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Margerin M, Ducloyer M, Morel B, Delbreil A, Mergy-Laurent M, Tasu JP, Dumas V. Imaging of sudden unexpected death in infancy: a comprehensive nationwide French survey. Pediatr Radiol 2024; 54:1720-1728. [PMID: 39115697 DOI: 10.1007/s00247-024-06013-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 07/21/2024] [Accepted: 07/22/2024] [Indexed: 09/07/2024]
Abstract
RATIONALE AND OBJECTIVES Introduction of post-mortem imaging has helped improve sudden unexpected death in infancy (SUDI) management in Europe. French guidelines were issued in 2007 to homogenise SUDI investigations including imaging. The aim of this study was to evaluate current imaging management of SUDI in France. MATERIAL AND METHODS Between January 2022 and July 2022, all 35 SUDI French referral centres were invited to answer an e-mailed online survey including 29 questions divided into four different sections covering imaging practices for SUDI including radiology department organisation, imaging modalities performed, methods of reading, and current training resources. Partial responses were secondarily completed by a personal call to the SUDI imaging consultant. The current implementation of the 2007 recommendations was compared with a previous evaluation from 2015 and with current North American practices. RESULTS The participation rate of centres performing SUDI imaging was 100% (35/35). Imaging was systematically performed in 94.3% (33/35) of the centres: 74.3% (26/35) using radiography; 5.7% (2/35) using ultrasound; 94.3% (33/35) using computed tomography (CT), including 89% (31/35) whole-body CT and 5.7% (2/35) brain CT; and 20% (7/35) using magnetic resonance imaging (MRI). Two centres (5.7%, 2/35) did not systematically perform brain imaging. One (2.9%, 1/35) used ultrasound-guided biopsy. In comparison with 2015, rates of brain imaging increased by 25.4% (P=0.008). There was no significant difference in the number of forensic MRIs performed between France and North America (P=0.663). CONCLUSION Despite improvements since 2015, full compliance with French guidelines for SUDI investigations remains incomplete. The use of imaging, particularly CT and brain imaging, has increased. Further efforts are needed to standardise imaging practices for optimal SUDI investigations.
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Affiliation(s)
- Mathilde Margerin
- Department of Radiology, Poitiers University Medical Center, CHU Poitiers, 2 Rue de La Milétrie, 86000, Poitiers, France
| | - Mathilde Ducloyer
- Department of Forensic Medicine, Nantes University Medical Center, Nantes, France
| | - Baptiste Morel
- Department of Radiology, Tours University Medical Center, Tours, France
| | - Alexia Delbreil
- Department of Forensic Medicine, Poitiers University Medical Center, Poitiers, France
| | - Martine Mergy-Laurent
- Department of Radiology, Poitiers University Medical Center, CHU Poitiers, 2 Rue de La Milétrie, 86000, Poitiers, France
| | - Jean Pierre Tasu
- Department of Radiology, Poitiers University Medical Center, CHU Poitiers, 2 Rue de La Milétrie, 86000, Poitiers, France
- LaTIM, INSERM, UMR 1101, Bâtiment 1 CHRU Morvan - 2 Av. Foch, 29238, Brest, France
| | - Victor Dumas
- Department of Radiology, Poitiers University Medical Center, CHU Poitiers, 2 Rue de La Milétrie, 86000, Poitiers, France.
- LabCom I3M, DACTIM-MIS Team, LMA CNRS 7348, Poitiers University Medical Center, Poitiers, France.
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2
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Edwards H, Shelmerdine SC, Arthurs OJ. Forensic post-mortem CT in children. Clin Radiol 2023; 78:839-847. [PMID: 37827594 DOI: 10.1016/j.crad.2023.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 03/30/2023] [Accepted: 06/02/2023] [Indexed: 10/14/2023]
Abstract
Post-mortem computed tomography (PMCT) imaging is gaining popularity and acceptance for use alongside forensic autopsies of children, predominantly to aid in the detection of traumatic injuries. Recent research on this topic has provided a breadth of new information regarding the appropriate usage, imaging guidance, and diagnostic accuracy for the identification of different paediatric pathologies. Additionally, advanced CT imaging techniques, such as PMCT angiography or ventilated PMCT, have been trialled, and post-mortem micro-CT is now being used in specialist centres for the assessment of subtle fractures in extracted bone specimens. Various image post-processing methods (e.g., three-dimensional printing from PMCT imaging data) are being used for the illustration of injuries in the medicolegal setting to a lay audience and provide another avenue for the future of forensic radiology research. In this review, the evidence-based principles and benefits of post-mortem imaging for forensic investigation in childhood deaths are presented, with a particular focus on PMCT and current practices. Variations in forensic imaging strategies around the world, published diagnostic accuracy rates, and expected normal post-mortem imaging findings are discussed, as well as potential future applications and research in this area.
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Affiliation(s)
- H Edwards
- Alder Hey Children's NHS Foundation Trust, Liverpool L12 2AP, UK
| | - S C Shelmerdine
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK; UCL Great Ormond Street Institute of Child Health, London, UK; NIHR Great Ormond Street Hospital Biomedical Research Centre, UK
| | - O J Arthurs
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK; UCL Great Ormond Street Institute of Child Health, London, UK; NIHR Great Ormond Street Hospital Biomedical Research Centre, UK.
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3
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Ghosh A, Bose S, Patton D, Kumar I, Khalkhali V, Henry MK, Ouyang M, Huang H, Vossough A, Sze RW, Sotardi S, Francavilla M. Deep learning-based prediction of rib fracture presence in frontal radiographs of children under two years of age: a proof-of-concept study. Br J Radiol 2023; 96:20220778. [PMID: 36802807 PMCID: PMC10161923 DOI: 10.1259/bjr.20220778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 02/08/2023] [Accepted: 02/10/2023] [Indexed: 02/22/2023] Open
Abstract
OBJECTIVE In this proof-of-concept study, we aimed to develop deep-learning-based classifiers to identify rib fractures on frontal chest radiographs in children under 2 years of age. METHODS This retrospective study included 1311 frontal chest radiographs (radiographs with rib fractures, n = 653) from 1231 unique patients (median age: 4 m). Patients with more than one radiograph were included only in the training set. A binary classification was performed to identify the presence or absence of rib fractures using transfer learning and Resnet-50 and DenseNet-121 architectures. The area under the receiver operating characteristic curve (AUC-ROC) was reported. Gradient-weighted class activation mapping was used to highlight the region most relevant to the deep learning models' predictions. RESULTS On the validation set, the ResNet-50 and DenseNet-121 models obtained an AUC-ROC of 0.89 and 0.88, respectively. On the test set, the ResNet-50 model demonstrated an AUC-ROC of 0.84 with a sensitivity of 81% and specificity of 70%. The DenseNet-50 model obtained an AUC of 0.82 with 72% sensitivity and 79% specificity. CONCLUSION In this proof-of-concept study, a deep learning-based approach enabled the automatic detection of rib fractures in chest radiographs of young children with performances comparable to pediatric radiologists. Further evaluation of this approach on large multi-institutional data sets is needed to assess the generalizability of our results. ADVANCES IN KNOWLEDGE In this proof-of-concept study, a deep learning-based approach performed well in identifying chest radiographs with rib fractures. These findings provide further impetus to develop deep learning algorithms for identifying rib fractures in children, especially those with suspected physical abuse or non-accidental trauma.
