Can one accurately date a bruise? State of the science

Artificial intelligence in forensic medicine and related sciences - selected issues

Aim

The aim of the work is to provide an overview of the potential application of artificial intelligence in forensic medicine and related sciences, and to identify concerns related to providing medico-legal opinions and legal liability in cases in which possible harm in terms of diagnosis and/or treatment is likely to occur when using an advanced system of computer-based information processing and analysis.

Material and methods

The material for the study comprised scientific literature related to the issue of artificial intelligence in forensic medicine and related sciences. For this purpose, Google Scholar, PubMed and ScienceDirect databases were searched. To identify useful articles, such terms as "artificial intelligence," "deep learning," "machine learning," "forensic medicine," "legal medicine," "forensic pathology" and "medicine" were used. In some cases, articles were identified based on the semantic proximity of the introduced terms.

Conclusions

Dynamic development of the computing power and the ability of artificial intelligence to analyze vast data volumes made it possible to transfer artificial intelligence methods to forensic medicine and related sciences. Artificial intelligence has numerous applications in forensic medicine and related sciences and can be helpful in thanatology, forensic traumatology, post-mortem identification examinations, as well as post-mortem microscopic and toxicological diagnostics. Analyzing the legal and medico-legal aspects, artificial intelligence in medicine should be treated as an auxiliary tool, whereas the final diagnostic and therapeutic decisions and the extent to which they are implemented should be the responsibility of humans.

Modalities of Post-Rhinoplasty Edema and Ecchymosis Measurement: A Systematic Review

Background:

Post-rhinoplasty edema and ecchymosis can influence patient satisfaction with surgery as well as result in poor quality of life. Methods to quantify such edema and ecchymosis have been described in the literature. Despite this, there is currently no collective understanding of which methods are the most effective. Hence, this systematic review aims to describe and analyze the literature on post-rhinoplasty edema and ecchymosis measurement techniques.

Methods:

Standard bibliographic databases (OVID Medline, EMBASE, and PubMed) were searched from their inception to December 2019 for the terms: “rhinoplasty”, “postoperative”, “edema”, and “ecchymosis”. Descriptive analysis was completed.

Results:

The search revealed 1116 articles of which 33 met inclusion criteria and were included for qualitative synthesis. A total of 1801 patients from all studies were included. Of the 33 included studies, there were 57 unique ecchymosis/edema measurements. The majority of studies measured edema/ecchymosis on post-operative day 1, 2, 3 and 7. Ninety-three percent of measurements described were taken subjectively from a human rater. Other techniques described included magnetic resonance imaging, ultrasound, 3-dimensional imaging, and digital analysis. Less than half of the subjective ecchymosis/edema gradings were completed by a blinded rater.

Conclusion:

There are a wide variety of post-rhinoplasty edema and ecchymosis techniques being used by rhinoplasty surgeons. The majority of post-rhinoplasty edema and ecchymosis measurements are completed by unblinded subjective raters. It is important that facial plastic surgeons select an accurate measurement tool so they may be able to initiate precise patient-specific management of edema and ecchymosis.

United States ED Visits by Adult Women for Nonfatal Intimate Partner Strangulation, 2006 to 2014: Prevalence and Associated Characteristics

INTRODUCTION

Nonfatal intimate partner strangulation poses significant acute and long-term morbidity risks and also heightens women's risk for future femicide. The lifetime prevalence of nonfatal intimate partner strangulation has been estimated to be approximately 10%, or 11 million women, in the general United States population. Given the potential for significant health risks and serious consequences of strangulation, this study adds to the limited literature by estimating prevalence and describing the associated characteristics of strangulation-related visits among United States ED visits by adult women after intimate partner violence.

METHODS

Prevalence estimation as well as simple and multivariable logistic regression analyses were completed using data from the Nationwide Emergency Department Sample spanning the years 2006 to 2014.

RESULTS

The prevalence of strangulation codes was estimated at 1.2% of all intimate partner violence visits. Adjusting for visits, hospital characteristics, and visit year, higher odds of strangulation were noted in younger women, metropolitan hospitals, level I/II trauma centers, and non-Northeast regions. Increases in strangulation events among intimate partner violence-related visits in recent years were also observed.

DISCUSSION

A relatively low prevalence may reflect an underestimate of true nonfatal intimate partner strangulation visits owing to coding or a very low rate of ED visits for this issue. Higher odds of strangulation among intimate partner violence visits by women in more recent years may be due to increased recognition and documentation by frontline clinicians and coding teams. Continued research is needed to further inform clinical, postcare, and social policy efforts.

