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Pathology:
doi: 10.1097/01.PAT.0000412601.60566.c5
Abstracts

Forensic Pathology

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ADVANCED FORENSIC PATHOLOGY: QUIZ

Neil Langlois

Forensic Science SA and University of Adelaide, Adelaide, SA, Australia

This will be a quiz session using the audience response keypads that have been funded by the Royal College of Pathologists of Australasia (RCPA) through the provision of Specialist Training Programme (STP) grants by the Australian Government Department of Health and Ageing (DoHA). This will allow anonymous answers to be collected and informative feedback provided for each question as the quiz progresses.

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NEUROTRAUMA: BASIC PRINCIPLES OF ADULT NEUROTRAUMA AND AREAS THAT CAUSE DIAGNOSTIC PROBLEMS

Colin Smith

Academic Department of Pathology, University of Edinburgh, Edinburgh, UK

Traumatic brain injury remains a major cause of morbidity and mortality, and a common problem in forensic pathology practice. A majority of cases are relatively straight forward, with only a small number of cases presenting diagnostic challenges. This talk will provide an overview of the major pathologies seen in blunt force head injury and, in particular, some time will be spent on diffuse traumatic axonal injury and its diagnosis. I will touch on some aspects of penetrating and blast head injuries, updating on recent research around blast injury in particular.

I will focus on specific issues of forensic interest such as ‘talk and die’, delayed traumatic intracerebral haemorrhage, and the settings in which diffuse traumatic axonal injury may be seen. The talk will finish with some discussion around the association (or otherwise) between neurodegeneration and long-term survivors of head injury.

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NON-ACCIDENTAL INJURY IN CHILDHOOD: AN UPDATE COVERING NEUROPATHOLOGY ASPECTS INCLUDING AN UPDATE ON THE CURRENT SITUATION IN THE UK

Colin Smith

Academic Department of Pathology, University of Edinburgh, Edinburgh, UK

Non-accidental head injury (NAHI) in childhood is the greatest area of controversy in forensic neuropathology. The concept of the ‘triad’ (bilateral thin film subdural haemorrhage, retinal haemorrhages, encephalopathy) and its relationship with head injury has been challenged both in courts and in the scientific peer reviewed literature. Equally mechanistic explanations (shaking or shaking-impact) for the injuries remain controversial.

This talk will explore what is known and what is controversial in this area, and will critically assess the existing literature. The talk will start with discussion of obstetric head injury and accidental childhood head injury, before moving onto NAHI. There will be discussion of animal data and how this relates to human NAHI, and a detailed assessment of each aspect of the triad, with critical assessment of the literature. There will also be discussion of some of the alternative ‘natural disease’ explanations for NAHI.

Reference

1. Squier W. The ‘Shaken Baby’ syndrome: pathology and mechanisms. Acta Neuropathol 2011; 122: 519-42.

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MECHANISMS OF CERVICAL SPINAL INJURY

Ellen Frydenberg, Timothy Steel

St Vincent's Hospital, Darlinghurst, NSW, Sydney

Cervical spinal injuries can cause a broad range of deficits. Injury to the spinal cord and nerves can lead to significant neurological impairment. Injury to the bones, discs, ligaments and muscles can cause a range of biomechanical syndromes.

In our recent review of road trauma patients, 8.5% sustained significant spine injuries.1 The cervical spine is particularly at risk in trauma as it is mobile compared to the thoracic spine, which is stabilised by ribs.

Allen's classification system is used for cervical spine injuries.2 Six mechanisms are described, taking into account the direction of impact and the position of the head and neck at time of injury: compressive flexion, vertical compression, distractive flexion, compressive extension, distractive extension and lateral flexion.

Spine injuries are most common amongst pedal cyclists (13.3% of all severe injuries), followed by rear-seat passengers, front-seat passengers, car drivers, motor cyclists and pedestrians.1

References

1. Frydenberg E, Curtis K, Chong S, et al. Road trauma, patterns of injury and mortality in an Australian trauma centre. J Australas College Road Safety 2012; 23(1).

2. Allen B, Ferguson R, Lehmann T, O’Brien R. A mechanistic classification of closed, indirect fractures and dislocations of the lower cervical spine. Spine 1982; 7: 27.

