Medicolegal Aspects Research Articles

Forensic aspects of trauma to the male external genitalia (TMEG), analysis of a series of 84 cases

ObjectivesDescribe the medico-legal aspects of trauma to the male external genitalia by specifying their epidemiological, clinical, paraclinical, therapeutic and evolutionary characteristics. Materials and methodsRetrospective study spread over a period of 3 years (2017–2019) concerning adult patients with trauma to the male external genitalia consulting in the surgical emergency and forensic medicine departments of the Ibn Rochd University Hospital Center in Casablanca. ResultsWe collected 84 cases of TMEG within the framework of evaluation of bodily injury aimed at fixing the duration of Total Temporary Incapacity (TTI) and the rate of Permanent Partial Incapacity (PPI). There was a predominance of bursa trauma (85.7%) followed by penis trauma (14.5%). The average age of the patients was 39 years (17–61 years). Road accidents are the cause of 42% of cases. Regarding bursa trauma, the clinical symptomatology was dominated by pain (100%) and increased scrotal volume (50%). Scrotal ultrasound found the main lesion to be scrotal hematomas (35.71%) followed by ruptures of the tunica albuginea (9.5%). Surgical exploration was indicated in 45.23% of cases, of which (38%) was conservative treatment.For trauma to the penis, the clinical examination revealed 1 case of fracture of the cavernous body, a hematoma of the penis in only 1 patient, a superficial wound of the penis in 1 patient and the rest of the patients (9 cases) showed no lesions. Surgical treatment was indicated in only one patient. The average duration of temporary total incapacity was 17.5 days and the average rate of partial permanent incapacity was 4%. ConclusionPhysicians who are experts in the evaluation of bodily injury are frequently confronted with the evaluation of the damage resulting from the TMEG. The medico-legal evaluation of these traumas remains difficult and very varied requiring a perfect knowledge of the mechanisms of these traumas, of the therapeutic and evolutionary principles helping in the judicial decision.

Sexual Assault in the Mahdia Region: Medico Legal Aspects

IntroductionDespite recent legislative changes through the enactment of 2017-58 law on the elimination of violence against women and children, sexual violence remains fairly frequent and is often underestimated.Objectivesto describe the epidemiological peculiarities of victims of sexual assault in the Mahdia region and to discuss their medico legal implications.Methodsthis is retrospective study of 110 cases of victims of sexual assault examined at the legal medicine department of the TAHER SFAR University Hospital in Mahdia. This work was carried out over the period from January 2016 to August 2018.Resultsthe majority of victims were female (80%) and the main vulnerability factor was an age under 15 (26%). The perpetrator was generally unique (74%). Sexual assault by penetration was mostly reported (51% of cases), and was almost exclusively penile (98,2 of cases). The gynecological examination revealed a torn hymn in 43 victims, a compliant hymen without traumatic lesions in 7 victims (8%) and recent vulvar traumatic lesions without hymenal crossing in 5 victims (5,6%). Recent anal penetration was diagnosed in 6 male victims (6,8%). Among female victims, recent anal penetration was diagnosed in 5 victims (22,7%). One in four victims reported a market psychological impact with female predominance in 85% of cases. Complications of the most reported sexual assaults were pregnancy in 7% of cases. In total, only 57,3% of the certificates issued made it possible to conclude that the injuries.ConclusionsThe care of victims of sexual assault requires a multi- disciplinary approach; medical, psychiatric, social and legal.DisclosureNo significant relationships.

Suicide presentation and the risk at the time of the mandatory quarantine for the SARS-Cov-2 pandemic: medico-legal and forensic aspects

IntroductionCOVID-19 pandemic is the most important health emergency of the 21st century. Since the high number of infected people and as there is still no specific therapy worldwide, the pandemic has been countered through the application of prevention measures based on social distancing and home isolation. These elements are known risk factors for the development of various psychiatric conditions. From a forensic point of view, these pathologies are related to a high suicide rate.Objectives It is no coincidence that during the previous pandemics that have occurred in history there has been a significant increase in suicides. By this work, we therefore want to highlight the psychological consequences of a pandemic and the importance of preventive strategies.MethodsIt is important to focus not only on physical well-being but also on the psychological aspects that the pandemic produces in the daily life of each individualResultsIf the infecting agent causes the death of millions of people around the world, the socio-economic context that is created indirectly determines as many deaths.Conclusions Therefore it is necessary to underline how it is advisable to implement preventive measures in order to significantly reduce deaths from suicide, a problem with an important impact in the social and forensic fields.DisclosureNo significant relationships.

