Re-examining so-called 'secondary identifiers' in Disaster Victim Identification (DVI): Why and how are they used?

Disaster victim identification (DVI) refers to the identification of multiple deceased persons following an event that has a catastrophic effect on human lives and living conditions. Identification methods in DVI are typically described as either being primary, which include nuclear genetic markers (DNA), dental radiograph comparisons, and fingerprint comparisons, or secondary, which are all other identifiers and are ordinarily considered insufficient as a sole means of identification. The aim of this paper is to review the concept and definition of so-called 'secondary identifiers" and draw on personal experiences to provide practical recommendations for improved consideration and use. Initially, the concept of secondary identifiers is defined and examples of publications where such identifiers have been used in human rights violation cases and humanitarian emergencies are reviewed. While typically not investigated under a strict DVI framework, the review highlights the idea that non-primary identifiers have proven useful on their own for identifying individuals killed as a result of political, religious, and/or ethnic violence. The use of non-primary identifiers in DVI operations in the published literature is then reviewed. Because there is a plethora of different ways in which secondary identifiers are referenced it was not possible to identify useful search terms. Consequently, a broad literature search (rather than a systematic review) was undertaken. The reviews highlight the potential value of so-called secondary identifiers but more importantly show the need to scrutinise the implied inferior value of non-primary methods which is suggested by the terms "primary" and "secondary". The investigative and evaluative phases of the identification process are examined, and the concept of "uniqueness" is critiqued. The authors suggest that non-primary identifiers may play an important role in providing leads to formulating an identification hypothesis and, using the Bayesian approach of evidence interpretation, may assist in establishing the value of the evidence in guiding the identification effort. A summary of contributions non-primary identifiers may make to DVI efforts is provided. In conclusion, the authors argue that all lines of evidence should be considered because the value of an identifier will depend on the context and the victim population. A series of recommendations are provided for consideration for the use of non-primary identifiers in DVI scenarios.

An Investigation of Micro-CT Analysis of Bone as a New Diagnostic Method for Paleopathological Cases of Osteomalacia.

OBJECTIVE: This paper looks to broaden the methodological possibilities for diagnosing osteomalacia in archaeological bone using micro-CT analysis. Increasing the identification of osteomalacia in paleopathology will provide support for important interpretive frameworks. MATERIALS: Nine embedded and two unembedded rib fragments were sourced from St. Martin's Birmingham and Ancaster, UK, and Lisieux Michelet, France. Of the 11 samples, nine were previously confirmed as osteomalacic, and presented with varying levels of diagenesis and two were non-osteomalacic controls, one of which exhibits diagenetic change. METHODS: Micro-CT, backscattered scanning electron microscopy, and light microscopy were employed. Micro-CT images were evaluated for osteomalacic features using corresponding microscopic images. RESULTS: Micro-CT images from osteomalacic samples demonstrated the presence of defective mineralization adjacent to cement lines, areas of incomplete mineralization, and resorptive bays/borders, three key diagnostic features of osteomalacia. Diagenetic change was also detectable in micro-CT images, but did not prevent the diagnosis of osteomalacia. CONCLUSIONS: Micro-CT analysis is a non-destructive method capable of providing microstructural images of osteomalacic features in embedded and unembedded samples. When enough of these features are present, micro-CT images are capable of confirming a diagnosis of osteomalacia. SIGNIFICANCE: Vitamin D deficiency has important health consequences which operate throughout the life course. Increasing the ability to detect cases of vitamin D deficiency provides researchers with a greater understanding of health and disease in past communities. LIMITATIONS: Only adult rib samples were used. SUGGESTIONS FOR FURTHER RESEARCH: Paleopathologists should look to test the utility of micro-CT analysis in diagnosing active rickets in subadult individuals.

Outcome of a rabbit model for late irradiation effects in mandibular oral mucosa and bone: A pilot study.

