Evaluating the morphological and metric sex of human crania using 3-dimensional (3D) technology.

Identifying the skeletal remains of an unidentified individual is a priority for the medico-legal system because identification increases the chances of finding the person responsible and provides closure to the family. The purpose of this research was to develop a combined morphological and metric cranial sex assessment method using 3D technology that accommodates the medico-legal system, and their use of 3D models facilitates the technological transition to digitally archived skeletal collections. A total of 91 individuals of European biogeographical ancestry from the William M. Bass Donated Skeletal Collection (University of Tennessee Knoxville) were imaged using photogrammetry, turned into 3D models using Agisoft PhotoScan, and digitally evaluated using 3D Studio Max. This novel method digitally evaluated five cranial traits, including the nasal aperture height, nasal aperture width, mastoid length, the general size and architecture, and the supraorbital ridges, combining techniques that can only be done digitally with those that can be completed on the actual bone. Preliminary statistical tests demonstrate an overall accuracy rate of 90% when tested against the training sample (20 males, 20 females) and 75% when tested against the test sample (51 individuals). Although no intra- or inter-observer error rate tests were done, and further testing on other skeletal collections is necessary, this method allows forensic anthropologists to perform relatively easy point-to-point measurements, the quantification of traditionally non-quantified traits, the possibility of reproducible results, and the ability for future analyses or research.

Improving efficiency and safety for patients who are unable to self-administer insulin.

A one-day 'snapshot' study was conducted to determine the nature and extent of specific safety issues faced by community nurses who care for patients unable to self-administer insulin. Community teams from 19 NHS trusts reported 607 patients requiring support with insulin administration. In total, 15.1% of insulin administration documents had an abbreviation for the word 'units', which is a serious safety hazard where any resulting serious harm would be classed as a 'never event'. Pens or disposable devices were used for 52.9% of all administrations, with 16.7% using an insulin device without any previous device-specific training. Major differences were discovered between trusts in many aspects of practice and insulin use, and comparative data can be used to benchmark activity and drive safety and cost improvement For example, 50.9% of patients had insulin administered more than once a day, but individual trusts reported figures ranging from 25.9% to 66.7%. If it were possible for all 19 trusts to manage 60% of patients on once-daily regimens, total annual service costs could be reduced by about pounds 200,000, or by pounds 3.5 million across the U.K.s.

Human information processing under stress.

This article is a review of literature focused on how human beings process information under stress. Three major theories on information processing are reviewed: cue utilization theory, attentional control theory, and working memory capacity theory. Different conditions that can cause an individual to feel stress are examined, how stress affects information processing, ways which stress may be beneficial, and different ways to mitigate stress, so they may process information more accurately and efficiently. Throughout the article, examples of how stress can affect incident commanders responding to a disaster situation are used to illustrate research findings.

Use of laser-scanning confocal microscopy in the detection of diagenesis in bone.

This research demonstrates the value of laser scanning confocal microscopy (LSCM) as a research tool in osteological studies, and diagenetic studies in particular. LSCM combines properties of light and scanning electron microscopy using laser light to excite fluorophores throughout the z-axis, developing a 3-D image. Using differential staining and selecting for specific wavelengths of light, one can image targeted materials. This research is divided into two parts: visualizing bone structures such as proteins and their decompositional products and visualizing diagenesis. Part one of this study utilized pig bones as a means of testing the overall ability of LSCM to fluoresce bone. Twenty-three samples were imaged, including 13 samples from a decompositional study conducted 5 years previous, and 10 "fresh" samples collected from a commercial butcher. This part of the study determined that protein and organic components of the bone could be fluoresced and diagenetic alteration could be imaged. The second part of the study used human samples as a means of imaging and mapping diagenetic alterations. The second part of the study used 13 samples, including 4 clinical, 7 ancient, and 2 modern controls. The pig study used Basic Fuchsin and SlowFade Gold stains, while the human study used toluidine blue. Images were also taken with unstained elements. The results of the non-human study found that a fresh bone fluoresced differently than that of a 5-year subset, while the results of the human study confirmed these findings and determined that the bone diagenesis can be mapped using LSCM.

Resolving Reflection and Resolution in 3D Imaging of Fresh Bone.

Structured light scanning is a noninvasive, accurate, and cost-effective 3D imaging technique, but due to reflection issues is yet to be utilized for tool mark analysis on fresh bone. During imaging, reflection from shiny surfaces, such as greasy bone, disrupts image formation. This study tested the David SLS-1 scanner's ability to image saw marks and explored six strategies to reduce reflection by [1] dulling the surface or [2] altering the projected light. The surface was dulled by freezing, talcum powder, dulling spray, or compressed air. The projected light was altered with a diffuser or limited to single pattern-coded. Results demonstrated that the resolution was insufficient for capturing minute details of striae. All six tests failed to reduce reflection sufficiently to produce complete images, but projecting vertical pattern-coded light showed the most promise. Future research is required concentrating on enhancing resolution and exploring the role of pattern-coded light in reducing reflection.

