Distinct age-related differences among victims in cases of suspected child abuse.

Evidence describing age-related differences among children with suspected physical and sexual child abuse is lacking. We describe findings in severe cases of suspected abuse. Cases with 756 children <15 years old were included during 2001-2013 at the Department of Forensic Medicine, Aarhus University, using forensic evaluation documents, medical records, and court proceedings. Eight percent of children <4 years old died from child abuse, 36% through violence resulting in death, and 64% by manslaughter, whereas 1% > 4 years old died, solely by manslaughter. External injuries were mainly located to head and torso in children <4 years old, changing to the upper and lower extremities in older children. Child sexual abuse was suspected in 52% of cases with living children <4 years old, 83% of children 4-7 years of age, 88% of children 8-11 years of age, and 93% of children >12 years old. Anogenital findings were mainly caused by other medical conditions in children <4 years old, hymenal clefts in the superior half of the hymenal rim were almost exclusively found in children between 8 and 11 years of age, whereas both superficial and complete hymenal clefts in the inferior half of the hymenal rim were found in children >12 years old. The present study describes age-related differences in victims of suspected child abuse. Fatal versus nonfatal child physical abuse and the significance of hymenal findings in child sexual abuse could be studied further.

Suspicion of child maltreatment: Knowledge and experiences with mandatory reports to social services among general practitioners in Denmark in 2019-20.

BACKGROUND: Child maltreatment has many consequences through the lifespan. The general practitioners (GPs) are in longitudinal contact with the family and can play an important role in identifying children in danger and reporting to the social services. OBJECTIVE: To explore how GPs manage suspicions of child maltreatment and to investigate potential demographic and geographic differences in reporting practices among Danish GPs. PARTICIPANTS AND SETTING: All registered GPs in Denmark retrieved from Medcom, a state-financed non-profit organization. METHODS: We mailed a questionnaire to all registered GPs with demographics, experiences, knowledge, and attitudes in the context of child maltreatment. RESULTS: We received 1252 completed questionnaires (response rate: 38 %). Most of the participants had suspected child maltreatment during their professional life (90 %) and had made a mandatory report (85 %). More than half had received feedback after the report (56 %) and said that their report led to action (56 %). Most GPs reported feeling confident in dealing with child maltreatment (79 %) and being willing to get involved in case of suspicion (8.9 on a 0-10 scale). We observed no geographical differences in reporting neither across the Danish regions nor among rural and urban practices, but GPs working in single practices made fewer reports to the social services. CONCLUSIONS: Participant GPs in this study are aware of their role in child protection, have experiences with mandatory reports, and are willing to get involved. Possible areas for attention include collaboration and support between different settings, especially between GP practice, hospitals, justice sector, and social services.

Histological Osteoarthritic Changes in the Human Cervical Spine Facet Joints Related to Age and Sex.

STUDY DESIGN: Cross-sectional autopsy study. OBJECTIVE: Quantify histological changes in the lower cervical spine facet joints with regard to age and sex using systematic random sampling of entire joints. SUMMARY OF BACKGROUND DATA: Neck pain is a common debilitating musculoskeletal condition and one of the highest ranked causes of years lived with disability. The cause of neck pain is multifactorial and osteoarthritis is one potential cause. The cervical spine facet joints have been implicated in the etiology of chronic neck pain. Hence, a detailed description of their anatomy and age- and sex-related changes is needed. METHODS: The lower four cervical spine segments (C4-C7 included) were obtained from 72 subjects during autopsy; 29 women (median age 53 years [22-77]) and 43 men (median age 38 years [20-78]). A total of 1132 articular facets were embedded in toto in hard plastic and sliced into 3-mm thick sections from where 10 µm thick histological sections were produced. Morphological variables were evaluated microscopically and histomorphometric variables were retrieved using random sampling methods. Data were analyzed with a linear regression model. RESULTS: Significant associations were found between increasing age and in particular splitting, fissures, osteophytes, thickness of the calcified cartilage, and subchondral bone plate. The thickness of the calcified cartilage and subchondral bone plate increased with increasing age, whereas the hyaline cartilage thickness decreased. Males had more extensive degenerative changes in the cartilage. CONCLUSION: Using semiquantitative histological methods, degenerative findings were observed at all spinal levels involving the articular cartilage and the osseous structures of the cervical spine facet joints similar to those observed in larger weight-bearing joints. In particular, the thickening of the calcified cartilage and the subchondral bone identified the osteocartilaginous junction as an important area in osteoarthritis. These findings may be relevant for the pathogenesis of osteoarthritis. LEVEL OF EVIDENCE: 3.

