Forensic Medical Expertise Research Articles

Formulation of the diagnosis, selection, and coding according to ICD-10 of the initial cause of death in fatal outcomes in patients with transplanted organs

BACKGROUND: Due to a lack of unified recommendations, difficulties often arise when making diagnoses, as well as selecting and coding according to ICD-10 of the initial cause of death in cases of fatal outcomes of patients after organ transplantation.
 AIM: To offer practical recommendations on the formulation of diagnoses, selection, and coding according to ICD-10 of the initial cause of death in cases of fatal outcomes based on the experience of the pathology department at the N.V. Sklifosovsky Research Institute of Emergency Medicine.
 MATERIALS AND METHODS: Sixty autopsy reports of fatal outcomes in patients after organ transplantation at the N.V. Sklifosovsky Research Institute of Emergency Medicine for 7 years (20162022) were analyzed.
 RESULTS: Based on the results of the analysis, taking into account the literature data, recommendations for making diagnoses, selecting, and coding according to ICD-10 of the initial cause of death of patients after organ transplantation were formulated.
 CONCLUSION: The developed recommendations on the formulation of diagnoses in patients death cases after organ transplantation can be used in the daily practice of forensic medical experts.

THE ROLE OF POST-MORTEM BIOCHEMISTRY IN THE FORENSIC MEDICAL DIAGNOSIS OF MECHANICAL INJURY (literature review)

Background. Mechanical trauma occupies one of the leading places in forensic medical examination. The main task of the expert, when conducting this kind of examination, is to provide a scientifically based answer to the questions of the pre-trial investigation bodies or the court, which relate not only to the determination of the mechanism of the injury, but also to the time period of its occurrence. Traditional methods of morphological research and methods of laboratory analyzes cannot always provide comprehensive information, especially in cases of determining the age of mechanical trauma in the early Post-mortem period. Therefore, new methods of biochemical research are being actively introduced into forensic medical practice.
 Aim: Analysis of the literature devoted to the application of various biochemical diagnostic methods in forensic medical practice to establish the antiquity of mechanical trauma.
 Results. In pathological conditions, such as, for example, trauma, certain molecular changes occur in the human body, which are associated with a systemic reaction to a stress factor and are manifested before the appearance of morphological changes in tissues and organs. Therefore, the use of biochemical research methods will significantly expand the possibilities of forensic diagnostics. The publication shows promising directions for the application of the biochemical method for forensic trauma diagnosis. Issues of establishing the statute of limitations for mechanical injuries are considered. Today, scientific studies of the body's stress state in cases of fatal injuries are becoming more and more common. Which is of great importance for forensic medical expert practice. Therefore, the role of manifestations of the body's systemic response to trauma is described. The role of natriuretic peptides, creatine kinase and procalcitonin in diagnosing the duration of the traumatic process is also shown.
 Conclusion. The relevance and practical significance of biochemical research for the forensic diagnosis of the time of occurrence of a mechanical injury, as well as the development of new diagnostic criteria for determining the body's systemic response to trauma, necessitated a deep and comprehensive study of the above problems.

Assessment of Forensic Medical Expert’s Involvement in Primary Crime Scene Investigation in Nairobi

