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Rohrbach JM. [Still room for dispute: on shaken baby syndrome and abusive head trauma (AHT)]. DIE OPHTHALMOLOGIE 2024; 121:328-330. [PMID: 38443493 DOI: 10.1007/s00347-024-01999-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Jens Martin Rohrbach
- Ophthalmopathologisches Labor/Forschungsbereich "Geschichte der Augenheilkunde", Universitäts-Augenklinik Tübingen, Elfriede-Aulhorn-Str. 7, 72076, Tübingen, Deutschland.
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Di Fazio N, Delogu G, Morena D, Cipolloni L, Scopetti M, Mazzilli S, Frati P, Fineschi V. New Insights into the Diagnosis and Age Determination of Retinal Hemorrhages from Abusive Head Trauma: A Systematic Review. Diagnostics (Basel) 2023; 13:1722. [PMID: 37238204 PMCID: PMC10217069 DOI: 10.3390/diagnostics13101722] [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: 04/14/2023] [Revised: 04/29/2023] [Accepted: 05/02/2023] [Indexed: 05/28/2023] Open
Abstract
(1) Background: Head trauma represents the first cause of death in abused children, but diagnostic knowledge is still limited. The characteristic findings of abusive head trauma (AHT) are retinal hemorrhages (RH) and additional ocular findings, including optic nerve hemorrhages (ONH). However, etiological diagnosis must be cautious. (2) Methods: The Preferred Reporting Items for Systematic Review (PRISMA) standards were employed, and the research focus was the current gold standard in the diagnosis and timing of abusive RH. (3) Results: Sixteen articles were included for qualitative synthesis. The importance of an early instrumental ophthalmological assessment emerged in subjects with a high suspicion of AHT, with attention to the localization, laterality, and morphology of the findings. Sometimes it is possible to observe the fundus even in deceased subjects, but the current techniques of choice consist of Magnetic Resonance Imaging and Computed Tomography, also useful for the timing of the lesion, the autopsy, and the histological investigation, especially if performed with the use of immunohistochemical reactants against erythrocytes, leukocytes, and ischemic nerve cells. (4) Conclusions: The present review has made it possible to build an operational framework for the diagnosis and timing of cases of abusive retinal damage, but further research in the field is needed.
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Affiliation(s)
- Nicola Di Fazio
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Giuseppe Delogu
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Donato Morena
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Luigi Cipolloni
- Department of Clinical and Experimental Medicine, Section of Legal Medicine, University of Foggia, 71100 Foggia, Italy;
| | - Matteo Scopetti
- Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, 00189 Rome, Italy;
| | - Sara Mazzilli
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
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Bharti D, Krishnan S. A Neonate with Bilateral Vitreous Hemorrhages After Intra-uterine Bowel Infarction Secondary to Volvulus. J Natl Med Assoc 2017; 110:242-244. [PMID: 29778125 DOI: 10.1016/j.jnma.2017.05.006] [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: 09/06/2016] [Revised: 05/09/2017] [Accepted: 05/16/2017] [Indexed: 11/16/2022]
Abstract
Vitreous hemorrhages are uncommon in the neonatal period. This article describes a neonatal who had bilateral vitreous hemorrhages after intrauterine bowel infarction.
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Affiliation(s)
- Des Bharti
- East Tennessee State University, P O Box 70578, Johnson City, TN 37614, USA.
| | - Sugantha Krishnan
- East Tennessee State University, P O Box 70578, Johnson City, TN 37614, USA
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Serinelli S, Arunkumar P, Filkins JA, Gitto L. Deaths Due to Child Abuse: A 6-Year Review of Cases in The Cook County Medical Examiner's Office. J Forensic Sci 2016; 62:107-118. [PMID: 27787884 DOI: 10.1111/1556-4029.13219] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 02/03/2016] [Accepted: 02/21/2016] [Indexed: 01/07/2023]
Abstract
Case files from the Cook County Medical Examiner's Office from 2007 to 2012 were reviewed to analyze homicides due to physical child abuse in children <3 years old. Fatal cases mostly involved younger subjects. Intracranial injuries were the leading cause of death, while death due to extracranial injuries was uncommon. Eyes were involved in most of the cases. Spinal cord was involved in about 1/3 of the cases, mostly in the thoracic area. In some cases, previous injuries were present. There were significant differences in the pattern of injuries between age groups. Subjects showing signs of impact to the head and subjects with no evidence of an impact showed no significant difference in internal injuries. The association of multiple injuries is highly suggestive of child abuse. In suspected child abuse, a postmortem examination including neuropathological, ophthalmological, and radiological information should be always evaluated, together with investigative reports and the medical history.
