Medico-legal Setting Research Articles

Cross-Validating the Atypical Response Scale of the TSI-2 in a Sample of Motor Vehicle Collision Survivors

This study was designed to evaluate the utility of the Atypical Responses (ATR) scale of the Trauma Symptom Inventory – Second Edition (TSI-2) as a symptom validity test (SVT) in a medicolegal sample. Archival data were collected from a consecutive case sequence of 99 patients referred for neuropsychological evaluation following a motor vehicle collision. The ATR’s classification accuracy was computed against criterion measures consisting of composite indices based on SVTs and performance validity tests (PVTs). An ATR cutoff of ≥ 9 emerged as the optimal cutoff, producing a good combination of sensitivity (.35-.53) and specificity (.92-.95) to the criterion SVT, correctly classifying 71–79% of the sample. Predictably, classification accuracy was lower against PVTs as criterion measures (.26-.37 sensitivity at .90-.93 specificity, correctly classifying 66–69% of the sample). The originally proposed ATR cutoff (≥ 15) was prohibitively conservative, resulting in a 90–95% false negative rate. In contrast, although the more liberal alternative (≥ 8) fell short of the specificity standard (.89), it was associated with notably higher sensitivity (.43-.68) and the highest overall classification accuracy (71–82% of the sample). Non-credible symptom report was a stronger confound on the posttraumatic stress scale of the TSI-2 than that of the Personality Assessment Inventory. The ATR demonstrated its clinical utility in identifying non-credible symptom report (and to a lesser extent, invalid performance) in a medicolegal setting, with ≥ 9 emerging as the optimal cutoff. The ATR demonstrated its potential to serve as a quick (potentially stand-alone) screener for the overall credibility of neuropsychological deficits. More research is needed in patients with different clinical characteristics assessed in different settings to establish the generalizability of the findings.

Cardiac Enlargement in a Medicolegal Autopsy Setting.

A key element for diagnosing cardiac enlargement in an autopsy setting is relevant heart weight references. However, most available references are to a large extent not representative of a medicolegal autopsy population, implying that reference weights are likely lower than those in the relevant population.To establish more applicable heart weight references in a medicolegal autopsy population, we designed a heart weight model that accounts for undiagnosed cardiac enlargement using data from 11,897 nontraumatic Swedish medicolegal autopsy cases autopsied between 2010 and 2019. The model was validated in 296 nonobese young adult suicidal hanging cases.For a decedent of average height (174 cm), the evidence that a heart weight was enlarged reached weak support at approximately 430 g, substantial support at approximately 480 g, and strong support at 520 g. The modeled prevalence of cardiac enlargement was very high among elderly and obese decedents.We believe that our model is more applicable in a medicolegal setting than those previously published. The presented quantification of the degree of uncertainty regarding diagnosis can help the pathologist in diagnosing cardiac enlargement. To facilitate the use of this model, we also made it available through a simple online tool ( https://formedum.shinyapps.io/HeartWeightCalc/ ).

Retronasal Olfaction Stimulation and its Implication for Health: A Commentary on the Available Evidence.

Retronasal olfaction is the perception of odors emanating from the oral cavity during eating and drinking, as opposed to orthonasal olfaction, which occurs during sniffing (Rozin, 1982). The retronasal olfactory pathway contributes to the perceived flavor of foods and drinks. Retronasal and orthonasal function are distinct physiologic processes, with evidence identifying divergent neurobiological mechanisms (Small et al., 2005). A diminished quality of life has been reported from dysfunctions of both retronasal and orthonasal olfaction, especially when adversity occurs with the identification of food and drinks (Oleszkiewicz et al., 2019). Until recently, interest in retronasal olfaction extended only to food-related questions, with its clinical significance being limited to a means for detecting malingerers in a medicolegal setting (Hummel et al., 1999). With the development of olfactory sciences and the field of aromachology, health implications that may arise from targeted stimulation of the retronasal olfactory pathway have come into the forefront of research.

Accuracy and Reliability of MRI Reports in Diagnosing the Symptomatic Knee in Patients Who Had Bilateral MRI.

