Regional sources of NH3, SO2 and CO in the Third Pole

The Third Pole (TP) is a high mountain region in the world, and is well-known for its pristine environment, but recent development activities in the region have degraded its air quality. Here, we investigate the spatial and temporal changes of the air pollutants ammonia (NH₃), sulphur dioxide (SO₂) and carbon monoxide (CO) in TP, and reveal their sources using satellite measurements and emission inventory. We observe a clear seasonal cycle of NH3 in TP, with high values in summer and low values in winter. The intense agriculture activities in the southern TP are the cause of high NH₃ (6-8 × 1016 molec./cm2) there. Similarly, CO shows a distinct seasonal cycle with high values in spring in the southeast TP due to biomass burning. In addition, the eastern boundary of TP in the Sichuan and Qinghai provinces also show high values of CO (about 1.5 × 1018 mol/cm2), primarily owing to the industrial activities. There is no seasonal cycle found for SO₂ distribution in TP, but relatively high values (8-10 mg/m2) are observed in its eastern boundary. The high-altitude pristine regions of inner TP are also getting polluted because of increased human activities in and around TP, as we estimate positive trends in CO (0.5-1.5 × 1016 mol/cm2/yr) there. In addition, positive trends are also found in NH₃ (0.025 × 1016 molec./cm2/yr) during 2008-2020 in most regions of TP and SO₂ (about 0.25-0.75 mg/m2/yr) in the Sichuan and Qinghai region during 2000-2020. As revealed by the emission inventory, there are high anthropogenic emissions of NH3, SO2 and CO within TP. There are emissions of pollutants from energy sectors, oil and refinery, agriculture waste burning and manure management within TP. These anthropogenic activities accelerate the ongoing development in TP, but severely erode its environment.

A gradual increase of aerosol pollution in the Third Pole during the past four decades: Implication for regional climate change

We analyse the long-term (1980-2020) changes in aerosols over the Third Pole (TP) and assess the changes in radiative forcing (RF) using satellite, ground-based and reanalysis data. The annual mean aerosol optical depth (AOD) varies from 0.06 to 0.24, with the highest values of around 0.2 in the north and southwest TP, which are dominated by dust from Taklimakan and Thar deserts, respectively. However, Organic Carbon (OC), Black Carbon (BC) and sulphate aerosols have significant contributions to the total AOD in the south and east TP. High amounts of dust are observed in spring and summer, but BC in winter. Trajectory analysis reveals that the air mass originated from East and South Asia carries BC and OC, whereas the air from South Asia, Central Asia and Middle East brings dust to TP. Significant positive trends in AOD is found in TP, with high values of about 0.002/yr in the eastern and southern TP. There is a gradual increase in BC and OC concentrations during 1980-2020, but the change from 2000 is phenomenal. The RF at the top of the atmosphere varies from -10 to 2 W/m2 in TP, and high positive RF of about 2 W/m2 is estimated in Pamir, Karakoram and Nyainquentanglha mountains, where the massive glacier mass exists. The RF has increased in much of TP during recent decades (2001-2020) with respect to previous decades (1981-2000), which can be due to the rise in BC and dust during the latter period. Therefore, the positive trend in BC and its associated change in RF can amplify the regional warming, and thus, the melting of glaciers or ice in TP. This is a great concern as it is directly connected to the water security of many South Asian countries.

Modulation of gut microbiota by bioactive compounds for prevention and management of type 2 diabetes

Type 2 diabetes mellitus (T2DM) is a chronic metabolic disorder characterized by hyperglycemia and insulin resistance. Gut microbiota (GM) are specific groups of microbes colonized in the gastrointestinal (GI) tract. They profoundly influence health, disease protection, and associated with metabolic activities, and play a vital role in the production of functional metabolites from dietary substances. Dysbiosis of GM has been linked to the onset of T2DM and can be altered to attain eubiosis by intervention with various nutritional bioactive compounds such as polyphenols, prebiotics, and probiotics. This review presents an overview of the evidence and underlying mechanisms by which bioactive compounds modulate the GM for the prevention and management of T2DM.

Novel pathways in bacteriocin synthesis by lactic acid bacteria with special reference to ethnic fermented foods

Ethnic fermented foods are known for their unique aroma, flavour, taste, texture and other sensory properties preferred by every ethnic community in this world culturally as parts of their eatables. Some beneficial microorganisms associated with fermented foods have several functional properties and health-promoting benefits. Bacteriocins are the secondary metabolites produced by the microorganisms mostly lactic acid bacteria present in the fermented foods which can act as lantibiotics against the pathogen bacteria. Several studies have been conducted regarding the isolation and characterization of potent strains as well as their association with different types of bacteriocins. Collective information regarding the gene organizations responsible for the potent effect of bacteriocins as lantibiotics, mode of action on pathogen bacterial cells is not yet available. This review focuses on the gene organizations, pathways include for bacteriocin and their mode of action for various classes of bacteriocins produced by lactic acid bacteria in some ethnic fermented foods.

Distribution and Diversity of Nisin Producing LAB in Fermented Food

An attempt was made, to characterize natural antibiotics or lantibiotics from unconventional sources and its antibacterial spectrum against food borne pathogens and drug resistant bacteria. Six different traditional fermented foods i.e., fermented fish, fermented soybeans, Soibum (fermented bamboo shoots), milk, idly and dosa batter were used for the isolation of bacteriocin producing Lactic acid bacteria (LAB). Among all bacterial cultures isolated from the various sources, 129 cultures have found to produce antimicrobial compounds. Nisin specific reporter bacteria was utilized as biosensor to identify the Nisin like bacteriocin, where 10 cultures found to be positive Nisin producer. Identified Nisin like bacteriocin was partially concentrated by using ammonium sulphate followed by butanol extraction. Minimum inhibitory concentration (MIC) was analyzed against food borne pathogen and drug resistant bacteria. MIC of partially purified Nisin (pp-Nisin) of all the LAB isolates against food-borne pathogens are ranged between 0.5 and 92 µg/ml respected to various Gram-positive bacteria. Similarly, the drug resistant bacteria were also inhibited by pp-Nisin (MIC ranged between 15 and 175 µg/ml). All samples of ppnisin exhibited auto induction ability. Taxonomic identification of the nisin producers was done by whole genome sequencing which reveals that cultures belongs to Lactococcus lactis ssp. lactis. Also it was found that Lactococcus lactis ssp. lactis C2d and Lactococcus lactis ssp. lactis SP2C4 harbor nisA gene and Lactococcus lactis ssp. lactis FS2 (L. lactis FS2) harbor nisQ gene. The finding of this study highlights the first case of L. lactis FS2 isolated from fermented fish harbor nisQ gene. Antibacterial activity of pp-Nisin against drug resistant LAB is also reported.

