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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Medicolegal aspects of victims of assault admitted to a tertiary care hospital in Sri Lanka(Academic Forensic Pathology, 2022) Jayasundara, M.S.; Thivaharan, Y.; Muthulingam, T.; Borukgama, N.; Kulathunga, D.L.; Kitulwatte, I.D.G.INTRODUCTION: Violence with physical assault is a common cause of morbidity and mortality prevalent but not limited to underdeveloped countries. The opinion of the forensic expert is often indispensable in such cases to determine the penalties. This study was planned to describe the pattern of presentation of the victims and evaluate the strengths and limitations in formulating a scientific medicolegal opinion based on the findings of the victim. METHODS: A retrospective descriptive study based on the case records of the victims of assault admitted to Colombo North Teaching Hospital, Ragama, Sri Lanka, was conducted for four years. RESULTS: Out of the 400 victims, the majority (72% n = 290) were males and of the age-group of 21 to 40 (n = 216). The reason for assault in the majority was sudden provocation (n = 99, 25%), followed by previous long-duration enmity (n = 89, 22%). The majority (83%) had isolated blunt force trauma, and the injuries were nongrievous (74%). Defense injuries were significantly associated with attempted defense (p = 0.000) and sharp force trauma (p = 0.002). The underlying reason for the assault was not significantly associated with the causative weapon (p = 0.228) or body region injured (p = 0.195). CONCLUSIONS: Even though the presentation and the pattern of injures are definitely of value in formulating a scientific opinion, the study identified the limitations of the forensic experts, and the need for a holistic approach at the investigations was highlighted.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 A study on medico legally significant blunt thoracic trauma.(Institute of Medico-legal Publications, 2023) Gunathilaka, M.M.A.C.; Kitulwatte, I.D.G.; Wijewardena, H.; Gunathilaka, K.M.T.B; Dissanayake, C.; Jayathilake, R.; Wijeratne, P.INTRODUCTION: Thoracic trauma (TT) accounts for significant mortality and morbidity. Blunt thoracic trauma is reported more frequently than sharp force trauma, where motor traffic collisions account for the majority. Addressing medico-legal issues is often a challenge in TT. The purpose of this study was to evaluate blunt chest trauma from a medico-legal point of view. METHODS: A retrospective descriptive study was conducted based on case records of the victims (living and dead) of TT over three years presented to a Teaching Hospital and a District General Hospital in Western Province. RESULTS: There were 248 living patients and 195 deceased. Road accidents accounted for TT in 236 (53.3%), followed by 166 (37.5%) assaults. Out of the deceased, 89% had a very short survival period. “Multiple chest injuries” was the cause of death in 83 (42.5%) dead, and 91 (46.7%) died due to TT. Road accidents accounted for N=71 (78% of deaths due to TT). Out of the live patients, 87 (35.8%) had grievous or above-category injuries to the chest, and victims of assault were commonly having non-grievous injuries with a significant association (p<0.001). A total of 175 (39.5%) had rib fractures, and 125 were following motor traffic accidents. CONCLUSIONS: Blunt TT accounts for significant mortality and morbidity, with the most common circumstances being road accidents. Most of them come under a severe category of hurt with a short survival period among the dead.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 Medico-legal opinion based on autopsy findings of a victim of an explosion involving mass fatality(Academic Forensic Pathology International, 2020) Thivaharan, Y.; Kitulwatte, I.D.G.Introduction: Investigation into explosions is one of the major areas in forensic medicine and pathology. Medico legal issues associated with these deaths are diverse and forensic experts are often expected to make clarifications. Assistance of a methodical scientific investigation of such a death in evaluation of unanswered medico legal issues, of an autopsy of one of the victims of Easter Sunday explosions is discussed. Case history: The deceased was a 15-year-old girl who was participating in the Easter mass at St. Sebastian’s Church - Kattuwapaitya, Negombo, Sri Lanka when a suicide bomber blew himself up. The mother of the deceased noticed the deceased being rushed to the hospital. However, she was pronounced dead on admission. Pre-autopsy radiology revealed spherical shrapnel in the temporal region. At