Medico-legal Practice Research Articles

Virchow's Second Protocol; a 21st-Century Review.

Rudolf Virchow published several autopsy protocols in his 1876 book on postmortem examinations. The protocols demonstrate the application of the 1875 Regulations to medicolegal practice. The book went through several editions and translations throughout the remainder of the 19th century, but the second autopsy protocol was subject to scathing criticism in 1915. This article summarizes the protocol and reviews the criticism, historic context, and conclusions. Application of 21st-century practice principles is also attempted in order to test the durability of Virchow's methods and protocol across centuries.

Skin simulants for wound ballistic investigation – an experimental study

Gunshot wound analysis is an important part of medicolegal practice, in both autopsies and examinations of living persons. Well-established and studied simulants exist that exhibit both physical and biomechanical properties of soft-tissues and bones. Current research literature on ballistic wounds focuses on the biomechanical properties of skin simulants. In our extensive experimental study, we tested numerous synthetic and natural materials, regarding their macromorphological bullet impact characteristics, and compared these data with those from real bullet injuries gathered from medicolegal practice. Over thirty varieties of potential skin simulants were shot perpendicularly, and at 45°, at a distance of 10 m and 0.3 m, using full metal jacket (FMJ) projectiles (9 × 19 mm Luger). Simulants included ballistic gelatine at various concentrations, dental silicones with several degrees of hardness, alginates, latex, chamois leather, suture trainers for medical training purposes and various material compound models. In addition to complying to the general requirements for a synthetic simulant, results obtained from dental silicones shore hardness 70 (backed with 20 % by mass gelatine), were especially highly comparable to gunshot entry wounds in skin from real cases. Based on these results, particularly focusing on the macroscopically detectable criteria, we can strongly recommend dental silicone shore hardness 70 as a skin simulant for wound ballistics examinations.

Assessing O.K.N.V.I. RESIST‑5 performance for post‑mortem biological samples: A prospective pilot study.

In recent years, the emergence of carbapenem-resistant strains has been increasing worldwide, including in Romania. Rapid tests for post-mortem examinations have been researched and currently have several applications. In the present study, we aimed to test the performance of O.K.N.V.I. RESIST-5 tests on impure post-mortem biological samples compared with a standard of pure cultures. When a death occurs during hospitalization and the issue of malpractice arises, the medico-legal practice would benefit from rapid tests applicable to post-mortem samples. Thus, detection and differentiation of the five targeted carbapenemases, namely oxacilinase-48, Klebsiella pneumoniae carbapenemase, New Delhi metallo-β-lactamase, Verona integron-encoded metallo-β-lactamase and imipenemase, could be useful in guiding sampling for third-party microbiological assessment and could also be an asset from an epidemiological standpoint. The present prospective and observational pilot study included medico-legal autopsy cases performed at Mina Minovici National Institute of Legal Medicine (Romania) between June and July 2022. A total of two sets of O.K.N.V.I. RESIST-5 tests were performed: Test I, which was performed on-site from biological samples obtained during autopsy; and Test II, which was performed on pure cultures after sample inoculation and incubation. Total of 39 O.K.N.V.I. RESIST-5 rapid tests were performed on 19 biological samples, at least one sample per case. The O.K.N.V.I. RESIST-5 tests performed on-site showed an overall sensitivity of 92.3% with a 100% specificity. The results obtained through rapid tests using post-mortem impure samples were comparable to the results obtained from sample cultures with good sensitivity and specificity. Through post-mortem screening for carbapenem resistance, it would be possible to narrow down the number of cases that require further bacteriological assessment.

