Umeå University's logo

The amalgamizing of shaken baby syndrome (SBS) with the much broader and heterogeneous abusive head trauma (AHT) diagnosis is problematized. We suggest that the reason why American Academy of Pediatrics (AAP) took this step in 2009 was a response to another theory being presented and discussed from 2001 and onwards. This theory had completely different legal consequences as it suggested that the medical findings on which the SBS diagnosis were based, i.e. “the triad” (subdural hemorrhages/SDH, retinal hemorrhages/RH, and encephalopathy) were non-traumatic. If such an explanation was accepted, this would reveal not only that serious legal abuses had occurred in the past and that the pediatricians should be held responsible for this, but also that it would in the future be more difficult to protect the child by claiming abuse in cases of unclear diagnosis. We present also other steps, taken by other pediatric organizations, having similar effects upon the current SBS controversy. We suggest that these value-based considerations were the underlying reasons why SBS was integrated in the AHT concept, and why competing theories and evidence-based criticism is ignored, allowing to always interpret triad findings as the result of abuse. If the ethical principle to protect the child is more important to AAP than the scientific ambition to develop evidence-based diagnostic procedures, we encourage AAP to be honest and admit this prioritization. Or at least to admit that in this ethical dilemma, AAP finds that the least bad choice is First of all, protect the child! despite the price is that many infants and its siblings may be separated on wrong grounds from their family, and that caregivers might be falsely accused and convicted of child abuse.

In an interesting article, Dr Zuzana Parusniková claimed: (i) that Semmelweis’ colleagues did not recognise the importance of his animal experiments, (ii) that the resistance to Semmelweis’ hypothesis and results was due mainly to applying mono-causality and (iii) Semmelweis inability to communicate, (iv) that the New Vienna Medical School applied evidence-based medicine, and (v) that the philosophy of Karl Popper is the best interpretation of Semmelweis’ scientific approach. Here, we present some factual aspects of Semmelweis’ text from 1861 and discuss Dr Parusniková’s claims against this backdrop. We conclude that Semmelweis might intentionally have abstained from communicating his hypothesis and results between 1847 and 1849 – including the results from his animal experiments – as he thought that they would eventually be understood and accepted. Semmelweis’ hypothesis was that cadaveric matters and decaying particles were the cause of childbed fever and increased maternal mortality. This hypothesis might have been controversial, but we claim that the major reason for the resistance was eminence-based and induced by the publication of preliminary and suboptimal results, based on a premature version of his hypothesis. If the New Vienna Medical School had been influenced by evidence-based medicine, we believe that Semmelweis’ empirical results would have been accepted - as they were based on an almost randomised controlled trial - and if the results had not been associated with his hypothesis but instead had focused on a black box procedure. We agree that the philosophy of Popper might be appropriate when analysing Semmelweis’ scientific approach when abandoning low-level theories. However, to understand the resistance against Semmelweis’ hypothesis and results, it is not sufficient to refer to a Pickwickian discussion; a Kuhnian framework is more adequate.

This chapter presents the organization of forensic medicine in Sweden, which covers both medico-legal autopsies (forensic pathology) and examination of living persons (clinical forensic medicine). A national body, the National Board of Forensic Medicine, is responsible for all medico-legal autopsies and most issued certificates of medical evidence in clinical forensic medicine. In Sweden, forensic medicine is a recognized medical specialty, tasked to deliver impartial and evidence-based medical expert opinions to the legal system, and the only medical specialty which does not involve medical care or “patients.”

During the 1980′s a sudden life-lessness attack in a very young infant was described as “near-SIDS”, and a caregiver who observed and tried to revive the infant was considered to be reliable and honourable. If, after the later acceptance of the traditional shaken baby theory, bilateral thin subdural hemorrhages (SDH) and retinal hemorrhages (RH) are detected after a lifelessness attack such a reliable caregiver has by default been transformed into an unreliable perpetrator of violent shaking. In 2016, the term “near-SIDS” was – via “apparent life-threatening event” (ALTE) − replaced by “brief resolved unexplained event” (BRUE). We suggest that such a life-threatening event is not always brief, and not always resolved. Based on a neglected hypoxia theory from 2004 we suggest as a hypothesis that a prolonged episode of apnea can result in brain hypoxia, brain edema, SDH, RH and increased intracranial pressure. The new hypothesis includes two new concepts: Prolonged Non-fatal Unexplained Event (PNUE) and Prolonged Fatal Unexplained Event (PFUE) which together with the hypoxia theory might explain why these two separate diagnoses have been conflated into one, viz. shaken baby syndrome (SBS). We suggest a study design that might corroborate or falsify the hypothesis, and if our hypothesis is corroborated, current “unreliable perpetrators” could be re-established as reliable resuscitators.

Myocarditis is an inflammatory disease of the myocardium with either focal or diffuse involvement and usually gives rise to chest pain, dyspnea, palpitations, and fatigue. In severe cases, arrythmias, syncope, and cardiogenic shock may occur. Acute myocarditis is most commonly caused by a variety of viruses with cardiotropic properties. Rare causes of myocarditis include bacterial infections. We, herein, describe a case of acute myocarditis caused by the intracellular bacterium Francisella tularensis. A young and previously healthy male in Northern Sweden was referred to the emergency department due to intense upper-chest pain and dyspnea. ECG exhibited minimal ST-segment elevations and laboratory parameters revealed pathological levels of high-sensitivity cardiac troponin and C-reactive protein. Radiological imaging showed increased metabolism in enlarged lymph nodes in the chest and signs that could be compatible with increased metabolism in the left ventricular of the heart. The combination of acute myocarditis and enlarged lymph nodes was believed to be caused by the intracellular bacterium Francisella tularensis, endemic in the Northern Sweden, and was verified with positive serology. The patient showed full recovery after antimicrobial treatment. As this is the fifth published case of myocarditis associated with Francisella tularensis, we suggest considering tularemia in acute myocarditis in tularemia-endemic area.

The process used to diagnose Shaken Baby Syndrome (SBS), a subgroup of Abusive Head Trauma (AHT) without signs of relevant trauma, is not reliable and remains uncertain. There is insufficient scientific evidence for any doctor or medical expert to conclude that if a child has three medical findings, the “triad”, then the infant must have been shaken or abused. All studies showing a ‘strong’ association between the triad and the diagnostic accuracy of the SBS diagnosis rely on circular reasoning., There is insufficient scientific evidence that the isolated triad can predict traumatic shaking, as there is a high risk of bias. There is an ongoing scientific controversy within the area. The aim of the present article is to facilitate a better understanding of this scientific controversy for those who are not themselves medical scientists -, such as lawyers, prosecutors, and judges. The legal and medical consequences of the current scientific controversy is that an incorrect diagnosis may delay the correct diagnosis, harm the infant and its family, and jeopardis e rule of law.

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/).