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By: L. Kamak, M.B. B.CH., M.B.B.Ch., Ph.D.
Clinical Director, University of Florida College of Medicine
All signs of recent or old medical and surgical intervention and resuscitation must be described hiv infection greece discount zovirax line. Medical devices must not be removed from the body before the intervention of the medico-legal expert how long after hiv infection will symptoms appear buy discount zovirax on-line. A decision has to hiv infection rates scotland purchase zovirax 200 mg overnight delivery be taken at this stage as to the strategies of investigation and the necessity of documentation by X-rays and other imaging procedures. Relevant ducts have to be dissected, for example, central and peripheral airways, biliary ducts and ureters. All hollow organs have to be opened and their content described by colour, viscosity, volume (samples should be retained, where appropriate). If injuries are present, the dissection procedure may have to vary from the normal one: this should be appropriately described and documented. Injury tracks must be described in order to include their direction as regards the organ anatomy. B Detailed 1 Head a Before opening the skull, the periosteum must be scraped off in order to display or exclude any fractures. The description of the bones must also include an examination of their intactness, including the connection between the skull and the first two vertebrae. In situ dissection is necessary in certain cases, particularly for the demonstration of injury tracks and evacuation of fluids. Dissection of organs should observe anatomical continuity of systems, where possible. The first stage of the autopsy in such a case must be a careful partial opening of the thorax and dislocation of the lower three-quarters of the sternum with the subsequent opening of the heart under water, allowing the measurement and sampling of escaping air or gas. However, the following minimum rules should be applied: a in all autopsies, the basic sampling scheme includes specimens from the main organs for histology and peripheral blood sampling (such as for alcohol and drug analyses and genetic identification), urine and gastric contents. The hyoid bone and the laryngeal cartilages must be dissected very carefully; biological samples must be collected in tightly closed jars, properly preserved and placed under seal and transported to the laboratory in perfect safety; certain specimens and fluids need to be sampled in a special way and analysed without delay. The autopsy report should be an integral part of the autopsy procedure and be drafted carefully. Reference should be made to the provisions of Principle V above; o a list of all samples retained for toxicology, genetic identification, histology, microbiology and other investigations should be included; all such specimens should be identified and attested by the medico-legal expert according to the legal system of the state concerned, for continuity of evidence; p results of ancillary investigations, such as radiology, odontology, entomology and anthropology should be included, when such results are available; q one of the most important parts of the autopsy report is the evaluation of the significance of the accumulated results by the medico-legal expert. After termination of the autopsy, evaluation is usually provisional because later findings and later knowledge of other circumstantial facts can necessitate alteration and modification. Medico-legal experts must interpret the overall findings so that the maximum information and opinion can be offered. Also questions that have not been raised by the competent authority must be addressed if they could be of significance; r based on the final interpretation, the cause of death (in the International Classification of Disease should be given. Where several alternatives for the cause of death exist and the facts do not allow a differentiation between them, the medico-legal expert should describe the alternatives and, if possible, rank them in order of probability. The date of the autopsy and the date of the final report should be as close together as possible. Differences in widths of the pupils, localization of hypostasis, presence and distribution of congestion. Dissection of the soft tissues, of the musculature and of the organs of the neck in a bloodless field is essential. Technique: sampling of gastric contents, precise description of the lungs (weight, measurement, extent of emphysema), sampling, lung fluid, liver and other tissues, for the possible demonstration of diatoms and other contaminants. If required, sampling of drowning medium (for example river, bath water) should be carried out. Search for and sampling of foreign biological material must include pubic hairs and secretions on the body surface as for instance originating from bites. It is also necessary to proceed to the careful removal and sampling of material under the fingernails and control hairs. Consider the removal of a variety of tissues: for example all injuries, regional lymph nodes in malnutrition, endocrine organs, immuno-competent tissues, specimens from different parts of the intestine. The umbilical cord and the placenta must be subject to morphological and histological examination. Cases belonging to this category can usually be regarded as sufficiently solved; b findings that could explain the death but allow other explanations.
