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The purpose of this study is to examine forensic documentation of non-fatal strangulation (NFS) in domestic violence cases. Research has pointed to the importance of forensic evidence in the prosecution of strangulation offenders. However, limited research has examined the type of evidence that is gathered during a forensic examination for NFS that occurs during a domestic violence situation. To address this gap in the literature, this study analyzed 63 NFS forensic examination records and body sketches for victims who were referred by police during a domestic violence incident. Results reflect the seriousness of NFS with multiple strangulation attacks in the current incident recorded in 52% of the reports, loss of consciousness recorded in 13.1% of the reports, and a history of strangulation in the relationship recorded in 60% of the reports. It is argued that a forensic exam is essential to identify and mitigate serious symptoms and injuries, as well as to collect valuable evidence that can be used during legal proceedings. Implications for practice and policy are discussed.

AIM Birth asphyxia can lead to organ dysfunction, varying from isolated biological acidosis to hypoxic-ischemic encephalopathy (HIE). Pathophysiology of moderate or severe HIE is now well known and guidelines exist regarding the care required in this situation. However, for newborns without moderate or severe HIE, no consensus is available. Our objective was to describe the immediate neonatal consequences and need for care of asphyxiated newborns without moderate or severe HIE. METHODS Multicentre retrospective study from January 2015 to December 2017 in two academic centres, including neonates ≥37 gestational weeks with pathological foetal acidemia (umbilical arterial pH

Anaplastic thyroid cancer is a rare and rapidly progressive cancer with an extremely poor prognosis. Besides surgical control, no clear treatment has been found, mainly due to the small population affected and high mortality rate.To propose evidence-based treatment guidelines based on a 5-year retrospective study of patients with anaplastic thyroid cancer treated at our facility. There have been no clearly defined guidelines for treatment plan for undifferentiated thyroid cancer. Our paper presents a retrospective analysis on the treatment of patients with undifferentiated thyroid cancer at our hospital.We retrospectively evaluated the data of patients diagnosed with anaplastic thyroid cancer from April 2017 to March 2022. The total number of patients diagnosed and treated was seven. Two of these patients had operable cancer; five were inoperable and treated with lenvatinib or paclitaxel maintenance therapy. The median time from the first visit to death was 3.84 months, and six of the seven patients died before this study started. Three of them had Stage IVB cancer and died due to deterioration of their general condition, including lung metastasis; the other three had Stage IVC cancer and died of suffocation. The survivor had Stage IVB cancer, was treated by surgery combined with chemical radiotherapy, and survived240 days.Considering the above findings, personalized surgical treatment should be prioritized to prevent suffocation. Especially in Stage IVB cancer, local control can be achieved by surgical and anticancer drug treatment to avoid death from suffocation.

Objective: Non-fatal strangulation assessment is challenging for clinicians as clear guidelines for evaluation are limited. The prevalence of non-fatal strangulation events, clinical findings, frequency of injury on computed tomography angiogram (CTA) and outcomes across two trauma centres will be used to improve this assessment process. Methods: This is a retrospective observational study of adult presentations during 2-year period to two major-trauma referral hospitals and subsequent 12 months to identify delayed vascular injury. Patients included using standardised search terms. Demographic data, clinical findings, radiological reports and outcomes were included for review. Results: A total of 425 patients were included for analysis. Self-inflicted injury comprised 62.1%, with domestic violence (28.5%) and assault (9.4%) the remainder. Manual strangulation events 36.7% of overall presentations and 63.3% following ligature strangulation (ligature strangulation, incomplete and complete hanging). On examination soft signs present in 133 (31.2%) cases, commonly neck tenderness in isolation. No hard signs suggesting vascular damage. Vascular injury was demonstrated in three cases (0.7% of the total cohort and 1.5% of CTA scans completed), and all occurred in ligature strangulation events as a result of hanging. No patients had delayed vascular injury in the 12-month period post-initial presentation. Conclusions: In non-fatal strangulation presentations, the majority have subtle signs of neck injury on examination with inconsistent documentation of findings. Low rate of vascular injury overall (0.7%), and entirely in hanging events. No longer-term vascular sequalae identified. Improving documentation focusing on hypoxic insult and evidence of airway trauma is warranted, rather than a reliance on computed tomography imaging to delineate a traumatic event in non-fatal strangulation.

Neonatal hypoxic-ischaemic (HI) injury is a serious complication of neonatal asphyxia and the leading cause of neonatal acute death and chronic neurological injury, and the effective therapeutic method is lacking to improve patients' outcomes. We reported in this study that panax notoginseng saponin (PNS) may provide a treatment option for HI. HI model was established using neonatal Sprague-Dawley rats and then intraperitoneally injected with different dosage of PNS, once a day for 7 days. Histological staining and behavioural evaluations were performed to elucidate the pathological changes and neurobehavioural variation after PNS treatment. We found PNS administration significantly reduced the infarct volume of brain tissues and improved the autonomous activities of neonatal rats, especially with higher dosage. PNS treatment at 40 mg/kg reduced neuronal damage, suppressed neuronal apoptosis and depressed astroglial reactive response. Moreover, the long-term cognitive and motor functions were also improved after PNS treatment at 40 mg/kg. Importantly, PNS treatment elevated the levels of BDNF and TrkB but decreased the expression of p75NTR both in the cortex and hippocampus of HI rats. The therapeutic efficacy of PNS might be correlated with PNS-activated BDNF/TrkB signalling and inactivation of p75NTR expression, providing a novel potential therapy for alleviating HI injury.

