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PubMed1998

Handedness identification from intertubercular sulcus of the humerus by discriminant function analysis.

The accurate determination of skeletal handedness is a critical requirement in physical anthropology and forensic science. To differentiate handedness, discriminant function analysis is applied using the parameters of right and left intertubercular sulci. A total of 200 matched unpaired adult humeri (100 right and 100 left), collected from the Department of Anatomy, were used to measure four parameters of the intertubercular sulcus namely, width (X1), depth (X2), angle of medial wall (X3) and angle of lateral wall (X4) and to note the presence of supratubercular ridge of Meyer (X5). The discriminant function obtained with the significant variables, angle of medial wall (X3), angle of lateral wall (X4) and presence of the supratubercular Meyer (X5) is: Y = 0.093X3 + 0.056X4 + 0.775X5 - 13.46. The accuracy of correct classification using the discriminant function is 89% which is the best starting point for handedness determination approach. The methodology of using discriminant function can be crucial for medicolegal jurisprudence.

Adult↗

PubMedDate not supplied

The medical and scientific evidence in alleged tubocurarine poisonings. A review of the so-called Dr. X case.

The problem of proving the presence or absence of a poison in a buried cadaver is the central theme of this presentation. Certain general questions are posed which may serve to guide those seeking to determine the cause of death in buried cadavers and allegedly due to a poison. Medicolegal and scientific evidence is presented from the court records of five deaths which were alleged homicides due to intravenous tubocurarine. As to the medical evidence: The prosecution claimed absence of adequate medical causes but full congruence with intravenous tubocurarine as the cause of death. The defense claimed and presented its evidence, including history, clinical picture, gross and microscopic pathological findings--for the deaths having occurred from competent natural causes in all but one case. In that one case the cause was undetermined. In two of the four cases evidence was presented for the mechanism of death and why they died at the time that they did. As to the forensic toxicological evidence: The prosecution claimed qualitative identification but with no particular quantitative detection or identification limits of tubocurarine in the remains based on results of combinations of HPLC followed by RIA and of some selected ion direct inlet mass spectrometry. The defense corroborated--along with a quantitative estimate--the presence of a substantial concentration of tubocurarine in the liver specimen of one case. However the chain of custody of this particular specimen was compromised for a period of several days between post-exhumation autopsy and submission to the prosecution toxicologists. With respect to all the other specimens examined by the defense, direct inlet mass spectrometry failed to show ions which are critical for establishing the identity of tubocurarine. The defense also presented results of experiments which showed that the tissues of the cases in question destroyed tubocurarine at such a rate that no reasonably conceivable administered amount could have survived the 10 years of burial of these cases. In each of the five cases exhumation and re-autopsy would have been found to be neither justified nor even indicated had an objective examination of the available record been made and supplemented by a similarly objective review of the literature and the simple stability experiments used by the defense. After an 8-month trial, the jury brought in a not guilty verdict on all counts after less than 2 h of deliberations.

Adult↗

PubMed2003

Mummified trophy heads from Peru: diagnostic features and medicolegal significance.

Several forms of mummified human trophy heads were produced by prehistoric and historic native groups in South America. This paper describes the diagnostic features of trophy heads produced by the Nasca culture of ancient Peru. A growing interest in these mummified heads among collectors of Pre-Columbian art and antiquities has led to their illegal exportation from Peru, in violation of national and international antiquities laws. Requests from the Peruvian government to protect its cultural patrimony led the United States in 1997 to declare these heads as items subject to U.S. import restriction, along with six other categories of human remains. Despite such restrictions, Nasca trophy heads continue to reach private collectors outside of Peru and thus may be encountered by local, state, or federal law enforcement officials unfamiliar with their characteristic features and origin. The objective of this paper is to describe the features that allow Nasca trophy heads to be identified and distinguished from other archaeological and forensic specimens that may be submitted to a forensic anthropologist for identification.

Forensic Anthropology↗

PubMed1996

High autopsy rates at a university medical center. What has gone right?