BACKGROUND/AIM/OBJECTIVE: Late side effects of radiotherapy (RT) in the treatment for head and neck (HN) malignancies involve an inadequate healing response of the distressed tissue due to RT-induced hypovascularity. The aim of this study was to develop a pilot model in which vascular alterations associated with the onset of late irradiation (IR) injury could be measured in rabbit oral mucosa and mandibular bone. MATERIALS AND METHODS: Eight male New Zealand white rabbits were divided over four treatment groups. Group I-III received four fractions of RT (5.6 Gy, 6.5 Gy, and 8 Gy, respectively) and Group IV received 1 fraction of 30 Gy. Oral microcirculatory measurements were performed at baseline (before RT) and once a week during 11 consecutive weeks after RT assessing perfusion parameters, that is, total vessel density (TVD), perfused vessel density (PVD), proportion of perfused vessels (PPV), and microvascular flow index (MFI). Post-mortem histopathology specimens were analyzed. RESULTS: Five weeks after RT, TVD, and PVD in all groups showed a decrease of >10% compared to baseline, a significant difference was observed for Groups I, II, and IV (P<0.05). At T11, no lasting effect of decreased vessel density was observed. PPV and MFI remained unaltered at all-time points. Group IV showed a marked difference in scattered telangiectasia such as microangiopathies, histological necrosis, and loss of vasculature. CONCLUSION: No significant lasting effect in mucosal microcirculation density due to IR damage was detected. Observed changes in microcirculation vasculature and histology may align preliminary tissue transition towards clinical pathology in a very early state associated with late IR injury in the oral compartment. RELEVANCE FOR PATIENTS: Enhancing knowledge on the onset of late vascular IR injury in the HN region could help the development, monitoring, and timing of therapies that act on prevention, discontinuation, or repair of radiation pathology.

Dry bone histology of bone tumours.

This article focuses on the application of dry bone histology in the diagnosis of a series of different bone tumours. It provides a short introduction on bone tumour classification and how tumours may affect the skeleton. To illustrate the value of dry bone histology in the diagnostic process we studied the 'fresh' and 'dry' bone histology of a series of well-documented, recent clinical cases of various benign and malignant bone tumours. We show that histology is a valuable instrument to assess bone tissue architecture, which provides information on the biological behaviour of a tumour. Though histology may reveal the specific 'tumorous' bone deposition of high-grade conventional osteosarcomas, all other bone tumours display common, unspecific features. This holds for the following tumours: osteochondroma, hyperostotic meningioma, high-grade angiosarcoma, grade 2 chondrosarcoma, myoepithelial carcinoma, high-grade osteosarcoma and four carcinoma metastases. We conclude that histology is useful in cases where the biological behaviour of a tumour is to be defined, and is particularly an aide in the diagnosis of high-grade conventional osteosarcomas. Nevertheless, the differential diagnosis on the bone tumours in our series should primarily be based on a combination of physical anthropological patient data (age, sex), gross anatomy (e.g. tumour morphology and location), and radiography.

Four possible cases of osteomalacia: The value of a multidisciplinary diagnostic approach.

Rickets and residual rickets are often encountered in Dutch archeological skeletal samples. However, no archeological Dutch paleopathological case of adult osteomalacia has been described in literature to date. This paper describes the first four archeological Dutch paleopathological cases of osteomalacia and assesses the value of the various modalities (macroscopic assessment, radiology and histology) that may be used for diagnosis. The skeletal remains investigated originate from the Meerenberg psychiatric hospital cemetery in Bloemendaal, the Netherlands, and date from 1891 - 1936. The remains of 69 adult individuals were inspected for macroscopic lesions which may be associated with osteomalacia. In cases suspect for osteomalacia, complimentary radiological and histological investigations (BSE-SEM and light microscopy) were performed. Macroscopically, four individuals presented with lesions (highly) suggestive of osteomalacia. Histological examination (both BSE-SEM and light microscopy) provided valuable information to come to an eventual diagnosis of osteomalacia in all four cases. Light microscopy proved to be an feasible alternative for BSE-SEM. The added value of radiological analyses was limited. The individuals identified were most likely patients in the psychiatric hospital, and the reason for their institutionalization and/or the regime in the institution may have played a role in the development of the osteomalacia observed.