Objective: Birth asphyxia is a major cause of hypoxic-ischemic encephalopathy (HIE) in neonates and often associated with mortality, neonatal seizures, brain damage, and later life motor, cognitive, and behavioral impairments and epilepsy. Preclinical studies on rodent models are needed to develop more effective therapies for preventing HIE and its consequences. Thus far, the most popular rodent models have used either exposure of intact animals to hypoxia-only, or a combination of hypoxia and carotid occlusion, for the induction of neonatal seizures and adverse outcomes. However, such models lack systemic hypercapnia, which is a fundamental constituent of birth asphyxia with major effects on neuronal excitability. Here, we use a recently developed noninvasive rat model of birth asphyxia with subsequent neonatal seizures to study later life adverse outcome. Methods: Intermittent asphyxia was induced for 30 min by exposing male and female postnatal day 11 rat pups to three 7 + 3-min cycles of 9% and 5% O-2 at constant 20% CO2. All pups exhibited convulsive seizures after asphyxia. A set of behavioral tests were performed systematically over 14 months following asphyxia, that is, a large part of the rat's life span. Video-electroencephalographic (EEG) monitoring was used to determine whether asphyxia led to the development of epilepsy. Finally, structural brain alterations were examined. Results: The animals showed impaired spatial learning and memory and increased anxiety when tested at an age of 3-14 months. Video-EEG at similar to 10 months showed an abundance of spontaneous seizures, which was paralleled by neurodegeneration in the hippocampus and thalamus, and by aberrant mossy fiber sprouting. Significance: The present model of birth asphyxia recapitulates several of the later life consequences associated with human HIE. This model thus allows evaluation of the efficacy of novel therapies designed to prevent HIE and seizures following asphyxia, and of how such therapies might alleviate long-term adverse consequences.

OBJECTIVE To investigate the relationship between mild congenital pulmonary airway malformation (CPAM) and its long-term prognosis in childhood and to explore whether surgery is necessary. METHODS We conducted a retrospective cohort of fetuses with mild CPAM diagnosed prenatally with available long-term outcomes in childhood from 2004 to 2016. The patients were divided into two groups according to the fetal CPAM-to-volume ratio (CVR) of less than 1.0 and 1.0-1.6. The primary outcome was a postnatal composite outcome including CPAM-associated respiratory symptoms and surgical resection of the lesion. The secondary outcomes included neonatal asphyxia, perinatal morbidity and mortality. RESULTS Forty-two fetuses were identified as having CVR

Key points We have previously shown that high dose constant infusion of rEPO started 30 min after asphyxia in preterm fetal sheep reduced histological injury and improved electrophysiological recovery. This study shows that high dose infusion of rEPO started 6 h after asphyxia did not improve EEG recovery, oligodendrocyte and neuronal survival at one-week post-asphyxia. Of concern, intermittent rEPO boluses started 6 h after asphyxia were associated with impaired EEG recovery and bilateral cystic injury of temporal lobe intragyral white matter. Intermittent boluses of rEPO were associated with significantly increased cerebral vascular resistance and hypoperfusion, particularly after the first dose, but did not affect seizures, suggesting mismatch between perfusion and brain activity. Abstract Recombinant human erythropoietin (rEPO) is a promising treatment for hypoxic-ischaemic (HI) brain injury. Disappointingly, a large randomised controlled trial in preterm infants found that prophylactic, repeated high-dose rEPO boluses started within 24 h of birth did not improve neurodevelopmental outcomes. We examined if initiation of a continuous infusion of rEPO at the end of the latent phase after HI might improve outcomes compared to intermittent bolus injections. Chronically instrumented preterm (0.7 gestation) fetal sheep received sham asphyxia or asphyxia induced by complete umbilical cord occlusion for 25 minutes. Six hours after asphyxia, fetuses received either a continuous infusion of rEPO (loading dose 2000 IU, infusion at 520 IU/h) from 6-72 hours post-asphyxia or intravenous saline or 5000 IU rEPO, with repeated doses every 48 hours for 5 days. Continuous infusion of rEPO did not improve EEG recovery, oligodendrocyte and neuronal survival at one-week post-asphyxia. By contrast, intermittent rEPO boluses were associated with impaired EEG recovery and bilateral cystic injury of temporal lobe intragyral white matter in 6/8 fetuses. These studies demonstrate for the first time that initiation of intermittent rEPO boluses 6 hours after HI, at a dose comparable with recent clinical trials, exacerbated neural injury. These data reinforce the importance of early initiation of many potential neuroprotective therapies. This article is protected by copyright. All rights reserved.

Most patients that resuscitate successfully from cardiac arrest (CA) suffer from poor neurological prognosis. DL-3-n-butylphthalide (NBP) is known to have neuroprotective effects via multiple mechanisms. This study aimed to investigate whether NBP can decrease neurological impairment after CA. We studied the protective role of NBP in the hippocampus of a rat model of cardiac arrest induced by asphyxia. Thirty-nine rats were divided randomly into sham, control, and NBP groups. Rats in control and NBP groups underwent cardiopulmonary resuscitation (CPR) 6 min after asphyxia. NBP or vehicle (saline) was administered intravenously 10 min after the return of spontaneous circulation (ROSC). Ultrastructure of hippocampal neurons was observed under transmission electron microscope. NBP treatment improved neurological function up to 72 h after CA. The ultrastructural lesion in mitochondria recovered in the NBP-treated CA model. In conclusion, our study demonstrated multiple therapeutic benefits of NBP after CA.

Background: Living with chronic obstructive pulmonary disease stage III or IV has a major impact on a person's everyday life. This qualitative study focuses on women with chronic obstructive pulmonary disease stage III or IV. Aim: The aim of this study was to describe women's experiences of living with chronic obstructive pulmonary disease stage III or IV. Method: A purposive sample of fifteen women with chronic obstructive pulmonary disease stage III or IV participated in the study. Data were collected through individual semi-structured interviews that were subjected to qualitative content analysis. Findings: One theme was identified, stabilizing an ever-present breathlessness by restoring strength, and three categories are as follows: managing a restricted everyday life as an expert of their illness, being afraid of contracting infections leading to suffocation and suffering and importance of continuous help and support from significant others and digital media. Breathlessness restricted women with chronic obstructive pulmonary disease, living with a body they have to wait for. Managing everyday life was adapted to their limited abilities and energy. This required detailed planning, good knowledge of their breathing and body. Women were afraid of contracting life-threatening infections that caused suffering, especially COVID-19. The fear leads to isolation and digital media was described as an important means of communication. Significant others gave support and help that was practical and emotional. Women with chronic obstructive pulmonary disease experienced lack of continuous help and support from healthcare professionals. Conclusion: Stabilizing an ever-present breathlessness by restoring strength required women with chronic obstructive pulmonary disease stage III or IV to conduct detailed planning to manage everyday life. Being afraid of contracting infections and the consequences of suffocation had increased since the pandemic COVID-19 outbreak, which led to self-isolation and an inactive everyday life. To get help, support and socialize, women used digital media.

