Medicine
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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty
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Item Analysis of medicolegal examination in alleged sexual abuse presented to a tertiary care hospital in Sri Lanka(Wolters Kluwer - Medknow, 2023) Kitulwatte, I.D.G.; Wijewardena, H.P.; Edirisinghe, P.A.S.; Senarathne, U.D.Forensic experts are often expected to provide an opinion on alleged physical or sexual contact between individuals following medicolegal examination of a case of sexual abuse (SA). There are many factors influencing the opinion. A retrospective descriptive study was performed to study the factors influencing the medicolegal opinion in SA forensic examination using medical and medicolegal records of alleged SA victims to extract data. Records of 441 victims were studied. A majority, 180 (40%), presented due to the guardian’s concerns – 302 (68%) presented for medicolegal examination 72 h after the incident. Recent injuries were observed in only 15% of the victims. Genital injuries were observed in 74% of the victims brought due to concerns of the guardians, with 12 victims having recent injuries. Of the 172 victims who complained of vaginal intercourse, 21% had recent injuries. A firm positive medicolegal opinion could be given in 63% of all cases. In 124 individuals, a firm positive or negative opinion could not be given. A majority (n = 90, 73%) of these individuals did not have any injuries, while 23% had healed injuries. According to the nature of the complaint, in a significant number of victims (53%), no scientific evidence was present to make a firm opinion. The nature of the sexual act and the absence of injuries influence the medicolegal opinion on SA, making it a challenging task for forensic experts.Item Medico legal and ethical aspects of surrogacy; A case report of a tragic maternal death from Sri Lanka(Elsevier Ltd, 2022) Kitulwatte, I.D.G.; Gangahawatte, S.; Perera, U.L.M.S.; Edirisinghe, P.A.S.A case report from Sri Lanka on surrogacy leading to a tragic maternal death; medico-legal and ethical aspects. Surrogacy, with multiple ethical and legal issues associated with it, is practised worldwide. Although regulations are not available in Sri Lanka, we report a woman who had a tragic death as a complication of surrogate pregnancy. The body of a young mother with four living children was brought for autopsy examination. According to the documents provided, there was a controversy about the deceased’s identity. A woman volunteered to show a pillow trapped in her abdomen, simulating a pregnancy. By surrogacy, her husband’s sperm were inseminated in this woman’s uterus artificially according to a contract. She was diagnosed and managed for pregnancy-induced hypertension in the second trimester. At 36 weeks of gestation, she was admitted to the hospital in labour. On admission, she was icteric with elevated blood pressure. A cesarean section delivered a baby, and it was noted that she had an abruption of the placenta. She developed a postpartum haemorrhage following delivery, and resuscitation failed, resulting in her death. She had elevated liver enzymes and low serum proteins before death. Autopsy findings included intense icterus, congested lungs, global ischemic changes in the myocardium, pale kidneys and fatty soft yellow liver. This case discusses many unanticipated legal and ethical issues related to surrogate pregnancy, especially in a lack of regulations regarding the practice and relatively cheap medical expenses.Item A Study on victims of intimate partner violence reported to Colombo North Teaching Hospital, Sri Lanka during 2019-2021(Academic Forensic Pathology International, La Jolla, CA, 2022) Muthulingam, T.; Edirisinghe, P.A.S.; Wijewardhane, H.P.; Thivaharan, Y.; Jayasundara, M.M.S.; Borukgama, N.; Kulathunga, D.L.; Alwis, D.N.; Govinnage, P.S.; Kitulwatte, I.D.G.Introduction: Intimate partner violence (IPV) is a common issue in any society and the reported cases are just the tip of an iceberg as most of the victims are reluctant to come to the criminal justice system. Forensic experts are often encountering the victims who chose to seek justice. Evaluation of the nature, consequences, and underlying factors are needed in planning preventive measures. Objectives: To describe the patterns and associated factors of IPV among victims who reported to Office of the Judicial Medical Officer of Colombo North Teaching Hospital and to specifically describe the patterns prior and during the COVID-19 pandemic. Methods: A retrospective descriptive study based on 471 medicolegal records of the victims who had undergone medicolegal examination following IPV during last two years (March 2019 to February 2021). Results: Out of 471, 206 cases were reported prepandemic and 265 reported postpandemic periods. Even though majority were females there were 21 males. Types of abuse were complex and often