Medicolegal Purposes Research Articles

OC-046 THE INGUINAL HERNIA OPERATION NOTES (GROIN) QUALITY IMPROVEMENT PROJECT

Abstract Aim Accurate and comprehensive operation notes are crucial for patient safety, quality assurance and medico-legal purposes. Inguinal hernia repair is one of the most common surgical procedures. Thus, operative documentation should be precise and standardised. The GROIN project aims to improve the quality of inguinal hernia operation notes using an evidence-based proforma and an operation note composition software. Methods We retrospectively reviewed operation notes of inguinal hernia repair performed at our institution between August and November 2022. Operation notes were assessed against the Royal College of Surgeons’ Good Surgical Practice standard, consisting of 18 items. Results The operation notes from 89 cases were reviewed. High-scoring items included: operation name (100%), operative findings (99%), surgeon's name (99%), closure technique (98%), operation date (90%) and signature (90%). Postoperative instructions were sufficiently detailed in 79% of cases. Regarding mesh placement, 63% of notes described mesh size and type, whereas 30% documented only the mesh type. The lowest-scoring items were: venous thromboembolism prophylaxis (31%), designation as elective or emergency (22%), operative diagnosis (6%), and estimated blood loss (2%). Conclusions We identified several areas for improvement in inguinal hernia operation notes based on our results. The next step of the GROIN project is to standardise operation note creation by implementing an evidence-based template, which will be delivered through a novel operation note composition software. This will allow accurate record-keeping and efficient operative data extraction analysis. Efforts to standardise operative notes and enhance their quality on a national and international level are imperative for patient safety.

Cone Beam Computed Tomographic Evaluation of Shape, Linear Dimensions and Volume of Sella Turcica: A Retrospective Observational Study

Background: Sella turcica is an important saddle shaped structure that houses the pituitary gland. Any deviation in the development of the pituitary gland may affect the size and shape of the sella turcica as well. So, the morphology of the sella turcica gains special importance in certain clinical conditions. The aim of this study was to assess the shape, linear dimensions and volume of sella turcica in healthy adults using cone beam computed tomography (CBCT). Material and Methods: This retrospective study involved CBCT images of 108 healthy adults. The sagittal, axial, and coronal slices of CBCT images were used to evaluate the shape, volume and linear dimensions. Results: The overall linear dimensions of sella turcica were length 8.59 ±1.49 mm, depth 7.27 ±1.16 mm, diameter 10.24 ±1.75 mm and volume 1499.69 ± 395.5 mm3 respectively. The length of sella turcica was higher in males than females which was statistically signifcant (p = 0.015) while the depth, diameter and volume reported non-signifcant results. The most frequent shape of sella turcica was normal and the least frequent was sella turcica bridging. The Pearson correlation co-efcient was statistically significant for the length vs diameter and volume along with diameter vs volume in both genders (p < 0.01). The depth was statistically correlated with length, diameter and volume in males (p <0.01). Conclusion: The sella turcica shape and dimensions can be used in forensic and medicolegal purposes. So, a thorough of knowledge about this important structure is necessary.

Mismatch negativity as an early biomarker of cognitive impairment in schizophrenia

BackgroundDue to its disturbance in schizophrenic patients, mismatch negativity (MMN) generation is believed to be a potential biomarker for recognizing primary impairments in auditory sensory processing during the course of the disease. However, great controversy exists regarding the type and onset of MMN-related impairments, with the deficits to frequency deviants is more debatable. This cross-sectional, case–control study was conducted to assess the cognitive functions among 33 eligible Egyptian schizophrenics (15 early and 18 chronic), and 30 matched healthy controls by assessing their psychometric tests and correlating them to the coexisting frequency deviant MMN responses (using both tone and speech stimuli).ResultsDeficits in frequency MMN and neuropsychological tests were evident among early and chronic schizophrenics compared to their matched control counterparts, and also between early versus chronic schizophrenia in favor of the later. MMN deficits to speech stimuli were more elicited than tone stimuli among schizophrenics. Moreover, significant correlations were identified between MMN parameters and the results of psychiatric cognitive scales.ConclusionsWe demonstrated that frequency-deviant MMN deficits are evident feature among the enrolled Egyptian schizophrenics. The cognitive functions as indexed by MMN seem affected early, with the striking decrease of MMN amplitude and delay of latency point towards the progression of the illness. The normal lateralization of MMN was absent in chronic schizophrenia. These findings could be helpful in using the MMN as an additional objective tool for confirming cognitive impairments among schizophrenics and to differentiate between early- and chronic-schizophrenic patients for medico-legal purposes and clinical implication for medications.

