F. Rocko. Simpson College, Redding California.

Most occur in the midportion and are similar in location to those resulting from accidental trauma order levitra professional line impotence at 46. Fractures of the distal ends of the clavicle are less common and are caused by sudden traction on the extremity order generic levitra professional pills erectile dysfunction market. The Shaken Baby Syndrome “If any one of them can explain it discount 20mg levitra professional with visa erectile dysfunction patient.co.uk doctor,” said Alice … “ I’ll give him sixpence. In other words, these injuries were not caused by direct-impact injuries to the head, but rather by indirect acceleration–deceleration traction stresses caused by the head’s whipping back and forth. Caffey’s paper also suffered from a number of problems in regard to his case material, e. If death occurred, autopsies were not always performed and scant mention was made of the findings. Following the initial description, as more cases of this syndrome were diagnosed and studied, injuries to the scalp and skull (contusions and fractures), explainable only by impact trauma, began to be detected in alleged cases. At autopsy, however, all 13 children had evidence of blunt head trauma: eight had soft tissue contusions and five had contusions and skull fractures. Of the seven deaths in which blunt trauma to the head was missed clinically, four presented with the classical symptoms of retinal hemorrhage, subdural hematoma, and subarachnoid hemorrhage. The other three, while having subdural hematoma and subarachnoid hemorrhage, did not have retinal hemorrhage. No way of differentiating pre-impact intracranial trauma from post- impact is given. To many observers, the “shaken impact syndrome” appears to be an attempt to explain away inconvenient observations that call into question the existence of the shaken baby syndrome itself. The way to accomplish this is by exper- imentation and repeated objective observations to exclude other possible explanations. Establishment of the validity of a hypothesis by observation is dependent on the quality of the observations and the observer. Observations might be handicapped by limitations of the senses or equipment employed. The quality of the observer is determined by training and experience but might be mod- ified by prejudice and emotions. These latter qualities might cause individuals to either consciously or unconsciously distort the evidence to fit a precon- ceived theory. The individual charged with injury to a child cannot be con- sidered an objective unbiased observer. Most people charged with injuring or killing a child would rather confess to or be charged with shaking a baby than slamming its head against an object or throwing it across a room like a football. Obviously, it is easier to claim as a defense ignorance of the consequences of shaking, rather than the other actions. The original observations, in which head impact was “excluded,” were almost all clinical and did not involve autopsies. Cases where the child does not die and the absence of signs of impact are based on external and radiological examinations cannot be used to substantiate the existence of this entity, as there can be extensive impact injury, such as skull fractures, without either external or radiologic evidence of trauma. Absence of external or radiological evidence of injury, in cases where massive trauma is demonstrated at autopsy, is routinely seen by all experienced forensic pathologists. One cannot blithely propose two causes for injuries in a case where one will be sufficient just because this fits a preexisting theory or prejudice. After each shaking episode, the occipital area of the model was impacted against either a metal bar or padded surface. The results of 69 Neonaticide, Infanticide, and Child Homicide 361 shaking tests were then compared with 60 impacts. Thus, acceleration due to impact exceeded acceleration due to shaking by a factor of nearly 50 times. As expected, impact against a padded surface was associated with significantly smaller acceleration (mean 380. Both the magnitude of angular acceleration and the time interval of the acceleration are important biomechanical factors influencing the nature of the injuries. Large angular accelerations over short time intervals tend to result in subdural hematomas, while longer intervals are associated with diffuse axonal injury. Based on work by Thibault and Gennarelli on subhuman primates, the angular acceleration and velocity associated with shaking is below the injury range for concussion, subdural hematoma or diffuse axonal injury, while the results from the impacts are within the range. What about the rare case of traumatic intracranial bleeding in a child where there is no evidence of impact on the scalp or skull? The authors have seen numerous cases of witnessed impact involving both adults and children who subsequently died of head trauma in which there was no evidence of impact in the scalp or skull at autopsy. This observation is in agreement with the opinions of Bernard Knight, who, in his book Forensic Pathology, in discussing acute subdural hematomas, states “… blunt impacts may leave no sign in the scalp, externally or internally, and no skull fracture. This situation may well have arisen because a blunt impact upon the head of an infant, if