Integrated Assessment of GFAP and UCH-L1 for their utility in severity assessment and outcome prediction in Traumatic Brain Injury.

OBJECTIVES: This study aimed to explore the potential of glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase-L1 (UCH-L1) as biomarkers for diagnosis and prognosis in mild and severe TBI cases, including TBI-related deaths. METHODS: This prospective cohort study includes 40 cases each of mild, severe, fatal TBI cases, and 40 healthy controls. Serum samples were collected from live patients at 8 and 20 h post injury for UCH-L1 and GFAP respectively, and from deceased patients within 6 h of death. RESULTS: Elevated levels of both GFAP and UCH-L1 were observed in patients with severe and fatal TBI cases. These biomarkers exhibited promising potential for predicting various Glasgow Outcome Scale Extended (GOSE) categories. Combining GFAP and UCH-L1 yielded higher predictive accuracy both for diagnosis and prognosis in TBI cases. The study additionally established specific cut-off levels for GFAP and UCH-L1 stratified according to the severity and prognosis. CONCLUSION: GFAP and UCH-L1 individually demonstrated moderate to good discrimination capacity in predicting TBI severity and functional outcomes. However, combining these biomarkers is recommended for improved diagnostic and prognostic utility. This precision tool can enhance patient care, enabling tailored treatment plans, ultimately reducing morbidity and mortality rates in TBI cases.

Growth Differentiation Factor-15 as a Candidate Biomarker in Gynecologic Malignancies: A Meta-analysis.

Growth differentiation factor-15 (GDF-15), though emerged as a novel marker in gynecological cancers, is yet to be recognized in clinical diagnostics. Eligible studies were sorted from multiple online databases, namely PubMed, Cochrane, ClinicalTrials.gov, Google Scholar, Web of Science, Embase, Scopus, LILACS, and Opengrey. From six studies, histopathologically diagnosed cases without prior treatment, and with diagnostic accuracy data for GDF-15 in gynecological cancers, were included. Our meta-analysis shows that GDF-15 has pooled diagnostic odds ratio of 12.74 at 80.5% sensitivity and 74.1% specificity, and an area under the curve of 0.84. Hence, GDF-15 is a potential marker to differentiate gynecological malignancy from non-malignant tumors.

Estimation of Sex From Dental Arch Dimensions: An Odontometric Analysis.

ABSTRACT: Sex estimation is one of the "big three" of human identification and is a vital aspect of the process of generating biological profile of unknown deceased. Anthropometric and odontometric methods that utilize measurement of distances between certain landmarks are commonly employed to differentiate between the 2 sexes. Teeth are the most robust and well-preserved parts of the human body, and studies have shown that the sex of an unknown individual can be estimated using their measurements. The present study was carried out to analyze the sex differences based on the dental arch dimensions of both the jaws in an Indian population. A proper understanding of dental arch dimensions not only help forensic odontologists in human identification, but also help dental practitioners in teeth restoration, and to quantify selection of anterior teeth in bonding of dentures. The dental arch dimensions of the canines, premolars, and the molars of both the jaws were recorded in dental casts of 307 participants. Comparison of the dental arch dimensions of males and females was done and logistic regression models were generated to estimate sex. Receiver Operating Characteristic analysis was done to find out the potential to estimate sex for all the dental arch dimensions in both the sexes. It was observed that maxillary intermolar II distance gave the best results in estimating the sex. The sexing accuracy is seen to increase as we go distally from canines to molars in each jaw; minimum for intercanine distance and maximum for distance between the 2nd molars. The sexing accuracy from dental arch dimensions was found to be between 72.7% and 86.5%. The models derived for estimation of sex from dental arch dimensions can be used in cases of skeletal remains.

Telemedicine and virtual consultation: The Indian perspective.

Telemedicine was considered futuristic and experimental some years ago, but it is a reality today. It is now emerging as an important tool for convenient as well as specialized healthcare, particularly for patients in remote locations with limited access to standardized healthcare services. However, there are multiple challenges to realizing its full potential. We focus on some key medicolegal and ethical issues such as doctor-patient relationship, informed consent, rights of the patient, malpractice, and principles of confidentiality relevant to the practice of telemedicine and virtual consultation. We explore the global as well as the Indian legal perspective pertaining to the application of telemedicine. The absence of specific laws for registration and practice of telemedicine and virtual consul-tation in India acts as a deterrent for medical practitioners to engage in its potential use. Hence, there is a need for specific legislation.

