A 25-year retrospective review of deaths due to pediatric neglect

Neglect, defined as the failure of a caregiver to adequately provide safety, food, clothing, shelter, education, protection, medical/dental care, and supervision for a child in his/her care, is a relatively uncommon but important cause of child mortality. A retrospective review of pediatric deaths (age 18 years or less) referred to the Medical University of South Carolina Forensic Pathology Office for autopsy over the past 25 years revealed 16 deaths due to some type of pediatric neglect. Cases were analyzed as to age, sex, race, cause and manner of death, autopsy findings, ancillary studies, past medical history, social/family history, and caregiver. Six cases of malnutrition/starvation and/or dehydration were identified, composing the most common cause of death in the neglect cases identified and the majority of the homicides due to neglect. Other deaths in which neglect contributed significantly included toxic ingestions (2 cases), hyper-/hypothermia (2 cases), unusual drowning/aspiration (4 cases), electrocution (1 case), and delayed/absent medical therapy (2 cases, including one of the previously mentioned ingestions). Of these additional cases, 7 were certified as accidental manner, 2 as natural, and 1 as a homicide. Cases which fell into a "gray zone" in which the appropriateness of invoking neglect was a matter of opinion or societal convention were excluded from the review; examples included conventional accidental drowning, choking on food or aspiration of foreign body, overlying/wedging during sleep, accidental hanging, and motor-vehicle traffic accidents (pedestrians, unrestrained passengers). The findings of this review reinforce the fact that malnutrition/starvation and dehydration compose the most common form of lethal pediatric neglect while highlighting less common forms of neglect and the difficulty of determining manner of death in cases in which neglect plays a more questionable role than in seemingly clear-cut malnutrition/starvation and dehydration cases. We demonstrate the typical victim and scenario that investigators will encounter in cases of fatal pediatric neglect, often a child under the age of 1 year who has been deprived of food and/or drink for some time, or an older, more independently mobile child who has not been adequately supervised. These children may or may not have a demonstrable prior history of maltreatment or (nonfatal) neglect, and review of medical records is an important part of the investigation. We additionally discuss key gross autopsy findings, appropriate specimen collection, helpful ancillary studies, microscopic findings of significance, potential mimickers of neglect, and other special considerations in cases of pediatric neglect.     

Ancillary studies in amniotic fluid embolism: a case report and review of the literature

The incidence of amniotic fluid embolism during pregnancy is approximately 1/50,000 and has a mortality rate in excess of 80%. The postmortem diagnosis of amniotic fluid embolism can be challenging for forensic investigators and pathologists. At autopsy, usually signs of disseminated intravascular coagulation suggest an amniotic fluid embolism. A definitive diagnosis of amniotic fluid embolism cannot be made until ancillary studies are performed on the decedent's tissues. We report a case of a 37-year-old G3P2 white female who was 36 weeks gestation when her membranes spontaneously ruptured. She suddenly became breathless, went into cardiogenic shock, and died. The autopsy revealed gross and microscopic findings of amniotic fluid embolism, which was confirmed with ancillary studies consisting of special stains, immunohistochemistry, and a serum tryptase level. The authors hope this case report, including gross and microscopic autopsy findings with procedural and ancillary studies, and review of the literature will help investigators and pathologists in the diagnosis of amniotic fluid embolism.     

Quantitative analysis of multiple illicit drugs in preserved oral fluid by solid-phase extraction and liquid chromatography-tandem mass spectrometry

