Seaweed traditionally consumed as sea vegetable [69].
Algae, including micro-algae and macro-algae or seaweeds, constitute the primary producers in the aquatic food chain. Algae sustain the production of a hundred million tons per year of marine fisheries and a large portion of the aquaculture production, securing a stable human food supply. The annual seaweed production both from nature and aquaculture farms was 28.4 million tons in 2014, and 96% of seaweeds is produced by aquaculture with the value of 6.4 billion US dollar in 2013 [23]. About 40% of the seaweed production in 2014 represents seaweeds traditionally eaten in Japan. In 2014, 7.7 million of tons of Kombu (Saccharina japonica), 2.4 million tons of Wakame (Undaria pinnatifida), and 1.8 million tons of Nori (Porphyra sp.) which is particularly used dried in sushi preparation were produced [23]. Among the seaweeds, 13% have been used for the production of hydrocolloids (polysaccharides), such as agar, alginate or alginic acid, and carrageenan, while 75% are used for food, and the remaining (12%) are used by agriculture industry [34].
\nThere has been a long traditional use of algae, especially seaweeds or sea vegetables, as food in Pacific and Asian countries for several centuries. In Pacific countries such as Indonesia, the Philippines, Maori of New Zealand, and Hawaii and Asian countries such as China, Japan, and Korea, seaweeds have long been consumed in a variety of dishes such as raw salads, soups, cookies, meals, and condiments [56]. In Iceland, Wales, France, as well as the Canadian and US Maritimes, there exists a traditional consumption of seaweed-based foods which varies in importance depending between country and regions but which is overall less prominent than in Asia [12].
\nThe increase of vegetable consumption, including seaweeds, has been promoted to exert health benefits during Inuit childhood and life course [32, 43]. Thus, it is possible to see many cooking books incorporating recipes using “sea vegetables” in many countries around the world. And, more recently there has been a strong movement in European countries to introduce sea plants into the European cuisine. With the current trend for consumers, as “natural” food sources, marine plants receive an increasing acceptance [56].
\nAll these advantages, together with available modern technologies and the proximity of European and Asian markets, encourage the development of sustainable seaweed cultivation for a variety of profitable end-products, such as protein, vitamins, minerals, phycocolloids, pigments, etc. In Turkey, algae cultivation is limited to micro-algae production in fish hatcheries. However, natural resources necessary for commercial seaweed cultivation, such as diversity of seaweed species, clean water, sunlight, and coastlines, are abundant. For example, in Turkey, more than 1000 seaweed species have been identified and species of Porphyra, Gracilaria, juvenile Laminaria, Cystoseira, Sargassum, and Ulva being particularly abundant [14]. In the overall Turkish population, the consumption of algae as a food is mostly limited to traditional algal cuisine from Asia [45, 84].
\nSeaweeds are well known for their abundance in several nutrients as dietary fibers, minerals (i.e., iodine), and certain vitamins (i.e., B12) and also contain numerous proteins/peptides, polyphenols, and polyunsaturated fatty acids (omega-3) [10]. A diet rich in seaweed in Asian countries has been consistently associated with a low incidence of cancers [13], and other potential health benefits of seaweeds have been reported, including cardioprotective, neuroprotective, and anti-inflammatory effects as well as beneficial impacts on gut function and microbiota [13]. These results not only strongly support the use of seaweeds in functional food development but also promote new utilization in food products and in the kitchen of consumers.
\nThe objective of this chapter is to review the main uses of whole seaweeds in food formulations, including Ulva, and the interest of using some components such as seaweed polysaccharides and PCs as ingredients that could play roles in food as well as some nutritional attributes of seaweeds.
\nThe recent popularity of sushi and Asian cuisine in Western countries, including Turkey, has stimulated the seaweed economy. The migration of Asian population across the world has promoted the discovery of new ingredients from seaweeds and has given courage to the creation of new dishes by chefs in restaurants. Among the seaweeds traditionally consumed by Asian population, Ulva, Laminaria, and Porphyra [1] are well-known species in addition to the other species used in Asian cuisine (Table 1). Species such as Wakame or Kombu requires cooking to overcome their chewy texture, while others can be eaten raw such as Nori and sea lettuce [59]. The valorization of seaweed as sea vegetables generally involves drying or salting processing treatments. Seaweed drying is one of the primary steps to allow their storage and transportation. They are either sun dried, air-dried, or dehydrated by salt addition [29, 87]. Seaweed can also be macerated with specific enzymes to improve protein bioaccessibility through hydrolysis of dietary fibers resistant to human digestion, but this process has not reached any commercial application yet [26, 29]. However, there are some recent studies on Ulva lactuca that is fermented with specific enzymes to improve protein bioaccessibility resistant to fish digestion [78]. During fermentation the growth of lactic acid bacteria was dependent on the seaweed species, the presence of fermentable carbohydrates such as laminaran, and the heating treatment applied prior to the inoculation step [33]. All these processing treatments are likely to affect seaweed’s nutrients but to our knowledge, there are a limited number of studies describing their impact. More research may provide useful information to promote their usage in innovative dish and food preparation.
\nA green seaweed sea lettuce or Ulva is used in Scotland, where it is added to soups or used in salads, and today in Japan, where it is used in making sushi also with a red seaweed Nori or Porphyra. In Turkey, in the formulation of innovative seaweed dishes and food preparation samples, traditional mezze recipes belong to some vegetables replaced with Ulva (freshly harvested with 22.42% protein, dry weight) [84]. The seaweed dishes were prepared according to traditional recipes of stuffed grape leaves, spinach with rice, lamb’s lettuce salad, Salicornia mezze, spicy tartare meatballs, and fresh sardines in grape leaves [3].
\nThe preparation of stuffed Ulva spp. for six servings according to the stuffed grape leave recipe started with soaking 225 g rice in warm and salted water for 10 min, followed by draining and rinsing. To prepare the filling, two onions were finely chopped, and two cloves of garlic were softened in two tablespoons of olive oil and a little butter. Then, one not quite full tablespoon of sugar, two tablespoons of currants soaked in water, and two tablespoons of pine nuts were added and cooked for 2–3 min. Next, one-half teaspoon of ground allspice, one-half teaspoon of ground cinnamon, and one-half teaspoon of ground cloves, salt, and freshly ground black pepper were added, and the mixture was covered with just enough water and brought to a boil. It was simmered for 10–15 min at reduced heat until the water was almost absorbed. Then, it was mixed with herbs (bunch of fresh parsley, dill, and mint) with a fork; the pan was covered and left for 5 min. The rice still had a bite to it. Ulva spp. were placed on the bottom of a wide pan. The rest of the Ulva spp., 24–30 pieces replacing a similar number of vine leaves in the original recipe, was laid on a flat surface, and a spoonful of the rice mixture was placed in the middle of each Ulva. The near end of each Ulva was folded over the mixture, and the side was flapped to seal it in and rolled up. The stuffed Ulva rolls were arranged in the pan, tightly packed. The cooking liquid—including 150 mL water, two tablespoons of olive oil, and two tablespoons of lemon juice—was poured over the rolls. A plate was placed on top to prevent them from unraveling, and the pan was covered with a lid. The liquid part was brought to a boil; then, the heat was reduced and cooked gently for 1 h. Finally, the rolls were left to cool in the pan and served cold with wedges of lemon (Picture 1A).