Euthanasia: Global Scenario and Its Status in India.

The legal and moral validity of euthanasia has been questioned in different situations. In India, the status of euthanasia is no different. It was the Aruna Ramachandra Shanbaug case that got significant public attention and led the Supreme Court of India to initiate detailed deliberations on the long ignored issue of euthanasia. Realising the importance of this issue and considering the ongoing and pending litigation before the different courts in this regard, the Ministry of Health and Family Welfare, Government of India issued a public notice on May 2016 that invited opinions from the citizens and the concerned stakeholders on the proposed draft bill entitled The Medical Treatment of Terminally Ill Patients (Protection of Patients and Medical Practitioners) Bill. Globally, only a few countries have legislation with discreet and unambiguous guidelines on euthanasia. The ongoing developments have raised a hope of India getting a discreet law on euthanasia in the future.

Frothing in a Case of Electrocution: A Rare Case and Review of Literature.

Electrocution is a leading cause of unnatural deaths, especially in industrial and developing regions like India. In a recent case, an individual was brought in for autopsy following an apparent accidental electrocution. Strikingly, the postmortem examination revealed no typical entry or exit wounds associated with electric shocks. The body exhibited rigor mortis and a unique sign: reddish froth draining from the nasal cavities. Internal examination unveiled distinctive findings. Multiple tiny hemorrhages were observed over the heart's left ventricle, while the heart's blood vessels and valves remained unobstructed. In contrast, the lungs showed a frothy, whitish-red appearance extending into the bronchioles. This case presents an unprecedented observation: the presence of froth in the respiratory tract during electrocution. This case underscores the need for thorough autopsies. Even when specific indicators are absent, it highlights the importance of considering electrocution when froth is found in the respiratory tract. Such cases remind forensic pathologists of the diverse and occasionally unexpected manifestations they may encounter, encouraging the exploration of new phenomena within forensic medicine.

A critical appraisal of the role of metabolomics in breast cancer research and diagnostics.

Breast cancer (BC) remains the most prevalent cancer among women worldwide, despite significant advancements in its prevention and treatment. The escalating incidence of BC globally necessitates continued research into novel diagnostic and therapeutic strategies. Metabolomics, a burgeoning field, offers a comprehensive analysis of all metabolites within a cell, tissue, system, or organism, providing crucial insights into the dynamic changes occurring during cancer development and progression. This review focuses on the metabolic alterations associated with BC, highlighting the potential of metabolomics in identifying biomarkers for early detection, diagnosis, treatment and prognosis. Metabolomics studies have revealed distinct metabolic signatures in BC, including alterations in lipid metabolism, amino acid metabolism, and energy metabolism. These metabolic changes not only support the rapid proliferation of cancer cells but also influence the tumour microenvironment and therapeutic response. Furthermore, metabolomics holds great promise in personalized medicine, facilitating the development of tailored treatment strategies based on an individual's metabolic profile. By providing a holistic view of the metabolic changes in BC, metabolomics has the potential to revolutionize our understanding of the disease and improve patient outcomes.

3D CT based age estimation from the pubic symphyseal surface in an Indian population using the Chen et al. method.

The pubic symphyseal surface is one of the reliable parameters used to estimate age, as it consistently shows degenerative observational variations throughout the lifespan, particularly from the 3rd decade onwards. These changes have been extensively studied to generate population-specific models for forensic age estimation. In the past, there have been many studies used to estimate age at death from the pubis symphysis using skeletal remains. However, due to dearth of contemporary skeletal repositories, and the resource intensive maceration process required for obtaining examination quality bones, studies on cadaver are difficult to conduct. Moreover, due to recent advancements in the science of medical imaging, newer radiological modalities like computed tomography (CT) can be used to visualize previously inaccessible areas such as the pubic symphysis in cadavers and the living alike, and subsequent age estimation is feasible. Recently, Chen et al. (2008, 2011) conducted a study on the cadaveric Chinese Han population in both males and females separately by using nine morphological changes and scoring them according to the changes that occurred. The present study aimed to estimate an individual's age using CT images of the pubic symphysis, by applying the scoring method for its morphological changes given by Chen et al. The present study was conducted on 263 randomly selected participants (Males = 154, Females = 109), who came for diagnostic purposes to the hospital. The CT images of these individuals were collected after obtaining ethical approval and proper consent from the study participants. Each of the morphological indicators was assessed, and appropriate scores were given according to criteria given by Chen et al. In the present study, both linear and multiple regression models to estimate age using the pubic symphyseal morphological changes were developed. From the results of the present study, it was concluded that the Chen et al. scoring method can be used to accurately estimate age from 3DCT images of the living, and the models derived in the present study could be applicable to individuals from the Indian subcontinent.