It is of great importance to include Forensic Medical Experts (FMEs) in Primary Crime Scene (PCS) investigation team especially in murder, rape and defilement in investigation framework. The criminal justice system in Kenya has not been effective due to the shortage of FMEs as well as the poor specialization among forensic experts and police officers in implementing Medico-legal services within the country. This research sought to assess the need to involve FMEs in PCS investigation in Starehe sub-county, which comprises of five stations, for the purpose of improving the quality of criminal investigation in the country. A systematic random sampling technique of case files brought back from court was used. The sample size was calculated by dividing the entire case files by interval. There were one hundred and thirty-five (135) case files numbered from one to one hundred and thirty-five (135), then picked at an interval of two from a random number. Sixty-seven (67) case files were sampled, studied and analyzed. Three hypotheses were developed to be tested. The main objective was to assess forensic medical expert’s involvement in PCS investigation in starehe police division, Nairobi County, Kenya. Data analysis was done using SPSS and presented with tables, and narrative. From the tested hypothesis we were able to discover that the FMEs in Kenya are not well trained and professional in the use of SOPs for collecting forensic evidence at PCS H1 (p=0.754); the Kenyan criminal justice system framework does not involve FMEs at all primary stages of investigations H2 (p=0.878); Cases in Kenyan courts are not very successful without the use of FMEs H3 (p=0.247). Involvement of the FMEs in primary crime scenes investigation ensures that there is adequate and sufficient evidence to prosecute criminals convicted of such criminal acts. Cases without forensic evidence component failed to secure a conviction indicating that their absence impacts the quality of evidence submitted to present a sound case to prosecute offenders. FMEs should respond alongside police crime scene investigators and be linked to crime scenes at all stages of investigation to collect forensic evidence to identify suspects responsible for committing criminal activities at the PCS. Forensic evidence should be presented by a qualified professional who complies with standards that enhance efficiency and fairness. The forensic medical evidence at the primary crime scene is best armed with skills, knowledge and tools that are required to aid the investigators to make maximum use of scanty resources available with regard to collection and analysis of biological and chemical evidence. There should be clearer guidelines on the steps to follow in regard to evidence collection. The results of this study will be used by policy makers and health care providers to improve forensic evidence gathering for better and successful prosecution.

THE STAFFING CONCEPT REFORM OF THE FORENSIC MEDICAL SERVICE OF UKRAINE

The foreign experience in the training of forensic experts is analyzed in the article. This experience is compared with the corresponding training system for forensic doctors that existed in Ukraine until 2022. A reasoned assessment of the reform of the training of forensic medical experts in Ukraine is given. Proposals have been made to change this reform, which consist in the fact that pathologists would be trained instead of pathologist doctors. The proposed concept of a training program for pathologists is a synthesis of training programs for pathologists and forensic medical experts. According to the authors’concept of the pathologist should acquire a sufficient amount of competencies for practical work as a pathologist and a scope of competencies that will be acceptable for training a forensic medical expert on its basis.

MODERN POSSIBILITIES OF SOLVING THE PROBLEM OF DETERMINING THE DEGREE OF BLOOD LOSS IN FORENSIC MEDICAL PRACTICE

During the forensic medical examination of a corpse in cases of acute blood loss, the most important issue for forensic medical experts is the determination of its amount. However, calculating the exact amount of blood lost is quite a difficult task. After all, a sufficiently accurate quantitative system for measuring the volume of blood in a corpse has not been developed, therefore, forensic medical experts in their calculations rely on well-known morphological signs of blood loss, which can often be quite subjective.
 That is why the analysis of the methods proposed by world scientists is relevant, as well as the development of new, digital methods for determining the degree of blood loss, which could provide reliable scientifically based conclusions.

Impact of (forensic) expert opinions according to the Istanbul Protocol in Germany—results and insights of the in:Fo-project

As part of a third-party funded project, expert opinions according to the Istanbul Protocol (IP) standards were compiled in Germany on a larger scale for the first time. The assessment process was initiated for 130 project participants. Statistical analysis on numerous variables was performed to test the impact of the expert opinions, foremost of the forensic medical expert opinions, on the individuals’ asylum proceedings. The variables were drawn from forensic medical expert opinions and reports of findings, questionnaires for the study participants’ counsellors in the project and a query on the asylum status of the study participants. Regression analysis and bivariate analysis on two dependent variables—subjective impact on the asylum procedure from the counsellors’ point of view and objective change in the asylum status—were performed to test for an influence on asylum procedures. No statistically significant results were obtained for the objective change of the study participants’ asylum status. For the subjective dependent variable, a positive prediction was possible when simultaneously controlling for the independent variables introduction of a forensic medical expert opinion and highest IP grade; a negative prediction was possible when simultaneously controlling for the independent variables introduction of a forensic medical expert opinion and use of IP grading. Apart from the statistical analysis, a positive effect of the assessment on the psychosocial well-being of the study participants could be demonstrated. The results differed from other European studies which demonstrated a correlation between the objective outcome of an asylum procedure (asylum status) and, for example, specific types of violence or the number of documented injuries. Differences also occurred in the use of the plausibility grades proposed by the IP, which questions their use in cases in which the reported torture happened a relevant time ago. Therefore, compiling individually worded evaluations instead of using the IP grading system—if possible, by an experienced forensic physician—is recommended in this scenario. Still, the assessment of alleged torture experiences should follow the IP guidelines, since psychological assessments are of especially high importance in cases with healed physical injuries and since the results also demonstrated a positive effect on the psychosocial well-being of the study participants.