The auriculotemporal nerve antiviral state buy zovirax overnight delivery, a sensory branch of the trigeminal nerve statistics regarding hiv infection rates in nsw safe 400 mg zovirax, lies posterior to pictures of hiv infection symptoms buy zovirax australia the superficial temporal vessels and above the superficial temporal fascia; it proceeds to innervate the temporal scalp. The temporoparietal fascia free flap is a thin, highly vascularized unit having a consistently reliable pedicle. It can drape over cartilage stripped of perichondrium and maintain the definition of the underlying framework in ear and nasal reconstruction. Likewise, it can contour into bony concavities as part of the treatment of chronic osteomyelitis. Temporoparietal fascial free flaps have proven especially useful in hand reconstruction, in simultaneously restoring a gliding apparatus for tendons denuded of paratenon and providing an elastic vascularized surface in wound closure. Drawbacks of this flap include alopecia at the donor site and tedious elevation of the scalp flaps. It may be prevented by deepening the dissection and not exposing the hair follicles when raising the scalp flaps. An osteofascial flap consisting of the outer table of the frontoparietal calvarium may be transferred by the superficial temporal pedicle. Because it is vascularized and contains membranous bone, this flap is appropriate for bony reconstructions in unfavorable recipient sites, for example, scarred, irradiated beds, hypoplastic zygomaticomaxillary complex reconstructions in TreacherCollins syndrome, or clinically infected hand defects requiring grafting to the metacarpals. Within the past decade, this donor site is still commonly reported for clinical use in microsurgical reconstruction. It is continuous with the galea aponeurotica superiorly, the occipitalis posteriorly, the frontalis anteriorly, and the deep investing fascia overlying the parotid gland and the muscles of facial expression inferiorly. It lies immediately beneath the hair follicles of the temporoparietal scalp and is progressively more adherent to the subdermal fibrofatty layer in which they lie, as it proceeds from the level of the zygomatic arch cephalad toward the vertex of the skull. The subdermal layer of the scalp is also attached to the superficial temporal fascia by numerous small vessels. The superficial temporal fascia overlies the deep temporal fascia and is separated from it by a loose, areolar plane. Near the lateral orbital rim in the frontozygomatic area, the frontal branches of the facial nerve lie deep to an attenuated portion of the superficial temporal fascia, thus increasing its vulnerability during dissection. A rhytidectomy incision is outlined to extend vertically and to bifurcate in lofty "Y" fashion two thirds of the distance to the apex of the skull at the upper temporal fascia. Elevation of the scalp flaps begins inferiorly where the plane between the dermis and superficial temporal fascia (2) is more easily identified. As dissection proceeds cephalad, separation becomes increasingly difficult because the fibrous septae and piercing vessels within the subcutaneous fat connecting the superficial temporal artery to the overlying scalp are quite dense. This plane is painstakingly developed so that it is deep enough to avoid exposure of the hair follicles, yet superficial enough not to injure the superficial temporal fascia (2). When dissecting in the frontozygomatic region, a nerve stimulator may help in localizing the frontal branch of the facial nerve (3). The auriculotemporal nerve (4) is invariably incorporated within the fascial flap. The superficial temporal fascia is incised and readily elevated along with its pedicle in retrograde fashion. This is expedited by the loose, areolar plane that separates the superficial and deep temporal fasciae (2,5). To avoid damage to the branches of the facial nerve, further dissection of the vascular pedicle (1) in the parotid gland (6) is not recommended. The deep temporal fascia is a dense, semicircular fascial sheath that invests the temporal muscle. At each margin, this fascial layer ends by attaching to the periosteum of the frontal, temporal, and parietal bones, and the upper edge of the zygomatic arch. The middle temporal vessel (4) originating from the superficial temporal artery (1) and supplying the deep temporal fascia (3) is preserved. The double-leaf arrangement is particularly suited to tendon reconstruction in simultaneously providing vascularized coverage and an envelope of gliding surfaces. The superficial temporal, occipital, and supratrochlear vessels form a rich, anastomotic network located just above the galea. As part of this complex, the superficial temporal artery, ~1 to 2 cm beyond the temporal line (a ridge that begins at the zygomatic process of the frontal bone coursing upward and backward across the frontal and parietal bones and ending at the supramastoid crest, representing the cephalic-most portion of the temporalis muscle), sends perforators down through the galea and periosteum. This is accomplished by suturing the galea and periosteal layers and drilling holes at the periphery of the bone to prevent shearing at the deep surface of the galea.
