Contamination of duodenoscopes is a significant concern due to the transmission of multidrug-resistant organisms (MDROs) among patients who undergo endoscopic retrograde cholangiopancreatography (ERCP), resulting in outbreaks worldwide. In July 2020, it was determined that three different patients, all had undergone ERCP with the same duodenoscope, were infected. Two patients were infected with bla_CTX-M-15 encoding Citrobacter freundii, one experiencing a bloodstream infection and the other a urinary tract infection, while another patient had a bloodstream infection caused by bla_SHV-12 encoding Klebsiella pneumoniae. Molecular characterization of isolates was available as every ESBL-producing isolate undergoes Next-Generation Sequencing (NGS) for comprehensive genomic analysis in our center. After withdrawing the suspected duodenoscope, we initiated comprehensive epidemiological research, encompassing case investigations, along with a thorough duodenoscope investigation. Screening of patients who had undergone ERCP with the implicated duodenoscope, as well as a selection of hospitalized patients who had ERCP with a different duodenoscope during the outbreak period, led to the discovery of three additional cases of colonization in addition to the three infections initially detected. No microorganisms were detected in eight routine culture samples retrieved from the suspected duodenoscope. Only after destructive dismantling of the duodenoscope, the forceps elevator was found to be positive for bla_SHV-12 encoding K. pneumoniae which was identical to the isolates detected in three patients. This study highlights the importance of using NGS to monitor the transmission of MDROs and demonstrates that standard cultures may fail to detect contaminated medical equipment such as duodenoscopes.

Inflicted shaking trauma can cause injury in infants, but exact injury mechanisms remain unclear. Controversy exists, particularly in courts, whether additional causes such as impact are required to produce injuries found in cases of (suspected) shaking. Publication rates of studies on animal and biomechanical models of inflicted head injury by shaking trauma (IHI-ST) in infants continue rising. Dissention on the topic, combined with its legal relevance, makes maintaining an up-to-date, clear and accessible overview of the current knowledge-base on IHI-ST essential. The current work reviews recent (2017–2023) studies using models of IHI-ST, serving as an update to two previously published reviews. A systematic review was conducted in Scopus and PubMed for articles using animal, physical and mathematical models for IHI-ST. Using the PRISMA methodology, two researchers independently screened the publications. Two, five, and ten publications were included on animal, physical, and mathematical models of IHI-ST, respectively. Both animal model studies used rodents. It is unknown to what degree these can accurately represent IHI-ST. Physical models were used mostly to investigate gross head-kinematics during shaking. Most mathematical models were used to study local effects on the eye and the head’s internal structures. All injury thresholds and material properties used were based on scaled adult or animal data. Shaking motions used as inputs for animal, physical and mathematical models were mostly greatly simplified. Future research should focus on using more accurate shaking inputs for models, and on developing or and validating accurate injury thresholds applicable for shaking.

Forensic reconstruction and scenario evaluation are crucial in investigations of suspicious deaths related to falls from a height. In such cases, distinguishing between accidental falls, being pushed or jumping is an important but difficult task, since objective methods to do so are currently lacking. This paper explores the possibility of repurposing a passive rigid body model of a human from commercially available crash simulation software for forensic reconstruction and scenario evaluation of humans dropping from heights. To use this approach, a prerequisite is that the human body model can produce realistic movements compared to those of a real human, given similar environmental conditions. Therefore, this study assessed the validity of the commercially available Simcenter Madymo Pedestrian Model (MPM) for simulating human fall movements. Experimental kinematic and kinetic data was collected from nine participants, who dropped from a height in three different ways: passively tilting over, getting pushed, and jumping. Next, the performance of the MPM in reproducing the kinematics of the experimental falls was assessed by comparing the orientation of the body 0.3 s after platform release. The results show that the MPM currently does not consistently reproduce the experimentally recorded falling movements across multiple falling conditions and outcome measures. The MPM must therefore be adapted if to be used for forensic reconstruction and scenario evaluation, for example by implementing active movement.