Breaking the binary: The identification of trans-women in forensic anthropology.

In the cases of transgender and gender non-conforming people, a description of their physical remains, including biological sex, may have little correlation with their social identity, delaying and often confusing the issue of identification. Some transgender individuals have sought to alter their physical appearance in order to better reflect their gender. One group of surgical modifications for trans-women, or individuals transitioning from MTF (male-to female), is known as facial feminization surgery (FFS) which involves the reduction and contour of the forehead, chin and jaw contour, and rhinoplasty to give trans-women smoother, smaller facial features. The purpose of this research is to examine the impact of FFS on measurement-based methods of cranial sex assessment, such as discriminant function analysis. The goal is to develop guidelines for correctly recognizing and supporting the identification of trans-women. The results of this study demonstrate that evidence of gender can be found in the facial skeletons of MTF transgender individuals who have undergone facial feminization surgery, and that forensic anthropologists should consider individuals who do not fit into the traditional sex binary when assessing the sex of unidentified skeletal remains.

Reprint of: Breaking the binary: The identification of trans-women in forensic anthropology.

In the cases of transgender and gender non-conforming people, a description of their physical remains, including biological sex, may have little correlation with their social identity, delaying and often confusing the issue of identification. Some transgender individuals have sought to alter their physical appearance in order to better reflect their gender. One group of surgical modifications for trans-women, or individuals transitioning from MTF (male-to female), is known as facial feminization surgery (FFS) which involves the reduction and contour of the forehead, chin and jaw contour, and rhinoplasty, to give trans-women smoother, smaller facial features. The purpose of this research is to examine the impact of FFS on measurement-based methods of cranial sex assessment, such as discriminant function analysis. The goal is to develop guidelines for correctly recognizing and supporting the identification of trans-women. The results of this study demonstrate that evidence of gender can be found in the facial skeletons of MTF transgender individuals who have undergone facial feminization surgery, and that forensic anthropologists should consider individuals who do not fit into the traditional sex binary when assessing the sex of unidentified skeletal remains.

Standardization of clinical care pathway leads to sustained decreased length of stay following Nuss pectus repair: A multidisciplinary quality improvement initiative.

BACKGROUND AND PURPOSE: Postoperatively, standardized clinical care pathways (SCCPs) help patients reach necessary milestones for discharge. The objective of this study was to achieve 90% compliance with a pectus specific SCCP within 9 months of implementation. We hypothesized that adherence to a pectus SCCP following the Nuss procedure would decrease postsurgical length of stay (LOS). METHODS: A multidisciplinary team implemented the pectus SCCP, including goals for mobility, lung recruitment, pain control, intake, and output. The full protocol included 42 components, tracked using chart reviews and a patient-directed checklist. The primary process measure was compliance with the pectus SCCP. The primary outcome measure was LOS; secondary outcomes were patient charges, patient satisfaction, and hospital readmission. RESULTS: Total study patients were n = 509: 159 patients pre-intervention, 350 patients post-intervention (80 implementation group; 270 sustain group). SCCP compliance data were collected on 164 patients post-intervention - 80 implementation, 84 sustain. LOS, ED visits, and hospital readmissions were recorded for all 509 patients. Mean LOS decreased from 4.5 days to 3.4 days, with >90% adherence to the pectus SCCP postintervention. There were no readmissions owing to pain despite earlier termination of epidural analgesia. Total patient charges decreased by 30% and patient satisfaction was high. CONCLUSION: Using quality improvement methodology with strict adherence to a pectus SCCP, we had significant reduction in LOS and patient charge without compromising effective postoperative pain management or patient satisfaction. TYPE OF STUDY: Clinical research; quality improvement. LEVEL OF EVIDENCE: V.

Sex determination of adolescent skeletons using the distal humerus.

Accurate determination of the sex of immature skeletal remains is difficult in the absence of DNA, due to the fact that most sexually dimorphic features of the human skeleton develop as secondary sex characteristics during adolescence. Methods of assessment of adult skeletons cannot reliably be applied to adolescent skeletons because of the transitional nature of the skeleton at puberty and the variability of the adolescent growth spurt. The purpose of this work was to evaluate the accuracy of Rogers's method of morphological sex determination using the distal humerus (Rogers: J Forensic Sci 44 (1999) 55-59) to assess the sex of adolescent skeletons. The sample consists of 7 documented adolescent skeletons from the Christ Church Spitalfields collection at the British Museum of Natural History and 35 from the Luis Lopes skeletal collection housed in the National History Museum (Museu Bocage) of the University of Lisbon, Portugal. Ages range from 11 to 20 years. The technique achieved an accuracy of 81% on the combined sample of 42. This method can be applied to adolescent skeletons once the trochlea begins fusing to the humeral diaphysis, which occurred by age 11 years in the test samples.

