A proposta deste trabalho é fazer uma apreciação crítica dos laudos periciais realizados em ações judiciais de responsabilidade civil por alegado erro médico. A prova pericial deve orientar o julgador para que este possa fixar os limites da responsabilidade do médico ou profissional de saúde. O perito deve responder adequadamente as questões discutidas no processo, bem como trazer ao juiz os elementos que considerar úteis ou necessários para auxiliar a decisão judicial. Na parte teórica são estudados os campos de apuração da responsabilidade por erro médico, os pressupostos da responsabilidade civil, os tipos de prova que podem ser produzidos no processo, quais são os elementos essenciais do laudo pericial e os critérios que devem ser usados pelo perito para determinar se estão presentes os requisitos do dever de indenizar. Em seguida, utilizando-se dados obtidos em processos judiciais, são abordados os aspectos mais relevantes nas ações desta espécie, como a incidência dos tipos de dano alegados pelos autores, as especialidades médicas mais acionadas judicialmente, o tempo médio entre o ajuizamento da ação e a sentença judicial e a relevância dos laudos nas decisões judiciais observadas. Ao final, é realizada uma análise crítica dos conteúdos dos laudos, verificando se eles contêm todos os elementos recomendados e descritos na parte teórica, fazendo-se críticas sobre se eles cumpriram sua função de forma adequada e propondo instrumentos para seu aperfeiçoamento. / The aim of this work is to do a critical appreciation of the expert reports in judicial proceedings for alleged medical malpractice. The expert report should guide the judge and help to determine the limits of the physician\'s or health professional\'s responsibility. The expert must answer appropriately the questions discussed in the lawsuit, as well as bringing the elements that he or she might consider useful or necessary to aid the judicial decision. The theoretical section concerns the medical malpractice responsibility verification, the presupposed civil responsibility, the kinds of proof that can be produced in the process, what are the essential elements of the expert report, and which criteria that should be used by the expert to determine if the requirements of the duty of compensating are present. Then, using data obtained from judicial proceedings, the most important aspects in this kind of lawsuit are exposed, such as the incidence of types of damage alleged by the authors, the most prosecuted medical specialties, the average time between the beginning of the action and the judicial sentence, and the relevance of the expert reports in the observed judicial decisions. At the end, a critical analysis of the reports is accomplished, verifying if they contain all the recommended elements described in the theoretical part, criticizing the accomplishment of their function, and proposing instruments for their improvement.

Thesis (MPhil)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: This thesis discusses ethical dilemmas faced by district surgeons in South Africa. District surgeons render clinical forensic services, which means that they deal mainly with detainees and victims of crime. The main functions of district surgeons are the collection of forensic evidence from patients and the care of detainees. So the focus is to assist in the administration of justice rather than improvement of patient wellbeing. The district surgeon may therefore find himself in a situation where patients’ interests are in conflict with those of law enforcement agencies. Being a medical practitioner in clinical forensic medicine, the district surgeon has an obligation to assist in the administration of justice, as opposed to the traditional obligation to care for patients and put patient’s interests first. This allegiance to both administration of justice as well as patient wellbeing lead to an ethical dilemma of dual loyalties. A dual obligations presents an ethical dilemma for the district surgeon, especially if they are in conflict and mutually exclusive. I discuss the detention and subsequent death of Steve Biko to illustrate how dual obligations can lead to serious human rights violations and even death. Dual obligations are however not limited to detainees and police custody settings, and I demonstrate this by discussing three other scenarios commonly encountered by district surgeons. There is a lack clear guidance for district surgeons who are faced with a conflict of obligations. I explore several ethical theories