spread over a wide area following contact with a flat surface, can leave no external scalp mark, no subscalp bleeding and no fracture of the skull — yet the transmitted forces can still be sufficient to cause high strain — shearing stresses within the cranial cavity leading to subdural bleeding. First, the underlying premise (the existence of the shaken baby syndrome) is unproven. Second, retinal hemorrhage occurs with other etiologies: acci- dental trauma (especially subdural hematoma); resuscitation (rarely); papilledema; in 14. Suggested are increased retinal venous pressure, extravasation of subarachnoid blood, and traction of retinal vessels at the vitreo-retinal inter- face due to angular deceleration. If the head is whipping back and forth with such velocity as to tear cerebral blood vessels and cause retinal hemorrhage, why are there no fractures of the cervical spinal column? When challenged in regard to this, the reason is said to be the suppleness (bendability) of the spine in small children. The cord should be crushed by the “supple” vertebrae shifting back and forth — or, if not crushed, at least torn or severely stretched. They concluded that the presence of epidural hemorrhage in the cervical cord area was not related to trauma, not damaging to the cord, and probably due to hemodynamic forces. Case, in a study of this phenomenon in 50 children below the age of 3 years, some of whom had been allegedly shaken, found no relationship between shaking and epidural hemorrhages. Since then, we have had no reason to change this opinion but rather to solidify it. The authors feel that head injury ascribed to shaking is due to impact of the head Unintentional Causes of Intracranial Hemorrhage While most children presenting in the first few years of life with intracranial bleeding and retinal hemorrhage are victims of child abuse, this is not abso- lute. Typically presenting 4–6 weeks after birth, it is manifested by intracranial bleeding (subdural, subarachnoid, intracerebral) as well as bleed- ing in the skin, gastrointestinal tract and urogenital tract. In this case, because the child lived long enough to get to the hospital and survived 24 hours, hematological tests could be performed. They revealed prolonged prothrombin and partial thromboplastin times with a normal thrombin time and fibrinogen levels. Severe vita- min K deficiency results in production of this nonfunctioning protein. This and other tests confirmed the diagnosis of late-form hemorrhagic disease of the newborn.

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The patient should have intractable pain and have spine will ease the advancement into the intrathecal space failed more conservative options cheap levitra professional 20 mg with mastercard impotence at 30 years old. The cathe- pain that is amenable to an intrathecal infusion therapy and ter can be advanced posteriorly to the spinal cord in the low should have no major contraindications to this therapy thoracic spine purchase on line levitra professional impotence and alcohol. The negative pressure draws medication from the syringe during pump reflls rather than requiring positive There are several commercially available intrathecal drug pressure from the syringe plunger cheap levitra professional 20 mg impotence high blood pressure. This reduces the risk of delivery pumps offering both programmable and nonpro- inadvertent injection into the pump pocket rather than grammable models. The pump uses a peristaltic roller system to move the more commonly utilized in Europe. The contained propel- drug from the reservoir to the implanted intrathecal catheter. By contrast, the programmable This device uses a pressurized gas chamber as the driving pump can deliver the drug or compounded mixture at a force. The advantage of the Prometra pump is much electronic module allowing adjustment of the fow rates and lower energy requirements. Since the batteries are used to communication to allow frequent dose adjustments including control the electronics only and not to pump the drug, the bolus options which are possible through a telemetry device. It is only available in a 20 mL volume programmable pumps are capable of on-demand dosing that reservoir. Choice of gas as the driving force and a ceramic drive fow valve sys- equipment should be based on the individual medication tem to maintain the infusion rate. The pump has either a requirements of the patient and personal patient preference. The Medallion system offers compatibility that have reduced complications and improved safety improvements with the use of a negative pressure patient outcomes. There are sev- eral commercially available pumps that can deliver predetermined doses of medications continuously with the Fig. They have been demonstrated to provide superior pain con- Psychological Evaluation trol with a lower side effect profle in cancer-related pain [6]. In addition, they are cost-effective and may lower the risk of During patient selection, one has to consider the diversion and abuse of systemic opiate medications. Specifc psychological aspects of intrathecal therapy and implant- techniques have been advocated on insertion of the device to able devices. Chronic pain patients may have comorbid minimize the risk of complications [13, 14]. When implanting the device, care should be taken to avoid placing the