\n(A) Stuffed Ulva, (B) Ulva with rice, (C) Ulva salad, (D) sea lettuce Ulva mezze, (E) spicy tartare meatballs with Ulva spp., and (F) fresh sardines in Ulva.
The preparation of Ulva spp. with rice according to a spinach with rice recipe for four to six servings started with frying one chopped onion with three to four cloves of garlic and one tablespoon of olive oil. Then, one glass of rinsed rice was added into the pan with some salt and black pepper and cooked for 2–3 min. Five hundred grams chopped fresh Ulva, instead of 500 g finely chopped fresh spinach, was added into the rice mixture, covered with just enough water, and brought to a boil. It was simmered for 10–15 min at reduced heat until the water was almost absorbed. The pan was then covered and left for 5 min (Picture 1B).
\nIn the preparation of Ulva salad according to a lamb’s lettuce salad recipe for four to six servings, 500 g chopped fresh Ulva was used instead of 500 g lamb’s lettuce. The chopped Ulva spp. were placed in a salad bowl, tossed in a little olive oil and lemon juice, and seasoned with salt and freshly ground black pepper. Two to three tablespoons of soft hick yogurt were mixed with two cloves of crushed garlic and added to the bowl; the mix was tossed well and served (Picture 1C).
\nIn the preparation of Ulva mezze according to a Salicornia mezze recipe for four to six servings, 500 g chopped fresh Ulva was replaced with 500 g of Salicornia. The chopped Ulva spp. were placed in a salad bowl, tossed in a little olive oil and lemon juice, and seasoned with salt and freshly ground black pepper. Two cloves of crushed garlic were also added to the bowl; the mix was tossed well and served (Picture 1D).
\nSpicy tartare meatballs were prepared with Ulva spp. instead of lettuce leaves for four to six servings. Two hundred twenty-five grams of boiled bulgur was squeezed and allowed to cool (about 30 min), then put in a bowl with 225 g minced lamb or beef meat, and kneaded well (slapping it against the side of the bowl until well mixed). Two finely chopped onions, six finely chopped cloves of garlic, and two tablespoons of concentrated tomato purée were then kneaded into the mixture, followed by one teaspoon of red pepper, one-half teaspoon of roasted red pepper, one-half teaspoon of ground chili pepper, one-half teaspoon of ground coriander, one-half teaspoon of ground cumin, one-half teaspoon of ground allspice, one-half teaspoon of ground cinnamon, one-half teaspoon of ground cloves, one-half teaspoon of ground fenugreek, a little chopped parsley, and salt. The mixture was kneaded thoroughly for 20–30 min. Small portions of the mixture were then shaped into balls, indented with a finger, and arranged on a bed of parsley (Picture 1E).
\nUlva was replaced with grape leaves in a dish filled with fresh sardines. For four to six servings, 20–30 fresh sardines were wrapped in 25–30 Ulva spp., leaving the sardine heads peeping out. They were packed tightly in the base of a wide saucepan. Two tablespoons of olive oil, juice of one lemon, two crushed cloves of garlic, salt, and freshly ground black pepper were mixed to taste and poured over the sardines. A plate was placed directly on top of the sardines, the pan was covered, and it was cooked gently for 5–8 min. The dish was served hot or left to cool and sprinkled with salt or lemon juice (Picture 1F).
\nAs it was seen, seaweeds contribute in a food either if they are used as a whole or through the numerous ingredients that have been produced from various species. In Turkey, Hypnea musciformis also known as Crozier weeds is a red seaweed species containing carrageenan, a gelling and thickening agent. Under its purified form, carrageenan is used by the food industry. Again, Gracilaria gracilis or Gracilaria verrucosa is a red seaweed species containing agar, a gelling and thickening agent. Under its purified form, agar is used by the food industry. Cystoseira spp. and Sargassum vulgare are brown seaweeds containing alginate or alginic acid with other important agents as well used by food industry.
\nPurified polysaccharides, such as agar, alginate, and carrageenan, are widely used in the food industry as clarifying, gelling, emulsifying, stabilizing, thickening, and flocculating agents in various food products such as ice cream, yogurt, candy, meat product, beverages, etc. The main structure and the functionality of polysaccharides extracted from seaweeds are presented in Table 2.
\nSeaweed species | \nCommon names | \n
---|---|
Alaria esculenta | \nDabberlocks, Bladderlocks, Edible Kelp, Honeyware, Winged Kelp, Bladderlochs, Tangle, Henware, Murlins, Stringy Kelp, Horsetail kelp, Fruill, Rufaí, Láracha, Láir bhán, Sraoilleach, Láir, Essebarer Riementang, Marinkjarni, Chigaiso | \n
Himanthalia elongata | \nSea Spaghetti, Sea thong, Thongweed, Buttonweed, Sea Haricots, Thongweed | \n
Hizikia fusiformis | \nHijiki, Hai tso, Chiau tsai, Hai ti tun, Hai toe din, Hai tsao, Hoi tsou, Nongmichae | \n
Laminaria digitata | \nTangle, Sea girdles, Tangle tail, Wheelbangs, Sea wand, Sea ware, Sea Tangle, Horsetail Kelp, Kelp, Strap wrack, Oarweed, Oar weed, Horsetail tangle, Sea Girdle, Coirrleach, Screadhbhuidhe, Coirleach, Ribíní, Feamnach dhubh, Leathrach | \n
Laminaria japonica or with its new name Saccharina japonica | \nKombu, Hai Dai, Hai Tai, Kunpu, Royal Kombu, Makombu, Shinori-Kombu, Hababiro-Kombu, Oki-Kombu, Uchi Kombu, Moto-Kombu, Minmaya-Kombu, Ebisume, Hirome, Umiyama-Kombu, Hoiro-kombu, ae tae, Tasima | \n
Undaria pinnatifida | \nWakame, Qun dai cai, Sea mustard, Precious sea grass, Miyok, Miyeouk | \n
Ulva lactuca | \nSea lettuce, Tahalib, Hai Tsai, Shih shun, Haisai Kun-po, Kwanpo, Lettuce laver, Green Laver, Sea Grass, Thin stone brick, Chicory sea lettuce, Meersalat, Aosa, Klop-tsai-yup, Alface-do-mar, Luche, Luchi, Havssallat | \n
Chondrus crispus | \nIrish Moss, Iers mos, Carragheen, Carragheen Moss, Dorset weed, Pearl Moss, Sea Moss, Sea Pearl Moss, Jelly Moss, Rock Moss, Gristle Moss, Curly Moss, Curly Gristle Moss, Carrageen, Carraghean, Carrageenin, Punalevä-laji, Cruibín chait, Carraigín, Cosáinín carriage, Irischmoos, Irisches moos, Muschio Irlandese, Musgo-gordo, Botelho, Botelha, Cuspelho, Musgo, Limo-folha, Musgo gordo, Folha-de-alface, Condrus, Karragener | \n
Palmaria palmata | \nDulse, Dillisk, Dillesk, Crannogh, Water Leaf, Sheep Dulse, Dried dulse, Shelldulse, Duileasc, Creathnach, Saccha, Sol, Darusu, Sou Sol, Botelho-comprido, Sea grass, American dulse, Dillisc, Sheep’s weed, Sea devil, Horse seaweed, Creannach | \n
Porphyra umbilicalis, Porphyra yezoensis, Porphyra tenera | \nNori, Laverbread, Purple laver, Sloak, Slook, Laver, Tough, Chishima-kuronori, Folhuda | \n
Seaweed traditionally consumed as sea vegetable [69].