Hymenal lesions and legal outcome in sexually abused girls with a history of vaginal penetration.

PURPOSE: In many cultures, it is commonly accepted that the hymen remains unchanged throughout childhood, until it is torn at the first episode of sexual intercourse. Therefore, the definition of virginity is directly linked to a normal hymen. However, most girls referred for medical forensic colposcopic examination have normal or nonspecific findings, the prevalence of abnormal findings in girls with a history of genital penetration being only 4-6%. The aim of this study was to investigate the relation between hymenal findings seen at the colposcopic examination and the legal outcome: prosecution in court and conviction in court. RESULTS: During the 80-month period of our study, 426 girls with a median age of 9 years (range 0-15 years) were included. A history of at least one vaginal penetration was given in 226 of the girls with a median age of 12 years (range 2-14 years). The hymenal findings were described as normal in 125 of the 226 cases (55%). In 50 cases (22%), hymenal clefts were found, 17 (34%) of which were complete and 33 (66%) incomplete. The finding of hymenal clefts increased with age. Of the 226 cases of girls being sexually assaulted with vaginal penetration, 119 cases (53%) were prosecuted in court, 102 of which (86%) resulted in conviction. Thirty-five (70%) of the cases with hymenal clefts and 100 (57%) of the cases without hymenal clefts were prosecuted in court, showing a correlation between hymenal clefts and conviction; however, the correlation was not significant (χ(2) test=2.1 and P=0.14). In total, 29 (58%) of the cases with hymenal clefts and 88 (50%) of the cases without hymenal clefts were convicted in court, which shows no significance (χ(2) test=1.0 and P=0.33). CONCLUSIONS: The single most important feature for conviction in court is the child's testimony and not hymenal findings seen at the colposcopic examination. Especially the testimony of the older children leads to conviction, raising the question whether the videotaped testimonies are aimed at the court proceedings, or whether hearing the child's testimony directly in court has a more powerful effect. Overall, it is crucial that the videotaped police questioning of the younger children is performed by specialized personnel, with the aim of presenting the testimony in a detailed and credible manner in court, giving children of all ages a fair trial.

The unexpected finding of a benign mature teratoma in a forensic pathology autopsy: a rare cause for sudden, unexpected death.

Intracranial teratomas are rare tumors that are usually discovered in infancy due to progressive symptoms. We describe a case of a 38-year-old man who was found dead 9 hours after the last sign of life. The deceased's medical history could not explain the sudden, unexpected death. A forensic autopsy revealed an asymptomatic, mature teratoma in the left frontal and temporal lobes. We concluded that the cause of death must have been a generalized epileptiform seizure originating in the tumor site(s) leading to aspiration of the stomach contents and unfavorable positioning, resulting in asphyxia.

Forensic medical examination of adolescent and adult victims of sexual violence.

The acute care and examination of a victim of sexual violence must be carried out by a competent forensic examiner in a setting appropriate for crisis intervention, forensic evidence collection, and medical follow up. The aim of forensic evidence and biological material collection is to document an alleged physical or sexual contact between individuals and to corroborate the victim's and the assailant's history. This is why the forensic examiner is expected to be objective and in possession of specialised technical and scientific skills. These skills are addressed and recommendations are made on how to carry out a forensic examination. This includes medical and assault history, top-to-toe examination, biological material collection, and documenting injuries while obtaining the chain of custody. Yet, consensus on time limitations for forensic evidence collection is lacking. Available forensic evidence has been shown to benefit prosecution. To meet the legal system's needs, an interpretation of the findings in a written legal report is mandatory.

