Visual assessment of the timing of bruising by forensic experts

Predictive accuracy of histopathological profile and immunohistochemical markers for the aging of abrasion: an autopsy-based study

Wound age estimation is a crucial medicolegal task for forensic pathologists. The main objective of the current study was to evaluate the ability of the histopathological profile and immunohistochemical markers (CD14 and IL-8) to predict the age of abrasion and, furthermore, identify the relationship between the histopathological profile and immunohistochemical markers in abrasion aging. The study involved postmortem cases (n = 246) of abrasion injuries in which the injury infliction time was known. The test skin samples were taken from the abrasion site, and an adjacent area of uninjured skin was sampled for control. Hematoxylin and eosin stain was applied to tissue sections for the histopathological analysis. The semi-quantitative evaluation was made for expressing immunohistochemical markers CD14 and IL-8 on the infiltrating inflammatory cells. The study showed that the age of abrasion was significantly higher (p < 0.05) among the cases with positive staining than those with negative staining for both CD14 and IL-8. Additionally, the study found a significant association between the age of the abrasion and the IHC staining for IL-8. However, no significant association was seen between the age of abrasion and the CD-14 IHC staining. The odds ratio (95% confidence interval) for more than 72 h of the age of abrasion was compared to 0 to 72 h of the age of abrasion. The odds ratios were 39.00 (4.177-364.13) for the predominant mononuclear cell infiltration and 84.50 (9.287-768.814) for cases with the appearance of fibroblast, granulation tissue, and collagen deposition when compared to an unremarkable change on histopathological examination. Positive staining of immunohistochemical markers CD14 and IL-8 for the age of abrasion of more than 72 h showed a sensitivity of 40% and 80.95%, respectively, and specificity of 71.6% and 52.5%, respectively. The quantification of the histopathological changes of predominant mononuclear cell infiltration and the appearance of fibroblast, granulation tissue formation, and collagen deposition showed a significant correlation for the age of abrasion of more than 72 h. The immunohistochemical analysis revealed IL-8 as a more accurate marker than CD14 in identifying abrasions older than 72 h.

The role of alternative hypotheses in reducing bias in forensic medical experts' decision making

Medical opinions are often essential evidence in criminal cases but relatively little is known about the factors that impact forensic doctors' decision making. This research examines the role and impact of having an alternative hypothesis while forming a medical opinion. A scenario-based experiment with forensic doctors (n = 20) was conducted. In two out of three scenarios, the existence of alternative hypotheses impacted the actual opinions reached, the confidence in the judgments and the perceived consistency with the plaintiff hypothesis. Investigative and legal actors should be aware of the possibility of biases and importance of having alternative hypotheses when requesting and evaluating medical opinions.

Pulsed Photothermal Radiometric Depth Profiling of Bruises by 532 nm and 1064 nm Lasers

Optical techniques are often inadequate in estimating bruise age since they are not sensitive to the depth of chromophores at the location of the bruise. To address this shortcoming, we used pulsed photothermal radiometry (PPTR) for depth profiling of bruises with two wavelengths, 532 nm (KTP laser) and 1064 nm (Nd:YAG laser). Six volunteers with eight bruises of exactly known and documented times of injury were enrolled in the study. A homogeneous part of the bruise was irradiated first with a 5 ms pulse at 532 nm and then with a 5 ms pulse at 1064 nm. The resulting transient surface temperature change was collected with a fast IR camera. The initial temperature-depth profiles were reconstructed by solving the ill-posed inverse problem using a custom reconstruction algorithm. The PPTR signals and reconstructed initial temperature profiles showed that the 532 nm wavelength probed the shallow skin layers revealing moderate changes during bruise development, while the 1064 nm wavelength provided additional information for severe bruises, in which swelling was present. Our two-wavelength approach has the potential for an improved estimation of the bruise age, especially if combined with modeling of bruise dynamics.

Visual Assessment of Contusion-Like Lesions Caused by Live Sharksucker (Echeneis naucrates) Attachment in an Indo-Pacific Humpback Dolphin (Sousa chinensis)

We observed contusion-like lesions caused by live sharksucker (Echeneis naucrates) attachment in an Indo-Pacific humpback dolphin (Sousa chinensis). Our report assists in differentiating epidermal lesions for visual health assessment in this vulnerable species and other cetaceans, and this adds new host and epibiont records for E. naucrates and S. chinensis, respectively.