Features of Hair Research for Biological and Forensic Chemical Research

The subject of the study is human hair. The authors consider the issues of hair research for biological and forensic chemical research. Currently, despite the large number of studies conducted by forensic medical experts and clinicians, there is no complete, targeted program for the study of hair for elemental composition, psychoactive and toxic substances, enzyme system, in which methods of hair research would be announced not only for forensic, but also for clinical, environmental practice. Forensic doctors have developed methods and techniques for conducting such studies. However, there are no such developments for clinicians, toxicologists. Removal and examination of hair to study the morphological structure is carried out without following the rules (length, description of the structure, indication of magnification of the microscope, characteristics of inclusions and others). The novelty of the study lies in the fact that the lack of widely available data on the characteristics of hair; by determining the content of foreign substances introduced into the body, gives rise to contradictory and even erroneous data. A special contribution of the authors to the study of hair is the proposed algorithm for morphological examination of their elements, which includes such sections as hair removal, macroscopic examination and microscopic examination. The described lesions in the form of inclusions of "black color", "flask-like formations" and "thickening of the core" are characteristic of normal hair and are not signs of exposure to any toxicant. The morphological shape of some hair indicates the effect on the hair of a toxic agent that affected their structure, as a result of which their loss occurred. The damaging factor acts on the desmosomes of the cuticle of the rod and the vaginal membranes of the hair and is exfoliated from its own hair bed. It was determined that the hair carries information about the entry of an intoxicant into the body in the phase of active growth – anagen.

Features of methodology for the formation of standard operational procedure in the practice of bureau of forensic medical expertise

To analyze and summarize data on formation and implementation in practice of standard operational procedures for developing algorithm to improve the quality management system of bureau of forensic medical expertise. Normative legal documents regulating principles of standardization in healthcare were studied. Literature was analyzed in PubMed, Google Scholar, eLIBRARY search engines in English and Russian languages on the issues of development and implementation of standard operational procedures in practice. Data on using standard operational procedures as a standardization element in medical practice have been analyzed and generalized. Specific proposals for developing system of standard operational procedures, based on general principles for the creation of such documents, in forensic medical expert institutions have been proposed. Suggested recommendations can be used in practice to develop new common standard operational procedures.

ORGANIZATIONAL AND PROCEDURAL PROBLEMS OF ESTABLISHING THE SEVERITY OF HARM TO HEALTH

Abstract: the article outlines the grounds for the appointment and production of a forensic examination to establish the severity of harm to health in living persons, namely a forensic medical examination; gives the basic concepts; presents regulatory legal acts regulating the appointment and production of this type of expertise; considers organizational and procedural problems faced by law enforcement officers when raising questions for a forensic medical expert, ways to solve them, as well as some difficulties in drawing up a conclusion by a forensic medical expert.

Individual Tolerance to Acute Ethanol Intoxication

Relevance: In order to figure out the cause of death and present the evidences to the court, law enforcement authorities instructed forensic medicine experts to carried out differential diagnosis, by using the posthumous exogenous alcoholemia to differentiated between the severity of acute ethanol intoxication, and death caused by alcohol poisoning. However, the experts are difficult to carried out the assessment to determine the severity of alcohol intoxication, even using the following criteria: exogenous alcoholemia level, signs of conditionally fatal ethanol poisoning with trauma. There are differences in the ethanoloxidizing dehydrogenase enzymatic activity, make it easier to determine individual ethanol tolerance, which can be used for forensic medical substantiation to determine severity of acute alcohol intoxication and fatal ethanol poisoning. Purpose of the Study: We carried out the research by evaluating the severity of the acute alcohol intoxication, by taking into account the blood ethanol concentration level and the death caused by the fatal ethanol poisoning; we use the 2 indicators of the ethanol- oxidizing enzymatic activity, which are the alcohol dehydrogenase in liver, and acetaldehyde dehydrogenase in the brain. Material and Methods: Forensic medical experts using 72 corpses to carried out the research, we had identified ethanoloxidizing enzymatic activities in the brain stem and liver and divided into 3 observation groups : Group I – death from fatal ethanol poisoning (FEP) with blood ethanol concentration between the range from 3.0 to 5.3 g/L (22 cases); Group II – death caused by car accidents as the drivers who are having severe ethanol intoxication with vehicle’s mechanical damage, the blood ethanol concentration between the range from 3.0 to 4.8 g/L (25 cases); Group III (controlled group) – death caused by car accidents with vehicle’s mechanical damage without exogenous alcoholemia (25 cases). Results: In the fatal ethanol poisoning group, we compared with the controlled group, there are decrease in enzymatic activities, and there were significant statistically decreases (P<0.05). When comparing these enzymatic activities between IInd and IIIrd group , there were no significant statistically differences (P>0.05).

