Barriers and solutions for the management of severe hypoglycaemia in people with diabetes in Spain: A Delphi survey

BACKGROUND AND OBJECTIVE

Severe hypoglycaemia (SH) imposes a significant burden for people with diabetes (PwD), their caregivers (CGs), and the healthcare system. The study aimed to identify barriers and solutions in the management of SH in PwD in Spain, gathering consensus from physicians and nurses.

MATERIAL AND METHODS

Expert opinion from physicians and nurses who manage PwD was collected via a 2-round online Delphi method. Consensus was predefined as ≥ 70% of the panellists agreeing or disagreeing with the statement.

RESULTS

Physicians (n = 25) and nurses (n = 17) reached ≥ 90% consensus on the following barriers for the management of SH: absence of symptoms, cost to the health system, lack of implementation of glucose monitoring devices, lack of patient training to identify and manage SH, and the fear of SH in children and CGs. Main solutions, identified with ≥ 70% consensus, included training, education, and psychological support using diabetes nurse educators and the use of new glucose monitoring technologies and applications.

CONCLUSIONS

This study provides valuable insights on the barriers and solutions in the management of SH in Spain. Structured self-management training, the support of diabetes educators, and the use of insulin delivery devices and glucose monitoring technologies is required for the management of SH.

Roadblocks at every turn: What reproductive health experts say about barriers to legislative abortion advocacy

OBJECTIVES

Advocacy is an important part of the reproductive health care profession, but barriers to participating in the legislative process are not well understood. This study examines the barriers experts in reproductive health experience to testifying at state legislative committee hearings regarding abortion.

STUDY DESIGN

We conducted in-depth semistructured interviews with 40 experts in reproductive health, including obstetrician gynecologists (OBGYNs), midwives, pediatricians, nurses, primary care providers, and professional advocates. We analyzed the interview transcripts using an inductive coding process.

RESULTS

We identified four barriers to testifying at state legislative committee hearings regarding abortion. First, our interviewees described a tension between claiming expertise and stigma: those without direct experience in abortion care often felt too unqualified to testify, but representing oneself as an abortion provider came with stigma that made communicating with legislators difficult. Second, issues of power and identity informed interactions in committee chambers, as well as the structure of advocacy work more broadly. Third, institutional constraints shaped what experts could say and whether they could rely on their professional affiliations for support. Finally, fear of harassment and violence kept many of our interviewees from testifying, especially those who were active abortion providers.

CONCLUSIONS

These barriers appear unique to testifying on abortion and represent a complex web of hurdles that experts in reproductive health must navigate to participate in this part of the policymaking process.

IMPLICATIONS

Our findings suggest multiple strategies for improving the state of expert involvement in abortion policymaking, including expanding the pool of testifiers to include nonabortion providers and experts with a range of backgrounds, as well as supporting organizations that link experts to training and advocacy networks.

Experts' decision-making processes in Swedish forensic psychiatric investigations: A case vignette study

It has previously been demonstrated that decisions made by forensic experts can suffer from issues with both bias and poor reliability. The outcome of Swedish forensic psychiatric investigations can have a major impact on the courts' choice of sanction for a mentally disordered offender. These investigations are performed by multi-professional teams of experts, where each expert is obliged to state their opinion on whether the client has a severe mental disorder (SMD) or not. In the present study, a case vignette design was used to simulate the decision-making process of forensic psychiatric investigations. Of the 73 Swedish experts working with forensic psychiatric investigations, a total of 27 (37%) participated in the study. The results showed that the Swedish experts formulated multiple diagnostic hypotheses about cases throughout the process and revised these hypotheses when presented with new information. There was substantial variation between the experts in which hypotheses were seen as most relevant. While the experts grew more certain of their opinions on SMD during the simulated investigation, there was considerable variation in their opinions both throughout and at the end of the process. Although low statistical power and the sample not being randomized limit generalizations, the results indicate no idiosyncratic patterns in the decision-making processes of Swedish experts or signs of confirmation bias. If used properly, the variation in both process and outcome could be used to safeguard and possibly increase the reliability and validity of the final decision of Swedish forensic psychiatric investigations.

Recommendations for clinical management of excessive daytime sleepiness in obstructive sleep apnoea - A Delphi consensus study

STUDY OBJECTIVE

Excessive daytime sleepiness is common with obstructive sleep apnoea and can persist despite efforts to optimise primary airway therapy. The literature lacks recommendations regarding differential diagnosis and management of excessive daytime sleepiness in obstructive sleep apnoea. This study sought to develop expert consensus statements to bridge the gap between existing literature/guidelines and clinical practice.

METHODS

A panel of 10 international experts was convened to undertake a modified Delphi process. Statements were developed based on available evidence identified through a scoping literature review, and expert opinion. Consensus was achieved through 3 rounds of iterative, blinded survey voting and revision to statements until a predetermined level of agreement was met (≥80 % voting "strongly agree" or "agree with reservation").

