Robert A. C. Bilo

Nonaccidental trauma: clinical aspects and epidemiology of child abuse

Radiologists play a key role in the recognition of child abuse. In the last century, radiologists pioneered the identification of nonaccidental injuries, including fractures and brain injury, and together with colleagues in paediatrics advocated the protection of children from abuse. Prevalence studies in many countries have revealed the widespread and hidden nature of child maltreatment. New and complex forms of abuse, e.g. fabricated or induced illness, have been recognized. Physical abuse affects 7–9% of children in the UK, although fewer suffer the severe or life-threatening injuries seen by radiologists. A high index of suspicion of nonaccidental trauma is required where known patterns of injury or inconsistencies of presentation and history are detected. In many cases the diagnosis is readily made, although some cases remain contentious or controversial and consume much clinical time and energy. Differences of view between doctors are tested in the courts. Adverse publicity has made this work unpopular in the UK. Knowledge of the differential diagnosis of unexplained or apparent injury is essential for accurate diagnosis, vital where errors in either direction can be disastrous. New UK radiological guidelines will assist radiologists in achieving best evidence-based practice.

Radiology in suspected non-accidental injury: Theory and practice in the Netherlands

INTRODUCTION This study evaluates radiological imaging in suspected non accidental injury (NAI) in children below the age of 2 years in the Netherlands. MATERIAL AND METHODS The study consisted of two parts; first an on-line questionnaire on suspected NAI, amongst radiological practices within the Netherlands. The second part of the study was a retrospective analysis of skeletal surveys in children under the age of 2 years, which were reviewed in an expert centre of forensic medicine on request of the public prosecutor. RESULTS Out of 116 hospitals 45 (39%) radiologists completed the on-line questionnaire; 8 (8%) of the proposed skeletal surveys complied with the ACR criteria. A total of 29 skeletal surveys in 26 children were reviewed. The median age at the time of the radiographic exam was 3 months for both boys and girls. Only 2 (7%) studies complied with the ACR criteria. DISCUSSION The results of our study show that, in theory as well as in practice, Dutch radiological practices show a large variation in imaging protocols for suspected NAI.

Educational paper : Abusive Head Trauma Part II: Radiological aspects

Abusive head trauma (AHT) is a relatively common cause of neurotrauma in young children. Radiology plays an important role in establishing a diagnosis and assessing a prognosis. Computed tomography (CT), followed by magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI), is the best tool for neuroimaging. There is no evidence-based approach for the follow-up of AHT; both repeat CT and MRI are currently used but literature is not conclusive. A full skeletal survey according to international guidelines should always be performed to obtain information on possible underlying bone diseases or injuries suspicious for child abuse. Cranial ultrasonography is not indicated as a diagnostic modality for the evaluation of AHT. If there is a suspicion of AHT, this should be communicated with the clinicians immediately in order to arrange protective measures as long as AHT is part of the differential diagnosis. Conclusion: The final diagnosis of AHT can never be based on radiological findings only; this should always be made in a multidisciplinary team assessment where all clinical and psychosocial information is combined and judged by a group of experts in the field.

Abusive head trauma in young children in the Netherlands: evidence for multiple incidents of abuse

We investigated the prevalence of risk factors for and the prevalence of prior abuse in abusive head trauma victims in the Netherlands.

Using the table in the Swedish review on shaken baby syndrome will not help courts deliver justice

1.Department of Forensic Medicine, Section on Forensic Pediatrics, Netherlands Forensic Institute, The Hague, The Netherlands 2.Institute of Legal Medicine/University Hospital of Cologne, Cologne, Germany 3.Department for Pediatric and Adolescent Medicine, Child Protection Center, Klinikum Kassel, Germany 4.Department of Forensic Medicine, Netherlands Forensic Institute, The Hague, The Netherlands 5.Forensic Pathology, University Medical Center, Maastricht, The Netherlands 6.Forensic (Paediatric) Radiology, Amsterdam Medical Center, Amsterdam, The Netherlands 7.Department of Legal Medicine, University Medical Center, Hamburg-Eppendorf, Germany 8.Forensic Pathology and Clinical Forensic Medicine, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway

Cutaneous Manifestations of Child Abuse and Their Differential Diagnosis

No wonder you activities are, reading will be always needed. It is not only to fulfil the duties that you need to finish in deadline time. Reading will encourage your mind and thoughts. Of course, reading will greatly develop your experiences about everything. Reading cutaneous manifestations of child abuse and their differential diagnosis is also a way as one of the collective books that gives many advantages. The advantages are not only for you, but for the other peoples with those meaningful benefits.

