Classification of trauma-related preventable death; protocol of a Delphi procedure.

BACKGROUND: Trauma-related (preventable) death is used to evaluate the management and quality of trauma care worldwide. Therefore, it is necessary to identify fatalities in the trauma care population and assess them on preventability. However, the definition on trauma-related preventable death lacks validity due to differences in terminology and classifications. This study aims to reach consensus on the definition of trauma-related preventable death by performing a Delphi procedure, thereby, improving the assessment of trauma-related preventable death and thereby enhancing the quality of trauma care. METHODS: Based on the results of a recently performed systematic review Hakkenbrak (2021). The definitions used to describe trauma-related preventable death could be divided into four categories: 1) Clinical definition based on panel review or expert opinion, 2) Trauma prediction algorithm, 3) Clinical definition with an additional trauma prediction algorithm and 4) Others (e.g., errors in care or detailed clinical definition). A three round, electronic Delphi study will be performed in the Netherlands to reach consensus. Experts from the department of Trauma surgery, Neurosurgery, Forensic medicine, Anaesthesiology and Emergency medicine, of the designated Level 1 trauma centres in the Netherlands, will be invited to participate. In the first round the panel will comment on the composed categories and trauma prediction algorithms. In the second and third round a feedback report will be presented and the questions with disagreement will be retested. DISCUSSION: The identification and assessment of trauma-related preventable death is necessary to evaluate and improve trauma care. Therefore, a valid, fair, and applicable definition of trauma-related preventable death is required. The Delphi technique is utilized to reach group consensus to obtain a scientifically valid definition of trauma-related preventable death.

[What to do when elder abuse is suspected?] / Wat te doen als je ouderenmishandeling vermoedt?

Elder abuse is a worldwide problem with serious consequences for individuals and society. The recognition of elder abuse is complex due to a lack of awareness and knowledge. We present a case of a patient with signs of elder abuse. This case concerns a patient who showed signs of neglect and physical abuse as a result of possible derailed informal care provision. The mandatory reporting code on domestic violence of The Royal Dutch Medical Association was followed and measures were taken by the general practitioner. In the discussion, information on signs and types of elder abuse were provided, together with the description of risk factors.

Internet-Purchased Sodium Azide Used in a Fatal Suicide Attempt: A Case Report and Review of the Literature.

There has been a significant increase in sodium azide intoxications since the 1980s. Intoxications caused by sodium azide are becoming increasingly prevalent in the Netherlands as a result of its promotion for the purpose of self-euthanasia. The mechanism of toxicity is not completely understood but is dose-dependent. The presented case describes a suicide by sodium azide of a young woman (26 years old) with a history of depression and suicide attempts. The decedent was found in the presence of prescription medicine, including temazepam, domperidone in combination with omeprazole, and the chemical preservative sodium azide. Quantitative toxicology screening of whole blood revealed the presence of 70 µg/L temazepam (toxic range > 1000 µg/L) and 28 mg/L sodium azide (fatal range: 2.6-262 mg/L). Whole blood qualitative analysis revealed the presence of temazepam, temazepam-glucuronide, olanzapine, n-desmethylolanzapine, and acetaminophen. In circles promoting sodium azide, it is recommended to use sodium azide in combination with medications targeting sodium azide's negative effects, such as analgesics, antiemetics, and anti-anxiety drugs. The medicines recovered at the body's location, as well as the results of the toxicology screens, were consistent with the recommendations of self-euthanasia using sodium azide.

Types, characteristics and anatomic location of physical signs in elder abuse: a systematic review : Awareness and recognition of injury patterns.