Influence of Pre-Drying Treatments on Physico-Chemical and Phytochemical Potential of Dried mahua Flowers

Mahua (Madhuca longifolia) flowers are boon for the local tribes of India and have been successfully utilized traditionally for the value addition, and are very prone for microbial spoilage. Local folks utilized malpractices of drying which deteriorates the quality attributes of the mahua flowers and ultimately fails to fetch a good price in the market. Present investigation was led to consider the impact of different pre-treatments i.e., blanching time; and dip of potassium meta-bisulfite (KMS) and citric acid (CA) on the physico-chemical and phytochemical potential of dried mahua flowers using response surface methodology (RSM). Maximum physico-chemical and phytochemicals attributes were observed under optimum conditions i.e., a blanching of 4.1 min followed by dipping in solution having 1285 ppm KMS and 0.77% citric acid. Qualitative analysis through Fourier transform infrared spectroscopy (FTIR) supported the findings. Sugar and phytochemical profiling by high performance liquid chromatography (HPLC) proved the significant effect of each variable. No specific cluster formation was observed during cluster analysis of whole data indicating the significant and equal effect of all variable on the quality of dried mahua flowers. The optimized conditions will definitely help the local processors as well as the industrialist to maintain the quality attributes of the dried mahua.

Multi-drug Resistant and Extended Spectrum β-lactamase Producing Salmonella Species Isolated from Fresh Chicken Liver Samples

Background Emergence of antibiotic resistance among microbes contaminating the fresh meat products is a global public health concern as they can be easily transmitted to humans through their consumption and contact. Objective The current study was conducted to determine the distribution of antimicrobial resistance among Salmonella species isolated from fresh chicken liver samples with special emphasis on extended spectrum beta-lactamase (ESBL) production. Method A total of 200 fresh chicken liver samples were cultivated for the isolation of Salmonella and further subcultivated to detect extended spectrum beta-lactamase production among them. Antimicrobial susceptibility testing (AST) was done by disk diffusion method using a panel of 7 antimicrobials. Result Out of 200 samples analyzed, 61 (30.5%) samples harbored Salmonella species out of which 15 (7.5%) samples showed the presence of Salmonella Typhi. A significant association was noted in the incidence of Salmonella with various factors pertaining to the butchers, such as age, sex, literacy rate, practices of washing knives and chopping board, wearing aprons and gloves and type of water used (p < 0.05). Salmonella isolates were highly sensitive to amikacin (82.0%) and least sensitive to tetracycline (3.3%). All the isolates were resistant to colistin. Sixty (98.4%) isolates were identified as multi-drug resistant (MDR). The total number of extended spectrum betalactamase producers reported among Salmonella isolates was 29 (47.5%). Conclusion The results indicate that the fresh chicken liver samples sold in Bharatpur Metropolis are reservoirs of multi-drug resistant Salmonella, including extended spectrum betalactamase producers, that could potentially be transmitted to the humans by direct contact or through inadequate cooking.

Microbial maceration: a sustainable approach for phytochemical extraction

A rapid change in the lifestyle has witnessed poor health with the increased incidences of numerous diseases in the recent years, and ultimately increasing the demand of nutritious foods containing phytochemicals. A wide range of phytochemicals (secondary metabolites) is being synthesized in plants, which influence the human health upon consumption as dietary component. Recently, a number of the technologies (conventional and non-conventional methods) have been standardized by the different researchers for the extraction of these phytochemicals depending upon the raw material. However, selection of extraction method for commercial use depends upon various factors such as extraction efficiency, time required, and cost of operation. Considering these factors, microbial maceration is one of the viable approaches which is easy to handle, cost-effective, energy efficient, less hazardous and having high extraction rate. Recently, researchers have utilized this technique for the maceration of different plant-based substrates (such as legumes, cereals, pulses, fruits and vegetables) and their respective wastes for the efficient extraction of numerous phytochemicals with increased efficiency. However, scale up studies and analysis of toxic compounds produced by microbes are still a lacking field and need to be explored further by the researchers and industrialists to bring it into reality. Therefore, the present review aims to document the recent findings related to microbial maceration in a crisp way to provide the complete information to the readers.

Phacoemulsification surgery by a nationally-trained cataract surgeon of Nepal

INTRODUCTION

A one month phacoemulsification training course had been implemented by the Nepal Netra Jyoti Sangh (NNJS) in collaboration with Association for Ophthalmic Cooperation to Asia, Japan (AOCA).

OBJECTIVE

To evaluate the visual outcomes of phacoemulsification surgery by a nationally trained surgeon in Nepal.

MATERIALS AND METHODS

A retrospective study of patients that underwent phacoemulsification with foldable intraocular lens implantation during a period of 18 months was carried out. Cases that had a six-week follow-up period were included. Effective phaco time (EPT), intra-operative and postoperative complications were noted. Uncorrected visual acuity (UCVA) at day 1 and best corrected visual acuity (BCVA) at week 6 were noted. The data were analyzed using SPSS 11.5.

RESULTS

A total of172 patients that had completed a 6 week follow-up evaluation were included in the study. The mean age of patients was 57.12±10.19 years. The mean effective phaco time (EPT) was 9.74±7.41 seconds. Posterior capsule rupture (PCR) with vitreous loss occurred in 2 eyes (1.2%), Descemet's membrane detachment in 1 eye (0.6%), capsulorhexis extension in 1 eye (0.6%) and wound site thermal injury (WSTI) occurred in 3 eyes (1.7%). Postoperative complications were mild to moderate striate keratopathy (9/ 172), corneal edema (1/172), corneal epithelial defect (1/172) and uveitis (1/172). At 6 weeks post-operatively, 165 eyes (95.9%) had a BCVA better than 6/18 and 7 eyes (4.1%) had a BCVA of 6/18 to 6/60.

CONCLUSION

Patients undergoing phacoemulsification had a good visual outcome as a result of the procedure performed by cataract surgeon trained from AOCA/NNJS national phacoemulsification training program of Nepal.