interrelated. There were 463 who had experienced physical injuries while there were 20 who had been subjected to sexual violence. Face was the commonest target of assault (63%). Substance abuse was identified as the commonest predisposing factor (56%). Even though repeated abuse was common, 42.5% of the victims had never made any complaints to the police. Despite multiple complains, 39.7% had experienced repeated violence. Conclusion: Victims of IPV are silently suffering for many long years. Failure in the response from authorities was identified. COVID-19 pandemic has become an additional risk factor for IPV. Strengthening of legal and social responses is the need of the hour.Item Trends and challenges of facial trauma presented for medico legal examination(South India Medicolegal Association, 2018) Kitulwatte, I.D.G.; Edirisinghe, P.A.S.ABSTRACT: Maxillofacial injuries occur in a significant proportion of medico-legal cases and pose a challenge when forming a medico legal opinion at times. The penal code of Sri Lanka identifies disfiguration to the head or face as a form of grievous hurt. The study was conducted to analyze the pattern, magnitude and the medico-legal challenges of maxillofacial trauma in victims presented for medico-legal examination in a Teaching Hospital in Sri Lanka. A retrospective analysis was done on maxillofacial trauma presented for medico-legal examination during a period of 2 years. Out of the 460 cases of maxillofacial trauma 370 (80%) were males while there were 90 (20%) females. 264 (57%) were due to assaults while there were 172(37 %) following road traffic accidents. Blunt soft tissue injuries were observed in a majorityi.e.: 310 (67%). Forehead was identified as the commonest area of injury 262(57%). Commonest associated injuries were found on limbs, (27%) Isolated facial injuries were observed in 176, (38%) while a majority (62 %) of them were non grievous. There were 20 (11%) isolated facial injuries in which the category of hurt was not ascertained but a remark on possible facial disfiguration was made. Facial injuries were commonly reported following assaults and a majority of them were blunt soft tissue injuries. Providing a strong medico legal opinion on the category of hurt in facial trauma is a challenge for the medical experts due to the difficulties in determining possible facial disfiguration. © 2018 South India Medico-Legal Association. All rights reserved.Item Study on existence of inflammation in the myocardium in unequivocal acute traumatic deaths(Elsevier., 2020) Kitulwatte, I.D.G.; Edirisinghe, P.A.S.BACKGROUND: Over-diagnosis of myocarditis is possible, where presence of scant/negligible inflammatory foci are interpreted as active myocarditis in autopsy cases. A Prospective descriptive study on 100 young healthy individuals who died of known sudden traumatic causes was performed to study the existence, frequency and severity of inflammatory foci in myocardium of a normal population who died suddenly of acute trauma, in order to develop an autopsy diagnostic criteria. RESULTS: Out of 100 hearts, 48 had scant inflammatory foci. Thirteen had mild inflammation and three with moderate inflammation. Presence of scant inflammation was significantly associated with the age of the individual (P = 0.0182). However, the presence or severity of inflammation did not show any significant association with the clinical symptoms (P = 0.4924), gross pathology (P = 0.3954) or weight of the heart (P = 0.3109). CONCLUSIONS: Presence of scant inflammation in the myocardium is a common occurrence and it may be an age related change, which cannot account for the cause of death. Much severe forms of myocarditis with no clinically apparent picture could exist among young individuals. Thus, in the absence of other causes of death, conclusion of myocarditis as a cause of death in these cases needs a careful evaluation of other positive signs. KEYWORDS: Age related; Healthy young individuals; Inflammatory index; Myocarditis; Scant inflammation.Item An Analysis of medicolegal reporting in workman injuries referred for medicolegal examination in a Tertiary Care Hospital of Sri Lanka(Wolters Kluwer Medknow Publications, 2020) Kitulwatte, I.D.G.; Edirisinghe, P.A.S.INTRODUCTION: A reasonable number of workman injuries are reported for medicolegal examination every year. In addition to report on the degree of severity and consistency of the injuries with the historical evidence, the medical officers are expected to opine on degree of disability as well. However, routine Medicolegal Examination Form or Report used in Sri Lanka to report these cases does not carry a section for disability or impairment. Objective: To gain an insight into the pathology of workplace injuries and to evaluate the role of medicolegal examination and reporting among the victims presented with injuries at work. Methods: A retrospective descriptive study was carried out on workmen who were referred for medicolegal examination during a period of 5 years in a Tertiary Care Hospital in the Western Province of Sri Lanka. Results: Out of 172 subjects who got injured at work, none had claimed for a report of compensation. 