- Email: [email protected]
Bruise detection and visibility under alternate light during the first three days post-trauma
Journal Pre-proof Bruise detection and visibility under alternate light during the first three days posttrauma Katherine N. Scafide, Shashi Sharma, Natalie E. Tripp, Matthew J. Hayat PII:
S1752-928X(18)30640-1
DOI:
https://doi.org/10.1016/j.jflm.2019.101893
Reference:
YJFLM 101893
To appear in:
Journal of Forensic and Legal Medicine
Received Date: 13 November 2018 Revised Date:
5 June 2019
Accepted Date: 17 December 2019
Please cite this article as: Scafide KN, Sharma S, Tripp NE, Hayat MJ, Bruise detection and visibility under alternate light during the first three days post-trauma, Journal of Forensic and Legal Medicine (2020), doi: https://doi.org/10.1016/j.jflm.2019.101893. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Ltd.
Bruise Detection and Visibility Under Alternate Light During the First Three Days Post-Trauma
Katherine N. Scafidea Shashi Sharmaa Natalie E. Trippb Matthew J. Hayatb
a
George Mason University, College of Health and Human Services 4400 University Drive, Mail Stop Number 3C4 Fairfax, Virigina 22030, United States b Georgia State University, School of Public Health PO Box 3995 Atlanta, Georgia 30302, United States Corresponding Author: Dr. Katherine Scafide Email: [email protected] Phone: +011-703-993-3595 Declarations of interest for all authors: none
1 Abstract Introduction: Cutaneous bruises are often hard to detect particularly on individuals with a darker complexion. Researchers and federal agencies have recommended the use of alternate light to aide in the assessment of subtle injury. However, studies are limited in their evaluation of wavelength performance during the first few days of bruise healing. The purpose of this pilot study was to examine whether an alternate light source (ALS) improves detection of bruises when compared to normal light typical of clinical practice during the first three days following induction. Methods: A sample of eight healthy adults between 22 and 36 years of age with diverse skin color were recruited for this study. One bruise was induced on each participant by dropping a 4oz (113g) steel ball through a 5-ft (1.5m) vertical pipe onto the anterior surface of the forearm. Using the ALS, bruises were assessed under 14 different combinations of ultraviolet and short narrowband visible wavelengths and filters along with overhead fluorescent “examination” lighting. Participants were examined 3 to 4 times per day at approximately 4-hour intervals for three consecutive days post induction. Results: Repeated bruise assessments on 8 subjects resulted in 59 bruise assessments and 885 total observations under the different wavelengths and filters combinations. A bruise was detectable in 46 (78%) of the assessments, with bruise ages ranging from 30 minutes to 57 hours. Twenty (34%) bruises not detectable under normal light were visible with ASL. Multilevel modeling revealed a strong association between time and detection for shorter wavelengths, such as 365nm (ultraviolet) and 450nm. Conclusion: The results of our study suggest alternate light is more likely to detect faint bruises than normal lighting during the first three days post injury. However, more research is needed to determine which wavelengths and filter combinations are most effective during that time frame.
Keywords: bruises, alternate light, detection, ultraviolet, visible spectrum, forensic assessment
2
Introduction Bruises are the most common soft tissue injury among victims of violence.1–4 The clinical evaluation of bruises by forensic practitioners is usually limited to visual and tactile assessment.5 However, a bruise’s visibility is often hampered by skin color or the depth and age of the injury6. The resulting challenge is that many bruises often go unnoticed and undocumented on individuals with dark skin or who delay treatment. In the United States, the Department of Justice recommends incorporating technology, such as an alternate light source (ALS), to assist in identifying “subtle injury”7 (see pp 67-68). Alternate light involves the projection of light of a specific wavelength, usually within the narrowband visible or ultraviolet spectrums8. Generally, light is either reflected by the skin’s surface or penetrates the skin at varying depths depending on the wavelength9. Hemoglobin and its breakdown products absorb light at certain wavelengths10, resulting in a darker appearance under ALS compared to the surrounding tissue11. To view the absorbed light, the reflected light must be filtered either through goggles worn by the observer or using camera equipment. Recent studies have demonstrated the potential for using ALS to detect or enhance the visibility of bruises12–14. However, research has yet to thoroughly explore how wavelength performance may change during the first few days post injury while controlling for variation in trauma. It also remains unclear whether light within the 550nm bandwidth may improve bruise detection given the broad absorption peak of hemoglobin within that range15. The purpose of this pilot study was to compare bruise detection using an ALS to normal lighting typical of practice settings on a diverse sample with identical injuries. Materials and Methods Sample A convenience sample of 8 healthy adults participated in this study, including five males and three females. The mean age was 28 (SD=5.3) years. Three of the subjects had light skin tone (white/Caucasian), while the other five subjects had a dark complexion (originating from Southern India or Africa). Because this study involved the creation of a bruise, subjects were excluded if they had certain medical conditions or took medications that interfered with coagulation or inflammation. Each study participant provided informed consent and was compensated $5.00 USD per assessment visit. This study was approved and conducted in accordance to the Institutional Review Board (IRB) ethics committee at [redacted]. Bruise Induction The body location and methodology chosen for bruise induction was previously published by Lombardi et al.13 The method was chosen due to its limited risk to participants and ease of controlled anatomical placement, which allowed us to avoid vessels or other structures that could interfere with bruise assessment. The bruise site was the anterior forearm approximately 5-7 cm from the antecubital fossa. Five participants opted to have the bruise created on the right arm, while three on the left. The skin at the bruising site was screened for pre-existing injuries, lesions (e.g., tattoos), or artifact visible under normal illumination (i.e., fluorescent lighting) or alternative light. If an injury or lesion was identified, the opposite arm was screened. Subjects were excluded if both anterior forearms screened positive for injuries, lesions, or artifact.
