Neuropathological changes in a lamb model of non-accidental head injury (the shaken baby syndrome).

Non-accidental head injury (NAHI), also termed the "shaken baby syndrome", is a major cause of death and severe neurological dysfunction in children under three years of age, but it is debated whether shaking alone is sufficient to produce brain injury and mortality or whether an additional head impact is required. In an attempt to resolve this question, we used a lamb model of NAHI since these animals have a relatively large gyrencephalic brain and weak neck muscles resembling those of a human infant. Three anaesthetised lambs of lower body weight than others in the experimental group died unexpectedly after being shaken, proving that shaking alone can be lethal. In these lambs, axonal injury, neuronal reaction and albumin extravasation were widely distributed in the hemispheric white matter, brainstem and at the craniocervical junction, and of much greater magnitude than in higher body weight lambs which did not die. Moreover, in the eyes of these shaken lambs, there was damage to retinal inner nuclear layer neurons, mild, patchy ganglion cell axonal injury, widespread Muller glial reaction, and uveal albumin extravasation. This study proved that shaking of a subset of lambs can result in death, without an additional head impact being required.

The significance of bruising in infants--a forensic postmortem study.

OBJECTIVE: To determine the significance of bruises in cases of infant death to ascertain if their presence was associated with other injuries or homicide. DESIGN: Retrospective cohort study. SETTING: Forensic Science South Australia, Adelaide, South Australia, Australia. PATIENTS: 135 infants aged between 7 and 364 days autopsied over a 9-year period from June 1999 to May 2008. OUTCOME MEASURES: Coronial forensic autopsy reports. METHODS: Examination of autopsy reports to determine how many infants had bruising and whether bruising was associated with other injuries or lesions of concern. Cause and manner of death were also recorded. RESULTS: There were 83 boys and 52 girls. Twenty-one infants (15.6%) had one or more bruises, and 114 had no bruises. In the group of 21 infants with bruises, 17/21 had other injuries/lesions (81%), with 5/21 homicides (24%). Of the 114 non-bruised infants, only 9 (8%) had other injuries/lesions with only 4 homicides (3.5%). The incidence of other injuries/lesions was significantly higher in bruised infants compared with the non-bruised group (p<0.001), as was the occurrence of homicide (p=0.003). Bruises were found in 15.6% of infants presenting to coronial autopsy, with a sensitivity of 65% and a specificity of 96% as markers for other injuries (positive predictive value 0.81; negative predictive value 0.92). At <6 months of age, this increased to a sensitivity of 71%, with a similar specificity of 95%. CONCLUSIONS: Bruising is a significant marker for other injuries in infants presenting to coronial autopsy. Homicide occurs more commonly in this group.

Childhood glioblastoma multiforme of the spinal cord.

Astrocytoma accounts for more than 50% of all central nervous system tumours diagnosed, with particular prevalence in the 15- to 34-year-old age bracket, rarely arising in younger children. In 1995, a 7-year-old boy presented in Emergency with a 3-day history of severe radicular back pain and associated muscle spasms, exacerbated by lying on his back. Both bone scan and plain X-rays were unremarkable; however, MRI showed a 3-cm space-occupying lesion at the level of T5-T6. The patient proceeded to biopsy and partial excision of the tumour through laminectomy, histology confirming an anaplastic astrocytoma (glioblastoma multiforme), St Anne Mayo grade 4. Treatment consisted of a radical course of radiotherapy alone, delivering a total dose of 44.8 Gy at 1.6 Gy per fraction. The treatment comprised of three phases using two oblique wedged fields on a 6 MV linear accelerator. The patient remains disease free 7 years post treatment, with the only effect noted being a slight kyphoscoliosis at the site of the laminectomy and radiation. This report highlights the efficacy of combined surgery and radiation therapy in the management of spinal cord glioblastoma multiforme in preventing tumour recurrence, with acceptable morbidity. Further evaluation of the treatment efficacy would be difficult because of the scarcity of such cases.

Diabetic ketoacidosis--a possible complicating factor in deaths associated with drug overdose: two case reports.