A novel approach towards identification: A case report and review of literature.

A primary objective of a medico-legal autopsy is to determine the identity of the deceased. The act of praying for prolonged periods of time can lead to the development of skin marks in Muslims, commonly referred to as "Naamaj signs" or prayer marks. An elderly male of unknown identity was brought dead to the hospital, where a post-mortem examination was performed. The patient's name in the treatment records suggested that the deceased was a member of the non-Muslim community, conflicting with the post-mortem examination report indicating circumcision and belonging to the Muslim Community. The disposal authority questioned whether cremation or burial was more suitable for the deceased. When it comes to cases involving religious identification, basing a decision on a single feature alone is not enough to permit the disposal of a deceased body. It is crucial to take into account other characteristics before determining the appropriate disposal method.

The Investigation of an Accident Site With an Atypical Electrocution Exit Wound and Burn in an Unusual Location: A Rare Case Report and Review of Literature.

Cases involving electrocution burns are tough to investigate for the clinical forensic practitioner. Burns from high-voltage electrocution might seem like burns from other sources, especially if the victim is in an unconscious state. In this situation, circumstantial evidence in addition to clinical symptoms may be used to exclude other burns. Furthermore, the investigation of accident site results to aid in explaining the pattern of injuries discovered during a clinical evaluation. In this case study, we reported a case of a 33-year-old male who came in contact with a high-voltage transmission wire and was burned over both hands and lower back region. The exit wound was atypical in appearance, with a scorched area of peeling blistering skin, charring, and severe scorching over the lower back region which were correlated with the accident site, and the circumstances that led to electrocution injury.

Therapeutic artifact: Case series.

Artifacts are pervasive in every realm of biological science, and this includes the field of medicine. Unless explicitly recognized by scientific experts, artifacts can be found and may influence research and findings in the medical domain, just as they do in other branches of biological science. Therapeutic artifacts are changes that occur in the body as a result of medical interventions. These artifacts can sometimes pose challenges in forensic investigations, as they may be misinterpreted or mistaken for signs of trauma or foul play. This case series presents three cases illustrating different types of treatment artifacts encountered in forensic medicine. These three cases highlight the importance of considering medical interventions and therapies when interpreting autopsy findings. It is crucial for forensic experts to have a comprehensive understanding of therapeutic artifacts to accurately differentiate them from genuine injuries or pathologies. By recognizing and properly interpreting these artifacts, forensic investigations can be conducted with increased accuracy and ensure that justice is served.

Prevention of the spread of infection during highly infectious autopsy using a craniotomy box.

In cranial autopsies, the post-mortem examination requires the use of a saw for the removal of the skull cap. In these procedures, sawing of bone becomes a critical source of infectious aerosols which spread instantaneously in the immediate environment, generating liquid aerosols including droplets of cerebrospinal fluid and blood, and leading to exposure of all autopsy personnel. In high-risk cases like prion disease, tuberculosis, severe acute respiratory syndrome (SARS), COVID-19, etc. where the skull would require sawing, the prime concern is the saw operator's exposure to these pathogens. Therefore, the author suggests the use of an ingenious ergonomic semi-circular craniotomy box during skull cap and brain removal in the autopsy procedure to successfully prevent the contamination of the entire autopsy hall. A transparent acrylic plastic box has been customized, which is semi-circular in shape having three walls, one semi-circular dome without a floor, a front wall with adjustable zipper closure, and a hind wall with circular holes with sleeves made of 5-layer fabrics. The dome contains one outlet for a vacuum suction pipe on the side, two holes on each side of the dome with non-woven fabric arms for the saw operator, and assistants' arms for performing skull opening procedures. The use of this box allowed the author to prevent and limit the spread of the generation of infectious aerosols in the autopsy hall as the bone dust collected in the vacuum ensures the safety of autopsy surgeons.

The impact of RNA stability and degradation in different tissues to the determination of post-mortem interval: A systematic review.