AIM The purpose of this study was to evaluate the current state and clinical characteristics of spontaneous hemoperitoneum in pregnancy (SHiP) in Japan by performing a comprehensive survey. METHODS We reviewed data on pregnant women who developed SHiP during 2013-2017 (for 5 years), and were admitted to any of the perinatal centers in Japan. The survey assessed maternal background and maternal and neonatal prognosis. We divided the cases into two groups, favorable and poor prognosis groups, and made comparisons between the two groups. RESULTS Of the 407 facilities in Japan, 267 (66%) facilities responded to our survey. Overall, 31 cases of SHiP were registered. Maternal death occurred in one case (3%) due to liver bleeding with an unknown cause. Of 23 cases with a SHiP onset during pregnancy, 12 (53%) had been misdiagnosed as placental abruption. The prognosis for the fetuses included miscarriage or stillbirth in three cases (10%) and asphyxia in 12 cases (42%). There was no significant correlation between the amount of intra-abdominal blood loss and neonatal prognosis based on umbilical artery pH. Incidences of preterm birth

Ludwig's angina is characterized by inflammation of the sublingual and submandibular spaces and is mainly caused by odontogenic infection, which leads to cellulitis of the soft tissues of the floor of the mouth and the neck. This causes asphyxia due to elevation and posterior deviation of the tissues of the floor of the mouth. We report a fatal case of airway obstruction due to Ludwig's angina. A woman in her forties who had no physical complications, but had a mental illness, was undergoing outpatient dental treatment for caries in the first premolar of the left mandible. She was admitted to a psychiatric hospital because of insomnia caused by pain, where she developed cardiopulmonary arrest while sleeping and died 14 days after onset of the dental infection. Postmortem computed tomography (PMCT) prior to autopsy showed swelling of the soft tissues-from the floor of the mouth to the oropharyngeal cavity, the supraglottic larynx, and the prevertebral tissue. Autopsy revealed a markedly swollen face and neck, an elevated tongue, and a highly edematous epiglottis and laryngopharyngeal mucosa. There was also cellulitis and abscess of the facial, suprahyoid, and neck musculature, which suggested that the cause of death was asphyxiation due to airway obstruction. This was an alarming case, with mental illness leading to risk of severe odontogenic infection, and in which obesity and use of antipsychotic medication might have acted synergistically leading to airway obstruction. This is also a case of Ludwig's angina captured by PMCT, which has rarely been reported.

Traumatic dislocation of the eye is usually encountered in high-energy injuries. These include traffic accidents, accidents at work, sporting accidents, falling from a height, impact of the hooves or horns of animals, gunshot injuries, and physical assault. Such incidents are accompanied by facial soft tissue damage and injuries to the facial skeleton, especially the orbit, and can be associated with varying degrees of dislocation of the eye. We describe a rare case of non-fatal traumatic eye dislocation into the maxillary sinus, coupled with an orbital fracture resulting from a physical assault on a 63-year-old woman. The cause of death was asphyxiation due to manual strangulation and mechanical asphyxia. Even though dislocations of the eye are relatively rare, forensic pathologists should be aware of such injuries to correct assessment of injury mechanism. The available literature regarding eye dislocation is summarized, and the forensic issues applicable to the assessment of such cases are reviewed.

Objective: Cardiotocography is widely used to assess fetal well‐being during labour. The positive predictive value of current clinical algorithms to identify hypoxia‐ischaemia is poor. In experimental studies, fetal hypotension is the strongest predictor of hypoxic‐ischaemic injury. Cohort studies suggest that deceleration area and deceleration capacity of the fetal heart rate trace correlate with fetal acidaemia, but it is not known if they are indices of fetal arterial hypotension. Design: Prospective, controlled study. Setting: Laboratory. Sample: Near‐term fetal sheep. Methods: 1 min of complete umbilical cord occlusions (UCOs) every 5 min (1:5min, n=6) or every 2.5 min (1:2.5min, n=12) for 4 h or until fetal mean arterial blood pressure fell Main Outcome Measures: Deceleration area and capacity during the UCO series were related to evolving hypotension. Results: The 1:5min group developed only mild metabolic acidaemia, without hypotension. By contrast, 10/12 fetuses in the 1:2.5min group progressively developed severe metabolic acidaemia and hypotension, reaching 16.8±0.9mmHg after 71.2±6.7 UCOs. Deceleration area and capacity remained unchanged throughout the UCO series in the 1:5 min group, but progressively increased in the 1:2.5 min group. The severity of hypotension was closely correlated with both deceleration area (p Conclusions: Both deceleration area and capacity were strongly associated with developing fetal hypotension, supporting their potential to improve identification of fetuses at risk of hypotension leading to hypoxic‐ischaemic injury during labour.

In Central-Africa, neonatal infections, asphyxia and prematurity are main reasons for admission to the neonatal intensive care unit and major determinants of newborn survival. Also, the outcome of newborns with congenital anomalies is expected to be poor, due to a lack of state-of-the art care. We conducted a study of 102 newborns recruited in the Neonatal Intensive Care Unit (NICU) at the University Hospitals of Kinshasa, DR Congo, to assess the impact of congenital anomalies. The presence of a major anomaly was associated with a hazard ratio of death of 13.2 (95%CI: 3.7-46.7, p < .001). In addition, the presence of three or more minor anomalies was associated with a 4.5-fold increased risk of death (95%CI: 1.1-18.6, p = .04). We conclude that like major anomalies, the presence of three or more minor anomalies should also be given particular attention and that the evaluation of dysmorphism should be promoted in NICU.

