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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 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 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.