RESULTS

Consensus was achieved for 32 final statements. The panel agreed excessive daytime sleepiness is a patient-reported symptom. The importance of subjective/objective evaluation of excessive daytime sleepiness in the initial evaluation and serial management of obstructive sleep apnoea was recognised. The differential diagnosis of residual excessive daytime sleepiness in obstructive sleep apnoea was discussed. Optimizing airway therapy (eg, troubleshooting issues affecting effectiveness) was addressed. The panel recognised occurrence of residual excessive daytime sleepiness in obstructive sleep apnoea despite optimal airway therapy and the need to evaluate patients for underlying causes.

CONCLUSIONS

Excessive daytime sleepiness in patients with obstructive sleep apnoea is a public health issue requiring increased awareness, recognition, and attention. Implementation of these statements may improve patient care, long-term management, and clinical outcomes in patients with obstructive sleep apnoea.

IRMS based evidence passes the test

At the two latest FIRMS (The Forensic Isotope Ratio Mass Spectrometry Network Ltd) conferences, presentations were made describing the status of IRMS based evidence in criminal proceedings [S. Doyle, T. Chau and J. Howa, IRMS based evidence passes the 'test' (aided by FIRMS) - an important milestone, in: 8th FIRMS Conference, 2022; J. Ehleringer, J. Howa and T. Chau, Stable isotope evidence in the U.S. courts, in: 7th FIRMS Conference, 2019]. One of those cases was of particular significance in that it established the admissibility of IRMS (isotope ratio mass spectrometry) based expert testimony having satisfied the US Federal Rule of Evidence (FRE)702 'Testimony by Expert Witnesses' in the State of Colorado. While specific to the State of Colorado and the particulars of the case, the admissibility of IRMS based evidence in other cases might be supported by such a ruling. This paper provides the detail of the process by which IRMS based evidence was found to be admissible and in so doing also provides practical guidance on how to satisfy FRE 702 and meet a Daubert challenge. It also highlights the role of approval by the FIRMS Network of both practitioners and their methods in support of admissibility [The FIRMS Network Ltd., FIRMS Approved Practitioners, [Online]. Available: https://www.forensic-isotopes.org/fafp.html [Accessed 11 May 2023].].

Implanting rich autobiographical false memories: Meta-analysis for forensic practice and judicial judgment making

Objective

The implanting of rich autobiographical false memories is crucial for judicial decision-making, and the forensic evaluation of a testimony. In order to assess this issue, a meta-analytical review of the probability of implanting rich autobiographical false memories was performed.

Method

A total of 30 primary studies analysing the probability of implanting rich autobiographical false memories were retrieved. Random-effects meta-analyses correcting the effect size for sampling error were performed.

Results

The results revealed a significant, positive, generalizable (the lower limit for the 80% credibility value was d = 1.13), and more than large mean effect size (d = 1.43[1.33, 1.53]) for the implanting of false memory. The moderating effects of stimulus type showed that the effect of the probability of implanted false memory was significantly higher in experienced events (d = 2.03[1.63, 2.43]) than in false narratives (d = 1.35[1.23, 1.47]), and in doctored photographs (d = 1.29[1.06, 1.52]). A similar effect for memory implantation was observed in both the underage (d = 1.44[1.29, 1.59]), and in adults (d = 1.36[1.22, 1.50]). The moderator techniques for implanting false memories revealed a significantly lower probability of implanting false rich memory with non-directive instructions (d = 0.90[0.53, 1.27]) than with guided imagery (d = 1.45[1.32, 1.58]), or with pressure to answer (d = 1.56[1.17, 1.95]) instructions. The event emotional valence moderator exhibited the same effect for positive (d = 1.27[1.09, 1.45]) and negative valence events (d = 1.30[1.17, 1.43]).

Conclusions

The implications of the results for forensic testimony evaluation, police interrogations, and judicial cross-examination are discussed.

Developing inpatient suicide prevention strategies in medical settings: Integrating literature review with expert testimony

OBJECTIVE

According to some recent evidence, suicide rate is higher in inpatients than in the general population around the world. However, suicide prevention strategies (SPS) are poorly focused and understood in medical settings. This study aimed to develop effective SPS and interventions in medical settings of Iran and provide evaluation checklists/procedures for them.

METHODS

The study was performed in two steps, including literature review and expert opinions panel. In the first stage, we conducted a comprehensive literature review to find relevant suicide prevention programs, strategies, interventions, or any efforts to prevent suicide in the medical settings. In the second stage, an expert panel was arranged for developing effective and feasible SPS in medical settings. Data were analyzed through content analysis approach.

RESULTS

Overall, 11 records were included in the literature review. SPS varied from staff training, safety plan and quality improvements, and prevention programs to therapy methods. Finally, in the second stage, the following seven major SPS were recommended by the expert panel: 1) Integration and application of obtained suicidal behavior data through evaluating medical records, 2) Screening and suicide risk assessment, 3) Staff training, 4) Quality improvement, 5) Follow-up of inpatients with high-risk behaviors, 6) Reducing stigma and improving public awareness, and 7) Follow-up of discharged high-risk inpatients. Also, 23 interventions within the strategies were presented.

CONCLUSION

Given that SPS are poorly focused in medical settings, the practical framework that emerged in this study could be used to develop or advance SPS in various medical settings.