Ophthalmology Operation Note Encoding with Open-Source Machine Learning and Natural Language Processing

Introduction: Accurate assignment of procedural codes has important medico-legal, academic, and economic purposes for healthcare providers. Procedural coding requires accurate documentation and exhaustive manual labour to interpret complex operation notes. Ophthalmology operation notes are highly specialised making the process time-consuming and challenging to implement. This study aimed to develop natural language processing (NLP) models trained by medical professionals to assign procedural codes based on the surgical report. The automation and accuracy of these models can reduce burden on healthcare providers and generate reimbursements that reflect the operation performed. Methods: A retrospective analysis of ophthalmological operation notes from two metropolitan hospitals over a 12-month period was conducted. Procedural codes according to the Medicare Benefits Schedule (MBS) were applied. XGBoost, decision tree, Bidirectional Encoder Representations from Transformers (BERT) and logistic regression models were developed for classification experiments. Experiments involved both multi-label and binary classification, and the best performing model was used on the holdout test dataset. Results: There were 1,000 operation notes included in the study. Following manual review, the five most common procedures were cataract surgery (374 cases), vitrectomy (298 cases), laser therapy (149 cases), trabeculectomy (56 cases), and intravitreal injections (49 cases). Across the entire dataset, current coding was correct in 53.9% of cases. The BERT model had the highest classification accuracy (88.0%) in the multi-label classification on these five procedures. The total reimbursement achieved by the machine learning algorithm was $184,689.45 ($923.45 per case) compared with the gold standard of $214,527.50 ($1,072.64 per case). Conclusion: Our study demonstrates accurate classification of ophthalmic operation notes into MBS coding categories with NLP technology. Combining human and machine-led approaches involves using NLP to screen operation notes to code procedures, with human review for further scrutiny. This technology can allow the assignment of correct MBS codes with greater accuracy. Further research and application in this area can facilitate accurate logging of unit activity, leading to reimbursements for healthcare providers. Increased accuracy of procedural coding can play an important role in training and education, study of disease epidemiology and improve research ways to optimise patient outcomes.

Diatomological Profile at Discrete Depths of Powai Lake, Mumbai for Medico-Legal Purposes

Diatoms are photosynthetic microorganisms that play important role in forensic diatomology in the diagnosis of drowning deaths. In the present study, the Diatomological profile of Powai lake was prepared for medico-legal purposes using the Shannon-Wiener index. Powai lake (19.1266° N, 72.9062° E) is a large artificial lake situated in a northern suburb of Mumbai. Diatoms sampling was conducted in February 2017 from this lake. This study aimed to identify the various genera of diatoms and to determine the relative abundance, generic counting, and diversity index of diatoms for the medico-legal purposes. Littoral benthic diatoms of five locations were sampled from this lake. Diatoms slides were prepared by scraping the rock surface with an area of 3x3 cm, diluting in 50 ml distilled water, and identification under the microscope with 1000 magnification. Identification of 17 genera of diatoms was done using the web-based visual guide ‘Diatoms of the United States’. Diatoms belong to both the orders Centrales and Pennales. The pH of the lake water was found to be 7.64 i.e. slightly alkaline and the temperature was 27°C. Water quality parameters showed a fairly good value for the growth of diatoms. Samples were dominated by class Bacillariophyceae, which included 9 genera followed by Coscinodiscophyceae, with 6 genera, and Fragilariophyceae, with 2 genera. Generic counts of diatoms were obtained by using the ‘Neubauer’ Counting chamber. The Shannon-Wiener diversity index (H') ranges from 1.042 in Epipelic to 0.454 in Emerged Epiphytic diatoms. The purpose of this study was to prepare a diatomological profile of diatoms at discrete depths for medico-legal purposes.