Polysaccharide | \nMain structure | \nMw (kDa) | \nSolubility | \nGelling condition and properties | \nFunctional properties | \n
---|---|---|---|---|---|
Food grade polysaccharides | \n|||||
Agar | \n(1,3)-α-d-galactose, (1,4)-β-l-galactose, 3,6-anhydrogalactose ring, <4.5% sulfate groups | \n36–386 | \n>85°C | \n0.5–2%; melting 85°C | \nClarifying, gelling, stabilizing, and flocculating agent | \n
Alginate or alginic acid | \nβ-d-mannuronic acid (M), α-l-guluronic acid (G) linked in β-(1,4) or α-(1,4) | \n150–1700 | \nSalt, ionic strength, and pH | \n0.5–2%; melting 85°C; Ca or Mg | \nGelling, emulsifying, film-forming, stabilizing, and thickening agent | \n
Carrageenan | \n(1,3)-α-d-galactose, (1,4)-β-l-galactose, 3,6-anhydrogalactose ring, 25–35% sulfate groups | \n300–600 | \nι- > 70°C κ- > 70°C λ- cold | \n0.5–3%; ι- Ca melting 50–80°C; κ- Ca or K melting 40–75°C; λ- n/a | \nGelling, thickening, suspension, and stabilizing agent | \n
Mannitol | \nD-Mannitol monomers | \nn/a | \nnd | \nn/a | \nSweetener, low glycemic index | \n
Nonfood grade polysaccharides | \n|||||
Fucoidan | \nα-(1,3) and α-(1,4)-l-fucose, <22% sulfate groups | \n6.8–1600 | \nnd | \nNone | \nNone | \n
Ulvan | \nβ-d-glucuronosyluronic acid-(1,4)-α-l-rhamnose 3-sulfate, α-l-iduronopyranosic acid-(1,4)-α-l-rhamnose 3-sulfate, 15–20% sulfate groups | \n150–2000 | \nnd | \n1.6%; Cu2+ and B3− | \nNone but potential gelling application | \n
Seaweed polysaccharide structure and functionality [69].
Mw, molecular weight; n/a, not applicable; nd, not determined.
Agar and carrageenans are both found within red algae. Agar is mostly extracted from Gelidium and Gracilaria [56], and their cell wall holds up to 30% [31] and 20% [73], respectively. Agar structure is made of alternating d-galactose and l-galactose units (Table 2) [48, 60, 79]. It also contains (3,6)-anhydrogalactose rings and small amounts of sulfate groups (<4.5%) [40, 60]. Agar forms stable gels upon cooling between 32 and 43°C and at concentrations varying from 0.5 to 2% over a wide range of pH (Table 2). The gels are odorless and tasteless since no cations are necessary to promote the gel formation, and they are stable at temperature up to 85°C. The gel strength is influenced by the polysaccharide concentration, the number of 3,6-anhydrogalactose rings, the molecular weight, and the rate of cooling [6, 88]. One of agar gel characteristics is its in-mouth juiciness caused by the gel syneresis during mastication [62]. Agar gels are currently part of many traditional Japanese foods. Yokan (agar jelly with red bean paste), Mitsumame (canned fruit salad with agar jelly), and Tokoroten (noodlelike agar gel) are some examples of the culinary applications of agar [62, 79]. Worldwide, agar is also used as an additive in numerous food products such as dairy, bakery, and canned meat/fish products. It is also found in soups, sauces, and beverages. Carrageenans are sulfated polysaccharides extracted from seaweed such as Chondrus crispus, Kappaphycus alvarezii, and Eucheuma denticulatum [5, 56]. The seaweed cell wall can contain up to 80% of polysaccharides. Carrageenan’s structure depends on the number of sulfate groups and (3,6)-anhydro-d-galactose rings (Table 2). The structure of carrageenans controls its gelling properties, and this has an important impact for its utilization in food systems. For example, the absence of (3,6)-anhydro-d-galactose ring units prevents λ-carrageenan gelation.
\nCarrageenan may be found under three main structures influencing its gelling capacity. Lambda-carrageenan does not form gels but increases the solution viscosity to stabilize the overrun (whipped cream and shakes) or improve mouthfeel (pasteurized chocolate milk) [41]. It is also sometimes used in combination with κ-carrageenan to favor the formation of creamy gels (i.e., puddings and cream desserts) [39]. Kappa- and ι-carrageenans form gels at concentration varying between 0.5 and 3% and upon cooling at temperature ranging from 40 to 60°C in the presence of cations such as Ca or K [89]. Gels are thermally reversible at temperature up to 75 and 80°C for, respectively, κ- and ι-carrageenans and are stable at room temperature [39]. They are not only used in several water-based gelled desserts and cake frosting but also used in dairy products alone (flan, process cheese, sterilized chocolate, and evaporated milks) or in combination with other gums such as locust bean gum (cream cheese and ice cream). In brown seaweed, alginate may be isolated and found at concentrations up to 40% according to the seaweed species [57, 89].
\nAlginate is extracted from several brown algae including Ascophyllum nodosum, Laminaria digitata, Laminaria hyperborea, Laminaria saccharina, Laminaria japonica, Ecklonia maxima, Macrocystis pyrifera, Lessonia nigrescens, and Lessonia trabeculata [37, 56]. Alginate is a derivative of alginic acid, and it is found under the form of sodium, calcium, or magnesium alginate. It is composed of a mixture of β-d-mannuronic acid (M) and α-l-guluronic acid (G). These monomers are organized in segments containing MM, GG, or MG/GM blocks which are linked β-(1,4) for MG block or α-(1,4) in the case of GG block. The proportion of each segment affects the gelling properties of alginate. Alginate containing high amounts of GG blocks will lead to firm and rigid gel [20]. Alginate is used as a thickening agent in ice cream, ketchup, mayonnaise, sauces, and purees [57, 89]. The viscosity of the solution may be controlled by the addition of Ca. Alginate gelling property is useful in several food applications such as jams, puddings, and restructured food (chili found in green olives or onion rings made with onion powder). Its film-forming capacity reduces water loss and regulates water diffusion in food products [37]. The pastries fruit filling is often covered with an alginate film to prevent cake moistening.
\nThe food industry in collaboration with polysaccharide suppliers has developed a thorough knowledge regarding the usage of algal polysaccharides in food products. However, the culinary usages might at some point be less known by chefs. Recently, the culinary use of those purified ingredients was reviewed in the book Modernist Cuisine [61]. The functional properties such as solubility, foaming, as well as gelation are potentialized and presented for culinary purposes. For example, agar gels may be used in terrine (appetizer), agar beads flavored with fruit or vegetable juices, Chantilly without cream, pasta, eggless mayonnaise, foams, etc. Alginate main usages in modern cuisine are under the form of moldable forms (spaghetti, beads, etc.). Propylene glycol alginate may also be used to produce eggless citrus curd [61]. The proper combination of κ - and ι-carrageenans allowed the formation of a dashi-flavored gel to coat cremini mushrooms [61]. Also, these polysaccharides may be used in combination to stabilize a beurre blanc sauce emulsion, processed cheese, etc.