Telemedicine and Plastic Surgery: Principles from the American Society of Plastic Surgeons Health Policy Committee.

In the wake of the recent coronavirus disease of 2019 public health emergency, care delivery by means of telemedicine using audiovisual virtual platforms has become an important tool for patient communication. There are many logistic, medicolegal, and practical aspects of telemedicine that should be considered by the practicing plastic surgeon. Successful virtual patient interactions require an understanding of medical licensure requirements to perform telemedicine visits in a certain region. In addition, it is imperative to be familiar with specific liability and malpractice concerns, in addition to Health Insurance Portability and Accountability Act regulations before conducting electronic visits. During consultations, providers should be aware of proper physician conduct and the potential role of chaperones. Furthermore, appropriate visit documentation, in addition to telemedicine billing and coding, has to be ensured. Lastly, plastic surgeons should adhere to the rules of controlled substance prescription by means of telemedicine platforms. This article describes these salient topics surrounding telemedicine visits that are faced by plastic surgeons and discusses strategies to optimize and ensure safe use of virtual platforms.

Forensic point of view on proving virginity

Aim: Chastity is a moral virtue, whereas virginity is a physiological state indicated, but not conclusively, by an intact hymen. Sometimes, the post-pubertal hymen can be elastic, and hence some sexually active women were found to have intact hymens. Therefore, the absence of any hymen injuries should be used to rule out the possibility that the adolescent has experienced vaginal penetration. Consequently, a false virgin may claim to be a true virgin. Objectives: The current study aims to establish medico-legal aspects concerning proving virginity among Egyptian candidates. Subjects & Methods: A comparative study of two examined groups of married females coming to private section during the first week after the wedding. One group complained of bleeding, and the other complained of severe bleeding with the first intercourse, discussing the types of hymens found, medico-legal and ethical concerns regarding virginity concepts, and their husbands' feelings and attitudes. Results: The results revealed that of 189 women examined for bleeding with the first intercourse, 82.5% of them were found to have an annular elastic hymen. Only 15.8 % of 114 cases examined for severe bleeding during the first intercourse had a deflorated hymen, and the rest had an elastic hymen.

Applications and Current Medico-Legal Challenges of Telemedicine in Ophthalmology.

Background: The digital revolution is redesigning the healthcare model, and telemedicine offers a good example of the best cost-effectiveness ratio. The COVID-19 pandemic has catalysed the use of the telemedicine. The aim of this review is to describe and discuss the role and the main applications of telemedicine in the ophthalmic clinical practice as well as the related medico-legal aspects. Methods: 45 original articles and 5 reviews focused on this topic and published in English language from 1997 and 2021 were searched on the online databases of Pubmed, Scopus, Web of Sciences and Embase, by using the following key words: “telemedicine”, “privacy”, “ophthalmology”, “COVID-19” and “informed consent”. Results: Telemedicine is able to guarantee patient care using information and communication technologies. Technology creates an opportunity to link doctors with the aim of assessing clinical cases and maintaining high standards of care while performing and saving time as well. Ophthalmology is one of the fields in which telemedicine is most commonly used for patient management. Conclusions: Telemedicine offers benefits to patients in terms of saving time and costs and avoiding physical contact; however, it is necessary to point out significant limitations such as the absence of physical examinations, the possibility of transmission failure and potential violations of privacy and confidentiality.