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Affiliation(s)
- Serenella Serinelli
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza-University of Rome, Viale Regina Elena 336, 00185, Rome, Italy
| | - Ponni Arunkumar
- Cook County Medical Examiner's Office, 2121 W Harrison Street, Chicago, IL, 60612
| | - James A Filkins
- Cook County Medical Examiner's Office, 2121 W Harrison Street, Chicago, IL, 60612
| | - Lorenzo Gitto
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza-University of Rome, Viale Regina Elena 336, 00185, Rome, Italy
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Cirovic S, Bhola RM, Hose DR, Howard IC, Lawford PV, Parsons MA. Mechanistic hypothesis for eye injury in infant shaking : An experimental and computational study. Forensic Sci Med Pathol 2015; 1:53-9. [PMID: 25869837 DOI: 10.1385/fsmp:1:1:053] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2005] [Indexed: 11/11/2022]
Abstract
The terms abusive head injury and shaken baby syndrome are used to describe a unique pattern of nonaccidental traumatic injuries occurring in children that many clinicians and researchers have good reason to believe is caused by violent shaking. Typical injuries include severe brain injury, with intracranial and retinal hemorrhages, but the pathogenesis of injuries is poorly understood. A major paradox in head trauma in infants is that the injuries induced by a shaking event are much more severe than those caused by even very violent single-impact head trauma, despite the relatively low accelerations in shaking.We have developed a finite element computer model of the eye, orbit, and orbital bone and used it to simulate the effects of single-impact and oscillatory motion inputs. The model was informed by data from semiquantitative in vitro anatomical traction experiments on in situ rabbit eyes. The new results reported here strongly suggest that suction between the eye and its surrounding fat dominates the dynamical stability of the system composed of the eye, its socket, and the components and material supporting the eye. Computer simulations incorporating this functional anatomical relationship show that deceleration of the head generates pressure gradients inside and outside the eye; these could cause damaging shear stresses in structures such as the retina and blood vessels. Simulations also show that oscillating the bone of the orbit causes the eye to move anteriorly and posteriorly with an increasing amplitude, building up the stresses within the eye over time. This is the first time that any biomechanical mechanism has been identified that might explain the disproportionally severe injuries caused by an oscillatory mechanism such as violent shaking of an abused infant. However, further study is required and this conclusion is therefore preliminary and provisional.
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Affiliation(s)
- S Cirovic
- Department of Mechanical Engineering, the University of Sheffield, Sheffield, UK
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Affiliation(s)
- P Watts
- Department of Ophthalmology, University Hospital of Wales, Cardiff, UK
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Rahman W, Osbourne S, Bhan A, Orr GM, Gregson R. Vitrectomy in cases of nonaccidental injury. J Pediatr Ophthalmol Strabismus 2010; 47:163-7. [PMID: 20507001 DOI: 10.3928/01913913-20100505-07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2007] [Accepted: 04/29/2008] [Indexed: 11/20/2022]
Abstract
Nonaccidental head injuries may present in several ways, requiring prompt recognition and management because of the risk of death or permanent neurologic and visual impairment. Dense amblyopia and high anisometropic myopia induced by prolonged occlusion of the macula by hemorrhage is a concern in these infants, although the prognosis also depends on the extent of associated brain injury. There are few reports of the visual and general outcome of children with a diagnosis of nonaccidental injury who have undergone vitrectomy. This report describes the outcome in six eyes of four patients diagnosed as having nonaccidental injury who underwent vitrectomy. The results are more favorable than in previous reports.