Two cases are described where diabetic ketoacidosis was found in conjunction with significant levels of prescription drugs. Case 1: A 45-year-old woman with a history of insulin-dependent diabetes mellitus was found to have Armanni-Ebstein nephropathy characteristic of hyperglycaemia with a vitreous humour glucose level of 63.1 mmol/L and a beta-hydroxybutyrate level of 14.25 mmol/L. Ancillary toxicological evaluation revealed a lethal level of sertraline (2.5 mg/L), with an elevated level of methadone (0.23mg/L). Death was due to diabetic ketoacidosis complicating mixed drug toxicity. Case 2: A 27-year-old man with a history of insulin-dependent diabetes mellitus was found to have Armanni-Ebstein nephropathy with a vitreous humour glucose level of 51.7 mmol/L and a beta-hydroxybutyrate level of 18.6mmol/L. Ancillary toxicological evaluation revealed a potentially lethal level of methadone of 0.39mg/L. Death was attributed to diabetic ketoacidosis complicating methadone toxicity. These cases demonstrate a situation where drug toxicity led to diabetic ketoacidosis resulting in death most likely from a combination of factors. Measuring vitreous humour glucose and beta-hydroxybutyrate levels is important in individuals with histories, or scene evidence, of insulin-dependent diabetes mellitus, in addition to toxicological screening when there is evidence of possible drug taking. It appears that drug intoxication in both cases had impaired the ability to administer insulin, resulting in the development over time of diabetic ketoacidotic states. Lethal mechanisms were, therefore, more complex than simple drug toxicity or diabetic ketoacidosis in isolation.

Child booster seats and lethal seat belt injury.

A 7-year-old boy travelling in the rear seat of a sedan car was wearing a lap-shoulder seat belt and sitting on a booster seat. Following a collision the boy 'submarined' under the seat belt sustaining trauma to the anterior aspect of his neck, cardiac arrest and subsequent death from hypoxic-ischaemic encephalopathy. This case demonstrates a potential problem with unsecured older-style booster seats. Movement of a seat in a collision may cause a child to slip under a seat belt and sustain significant neck injuries. Seatbelts for children must be correctly fitted, booster seats or capsules must be securely fastened and manufacturer's recommendations for size and weight limits should be followed. Unfortunately older booster seats may not have attached instructions for installation and use, may not fit later model vehicles, may not conform to current safety recommendations and may have worn webbing. For these reasons their use should be discouraged.

Suicide methods in the elderly in South Australia 1981-2000.

The files of the Forensic Science Centre in Adelaide, Australia were examined over a 20-year period from 1981 to 2000 for cases of suicide in individuals aged 65 years and over. A total of 445 cases were found (13.8% of all suicides) with an age range of 65-94 years (average= 73.5 years). All cases had undergone full autopsies and police investigation. There were significantly more male than female victims; M:F = 330:115 (p < 0.001). Hangings accounted for the highest proportion of cases (107/445; 24%) followed by gunshot wounds (96/445; 21.6%), drug toxicity (82/435; 18.9%), drowning (66/445; 14.8%), and carbon monoxide toxicity (52/445; 11.7%). A miscellaneous group accounted for 42 of 445 cases (9.2%). No significant changes occurred in either the total suicide rate or in the rates in males and females, except for drowning deaths in males, which showed a significant decrease over time (p < 0.01). Female victims tended to avoid violent methods such as gunshot wounds in favour of drug overdose. Gunshot wound deaths were far less common than published data from other countries would indicate, with relative increases in deaths due to hanging, drug toxicity, drowning and carbon monoxide toxicity. An awareness of the considerable variability that occurs among populations in suicide methods and rates is important in determining local requirements for suicide prevention campaigns.

Research and sudden infant death syndrome: definitions, diagnostic difficulties and discrepancies.

The diagnosis of causes of sudden infant death is an often complex and difficult process. Variable standards of autopsy practice and the use of different definitions for entities such as sudden infant death syndrome (SIDS) have also contributed to confusion and discrepancies. For example, the term SIDS has been used when the requirements of standard definitions have not been fulfilled. In an attempt to correct this situation recent initiatives have been undertaken to stratify cases of unexpected infant death and to institute protocols that provide frameworks for investigations. However, if research is to be meaningful, researchers must be scrupulous in assessing how extensively cases have been investigated and how closely cases fit with internationally recognized definitions and standards. Unless this approach is adopted, evaluation of research findings in SIDS will be difficult and the literature will continue to be beset by contradictions and unsubstantiated conclusions.

Infant bath seats, drowning and near-drowning.

OBJECTIVE: To investigate the possible role of infant bathtub seats in drowning and near-drowning episodes in infants. METHODS: A review was conducted of the files of the Forensic Science Centre and Child Protection Unit, Women's and Children's Hospital, Adelaide, South Australia, for significant immersion incidents in infants involving bathtub seats from January 1998 to December 2003. RESULTS: A total of six cases of drowning occurred over the 6-year period of the study in children under 2 years of age, including two infants. One of these cases, a 7-month-old boy, had been left unattended for some time in an adult bath in a bathtub seat. He was found drowned, having submerged after slipping down and becoming trapped in the seat. Three near-drowning episodes occurred in children under the age of 2 years, including two boys aged 7 and 8 months, both of whom had been left for some time in adult baths in bath seats. Both were successfully resuscitated and treated in hospital. CONCLUSIONS: These cases demonstrate the vulnerability of infants to immersion incidents when left unattended in bathtubs. Bathtubs are particularly dangerous for infants as the slippery and smooth surfaces predispose to loss of balance and make escape from water difficult. Infant bathtub seats may give parents and child carers a false sense of security leading to infants being left unattended. Unfortunately, however, infants may fall out of, or slip and become trapped in, such seats. Infants and young children cannot be left unsupervised in water, and devices used as bathing aids such as bathtub seats may contribute to immersion incidents.