Trusting scientific experts in an online world

A perennial problem in social epistemology is the problem of expert testimony, specifically expert testimony regarding scientific issues: for example, while it is important for me to know information pertaining to anthropogenic climate change, vaccine safety, Covid-19, etc., I may lack the scientific background required to determine whether the information I come across is, in fact, true. Without being able to evaluate the science itself, then, I need to find trustworthy expert testifiers to listen to. A major project in social epistemology has thus become determining what the markers of trustworthiness are that laypersons can appeal to in order to identify and acquire information from expert testifiers. At the same time, the ways in which we acquire scientific information has changed significantly, with much of it nowadays being acquired in online environments. While much has been said about the potential pitfalls of seeking information online (e.g. the prevalence of filter bubbles, echo chambers, and the overall proliferation of "fake news"), little has been said about how the nature of seeking information online should make us think about the problem of expert testimony. Indeed, it seems to be an underlying assumption that good markers of trustworthiness apply equally well when seeking information from expert testifiers in online and offline environments alike, and that the new challenges and opportunities presented by online environments merely affects the methods by which we can acquire evidence of said trustworthiness. Here I argue that in making this assumption one risks failing to account for how unique features of the ways in which we acquire information online affect how we evaluate the trustworthiness of experts. Specifically, I argue for two main claims: first, that the nature of information-seeking online is such that the extent to which information is susceptible to manipulation is a dominant marker of trustworthiness; second, as a result, one will be more likely to seek out a particular kind of expert testifier in online environments, what I call a cooperative as opposed to preemptive expert. The result is that criteria for expert trustworthiness may look significantly different when acquiring information online as opposed to offline.

Highly cited forensic practitioners in the discipline legal and forensic medicine and the importance of peer-review and publication for admission of expert testimony

Peer-review of manuscripts submitted to scholarly journals for publication dates back ~ 350 years and this process represents the foundation of scientific publishing. After a manuscript has undergone and survived a rigorous peer-review, this conveys a stamp of approval, because it signifies the work has been checked by independent experts in the scientific discipline concerned. The publication and citation track records of people instructed to appear as expert witness in civil and criminal litigation are important considerations. Using a publically available database, the most highly cited scientists in the discipline legal and forensic medicine were identified. For each scientist, a composite score was calculated based on six different citation metrics; (i) Total number of citations, (ii) H-index, (iii) H_m-index, which modifies the H-index for multi-authored papers, (iv) Citations to single-author papers, (v) Citations to single and first author papers and (vi) citations to single, first and last author papers. The top 100,000 most highly cited scientists from all disciplines were identified along with the top 2% of the most highly cited in each of 176 sub-fields. The latest version of the citation databases, up to the end of 2020, classified 14.163 people as having legal and forensic medicine as their primary research discipline. Of these, there were 29 names listed among the top 100,000 most highly cited in all disciplines and 299 were among the top cited 2% in their particular sub-field. More than 50% of the highly cited forensic practitioners resided in four countries (USA, Germany, UK and Australia). The top-ten most highly cited individuals were the same in all four versions of the database (2017, 2018, 2019 and 2020) and represented the sub-disciplines of toxicology (n = 3), genetics/DNA/heredity (n = 3), whereas two specialized in pathology/toxicology and two in pathology/genetics.

The decision-making process in Swedish forensic psychiatric investigations

Forensic psychiatric investigations in Sweden can have a major impact on the choice of sentence in criminal cases. Previous research shows that the decisions in several forensic fields, including forensic psychiatry, can be affected in a negative way by factors not relevant to the case. In the present study, the decision-making process of forensic psychiatric investigations was explored by using semi-structured interviews with experts (n = 38) and analyzing these interviews thematically. The results showed that the decision-making process is both complex and iterative, where the experts use and shape a substantial amount of information to reach their decisions. The experts work in teams, which add both benefits and risks to the process, and feel that particularly time constraints may reduce the quality of their decisions. In summary, the decision-making process of Swedish forensic psychiatric investigations creates a potential for high validity, but also contains risks for bias effects that could warrant further mitigation.

Expert participation in 25 years of Wisconsin abortion policymaking

OBJECTIVE

State-level abortion restrictions grew considerably in number over the last two decades. This study examines the scope of expert testimony given in legislative committee hearings at which these laws are first debated.

STUDY DESIGN

We gathered 265 testimonies given by experts at Wisconsin legislative committee hearings on 34 abortion bills from 1995-2019. We coded testimonies to identify testifiers' ideological leaning and source of expertise. We conducted descriptive analyses of testifiers' participation.

RESULTS

Experts with anti-abortion rights views testified more often than experts with pro-abortion rights views (2.1 vs 1.4 testimonies per expert). Experts with an activism background testified more often than experts in medicine (2.5 vs 1.3 testimonies per expert). Anti-abortion activist experts represented the largest proportion of testimonies (32%) but the smallest proportion of testifiers (16%). Pro-abortion rights medical experts gave the fewest testimonies (24%) relative to their proportion of testifiers (31%). The number of testimonies given by pro-abortion rights activist experts remained stable over the study period. Testimonies given by all other kinds of experts were more numerous in recent years.