including consequentialism, deontology and virtue ethics, in search of an ethical framework suitable for resolving conflicts in clinical forensic medicine. I therefore argue that a duty based ethical framework is central to clinical forensic medicine and the resolution of loyalty conflicts. I recommend the resolution of conflicts by using an approach developed by Benjamin (2006). This approach involves weighing -up the different duties in conflict, applying philosophical reasoning and then amelioration. By adopting a structured and wellreasoned ethical framework, district surgeons will be able to deal with conflicts of obligations better. / AFRIKAANSE OPSOMMING: Hierdie tesis bespreek etiese dilemmas wat in die gesig gestaar word deur distriksgeneeshere in Suid-Afrika. Distriksgeneeshere lewer kliniese forensiese dienste, wat beteken dat hulle handel hoofsaaklik oor die gevangenes en slagoffers van misdaad. Die belangrikste funksies van distriksgeneeshere is die insameling van forensiese getuienis van pasiënte, en die sorg van gevangenes. Met hierdie benadering is die fokus om te help met die administratiewe doeleindes van geregtigheid, eerder as die verbetering van die pasiënt se welstand. Die distriksgeneesheer kan hom dus in 'n situasie vind waarby die pasiënte se belange in konflik is met dié van wetstoepassingsagentskappe. As 'n geneesheer in kliniese forensiese geneeskunde, het die distriksgeneesheer 'n verpligting om te help met die administrasie van geregtigheid, in teenstelling met die tradisionele verpligting om te sorg vir hul pasiënte, en hul welstand eerste te plaas. Hierdie getrouheid gaan gepaard met beide regspleging, sowel as die welstand van die pasiënt, wat kan lei tot 'n etiese dilemma van dubbele lojaliteit. Dubbele verpligtinge bied 'n etiese dilemma vir die distriksgeneesheer, veral as hulle in konflik en wedersyds uitsluitend is. Ek bespreek die aanhouding en die daaropvolgende dood van Steve Biko om te illustreer hoe dubbele verpligtinge kan lei tot ernstige skending van menseregte en selfs die dood. Dubbele verpligtinge is egter nie beperk tot die gevangenes en polisie-aanhouding instellings nie, en ek demonstreer dit deur die bespreking van drie ander “scenario's” wat oor die algemeen eervaar word deur distriksgeneeshere. Daar is 'n gebrek aan duidelike riglyne vir distriksgeneeshere wat 'n botsing van verpligtinge in die gesig staar. Ek verken verskeie etiese teorieë insluitende konsekwensialisme, deontologie en deugde-etiek, op soek na 'n etiese raamwerk geskik vir die oplossing van konflikte in kliniese geregtelike geneeskunde. Ek argumenteer dus dat 'n pligsgebaseerde etiese raamwerk sentraal is tot kliniese forensiese geneeskunde, en die resolusie van lojaliteit konflikte. Ek beveel die oplossing van konflikte deur die gebruik van 'n benadering wat ontwikkel is deur Benjamin (2006). Hierdie benadering behels 'n gewigsoorweging tussen die verskillende pligte in konflik, die toepassing van filosofiese redenasie en verbetering. Deur die aanneming van 'n gestruktureerde en beredeneerde etiese raamwerk, sal distriksgeneeshere dus in staat wees om konflikte van verpligtinge beter te hanteer.

O presente trabalho tem por finalidade apresentar algumas contribuições da Medicina Legal para a compreensão da violência doméstica contra a mulher. Para tanto, o trabalho parte de uma visão geral sobre a violência como fenômeno social para se chegar à ideia de violência de gênero, na qual a violência doméstica contra a mulher se encontra inserida. Após, são apresentados alguns documentos internacionais sobre violência contra a mulher para se chegar ao processo de formação da Lei nº 11.340/06. As inovações da Lei nº 11.340/06 quanto ao crime de lesão corporal são apresentadas a seguir, culminando com a apresentação de tópicos de relevância médico-legal pertinentes à questão da violência doméstica contra a mulher. / The present work aims to present some contributions of Forensic Medicine to understanding domestic violence against women. To this end, the work presents an overview of violence as a social phenomenon to arrive at the idea of gender violence, in which domestic violence against women is inserted. In the following, some international documents on violence against women are presented to reach at Lei nº 11.340/06s formation process. The innovations of Lei nº 11.340/06 regarding the crime of personal physical injury are presented below, culminating with the presentation of relevant topics pertaining to the medical-legal issue of domestic violence against women.