OBSERVATION OF COMPLEX MECHANISM OF DEATH IN A PERSON WITH A PACEMAKER AND COMPETING DISEASES

The article deals with a rare observation from forensic medical practice concerning systemic amyloidosis with predominant heart impairment and complex cardiac mechanism of death of a man with a pacemaker and the presence of two competing diseases with a morphological signs of senile cardiac amyloidosis and the phenomena of fatal ventricular fibrillation of the heart. The obtained autopsy and histological data are described, which makes it possible to assess the thanatogenetic picture and partially answer the questions posed to the forensic medical expert. Taking into account the fact that cases of cardiac death with manifestations of cardiac arrhythmias in the presence of artificial pacemakers (permanent pacemakers) are quite common in the practice of pathologists and forensic medical experts, we have carefully reviewed Russian and foreign literature, which allows us to highlight some of the questions that have arisen about the mechanism of death in this case.

A BRIEF HISTORY OF THE ALCOHOL BIOMARKER CDT AND ITS APPLICATION IN FORENSIC MEDICAL EXPERTISE IN ROAD ACCIDENT INVESTIGATIONS"

It is well known that large-scale binge drinking is one of the leading risk factors for poor public health around the world. This is why an objective assessment of the current state of alcohol abuse is critical to protecting public health and safety, especially in clinical, professional context and in the context of road traffic. The article is devoted to the current problem of the history of the formation of the process of one of the most commonly used biostandards of consumed alcohol, namely carbohydrate-deficient transferrin. Taking into account the observed increase in road accidents while intoxicated, the article substantiates the importance of the CDT biomarker when conducting medical expertise. Keywords: CDT biomarker, road accident, forensic medical expertise, alcohol intoxication, public health protection.

Improving Evidence-Based Practice in Forensic Medicine: Validation of INtegration of Forensic Epidemiology and the Rigorous EvaluatioN of Causation Elements and Principles of Evidence-Based Reporting in FORensic Medicine-Pathology version in Indonesia

Abstract Introduction Expert opinions presented in legal proceedings should be scientifically accountable, which is known as evidence-based practice (EBP). Although forensic medical expert opinions are essential in legal proceedings, the methods used to formulate them are not always evidence based or based on standard methods. In forensic medicine, EBP has not been explicitly applied, including in Indonesia. One potential approach to formulate evidence-based expert opinions is called INtegration of Forensic Epidemiology and the Rigorous EvaluatioN of Causation Elements (INFERENCE). In addition, there is also no universal guideline for making forensic pathological reports. One prospective guideline is named the Principles of Evidence-based Reporting in FORensic Medicine-Pathology version (PERFORM-P). Methods This article describes the validation process of INFERENCE and PERFORM-P in Indonesia. This study uses a mixed method through three interrelated phases, i.e., (1) a cross-sectional survey to determine the characteristics of Indonesian forensic doctors and their current practice, (2) the adaptation and validation process of the two tools through a review by the Indonesian College of Forensic Medicine, and (3) a one-group pre–postintervention study to assess the validity and reliability of forensic medical expert opinions formulated using Indonesian-INFERENCE (i-INFERENCE) and reported using Indonesian-PERFORM-P (i-PERFORM-P). Results and Discussion In general, both tools received a positive reception and can potentially be used in the Indonesian setting with some additions/clarifications in the user manuals. Participants envision that both tools will be most useful in complex cases. Conclusions By obtaining the i-INFERENCE and the i-PERFORM-P, it is hoped that Indonesian forensic medical doctors are better equipped in analyzing and reporting complex cases, and the implementation of EBP can be improved.