CONCLUSIONS

The experts who testify most frequently tend to espouse anti-abortion views and have backgrounds in activism rather than healthcare. These repeat testifiers may have more opportunities to build relationships with legislators and thus influence policy. Anti-abortion rights activist experts' outsized role in legislative hearings, especially in recent years, should concern advocates of evidence-based reproductive health policy. Medical experts may be deterred from giving testimony by logistical or other structural barriers in the legislative process.

IMPLICATIONS

The family planning field should conduct more research on the role of experts in abortion policymaking. Future studies should examine testifiers in other states and identify barriers pro-abortion medical experts may face to testifying, as these experts are key for creating evidence-based abortion policy.

Overturned abusive head trauma and shaken baby syndrome convictions in the United States: Prevalence, legal basis, and medical evidence

BACKGROUND

Media reports and the Innocence Network assert that wrongful Abusive Head Trauma (AHT)/Shaken Baby Syndrome (SBS) convictions pervade the United States (U.S.) criminal justice system. Yet, no empirical evaluation of overturned AHT/SBS convictions has been conducted.

OBJECTIVE

To evaluate the prevalence, legal basis, and characteristics of appellate rulings of AHT/SBS convictions.

PARTICIPANTS AND SETTING

U.S. appellate cases in a legal database, Westlaw.

METHODS

Retrospective review of AHT/SBS convictions that had appellate rulings from January 2008 through December 2018. Multiple search terms ensured all potential AHT/SBS cases were included. A mixed-methods analysis was conducted on overturned AHT/SBS convictions.

RESULTS

We identified a total of 1431 unique AHT/SBS criminal convictions that had appellate rulings since 2008. Of those, 49 convictions (3%) were overturned, and 1382 (97%) were affirmed/upheld. Of those overturned, 20 cases (1% overall) were overturned on medical evidence-related grounds. The most common themes from the medical evidence-related reversals were controversy over the AHT/SBS diagnosis (n = 12) and accidental injury mechanism (n = 11). After being overturned on appeal, upon retrial, 42% of defendants either re-plead guilty to or were convicted again of the same offense.

CONCLUSION(S)

AHT/SBS convictions are rarely overturned on medical evidence-related grounds. When overturned, medical evidence-related themes seldom reflect new scientific or clinical discoveries, but rather are alternative or differing medical opinions from those offered at the original trial. Our data tends to support the concerns of other authors regarding irresponsible communication of medical information in AHT/SBS cases.

[Intervertebral disc-related occupational diseases of the lumbar and cervical spines]

Intervertebral disc-related diseases of the cervical and lumbar spine are considered to be occupational diseases, if the occupational and medical prerequisites are fulfilled and the causal connection between the prerequisites is likely. The working conditions include occupational burdens with long-term lifting and carrying of heavy loads or long-term activities in an extremely bent position of the torso, long-term carrying of heavy loads on the shoulders and long-term effects of whole-body vibration in a sitting position. A medical prerequisite is fulfilled by a damage pattern with chronic lower back or neck pain and damage of the cervical or lumbar vertebrae in a conform manner.In the legal assessment the occupational conditions are examined by the preventive services of the statutory accident insurance and the medical conditions by the medical expert. Furthermore, the medical expert examines the causal connection between the fulfilled prerequisites, whereby the temporal connection (reaching the minimum load dose before realization of the conform damage pattern) and by exclusion of other competing factors are essential. As of 1 January 2021 the necessity to quit the burdening occupation has been omitted by law.

The use of cardiac computed tomography angiography in the assessment of percutaneous left atrial appendage closure - Review and experts recommendations endorsed by the Société française d'imagerie cardiaque et vasculaire diagnostique et interventionnelle

Atrial fibrillation is the most common cause of arrhythmia which is responsible for over 15% of ischemic strokes, most of these being secondary to migration of a left atrial appendage (LAA) thrombus. In patient with contraindication to anticoagulant therapy, percutaneous closure system placement may be indicated. Cardiac computed tomography (CT) angiography plays a central role in the initial assessment as well as in the follow-up. The purpose of the pre-implantation cardiac CT angiography is to evaluate the anatomy of the LAA in order to select the most suitable prosthesis and check for any contraindication to device implantation. Image analysis is divided into four steps that include analysis of the approach; search for a thrombus in the LAA; investigation of the anatomy of the LAA (morphology of the LAA, dimensions of the LAA and choice of device) and cardiac and thoracic assessments. Follow-up involves CT examination to check for correct placement of the device and to detect any complications. On the basis of the results of currently available published research, a panel of experts has issued recommendations regarding cardiac CT angiography prior to percutaneous LAA closure device placement, which were further endorsed by the Société française d'imagerie cardiaque et vasculaire diagnostique et interventionnelle (SFICV).

Expert opinion on the way forward for improving maternal influenza vaccination in India

INTRODUCTION

: Rates of maternal vaccination against influenza are extremely low in India. An expert panel of obstetric-gynecologists and pediatricians met to develop consensus-based recommendations for improving awareness of the benefits of influenza vaccination during pregnancy in India.