3 While seated, the subject’s arm was placed horizontally, palm-up, on a table surface, at or just below chest level. A 4-ounce (113 grams) steel ball was dropped through a vertical, 5-ft (1.5m) polyvinyl chloride (PVC) pipe onto the ventral surface of the forearm at the desired location. The end of the pipe was held close to, but not touching, the skin’s surface. Equipment and Data Collection The HandScope Xenon FLS HSX-5000 (SPEX Forensics, Edison, NJ) was used as the alternate light source. This handheld unit uses a drum of internal, bandwidth filters to control the emitted xenon arc light. To visualize light absorption, long pass filter goggles were worn by the investigator to block shorter wavelengths being reflected by the skin’s surface. The specific wavelengths and filters evaluated are presented in Table 1. Overhead fluorescent lighting typical of a clinical practice environment provided the “normal” light comparison. After the bruise was created, the injury site was assessed 3 to 4 times a day, each day, for a period extending over 3 days. Bruise assessments were conducted by either author K.S. or S.S. who have a combined 40 years of experience performing skin assessments as part of their nursing practice. Both were trained on the equipment. The skin was first examined under normal fluorescence lighting for the presence of visible bruising at the induction site. Subsequently, the room was darkened, and the examiner observed the same area of the skin using ALS for the presence of visible absorption. The order of the ALS application of the fourteen different wavelengths/filters combinations is the same as presented in Table 1. The participants were provided UV filtering goggles to protect their eyes during the assessment. The first bruise assessment was conducted 30 minutes post-trauma to allow for the immediate histamine response to subside. Subsequent bruise assessments were scheduled approximately 4 hours apart; however, the actual amount of time between visits varied. Data Analysis Data were analyzed with IBM SPSS for Windows, version 23.0 (IBM Corp., Armonk, NY), and the SAS Software System, version 9.4 (SAS Institute Inc., Cary, NC). Frequency distributions were used to summarize bruise visibility by wavelength and filter. A visual representation with a stacked bar chart is used to display frequency of bruise detection over time using normal lighting and ALS. Data were collected on repeated bruise assessments using multiple wavelengths and filers. In order to account for the correlation inherent in repeated measures on a bruise, a multilevel marginal model was applied with generalized estimating equations used for estimation. This modeling framework accounts for repeated measures data and enables comparison of light source performance and quantifies factors associated with bruise detection16 Results As a result of the bruise induction, each of the subjects had a detectible bruise, either under ALS or normal lighting, within one-hour, post-trauma induction. The bruises were very faint in appearance. Participants completed 59 bruise assessments, averaging 7 to 8 assessments (range 3-10) per subject. One subject withdrew from the study early due to an unrelated illness. A total of 885 bruise observations were completed, with 59 under normal lighting and 826 under the different ALS lighting conditions. The age of the bruise at time of assessment ranged from 30 minutes to 56.75 hours post-induction.