Análise semiquantitativa do parênquima distal de pulmões obtidos em autópsia de vítimas de morte por ação do fogo e por sufocação, foi feita para avaliar as alterações em bronquíolos e tecido alveolar (ductos e alvéolos). A análise discriminante dos parâmetros obtidos permitiu classificação de 74% / A semiquantitative analysis of the distal parenchyma in lung autopsies of victims of death by fire and death by suffocation, was done to evaluate the changes in membranous bronchiolar and alveolar tissue (alveolar ducts and alveoli). The discriminant parameters obtained permitted classification of 74% of cases

Este ensaio inicia-se com um sucinto painel a respeito de uma pesquisa bibliográfica sobre Medicina Legal que começa com Ambroise Paré em 1532 e chega ao ano de 2008; pesquisa esta que muito nos ajudou no planejamento desta Tese. É preciso que se diga que o conceito de Medicina Legal só aparece em 1621 com Paolo Zacchia (Quaestiones Medico Legales...). Nosso objetivo neste trabalho envolve diferentes aspectos teóricos dessa ciência. O primeiro é o de demonstrar que a Medicina Legal pode ser a ciência de uma classe no sentido da Lógica e que ela não seria, portanto, a exemplo da Medicina Clínica, uma ciência do indivíduo, como diz Gilles Granger em sua obra sobre Epistemologia já tornada célebre. O segundo aspecto teórico seria o de propor a Medicina Legal como uma ciência do freqüente aristotélico (hòs epì tò polú ws epi to polu - termo cunhado pelo helenista Porchat Pereira, enquanto conceito filosófico) graças ao qual situamos nossa ciência entre o acidental e o necessário e universal do pensamento lógico-matemático. Em terceiro lugar discorreremos sobre o fato de que os laudos médico-legais estão normalmente restritos a constatação empírica e, então, iremos demonstrar a também indispensável consideração das condições a priori da possibilidade de se estabelecer o visum et repertum, ou seja, a consideração do papel do encéfalo na leitura da experiência possível ao ser humano, numa linguagem atual. No que diz respeito à prática, realizamos uma pesquisa na qual analisamos 996 laudos médico-legais, no Brasil, cujos problemas nos remeteram à questão do Método. Sobre o Método, consideramos as teorias de Aristóteles, Descartes, Kant, Popper, Piaget e Granger, deixando de lado os grandes empiristas como Francis Bacon, David Hume, Stuart Mill, na medida em que suas teorias, devido às crenças embutidas no próprio Empirismo, não há lugar para o cérebro como condição primeira de qualquer tipo de leitura da experiência no mundo sensível. Ora, muitos biólogos, inclusive no Brasil, a partir do Prêmio Nobel em Fisiologia ou Medicina, Konrad Lorenz, consideram que o a priori kantiano pode ser interpretado hoje, como o aspecto endógeno, orgânico, da possibilidade humana de conhecer o mundo (o encéfalo) necessário a toda e qualquer leitura da experiência vivida, sobretudo quando houver a necessidade de explicá-la e reportá-la a terceiros. No caso da Medicina Legal, reportá-la à Justiça, com muitíssimas implicações psico-sociais. Nós proporemos então, à Medicina Legal, um Método Dialético, procurando demonstrar suas vantagens teóricas e práticas. / This essay begins with an overview of a bibliographic research on Forensic Medicine, from its early onset with Ambroise Paré, in 1532, up to the present. This research played an important role on the planning of this thesis (it is important to emphasize that the proper concept of Forensic Medicine, however, appears only in 1621 with Paolo Zacchia,-Quaestiones-Medico-Legales...). Our purpose in this work includes many theoretical aspects of this science, first of all, to show that Forensic Medicine should be considered a science of a class in the sense of Logic, instead of, as in Clinical Medicine, \"a science of the individual\", as stated by Gilles Granger in his already classical work on epistemology. The second theoretical objective will be to propose Forensic Medicine as a science of the \"Aristotelian frequent (hòs epì tò polú term coined by the Hellenist Porchat Pereira as a philosophical concept), through which such science should find its place between the realm of the mere accidental, and that of the necessary and universal, proper to the logic-mathematical reasoning. Thirdly, we also address the problem that the forensic reports are usually limited to empirical observations, and, then, we will also demonstrate the necessity to take into account a priori conditions of the possibility of the making of Visum et repertum, that means, we aim to consider the role of the brain in the framing of the human beings accessible experience, through a contemporary approach. On the empirical side, we conducted an extensive research, analyzing 996 Brazilian forensic reports, whose problems led us to questioning the generally used method. On the method, we discussed the theories of Aristotle, Descartes, Kant, Popper, Piaget and Granger, leaving aside the great empiricists such as Francis Bacon, David Hume, Stuart Mill, as in their theories, due to the embedded beliefs of empiricism, there is no room for the brain as the first condition of the possibility of any kind of sensory experience of the world. However, many biologists worldwide (Brazil included), since the work of Konrad Lorenz (Nobel Prize, Physiology or Medicine, 1973) has begun to circulate amid the scientific community, moved to consider that the Kantian a priori can be interpreted as the endogenous aspect (organic) of the human ability to apprehend the world, necessary to any construction of actual experience, especially when there is an intent to explain and report it to others. In the case of Forensic Medicine, it means reporting the findings to the Judicial System, which entails many psycho-social effects. Finally, we propose to Forensic Medicine a dialectical method, aiming to demonstrate its theoretical and practical advantages.