We present a validated method for the simultaneous analysis of basic drugs which comprises a sample clean-up step, using mixed-mode solid-phase extraction (SPE), followed by LC-MS/MS analysis. Deuterated analogues for all of the analytes of interest were used for quantitation. The applied HPLC gradient ensured the elution of all the drugs examined within 14 min and produced chromatographic peaks of acceptable symmetry. Selectivity of the method was achieved by a combination of retention time, and two precursor-product ion transitions for the non-deuterated analogues. Oral fluid was collected with the Intercept, a FDA approved sampling device that is used on a large scale in the US for workplace drug testing. However, this collection system contains some ingredients (stabilizers and preservatives) that can cause substantial interferences, e.g. ion suppression or enhancement during LC-MS/MS analysis, in the absence of suitable sample pre-treatment. The use of the SPE was demonstrated to be highly effective and led to significant decreases in the interferences. Extraction was found to be both reproducible and efficient with recoveries >76% for all of the analytes. Furthermore, the processed samples were demonstrated to be stable for 48 h, except for cocaine and benzoylecgonine, where a slight negative trend was observed, but did not compromise the quantitation. In all cases the method was linear over the range investigated (2-200 microg/L) with an excellent intra-assay and inter-assay precision (coefficients of variation <10% in most cases) for QC samples spiked at a concentration of 4, 12 and 100 microg/L. Limits of quantitation were estimated to be at 2 microg/L with limits of detection ranging from 0.2 to 0.5 microg/L, which meets the requirements of SAMHSA for oral fluid testing in the workplace. The method was subsequently applied to the analysis of Intercept samples collected at the roadside by the police, and to determine MDMA and MDA levels in oral fluid samples from a controlled study.     

Accuracy of facial soft tissue thickness measurements in personal computer-based multiplanar reconstructed computed tomographic images

The purpose of this study was to determine the precision and accuracy of facial soft tissue measurement using personal computer (PC)-based multiplanar reconstructed (MPR) computed tomography (CT) images and to evaluate the effect of the various CT scanning protocols on the facial soft tissue thickness measurement. Thirteen different CT imaging protocols were used to image a cadaver head. MPR reformations and three-dimensional (3D) reconstructions viewed on a laptop PC were used to make measurements at six specific sites on each set of images. These measurements were compared to physical measurements at the same sites. Increasing the slice thickness resulted in decreased image quality. Within the same slice thickness, increasing the pitch ratio in the spiral mode, resulted in decreasing image quality. The image quality of conventional CT scanning was relatively poorer than that of the spiral CT scanning. However, the mean deviation from the physical measurement was within 0.43 mm in every instance. This mean deviation was quite small and clinically acceptable for measuring the soft tissue thickness of the facial area. PC-based MPR CT images of the face using routine scanning CT protocols can be used to accurately measure soft tissue thickness in the facial region. However, for more fine and accurate data collection, scanning protocols with slice thicknesses less than 5mm, and a spiral/helical mode pitch less than 2:1 are recommended.     

Allele frequencies for nine STR loci in a Korean ethnic group from northeast China

Allele frequencies for the nine tetrameric short tandem repeats (STR) loci D3S1358, vWA, FGA, D8S1179, D21S11, D18S51, D5S818, D13S317, D7S820 (AmpFlSTR) Profiler Plus PCR Amplification kit, PE Applied Biosystems) were determined in 109 unrelated Korean ethnic group individuals from northeast China.     

When Loving Means Hurting: An Exploration of Attachment and Intimate Abuse In a Community Sample

Intimate relationship abuse can be understood by considering two critical tenets of attachment. First, attachment fulfills a basic need for survival. Thus, the tenacity of the attachment bond is independent of relationship quality. Second, individuals whose attachment needs have been frustrated may strike out violently to regain proximity to the perceived loss of an intimate partner. We examined how individual differences in attachment were associated with women's and men's relationship abuse. A telephone survey assessed levels of psychological and physical abuse in 1249 Vancouver residents. Of these, 128 completed an attachment interview exploring their interpersonal relationships. Hierarchical regressions revealed that attachment variables contributed significant variance to prediction of both receipt and perpetration of psychological and physical abuse, with preoccupied attachment acting as an independent predictor. There was no evidence that gender moderated these associations. The findings suggest that attachment preoccupation in either partner may increase likelihood of abuse in couples.     

