suggested hemorrhage of the cervical muscles as a general sign of typical and complete/ full hanging.

Bone and cartilage fractures in the neck: In the literature, 23–76% of suicide by hanging subjects develop fractures in the neck's hard tissue.⁽^{3,4,18,22,35,37–40}⁾ In our study, 61.1% of the cases had bone or cartilage fractures in the neck, accompanied by soft tissue hemorrhage in the surrounding regions. There were not any statistically significant results between fractures and type of hanging, method of hanging and the ligature materials (Table 5), but we found that thyroid cartilage fractures were positively correlated with age (Table 6). This may be due to age-related changes or due to weight differences.

A previous Turkish study found that 67.6% of hanging subjects had fractures in cervical bones, and the fractures were significantly and positively correlated with age. The incidence of fractures was not associated with the method of hanging but increased with typical hanging – i.e. when the knot is at the nape of the neck.⁽³⁾ Another study reports that hyoid bone fractures increase with complete/full hanging and are also affected by the position of the knot.⁽²²⁾ Consistent with our study, many studies report that the incidence of fractures in neck structures increases with age.⁽^3,18,36–41⁾

In this study, which includes a large series, some regional and gender differences were observed. Careful and detailed examination was important to diagnose antemortem vitality findings of hanging.

Conclusion

Although our results are generally compatible with the literature, our series with 175 hanging autopsy cases gives some different regional features and gender differences:

- Complete hanging was more common than incomplete hanging.

- Softer materials as a hanging tools were more commonly used in incomplete hangings.

- Females utilized soft materials more than males.

- Males used atypical hanging more than females.

- Bilateral hemorrhage in the neck muscles was more common with typical hanging.

- Facial congestion was more common in atypical hanging, whereas typical hanging had more commonly caused hemorrhage in bilateral muscles of the neck.

- There was a significant relationship between tongue protrusion and hemorrhage at the clavicular head of sternocleidomastoid muscle.

- There may be some religious rituals for Muslims in suicide such as pubic hair shaving.

- Sheets were especially common as a hanging tool in prisons.

- Detailed macroscopic examination is required for cases of suicide by hanging.

Footnotes

Authors contributions

Study conception and design: Dr Yasemin Balcı, Dr Ümit Ünüvar Göçeoğlu

Acquisition of data: Dr Elçin Kıymet, Dr Çetin Seçkin

Analysis and interpretation of data: Dr Yasemin Balcı, Dr Ümit Ünüvar Göçeoğlu

Drafting of manuscript: Dr Ümit Ünüvar Göçeoğlu, Dr Yasemin Balcı

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iD

Dr Ümit Ünüvar Göçeoğlu

Supplemental material

Supplemental material for this article is available online.

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