Screening analysis for medicinal drugs and drugs of abuse in whole blood using ultra-performance liquid chromatography time-of-flight mass spectrometry (UPLC-TOF-MS)--toxicological findings in cases of alleged sexual assault.

An ultra-performance liquid chromatography time-of-flight mass spectrometry (UPLC-TOF-MS) method for simultaneous screening of 46 medicinal drugs and drugs of abuse in whole blood was developed and validated. The method includes most of the commonly used and abused drugs such as amphetamines, cocaine, benzodiazepines, and opioids. Chromatographic separation of the targeted drugs was achieved using a Waters ACQUITY UPLC coupled to a Waters Micromass LCT Premier XE time-of-flight mass spectrometer. The total chromatographic run time was 13.5 min injection to injection. The estimated method LOQ is in the range of 0.06-27 ng/g, which is below the therapeutic levels for each of the drugs analyzed but LSD. The extraction recovery ranged from 6% to 197% with median value 95% and mean value 82%. Matrix effect ranged from 81% suppression to 29% enhancement of the signals compared to signals obtained in the absence of biological matrix. The method was tested on 55 authentic forensic toxicology samples confirming the same positive results as found using the routine analytical procedures as well as some additional compounds. Recently there has been considerable attention paid to drug-facilitated sexual assault and the toxicological findings in these cases. As part of a pilot study to investigate the prevalence of medicinal drugs, drugs of abuse, and alcohol in victims of alleged sexual assault, biological specimens were obtained from 167 victims being examined at the Sexual Assault Center in Aarhus, Denmark. The obtained blood samples were analyzed using the novel screening method supported by additional analyses for e.g. THC and alcohol. 124 victims reported they have been drinking alcohol prior to the assault (74%). Alcohol analyses revealed 59 positive findings (48%). 35 of the cases were found positive for one or more drugs excluding alcohol (21%). 20 of the victims reported they have been subject to a drug-facilitated sexual assault (12%). For the victims suspecting drug-facilitated sexual assault, the toxicological analyses revealed four positive for alcohol and nine victims were positive for one or more drugs, with six of the victims found positive for benzodiazepines or other drugs with sedative effects. It was notable that victims tested positive for medicinal drugs and drugs of abuse as well as victims of alleged drug-facilitated sexual assault in average underwent medical examination later than the whole study population.

Lethal esophageal rupture following treatment with Sengstaken-Blakemore tube in management of variceal bleeding: a 10-year autopsy study.

We report six cases of lethal esophageal rupture following treatment with Sengstaken-Blakemore (SB) tube in management of acute variceal bleeding. Esophageal rupture is a known complication to SB tube treatment which unfortunately often is a result of iatrogenic misplacement of the tube. Our report indicates that despite additional guidelines to verify correct placement and new promising treatment modalities, lethal esophageal rupture still occurs. For a proper evaluation of potential malpractice cases we find it important for forensic pathologists to have knowledge of procedures and complications to treatment with SB tube.

Medical findings and legal outcomes in sexually abused children.

A previous study published in 2000 on a small group of children concluded that the medical examination in cases of sexual child abuse seldom provided legal proof of sexual abuse [J Forensic Sci 45(2000):115-7]. The present consecutive study included children referred to the police for a forensic medical examination. A colposcope was used to evaluate the anogenital findings which were classified as normal, nonspecific, and abnormal. Four hundred and eighty-two children were included. Abnormal anogenital findings were found in 38% of the girls and 20% of the boys, but there was no relation between abnormal anogenital findings and the two legal outcomes: "appearing in court" and "being convicted." However, the age of the child turned out to be a more important factor in relation to legal outcome than the physical findings. The results of this study suggest that the child's statement and not the physical findings were important for legal outcome.