PURPOSE: Elder abuse is a worldwide problem with serious consequences for individuals and society. The recognition of elder abuse is complex due to a lack of awareness and knowledge. In this systematic review, types, characteristics and anatomic location of physical signs in elder abuse were identified. METHODS: Databases of MEDLINE, COCHRANE, EMBASE and CINAHL were searched. The publication dates ranged from March 2005 to July 2020. In addition to the electronic searches, the reference lists and citing of included articles were hand-searched to identify additional relevant studies. The quality of descriptive and mixed-methods studies was assessed. RESULTS: The most commonly described physical signs in elder abuse were bruises. The characteristics of physical signs can be categorized into size, shape and distribution. Physical signs were anatomically predominantly located on the head, face/maxillofacial area (including eyes, ears and dental area), neck, upper extremities and torso (especially posterior). Physical signs related to sexual elder abuse were mostly located in the genital and perianal area and often accompanied by a significant amount of injury to non-genital parts of the body, especially the area of the head, arms and medial aspect of the thigh. CONCLUSIONS: Most common types, characteristics and anatomic location of physical signs in elder abuse were identified. To enhance (early) detection of physical signs in elder abuse, it is necessary to invest in (more) in-depth education and to include expertise from a forensic physician or forensic nurse in multidisciplinary team consultations.

High prevalence of non-accidental trauma among deceased children presenting at Level I trauma centers in the Netherlands.

PURPOSE: Between 0.1-3% of injured children who present at a hospital emergency department ultimately die as a result of their injuries. These events are typically reported as unnatural causes of death and may result from either accidental or non-accidental trauma (NAT). Examples of the latter include trauma that is inflicted directly or resulting from neglect. Although consultation with a forensic physician is mandatory for all deceased children, the prevalence of fatal inflicted trauma or neglect among children is currently unclear. METHODS: This is a retrospective study that included children (0-18 years) who presented and died at one of the 11 Level I trauma centers in the Netherlands between January 1, 2014, and January 1, 2019. Outcomes were classified based on the conclusions of the Child Abuse and Neglect team or those of forensic pathologists and/or the court in cases referred for legally mandated autopsies. Cases in which conclusions were unavailable and there was no clear accidental cause of death were reviewed by an expert panel. RESULTS: The study included 175 cases of childhood death. Seventeen (9.7%) of these children died due to inflicted trauma (9.7%), 18 (10.3%) due to neglect, and 140 (80%) due to accidents. Preschool children (< 5 years old) were significantly more likely to present with injuries due to inflicted trauma and neglect compared to older children (44% versus 6%, p < 0.001, odds ratio [OR] 5.80, 95% confidence interval [CI] 2.66-12.65). Drowning accounted for 14 of the 18 (78%) pediatric deaths due to neglect, representing 8% of the total cases. Postmortem radiological studies and autopsies were performed on 37 (21%) of all cases of childhood death. CONCLUSION: One of every five pediatric deaths in our nationwide Level I trauma center study was attributed to NAT; 44% of these deaths were the result of trauma experienced by preschool-aged children. A remarkable number of fatal drownings were due to neglect. Postmortem radiological studies and autopsies were performed in only one-fifth of all deceased children. The limited use of postmortem investigations may have resulted in missed cases of NAT, which will result in an overall underestimation of fatal NAT experienced by children.

Suicide by helium inhalation in the Netherlands between 2012 and 2019.

INTRODUCTION: In 2012 and 2013 a movie and a book about a 'dignified end of life' were published in the Netherlands. These items described suicide using an 'exit bag' to establish asphyxiation using helium (the helium method). 'Right-to-die-organisations' inform the elderly about this method. The purpose of this study is to investigate whether the use of suicidal asphyxiation by means of the helium method substituted other, related, methods following its publication in the Netherlands. MATERIAL AND METHODS: We analysed suicides in the Netherlands over the period from 1 July 2012 to 30 June 2019. We compared the number of deaths caused by the helium method with other, related, cases. Secondly, we related these deaths to the total number of inhabitants and suicides recorded by Statistics Netherlands. RESULTS: The study showed a stable trend in the use of the helium method in the period 2012-2019 and this was the same for the other, related methods. Individuals using the helium method were significantly younger than those using other, related, methods. At the scene of death, information about suicide and suicide notes were found more often at 'helium method' cases than with the 'other, related, methods' cases. Family was significantly more often present during a helium method suicide than during suicide by other, related, methods. DISCUSSION: The number of suicides by the helium method and other, related, cases is stable in the Netherlands over the past years. Therefore, we conclude that there is no substitution effect within this category of suicides. Whilst 'right-to-die-organisations' strive to inform the old and sick of the helium method, it is noteworthy that the individuals using the helium method are significantly younger than the individuals who choose other, related, methods.