OBJECTIVE: Identification of factors that contribute to a high autopsy rate at our institution. DESIGN: An objective analysis of the Autopsy Service's organization, functions, and process flow to identify factors that impact the autopsy rate. SETTING: The University of Texas Medical Branch at Galveston, Tex. METHODS: Statistics were collected using the autopsy log book and computerized data bank. The events starting at the time of a patient's death through the completion of the autopsy report were reviewed. The role of each significant event was analyzed. RESULTS AND CONCLUSIONS: The annual autopsy rates between 1981 and 1995 ranged between 45% and 59%. The largest number of nonmedicolegal autopsies were received from the Department of Internal Medicine. The Texas Department of Criminal Justice Hospital contributed the largest number of medicolegal autopsies. We conclude that the following key factors contribute to our high autopsy rates: (1) the organization and multiple functions of the Autopsy Service, particularly the presence of a Decedent Affairs Office, dedicated resident assignments, and internal and external quality control of the autopsies; (2) close interactions with clinicians, including timely communication of autopsy results to clinicians and a fostering of positive attitude among clinical residents and faculty; and (3) other factors such as the contributions to hospital risk management, disproving the idea that there may be increased litigation related to high autopsy rates, and support by the hospital administration.

Academic Medical Centers↗

PubMed2003

Adolescent Foley catheter technique for visualizing hymenal injuries in adolescent sexual assault.

OBJECTIVES: To determine the usefulness of the Foley catheter balloon technique for visualizing injuries of the estrogenized hymen in adolescent sexual assault victims compared with supine labial traction. METHODS: A prospective clinical trial of 20 adolescent (age 13-16 years old) victims of sexual assault evaluated at a free-standing Nurse Examiner Clinic was conducted over a four-month study period. The clinic, affiliated with an emergency medicine residency program, is staffed by registered nurses who have been specially trained to perform medicolegal examinations using colposcopy with digital imaging. The Foley catheter technique uses an inflated balloon in the distal vaginal vault to expand the estrogenized hymen to its full capacity so that the edge may be readily visualized for signs of trauma. The Foley technique was compared with gross inspection, using supine labial traction, to photodocument hymenal abnormalities. Photographs of the hymen were obtained using the labial traction technique and then with the Foley technique. Three emergency physicians independently examined each pair of photographs with high interrater agreement for the presence of injury (kappa = 0.88). RESULTS: Twenty adolescent sexual assault victims volunteered for the study; mean age was 14.8 years. Gross inspection of the hymen using supine labial traction identified hymenal injuries in three patients (15%). Use of the Foley catheter balloon technique allowed identification of hymenal abnormalities in nine additional cases (60%). The common injuries to the hymen included lacerations (30%), followed by ecchymosis and abrasions. One patient (5%) voiced discomfort (mild pressure sensation) during inflation of the balloon. CONCLUSIONS: The Foley catheter balloon technique is a simple method allowing improved photodocumentation of hymenal trauma in adolescent sexual assault victims compared with supine labial traction.

Adolescent↗

PubMed2003

A microdissection and molecular genotyping assay to confirm the identity of tissue floaters in paraffin-embedded tissue blocks.

CONTEXT: A recurring problem in surgical pathology practice is specimen mix-up and floater contamination. While many cases can be resolved histologically, a significant number remain unclear and may have serious clinical and medicolegal implications. OBJECTIVES: To design a microdissection and genotyping assay to identify contaminating floater tissues in paraffin-embedded tissues that is optimized for small samples, and to use the assay to resolve a series of clinical cases with floater tissues. MATERIALS AND METHODS: Twenty-one cases of possible tissue floater contamination in paraffin-embedded tissue blocks were included. Using 4 unstained, 4-microm-thick histologic sections, multiple sites were microdissected under direct visualization either by hand or by laser capture microdissection. Nonneoplastic and neoplastic tissues were sampled. Polymerase chain reaction was performed for a panel of 10 polymorphic microsatellite markers at 1p34, 3p26, 5q21, 9p21, 10q23, and 17p13. Allele size and content were analyzed semiquantitatively by fluorescent capillary electrophoresis, and the genotypes for the tissues in the paraffin-embedded tissue blocks were compared for identity. RESULTS: Tissue identification was successful in all cases, despite small tissue sample size and fixation effects. Comparative analysis of neoplastic tissue floaters and the presumptive source tumor was performed when possible to control for possible allelic loss or microsatellite instability. CONCLUSIONS: Microdissection and genotyping are effective and reliable means to objectively resolve problems of possible floater contamination. Even minute tissue samples provide sufficient DNA template for polymerase chain reaction microsatellite analysis. Because of the potential clinical implications of floaters, we recommend that all suspected floaters that would change a diagnosis from benign to malignant be subjected to genotyping assay to confirm the identity of the floater tissue.

Biopsy↗

PubMed1998

[Compliance with regulations for medical records in 15 Aquitaine public health facilities. Aquitaine DIM Physician's Group].