\nFinally, other polysaccharides such as fucoidan and ulvan could potentially be interesting for culinary applications. Fucoidan is a sulfated polysaccharide mainly of l-fucose (>50%), and up to 10% of this polysaccharide was isolated in several brown seaweeds [42, 83]. Fucoidan is not used as a food ingredient in Turkey but is included in food as a nutraceutical in Asia [25]. This polysaccharide has no gelling or thickening capacity (Rioux et al., 2007) as compared to others such as alginate. However, when the whole brown seaweed Kombu or Wakame is consumed, substantial amount of fucoidan may be ingested and have beneficial effects in humans. Ulvan is a water-soluble polysaccharide found within green algae Ulva spp. The algae contains between 8 and 29% ulvan on dry basis [47]. Ulvan is mainly composed in l-rhamnose and d-glucuronic acid under the form of ulvanobiuronic acids A and B [46, 67]. Ulvan molecular weight ranges between 150 and 2000 kDa depending on the extraction method and seaweed species [64, 77, 91]. Ulvan possesses interesting gelling and viscosifying properties dictated by the amount of uronic acids that may be useful in food products [76, 77, 90]. Most recent studies were oriented toward biomedical applications [58, 86]. This polysaccharide could be of interest for new food application.
\nThe production of plant protein concentrates (PCs) is of growing interest to the food industry [81]. Recently, PCs were extracted from three edible green seaweed species of Enteromorphaor Ulva and were investigated for their functional properties as functions of salt and pH [44]. The protein contents in the PCs varied from around 33 to 60%. In all three PCs, the minimum nitrogen solubility was observed at pH 4, and foaming capacity and stability were pH-specific. Also, PC of red alga Kappaphycus was extracted, and its functional properties were evaluated [81]. The PC contained around 62% proteins, and the results obtained in this investigation suggest great emulsion stability with oil extracted from Jatropha, a plant species of the Euphorbiaceae family native to Brazil. Although these results are promising, before considering these PCs as ingredients in food formulations, food-grade solvents have to be chosen during the extraction method avoiding chemical residues, which could be toxic [69]. Indeed, solvent choice influences potential applications of algal protein extracts in terms of human consumption [75].
\nSeaweed’s main constituents vary according to the seaweed species, harvest location and time, wave exposition, and water temperature. Also, the methodology used to determine these constituents may differ which may explain why large variations are sometimes observed (Table 3). Seaweeds are rich in carbohydrates, and concentration up to 76% of the algae dry weight was reported. Also, an important proportion of proteins was quantified. Ulva sp. contains up to 44% of proteins based on the algae dry weight. The mineral content also reaches values as high as 55% that were found for Ulva sp. Generally, seaweed lipid content is relatively low (<5%) independently of the species.
\nSeaweed species | \nPolysaccharide (%) | \nProtein (%) | \nLipid (%) | \nAsh (%) | \n
---|---|---|---|---|
Ulva sp. | \n15–65 | \n4–44 | \n0.3–1.6 | \n26; 52–55 | \n
Laminaria longicruris or Saccharina longicruris | \n38–61 | \n3–21 | \n0.3–2.9 | \n15–45 | \n
Ascophyllum nodosum and Fucus vesiculosus | \n42–70 | \n1.2–17 | \n0.5–4.8 | \n18–30 | \n
Undaria pinnatifida | \n35–45 | \n11–24 | \n1–4.5 | \n27–40; 14 | \n
Sargassum sp. | \n68 | \n9–20 | \n0.5–3.9 | \n44 | \n
Chondrus crispus | \n55–66 | \n6–29 | \n0.7–3 | \n21 | \n
Porphyra sp. | \n40–76 | \n7–50 | \n0.12–2.8 | \n7–21 | \n
Gracilaria sp. | \n36; 62–63 | \n5–23 | \n0.4–2.6 | \n8–29 | \n
Palmaria palmata | \n38–74 | \n8–35 | \n0.2–3.8 | \n12–37 | \n
Composition of different seaweed species [69].
Values are expressed in percentage (%) of dry weight.
Seaweed carbohydrates or polysaccharides are mostly found within the algae cell wall with exception of the storage polysaccharides which are located in the plastid. The seaweed cell wall (extracellular matrix) has an important structural role. It is a physical barrier against wave, ice, and sun dehydration [65], but it also regulates many other functions such as solute accumulation, turgor, and cell growth [8, 68]. The main cell wall polysaccharides are agar and carrageenan (Rhodophyta), sulfated fucans and alginates (Ochrophyta), and cellulose and hemicellulose (Chlorophyta). Seaweeds within the Ochrophyta and Rhodophyta phyla also contain variable amounts of cellulose and/or hemicellulose according to the seaweed species [2, 18].
\nThe storage carbohydrates are equivalent to the human glycogen and serve as the principal energy source [9]. According to the seaweed species, other small polysaccharides may be found within the chloroplast (laminaran and starch) or in the cytoplasm (floridean starch) [85]. Smaller solutes are found when seaweeds are grown under high salinity conditions. Mannitol, sucrose, floridoside, isofloridoside, and digeneaside were reported for some seaweed. They can serve as photosynthetic reserve or as osmoregulator [19, 68].
\nSeaweeds are good sources of fibers since they contain valuable carbohydrates undigested by the human gastrointestinal track [69]. Dietary fibers, or fibers from food source, remain intact in the small intestine while they are partially or sometimes completely fermented by the gut microbiota [24]. The total dietary fiber within food may be found under two forms, such as soluble and insoluble, depending on the polysaccharide structure. Soluble fibers refer to polysaccharides that may be solubilized in water. They are known to increase the viscosity in the gastrointestinal track and are fermented by the microbiota. At the opposite, insoluble fibers have a bulking action and are rarely fermented [69]. Seaweeds with their high polysaccharide contents (Table 2) have interesting nutritional properties since their total dietary fiber may reach up to 38% (dry weight) according to the seaweed species [29]. Among them, some polysaccharides are already considered as valuable food ingredients and are, therefore, available on the market as purified polysaccharides such as agar, alginate, and carrageenan.