Background: Surgical process model (SPM) analysis is a great means to predict the surgical steps in a procedure as well as to predict the potential impact of new technologies. Especially in complicated and high-volume treatments, such as parenchyma sparing laparoscopic liver resection (LLR), profound process knowledge is essential for enabling improving surgical quality and efficiency. Methods: Videos of thirteen parenchyma sparing LLR were analyzed to extract the duration and sequence of surgical steps according to the process model. The videos were categorized into three groups, based on the tumor locations. Next, a detailed discrete events simulation model (DESM) of LLR was built, based on the process model and the process data obtained from the endoscopic videos. Furthermore, the impact of using a navigation platform on the total duration of the LLR was studied with the simulation model by assessing three different scenarios: (i) no navigation platform, (ii) conservative positive effect, and (iii) optimistic positive effect. Results: The possible variations of sequences of surgical steps in performing parenchyma sparing depending on the tumor locations were established. The statistically most probable chain of surgical steps was predicted, which could be used to improve parenchyma sparing surgeries. In all three categories (i–iii) the treatment phase covered the major part (~ 40%) of the total procedure duration (bottleneck). The simulation results predict that a navigation platform could decrease the total surgery duration by up to 30%. Conclusion: This study showed a DESM based on the analysis of steps during surgical procedures can be used to predict the impact of new technology. SPMs can be used to detect, e.g., the most probable workflow paths which enables predicting next surgical steps, improving surgical training systems, and analyzing surgical performance. Moreover, it provides insight into the points for improvement and bottlenecks in the surgical process.

Child abuse, irrespective of the type of child abuse, probably is the most prevalent risk factor for the development of children. Physical abuse is the type of abuse with the highest risk of infliction of injuries. The most injured organ due to physical abuse is the skin, with bruises being the most prevalent cutaneous injury. Other cutaneous injuries such as abrasions, lacerations, burns and scalds can also be seen. Fractures are also regularly found in child abuse. Other injuries, often with serious and lifethreatening consequences are intracranial injuries, and abdominal and thoracic injuries. In this chapter child abuse, trauma and injuries will be defined. Also the cause and manner of injuries will be defined and discussed and some epidemiological data will be given.

A fracture is a partial or complete disruption of the continuity of bone or cartilage, due to mechanical forces exceeding the strength of the bone or cartilage to withstand these forces.Fractures are common in children. In a large Swedish study, the overall annual incidence of fractures in children was 2.1% (2.6 for boys; 1.7 for girls). Most fractures in children are the result of accidental trauma and conventional radiography (x-rays) is by far the preferred modality to diagnose them. This chapter discusses the anatomy of the bones, types of fractures and the terminology to describe fractures in an unequivocal way. In addition, fractures are discussed in the context of the trauma mechanism, the circumstances under which a fracture occurs and the age of the patient. Any discrepancies between the type of fracture and the alleged trauma mechanism (history as provided by the parents) should arise suspicion of non-accidental injury, where in general the younger the child, the greater the probability of inflicted injuries.

Inflicted head injury by shaking trauma (IHI-ST) in infants is a type of abusive head trauma often simulated computationally to investigate causalities between violent shaking and injury. This is commonly done with the head’s rotation center kept fixed over time. However, due to the flexibility of the infant’s neck and the external shaking motion imposed by the perpetrator it is unlikely that the rotation center is static. Using a test-dummy, shaken by volunteers, we demonstrated experimentally that the location of the head’s rotation center moves considerably over time. We further showed that implementation of a spatiotemporal-varying rotation center in an improved kinematic model resulted in strongly improved replication of shaking compared to existing methods. Hence, we stress that the validity of current infant shaking injury risk assessments and the injury thresholds on which these assessments are based, both often used in court cases, should be re-evaluated.

Surgical process modelling is an innovative approach that aims to simplify the challenges involved in improving surgeries through quantitative analysis of a well-established model of surgical activities. In this paper, surgical process model strategies are applied for the analysis of different Minimally Invasive Liver Treatments (MILTs), including ablation and surgical resection of the liver lesions. Moreover, a generic surgical process model for these differences in MILTs is introduced. The generic surgical process model was established at three different granularity levels. The generic process model, encompassing thirteen phases, was verified against videos of MILT procedures and interviews with surgeons. The established model covers all the surgical and interventional activities and the connections between them and provides a foundation for extensive quantitative analysis and simulations of MILT procedures for improving computer-assisted surgery systems, surgeon training and evaluation, surgeon guidance and planning systems and evaluation of new technologies.

