External Hydrocephalus as a Cause of Infant Subdural Hematoma: Epidemiological and Radiological Investigations of Infants Suspected of Being Abused

Background Acute subdural hematoma (ASDH) and chronic subdural hematoma (CSDH) in infants have been regarded as highly specific for abuse. Other causes of CSDH have not been investigated in a large population. Purpose The purpose of this study was to investigate to what extent external hydrocephalus is present in infants with ASDH and CSDH undergoing evaluation for abuse. Material and methods Eighty-five infants suspected of being abused, with ASDH (n = 16) or CSDH (n = 69), were reviewed regarding age, risk factor profiles, craniocortical width (CCW), sinocortical width (SCW), frontal interhemispheric width (IHW), subarachnoid space width (SSW), and head circumference (HC). In infants with unilateral subdural hematoma (SDH), correlations between contralateral SSW and ipsilateral CCW and SDH width were investigated. Results Infants with CSDH had significantly lower mortality, were more often premature and male, and had significantly higher CCW, SCW, IHW, and SSW than infants with ASDH (P 5 mm, in addition to increased HC. Conclusion A substantial proportion of infants with CSDH who had been suspected of being abused had findings suggesting external hydrocephalus.publishedVersio

Epidemiology of subdural haemorrhage during infancy : A population-based register study

Objectives To analyse subdural haemorrhage (SDH) during infancy in Sweden by incidence, SDH category, diagnostic distribution, age, co-morbidity, mortality, and maternal and perinatal risk factors; and its association with accidents and diagnosis of abuse. Methods A Swedish population-based register study comprising infants born between 1997 and 2014, 0-1 years of age, diagnosed with SDH-diagnoses according to the (International Classification of Diseases, 10th version (ICD10), retrieved from the National Patient Register and linked to the Medical Birth Register and the Death Cause Register. Outcome measures were: 1) Incidence and distribution, 2) co-morbidity, 3) fall accidents by SDH category, 4) risk factors for all SDHs in the two age groups, 0-6 and 7-365 days, and for ICD10 SDH subgroups: S06.5 (traumatic SDH), I62.0 (acute nontraumatic), SDH and abuse diagnosis. Results Incidence of SDH was 16.5 per 100 000 infants (n = 306). Median age was 2.5 months. For infants older than one week, the median age was 3.5 months. Case fatality was 6.5%. Male sex was overrepresented for all SDH subgroups. Accidental falls were reported in 1/3 of the cases. One-fourth occurred within 0-6 days, having a perinatal risk profile. For infants aged 7-365 days, acute nontraumatic SDH was associated with multiple birth, preterm birth, and small-for-gestational age. Fourteen percent also had an abuse diagnosis, having increased odds of being born preterm, and being small-for-gestational age. Conclusions The incidence was in the range previously reported. SDH among newborns was associated with difficult birth and neonatal morbidity. Acute nontraumatic SDH and SDH with abuse diagnosis had similar perinatal risk profiles. The increased odds for acute nontraumatic SDH in twins, preterm births, neonatal convulsions or small-for-gestational age indicate a perinatal vulnerability for SDH beyond 1st week of life. The association between prematurity/small-for-gestational age and abuse diagnosis is intriguing and not easily understood.Peer reviewe

Troubled social background of male anabolic-androgenic steroid abusers in treatment

<p>Abstract</p> <p>Background</p> <p>The aim of this study was to investigate the social background and current social situation of male abusers of anabolic-androgenic steroids (AAS).</p> <p>Methods</p> <p>We compared thirty-four AAS-abusing patients from an Addiction Centre (AC) with two groups, 18 users and 259 non-users of AAS from a public gym in Orebro, Sweden. The study is based on semi-structured interviews and questionnaires.</p> <p>Results</p> <p>Histories of a troubled childhood as well as current social disadvantage were both more frequent among the AAS users. Users also reported poor relationships with their parents and almost half of them had experienced physical or mental abuse. The AC group's experiences from school were mostly negative, and included concentration problems, boredom and learning difficulties. Their current circumstance included abuse of other drugs, battering of spouses and other criminality such as assault, illegal possession of weapons and theft.</p> <p>Conclusion</p> <p>In conclusion, this study shows that abusers of AAS often have a troubled social background. This underlines the importance of making a thorough social assessment as a part of the treatment programme. The results of the study may help in directing appropriate questions relevant to the abuse of AAS.</p