Introduction: Fetal growth restriction is associated with adverse perinatal outcome and the clinical management of these pregnancies is a challenge. The aim of this study was to investigate the potential of cerebroplacental ratio (CPR) to predict adverse perinatal outcome in high-risk pregnancies in the third trimester. Another aim was to study whether the CPR has better predictive value than its components, middle cerebral artery (MCA) pulsatility index (PI) and umbilical artery (UA) PI. Material and methods: The study was a retrospective cohort study including 1573 singleton high-risk pregnancies with Doppler examinations performed at 32+0 to 40+6 gestational weeks at Lund University Hospital and the University Hospital of Malmo between 29 December 1994 and 31 December 2017. Receiver operating characteristics (ROC) curves were used to investigate the predictive value of the gestational age-specific z-scores for CPR, UA PI and MCA PI, respectively, for the primary outcome “perinatal asphyxia/mortality” and the secondary outcomes “birthweight small for gestational age (SGA)” and two composite outcomes: “appropriate for gestational age/large for gestational age liveborn infants with neonatal morbidity” and “SGA liveborn infants with neonatal morbidity.”. Results: The performance in predicting perinatal asphyxia/mortality was poor for all three variables and did not differ significantly. The ROC area under curve (AUC) was 0.56, 0.55 and 0.53 for CPR, UA PI and MCA PI z-scores, respectively. The ROC AUC for CPR z-scores to predict SGA was 0.73, significantly higher than that for either UA PI or MCA PI (P

Introduction Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy specific liver disease characterised by pruritus and abnormal liver function tests and it has been associated with intrauterine fetal distress and stillbirth. We compared two guidelines of the management of ICP: One mandating induction at 38 weeks of gestation (Rigshospitalet and Hvidovre Hospital before 2012) and another separating ICP into a mild and severe form and only women with severe ICP were recommended induction at 38 weeks (Hvidovre Hospital after 2012). Material and methods We performed a historical cohort study at two Copenhagen Hospitals from 2004 to 2015. We included 62,937 women with singleton deliveries at Rigshospitalet and 71,015 at Hvidovre Hospital of which 971 women (1.5%) and 998 women (1.4%) were diagnosed with ICP at Rigshospitalet and Hvidovre Hospital respectively. Data was retrieved from a local medical database. For the analysis of induction and comparison of obstetrical outcomes we only included pregnancies with an ICP diagnosis and excluded women with other medical conditions that could mandate induction. Main outcome measures were induction and cesarean section rates, asphyxia and stillbirth. Results We found no changes in the rate of spontaneous labor, cesarean section and induction over the years at Rigshospitalet (p = 0.17) and Hvidovre Hospital (p = 0.38). For women with intended vaginal delivery we found no change in the final mode of delivery over the years at Rigshospitalet (p = 0.28) and Hvidovre Hospital (p = 0.57). Conclusions The two approaches to the management of mild ICP regarding the timing of induction are comparable. Women with mild ICP and their clinicians should be encouraged to engage in shared decision making when discussing timing of induction.

Introduction The aim of the present study was to identify possible associations of fetal heart rate (FHR) patterns during the last 2 hours of labor with fetal asphyxia expressed by umbilical artery acidemia at birth and with neonatal complications in a large obstetric cohort. Material and methods Cardiotocographic recordings from 4988 singleton term childbirths over 1 year were evaluated retrospectively and blinded to the pregnancy and neonatal outcomes in a university teaching hospital in Helsinki, Finland. Umbilical artery pH, base excess and pO(2), low Apgar scores at 5 minutes, need for intubation and resuscitation, early neonatal hypoglycemia, and neonatal encephalopathy were used as outcome variables. According to the severity of the neonatal complications at birth, the cohort was divided into three groups: no complications (Group 1), moderate complications (Group 2) and severe complications (Group 3). Results Of the 4988 deliveries, the ZigZag pattern (FHR baseline amplitude changes of >25 bpm with a duration of 2-30 minutes) occurred in 11.7%, late decelerations in 41.0%, bradycardia episodes in 52.9%, reduced variability in 36.7%, tachycardia episodes in 13.9% and uterine tachysystole in 4.6%. No case of saltatory pattern (baseline amplitude changes of >25 bpm with a duration of >30 minutes) was observed. The presence of the ZigZag pattern or late decelerations, or both, was associated with cord blood acidemia (odds ratio [OR] 3.3, 95% confidence interval [CI] 2.3-4.7) and severe neonatal complications (Group 3) (OR 3.3, 95% CI 2.4-4.9). In contrast, no significant associations existed between the other FHR patterns and severe neonatal complications. ZigZag pattern preceded late decelerations in 88.7% of the cases. A normal FHR preceded the ZigZag pattern in 90.4% of the cases, whereas after ZigZag episodes, a normal FHR pattern was observed in only 0.9%. Conclusions ZigZag pattern and late decelerations during the last 2 hours of labor are significantly associated with cord blood acidemia at birth and neonatal complications. The ZigZag pattern precedes late decelerations, and the fact that normal FHR pattern precedes the ZigZag pattern in the majority of the cases suggests that the ZigZag pattern is an early sign of fetal hypoxia, which emphasizes its clinical importance.

Objective This study investigated whether the delayed umbilical cord clamping can influence the pain during suturing perineal tears. Design This randomised controlled study applied the Consolidated Standards of Reporting Trials statement. Methods The sample comprised 288 pregnant women who gave birth through vaginal delivery in our hospital from November 2019 to December 2019. They were randomly divided into 2 groups-early umbilical cord clamping (n = 147) and delayed umbilical cord clamping (n = 141)-without severe pregnancy complications. There was no intrauterine infection, neonatal asphyxia or premature birth in the 288 newborns. The pain scores of the Numerical Rating Scale, Visual Analogue Scale, Verbal Rating Scale and Faces Pain Scale-Revised were used as indicators to evaluate the mothers' pain. The Mann-Whitney U test was used, and the statistical significance was set to p Result All indicators suggest that perineal suture pain of delayed umbilical cord clamping was lower than that of the control group. For the experience group, the perception of pain for the mothers who received analgesia was less than that for those who did not. For the control group, the Verbal Rating Scale suggests a statistical difference in suturing pain between acceptable and unacceptable labour analgesia. The degree of cooperation of the experience group was higher than that of the control group, but labour analgesia did not affect cooperation degree in both groups. Conclusion Delayed umbilical cord clamping can alleviate maternal pain when suturing perineal tears and improve the delivery experience. Labour analgesia can enhance the pain relief effect. Trial registration was performed on www.chictr.org.cn (ChiCTR1900026797). Relevance to clinical practice As a part of perinatal nursing, delayed umbilical cord clamping can help alleviate the pain of perineal suture and improve the experience of parturient. The method is simple and can be used as a routine nursing operation.