Mechanisms of unexpected death in tuberous sclerosis.

Tuberous sclerosis complex is a protean autosomal dominant disorder characterized by multifocal tissue lesions arising from defects in cellular migration, proliferation, and differentiation. It has an association with sudden death. In the current study, review of all cases of sudden death due to tuberous sclerosis was undertaken at the Forensic Science Centre in Adelaide, Australia from 1991 to 2001, in addition to an analysis of cases from the literature. There were two local cases where unexpected death had occurred in individuals with known tuberous sclerosis, involving a 31-year-old male (epilepsy), and a 24-year-old female (massive hemorrhage into a renal angiomyolipoma). Fatal mechanisms in cases of tuberous sclerosis may be associated with underlying cardiovascular, renal and cerebral abnormalities. Sudden death may be due to cardiac arrhythmia, epilepsy, and intra-tumoral hemorrhage with additional complications including cardiac outflow obstruction, obstructive hydrocephalus, aneurysm rupture, and spontaneous pneumothorax. An awareness of the highly variable tissue manifestations of tuberous sclerosis and the mechanisms that may be responsible for death is necessary to establish correctly the diagnosis in occult cases (possibly with molecular confirmation), and to chart accurately organ changes in individuals with established disease.

Death due to electrocution in childhood and early adolescence.

OBJECTIVES: To delineate the clinicopathological features of fatal childhood electrocutions and to identify specific risk factors. METHODS: Coronial files in Adelaide (Australia) were searched from 1967 to 2001 and Medical Examiners' files in San Diego (USA) were searched from 1988 to 2001, for cases of deaths of children and adolescents younger than 16 years attributed to electrocution. RESULTS: Sixteen cases were identified aged between 10 months and 15 years (mean 8.0 years) with a male : female ratio of 5 : 3. Deaths were due to accidents occurring while playing with or near faulty electrical equipment at home or at school (n = 8), electrical equipment while in the bath (n = 2), damaged outdoor electrical equipment (n = 1), overhead wires (n = 1), and a high voltage electricity substation (n = 1). In addition, one death was due to suicide involving an electrical appliance placed in a bath, and two other deaths occurred in older children who were moving equipment under overhead wires. No homicides were identified. CONCLUSIONS: Childhood deaths due to electrocution are rare and are more likely to occur when children are playing around electrical wires or equipment, and often result from either faulty apparatus, or a lack of understanding of the potential dangers involved. The majority of deaths (11/16; 69%) occur in the home environment. In contrast to adult electrical deaths, high-voltage electrocutions, suicides and workplace deaths are uncommon. Strategies for eliminating childhood electrocution should concentrate on ensuring safe domestic environments with properly maintained electrical devices.

Fatal unintentional traumatic asphyxia in childhood.

OBJECTIVE: The present study was undertaken to examine specific features of unintentional traumatic asphyxial deaths in childhood. METHODS: Coronial files and records at the Forensic Science Centre in Adelaide, South Australia, were examined over a 35-year period from 1966 to 2000 for all cases of traumatic asphyxial death occurring in children under the age of 17 years. RESULTS: Six cases of unintentional fatal traumatic asphyxia were identified. All of the victims were boys with an age range of 2-15 years (mean 6.8 years) and all were found dead at the scene. Fatal traumatic asphyxia resulted from entrapment beneath a chest of drawers, beneath a table tennis table, between a pile of wooden pallets and a metal fence, between a conveyor belt and its frame, and under a motor vehicle (in two cases). CONCLUSIONS: Fatal traumatic asphyxia in childhood is a rare event, with younger children commonly being trapped by furniture or by industrial equipment while playing, and older children being trapped under motor vehicles in similar circumstances to adult traumatic asphyxial deaths. Unsupervised play of young children around heavy and potentially unstable pieces of furniture may be dangerous, particularly if more than one child is present. Unsupervised play of young children in industrial yards should be avoided.

Childhood sporting deaths.