Artificial Intelligence: Revolutionizing the Medicolegal Field

Abstract Artificial intelligence (AI) is transforming healthcare and holds immense potential for the medicolegal field. It also presents significant challenges for these systems and their participants. This article overviews core AI concepts such as machine learning and large language models. It highlights current medical applications spanning clinical decision support, computer vision, robotics, and predictive analytics. AI can aid research, summarize documents, draft reports, and enhance quality and efficiency in a medicolegal practice. Limitations must be recognized and managed. Human expertise remains irreplaceable for nuanced analysis, and oversight is crucial. With thoughtful adoption, AI can augment medicolegal evaluations and enhance quality and efficiency. But human skills like critical thinking, judgment, and compassion must persist at the heart of this profoundly human profession.

Post-mortem detection of neuronal and astroglial biochemical markers in serum and urine for diagnostics of traumatic brain injury.

Currently available epidemiological data shows that traumatic brain injury (TBI) represents one of the leading causes of death that is associated with medico-legal practice, including forensic autopsy, criminological investigation, and neuropathological examination. Attention focused on TBI research is needed to advance its diagnostics in ante- and post-mortem cases with regard to identification and validation of novel biomarkers. Recently, several markers of neuronal, astroglial, and axonal injury have been explored in various biofluids to assess the clinical origin, progression, severity, and prognosis of TBI. Despite clinical usefulness, understanding their diagnostic accuracy could also potentially help translate them either into forensic or medico-legal practice, or both. The aim of this study was to evaluate post-mortem pro-BDNF, NSE, UCHL1, GFAP, S100B, SPTAN1, NFL, MAPT, and MBP levels in serum and urine in TBI cases. The study was performed using cases (n = 40) of fatal head injury and control cases (n = 20) of sudden death. Serum and urine were collected within ∼ 24h after death and compared using ELISA test. In our study, we observed the elevated concentration levels of GFAP and MAPT in both serum and urine, elevated concentration levels of S100B and SPTAN1 in serum, and decreased concentration levels of pro-BDNF in serum compared to the control group. The obtained results anticipate the possible implementation of performed assays as an interesting tool for forensic and medico-legal investigations regarding TBI diagnosis where the head injury was not supposed to be the direct cause of death.

Evaluation of Bonwill's triangle parameters using cone-beam computed tomography for gender determination: A retrospective study

Background: The mandible is considered one of the most reliable bones available for gender discrimination. The mandibular Bonwill's triangle measurements can be used for the identification of gender either on the dry mandible or through three-dimensional imaging like computed tomography (CT) or cone-beam CT (CBCT). Aim: The aim of this study was to evaluate the mandibular Bonwill's triangle parameters using CBCT for gender determination. Materials and Methods: Morphometric analysis was performed on 80 CBCT images of Indian participants. The mandibular Bonwill's triangle parameters (C-LR, IC-L, IC-R, and semi-perimeter) were measured in the axial sections of CBCT images to predict the gender. Statistical Analysis: The Mann–Whitney test was used to compare the mean values between males and females, and the Kruskal–Wallis test was used to compare the mean values among different age groups. Results: The participants' ages ranged from 20 to 60 years, with an equal number of males (40) and females (40). The mean distance of C-LR was 106.72 mm in males and 102.59 mm in females. The mean distance of IC-L was 105.09 mm in males and 100.10 mm in females, while that of IC-R was 104.02 mm in males and 99.50 mm in females. The mean value of the semi-perimeter of the Bonwill's triangle was 157.93 mm in males and 151.09 mm in females. All these differences in variables between males and females were statistically significant. Using these variables, the overall prediction accuracy of this study was 75%, with 77.5% in males and 72.5% in females. Conclusion: The parameters of the mandibular Bonwill's triangle in the Indian population were observed to be larger in males than females. Hence, these parameters can be used for gender identification in forensic and medicolegal practice.

Non-accidental head injury of infants: legal implications for the pediatric neurosurgeon.