\nIncreasing world population and the consumer demand for healthy foods have driven the search for unconventional protein sources as ingredients to be incorporated in new high-value products [15, 52, 70]. Seaweeds have long been used in Asia as traditional foodstuffs [22]. Also, they have been recently promoted in the cuisine of several American and European countries and evaluated for the nutritional value of their proteins, which is mainly defined by their amino acid composition and digestibility [56]. Proteins are present in algae in a variety of forms and distributed in various cellular compartments. They are part of the intracellular components or the cell wall, are enzymes, or are bound to pigments and polysaccharides [80]. The protein content is variable according to the species, season, geographic distribution, population, cultivation conditions, and nutrient supply during growth phase [4, 17, 27, 36, 52, 54]. In general, the red and green species contain relatively high protein levels, with an average value of 4–50% (w/w) dry weight, compared to brown species, which contain between 1 and 29% (w/w) dry weight (Table 3) [35]. The protein concentrations of red species are comparable to those found in high-protein vegetables such as soybeans where proteins represent 35% of the dry weight [63]. A review of the nutrient composition of edible seaweeds has been reported comparing different protein contents of red, green, and brown species [66]. Seaweed proteins display a very good profile of essential amino acids, which is equivalent to other food proteins such as legumes or eggs [28], and their levels are comparable to those of the FAO/WHO requirements of dietary proteins [63]. Algal proteins usually contain most amino acids particularly glycine, alanine, arginine, proline, and glutamine and aspartic acids [11]. Both aspartic and glutamic acids are abundant in most seaweed species (brown, red, and green), and they exhibit interesting features in flavor development. Hence, glutamic acid is the main component in the taste sensations of umami [63], and the average proportion is higher in brown seaweed (153 mg/g proteins) compared to the red (117 mg/g proteins) and green (119 mg/g proteins) seaweeds [21]. In comparison with other protein-rich food sources, seaweeds are limited by lysine, threonine, tryptophan, and sulfur amino acids (cysteine and methionine), even though their levels are generally higher than those found in vegetables and cereals [38]. Seaweeds contain a proportion of free amino acids including taurine, alanine, amino butyric acid, ornithine, citrulline, and hydroxyproline. Numerous seaweed species also contain unusual amino acids among those, mycosporine-like amino acids (MAAs) known as demonstrating antioxidant properties [35].
\nSeaweeds contain relatively low levels of lipids (1–5%) when compared to other plant seeds such as soy and sunflower, but majority of those lipids are polyunsaturated fatty acids (PUFAs) [50, 51]. PUFA’s health benefits are well documented for fish, and seaweeds may also provide a sustainable source of these compounds. Algal PUFAs are under the form of ω-3 fatty acids such as eicosapentaenoic acid (EPA, C20:5) or docosahexaenoic acid (DHA, C22:6). EPA and DHA may both be metabolized from α-linolenic acid (ALA, C18:3), an essential fatty acid not only synthesized by humans but also found in seaweeds. Red seaweeds can contain up to 50% of EPA, while much lower levels were found in brown species [30]. Amounts of ω-6 fatty acids such as arachidonic acid (ARA, C20:4) are also found in seaweeds, and their levels are equivalent to the proportion of ω-3 with an ω-6/ω-3 ratio that is ranging from 0.1 to 1.5 [16, 50]. This is particularly interesting since a balanced ω-6/ω-3 ratio was associated to a decreased risk of mortality. Readers are referred to recent review papers discussing the health benefits of algal PUFAs for more details [7, 10].
\nThe lipid content and fatty acid composition of seaweeds vary by species, geographical location, season temperature, salinity, and light intensity [72]. Based on the fatty acid composition and potential health benefits such as anti-inflammatory activity, seaweed species could be selected for cultivation toward food and health markets [55]. The lipid characterization of cultivated seaweeds during a year-round could contribute to a better control in aquaculture settings in order to identify the best harvest time for the choice of lipid quantity and quality. For example, PUFAs are made up more than half of the fatty acids with a maximum in July for Saccharina latissima cultivated in Denmark [53]. In addition, the Saccharina latissima species presents a better source of PUFAs compared to traditional vegetables, such as cabbage and lettuce.
\nThe growing interest in PUFA-rich lipids from seaweeds for incorporation into foods has led to look for alternative extraction techniques with higher yields together with food grade solvent uses. As a result, the highest levels of PUFAs were obtained by the extraction with ethanol [74]. Seaweeds are also generally tested after food processing (drying, canning, etc.), due to its possible detrimental effect on fatty acid levels [72].
\nThe mineral content of seaweed is of great importance since up to 45% of the algal dry mass may be found (Table 3) [71, 82]. The values varied according to the seaweed species, seasonal variation, harvest time, and location [49]. Seaweed contains several mineral elements required in human nutrition such as Na, K, Ca, Mg, Fe, Zn, Mn, and Cu. For example, 948 and 2782 mg/100 dry weight of Ca were found, respectively, for Gracilaria salicornia and Ulva lactuca. These values are much higher than the one found in terrestrial plants such as spinach (851 mg/100 dry weight), broccoli (503 mg/100 dry weight), and cabbage (369 mg/100 dry weight) [82]. Their elevated amount in I content is one important feature of seaweeds. Holdt and Kraan [38] have reviewed that the distribution within several seaweed species including Laminaria sp. contains up to 8000 times of the recommended daily value.
\nSeaweed contains a wide array of nutritional compounds also possessing several functional properties that may lead to many dish and food preparation innovations. For example, seaweeds may be used with or in the replacement of other commonly used vegetables to promote healthy food. Until now only few applications have been taking profit of both attributes, and this should be more deeply exploited in the future. Collaboration with creative chefs can increase the visibility and acceptance of this resource by offering recipes or dishes where seaweeds are displayed. Future work connecting culinary and food science may support the usage of seaweeds not only at home but also in food products.
\nFalls from height cause significant death and disability worldwide, due to the severe traumatic load inflicted on their victims [1, 2, 3, 4]. According to the WHO, the yearly mortality due to suicide worldwide is approximately 800,000 people. What is more important is the fact that it affects mainly young people, suicide being the primary cause of death in the age group of 25–34 years [5]. The mean incidence of suicides across Europe in 2013 was of 11.7 deaths per 100,000 people. Low rates, under 8 deaths per 100,000 inhabitants were recorded in Italy, Malta, Cyprus and the United Kingdom. The lowest incidence was observed in Greece (4.8 cases per 100,000 people) [6]. There was a lag between the beginning of the economic crisis in Europe, and the manifestation of its effects on the Greek population. These became evident 3 or 4 years later, in the form of a reduction of household income and an increase in the rate of unemployment [7, 8, 9].
Causes for this mechanism of injury include both accidental falls and deliberate suicide attempts [10]. The latter constitutes a major social problem, with implications for the entire society, but particularly for the affected family. The psychological profile of people committing suicide is complex and unique for each case [11]. Thus, identifying contributing factors that may lead to suicide and establishing strategies for the safekeeping of mental health in communities are of paramount importance.
The type of injuries incurred after a fall constitute a unique pattern of blunt trauma, with a characteristic distribution of damage (multiple lesions in a variety of body areas) [1, 12, 13]. The most common form of trauma are fractures, followed by other areas, such as the head, the thorax, the abdomen as well as the retroperitoneum, being injured by varied degrees [14]. The quantity and the quality of traumatic load absorbed depend on factors like the height from which the fall occurred, the part of the patient’s body that had the first impact, the surface where the impact occurred and the victim’s age, taking into account the associated comorbidity, and reduced physiologic reserve that advanced age implies [15, 16, 17]. Anticipation and prediction of the exact areas being injured are not possible, because of the multitude of factors involved, and the exact unpredictability of the fall’s kinematic [18, 19].
As aforementioned, one can infer that the differential diagnosis of falls from height from other types of blunt trauma (for example, a road-traffic-collision with expulsion of the occupants from the vehicle) is difficult. Thus, a high index of suspicion must be maintained concerning the initial cause in cases of polytrauma in victims with an unknown history [20]. An array of papers have dealt with injury-related deaths in general, while others have differentiated between unintentional and intentional injury-related deaths [21, 22, 23, 24]. There are few studies though that have looked into patients with intentional or unintentional injuries, due to a fall from height, at a single centre [13, 25].