Use of ImageJ as an image processing method for the assessment of post-surgical bruises

PURPOSE

To develop, through ImageJ, an automated, non-invasive, objective method to analyze images of bruises that allowed quantifying variation in its size overtime for its later use in clinical trials.

METHODS

The ImageJ software was used to create automated macros that were executed on 38 images of the untreated eyes of 19 patients that participated in a post-marketing, randomized, controlled clinical trial that assessed the efficacy of a cream to reduce post-blepharoplasty minor hematomas. Three image processing systems were used with the macros created with ImageJ: RGB, RGB2, and HSB. The area of the bruises and the percentage of reduction were estimated for each one. Ophthalmologists also reviewed photographs by direct visual examination.

RESULTS

All three processing systems were useful for identifying the area of the bruise and studying its variation over time. RGB2 results were the most consistent with the direct visual examination conducted by ophthalmologists.

CONCLUSION

RGB2-automated image processing was considered the most appropriate for bruise analysis and represented an advantage over other manual techniques. However, it will be necessary to test it in clinical trials and other studies with a more significant number of samples and different locations.

Bruise dating using deep learning

The bruise dating can have important medicolegal implications in family violence and violence against women cases. However, studies show that the medical specialist has 50% accuracy in classifying a bruise by age, mainly due to the variability of the images and the color of the bruise. This research proposes a model, based on deep convolutional neural networks, for bruise dating using only images, by age ranges, ranging from 0-2 days to 17-30 days, and images of healthy skin. A 2140 experimental bruise photograph dataset was constructed, for which a data capture protocol and a preprocessing procedure are proposed. Similarly, 20 classification models were trained with the Inception V3, Resnet50, MobileNet, and MnasNet architectures, where combinations of learning transfer, cross-validation, and data augmentation were used. Numerical experiments show that classification models based on MnasNet have better results, reaching 97.00% precision and sensitivity, and 99.50% specificity, exceeding 40% precision reported in the literature. Also, it was observed that the precision of the model decreases with the age of the bruise.

From unloading to trimming: studying bruising in individual slaughter cattle

Livestock bruising is both an animal welfare concern and a detriment to the economic value of carcasses. Understanding the causes of bruising is challenging due to the numerous factors that have been shown to be related to bruise prevalence. While most cattle bruising studies collect and analyze data on truckload lots of cattle, this study followed a large number (n = 585) of individual animals from unloading through postmortem processing at five different slaughter plants. Both visual bruise presence and location was recorded postmortem prior to carcass trimming. By linking postmortem data to animal sex, breed, trailer compartment, and traumatic events at unloading, a rich analysis of a number of factors related to bruise prevalence was developed. Results showed varying levels of agreement with other published bruising studies, underscoring the complexity of assessing the factors that affect bruising. Bruising prevalence varied across different sex class types (P < 0.001); 36.5% of steers [95% confidence interval (CI): 31.7, 41.6; n = 378], 52.8% of cows (45.6, 60.0; 193), and 64.3% of bulls (no CI calculated due to sample size; 14) were bruised. There was a difference in bruise prevalence by trailer compartment (P = 0.035) in potbelly trailers, indicating that cattle transported in the top deck were less likely to be bruised (95% CI: 26.6, 40.4; n = 63) compared to cattle that were transported in the bottom deck (95% CI: 39.6, 54.2; n = 89). Results indicated that visual assessment of bruising underestimated carcass bruise trimming. While 42.6% of the carcasses were visibly bruised, 57.9% of carcasses were trimmed due to bruising, suggesting that visual assessment is not able to capture all of the carcass loss associated with bruising. Furthermore, bruises that appeared small visually were often indicators of larger, subsurface bruising, creating an “iceberg effect” of trim loss due to bruising.