Effect of the First Year of COVID-19 Pandemic on Ophthalmological Practice: A Multi-Centre Italian Study with a Focus on Medico-Legal Aspects

During the COVID-19 era, several restrictions on surgery have been imposed to reduce the infectious risk among patients and staff and further preserve the availability of critical care resources. The aim of the study was to assess their impact on the ophthalmological practice and its medico-legal implications. A retrospective review of electronic medical records of the ophthalmological departments of the University of Cagliari (SGD) and University Magna Græcia of Catanzaro (UMG), from 16 March 2020 to 14 March 2021 (52 weeks), were compared with data from the corresponding period of the previous year. Weekly data on the number and type of diagnoses and procedures performed were collected and analysed in relation to the weekly average of the total number of COVID-19 patients in intensive care units (ICUs) and inpatients in Sardinia and Calabria. Results showed a significant decrease in cataract surgery operations by 47% and 31%, respectively, in the SGD and UMG (p < 0.05) during the second semester of the year; this drop occurred at the same time as the increase in COVID-19 patients in ICU and those hospitalised in both regions. Additionally, anterior segment surgery decreased at the UMG by 30% (p < 0.05). Vitreoretinal surgery decreased by 27% at the SGD, differently increased amount 31.5% at UMG (p < 0.05). The pandemic had a dramatic impact on elective surgery in ophthalmology, quantifying the backlog is the first step in order to understanding the measures to be taken in near future.

Teledermatology for managing COVID-19 patients with cutaneous manifestation: case series study in a rural primary hospital

Background: To provide information and experience about using WhatsApp as a tool in teledermatology to facilitate the identification, treatment, and follow-up of skin problems in COVID-19 patients hospitalized at one of a rural primary hospital located in Indonesia.Methods: All COVID-19 patients with the dermatology manifestation were included in this study. All symptoms and signs of cutaneous manifestation and teledermatology consultation aspect were recorded.Results: There were 7 cases confirmed with skin manifestation (0.9%) from 783 hospitalized patients from March 2020 to June 2021. There were 5 males and 2 females. The age range was 50 - 66 years old. Pruritus is the main complaint, followed by pain and swelling. The cutaneous lesions were mainly maculopapular, followed by papulovesicular and edematous eruptions. The onset of the lesions appeared between the 2nd and 12th day during hospitalization. Both patients and physicians feel comfortable using this platform in consultation.Conclusion: There are advantages and disadvantages to utilizing this concept in the medicolegal aspects, including non-uniform audio-visual quality and also ethical and privacy issues, especially in a rural area.

Physical Assaults assessment concerning their pattern, severity & bone of contention, in rural areas of Punjab

Background: The rural areas of Punjab have a very high prevalence of physical assault due to illiteracy, pride of cast system, related to agricultural land disputes, illegal breaches in violating the watering system of their crops, political motives of landlords in their area, and social issues related to marriages, love affairs, and illegal interference into the privacy of others. Aim: To analyze different forms of physical assaults related to their pattern, severity, and reasons behind these physical assaults keeping in view their medico-legal aspects. Methods: The data of physical assaults in medico-legal cases were collected from the peripheral rural areas of Faisalabad, Sargodha and Mianwali on specifically designed Performa. The cases were selected from these districts reported in Causality & Accident departments of the district and tertiary care Hospitals during one year June 2020 to May 2021. The inclusion criteria were based on non-probability with random sampling in this retrospective study. In total 200 cases were selected for this study. Association with demographic parameters like age, sex, type of weapon used, the pattern of injury. Results: Physical Assaults had a direct association with male predominance; the age of 20 to 30 years of age, blunt weapons especially fists, kicks, and daggers, wooden sticks were used for offense as determined by the findings in this study. Various social reasons related to cast & clan system, disputes of agricultural land, family issues related to inheritance, illiteracy, pride of cast system, domestic violence, illegal breaches in violating the watering system of their crops, political motives of landlords in their area and social issues related to marriages, love affairs and illegal interference into the privacy of others, were the main bone of contentions. Conclusions: Different variety of weapons used in the rural setting. Males as predominant participants of assault suggest a socially active status of men in the rural setup of Punjab where male dominance is evident. The feudal system of landlords main responsible for social injustice and exploitation of the low class, is determined in this study. There need reforms through social literacy, justice provision for all, reforms in medico legal reporting and social awareness of human rights. Keywords: Physical assaults (PA), blunt trauma, domestic violence, rural areas, and bone of contention

Ethicomedicolegal aspects of the COVID-19 health services in preparing regulations and intermediaries for clinical dispute resolution: a systematic review