Aims and objectives To explore parental experiences of therapeutic hypothermia (TH) in their newborn infant suffering from hypoxic ischaemic encephalopathy following perinatal asphyxia. Background Since more than a decade, newborn infants are treated with TH following perinatal asphyxia to reduce mortality and disabilities and to improve neurological outcome. The infants' body temperature is lowered to 33.5°C for 72 hr, and the infant is usually cared for in an open incubator. The parents are not able to hold their infant skin to skin, which risks causing emotional reactions in parents and a loss of normal parent-infant bonding. Design A qualitative descriptive design using semi-structured interviews. Methods Up to 7 months after the event, interviews were conducted with 14 parents of seven infants who had received TH in a neonatal intensive care unit (NICU) in Sweden. The interviews were transcribed and analysed using framework approach. Findings were reported following the Standard for Reporting Qualitative Research (SRQR) checklist. Results From the interviews, an overall theme was found: Transition through a life-altering time, and three categories: (a) trepidation about prognosis, (b) transitioning into parenthood supported by the caring philosophy of family-centred care (FCC) and (c) rewarming as a milestone. Conclusions Parental experiences of TH are based on the immediate emotions and stress of uncertainty of the infant's prognosis. The values of FCC in the NICU append a natural transitioning into parenthood by parental involvement in nursing care and decisions. The rewarming of the infant is seen as a restart to more or less normal circumstances from the critical period of delivery and TH. Relevance for clinical practice The management of NICUs should update the awareness of and deepen knowledge about FCC. The emphasis ought to be on adequate information about TH and the values of FCC to parents in the NICU context.

Cerebral palsy (CP) is the most common non-progressive neurodevelopmental disorder in which the impairment of motor and posture functions occurs. This condition may be present in many different clinical spectra. Various aetiological and risk factors play a crucial role in the causation of CP. In various cases, the causes of CP may not be apparent. Interruption in the supply of oxygen to the fetus or brain asphyxia was considered to be the main causative factor explaining CP. Antenatal, perinatal, and postnatal factors could be involved in the origin of CP. Understanding its pathophysiology is also crucial for developing preventive and protective strategies. A major advancement in the brain stimulation techniques has emerged as a promising status in diagnostic and interventional approaches. This review provides a brief explanation about the various aetiological factors, pathophysiology, and recent therapeutic approaches in the treatment of cerebral palsy.

KEY POINTS: In mammals, pregnancy complications can trigger an embryonic or fetal origin of cardiac dysfunction. However, underlying mechanisms remain uncertain because the partial contributions of the challenge on the mother, placenta or offspring are difficult to disentangle. The avian embryo permits isolation of the direct effects of suboptimal conditions during development on the cardiac function of the offspring, independent of additional effects on the mother and/or the placenta. Therefore, the objectives of this work were to adapt the isolated Langendorff technique using the chicken embryo to study the physiology of the developing heart. Here, we introduce a novel technique and show the utility of the technique for exploring cardioprotective roles of H2 S in the chicken embryo heart. This work lays the foundation for studying the direct effects of H2 S therapy on the embryonic heart independent of effects on the mother and the placenta in adverse development. ABSTRACT: This study adapted the isolated Langendorff preparation to study the chicken embryo heart in response to ischaemia-reperfusion (IR) injury. The utility of the technique was tested by investigating cardioprotective effects of hydrogen sulphide (H2 S) and underlying mechanisms. Embryonic hearts (19 out of 21 days of incubation) mounted on a Langendorff preparation were exposed to IR (30 min ischaemia) after 4 treatments administered randomly, all as a 1 mm bolus, into the perfusate: saline vehicle (control); sodium hydrogen sulphide (NaHS); NaHS plus glibenclamide, an antagonist of KATP opening (NaHS Glib), and Glib alone (Glib). Relative to controls, NaHS treatment improved cardiac function after ischaemia (mean ± SD for area under the curve, AUC, for left ventricular developed pressure, LVDP: 1767.3 ± 929.5 vs. 492.7 ± 308.1; myocardial contractility, dP/dtmax : 2748.9 ± 1514.9 vs. 763.7 ± 433.1) and decreased infarct size (22.7 ± 8.0 vs. 43.9 ± 4.2%) and cardiac damage (% change in creatinine kinase, 49.3 ± 41.3 vs. 214.6 ± 155.1; all P < 0.05). Beneficial effects of NaHS were blocked by Glib. Glib alone had no effects. NaHS increased coronary flow rate (CFR) during baseline (mean ± SD for AUC: 134.3 ± 91.6 vs. 92.2 ± 35.8) and post IR (1467 ± 529.5 vs. 748.0 ± 222.1; both P < 0.05). However, this effect was not prevented by Glib. Therefore, the chicken embryo heart is amenable for study via the Langendorff preparation under basal conditions and during IR. The data show that H2 S confers embryonic cardiac protection via opening of myocardial KATP channels and not via increasing CFR. H2 S may prove a useful therapeutic agent to protect the human fetal heart against IR injury, as may occur in complicated labour.

The contribution of positional asphyxia in opioid-related deaths is currently unknown. Diagnostic criteria for positional asphyxia include finding the decedent in a position that does not allow for adequate respiration and an inability to extricate themselves from the position due to various conditions. Our primary objective was to assess whether positional asphyxia and the resulting airway compromise were a contributing factor to death due to the toxic effects of opioids. We evaluated 225 deaths where the death scene investigation contained adequate information to evaluate for positional asphyxia and performed a Pearson chi-square test to determine if the proportion of deaths found in an airway compromising position was higher when opioid(s) caused the death. The proportion of decedents found in a potential airway compromising position was greater when the death was related to opioid use (p < 0.0001). Further, narrowing the dataset to decedents who were definitely in an airway compromising position [Yes (24.49%) vs. No (11.02%)] showed a statistically significant association between positional asphyxia and deaths related to opioid use (p = 0.0021). Carefully documenting the position in which the decedent was initially found may be a significant factor in accurate reporting and in harm reduction efforts to decrease the opioid mortality rate.