<p>Kratki uzastopni ponovci predstavljaju klasu mikrosatelitskih segmenata DNK, rasprostranjenih &scaron;irom genoma čoveka. Građeni su od uzastopno ponavljajućih sekvenci dužine 2-6 parova nukleotida. Zahvaljujući različitom broju ponavljanja repetitivne jedinice, većina mikrosatelitskih markera pokazuje visok stepen polimorfizma dužine, koji je moguće ispitati primenom tehnike lančane reakcije polimeraze. Pored utvrđivanja spornih srodničkih odnosa, analiza X hromozom mikrosatelitskih markera može se uspe&scaron;no koristiti i u oblastima kriminalistike, humane identifikacije, populaciono-genetičkim i demografskim istraživanjima i dr. Cilj istraživanja je izrada populacione studije, iz koje će se izračunati broj i frekvencija alela, struktura i frekvencija haplotipova, utvrditi vrednosti relevantnih statističkih parametara, oceniti mogućnost primene analize X-STR markera u slučajevima iz oblasti medicinske kriminalistike, humane identifikacije i ve&scaron;tačenja spornih srodničkih odnosa u populaciji Vojvodine. Istraživanjem je obuhvaćeno 200 odraslih, međusobno nesrodnih osoba. Izolacija DNK materijala iz krvnih mrlja vr&scaron;ena je Chelex metodom, a amplifikacija dobijenih uzoraka DNK metodom PCR, uz kori&scaron;ćenje komercijalnog Mentype&reg; Argus X-12 PCR Amplification Kit &ndash; a. Razdvajanje i detekcija dobijenih fragmenata izvr&scaron;eno je kapilarnom elektroforezom GeneScan i Genotyper programom. Statististička obrada rezultata izvr&scaron;ena je pomoću Arlequin i GENEPOP programa. Za vizuelizaciju interpopulacionih genetičkih odnosa, upotrebljen je program POPTREE2 i koordinatna analiza (Principal Coordinate Analysis - PCoA). Dobijeni rezultati ukazuju da se analiza ispitivanih X-STR markera može uspe&scaron;no primeniti u slučajevima iz oblasti medicinske kriminalistike, humane identifikacije i ve&scaron;tačenja spornih srodničkih odnosa u populaciji Vojvodine, kao i da mogu poslužiti kao osnova za dalja istraživanja u&nbsp; populacionogenetičkim, antropolo&scaron;kim, demografskim i drugim oblastima.</p> / <p>Short tandem repeats (STR) represent a class of microsatellites, widely spread throughout the human genome, consisting of tandemly repeated sequences of 2-6 bp. Related to variation in the number of repeat unit displayed, most of microsatellites show a high degree of length polymorphism, investigated by the PCR techniques. The aim of this research is to create a population study, which will be used to calculate allele and haplotype frequencies, determine the value of relevant statistical parameters and assess the possibility of applying X-STR markers analysis in the fields of forensics, human identification and kinship testing. The study included 200 unrelated adults. DNA isolation was performed by Chelex method and DNA amplification by PCR, using commercial Mentype Argus X-12 PCR Amplification Kit. Separation and detection of fragments was obtained by capillary electrophoresis using Gene Scanand Genotyper program. Statistical analysis of the result was performed using Arlequin and GENEPOP program. For visualization of inter population genetic distances POPTREE2 program and coordinate analysis (PCoA) was used. The results show that the analysis of X-STR markers can be successfully applied in the field of forensics, human identification and kinship testing in the population of Vojvodina, as well as to serve as a basis for further research in population genetic, anthropological, demographic and other scientific areas.</p>

Due to concerns about international differences in treatment effectiveness, many countries are reluctant to extrapolate overseas clinical data to form the basis of guideline recommendations and intervention approval processes. The evidence on which these concerns are based, however, comes from a limited dataset, with few studies directly assessing international differences in treatment effectiveness. This study aims to assess differences in the results of cardiovascular trials between Europe, North America, and Asia using the panoramic meta-analysis approach. All meta-analyses containing randomised control trials for the treatment or prevention of