47% (81) of the injured workers were in the age group of 19–30 years. 81% (139) were males. Factory workers were the most vulnerable workers (34%) followed by drivers (15%). A majority 39% (67) of injuries were located on upper limbs. 52% (90) of the victims had grievous injuries. However, a majority 61% (105) had no permanent disability. Conclusions: Disability is not a direct reflection of the category of hurt. Therefore, testifying on routine medicolegal reports on cases of workman compensation will not serve justice to the patient. KEYWORDS: Category of hurt, disability, injury, medicolegal examination, workmanItem Adequacy and relevance of medical records of patients admitted following Medico-legally significant trauma(College of Forensic Pathologists of Sri Lanka., 2020) Priyanath, D. C.; Dharmadasa, L.S.; de Silva, R.L.S.K.; Gunathilaka, M.M.A.C.C.; Nanayakkara, E.H.H.G.; Shakoor, M.S.; Samarawickrama, S.; Kitulwatte, I.D.G.; Edirisinghe, P.A.S.INTRODUCTION: Details mentioned in Bed head ticket (BHT) and investigations are taken into consideration when an opinion is made with regards to the medico legally significant trauma. Shortfalls of documents can lead to misdiagnosis or wrongful diagnosis. This study was conducted to find out the adequacy of records on BHTs and availability of investigations on patients who had been admitted following trauma with medico legal significance. METHODS: A prospective descriptive study was carried out on patents who were admitted following medico-legally significant trauma during a period of one year, from Aug 2017 to Aug 2018 by perusing their records. The adequacy of the documentation was assessed according to a pre-prepared scale. RESULTS: Analysis of on admission historical and preliminary details revealed that out of 1102 records, only 26% (n=286) had mentioned the time duration since the incident. Recorded cardiovascular stability on admission was above 86% (n=950) though level of consciousness was not mentioned by 19% (n=211). Nature of the injuries were correctly recorded by 65% (n=720) while the location of them were correctly recorded only by 29% (n=316). Surgical procedures were adequately mentioned only among 39% (n=425). CONCLUSIONS: The study revealed that there are gross inadequacies with regard to the records on BHTs made by the doctors. This can lead to limitations in addressing medico-legal issues and sometimes can result in wrong opinions leading to injustice. Need for continuous professional training with special attention to record keeping is highlighted. Further, the quality of records can be further improved with regular audits, continuous professional developmental activities and introducing a common format for documentation in admission, surgical procedures and investigations. KEYWORDS: Medico-legal issues, Medical record keeping, Adequacy, Investigations, BHTItem Ethical dilemmas in forensic medical practice(Department of Forensic Medicine, Faculty of Medicine, University of Peradeniya, 2019) Kitulwatte, I.D.G.; Edirisinghe, P.A.S.ABSTRACT: Forensic practitioners need to ensure that basic medical obligations towards individual patients, judiciary and the public are met while balancing their responsibilities to these parties. Unlike in clinical practice the patient does not present for treatment but for forensic evaluation. Even so, medical practitioners are expected to ensure that ethical standards like for any other medical discipline are maintained in medicolegal practice. At a forensic medical examination, there is an obligation to act in the best interest of the patient and to attend to his/her critical needs. However, attending to the needs of the patient may be viewed as taking undue interest or being fractional by the judiciary. On the other hand, in medical practice, responsibility to patients should overide the interests of third parties. In examination of the dead for medico-legal purposes, the question that can arise is whether there is actually a doctor patient relationship since the examinee is already dead. While there is a duty towards the judiciary to find out the truth about the cause and manner of death there is a duty towards the relatives of the deceased to reveal the true findings especially after having contact with them at the preliminary inquiry. Many of the conclusions made in forensic practice are matters of opinion, and therefore, disagreement is expected which can lead to personal friction specially in handling cases of medical negligence. If forensic practitioners follow the basic principles of medical ethics, while maintaining the highest standards based on scientific evidence they can overcome the majority of the conflicting issues and can perform their duty in the administration of justice. KEYWORDS: