Histologic evidence of repetitive blunt force abdominal trauma in four pediatric fatalities

Liver Trauma: Management in the Emergency Setting and Medico-Legal Implications

Traumatic abdominal injuries are life-threatening emergencies frequently seen in the Emergency Department (ED). The most common is liver trauma, which accounts for approximately 5% of all ED admissions for trauma. The management of blunt liver trauma has evolved significantly over the past few decades and, according to the injury’s severity, it may require massive resuscitation, radiological procedures, endoscopy, or surgery. Patients admitted to the ED with blunt abdominal trauma require a multidisciplinary evaluation, including emergency physicians, surgeons, radiologists, and anesthetists, who must promptly identify the extent of the injury to prevent serious complications. In case of a patient’s death, the execution of a forensic examination carried out with a multidisciplinary approach (radiological, macroscopic, and histological) is essential to understand the cause of death and to correlate the extent of the injuries to the possibility of survival to be able to manage any medico-legal disputes. This manuscript aims to collect the most up-to-date evidence regarding the management of hepatic trauma in the emergency room and to explore radiological findings and medico-legal implications.

The Pancreas in Child Abuse

The pancreas can be a critical indicator of inflicted injury in young children. Due to its retroperitoneal location and the amount of incursion of the abdomen required to cause injury, the pancreas is unlikely to be significantly injured in minor trauma incidents. Typical blunt force injury mechanisms for the pancreas include motor vehicle collisions, inflicted injury from blows or kicks, and bicycle handlebar injuries with deep incursion of the abdomen. The death of a toddler is described in which a pancreatic injury was a critical indicator of abusive injury rather than the claimed accidental fall or cardiopulmonary resuscitation-related trauma. Review of the medical literature regarding the epidemiology, etiology, and pathology of childhood pancreatic injuries is discussed. Pancreatic injury is a marker of severe blunt force trauma and should rouse a suspicion of nonaccidental trauma in young children. In the absence of a severe, high velocity or deep abdominal incursion traumatic mechanism, such as motor vehicle collision or bicycle handlebar injury, pancreatic laceration specifically is a marker of inflicted injury in children under the age of five. Acad Forensic Pathol. 2018 8(2): 219-238.

Are There Hallmarks of Child Abuse? II. Non-Osseous Injuries

Certain conditions have been considered hallmarks of child abuse. Such pathognomonic conditions have led to an inevitable diagnosis of inflicted injury. Forensic pathologists are faced with complex analyses and decisions related to what is and what is not child abuse. In this review, we examine the literature on the specificity of five conditions that have been linked to inflicted injury to varying degrees of certainty. The conditions examined include tears of the labial frena (frenula), cigarette burns, pulmonary hemorrhage and intraalveolar hemosiderin-laden macrophages as markers of upper airway obstruction, intraabdominal injuries, and anogenital injuries and postmortem changes. Analysis of the literature indicates that frena tears are not uniquely an inflicted injury. Cigarette burns are highly indicative of child abuse, though isolated cigarette burns may be accidental. Pulmonary hemorrhage is seen more commonly in cases with a history suggestive of upper airway obstruction, but is not diagnostic in an individual case. Hemosiderin-laden macrophages may be seen in cases with inflicted injuries and in natural deaths. Abdominal injuries may be seen in accidents and from resuscitation, though panreatico-duodenal complex injuries in children under five years of age are not reported to be seen in falls or resuscitation. The understanding of anogenital injuries is increasing, but misunderstanding of postmortem changes has led to miscarriages of justice.

The National DNA Data Bank of Canada: a Quebecer perspective

The Canadian National DNA Database was created in 1998 and first used in the mid-2000. Under management by the RCMP, the National DNA Data Bank of Canada offers each year satisfactory reported statistics for its use and efficiency. Built on two indexes (convicted offenders and crime scene indexes), the database not only provides increasing matches to offenders or linked traces to the various police forces of the nation, but offers a memory repository for cold cases. Despite these achievements, the data bank is now facing new challenges that will inevitably defy the way the database is currently used. These arise from the increasing power of detection of DNA traces, the diversity of demands from police investigators and the growth of the bank itself. Examples of new requirements from the database now include familial searches, low-copy-number analyses and the correct interpretation of mixed samples. This paper aims to develop on the original way set in Québec to address some of these challenges. Nevertheless, analytic and technological advances will inevitably lead to the introduction of new technologies in forensic laboratories, such as single cell sequencing, phenotyping, and proteomics. Furthermore, it will not only request a new holistic/global approach of the forensic molecular biology sciences (through academia and a more investigative role in the laboratory), but also new legal developments. Far from being exhaustive, this paper highlights some of the current use of the database, its potential for the future, and opportunity to expand as a result of recent technological developments in molecular biology, including, but not limited to DNA identification.

Sudden death due to adrenal neuroblastoma: child abuse mimic?

Neuroblastoma is one of the most common malignancies in children. It is a tumor that can clinically present with varied symptoms that can mimic other entities, including child abuse. It is important that forensic pathologists are aware of the diseases that can masquerade as child abuse. A case of sudden, unexpected death in a 2-year-old due to previously undiagnosed neuroblastoma is presented. At initial presentation of the child in the emergency department, child abuse was considered as a possible explanation for the sudden demise. Death occurred before a full clinical workup could be completed and an autopsy was performed which unveiled the cause of death.