Newly symptomatic chronic musculoskeletal illness is often misinterpreted as new pathology, particularly when symptoms are first noticed after an event. In this study, we were interested in the accuracy and reliability of identifying the symptomatic knee based on bilateral MRI reports. We selected a consecutive sample of 30 occupational injury claimants, presenting with unilateral knee symptoms who had bilateral MRI on the same date. A group of blinded musculoskeletal radiologists dictated diagnostic reports, and all members of the Science of Variation Group (SOVG) were asked to indicate the symptomatic side based on the blinded reports. We compared diagnostic accuracy in a multilevel mixed-effects logistic regression model, and calculated interobserver agreement using Fleiss' kappa. Seventy-six surgeons completed the survey. The sensitivity of diagnosing the symptomatic side was 63%, the specificity was 58%, the positive predictive value was 70%, and the negative predictive value was 51%. There was slight agreement among observers (kappa= 0.17). Case descriptions did not improve diagnostic accuracy (Odds Ratio: 1.04; 95% CI: 0.87 to 1.3; P=0.65). Identifying the more symptomatic knee in adults based on MRI is unreliable and has limited accuracy, with or without information about demographics and mechanism of injury. When there is a dispute concerning the extent of the injury to a knee in a litigious, medico-legal setting such as Workers' Compensation, consideration should be given to obtaining a comparison MRI of the uninjured, asymptomatic extremity.

An evaluation of the convergent validity of a face-to-face and virtual neuropsychological assessment counter balanced.

The COVID-19 pandemic has highlighted the need for further research evaluating the validity of conducting a battery of neuropsychological assessments virtually compared with face-to-face administration. Previous research has suggested that some neuropsychological assessments yield valid results when administered virtually, however, much of the previous research focused on older adults. To determine the validity of virtually administered neuropsychological tests, 28 healthy participants were assessed using a within-subjects, counter-balanced design. Participants completed a neuropsychological assessment battery covering tests of general intellectual functioning, memory and attention, executive functioning, language and information processing speed, as well as effort. There was no significant difference between face-to-face administration of the neuropsychological battery compared with virtual administration for the majority of the tests used. However, there were significant differences in the Colour Naming Task, with participants making fewer errors on the colour naming task and inhibition/switching task when administered virtually compared with face-to-face administration. There was also a significant age cohort effect in the inhibition/switching task. There was also a trending significant difference in mode of administration for the Verbal Fluency Task. Virtually administered neuropsychological assessments largely provide a valid alternative to face-to-face assessments; however, consideration must be given to test selection as well as the population of participants that are being assessed. Other important considerations must focus on preserving the security and integrity of test materials, as well as administration in a medico-legal setting. Future research should focus on validating assessments with specific patient populations and developing a neuropsychological assessment battery using information technology.

Explanatory Models Differentiating Servicemember Malingering from Delayed Symptom Report.

The military mental health clinic is a medico-legal setting that provides servicemembers with treatment, administrative, and forensic services. Clinicians must be vigilant for malingering in this setting but flexible enough to recognize genuine symptoms. This task is often complicated by servicemembers' delayed report of symptoms. Three explanatory models are proposed that distinguish delayed report from malingering: genuine delayed report of symptoms, acute distress malingering, and disability malingering. These explanatory models improve clinician objectivity and offer a systematic understanding of these different presentations.

Failing Performance Validity Cutoffs on the Boston Naming Test (BNT) Is Specific, but Insensitive to Non-Credible Responding

ABSTRACT This study was designed to examine alternative validity cutoffs on the Boston Naming Test (BNT). Archival data were collected from 206 adults assessed in a medicolegal setting following a motor vehicle collision. Classification accuracy was evaluated against three criterion PVTs. The first cutoff to achieve minimum specificity (.87-.88) was T ≤ 35, at .33-.45 sensitivity. T ≤ 33 improved specificity (.92-.93) at .24-.34 sensitivity. BNT validity cutoffs correctly classified 67–85% of the sample. Failing the BNT was unrelated to self-reported emotional distress. Although constrained by its low sensitivity, the BNT remains a useful embedded PVT.