OBJECTIVE To evaluate maternal and perinatal outcomes in cases of third-trimester malaria (TTM). METHODS A parity-matched comparative cohort study was carried out between December 1, 2018, and April 30, 2019, in three university teaching hospitals in Yaounde (Cameroon). Women with and without TTM were followed up till delivery. The variables analyzed included maternal and gestational ages at delivery, the regimen of intermittent preventive treatment, usage of insecticide-treated net, history of malaria recorded during pregnancy, birth and placenta weights, Apgar score, and early neonatal outcomes. Fisher exact test, t-test, and logistic regression were used for comparison. P

Aim To determine the health facility‐based perinatal mortality rate, its causes and avoidable factors using the perinatal mortality surveillance and response guidelines. Design This was an action study conducted in one of the districts in Western Uganda from 1 January–31 December 2019. Methods A total of 20 perinatal death cases were recruited consecutively. Data were collected using a Ministry of Health Perinatal Death Surveillance and Response (PDSR) questionnaire containing questions on pregnancy, delivery and immediate postnatal care. We used descriptive statistics to describe key data elements. Results We found a health facility‐based perinatal mortality rate of 17.3 deaths per 1,000 live births. Birth asphyxia was the most common cause of perinatal deaths. Seven, three and ten mothers delayed seeking, reaching and receiving appropriate health care, respectively.

Aim This study aimed to systematically analyse the pregnancy, birth and demographic‐related factors associated with age of death in sudden unexpected infant death (SUID). Methods Data were analysed from the Centers for Disease Control and Prevention's Cohort Linked Birth/Infant Death data set (2011‐2013; 11 737 930 live births). SUID was defined as deaths from sudden infant death syndrome, ill‐defined causes, or accidental suffocation and strangulation in bed. There were 9668 SUID cases (7‐364 days; gestation >28 weeks; 0.82/1000 live births). The odds of death at different ages were compared to determine which variables significantly affect the SUID age of death. Results Forty‐three features indicated a significant change in age of death with two main patterns: (a) younger chronologic age at death was associated with maternal smoking and factors associated with lower socio‐economic status, and (b) older age was associated with low birthweight, prematurity and admission to the neonatal intensive care unit. However, when age was corrected for gestation, these factors were associated with younger age. Conclusion Factors that varied with age of death are well‐documented risk factors for SUID. The majority of these risk factors were associated with younger age at death after allowing for gestational age at birth.

Aim Extraction of the fetal body is typically performed immediately after delivery of the head in Western obstetric care. Reports justifying immediate extraction are few. Two-step delivery entails waiting for the next uterine contraction after delivery of the head. The present study evaluates neonatal asphyxia and respiratory impairment in two-step delivery using the head-to-body delivery interval. Methods This prospective observational study performed at a single birth clinic used the data of 262 low-risk pregnant women with two-step delivery. We measured the time interval of head-to-body delivery and correlation analysis and simple linear regression analysis between the head-to-body delivery interval and umbilical artery pH. The women were divided into two groups according to the head-to-body delivery interval: ≤60 or >60 s. The prevalence of neonatal asphyxia and neonatal respiratory impairment was compared between the groups. Results The mean head-to-body delivery interval was 88.9 ± 71.3 s. The umbilical artery pH tended to decrease with increasing head-to-body delivery interval; however, there was almost no correlation and the decline of pH was only 0.010 for every additional minute. Low Apgar score incidence at 5 min did not differ significantly between the groups. No cases of shoulder dystocia were reported, and tachypnea at 4 h after birth occurred in 3% of the births. Conclusions A longer head-to-body delivery interval is not associated with negative outcomes in two-step delivery. We believe that two-step delivery could have some superior outcomes compared with one-step delivery outcomes, particularly as to improving fetal circulation and preventing shoulder dystocia.

Background The effects of therapeutic hypothermia (TH) on renal function are not widely reported, especially in longer-term animal models. The hypothesis of this study was that TH of the kidneys of hypoxic-ischemic newborn piglets would reduce pathological renal fibrosis. Methods Twenty-five newborn piglets obtained within 24 h of birth were classified into a Control group (n = 5), hypoxic insult with normothermia (HI-NT) group (n = 12), and hypoxic insult with TH (HI-TH) group (33.5°C ± 0.5°C for 24 h; n = 8). Five days after the insult, all piglets were sacrificed under deep anesthesia by isoflurane inhalation. The kidneys were perfused with phosphate-buffered paraformaldehyde and immersed in formalin buffer. Territory fibrosis was studied and scored in the renal medulla using Azan staining. Results Fibrosis area scores (mean ± standard deviation) based on Azan staining were 1.00 ± 0.46 in the Control group, 2.85 ± 0.93 in the HI-NT group, and 3.58 ± 1.14 in the HI-TH group. The fibrosis area of the HI-NT and HI-TH groups was larger than that of the Control. The HI-NT and HI-TH groups were not statistically different. Conclusion Renal fibrosis is affected by perinatal asphyxia and cannot be prevented by TH, based on histopathological findings.

Objective : To review domestic and family violence (DFV) and non-lethal strangulation (NLS) presentations to an ED with 24-h social work. Methods : Retrospective cohort study of 12 months of DFV presentations comparing demographics, perpetrator relationship, social work review, injuries and NLS incidence and assessment. Results : Women represent 90% of DFV presentations. In 26% of DFV presentations NLS was identified, with 47.5% clinically assessed appropriately. Social work did not review 34% of DFV presentations, 64% due to no referral. Conclusions : Social work referral for DFV is regularly missed despite 24-h access. Assessment of NLS in ED requires improvement and standardised national guidelines.

Elevators are mechanical transportation devices used to move vertically between different levels of a building. When first developed, elevators lacked the safety features. When safety mechanisms were developed, elevators became a common feature of multistory buildings. Despite their well-regarded safety record, elevators are not without the potential for danger of injury or death. Persons at-risk for elevator-related death include maintenance and construction workers, other employees, and those who are prone to risky behavior. Deaths may be related to asphyxia, blunt force, avulsion injuries, and various forms of environmental trauma. In this review, we report on 48 elevator-related deaths that occurred in nine different medicolegal death investigation jurisdictions within the United States over an approximately 30-year period. The data represents a cross-section of the different types of elevator-related deaths that may be encountered. The review also presents an overview of preventive strategies for the purpose of avoiding future elevator-related fatalities.