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Affiliation(s)
| | - Saurav Bose
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Daniella Patton
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ishaan Kumar
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Vahid Khalkhali
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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4
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Cinematic rendering of paediatric musculoskeletal pathologies: initial experiences with CT. Clin Radiol 2022; 77:274-282. [PMID: 35164928 DOI: 10.1016/j.crad.2022.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 01/06/2022] [Indexed: 11/22/2022]
Abstract
Cinematic rendering (CR) is a novel post-processing technique similar to volume rendering (VR), which allows for a more photorealistic imaging reconstruction by using a complex light modelling algorithm, incorporating information from multiple light paths and predicted photon scattering patterns. Several recent publications relating to adult imaging have argued that CR gives a better "realism" and "expressiveness" experience over VR techniques. CR has also been shown to improve visualisation of musculoskeletal and vascular anatomy compared with conventional CT viewing, and may help non-radiologists to understand complex patient anatomy. In this review, we provide an overview of how CR could be used in paediatric musculoskeletal imaging, particularly in complex diagnoses, surgical planning, and patient consent processes. We present a direct comparison of VR and CR reconstructions across a range of congenital and acquired musculoskeletal pathologies, highlighting potential advantages and areas for further research.
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5
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Child Abuse, a Post-mortem Forensic Perspective. FORENSIC IMAGING 2022. [DOI: 10.1007/978-3-030-83352-7_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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6
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Doyle E, Dimmock M, Lee K, Ng J, Bassed R. A systematised literature review: Can low-dose whole-body computed tomography replace a radiographic skeletal survey when investigating paediatric non-accidental injury? FORENSIC IMAGING 2021. [DOI: 10.1016/j.fri.2021.200481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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7
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Pomeranz CB, Barrera CA, Servaes SE. Value of chest CT over skeletal surveys in detection of rib fractures in pediatric patients. Clin Imaging 2021; 82:103-109. [PMID: 34801840 DOI: 10.1016/j.clinimag.2021.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 10/25/2021] [Accepted: 11/10/2021] [Indexed: 11/03/2022]
Abstract
Recent literature has raised concerns about the sensitivity and accuracy of radiographs at diagnosing rib fractures. Studies have shown that chest computed tomography (CT) has far greater sensitivity at detecting rib fractures than radiographs. The purpose of this study was to evaluate the sensitivity of skeletal survey (SS) radiographs at diagnosis of rib fractures compared to CT in the pediatric population. This retrospective review included 57 patients who had undergone both a SS and a CT chest or CT chest/abdomen/pelvis within 30 days of each other for the indication of either non-accidental (NAT) or accidental trauma between 2009 and 2017. Images and reports were analyzed by a pediatric radiology fellow for presence/absence of fracture, evidence of healing and location of rib fracture, including rib level, location within the rib (anterior, lateral, and posterior), and side (right versus left). 225 rib fractures were identified in 25 patients on CT. 38 of those fractures were missed on the preceding SS, yielding a miss rate of 17%. Acute fractures were more likely to be missed than chronic or healing fractures (p ≤ 0.01). Location within the rib did not impact rib detection on radiographs. Left-sided rib fractures were not more common in NAT patients, compared to accidental trauma. SS miss approximately 17% of all rib fractures and CT is more sensitive modality in the detection of rib fractures, particularly acute rib fractures, regardless of location. Low-dose Chest CT could be a helpful modality in the work-up of NAT trauma.
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Affiliation(s)
- Christy B Pomeranz
- Department of Radiology, New York Presbyterian Hospital- Weill Cornell Medical School, New York, NY, United States of America.
| | - Christian A Barrera
- Department of Radiology, University of Pennsylvania School of Medicine and the Children's Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Sabah E Servaes
- Department of Radiology, University of Pennsylvania School of Medicine and the Children's Hospital of Philadelphia, Philadelphia, PA, United States of America
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8
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Lawson M, Tully J, Ditchfield M, Metcalfe P, Qi Y, Kuganesan A, Badawy MK. A review of current imaging techniques used for the detection of occult bony fractures in young children suspected of sustaining non-accidental injury. J Med Imaging Radiat Oncol 2021; 66:68-78. [PMID: 34176229 DOI: 10.1111/1754-9485.13270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 06/01/2021] [Indexed: 11/30/2022]
Abstract
Non-accidental injuries remain a leading cause of preventable morbidity and mortality in young children. The accurate identification of the full spectrum of injuries in children presenting with suspected abuse is essential to ensure the appropriate protective intervention is taken. The identification of occult bone fractures in this cohort is important as it raises the level of concern about the mechanism of injury and maintaining the child's safety. Radiographic imaging remains the modality of choice for skeletal assessment; however, current studies report concerns regarding the ability of radiographs to detect certain fractures in the acute stage. As such, alternative modalities for the detection of fractures have been proposed. This article reviews the current literature regarding fracture detectability and radiation dose burden of imaging modalities currently used for the assessment of occult bony injury in young children in whom non-accidental injury is suspected.
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Affiliation(s)
- Michael Lawson
- Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,Centre for Medical and Radiation Physics, School of Physics, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | - Joanna Tully
- Victorian Forensic Paediatric Medical Service, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Michael Ditchfield
- Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter Metcalfe
- Centre for Medical and Radiation Physics, School of Physics, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | - Yujin Qi
- Centre for Medical and Radiation Physics, School of Physics, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | | | - Mohamed K Badawy
- Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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9
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Harty MP, Gould SW, Harcke HT. Navigating the perils and pitfalls of pediatric forensic postmortem imaging in the United States. Pediatr Radiol 2021; 51:1051-1060. [PMID: 33999245 DOI: 10.1007/s00247-020-04833-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 05/28/2020] [Accepted: 08/27/2020] [Indexed: 02/06/2023]
Abstract
Postmortem CT is widely used in the general adult and military populations. It is used extensively in pediatric death investigations in Europe and Asia, but distinctive challenges are encountered when launching a postmortem imaging program in the United States. We describe the issues we have encountered specific to establishing a pediatric postmortem imaging service in this country and propose potential solutions.
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Affiliation(s)
- Mary P Harty
- Department of Medical Imaging, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA.
| | - Sharon W Gould
- Department of Medical Imaging, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA
| | - Howard T Harcke
- Department of Medical Imaging, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA
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10
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Hu Y, He X, Zhang R, Guo L, Gao L, Wang J. Slice grouping and aggregation network for auxiliary diagnosis of rib fractures. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2021.102547] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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11
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Baier W, Norman DG, Williams MA. Micro-CT for the examination of paediatric rib injuries: A case series. Forensic Sci Int 2021; 325:110789. [PMID: 34217913 DOI: 10.1016/j.forsciint.2021.110789] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 03/17/2021] [Accepted: 04/07/2021] [Indexed: 10/21/2022]
Abstract
Cases of child abuse and homicide are amongst the biggest challenges investigators face, with complex evidence bases often strongly contested and reliant on specialist interpretation of the medical evidence. In many cases, this medical evidence includes examination of the deceased's skeleton using different macroscopic and microscopic imaging methods. Rib fractures are a common concern when examining suspicious cases and much research has been conducted on their causes. The role of CPR in particular has been controversial and therefore a clear assessment of the fracture distribution is crucial. Recent studies have shown the benefit of imaging techniques such as Computed Tomography, although the gold standard remains histology. This paper presents three cases of suspected non-accidental rib fractures of infants which had been examined using micro-CT and histology. Micro-CT has been shown to be superior to medical CT as it achieves a greater resolution, making it effective for paediatric post-mortem imaging. Micro-CT observations were compared retrospectively to the histology, which demonstrated that micro-CT found 69% of the fractures identified histologically as well as an additional 22% not identified through histology. As well as complimenting histological analysis, the extent to which micro-CT can enhance the overall examination of paediatric non-accidental injuries is also discussed.