Histopathological Evaluation of Burn Injury

Background: Burns always have posed a threat to the sensitive human body. It is a common catastrophe today as burn injury cases are one of the common emergencies admitted to any hospital. In a medico-legal setting, the main difficulty arises when a burnt body found in unknown circumstances is brought for post-mortem examination. In such a case, a forensic expert has to opine whether the burn injuries sustained are antemortem or post-mortem. It is also of paramount importance to determine the age of burn injuries sustained. Aging of burn injuries by the naked eye is sometimes difficult and unreliable. By histopathological examination of burnt tissue, one can predict whether the victim was alive or dead when the fire was going on and determine the age of burn injuries. Materials and Methods: The present cross-sectional study was carried out in the Department of Forensic Medicine and Toxicology, Pt. B.D.Sharma PGIMS, Rohtak. Total 3033 autopsies were conducted in the mortuary of the Department of Forensic Medicine andToxicology, PGIMS, Rohtak, from November 5, 2011`to November 5, 2013. During that period, out of 486 cases reported burns, randomly 100 cases were selected for this study. Results and Conclusions: In the present study, efforts were made to determine burn wound vitality and age by histopathological evaluation. The study revealed that the inflammatory infiltrate consisted mainly of polymorphonuclear leucocytes in initial stages (up to 3rd-day post-burn) with gradual lymphocytes, macrophages, and fibroblasts forming immature granulation tissue. On the 14th-day post-burn, the burn wound revealed repair by regeneration, increased collagen deposition, fibrosis, and granulation tissue formation. It was infiltrated with fibroblasts, macrophages, and lymphocytes. Our study demonstrated that evaluation of various histopathological changes occurring during the distinctive phases of burn wound healing help in the estimation of its vitality and age.

Principles and Methods for Evidence-Based Quantification of the Effect of Seat Belt Non-Use in Crash-Related Litigation

Traffic crashes are a common cause of injury and death, and often result from the negligent actions of an inattentive, speeding, or impaired driver. In such cases, a civil legal action may be brought by an injured claimant for compensation for injuries resulting from a crash. Crash-related litigation is defended on various theories, one of which is to raise the issue of contributory negligence when the claimant was not using an available seat belt at the time of the crash, based on the assertion that the claimed injuries would have been avoided or minimized to some degree if the claimant had been restrained. At present, there are no published standards or systematic approach for assessing and quantifying the contribution of seat belt non-use to the cause of a claimant’s specific injury. A reliable medicolegal analysis that addresses whether contributory negligence can be proven in a specific case requires a multidisciplinary approach: First, the nature and severity of the crash must be reconstructed as it affected the vehicle kinetics (engineering) and in turn affected the kinematics of the occupant (biomechanics), next, the injuries must be described and scaled for severity (medicine/pathology), and finally, the risk of the known injuries given the actual circumstances of the crash and occupant (i.e., unbelted) are compared to the risk of the same injuries, and the same crash circumstances, but in the hypothetical scenario in which the claimant is belted. In the present discussion, methods for analyzing the presence and quantifying the degree of contributory negligence for seat belt non-use, suitable for presentation in a medicolegal setting, are described and illustrated with an example from the author’s personal case inventory. A detailed reconstruction of the crash is described, along with the associated occupant kinematics, and the resulting observed injuries. The injuries are then categorized by their anatomical location, type, and severity using Abbreviated Injury Scale designations. Quantification of the injury risk for the actual (unbelted) vs. hypothetical (belted) scenario is based on case-specific analysis of data accessed from a US national crash injury database The difference in risk for the two exposure scenarios can be quantified in terms of either relative risk (a risk ratio) or attributable risk (a risk proportion), with the goal to determine whether the analysis meets the threshold of a relative risk of >2.0, or an attributable risk of 50%, in order to meet the “more probable than not” standard typically required by courts. As a final step in a reliable analysis that exceeds the legal threshold for relevant evidence, the absolute increase in risk is used to quantify the degree to which the claimant’s seat belt non-use contributed to the likelihood of their injuries.