We report a fatal case of airway obstruction caused by spontaneous retropharyngeal hematoma (RH) in the setting of treatment with dipyridamole. A 90-year-old woman presented with cervical swelling, neck and chest ecchymoses, and complaints of dyspnea. She suffered cardiopulmonary arrest in the ambulance, and her death was confirmed after transportation to the hospital. The major finding of postmortem computed tomography (PMCT) prior to autopsy was widening of the prevertebral soft tissue. The results of the autopsy indicated that the cause of death was mechanical asphyxia, secondary to pharyngeal and laryngeal compression caused by the RH. There were no evident injuries, medical interventions, or particular diseases, suggesting the spontaneous cause of the RH. To the best of our knowledge, this is the first report of a fatal case secondary to spontaneous RH that was revealed through PMCT imaging.

AIM This study assessed the incidence of epilepsy in preterm infants and those small for gestational age (SGA) at term and identified risk factors associated with higher epilepsy incidence in these children. METHODS We enrolled children (from 2000 to 2010) who were premature (n = 21 474) or SGA (n = 2206); we then included a matched control cohort (n = 94 720). Cox regression was used to assess the epilepsy risk in preterm and SGA children. To determine the associated factors for epilepsy, the preterm and SGA infants were divided into six groups according to the common complications related to brain development and were separated into three subgroups based on birthweight (BW). RESULTS The cumulative incidence of epilepsy was significantly higher in preterm or SGA children than in the control group. The overall incidence densities (per 1000 person-years) of epilepsy were: 0.37 in the control, 2.96 in the preterm, 2.90 in the SGA, 15.9 in the preterm with cerebral haemorrhage, 14.6 in the SGA with cerebral haemorrhage, 6.92 in the preterm with asphyxia, 3.82 in the SGA with asphyxia, 14.3 in the preterm with congenital brain anomalies, and 25.4 in the SGA with congenital brain anomalies cohorts. Infants with BW

Forensic suicidology is a growing discipline as the world struggles to reduce escalating suicide rates. Most research focuses on trends and risks, but no study examines the relationship between cultural identity and suicide modality as a means of understanding hyper-local risk factors. This study cross-referenced race and suicide method for 720 coroner decedents. More than half (58%) of Asian suicides are asphyxial, while 20% are firearm-related. Comparatively, 26% of White suicides are asphyxial; 35% are firearm-related. Males outnumber females at greater than 2:1 in every racial category except Asian. While the study demographic is unique, many trends confirm conventional suicide wisdom. The finding of male predominance in the White and Hispanic groups confirms long-standing clinical knowledge regarding sex-related risk for suicide. Understanding patterns unique to a locality can leverage policy and practices that reduce access to suicide means, aiding preventative efforts, and benefitting the growing field of death investigation.

A decision by a society to sanction assisted dying in any form should logically go hand-in-hand with defining the acceptable method(s). Assisted dying is legal in several countries and we have reviewed the methods commonly used, contrasting these with an analysis of capital punishment in the USA. We expected that, since a common humane aim is to achieve unconsciousness at the point of death, which then occurs rapidly without pain or distress, there might be a single technique being used. However, the considerable heterogeneity in methods suggests that an optimum method of achieving unconsciousness remains undefined. In voluntary assisted dying (in some US states and European countries), the common method to induce unconsciousness appears to be self-administered barbiturate ingestion, with death resulting slowly from asphyxia due to cardiorespiratory depression. Physician-administered injections (a combination of general anaesthetic and neuromuscular blockade) are an option in Dutch guidelines. Hypoxic methods involving helium rebreathing have also been reported. The method of capital punishment (USA) resembles the Dutch injection technique, but specific drugs, doses and monitoring employed vary. However, for all these forms of assisted dying, there appears to be a relatively high incidence of vomiting (up to 10%), prolongation of death (up to 7 days), and re-awakening from coma (up to 4%), constituting failure of unconsciousness. This raises a concern that some deaths may be inhumane, and we have used lessons from the most recent studies of accidental awareness during anaesthesia to describe an optimal means that could better achieve unconsciousness. We found that the very act of defining an 'optimum' itself has important implications for ethics and the law.

Non-fatal strangulation (NFS) can be a cause of severe injury. However, the prevalence and rates of injuries from NFS are unknown, as few victims present to medical attention after strangulation. As up to 40% of fatal strangulations have no external signs, and the majority of surviving victims have few or minor injuries, finding those people severely injured remains challenging. The majority of the evidence regarding NFS is largely based on case reports and case series with no robust studies estimating rates of injuries or the best investigation tools. The injuries that are reported make clear that strangulation is a potentially lethal form of injury that should not be ignored in those presenting having been strangled, or in those presenting with neurological symptoms, including strokes, seizures and vascular abnormalities. The safety implications of strangulation are also important as it can be a prelude to homicide. A search of the literature was carried out with the following terms: Nonfatal strangulation (10), Nonfatal strangulation (17), 'Strangulation injuries' (19), 'Manual strangulation' (92) - laboratory testing eliminated, and 'choking game'. The PubMed database was used first, followed by the collections of Monash University and the Strangulation Institute (as some articles were too old to find electronically). This article summarises the injuries that can occur following strangulation and discusses the quality of the evidence thus far.

We adapted and tested an innovative noncontact speckle contrast diffuse correlation tomography (scDCT) system for 3D imaging of cerebral blood flow (CBF) variations in perinatal disease models utilizing neonatal piglets, which closely resemble human neonates. CBF variations were concurrently measured by the scDCT and an established diffuse correlation spectroscopy (DCS) during global ischemia, intraventricular hemorrhage, and asphyxia; significant correlations were observed. Moreover, CBF variations associated reasonably with vital pathophysiological changes. In contrast to DCS measurements of mixed signals from local scalp, skull and brain, scDCT generates 3D images of CBF distributions at prescribed depths within the head, thus enabling specific determination of regional cerebral ischemia. With further optimization and validation in animals and human neonates, scDCT has the potential to be a noninvasive imaging tool for both basic neuroscience research in laboratories and clinical applications in neonatal intensive care units.