4 Table 2 presents the frequency of bruise detection by light and filter combination. A bruise was detectable during 46 (78%) of the 59 assessments. Of the 46 assessments in which a bruise was detected, 45 (98%) were detected by the ALS while only 11 (24%) were by normal light. Bruises not detectable under normal light were visible under ALS during twenty (34%) of the 59 assessments. The frequency of bruise detection over time using normal lighting and ALS is displayed in Figure 1. Normal lighting was more effective in visualizing bruises closer in time to bruise creation; whereas, ALS detected bruises more consistently over time. The multilevel marginal model results are presented in Table 3. Estimates for the log odds of the outcome are displayed for reproducibility. The likelihood of bruise detection under ALS decreased with an aging bruise (-0.01, 95% CI [-0.02, 0.0006]). Shorter wavelengths (e.g., UV and 415 or 450 nm) had a greater likelihood of detecting bruises under ALS (-0.01, 95% CI [-0.02, 0.01]). However, an association was not found with the selection of the colored filter. For any given wavelength, the yellow and orange filters were not significantly associated with an increase in likelihood of detection over red (p=0.453). Discussion In this study, the ALS was able to detect absorption at the bruise site more often than normal overhead lighting typically used in clinical practice. These findings are consistent with previous research investigating existent bruises on living individuals 12,14,17. However, by creating bruises, we controlled for baseline artifact that may have mimicked bruising under alternate light, such as other skin lesions17 and certain topical products18. Such a design improves confidence that the absorption detected is more likely a result of the bruise and its breakdown products than an existing condition. The bruises in this study were evaluated frequently during the first three days post trauma in order to explore whether the performance of wavelengths varied as the injury healed. According to animal models, the local concentration of macrophage-produced heme-oxygenase peaks during this time contributing to the catabolism of hemoglobin into its breakdown products19. In our marginal model, shorter ALS wavelengths had a greater likelihood of detecting bruises. These finding are consistent with the known, absorption peaks of oxyhemoglobin (415nm), de-oxygemoglobin (430nm), and bilirubin (460nm) within this portion of the visible spectrum10,15. Our research findings support prior experiments where the bruise’s age is known with confidence. Using the same bruise induction procedure, Lombardi et al. found no variation in latent bruise detection sensitivity (73-75%) across UV and short narrow-band visible spectrums (300nm-555nm) one day after trauma13. Unfortunately, that prospective study was limited to one observation during the first three days. Research on simulated fresh bruises also found significant enhancement in visualization compared to white light across bandwidths between 350-510nm.20 More research is needed to determine whether time is a factor in which wavelength and filters are most effective in detecting bruises on a larger, diverse sample. There are several limitations to our pilot study. First, the bruise induction technique used in this study was developed by its original authors to create “subclinical” (i.e., latent) injuries13. Thus, the resulting bruises we created were faint and could have been mistaken for natural skin artifact. Future use of this technique should include a heavier weight (>113g). Second, our sample size was diverse but small, which may have contributed to our inability to identify a recognizable pattern to filter performance over time. Finally, we did not compare the overall clarity of bruise visualization between the two sources of light due to a lack of existing reliable
5 metrics. Using photographic analysis to quantify the enhanced visibility of faint bruises, such as those used by Olds et al.20, may increase the support for the clinical utility of the ALS. Conclusions Alternate light within ultraviolet and short narrow-band visible spectrums has been suggested by researchers and agencies to aid in the assessment of subtle bruising. In this pilot study, we examined whether an ALS could improve detection of bruises in the first few days after trauma when compared to normal lighting typical of the clinical practice setting. The results suggest an ALS has greater likelihood of detecting faint bruises during the first three days post injury using shorter, visible wavelengths. However, more research is needed to further determine which wavelengths and filter combinations are most effective during that time frame.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no real or perceived conflicts of interest when conducting this research study.