Role of integrin and its potential as a novel postmortem biomarker in traumatic axonal injury.

Traumatic axonal injury (TAI) accounts for a large proportion of the mortality of traumatic brain injury (TBI). The diagnosis of TAI is currently of limited use for medicolegal purposes. It is known that axons in TAI are diffusely damaged by secondary processes other than direct head injury. However, the physiopathological mechanism of TAI is still elusive. The present study used RGD peptide, an antagonist of the mechanotransduction protein integrin, to explore the role of integrin-transmitted mechanical signalling in the pathogenesis of rat TAI. The rats were subjected to a linearly accelerating load, and changes in beta-amyloid precursor protein (β-APP) expression, skeleton ultrastructure, skeleton protein neurofilament light (NF-L), and α-tubulin in the brainstem were observed, indicating that RGD could relieve the severity of axonal injury in TAI rats. In addition, the expression of β-integrin was stronger and centralized in the brainstem of the deceased died from TAI compared to other nonviolent causes. This study examined the pathophysiology and biomechanics of TAI and assessed the role of integrin in the injury of microtubules and neurofilaments in TAI. Thus, we propose that integrin-mediated cytoskeletal injury plays an important role in TAI and that integrin has the potential as a biomarker for TAI.

Mandibular Ramus: An Indicator of Gender and Chronological Age - A Digital Radiographic Study

Background: The determination of sex and age of individual is important in forensic practice and medico legal purposes. Mandible may play a vital role in sex estimation as it is the most dimorphic bone of skull that often is recovered intact. The present study was conducted to evaluate the reliability of mandibular measurements in gender determination and age estimation as seen on digital panoramic radiographs. Aims and Objectives: The aim of the study was to evaluate and compare seven parameters of the mandibular ramus obtained from digital orthopantomographs, and to assess the usefulness of these parameters as aids in gender and age estimation. The objectives were: 1. To assess:-Maximum ramus breadth in mm, Minimum ramus width in mm, Projective height of ramus in mm, Maximum height of the ramus in mm, Maximum coronoid height in mm, Gonial width in mm and Bigonial angle in degrees, 2. To correlate each of these seven variables with the age of the patient, and 3. To compare these seven parameters between males and females. Materials and Methods: OPGs of 500 patients satisfying inclusion and exclusion criteria selected from the Dept. of Oral Medicine and Radiology, Govt. Dental College, Kottayam, were being studied. Permission from the concerned departments was taken. The measurements were made on this radiograph using GIMP 2.8 Software. Results: All the parameters were found to show statistically significant difference between males and females. After performing logistic regression, an equation was formulated to determine gender from the parameters that were statistically significant in regression analysis. The cut off was set at 0.5. Values above the cut off value were interpreted as males and values below the cut off were interpreted as females. The overall accuracy of sex determination at this cut off value from this method was 73.9%. Significant correlation was not noted between the mandibular parameters and age of the individual. Conclusion: It can be concluded that the mandibular ramus can be considered as a valuable tool in gender estimation since it possesses resistance to damage and disintegration processes. Nevertheless, the age of the individual cannot be determined using this method.