Purpose: To utilize navigated mandibular (reconstructive) surgery, accurate registration of the preoperative CT scan with the actual patient in the operating room (OR) is required. In this phantom study, the feasibility of a noninvasive hybrid registration method is assessed. This method consists of a point registration with anatomic landmarks for initialization and a surface registration using the bare mandibular bone surface for optimization. Methods: Three mandible phantoms with reference notches on two osteotomy planes were 3D printed. An electromagnetic tracking system in combination with 3D Slicer software was used for navigation. Different configurations, i.e., different surface point areas and number and configuration of surface points, were tested with a dentate phantom (A) in a metal-free environment. To simulate the intraoperative environment and different anatomies, the registration procedure was also performed with an OR bed using the dentate phantom and two (partially) edentulous phantoms with atypical anatomy (B and C). The accuracy of the registration was calculated using the notches on the osteotomy planes and was expressed as the target registration error (TRE). TRE values of less than 2.0 mm were considered as clinically acceptable. Results: In all experiments, the mean TRE was less than 2.0 mm. No differences were found using different surface point areas or number or configurations of surface points. Registration accuracy in the simulated intraoperative setting was—mean (SD)—0.96 (0.22), 0.93 (0.26), and 1.50 (0.28) mm for phantom A, phantom B, and phantom C. Conclusion: Hybrid registration is a noninvasive method that requires only a small area of the bare mandibular bone surface to obtain high accuracy in phantom setting. Future studies should test this method in clinical setting during actual surgery.

Image-to-patient registration in navigated mandibular surgery is complex due to the mobile nature of the mandible compared with other craniofacial bones. As a result, surgical navigation is rarely employed in the mandibular region. This systematic review provides an overview of the different registration methods that are used for surgical navigation of the mandible. A systematic search was performed in the MEDLINE Ovid, Scopus, and Embase databases on March 25, 2021. Search terms included synonyms for mandibular surgery, surgical navigation, and registration methods. Articles about navigated mandibular surgery, where the registration method was explicitly mentioned, were included. The database search yielded a total of 2952 articles, from which 81 articles remained for analysis. Four main registration methods were identified: point registration, surface registration, hybrid registration, and computer vision-based registration. The mobility of the mandible is accounted for by either keeping the mandible in a fixed position during preoperative imaging and surgery, or by tracking the mandibular movements. Although different registration methods are available for navigated mandibular surgery, there is always a trade-off between accuracy, registration time, usability, and invasiveness. Future studies should focus on testing the different methods in larger patient studies and should report the registration accuracy.

Purpose: Smothering to death is most often done with a soft cover, such as a pillow. This is one of the hardest to diagnose causes of death. Knowing more about how people perform such an act and whether there is any correlation between perpetrator characteristics and smothering approaches may help in solving criminal cases involving smothering. Methods: A total of 181 visitors of a music festival were asked to smother a dummy with a pillow. Each participant provided their age, gender, dominant hand, length, weight, alcohol use (last 24 h) and drug use (last 24 h) in a questionnaire. Forces applied by the participant on the dummy head with the pillow were continuously measured and the smothering modus operandi (described by aspects such as the placement of the hands, feet and body weight) was obtained from video recordings. Results: Participants with high alcohol consumption provided higher smothering forces. Increases were also found for taller participants and those who had used drugs. Smothering seemed most effective when placing both hands on the pillow on the head and when placing the center of mass as much directly above the dummy head as possible. A stable, central stance also benefitted smothering effectiveness. Conclusion: Forensic case work may potentially benefit from these results in the future by linking the current results to the location of hand and finger marks on a pillow.

In order to investigate potential causal relations between the shaking of infants and injuries, biomechanical studies compare brain and skull dynamic behavior during shaking to injury thresholds. However, performing shaking tolerance research on infants, either in vivo or ex vivo, is extremely difficult, if not impossible. Therefore, infant injury thresholds are usually estimated by scaling or extrapolating adult or animal data obtained from crash tests or whiplash experiments. However, it is doubtful whether such data accurately matches the biomechanics of shaking in an infant. Hence some thresholds may be inappropriate to be used for the assessment of inflicted head injury by shaking trauma in infants. A systematic literature review was conducted to 1) provide an overview of existing thresholds for head- and neck injuries related to violent shaking, and 2) to identify and discuss which thresholds have been used or could be used for the assessment of inflicted head injury by shaking trauma in infants. Key findings: The majority of studies establishing or proposing injury thresholds were found to be based on loading cycle durations and loading cycle repetitions that did not resemble those occurring during shaking, or had experimental conditions that were insufficiently documented in order to evaluate the applicability of such thresholds. Injury thresholds that were applied in studies aimed at assessing whether an injury could occur under certain shaking conditions were all based on experiments that did not properly replicate the loading characteristics of shaking. Somewhat validated threshold scaling methods only exist for scaling concussive injury thresholds from adult primate to adult human. Scaling methods that have been used for scaling other injuries, or for scaling adult injury thresholds to infants were not validated. There is a clear and urgent need for new injury thresholds established by accurately replicating the loading characteristics of shaking.