6 Reference 1. Savall F, Lechevalier A, Hérin F, Vergnault M, Telmon N, Bartoli C. A ten-year experience of physical Intimate partner violence (IPV) in a French forensic unit. J Forensic Leg Med. 2017;46:12-15. doi:10.1016/j.jflm.2016.12.007 2. Kemp AM, Maguire SA, Nuttall D, Collins P, Dunstan F. Bruising in children who are assessed for suspected physical abuse. Arch Dis Child. 2014;99(2):108-113. doi:10.1136/archdischild-2013-304339 3. Alempijevic D, Savic S, Pavlekic S, Jecmenica D. Severity of injuries among sexual assault victims. J Forensic Leg Med. 2007;14(5):266-269. doi:10.1016/j.jcfm.2006.08.008 4. Wiglesworth A, Austin R, Corona M, et al. Bruising as a Marker of Physical Elder Abuse. J Am Geriatr Soc. 2009;57(7):1191-1196. doi:10.1111/j.1532-5415.2009.02330.x 5. Nash KR, Sheridan DJ. Can one accurately date a bruise? State of the science. J Forensic Nurs. 2009;5(1):31-37. doi:10.1111/j.1939-3938.2009.01028.x 6. Sommers MS, Zink TM, Fargo JD, et al. Forensic sexual assault examination and genital injury: is skin color a source of health disparity? Am J Emerg Med. 2008;26(8):857-866. doi:10.1016/j.ajem.2007.11.025 7. U.S. Department of Justice. A National Protocol for Sexual Assault Medical Forensic Examinations: Adults/Adolescents (2nd Ed.). Washington, D.C.: U.S. Department of Justice, Office on Violence Against Women; 2013. 8. Marin N, Buszka JM. Alternate Light Source Imaging: Forensic Photography Techniques. Routledge; 2013. 9. Wright FD, Golden GS. The use of full spectrum digital photography for evidence collection and preservation in cases involving forensic odontology. Forensic Sci Int. 2010;201(1– 3):59-67. doi:10.1016/j.forsciint.2010.03.013 10. Hughes VK, Ellis PS, Burt T, Langlois NEI. The practical application of reflectance spectrophotometry for the demonstration of haemoglobin and its degradation in bruises. J Clin Pathol. 2004;57(4):355-359. doi:10.1136/jcp.2003.011445 11. Baker HC, Marsh N, Quinones I. Photography of Faded or Concealed Bruises on Human Skin. J Forensic Identif. 2013;63(1):103-125. 12. Limmen RM, Ceelen M, Reijnders UJL, Joris Stomp S, de Keijzer KC, Das K. Enhancing the Visibility of Injuries with Narrow-Banded Beams of Light within the Visible Light Spectrum. J Forensic Sci. 2013;58(2):518-522. doi:10.1111/1556-4029.12042 13. Lombardi M, Canter J, Patrick PA, Altman R. Is Fluorescence Under an Alternate Light Source Sufficient to Accurately Diagnose Subclinical Bruising? J Forensic Sci. 2015;60(2):444-449. doi:10.1111/1556-4029.12698
7 14. Mimasaka S, Oshima T, Ohtani M. Visualization of old bruises in children: Use of violet light to record long-term bruises. Forensic Sci Int. 2018;282:74-78. doi:10.1016/j.forsciint.2017.11.015 15. Langlois NEI. The science behind the quest to determine the age of bruises—a review of the English language literature. Forensic Sci Med Pathol. 2007;3(4):241-251. doi:10.1007/s12024-007-9019-3 16. Hayat MJ, Hedlin H. Modern Statistical Modeling Approaches for Analyzing RepeatedMeasures Data. Nurs Res. 2012;61(3):188-194 7p. doi:10.1097/NNR.0b013e31824f5f58 17. Holbrook DS, Jackson MC. Use of an alternative light source to assess strangulation victims. J Forensic Nurs. 2013;9(3):140-145. doi:10.1097/JFN.0b013e31829beb1e 18. Pollitt EN, Anderson JC, Scafide KN, Holbrook D, D’Silva G, Sheridan DJ. Alternate Light Source Findings of Common Topical Products: J Forensic Nurs. 2016;12(3):97-103. doi:10.1097/JFN.0000000000000116 19. Langlois NEI, Olds K, Ross C, Byard RW. Heme oxygenase-1 and heme oxygenase-2 expression in bruises. Forensic Sci Med Pathol. 2015;11(4):482-487. doi:10.1007/s12024015-9660-1 20. Olds K, Byard RW, Winskog C, Langlois NEI. Validation of ultraviolet, infrared, and narrow band light alternate light sources for detection of bruises in a pigskin model. Forensic Sci Med Pathol. 2016;12(4):435-443.
Table 1. Alternate light source wavelengths and filters measured in this study. Longpass Filters Wavelength (nm)
Color
50% Transmission (nm)*
365 (ultraviolet)
Clear
418
415, 450, 475, 495
Yellow
515
450, 475, 495, 515, 535
Orange
562
495, 515, 535, 555
Red
602
* Transmission of Safety Goggles, SPEX Forensics.
Table 2. Frequency of bruise detection during assessment visits based on light and filter combination (n=59 assessments) Filter Light Normal Light
Clear/ None 11
Yellow
Orange
Red
Alternate Light Ultraviolet
23
415nm
11
450nm
12
14
475nm
8
13
495nm
1
6
5
10
22
515nm 535nm
16
555nm
3
Table 3. Multilevel modeling results for quantifying factors associated with bruise detection under alternative light source*
Covariate Intercept Wavelength
Parameter Estimate 2.32
95% Confidence Interval Lower Upper -7.00 11.65
-0.01
-0.02
0.01
Yellow
3.83
-7.02
14.67
Orange
6.42
-4.78
17.61
-0.06
-3.00
2.87
Filter color
Clear Red
-0.01
-0.03
0.01
Wavelength x orange
-0.01
-0.04
0.01
-0.02
0.0006
*
.630 .002 .528
Reference
Wavelength by filter color Wavelength x yellow
.453
Wavelength x clear
Reference
Wavelength x red
Reference
Bruise age
p-value
-0.01
.035
A marginal model with generalized estimating equations was used to account for repeated measurements on each bruise. A total of 8 subjects received repeated bruise assessments amounting to 59 measurements over a period of three days. Results for modeling of log odds of probability of bruise detection displayed. p<.05 in bold.
Figure 1. Frequency of bruise detection over time using normal lighting and an alternate light source. No measures were obtained between 12-18 hours and 36-45 hours.
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Highlights • • • •
Bruises are often challenging to detect in the clinical setting. Using an alternate light to augment visualization may improve bruise detection during the first few days after injury Shorter wavelengths in the ultraviolet and visible spectrums improve the likelihood of detection More research is needed to evaluate time as a factor in alternate light performance.