Determination of the age of bruises using a bilirubinometer

The dating of bruises can be of crucial interest in clinical forensic medicine, but the macroscopic or photographic evaluation of a bruise has not been regarded as reliable. Several methods have thus been regularly evaluated for this purpose, with reflectance spectrometry yielding promising results. The objective of this study is to evaluate the value of a bilirubinometer as a tool for dating bruises on living victims. A clinical follow-up was carried out on patients presenting a bruise with a known onset. Using a bilirubinometer, we obtained daily measurements of the bruise (bili-bruise) and of healthy skin (bili-skin). Potential confounding factors were collected: age, sex, body mass index, trauma mechanism and Fitzpatrick skin phototype. We followed 20 patients for a total of 88 measurements of bruises. Bili-skin values showed significant differences according to skin phototype. Differences between the bili-bruise and bili-skin values (Δ-bili) followed an increase phase, peaking between 3 and 5 days, and then there was a decrease phase. No significant Δ-bili value differences were observed based on the suspected confounding factors. Our results are in favour of a peak Δ-bili value generally at day 4 or 5 post-trauma. Notably, decreasing values were not observed before day 3. Decreasing Δ-bili values would then indicate a bruise resulting from an injury formed at least 3 days before the first measurement. Complementary work confirming such data would enable improvement of the performance of bruise dating in forensic medicine.

A pilot study demonstrating the efficacy of transcutaneous bilirubin meters to quantitatively differentiate contusions from Congenital Dermal Melanocytosis

OBJECTIVE

Congenital Dermal Melanocytosis (CDM) can be difficult to differentiate from contusions. The need for a prompt and accurate diagnosis is best illustrated in cases where child abuse and maltreatment is of concern. Transcutaneous bilirubin (TCB) spectrophotometry has been well established to measure bilirubin under the skin for jaundice in infants. The use of TCB spectrometry has not been used to identify or differentiate contusions from CDM. We hypothesized that bilirubin, a degradation product of hemoglobin, would be elevated in contusions but not in CDM thus demonstrating the efficacy of a novel diagnostic technique to compliment or improve on physical assessment alone.

METHODS

Pilot study with thirty-seven infants and children noted to have CDM and fifty-six infants, children and adults with contusions underwent measurement of their lesion with TCB spectrometry. In each patient, the affected skin was scanned along with the adjacent unaffected native skin allowing an internal control for individual pigment variation.

RESULTS

TCB measurements of CDM resulted in lower transcutaneous bilirubin values that were not significantly different from adjacent native skin pigmentation. This was in contrast to cutaneous contusions, which resulted in a higher measured value (mean 5.01 mg/dL) compared to adjacent native tissue (1.24 mg/dL) demonstrating a four-fold increase in measurement at the lesion site (P < 0.001). Direct comparison of a ΔTCB value (lesion measurement minus the adjacent tissue) demonstrated a significantly higher value in contusions compared to CDM with a mean value of 3.77 and 0.12 mg/dL, respectively (P < 0.001).

CONCLUSIONS

TCB Spectrometry as a novel diagnostic technique has the potential to discern contusions from CDM and may therefore have the ability to compliment the use of physical assessment alone.

Pre-slaughter cattle welfare indicators for use in commercial abattoirs with voluntary monitoring systems: A systematic review

Animal welfare has become an important subject of public, economic and political concern, leading to the need to validate indicators that are feasible to use at abattoirs. A systematic review was carried out, which identified 72 cattle welfare indicators (CWI) that were classified into four categories (physiological, morphometric, behavioral and meat quality). Their validity and feasibility for use in abattoirs were evaluated as potential measures of cattle welfare during transportation to the abattoir and at the abattoir itself. Several highly valid indicators were identified that are useful to assess welfare at abattoirs, including body condition score, human-animal interactions, vocalizations, falling, carcass bruising, and meat pH. In addition, some intermediate valid indicators are useful and should be investigated further. Information along the food chain could be used systematically to provide a basis for a more-risk-based meat inspection. An integrated system based on the use of key indicators defined for each inspection step with the setting of alarm thresholds could be implemented.

A Study on Postmortem Wound Dating by Gross and Histopathological Examination of Abrasions

Introduction

Abrasions are the most common blunt force injuries. The precise dating of injury is extremely important in forensic medicine practice. As we know, the wound healing occurs in well-orchestrated sequence, consisting of inflammation, proliferation, and maturation.

A study of occurrence of such phases will help in understanding the sequence of events in wound healing. In this context, this study of wound dating from gross and microscopic level was taken.

Materials and Methods

Postmortem study of wound dating by gross and histopathological examination of abrasions was carried out in the Department of Forensic Medicine, in M.S. Ramaiah Medical College. A total of 101 abrasions were correlated to time frame the occurrence of different gross changes and microscopic changes that follow the blunt trauma. Abrasions ranging from 0 hour to a maximum of 45 days were studied.