[Deaths that seem natural]. / Sterfgevallen die natuurlijk lijken.

Every dead body is examined by a doctor to establish the manner of death. In the Netherlands, however, both the quality of post-mortem examinations and the number of autopsies carried out in a clinical or forensic setting are low. Not all causes of death can be determined by post mortem examination alone; the law should, therefore, be changed to allow a forensic physician to legally request additional investigations, such as a toxicological or radiological report, to ensure the detection of crimes such as murder. Additional investigation could increase the quality of post-mortem examinations, and might bridge the quality gap between full autopsy and a simple post mortem. The information obtained could, for instance, be informative for relatives in the context of hereditary research. Finally, to improve the quality of post-mortem examination and identify all cases of murder, it is of the utmost importance that there is sufficient focus on post mortem examination of the cadaver during medical specialist training.

[Increase in reporting of child deaths; analysis of recent forensic services data]. / Dood minderjarige steeds vaker gemeld.

OBJECTIVE: We investigated the degree of reporting of child deaths in 2017 and compared this with data from 2012. Furthermore, we assessed the characteristics of these deaths and in how many cases the forensic doctor performed a post-mortem examination. DESIGN: Observational research. METHOD: We requested data from 25 public health services (GGDs in Dutch) and the private organization Forensisch Artsen Rotterdam-Rijnmond (FARR) concerning child deaths that occurred in 2017. We distinguished between stillbirths, live births with death occurring ≤28 days post-partum and live births with death occurring > 28 days post-partum. Using mortality figures for 2017 obtained from Statistics Netherlands (CBS), the percentage of child death cases where discussions took place between the treating physician and a forensic doctor was determined both at regional and national level. RESULTS: In 2017, a total of 928 out of 1303 child death cases known to CBS was reported to the regional forensic doctor; this means a reporting rate of over 70%. For stillbirths the national reporting rate was 46.0% (200/435), for live births who died ≤ 28 days post-partum 84.0% (300/357) and for live births where death occurred > 28 days post-partum 83.8% (428/511). The reporting rate differed per province, Zuid-Holland having the highest reporting rate (93.1%) and Gelderland the lowest (74.1%). The reporting rate increased compared to 2012 in relation to stillbirths as well as live births. The forensic doctor was most likely to perform a post-mortem examination in cases where the death occurred outside the hospital and where it involved the death of minors older than 28 days. CONCLUSION: Treating physicians are increasingly fulfilling their legal obligation to report deceased minors to a forensic doctor, but the reporting rate is still not 100%. We therefore advise continued investment in order to improve the reporting rate, especially in regions where figures lag behind the national average.

Characteristics and Post-Decision Attitudes of Non-Reporting Sexual Violence Victims.

Although the physical and psychological consequences of sexual violence can be severe, many victims do not report the violence to the police force. The current study examined the characteristics and the post-decisional attitude of the non-reporting sexual violence victims. In total, 287 victims of sexual violence completed an anonymous online questionnaire that assessed characteristics of the violence, whether or not the crime was reported, reasons for not reporting, and aspects that would have convinced non-reporters to report in retrospect. Eighty percent of the victims did not report the most recent sexual violence incident to the police ( n = 229). Nevertheless, 65% of the non-reporting victims ( n = 148) in retrospect would have reported to the police ("potential reporters"). Specific reasons for non-reporting and incident characteristics appear to relate to the post-decision attitude of non-reporting victims of sexual violence. "Lack of evidence" and "feelings of shame, guilt, and other emotions" appear to be more frequently mentioned by potential reporters as reasons for their decision to not report as compared with the definitive non-reporters. Likewise, being raped or sexually assaulted is predictive of potential reporting. Our findings are useful for policy makers to develop strategies to increase reporting rates of sexual violence victims.

