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The American Academy of Pediatrics' Committee on Child Abuse and Neglect, Section on Ophthalmology, acknowledges that searching for retinal hemorrhages (RHs) in infants only in cases of suspected of abuse creates selection bias. However, they also recommend that postmortem eye removal might not be indicated 'in children who have clearly died from witnessed severe accidental head trauma or otherwise readily diagnosed systemic medical conditions.' Although infrequently described in the child abuse literature, peripapillary intrascleral hemorrhages (bleeding in the sclera at the optic nerve insertion)-putatively from severe repetitive acceleration/deceleration forces with or without blunt head trauma-have been considered essentially pathognomonic for abusive head trauma (shaken baby syndrome). We present two neonates who sustained accidental, severe in utero head injuries and had associated extensive RHs and optic nerve sheath hemorrhages with peripapillary intrascleral hemorrhages detected at autopsy. Neither neonate had a documented clinical fundal examination in the intensive care unit. [ABSTRACT FROM AUTHOR]

The medical usefulness of smartphones continues to evolve as third-party applications exploit and expand on the smartphones' interface and capabilities. This technical report describes smartphone still-image capture techniques and video-sequence recording capabilities during postmortem monocular indirect ophthalmoscopy. Using these devices and techniques, practitioners can create photographic documentation of fundal findings, clinically and at autopsy, without the expense of a retinal camera. Smartphone image acquisition of fundal abnormalities can promote ophthalmological telemedicine-especially in regions or countries with limited resources-and facilitate prompt, accurate, and unbiased documentation of retinal hemorrhages in infants and young children. [ABSTRACT FROM AUTHOR]

Background: Fatty acid oxidation disorders may cause sudden and unexpected infant death and are associated with the histological hallmark of hepatic steatosis. The goal of the present study was to assess the value of post-mortem molecular analysis for medium-chain acyl-coenzyme A dehydrogenase (MCAD) and mitochondrial trifunctional protein (MTP) defects in unexplained sudden infant death (SID) associated with fatty infiltration of the liver. MCAD catalyzes the first step of medium-chain fatty acid oxidation while MTP catalyzes the last three steps of long-chain fatty acid oxidation. Methods: In a retrospective study, 220 consecutive cases of sudden and unexplained infant death certified by medical examiners at Wake Forest University Medical Center were assessed for hepatic steatosis. Subjects with evidence of hepatic steatosis were screened for mutations in MCAD and MTPα-subunit using DNA isolated from paraffin-embedded liver tissue, single-strand conformation variance, and nucleotide sequence analyses. Results: Sixteen cases (7.3%) were associated with diffuse micro-vesicular or mixed micro- and macro-vesicular hepatic steatosis. Two of these 16 cases (12.5%) had disease-causing mutations. One was homozygous for the prevalent MCAD A985G mutation. The second was a compound heterozygous for the prevalent MTP G1528C mutation and a novel 1 bp deletion in exon 18 of the MTPα-subunit gene. Conclusions: A significant proportion (7.3%) of SID is associated with hepatic steatosis. The present data support post-mortem molecular analysis for the MCAD A985G and MTP G1528C prevalent mutations in cases of sudden and unexplained infant death associated with hepatic steatosis. [ABSTRACT FROM AUTHOR]

Abstract: Background: Foreign body aspiration in children is commonly seen in emergency departments and carries a significant mortality. Abusive foreign body suffocation is not well described. Methods: We present a case-series of four infants who presented with aspiration of a baby wipe. Results: Each child was found to be a victim of child physical abuse with substantial morbidity and mortality associated with the aspiration of the wipe and associated injuries. Conclusions: We recommend that infants who present with a baby wipe aspiration should be considered as likely victims of child abuse and physicians should evaluate each infant for associated injuries of the oropharynx, skin, skeleton, and head. [Copyright &y& Elsevier]

Features the postmortem monocular indirect ophthalmoscope used by ophthalmologists in the U.S. Contribution of the technology in forensic investigation; Mechanics of the operation; Presentation of an optical diagram depicting indirect ophthalmoscope and direct ophthalmoscope.