Dutch population specific sex estimation formulae using the proximal femur.

Sex estimation techniques are frequently applied in forensic anthropological analyses of unidentified human skeletal remains. While morphological sex estimation methods are able to endure population differences, the classification accuracy of metric sex estimation methods are population-specific. No metric sex estimation method currently exists for the Dutch population. The purpose of this study is to create Dutch population specific sex estimation formulae by means of osteometric analyses of the proximal femur. Since the Netherlands lacks a representative contemporary skeletal reference population, 2D plane reconstructions, derived from clinical computed tomography (CT) data, were used as an alternative source for a representative reference sample. The first part of this study assesses the intra- and inter-observer error, or reliability, of twelve measurements of the proximal femur. The technical error of measurement (TEM) and relative TEM (%TEM) were calculated using 26 dry adult femora. In addition, the agreement, or accuracy, between the dry bone and CT-based measurements was determined by percent agreement. Only reliable and accurate measurements were retained for the logistic regression sex estimation formulae; a training set (n=86) was used to create the models while an independent testing set (n=28) was used to validate the models. Due to high levels of multicollinearity, only single variable models were created. Cross-validated classification accuracies ranged from 86% to 92%. The high cross-validated classification accuracies indicate that the developed formulae can contribute to the biological profile and specifically in sex estimation of unidentified human skeletal remains in the Netherlands. Furthermore, the results indicate that clinical CT data can be a valuable alternative source of data when representative skeletal collections are unavailable.

Diagnostic dry bone histology in human paleopathology.

Paleopathology is the study of trauma and disease as may be observed in ancient (human) remains. In contrast to its central role in current medical practice, microscopy plays a rather modest role in paleopathology. This is at least partially due to the differences between fresh and decomposed (i.e., skeletonized or "dry bone") tissue samples. This review discusses these differences and describes how they affect the histological analysis of paleopathological specimens. First, we provide a summary of some general challenges related to the histological analysis of palaeopathological specimens. Second, the reader is introduced in bone tissue histology and bone tissue dynamics. The remainder of the paper is dedicated to the diagnostic value of dry bone histology. Its value and limitations are illustrated by comparing several well-studied paleopathological cases with similar contemporary, clinical cases. This review illustrates that due to post-mortem loss of soft tissue, a limited number of disorders display pathognomonic features during histological analysis of skeletonized human remains. In the remainder of cases, histology may help to narrow down the differential diagnosis or is diagnostically unspecific. A comprehensive, multidisciplinary diagnostic approach therefore remains essential. Clin. Anat. 29:831-843, 2016. © 2016 Wiley Periodicals, Inc.

A lethal case of the dapsone hypersensitivity syndrome involving the myocardium.

In the Netherlands dapsone is used for the treatment of dermatitis herpetiformis, leprosy and Pneumocystis jiroveci pneumonia and prophylaxis in case of cotrimoxazole allergy. An idiosyncratic drug reaction, known as the dapsone hypersensitivity syndrome (DHS), appears in about 0.5-3.6% of persons treated with dapsone. DHS can be associated with fever, rash and systemic involvement. We present a 35-year-old woman who developed severe DHS seven weeks after starting dapsone. Six weeks after being discharged in a good clinical condition she died from fulminant myocarditis, 11 weeks after the first DHS symptoms and the discontinuation of dapsone.

Human cranial vault thickness in a contemporary sample of 1097 autopsy cases: relation to body weight, stature, age, sex and ancestry.