Mathematical modeling using finite element analysis in forensic medical examination

The purpose of the work is to develop methods of mathematical modeling using finite element analysis in forensic medical examination. The stages of the methodology for solving problems of deformable body mechanics in forensic medicine are considered, which allows to reliably establish the possibility of formation and morphology of damage under specific conditions and circumstances, to focus the researcher's attention on problem points when creating and evaluating the model. The use of simplified models of the human body makes the expert's conclusion more reasonable, which increases the confidence of law enforcement agencies in the activities of the forensic medical expert service and allows for a new look at solving the problems of forensic medicine and forensic medical examination.

Forensic medical assessment of lidocaine and bupivacaine systemic toxicity

Was to assess the lidocaine and bupivacaine systemic toxicity in forensic medical practice. The number of patients' clinical observations equal three with local anesthetic systemic toxicity (LAST) from the practice of forensic medical experts were studied, and a search of scientific publications for the last 5 years in PubMed database was conducted. The amount of publications, describing cases with LAST, equal four were selected. Differential diagnostic features between LAST and anaphylaxis were considered. The literature data about relationship between lidocaine's concentration in the blood serum and clinical features are shown. The forensic medical assessment of LAST is proposed.

Forensic medical characteristic of hanging incidents among juvenile

Was to conduct the epidemiological analysis of juveniles' deaths by hanging, registered in the Bureau of Forensic Medical Expertise, Moscow for 2017-2021 years. The number of incidents equal 61 was revealed (2.65% of whole hanging incidents for the researched period). The amount of hanging deaths among juveniles and their percent in the total quantity of deaths from this type of strangulated asphyxia increased in 2017, 2018 and 2019 years to 8 (1.6%), 15 (3.1%) and 18 (3.6%) incidents respectively; decreased in 2020 year to 7 (1.7%) incidents and increased again in 2021 year to 13 (3.0%) incidents. Juveniles died by hanging were mostly male (73.8%) aged from 15 to 18 years (63.9%). The median age for girls was 16 years (IQR 15.0-16.75) and for boys 15 years (IQR 13.0-16.5). Most of juveniles' corps were found in their place of residence: in apartments or residential houses (the whole number was 49 or 80.4%). Generally, juvenile hanging occurred between November and January (36.1% of all incidents) and in April (11.5%); less frequently were in February (1.6%), June and July (9.8%). Alcohol was found in blood of 18.2% juveniles aged from 15 to 18.

Algorithm of spleen and sterno-vertebrocostal segment models creation to simulate blunt abdominal trauma as a part of situational forensic medical examinations production

The algorithm of spleen and sterno-vertebrocostal segment models creation, the use of which allows to simulate various variants of conditions of spleen damage occurrence, is proposed. These data can be used for simulation of blunt abdominal trauma as a part of situational forensic medical examinations production. The results of performed experimental works on this issue showed the efficacy and adequacy of created models, which makes implementation of spleen injuries modelling into routine forensic medical expert practice promising.

Possibilities of diagnosing stab-cut wounds in living persons using computed tomography results

Currently, modern research methods such as computed tomography and magnetic resonance imaging have been introduced into the medical and diagnostic practice of large hospitals. These research methods are used almost everywhere for the diagnosis of various injuries, and their results, together with the medical documents of the victims, law enforcement officials, and courts provide state forensic medical expert institutions for the production of forensic medical examinations. The study of computed tomography and magnetic resonance imaging results allows solving expert questions in examinations and studies of living persons.
 The article presents a case from expert practice demonstrating the possibility of establishing the morphology and localization of stab-cut injuries, number of traumatic effects, and direction of wound channels using the results of in vivo computed tomography and three-dimensional modeling. In the described expert case, initially, in the submitted medical documents, data were contradictory about the number, localization and mechanism of formation of wounds. To eliminate existing contradictions, the scars on the victims body and results of a computed tomography upon admission were examined. For a more complete visualization of external injuries, a three-dimensional model of the victims body was recreated from computed tomography data. The results of computed tomography and three-dimensional modeling made it possible to clearly recreate the picture of the victims injuries and answer questions about the mechanism and conditions of their infliction.
 The described case demonstrates the possibilities of expert research and new methodological approaches to solving forensic problems, which is currently quite relevant, since virtopsia has been actively developing in forensic medicine in recent years. The proposed research techniques applied to a corpse with stab wounds will make it possible to more accurately visualize the direction and shape of the wound canal.