OBJECTIVE: Record keeping contributes to the quality of health care in addition to fulfilling medicolegal and accreditation regulations. We conducted an audit of patient files in 15 public hospitals in Aquitaine to determine their compliance with national laws. METHODS: One hundred patient files were randomly selected in each hospital. Their compliance with 18 criteria established in 1992 by the ANDEM was studied. These 18 criteria were updated in accordance with the latest decrees from the health ministry and precisely defined in order to achieve good reproducibility of the measurements. RESULTS: Ten percent of the files fulfilled all 18 criteria. Each component of the record was correctly identified and the name of the general practitioner, admission documents, and delivery, anesthesia and transfusion records were almost always present. Surgery reports were found in 65 to 89% of the files. Low compliance with three criteria was observed: authorization to give health care to a minor (39 to 80% of the files), identification of the physician who prescribed the drugs during hospitalization (6 to 32%) and discharge prescription (42 to 95%). We also pinpointed problems concerning archiving and retrieval, especially concerning the results of complementary exams which were not necessarily stored with the patient files. CONCLUSION: This audit allowed us to define the first steps of a quality improvement project for patient records. We were able to deduct recommendations for analyzing compliance with legal requirements and suggest that the 1992 ANDEM criteria be updated to allow for valid comparisons between health care establishment.

Accreditation↗

PubMed1998

Comparability of gestational age values derived from diaphyseal length and foot length from known forensic foetal remains.

A partially macerated human male foetus was submitted to the Human Identification Laboratory at The University of Arizona for the purpose of gestational age determination. This paper compares radiographic diaphyseal length of most long bones to foot length as measured from the forensic case submitted for analysis. The methods included radiography of complete antebrachial and crural segments and foot length measurements. As calculated from ulnar, radial, tibial and fibular diaphyseal length, gestational age was estimated to be between 25 and 28 lunar weeks (between 22 and 25 gestational weeks), while age determined from foot length was between late 23 and early 26 gestational weeks. These results highlight a general correspondence in age estimation between these two techniques. Case history obtained after this analysis confirmed an age of 23 weeks and 6 days based on ultrasonographic criteria. The correspondence between these techniques is significant, since either technique yields approximately the same gestational age. Accuracy of gestational age determination is essential to assess foetal viability. While national laws vary regarding foetal remains, courses of appropriate medicolegal action are contingent upon the determination of foetal viability.

Abortion, Legal↗

PubMed2005

A review of surgical simulation with attention to validation methodology.

The use of simulation technology for teaching and evaluating surgical skills has gained considerable attention in recent years. This is driven by interest in quality of care, concerns over increasing operative complexity, constraints on the use of animal models, limited available patient material, medicolegal pressures, and fiscal mandates for cost-effective performance. Traditional mechanical models are yielding to techniques dependent on electronic technology, including virtual reality. Data to support the validity of simulation techniques for surgical training, assessment, and certification represent only a fraction of the literature available on the subject. Literature searches were conducted in MEDLINE and ERIC, covering the period from 1966 to the present. The electronic and bioengineering literature was not surveyed due to the extensive literature on technology development, distinct from assessment of context specific validity. The search results and the bibliographies of key review articles were examined to identify articles that contained original data, measured performance between cohorts, defined performance measures, and described a standard against which performance was compared. Most of the literature pertaining to simulation techniques for surgical training has been published within the past 5 years and consist of review, opinion, and feasibility articles. There is an emerging body of evidence to establish the validity of simulation techniques for assessing surgical skills. Further refinement of simulation techniques, identification of specific performance measures, longitudinal evaluations, and comparison to practice outcomes are still needed to establish the validity and the value of surgical simulation for teaching and assessing surgical skills prior to considering implementation for certification purposes.

Animals↗

PubMed1996

Picture archiving and communication system training for physicians: lessons learned at the Baltimore VA Medical Center.

