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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Death of a child following a superstitious ritual of exorcism(Elsevier, 2022) Thivaharan, Y.; Dias, V.; Edirisinghe, A.; Kitulwatte, I.D.G.Introduction: Diseases, especially those related to the psyche produced by demons, are an accepted belief in many communities. This paper elaborates on the death of a child, a victim of an exorcism ritual, and calls for adequate awareness and preventive measures. Case report: The deceased, a 9-year-old child, was taken by her mother to an exorcist to ’expel a demon from her body. The exorcist caned the child for two days while giving ’water’ to drink. On the second day, the child lost consciousness and was pronounced dead on admission. On direct questioning, it was revealed that the child had been made to consume some medicinal syrups forcefully by the mother and the exorcist. The autopsy revealed multiple abrasions, tram-line contusions and burns on the body. There was mottling and consolidation in the lungs. Blood-stained secretions were found in the trachea, bronchi, and stomach. Musculoskeletal dissection revealed subcutaneous haemorrhages and muscular contusions over the buttocks and limbs. Histology revealed evidence of well-established aspiration pneumonia. There was no other significant pathology, especially no evidence of acute kidney injury due to rhabdomyolysis. Toxicological analysis was negative for common poisons, therapeutic drugs, and heavy metals. The cause of death was concluded as aspiration pneumonia in a child subjected to physical violence. Conclusion: With the forceful feeding of the syrup, the child can have aspiration, resulting in aspiration pneumonia. At the same time, it appears that even after the child became symptomatic, she had not been brought for medical treatment but had continued with the same exorcistic therapy. While the caregivers become responsible for the child’s death, the lessons to be learnt are enormous. Thus, banning such practices against children is a need of the hour.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 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 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.Item Death following ceftazidime-induced Kounis syndrome(London : Sage, 2017) Kitulwatte, I.D.G.; Gangahawatte, S.; Perera, U.L.M.S.; Edirisinghe, P.A.S.Kounis syndrome, also known as allergic myocardial infarction or allergic angina syndrome, coincides with chest pain and allergic reactions. It involves the activation of interrelated inflammatory cells following allergic, anaphylactic or anaphylactoid insults. We report a case of Kounis syndrome complicated by an injection of ceftazidime. A 52-year-old man developed shortness of breath and hypotension, leading to immediate unconsciousness, after a ceftazidime injection. Despite intensive care management, he showed no improvement and died approximately 19 h after ceftazidime administration. Autopsy showed massive laryngeal oedema, mucous plugging and collapsed lungs. An ImmunoCAP tryptase assay showed the tryptase level in an autopsy sample to be 118 µg/L (normal < 11.4 µg/L). Microscopy of the myocardium showed cellular infiltration preceding myocardial necrosis. These findings support the pathophysiological theory of Kounis syndrome, with cellular infiltration proposed as the cause of myocardial injury rather than an effect related to the healing process.Item Female victims of unnatural deaths(Faculty of Medicine, University of Kelaniya, Sri Lanka, 2016) Kitulwatte, I.D.G.; Edirisinghe, P.A.S.; Mendis, H.K.N.L.P.; Abeyrathna, A.A.R.M.BACKGROUND: Unnatural deaths indicate the level of social and mental wellbeing of a society. Female unnatural deaths are often associated with their long history of deprivation of socio-economic rights. Traumatic injuries among females remain under-reported globally and studies on this area are scares. OBJECTIVES: The aim of the study was to analyse the profile of unnatural deaths among females with a view to determine the factors influencing these deaths. METHODS: A retrospective descriptive study was conducted on the post mortem records of the female victims of trauma during last 3 years (2013-2015) reported to a tertiary care hospital of Sri Lanka. The historical details, scene and autopsy findings, investigations, opinion and conclusions given were obtained to fill the pro-forma. RESULTS: Of the 139 deaths, majority 71(51%) were less than 40 years of age. Commonest cause of death (40%; n=56) was accidents especially road traffic accidents followed by suicides amounting to 45 (32%). Poisoning (31%; n=14)) was the commonest method of suicide followed by hanging (26%; n=12) ). Among the 45 suicides, majority (53%; n=24) were young women. Family disputes and love affairs were the main reasons for suicide in 21 (47%) and murder in 13 (39%) deaths. Husband or a known person was the alleged perpetrator in 20 (61%) homicides. CONCLUSIONS: Comprehensive research into occurrence of unnatural fatalities, assists authorities in the prevention of such deaths. The study highlights the importance of timely interventions on road safety and the need for effective and timely counselling services on family matters to prevent most intentional deaths of women.Item Blood alcohol concentration in motorcycle fatalities reported to a tertiary care hospital in Sri Lanka(Faculty of Medicine, University of Kelaniya, Sri Lanka, 