Performance and symptom validity testing in neuropsychological assessments in Australia: a survey of practises and beliefs

ABSTRACT Objective: Validity test failures within neuropsychological assessments are common. This study aimed to assess current practise. Method: Australian psychologists completed an online survey evaluating their approach to validity issues. Results: There were 102 participants (75% female, mean age 41.68 (11.72), 88% clinical neuropsychologists or registrars, 35% conducting 10+ assessments in medico-legal settings, 88% conducting 10+ assessments in clinical settings). Performance validity tests were used by most clinicians in a medico-legal setting, but in less than 50% of assessments in clinical settings. Symptom validity tests were used significantly more frequently in medico-legal settings as compared to clinical settings. Less objective methods (e.g., qualitative observation) were more frequently used to evaluate validity in clinical settings. Conclusions: Overall, validity testing in Australia is not consistent with published North American guidelines or practise trends. In Australia, psychologists practising in clinical settings appear to be relying on subjective judgements more frequently than on objective test findings. Australian guidelines that reflect recent research findings regarding validity test failure rates in clinical settings are required. The most frequently cited reason for not including validity tests was insufficient time, so future research should continue to examine time-efficient ways of incorporating validity testing. Key Points What is already known about this topic: (1) Performance validity and symptom validity test failure occur in both medico-legal and clinical settings. (2) Professional guidelines for validity testing published by professional bodies in North America emphasise the importance of validity tests in medico-legal and other settings. (3) Validity test use varies between countries, with high rates in North America but lower rates in Europe and New Zealand. What this paper adds: (1) Based on North American guidelines, performance validity tests are used less frequently than recommended in clinical settings in Australia, whilst symptom validity tests are used less frequently than recommended in both clinical and medico-legal settings. (2) Lack of time is the biggest barrier to incorporating validity tests into neuropsychological assessments; more time-efficient validity testing methods would help redress this issue. (3) There is an urgent need for Australian guidelines for validity testing in neuropsychological assessments.

Adaptation and initial validation of the Arabic version of the Word Memory Test (WMTARB)

Background The feigning of cognitive impairment is common in neuropsychological assessments, especially in a medicolegal setting. The Word Memory Test (WMT) is a forced-choice recognition memory performance validity test (PVT) which is widely used to detect noncredible performance. Though translated to several languages, this was not done for one of the most common languages, Arabic. The aim of the current study was to evaluate the convergent validity of the Arabic adaptation of the WMT (WMTARB) among Israeli Arabic speakers. Methods We adapted the WMT to Arabic using the back-translation method and in accordance with relevant guidelines. We then randomly assigned healthy Arabic speaking adults (N = 63) to either a simulation or honest control condition. The participants then performed neuropsychological tests which included the WMTARB and the Test of Memory Malingering (TOMM), a well-validated nonverbal PVT. Results The WMTARB had high split-half reliability and its measures were significantly correlated with that of the TOMM (p < .001). High concordance was found in classification of participants using the WMTARB and TOMM (specificity = 94.29% and sensitivity = 100% using the conventional TOMM trial 2 cutoff as gold standard). As expected, simulators' accuracy on the WMTARB was significantly lower than that of honest controls. None of the demographic variables significantly correlated with WMTARB measures. Conclusion The WMTARB shows initial evidence of reliability and validity, emphasizing its potential use in the large population of Arabic speakers and universality in detecting noncredible performance. The findings, however, are preliminary and mandate validation in clinical settings.

The utility of lung weight to heart weight ratio as a means to identify suspected drug intoxication deaths in a medico-legal autopsy population.

Fatal intoxications are common in a medico-legal autopsy setting and are associated with sparse findings during autopsy. It has been suggested that an increased lung weight may be associated with such fatalities. Previous literature is generally limited to a descriptive approach, including only opioid deaths, and lacking a definition of "heavy" lungs. Our aim was to create a model to identify cases with heavy lungs and to assess the predictive power of "heavy" lungs in identifying cases of different types of fatal intoxications during autopsy in an unselected medico-legal autopsy population. We identified all medico-legal autopsy cases ≥18years in Sweden from 2000 through 2013. The lung weight to heart weight (LWHW) ratio was calculated. The positive predictive values (PPV) and negative predictive values (NPV) of both lung weight and LWHW ratio were calculated. Mean lung weight was higher in the intoxication group but the predictive power in the individual case was limited. Lung weight to heart weight ratio had better predictive power than lung weight alone, with a PPV of at most 0.15(0.14, 0.16 95% CI), while the NPV was 0.96 (0.95, 0.96 95% CI). The association between fatal intoxication and increased lung weight was positive, regardless of method and cutoffs used. While the PPV was poor, the NPV could reduce suspicion of fatal intoxication in the absence of other information. LHWH ratio is only a probability factor for fatal intoxication; accurate cause of death determination-as always-requires consideration of circumstances, autopsy, and toxicologic findings.