Postmortem interval (PMI) in legal medicine is extremely important for both criminal and civil cases, and several sorts of techniques have been recommended. This systematic review solely focuses on approaches linked to RNA analysis, instead of including all proposed methods for determining the PMI. The term PMI will be used in this review to indicate the time between a person's death and the postmortem examination of the body. We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines when conducting this systematic review. The majority of studies on various tissues at various time intervals at various temperatures are non-human, and just a small number are on humans. The results are then provided using various statistical approaches. To calculate the PMI, post-mortem RNA degradation was examined using several tissues. The result so obtained had an opposite polarity. While some studies show that RNA stability in various tissues remained constant for several days after death, the other group of studies showed evident RNA degradation over time post-mortem, which was significantly influenced by temperature and other agonal factors. These factors have an impact on the multi-parametric mathematical model of ante and post-mortem factors on RNA degradation, as well as its applicability and feasibility. The estimation of PMI using RNA degradation can prove to be highly objective and efficient after controlling for the various factors and challenges that pose the estimation of RNA in forensic samples difficult.

Expression of human cardiac-specific genes: a novel method for post-mortem interval estimation.

In legal medicine, the determination of post-mortem interval (PMI) is not only an important but also one of the most difficult aspects. Several methods are used to estimate PMI such as physicochemical, entomological, biochemical, metabolic, autolytic, and physical methods. These methods provide a wide range of PMI as they are affected by different factors. The approach behind the present study is to calculate an accurate PMI by using mRNA degradation and fold change expression (FCE) of cardiac-specific genes viz. N-terminal pro-B-type natriuretic peptide (NPPB) and cardiac troponin I (TNNI3). Seventeen cadaver heart tissues were analysed within a time frame of up to 12 hours from the time since death, at different time intervals at room temperature. Gene expression was determined and the data were analysed using the value of average delta Ct (ΔCt) value of the assessed gene and housekeeping gene. Delta delta Ct (ΔΔCt) method was used to calculate the FCE at the different 7-time groups. The FCE of TNNI3 was almost stable till 15 hours of PMI and then after 15 hours, expression shows a decrease up to 24 hours after death; whereas, NPPB shows that FCE was stable till 12 hours of PMI and then after 12 hours, expression shows a decrease up to 24 hours after death. The FCE of NPPB and TNNI3 was almost stable till 12 hours. Thus, the estimation of PMI by analysis of the FCE of cardiac-specific genes can be a new promising method in forensic medicine.

Knowledge, Attitude and Practices (KAP) of Medical Professionals on Euthanasia: A Study From a Tertiary Care Centre in India.

INTRODUCTION: Euthanasia or mercy killing has remained as a matter of extensive debate and ethical conflicts in the scientific literature. Discussions on this theme have got legal, religious, political and philosophical ramifications. AIM OF THE STUDY: The present study aimed to assess the knowledge, attitude and practices of medical professionals in a tertiary care hospital. METHODS: After taking prior approval from the institutional ethics committee a structured questionnaire was prepared and distributed among 200 consenting medical professionals in a tertiary care centre in the North-Western region of India. RESULTS: 50% of the respondents said that they were sure of the existing regulation on euthanasia in India. When gender differences were considered a significant difference (p=0.0147) was found between the two sexes regarding the alternate decision maker for deciding euthanasia. It was observed that there was a significant difference(p=0.0055) between those with the age more than 30 years and aged less than 30 years regarding the type of euthanasia that is justifiable. DISCUSSION: In the present study, the percentage of doctors favouring euthanasia is higher than compared in previous studies. The view of euthanasia is highly variable in different studies. Even though passive euthanasia has been legalised recently, there is an apprehension that it might be misused.

Computed Tomographic Evaluation of Cranial Suture Obliteration for Age Estimation in an Indian Population.

BACKGROUND: Age estimation is a critical aspect of human identification. Age is assessed using cranial suture obliteration, pelvic morphological changes, epiphyseal fusion of long bones, dental maturation, and other standard methods. METHODS: The present study investigated three-dimensional (3D) computed tomography (CT) scans of 263 individuals (183 males and 80 females) to assess the extent of ectocranial suture closure. The assessment of obliteration was done using a three-stage scoring method. Spearman's correlation coefficient (p < 0.05) was calculated to assess the relationship between cranial suture closure and chronological age. Simple and multiple linear regression models were developed using the cranial suture obliteration scores to estimate age. RESULTS: The standard errors of the estimate using multiple linear regression models developed for estimating age using obliteration scores of sagittal, coronal, and lambdoid sutures were 15.08 years in males, 13.27 years in females, and 14.74 years in the total study population. CONCLUSION: This study concludes that in the absence of additional skeletal age markers, this method can be used alone or in conjunction with other well-established methods of age assessment.

