The National Association of Medical Examiners Position Paper on the Investigation and Certification of Pediatric Deaths From Environmental Neglect.

ABSTRACT: Pediatric deaths that occur because of environmental neglect often involve 4 common scenarios: (1) hyperthermia due to environmental exposure, (2) ingestion of an accessible drug or poison, (3) unwitnessed/unsupervised drownings, and (4) unsafe sleep practices. Given the same fact pattern, the manner of death will vary from accident to homicide to undetermined based on local custom and/or the certifier's training and experience. Medical examiner/coroner death certifications are administrative public health determinations made for vital statistical purposes. Because the manner of death is an opinion, it is understandable that manner determinations may vary among practitioners. No prosecutor, judge, or jury is bound by the opinions expressed on the death certificate. This position paper does not dictate how these deaths should be certified. Rather, it describes the challenges of the investigations and manner determinations in these deaths. It provides specific criteria that may improve consistency of certification. Because pediatric deaths often are of public interest, this paper provides the medical examiner/coroner with a professional overview of such manner determination issues to assist various stakeholders in understanding these challenges and variations.

Assessing Neglect in Pediatric Environmental Deaths: A Survey of Manner of Death Determinations.

ABSTRACT: There are 4 common types of environmental pediatric deaths that may involve various degrees of neglect: hyperthermia, ingestion, drownings, and unsafe infant sleep practices. Because the circumstances surrounding each are disparate, there is no set of standards by which these factors may be weighed and interpreted. Given the same facts, the manner of death certification may differ depending upon training/experience and/or local practice.To assess certification variations, 147 board-certified forensic pathologists were surveyed for the choice of manner in scenarios with different degrees of negligence intent. In addition to evaluating certification consistency, the survey examined whether certain factors affected the choice. The results demonstrated strong consistency in certain scenarios and widely disparate certifications in others.Medical examiner/coroner certifications are administrative decisions for vital statistical purposes. The manner of death reflects an evidence-based conclusion, but because it is ultimately an opinion, determinations may vary. Based on the survey, some certification criteria were identified (ie, intent, child age, and knowingly placing a child in an environment with a reasonable risk of harm). Using these criteria may improve consistency, but it is unreasonable to expect 100% concordance. Understanding the certificate's role helps to place the manner in the proper legal and public health contexts.

Malignant solitary fibrous tumor: report of 3 cases with unusual features.

Malignant solitary fibrous tumor (MSFT) is a rare neoplasm. Three cases of MSFT with unusual features, including 1 pleural and 2 extrapleural, are reported. A 64-year-old woman with a large right thoracic MSFT and episodes of severe hypoglycemia experienced resolution of her hypoglycemia immediately after resection of the MSFT. A 27-year-old woman with primary retroperitoneal MSFT had pulmonary metastases 10 months after resection of the primary tumor. A 54-year-old man with an intracranial solitary fibrous tumor suffered from multiple pulmonary metastases and local recurrence 21 and 28 months after resection of the primary tumor, respectively. All 3 cases of solitary fibrous tumor displayed malignant features. The tumor cells in each case were positive for CD34 and Bcl-2, but negative for cytokeratin, smooth muscle actin, S-100, and c-kit. In addition, the tumor cells in the case with concomitant hypoglycemia were strongly positive for insulin-like growth factor-II. The histopathologic diagnostic criteria for MSFT, the differential diagnosis with other spindle cell tumors, and the mechanism of MSFT-derived hypoglycemia via insulin-like growth factor-II are discussed.

Differential diagnosis of the swollen red eyelid.

The differential diagnosis of eyelid erythema and edema is broad, ranging from benign, self-limiting dermatoses to malignant tumors and vision-threatening infections. A definitive diagnosis usually can be made on physical examination of the eyelid and a careful evaluation of symptoms and exposures. The finding of a swollen red eyelid often signals cellulitis. Orbital cellulitis is a severe infection presenting with proptosis and ophthalmoplegia; it requires hospitalization and intravenous antibiotics to prevent vision loss. Less serious conditions, such as contact dermatitis, atopic dermatitis, and blepharitis, are more common causes of eyelid erythema and edema. These less serious conditions can often be managed with topical corticosteroids and proper eyelid hygiene. They are differentiated on the basis of such clinical clues as time course, presence or absence of irritative symptoms, scaling, and other skin findings. Discrete lid lesions are also important diagnostic indicators. The finding of vesicles, erosions, or crusting may signal a herpes infection. Benign, self-limited eyelid nodules such as hordeola and chalazia often respond to warm compresses, whereas malignancies require surgical excision.