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Matschke J, Herrmann B, Sperhake J, Körber F, Bajanowski T, Glatzel M. Shaken baby syndrome: a common variant of non-accidental head injury in infants. DEUTSCHES ARZTEBLATT INTERNATIONAL 2009; 106:211-7. [PMID: 19471629 PMCID: PMC2680569 DOI: 10.3238/arztebl.2009.0211] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Accepted: 01/02/2009] [Indexed: 11/27/2022]
Abstract
BACKGROUND Recent cases of child abuse reported in the media have underlined the importance of unambiguous diagnosis and appropriate action. Failure to recognize abuse may have severe consequences. Abuse of infants often leaves few external signs of injury and therefore merits special diligence, especially in the case of non-accidental head injury, which has high morbidity and mortality. METHODS Selective literature review including an overview over national and international recommendations. RESULTS Shaken baby syndrome is a common manifestation of non-accidental head injury in infancy. In Germany, there are an estimated 100 to 200 cases annually. The characteristic findings are diffuse encephalopathy and subdural and retinal hemorrhage in the absence of an adequate explanation. The mortality can be as high as 30%, and up to 70% of survivors suffer long-term impairment. Assessment of suspected child abuse requires meticulous documentation in order to preserve evidence as well as radiological, ophthalmological, laboratory, and forensic investigations. CONCLUSIONS The correct diagnosis of shaken baby syndrome requires understanding of the underlying pathophysiology. Assessment of suspected child abuse necessitates painstaking clinical examination with careful documentation of the findings. A multidisciplinary approach is indicated. Continuation, expansion, and evaluation of existing preventive measures in Germany is required.
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Affiliation(s)
- Jakob Matschke
- Forensische Neuropathologie, Institut für Neuropathologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg.
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Ocular pathology in shaken baby syndrome and other forms of infantile non-accidental head injury. Int J Legal Med 2008; 123:189-97. [DOI: 10.1007/s00414-008-0293-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2008] [Accepted: 10/01/2008] [Indexed: 10/21/2022]
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Guidelines for Postmortem Protocol for Ocular Investigation of Sudden Unexplained Infant Death and Suspected Physical Child Abuse. Am J Forensic Med Pathol 2007; 28:323-9. [DOI: 10.1097/paf.0b013e31815b4c00] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Bruising and bleeding are commonly seen in children and are usually associated with minor injury and trauma. However, in two groups of children the bruising may be more significant than expected: those with an underlying haemostatic abnormality, such as an inherited bleeding disorder, or those who have been subjected to non-accidental injury (NAI). Diagnosing inherited bleeding disorders in children is fraught with difficulty, from venous access to interpretation of results; the possibility of NAI should be borne in mind, even in those children with proven significant bleeding disorders when the severity of the injury and the history are non-compatible. We describe the investigation of the haemostatic system in children with bruising and/or bleeding with emphasis on the key haemostatic disorders that need to be excluded.
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Affiliation(s)
- Kate Khair
- Haemophilia Comprehensive Care Centre, Great Ormond St NHS Trust, London, UK.
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Fledelius HC. Retinal haemorrhages in premature infants: a pathogenetic alternative diagnosis to child abuse. ACTA ACUST UNITED AC 2005; 83:424-7. [PMID: 16029264 DOI: 10.1111/j.1600-0420.2005.00471.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To present the occasional observation of retinal haemorrhages in premature babies, as a diagnostic alternative to those observed as part of shaken baby syndrome. METHODS We carried out an observational study on 11 infants in whom retinal and/or vitreous haemorrhages had been observed within their first months of life. Ten infants were under surveillance for retinopathy of prematurity (ROP), with gestational ages and birth weights in the ranges of 27--34 weeks and 790--1665 g, respectively. One infant was diagnosed with Zellweger's syndrome and one received substitution therapy for coagulation factor II deficiency. The last child had been delivered at 38 weeks, weighing 2070 g; he died on day 5 from severe brain oedema with incarceration and extensive bilateral fundus bleeding. RESULTS Four of the 11 infants had some evidence of ROP, and two later received retinal ablation therapy. Contrary to the quick absorption (<1-2 weeks only) usually seen in most newborn term infants, the ocular bleeding in preterms was generally longstanding. A quick increase in intracranial pressure probably played a role in the lethal case with delivery near term, and one infant received lung physiotherapy for pneumonia at the age of 6 months. Some bleeding appeared to be truly postnatal (i.e. it was observed as a new occurrence during the course of surveillance). CONCLUSIONS In the series under study there was no suspicion of child abuse. In term infants, retinal haemorrhages are extremely rare except when due to shaking, but other diseases should be ruled out, coagulopathies in particular. We suggest that prematurity as such is added to the list of possibly underlying causes when retinal bleedings are evaluated in very small infants and shaken baby mechanisms are suspected.