Caused by a novel type of virus, severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), coronavirus disease 2019 (COVID‐19) constitutes a global public health emergency. Pregnant women are considered to have a higher risk of severe morbidity and even mortality due to their susceptibility to respiratory pathogens and their particular immunologic state. Several studies assessing SARS‐CoV‐2 infection during pregnancy reported adverse pregnancy outcomes in patients with severe conditions, including spontaneous abortion, preterm labor, fetal distress, cesarean section, preterm birth, neonatal asphyxia, neonatal pneumonia, stillbirth, and neonatal death. However, whether these complications are causally related to SARS‐CoV‐2 infection is not clear. Here, we reviewed the scientific evidence supporting the contributing role of Treg/Th17 cell imbalance in the uncontrolled systemic inflammation characterizing severe cases of COVID‐19. Based on the recognized harmful effects of these CD4+ T‐cell subset imbalances in pregnancy, we speculated that SARS‐CoV‐2 infection might lead to adverse pregnancy outcomes through the deregulation of otherwise tightly regulated Treg/Th17 ratios, and to subsequent uncontrolled systemic inflammation. Moreover, we discuss the possibility of vertical transmission of COVID‐19 from infected mothers to their infants, which could also explain adverse perinatal outcomes. Rigorous monitoring of pregnancies and appropriate measures should be taken to prevent and treat early eventual maternal and perinatal complications.

Introduction - The Norwegian Board of Health Supervision inspects healthcare institutions to ensure safety and quality of health and welfare services. A planned inspection of 12 maternity units aimed to investigate the practice of obstetric care in the case of birth asphyxia, shoulder dystocia and severe postpartum hemorrhage. Material and methods - The inspection was carried out at two large, four medium and six small maternity units in Norway in 2016 to investigate adverse events that occurred between 1 January and 31 December 2014. Six of them were selected as control units. The Norwegian Board of Health Supervision searched the Medical Birth Registry of Norway to identify adverse events in each of the categories and then requested access to the medical records for all patients identified. Information about guidelines, formal teaching and simulation training at each unit was obtained by sending a questionnaire to the obstetrician in charge of each maternity unit. Results - The obstetric units inspected had 553 serious adverse events of birth asphyxia, shoulder dystocia or severe postpartum hemorrhage among 17 323 deliveries. Twenty-nine events were excluded from further analysis due to erroneous coding or missing data in the patients’ medical records. We included 524 cases (3.0% of all deliveries) of adverse events in the final analysis. Medical errors caused by substandard care were present in 295 (56.2%) cases. There was no difference in the prevalence of substandard care among the maternity units according to their size. Surprisingly, we found significantly fewer cases with substandard care in the units which the supervisory authorities considered particularly risky before the inspection, compared with the control units. Seven of the 12 units had regular formal teaching and training arrangements for obstetric healthcare personnel as outlined in the national guidelines. Conclusions - Prevalence of adverse events was 3% and similar in all maternity units irrespective of their size. A breach in the standard of care was observed in 56.2% of cases and almost half of the maternity units did not follow national recommendations regarding teaching and practical training of obstetric personnel, suggesting that they should focus on implementing guidelines and training their staff.

OBJECTIVE: To study vaginal delivery outcomes and neonatal prognosis and summarize the management of vaginal delivery during the COVID-19 pandemic. METHODS: A retrospective analysis of medical records and comparison of vaginal delivery outcomes between 10 pregnant women with clinical diagnosis of COVID-19 and 53 pregnant women without COVID-19 admitted to Zhongnan Hospital of Wuhan University between January 20 and March 2, 2020. Results of laboratory tests, imaging tests, and SARS-CoV-2 nucleic acid tests were also analyzed in neonates delivered by pregnant women with clinical diagnosis of COVID-19. RESULTS: There were no significant differences in gestational age, postpartum hemorrhage, and perineal resection rates between the two groups. There were no significant differences in birth weight of neonates and neonatal asphyxia rates between the two groups. Neonates delivered by pregnant women with clinical diagnosis of COVID-19 tested negative for SARS-CoV-2 infection. CONCLUSIONS: Under the premise of full evaluation of vaginal delivery conditions and strict protection measures, pregnant women with ordinary type COVID-19 can try vaginal delivery without exacerbation of COVID-19 and without increasing the risk of SARS-CoV-2 infection in neonates.

Aim To study brain-sparing physiological responses in a rodent model of birth asphyxia which reproduces the asphyxia-defining systemic hypoxia and hypercapnia. Methods Steady or intermittent asphyxia was induced for 15-45 min in anesthetized 6- and 11-days old rats and neonatal guinea pigs using gases containing 5% or 9% O2 plus 20% CO2 (in N2). Hypoxia and hypercapnia were induced with low O2 and high CO2, respectively. Oxygen partial pressure (PO2) and pH were measured with microsensors within the brain and subcutaneous (?body?) tissue. Blood lactate was measured after asphyxia. Results Brain and body PO2 fell to apparent zero with little recovery during 5% O2 asphyxia and 5% or 9% O2 hypoxia, and increased more than twofold during 20% CO2 hypercapnia. Unlike body PO2, brain PO2 recovered rapidly to control after a transient fall (rat), or was slightly higher than control (guinea pig) during 9% O2 asphyxia. Asphyxia (5% O2) induced a respiratory acidosis paralleled by a progressive metabolic (lact)acidosis that was much smaller within than outside the brain. Hypoxia (5% O2) produced a brain-confined alkalosis. Hypercapnia outlasting asphyxia suppressed pH recovery and prolonged the post-asphyxia PO2 overshoot. All pH changes were accompanied by consistent shifts in the blood-brain barrier potential. Conclusion Regardless of brain maturation stage, hypercapnia can restore brain PO2 and protect the brain against metabolic acidosis despite compromised oxygen availability during asphyxia. This effect extends to the recovery phase if normocapnia is restored slowly, and it is absent during hypoxia, demonstrating that exposure to hypoxia does not mimic asphyxia.

Chronic expanding hematoma (CEH) is a rare disease that can develop in any region of the body, but it most frequently develops in the thorax. When intrathoracic CEH is left untreated, gradually expanding hematoma can be life-threatening, leading to respiratory failure or hemoptysis. We encountered an 89-year-old man with cardiopulmonary arrest on arrival. He had been healthy, and it was unclear whether CEH had previously been detected. A very large mass was observed on chest computed tomography (CT), but the cause of death could not be determined. In the autopsy, this mass was identified as CEH and no malignant findings were noted. A fresh hemorrhage had occurred in the hematoma and perforated the bronchial lumen, which caused airway obstruction/asphyxia and resulted in sudden death. CEH should be suspected when a very large tumorous lesion occupying the entire hemithorax is observed on chest imaging, and it is important to recognize that sudden death can occur in the natural course of CEH.