Role of reactive oxygen species in transforming growth factor-beta1-induced extracellular matrix accumulation in renal tubular epithelial cells

Tubulointerstitial fibrosis, which is characterized by the progressive accumulation of extracellular matrix (ECM), is the main feature of chronic renal allograft dysfunction. Transforming growth factor-β1 (TGF-β1) is the key inducer of tubulointerstitial fibrosis. Plasminogen activator inhibitor-1 (PAI-1), a major inhibitor of ECM degradation, is increasingly recognized to play an important role in renal fibrosis. ECM accumulation is the net result of ECM synthesis and degradation. We previously reported that reactive oxygen species (ROS) and subsequent activation of mitogen-activated protein kinase (MAPK) are required for the TGF-β1-induced epithelial-to-mesenchymal transition in renal proximal tubular epithelial cells. In the present study, we examined the role of the ROS-MAPK pathways in TGF-β1-induced fibronectin and PAI-1 up-regulation in renal tubular epithelial cells. Growth arrested, synchronized normal rat kidney epithelial (NRK-52E) cells were stimulated with TGF-β1 (0.2-20 ng/mL) or H(2)O(2) (1-500 μmol/L) in the presence or absence of inhibitors of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase (diphenyleneiodonium [DPI] and apocynin [Apo]) and MAPK (PD98059, an MEK inhibitor, or a p38 MAPK inhibitor) for up to 48 hours. Both TGF-β1 and H(2)O(2) increased fibronectin and PAI-1 secretion in dose-dependent manners. Chemical inhibition of NADPH oxidase, extracellular signal-regulated kinase (ERK), or p38 MAPK all inhibited TGF-β1-induced and H(2)O(2)-induced fibronectin and PAI-1 up-regulation. These results suggested that NADPH oxidase-mediated ROS and subsequent ERK and p38 MAPK activation play important roles in ECM accumulation in the renal tubulointerstitium.

A profile of eye-lid conditions requiring reconstruction among the patients attending an oculoplasty clinic in mid-western region of Nepal

INTRODUCTION

Some eyelid defects require reconstruction.

OBJECTIVE

To study the eyelid conditions requiring reconstruction among the patients attending an oculoplasty clinic of a tertiary level eye institute.

MATERIALS AND METHODS

All the cases of eyelid reconstruction surgery of two years were retrospectively included in this study. The parameters studied were causes of eyelid defects, age and gender of the patients and the reconstructive surgical procedures.

RESULTS

Of 43 cases that required eyelid reconstructive surgery 17 (39.53 %) had ocular tumors and 16 (37.2%) had trauma. The mean age of presentation was 42 years ± 13.89 (4- 84 years. Of the eyelid tumors, benign lesions were found in 7 (41.1%) followed by basal cell carcinoma in 5 (29%). The surgical procedures carried out were direct closure of defects in 15 (35%), excision of cicatrized tissue with skin graft in 7 (16%), reconstruction with rotational flap in 6 (14%), blepharoplasty in 4 (9%), gold weight in 4 (9%), lid sharing procedure (Cutler-Beard procedure) in 3(7%), lateral tarsorraphy in 2 (5%) and canalicular repair with silastic tube intubation in 2 (5%).

CONCLUSION

Ocular tumors are the most frequent conditions requiring eyelid reconstructive surgery. The common reconstructive procedures are direct closure followed by excision of cicatrized tissue with skin graft.

Outcome of cluster endophthalmitis in western plain region of Nepal

BACKGROUND

Post-operative endophthalmitis remains one of the most visually devastating complications of cataract surgery. Cluster endophthalmitis is defined as five or more cases of endophthalmitis occurring on a particular day in a single operating room in one centre. Excessive inflammation, particularly in the early post-operative phase, should be regarded as infective endophthalmitis. Early diagnosis and immediate intervention in such case, lead to salvage of eye as well as better visual outcome.

OBJECTIVE

To find out the causative organisms and visual outcome after an outbreak of post-operative endophthalmitis in high volume cataract surgical centre.

MATERIALS AND METHODS

Retrospective, interventional case series of 19 patients with acute post-operative endophthalmitis after manual small incision cataract surgery in a single day, underwent vitreous tap and received intravitreal Vancomycin, amikacin and Dexamethasone. Subconjunctival vancomycin was given at the end of the procedure. Vitreous samples were stained using Grams stain, Giemsa stain and KOH mount. Samples were sent to the hospital's microbiology laboratory for culture and sensitivity testing. All patients received intravenous ciprofloxacin for 3 days and oral ciprofloxacin for 7 days. Topical Prednisolone acetate, Ofloxacin, Gentamycin and atropine were given to all patients. Patients were followed up till 6 weeks.

RESULTS

10 eyes had vitreous tap culture negative (52.6%) where as 9 eyes (47.4%) had bacterial culture growth. The culture reports showed 4 cases (21%) of Staphylococcus epidermidis, 3 cases (15.8%) of Staphylococcus aureus and 2 cases (10.5%) of mixed growth. 48 hours after the intervention, 15 patients improved clinically. On sixth week follow up, 7 eyes (37%) had visual acuity better than 6/18, 7 eyes had 6/18 to 6/60 and 5 eyes had visual acuity between 1/60 to 5/60.

CONCLUSION

Intravitreal antibiotics and steroid, along with systemic ciprofloxacin and subconjunctival vancomycin has good visual outcome for post operative cluster endophthalmitis.

Surgical outcome of pars plana vitrectomy: a retrospective study in a peripheral tertiary eye care centre of Nepal

BACKGROUND

Trans-pars plana vitrectomy (TPPV) is an effective surgical procedure to retain the useful vision in vitreoretinal diseases.

OBJECTIVE

To evaluate the surgical outcome of pars plana vitreoretinal surgery.

STUDY DESIGN

Retrospective non-comparative interventional case series.

MATERIALS AND METHODS

A hospital-based retrospective interventional study of series of cases was carried out in retina clinic of Lumbini Eye Institute, Nepal, over a period of one-and-a-half years. Records of 64 patients who underwent vitreo-retina surgeries were reviewed. Demography, duration of symptoms, risk factors and indications, preoperative and post-operative visual acuity, intra-operative and post-operative complications were analyzed.

OUTCOME MEASUREMENT

The parameters studied were post-operative visual acuity and complications.

RESULTS

Of 64 patients, 61% presented 2 months after the onset of symptoms. Preoperatively, 65.5% had visual acuity of hand motions to 3/60 followed by perception of light only in 26.6%. The main indication for TPPV was vitreous haemorrhage (VH), in 53%. The visual acuity improved to better than 6/60 in patients with VH (68%), whereas, overall, in 72% of the subjects, it improved by 2 lines postoperatively. The commonest intra-operative complications were iatrogenic retinal break (5, 7.8%) at the sclerostomy site.

CONCLUSION

The main indication for TPPV is vitreous haemorrhage. Useful vision can be restored by pars plana vitrectomy in the majority of the patients. Retinal break is the commonest complication of TPPV.

Preliminary experiences with limbal relaxing incision for treatment of astigmatism during phacoemulslfication

INTRODUCTION

this small study relates our early experiences with the Limbal Relaxing Incision (LRI) for management of astigmatism in patients undergoing cataract surgery.