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Affiliation(s)
- Waltraud Baier
- WMG, International Manufacturing Centre, University of Warwick Coventry, CV4 7AL, UK.
| | - Danielle G Norman
- WMG, International Manufacturing Centre, University of Warwick Coventry, CV4 7AL, UK
| | - Mark A Williams
- WMG, International Manufacturing Centre, University of Warwick Coventry, CV4 7AL, UK
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12
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Alzahrani NM, Jeanes A, Paddock M, Shuweihdi F, Offiah AC. The diagnostic performance of chest computed tomography in the detection of rib fractures in children investigated for suspected physical abuse: a systematic review and meta-analysis. Eur Radiol 2021; 31:7088-7097. [PMID: 33725188 PMCID: PMC8379101 DOI: 10.1007/s00330-021-07775-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/08/2021] [Accepted: 02/11/2021] [Indexed: 02/01/2023]
Abstract
Objectives To assess the diagnostic performance of chest CT in the detection of rib fractures in children investigated for suspected physical abuse (SPA). Methods Medline, Web of Science and Cochrane databases were searched from January 1980 to April 2020. The QUADAS-2 tool was used to assess the quality of the eligible English-only studies following which a formal narrative synthesis was constructed. Studies reporting true-positive, false-positive, true-negative, and false-negative results were included in the meta-analysis. Overall sensitivity and specificity of chest CT for rib fracture detection were calculated, irrespective of fracture location, and were pooled using a univariate random-effects meta-analysis. The diagnostic accuracy of specific locations along the rib arc (anterior, lateral or posterior) was assessed separately. Results Of 242 identified studies, 4 met the inclusion criteria. Of these, 2 were included in the meta-analysis. Chest CT identified 142 rib fractures compared to 79 detected by initial skeletal survey chest radiographs in live children with SPA. Post-mortem CT (PMCT) has low sensitivity (34%) but high specificity (99%) in the detection of rib fractures when compared to the autopsy reference standard. PMCT has low sensitivity (45%, 21% and 42%) but high specificity (99%, 97% and 99%) at anterior, lateral and posterior rib locations, respectively. Conclusions Chest CT detects more rib fractures than initial skeletal survey chest radiographs in live children with SPA. PMCT has low sensitivity but high specificity for detecting rib fractures in children investigated for SPA. Key Points • PMCT has low sensitivity (34%) but high specificity (99%) in the detection of rib fractures; extrapolation to CT in live children is difficult. • No studies have compared chest CT with the current accepted practice of initial and follow-up skeletal survey chest radiographs in the detection of rib fractures in live children investigated for SPA. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-021-07775-3.
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Affiliation(s)
- Nasser M Alzahrani
- Diagnostic Radiology Department, College of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia. .,Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Damer Street Building, Western Bank, Sheffield, S10 2TH, UK.
| | - Annmarie Jeanes
- Department of Paediatric Radiology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX, UK
| | - Michael Paddock
- Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Damer Street Building, Western Bank, Sheffield, S10 2TH, UK.,Medical Imaging Department, Barnsley Hospital NHS Foundation Trust, Gawber Road, Barnsley, S75 2EP, UK
| | - Farag Shuweihdi
- Leeds Institute of Health Sciences, University of Leeds, Leeds, LS2 9NL, UK
| | - Amaka C Offiah
- Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Damer Street Building, Western Bank, Sheffield, S10 2TH, UK.,Radiology Department, Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield, S10 2TH, UK
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13
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Spies AJ, Steyn M, Prince DN, Brits D. Can forensic anthropologists accurately detect skeletal trauma using radiological imaging? FORENSIC IMAGING 2021. [DOI: 10.1016/j.fri.2020.200424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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14
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Temporal Pattern of Radiographic Findings of Costochondral Junction Rib Fractures on Serial Skeletal Surveys in Suspected Infant Abuse. AJR Am J Roentgenol 2020; 216:1649-1658. [PMID: 32845713 DOI: 10.2214/ajr.20.24106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND. Costochondral junction (CCJ) rib fractures pose a challenge in the radiographic detection and dating of infant abuse. OBJECTIVE. The purpose of this article was to assess the temporal pattern of radio-graphic findings of CCJ fractures on a serial skeletal survey (SS). METHODS. Reports of SSs performed for suspected infant abuse were reviewed to identify those reporting a CCJ fracture. Study inclusion required undergoing initial and approximately 2-week follow-up SSs that included anteroposterior and bilateral oblique radiographs of the reported CCJ rib fracture. Two pediatric radiologists retrospectively classified fractures in terms of the primary injury pattern (bucket-handle: visible crescentic fracture line; corner: visible triangular fracture line; other) and secondary healing pattern (growth disturbance; sclerosis; subperiosteal new bone formation [SPNBF]). Discrepant readings were resolved by consensus. RESULTS. The final cohort included 26 infants with 81 CCJ fractures. On initial SS, 59% (48/81) of fractures showed a primary pattern, most commonly a bucket-handle pattern (46%; 37/81); 6% (5/81) showed a primary pattern on follow-up SS (p < .001). On initial SS, the prevalence of a secondary pattern was 89% (72/81), most commonly a growth disturbance (85%; 69/81), followed by sclerosis (57%; 46/81); 80% (65/81) showed a secondary pattern on follow-up SS (p = .12). Overall prevalence of SPNBF was 28% (23/81). Addition of bilateral oblique views on initial SS resulted in a significant increase relative to the anteroposterior views alone in the detection of primary and secondary patterns by 15% (p = .04) and 30% (p < .001), respectively. CONCLUSION. A bucket-handle appearance is the most common primary pattern of fracture. The significantly lower prevalence of a primary pattern on follow-up vs initial SSs suggests that the CCJ fracture line is usually visible for only approximately 2 weeks. A growth disturbance of the rib end is the most common secondary pattern, followed by bony sclerosis, consistent with a healing injury. SPNBF is uncommon. Most CCJ fractures are in a healing phase at initial diagnosis. The signs of repair commonly remain visible on 2-week follow-up. The increased diagnostic yield of oblique views provides support to the inclusion of these projections in routine SS protocols. CLINICAL IMPACT. The findings will help radiologists improve the diagnosis and dating of CCJ rib fractures.