Correlates of Ideal Body Size Among Black and White Adolescents

Cultural differences have been found in body image perceptions among Black and White adolescents, however little is known about the factors associated with perceptions of an ideal body size (IBS). This study examined differences in correlates of IBS among 265 Black (116 girls and 62 boys) and White (63 girls and 24 boys) adolescents. IBS for White girls and boys was related to perceptions of how their parents wanted them to look, while IBS for Black girls was related to perception of how peers look and would like to look. IBS for Black boys was significantly related to perceptions of their current size, how peers would like to look, how parents think they look, and depressive symptoms. Findings suggest cultural differences in the factors related to body image perceptions and have implications for educational programs promoting healthy body image development among Black and White adolescents.Assistant Professor, Department of Preventive Medicine and Public Health, University of Kansas Medical Center. Received PhD in Counseling Psychology from University of Missouri-Kansas City. Research interests include environmental and cultural correlates of obesity, obesity prevention, nicotine and tobacco addiction, and health promotion interventions.Assistant Professor, Department of Pediatrics, University of Minnesota. Received medical degree from Christian Medical College, Punjab, India, and Master of Public Health from University of Kansas School of Medicine. Research interests include diet and physical activity behaviors, role of the environment in obesity and obesity prevention, especially among children and adolescents.Research Associate, Department of Preventive Medicine and Public Health, University of Kansas Medical Center. Completing PhD in clinical psychology from University of Kansas and Master of Public Health from University of Kansas School of Medicine. Research interests include obesity prevention, smoking cessation, and positive psychology.Assistant Professor and Director, MPH Program, Department of Preventive Medicine and Public Health, University of Kansas Medical Center. Received MPH from Boston University and PhD in epidemiology from the University of California/San Diego State University. Research interests include behavioral epidemiology of tobacco use among adolescents and ethnic minorities.Professor of Medicine and School of Public Health, University of Illinois at Chicago, Associate Director, Midwest Center for Health Services and Policy Research, Jesse Brown VA Medical Center, Director, Section of Health Promotion Research, Department of Medicine, University of Medicine, University of Illinois at Chicago. Received PhD in clinical psychology from Long Island University. Research interests include obesity prevention, binge eating, and cultural differences in eating behavior.Medical Epidemiologist, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention. Received MD and MPH from Tongji Medical University, Wuhan, China and PhD from University of Southern California Keck School of Medicine. Research interests include the etiology, epidemiology, and prevention ofobesity, metabolic syndrome, and diabetes.Research Instructor, Department of Preventive Medicine and Public Health, University of Kansas Medical Center. Received MBBS from Allama Iqbal Medical College, Punjab University, Lahore, Pakistan and MPH from University of Kansas Medical Center. Research interests include smoking cessation, database design, implementation, data management and analysis, and use of information technology in health care settings.Professor Department of Medicine and Office of Clinical Research, University of Minnesota School of Medicine. Received MD/MPH from Tulane University and MS from Harvard School of Public Health. Research interests include disparities in healthcare; smoking cessation among underserved populations, specifically African Americans; diet, nutrition, obesity, and physical activity.     

Defining the limits of the North Korean Human Rights Act: A security and legal perspective

The introduction of the North Korean Human Rights Act of 2004 (HR 4011 or the Act) was hailed by many in the U.S. Congress as a significant and much-needed legislative effort that would substantially improve the human rights conditions of North Korea, considered to be one of the most unpredictable and undemocratic regimes in the world today. The passage of HR 4011 effectively marked a new and notable phase within U.S. foreign policy, in which the issue of human rights was directly linked to the issue of North Korean nuclear non-proliferation in a Helsinki-style framework. Relating to the Act, this paper argues from cross-cultural, security, and legal perspectives that HR 4011 may encounter specific limitations, which may hinder the Act from reaching its stated objectives of furthering “respect for and protection of fundamental human rights in North Korea” and “to promote a more durable humanitarian solution to the plight of North Korean refugees.” Although improving human rights is a fundamentally important issue, linking human rights with DPRK nuclear non-proliferation through HR 4011’s explicit Helsinki-style approach may exacerbate rather than eradicate North Korean human rights violations as well as the DPRK’s ongoing nuclear standoff with the international community.