Though the neurosurgeon's role in non-accidental head injury (NAHT) is the prompt recognition and care of the inflicted injuries, he/she should be aware of the possible legal implications related to this particular neurosurgical condition. Based on published data and their own clinical and medico-legal practice, the authors review the role of the neurosurgeon in NHAT. Besides the contribution that can be given by the neurosurgeon to a correct differential diagnosis, he/she is likely to be involved in the interpretations of the pathological findings in the case where the judge may request for a medical opinion concerning etiology, circumstances, severity, and consequences. As a member of a multidisciplinary team, usually the neurosurgeon is only requested for information regarding the lesions he was called to recognize and treat. Nevertheless, such information may have a pivotal part in the evaluation process. Consequently, the neurosurgeon should be able to reach a correct differential diagnosis of NAHT among all the events that may share similar clinical and anatomo-pathological characteristics and be aware of the ongoing scientific controversies related to the diagnosis and pathophysiology. In practical terms, the pediatric neurosurgeon is called to individuate and record all the precise details of the condition to be eventually offered to the judge in case of controversy. Whereas the diagnosis of NAHT should be evoked at the initial phase in order not to leave the child unprotected, all possible alternative hypotheses should be ruled out "beyond reasonable doubt" for the court. The medical file should be maintained in the record carefully and be accessible even after a long time.

Abusive head injuries in infants: from founders to denialism and beyond.

Abusive head injuries is a major cause of severe morbidity and the main cause of mortality by head trauma ininfants. Based on published data and their own clinical and medicolegal practice, the authors review briefly the historicalroots and emergence of the concept of abusive head injuries (AHI), until the present scientific understanding ofshaken baby syndrome (SBS) and Silverman syndrome. They then discuss the present epidemic of denialism andhow this challenge to science should be seen as a stimulus to increase research and improve the accuracy ofdiagnosis and medical practice. The denial of SBS is especially damaging because it undermines the possibilities of prevention and reparation forvictims. The authors expand on AHI being part of a wider context of domestic violence and the prevention of childabuse being part of a broad and long-term endeavor to defend civilization values. Prevention of AHI is a major challenge for the future. In the fields of science and prevention of child abuse, theinput of pediatric neurosurgeons should not be underestimated.

Occupational therapy clinical report writing in South Africa - factors influencing current practice

INTRODUCTION: Report writing is considered an essential competency for all health professionals. Current research indicates that this area of professional practice appears to be routinely neglected or poorly executed. Previous studies have aimed at understanding the reasons for this neglect; however studies specific to occupational therapy practice are lacking. PURPOSE: This study aimed to explore occupational therapists' perceptions of the factors influencing current practice in report writing within the South African context. METHOD: This qualitative study included six focus group interviews with occupational therapy participants from a variety of clinical sites, fields of practice and health sectors in South Africa, with the exception of medicolegal practice. The qualitative data were inductively analysed to determine specific themes to understand the research question. RESULTS: While occupational therapists voiced uncertainty about ethical and legal aspects concerning report writing, certain profession-specific challenges, such as professional identity and the use of professional language, are perceived to cause a disconnect between the occupational therapists' reporting and their clinical practice. CONCLUSIONS: The findings of the study indicate that participants were unsure of the details regarding the legal and ethical requirements of practice for report writing and voiced both positive and some negative sentiments in terms of reflecting professional identity and profession-specific, occupation-based language, acknowledging the challenge of being in a medical setting. The complexity of writing occupational therapy reports was perceived to be influenced by the audience receiving reports, which varied widely.

Preliminary Study on the Possibility to Detect Virus Nucleic Acids in Post-Mortem Blood Samples.