Non-fatal injuries to the cervical spine facet joints after a fatal motor vehicle crash: a case report.

Injuries to the lower cervical spine facet joints may be identified in people killed in road traffic crashes. However, many of these injuries are not identified on diagnostic imaging procedures despite histological evidence of injury. This case report illustrates possible non-lethal pathological conditions in the facet joints following fatal road traffic trauma. The cervical spine segments C4 to C7 were removed en bloc and examined with magnetic resonance imaging, computed tomography and conventional radiology. The specimen was fixated in alcohol, embedded in methylmethacrylate, and divided into 3 mm thick parasaggital slices from where 10 microm thick sections were produced and evaluated with light microscopy. Injuries identified on microscopy included haemarthrosis, capsular avulsion, synovial fold contusions and subchondral fractures. None of the injuries were detected on diagnostic imaging or at routine autopsy. Discrete injuries to the cervical spine facet joints were identified using supplemental histological procedures in this case report. Post-mortem diagnostic imaging did not reveal these injuries and future studies should investigate the nature, prevalence and clinical relevance of such lesions.

Pathoanatomy of the lower cervical spine facet joints in motor vehicle crash fatalities.

Non-lethal injuries to the cervical spine facet joints have previously been described in decedents from motor vehicle crashes and in clinical settings these joints have been identified as potential culprits in chronic neck pain syndromes. The aim of this study was to conduct a detailed examination of the lower cervical spine facet joints in a forensic cohort of motor vehicle crash victims and controls using comparable data from medicolegal autopsy, stereomicroscopy and histological evaluations. Injuries to the cervical spine facet joints were common in the trauma cases and included facet fractures, haemarthrosis, and disruption and bleeding in the synovial folds. The injuries could not be reliably verified on stereomicroscopic evaluation, and routine autopsy procedures did not reveal any of the injuries to the facet joints. Despite the presence of these pathoanatomical lesions in road traffic crash fatalities their prevalence and potential clinical implications in survivors from motor vehicle crashes is unknown.

Imaging occult lesions in the cervical spine facet joints.

Discrete injuries in the lower cervical spine facet joints have been reported in studies of motor vehicle crash victims. We conducted a detailed investigation of these joints from 20 motor vehicle crash fatalities and 22 decedents due to nontraumatic causes, using conventional radiology, computed tomography, and magnetic resonance imaging to examine whether the diagnostic imaging procedures could identify injuries in the facet joints. The diagnostic imaging procedures identified facet joint fractures in 4 of the 19 trauma cases with computed tomography having the highest sensitivity and obtaining good correlation with findings from the microscopical evaluation. No diagnostic imaging procedure could reliably evaluate the integrity of the synovial folds or the joint spaces for bleeding despite microscopical evidence of such findings in these structures in a large proportion of the motor vehicle crash fatalities. This study emphasizes the need for scientific evidence of validity and reliability of advanced diagnostic imaging procedures in forensic settings, in particular, with regard to occult soft tissue lesions, and cautions uncritical use of negative results from these procedures until such evidence has been produced.

An unusual case of sudden unexpected death: postmortem investigation and biomechanical analysis of the cervical spine.

A naked man died under peculiar circumstances and the postmortem examination revealed unexpected lesions in the cervical spine. Investigations of the cervical spine (computed tomography, magnetic resonance imaging, and histological examination) showed that a piece of bone was torn of the anterior part of vertebra C6 and that there was fresh bleeding in the surrounding tissue. The cause of death remained unclear but was most likely cardiac arrhythmia initiated by beta-2 agonist inhalation due to an acute asthmatic attack. Data from biomechanical investigation using finite element analysis supported the conclusion that the cervical spine injury was secondary to impact during falling as a consequence of the cardiac arrhythmia.

[Forensic examination of children subjected to sexual abuse]. / Retslaegelige undersøgelser af børn udsat for seksuelt overgreb. Professortiltraedelsesforelaesning.