S1752-928X(18)30640-1
DOI:
https://doi.org/10.1016/j.jflm.2019.101893
Reference:
YJFLM 101893
To appear in:
Journal of Forensic and Legal Medicine
Received Date: 13 November 2018 Revised Date:
5 June 2019
Accepted Date: 17 December 2019
Please cite this article as: Scafide KN, Sharma S, Tripp NE, Hayat MJ, Bruise detection and visibility under alternate light during the first three days post-trauma, Journal of Forensic and Legal Medicine (2020), doi: https://doi.org/10.1016/j.jflm.2019.101893. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Ltd.
Bruise Detection and Visibility Under Alternate Light During the First Three Days Post-Trauma
Katherine N. Scafidea Shashi Sharmaa Natalie E. Trippb Matthew J. Hayatb
a
George Mason University, College of Health and Human Services 4400 University Drive, Mail Stop Number 3C4 Fairfax, Virigina 22030, United States b Georgia State University, School of Public Health PO Box 3995 Atlanta, Georgia 30302, United States Corresponding Author: Dr. Katherine Scafide Email: [email protected] Phone: +011-703-993-3595 Declarations of interest for all authors: none
1 Abstract Introduction: Cutaneous bruises are often hard to detect particularly on individuals with a darker complexion. Researchers and federal agencies have recommended the use of alternate light to aide in the assessment of subtle injury. However, studies are limited in their evaluation of wavelength performance during the first few days of bruise healing. The purpose of this pilot study was to examine whether an alternate light source (ALS) improves detection of bruises when compared to normal light typical of clinical practice during the first three days following induction. Methods: A sample of eight healthy adults between 22 and 36 years of age with diverse skin color were recruited for this study. One bruise was induced on each participant by dropping a 4oz (113g) steel ball through a 5-ft (1.5m) vertical pipe onto the anterior surface of the forearm. Using the ALS, bruises were assessed under 14 different combinations of ultraviolet and short narrowband visible wavelengths and filters along with overhead fluorescent “examination” lighting. Participants were examined 3 to 4 times per day at approximately 4-hour intervals for three consecutive days post induction. Results: Repeated bruise assessments on 8 subjects resulted in 59 bruise assessments and 885 total observations under the different wavelengths and filters combinations. A bruise was detectable in 46 (78%) of the assessments, with bruise ages ranging from 30 minutes to 57 hours. Twenty (34%) bruises not detectable under normal light were visible with ASL. Multilevel modeling revealed a strong association between time and detection for shorter wavelengths, such as 365nm (ultraviolet) and 450nm. Conclusion: The results of our study suggest alternate light is more likely to detect faint bruises than normal lighting during the first three days post injury. However, more research is needed to determine which wavelengths and filter combinations are most effective during that time frame.
Keywords: bruises, alternate light, detection, ultraviolet, visible spectrum, forensic assessment
2
Introduction Bruises are the most common soft tissue injury among victims of violence.1–4 The clinical evaluation of bruises by forensic practitioners is usually limited to visual and tactile assessment.5 However, a bruise’s visibility is often hampered by skin color or the depth and age of the injury6. The resulting challenge is that many bruises often go unnoticed and undocumented on individuals with dark skin or who delay treatment. In the United States, the Department of Justice recommends incorporating technology, such as an alternate light source (ALS), to assist in identifying “subtle injury”7 (see pp 67-68). Alternate light involves the projection of light of a specific wavelength, usually within the narrowband visible or ultraviolet spectrums8. Generally, light is either reflected by the skin’s surface or penetrates the skin at varying depths depending on the wavelength9. Hemoglobin and its breakdown products absorb light at certain wavelengths10, resulting in a darker appearance under ALS compared to the surrounding tissue11. To view the absorbed light, the reflected light must be filtered either through goggles worn by the observer or using camera equipment. Recent studies have demonstrated the potential for using ALS to detect or enhance the visibility of bruises12–14. However, research has yet to thoroughly explore how wavelength performance may change during the first few days post injury while controlling for variation in trauma. It also remains unclear whether light within the 550nm bandwidth may improve bruise detection given the broad absorption peak of hemoglobin within that range15. The purpose of this pilot study was to compare bruise detection using an ALS to normal lighting typical of practice settings on a diverse sample with identical injuries. Materials and Methods Sample A convenience sample of 8 healthy adults participated in this study, including five males and three females. The mean age was 28 (SD=5.3) years. Three of the subjects had light skin tone (white/Caucasian), while the other five subjects had a dark complexion (originating from Southern India or Africa). Because this study involved the creation of a bruise, subjects were excluded if they had certain medical conditions or took medications that interfered with coagulation or inflammation. Each study participant provided informed consent and was compensated $5.00 USD per assessment visit. This study was approved and conducted in accordance to the Institutional Review Board (IRB) ethics committee at [redacted]. Bruise Induction The body location and methodology chosen for bruise induction was previously published by Lombardi et al.13 The method was chosen due to its limited risk to participants and ease of controlled anatomical placement, which allowed us to avoid vessels or other structures that could interfere with bruise assessment. The bruise site was the anterior forearm approximately 5-7 cm from the antecubital fossa. Five participants opted to have the bruise created on the right arm, while three on the left. The skin at the bruising site was screened for pre-existing injuries, lesions (e.g., tattoos), or artifact visible under normal illumination (i.e., fluorescent lighting) or alternative light. If an injury or lesion was identified, the opposite arm was screened. Subjects were excluded if both anterior forearms screened positive for injuries, lesions, or artifact.