Estimation of the degree of force used in stabbing the amount of force required to hiv infection game buy zovirax master card inflict any given stab wound is often a matter of extensive debate in criminal trials antiviral soap 800 mg zovirax amex. This tends to hiv infection process in the body order zovirax 200 mg with mastercard confirm the intention to stab, whereas the defence proposition is often that the victim inadvertently fell or was pressed against a weapon held passively by the accused. An expert medical witness has difficulty in replying to the almost inevitable question by counsel: `What amount of force was necessary to cause this wound, doctor? Physical units such as dynes/cm2, even if they can be measured, mean nothing to a judge and jury. Apart from bone or calcified cartilage, the tissue most resistant to knife penetration is the skin (Knight 1975), followed by muscle where large muscle bundles underlay the fascia. The sharpness of the extreme tip of the knife is the most important factor in skin penetration. The cutting edge of the knife, once the tip has penetrated, is of relatively minor importance. The speed of approach of the knife is particularly important in achieving penetration. A knife held against the skin, then steadily pushed, requires far more force to penetrate than the same knife launched against the skin like a dart. As in blunt injury, this is an example of the physical law that requires that the force varies directly not with the mass of the weapon, but also with the square of the velocity. The chest wall, where skin tends to be intermittently supported by underlying ribs, is relatively easy to puncture with a sharp knife as the skin and tissues are stretched over intercostal spaces in the manner of a drum membrane. Though the thick skin of the palms and soles is much tougher than on the rest of the body, the variation in resistance of the rest of the skin to a sharp knife is of little importance compared with other factors. Similarly, the skin of the aged, or of women, is not appreciably less resistant to a sharp point than that of men or young persons. When a knife-point impacts against skin, the latter dimples and resists until penetration suddenly occurs. Thus no additional effort is needed by the assailant to achieve deep or even full penetration up to the hilt. It is sometimes incorrectly claimed by the prosecution that a deep stab wound must imply extreme force or continued pushing after penetration. This is not so and experiments have shown that once penetration occurs, it is difficult or even impossible to prevent deep penetration because of the suddenness of the breakthrough. When the knife penetrates the skin rapidly, for example, if the body falls or runs on to the blade, the knife does not need to be held rigidly in order to prevent it being pushed backwards. Its inertia, if the tip is sharp, is quite sufficient to hold it in place while the body spears itself on the blade. Although each end of the wound is identical, the weapon was a single-edged kitchen knife. The end of the wound adjacent to the back of the blade has split making it impossible to say if a single- or double-edged knife was used. The sternum beneath was penetrated to reach the heart, so considerable force must have been used. Uncalcified cartilage, especially that in the costal cartilages of young and middle-aged persons, is easily penetrated by a sharp knife, though naturally more force is required than if the blade passed through an intercostal space. Calcified rib and bone provide a much more resistant barrier, but a forceful stab from a strong, sharp knife can easily penetrate rib, sternum or skull. Firm tissues like myocardium, liver and kidney are easily traversed by all but the most blunt of weapons, and their resistance is far less than that of cartilage or skin. Razors and broken glass have extremely sharp edges so that, when applied tangentially or at a small angle to the skin, undercutting may be a marked feature. The wound may appear as a shallow slice which bleeds profusely and, in a hairy area such as the scalp, it will reveal cut hair bulbs on the shelved surface. Deliberate wounds with razors or sharp knives may exhibit patterns or even words; these may occur in gang fights or sadistic homicides. Glass can be employed as a cutting weapon, again typically in bar fights or gang vendettas, where a broken bottle may be beld by the neck or a smashed beer tankard by the handle. The knife had entered obliquely through the inner side of the right breast, emerged into the cleavage and re-entered the mid-line. Although this location is commonly the site of laceration from blunt blows, this injury is sharp-edged and has unbruised margins, indicating that it is an incised wound.