ЗНАЧЕНИЕ КЛАССИФИКАЦИЙ МЕХАНИЧЕСКИХ ТРАВМ ОРГАНА ЗРЕНИЯ ДЛЯ РЕШЕНИЯ ЗАДАЧ СУДЕБНО-МЕДИЦИНСКОЙ ЭКСПЕРТИЗЫ

Abstract. Introduction. The development of a unified classification of injuries of the organ of vision is necessary not only for clinicians, but it is also important for forensic medical experts, both for scientific developments and for solving practical forensic problems, especially in cases of examination of injuries of mechanical origin to establish the severity of the harm caused to health. Aim. Aim is to identify the most rational classification of mechanical injuries of the organ of vision to solve the problems of forensic medical examination of damage to these structures. Material and methods. Studies were conducted on both clinical (150) and expert (178) materials. The main literature of recent years on the problem of injuries of the organ of vision is analyzed. Results and discussion. Currently, there is no unified classification of injuries of the organ of vision, covering all the clinical and morphological aspects of this problem. To solve forensic problems, the classifications of injuries of the organ of vision (2002). In this case, the classification should take into account the nature, localization of damage to the external and internal structures of the eyes, as well as the presence of combined damage to adjacent anatomical structures – the head and orbit structure, as well as the zygomatic bone. The forensic medical qualification of the severity of the harm caused to health also depends on the complications and long-term outcomes of injuries to the structures of the eyeball and its appendages. Conclusion. With penetrating wounds of the cornea, in most cases it leads to loss or a sharp decrease in vision. With non-penetrating wounds of the cornea, visual function is usually preserved. The main qualifying criteria for assessing the severity of these injuries are the duration of the health disorder and the amount of loss of stable general ability to work. There is a high risk of developing post-traumatic inflammatory processes, atrophy of the optic nerve and subatrophy of the eyeball. The criteria for qualifying the severity of bodily injuries for these groups of injuries are the amount of permanent loss of general ability to work or complete loss of vision.

Dynamics and structure of forensic medical investigations of violent death in St. Petersburg over the past 10 years

BACKGROUND: Among other things, changes in the structure of forensic medical expert material serve as an indicator of dynamic processes in society. The levels of injuries and violent and nonviolent death somehow depend on the state of the economy and health care in the region and the state as a whole. In recent years, the spread of coronavirus disease 2019 (COVID-19), which was proclaimed as a pandemic with tangible social and economic damage to States, has been one of the determining factors. AIMS: This study aimed to investigate the dynamics of the volume and structure of violent death in the Russian Federation over the past 10 years, including the pandemic period, using the megalopolis example. MATERIAL AND METHODS: This study reviewed the annual reports of the Bureau of Forensic Medical Examination of St. Petersburg using data grouping, frequency analysis, correlation analysis, comparison, system analysis, and inductive generalization. RESULTS: Over the past 10 years, several significant changes have occurred in St. Petersburg in the scope and structure of forensic medical investigations of violent deaths. The main positive trend was a decreased absolute and relative number of cases of violent death. Statistically significantly (p 0.05) decreased number of cases of transport injuries, injuries resulting from the action of blunt and sharp objects, gunshot, thermal injury, and mechanical asphyxia, as well as poisoning with ethanol and carbon monoxide, significantly decreased infant mortality, and fewer unidentified and unclaimed corpses were observed. Additionally, a steady increase in the number of drug poisoning was found, and the fatal injury level due to falling from a height remained consistently high. The background incidence of COVID-19 in 2020 was 2.43.2%. CONCLUSION: The proportion of cases of falling from a height, thermal burns, and strangulation with a noose increased among the dead with a confirmed COVID-19 diagnosis, and transport (primarily rail), gunshot and explosive injuries, cases of drowning, poisoning with drugs, and alcohol detection in the biological environments of the body of the victims were less common.