3 While seated, the subject’s arm was placed horizontally, palm-up, on a table surface, at or just below chest level. A 4-ounce (113 grams) steel ball was dropped through a vertical, 5-ft (1.5m) polyvinyl chloride (PVC) pipe onto the ventral surface of the forearm at the desired location. The end of the pipe was held close to, but not touching, the skin’s surface. Equipment and Data Collection The HandScope Xenon FLS HSX-5000 (SPEX Forensics, Edison, NJ) was used as the alternate light source. This handheld unit uses a drum of internal, bandwidth filters to control the emitted xenon arc light. To visualize light absorption, long pass filter goggles were worn by the investigator to block shorter wavelengths being reflected by the skin’s surface. The specific wavelengths and filters evaluated are presented in Table 1. Overhead fluorescent lighting typical of a clinical practice environment provided the “normal” light comparison. After the bruise was created, the injury site was assessed 3 to 4 times a day, each day, for a period extending over 3 days. Bruise assessments were conducted by either author K.S. or S.S. who have a combined 40 years of experience performing skin assessments as part of their nursing practice. Both were trained on the equipment. The skin was first examined under normal fluorescence lighting for the presence of visible bruising at the induction site. Subsequently, the room was darkened, and the examiner observed the same area of the skin using ALS for the presence of visible absorption. The order of the ALS application of the fourteen different wavelengths/filters combinations is the same as presented in Table 1. The participants were provided UV filtering goggles to protect their eyes during the assessment. The first bruise assessment was conducted 30 minutes post-trauma to allow for the immediate histamine response to subside. Subsequent bruise assessments were scheduled approximately 4 hours apart; however, the actual amount of time between visits varied. Data Analysis Data were analyzed with IBM SPSS for Windows, version 23.0 (IBM Corp., Armonk, NY), and the SAS Software System, version 9.4 (SAS Institute Inc., Cary, NC). Frequency distributions were used to summarize bruise visibility by wavelength and filter. A visual representation with a stacked bar chart is used to display frequency of bruise detection over time using normal lighting and ALS. Data were collected on repeated bruise assessments using multiple wavelengths and filers. In order to account for the correlation inherent in repeated measures on a bruise, a multilevel marginal model was applied with generalized estimating equations used for estimation. This modeling framework accounts for repeated measures data and enables comparison of light source performance and quantifies factors associated with bruise detection16 Results As a result of the bruise induction, each of the subjects had a detectible bruise, either under ALS or normal lighting, within one-hour, post-trauma induction. The bruises were very faint in appearance. Participants completed 59 bruise assessments, averaging 7 to 8 assessments (range 3-10) per subject. One subject withdrew from the study early due to an unrelated illness. A total of 885 bruise observations were completed, with 59 under normal lighting and 826 under the different ALS lighting conditions. The age of the bruise at time of assessment ranged from 30 minutes to 56.75 hours post-induction.