AIMS

to evaluate the efficacy of LRI in the management of primary astigmatism when combined with phacoemulsification.

SUBJECTS AND METHODS

limbal relaxing incisions were performed to correct primary astigmatism in 12 eyes of 12 cataract patients who underwent phacoemulsification as the primary procedure. The length and number of incisions were determined using the AMO LRI calculator software programme using Donnenfield and NAPA nomograms. Keratometric astigmatism was measured preoperatively and postoperatively on day 1 and after 3 weeks or more. Surgically-induced astigmatism (SIA) and the intended angle of error were evaluated by the vector analysis method. Preoperative and postoperative uncorrected visual acuity (UCVA) and best spectacle corrected visual acuity (BSCVA) were evaluated in each visit.

RESULTS

The mean age of patients was 52.92 +/- 10.91 years. There were 75 % male and 25 % female patients. The mean keratometric preoperative astigmatism was 2.08 +/- 1.05 diopter. The mean 1st postoperative day keratometric astigmatism was 1.74 +/- 1.32 diopter and the mean final keratometric astigmatism at 3 weeks postoperatively was 1.05 +/- 0.68 diopter. The mean SIA on the 1st postoperative day was 2.97 +/- 1.72 diopter at 103.25 +/- 56.57 degree with intended angle of error 6.53 +/- 9.61 degree. The mean SIA on the 3rd postoperative week was 2.26 +/- 0.87 Diopter at 107.08 +/- 49.96 degrees with intended angle of error 2.90 +/- 7.87 degrees.

CONCLUSION

limbal relaxing incisions are effective method to reduce postoperative astigmatism with good predictability of intended angle.

Non endoscopic endonasal dacryocystorhinostomy versus external dacryocystorhinostomy

AIMS AND OBJECTIVES

To compare the success rates of non endoscopic endonasal dacryocystorhinostomy and conventional external dacryocystorhinostomy for the surgical management of primary acquired nasolacrimal duct obstruction.

MATERIAL AND METHODS

A retrospective, nonrandomized, comparative interventional case series of 302 patients who underwent either endonasal or external dacryocystorhinostomy over a period of 2 years. All surgeries were performed by a single surgeon and patients with primary nasolacrimal duct obstruction with a minimum of 6 months post operative follow up were included in the study. While external dacryocystorhinostomy was performed using traditional technique, endonasal dacryocystorhinostomy was performed using direct method of nonendoscopic visualization.

RESULTS

Of the 302 cases included in the study 165 patients had endonasal dacryocystorhinostomy whereas 137 underwent external dacryocystorhinostomy. Success was defined by resolution of symptoms of tearing, a negative fluorescein dye disappearance test and patency of the canalicular system on lacrimal irrigation. In the external dacryocystorhinostomy group 124 (90.5%) patients had surgical success whereas 146 (88.5%) of the endonasal dacryocystorhinostomy patients had successful outcome. The overall success rate was 89.4%, and the difference of surgical success between the two groups was not statistically significant ( P=0.57).

CONCLUSION

Non endoscopic endonasal dacryocystorhinostomy gives surgical results comparable to those of external dacryocystorhinostomy and is a viable alternative where dacryocystorhinostomy is indicated for primary acquired nasolacrimal duct obstruction.

Forensic considerations of pregnancy-related maternal deaths: an overview

During the 20th century, risks to women associated with childbirth in developed countries have been dramatically reduced on account of many factors that include technological advancements in obstetrical care, greater access to health services and fewer births occurring at the extremes of women's reproductive age span. However, pregnancy-related maternal deaths continue to be a major health concern in developing countries. In the year 2005, an estimated 536,000 women died of maternal causes worldwide of which 86% occurred in sub-Saharan Africa and South Asia and less than 1% in more developed countries. The large regional differences in maternal deaths demonstrate that most of these deaths are preventable. It is nevertheless important to monitor patterns of pregnancy-related mortality and serious morbidity and to be sensitive to what observed patterns or changes may tell us in order to continue to safeguard women during this critical period and the monitoring process must begin with ascertainment of the accuracy of routine reporting of deaths associated with pregnancy and childbirth. We examine the pregnancy-related maternal deaths with a forensic view point.

Disaster management following explosion

Explosions and bombings remain the most common deliberate cause of disasters involving large numbers of casualties, especially as instruments of terrorism. These attacks are virtually always directed against the untrained and unsuspecting civilian population. Unlike the military, civilians are poorly equipped or prepared to handle the severe emotional, logistical, and medical burdens of a sudden large casualty load, and thus are completely vulnerable to terrorist aims. To address the problem to the maximum benefit of mass disaster victims, we must develop collective forethought and a broad-based consensus on triage and these decisions must reach beyond the hospital emergency department. It needs to be realized that physicians should never be placed in a position of individually deciding to deny treatment to patients without the guidance of a policy or protocol. Emergency physicians, however, may easily find themselves in a situation in which the demand for resources clearly exceeds supply and for this reason, emergency care providers, personnel, hospital administrators, religious leaders, and medical ethics committees need to engage in bioethical decision-making.

Infection in patients with severe burns: causes and prevention thereof

The better understanding of burn pathophysiology has resulted in effective fluid resuscitation in the acute stage, but the morbidity and mortality of burn patients are mostly linked to the burn wound consequences. Once the initial acute phase is over, the burn wound becomes the source of virtually all ill effects, local and systemic. The dysfunction of the immune system, a large cutaneous bacterial load, the possibility of gastrointestinal bacterial translocation, prolonged hospitalization, and invasive diagnostic and therapeutic procedures all contribute to infectious complications. Wound infection may lead to septicemia that may not only consume additional resources but is associated with significant morbidity and mortality despite the advances in burn care.

Misuse of prenatal diagnostic technology for sex-selected abortions and its consequences in India

During 1800, the British Government found that there were no daughters in a village in the Eastern Uttar Pradesh region of India. According to the 2001 Census, there were less than 93 women for every 100 men in the Indian population. The prevailing concept that the birth of a female child can signal the beginning of financial ruin and extreme hardship for a poor Indian family is understandable. What is surprising is that even high-income families do not want a female child. The Government of India in its 10th Plan recognized the rights of the female child to equal opportunity, to be free from hunger, illiteracy, ignorance and exploitation. In the National Policy for the Empowerment of Women 2001, a policy framework was laid down for the elimination of discrimination against, and violation of, the rights of the female child. However, the situation continues to worsen, and studies have revealed that sex-selected abortions are practised among all communities despite enactment of laws prohibiting prenatal sex determination. In this paper, we examine the functioning and consequences of the misuse of this technology.