Ethics, Forensic medicine and pathology, Best interest, Doctor patient relationship, JudiciaryItem Profile of suicidal hanging presented to a tertiary care hospital: a descriptive study(Department of Forensic Medicine, Faculty of Medicine, University of Peradeniya, 2019) Edirisinghe, P.A.S.; Senarathne, U.D.; Pratheepa Mendis, H.K.N.L.; Wijesinghe, P.R.; Fernando, A.; Kitulwatte, I.D.G.ABSTRACT: When a body is found suspended, the forensic pathologist is expected to give an opinion on the manner of death excluding or confirming possible criminal involvement. Conclusion is easy when findings are classic. However, it is a dilemma when there are atypical findings. OBJECTIVES: To analyze the autopsy findings in deaths due to hanging and to have an insight into the typical and atypical findings in order to appreciate the difficulties in interpretation. METHODS: A retrospective descriptive study on post mortem records of the victims of hanging during a period of three years, brought to a tertiary care hospital. The findings of death investigation including background information, scene, and autopsy examination were analysed. RESULTS: Total of hundred and twelve records of deaths due to suicidal hanging were perused and 97 (86.6%) out of them were males. The majority of victims (37%) were in the age group of 21 to 40 years. The complete suspensions was identified in most cases (79.5%). The commonest ligature material (25%) was the coir rope. Sixty-nine were having a ligature mark rising to an inverted ‘V’. Classic signs were observed in 47% and the presence of classic signs was significantly associated with partial suspension (p<0.001). Internal injuries were observed in 34% and the majority were fractures. Internal injuries had no significant association to the degree of suspension (p=0.11). KEYWORDS: Hanging, Ligature material, Ligature mark, Classic signs, Internal injuries, FracturesItem Knowledge, attitude and practice regarding the use of digital photographs in the examination of the dead and living among doctors practicing forensic medicine in Sri Lanka(Elsevier, 2020) Edirisinghe, P.A.S.; Kitulwatte, I.D.G.; Nadeera, D.R.BACKGROUND: Forensic medical photography alludes to creating images of injuries/ conditions to be used in the legal process. In many parts of the world obtaining digital forensic medical photographs are done by trained police officers. in Sri Lanka, such practice is not seen. Thus, it is not uncommon to see many forensic medicine experts develop skills of taking photographs related to injuries in the living or dead. OBJECTIVES: To study the knowledge, attitude and practice on medico-legal usage of digital forensic photographs among doctors practicing forensic medicine in Sri Lanka. METHOD: A cross-sectional descriptive study was conducted using a self-administered questionnaire among doctors who engage in forensic work in all provinces of Sri Lanka. The study was conducted mainly as an on-line survey from October to December 2018 while some returned the survey via post. RESULTS: Out of 170 forensic doctors 135 participated the study. Half of them (n=68, 50.4%) were medical officers with basic MBBS degree where 23.6% (n= 36) had more than 10 years of experience. Even though the majority (n=98, 72.6%) stated that they have a Digital SLR camera in their institutions most of them (n=110, 81.5%) didn't have external light sources. More than half of them (n=73, 54.1%) used camera phones instead of DSLR (n=48, 35.6%) to take forensic photographs. The main purpose of obtaining photographs was for the recording of evidence for later usage (n=126, 93.3%) followed by as reviewable materials for a second opinion (n=120, 88.9%). The study showed 112 doctors (83.0%) used their personal computers to store photographs whereas, 57 (42.2%) saved them in their institutional computers too. Evaluation of basic technical knowledge on exposure triangle and camera sensor showed only 13.5% (n=18) doctors were having satisfactory knowledge. The knowledge of legal aspects showed a significant difference between doctors with postgraduate qualifications and those who are either in PG training or grade medical officers. Further, there was a significant difference in the belief that including photographs in reports will provide unnecessary information to defense lawyers resulting in questioning among PG qualified and Non-PG qualified doctors. CONCLUSIONS: This study showed a big gap in the technical knowledge of taking good quality digital photographs by forensic doctors while the usage of camera phones is getting popular. There are many gaps in the practice from storage to usage. There are negative attitudes among doctors of using photographs to courts especially among grade medical officers and PG trainees. A robust educational programme followed by guidelines on quality medico-legal photographs is the need of the hour. KEYWORDS: Attitude; Digital photographs; Forensic medical photography; Knowledge; Practice.