Air embolism is often unrecognized and underreported. Published case reports or case series describe only rare fundal examinations of retinal air emboli (RAE)—a distinctive sign of systemic air embolism. We report an infant, found unresponsive at home, who died in the emergency department after unsuccessful resuscitative efforts. Before the autopsy, diagnostic RAE were recognized and imaged during postmortem funduscopy. Postmortem radiography and an autopsy confirmed systemic (paradoxical) air embolism due to inflicted abdominal and thoracic blunt force injuries. While a few descriptions and illustrations of RAE occur in case reports, we found no published photographic images of RAE in infants, children, or adults. This case report describes and photographically documents classic RAE associated with fatal systemic (paradoxical) air embolism. Complementing postmortem radiography and judicious autopsy techniques, the detection of RAE can aid pathologists in diagnosing systemic air embolism. [ABSTRACT FROM AUTHOR]

Although the ophthalmoscope was invented by Hermann von Helmholtz in 1851, pathologists until recently have relied almost exclusively on ocular enucleation to identify and describe postmortem fundal abnormalities. An inexpensive but valuable tool for forensic pathologists, the postmortem monocular indirect ophthalmoscope consists of a light source attached to a headband along with a hand-held lens. This permits a wide view of the fundus after death but the technique can be challenging to master for pathology residents and forensic pathology fellows. To facilitate skill acquisition in monocular indirect ophthalmoscopy, a simple and inexpensive teaching model can be constructed from hinged, cylindrical plastic containers. An artificial pupil created in the lid and a removable color fundal image placed in the bottom of the opaque container allows the pathologist-in-training to practice the technique of monocular indirect ophthalmoscopy and correctly identify, localize, and describe fundal abnormalities such as retinal hemorrhages. [ABSTRACT FROM AUTHOR]

A response by Patrick E. Lantz and colleagues to a letter to the editor about their article "Fatal acute intracranial injury, subdural hematoma, and retinal hemorrhages caused by stairway fall," in the 2011 issue, is presented.

We describe an infant with an acute subdural hematoma, a fatal head injury, and severe hemorrhagic retinopathy caused by a stairway fall. His cerebral and ocular findings are considered diagnostic of abusive head trauma by many authors. Our literature search of serious injuries or fatalities from stairway or low-height falls involving young children yielded 19 articles of primary data. These articles are discrepant, making the classification of a young child's death following a reported short fall problematic. This case report contradicts the prevalent belief of many physicians dealing with suspected child abuse that low-height falls by young children are without exception benign occurrences and cannot cause fatal intracranial injuries and severe retinal hemorrhages. The irreparable harm to a caregiver facing an erroneous allegation of child abuse requires physicians to thoroughly investigate and correctly classify pediatric accidental head injuries. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Fibromuscular dysplasia is an idiopathic, nonatheromatous, and noninflammatory arterial disease that most commonly affects the renal and carotid arteries. We report a child with subarachnoid and ocular hemorrhage associated with an aneurysm due to fibromuscular dysplasia. Computed tomography following a witnessed collapse revealed diffuse subarachnoid hemorrhage and severe cerebral edema. An autopsy confirmed the radiographic findings and detected bilateral retinal hemorrhages, optic nerve sheath hemorrhages, and a ruptured saccular aneurysm due to focal fibromuscular dysplasia involving the intracranial right vertebral artery. This case documents a fatal subarachnoid hemorrhage in a child with an intracranial saccular aneurysm caused by fibromuscular dysplasia. The associated retinal hemorrhages are easily detected by postmortem monocular indirect ophthalmoscopy. [ABSTRACT FROM AUTHOR]

Background: Hemophagocytic lymphohistiocytosis (HLH) is an uncommon hyperinflammatory condition in children that may acutely mimic septic shock. Sudden out-of-hospital cardiac arrest in children is also uncommon and may be of unclear etiology upon initial presentation.Case Report: A 10-year-old previously healthy child presented with sudden cardiac arrest after an insidious course of throat pain, fever, and progressive altered mental status. He was subsequently diagnosed with Epstein-Barr virus-associated HLH and suffered cerebral edema and death. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: HLH has not previously been described as a cause of sudden out-of-hospital cardiac arrest in children. Rapid diagnosis of underlying cause of an unexpected cardiac arrest may help guide appropriate therapy to salvage organ function. [ABSTRACT FROM AUTHOR]