cardiovascular diseases were searched for in The Cochrane Library (2000 to 2008) and Medline (2005-2008). Analysis was then conducted within and over the included meta-analyses by performing pair-wise comparisons of the trial results between Europe and North America, Europe and Asia, and North America and Asia and a universal comparison of all three continents’ trial results together. All analyses were conducted over fatal and non-fatal endpoints. The findings suggested that for both endpoints, interventions performed best in Asian trials. For fatal endpoints, a high proportion of positive trial results were observed for Japan. Further investigation showed that between-continent differences in treatment effect could be explained by between-continent differences in trial quality. However, the types of intervention prone to inter-continental differences could not be identified for fatal or non-fatal endpoints. These findings suggest that those developing guidelines and approving interventions should be cautious when extrapolating overseas data. In particular, this study highlights the importance of taking trial quality into account when extrapolating and interpreting clinical trial data from different regions.

A saliva pode ser utilizada como fonte eficiente de DNA para tecnicas de identificacao humana, as quais sao aceitas como prova legal, sendo o parecer do profissional superlativo para a formulacao da sentenca. Esse material pode ser coletado de maneira indolor e nao-invasiva e utilizado mesmo quando armazenado em diferentes condicoes. Este trabalho objetiva avaliar a qualidade do DNA obtido de saliva humana armazenada e sua aplicabilidade da identificacao de pessoas. Foram analisadas amostras salivares de n=100 sujeitos da pesquisa, coletadas nas formas de saliva in natura e saliva coletada de swab. A saliva foi armazenada a -20ºC. Apos 7 dias, realizou-se a primeira etapa, quando o DNA foi extraido das 200 amostras de saliva utilizando-se a resina InstaGene (Bio-Rad Laboratories, Inc., Hercules, CA, USA) e, posteriormente, submetido a PCR e a eletroforese. Apos 180 dias de armazenamento da saliva, repetiu-se a mesma tecnica da primeira fase, porem em apenas 20 amostras, selecionadas aleatoriamente do total de 100 amostras de saliva coletadas por swab bucal. Os resultados da primeira etapa indicaram que o DNA foi extraido com sucesso em 96% das reacoes realizadas para as 200 amostras de saliva, fato observado tambem quando se analisou as amostras em separado, de saliva in natura (94%) e saliva advinda do swab (98%). Alem disso, nao houve diferencas estatisticamente significantes na extracao do DNA entre as duas formas de coleta de saliva utilizadas. Na segunda fase, foi possivel a deteccao do gene alvo nas 20 amostras analisadas (100%). Posteriormente, objetivando-se aprofundar a analise do DNA salivar de maneira mais proxima ao padrao exigido em um processo de identificacao, o gene SIX3-2 foi testado nas amostras e tambem foi feita a digestao do produto da PCR com a enzima de restricao MbO1 para avaliar polimorfismo do gene ADRA-2. Os resultados mostraram que a quantidade e a qualidade do DNA advindo de saliva do swab bucal, bem como as tecnicas empregadas estao adequadas a analise forense do DNA. Portanto, a saliva humana e bastante util como fonte de DNA e pode ser armazenada, em temperatura e condicoes ideais, para analise posterior. / The saliva can be used as efficient DNA source for human identification techniques in which they are accepted as forensic proof, being the superlative professionals opinion for the sentence formulation. This material can be collected in a painless and noninvasive way and it is used even when stored in different conditions. This paper aims at evaluating DNA quality obtained from stored human saliva and its applicability in people identification. Saliva samples from n=100 research subjects were analyzed. They were collected in two ways: in natura and swab. The saliva was stored at the temperature of -20°C. After 7 days, the first phase was performed, when the DNA was extracted from the 200 saliva samples using the InstaGene resin (Bio-Rad