AREAS COVERED

: The group discussed experiences of influenza infection in pregnancy and infancy before focusing on maternal vaccination practices in India, including the degree of communication between obstetric-gynecologists and pediatricians and opinions on optimal timing for vaccination. The impact of inconsistent vaccine prescription practices by healthcare providers was discussed, as well as current clinical recommendations on maternal influenza vaccination.

EXPERT OPINION

: Although clinical evidence demonstrates the benefit of maternal influenza vaccination in any trimester, influenza vaccination is not widely accepted in India as an integral part of antenatal care. There is a lack of familiarity among obstetricians of clinical guidelines on maternal influenza vaccination. This can be addressed with an education campaign targeting obstetricians and other providers of maternal healthcare. With variable influenza seasons between regions in India, common vaccine stock shortages, and data suggesting influenza vaccination is feasible anytime in pregnancy, all opportunities to offer vaccination to this high-risk group for severe influenza disease should be considered.

Juror appraisals of forensic evidence: Effects of blind proficiency and cross-examination

Forensic testimony plays a crucial role in many criminal cases, with requests to crime laboratories steadily increasing. As part of efforts to improve the reliability of forensic evidence, scientific and policy groups increasingly recommend routine and blind proficiency tests of practitioners. What is not known is how doing so affects how lay jurors assess testimony by forensic practitioners in court. In Study 1, we recruited 1398 lay participants, recruited online using Qualtrics to create a sample representative of the U.S. population with respect to age, gender, income, race/ethnicity, and geographic region. Each read a mock criminal trial transcript in which a forensic examiner presented the central evidence. The low-proficiency forensic examiner elicited a lower conviction rate and less favorable impressions than the control, an examiner for which no proficiency information was disclosed. However, the high-proficiency examiner did not correspondingly elicit a higher conviction rate or more favorable impressions than the control. In Study 2, 1420 participants, similarly recruited using Qualtrics, received the same testimony, but for some conditions the examiner was cross-examined by a defense attorney. We find cross-examination significantly reduced guilty votes and examiner ratings for low-proficiency examiners. These results suggest that disclosing results of blind proficiency testing can inform jury decision-making, and further, that defense lawyering can make proficiency information particularly salient at a criminal trial.

European reference network for rare vascular diseases (VASCERN) consensus statement for the screening and management of patients with pathogenic ACTA2 variants

The ACTA2 gene encodes for smooth muscle specific α-actin, a critical component of the contractile apparatus of the vascular smooth muscle cell. Pathogenic variants in the ACTA2 gene are the most frequently encountered genetic cause of non-syndromic hereditary thoracic aortic disease (HTAD). Although thoracic aortic aneurysm and/or dissection is the main clinical manifestation, a variety of occlusive vascular disease and extravascular manifestations occur in ACTA2-related vasculopathy. Current data suggest possible mutation-specific manifestations of vascular and extra-aortic traits.Despite its relatively high prevalence, comprehensive recommendations on the care of patients and families with pathogenic variants in ACTA2 have not yet been established. We aimed to develop a consensus document to provide medical guidance for health care professionals involved in the diagnosis and treatment of patients and relatives with pathogenic variants in ACTA2.The HTAD Working Group of the European Reference Network for Rare Vascular Diseases (VASCERN) convened to review current literature and discuss expert opinions on clinical management of ACTA2 related vasculopathy. This consensus statement summarizes our recommendations on diagnosis, monitoring, treatment, pregnancy, genetic counselling and testing in patients with ACTA2-related vasculopathy. However, there is a clear need for additional prospective multicenter studies to further define proper guidelines.

Communicating forensic scientific expertise: An analysis of expert reports and corresponding testimony in Tasmanian courts

Forensic criminology examines the use of forensic science in society. Justice can be hampered, for example, if the communication of forensic scientific findings is unclear or misleading, even if unintentionally. Although various recommendations guide the communication of forensic science, it is unclear whether they are reflected in practice. This study explored the communication of forensic biology in 10 cases of major crimes against the person heard in the Tasmanian Supreme Court, where the standard practice is to issue brief summary reports in the first instance. The content of expert reports and corresponding testimony was analysed to determine its adherence to recommendations outlined in standards, practice notes, and research. While reports were found to be very brief, testimony elaborated on all major elements. Mostly elicited by the prosecution, some elements were volunteered by expert witnesses, or raised by defence. Overall, expert evidence in courts-but not reports (due to the use of brief summary reports)-largely adhered to recommendations. Further research is needed to determine the prevalence and effectiveness of alternative approaches to communication that were identified in certain cases.

Juror comprehension of forensic expert testimony: A literature review and gap analysis

Forensic scientists and commentators including academics and statisticians have been embroiled in a debate over the best way to present evidence in the courtroom. Various forms of evidence presentation, both quantitative and qualitative, have been championed, yet amidst the furor over the most "correct" or "accurate" way to present evidence, the perspective of the fact-finder is often lost. Without comprehension, correctness is moot. Unbeknownst to many forensic practitioners, there is a large, though incomplete, body of literature from the cognitive psychology domain that explores the question of what jurors understand when forensic scientists testify. This body of work has begun to test different proposed methods of testimony in an effort to understand which are most effective at communicating the strength of evidence that is intended by the expert. This article is a review of that literature that is intended for the forensic scientist community. Its aim is to educate that community on the findings of completed studies and to identify suggestions for further research that will inform changes in testimony delivery and ensure that any modifications can be implemented with confidence in their effectiveness.