Cerebral Palsy and Criteria Implicating Intrapartum Hypoxia in Neonatal Encephalopathy - An Obstetric Perspective for the South African Setting.

The science surrounding cerebral palsy indicates that it is a complex medical condition with multiple contributing variables and factors, and causal pathways are often extremely difficult to delineate. The pathophysiological processes are often juxtaposed on antenatal factors, genetics, toxins, fetal priming, failure of neuroscientific autoregulatory mechanisms, abnormal biochemistry and abnormal metabolic pathways. Placing this primed compromised compensated brain through the stresses of an intrapartum process could be the final straw in the pathway to brain injury and later CP. It is thus simplistic to base causation of cerebral palsy on only an intrapartum perspective with radiological 'confirmation', as is often the practice in medicolegal cases in South African courts. The present modalities (MRI and CTG when available) that retrospectively attempt to determine causation in courts are inadequate when used in isolation. Unless a holistic scientific review of the case including all contributing clinical factors (antepartum, intrapartum and neonatal), fetal heart rate monitoring, neonatal MRI if possible (and preferred) or late MRI, and histology (placental histology if performed) are taken into account, success for plaintiff or defendant currently in a court of law will depend on eloquent legal argument rather than true scientific causality. The 10 criteria set out in this document to implicate acute intrapartum hypoxia in hypoxic ischaemic encephalopathy/neonatal encephalopathy serve as a guideline in the medicolegal setting.

Cerebral Palsy and Criteria Implicating Acute Intrapartum Hypoxia in Neonatal Encephalopathy - An Obstetric Perspective for the South African Setting.

The science surrounding cerebral palsy indicates that it is a complex medical condition with multiple contributing variables and factors, and causal pathways are often extremely difficult to delineate. The pathophysiological processes are often juxtaposed on antenatal factors, genetics, toxins, fetal priming, failure of neuroscientific autoregulatory mechanisms, abnormal biochemistry and abnormal metabolic pathways. Placing this primed compromised compensated brain through the stresses of an intrapartum process could be the final straw in the pathway to brain injury and later CP. It is thus simplistic to base causation of cerebral palsy on only an intrapartum perspective with radiological 'confirmation', as is often the practice in medicolegal cases in South African courts. The present modalities (MRI and CTG when available) that retrospectively attempt to determine causation in courts are inadequate when used in isolation. Unless a holistic scientific review of the case including all contributing clinical factors (antepartum, intrapartum and neonatal), fetal heart rate monitoring, neonatal MRI if possible (and preferred) or late MRI, and histology (placental histology if performed) are taken into account, success for plaintiff or defendant currently in a court of law will depend on eloquent legal argument rather than true scientific causality. The 10 criteria set out in this document to implicate acute intrapartum hypoxia in hypoxic ischaemic encephalopathy/neonatal encephalopathy serve as a guideline in the medicolegal setting.

Postmortem radiologic and pathologic findings in COVID-19: The Toronto experience with pre-hospitalization deaths in the community