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Affiliation(s)
- Hans C Fledelius
- Rigshospitalet, Eye Department, Copenhagen University, Copenhagen, Denmark.
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Adams G, Ainsworth J, Butler L, Bonshek R, Clarke M, Doran R, Dutton G, Green M, Hodgkinson P, Leitch J, Lloyd C, Luthert P, Parsons A, Punt J, Taylor D, Tehrani N, Willshaw H. Update from the Ophthalmology Child Abuse Working Party: Royal College Ophthalmologists. Eye (Lond) 2004; 18:795-8. [PMID: 15218524 DOI: 10.1038/sj.eye.6701643] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- G Adams
- Children's Hospital Birmingham, UK
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Adams GGW, Luthert PJ. Shaken baby syndrome. Br J Neurosurg 2003; 17:16-7. [PMID: 12779195 DOI: 10.3109/02688690309177965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- G G W Adams
- Moorfields Eye Hospital, City Road, London EC1V 2PD, UK
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Saeed MU, Parmar DN, Ohri R. The role of an ophthalmologist in suspected non-accidental injury. Eye (Lond) 2003; 17:93-5. [PMID: 12579179 DOI: 10.1038/sj.eye.6700265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Abstract
Critically ill and injured children due to abusive or inflicted injury represent a growing challenge for pediatric intensive care unit personnel in terms of the number of patients seen each year in the United States and the intellectual and emotional response required to deal with this tragic problem. We present a distillation of the current knowledge of childhood physical abuse with a focus on the child with inflicted injury who is admitted to the pediatric intensive care unit. In addition to a discussion of the epidemiology, clinical presentation, an approach to diagnosis, and treatment strategies, we also explore the legal issues that confront pediatric intensive care unit physicians in relation to determination of brain death, suitability of victims for organ donation, and the physician's role in the criminal investigation of child abuse and as a witness for court proceedings.
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Affiliation(s)
- Joseph Zenel
- Division of General Pediatrics, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, OR, USA
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Clark BJ, Adams GGW, Luthert PJ. Retinal haemorrhages in infant head injury. Brain 2002; 125:677-8; author reply 678. [PMID: 11872623 DOI: 10.1093/brain/awf067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Geddes JF, Whitwell HL. Head injury in routine and forensic pathological practice. CURRENT TOPICS IN PATHOLOGY. ERGEBNISSE DER PATHOLOGIE 2001; 95:101-24. [PMID: 11545051 DOI: 10.1007/978-3-642-59554-7_3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Affiliation(s)
- J F Geddes
- Department of Morbid Anatomy, Royal London Hospital, Whitechapel, London E1 1BB, UK
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Affiliation(s)
- F M Nadel
- Division of Emergency Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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May K, Parsons MA. Mechanistic considerations when contemplating a diagnosis of non-accidental injury in an infant with vitreous haemorrhage and retinopathy of prematurity. Comment on: Kwok et al. Can vitreous haemorrhage indicate non-accidental injury if mild retinopathy of prematurity is present? Eye 2000; 14:812-3. Eye (Lond) 2001; 15:3-4. [PMID: 11318289 DOI: 10.1038/eye.2001.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Russell-Eggitt IM, Thompson DA, Khair K, Liesner R, Hann IM. Hermansky-Pudlak syndrome presenting with subdural haematoma and retinal haemorrhages in infancy. J R Soc Med 2000; 93:591-2. [PMID: 11198692 PMCID: PMC1298152 DOI: 10.1177/014107680009301110] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- I M Russell-Eggitt
- Department of Ophthalmology, Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH, UK.
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Affiliation(s)
- D Taylor
- Eye Department, Great Ormond Street Hospital, London, UK
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Affiliation(s)
- T J David
- Booth Hall Children's Hospital, Blackley, Manchester, UK.
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