BACKGROUND The COVID-19 pandemic has caused many medical, ethical, and medicolegal changes, including constant adjustments in service guidelines. Continuing to revise healthcare regulations and guidelines can potentially cause clinical disputes or medical negligence that require ethical and legal solutions. This study aimed to determine the ethical and medicolegal aspects of the potential factors that cause clinical disputes during the pandemic and provide anticipative solutions to national ethicomedicolegal policies.
 METHODS A systematic literature search in PubMed, ScienceDirect, ClinicalKey, and Google Scholar was performed using keywords “clinical dispute,” “ethics,” “medicolegal,” “ethicolegal,” and “COVID-19”. The inclusion criteria were articles that contained information on shortage, justice, ethical distribution in intensive care, the possibility of lawsuits and disputes among stakeholders during the pandemic, and stakeholders’ roles in managing the pandemic. Key evidence was analyzed and synthesized following national ethicomedicolegal policies.
 RESULTS We identified 19 articles from the 4 databases. Based on the literature, the main ethicomedicolegal impact of the COVID-19 pandemic appears in 3 aspects: (1) a shortage of fair and ethical intensive care services with fair and ethical distribution efforts, (2) legal protection for medical personnel from legal charges while providing health services during the pandemic, and (3) the government’s role in managing the pandemic together with the stakeholders involved.
 CONCLUSIONS Ethicomedicolegal clinical dispute management and its norms require an update, especially when deciding the complexity of COVID-19 service standards. Ethicomedicolegal professionals are needed as intermediaries to manage cases of clinical disputes and to implement fair malpractice criteria in Indonesia.

Death Due to Domestic Violence in Imphal: A Retrospective Study of 10 Years

Introduction: Death due to domestic violence is an issue throughout the country and the worldand Manipur is not an exception. Violence ranges from mental torture to physical and ultimatelyto death. Victims are man to man, man to women and women to men but the majority of cases,women are the most sufferers along with morbidity and mortalities. This retrospective analysis istargeted to dig out the actual scenario of the state.Objective: To find out the socio-demographic profile of domestic violence death cases, differentmode of killing, motives, patterns of injuries & cause of death etc.Materials and Methods: A descriptive retrospective autopsy based study of deaths due to domesticviolence is conducted in the Department of Forensic Medicine, Regional Institute of MedicalSciences, Imphal Manipur during the period from the year 2004 to 2013.Results: In this study a total of 61 cases of domestic violence deaths out of 4313 cases of postmortemduring the study period is analysed in various medico-legal aspects. The maximum deaths wereamong males and reported against the 2nd & 3rd decade’s age group and land disputes and personalviolence were the common reason for such fatalities.Conclusion: The study has demonstrated that deaths out of domestic violence are of increasingtrend in all format of society all over the state. Strict legislation and appropriate implementationexisting law and order is need of the hour and further laws are to be adopted to curb this menaceof the society is required.

An Outline on Awareness and Knowledge of Healthcare Ethics and Medico-legal Aspects among Budding Doctors in a Tertiary Care Hospital

Introduction: Numerous litigations have been filed against doctors in the recent past by thepatients on account of medical negligence, unethical behaviour and unethical association withallied healthcare industries.Objectives: This study aims to study the awareness of healthcare ethics among budding doctors(CRRIs and Post graduate students) in a tertiary care hospital.Materials and Method: A descriptive cross sectional study was conducted among 100 youngdoctors working in a tertiary care hospital in Coimbatore, Tamil Nadu using a self-structuredquestionnaire in September 2018 and the results were tabulated.Results: Of the 100 doctors, 50 were CRRIs and 50 were post graduates with 55.1% of the doctorsable to answer accurately for the questions on knowledge of medicolegal aspects.Conclusions: Our study concludes that the interns and post graduates are aware of the ethicalaspects and medicolegal issues in their practice but lacked the finer details in them. Howeverdefinite steps are needed to improve the overall knowledge and awareness on healthcare ethics andits implications in young medical professionals.

A panorama of the medicolegal aspects of suicide assessments: integrating multiple vantage points in improving quality, safety, and risk management.

Epidemiological trends in global suicides have been of serious concern in the last decade. The burden of higher expectations in the assessment of suicidal behaviors on mental health professionals is mounting. However, the suicidal risk assessment has many evolving and moving parts, and is one of the most heavily researched fields in psychiatry. Although it is clear from current empirical research that suicide cannot accurately be predicted, the standard of care from regulatory bodies and professional organizations dictates the use of established measures and following consensus guidelines. However, the legal system has different parameters to assess for the deviation from these standards and views it from a different vantage point. Therefore, it is imperative to know these critical multifaceted panoramas of suicide assessment. Considering the gaps within suicide risk assessment tools, we propose that appropriate documentation and thorough treatment planning are key to navigating the complex medicolegal risks. These approaches are useful for risk management and improve clinical outcomes, quality of care, and overall patient safety.