Over a year after the initial emergence of the disease, the COVID-19 pandemic continues to strain healthcare systems worldwide. The value of feedback and connection between clinical care, public health, and death investigation systems has never been more clear. To this end, knowledge of the radiologic and histopathologic features of fatal COVID-19 is critical for those working with the living and the dead. Most of the medical descriptions of COVID-19 are either focused on clinical in vivo medical imaging or autopsies performed following an intensive course of treatment over days to weeks prior to death, rather than deaths in the community prior to hospitalization. Here we report the postmortem computed tomography (PMCT) and lung histopathology in five fatal cases of COVID-19 that were subject to medicolegal death investigation. All individuals died in the community without medical treatment, or after a brief terminal admission to hospital. In these cases, the main PMCT findings included: diffuse lung changes including ground glass-type opacifications, a “crazy paving” appearance, variable areas of more dense consolidation, and relatively few areas of spared/less involved lung parenchyma. The unifying histopathology was diffuse alveolar damage in various stages of cellular evolution. In all cases, the pattern of PMCT and the lung histopathology corroborated the diagnosis of COVID-19. We propose the routine use of PMCT as a potential screening tool for the identification of COVID-19 related fatalities in the medicolegal setting where a paucity of historical information may not otherwise permit the identification of this disease prior to autopsy.

Decision-making capacity evaluations: the role of neuropsychological assessment from a multidisciplinary perspective

Decision-making capacity (DMC) in aging adults has become increasingly salient as the number of older adults, life expectancy, and the amount of wealth to be transferred from older generations have all increased. The accurate and reliable determination of older adults’ DMC is a particularly important topic given its implication in legal, financial, and health decisions. Based upon the four-ability DMC model promulgated by Appelbaum and Grisso in the 1980’s, a number of MacArthur Competence Assessment Tools have been developed and widely utilized. However, these tools do not include cognitive testing or other sources of objective data and have limited validity in a medico-legal setting, necessitating additional options for the evaluation of DMC. This is significant from the perspective of the patient because they have a vested interest in accurate and objective assessment of their DMC across domains.Given the disparities in the assessment of DMC, the authors propose, through this debate article, that the evaluation of DMC in the aging adult population utilize a combination of traditional interview and domain specific instruments and neuropsychological testing. To achieve a consensus on the issue, medical experts in a number of fields related to capacity evaluation, including psychiatry, neurology, neuropsychology, and general medicine were consulted and recruited as authors. Experts in Swiss law and ethics were also consulted and provided input.A tendency to focus on a single capacity, and in particular, the ability to consent to medical treatment, arose in the literature. Similarly, there are many instruments purporting to evaluate a single capacity (e.g., consenting to medical treatment, managing finances), while other areas important to the evaluation of DMC received little attention (e.g., activities of daily living, the ability to live independently, to marry, to resist undue influence, and to make a will or advanced care directive). Medical and legal experts in the multidisciplinary group agreed that there is a clear need for more consistency across evaluation of DMC domains and that a combined approach of traditional methods and neuropsychological testing provides a more thorough evaluation and better serves the patient.

Nurses and Medicolegal Death Investigation.

Forensic nurses currently serve in medicolegal death investigation settings nationwide, yet registered nurses seldom recognize death investigation as a career option. The purpose of this article is to describe medicolegal death investigation in the United States and the roles nurses can achieve, depending upon state and agency job requirements. Duties and qualifications for job positions, whether filled by election, appointment, or staff hiring, are described to provide examples of nurses' roles within the medicolegal death investigation setting and to present career options. Forensic nurses have the educational preparation, medical skills, and forensic knowledge to serve within death investigation systems as a chief officer (e.g., coroner), deputy officer, or staff investigator.

When a virus (Covid-19) attacks human rights: The situation of asylum seekers in the medico-legal setting.

The Covid-19 pandemic is a global health emergency that requires immediate, effective action by governments to protect the health and basic human rights of everyone's life. Refugees and migrants are potentially at increased risk because they typically live in overcrowded conditions often without access to basic sanitation. Since the beginning of the official lockdown for Covid-19, the medico-legal assessment of physical violence related to obtaining status or other forms of human protection has been frozen.