Results

The gross changes of abrasions were in correlation with the microscopic changes; however, the role of the comorbid conditions is significant because the results showed variations with respect to healing process.

Conclusions

This study signifies that, if naked eye examination is studied along with histopathological examination, the reliability and accuracy of dating of wound increase. Whenever accurate determination of age is required, the autopsy surgeon can subject the samples for histopathological examination and correlate before opining the age of injury.

A novel, comprehensive, and reproducible porcine model for determining the timing of bruises in forensic pathology

PURPOSE

Calculating the timing of bruises is crucial in forensic pathology but is a challenging discipline in both human and veterinary medicine. A mechanical device for inflicting bruises in pigs was developed and validated, and the pathological reactions in the bruises were studied over time in order to identify gross and histological parameters that may be useful in determining the age of a bruise.

METHODS

The mechanical device was able to apply a single reproducible stroke with a plastic tube that was equivalent to being struck by a man. In each of 10 anesthetized pigs, four strokes that resulted in bruises were inflicted on the back. In addition, 2 control pigs were included in the study. The pigs were euthanized consecutively from 1 to 10 h after the infliction of bruises. Following gross evaluation, skin, and muscle tissues were sampled for histology.

RESULTS

Grossly, the bruises appeared uniform and identical to the tramline bruises seen in humans and pigs subjected to blunt trauma. Histologically, the number of neutrophils in the subcutis, the number of macrophages in the muscle tissue, and the localization of neutrophils and macrophages in muscle tissue showed a time-dependent response. Combining these parameters, bruises could be grouped as being either less than 4 h old or between 4 and 10 h of age. Gross lesions and changes in the epidermis and dermis were inconclusive with respect to time determination.

CONCLUSIONS

The model was reproducible and resembled forensic cases of bruises in pigs and humans. Therefore, the histological parameters are suitable for age determination of bruises in pigs and likely also in humans.

Comparing corporal punishment and children's exposure to violence between caregivers: Towards better diagnosis and prevention of intrafamilial physical abuse of children

Any intervention involving child victims of intrafamilial abuse must take the alleged underlying motives for the abuse into account. The aim of this study is to further our understanding of intrafamilial physical abuse of children, by comparing its various aspects while considering the alleged underlying motives. A preliminary sample of 1656 cases of alleged physical abuse in the northern region of Portugal was analysed, with two main motives being identified: corporal punishment (CP) (G1 = 927) and exposure to violence between caregivers (EVC) (G2 = 308). Statistically significant differences were found between the two motives (p < 0.05) for the following variables: (1) age of the alleged victims, (2) sex of the alleged abuser, (3) risk factors affecting the alleged abuser, (4) abuser/victim relationship, (5) injury-producing mechanism, (6) time between last abuse and forensic medical examination and (7) location of injuries. Evidence-based knowledge of these differences may help in accurate diagnosis by doctors (particularly forensic physicians) and prevention of this type of violence through support strategies (including tertiary prevention strategies).

Age determination of soft tissue hematomas

In clinical forensic medicine, the estimation of the age of injuries such as externally visible subcutaneous hematomas is important for the reconstruction of violent events, particularly to include or exclude potential suspects. Since the estimation of the time of origin based on external inspection is unreliable, the aim of this study was to use contrast in MRI to develop an easy-to-use model for hematoma age estimation. In a longitudinal study, artificially created subcutaneous hematomas were repetitively imaged using MRI over a period of two weeks. The hemorrhages were created by injecting autologous blood into the subcutaneous tissue of the thigh in 20 healthy volunteers. For MRI, standard commercially available sequences, namely proton-density-weighted, T2 -weighted and inversion recovery sequences, were used. The hematomas' MRI data were analyzed regarding their contrast behavior using the most suitable sequences to derive a model allowing an objective estimation of the age of soft tissue hematomas. The Michelson contrast between hematoma and muscle in the proton-density-weighted sequence showed an exponentially decreasing behavior with a dynamic range of 0.6 and a maximum standard deviation of 0.1. The contrast of the inversion recovery sequences showed increasing characteristics and was hypointense for TI = 200ms and hyperintense for TI =1000ms. These sequences were used to create a contrast model. The cross-validation of the model finally yielded limits of agreement for hematoma age determination (corresponding to ±1.96 SD) of ±38.7h during the first three days and ±54 h for the entire investigation period. The developed model provides lookup tables which allow for the estimation of a hematoma's age given a single contrast measurement applicable by a radiologist or a forensic physician. This is a first step towards an accurate and objective dating method for subcutaneous hematomas, which will be particularly useful in child abuse.