Organ Donation and the Medicolegal Aspects

Context: In India, the majority of brain-dead organ donors are victims of road traffic accidents, thereby making them entities in medicolegal cases (MLC). This places an additional burden and complicates the organ donation process, as an inquest must be conducted by the police station closest to the accident spot before the possibility of organ donation is considered. Following organ retrieval and donation, a postmortem is required before the body is handed back to the police. These procedures cause delays in the organ donation process and subsequently in families receiving the body of their loved ones. The problem is compounded by the fact that there are variations in the inquest and postmortem procedures in different states. Aim: The study aims to comprehensively enumerate the medicolegal protocols followed by the states having an active deceased organ donation program. Design and Methods: A survey, using a structured questionnaire, was conducted among the senior Transplant Coordinators (key stakeholders in the organ donation process) of eight states. Their experiences handling MLC and the state protocols adhered to were captured. Results: It was found that there were differences in protocols followed by the states with respect to medicolegal organ donation cases. Significant variations were observed in the police inquest and postmortem procedures. A need for training of the police personnel in the medicolegal aspects of the organ donation process is evident from the survey responses. Conclusions: The undue delays lead to difficulties in completing the donation and also cause distress among the family members who have said yes to organ donation despite their grief. The study recommends the need for uniformity in protocols to ease pain points in this program. This is of paramount importance in instances of interstate-organ donation cases.

Forensic and Ethical Particular Issues in the Case of Idiopathic Burning Mouth Syndrome (BMS)

Burning mouth syndrome (BMS) is a chronic clinical condition, characterized clinically by the persistent sensation of pain perceived in the form of burning or stinging in the oral mucosa, which does not yield to the usual local or systemic therapies, without being accompanied by BMS normal clinical or biological results. It is a little-known disease outside oral pathology, so it is frequently underdiagnosed, late-diagnosed therapies are often inadequate and sometimes can be a cause of iatrogenicity and polypragmasia. In our article, we want to expose a series of ethical and medico-legal aspects about burning mouth syndrome that will facilitate the understanding of the sources of diagnostic errors and possible malpractice in addressing this condition. It is our belief that as this pathology is better known and understood, including from an ethical and forensic perspective, therapeutic goals can be achieved more easily, within the current knowledge of the disease.

Factors affecting knowledge, attitude and practice of physicians towards medico-legal aspects in clinical practice in Menoufia governorate hospitals

Factors affecting knowledge, attitude and practice of physicians towards medico-legal aspects in clinical practice in Menoufia governorate hospitals

202 VTE Prophylaxis Post-Laparoscopic Cholecystectomy

Abstract Introduction VTE refers to a clot that causes stenosis or blockage of the blood flow in a vein. VTEs are classified as hospital-acquired if they occur within 90 days of hospital admission. Recent hospitalisation and associate immobilisation are well-acknowledged risk factors also included in Well’s score, which is used as part of the diagnostic work up. NICE guidelines state that patient over 16 years old must be offered VTE prophylaxis either in the form of LMWH or fondaparinux for at least 7 days after an abdominal surgery. The aim of the audit is to explore whether NICE guidelines regarding the VTE prophylaxis post-laparoscopic cholecystectomy are followed. Method The data from all the patients who had laparoscopic cholecystectomy in a two-month period was collected and discharge summaries and TTOs were reviewed to identify whether thromboprophylaxis was prescribed for 7 days following the operation. A second cycle was completed after results of first cycle presented to the surgical team. Results Increased in compliance with VTE prophylaxis guidelines observed, although though still suboptimal. 14% of patients received prophylaxis in first cycle, and 34% in the second. Conclusion Increased compliance with VTE guidelines observed, however the second cycle only included a small sample of patients which limited reliability. Furthermore, as highlighted by the surgical team, NICE guidelines are vague. There is no clarification regarding types of abdominal operations. No VTE incidences are yet to be identified post-operatively. Medico-legal aspects were also considered.