Physicians practicing at the "filmless" Baltimore VA Medical Center need to be proficient in the use of the picture archiving and communication system (PACS) to be able to view radiologic images and accompanying reports. PACS training is necessary to assure optimal patient care and to satisfy potential medicolegal requirements. Providing such training is the responsibility of both the Imaging Department and the hospital. Training in the use of the PACS at the Baltimore VA is conducted by an on-site application specialist. Data were collected from interviews with the trainer, training log sheets, and physician surveys. Although 100% of radiologists received formal training, only 22% of nonradiologists were formally trained; 32% of these physicians identified themsleves as having been trained by their peers and 41% stated they were self-trained. We identified two goals of a PACS training program. The first is to teach physicians how to retrieve images and reports from current as well as prior studies and display them on a computer workstation. Secondly, the training should include instruction on the use of the various workstation tools to enhance image interpretation. Imaging requirements and usage by different physician groups vary, and PACS training should be tailored accordingly. Difficulties in the scheduling of training sessions during working hours and the widespread use of a "generic" log-on identification have contributed to the low (22%) compliance of nonradiologists with the formal training program. Although we believe that one-on-one training is most effective and can be best tailored to the needs and computer expertise of an individual particular physician, computer based training (both on and off-line) may provide an acceptable, and in some cases, a preferred alternative.

Baltimore↗

PubMed1993

[Autologous blood donation and isovolemic hemodilution--indications and practical implementation].

OBJECTIVE: The state of the art of autologous blood transfusion is described with special emphasis on safety aspects, indications and medicolegal implications. DATA SOURCES AND SELECTION CRITERIA: Literature was retrieved using the MEDLINE literature database. Medical and legal expert opinions on autologous blood transfusion programmes are presented as well as the actual German jurisdiction. Guidelines for autologous predeposit and haemodilution used in the University of Münster are described. RESULTS: In the past decade all forms of autologous transfusions gained increasing influence in haemotherapy due to the ongoing discussion on the safety of blood products. The German Federal Court has demanded that whenever homologous perioperative transfusion is considered likely, patients have to be offered autologous predeposit. Legal conditions for autologous programmes directed by anaesthetists not specialised in transfusion medicine are described. Whole-blood predeposit should be limited to two autologous units. In cases with minor blood loss, isovolaemic haemodilution may be performed instead of autologous predeposit. However, autologous transfusions have their specific risks that are either related to the patient or to the procedure of autologous predeposit, e.g., clerical error, contamination of blood products and technical faults. Standard procedures of the University of Münster to ensure low-risk autologous transfusion are presented. They consist in adequate handling and proper identification, testing of donor for virus infection markers, bacterial culture from blood products and a list of contraindications: anaemia, unstable angina, myocardial infarction within 3 months, decompensated heart insufficiency, aortic valve stenosis with angina, and cases with infection and fever. CONCLUSION: The risks related with autologous transfusion should be lower compared to homologous transfusions. Well-defined standards concerning indications and techniques are required to reach this goal.

Blood Donors↗

PubMed1992

[Identification of optical isomers of methamphetamine and its application to forensic medicine].

In order to identify optical isomers (d and l-) of methamphetamine (MAMP), GC-MS analysis using optically resolvable reagent of N-trifluoroacetyl-L-prolyl chloride (L-TPC) and HPLC analysis using chiral cellulose-based columns were compared. In analysis of d- or l-MAMP (M) of TPC (T) derivatives by the GC-MS, contrary to the expectation that only d(M)-L(T) or l(M)-L(T) could be detected chemically, two diastereomers of d(M)-L(T) and d(M)-D(T) for d-MAMP and two of l(M)-L(T) and l(M)-D(T) for l-MAMP were demonstrated respectively. This results was attributed to a small percentage of D-TPC present in L-TPC. For racemic (dl)-MAMP, none of these four isomers could be individually isolated, and they were detected as two overlapping peaks. In the HPLC analysis using chiral columns, d- and l-isomers of MAMP and amphetamine (AMP) could be clearly isolated with merely one analytical procedure, and the l/d ratio was possible to calculate with facility. From the rats urine administered d- or l-MAMP, only the corresponded optically active form of the administered drug was detected, and when racemic (dl)-MAMP was administered, d-MAMP, l-MAMP and their metabolites AMP were distinctly detected. The l/d ratio calculated from amount of MAMP and AMP excreted in rat urine within 24 hr was not in accordance with that of the administered dl-MAMP (l/d = 1.01): the l/d ratio was 0.45 for MAMP and 0.58 for AMP, and 0.50 for the total of MAMP and AMP. The similar results were observed in case of racemic (dl)-AMP. From several human specimens obtained from the cadavers dead by MAMP poisoning, only d-MAMP and the metabolite d-AMP were detected, and neither l-MAMP or l-AMP were demonstrated. In particular, a high concentration of d-MAMP was detected in gastric contents, brain, lung and liver. From the MAMP powder in possession, only d-MAMP was detected. These results suggest that this chiral column-HPLC procedure could be applied to medicolegal practice and forensic scientific investigation.

Animals↗