A Closed-Loop Audit for Orthopedic Trauma Operation Notes Comparing Typed Electronic Notes With Handwritten Notes

IntroductionOperation notes are important documents for ensuring patient safety, effective communication between clinicians, and for medicolegal purposes. It is essential that they are clear and accurate. We audited the quality of our operation notes against the Royal College of Surgeons (RCS) of England's Good Surgical Practice Guidelines.MethodsThis was a prospective audit of 99 orthopedic trauma operation notes. In the first cycle, we audited 58 operation notes for orthopedic trauma surgical procedures. We audited 17 parameters per note. We presented our findings, implemented changes including the use of a typed operation note template, and performed a re-audit using 41 operation notes.ResultsOur documentation for 3/17 parameters was up to standard in both cycles. Post-intervention, there was an improvement in documentation for 12/17 of the parameters with marked improvements in indication for surgery (45% vs 75%), tourniquet time (20% vs 45%), antibiotic prophylaxis (71% vs 89%), closure technique (62% vs 86%) and detailed postoperative instruction (40% vs 92%). Other parameters, particularly estimated blood loss (7% vs 8%) remained unchanged. In the second cycle, we noted that 25% of the typed notes had 100% compliance with the standards, whereas no handwritten note achieved this. However, there was no statistically significant difference in the mean number of correctly documented parameters between the typed and handwritten notes (p < 0.05).ConclusionThe use of operation note templates (preferably typed) can improve appropriate documentation in orthopedic trauma operation notes. These templates should be made easily accessible to all surgeons. We will recommend orthopedic trauma units to apply similar non-rigid templates that can be tailored to suit different categories of trauma surgery.

An Audit of Orthopaedic Operative Notes : Do we Need Improvement?

Accurate and detailed operation notes are of great importance in all surgical specialties not only for safe patient care but also for providing information for research, audit, and medico legal purposes. Thus, importance of complete and legible operation notes is indisputable. Orthopaedic operation notes at the Government Medical College, Amritsar were audited against guidelines regarding content and legibility. Although of generally good standard it was found that in some cases important information was being missed and that a high proportion of notes had sections that were deemed illegible. A computerized pro forma for writing notes has been proposed. Also. It has been proposed that all the Resident Doctors of Department should undergo training for writing notes and Aide Memoires be placed throughout the OT Complex.&#x0D; Keywords: orthopaedic, operation notes, audit.

390 Assessing the Standard of Operative Notes Within a Vascular Surgery Department: An Audit Cycle

Abstract Aim Both the General Medical Council and Royal College of Surgeons of England’s (RCSEng) ‘Good Surgical Practice’ state that all clinical documentation must be recorded clearly, accurately, and legibly. The operative note is not just a means of communicating post-operative plans but can also be used for medico-legal purposes. The aim of this audit cycle was to ascertain how well the operative notes within a Vascular Surgery department adhered to the guidelines devised by RCSEng. Method 40 operative notes were analysed prospectively against the criteria stated in the ‘Good Surgical Practice'. The surgeons were made aware of the initial results via a departmental meeting. Using the Plan-Study-Do-Act (PDSA) model, we studied the pre-existing operative note template and created an aide-memoire highlighting the criteria with poor compliance. This was placed in all the vascular theatres. A re-audit was then undertaken 2 months after. Results In the first audit, we noted good compliance in areas that were included in the pre-existing template such as date (97.5%), name of operator (97.5%), name of anaesthetist (100%), operative procedure (100%), and closure technique (95%). Areas in need for improvement included time (0%), anticipated blood loss (2.5%) and elective/emergency procedure (10%). The second cycle demonstrated improvements (100% compliance) in most parameters. Documentation of time, elective/emergency procedure, and legibility showed minimal improvement. Conclusions This audit highlighted the importance of greater awareness of the expected standard of note documentation. Implementation of proformas and electronic documentation can effectively circumvent issues related to variability and legibility, and ultimately improve patient safety.

The Introduction of a New Diagnostic Tool in Forensic Pathology: LiDAR Sensor for 3D Autopsy Documentation.