autopsy, the fatal injury was found on the head and a detailed study revealed skull fractures associated with penetration by 3 shrapnels. There was a keyhole lesion among the penetrations. Internal examination revealed an extensive dural tear underlying the compound fracture. The brain was grossly edematous with lacerations on the frontal and parietal lobes associated with localized subarachnoid hemorrhage. There were multiple underlying contusions on bilateral frontal white matter. Small subarachnoid haemorrhage was noted on the basal aspect of the brain. Discussion: Careful evaluation of the autopsy findings assisted in formulating the opinion scientifically on event reconstruction including the proximity of the victim to the epicenter of explosion and nature of explosive device, period of survival, mechanism of causation of skull fractures and the mechanism of death in addition to the cause of death. Conclusion: A forensic pathologist following a meticulous autopsy examination, along with a team of ballistic experts and specially trained police personnel play a pivotal task in analyzing a scene of explosion and an autopsy of a victim, in concluding the case and in bringing justice to all the victims and survivors of the catastrophe.Item Study on heart measurements of the people between the age 20-40 years present to the teaching hospital colombo north – post mortem study(Dept. of Forensic Medicine, New Delhi, 2021) de Silva, R.L.S.K.; Kitulwatte, I.D.G.; Priyanath, D.C.; Gunathilake, M.M.A.C.; Senanayake, T.A.A.W.; Kumari, M.K.J.K.Introduction: Presence of an enlarged heart provides a basis for determination of the cause and mechanisms of death. Gender, physical activity, and Body Mass Index (BMI) may affect the size of organs. Knowledge on such normal variations is needed in order to recognize the abnormalities.Objectives- This research was conducted to study the dimensions of the heart(heart weight, left ventricular thickness and valvular circumferences) among the young adult healthy deceased autopsies and evaluate their association with different variables.Methods:It was a descriptive cross-sectional study and 20-40 years of age healthy, young, adult, males and females in equal numbers who had died suddenly were studied by considering the inclusion and exclusion criteria. Details of the past history and the measurements were entered into a proforma and the anonymous data were used for analysis.Results: The study revealed that the mean values of the heart weight was 280.52g (SD+/- 42.60), it was 293.94g (SD+/-39.29) for males and 267.10g (SD+/-42.64) for females. There was no significant association of heart weight with gender (P= 0.46410). There was a significant association between BMI and the heart weight of the females (P= 0.0387), no such association for left ventricular wall thickness. Further, there was a significant difference of the tricuspid valve circumference among two genders and the values were 11.6cm (SD+/-0.82) for males and 10.7cm (SD+/-0.6) for females.Conclusions: Majority of the findings was consistent with the findings of the studies globally on Caucasians. Increased body mass index was significantly associated with increased heart weight among females which could probably be explained as a consequence of increased epicardial fat since there was no such association for left ventricular wall thicknessItem Study on evaluation of knowledge, attitude, and practice of Sri Lankan traffic police officers related to examination of drunk drivers, in two most populated districts of Sri Lanka(Sage Women's Educational Press, 2021) Thivaharan, Y.; Kitulwatte, I.D.G.; Muthulingam, T.Introduction: Driving under the influence (DUI) of alcohol is one of the substantial predisposing factors for mishaps among road users. A traffic police officer will be the first authoritative personnel a drunk driver encounters in the legal system. The absence of accurate skills and knowledge of these officers impedes the structuring of legal procedures and may lead to miscarriage of justice. Objective: To assess the knowledge, attitude and practice of Sri Lankan traffic police in handling and managing an alleged case of driving under influence of alcohol. Methods: This was a descriptive cross sectional study carried on a sample of 384 traffic police officers attached to the districts of Colombo and Gampaha, through a questionnaire. Results: Out of 384, only 75 of police officers knew the correct preliminaries to perform before administering a breathalyzer test. 79.7% knew the correct instructions for using a breathalyzer, but only 3.4% knew the colour changes of the breathalyzer. Significantly