pump to close to the rib mar- gin or the iliac crest. This can be achieved by marking the site preoperatively with the patient in the sitting posi- tion. In this position, the site should not hit the lower rib margin or the iliac crest. Intravenous preoperative antibiotics are typically admin- istered at least 30 min prior to skin incision with coverage of typical gram-positive fora. It is typically best, if a patient can tolerate it, to insert the catheter portion of the device under light sedation with Fig. This will allow for patient feedback for improved safety and reduced risk of neu- long-term effcacy of therapy. Once the treatment goals and set realistic expectations during trial catheter is in place, a spinal anesthetic can be adminis- and intrathecal therapy. Although it is not mandatory for tered through the catheter to provide anesthesia for the cancer pain patients, most insurance carriers will require a remainder of the implant. Most practitioners per- ment or a midline incision can be made after the para- form an intrathecal catheter-based trial for intrathecal opi- median placement of the needle using a combination ates and consider single-shot trials for Prialt [17]. The argument approach to the lumbar spine, the Tuohy needle is is that there are many different drugs and combinations that advanced to the intrathecal space (Fig. The can be considered, and it can take months to fnd the right epidural space can first be identified using the loss drug and dose [18]. Once the epidural space is catheter-based trial to proceed with an implanted pump. The fnal location of the catheter can either be in the • Work-up: An appropriate work-up generally involves an low thoracic spine or more cephalad for upper chest appropriate history physical examination, laboratory wall and upper extremity problems. The physical examination ers believe that when one utilizes more lipophilic 45 Intrathecal Drug Delivery Systems 677 Fig. However, in very obese patients, – If using a midline incision, dissection should be per- the depth of this fascia may be too deep, and it is accept- formed laterally just above the dorsal lumbar fascia able to place the pump in the subcutaneous fat. Once the entire circumference it is important to make sure the pocket is small enough to of the needle is free, the needle can be removed and the minimize the risk of rotation. An abdominal binder should proximal catheter end brought into the wound to exit be used for the frst 30 days until a capsule forms to hold the midline incision. All wounds are meticulously irrigated and fold of fascia on either side of the anchor and suture to hemostasis is obtained prior to closure. In this case, the pump can then be started in the offce without a priming bolus as the diffusion of drugs from the reservoir will equilibrate in the catheter. Some Side Effects and Complications advocate this as it avoids a priming bolus and the risk of bolus drug dosing due to the rate of diffusion There are a number of complications that can occur with exceeding the priming bolus rate. Complications can basically be subdivided in to two facets: (1) the initial technical implanta- tion of the pump and (2) long-term complications associated Drugs with the therapy (Table 45. With appropriate work- up, good surgical technique, and postoperative vigilance, the There are multiple drugs that are widely used for intrathecal complications should be rare. The current Bupivacaine 1–4 mg/d standard of care of intrathecal therapies refects on current Clonidine 40–100 mcg/d knowledge from literature and clinical experience. Analysis Sufentanil 10–20 mcg/d of published literature is combined with clinical experience of a large panel of scientist and clinicians to form recom- Table 45. These recommendations should guide Maximum clinical practice, but are not a substitute for clinical judge- Drugs concentration Maximum daily dose ment and are not meant to be a legal document establishing Morphine 20 mg/ml 15 mg the standard of care (Table 45. Hydromorphone is recommended on the basis of widespread clinical use and apparent safety. Fentanyl has been upgraded to frst-line use by the consensus conference Line 2: Bupivacaine in combination with morphine, hydromorphone, or fentanyl is recommended. Alternatively, the combination of ziconotide and an opioid drug can be employed Line 3: Recommendations include clonidine plus an opioid (i. An alternate recommendation is sufentanil in combina- tion with either bupivacaine or clonidine Line 5: The triple combination of sufentanil, bupivacaine, and clonidine is suggested 45 Intrathecal Drug Delivery Systems 679 Table 45. Surgical implantation of both the catheter and pump take implant very specifc skills. Complications and success dependent Early complications Late complications on surgical implantation. Prior to implant, the patient should undergo a proper Dural leak Pump refll (miss reservoir port) medical and psychological evaluation and have reason- Pain at insertion site Drug effects (low testosterone) able expectation of good outcomes in terms of pain relief Spinal cord or nerve injury Catheter break or failure (withdrawal) and quality of life. Management of intrathecal pump patients requires vigi- Pump overdose lance and continued monitoring of benefts and complica- tions such as intrathecal granuloma and pocket refll.