Autopsy is a complex and unrepeatable procedure. It is essential to have the possibility of reviewing the autoptic findings, especially when it is done for medico-legal purposes. Traditional photography is not always adequate to record forensic practice since two-dimensional images could lead to distortion and misinterpretation. Three-dimensional (3D) reconstructions of autoptic findings could be a new way to document the autopsy. Besides, nowadays, smartphones and tablets equipped with a LiDAR sensor make it extremely easy to elaborate a 3D model directly in the autopsy room. Herein, a quality and trustworthiness evaluation of 3D models obtained during ten autopsies is made comparing 3D models and conventional autopsy photographic records. Three-dimensional models were realistic and accurate and allowed precise measurements. The review of the autoptic report was facilitated by the 3D model. Conclusions: The LiDAR sensor and 3D models have been demonstrated to be a valid tool to introduce some kind of reproducibility into the autoptic practice.

Third trimester intrauterine fetal death: proposal for the assessment of the chronology of umbilical cord and placental thrombosis

The timing of umbilical cord and placental thrombosis in the third trimester intrauterine fetal death (TT-IUFD) may be fundamental for medico-legal purposes, when it undergoes medical litigation due to the absence of risk factors. Authors apply to human TT-IUFD cases a protocol, which includes histochemistry and immunohistochemistry (IHC) for the assessment of thrombi’s chronology. A total of 35 thrombi of umbilical cord and/or placenta were assessed: 2 in umbilical artery, 6 in umbilical vein, 15 in insertion, 10 in chorionic vessels, 1 in fetal renal vein, 1 in fetal brachiocephalic vein. Thrombi’s features were evaluated with hematoxylin–eosin, Picro-Mallory, Von Kossa, Perls, and immunohistochemistry for CD15, CD68, CD31, CD61, and Smooth Muscle Actin. The estimation of the age of the thrombi was established by applying neutrophils/macrophages ratio taking into consideration, according to literature, the presence of hemosiderophagi, calcium deposition, and angiogenesis. To estimate an approximate age of fresh thrombi (< 1 day), a non-linear regression model was tested. Results were compared to maternal risk factors, fetal time of death estimated at autopsy, mechanism, and cause of death. Our study confirms that the maternal risk factors for fetal intrauterine death and the pathologies of the cord, followed by those of the placental parenchyma, are the conditions that are most frequently associated with the presence of thrombi. Results obtained with histological stainings document that the neutrophile/macrophage ratio is a useful tool for determining placental thrombi’s age. Age estimation of thrombi on the first day is very challenging; therefore, the study presented suggests the N/M ratio as a parameter to be used, together with others, i.e., hemosiderophagi, calcium deposition, and angiogenesis, for thrombi’s age determination, and hypothesizes that its usefulness regards particularly the first days when all other parameters are negative.

Assessment of condyle-coronoid angle and gonial angle for gender determination: A digital panoramic study in Bagalkot population.

The determination of gender is of utmost importance for forensic science and medico-legal purposes. The mandibular bone may play a vital role in gender determination as it is the most dimorphic bone of the skull that is often recovered intact. In this respect, orthopantomograms are of great value in accurate age and sex estimation. The mandibular angles, especially the gonial angle is an important parameter of the craniofacial complex giving an indication about the vertical parameters and symmetry of the facial skeleton. The purpose of the current study was to evaluate the usefulness of mandibular gonial and coronoid-condyle angle measurements on digital panoramic images as an indicator for gender determination in the Bagalkot population. A total of 200 panoramic images (100 males and 100 females) of Bagalkot district patients aged (18-58) yrs old were selected. Two mandibular parameters 1) gonial angle and 2) condyle-coronoid angle were analyzed using trophy DICOM 6.1.2.0, masterview 4.2.0. Two-way analysis of variance (ANOVA) test and Tukey's multiple post hoc procedures were used to compare the gender and two sides (left and right) with respect to gonial angle and condyle-coronoid angle. The analysis of the present study confirmed a statistically significant difference between the right and left sides of the gonial angle and condyle-coronoid angle in both genders. The mean comparison also shows a variation between males and females, based on gonial angle and condyle-coronoid values; females have statistically significant higher mean values than males. Based on the analysis, the present study concludes that this difference between males and females from both sides suggests that the gonial angle and condyle-coronoid angle help in gender determination. The results of the study show that greater mandibular angle aids in gender dimorphism and proves to be beneficial in gender estimation. Gonial angle and condyle-coronoid angle can be used to differentiate gender with high accuracy.