poor attitude was observed among the police officers, regarding the importance of producing a drunk driver for medico-legal examination (P = 0.001) Only 222 (57.8%) answered correctly that a drunk driver needs to be subjected to a medico-legal examination as early as possible. Significantly poor practice and attitude was observed in officers with longer service duration but no significant association was observed between ranks of officers and attitude and practice (P = 0.199). Conclusions: The results of our study demonstrate that the knowledge attitude and practice on efficiently handling a case of DUI among traffic police officers is poor, even though all of them are engaged in DUI duties irrespective of their service duration. The need for continuous professional development programmes was highlighted.Item Rhabdomyolysis associated acute kidney injury following a physical violence(Science Resource Online, 2021) Thivaharan, Y.; Kitulwatte, I.D.G.Introduction: Physical violence can lead to serious and, rarely, fatal injuries. In addition to head injury, which is the leading cause of death and long-term disability, injuries of the musculoskeletal system and internal organs are important cause of assault-related morbidity. This paper discusses such rare complication of an interpersonal violence - rhabdomyolyis associated with Acute Kidney Injury (AKI). Case: A 37-year-old man who claims to be assaulted by a group of people, presented with focal contusions and extensive grazed abrasions over the trunk and limbs. Injuries to brain and other visceral organs were excluded. Serum creatinine and urea were elevated significantly, along with increase in C-reactive protein and liver enzymes. Urinalysis contained red cells and leukocyte esterase, following which rhabdomyolysis was diagnosed. He developed oliguric AKI, and haemodialysis was initiated. He was discharged after eleven days of hospitalization, following improvement in renal functions. Discussion: Rhabdomyolysis is a common cause for oliguric renal failure, and can be traumatic or non-traumatic. Rhabdomyolysis has specific clinical and laboratory parameters, but still requires high level of suspicion, for timely diagnosis. Highly elevated levels creatinine phosphokinase (CPK) is the most specific parameter for the diagnosis of rhabdomyolysis. Myoglobinuria, elevated levels of lactase dehydrogenase and transaminases are also considered valuable markers of rhabdomyolysis. AKI is the commonest systemic complication of rhabdomyolysis and various causative mechanisms have been explained. Conclusion: Rhabdomyolysis requires high index of suspicion when acute kidney injury and altered metabolite levels are suspected in a patient with major or minor muscle injuries, in order to prevent complications or death.Item Study on victims of child abuse: A study conducted in two teaching hospitals in Sri Lanka(College of Forensic Pathologists of Sri Lanka, 2021) Dharmadasa, L.S.; Kitulwatte, I.D.G.; Priyanath, D.C.; Gunathilaka, M. A.C.; Silva, L.S.K.D.; Kumari, M.K.J.K.INTRODUCTION: Child abuse is a global public health problem and proper intervention strategies need a greater understanding of risk factors that can contribute to it. This study was conducted in order to identify the undetected contributory factors that lead to child abuse cases. METHODOLOGY: All children (less than 18 years of age) who were brought for medico legal examination with alleged abuse to two reputed teaching hospitals during a period of 1 and ½ years were included. Required details were obtained through an interviewer administered questionnaire after obtaining the consent. RESULTS: Out of the 186 children, more than 80% presented following sexual abuse and the majority (n=173) were females. Further, n=118 (75%) of the victims of child sexual abuse were between the age group of 13 to 15 years. Moreover, 75% of the victims of sexual abuse were from low income families. Parents of 100% of the victims of physical abuse and 60% of the victims of sexual abuse had educational qualifications below ordinary level. 82% of the victims of physical abuse were having dysfunctional family background, specially use of ethanol by parents (65%). Parental separation was the form of family dysfunction that was associated with sexual abuse. Conclusion: Poor income, poor parental education and dysfunctional family background could be identified as predisposing factors for child abuse. However, the association of these factors vary with different types of child abuse, thus preventive strategies should be planned accordingly.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, workman