Anabolic androgenic steroids and violence : a medicolegal and experimental study

Non-medical use of anabolic androgenic steroids (AAS) has been linked to various psychological and behavioural complications in case and survey reports. Judging from these reports, the symptoms most consistently associated with AAS use are extreme irritability, increased aggressiveness and mood swings. There are also a limited number of reports connecting AAS-associated aggressivity with violent acts including homicide, while reports of self-injurious behaviour associated with use of AAS are extremely rare. With the objective to evaluate the possible role of AAS-related behavioural changes for outwardly or self-directed violence, violent acts committed by AAS users and premature death among users of AAS, were studied by reviewing autopsy and police reports, court records, forensic psychiatric evaluations and medical records. In a subset of AAS-using suicide victims further information was gained by means of psychological autopsy, i.e. semi-structured interviews with survivors. Hypotheses regarding the effects of AAS on mental processes brought out by observations in the medicolegal studies were tested in experimental animal studies. Different patterns of violence were associated with different phases of AAS use that in turn were associated with specific patterns of psychological changes. Mood swings, impulsive aggression with violent outbursts resulting in violence towards other persons - including homicide - or damage of property were associated with current use of AAS in subjects with a history of prolonged AAS use. The same phase of AAS use was also associated with homicidal death, impulsive suicide and death from impulsive intake of high amounts of analgesics in combination with benzodiazepines and/or alcohol without a clear suicidal intent. A mental state dominated by depressive symptoms, suicide with high suicidal intent and execution-like homicides in response to perceived humiliation were associated with AAS abstinence. Hypomania-like symptoms and planned criminal activity were associated with short-time intake of AAS. In most but not all cases in which a detailed background history was obtained, pre-existing psychopathology and/or abuse of other psychotropic drugs was reported. Acute influence of pharmaceuticals/illicit drugs and/or alcohol was also prevalent. In eight cases a mixed substance abuse was established after the use of AAS commenced. Administration of AAS at low doses resulted in a reduction of vigilance and fear in rats. High-dose treatment of AAS resulted in alterations in dopaminergic, serotonergic and cholinergic systems suggestive of increased neuronal activity in brain areas regulating mood, emotion and motivation. The observations in the present study indicate that long-term use of AAS may aggravate pre-existing and possibly may precipitate new psychiatric symptoms to a degree of severe outwardly directed violence, completed suicide or lethal mixed substance abuse. The sporadic use of AAS by criminals suggests that early effects of AAS on mental processes may involve reduction of anxiety and/or enhancement of antagonism. The observations of early central stimulatory effects of AAS gain support from the experimental studies showing a reduction of vigilance and fear and increased dopaminergic and serotonergic activity in limbic structures in AAS-treated rats. The observed shift from early hypomania-like symptoms in early AAS career towards symptoms characterised by impulsive aggression, mood swings, and depression in later career, together with the experimentally demonstrated effects on neurotransmission, suggests that stimulatory effects of AAS may later fatigue central systems regulating mood, emotion and motivation

Rib fractures in infancy, case-series and register case-control study from Sweden

Objectives: To assess cases with rib fractures in infants under observation for or with an abuse diagnosis, and to compare risk factors with that in infants with fractures but no abuse diagnosis. Methods: Design was case-series and register case-control of infants (aged &lt;1 year) with rib fractures. Data was clinical records for the case-series (n = 26) and from national health registers for the case-controls (n = 28 and n = 31). Outcome measures were maternal and perinatal characteristics, reasons for appointment, examination, diagnoses, blood tests, and radiologic findings. Results: The case-series had a median age of 70 days. A majority were detected through a skeletal survey for abuse investigation. Sixteen were boys, three were preterm and six were small-for-gestational age. Three carers had noticed popping sound from the chest; no infants showed signs of pain at physical examination. Mean number of fractures was 4.2, and 24 had callus. Bone mineralisation was scarcely reported. Metabolic panel was not uniformly analysed. The register case-control had a median age of 76 days, sharing risk factors such as maternal overweight/ obesity, male sex, prematurity, and being small-for-gestational age. Cases more often had subdural haemorrhage, retinal haemorrhage, or long-bone fractures, controls more often had neonatal morbidity, respiratory infection, or a fall accident. Detection of fracture at time of a major surgery (n = 6) and rickets/vitamin D deficiency (n = 5) appeared in both groups, but was delayed among the cases. Conclusions: Rib fractures in young infants, diagnosed as abuse, are usually asymptomatic and healing. A substantial proportion had metabolic risk factors, suggesting false positive cases

Quantifying Homicide Injuries: A Swedish Time Trend Study Using the Homicide Injury Scale

Studies report that the homicide rate has decreased considerably in most Western countries since the 1990s. However, few studies have examined the level of injury in homicides. The injury severity in homicide victims was studied in the Stockholm area using both the Homicide Injury Scale (HIS) and the number of lethal injuries per victim. Cases were included from four periods; 1976-78, 1986-88, 1996-98, and 2006-08. The number of homicides with overkill according to the HIS was significantly higher in 1996-98 compared to 1976-78. Compared with 1976-78, the number of lethal injuries per victim was significantly higher both in 1996-98 and 2006-2008. There are various possible reasons for the changes, including a brutalization of lethal violence or a more effective trauma care. More in-depth analysis of individual cases together with research on victims of attempted homicides is needed to explain these shifts in injury severity

Quantifying Homicide Injuries : A Swedish Time Trend Study Using the Homicide Injury Scale

Studies report that the homicide rate has decreased considerably in most Western countries since the 1990s. However, few studies have examined the level of injury in homicides. The injury severity in homicide victims was studied in the Stockholm area using both the Homicide Injury Scale (HIS) and the number of lethal injuries per victim. Cases were included from four periods; 1976-78, 1986- 88, 1996-98, and 2006-08. The number of homicides with overkill according to the HIS was significantly higher in 1996-98 compared to 1976-78. Compared with 1976-78, the number of lethal injuries per victim was significantly higher both in 1986-88 and 1996-98. There are various possible reasons for the changes, including a brutalization of lethal violence or a more effective trauma care. More in-depth analysis of individual cases together with research on victims of attempted homicides is needed to explain these shifts in injury severity