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15
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Obertová Z, Leipner A, Messina C, Vanzulli A, Fliss B, Cattaneo C, Sconfienza LM. Postmortem imaging of perimortem skeletal trauma. Forensic Sci Int 2019; 302:109921. [DOI: 10.1016/j.forsciint.2019.109921] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 07/31/2019] [Accepted: 08/04/2019] [Indexed: 12/30/2022]
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16
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Gould SW, Harty MP, Givler NE, Christensen TE, Curtin RN, Harcke HT. Pediatric postmortem computed tomography: initial experience at a children's hospital in the United States. Pediatr Radiol 2019; 49:1113-1129. [PMID: 31201439 DOI: 10.1007/s00247-019-04433-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 04/17/2019] [Accepted: 05/16/2019] [Indexed: 12/18/2022]
Abstract
Postmortem CT might provide valuable information in determining the cause of death and understanding disease processes, particularly when combined with traditional autopsy. Pediatric applications of postmortem imaging represent a new and rapidly growing field. We describe our experience in establishing a pediatric postmortem CT program and present a discussion of the distinct challenges in developing this type of program in the United States of America, where forensic practice varies from other countries. We give a brief overview of recent literature along with the common imaging findings on postmortem CT that can simulate antemortem pathology.
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Affiliation(s)
- Sharon W Gould
- Department of Medical Imaging, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA.
| | - M Patricia Harty
- Department of Medical Imaging, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA
| | - Nicole E Givler
- Department of Medical Imaging, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA
| | - Theresa E Christensen
- Department of Biomedical Research, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Riley N Curtin
- Department of Biomedical Research, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Howard T Harcke
- Department of Medical Imaging, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA
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17
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Awais M, Salam B, Nadeem N, Rehman A, Baloch NU. Diagnostic Accuracy of Computed Tomography Scout Film and Chest X-ray for Detection of Rib Fractures in Patients with Chest Trauma: A Cross-sectional Study. Cureus 2019; 11:e3875. [PMID: 30899626 PMCID: PMC6420333 DOI: 10.7759/cureus.3875] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Rib fractures are a major source of morbidity in patients with chest trauma. Computed tomography (CT) scout film is a low-dose image that is obtained prior to a complete chest CT study for all patients undergoing a CT scan. In this study, we evaluated the diagnostic performance of CT scout film vis-à-vis that of chest X-ray for detection of rib fractures using chest CT scan as the reference standard. METHODS A cross-sectional study was performed at the radiology department of Aga Khan University Hospital (Karachi, Pakistan) from October 1, 2013 to September 31, 2014. Patients who underwent CT chest for evaluation of thoracic trauma were included in the study. Sensitivity and specificity of chest X-ray and CT scout film were calculated. RESULTS A total of 207 patients were included in the study (193 were male). Penetrating and blunt thoracic injuries affected 104 (50.2%) and 103 (49.8%) patients respectively. On CT chest, 75 (36.2%) patients had evidence of rib fractures. Sensitivity and specificity of CT scout film for detection of rib fractures were 56% and 87.9%, while those of chest X-ray were 61.3% and 98.5% respectively. The overall accuracy of CT scout film and chest X-ray for detection of rib fractures were 76.3% and 85% respectively. CONCLUSION Diagnostic performance of CT scout film for detection of rib fractures was comparable to that of the plain chest radiograph. CT scout film does not provide any additional information or advantage over a plain chest radiograph. In patients with severe thoracic trauma, CT chest remains the modality of choice for accurate delineation of rib fractures and associated internal injuries.
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Affiliation(s)
| | - Basit Salam
- Radiology, The Aga Khan University, Karachi, PAK
| | - Naila Nadeem
- Radiology, The Aga Khan University, Karachi, PAK
| | - Abdul Rehman
- Internal Medicine, Rutgers New Jersey Medical School, Newark, USA
| | - Noor U Baloch
- Internal Medicine, Rutgers New Jersey Medical School, Newark, USA
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Chest radiographs versus CT for the detection of rib fractures in children (DRIFT): a diagnostic accuracy observational study. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:802-811. [PMID: 30249541 PMCID: PMC6350458 DOI: 10.1016/s2352-4642(18)30274-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 08/07/2018] [Accepted: 08/14/2018] [Indexed: 11/21/2022]
Abstract
Background Internationally, chest radiography is the standard investigation for identifying rib fractures in suspected physical abuse in infants. Several small observation studies in children have found that chest CT can provide greater accuracy than radiography for fracture detection, potentially aiding medicolegal proceedings in abuse cases; however, to our knowledge, this greater accuracy has not been comprehensively evaluated. We aimed to determine differences in rib fracture detection rates between post-mortem chest radiographs and chest CT images, using forensic autopsy as the reference standard. Methods In this retrospective diagnostic accuracy study, we searched the Great Ormond Street Hospital (London, UK) radiology information system for all children aged 0–16 years who had a post-mortem skeletal survey (ie, full-body radiography), CT, and full autopsy between Jan 1, 2012, and Jan 1, 2017, for a purpose of death investigation. Cases were excluded if the imaging was done for a reason other than a forensic investigation or if image quality was suboptimal. Radiologists were recruited as reporters on a voluntary basis via membership databases from international radiology and post-mortem imaging societies with no specific inclusion or exclusion criteria. Reporters were sent a set of chest radiographs on a password protected and encrypted USB flash drive or via a secure filesharing website and independently reported on the presence of rib fractures, fracture location, and the confidence level of their interpretation. They were masked to the clinical information of the images. 1 month later, the same reporters were sent CTs for the same cases in a random order and asked to report on the same features. The primary objective was to compare the accuracy of detection of rib fractures by use of post-mortem chest radiographs and CTs, with autopsy data as reference standard. Accuracy was assessed by comparison of diagnostic statistics, calculated using random-intercept multilevel logistic models with reporter and patient included as cross-classified random-effects. Findings 25 cases of children (aged 1 month to 7 years), with 136 rib fractures at autopsy with paired post-mortem chest radiographs and CTs, were selected for analysis. 38 radiologists were recruited as reporters from 23 international centres; 12 (32%) were consultants, median experience of 14·5 years (range 6–27), and 26 (68%) were registrars, median experience of 4 years (range 2–9). Across all radiologists, three times as many rib fractures were correctly detected by use of chest CTs compared with chest radiography (sensitivity 44·9% [95% CI 31·7–58·9] vs 13·5% [8·1–21·5]; difference 31·4% [23·3–37·8; p<0·001]). Sensitivity for detection on the correct rib was higher by use of CT than by use of radiography (62·4% [95% CI 44·9–77·1] vs 23·1% [12·9–37·8]; difference 39·3% [31·9–42·2; p<0·001]), as was diagnosis of a patient with any rib fracture or fractures (81·5% [75·8–86·0] vs 64·7% [57·3–71·4]; difference 16·7% [11·5–22·2; p<0·001]). Radiologist confidence was higher when using CT images than radiographs (highest confidence rating given on 3317 [63·6%] of 5218 fractures for CT vs 1518 [46·6%] of 3303 on radiographs) and was a predictor for accurate fracture detection. Interpretation Chest CT provides greater accuracy than conventional chest radiography for post-mortem rib fracture detection, irrespective of radiologist experience or fracture location, although both methods detected a substantial number of false positives. The diagnostic accuracy of CT should be studied further in live children ideally in a multicentre trial to assess the applicability of our results. Funding Great Ormond Street Children's Charity, Medical Research Council, Royal College of Radiologists, Research Councils UK, National Institute for Health Research.