Laboratories, Inc., Hercules, CA, USA) and, subsequently, submitted to PCR and electrophoresis. After 180 days of the saliva storage, the same technique used in the first phase was repeated; however, in only 20 samples, selected at random from the total of 100 ones collected from mouth swab. The results of the first phase indicated that the DNA was successfully extracted in 96% of the reactions performed for the 200 saliva samples. This fact was also observed when the separate saliva samples in natura (94%) and swab (98%) were analyzed. In addition, there were no statistically significant differences in the extraction of the DNA between the two ways used for collecting saliva. In the second phase, the target gene detection was possible in the 20 samples analyzed (100%). Subsequently, the SIX3-2 gene was tested in the samples with the objective of deepening the salivary DNA analysis as close as the standard required in an identification process. Also, the digestion of the PCR product with the enzyme of MbO1 restriction was performed to evaluate the polymorphism of the ADRA- 2 gene. The results showed that the DNA quantity and quality from the mouth swab saliva, as well as the techniques applied are suitable for the forensic analysis of DNA. Therefore, the human saliva is very useful as DNA source and can be stored in ideal temperature and conditions for further analysis.

Análise semiquantitativa do parênquima distal de pulmões obtidos em autópsia de vítimas de morte por ação do fogo e por sufocação, foi feita para avaliar as alterações em bronquíolos e tecido alveolar (ductos e alvéolos). A análise discriminante dos parâmetros obtidos permitiu classificação de 74% / A semiquantitative analysis of the distal parenchyma in lung autopsies of victims of death by fire and death by suffocation, was done to evaluate the changes in membranous bronchiolar and alveolar tissue (alveolar ducts and alveoli). The discriminant parameters obtained permitted classification of 74% of cases

How do medical students experience autopsy demonstrations that form part of the undergraduate curriculum? This was the primary question guiding this phenomenological study within the interpretive paradigm. Both explicit cognitive outcomes and elements of the “hidden curriculum” associated with autopsies were evaluated. Most previous studies on this topic employed survey questionnaires and were conducted prior to the radical curriculum reformations in medical undergraduate training. Some of these pedagogical changes have threatened the use of autopsies for teaching. More recently some other studies concentrated on aspects that were not directly related to educational outcomes. Burton (2003) conducted a phenomenological study interviewing medical educators about the uses of autopsy in the modern undergraduate curriculum, essentially detailing the “delivered curriculum”. Therefore this study focused on the “received curriculum”. Interviews were conducted with 10 medical students in their 4th year of study, having attended medico-legal autopsy demonstrations forming a central part of a course in Forensic Medicine. The underlying assumption of the study is that ‘student voices’ need to be heard in determining what is taught and how (Brooker & MacDonald, 1999), something typically determined by academic staff. This need is especially highlighted in a climate of “self-directed learning” promoted by modern medical curricula. The data are analysed qualitatively using a theoretical framework of three dimensions of learning (Illeris, 2004): (1) cognitive content dimension, (2) emotional psychodynamic, attitudinal and motivational dimension, (3) social-societal dimension. Findings of the study show that medical students perceive autopsy demonstrations to be of considerable benefit to their learning; both cognitive and affective outcomes are discussed detailing individual contextual factors that influenced the outcomes. Some suggestions regarding curriculum and autopsy-based teaching are made in the light of various factors found to influence students’ attitudes towards autopsies. / Thesis (M.Ed.)-University of KwaZulu-Natal, Pietermaritzburg, 2007.