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SOFT TISSUE NECK INJURIES

Ricardo Hamilton

Liverpool Hospital, Sydney, NSW, Australia

The management of neck injuries differs with penetrating versus blunt and is highly dependent on the haemodynamic and physiological status of the patient.1 Traditionally our practice guidelines for penetrating injuries were firmly directed if platysma was breached, with the only variability being time to intervention based upon the anatomic level or ‘zone’ of injury. Today, the dogma of mandatory exploration, especially in Zone II, is being challenged as greater clinical experience and new imaging capabilities evolve.2 Blunt trauma composes only about 5% of all neck trauma with the most common injuries being contusions, muscle strains and ligamentous sprains. In both mechanisms of trauma, those injuries that become life threatening or have significant morbidity or mortality involve the airway, aerodigestive tract, vascular structures and/or nerves. By following the sound principles of Advanced Trauma Life Support (ATLS), the obvious threats are noted and addressed quickly. However, those that are subtle can be missed, have insidious onsets and are often only discovered at a severely deteriorated clinical state or at post-mortem.1

References

1. Rathlev NK, Medzon R, Bracken ME. Evaluation and management of neck trauma. Emerg Med Clin N Am 2007; 25: 679–94.

2. Tisherman SA, Bokhari F, Collier B, et al. Clinical Practice Guidelines: Penetrating Neck Trauma. Chicago: Eastern Association for the Surgery of Trauma, 2008. http://www.east.org/Content/documents/practicemanagementguidelines/neck-penetrating-tra.pdf

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SPINAL CORD AND VASCULAR CONSEQUENCES OF NECK INJURIES

Colin Smith

Academic Department of Pathology, University of Edinburgh, Edinburgh, UK

The spinal cord is often neglected at autopsy and as such can cause problems in interpretation for pathologists not used to assessing spinal injury. This talk will cover both brainstem and spinal cord pathologies associated with trauma, providing a simple classification of such injuries. The talk will also cover injury to the vertebral arteries as a cause of traumatic subarachnoid haemorrhage, and will also cover other potential causes of traumatic subarachnoid haemorrhage.

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MATERNAL DEATH FROM RUPTURED SPLENIC ARTERY ANEURYSM

Nadine Forde

Queensland Forensic and Scientific Services, Pathology Queensland, Qld, Australia

A maternal death is defined as the death of a woman while pregnant or within 42 days of the termination of pregnancy from any cause related to, or aggravated by, the pregnancy or its management. Australia has a maternal mortality ratio of approximately 8 deaths per 100 000 live births. The case of a young woman who collapsed at home in her third trimester as a result of catastrophic abdominal haemorrhage is presented. At autopsy, the cause was found to be ruptured splenic artery aneurysm. This is followed by a discussion of the classification of maternal deaths together with a review of the current literature regarding splenic artery aneurysms, their causes, clinical presentation, management and the autopsy findings in fatal cases.

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ECMO, CVVHDF, ETC: New ICU/HDU TREATMENTS AND OTHER TLAS

Amy Hewison

Path West Laboratory Medicine WA, Australia

This is a review of current and upcoming intensive care unit (ICU) and high dependency unit (HDU) therapies with a focus on post-mortem findings and artefacts complicating post-mortem examination.

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BODIES IN WHEELIE BINS

Jennifer Pokorny

Department of Forensic Medicine, Sydney, NSW, Australia

The discovery of a body in a wheelie bin is an infrequent occurrence in forensic practice and typically triggers its investigation as a suspicious case. The scene often appears complex or altered and the cause of death may not be readily apparent. However, pathological and investigative evidence may reveal one of a number of causes and manners of death, and not every case will represent a homicide. This talk presents four recent cases from the Department of Forensic Medicine in Sydney, as well as a brief review of the relevant literature, discussing possible causes of death that may present in this way and exploring their features.

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PROTOCOLS IN FORENSIC NEUROPATHOLOGY

Colin Smith

Academic Department of Pathology, University of Edinburgh, Edinburgh, UK

The practice of forensic neuropathology has changed due to both changes in attitudes to brain retention and to the availability of neuropathologists. This talk will cover alternative approaches to brain examination which do not require whole organ retention but do provide an adequate neuropathological examination. I will cover examination with no fixation, rapid fixation, delayed examination, and will touch on single slice retention, although this will be covered in greater detail in the talk by Dr Iles.