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Raynor E, Konala P, Freemont A. The detection of significant fractures in suspected infant abuse. J Forensic Leg Med 2018; 60:9-14. [PMID: 30196192 DOI: 10.1016/j.jflm.2018.09.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 07/05/2018] [Accepted: 09/03/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Skeletal survey is a commonly used means of detecting fractures in infants, and is used as a screen in suspected cases of physical abuse. It is recognised that in live infants, a repeat survey some days after a suspected episode of injury will detect more fractures than one taken shortly after the suspected injury, indicating that the latter lacks sensitivity. In infants who die soon after a suspected episode of physical abuse, the managing clinicians do not have the option of a second survey; however there is the opportunity for the microscopic examination of bones removed at autopsy. Increasingly Osteoarticular Pathology at the Manchester University NHS Foundation Trust (MFT) is being sent samples of bones from infants suspected of inflicted injury for histological examination, both from bones with fractures detected at autopsy or skeletal survey and from posterior ribs and long bone metaphyses (sites of significance in assessing for abusive injury) when there is no evidence of fracture on skeletal survey or autopsy. Here we report the results of an audit of the anonymised data from a series of such cases, to establish the sensitivity of skeletal survey (SS) to detect fractures and to define the medico-legal value of submitting bones for histological examination. METHODS This was an audit of skeletal injuries in 38 infants aged <18 months presenting to MFT for specialist histopathological evaluation of suspected non-accidental fractures between January 2011 and June 2017. Histopathological examination was performed on all bones submitted and compared with contact radiography of isolated bones and post-mortem skeletal surveys undertaken by specialist paediatric or musculoskeletal radiologists for the presence of fracture. RESULTS A total of 318 fractures were detected histologically; of these, 178 (56%) were of the ribs, 119 (37.5%) were of major limb long bones, 10 (3%) were of the skull, and 11 (3.5%) were recorded as 'other'. Excluding refractures, skeletal survey detected 54% of the fractures recorded histologically. No fractures were detected radiologically that were not seen histologically. Generally, for skeletal survey, detection rates improved with the age of the lesion, and rib fractures were more difficult to detect than long bone fractures. Ribs 5-8 were the most frequently fractured ribs, and metaphyses around the knee accounted for most metaphyseal limb long bone fractures undetected by SS. CONCLUSION In infants coming to post-mortem, histopathology is more sensitive than SS for the detection of clinically significant fractures. In children suspected of non-accidental injuries but with negative or equivocal SS, sampling of the anterior and posterior end of ribs 5-8 and the bones around the knee for histological examination could reveal clinically unsuspected fractures and significant evidence of physical abuse. 71% of infants showed evidence of old fractures typical of non-accidental injury.
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Affiliation(s)
- Emma Raynor
- University of Manchester, School of Medical Sciences, Stopford Building, Oxford Road, Manchester, M13 9PT, United Kingdom.
| | - Praveen Konala
- Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, United Kingdom.
| | - Anthony Freemont
- Manchester Molecular Pathology Innovation Centre, 3rd floor Citylabs, Nelson Street, Manchester, M13 9NQ, United Kingdom.
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20
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Keneally RJ, Shields CH, Hsu A, Prior HI, Creamer KM. Pediatric Thoracic Trauma in Iraq and Afghanistan. Mil Med 2018; 183:e596-e602. [DOI: 10.1093/milmed/usy044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Indexed: 12/25/2022] Open
Affiliation(s)
- Ryan J Keneally
- Department of Anesthesiology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
| | - Cynthia H Shields
- Department of Anesthesiology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
| | - Albert Hsu
- Department of Anesthesiology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
| | - Howard I Prior
- Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
| | - Kevin M Creamer
- Department of Pediatrics, George Washington University School of Medicine, 2300 I St NW, Washington, DC
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Gould SW, Harty MP, Givler N, Christensen T, Harcke HT. Pediatric Postmortem CT: Initial Experience at a Tertiary Care Children’s Hospital. CURRENT RADIOLOGY REPORTS 2017. [DOI: 10.1007/s40134-017-0250-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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22
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Arthurs OJ, Hutchinson JC, Sebire NJ. Current issues in postmortem imaging of perinatal and forensic childhood deaths. Forensic Sci Med Pathol 2017; 13:58-66. [PMID: 28083782 PMCID: PMC5306347 DOI: 10.1007/s12024-016-9821-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2016] [Indexed: 11/27/2022]
Abstract
Perinatal autopsy practice is undergoing a state of change with the introduction of evidence-based cross-sectional imaging, driven primarily by parental choice. In particular, the introduction of post mortem magnetic resonance imaging (PMMR) has helped to advance less-invasive perinatal autopsy in the United Kingdom (UK) and Europe. However, there are limitations to PMMR and other imaging techniques which need to be overcome, particularly with regard to imaging very small fetuses. Imaging is also now increasingly used to investigate particular deaths in childhood, such as suspected non-accidental injury (NAI) and sudden unexpected death in infancy (SUDI). Here we focus on current topical developments the field, with particular emphasis on the application of imaging to perinatal autopsy, and pediatric forensic deaths. Different imaging modalities and their relative advantages and disadvantages are discussed, together with other benefits of more advanced cross-sectional imaging which currently lie in the research domain. Whilst variations in local imaging service provision and need may determine different practice patterns, and access to machines and professionals with appropriate expertise and experience to correctly interpret the findings may limit current practices, we propose that gold standard perinatal and pediatric autopsy services would include complete PMMR imaging prior to autopsy, with PMCT in suspicious childhood deaths. This approach would provide maximal diagnostic yield to the pathologist, forensic investigator and most importantly, the parents.
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Affiliation(s)
- Owen J Arthurs
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.
- Institute of Child Health, UCL, London, UK.
| | - John C Hutchinson
- Institute of Child Health, UCL, London, UK
- Department of Histopathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Neil J Sebire
- Institute of Child Health, UCL, London, UK
- Department of Histopathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Diagnostic accuracy of postmortem imaging vs autopsy-A systematic review. Eur J Radiol 2016; 89:249-269. [PMID: 28089245 DOI: 10.1016/j.ejrad.2016.08.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Revised: 07/11/2016] [Accepted: 08/02/2016] [Indexed: 11/23/2022]
Abstract
Background Postmortem imaging has been used for more than a century as a complement to medico-legal autopsies. The technique has also emerged as a possible alternative to compensate for the continuous decline in the number of clinical autopsies. To evaluate the diagnostic accuracy of postmortem imaging for various types of findings, we performed this systematic literature review. Data sources The literature search was performed in the databases PubMed, Embase and Cochrane Library through January 7, 2015. Relevant publications were assessed for risk of bias using the QUADAS tool and were classified as low, moderate or high risk of bias according to pre-defined criteria. Autopsy and/or histopathology were used as reference standard. Findings The search generated 2600 abstracts, of which 340 were assessed as possibly relevant and read in full-text. After further evaluation 71 studies were finally included, of which 49 were assessed as having high risk of bias and 22 as moderate risk of bias. Due to considerable heterogeneity - in populations, techniques, analyses and reporting - of included studies it was impossible to combine data to get a summary estimate of the diagnostic accuracy of the various findings. Individual studies indicate, however, that imaging techniques might be useful for determining organ weights, and that the techniques seem superior to autopsy for detecting gas Conclusions and Implications In general, based on the current scientific literature, it was not possible to determine the diagnostic accuracy of postmortem imaging and its usefulness in conjunction with, or as an alternative to autopsy. To correctly determine the usefulness of postmortem imaging, future studies need improved planning, improved methodological quality and larger materials, preferentially obtained from multi-center studies.