Macroscopic Study of Temporoparietal Suture Closure at Autopsy for Estimation of Age

Introduction: Age estimation is an integral part of identification of an individual which is needed for social and medicolegal purposes, whether in living, dead or in skeletal remains. Aim: To evaluate the utility of fusion of temporoparietal cranial suture for estimation of age at autopsy. Materials and Methods: This cross-sectional study was conducted on the medicolegal postmortem cases that came to the Department of Forensic Medicine and Toxicology, Government Medical College and Hospital, Chandigarh, India during the period between October 2018 and July 2019. A total of 280 cases were studied. The fusion of temporoparietal suture was studied macroscopically during the routine postmortem examination. The temporoparietal suture was studied ectocranially and endocranially by dividing it into two equal parts (T1 and T2), and applying Acsadi-Nemeskeri scale (0-4). Mean and standard deviation were calculated for ectocranial and endocranial suture closure (left and right sides). Also, it was calculated for total mean of the segments (T1+T2) taken together on both sides. Actual age and the scored values were plotted in a linear regression curve and estimated age was calculated. Statistical analysis was carried out by using Statistical Package for the Social Sciences (SPSS) software version 22.0. Spearman’s correlation analysis was applied to determine the variable correlations. The p-values of less than 0.05 were considered statistically significant. Estimated age for males and females was tested by Student’s t-test of significance. Results: Out of total 280 cases studied, maximum (219) were males. Maximum number of males and females were found to be in age group of 26 to 35 years. It was observed that closure commenced at the age of 18 to 25 years (Acsadi-Nemeskeri scale mean of 0.87, 0.84 for T1, T2, respectively on left side) and (Acsadi- Nemeskeri scale mean 0.84 for T1 and T2 on right side). Closure was not complete even at the age of 76 years and above (Acsadi- Nemeskeri scale mean 2.67, 2.50 for T1, T2, respectively on left side) and (mean 2.33, 2.67 for T1, T2, respectively on right side). Conclusion: From the present study, it can be concluded that endocranially temporoparietal suture was closed at 18 years and above of age and it was found unfused even at age of more than 76 years for the identification of an individual especially in advanced age, and was consistent with the studies conducted by various authors.

Frontal sinus pattern analysis for human identification using non-contrast computed tomography images: A Sri Lankan experience.

Morphometry of frontal sinuses has been studied extensively in many countries. However, these findings cannot be generalized due to genetic and environmental factors affecting the skeletal structure. The main aim of this study was to morphometrically analyze the frontal sinuses in patients who underwent non-contrast computed tomography (NCCT) skull imaging at Teaching Hospital Peradeniya and to assess its association with age and sex. This retrospective study included 300 NCCT skull images obtained by a multi-slice computed tomography(MSCT) scanner at the Teaching Hospital Peradeniya. This age- and sex-matched sample was selected using consecutive sampling and consists of seven age groups (20-29, 30-39, 40-49, 50-59, 60-69, 70-79, and 80-89). Right and left frontal sinus values (length, height, width of each sinus, and total width) were measured using the RadiaAnt DICOM Viewer 2020.2.3 software, and age and sex were obtained from the CT images. The association among the variables was analyzed using the t-test and binary logistic regression model. In our study sample, 59% (n = 177) were male and the mean age was 57.94 years. The means of left side sinus values were larger than right sinus values, which was statistically significant. A statistically significant association was seen between frontal sinus parameters and sex; those of males were higher than that of females. No significant association between the sinus size and age was observed. Morphometric analysis of frontal sinuses using NCCT images is useful for the sex differentiation of unknown bodies for medico-legal purposes. Furthermore, the mean sinus values specific to the current study population will also be helpful in ethnic differentiation.