The correlation between the Aquatic Decomposition Score (ADS) and the post-mortem submersion interval measured in Accumulated Degree Days (ADD) in bodies recovered from fresh water.

The Aquatic Decomposition Score (ADS) made by van Daalen et al., was developed to approximate the Post-Mortem Submersion Interval (PMSI) in bodies recovered in salt water. Since the decomposition process in salt water differs from the process in fresh water due to salinity, the temperature, and the depth of the water, we wanted to investigate whether there is a correlation between the ADS and the PMSI and if the ADS can be used to make an estimation of the PMSI in bodies recovered from fresh water. For the latter, the PMSI was measured using Accumulated Degree Days (ADD). In our study we included seventy-six human remains found outdoors in fresh water. Their decomposition was measured using the ADS. A strong correlation was found between the ADS and the PMSI. Also, it was found that the ADS can significantly estimate the ADD. Despite the more varied circumstances under which bodies in fresh water are found when compared to those found in salt water, the ADS can be used to measure the decomposition and accurately estimate the ADD, and thus the PMSI. More research is needed to validate our method and make a prediction model with smaller confidence intervals.

A record linkage study on former police detainees who died in Amsterdam between 2013 and 2015.

BACKGROUND: Police detainees are known to have inferior health. This study identifies the number of former police detainees who received medical care among deaths examined by forensic physicians and presents their death characteristics. METHODS: We included all deaths that were examined by forensic physicians of the Public Health Service Amsterdam from 2013 to 2015. Patient files of subjects were scanned for the presence of a prior medical consultation in the police cell and death characteristics were collected from post-mortem examination reports. We performed statistical analyses to discover what characteristics at post-mortem examination were associated with a prior consultation in the police cell. RESULTS: We identified n = 2618 subjects that met the inclusion criteria. Eight percent of subjects had one or more medical consultation(s) in the police cell in a mean follow up time of 4.8 (±3.0) years. No difference was found in the share of unnatural deaths between subjects with and without a prior consultation (68%), but distribution of death causes differed significantly. Male gender OR 2.3 (p < 0.001), age OR 0.98 (p < 0.001), unspecified unnatural dead OR 1.8 (p = 0.002), crime related dead OR 2.2 (p = 0.012) and accidental drowning and submerging death OR 4.6 (p < 0.001) were independently associated with the presence of an earlier consultation in the police cell. CONCLUSION: Our data suggest that a small percentage of police detainees seen by forensic physicians for provision of medical care are also examined after death by these physicians, typically young males who seem to display risk-taking and criminal behavior resulting in unnatural dead.

Post-mortem findings in 22 fatal Taxus baccata intoxications and a possible solution to its detection.

BACKGROUND: The yew (Taxus baccata) is a common evergreen tree containing the toxin taxine B. Between 42 and 91 g of yew leaf is lethal to a 70-kg adult. The objective of this article is to present an overview of findings in fatal yew intoxications. METHODS: A search using MeSH terms was performed in PubMed for yew intoxications in the period between January 1960 and August of 2016. RESULTS: We describe a total of 22 cases. Fatal intoxications can be divided into intoxications by leaves, by pulp, by bark and by yew tea. Recognizing yew tea intoxication is difficult since tea no longer contains any botanically recognisable parts. In autopsy and external examination no characteristic findings are reported, regarding the presence of parts of plants. CONCLUSIONS: Indications for yew tree intoxications at a post-mortem examination and autopsy are limited to finding parts of yew tree. The absence of recognisable parts can result in yew intoxications being overlooked. Therefore toxicological screening is recommended in unexplained deaths.