In many forensic cases, the medical records of the deceased are not available at the time of the autopsy; therefore, no information about the deceased's state of health, including any infectious diseases contracted during life, is accessible. The detection of some of the principal viral infections, such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus type 1 (HIV-1), could contribute to determining causes of death and interesting applications could be found in medico-legal practice, such as occupational risk assessment. To date, accurate and sensitive serological and molecular assays capable of detecting these viruses have been validated on biological samples taken from living beings, while their efficiency on forensic post-mortem biological samples has yet to be thoroughly assessed. To further this aim, this study evaluated whether the nucleic acid amplification techniques (NAATs) for the detection of viral genomes that are applied in clinical settings can be used, with the same success rate, for these latter samples. Manual viral nucleic acid extraction processes and fully-automated amplification-based detection techniques developed in-house were evaluated on blood samples taken during the routine autopsies of 21 cadavers performed 2 to 9 days after death. Information on HBV, HCV, and HIV-1 seropositive status was previously known for only four of these cadavers. Using automated quantitative real-time PCR (qPCR) and qualitative PCR (end-point) analyses, it was possible to confirm the presence of viral genomes in the four post-mortem whole blood samples with previously reported specific serological positivity. In addition, the genomes of HCV and/or HIV-1 genomes were detected in three other blood samples with unknown serological status at the time of autopsy. Therefore, our findings suggest that molecular assays may detect the presence of viral genomes in forensic post-mortem blood samples up to five days after death. This provides an additional means of investigation that can contribute to the determination of the deceased's cause of death.

Medicolegal Practice in India

In India, most of the medicolegal records are still kept as paper documents, even though technology has become integral in every other field of the health sector. Digitalization of the medicolegal processes would allow records to be easily stored and accessed. In addition, it would improve security, accuracy, and readability. Despite some steps in the right direction, most Forensic Medicine departments in India seem to be lagging behind. The authors will attempt to highlight the pressing need for the digitalization of medicolegal services in our country.

Electrical injury: Chronic pain, somatosensory dysfunction, post traumatic stress and movement disorders

Introduction and aimsWe aimed in this case series to identify shortcomings in assessment of long-term painful and psychosocial consequences of EI and to demonstrate the value of biopsychosocial assessment and the commonalities in outcomes. MethodsWe retrospectively analyzed 15 cases from 2004 to 2019 of adult claimants assessed in a medico-legal practice for complex chronic pain disorders secondary to EI. Extensive biopsychosocial information, including 165 data items on pre- and post-injury observations, were collected on each. Cutaneous and deep pressure somatosensory examination was performed and questionnaires for psychological evaluation and restless legs syndrome completed. A comprehensive literature review and descriptive analysis was conducted. ResultsPre-injury, most claimants worked (12/15), did not receive government benefits (14/15) and had no primary pain disorder (9/15). EIs were severe (14/15), where chronic post-traumatic pain, typically high impact with nociplastic features, was regional in 5 and widespread in 10. Somatosensory signs in wide distribution in all cases implied central sensitization. Movement disorders included digital dyskinesia (5/15), involuntary muscle contractions (7/15) and restless legs syndrome in 7. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) post-traumatic stress disorder (PTSD) criteria were met in 12/15, and 14/15 experienced depression and impaired sleep. Severe social impacts, notably including loss of employment resulting in financial stresses, were common. ConclusionsBiological, psychological and social consequences of EI revealed extensive similarities. Disability was generally severe, moreso than indicated in clinical records, influenced by relative paucity of primary pathology, inadequate pain-orientated somatosensory testing and insufficient application of biopsychosocial assessment and management.

THE MOMENT OF DEATH: LAW, SOCIETY AND SCIENCE

To determine the moment of death is very important for various purposes in medico-legal practice. The moment of death may not only assist and be regarded as valuable evidentiary material in criminal investigations but it is also important in the context of organ transplantation, questions regarding euthanasia, insurance claims, the termination of a marriage or business partnership as well as in the legal domain of succession. A diagnosis of death is furthermore important and necessary for society to commence with religious and/or traditional rituals, burials etcetera. In order to determine the exact moment of death, however, is not an easy task, least of all a very simple and straightforward undertaking as Prof Christiaan Barnard suggested by asserting that a person is dead when the doctor says that the person is dead! To determine the exact moment of death, a definition of death is required as well as a standard to diagnose death – diagnostic criteria. This note will show that what initially may be regarded as general medical and legal requirements as well as basic semantics when referring to a definition of death, a concept of death and the criteria for the purposes of diagnosing death, is actually a very complicated, multifaceted and unsettled area of debate. The focus of this note will be on the moment of death in the broader context of medico-legal practice and with specific reference to the amendments made by the National Health Act 61 of 2003 in this regard. Owing to the vast scope of the topic, the note will highlight the main debates regarding the moment of death, the definition for death and criteria for determining death. The basic principles and comments on recent developments in this particular area of medical law will also be discussed.