The Accuracy and Applicability of 3D Modeling and Printing Blunt Force Cranial Injuries.

The purpose of this study was to determine the factors affecting the accuracy of 3D models and 3D prints of cranial blunt force trauma, to evaluate the applicability and limitations of modeling such injuries. Three types of cranial blunt force lesions were documented (hinge, depressed, and comminuted) using three forms of surface scanning (laser, structured light scanner, and photogrammetry) at two different quality settings (standard and high). 3D printed models of the lesions were produced using two different materials (a gypsum-like composite powder called VisiJet® PXL and an acrylic engineered composite plastic called VisiJet® M3 in crystal colour). The results of these analyzes indicate the prints in this study exhibit some statistically significant differences from the actual bone lesions, but details of the lesions can be reproduced to within 2 mm accuracy.

Association between a positive ED FAST examination and therapeutic laparotomy in normotensive blunt trauma patients.

Although a positive FAST (focused assessment with sonography for trauma) examination in hypotensive blunt trauma patients generally suggests the need for emergent laparotomy, this finding's significance in normotensive trauma patients is unclear. We tested the association between a positive FAST and the need for therapeutic laparotomy in normotensive blunt trauma patients. This was a retrospective cohort analysis of consecutive normotensive blunt trauma patients presenting to two trauma centers. The outcome was therapeutic laparotomy. The unadjusted association between a positive FAST and laparotomy was odds ratio (OR) 116 (95% confidence interval [CI] 49.5-273). This association persisted after adjusting for confounding variables (OR 44.6, 95% CI 1.77-1124). Thirty-seven percent of patients with a positive FAST required therapeutic laparotomy vs. 0.5% with a negative FAST. Among normotensive blunt trauma patients, there was a strong association between a positive FAST and the need for therapeutic laparotomy. Very few normotensive patients with a negative FAST required therapeutic laparotomy.

Taphonomic changes to blunt force trauma: a preliminary study.

This study examines the effects of taphonomic processes on blunt force trauma (BFT) through an experimental study involving pig heads. Of particular concern is the possibility that taphonomic changes can create pseudo-trauma and/or conceal evidence of actual trauma. BFT was inflicted on 10 pig skulls using a hammer. The skulls were subsequently exposed to the environment for 12 months. Seven taphonomic changes were evaluated: the freeze-thaw cycle; rodent gnawing; carnivore scavenging; presence/weight of soil; presence/weight of rain and snow; movement/displacement of bones; and discoloration due to sun bleaching and grass staining. Taphonomic effects varied between cancellous, compact, fresh, and degreased bone. Freezing and thawing, exposure to rain and snow, movement of the skulls, and soil erosion altered and, in some cases disguised, pre-existing trauma. Rodent and carnivore activity did not obliterate evidence of BFT. Recommendations for evaluating BFT on remains affected by taphonomic processes are presented. As each taphonomic process outlined by this study has the potential to disguise antemortem injury, the authors propose that one must carefully examine large, circular openings in the skull that may represent the remnant evidence of BFT.

A collaborative evaluation of pharmacy interventions in the care of inpatients in community hospitals.

OBJECTIVES: To quantify medication-related errors, in particular prescribing errors, identified by pharmacists and assess their potential impact on inpatients in community hospitals. METHODS: Pharmacists recorded all interventions to optimise medication for community hospital inpatients over 14 days in November 2013. Interventions were subsequently classified by type (prescribing error; omitted or delayed drug administration; or attributable to other issues) and rated for potential clinical impact. RESULTS: 15 organisations participated in the study reporting on 4077 medication charts. In total, 52 033 medication orders were screened by pharmacists. A medication-related intervention was made on 1 in 3 charts for one or more medications. A total of 2782 interventions were recorded. The majority were categorised as a prescriber error (67%, 1872/2782). The remainder (33%, 910/2782) were not directly attributable to prescriber error; of these omitted and delayed medicine administration accounted for 11% (298/2782). Of the 1872 interventions classed as prescriber error, a third, if left undetected, might have caused moderate or severe patient harm. The prescribing error rate was 3.6 errors per 100 medication orders. CONCLUSIONS: Pharmacists reported intervening to improve the care provided to over a third of patients in this study. Two-thirds of interventions were in response to prescribing errors, a third of which, if left undetected, could have led to harm. The results suggest that inpatients in community hospitals are subject to prescribing errors at a rate comparable to those seen in acute and mental health hospitals. A clinical pharmacy service is vital to ensure patient safety in community hospitals.

An Evaluation of the Calce Method for Age Estimation.