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The inside wing of the spinning aircraft is usually the first to strike the ground discount levitra professional 20 mg amex erectile dysfunction 20 years old, with the outside wing creating a ground scar directly opposite the scar produced by the inside wing buy cheap levitra professional thyroid erectile dysfunction treatment. While most airplane crashes impacting in spin-type accidents do nose down discount generic levitra professional uk impotence at 19, occasionally some will impact flat. When a plane hits the ground while spiraling, the spiral impact pattern is created. Unlike the pattern from the spin impact, however, wreckage is spread over a relatively large, fan-shaped area. The wings may be torn from the aircraft but come to rest some distance from the fuselage. The engines usually separate from their mounts when mounted on the wing and remain near the initial point of impact. The low-speed, small-angle-of-impact accident is usually the result of a forced landing. Here, the aircraft damage is substantially less than that of a high- speed impact and individuals may survive. In the high-speed, small-angle- of-impact, there are long, fan-shaped debris patterns, with the aircraft break- ing into many pieces, the heavier parts traveling the farthest forward in the pattern of debris. As the plane begins to impact, the first mark seen could be from the wheels if the landing gear is down, or the propellers, if the plane is a propeller aircraft. In wooded areas, the wings can be damaged by tree tops long before contacting the ground. High-speed, small-angle-of-impact accidents are essentially caused by a controlled flight into the ground because of flying too low. In in-flight disintegration, major parts of the aircraft are scattered over a wide area without an apparent logical pattern. This type of pattern-less scattering is seen in in-flight explosions, major structural failure and midair collisions. The bodies should be X-rayed for bomb fragments or fragments of the Airplane Crashes 323 plane propelled into the body by an explosion. In-Flight Fire In-flight fires are indicated by elevated carbon monoxide levels in the pas- sengers or crew, as well as the presence of soot downstream from the area of fire damage in the aircraft. Beads of molten aluminum will also be blown downwind along the fuselage from the area of fire damage. In post-crash fires, there is a widespread pattern of soot and fire damage without any specific distribution of soot and melted aluminum. The only unusual aspect of these crashes, compared with those involving fixed-wing aircraft, is that, if a helicopter loses power or is somehow incapacitated in flight (e. The resultant injuries might be more similar to those from falls rather than traditional aircraft crashes Hot-Air Balloons Hot-air ballooning is popular in some areas of the U. Contact with a power line can cause the basket to overturn, or the basket cables to be severed by the wires, or electrocution. Thus, Cherington and Mathys were able to identify only 40 such incidents from 1963–1989. Lightning can cause an accident by (1) entering the fuel compartment and igniting the fuel, (2) temporarily blinding the pilot by the bright flash, or (3) disrupting the electrical system. Because of upgrad- ing of the fuel, electrical and automatic control systems, Cherington and Mathys felt that accidents caused by lightning should become even less com- mon. With the use of composite materials in airplane construction, another problem has arisen. Thus, if they are stuck by lightning, the lightning could burn a hole through the material. Manufactures are developing methods to conduct electricity from lightning strike points. Cherington M and Mathys K, Deaths and injuries as a result of lightning strikes to aircraft. These facts are often misunderstood by both the public and the medical profession. This does not detract from the fact, however, that the vast majority of these cases are of a natural etiology. The former con- dition was manifested by an “enlarged” thymus, in fact, a normal finding in infants. Interstitial pneumonitis was just as nonexistent and essentially referred to the normal hypercellular appearance of the alveolar septae of an infant. In the 1930s and early 1940s, crib deaths were often thought to be caused by suffocation from blankets, bedclothing, or mattresses. Thus, Abramson, in a paper in 1944, reported 139 deaths from suffocation during a 5-year period in New York City alone, a number greater than the total number of deaths from measles, scarlet fever, and diphtheria. Wooley pointed out that he had analyzed the atmosphere 325 326 Forensic Pathology breathed by infants covered in various manners by different types of bedding. He also attempted to induce anoxia by having the subject sleep with the nose and mouth closely pressed to pillows and mattresses. Even the smallest child, however, was capable of rolling aside to obtain a patent airway. Wooley thus concluded that the importance of suffocation as an explanation of sudden death in infancy could not be substantiated. This modification was made so as to prevent infants placed on their sides rolling onto their stomachs. Presentation of Cases As stated previously, there are approximately 3000–4000 deaths per year in the U. While these may also be of unknown etiology, they are most probably not the result of the same conditions that cause death after a month of age. Most probably, these are disorders associated with neonatal development and adaptation to a new world. Race does not appear to be a factor, but the socioeconomic status of the family does. Most chil- dren are found dead in their cribs in the morning when their parents go to feed them. The second death by the same mother is labeled undetermined, and a more intensive investigation of the circumstances surrounding the death is conducted. The police are usually asked to interview the family, though in a discreet fashion. A third death with the same mother is thought by the authors to be homicide until proven otherwise. Allusions are made to mitochondrial disorders, fatty acid oxidation disorders etc. When autopsying the third case, one might consider saving frozen samples of skin, muscle, liver, kidney, lung, brain and heart as well as performing the most recent battery of tests for hereditary disease. Part of the toxicological screen should consist of an electrolyte exam- ination performed on the vitreous. Petechiae of the thymus, epi- cardium, and pleural surfaces of the lungs are common. There have been reports of hypertrophy and hyperplasia of the muscular media of small pulmonary arteries, right ventricular hypertrophy, and brain stem gliosis.