Systematic reviews of bruising in relation to child abuse-what have we learnt: an overview of review updates

BACKGROUND

Dogma has long prevailed regarding the ageing of bruises, and whether certain patterns of bruising are suggestive or diagnostic of child abuse.

OBJECTIVES

We conducted the first Systematic Reviews addressing these two issues, to determine the scientific basis for current clinical practice. There have been seven updates since 2004.

METHODS

An all language literature search was performed across 13 databases, 1951-2004, using >60 key words, supplemented by 'snowballing' techniques. Quality standards included a novel confirmation of abuse scale. Updates used expanded key words, and a higher standard for confirmation of abuse.

RESULTS

Of 1495 potential studies, only three met the inclusion criteria for ageing of bruises in 2004, confirming that it is inaccurate to do so with the naked eye. This was roundly rejected when first reported, generating a wave of new studies attempting to determine a scientifically valid method to age bruises, none of which are applicable in children yet. Regarding patterns of bruising that may be suggestive or diagnostic of abuse, we included 23 of 167 studies reviewed in 2004, although only 2 were comparative studies. Included studies noted that unintentional bruises occur predominantly on the front of the body, over bony prominences and their presence is directly correlated to the child's level of independent mobility. Bruising patterns in abused children, differed in location (most common site being face, neck, ear, head, trunk, buttocks, arms), and tended to be larger. Updates have included a further 14 studies, including bruising in disabled children, defining distinguishing patterns in severely injured abused and non-abused children, and importance of petechiae.

CONCLUSIONS

Systematic Reviews of bruising challenged accepted wisdom regarding ageing of bruises, which had no scientific basis; stimulated higher quality research on patterns of bruises distinguishing abusive and non-abusive bruising patterns, and highlighted the benefits of regular updates of these reviews.

The use of photographs to record variation in bruising response in humans

There is considerable value in developing tools capable of accurately and reliably determining when bruises were inflicted in humans. Previous work has focused on the visual changes observed in a bruise as the injury develops and heals. However, due to variables such as how and where on the body the bruise was inflicted, differing tissue compositions at the injured skin site between individuals and inter- and intra-observer variation; a technique sufficiently robust for use in a clinical or medicolegal setting has not yet been identified. In this study we present a series of photographs taken under controlled conditions illustrating standardised bruises induced on participants using a weight dropping mechanism. We show that variation in the appearance of bruises over time across individuals is large and, although photography may be a suitable technique for the recording of injuries, it is not sufficiently reliable for determining the age of a bruise.

The development of a colorimetric scale as a visual aid for the bruise age determination of bite marks and blunt trauma

Medical examiners and forensic odontologists are frequently asked to establish the age of a bruise or bitemark on either a living and deceased subjects. The age of bruising has an important medico-legal significance and may be relevant in the investigations related to such crimes as child abuse, domestic violence and homicide. A colorimetric scale for forensic photography based on the colors of the bruise itself, has never been proposed due to the fact that photographic reproduction of color is unreliable and depends on several factors; the camera used, lighting, printer and photo-editing color calibration. The authors propose two colorimetric scales, both with and without linear measurements, and with 90° angulations, six bruise colors, and three circles with black and white calibrators, which are to be used for the forensic photography of injuries involving the epidermis of Caucasian subjects. The two scales could also be employed on living subjects during different stages of the healing process, or on cadavers in order to provide evidential documentation, image verification and analysis. Such an aid would provide a reliable standard condition and allow for color calibration. The colors represented on the scales would be an aid for the interpretation and objectivity required in estimating the age of the bruise, particularly when the analysis is made directly onto computer images prior to printing. The proposed colorimetric scales do not attempt to give a definitive account of the diverse scientific methods available for the assessment of the age of bruising. The observation of a large sample of blunt trauma and bite mark injuries employing the proposed colorimetric scales would be needed in order to verify and validate the use of these scales. It should be borne in mind that bruise age estimation requires an expert opinion with several degrees of accuracy and variability involved. The age of a bruise cannot be determined by color alone.