An Observational Study of Correlation between Age Determinations from Radiological Examination of Wrist in Relation to Birth Certificates in 16-20 Years Age Group

Background: In medico legal practice we frequently came across cases of age estimation, especially to find out whether the individual is minor or major age group. Material and Method: In this study 109 subject of age group 16-20 years were radio graphed for wrist joint from April 2021 to March 2022 in J.L.N. Medical College Ajmer. Obtained data of fusion of lower end of radius and ulna is analysed and reviewed with respect to physical development and reliable document of date of birth. Results: Out of 109 cases 64.22% (70 cases) were of females while 35.78%(39 cases) were of males of age group 16-20 years. Among female cases(56) in 16-18 years age group showed epiphyseal fusion of lower end of radius 28.57% (16 cases),in process of fusion 48.21%(27 cases) while non fusion in 23.21%(13 cases) and in 18-20 age group(14 cases) all cases showed epiphyseal union. Among female cases(56) in 16-18 years age group showed epiphyseal fusion of lower end of ulna 60.70% (34 cases),in process of fusion 8.92%(5 cases) while non fusion in 30.35%(17 cases) and in 18-20 age group(14 cases) all cases showed epiphyseal union. Among male cases(39) in 18-20 years age group showed epiphyseal fusion of lower end of radius 84.61% (33 cases),in process of fusion 10.24%(4 cases) while non fusion in 5.12%(2 cases) while epiphyseal fusion of lower end of ulna showed in 89.74% (35 cases),in process of fusion 10.24%(4 cases).

Ureteric injury in gynecology

Ureteric damage is a rare but a well known complication in obstetric and gynaecological practice. It has repercussions in terms of morbidity and medico-legal practice. There is wide variation of reported incidence is related to the type of surgery. Preoperative and intraoperative precautions can prevent the injury up to a point the injury but the effectiveness of these actions has not been fully assessed.

ANTHROPOMETRIC STUDY OF FEMUR IN SOUTH INDIA

Background: Anthropometry provides scientic method and technique for taking various measurements in different geographic regions and races. The femur is the weight bearing typical long bone of lower limb which extends from the pelvis to the knee. The anatomical knowledge of different dimensions of femur specially head and neck of the femur is very essential in anthropological and medico-legal practice for sex determination and as well as to radiologists, rheumatologists and orthopaedic surgeons for diagnosis and planning of treatment. Objectives: The objectives of present study to nd out the measurements of Platymeric index,Robusticity index and Foraminal index. Materials And Methods: In present study have used 250 femurs from different colleges in south India. The following measurements were conducted Platymeric index, Robusticity index and Foraminal index for both right and left femur. Results: The results of present study are the Physiological length of left femur was 44.15+2.35 and right was 43.98+2.15, the Rubusticity index of left femur was 15.26+1.17 and right was 14.34+1.21the Platymetric index of left femur was 85.70+6.35 and right was 86.32+6.15, the Foraminal index of left femur was between 37-65% and right was 35-62%. Conclusion: The present study shows that there is signicance different in between right and left femurs measurements. The anatomical knowledge of different dimensions of femur is very essential in anthropological and medico-legal practice for sex determination and as well as to radiologists, rheumatologists and orthopedic surgeons for diagnosis and planning of treatment.