Suicide by asphyxiation with or without helium inhalation in the region of Amsterdam (2005-2014).

INTRODUCTION: Annually about 28% of the 5800 death of unnatural cause in the Netherlands are a result of suicide. In 2012 and 2013 a movie and a book were published about a "dignified end of life" which also described the suicide using the exit bag to establish asphyxia using helium. The purpose of this study is to investigate if the suicide methods changed since the publicity in 2013 about suicidal asphyxiation by using helium gas. This study especially focuses on suicide using the 'exit bag' with or without helium gas. MATERIAL AND METHODS: In the period 2005 to 2014 all suicides in the region of Amsterdam-Amstelland and Zaanstreek-Waterland were analyzed and from these suicides cases using the exit bag were selected. RESULTS: The study shows a rising trend with the use of the helium (P > 0.01) and a decreasing trend for suicide by asphyxia using an exit bag (P < 0.05). The data does not show a sudden difference, but there seems to be a gradually change. DISCUSSION: The number of suicides using the helium method is rising in Amsterdam-Amstelland and Zaanstreek-Waterland, while suicides by asphyxiation without helium are decreasing. The specific publicity of books about suicides using helium may have influenced this transition.

Assessment of Musculoskeletal Injuries from Domestic Violence in the Emergency Department.

Domestic violence is one of the most common causes of nonfatal injury in women, with musculoskeletal injuries representing the second most prevalent manifestation of this form of violence. It is therefore of great importance that healthcare providers such as emergency department (ED) physicians and surgeons are able to recognize and assess these kinds of injuries. In this case report, a woman is described visiting an ED with injuries caused by a fall. Thanks to the knowledge and attention of the ED physician, the real cause of the injury was discovered. What appeared to be an unsuspicious accident was actually the result of intimate partner violence.

Analysis of inflammatory cells and mediators in skin wound biopsies to determine wound age in living subjects in forensic medicine.

OBJECTIVE: In forensic medicine it is important to determine the age of skin wounds in living subjects. The aim of this study was to assess whether analysis of inflammatory cells and inflammatory mediators in skin biopsies of wounds from living subjects could improve wound age determination. METHODS: Biopsies (n=101), representing the superficial border area of a skin wound, were taken from skin injuries of known wound age (range: 4.5 hours to 25 days) of living subjects. All biopsies were analyzed for 3 inflammatory cell markers (MPO, CD45 and CD68) and 4 inflammatory mediators (MIP-1, IL-8, CML and vitronectin). For quantification, biopsies were subdivided in 4 different timeframes: 0.2-2 days, 2-4 days, 4-10 days and 10-25 days old wounds. Subsequently, a probability scoring system was developed. RESULTS: MPO, CD45, MIP-1, IL-8 (inflammatory cell markers) and N(epsilon)-(carboxymethyl)lysine (CML) positivity were maximal in wounds of 0.2-2 days old and then decreased in time. Remarkably, CD45, CD68 and CML showed a minor but non-significant increase again in 10-25 days old wounds. MPO and CD68 positivity was significantly lower in 4-25 days old wounds compared to 0.2-4 days old wounds. MPO positivity was also significantly lower in 10-25 days old wounds compared to 0.2-10 days old wounds. For CD45, MIP-1, IL-8 and CML no significant differences between the age groups were found. In case of vitronectin positivity in the extravasate or when the number of MIP-1 or IL-8-positive cells was more than 10 cells/mm(2) the probability that a wound was more than 10 days old was 0%. A probability scoring system of all analyzed markers can be used to calculate individual wound age probabilities in biopsies of skin wounds of living subjects. CONCLUSIONS: We have developed a probability scoring system of inflammatory cells and mediators that can be used to determine wound age in skin biopsies of living subjects.

Analysis of morphological characteristics and expression levels of extracellular matrix proteins in skin wounds to determine wound age in living subjects in forensic medicine.