4 Table 2 presents the frequency of bruise detection by light and filter combination. A bruise was detectable during 46 (78%) of the 59 assessments. Of the 46 assessments in which a bruise was detected, 45 (98%) were detected by the ALS while only 11 (24%) were by normal light. Bruises not detectable under normal light were visible under ALS during twenty (34%) of the 59 assessments. The frequency of bruise detection over time using normal lighting and ALS is displayed in Figure 1. Normal lighting was more effective in visualizing bruises closer in time to bruise creation; whereas, ALS detected bruises more consistently over time. The multilevel marginal model results are presented in Table 3. Estimates for the log odds of the outcome are displayed for reproducibility. The likelihood of bruise detection under ALS decreased with an aging bruise (-0.01, 95% CI [-0.02, 0.0006]). Shorter wavelengths (e.g., UV and 415 or 450 nm) had a greater likelihood of detecting bruises under ALS (-0.01, 95% CI [-0.02, 0.01]). However, an association was not found with the selection of the colored filter. For any given wavelength, the yellow and orange filters were not significantly associated with an increase in likelihood of detection over red (p=0.453). Discussion In this study, the ALS was able to detect absorption at the bruise site more often than normal overhead lighting typically used in clinical practice. These findings are consistent with previous research investigating existent bruises on living individuals 12,14,17. However, by creating bruises, we controlled for baseline artifact that may have mimicked bruising under alternate light, such as other skin lesions17 and certain topical products18. Such a design improves confidence that the absorption detected is more likely a result of the bruise and its breakdown products than an existing condition. The bruises in this study were evaluated frequently during the first three days post trauma in order to explore whether the performance of wavelengths varied as the injury healed. According to animal models, the local concentration of macrophage-produced heme-oxygenase peaks during this time contributing to the catabolism of hemoglobin into its breakdown products19. In our marginal model, shorter ALS wavelengths had a greater likelihood of detecting bruises. These finding are consistent with the known, absorption peaks of oxyhemoglobin (415nm), de-oxygemoglobin (430nm), and bilirubin (460nm) within this portion of the visible spectrum10,15. Our research findings support prior experiments where the bruise’s age is known with confidence. Using the same bruise induction procedure, Lombardi et al. found no variation in latent bruise detection sensitivity (73-75%) across UV and short narrow-band visible spectrums (300nm-555nm) one day after trauma13. Unfortunately, that prospective study was limited to one observation during the first three days. Research on simulated fresh bruises also found significant enhancement in visualization compared to white light across bandwidths between 350-510nm.20 More research is needed to determine whether time is a factor in which wavelength and filters are most effective in detecting bruises on a larger, diverse sample. There are several limitations to our pilot study. First, the bruise induction technique used in this study was developed by its original authors to create “subclinical” (i.e., latent) injuries13. Thus, the resulting bruises we created were faint and could have been mistaken for natural skin artifact. Future use of this technique should include a heavier weight (>113g). Second, our sample size was diverse but small, which may have contributed to our inability to identify a recognizable pattern to filter performance over time. Finally, we did not compare the overall clarity of bruise visualization between the two sources of light due to a lack of existing reliable
5 metrics. Using photographic analysis to quantify the enhanced visibility of faint bruises, such as those used by Olds et al.20, may increase the support for the clinical utility of the ALS. Conclusions Alternate light within ultraviolet and short narrow-band visible spectrums has been suggested by researchers and agencies to aid in the assessment of subtle bruising. In this pilot study, we examined whether an ALS could improve detection of bruises in the first few days after trauma when compared to normal lighting typical of the clinical practice setting. The results suggest an ALS has greater likelihood of detecting faint bruises during the first three days post injury using shorter, visible wavelengths. However, more research is needed to further determine which wavelengths and filter combinations are most effective during that time frame.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no real or perceived conflicts of interest when conducting this research study.