Death during or following surgical procedure and the allegation of medical negligence: An overview

A great variety of mishaps can occur during or following the administration of anesthesia and operative or investigational procedures that do not necessarily convey an error of judgment or negligence on the part of the surgeon or the anesthetist. However, all deaths occurring during the course of anesthesia and surgery or within a reasonable period thereafter (commonly referred to as peri-operative period) have to be reported to the police as these deaths cannot be regarded as natural. Despite the death occurring due to some preexisting disease or some co-existent condition, there may be a tendency on the part of the relatives of the deceased to impute negligence on the part of the anesthetist and/or the surgeon merely because of the fact that the death was closely associated with the anesthesia and surgical intervention. As such, any death suspected to be caused, or contributed to, by any of these procedures needs to be adequately investigated both from the point of view of the relatives of the deceased as well as instituting future safety measures. This paper examines the medical, ethical and legal aspects of such deaths with reference to the allegations of medical negligence in these cases.

Forensic considerations of missed diagnoses in trauma deaths

Injuries missed at initial diagnoses or operations have the potential to cause disastrous complications in trauma patients. Understanding the etiology of unrecognized injuries is essential in minimizing its occurrence. For this purpose, we scrutinized the treatment and the autopsy records of the trauma deaths from 2000 to 2004 to determine the frequency, body regions, severity and causes of injuries that escaped recognition during the initial assessment, primary, secondary and tertiary surveys by the clinical team in patients who died of trauma. We also examined the accuracy of the cause of death as recorded on death certificates. The frequency of unrecognized injuries was found to be 11% in all trauma deaths. Abdomen (40%) and head (29%) were the more common regions of the body where injuries were frequently missed. System related errors (68%) and patient related factors (32%) were responsible for the injury remaining unrecognized. It was concluded that the injuries may be missed at any stage of the management of patients with major trauma and repeated assessments both clinical and radiological are mandatory not only to diminish the problem but to avoid litigation as well.

Sudden Infant Death Syndrome

During the last decade, much attention has been paid to the risk factors of sudden infant death syndrome (SIDS). Many researchers have demonstrated that infant-care practices are linked to the risk of SIDS. Prone sleeping, bed sharing, maternal substance abuse, and cigarette smoking have been reported to be significant potentially modifiable risk factors for SIDS. Despite the reports that the incidence of SIDS has decreased by 38% in the United States, it remains the leading cause of death in the first year of life. Deaths resulting from child abuse or neglect inflicted or permitted by their caretakers being second only to SIDS in infant mortalities and some recommendations regarding the differentiation of SIDS and child abuse have generated speculation that some cases of infanticide were misdiagnosed as SIDS. To reach a proper conclusion as to the cause and manner of death of an infant who died suddenly and unexpectedly, investigation must be thorough and professional.

Emergency management of trauma in India: expectations and reality

Emergency management of trauma in the developing world is at a nascent stage of development. Industrialized cities, rural towns, and villages coexist, with an almost complete lack of organized trauma care. There is no leading national agency to coordinate the various components of a trauma system, and no mechanism for accreditation of trauma centers and professionals exists. Accelerated urbanization and industrialization over the last three to four decades has led to an alarming increase in the rate of accidental injuries, crime, and violence, and ever-increasing terrorist activities over the last two decades have ushered in man-made mass-casualty disasters. However, communicable diseases, maternal and child health, and population control continue to be government priorities, far ahead of trauma care, in countries like India. New initiatives under the National Health Policy 2002 were expected to result in improvements in the systems, but grossly inadequate funding allocation made any significant impact on the outcome impossible. Strengthening in several areas is severely needed to achieve a reasonable level of efficiency, despite significant efforts on the part of the private sector to develop trauma care systems.

Gender identity disorder and its medico-legal considerations

The general belief among behavioural scientists and physicians is that gender identity disorder or transsexualism is an identifiable and incapacitating disease which can be diagnosed and successfully treated by reassignment surgery in carefully selected patients. Although many advances have been made in the reassignment surgery techniques, phalloplasty still remains a major challenge; to date, no ideal technique has been developed. The new gender created by the reassignment surgery has, in turn, led to many legal complications for post-operative transsexuals because, in many developed and the developing countries, transsexuals are not given a legal identity, thereby adding to their agonies and miseries. This article examines the historical perspective, genesis and management of gender identity disorder, or transsexualism, and draws attention to the medico-legal considerations.

Septicemia as a cause of death in burns: an autopsy study

In burn victims, invasion by the bacteria is not unexpected, despite advances in antibiotics, and it has been reported that in the absence of topical therapy, the superficial areas of burn wound contain up to 100 million organisms per gram of tissue within 48h following the injury. We examined the autopsy reports of 334 cases who died because of complicated burns and who underwent medico-legal autopsy during a period of 5 years to study the rate of infection/sepsis. It was observed that in 65% of fatal burn cases, septicemia was the cause of death. Pseudomonas aeuroginosa and Klebsiella sp. were the most common organism, isolated either singly or in combination in 29% and 28% cases, respectively. High mortality from burns in young married women has been recognized as an alarming and contentious problem in India, particularly among the low socio-economic groups. We found that the females aged 21-25 were the most common victims accounting for 37% of burn fatalities due to septicemia. It was concluded that to carry out periodic review of patterns of isolation and susceptibility profiles of microorganisms infecting burn wounds should be a routine in all burn units. In view of the limited resources of developing countries, we recommend the use of available scoring systems to estimate burn outcome so that the best care can be directed to those who have a better chance of improvement.

Suicides in Northern India: comparison of trends and review of literature

Trends of suicide vary widely according to time, region, age group, sex, and race. Despite mixed trends of increases or decreases in suicide rates around the world, suicide remains an important public-health problem. In an effort to understand and prevent suicide, researchers have investigated medical, psychosocial, cultural, and socio-economic risk factors associated with the environment as a promising line of research. There is now considerable evidence that childhood and family adversities in general such as childhood sexual and physical abuse, witnessing domestic violence, parental separation or divorce and living with substance abusing, mentally ill or criminal family members may be both strongly interrelated and individually related to suicidal behavior in adolescents as well as adults. The approach towards prevention of suicide has to be multidisciplinary. To recognize that adverse childhood experiences that frequently take place as multiple events, identifying and treating those young people who have been exposed to such experiences, promoting increased awareness among parents, teachers, and health professionals of the important role that severe interpersonal difficulties and dysfunctional cognitions can play in the development of suicidal behavior in young people, and helping parents modify their maladaptive child-rearing behavior could help. Child and family support programs, employment support for mothers, and legal guarantees of gender equality, could moderate problems of socio-economic disparity and poverty, which predicts both parents' and children's suicidal behaviors in modern societies.