Credibility Judgment Predictors for Child Sexual Abuse Reports in Forensic Psychiatric Evaluations

OBJECTIVE

We intended to analyze the credibility judgment in written forensic psychiatric reports of child sexual abuse registered in Southern Taiwan.

METHODS

Ninety-six cases of child sexual abuse between August 2010 and October 2017 encountered in two hospitals were analyzed. The.

RESULTS

in these reports were categorized into credible and non-credible. We identified the factors that distinguished between the two groups in bivariate analyses using chi-square test. A binary logistic regression analysis was performed to determine whether the factors that significantly correlated in the bivariate analyses were independent predictors of credible judgments.

RESULTS

Among 96 cases, 70 (73%) were judged as credible. Consistent testimonies of children (odds ratio=40.82) and multiple abuse events (odds ratio=6.05) were positive variables independently related to the sexual abuse allegations judged as credible.

CONCLUSION

The number of allegations judged as credible in this study was slightly higher than that reported in other studies. Our findings about predictors for credible cases are not in line with those reported previously. Due to the differences in resources of the cases and backgrounds of the evaluators among multiple studies, direct comparisons with previous studies must be treated with caution.

Diminished Responsibility: Law Reform in the United Kingdom and Personal Perspective on Forensic Psychiatric Practice in Hong Kong

This commentary discusses law reform on diminished responsibility in the United Kingdom and provides a personal perspective on forensic psychiatric practice relating to diminished responsibility in Hong Kong.

[Design of a questionnaire on the knowledge and attitudes of the population of Madrid (Spain) facing the end-of-life]

OBJECTIVE

To create and validate a questionnaire about knowledge and attitudes of the general population in Madrid (Spain) about life's end stage.

METHOD

A descriptive study designed as a structured self-administered questionnaire, validated by seven Madrid Health Service professional experts and assessed through a pilot study.

RESULTS

The questionnaire consisted of 42 questions, divided into six modules: 1) decisions and psychological-physical care at life's end; 2) palliative care; 3) euthanasia and assisted suicide; 4) advance directives document; 5) spiritual factors; and 6) socio-demographic data.

CONCLUSIONS

The questionnaire was a useful, indirect method to ascertain the opinion of life's end in the Autonomous Region of Madrid. If it were applied in primary health care and hospital care, comparisons could be made among users in different autonomous regions of Spain.

The ongoing quandary of defining the standard of care for neonates

Despite extensive use of the term 'standard of care' (SOC), there is no such medical definition. How are neonatal therapies accepted as SOC with huge centre-to-centre variation? What defines SOC? We will consider paths to acceptance of multiple therapies (antenatal corticosteroids, preventing GBS, others). We conclude single-centre trials drive care, but are not consistently predictive for multicentre trials. Innovation/quality improvement initiatives also alter care, despite strong evidence practice changes take time. Furthermore, there are powerful medico-legal implications if a therapy is designated SOC.

CONCLUSION

Defining SOC is a quandary with more legal implications than medical, but what's most critical is keeping current in a rapidly changing field.

A Judicial Perspective on Expert Testimony in Marijuana Driving Cases

The decriminalization of marijuana and propagation of marijuana prescribed for medical reasons have resulted in an increase in driving while under the influence of marijuana. Currently, the legal definition of marijuana driving impairment varies by state across the United States. Expert witnesses such as drug recognition experts and medical toxicologists are needed during a discovery to educate attorneys and during a testimony to educate judges and juries. These proceedings provide an overview of the US case law about driving impairment, the current status of the legal thresholds used in the courts for the admission of the medical toxicologist as an expert witness in marijuana driving and related cases, and provides an understanding of evolving issues surrounding the admissibility of their scientific opinion testimony.

Updated Guidelines for the Medical Assessment and Care of Children Who May Have Been Sexually Abused

The medical evaluation is an important part of the clinical and legal process when child sexual abuse is suspected. Practitioners who examine children need to be up to date on current recommendations regarding when, how, and by whom these evaluations should be conducted, as well as how the medical findings should be interpreted. A previously published article on guidelines for medical care for sexually abused children has been widely used by physicians, nurses, and nurse practitioners to inform practice guidelines in this field. Since 2007, when the article was published, new research has suggested changes in some of the guidelines and in the table that lists medical and laboratory findings in children evaluated for suspected sexual abuse and suggests how these findings should be interpreted with respect to sexual abuse. A group of specialists in child abuse pediatrics met in person and via online communication from 2011 through 2014 to review published research as well as recommendations from the Centers for Disease Control and Prevention and the American Academy of Pediatrics and to reach consensus on if and how the guidelines and approach to interpretation table should be updated. The revisions are based, when possible, on data from well-designed, unbiased studies published in high-ranking, peer-reviewed, scientific journals that were reviewed and vetted by the authors. When such studies were not available, recommendations were based on expert consensus.