When sawing bone for medical or medico-legal procedures, fine, airborne dust is produced (aerosols) that can pose a health hazard when inhaled. The aim of this study was to determine the influence of saw blade frequency and contact load, bone condition, test environment, and saw blade type, on the production of aerosol particles. A custom test setup was designed, manufactured and used in 8 bone sawing experiments, using a particle counter to determine the production of aerosol particles while varying the 5 chosen parameters. The number of counted particles was highest with higher saw blade frequencies, lower saw blade contact loads, in dry completely skeletonized bone compared to fresh bone, and using an electrical oscillating saw compared to hand-sawing. Under all conditions, the high amount of aerosol counted posed potential health risks. The ventilation system that we tested was adequate in removing the produced particles, but these high-tech systems are not always available in developing countries or emergency situations. The production of aerosols can be reduced by optimizing the sawing parameters. However, even the lowest number of aerosol particles counted during the current study was high enough to cause potential health risks to practitioners. Safety precautions should be taken, such as external ventilation, proper breathing gear, and adequate protocols, to truly minimize the risk in all bone sawing scenarios.

Background and Aims: Worldwide, an increasing number of duodenoscope-associated outbreaks are reported. The high prevalence rate of contaminated duodenoscopes puts patients undergoing ERCP at risk of exogenous transmission of microorganisms. The contributing factors of the duodenoscope design to contamination are not well understood. This article reports on the investigation after the outbreak of a multidrug-resistant Klebsiella pneumoniae (MRKP) related to 2 Olympus TJF-Q180V duodenoscopes. Methods: We conducted a contact patient screening and microbiologic laboratory database search. Reprocessing procedures were audited, and both duodenoscopes were fully dismantled to evaluate all potential contamination factors. Outcomes were reviewed by an experienced independent expert. Results: In total, 102 patients who had undergone an ERCP procedure from January to August 2015 were invited for screening. Cultures were available of 81 patients, yielding 27 MRKP-infected or -colonized patients. Ten patients developed an MRKP-related active infection. The 2 duodenoscopes had attack rates (the number of infected or colonized cases/number of exposed persons) of 35% (17/49) and 29% (7/24), respectively. Identical MRKP isolates were cultured from channel flushes of both duodenoscopes. The review revealed 4 major abnormalities: miscommunication about reprocessing, undetected damaged parts, inadequate repair of duodenoscope damage, and duodenoscope design abnormalities, including the forceps elevator, elevator lever, and instrumentation port sealing. Conclusions: Outbreaks are associated with a combination of factors, including duodenoscope design issues, repair issues, improper cleaning, and systemic monitoring of contamination. To eliminate future duodenoscope-associated infections, a multipronged approach is required, including clear communication by all parties involved, a reliable servicing market, stringent surveillance measures, and eventually new duodenoscope designs and reprocessing procedures with a larger margin of safety.

Objective: The speed of pressure pulses traveling through the blood, the pulse wave velocity (PWV), is a metric that provides substantial information about the passive and active elasticity of the blood vessels. Therefore, PWV is a valuable parameter in the diagnosis of cardiovascular and vessel-related neurological diseases. The purpose of this study was to investigate whether a novel, simple, easy-to-use, photoplethysmography-based Multi Photodiode Array (MPA) provides PWV measurements that agree with measurements done with more complicated and harder-to-use systems currently used in clinical practice. Methods: An often-used vascular perturbation that changes the conduit artery vasomotor tone during reactive hyperemia was imposed on thirty healthy volunteers. The MPA was used alongside and its results compared to those of a commonly used measurement device, the Biopac-system, during flow-mediated dilation (FMD). This way it was investigated if measurements with these systems, measuring over two different, but partly overlapping vessel trajectories agree. Results: The baseline absolute PWV values were significantly lower for the MPA as compared to the Biopac-system. Additionally, Bland-Altman plots and Pearson's correlation tests suggested good agreement between the two PWV measurement techniques during the FMD. Conclusion: Measuring PWV with the MPA in clinical practice is feasible and provides reliable data. Significance: The MPA may substantially simplify PWV measurements and may enable long-term PWV monitoring as long as one is aware of the relation between PWV and the vascular trajectory over which it is measured.