The relation between human cranial vault thickness (CVT) and various elements of the physical anthropological biological profile is subject of ongoing discussion. Some results seem to indicate no correlation between CVT and the biological profile of the individual, whereas other results suggest that CVT measurements might be useful for identification purposes. This study assesses the correlation between CVT and body weight, stature, age, sex, and ancestry by reviewing data of 1097 forensic autopsies performed at the Netherlands Forensic Institute (NFI). In subadults (younger than 19 years of age at the time of death), all frontal, temporal, and occipital CVT measurements correlated moderately to strongly with indicators of growth (body weight, stature, and age). Neither sex nor ancestry correlated significantly with cranial thickness. In adults, body weight correlated with all CVT measurements. No meaningful correlation was found between CVT and stature or age. Females showed to have thicker frontal bones, and the occipital region was thicker in the Negroid subsample. All correlation in the adult group was weak, with the distribution of cranial thickness overlapping for a great deal between the groups. Based on these results, it was concluded that CVT generally cannot be used as an indicator for any part of the biological profile.

An accessory skull suture mimicking a skull fracture.

This paper describes an investigation of the sudden and unexpected death of a five-and-a-half-month-old boy. As in every Dutch case of sudden unexpected death in infancy (SUDI), a multidisciplinary diagnostic approach was used. This included post-mortem radiography, showing a linear discontinuity of the parietal bone. Originally this was interpreted as a skull fracture, but autopsy indicated no signs of mechanical trauma. Instead the defect was defined as a unilateral accessory suture of the parietal bone. The initial erroneous diagnosis had severe adverse consequences and thus every health care professional or forensic specialist dealing with paediatric mechanical traumas should be cautious of this rare anomaly.

Cranial trauma and the assessment of posttraumatic survival time.

Assessment of trauma on skeletal remains can be very difficult, especially when it comes to the estimation of posttraumatic survival time in partially healed lesions. The ability to reliably estimate the time an individual has survived after sustaining an injury is especially important in cases of child abuse and torture, but can also aid in determining the association between an injury and eventual death. Here a case from South Africa is reported, where the skeletal remains of an unknown individual were found with cranial and scapular fractures. These fractures all presented with macroscopic features indicative of healing. Using recently published data on the timing of fractures by De Boer et al., the two sets of cranial trauma and the scapular fracture were assessed by means of radiology, histology and microCT scanning. This was primarily done in order to obtain more information on the events surrounding the death of this individual, but also to assess the usability of the published methods on cranial fractures. It was found that the initial trauma was most likely sustained at least two weeks before death, whilst a neurosurgical procedure was performed at least one week before death. It seems that cranial fractures, especially if stable, may show some different healing features than postcranial fractures. The individual has since been identified, but unfortunately as is often the case in South Africa, limited information is available and the medical records could not be found.

The diagnostic value of microscopy in dry bone palaeopathology: A review.

Over recent decades histology has increasingly been used as a diagnostic tool in human dry bone palaeopathology. Still, the use of histology in human dry bone is associated with various problems, including a lack of pathognomonic histomorphology and a need for more experimental data. Consequently, the value of histology as diagnostic tool in human dry bone remains a subject for debate. Here we review all published palaeohistopathological research in human dry bone. A systematic search identified 3363 articles, with the 64 most relevant citations studied in depth. We specifically focused on the interpretation of histomorphological parameters and the use of comparative fresh bone tissue and/or experimental data. Our literature review shows that only a few disorders demonstrate a 'specific' histomorphology: Paget's disease, osteoporosis, hyperparathyroidism and possibly osteomalacia. In all other cases, histology may aid during the differential diagnostic process, but it is unable to confirm a definitive diagnosis. The histological diagnostic process and consequential recommendations for the use of histology are discussed per following disease categories: metabolic disease, neoplasm, infectious disease and trauma.

Survival analysis of human meniscal transplantations.