2016) Senarathne, U.D.; Edirisinghe, P.A.S.; Kitulwatte, I.D.G.BACKGROUND: Motorcycle, the common man’s vehicle in Sri Lanka when crashes is fatal due to its inherent instability and absence of an outside shield to absorb energy during a collision. Managing an unstable vehicle after consuming alcohol, a central nervous system depressant, increases the risk of a fatal collision. Research on motor-cycle fatalities and blood alcohol concentrations has not been reported from Sri Lanka earlier. OBJECTIVES: To describe the contribution of blood alcohol concentrations (BAC) to fatal motorcycle accidents. METHODS: A retrospective descriptive study based on post-mortems of motorcycle fatalities referred to a tertiary care hospital from 2010-2014 was done using a pro-forma. RESULTS: Out of 180 motorcycle accidents reviewed, 166(92%) were riders, 14(8%) were pillion riders. 171(95%) were males and majority (n=142, 79%) were between 20-60 years of age. BAC was requested for 88(49%) and reports were available only for 76(86%) victims. Out of them 34(45%) had BAC >80mg/100ml. The highest BAC reported was 428mg/100ml with the mean value being 104mg/100ml. Cause of death (COD) given for 78(43%) victims was head injury for 69(38%) multiple injuries. Presence of >25 injuries (p=0.028) and COD given as multiple injuries (p=0.029) were significantly associated with BAC >80mg/100ml. CONCLUSIONS: Having BAC >80mg/100ml significantly contributes to the motorcycle rider being subjected to more injuries in a collision. Since less than half the cases were subjected to BAC analysis, actual magnitude of the problem could be greater than illustrated by the study.Item A study on factors influencing medico legal opinion in alleged sexual abuse(Faculty of Medicine, University of Kelaniya, Sri Lanka, 2016) Kitulwatte, I.D.G.; Wijewardena, H.P.; Edirisinghe, P.A.S.; Senarathne, U.D.BACKGROUND: Aim of medico-legal examination in alleged sexual abuse is providing an opinion on physical/sexual contact between individuals. Supportive scientific evidence is often absent and experts are in a dilemma. OBJECTIVES: To identify the limitations of medico legal opinion in alleged sexual abuse and the factors influencing these limitations. METHODS: A retrospective descriptive study based on medico-legal case records of females who had been referred to a Teaching Hospital in the Western province of Sri Lanka following an allegation of sexual abuse during a period of 3 years (2012-2015). Data analysis was done with Statistical Package for Social Sciences (SPSS). RESULTS: Out of 441 medical records perused, the main complaint (n=180, 40%) was related to concerns of the guardians. Majority (n=302, 68%) had presented for medico-legal examination 72-hours after the incident. Giving a firm positive medico legal opinion as per the complaint had been possible in 280(63%). A firm opinion could not be given in 19 (86%) out of 22 victims reporting intracrural intercourse and for 22 (79%) out of 28 victims complaining of fingering. Out of 376 victims with no recent injuries, 276 (73%) presented late. Out of the 128 victims who had experienced physical threats, only 35 (27%) had supportive injuries. CONCLUSIONS: Many factors including late presentation and type of complaint influence the medico legal opinion in a case of sexual abuse and therefore it is a challenge to the forensic expert. Thus, proper administration of justice needs an insight into these factors, challenges and the limitations.Item A Comparative study of coronary atherosclerosis in young and old(Masson Publishing USA, 2015) Kitulwatte, I.D.G.; Pollanen, M.S.INTRODUCTION: Atherosclerotic coronary artery disease is an important cause of sudden and unexpected deaths in the young people. It is assumed that thrombosis and plaque hemorrhage are commonly associated with sudden deaths from coronary atherosclerosis in the young. In this study, we compared the histological patterns of atherosclerosis in young and old populations to see whether an association exists between the histological pattern of atherosclerosis in the young and thrombosis or plaque hemorrhage. METHODS AND RESULTS: All autopsy cases of coronary atherosclerosis in young people (aged younger than 40 years) in comparison with an equal number of randomly selected older people (older than 65 years) over a period of 4 and a half years in the Provincial Forensic Pathology Unit of the Ontario Forensic Pathology Service in Toronto, Canada, were reviewed to characterize the gross and histologic appearance. There were 28 cases of atherosclerosis in young people ("the young"). Twenty-three (82%) of the young had eccentric atherosclerosis compared with 11 (39%) of the old. An inflammatory response was seen in all 28 (100%) of the young in comparison with 17 (61%) of the old. Thirteen (47%) of the young compared with 3 (11%) of the old had thrombosis, whereas 9 (32%) of the young and 17 (61%) of the old had plaque hemorrhage. Pultaceous debris was the principal component in 11 atherosclerotic plaques (39%) in the young, followed by foam cells in 7 (25%). In the older group, pultaceous debris was the principal component in 18 (64%) followed by dense fibrous tissue in 5 (18%). CONCLUSIONS: The morphology in coronary atherosclerosis of the young is significantly different from the old. Coronary atherosclerosis in the young commonly shows an eccentric distribution with associated inflammation. Thrombosis is commoner among the young, whereas plaque hemorrhage is commoner among the old.