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Arthurs OJ, van Rijn RR, Whitby EH, Johnson K, Miller E, Stenzel M, Watt A, Taranath A, Perry DH. ESPR postmortem imaging task force: where we begin. Pediatr Radiol 2016; 46:1363-9. [PMID: 27412272 DOI: 10.1007/s00247-016-3639-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 05/04/2016] [Indexed: 11/24/2022]
Abstract
A new task force on postmortem imaging was established at the annual meeting of the European Society of Paediatric Radiology (ESPR) in Graz, Austria, in 2015. The postmortem task force is separate from the child abuse task force as it covers all aspects of fetal, neonatal and non-forensic postmortem imaging. The main focus of the task force is the guidance and standardization of non-radiographic postmortem imaging, particularly postmortem CT and postmortem MRI. This manuscript outlines the starting point of the task force, with a mission statement, outline of current experience, and short- and long-term goals.
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Affiliation(s)
- Owen J Arthurs
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK. .,Institute of Child Health, UCL, London, UK.
| | - Rick R van Rijn
- Department of Radiology, Emma Children's Hospital - Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Elspeth H Whitby
- Academic unit of Reproductive and Developmental Medicine, University of Sheffield, Sheffield, S10 1SF, UK
| | - Karl Johnson
- Radiology Department, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Elka Miller
- Department of Medical Imaging, Children's Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Martin Stenzel
- Department of Radiology, University Hospital Freiburg, Hugstetter Str. 55, D-79106, Freiburg, Germany
| | - Andrew Watt
- Department of Diagnostic Imaging & Clinical Physics, The Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF, UK
| | - Ajay Taranath
- Department of Medical Imaging, Women's and Children's Hospital, 72 King William St., North Adelaide, South Australia, Australia
| | - David H Perry
- Radiology Department, National Women's Health and Starship Children's Hospital, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand
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Glemser PA, Pfleiderer M, Heger A, Tremper J, Krauskopf A, Schlemmer HP, Yen K, Simons D. New bone post-processing tools in forensic imaging: a multi-reader feasibility study to evaluate detection time and diagnostic accuracy in rib fracture assessment. Int J Legal Med 2016; 131:489-496. [DOI: 10.1007/s00414-016-1412-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Accepted: 06/29/2016] [Indexed: 11/27/2022]
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26
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Slovis TL, Strouse PJ, Strauss KJ. Radiation Exposure in Imaging of Suspected Child Abuse: Benefits versus Risks. J Pediatr 2015; 167:963-8. [PMID: 26354874 DOI: 10.1016/j.jpeds.2015.07.064] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 05/29/2015] [Accepted: 07/30/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Thomas L Slovis
- Department of Radiology, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, MI
| | - Peter J Strouse
- Section of Pediatric Radiology, C. S. Mott Children's Hospital, Department of Radiology, University of Michigan Health System, Ann Arbor, MI.
| | - Keith J Strauss
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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27
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Gunes H, Unlu EN, Saritas A. CT versus grayscale rib series for the detection of rib fracture. Am J Emerg Med 2015; 33:1515-6. [DOI: 10.1016/j.ajem.2015.07.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 07/28/2015] [Indexed: 10/23/2022] Open
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Marin JR, Wang L, Winger DG, Mannix RC. Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits. J Pediatr 2015; 167:897-904.e3. [PMID: 26233603 PMCID: PMC4881390 DOI: 10.1016/j.jpeds.2015.06.052] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 05/21/2015] [Accepted: 06/25/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess variation in the use of computed tomography (CT) for pediatric injury-related emergency department (ED) visits. STUDY DESIGN This was a retrospective cohort study of visits to 14 network-affiliated EDs from November 2010 through February 2013. Visits were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Primary outcome was CT use. We used descriptive statistics and performed multivariable logistic regression to evaluate the association of patient and ED covariates on any and body region-specific CT use. RESULTS Of the 80 868 injury-related visits, 11.4% included CT, and 28.4% of those involved more than 1 CT. Across EDs, CT use ranged from 7.6% to 25.5% of visits and did not correlate with institutional Injury Severity Score (P = .33) or admission/transfer rates (P = .07). In multivariable analysis of nonpediatric EDs, trauma centers and nonacademic EDs were associated with CT use. Higher pediatric volume was associated with any CT use; however, there was an inverse relationship between volume and nonhead CT use. When the pediatric ED was included in multivariable modeling, the effect of level 1-3 trauma center designation remained, and the pediatric level 1 trauma center was less likely to use most body region-specific CTs. CONCLUSION There is wide variation in CT imaging for pediatric injury-related visits not attributable solely to case mix. Future work to optimize CT utilization should focus on additional factors contributing to imaging practices and interventions.
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Affiliation(s)
- Jennifer R Marin
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Li Wang
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Daniel G Winger
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Rebekah C Mannix
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
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Jalalzadeh H, Giannakopoulos GF, Berger FH, Fronczek J, van de Goot FRW, Reijnders UJ, Zuidema WP. Post-mortem imaging compared with autopsy in trauma victims--A systematic review. Forensic Sci Int 2015; 257:29-48. [PMID: 26284976 DOI: 10.1016/j.forsciint.2015.07.026] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 06/25/2015] [Accepted: 07/13/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Post-mortem imaging or virtual autopsy is a rapidly advancing field of post-mortem investigations of trauma victims. In this review we evaluate the feasibility of complementation or replacement of conventional autopsy by post-mortem imaging in trauma victims. MATERIALS AND METHODS A systematic review was performed in compliance with the PRISMA guidelines. MEDLINE, Embase and Cochrane databases were systematically searched for studies published between January 2008 and January 2014, in which post-mortem imaging was compared to conventional autopsy in trauma victims. Studies were included when two or more trauma victims were investigated. RESULTS Twenty-six studies were included, with a total number of 563 trauma victims. Post-mortem computer tomography (PMCT) was performed in 22 studies, post-mortem magnetic resonance imaging (PMMRI) in five studies and conventional radiography in two studies. PMCT and PMMRI both demonstrate moderate to high-grade injuries and cause of death accurately. PMCT is more sensitive than conventional autopsy or PMMRI in detecting skeletal injuries. For detecting minor organ and soft tissue injuries, autopsy remains superior to imaging. Aortic injuries are missed frequently by PMCT and PMMRI and form their main limitation. CONCLUSION PMCT should be considered as an essential supplement to conventional autopsy in trauma victims since it detects many additional injuries. Despite some major limitations, PMCT could be used as an alternative for conventional autopsy in situations where conventional autopsy is rejected or unavailable.