Multicystic encephalopathy in abusive head trauma

OBJECTIVE The proof of abusive head trauma (AHT) in infants is difficult, especially in cases with a long posttraumatic survival period. In the acute phase, injury to the cranio-cervical junction causes disturbances in respiratory and cardiac control, leading to apnea and bradycardia. Infants who survive the acute phase may subsequently develop multicystic encephalopathy. Because some types of changes are age-dependent, examination of the patterns of brain damage in these cases could provide information about the time in which they were inflicted. In particular, this could apply to the extent of the cystic changes, namely that the severity thereof may decrease with older age upon infliction of the trauma. This could potentially date the injury and thereby help to identify the perpetrator. We present an analysis of the patterns of brain damage in cases of AHT-induced multicystic encephalopathy and comment on the possible etiology and the implications thereof. MATERIALS Nine archival cases of trauma-induced multicystic encephalopathy, originating between the years 2005 and 2011, were identified. In 8 of these cases, hematoxilin-eosin-stained whole-hemisphere histologic slides, as well as small histologic slides of cerebellar hemispheres, were available for the evaluation of the topographic distribution of the macroscopic and microscopic changes. RESULTS The cerebral hemispheres were more affected than the cerebellum. The magnitude of the cystic changes did not correlate with the age at which the trauma had occurred, nor the surviva period. All cases showed asymmetrical affection of the cerebral hemispheres, which in 3 cases was very pronounced. The analysis revealed both ischemia- and hypoperfusion-induced injury patterns. CONCLUSION Analysis of the magnitude and the distribution of the damage do not assist in the estimation of the period at which the trauma had occurred. The evaluation showed that ischemia, and to a lesser extent, hypoperfusion, were the major mechanisms of brain injury in these cases, which does not narrow the differential diagnosis of the underlying problem. However, in cases of multicystic encephalopathy, in the absence of a plausible medical explanation for the development of this condition, a remote (abusive) head trauma should be considered.

Blunt-Force Trauma: Bruises

In humans, the skin is the most visible organ, and it is also the most frequently damaged organ when children sustain injuries. The injuries most commonly seen are bruises and abrasions. These injuries are usually the result of everyday activities at home, including play, sports, or during participating in traffic. In most cases, a skin injury is the only abnormality. However, sometimes an external injury is an indication for more serious internal damage (the “tip of the iceberg” phenomenon).

The Swedish Agency for health technology-report about traumatic shaking: much ado about nothing?

The 2016 Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) systematic review deals with the role of the ‘triad’ (subdural hematoma, retinal hemorrhages, and various forms of brain symptoms) in the medical investigation of suspected traumatic shaking. In this commentary we will not discuss the methodological shortcomings of the SBU-review but will concentrate on the effects of the review on the daily practice of protecting children and families in court procedures. In our opinion the report did not add anything to what was already known in clinical and forensic medicine. The SBU-review confirmed that shaking can cause the ‘triad’ and that there are other explanations for the ‘triad’ and its components. The report however did not provide a realistic list of these other explanations. The review reduced the discussion about inflicted head injury in young children to a discussion about the ‘triad’ and traumatic shaking, ignoring the fact that ‘diagnosing’ inflicted head injury concerns a complete clinical and forensic evaluation of all individual and combined findings, of which for example the presence of bruising or fractures, were excluded by the SBU-panel.

Statistical significance does not imply (forensic medical) relevance

Dear Editor, We have read the article “Dating the abusive head trauma episode and perpetrator statements: key points for imaging” by Adamsbaum et al. [1] with great interest, but we would like to comment on the statistical evaluation of their data. The authors state: “Indeed, in our personal series including 66 cases for which detailed confessions from police inquiries or judicial investigations were available, we have evaluated this age-different pattern of two frankly different densities in two distant locations (at least one hypodense subdural hematoma and one hyperdense subdural hematoma/clot among the five defined locations) and we have found that it was strongly associatedwith confessions of repeated episodes of violence (81%, or 26/32), yet present in only 44% (15/34) cases of a single episode of violence (P=0.006) (results presented at the International Conference on Shaken Baby Syndrome/Abusive Head Trauma, Paris, May 4–6, 2014). Of course, it is not possible to determine how many episodes of violence have occurred.” The results of Adamsbaum et al. [1] are, or at least seem to be, contrary to the results of other authors and researchers. In 1986, Sargent et al. [2] described the problems concerning the dating of subdural hematomas, while using CT scan findings. In a comprehensive review in this journal, Jaspan [3] in 2008 described why one should be cautious in dating subdural fluid collections based on neuroimaging findings, also in case of mixed densities on different locations. Demaerel [4] concluded that it was difficult, if not impossible, to exactly date subdural hematomas, either by CT scan or by MRI. Demaerel [4] and Bradford et al. [5] concluded that combining the CT and MRI findings with the clinical findings/symptoms is essential to define a time line in case of suspicion of inflicted head trauma. The systemic review done by Sieswerda-Hoogendoorn et al. [6] showed that dating (or staging) subdural fluid collections was unreliable because most time intervals of the different appearances of subdural hematomas on CT and MRI were broad and overlapping, and therefore CT or MRI findings cannot be used to accurately date subdural fluid collections/ hematomas. The conclusion of Adamsbaum et al. [1] that “two frankly different densities in two distant locations [...] was strongly associated with confessions of repeated episodes of violence” has far-reaching consequences if this conclusion is in a forensic medical report meant to be used in a criminal court procedure. The discrepancies of their findings with those of (above mentioned) others may play an important role in court cases. These discrepancies have already played a role in a court case in which one of the authors was involved. While preparing for court, we decided to have a closer look at the findings of Adamsbaum et al. [1], because those results were used as proof that hypodense and hyperdense subdural fluid collections, found in two locations, originated from at least two different events. In our opinion, it is questionable whether those findings and the calculated statistical significance (P=0.006; it is unclear to us what statistical test was performed) can be used to conclude that the finding of at least one hypodense subdural hematoma and one hyperdense subdural hematoma/clot * Robert A. C. Bilo r.bilo@nfi.minvenj.nl