Clinical forensic medicine in the present day trauma-care system--an overview

Criminal violence and its associated trauma comprise a critical health problem throughout the world. Clinical forensic medicine represents a new discipline of medical practice that is evolving in direct response to the sequelae of criminal and interpersonal violence. The application of the principles and standards of the forensic specialist has been increasingly recognized as playing a crucial role in trauma care; the results of the extremes of human behaviour-abused children, individuals suffering from blatant neglect and maltreatment, or self-inflicted injury, and victims of road-traffic accidents, firearm injuries and other assaults. These cases must be reported to a legal agency for investigation and follow-up. As trends in crime and violence change, new antiviolence legislation is likely to be implemented; consequently, new personnel resources are required to ensure that these legislative mandates effectively meet the needs of society.

Delayed death in burns and the allegations of medical negligence

Burns and deaths due to burns to remain an important public health and social problem in India. Most of the victims, who survive the initial 24h after burns, succumb to infection of the burnt area and its complications. Burns cause devitalization of tissues, leaving extensive raw areas, which usually remain moist due to the outflow of serous exudate. This exposed, moist area along with the dead and devitalized tissue provides the optimum environment favoring colonization and proliferation of numerous microorganisms, which is further enhanced by the depression of the immune response. All these factors, i.e., disruption of the skin barrier, a large cutaneous bacterial load, the possibility of the normal bacterial flora turning into opportunistic pathogens and the severe depression of the immune system, contribute towards sepsis in a burns victim, which usually is life threatening. Despite various advances in infection control measures, early detection of microorganisms and newer, broader spectrum antibiotics, management of burn septicemia still remains a challenge. Pulmonary, cardiac and other complications also contribute to the delayed deaths following severe burn.

Historical and medico-legal aspects of infanticide: an overview

In practice, all cases of abandoned newborn deaths are reported to the police/coroner, who asks for a post-mortem examination because only this can establish the viability of the infant, proof of separate existence, and the cause and manner of death in such cases. The pathologist who conducts the autopsy will have to use his skills and experience to assess a wide variety of marks and injuries so as to give his opinion fairly and frankly, not allowing any personal feelings to influence his findings. In some cases, he may be unable to give a firm opinion and should not shirk from stating this clearly. This paper examines some historical, legal and pathological aspects of infanticide.

Forensic considerations of surrogacy – an overview

In the past two decades, there has been a spectacular change in the field of reproductive technologies. Reproductive sciences have come in with techniques such as donor insemination; in vitro fertilization and embryo transfer methods, which have completely revolutionized the reproductive environment. These techniques have given hope to many infertile couples, who wish to have a child of their own. With the oncoming of surrogacy agreements, concepts of fatherhood and motherhood have been subject to much controversy. Motherhood was never under much scrutiny as it was rightly thought that childbirth was the natural and conclusive fact establishing it, though paternity was at times a controversial concept burdening legislators to provide for suitable tests. Medical sciences have now compartmentalized motherhood into the genetic, gestational and the social mother leading to a clash of interests. This paper reviews some medicolegal, ethical and social aspects of surrogacy.

Neck structure injuries in Hanging--comparing retrospective and prospective studies

Deaths due to hanging are common among suicides. Various studies in the forensic literature have reported considerable differences in the frequency of hyoid bone or thyroid cartilage fractures and injuries to the musculature and the vasculature of the neck. Some important reasons to which these variations could be attributed include: lack of a common method for examination of neck structures, varying degrees of thoroughness in examining the neck structures and lack of seriousness in the documentation of the findings (as cases of hanging are almost always suicidal) thus affecting the results of retrospective studies. The present study was conducted retrospectively (1994 to 1999) and prospectively (2000 to 2003) on 108 cases of hanging. Seventy-one per cent of the cases were male and 29% female, aged between 15 to 60 years. Hanging was typical in 20% of cases and atypical in 80%; it was complete hanging in 46% of cases and incomplete in 54% of cases. Neck structure fractures were found to be more common in atypical complete hangings; the incidence was found to be 10% in the retrospective group and 27% in the prospective group. Contusions and lacerations of musculature were found in 20% of cases in the retrospective group and 34% in the prospective group, thus stressing the need for thorough postmortem examinations and meticulous documentation of the findings.

The injury scale--a valuable tool for forensic documentation of trauma

An accurate method for quantitatively summarizing injury severity has many potential applications. The ability to predict outcome from trauma (i.e., mortality) is perhaps the most fundamental use of injury severity scoring, a use that arises from the patient's and the family's desires to know the prognosis. Field trauma scoring also is used to facilitate rational pre-hospital triage decisions, thereby minimizing the time from injury occurrence to definitive management. Another use of trauma scoring is for quality assurance by allowing evaluation of trauma care both within and between trauma centers, a contentious and controversial area that is likely to only increase in importance. However, the most important role for injury severity scoring is in trauma care research. Scientific study of the epidemiology of trauma and trauma outcomes would not be possible otherwise. Injury severity scoring is indispensable in stratifying patients into comparable groups for prospective clinical trials. Similarly, this technique can be used retrospectively to identify and control for differences in baseline injury severity between patient populations. More recently, physicians suggested that injury severity scoring could provide objective information for end-of-life decision-making and resource allocation. Unfortunately, trauma mortality prediction in the individual patient is limited and fraught with uncertainty. In fact, decisions for individual patients should never be based solely on a statistically derived injury severity score.

Missed diagnoses in trauma patients vis-à-vis significance of autopsy

Post-mortem examination is considered to be the gold standard for the critique of medical practice, providing a quality control tool for the retrospective evaluation of diagnoses and treatment. Performing autopsies also facilitates new insight about the pathogenesis of disease and effects of therapy, gives feedback to clinical research protocols, provides epidemiological information and occasionally helps to console and reassure grieving families that death was inevitable. Its significance becomes paramount in cases of missed diagnosis in trauma-related deaths. The true incidence of missed diagnoses in trauma-related deaths is unknown, because autopsy is conducted in only about 50% of injury-related deaths. Few studies have documented the frequency of missed diagnoses leading to deaths specifically in the trauma ICU population. The present study is an attempt to evaluate the incidence and nature of missed injuries and complications in trauma-related deaths given an autopsy rate of close to 100%. This study also sought to identify the primary factors contributing to each missed injury. However, the study is in no way intended to assigning blame to human or system errors. Rather, it is focussed specifically on the issue of whether autopsy can be useful to provide feedback in identifying clinical problems of trauma patients.