Effectiveness and Safety of Laparoscopic Sleeve Gastrectomy for Weight Loss in Mild Obesity: Prospective Cohort Study with 3-Year Follow-up.

Purpose Patients with mild obesity especially in absence of associated medical problems (OAMP) are commonly managed by non-surgical approaches. Laparoscopic sleeve gastrectomy (LSG) has proved itself to be effective and it is now the most performed weight loss procedure. We aimed to study the effectiveness and safety of LSG for weight loss in mild obesity.MethodsA prospective cohort study. Group A; BMI (30–34.9 kg/m2), and group B; BMI ≥ 40 or BMI ≥ 35 with OAMP. Demographic data, perioperative complications, % excess weight loss (EWL), % total weight loss (TWL), nutritional profile, and evolution of OAMP were recorded and statistically analyzed.ResultsA total of 250 patients, with 80 patients (32%) in group A, and 170 (68%) in group B. The majority were female. The mean preoperative weight, BMI, and excess weight were 90.1 ± 9.52, 32.7 ± 1.4, and 21.5 ± 4.9 in group A, and 129.88 ± 26.12, 47.8 ± 8.2, and 62.3 ± 23.6 kg in group B respectively. The low BMI group had significantly lower OAMP, with higher pre-LSG non-surgical procedures rate. Overall post-operative morbidity rate was significantly higher in group B. %TWL was significantly lower in low BMI group. Nutritional profile was within the normal range in both groups at 3-year follow-up.ConclusionLaparoscopic sleeve gastrectomy is a safe and effective weight loss solution for mild obesity with better outcome than for higher BMI. Further studies are warranted to reconsider NIH’s statement for medicolegal aspects, and for matching the current changes in bariatric surgery practice, safety evidence, and patients’ demand.Graphical abstract

Medico-legal assessment of acid attack (Vitriolage) injuries in Egypt: Fate, outcomes and permanent infirmity

BackgroundVitriolage is an aggressive criminal act that results in different degrees of burn injuries and serious health consequences. Vitriolage has been known as a popular method of assault in some developing countries. To our knowledge, this is the first study in Egypt to study the medicolegal aspects of vitriolage crime. PurposeThe current study was designed to study the pattern of vitriolage injuries and to evaluate the permanent infirmity of vitriolage reported cases in Egypt. Subjects and methodsAll cases of acid burn medicolegal reports throughout three years from 2015 to 2017 were included. 31 victims were studied as regards the demographic, medico-legal data and permanent infirmity assessment done on the victims. ResultsThe male: female ratio of caustic burn victims was 1:2.9. Females were being assaulted at a higher rate than males. Most of the victims were young working women aged 20–30 years old and most of them lived in urban areas. Regarding the gender of the offenders, 23 were males and 6 were females. Almost 90.3% of the offenders were known to their victims. Most attacks occurred in public 22 cases (70.9%). Revenge was the most mentioned motive for assault (58.1%, n = 18). Ocular damage and dermal disfigurement were the most frequent injuries. ConclusionEnsuring efficient implementation of multilevel policies is required to help survivors attain medical, psychological and community support. Legal socio-cultural reform with permanent infirmity evaluation modification is recommended to combat vitriolage.

Orthodontics mini implants – A brief review

In routine orthodontics practice anchorage is a critical factors that determining the success of an orthodontic treatment. For many years’ anchorage has been a strenuous factor. Many modalities have been tried for preventing the anchorage loss by using the extra oral and intraoral devices according to various scientific literature, yet the orthodontists did not find any convenient solutions to solve this problem until the mini- implants were emerged to the speciality. During the early 20 century introduction of various skeletal anchorage devices which includes prosthetic implants, palatal implants, mini-plates and screws. The implants used in orthodontics for the purpose of effective treatment are also known as Temporary Anchorage Devices (TADs), which helps in bringing down the strenuous efforts employed to prevent anchorage loss and they are easy and small and can be insert and remove without stenos efforts, they can be immediately loaded after insertion, and they can provide absolute anchorage for orthodontic treatment, which require minimal need patient compliance there by increasing its popularity. This article gives a brief reviews of indications, contraindications, safety zones for TADs, their insertion procedure, complications, failures and medico legal aspects.