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Affiliation(s)
- Hamid Jalalzadeh
- Department of Trauma Surgery, VU University Medical Centre, De Boelelaan 1117, 1081 HZ Amsterdam, The Netherlands; Department of General Surgery, Slotervaartziekenhuis, Louwesweg 6, 1066 EC Amsterdam, The Netherlands.
| | - Georgios F Giannakopoulos
- Department of Trauma Surgery, VU University Medical Centre, De Boelelaan 1117, 1081 HZ Amsterdam, The Netherlands; Department of General Surgery, Slotervaartziekenhuis, Louwesweg 6, 1066 EC Amsterdam, The Netherlands
| | - Ferco H Berger
- Department of Radiology and Nuclear Medicine, VU University Medical Centre, De Boelelaan 1117, 1081 HZ Amsterdam, The Netherlands
| | - Judith Fronczek
- Department of Pathology, VU University Medical Centre, De Boelelaan 1117, 1081 HZ Amsterdam, The Netherlands; Department of Pathology, Symbiant, Medisch Centrum Alkmaar, Wilhelminalaan 12, 1815 JD Alkmaar, The Netherlands
| | - Frank R W van de Goot
- Department of Pathology, VU University Medical Centre, De Boelelaan 1117, 1081 HZ Amsterdam, The Netherlands; Department of Pathology, Symbiant, Medisch Centrum Alkmaar, Wilhelminalaan 12, 1815 JD Alkmaar, The Netherlands
| | - Udo J Reijnders
- Department of Forensic Medicine, Public Health Service, P.O. Box 2200, 1000 CE Amsterdam, The Netherlands
| | - Wietse P Zuidema
- Department of Trauma Surgery, VU University Medical Centre, De Boelelaan 1117, 1081 HZ Amsterdam, The Netherlands
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The future of pediatric and perinatal postmortem imaging. Pediatr Radiol 2015; 45:509-16. [PMID: 25828354 DOI: 10.1007/s00247-014-3266-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 10/23/2014] [Accepted: 12/19/2014] [Indexed: 12/21/2022]
Abstract
The field and applications of postmortem imaging are exponentially growing. Its potential to identify the cause of death in trauma and ballistic cases is now properly documented, as well as its use in drug mule identification. In pediatric and perinatal practice, large significant series are less available, except for MRI and central nervous system analysis where scientific evidence is now robust. In this review, after a short historical review and analysis of current problems and challenges, we will try to depict the way we see the future of this subspecialty of postmortem cross-sectional imaging, including all specific situations: terminations of pregnancy, intrauterine death, sudden unexpected infant death and identification issues.
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Wood JN, Fakeye O, Mondestin V, Rubin DM, Localio R, Feudtner C. Development of hospital-based guidelines for skeletal survey in young children with bruises. Pediatrics 2015; 135:e312-20. [PMID: 25601982 PMCID: PMC4306798 DOI: 10.1542/peds.2014-2169] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To develop guidelines for performing an initial skeletal survey (SS) for children <24 months of age presenting with bruising in the hospital setting, combining available evidence with expert opinion. METHODS Applying the Rand/UCLA Appropriateness Method, a multispecialty panel of 10 experts relied on evidence from the literature and their own clinical expertise in rating the appropriateness of performing SS for 198 clinical scenarios characterizing children <24 months old with bruising. After a moderated discussion of initial ratings, the scenarios were revised. Panelists re-rated SS appropriateness for 219 revised scenarios. For the 136 clinical scenarios in which SS was deemed appropriate, the panel finally assessed the necessity of SS. RESULTS Panelists agreed that SS is "appropriate" for 62% (136/219) of scenarios, and "inappropriate" for children ≥ 12 months old with nonpatterned bruising on bony prominences. Panelists agreed that SS is "necessary" for 95% (129/136) of the appropriate scenarios. SS was deemed necessary for infants <6 months old regardless of bruise location, with rare exceptions, but the necessity of SS in older children depends on bruise location. According to the panelists, bruising on the cheek, eye area, ear, neck, upper arm, upper leg, hand, foot, torso, buttock, or genital area necessitates SS in children <12 months. CONCLUSIONS The appropriateness and necessity of SS in children presenting for care to the hospital setting with bruising, as determined by a diverse panel of experts, depends on age of the child and location of bruising.
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Affiliation(s)
- Joanne N. Wood
- Division of General Pediatrics and PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and,Leonard Davis Institute of Health Economics and,Departments of Pediatrics and
| | - Oludolapo Fakeye
- Division of General Pediatrics and PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Valerie Mondestin
- Division of General Pediatrics and PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - David M. Rubin
- Division of General Pediatrics and PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and,Leonard Davis Institute of Health Economics and,Departments of Pediatrics and
| | - Russell Localio
- Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chris Feudtner
- Division of General Pediatrics and PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and,Leonard Davis Institute of Health Economics and,Departments of Pediatrics and
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Iino M, Nakajima Y, Ueno M, Mikami K, Fujita MQ. A case of an infant suffered from a fatal scald injury - validity and limitations of postmortem CT imaging. Leg Med (Tokyo) 2014; 16:367-72. [PMID: 25092573 DOI: 10.1016/j.legalmed.2014.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 07/01/2014] [Accepted: 07/02/2014] [Indexed: 10/25/2022]
Abstract
A 9months-old infant has died of scald burn by the hot water from the fallen electric pot at home. Postmortem computed tomography (CT) scanning prior to autopsy contributed to exclude the possibilities of old and new bone fractures or hidden massive hemorrhages. This procedure helped the pathologists to avoid dissecting all the extremities, which is time-consuming, laborious and often hurtful to the innocent parents of the deceased. On the other hand it did not successfully show the distribution of the scald burn injury on the skin, which reminded us of the importance of external examination even when the whole-body CT is performed. The manner of death was considered to be accident since the cause of death was burn shock and there was no significant evidence suggesting child abuse. Scene investigation and reproductive experiment have revealed that there was a structural problem in the lid of the pot, which comes off very easily in a certain condition. In order to prevent a similar accident, report of the case to the manufacturer is essential for the improvement of the apparatus. This case, however, has been remained to be unreported because of the confidentiality of the investigative information in judicial autopsy. Finally, we recommend a partial revision of the reporting system in Japan to prevent the recurrence of such tragic accidents.
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Affiliation(s)
- Morio Iino
- Department of Legal Medicine (Forensic Medicine), Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
| | - Yasuhiro Nakajima
- Department of Legal Medicine (Forensic Medicine), Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
| | - Mari Ueno
- Department of Legal Medicine (Forensic Medicine), Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
| | - Kazue Mikami
- Department of Legal Medicine (Forensic Medicine), Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
| | - Masaki Q Fujita
- Department of Legal Medicine (Forensic Medicine), Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
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Hoffstetter P, Dornia C, Schäfer S, Wagner M, Dendl LM, Stroszczynski C, Schreyer AG. Diagnostic significance of rib series in minor thorax trauma compared to plain chest film and computed tomography. J Trauma Manag Outcomes 2014; 8:10. [PMID: 25152770 PMCID: PMC4141660 DOI: 10.1186/1752-2897-8-10] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 08/01/2014] [Indexed: 11/20/2022]
Abstract
Background Rib series (RS) are a special radiological technique to improve the visualization of the bony parts of the chest. Objectives The aim of this study was to evaluate the diagnostic accuracy of rib series in minor thorax trauma. Methods Retrospective study of 56 patients who received RS, 39 patients where additionally evaluated by plain chest film (PCF). All patients underwent a computed tomography (CT) of the chest. RS and PCF were re-read independently by three radiologists, the results were compared with the CT as goldstandard. Sensitivity, specificity, negative and positive predictive value were calculated. Significance in the differences of findings was determined by McNemar test, interobserver variability by Cohens kappa test. Results 56 patients were evaluated (34 men, 22 women, mean age =61 y.). In 22 patients one or more rib fracture could be identified by CT. In 18 of these cases (82%) the correct diagnosis was made by RS, in 16 cases (73%) the correct number of involved ribs was detected. These differences were significant (p = 0.03). Specificity was 100%, negative and positive predictive value were 85% and 100%. Kappa values for the interobserver agreement was 0.92-0.96. Sensitivity of PCF was 46% and was significantly lower (p = 0.008) compared to CT. Conclusions Rib series does not seem to be an useful examination in evaluating minor thorax trauma. CT seems to be the method of choice to detect rib fractures, but the clinical value of the radiological proof has to be discussed and investigated in larger follow up studies.