Ontogenetic Trends in Frontal Sinus Shape

Adult frontal sinus morphology has been studied in biological anthropology, both in terms of its function and variation. Overall, this structure is known to be highly variable among individuals, to such an extent that it is used to make positive identifications in the medicolegal setting. However, very little is known about the growth and developmental processes leading to the wide ranges of frontal sinus size and shape. Although several studies investigate frontal sinus ontogeny in terms of size and linear dimensions, much less is known regarding the ontogeny of its shape. This study partially addresses this gap by examining frontal sinus outlines using longitudinal radiographic data to evaluate when the frontal sinus attains its adult shape.Longitudinal radiographs for 107 individuals (57M/50F) spanning 5–29 years of age (yoa) were obtained from the AAOF Craniofacial Growth Legacy Collection ( www.aaoflegacycollection.org). Superior borders of frontal sinus outlines were digitally traced in ImageJ; the superior orbital border demarcated inferior sinus boundaries. Age of first appearance was also recorded. A total of 749 outlines were imported into SHAPE‐software, where elliptical Fourier (20 harmonics) and principal components (PC) analyses were conducted. PC1 (49.18% variation explained) reflects height‐to‐breadth relationships, while PC2 (11.74%) reflects asymmetry in right versus left lobe dominance.To assess when the frontal sinus attains its adult shape, Euclidean distances of PCs 1–9 (91.58% cumulative variance) between each age point and the 18‐year point were calculated within individuals; this process was repeated for the 20‐year point. Scatterplots with Loess curves for each distance plotted against age suggest adult shape is attained around 20yoa. Sexual dimorphic trends are evident in the Loess curves, whereby males exhibit greater distances from 20yoa at early ages. An analysis of variance confirms these sex‐based differences (F=7.063, P&lt;0.0001); Tukey post‐hocs further suggest that while adult females are not significantly different in shape from adult males or younger females/males (13–19yoa), adult males are significantly different from males 15yoa and younger. T‐tests failed to find significant sex‐based differences for age‐of‐first‐appearance (t=1.482, P=0.142) and adult‐shape (PC1: t=−0.670, P=0.505; PC2: t=1.827, P=0.058). Thus, it appears that while both sexes display similar start times in sinus development and reach similar adult‐shapes, females attain their adult shape sooner. This suggests a slower developmental process in males. Additional studies are needed to determine how these ontogenetic patterns in 2D sinus‐shape relate to the overall size and 3D dimensions of the sinus.

Non-Perfused Brain and Retino-Dural Hemorrhage

10 cases of pneumonia causing cardiac arrest and non-perfused brain occurred at ages 40 days-30 months, in a medico-legal setting. In each deceased child, both the pneumonia and non-perfused brain were verified histologically. Upper respiratory infection and mouth-breathing accompanied the pneumonia, with ongoing choking on formula or food in three cases, and vomiting in an additional five cases. In eight of the 10 cases, the pre-terminal event was a quiet respiratory arrest while sleeping, or being carried in the arms. Adrenaline was given up to 7 times during CPR lasting 44±32 minutes, with up to 2 hours CPR and fall in body temp to &amp;lt;32°C. Mean survival was 1.9±1.5 days and heparin was given for organ donation in 3 cases. The lungs showed chronic interstitial pneumonia as described by Katzenstein, with superadded acute bronchiolo-alveolar infiltrates in two cases of aspiration. The court permitted recuts and cellular characterization of the interstitial cells in one case, revealing the infiltrate was ~40% histiocytes, 5% T or B cells, and ~50% vimentin+ mesenchymal cells. All brains showed features of non-perfused brain and retino-dural hemorrhage. The observed features of non-perfused brain were blurring of the gray-white junction, edema, gross friability, histologic pallor, closure of the microcirculation, patchy acidophilic neurons and recent demarcated pan-necrosis, and pituitary infarction in one patient where hypophysis was sampled. Normally, from birth to 30 months, cerebral blood flow increases to 55% of cardiac output, accompanying physical brain growth. Restoration of high cardiac output using adrenaline-CPR means that on resuscitation, re-routing of blood that can no longer go through the non-perfused brain detours through dura, face, scalp, eyes and optic nerve sheaths. The diversion of blood around non-perfused brain results in facial bruising and retino-dural hemorrhage that can be misinterpreted as head trauma, and a common inference of child abuse in the courts. In the present series from Australia, Canada and the USA, outcomes ranged from acquittal to life imprisonment.LEARNING OBJECTIVESThis presentation will enable the learner to:1.Investigate infant deaths including workup for interstitial pneumonia.2.Know cerebral blood flow changes in development, and cranial blood flow dynamics in non-perfused brain.