As noted by research in the past, self-harm due to a fall is a rare phenomenon, being responsible for 4–7% of deaths from suicide in the developed world [26, 27, 28, 29]. On the other hand, studies have shown that psychiatric disorders are a frequent finding in patients suffering trauma [30, 31, 32]. Nevertheless, the connection between mental disorders and specific injury patterns has not been adequately described. Furthermore, the elucidation of patterns of injury incurred after accidental falls and after intentional suicide jumps, might be of help to forensic pathologists while investigating the circumstances of a death after a fall from height.
From January 1990 to October 2012, 64 patients (15 males and 49 females) were studied as a result of falls from height. Fall from height ≥ 3 m is classified as high energy trauma in accordance to ATLS guidelines [33]. The mean patient age was 34 years (range 16–65 years). These 64 cases comprised our series and, for comparison, were divided into those without mental disorders (n = 32, group I) and those with mental disorders (n = 32, group II). Group II cases were further stratified according to their psychiatric diagnosis.
The principles of Advanced Trauma Life Support were followed in the management of all patients. Basic laboratory screening included haemoglobin level, prothrombin time, type and crossmatch and arterial blood gas analysis. Data collected included age, gender, associated trauma, injury severity score (ISS), Glasgow Coma Scale (GCS), haemodynamic status (systolic blood pressure less than 90 mm Hg on arrival), length of intensive care unit (ICU) and hospital stay.
Also, the following trauma variables were analysed: specific intracranial injuries (epidural, subdural and subarachnoid haemorrhage and brain contusion), spinal injuries (cervical, thoracic and lumbar spine), thoracic injuries, specific intra-abdominal injuries (liver, spleen, kidney, and hollow viscus) and specific fractures (pelvis, femur and tibia). The diagnosis of mental disorder was ascertained by psychiatric specialists using the criteria of the International Classification of Disease Ninth Version Clinical Modification (ICD-9CM).
The mean height of fall was 5.4 m (range, 3–25 m). The patients were separated in two groups: group I, without mental disorders (n = 32), and group II, with mental disorders (n = 32). The demographic data, including age, gender, height of fall, ISS, GCS, initial shock (SBP <90 mm Hg), hospital stay (days), ICU stay (days) and deaths are summarized in Table 1. The mean hospital stay was 29 days (range 19–45) and the mean ICU stay was 9 (range, 5–13) (Table 1).
Data | Patients |
---|---|
Age | 35 (18–65) |
Gender (M:F) | 15:49 |
ISS | 20 (12–58) |
GCS | 9 (6–13) |
Haemodynamic status-SBP <90 mmHg | 34 |
Hospital stay (days) | 29 (19–45) |
ICU stay (days) | 9 (5–13) |
Deaths | 13 |
Comparisons of demographic data of patients with suicide attempts from height.
Concerning their background psychiatric disorder in group II, the diagnosis was schizophrenia in 32 patients, depression in 12, drugs or alcohol abuse in 3, personality disorder in one, manic depression in one, another psychiatric condition in one and 14 cases without a specific diagnosis (generally marital or work related).
Patients due to suicide attempts from height comprised of 15 males and 49 females with a mean of age 35 years (range: 18–65 years). Of those, 16 were single, 14 were married and 2 were divorced. Thirty-three patients were employed, 6 were housewives, 7 were unemployed, 3 were students/pupils and 15 had various occupations. As far as religion was concerned, 48 were Christian Orthodox, one Roman Catholic, one Jewish, one Muslim and 13 of other religions.
Regarding their family status: 20 had children, 6 had only their parents, 3 had only their spouse, 2 had a step family, 2 had parents who were divorced, 6 had parents and/or siblings, one had both parents and children and 24 had no family at all.
The falls had occurred from a roof or balcony in 39 cases, from a window in 12, from a bridge in 7 and inside the house in 6. The mean injury severity score (ISS) was 20 (range 12–58) for all victims of fall. Sixteen patients arrived at the emergency department in shock. The most common body region having sustained severe trauma were the fractured extremities and/or spine, followed by the chest, the head and the abdomen for both groups (Table 2).
Fall from | Patients |
---|---|
Roof/balcony | 39 |
Window | 12 |
Bridge | 7 |
Inside the house | 6 |
Associated injuries | |
Abdominal trauma | 4 |
Thoracic trauma | 32 |
Head injuries | 16 |
Extremity fractures | 199 |
Spinal fractures | 32 |
Location where the fall occurred and associated injuries.
Head injuries were revealed by CT scan in 16 patients. The mean GCS was 9 (range 6–13) for both groups. The most common intracranial injury was brain contusion and subarachnoid haemorrhage, followed by subdural hematoma and epidural hematoma. The incidence of subarachnoid haemorrhage in the suicide group was significantly higher than in the accidental group.
Associated abdominal injuries were present in 4 patients. The most common injury was liver laceration, followed by kidney and spleen laceration. One died with an operative finding of a large central retroperitoneal haematoma due to a vena cava rupture. In the remaining 3 patients, ultrasonography showed minimal intraperitoneal blood and these patients were not operated on. Thoracic injuries were present in 32 patients. The most common of these were rib fractures—26 cases. Twelve of these patients had a haemopneumothorax and 6 had a sternum fracture. Conservative treatment with assisted ventilation was necessary in these cases (Table 3).
Patients | |
Skull, thorax and upper extremities | |
Skull | 16 (25%) |
Shoulder | 4 (6.2%) |
Scapula | 6 (9.3%) |
Sternum | 6 (9.3%) |
Ribs | 26 (40.6%) |
Humerus | 8 (12.5%) |
Elbow joint | 8 (12.5%) |
Distal radius | 7 (10.9%) |
Hand | 4 (6.2%) |
Spinal fractures | 32 (50%) |
Pelvis | 27 (42.1%) |
Lower extremities | |
Acetabulum | 9 (14%) |
Femoral neck | 38 (59.3%) |
Femur | 18 (28.1%) |
Knee joint | 17 (26.5%) |
Tibia | 19 (29.6%) |
Ankle joint | 36 (56.2%) |
Calcaneum | 34 (53.1%) |
The distribution of fractures in percentage across body region for the two groups of patients.
Upper extremity fractures were found in 37 patients, while pelvic and lower extremity fractures were found in 198 cases. Spinal fractures were noted in 32 patients. As far as the level of injury was concerned, in 16 cases, it was in the lumbar level, in 9 cases in the cervical, in 5 cases in thoracic and in 2 cases the sacral vertebrae were concerned. Regarding the neurologic deficit, in 23 cases, the injury was incomplete (14 with ASIA C and 9 with ASIA D), and in 9 cases, it was complete (4 with ASIA A and 5 with ASIA B). Further details with our data of 32 patients with spinal cord injury as a result of deliberate self-harm have been published previously [34]. It seems that the neurological complications of spinal injuries were correlated with the increase of the height from which the fall occurred.
Patients with psychiatric disorders were more frequently shocked on arrival at the emergency department than those in the accidental group, the most common reason for death being head injury. Fatalities were more common when patients fell from greater heights (over 4 m), or when their head hit a hard surface, such as concrete.
The final causes of inpatients’ death were: head injury in 8 cases, multiple organ failure in 3 cases, pneumonia in one case and cardiac complications in another one. The majority of patients who died of organ failure had sustained significant head injury. In one case, death occurred after a second suicide attempt 2 years later.