Any blood or suspected semen stains anywhere on the body or clothing should be sampled either by the pathologist or by the forensic scientist or scene of crime police officer hiv infection rate south africa 2012 buy 800mg zovirax overnight delivery. The pubic hair should be examined for foreign material hiv symptoms first year infection generic 400mg zovirax fast delivery, hairs hiv transmission statistics male to male buy 200mg zovirax with mastercard, vegetation and dried seminal stains, and samples of hair and combings taken. The hair may be combed using a fine comb with the base of the teeth packed with cotton-wool to trap any loose fibres. Dried stains on hair may be cut away and placed in clean folded paper in an envelope, or plastic bag for transit to the laboratory. In forcible rapes, especially in young persons, there may be external signs of perineal tears, with laceration of the margin of the vaginal introitus or anus, sometimes causing a complete rip between the two orifices. Caution must be used in interpreting the degree of dilatation of the anus in a dead body, as the sphincter can become patulous and wide open as a normal post-mortem change. Unless the dilatation is very marked, the sole finding of an open anus in the absence of abrasion, bruising, or semen is difficult to sustain as proof of anal penetration. If any fluid is running from the vulva or anus, it should be picked up with clean pipettes and preserved in the smallest available tube, to prevent drying from evaporation. Then cotton-wool swabs on sticks (ensuring that those used for semen detection are plain swabs, not those containing albumin or other media) should be used to take the following samples by touching gently on to the mucosal surfaces: the interior of the vulval labia and around the vaginal orifice the margins and interior of the anus the mid-vagina, using a speculum or broad handle of a dissecting forceps to part the lower vaginal walls gently to allow the swab to reach the area without contamination from the lower vagina the upper vagina, cervix and posterior fornix, again using a spatulate instrument to open the canal to give access to the swab. If more fluid contents are seen higher in the vagina, either now or during the later dissection, they should be recovered by pipette. After samples are taken, the interior of the anus, vulva and vagina, as far as can be seen from the exterior, should be examined. Lacerations, abrasions, bruises and bleeding may be evaluated, though they can be seen in more detail at dissection. Where injuries are gross, especially in children, fistulae between the vagina and the rectum or even peritoneal cavity may be seen. The autopsy incision should be similar to that described for the examination of deaths associated with pregnancy, with an incision circumscribing the perineum, removal of the anterior part of the pelvic bones and the extraction of all the pelvic organs in continuity from ovaries to vulva and anus. Before this is done, the bladder should first be emptied of urine (either by catheter or through a small incision in the fundus) and the fluid retained for toxicological analysis, especially for alcohol. The vagina should be opened with large scissors, the track of the cut depending on the assessment of any injuries seen on external examination. If there are tears or bruises in the vulva or vagina, the cut should be orientated to avoid them wherever possible; the anus is later dealt with in a similar way. The vagina is laid open to the posterior fornix and all injuries carefully examined and photographed. Injuries may be of all types, from mere reddening or swelling to complete disruption of the vaginal canal. This may occur in small children from sheer brutality of penetration, especially if there is gross disproportion between the adult penis and infantile canal. It may also occur from instrumental injury, as it is by no means uncommon for deliberate incised wounds to be made. Vaginal injuries, especially by instrument, may continue up into the abdominal cavity, either via the posterior fornix or lateral vaginal walls. This will have been examined through the abdominal autopsy incision before removal of the pelvic organs. This does not exclude sexual activity short of penetration and technically rape can occur from even the minimal passage of a glans between the labia, which does not affect the hymen. Evidence of previous pregnancy, such as abdominal striae, old damage to the cervix and breast changes are almost incontrovertible evidence of previous sexual intercourse. A recently ruptured hymen, with swelling, a raw unepithelialized edge and bleeding may be found, though admittedly it is relatively uncommon except in children and previously virginal young persons. The lack of intact hymen, reddened and larger than normal orifice of the vagina as well as thickened skin and ulcers perianally (not shown) are in keeping with abuse.