We describe a prospective survival analysis of 63 consecutive meniscal allografts transplanted into 57 patients. The lateral meniscus was transplanted in 34, the medial meniscus in 17, and both menisci (combined) in the same knee in six. For survival analysis we used persistent pain or mechanical damage as clinical criteria of failure. A total of 13 allografts failed (5 lateral, 7 medial, 1 medial and lateral). A significant negative correlation (p = 0.003) was found between rupture of the anterior cruciate ligament (ACL) and successful meniscal transplantation. A significant difference (p = 0.004) in the clinical results was found between lateral and medial meniscal transplants. The cumulative survival rate of the lateral, medial and combined allografts in the same knee, based on the life-table method and the Kaplan-Meier calculation, was 76%, 50% and 67%, respectively. The survival of medial meniscal allografts may improve when reconstruction of the ACL is carried out at the same time as meniscal transplantation in an ACL-deficient knee.

Meniscal allografts: evaluation with magnetic resonance imaging and correlation with arthroscopy.

PURPOSE: To correlate clinical results to magnetic resonance imaging (MRI) and arthroscopy after cryopreserved nontissue-antigen-matched meniscal transplantations. TYPE OF STUDY: Blinded; the observers were blinded for each others' assessment. MATERIALS AND METHODS: Sixteen consecutive patients were included in the protocol. First, clinical evaluation and MRI were performed. Second, within 24 hours, arthroscopy was performed. RESULTS: The clinical results showed better correlation between clinical results and arthroscopy than between clinical results and MRI. In the present study, MRI was not beneficial in evaluating meniscal transplants. CONCLUSIONS: Using more sophisticated MRI techniques, the correlation between clinical results, arthroscopy, and MRI could probably be improved.

Human leukocyte antigen sensitization after cryopreserved human meniscal transplantations.

The presence of antibodies against human leukocyte antigens (HLA) in recipients of cryopreserved, non-tissue-antigen-matched human meniscal allografts was evaluated. Serological HLA typing was performed for both class I and class II antigens. The results showed that 11 of 18 recipients became sensitized.

Human meniscal transplantation. Preliminary results at 2 to 5-year follow-up.

In a prospective study, we evaluated the clinical results of 23 patients with a cryopreserved non-tissue-antigen-matched meniscal transplant at a follow-up of from two to five years. These early results were satisfactory in 20 patients. Three transplantations failed and the allografts were removed after 12, 20 and 24 months. Post-transplantation arthroscopy showed that most meniscal transplants had healed to the knee capsule. Histological examination showed revascularisation of the transplant and evidence of viable meniscal chondrocytes. The failures were probably caused by malalignment, resulting in impaired revascularisation of the graft.

Nonoperative treatment of Bennett's fracture: a 13-year follow-up.

We reviewed the treatment and results of 22 Bennett's fractures. Of these fractures, treated by closed reduction and plaster immobilization, 20 were available for follow-up. Eighteen patients had a subjectively satisfactory outcome, and seven had a radiographically confirmed arthrosis of the first carpometacarpal joint. Of these, two were severe and painfully impaired. Nonanatomic reduction was seen in six of the seven patients with arthrosis and is thus considered a prognostic factor of posttraumatic arthrosis.

Failed meniscus transplantation. A report of three cases.

Treatment of patients with an established disabling compartment arthrosis after total meniscectomy is an important clinical problem. Meniscal transplantation may be an alternative method of treatment. Between 1989 and 1992, 25 cryopreserved nontissue antigen matched meniscal transplantations were performed. In three patients with a medial meniscus, the transplantation failed because of partial loosening of the meniscus. The donor meniscus was removed in one case after 12 months and in the other two cases after 20 and 24 months. In two cases, there was a varus malalignment of the knee. In the third case, the knee was unstable because of an insufficient anterior and posterior cruciate ligament. The retrieved menisci were stained with enzyme and immunohistochemical reactions. Focal areas of degeneration were noted, with vital cells around the microvascular supply and at the synovial side. The growth potential of vital parts of the grafts, as shown by proliferation markers, seemed to be virtually nil. The success of meniscal transplantation seems to depend on factors responsible for vascularization. Malalignment and instability of the joint, causing abnormal pressure on the graft, may be responsible for vascular damage leading to degeneration and loosening of the graft.