Arterial stiffness is a reliable prognostic parameter for cardiovascular diseases. The effect of change in arterial stiffness can be measured by the change of the pulse wave velocity (PWV). The Complior system is widely used to measure PWV between the carotid and radial arteries by means of piezoelectric clips placed around the neck and the wrist. The Biopac system is an easier to use alternative that uses ECG and simple optical sensors to measure the PWV between the heart and the fingertips, and thus extends a bit more to the peripheral vasculature compared to the Complior system. The goal of this study was to test under various conditions to what extent these systems provide comparable and correlating values. 25 Healthy volunteers, 20–30 years old, were measured in four sequential position: sitting, lying, standing and sitting. The results showed that the Biopac system measured consistently and significantly lower PWV values than the Complior system, for all positions. Correlation values and Bland–Altman plots showed that despite the difference in PWV magnitudes obtained by the two systems the measurements did agree well. Which implies that as long as the differences in PWV magnitudes are taken into account, either system could be used to measure PWV changes over time. However, when basing diagnosis on absolute PWV values, one should be very much aware of how the PWV was measured and with what system.

Various types of complex biomechanical models have been published in the literature to better understand processes related to inflicted head injury by shaking trauma (IHI-ST) in infants. In this systematic review, a comprehensive overview of these models is provided. A systematic review was performed in MEDLINE and Scopus for articles using physical (e.g. dolls) and mathematical (e.g. computer simulations) biomechanical models for IHI-ST. After deduplication, the studies were independently screened by two researchers using PRISMA methodology and data extracted from the papers is represented in a “7-steps description”, addressing the different processes occurring during IHI-ST. Eleven papers on physical models and 23 papers on mathematical models were included after the selection process. In both categories, some models focus on describing gross head kinematics during IHI-ST events, while others address the behavior of internal head- and eye structures in various levels of detail. In virtually all physical and mathematical models analyzed, injury thresholds are derived from scaled non-infant data. Studies focusing on head kinematics often use injury thresholds derived from impact studies. It remains unclear to what extent these thresholds reflect the failure thresholds of infant biological material. Future research should therefore focus on investigating failure thresholds of infant biological material as well as on possible alternative injury mechanism and alternative injury criteria for IHI-ST.

Inflicted blunt force trauma and/or repetitive acceleration-deceleration trauma in infants can cause brain injury. Yet, the exact pathophysiologic mechanism with its associated thresholds remains unclear. In this systematic review an overview of animal models for shaking trauma and their findings on tissue damage will be provided. A systematic review was performed in MEDLINE and Scopus for articles on the simulation of inflicted head injury in animals. After collection, the studies were independently screened by two researchers for title, abstract, and finally full text and on methodological quality. A total of 12 articles were included after full-text screening. Three articles were based on a single study population of 13 lambs, by one research group. The other 9 articles were separate studies in piglets, all by a single second research group. The lamb articles give some information on tissue damage after inflicted head injury. The piglet studies only provide information on consequences of a single plane rotational movement. Generally, with increasing age and weight, there was a decrease of axonal injury and death. Future studies should focus on every single step in the process of a free movement in all directions, resembling human infant shaking. In part II of this systematic review biomechanical models will be evaluated.

Purpose: DNA is a highly valuable lead to identify people who were possibly involved in a crime. Even by small contact events, minute amounts of DNA (‘trace DNA’) can be transferred from a DNA source to an evidentiary item, which can be enough for a successful DNA analysis. The focus of this research is to get more insight in the collection of trace DNA from textiles by ‘stubbing’, which is a tape-lifting method using double-sided tape placed on a stub. The relation between the ‘stubbing force’ (the normal force that is applied during stubbing) and the collection efficiency of microspheres is investigated. Methods: Microspheres (Ø25 μm) were used as mock traces to mimic DNA-containing micro-traces. The particles were applied to textile substrates in a suspension of ethanol that was left to evaporate before sampling. Experiments were performed on three different polyester substrates. Traces were collected by stubbing while using 5 different stubbing forces. The number of microspheres placed on each substrate was counted before sampling and all stub-tapes were analysed after sampling to count how many of the microspheres were picked up, both by using stitched images from a digital light microscope. Custom-made image recognition software was used to automatically count the microspheres. Results: On all tested polyester substrates, the mean efficiency of the collection of microspheres increased with increasing stubbing force in a concave down increasing function. The increase of collection efficiency stagnated around 3–12 N, depending on the substrate material. The theoretical maximum collection efficiencies varied between 38% and 78%, depending on substrate material as well. Conclusions: Stubbing with a force higher than 12 N does not notably influence the collection efficiency from the variety of textiles that were tested. However, because the theoretical maxima of the collection efficiencies were far from 100%, it is highly likely that stubbing multiple times on the same spot of a substrate increases the total collection efficiency. The gained knowledge will help to standardize and improve the effectiveness of stubbing.