Each patient underwent a psychiatric evaluation by a consulting psychiatrist as soon as his condition and cooperation permitted. The assessment comprised of an interview. Regarding the type of treatment for the spinal fracture—dislocations, instrumentation devices included titanium rods, transpedicular screws, sacral bars and bone grafting in all patients. No new suicide attempt was recorded during the hospital stay.
All patients were discharged from hospital approximately 6–8 weeks after the operation with a custom-made thermoplastic thoracolumbar or lumbosacral orthosis for another 8 weeks and instructions for physical therapy and rehabilitation programs. The mean follow-up was 6 years (12 months to 10 years range). At follow-up, 27 patients were available for evaluation due to the death of 5 patients, 1–3 years post initial injury, because of suicide in one case (patient 7 of group II) and medical complications in 4 cases [renal failure in 3 cases (patients 8, 14 and 30 in group II) and pneumonia in one (patient 21)]. In the remaining patients, new unsuccessful attempts were recorded in 2 cases (7%) due to psychiatric disorders, 1–3 years after the first attempt (patients 10 and 24). All survivors received psychiatric follow-up. The overall mortality was significantly higher in those patients who fell from more than 10 m.
Suicides and suicide attempts constitute a major concern for public health services, with implications for both families and society [35]. Trauma incurred due to falls from height poses a great burden on health services due to its severity. This is particularly important if we take into account the fact that this is a largely preventable mechanism of injury. Prior knowledge of the possible traumatic patterns incurred after a fall from height can prove helpful in the initial evaluation of this group of patients. From an epidemiologic point of view, trauma due to falls may occur across all age groups, but it is the two extremes, the very young and elderly, which are particularly susceptible to it [36].
In this study, we have considered two groups of patients. Group I represented patients with no mental disorders and group II with mental disorders. It is quite difficult to identify someone who is prone to committing suicide. In addition, the observed number of suicides and suicide attempts being committed at a younger age (i.e. adolescence) has been a cause of concern worldwide and particularly in Europe [37]. The male-female ratio of suicide attempts varies across age groups. Thus, in the younger age group (15–24 years old), it is 1:1.9; and in the middle age group (45–54 years old) it is 1:1.7. This ratio further decreases for those older than 55 years to 1:1.4 [38]. In this study, the male-female ratio was 1:3. The female sex was associated with an increased likelihood of death due to a higher amount of energy involved in their attempted fall.
According to other studies [39, 40], young males tend to repeat suicide attempts more frequently than females and the methods used by them lead to an increased mortality. A suicide attempt in the past is a red flag for a possible attempt in the future; so, there is a strong correlation between suicide attempts and deaths from suicide both regionally and nationally, and particularly in young males [41]. Also, there is a strong correlation between repeated attempts and completed suicide, especially in the group of males who have used a violent method [42, 43].
The study by Dickson et al. had the aim of establishing a correlation between mortality and various factors, such as the patients’ injury severity score (ISS), the height from which the fall took place, the patient’s intention and the body regions that were injured. In addition, the height of the fall strongly correlated with the patient’s ISS and was an important predictor of mortality [44]. Head and/or chest injuries, if due to a fall from height, were strongly associated with an increased incidence of death. According to the authors, this mechanism of injury should be a triage priority when tasking ambulances. In addition, the best way of treating these injuries is their prevention. No other significant predictors of mortality were found in this study.
In the case series by Kent and Pearce, 282 suicide attempts were studied, 13 of which were completed. Of those, 8 happened at home, all patients were older than 49 years; and in 7 out of 8 deaths, ladders were implicated [45]. The retrospective study by Petratos et al. analysed in detail the musculoskeletal traumatic pattern resulting from falls from height, and focused particularly on the correlation between specific fracture patterns and the height from which the fall happened, as well as on the causation of the fall (suicide attempt vs. accident). According to their findings, with an increase in the height from which the fall occurred, the frequency of limb, thoracic and pelvic fractures also increased. Such a correlation was not evident for head injuries. Nevertheless, the anatomical regions having sustained fractures (including the cranium) varied in accordance with the height of the fall. Thus, we can infer a mechanism of injury that is varying proportionately to the height of the fall. There was no significant difference between the patients who attempted suicide and those who fell by accident as far as the number of fractures incurred or the regions having been injured were concerned. Nevertheless, with regard to our results that have been published previously, patients who attempted suicide had a significantly greater number of bilateral lower limb fractures than their accidental fall counterpart. In addition, logistic regression analysis shows a significant correlation between the cause of the fall and the presence of lower limb fractures. According to the authors, further research is necessary in order to establish a correlation between incurred traumatic pattern, the height of the fall and the patient’s intention [46].
Choi et al. in his recent study attempted to differentiate the characteristics of traumatic pattern between intentional and non-intentional falls [47]. In addition, he attempted to determine prognostic factors for suicide attempt-related injury and promote adequate measures for the prevention and management of such injuries. In this study, 8992 patients with an accidental fall (non-intentional group) and 144 patients who committed a suicide attempt (intentional group) were included. Falls from a height greater than 4 metres were more frequently encountered in the intentional group. Death prior to patient’s arrival in the accident and emergency department occurred in 54.9% of the cases of suicide attempt. Patients within the intentional group, having sustained increased traumatic load, had fallen from higher, were older and were more likely to be of lower educational level (high-school graduates, instead of college). Due to the fact that injuries sustained after an intentional fall were more likely to have a reserved outcome, the authors highlighted the importance of prevention. Such measures include telephone support and counselling lines, the installation of signs advising against suicide in high risk areas for an intentional fall, such as bridges, along with suggestions for government-coordinated programs aiming for the education of the public and the improvement of social conditions generally and the support of the community and family in particular.
The reasons behind a suicide attempt are multifactorial, hard to quantify and unique in every case. Nevertheless, the study of multiple suicide attempts puts into evidence some risk factors that would lead to such a decision. These are common across all age groups and include: the presence of mental illness, either currently or in the past, a history of alcohol or drug dependence, as well as the presence of depression [10]. Epidemiologically, one out of five persons who have attempted suicide will try once more within a year, and 10% of them will succeed in the end. Drug ingestion is the most common mechanism for a suicide attempt. Violent mechanisms such as hanging, falls from height and use of weapons are not common [48]. The persons who have attempted suicide by falling from height usually become polytrauma patients. The types of injuries incurred are two: deceleration injuries due to inertial phenomena, usually at viscera with vascular pedicles, and direct impact injuries [49].