Exercise-induced collapse and sudden death are unusual in childhood. For this reason, a study was undertaken of a series of 12 cases of sudden death in childhood occurring during physical exertion associated with sporting activities. The age range was 7 to 16 years (mean 12.3 years, M:F ratio 5:1). Deaths resulted from trauma associated with the sporting activity, from an idiosyncratic response to exertion, or from exacerbation of a known underlying disease. Trauma was directly fatal (n = 4: vascular trauma in 1, head injury in 2, drowning in 1), exacerbated an underlying medical condition (n = 1: hypertrophic obstructive cardiomyopathy), or followed collapse from underlying organic disease (n = 1: drowning in epilepsy). Deaths after exertion occurred when there was an unexpected response to underlying occult disease (n = 4: aortic stenosis in 1, cerebral arteriovenous malformation in 1, hypertrophic obstructive cardiomyopathy in 1, coronary atherosclerosis in 1) or to preexisting known disease (n = 2: surgically corrected transposition of the great vessels in 1, asthma in 1). The fatal episodes often resulted from a complex interplay of a variety of factors, including physical exertion, possible trauma, and underlying organic disease. Testing of other family members may be indicated in cases where a rare, possibly familial, disease is found. Evaluation of cases required descriptions of activities before death, information from the medical history of the deceased, and detailed findings from the autopsy.

Incapacitation or death of a socially isolated parent or carer could result in the death of dependent children.

A study was undertaken to investigate features of infant and childhood fatalities that were a consequence of care by socially isolated adults suffering from significant medical conditions. Autopsy records at the Forensic Science Centre in Adelaide from July 1996 to June 2001 were searched for all cases where infants or children had died as a result of the incapacitation or death of an adult carer. A total of two cases were found, involving three children. The carers were aged 51 years (grandfather) and 20 years (mother) and had died at home from ischaemic heart disease and epilepsy, respectively. The children were all boys and were aged 1 year, 2.5 years and 3 years. The child victims had died of dehydration following the adult deaths. These cases demonstrate that infants and young children in the care of socially isolated and unwell adults could be at risk of significant injury or death if the carer dies or becomes incapacitated. The provision of medical-emergency buttons for such families, and/or the setting up of regular contact with medical clinics or neighbours are steps that could be taken to diminish the risk of such an outcome.

Epithelial cell mitotic arrest--a useful postmortem histologic marker in cases of possible colchicine toxicity.

Following ingestion of 30 mg of presumed benztropine (Cogentin) a 39-year-old male developed nausea, vomiting and diarrhea. His admission to hospital was soon followed by collapse and death. Histological examination, however, revealed increased numbers of mitotic figures in otherwise normal epithelial cells of the esophagus and bronchioles, a feature characteristic of colchicine toxicity. Subsequent toxicological analyses confirmed the presence of colchicine in the urine, but not in the blood. A dispensing error had resulted in substitution of colchicine for Cogentin. Histological findings had, therefore, provided evidence of colchicine toxicity and had guided subsequent toxicological evaluation. In suspected cases of colchicine toxicity, histological samples should, therefore, be taken from multiple sites along the gastrointestinal and respiratory tract in addition to other organs and tissues so that diagnostic morphological changes can be looked for.

Fatal childhood vascular injuries associated with seat belt use.

The deaths of two children who were passengers in motor vehicles involved in accidents were directly attributable to vascular injuries derived from seat belts. In the first case, a 10-year-old boy died as a result of abdominal aortic transection by a lap seat belt, and in the second case a 15-year-old boy died as a result of transection of his common carotid artery by a lap-shoulder seat belt. Although these cases demonstrate rare fatalities associated with seat belt use, there is no doubt that seat belts have significantly reduced mortality and morbidity from traffic accidents. Although it is possible that a fatal outcome might have occurred in each of these cases from other injuries that might have been sustained had seat belts not been worn, appropriate positioning and size of seat belt harnesses might have avoided the lethal injuries.

Pathological findings in overlaying.

A 2-month-old girl is reported who was found in cardiorespiratory arrest beneath her unconscious mother. Full autopsy examination failed to reveal any features which would give an indication of the nature of the terminal event. This case confirms the non-specificity of autopsy findings in an infant who suffocated underneath an adult--a situation mimicking classical 'overlaying'. Given that there may be no specific histopathological findings when an infant suffocates underneath an adult, a diagnosis should not be formulated if a full death scene description is not available and no specific lesions or diseases are found. The manner of death should be designated as 'undetermined'.

Detecting organic toxins in possible fatal poisonings--a diagnostic problem.

Two fatal cases are reported where there was strong circumstantial evidence of plant toxin ingestion. In only one case however was a low urine level of hyoscine detected (in keeping with a history of Datura sp. consumption). Fatal cases of plant toxin ingestion may be a problem for the laboratory given the wide range and rarity of certain plant poisons, and the limitation of standard screening. Identification of plant materials at the scene of suspected poisoning may be crucial in directing toxicological investigations.