THE GHOST IN THE MACHINE? THE VALUE OF EXPERT ADVICE IN THE PRODUCTION OF EVIDENCE-BASED GUIDANCE: A MIXED METHODS STUDY OF THE NICE INTERVENTIONAL PROCEDURES PROGRAMME

OBJECTIVES

The aim of this study was to determine the aspects of expert advice that decision makers find most useful in the development of evidence-based guidance and to identify the characteristics of experts providing the most useful advice.

METHODS

First, semi-structured interviews were conducted with seventeen members of the Interventional Procedures Advisory Committee of the UK's National Institute of Health and Care Excellence. Interviews examined the usefulness of expert advice during guidance development. Transcripts were analyzed inductively to identify themes. Second, data were extracted from 211 experts' questionnaires for forty-one consecutive procedures. Usefulness of advice was scored using an index developed through the qualitative work. Associations between usefulness score and characteristics of the expert advisor were investigated using univariate and multivariate analyses.

RESULTS

Expert opinion was seen as a valued complement to empirical evidence, providing context and tacit knowledge unavailable in published literature, but helpful for interpreting it. Interviewees also valued advice on the training and experience required to perform a procedure, on patient selection criteria and the place of a procedure within a clinical management pathway. Limitations of bias in expert opinion were widely acknowledged and skepticism expressed regarding the anecdotal nature of advice on safety or efficacy outcomes. Quantitative analysis demonstrated that the most useful advice was given by clinical experts with direct personal experience of the procedure, particularly research experience.

CONCLUSIONS

Evidence-based guidance production is often characterized as a rational, pipeline process. This ignores the valuable role that expert opinion plays in guidance development, complementing and supporting the interpretation of empirical data.

[Clinical forensic imaging. Detection and documentation of internal injuries in living victims of violence]

External examination of the body surface with documentation of all visible findings can still be regarded as the status quo of clinical forensic injury assessment. It is obvious that internal findings cannot be detected using this technique. For obtaining such findings accessible well-established radiological techniques, such as computed tomography (CT) and magnetic resonance imaging (MRI) should be used. Especially MRI with no damaging radiation exposure for the examined person allows the detection of internal soft tissue and organ damage and offers a great potential regarding new techniques for allowing insights into tissue composition and function. Furthermore, imaging data collected in clinical institutions before the patient was transferred to the department of legal medicine will play a major role in the future. Although these data were obtained based on a different approach, they provide excellent and recent information on injuries in the respective (current) case und can therefore be of high value for the forensic expertise.

You can't do that! Hugo Münsterberg and misapplied psychology

This article examines a false start in the application of psychology to the law. While there had been expert testimony from physicians in criminal and civil cases in America since the nineteenth century, forensic psychology first emerged in the early twentieth century. Following European traditions of experimental psychology, Hugo Münsterberg applied the nascent science of memory research to the assessment of witness credibility. A brilliant and popular Harvard professor, Münsterberg touted his technique of word-association to determine truth. Forensic psychology's development was stalled by resistance from within legal authorities, including John Henry Wigmore, the leading expert on evidence. However, Münsterberg was a sensation in popular media. In this article, the authors examine early attempts to import experimental psychology into the courtroom and the arguments against them. Not only were Münsterberg's findings premature, they touched on a forbidden domain for witnesses: fact finding. While sincere, he learned that the determination of truth lay within the province of juries and judges, not psychologists. Thus, the application of psychology to the law was delayed. The authors review the lessons from Münsterberg's false start and comment on developments in the admissibility of scientific testimony.

Expert testimony in sexual assault cases: Alcohol intoxication and memory

At court-martial tribunals in the United States military, cases involving alcohol facilitated sexual assault often pivot on the alleged victim's level of intoxication or impairment and ability to consent to the sexual act. These cases frequently arise following a night of partying and heavy drinking among a group of friends and acquaintances, military and civilian. The determination of whether a sexual act was consensual may rest on estimates of the alleged victim's blood alcohol concentration and related behavioral indicia of impairment. Expert testimony may be presented by the prosecution and/or the defense, from forensic toxicologists and psychiatrists or psychologists regarding the potential involvement of alcohol and its impact on the participants relevant to the charges at court-martial. A review of the state of the science is offered to bring such testimony into perspective. Appellate cases illustrate that the experts' testimony may sometimes elucidate, sometimes obfuscate, and sometimes exceed professional expertise and invade the province of the factfinder.

Appropriateness of systemic treatments in unresectable metastatic well-differentiated pancreatic neuroendocrine tumors

AIM: To evaluate systemic treatment choices in unresectable metastatic well-differentiated pancreatic neuroendocrine tumors (PNETs) and provide consensus treatment recommendations.

METHODS: Systemic treatment options for pancreatic neuroendocrine tumors have expanded in recent years to include somatostatin analogs, angiogenesis inhibitors, inhibitors of mammalian target of rapamycin and cytotoxic agents. At this time, there is little data to guide treatment selection and sequence. We therefore assembled a panel of expert physicians to evaluate systemic treatment choices and provide consensus treatment recommendations. Treatment appropriateness ratings were collected using the RAND/UCLA modified Delphi process. After studying the literature, a multidisciplinary panel of 10 physicians assessed the appropriateness of various medical treatment scenarios on a 1-9 scale. Ratings were done both before and after an extended discussion of the evidence. Quantitative measurements of agreement were made and consensus statements developed from the second round ratings.