Elder abuse

Five types of elder abuse (physical, psychological, sexual, neglect and financial) are recognized. They are not new, occur worldwide and are associated with persistent morbidity and mortality. The forensic clinician has responsibilities to: (i) the patient, with competent history taking and examination, (ii) interpret findings and recognize patterns of harm and (iii) promulgate this issue in wider professional and public forums. Research into elder abuse is relatively recent; standardized terminology remains unsettled, and small-scale, local studies are hard to generalize. Cross-sectional, population-based studies of elder abuse should be possible, and standardized endpoints will require forensic science contributions.

Assessment of bruise age on dark-skinned individuals using tristimulus colorimetry

INTRODUCTION

Studies on the ageing of bruises have been reported on Caucasians or individuals of fair ethnicity. This study focuses on bruise changes in dark-skinned individuals using tristimulus colorimetry for forensic analysis in such individuals.

METHODS

Eighteen subjects of South Indian or Sri-Lankan ethnicity were recruited. Subjects were bruised using a vacuum pump and then daily colour measurements were taken of the bruise using a tristimulus colorimeter. The L*a*b* readings were recorded of a control area and of the bruise until it disappeared. Two Caucasians were used for comparison.

RESULTS

This study showed that, using colorimetry, bruises on dark-skinned individuals can be measured and analysed even if the bruises are unclear visually. As the bruise is beneath the skin, the colour difference ΔL*, Δa* and Δb* were calculated. All values showed a trend, indicating that the L*a*b* measuring technique is a reliable method to analyse bruises on dark-skinned individuals. Comparisons of Asian subjects and Caucasian subjects were performed. The largest difference was seen in the b* value. Statistical analysis showed that ΔL* colour difference was the most consistent (95% CI -4.05 to -2.49) showing a significant difference between days 1-4 and 5-8.

CONCLUSION

Objective assessment of bruises on dark-skinned individuals using the L*a*b* method of measuring gave reproducible results. Furthermore, the study showed that the yellowing of a bruise cannot be seen or measured with a tristimulus colorimeter on dark-skinned individuals due to the pigmentation of the skin. With further studies and more subjects, the age of bruises could potentially be assessed for use in forensic analysis.

Can we assess the age of bruises? An attempt to develop an objective technique

AIMS

The aims of this study were (A) to investigate whether the number of years of forensic experience affected the accuracy with which forensic experts (FEs) were able to age bruises and (B) to identify the properties and colours of a bruise that were utilized by FEs in their assessment of bruise age. The study then investigated the possibility of using a more objective technique. It was decided to use readily available digital photography and software to objectively assess changes in bruise colouration and to investigate if this can be used to age bruises.

METHODS

Twenty-three FEs were shown 25 photographs of bruises of varying but known ages and asked to estimate the ages. In part two of the study, bruises were inflicted on volunteers using a vacuum pump and photographs taken of the bruise daily from infliction to resolution. The images were analysed using Adobe Photoshop. Red, green and blue (RGB) values were recorded for each bruise and analyses carried out comparing the values over time between subjects and within subjects.

RESULTS

This study both enhanced and supported a previous conclusion that visual assessment of photographs is an unreliable method for ageing bruises. Additionally, it found that the degree of forensic experience had no effect on accuracy. It also identified that colour (particularly yellow, red and purple) and intensity of colour were the most commonly used properties of a bruise in the assessment of its age. The RGB method proved to be a reliable technique with which to measure bruise colour, but its validity in the assessment of bruise age was poor.

CONCLUSIONS

Visual assessment of bruises is unreliable and the accuracy of ageing was not improved by the degree of forensic experience. The RGB method gave highly reproducible results, but did not accurately assess bruise age. However, results within subjects suggested that there may be individual variation in haemoglobin metabolism.

Using moulage to enhance educational instruction

An understood goal of faculty when using simulations and role play as teaching strategies is to make them as realistic as possible. The author discusses moulage, a makeup technique that can be used to enhance a simulated learning experience and reinforce prior learning regarding cellular damage and repair. The use of moulage in other undergraduate didactic courses such as nursing research is presented.