The Calce method of skeletal age estimation (Am J Phys Anthropol, 148, 2012 and 11) uses the acetabular surface of the os coxa and was developed using 90 individuals from the J.C.B. Grant Skeletal collection. From this collection, pilot tests using a combined sample size of 55 randomized individuals yielded an accuracy of 54.5%. To eliminate the possible issue of variation within the collection, 30 individuals from those that Calce specifically used were assessed by two analysts. Accuracies of 53.3% and 56.7% were obtained, compared with Calce's reported accuracy of 81% (Am J Phys Anthropol, 148, 2012 and 11). This study also used 30 Japanese individuals from the Nagasaki University modern cadaver collection. Due to the high interobserver error (43.3%) and the low accuracies achieved (40% and 46.7%), the Calce method does not perform well on Japanese samples. The low accuracy of this method in general suggests that the trait descriptions should be refined to assist analysts in properly utilizing the method.

Recognition of cemetery remains in a forensic context.

The purpose of this paper is to provide guidelines for the recognition of human remains from modem and historic cemeteries found in a forensic context. Three avenues of evidence may be pursued to confirm the origin of cemetery remains: context, condition of the body, and associated artifacts. This article outlines types of North American cemeteries, demonstrating how land use over time has resulted in many being closed, moved, or forgotten, leaving only the context to indicate their presence. The condition of human cemetery remains varies considerably depending on cultural practices and burial environment, but many exhibit combinations of the following traits: dried or embalmed tissue; erosion of bony pressure points; cortical bone flaking; and bone damage due to autopsy or embalming. Examples of artifact types useful in recognizing cemetery remains are also provided. Two cases from British Columbia, Canada are presented to demonstrate the diagnostic features of a disturbed cemetery burial.

Determining the sex of human remains through cranial morphology.

Sex determination is the keystone of a biological profile, yet few qualitative methods of cranial sex determination have been tested. This analysis examines the accuracy and precision of 17 morphological features of the skull commonly used to determine the sex of unknown skeletal remains. The sample consists of 46 identified skulls from the 19th century St. Thomas' Anglican Church Cemetery in Belleville, Canada. Nasal aperature, zygomatic extension, malar size/rugosity, and supraorbital ridge proved the most useful; of secondary value are chin form and nuchal crest; mastoid size is of tertiary consideration; nasal size and mandibular symphysis/ramus size rank fourth; forehead shape ranks fifth; and palate size/shape are sixth. Skull size/architecture provides an internal standard to assess the relative sizes of other traits. This research is a necessary step in establishing the credibility of morphological sex determination with respect to the Daubert and Mohan criteria for admissibility in a court of law.

Crime scene ethics: souvenirs, teaching material, and artifacts.

Police and forensic specialists are ethically obliged to preserve the integrity of their investigations and their agencies' reputations. The American Academy of Forensic Sciences and the Canadian Society of Forensic Science provide no guidelines for crime scene ethics, or the retention of items from former crime scenes. Guidelines are necessary to define acceptable behavior relating to removing, keeping, or selling artifacts, souvenirs, or teaching specimens from former crime scenes, where such activities are not illegal, to prevent potential conflicts of interest and the appearance of impropriety. Proposed guidelines permit the retention of objects with educational value, provided they are not of significance to the case, they are not removed until the scene is released, permission has been obtained from the property owner and police investigator, and the item has no significant monetary value. Permission is necessary even if objects appear discarded, or are not typically regarded as property, e.g., animal bones.

Expert testimony and positive identification of human remains through cranial suture patterns.

North American forensic anthropological research should conform to the Daubert criteria (U.S.A.) and Mohan ruling (Canada) to ensure admissibility in a court of law. Positive identification through radiographic comparison of antemortem and postmortem cranial suture patterns was evaluated in light of these criteria. The technique is based on reliable principles, but problems with terminology and the resolution of radiographs make Sekharan's method difficult to apply. Using the location, length, and slope of a suture's component lines, rather than Sekharan's descriptions of sutural configurations, it is possible to determine the probability of a particular suture pattern occurring in more than one individual. A match of four consecutive lines is sufficient to establish positive identification. This approach meets the Daubert and Mohan criteria, although resolution of radiographs is still a major limitation. Computed tomography (CT) scans may prove a more useful modality for positive identification, due to better resolution and greater availability.

Identifying chop marks on cremated bone: a preliminary study.

The purpose of this analysis is to evaluate the effects of burning on hacking trauma inflicted with a cleaver and to assess the diagnostic potential of cleaver marks exposed to fire. Thirty pig forelimbs (radius and ulna) and 30 beef ribs were each subjected to five blows with a cleaver and five cuts with a knife prior to burning in an outdoor fire. Bones were deliberately agitated to ensure maximum cremation and induce fragmentation. Results indicate that hacking weakens bone, making fire-induced fragmentation more likely at the sites of trauma. Chop marks were easily identified on burned bone, their characteristics largely unaffected by cremation.