Serial estimation of gene expression of cardiac troponin I (cTnI) and autophagy gene HMGB1 to determine postmortem interval.

The estimation of accurate post mortem interval (PMI) is a crucial question in forensic medicine. Several approaches have been used to determine the PMI including physical, metabolic, autolytic, entomological, physiochemical and biochemical methods over time. For estimation of PMI, RNA degradation after death is reported to be an important tool. This study aimed to analyse the pattern of gene expression by serial estimation of cardiac specific cardiac troponin I (cTnI) gene and autophagy gene HMGB1 for determining PMI at room temperature by using housekeeping gene GAPDH. Right ventricular heart tissue weighing 10 g was collected and harvested from 17 medico-legal autopsies. The tissue was homogenized in phosphate-buffered saline (PBS) on ice. Further, homogenate of cardiac tissue was analysed by quantitative Real time polymerase chain reaction (qRtPCR) for gene amplification and gene expression of cTnI, HMGB1 gene and GAPDH, at different time intervals (0,6,12 h) at room temperature. The result revealed ∆Ct value of cTnI gene of the cardiac muscle showing almost equal degradation at equal time interval correlated with PMI within 0-12 h at room temperature, and the ∆Ct value of HMGB1 degraded to half in every subsequent 6-hour interval at room temperature. In conclusion, the estimation of PMI by analysis of serial estimation of gene expression is a decent new tool in forensic medicine. The study shows an equal degradation of cTnI gene at equal time interval and HMGB1 degrades to half at six-hour interval. Therefore, these can be useful for estimation for PMI.

Unusual cutaneous presentation in a corrosive acid ingestion.

Corrosive digestive tract injuries are considered to be a source of morbidity and mortality worldwide. The cases of acid ingestion in Forensic Medicine practice are not infrequent. Corrosive ingestion usually presents with injuries over the face, oropharynx, esophagus, and gastrointestinal tract. We report a case of a 65-year-old woman who was brought to the emergency department with a history of ingestion of toilet cleaner at her home. Following this, she developed blackish-brown discoloration over the abdomen. The patient survived for less than one day. An autopsy confirmed the perforation of the stomach and small intestine. 500 ml of blackish fluid was present in the peritoneal cavity which resulted in corrosive peritonitis. The chemical examiner's report showed corrosive mixtures comprising sulfate, nitrate, and chloride ions in the peritoneal contents. This case report highlights atypical cutaneous presentation over the abdomen following corrosive acid ingestion, which has not been reported previously. The possible explanation for this cutaneous manifestation was corrosive effects of the underlying viscera due to its close proximation to the abdominal wall and presence of minimal intra-abdominal fat. A direct physical connection between perforation and cutaneous findings was not identified. The case emphasizes the need for a comprehensive approach in managing such cases, analyzing ingested material, and following standard autopsy protocols in case of death.

Viricidal treatments for prevention of coronavirus infection.

Coronavirus disease 2019 (COVID-19), which causes severe acute respiratory syndrome and lung failure, is caused by the novel coronavirus, also known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Due to high transmission rates from individual to individual, it has progressed to a pandemic. However, indirect transmission from inanimate objects or surfaces that have come in contact with a patient poses an even more significant threat as it is difficult to trace the source of infection in these cases. Therefore, these surfaces and objects require disinfection with chemicals having potent viricidal activity. These include alcohols, aldehydes, quaternary ammonium compounds, chlorhexidine, and chlorine-based disinfectants, among others. They vary in their viricidal activity depending on their structure, concentrations, and mechanism of action. Several studies have looked into these agents and the transmission of the virus related to it. Moreover, certain viricides, if used as constituents of commercially available oral disinfectants, can further aid in preventing ventilator-associated pneumonia and maintain oral hygiene. However, these chemicals are not entirely free of potential hazards. In this review, we have compiled and critically appraised some commonly used viricidal agents in healthcare settings and the role they can play in the prevention of SARS-CoV-2 transmission.