A forensic medical examination of a child in a case of suspected sexual abuse can have important implications for both the legal outcome and the persons involved. Therefore, it is important to know how to interpret physical findings and how to document these findings in a report. Knowledge of anogenital findings in sexually abused children has increased since the introduction of the colposcope and has revealed that physical findings are seldom found, even in legally documented cases of sexual abuse.

Rape and attempted rape in Aarhus County, Denmark Police reported and unreported cases.

The aim of this study was to compare medical and nonmedical findings in police reported and unreported cases of rape and attempted rape in the county of Aarhus, Denmark, and to explore whether legal outcomes were influenced by medico-legal findings in the cases reported to the police.Data on rapes and attempted rapes were collected from the files of the Department of Forensic Medicine, police reports, and court files. Eighty-seven victims of alleged rape and attempted rape were included in a 14-month period. Of these, 60% were categorized as date rapes, 23% as stranger rapes, and 16% as partner rapes. Sixteen percent did not report the alleged crime to the police, but still participated in a medico-legal examination. Twenty-nine percent filed police reports, but did not have a medico-legal examination undertaken.Extra-genital lesions were more common among the women who filed police reports (63 vs 43%). Women who weee subjected to date rape and partner rape and had not suffered physical injuries were more reluctant to report to the police. Twelve cases were taken to court; 11 offenders were convicted with 1 acquitted. The presence of injuries, vaginal penetration, or the findings of semen, in this study, had not in fluenced the legal outcome.

[Violence in Aarhus over two decades]. / Vold i Arhus gennem to årtier.

INTRODUCTION: Data collected from hospitals and the police have on several occasions proved to be useful in gaining knowledge about violence. The casualty departments, the Institute of Forensic Medicine, and the police in Aarhus have co-operated in three earlier studies of inter-person violence, the latest in 1993-1994. The aim of this study was to update knowledge about the incidence and character of violence in Aarhus. MATERIAL AND METHODS: A dynamic cohort study was carried out in the period 1 April 1999 to 31 March 2000. Persons who arrived at the casualty wards or Institute of Forensic Medicine after having been exposed to violence were registered and interviewed. Data from the police were also collected. All results were compared to corresponding data collected in 1981-1982, 1987-1988, and 1993-1994. RESULTS: The number of victims decreased significantly to 1496. The annual incidence rate dropped to 4.6 victims/1000. This decrease in violence was particularly seen among 15-24-year-old males. The extent of violence against women remained unchanged in the years 1999-2000. Foreigners were significantly higher represented among the victims. The character and severity of the violence were unchanged. DISCUSSION: Similar findings with an overall decrease in the incidence of violence and, at the same time, an increase in violence among foreigners have been reported in studies from Norway and Britain. Preventive action should be considered in the groups of 15-24-year-old males and foreigners.

Two decades of violence. A cohort study from the Danish municipality of Aarhus.

INTRODUCTION: Data collected from hospitals and the police has on several occasions proved to be useful in gaining knowledge about violence. The two casualty departments, Institute of Forensic Medicine and the police in Aarhus have co-operated in three earlier studies about interpersonal violence, the latest in 1993-1994. The purpose of this recent study is to reveal updated information about the incidence and character of violence in Aarhus. METHODOLOGY: Dynamic cohort study during the period the 1st of April 1999 to the 31st of March 2000. Persons who after having been exposed to violence arrived at the casualty wards and Institute of Forensic Medicine were registered and interviewed. Also data from the police was collected. All results were compared to corresponding data collected from equally conducted studies in 1981-1982, 1987-1988, and 1993-1994. RESULTS: The number of victims significantly decreased to 1496. The annual incidence rate decreased to 4.6 victims/1000. The decrease in violence was particularly among the 15-24 year old males. The extent of violence against women remained unchanged in 1999-2000. Foreigners were significantly higher represented among victims. The character and severity of violence were unchanged. CONCLUSION: Similar findings with overall decreasing incidence of violence, and on the other hand increasing violence among foreigners have been found in similar studies from Norway and England. Preventive actions should be regarded against the 15-24 year old males and foreigners.