Quantifying the Degree of Bruise Visibility Observed Under White Light and an Alternate Light Source

BACKGROUND

Documentation of injuries associated with abuse and assault has pivotal impacts on clinical and legal outcomes. Before this study, no reliable and valid tools to consistently document the clinical visibility of bruises existed. The purpose of this study was to systematically evaluate reliability and validity of the Bruise Visibility Scale for documenting bruises visualized in normal (white) light and the Absorption Visibility Scale for documenting bruises visualized using an alternate light source (ALS).

METHODS

Bruises were induced using a paintball on the upper arms of 157 participants stratified into six skin color categories. Bruises were visualized 21 times over 4 weeks under white light and 10 ALS wavelength/goggle color combinations. Bruise size was measured using a metric ruler; bruise color was measured using a spectrophotometer. Interrater reliability was calculated using kappa and intraclass correlations coefficients. Construct validity was evaluated using generalized linear mixed modeling of associations between bruise size and color with both visibility scales.

RESULTS

Interrater agreement for bruise detection was over 90% for all but two ALS wavelength/goggle combinations. Kappa values indicated adequate interrater agreement under white light (κ = 0.76) and ALS (κ = 0.78). The visibility scale intraclass correlation coefficients were .91 for normal light and .93 for ALS. Statistical modeling showed greater bruise size was associated with higher visibility using either scale, and greater contrast in color or lightness was associated with higher Bruise Visibility Scale values.

IMPLICATIONS FOR PRACTICE

Both visibility scales showed satisfactory reliability and validity. Forensic nurses can use the scales to consistently document bruises.

Bruise detection and visibility under alternate light during the first three days post-trauma

INTRODUCTION

Cutaneous bruises are often hard to detect particularly on individuals with a darker complexion. Researchers and federal agencies have recommended the use of alternate light to aide in the assessment of subtle injury. However, studies are limited in their evaluation of wavelength performance during the first few days of bruise healing. The purpose of this pilot study was to examine whether an alternate light source (ALS) improves detection of bruises when compared to normal light typical of clinical practice during the first three days following induction.

METHODS

A sample of eight healthy adults between 22 and 36 years of age with diverse skin color were recruited for this study. One bruise was induced on each participant by dropping a 4-oz (113g) steel ball through a 5-ft (1.5 m) vertical pipe onto the anterior surface of the forearm. Using the ALS, bruises were assessed under 14 different combinations of ultraviolet and short narrowband visible wavelengths and filters along with overhead fluorescent "examination" lighting. Participants were examined 3 to 4 times per day at approximately 4-h intervals for three consecutive days post induction.

RESULTS

Repeated bruise assessments on 8 subjects resulted in 59 bruise assessments and 885 total observations under the different wavelengths and filters combinations. A bruise was detectable in 46 (78%) of the assessments, with bruise ages ranging from 30 min to 57 h. Twenty (34%) bruises not detectable under normal light were visible with ASL. Multilevel modeling revealed a strong association between time and detection for shorter wavelengths, such as 365 nm (ultraviolet) and 450 nm.

CONCLUSION

The results of our study suggest alternate light is more likely to detect faint bruises than normal lighting during the first three days post injury. However, more research is needed to determine which wavelengths and filter combinations are most effective during that time frame.

The Efficacy of Intense Pulsed Light Therapy in Postoperative Recovery from Eyelid Surgery

BACKGROUND

The purpose of this study was to evaluate the efficacy of postoperative intense pulsed light therapy on patients who undergo bilateral eyelid surgery.

METHODS

Patients presenting over a 3-month period for bilateral eyelid surgery were asked to participate in an institutional review board-approved study. Intense pulsed light therapy was administered three times to the same randomly assigned side on postoperative days 1 to 2, 5 to 7, and 10 to 12. Sham light therapy was administered to the contralateral side. Patient surveys and physician ratings were obtained based on photographic evaluation of ecchymosis, edema, and erythema. Three physicians, including the senior author (A.E.W.), submitted ratings, and these ratings were assessed for interobserver reliability.

RESULTS

Twenty-eight patients who underwent bilateral eyelid surgery followed by intense pulsed light therapy were enrolled. The mean age of the patients was 66 years (range, 44 to 81 years). Eighty-six percent of patients were female. The change in ratings between postoperative days 1 to 2 and 10 to 12, in the treatment and control groups, was statistically significant for severity of bruising by both patient and physician assessment and for color of bruising only by patient assessment. The interobserver reliability reached the greatest agreement in the ecchymosis category at each time point for the treatment group.

CONCLUSION

In a series of patients who underwent eyelid surgery, intense pulsed light therapy decreased the degree of ecchymosis compared with sham treatment in postoperative eyelid surgery patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

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.

Does the intensity of the inflammatory reaction in a bruise depend on its proximity to the site of trauma?