English

BACKGROUND Nutrient foramen of humerus is an opening in the shaft of humerus which conducts nutrient vessels for medullary cavity. Major source of blood supply to long bone is the nutrient artery. Knowledge regarding nutrient foramen is important for orthopaedic surgeons while doing any procedure on humerus like bone grafting, plating and also plays an important role in fracture healing. We wanted to determine the location, number, and direction of nutrient foramen of humerus. METHODS The observational study was conducted on 72 adult humeri (36 of right side and 36 of left side) collected from Department of Anatomy, Kurnool Medical College, Kurnool, Andhra Pradesh from 15th September to 31st October 2020. Each humerus was observed for location, number, and direction of nutrient foramen in relation with surface, border andzone. RESULTS In the present study it has been observed that 61 % of humeri had a single foramen, 31 % had two foramina and 8 % had 3 foramina. Majority of nutrient foramina (54.95 %) were present on antero-medial surface, 12.08 % on anterolateral surface, 12.08 % on posterior surface, 19.78 % on medial border, and 1.09 % on lateral border. It was also concluded that most (94.50 %) of the foramina were present in the zone II followed by zone III (3.30 %) then by zone I (2.19 %). CONCLUSIONS Knowledge of number and location of the nutrient foramina in humerus will be helpful in preventing intra-operative injury of nutrient artery during orthopaedic, plastic and reconstructive surgery; and will also be relevant in medico legal practice. KEY WORDS Nutrient Foramen, Humerus, Nutrient Artery, Foraminal Index, Clinical Implications

A child psychiatrist's expert roles in the criminal court: children as vulnerable witnesses

SUMMARYIn this article three main issues are addressed using anecdotal and anonymised illustrations of situations in which the author has been engaged, during 35 years of medico-legal practice, to assist in the process of obtaining and analysing the evidence of children to facilitate decision-making by various authorities and tribunals. Those issues are: the competence of a child to be a witness in the Crown Court; the process by which a child's evidence has been elicited; and the use of an analytical approach to the content (verbal, behavioural and emotional) of a child's evidence as an aid to jurists who have the task of reaching a decision as to the child's reliability, as distinct from their competence.

Rarest fungal myocarditis detected at post-mortem refuted criminal negligence

The small bowel of a patient got perforated during a laparoscopic surgery for long-standing gall stone disease. A poor communication to the relatives about the chances of this complication infuriated them. The non-recovery of the gall stone due to its possible downward migration to the large bowel by the surgical handling compounded the events. The perforation was repaired by another surgery. But, invasive Trichosporon fungal myocarditis caused the death of the diabetic female, otherwise alleged due to medical negligence. The rare fungal invasion was detected by histopathology and microbiology examination at autopsy by medico-legal and surgical specialty experts. The case highlights the value of rapport and empathy with the attendants of the patient in medical practice. The role of the preservation of the biological exhibits and team work in medico-legal autopsy practice is emphasized.

Dental and medical college professionals compatibility to face medico-legal practice: An awareness cross-sectional study at Kanpur, Uttar Pradesh

Context: Medicine is a noble profession, but the practice of medicine has been influenced by the transition in the relationship between doctor and patient and the advertising of the modern healthcare professional. The basic principles of medicine insist that doctors should be aware of the numerous medico-legal concerns that aid in documenting patient management information properly. Aims: The aim is to evaluate the knowledge and awareness on medico-legal Issues among Medical and Dental College Health Professionals of Kanpur, Uttar Pradesh. Settings and Design: A cross-sectional survey was conducted among health professionals. Subjects and Methods: A total of 316 health professionals (161 medical and 155 dental) participated in the study. A structured, closed-ended, self-administered questionnaire was used for the collection of data. Statistical Analysis Used: Chi-square test was used to compare the awareness of medico-legal issues between medical and dental health professionals Results: Among the 316 health professionals, 90.9% of medical and 99.3% of dental professionals were aware about the informed consent, 18.6% of medical and 10.3% of dental professionals had awareness about the Consumer Protection Act and only 18.6% of medical and 9.6% of dental professionals had attended any CDE/CME program regarding Medico-legal issues. Conclusions: The results revealed that there was little knowledge of medico-legal concerns among the participants. There is therefore an immediate need to update the understanding of these issues to be legally more secure.