RESULTS: Specialties represented were medical and surgical oncology, interventional radiology, and gastroenterology. Panelists had practiced for a mean of 15.5 years (range: 6-33). Among 202 rated scenarios, disagreement decreased from 13.2% (26 scenarios) before the face-to-face discussion of evidence to 1% (2) after. In the final ratings, 46.5% (94 scenarios) were rated inappropriate, 21.8% (44) were uncertain, and 30.7% (62) were appropriate. Consensus statements from the scenarios included: (1) it is appropriate to use somatostatin analogs as first line therapy in patients with hormonally functional tumors and may be appropriate in patients who are asymptomatic; (2) it is appropriate to use everolimus, sunitinib, or cytotoxic chemotherapy therapy as first line therapy in patients with symptomatic or progressive tumors; and (3) beyond first line, these same agents can be used. In patients with uncontrolled secretory symptoms, octreotide LAR doses can be titrated up to 60 mg every 4 wk or up to 40 mg every 3 or 4 wk.

CONCLUSION: Using the Delphi process allowed physician experts to systematically obtain a consensus on the appropriateness of a variety of medical therapies in patients with PNETs.

Child sexual abuse research knowledge among child abuse professionals and laypersons

The purposes of this study were to: (1) Assess child abuse professionals' and nonprofessionals' knowledge of scientific research findings that are relevant to forensic child sexual abuse (CSA) evaluations and (2) describe associations between child abuse professionals' levels of research knowledge and their education and experience. An 18-item multiple-choice test was administered to 188 child abuse professionals and 457 nonprofessionals (undergraduate college students) in Brazil and the United States. The nonprofessionals' average percent correct, M=44%, was not significantly different than what would be expected for random guessing (45%). The professionals' average percent correct, M=55%, was higher than that of nonprofessionals and random guessing (both ps<.001). The average percent correct score for the US-sample psychologists, M=76%, was higher than the average score of the other professionals, M=51%, p<.001. Professionals' educational level, as measured by the highest academic degree obtained, was positively associated with percent correct scores, Spearman's ρ=.46, p<.001. Controlling for educational attainment, professional experience, as measured by the total number of CSA evaluations performed, was weakly associated with percent correct scores, partial r=.15, p=.04. Percent correct scores were low for both nonprofessionals and professionals. Most of the participants in this study were uninformed or misinformed about scientific research findings that are important for conducting optimal forensic CSA evaluations and for making accurate judgments about the validity of sexual abuse allegations.

Advocacy opportunities for pediatricians caring for maltreated children

Pediatricians are advocates for children. It is one of the central elements of the job description. In the course of their work, pediatricians have many opportunities to advocate for abused and neglected children. The most effective form of advocacy that most pediatricians will engage in with regard to child abuse and neglect is by being highly skilled doctors who provide excellent clinical care to children and families, knowing how to recognize child abuse and what to do when they encounter it, and being familiar with the resources of their communities.

Uncertain testamentary capacity

This letter illustrates the significance of the legal rules that resolve uncertainty in assessments of testamentary capacity.

[Is the court-ordered treatment indication by the expert based on a medical diagnosis?]

Court-ordered treatment was created in 1998, as part of a law against sexual offense recidivism. The creation of court-ordered treatment is based on the premise that many offenders have psychiatric disorders. If the court-ordered treatment is appraised as an effective way to prevent recidivism by the lawmaker, the preeminent role of psychiatry, in the prevention of recidivism has generated controversy in the psychiatric community. Few studies have been conducted on court-ordered treatment in France, and have concerned epidemiological measures. Court-ordered treatment leads to an extension of the expert's mission. In order to prevent recidivism, the interest of a treatment is a new part of the expert's mission.

PURPOSE

The main purpose of this study was to assess the kind of diagnosis reported by the forensic psychiatrist who considered the court-ordered treatment as appropriate.

METHOD

We led a descriptive and retrospective study among the experts' reports of 68 subjects followed by three psychiatrists. We categorized each diagnosis found in the experts' reports in reference to DSM-IV-TR axis I and axis II. As the expert has no obligation to refer to the DSM-IV-TR, we also considered the "no DSM-IV-TR categorized disorder" as a category. The primary outcome was the proportion of each diagnosis category in experts' reports, in which the forensic psychiatrist agreed with the indication of a court-ordered treatment.

RESULTS

We analysed 123 experts' reports in which the mission was to diagnose a mental disorder and to assess the need for a court-ordered treatment. The expert agreed with the need for a court-ordered treatment in 112 reports. In those reports the diagnosis was "no disorder" in 27% of them, "no DSM-IV-TR categorized disorder" in 26% of them, "axis II disorder" in 24% of them, "axis I disorder" in 19% of them, and "association of an axis I and an axis II disorder" in 4% of them.

DISCUSSION

The diagnoses were heterogeneous. Their associations with the need for a court-ordered treatment seem to be contradictory when considering the association between "no mental disorder" and "need for a court-ordered treatment" found in 27% of the reports. These paradoxical results led us to question the meaning of mental disorder and treatment.