The severity of fractures incurred will depend on factors like the area over which the impact is applied [50]. The smaller the area of spread of the impact, the greater the local load. Therefore, patients landing on their legs tend to suffer more severe injuries than those who have landed on their flanks, or prone, or supine [51]. Patients due to accidental falls mostly suffered spinal fractures and upper extremities fractures in an attempt to protect themselves. Patients due to suicidal high falls attempts suffered mostly of lower limb fractures, pelvis, spinal fractures and head injuries. Distal radius and hand was the most common affected region in upper extremities in patients with non-intentional falls, in an attempt to protect mainly the head and grab something stable to prevent further fall. In patients with intentional falls, kinetic energy is absorbed mainly by the lower limbs, pelvis, spine and head, leading to characteristic fracture patterns [52]. The most common cause for death is head injury [51, 53, 54] and this is accordance to our results. Turk and Tsokos reviewed 68 medicolegal autopsy cases (22 females, 46 males, age range 13–89 years) of fatal falls from height from 1997 to 2001 [55]. The cause of instant death was head trauma in 24 (35%), internal blood loss in 9 (13%) and polytrauma in 30 (44%) cases. Other causes of death, when the individuals survived the trauma for a longer period, included septic multiple organ dysfunction syndrome and pulmonary embolism. In general, suicides were from greater heights than accidents (mean height 22.7 m for suicides and 10.8 m for accidents, respectively). Strikingly, severe head injuries predominantly occurred in falls from heights below 10 m (84%) and above 25 m (90%). Head trauma was the cause of death in 11 of the 19 cases that were from 9 m or less (58%). Of all cases, 51 (75%) died within a few minutes. A survival time of several hours up to 1 day was observed in 8 cases. Nine patients survived for several days (up to 16 days). Five of them fell from heights below 10 m. Patients with intentional fall from height have a higher early mortality than patients due to accidental fall from height [56].
The easiest way to underline the suspicion that the mode is suicide is if a suicide note is found at the jumping site; this is, however, closer to being the exception than the rule. Analysing the distance of the body from the site of descent may sometimes also help us determine the manner of death. The distance of the body from the site of descent includes the falling height and the horizontal distance. The falling height in suicide was statistically higher than that in accident [57, 58]. For similar heights, Wischhusen et al. have demonstrated that in passive falls, the horizontal distance is usually farther than jumps [59]. From a mechanical point of view, during a fall from height, potential (dynamic) energy is converted into kinetic and this leads to fractures upon impact. Another important factor of the severity of injuries is the height of fall, as the kinetic energy is increasing due to acceleration during the fall and is maximum at the time of impact [60]. In suicide falls, kinetic energy is absorbed mainly by the lower limbs, pelvis and spine, leading to characteristic fracture patterns. In accidental falls, patients most probably extend their arms and flex their hips, which lead to a damping effect that protects the spine [61]. Hence, the most important determinant of survival after a free fall is the position of the body at the time of impact [49]. There were only 3 patients (cases 1, 22 and 31) in group II who have sustained solely upper extremity fractures. The most common body position at the time of impact is with the patient standing and landing with the lower extremities first. This usually leads to calcaneal or pilon fractures, as well as thoracolumbar fractures. If the impact takes place with the patient seated, then higher thoracic or cervical injuries are more likely to happen, which are associated with a higher rate of mortality. Finally, an unpredictable fracture pattern takes place when the victim suffers multiple secondary impacts, in various postures, after bouncing from the primary impact. The amount of injury incurred will depend on the rate of dissipation and absorption of energy, through the patient’s body.
According to the paper by Teh et al., there is a difference to the traumatic pattern incurred by jumpers compared to fallers [13]. Namely, the jumpers tend to impact their dominant lower limb first, as well as sustaining right sided thoracic injuries in the process. We did not confirm the above-mentioned findings in our study. The severity of spinal cord injuries was more important in the suicide than the accidental group [52]. This was in accordance with studies performed in the past, which also showed the early neurologic involvement in such cases. As far as prognosis of spinal cord injury is concerned, complete injuries will be unaltered both in level and extent in a year’s time. On the other hand, incomplete injuries may show signs of improvement for a period of 2 years after the impact [62]. Our results regarding prognosis for ambulation in ASIA A patients and for functionality in ASIA C patients are in accordance with current knowledge [63].
Anderson et al. performed a retrospective study, regarding the rehabilitation outcome of patients with spinal cord injury, as a result of deliberate self-harm (DSH) [29]. According to them, spinal fractures in the DSH group were mainly the result of falls from height. Underlying causes were revealed, such as psychiatric disorders and substance abuse, necessitating formal psychiatric review. There was no difference in short-term rehabilitation results between the DSH and accidental spinal cord injury group. In addition, DSH seemed to impact the length of stay only in patients with a spinal fracture, but without cord injury.
According to the literature, there are three studies on the subject of acute spinal cord injury following a suicide attempt that stand apart. The first is by Stanford et al. In his paper, 56 cases were followed over a period of 30 years (1970–2000). Fifty five cases were due to a fall from height and one open injury, through the use of a gun. Follow-up of 8 years on average was available for 47 cases (84%). The vertebral levels most frequently injured were C5 and L1. About 23 patients suffered from a complete spinal cord injury and 32 had a severe traumatic load (ISS > 15). The psychiatric background of these patients included personality disorder in 27, schizophrenia in 16, depression in 14 and substance abuse/dependence in 20. Of these patients, 4 were successful in subsequent suicide attempts [28].
The following two studies on this subject are from the UK [26] and Denmark [27]. Both of those are observational and retrospective, with a long follow-up. According to the latter, there is an increasing incidence of suicide attempts and associated spinal cord injury from 1965 to 1987. Approximately one third of the patients who attempted suicide suffered from schizophrenia. According to other papers [64, 65], schizophrenia is strongly correlated with falls from height (from bridges in particular). There were 7 patients in our study who have sustained a fall from a bridge. Damage control surgery principles are followed initially for the treatment of life-threatening injuries and for both limb and spinal trauma [66]. The primary goals of fracture fixation are timely mobilization and safe transfer to psychiatric services. Conservative treatment measures are not usually recommended for this group of patients.
Our findings are in accordance with relevant bibliography [67, 68], regarding the psychiatric background of patients who attempt suicide by falling from height. The spectrum of conditions encountered encompasses bipolar disorder, substance dependence and abuse, personality disorder and schizophrenia.
From an epidemiological point of view, schizophrenia is encountered in 5–10% of cases of suicide attempt. These patients may have well planned their suicide or even suffered from an active self-harm ideation. From the above-mentioned, we gather that management of these patients from a trauma point of view must take into consideration their psychiatric needs. The latter may cause significant disturbance in the delivery of medical care [69]. Most of the patients in this study had a positive response following adequate psychiatric intervention. Hence, we gather that prevention and early identification of persons at risk for a suicide attempt with the use of appropriate screening tools by health care professionals are invaluable.
Education of medical and nursing staff regarding the demands and particularities of care of this population, suffering from both spinal cord injury and psychiatric disorders, cannot be overemphasized. Regular follow-up with multidisciplinary team input and future research are necessary for the provision of high-quality care to this population.
According to the literature, it has been difficult to obtain comparable international data on suicide attempts, owing to disparities in definitions, survey designs and study methods, because the combination of free falls and mental disorders produces a unique group of patients. It has been our experience that psychiatric conditions, and especially the suicidal risk, should be evaluated and treated as early as possible during the orthopaedic or surgical hospitalization. Management requires both psychopharmacological therapy and psychotherapy. It has to be directed towards the achievement of symptomatic relief and, if possible, towards the remission of the primary psychiatric disorder.
The management of these patients in the orthopaedic or surgical ward is difficult, because of restlessness, non-cooperation of the patient and the problem of staff inexperienced in handling the psychiatric patient. When prolonged orthopaedic and rehabilitation management are necessary, it is suggested that the patient be transferred to a psychiatric hospital while continuing the necessary orthopaedic treatment. The outcome data provide critical information concerning those individuals who have attempted suicide and suggests future methods for the identification of suicidal factors.
The authors declare that they have no conflicts of interest.
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