6 Reference 1. Savall F, Lechevalier A, Hérin F, Vergnault M, Telmon N, Bartoli C. A ten-year experience of physical Intimate partner violence (IPV) in a French forensic unit. J Forensic Leg Med. 2017;46:12-15. doi:10.1016/j.jflm.2016.12.007 2. Kemp AM, Maguire SA, Nuttall D, Collins P, Dunstan F. Bruising in children who are assessed for suspected physical abuse. Arch Dis Child. 2014;99(2):108-113. doi:10.1136/archdischild-2013-304339 3. Alempijevic D, Savic S, Pavlekic S, Jecmenica D. Severity of injuries among sexual assault victims. J Forensic Leg Med. 2007;14(5):266-269. doi:10.1016/j.jcfm.2006.08.008 4. Wiglesworth A, Austin R, Corona M, et al. Bruising as a Marker of Physical Elder Abuse. J Am Geriatr Soc. 2009;57(7):1191-1196. doi:10.1111/j.1532-5415.2009.02330.x 5. Nash KR, Sheridan DJ. Can one accurately date a bruise? State of the science. J Forensic Nurs. 2009;5(1):31-37. doi:10.1111/j.1939-3938.2009.01028.x 6. Sommers MS, Zink TM, Fargo JD, et al. Forensic sexual assault examination and genital injury: is skin color a source of health disparity? Am J Emerg Med. 2008;26(8):857-866. doi:10.1016/j.ajem.2007.11.025 7. U.S. Department of Justice. A National Protocol for Sexual Assault Medical Forensic Examinations: Adults/Adolescents (2nd Ed.). Washington, D.C.: U.S. Department of Justice, Office on Violence Against Women; 2013. 8. Marin N, Buszka JM. Alternate Light Source Imaging: Forensic Photography Techniques. Routledge; 2013. 9. Wright FD, Golden GS. The use of full spectrum digital photography for evidence collection and preservation in cases involving forensic odontology. Forensic Sci Int. 2010;201(1– 3):59-67. doi:10.1016/j.forsciint.2010.03.013 10. Hughes VK, Ellis PS, Burt T, Langlois NEI. The practical application of reflectance spectrophotometry for the demonstration of haemoglobin and its degradation in bruises. J Clin Pathol. 2004;57(4):355-359. doi:10.1136/jcp.2003.011445 11. Baker HC, Marsh N, Quinones I. Photography of Faded or Concealed Bruises on Human Skin. J Forensic Identif. 2013;63(1):103-125. 12. Limmen RM, Ceelen M, Reijnders UJL, Joris Stomp S, de Keijzer KC, Das K. Enhancing the Visibility of Injuries with Narrow-Banded Beams of Light within the Visible Light Spectrum. J Forensic Sci. 2013;58(2):518-522. doi:10.1111/1556-4029.12042 13. Lombardi M, Canter J, Patrick PA, Altman R. Is Fluorescence Under an Alternate Light Source Sufficient to Accurately Diagnose Subclinical Bruising? J Forensic Sci. 2015;60(2):444-449. doi:10.1111/1556-4029.12698
7 14. Mimasaka S, Oshima T, Ohtani M. Visualization of old bruises in children: Use of violet light to record long-term bruises. Forensic Sci Int. 2018;282:74-78. doi:10.1016/j.forsciint.2017.11.015 15. Langlois NEI. The science behind the quest to determine the age of bruises—a review of the English language literature. Forensic Sci Med Pathol. 2007;3(4):241-251. doi:10.1007/s12024-007-9019-3 16. Hayat MJ, Hedlin H. Modern Statistical Modeling Approaches for Analyzing RepeatedMeasures Data. Nurs Res. 2012;61(3):188-194 7p. doi:10.1097/NNR.0b013e31824f5f58 17. Holbrook DS, Jackson MC. Use of an alternative light source to assess strangulation victims. J Forensic Nurs. 2013;9(3):140-145. doi:10.1097/JFN.0b013e31829beb1e 18. Pollitt EN, Anderson JC, Scafide KN, Holbrook D, D’Silva G, Sheridan DJ. Alternate Light Source Findings of Common Topical Products: J Forensic Nurs. 2016;12(3):97-103. doi:10.1097/JFN.0000000000000116 19. Langlois NEI, Olds K, Ross C, Byard RW. Heme oxygenase-1 and heme oxygenase-2 expression in bruises. Forensic Sci Med Pathol. 2015;11(4):482-487. doi:10.1007/s12024015-9660-1 20. Olds K, Byard RW, Winskog C, Langlois NEI. Validation of ultraviolet, infrared, and narrow band light alternate light sources for detection of bruises in a pigskin model. Forensic Sci Med Pathol. 2016;12(4):435-443.
Table 1. Alternate light source wavelengths and filters measured in this study. Longpass Filters Wavelength (nm)
Color
50% Transmission (nm)*
365 (ultraviolet)
Clear
418
415, 450, 475, 495
Yellow
515
450, 475, 495, 515, 535
Orange
562
495, 515, 535, 555
Red
602
* Transmission of Safety Goggles, SPEX Forensics.
Table 2. Frequency of bruise detection during assessment visits based on light and filter combination (n=59 assessments) Filter Light Normal Light
Clear/ None 11
Yellow
Orange
Red
Alternate Light Ultraviolet
23
415nm
11
450nm
12
14
475nm
8
13
495nm
1
6
5
10
22
515nm 535nm
16
555nm
3
Table 3. Multilevel modeling results for quantifying factors associated with bruise detection under alternative light source*
Covariate Intercept Wavelength
Parameter Estimate 2.32
95% Confidence Interval Lower Upper -7.00 11.65
-0.01
-0.02
0.01
Yellow
3.83
-7.02
14.67
Orange
6.42
-4.78
17.61
-0.06
-3.00
2.87
Filter color
Clear Red
-0.01
-0.03
0.01
Wavelength x orange
-0.01
-0.04
0.01
-0.02
0.0006
*
.630 .002 .528
Reference
Wavelength by filter color Wavelength x yellow
.453
Wavelength x clear
Reference
Wavelength x red
Reference
Bruise age
p-value
-0.01
.035
A marginal model with generalized estimating equations was used to account for repeated measurements on each bruise. A total of 8 subjects received repeated bruise assessments amounting to 59 measurements over a period of three days. Results for modeling of log odds of probability of bruise detection displayed. p<.05 in bold.
Figure 1. Frequency of bruise detection over time using normal lighting and an alternate light source. No measures were obtained between 12-18 hours and 36-45 hours.
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Highlights • • • •
Bruises are often challenging to detect in the clinical setting. Using an alternate light to augment visualization may improve bruise detection during the first few days after injury Shorter wavelengths in the ultraviolet and visible spectrums improve the likelihood of detection More research is needed to evaluate time as a factor in alternate light performance.