Mandibular parameters as a predictor of sex: A digital orthopantomogram study

Background: The determination of age and sex is required for forensic practice and medicolegal purposes. Because the mandible is typically recovered intact, it plays a crucial role in determining sex. Orthopantomogram X-rays can be used to thoroughly examine the mandible. The availability of a large number of antemortem orthopantomograms could be extremely beneficial in terms of evaluating and developing population-specific sex determination standards. Objectives: To evaluate the usefulness of the mandibular ramus in sex determination by evaluating linear and angular measurements of the mandibular ramus on digital panoramic radiographs. Methods: An analytical cross-sectional study was conducted on 216 digital orthopantomogram from March 2021 to June 2021 in Kantipur Dental College. A convenient sampling technique was used to collect the radiographs. Mandibular parameters were traced using Image J Software, and angular and linear parameters were calculated. Radiographs with high image quality and sharpness of patients with full permanent dentition, no radiographic evidence of trauma were included in the study. Descriptive analysis was done using IBM SPSS Statistics for Windows, version 20 (IBM Corp., Armonk, N.Y., USA). The measures were compared using an Independent t-test, and the results were subjected to discriminant function analysis. Results: The male’s vertical parameters were found to be greater than the female’s. The coronoid height was shown to be the most dimorphic using discriminant analysis. The overall accuracy of the mandibular parameters was 63.4%. Conclusion: Mandible can be used as an adjunct in sex determination.

Evaluation of medical malpractice claims in obstetric ultrasonography: Opinion of The Council of Forensic Medicine in Turkey

AimThe Council of Forensic Medicine is an institution affiliated with the Ministry of Justice in the Republic of Turkey which acts in an official oversight capacity in cases of alleged medical malpractice in forensic medical science. Sonographers may face judicial sanctions as a result of ultrasonography examinations that they do not perform according to current guidelines. In this study we focused our attention to claims of medical malpractice related to obstetric ultrasonography that had been referred to the Council of Forensic Medicine. Our aim was to investigate the causes of malpractice claims related to obstetric ultrasonography and to present the expert opinions of our council about these claims in the light of literature. We have also planned to discuss what can be done with current guideline information to prevent situations that cause malpractice claims. Materials and methodsThe study herein was performed on 73 claims of medical malpractice in obstetric ultrasonography findings, all of which were referred by forensic authorities to the Second Specialization Board of Council Forensic Medicine from 2014 to 2018. A retrospective review of the reports generated from information contained within case files illuminates the reasoning behind medical error claims. Among the reasons examined are features of the ultrasonographic evaluation (number, week of examination, health institution), the traits of the evaluating physicians (institutions, branches, academic titles), congenital anomalies detected after birth, and maternal age. ResultsAnalysis of the data shows that 79.5% of ultrasonographic examinations leading to claims of medical malpractice were performed in private health institutions. All cases of medical malpractice claims were associated with undiagnosed congenital anomalies, and that the form for informed consent was obtained for only 19.1% of cases that underwent second level ultrasonographic examination. Further, 53.3% of cases with congenital anomalies subject to litigation were anomalies of the extremities, and all four cases of alleged malpractice within obstetric ultrasonography were associated with extremity anomalies. The variety of academic titles of physicians performing the ultrasonographic examinations was not statistically significant. It was concluded that two ultrasonography examinations performed by two nuclear medicine specialists were not in accordance with medical norms. ConclusionAlthough organizations such as AIUM, ACR, and ACOG try to set standards for ultrasound examination through practice guidelines, it is difficult to establish optimal standards for ultrasonographic examination. In light of the guidelines created by the above organizations, each country should set its own standard based on their own socioeconomic and health data. We conclude that it is not appropriate for obstetric ultrasonographic examinations to be performed by specialists in fields such as nuclear medicine, where ultrasonographic examinations are not a part of the core training curriculum. Obtaining a signed informed consent form from the patient prior to the second level ultrasonography examination will be useful for medicolegal defense purposes should a subsequent claim of malpractice be filed.