The talk will then address the issue of standard protocols for block taking in certain situations, the aim being to give the non-neuropathologist an approach that should allow diagnosis in most cases, and will be adequate for referral to a specialist centre if required. Time permitting there will be discussion of the role of specialists and the risk of loss of expertise within forensic pathology with too great a reliance on specialists.

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SEXUAL ASSAULT FORENSIC WORKSHOP

Christopher Lawrence

Statewide Forensic Medical Services, Tas, Australia

The Vincent Report into the Farah Jama Case highlights the issues regarding the taking of sexual assault evidence and the potential risks of contamination. This workshop aims to use the lessons learned in forensic medicine in relation to sexual assault in live victims and translated into better processes for examining the dead victims of sexual assault in order to prevent the risk of cross contamination.

We will be producing a number of scenarios and using mannequins to demonstrate the appropriate system for taking sexual assault evidence to minimise the risk of contamination and also to assist with the documentation and recognition of particular patterns of injury in sexual assault and their potential significance in recovering valid forensic evidence in these contexts.

The workshop will be run by Dr Cathy Lincoln who has extensive experience in distinguishing between genital injuries in sexual assault and consensual sex and Dr Chris Lawrence who is the Director of Statewide Forensic Medical Services for the State of Tasmania.

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SEXUAL HOMICIDES

Paul Bedford

Victorian Institute of Forensic Medicine, Melbourne, Vic, Australia

A number of cases will be presented highlighting issues relating to the investigation of deaths where there is a sexual element. In addition there will be a discussion as to what is meant by the term ‘sexual homicide’.

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PATHOLOGICAL APPROACH TO THE PELVIC EXAMINATION

Heinrich Bouwer

Victorian Institute of Forensic Medicine, Melbourne, Vic, Australia

It is occasionally necessary to remove the whole genital tract during autopsy. In forensic cases, where the death is associated with sexual offences, a meticulous external and internal pelvic examination may be necessary, especially in victims when pelvic trauma may be the immediate cause of death. After the external assessment, any samples required for microbiological, biochemical, toxicological or other analysis should be taken, before evisceration and organ dissection. It may also be necessary to examine the whole genital tract in maternal deaths during or following pregnancy, and deaths following abortion or miscarriage.

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SEXUAL ASSAULT SPECIMENS: WHAT HAPPENS IN THE LAB?

Robert Goetz

Division of Analytical Laboratories, NSW, Australia

Examination of exhibits taken from a patient of a suspected sexual assault for the presence of biological material has undergone massive change over the last few years. The presence of semen on one of the exhibits will invariably result in a DNA profile but even when semen is absent, trace DNA analysis can provide sufficient information to identify the alleged offender. With this increased sensitivity comes the increased likelihood of contamination, and protocols must be present to ensure that contamination is minimised. Nevertheless, while the correct result is an imperative, the criminal justice system must also be served by reducing the backlog of unexamined sexual assault kits and providing quick feedback of the results to the criminal investigator. This talk will discuss the success of newer methodologies available in the NSW DNA testing laboratory including the use of new extraction chemistries and liquid handling platforms which has resulted in higher throughput of samples. Using case examples it will examine the use of alternative methodologies such as Y-STR DNA kits in providing evidence to the courts. Lastly, it will address the increased sensitivity of detection and issues relating to contamination minimisation at a laboratory level.

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POST-SURGICAL COMPLICATIONS IN CONGENITAL HEART DISEASE AND THE FORENSIC AUTOPSY

D. M. Moss, J. White

Department of Forensic Pathology, PathWest, Perth, WA, Australia

Whilst congenital heart disease in infants and young children is not an uncommon problem in clinical paediatrics, they are not cases that are frequently dealt with by the forensic pathology community. When they do present as Coronial autopsies, though, they can present many problems to the pathologist. We will review some of the common types of congenital heart disease, and the relevant operative management before describing several recent cases from Western Australia that will highlight the difficulties faced at autopsy and also the advantages of having a close working relationship with paediatric pathologists, cardiothoracic surgeons and paediatric cardiologists.

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© 2012 Royal College of Pathologists of Australasia

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