OBJECTIVE: Wound age determination in living subjects is important in routine diagnostics in forensic medicine. Macroscopical description of a wound to determine wound age however is inadequate. The aim of this study was to assess whether it would be feasible to determine wound age via analysis of morphological characteristics and extracellular matrix proteins in skin biopsies of living subjects referred to a forensic outpatient clinic. METHODS: Skin biopsies (n=101), representing the border area of the wound, were taken from skin injuries of known wound age (range: 4.5h-25 days) in living subjects. All biopsies were analyzed for 3 morphological features (ulceration, parakeratosis and hemorrhage) and 3 extracellular matrix markers (collagen III, collagen IV and α-SMA). For quantification, biopsies were subdivided in 4 different timeframes: 0.2-2 days, 2-4 days, 4-10 days and 10-25 days old wounds. Subsequently, a probability scoring system was developed. RESULTS: For hemorrhage, collagen III, collagen IV and α-SMA expression no relation with wound age was found. Ulceration was only found in wounds of 0.2-2, 2-4 and 4-10 days old, implying that the probability that a wound was more than 10 days old in case of ulceration is equal to 0%. Also parakeratosis was almost exclusively found in wounds of 0.2-2, 2-4 and 4-10 days old, except for one case with a wound age of 15 days old. The probability scoring system of all analyzed markers, as depicted above, however can be used to calculate individual wound age probabilities in biopsies of skin wounds of living subjects. CONCLUSIONS: We have developed a probability scoring system, analysing morphological characteristics and extracellular matrix proteins in superficial skin biopsies of wounds in living subjects that can be applied in forensic medicine for wound age determination.

Enhancing the visibility of injuries with narrow-banded beams of light within the visible light spectrum.

The use of narrow-banded visible light sources in improving the visibility of injuries has been hardly investigated, and studies examining the extent of this improvement are lacking. In this study, narrow-banded beams of light within the visible light spectrum were used to explore their ability in improving the visibility of external injuries. The beams of light were induced by four crime-lites(®) providing narrow-banded beams of light between 400 and 550 nm. The visibility of the injuries was assessed through specific long-pass filters supplied with the set of crime-lites(®) . Forty-three percent of the examined injuries improved in visibility by using the narrow-banded visible light. In addition, injuries were visualized that were not visible or just barely visible to the naked eye. The improvements in visibility were particularly marked with the use of crime-lites(®) "violet" and "blue" covering the spectrum between 400-430 and 430-470 nm. The simple noninvasive method showed a great potential contribution in injury examination.

Assessment of abuse-related injuries: a comparative study of forensic physicians, emergency room physicians, emergency room nurses and medical students.

A comparative study was made investigating whether emergency room physicians, emergency room nurses, forensic physicians, and interns are competent in describing, recognising and determining the possible cause of injuries. The injury assessment scores varied from good--adequate--fail and remained blank in various participant groups. Forensic physicians scored significantly better than emergency room staff and interns in the assessment of abuse-related injuries. There were almost no differences noted between emergency room physicians and emergency room nurses. For the functional group with more or less than 4 to 6 years of experience, no significant differences were noted for scoring good in all 5 cases. The fact that forensic physicians scored better than the emergency room staff is probably explained by the fact that almost all practicing forensic physicians have been officially qualified. Training in this field for all professionals involved in such assessment should be mandatory.

Diagnosis and interpretation of injuries: a study of Dutch general practitioners.

This study explores the ability of Dutch general practitioners (GPs) in recognising types of injury. In the three sample cases, 48-91% classified the injury correctly. Only 9% of GPs recognised self-harm injury and in the 3rd case (child abuse) only 15% referred to the improbability of the account given. Only 13% appeared able to assess two or three cases (almost) correctly. Recognition and description by Dutch GPs of these injuries is inadequate. This may have far-reaching consequences for the victims. The increasing incidence of cases of violence demands that more attention should be paid to the issue during both basic and specialist medical training.