Sexual dimorphism in digital dermatoglyphics: A qualitative analysis of bengali hindu population, West Bengal, India

Dermatoglyphic characteristics for identification of sex play an important role in forensic and medico-legal purposes. Hence, it considered to be the most precise and reliable indicators for personal and gender identification. Such types of information on Bengali speaking Hindu population are very scanty. This was tempted the present authors to assess the sex-wise variation of digital dermatoglyphic traits in a sample from West Bengal, India.A total 168 participants were recruited to obtain basic information and fingertip impression of the participants. Impressions were taken by using Ink method (Calcutta Ink) and examined with hand-lens.The mean age for male participants was 31.30 ±16.13 and for females it was 32.11±13.30. The loop pattern is observed more frequent (46.13%) compared to whorl (36.25%), arch (10.89%) and composite (6.72%). Females have a more loop (47.84%) and arch (12.26%) patterns than males (43.48% and 8.79% respectively. The whorl (39.85%) and composite (7.88%) patterns are observed more frequently in males as compared to females (33.92% and 5.98% respectively). Furuhata’s Index is more frequent in males (91.64) than females (70.9) but both the Dankmeijer’s and Poll’s Index are higher in females (36.13 and 25.61 respectively) than males (22.05 and 20.21 respectively). However, in case of Pattern Intensity Index there is slightly a sex difference for males and females (12.32 and 11.57 respectively).It was concluded that differences in the finger print pattern, combinations and indices can be used as an important tool for the determination of sex in medico-legal and forensic purposes.

Major neurological complications following central neuraxial blockade – A multicentre pilot study in Aurangabad city (MGMA CNB Study)

Background and Aims:Incidence of major neurological complications following central neuraxial blockade (CNB) in India is not known. This information is essential for explaining risk preoperatively to patients and for medico-legal purposes. This study was undertaken to assess feasibility (recruitment process, protocol adherence, resources mobilisation, data management and evaluation of scientific outcome) for planning multicentric studies on major neurological complications following CNB at state/national level.Methods:This was a hospital-based, multicentre pilot study, with cross-sectional and follow-up components. Patients receiving CNB either perioperatively or during acute/chronic pain management were included in the study. Thirty-six randomly selected tertiary and nontertiary care institutes were included. Details of demographic information, CNB procedure and major neurological complications were collected anonymously via online tools. Feedback about study feasibility was collected from participating anaesthesiologists and study team.Results:Selected institutes continued participation throughout study period. About 99.98% of eligible patients were enroled. Complete data collection of 8053 patients and analysis was possible. Regular reminders from study coordinators helped to optimise data collection. Tertiary care institutes contributed to 74.50% of data. About 64.96% patients were females. Spinal anaesthesia was the most frequently used neuraxial block (93.41%). Bupivacaine and adjuvant were used in 95.53% and 16.5% patients, respectively. Two patients developed cardiac arrest and cause-effect relationship with CNB was established. Participants’ recruitment, protocol adherence, resources mobilisation, data management and evaluation of scientific outcomes were feasible.Conclusion:A multicentre state/nationwide study can be conducted based on this first-of-its-kind pilot study in India.

Case Report: Penetrating Thoracic Trauma by A Gunshot Involving the Heart

Firearm-related mortality is not frequently encountered in a country like Nepal where there are stringent laws prohibiting the buying, selling, carrying or storing of firearms. To possess a firearm a person must have a valid license. Wounds produced by firearms have typical characteristics the knowledge of which helps to identify the type of firearm used, range of fire, the position of the victim, and whether the manner of death was homicidal, suicidal, or accidental. The present case is the first autopsy-based study from Nepal which discusses the wounds produced by firearms with an interpretation of such findings for medicolegal purposes. The present case highlights a social problem where the victim, a psychiatric patient, had no access to prescription medication due to coronavirus disease (COVID-19) related lockdown.