Whole blood was withdrawn by tail vessel puncture from anesthetized adult male Sprague-Dawley rats and 0.1 ml was re-injected subcutaneously at each of two sites on their abdominal wall. In addition, two adjacent sites were injected with 0.1 ml of sterile saline, and two more sites were only punctured using an injecting needle. In the second part of the study anesthetized adult male Sprague-Dawley rats had two sites on the abdominal wall pinched using a small pair of forceps, two adjacent sites received an injection of 0.1 ml of whole blood obtained by tail vessel puncture, and two more sites were both pinched and injected with 0.1 ml of whole blood. At intervals of 3, 6, 12 h, 1, 2, 3, 5, and 7 days the animals were euthanized and the skin of the abdomen was processed for histological assessment. Hemosiderin staining in tissues from the first part of the study was assessed qualitatively by scoring sections as 0, 1, 2, or 3 (representing no staining, mild staining, moderate staining, and intense staining) and semi quantitatively using a Nanozoomer Digital Pathology Scanner (NDP Scan U10074-01, Hamamatsu Photonics K.K., Japan). No inflammatory reaction was observed at the sites subjected to needle puncture only. At the sites of saline injection a mild reaction occurred. At the sites where the blood had been injected an intense inflammatory cell response occurred centrally, but not toward the periphery where blood had tracked. In the second experiment the most intense inflammation was also observed in the sites where there had been a pinch and injection of blood. Again, this was maximal centrally with reduced inflammation peripherally. Perls' staining of hemosiderin was comparable in both models, with iron first observed at day 1 at the region of the injection site. At the sites of injection only, and the sites of injection plus pinch, blood had spread laterally. Hemosiderin staining appeared first and more intensely at the site of injection/trauma. The intensity of the inflammatory response in this animal model of bruising was, therefore, directly related to the proximity to the site of trauma; the appearance and intensity of hemosiderin staining was also influenced by the location within the bruises. This study has shown that histological changes that may be utilized to date bruises may be significantly influenced by the site of the biopsy.

Magnetic resonance imaging (MRI) of bruises: a pilot study

The purpose of this study was to investigate if magnetic resonance imaging (MRI) could be used to image the presence of hemosiderin in bruises and if there was the potential for this technique to be applied as a non-invasive method to estimate the age of bruises. To achieve this aim an animal model to produce lesions resembling bruises was created by injecting blood obtained from the tail vein subcutaneously into an area of the abdominal wall. The animals were euthanized at 3, 6, 12 h, 1, 2, 3, 5, and 7 days post injection and the skin of the abdominal wall was excised for MRI scanning and histological examination. The injected blood appeared as hypointense (dark) areas on the T2* MRI at 3 and 6 h. The image of the injected areas became indistinct at 12 h and continued to be indistinct at 1 and 2 days, although there appeared to be transitioning from hypointensity to hyperintensity (light). The magnetic resonance image appeared to better correspond to the histological appearance at 3 and 5 days, with the "bruise" appearing hyperintense (white); however, some hypointense (darker) areas at 3 day possibly corresponded to the development of hemosiderin. At 7 day the injected blood had been converted to hemosiderin with possible correlation between areas of blue staining in Perls' stained histologic sections and areas of extreme hypointensity in the T2* magnetic resonance image. This study has shown that a series of changes occur on MRI of bruises in an animal model that may relate to histological changes. Although variability in the intensity of the MRI signal and considerable soft tissue artifact currently make interpretations difficult, this may be a technique worth pursuing in the non-invasive evaluation of bruises.

Injuries from intimate partner and sexual violence: Significance and classification systems

While intimate partner violence (IPV) and sexual violence (SV) are highly associated with injury, the healthcare and legal significance of these injuries is controversial.

PURPOSE

Herein we propose to explore the significance of injury in IPV and SV and examine the current status of injury classification systems from the perspectives of the healthcare and criminal justice systems. We will review current injury classification systems and suggest a typology of injury that could be tested empirically.

FINDINGS

Within the published literature, we found that no commonly accepted injury typology exists. While nuanced and controversial issues surround the role of injury detection in the sexual assault forensic examination, enough evidence exists to support the continued pursuance of a scientific approach to injury classification. We propose an injury typology that is measurable, is applicable to the healthcare setting and criminal justice system, and allows us to use uses a matrix approach that includes a severity score, anatomic location, and injury type. We suggest a typology that might be used for further empirical testing on the validity and reliability of IPV and SV injury data.

CONCLUSION

We recommend that the community of scientists concerned about IPV and SV develop a more rigorous injury classification system that will improve the quality of forensic evidence proffered and decisions made throughout the criminal justice process.

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.