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Affiliation(s)
- Patrick Hoffstetter
- Radiology, Asklepios Medical Center, Bad Abbach, Germany ; Radiology, University Medical Center, Regensburg, Germany
| | - Christian Dornia
- Radiology, Asklepios Medical Center, Bad Abbach, Germany ; Radiology, University Medical Center, Regensburg, Germany
| | | | - Merle Wagner
- Radiology, University Medical Center, Regensburg, Germany
| | - Lena M Dendl
- Radiology, University Medical Center, Regensburg, Germany
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Le Blanc-Louvry I, Thureau S, Lagroy de Croutte E, Ledoux K, Dacher JN, Proust B. Comparaison du scanner post-mortem et de l’autopsie pour objectiver les lésions en fonction des différents sites anatomiques. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.medleg.2014.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Schulze C, Hoppe H, Schweitzer W, Schwendener N, Grabherr S, Jackowski C. Rib fractures at postmortem computed tomography (PMCT) validated against the autopsy. Forensic Sci Int 2013; 233:90-8. [DOI: 10.1016/j.forsciint.2013.08.025] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 07/15/2013] [Accepted: 08/27/2013] [Indexed: 10/26/2022]
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Chest computed tomography imaging for blunt pediatric trauma: not worth the radiation risk. J Surg Res 2013; 184:352-7. [DOI: 10.1016/j.jss.2013.04.044] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 04/16/2013] [Accepted: 04/19/2013] [Indexed: 01/13/2023]
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Le Blanc-Louvry I, Thureau S, Duval C, Papin-Lefebvre F, Thiebot J, Dacher JN, Gricourt C, Touré E, Proust B. Post-mortem computed tomography compared to forensic autopsy findings: a French experience. Eur Radiol 2013; 23:1829-35. [DOI: 10.1007/s00330-013-2779-0] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 01/16/2013] [Indexed: 10/27/2022]
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Love JC, Derrick SM, Wiersema JM, Pinto DC, Greeley C, Donaruma-Kwoh M, Bista B. Novel classification system of rib fractures observed in infants. J Forensic Sci 2013; 58:330-5. [PMID: 23406328 DOI: 10.1111/1556-4029.12054] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 02/14/2012] [Accepted: 03/03/2012] [Indexed: 11/30/2022]
Abstract
Rib fractures are considered highly suspicious for nonaccidental injury in the pediatric clinical literature; however, a rib fracture classification system has not been developed. As an aid and impetus for rib fracture research, we developed a concise schema for classifying rib fracture types and fracture location that is applicable to infants. The system defined four fracture types (sternal end, buckle, transverse, and oblique) and four regions of the rib (posterior, posterolateral, anterolateral, and anterior). It was applied to all rib fractures observed during 85 consecutive infant autopsies. Rib fractures were found in 24 (28%) of the cases. A total of 158 rib fractures were identified. The proposed schema was adequate to classify 153 (97%) of the observed fractures. The results indicate that the classification system is sufficiently robust to classify rib fractures typically observed in infants and should be used by researchers investigating infant rib fractures.
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Affiliation(s)
- Jennifer C Love
- Forensic Anthropology Division, Harris County Institute of Forensic Sciences, 1885 Old Spanish Trail, Houston, TX, 77054
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Carroll R, Wood JN. Sudden Unexpected Infant Death: A Compassionate Forensic Approach to Care. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2012. [DOI: 10.1016/j.cpem.2012.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Berdon WE, Feldman KW. A modest proposal: thoracic CT for rib fracture diagnosis in child abuse. CHILD ABUSE & NEGLECT 2012; 36:200-201. [PMID: 22284740 DOI: 10.1016/j.chiabu.2011.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Accepted: 07/18/2011] [Indexed: 05/31/2023]
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Imaging of Neonatal Child Abuse with an Emphasis on Abusive Head Trauma. Magn Reson Imaging Clin N Am 2011; 19:791-812; viii. [DOI: 10.1016/j.mric.2011.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Nolte KB, Mlady G, Zumwalt RE, Cushnyr B, Paul ID, Wiest PW. Postmortem X-ray Computed Tomography (CT) and Forensic Autopsy: A Review of the Utility, the Challenges and the Future implications. Acad Forensic Pathol 2011. [DOI: 10.23907/2011.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The utility of computed tomography (CT) for forensic autopsy is being defined. Small studies have indicated potential areas of use. Systematic studies are few. Evidence of the utility of CT as an autopsy substitute in fatal trauma cases has been inconsistent. Some studies show that there are injuries seen by CT that aren't detected by autopsy indicating that CT, at least, is likely useful as an autopsy adjunct. Research has been limited by small study populations, variation in postmortem interval, differences in protocols including CT slice thickness, who interpreted the scans (radiologists vs. pathologists), and how injuries were scored. Challenges exist to implement and use advanced imaging technology for the forensic autopsy. It is important to determine how to arrange these technologies into a coherent approach to postmortem diagnosis while not encumbering forensic pathologists. Forensic pathologists and radiologists require training in interpreting the unique aspects of postmortem CT scans. Some forensic pathologists might perceive imaging technology as a threat and express concern that it will make the autopsy obsolete. If CT is found to supplant or supplement autopsy in valuable ways, more comprehensive diagnostic information can be provided. If CT can supplant the use of autopsy in certain situations and significantly decrease autopsy numbers it will allow offices to achieve an annual cost savings and divert these resources to other needs. If CT becomes widely available and can supplant autopsy, it could make up some of the gap between the numbers of forensic pathologists available and the numbers needed nationally.
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Affiliation(s)
- Kurt B. Nolte
- Mexico Office of the Medical Investigator and Professor of Pathology at the University of New Mexico School of Medicine
- University of New Mexico - Department of Radiology, Albuquerque, NM (GM, BC, PW), Office of the Medical Investigator - Department of Pathology, Albuquerque, NM (RZ, IP)
| | - Gary Mlady
- University of New Mexico - Department of Radiology, Albuquerque, NM (GM, BC, PW), Office of the Medical Investigator - Department of Pathology, Albuquerque, NM (RZ, IP)
| | - Ross E. Zumwalt
- University of New Mexico - Department of Radiology, Albuquerque, NM (GM, BC, PW), Office of the Medical Investigator - Department of Pathology, Albuquerque, NM (RZ, IP)
| | - Brad Cushnyr
- University of New Mexico - Department of Radiology, Albuquerque, NM (GM, BC, PW), Office of the Medical Investigator - Department of Pathology, Albuquerque, NM (RZ, IP)
| | - Ian D. Paul
- University of New Mexico - Department of Radiology, Albuquerque, NM (GM, BC, PW), Office of the Medical Investigator - Department of Pathology, Albuquerque, NM (RZ, IP)
| | - Philip W. Wiest
- University of New Mexico - Department of Radiology, Albuquerque, NM (GM, BC, PW), Office of the Medical Investigator - Department of Pathology, Albuquerque, NM (RZ, IP)
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