Severe post thermal burn cicatricial ectropion with corneal ulceration: an illustrative case

Management of postburn cicatricial ectroption of the upper lid is always a challenge for the oculoplastic surgeon, as they are often associated with exposure keratitis and ulceration. Traditionally, split thickness grafts have been described for upper lid reconstruction and tarsorrhaphies have been discouraged. We present a case of corneal ulceration associated with postburn cicatricial ectropion presenting 10 years following the initial trauma. The patient underwent full thickness skin grafting and tarsorrhaphy to release the ectropion with resolution of corneal ulceration. We believe that full thickness skin grafts and tarsorrhaphy are effective in correcting upper lid cicatricial ectropion, without functional compromise.

Development of pre-hospital trauma-care system--an overview

Trauma is recognized as a serious health care problem world-wide and there is a general agreement that trauma is best addressed in a systematic manner. Accordingly, trauma systems must be designed to use efficiently the limited health care resources available. The majority of injuries are of only minor, or moderate, severity, and can be managed well at local community hospitals. On the other hand, a significant minority of injured patients will require extensive and expensive care in order to survive, or to minimize the morbidity of injury. For a trauma system to be optimally effective, given limited available resources and the need for urgent care of the seriously injured, it is critical to utilize a method of differentiating those injury victims, who need the specialized expertise and resources available in trauma centres, from those who can be cared for adequately locally. Rapid field assessment of injured patients is, therefore, an essential element of any effectively functioning trauma system. This review examines the evolution of pre-hospital trauma-care systems, during the triage of a trauma victim.

Dowry--a deep-rooted cause of violence against women in India

The world has entered the new millenium but it is a harsh reality that the woman in India has long been ill-treated in our male-dominated society. She is deprived of her independent identity and is looked upon as a commodity. She is not only robbed of her dignity and pride by way of seduction by the men outside, but also may become a victim of cruelty by her saviours, within the four walls of her own house. However, her trauma does not end here, it may even go to the extent of forcing her to commit suicide or she may be burnt to death for various reasons, including that of dowry. This type of violence transgresses the boundaries of caste, class, region or religion and is prevalent in almost all societies in India. The system of dowry is a social practice which on its own has claimed the lives of scores of women--both young and old, and has made life a virtual hell for many more. Unfortunately, education among women has not produced a reformative effect on their social outlook, nor encouraged any change in them conducive to social upliftment. Those parents who prefer not to take dowry for their well-qualified and settled male children, are in fact considered 'strange' by the society and doubts about 'the respectability of the groom's family' are usually raised. The present study makes an in-depth review of the dowry system in India and analyses the reasons which have demonized dowry into its present commercialized and institutionalized form.

Triage in trauma-care system: A forensic view

Trauma is a significant cause of death and suffering in society and there is strong evidence that mortality and morbidity may be reduced by provision of effective medical care through a trauma care system. It is reasonable to believe that severely injured patients should be transported as quickly as possible to a center where definitive medical care is possible. Conversely, it is also an argument that the resources of a trauma center must not be overwhelmed by assessment and treatment of minor trauma for patients who could be reasonably expected to do well with care in a clinic or a primary care hospital. Triage was developed to sort out those most likely to survive and to need medical care. Many triage tools have been developed and evaluated. However, the goal in setting triage criteria to provide a protocol for properly categorising injured patients, transporting them to appropriate hospitals, and ensuring an appropriate response to all trauma patients is yet to be achieved. Whatever the reasons and rate of failure due to different reasons, it is not unusual to read the reports wherein the quality of care becomes suspect in an increasingly litigious society. This paper examines the evolution of triage systems in trauma care from a forensic viewpoint.

Artistic assault: an unusual penetrating head injury reported as a trivial facial trauma

The authors report a case of penetrating head injury that presented with a deceptively mild complaint. To our knowledge, it is the first report of a paint brush penetrating the brain. The patient reported being punched in the left eye and presented with a minor headache, swelling around the left orbit, a small cut on the cheek and slightly reduced left eye abduction. After radiological evaluation, a penetrating head injury was diagnosed. Under general anesthesia, through a lateral eyelid incision a 10.5 cm long paint brush, which had penetrated from the left orbit to the right thalamus, was removed. No post-operative infection was seen at six months follow-up. This brief report serves to highlight that penetrating brain injury can occur without neurological deficit and that a minimally invasive surgical approach was successful in avoiding any complications.

Child abuse in Chandigarh, India, and its implications

Few abuses of human rights are so universally condemned but at the same time so universally practiced as child abuse. Over the centuries, children have been subjected to physical, sexual and emotional abuse as well as neglect. By any objective measures, this issue should rank high on the global agenda but in practice it is surrounded by a wall of silence and perpetuated by ignorance. Child sexual abuse is a dark reality that routinely inflicts our daily lives but in a majority of cases it goes unnoticed and unreported on account of the innocence of the victim, stigma attached to the act, callousness and insensitivity of the investigating and the law enforcement agencies, etc. A child who has been sexually abused is traumatized for life but it is only much later in life when the emotional and psychological trauma aggravates that such people seek medical help. There is an urgent need to take up the problem as a larger social issue where the society has a responsibility to help the victims overcome their trauma and move on with life as normally as possible. We report a retrospective review of children (age<16 years) referred for medicolegal examination, an autopsy in Chandigarh, India, between 2000 and 2003.

Cloning controversies: an overview of the science, ethics and politics

Man's quest for knowledge is boundless. It is because of this quest and his untiring efforts to acquire it, that we have made such tremendous breakthroughs in the fields of science and medicine. Vaccines for hitherto incurable diseases, genetic engineering, and the correction of congenital and hereditary diseases are a few of these. With the successful cloning of 'Dolly', 'Molly' and 'Polly' we are now standing at the threshold of another major breakthrough--human cloning. However, are we ethically, morally and politically mature enough to 'go all the way' in a purely scientific manner, for the benefit of the human kind? A review of the scientific, ethical and political events in this field may be pertinent in trying to answer this important question.

Ethical and Practical Principles Underlying the End of Life Decisions

"I will not relinquish old age, if it leaves my better part intact. But, if it begins to shake my mind, if it destroys its faculties one by one, if it leaves me not life but breath, I will depart from the putrid or tottering edifice. If I must suffer without hope or relief, I will depart, not through fear of the pain itself, but because it prevents all for which I would live." Seneca, the great Roman statesman of 1st century AD, spoke these words 2 millennia before the Netherlands became, on November 28, 2000, the first country in the world to legalize euthanasia. The decisions pertaining to end of life, whether legalized or otherwise, are practiced in many parts of the world but not reported on account of legal implications. Lack of awareness regarding the distinction between different procedures on account of legal status granted to them in some countries is the other area of concern. Debate among the medical practitioners, lawmakers, and the public taking into consideration the cultural, social, and religious ethos will lead to increased awareness, more safeguards, and improvement of medical decisions concerning the end of life.

Medicolegal and ethical issues of cloning: do we need to think again and again?

Research on the cloning of human cells holds the promise of medical benefits, but cloning humans is a far more complex and ethically disturbing issue. Some have argued strenuously that human cloning should be banned permanently. They have called it immoral, repugnant, and abhorrent. Most European countries have already banned it, and others are considering a proscription. While allowing fundamental research in the field to progress, we need a wide debate on human cloning. We need to think about what, if any, circumstances might warrant cloning, as well as the circumstances under which it should never be allowed.

Organ transplantation programme: an overview of the present situation

An ever-increasing demand for organs for transplantation has failed to keep pace with their availability. Social, religious and legal restrictions on the one hand and technological developments on the other have further worsened the existing shortage of organs. A correct definition of the 'moment of death', a more humane approach in breaking the news of death to relatives and de-linking the request for donation from the announcement of death may all go a long way in enhancing organ donation and procurement for needy patients. In India, the Transplantation of Human Organs Act was passed in 1994 to regulate the removal of organs from the living as well as the dead. However, it has certain fallacies. This paper reviews the various criteria in use to define the 'moment of death' around the world and with reference both to the Transplantation of Human Organs Act 1994 and the urgent need for organ retrieval in the present day paucity of donors.

Withholding and Withdrawing of Life Support

The developments in medicine in general and the technology of life support in particular have provided the means of maintaining organ function for prolonged periods of time. However, there are many situations where life-sustaining treatment in an intensive care unit (ICU) may lead to a death with lingering and suffering of the patient, as well as burdening their family. Although often equated, withholding and/or withdrawing life-prolonging treatments that allow the patient to die needs to be differentiated from the physician-assisted suicides and euthanasia that involve the active ending of life. There is a difference between an unintended but accepted consequence of forgoing therapy and an intended result of death from suicide or euthanasia. The present-day physicians view most patient deaths as an inevitable process secondary to disorders unresponsive to treatment and/or multiple organ dysfunction syndromes. The large majority of patients dying in ICUs today succumb not after cardiopulmonary resuscitation, but rather, after the forgoing of life-sustaining treatment. Such approach has frequently caused families, institutions, and conservators of patients to resort to judicial fiat for resolution.

The end of life decisions – should physicians aid their patients in dying?

Decisions pertaining to end of life whether legalized or otherwise, are made in many parts of the world but not reported on account of legal implications. The highly charged debate over voluntary euthanasia and physician assisted suicide was brought into the public arena again when two British doctors confessed to giving lethal doses of drugs to hasten the death of terminally ill patients. Lack of awareness regarding the distinction between different procedures on account of legal status granted to them in some countries is the other area of concern. Some equate withdrawal of life support measures to physician assisted suicide whereas physician assisted suicide is often misinterpreted as euthanasia. Debate among the medical practitioners, law makers and the public taking into consideration the cultural, social and religious ethos will lead to increased awareness, more safeguards and improvement of medical decisions concerning the end of life. International Human Rights Law can provide a consensual basis for such a debate on euthanasia.

Plasma cortisol response to 1-24 adrenocorticotropin in patients with treated/untreated sellar & suprasellar mass lesions

BACKGROUND & OBJECTIVES

One microgram short synacthene test is widely recommended as a screening test for evaluation of hypothalamo-pituitary-adrenocortical axis in patients with secondary adrenal insufficiency. Information on adequacy of cortisol response to this dose at different periods of the day in patients with hypothalamic-pituitary disorders is not available. Hence, this study was designed to assess the adequacy of cortisol response to 1 microg 1-24 adrenocorticotropin (ACTH) at 0800 h and 1600 h in patients with sellar and suprasellar mass lesions.

METHODS

Thirty five consecutive patients with sellar and suprasellar mass lesions with mean age of 43.0+/-14.4 yr and 36 healthy controls with mean age of 32.3+/-9.0 yr were studied after obtaining informed consent. Maintenance doses of glucocorticoids in these patients were discontinued appropriately. On day 1, prestimulated and stimulated plasma cortisol samples at 0800 h and at 30 and 60 min following i.v. bolus of 1 microg 1-24 ACTH were collected. While on day 3, plasma cortisol samples were similarly collected at 1600 h. Cortisol estimation was done by a sensitive and specific radioimmunoassay. Stimulated plasma cortisol of 500 nmol/l or higher was defined as a normal response.

RESULTS

In healthy controls, the prestimulated and peak cortisol levels at 0800 h (377.5+/-93.3 and 729.1+/-183.2 nmol/l) were higher (P<0.001 and P<0.01) than those at 1600 h (230.1+/-75.7 and 665.8+/-138.6 nmol/l). All subjects had a cortisol response of 500 nmol/l or higher in response to 1 microg 1-24 ACTH both at 0800 and 1600 h. In the patients' group, the prestimulated plasma cortisol at 0800 h (250.3+/-169.7 nmol/l) was higher (P<0.001) than that at 1600 h (166.3+/-128.9 nmol/l), while the peak cortisol response was comparable (P>0.05) in the morning as well as in the evening (490.9+/-309.4 vs 464.8+/-318.4). In 27 patients (77%) the morning and evening stimulated cortisol response to 1 microg 1-24 ACTH was consistent (normal in 13 and subnormal in 14) but was discrepant in the remaining 8 (23%). In 7 of these 8 patients, cortisol response was normal at 0800 h but not at 1600 h, while in only one, normal response was seen at 1600 h but not at 0800 h.

INTERPRETATION & CONCLUSION

The demonstration of normal peak cortisol response to 1 microg 1-24 ACTH at 0800 h but not at 1600 h in substantial number of patients with sellar and suprasellar mass lesions suggests preference to morning for performing this test.

Clinical forensic medicine – management of crime victims from trauma to trial

The loss of human life and function due to violence constitutes a phenomenon that affects millions of patients annually. Society demands an investigation of trauma associated with criminal activity. No longer is it acceptable for health care professionals to operate in isolation of forensic philosophies and principles. It is assumed that the individuals responsible for the performance of the examination of forensic victims have the necessary basic education, experience, and skills. Health care professionals involved in the initial response to these victims, in the emergency department, are faced with unique problems, as social changes require continual reevaluation of standards and professional responsibility. The role of forensic medicine has been expressly designed to provide solutions to some of the most urgent concerns in our society. Forensic medicine focuses on the areas in which medicine and human behavior interface with the law. Existing problems are great and multifaceted and call for new solutions. The application of forensic science to contemporary medical practice reveals a wider role in the investigation of crime and the legal process that contributes to public health and safety. The responsibility of the forensic medicine is to provide continuity of care from the health care institution or the crime scene to courts of law...from trauma to trial.